Therefore, for a person to become an effective and successful user of hearing aids, they need to have the knowledge to understand how hearing aids work within everyday communication situations, often involving other people. Crucially, as will be discussed later, Boothroyd highlighted that “. . . there is a difference between ‘instruction’ and ‘telling’ . . .” (p. 65). The information offered to hearing aid users needs to be understood, assimilated, and acted upon within the context of their communication and participation in everyday life. At that time, there was relatively little research on the effectiveness of instruction, often known as hearing aid orientation (Reese & Hnath-Chisolm, 2005). However, over the last decade a number of interventions have been developed to help improve hearing aid knowledge and communication using a range of delivery systems. These methods include group work (Hickson, Worrall, & Scarinci, 2007), and remote delivery using videotapes (Kramer, Allessie, Dondorp, Zekveld, & Kapteyn, 2005), DVDs, and online materials (Ferguson, Brandreth, Leighton, Brassington, & Wharrad, 2016; Thorén, Öberg, Wänström, Andersson, & Lunner, 2014).
In the U.K., recent national guidelines on hearing loss recommend that good quality information should be provided for both those with hearing loss and their families (National Institute for Health and Care Excellence, 2018). However, clinical provision of information to promote knowledge on hearing loss, hearing aids and communication is often delivered verbally or through written materials. This often comes in the form of passive telling rather than active instruction, which is more likely to promote learning. In education and other health care fields, remote digital educational interventions have been shown to improve knowledge acquisition, satisfaction, and adherence.
To address knowledge limitations of hearing aid users and promote greater hearing aid use and better communication, a series of multimedia, interactive educational videos (or reusable learning objects, RLOs) have been developed. These RLOs, known collectively as C2Hear, provide education on important practical and psychosocial aspects of hearing loss, hearing aids, and communication. In addition to the RLOs, C2Hear includes a short introduction, patient testimonials, and a multiple-choice quiz after each RLO. Originally developed for remote delivery via DVD for television, personal computer, and the internet, C2Hear has been freely available online via YouTube since 2015 (http://www.youtube.com/C2HearOnline). More recently in 2019, a standalone, freely available “go-to” website (http://c2hearonline.com) was launched that contains a range of resources including the RLOs, demo and waiting room clips, and journal and newsletter articles. This chapter focuses on the C2Hear research program and will discuss the (a) theoretical underpinning, including self-management of hearing loss; (b) development of C2Hear; (c) evaluation of C2Hear when used with patients, partners, and professionals; and (d) current developments to increase individualization and interactivity.
Theoretical Underpinning to Support Development of Educational Interventions
Development and evaluation of an intervention based on theory is more likely to lead to an effective intervention than using an empirical or pragmatic approach (Medical Research Council, 2006). A theoretical underpinning can provide an understanding of how an intervention might affect change in terms of what can be expected and achieved. Here, we focus on two theories that have informed the development of the C2Hear RLOs and their further development: (a) the constructivist learning theory, incorporating pedagogical participatory design principles; and (b) the health behavior change theory, specifically the COM-B model.
The constructivist learning theory posits that learning is an active process of constructing and conceptualizing knowledge whereby the learner constructs an internal representation of the learning materials. By actively interacting with learning materials, particularly in the form of relevant and specific activities, the learner is more engaged and motivated to learn than if the learning environment was passive. Incorporating past experiences and prior knowledge, the learning can result in a unique version of knowledge for the individual, resulting in more effective knowledge acquisition. The use of interactive videos delivered within an e-learning environment has been shown to provide better learning performance and greater satisfaction than more passive and traditional learning environments (Zhang et al., 2006).
The pedagogical design principles for C2Hear were based on the principles of learning theory, and used an e-learning format known as the RLO (Windle & Wharrad, 2010). RLOs are bite-sized chunks of interactive multimedia e-learning that focus on a specific learning goal. They are used widely in the educational field (e.g., universities), and have also been used in health care education. The theoretical framework underpinning the pedagogical design of the RLOs is the International Machine Standard (IMS) Learning Design (Koper, 2003). Activities and self-assessments are built into the RLOs and are aligned with a specific learning goal (Biggs, 2003). These activities are important because they help users to actively engage in the process of learning, and feedback from self-assessments helps users to determine whether they have successfully achieved the learning goal.
RLOs comprise four components: (a) presentation of the concept or procedure to support the learning goal; (b) an activity that enables the learner to engage with the content; (c) self-assessment to test for mastery of the content; and (d) links to other resources to reinforce the learning. The visualization process that forms the computerized animations or videos is an important feature as this enhances learning and enables a more effective way to demonstrate complex concepts compared with learning from static text (Thatcher, 2006). Key to the effectiveness of RLOs is a sense of control and ownership of the learning process, along with the ability to reuse the resources on multiple occasions (Windle, McCormick, Dandrea, & Wharrad, 2010).
A weakness of many e-health and educational interventions is that there is limited or no involvement of end users (van Velsen, Wentzel, & van Gemert-Pijnen, 2013). The use of participatory and codesign approaches are increasingly being used to ensure that both end users and key stakeholders are at the core of the design and development of such interventions. This coproduction ensures educational materials are aligned to the needs of the end user, and improve usability and satisfaction (Bruno & Muzzupappa, 2010; Latif, Carter, Rychwalska-Brown, Wharrad, & Manning, 2017). Coproduction of RLOs typically involves end users and stakeholders in a design workshop that provides a forum for discussion and engagement with others to create the RLO content. This leads to high-quality and relevant materials, specifically designed to meet the needs of the end user. Behavior change is also a desirable outcome from an educational intervention (Yardley et al., 2016). The creative workshops allow personal stories and anecdotes to be captured during the storyboarding process, which can provide triggers for behavior change. A participatory and codesign approach initiated through workshops is a key feature of RLO development methodology.
Health behavior change is relatively new to audiology, whereas the field of health psychology has worked with behavior change for more than four decades. In recent years, audiology has focused on some of the more popular models that aim to understand, predict and promote health-related behavior (Coulson, Ferguson, Henshaw, & Heffernan, 2016). Examples include the Health Belief Model (Rosenstock, 1974), the Transtheoretical Model (Prochaska & DiClemente, 1983), and the Theory of Planned Behavior (Ajzen, 1991).
The use of these models to provide theoretical underpinnings to hearing research has been a positive development. However, within the field of health psychology there is a well-developed body of literature to suggest that these models do not, and cannot, reliably explain the variability in health behaviors (Coulson et al., 2016). More recently, a new approach has been developed to address these limitations that has a psychological model of human behavior at its core, known as the COM-B system of health behavior change (Michie, van Stralen, & West, 2011). (Editors’ note: For additional information on health behavior change, the reader is referred to Chapter 8 of this text.)
The Behavior Change Wheel is an overarching framework specifically developed to characterize behavior change interventions and link them to analysis of the target behavior (Michie et al., 2011) (see link http://www.behaviourchangewheel.com/about-wheel). The hub of the Behavior Change Wheel is the COM-B system that has three core components predicting behavior via capability, opportunity, and motivation. Capability is the individual’s psychological and physical capacity to engage in a behavior, including having the necessary knowledge and skills. Opportunity considers factors that are external to the individual that prompt or make the behavior possible. Motivation considers brain processes that energize and direct behavior, including habitual processes, emotional responses, and analytical decision making.
The Theoretical Domains Framework (TDF) (Cane, O’Connor, & Michie, 2012) enables theoretical constructs relating to behavior change to be mapped directly onto the COM-B system. The Behavior Change Technique (BCT) Taxonomy (Michie et al., 2013) enables users to specify the smallest components of interventions that can bring about behavior change. This provides a common language by which to develop, define, and report behavior change interventions in terms of their “active ingredients.” Components of the Behavior Change Wheel, namely the COM-B system, TDF, and the BCT Taxonomy, are now being used in audiological rehabilitation research to improve understanding of the underpinning mechanisms of health behavior change, and to theoretically inform intervention development and assessment (Barker, Atkins, & de Lusignan, 2016; Barker, Mackenzie, & de Lusignan, 2016; Maidment & Ferguson, 2017; van Leeuwen et al., 2018).
Self-Management of Hearing Loss
Self-management of hearing loss as a long-term chronic condition is also coming to the forefront in hearing research. More generally, there is a growing awareness that self-management of long-term conditions (LTCs) can enhance the efficiency of health and social care. Self-management is defined by the U.S. Institute of Medicine as “the tasks that individuals must undertake to live with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management and emotional management of their conditions” (Corrigan, Greiner, & Adams, 2004, p. 57). Self-management focuses on behaviors relating to a specific health condition. Those who take an active role in their self-management, and who are appropriately motivated to participate actively in their care, are more likely to adopt better health behaviors. This in turn leads to better patient outcomes (Mosen et al., 2006). (Editors’ note: For additional information on self-efficacy, the reader is referred to Chapter 13 of this text.)
A meta-review of a range of LTCs has highlighted five key components of self-management (Taylor et al., 2014). These are:
1. provision of education about the LTC;
2. psychological strategies to support adjustments to life with a LTC;
3. strategies to support adjustment to life with a LTC as well as adherence to treatments;
4. practical support tailored to the individual with the LTC; and
5. social support.
In terms of interventions to support self-management of LTCs, Pearce et al. (2016) developed a 14-item taxonomy of self-management support that classifies components of interventions. The taxonomy includes four specific elements: mode of delivery; personnel who deliver the support; target of the intervention; and intensity, frequency, and duration of the intervention. Such a taxonomy would help underpin the development and evaluation of interventions for self-management of hearing loss.
More recently, there has been a growing awareness about self-management of hearing loss. A Cochrane systematic review has examined the use of interventions to promote hearing aid use (Barker et al., 2016b), based on the generic Chronic Care Model (CCM) used to describe self-management of LTCs (Bodenheimer, Wagner, & Grumbach, 2002). The review included 37 randomized controlled trials (RCTs), which included a range of interventions associated with adult aural rehabilitation (e.g., education, auditory training, counseling), with the primary outcome being hours of hearing aid use. The quality of the evidence was rated as very low to low. Therefore, the results of the numerous meta-analyses conducted, aligned to the components of the CCM, need to be considered within the context of the low-quality evidence. Overall, the review concluded that any improvements in outcomes had small effect sizes, and only some people showed improvements in certain outcomes. Although there were improvements in hearing “handicap” and verbal communication in the short term, there were no improvements in either the short-, medium-, and long-term outcomes for hours of hearing aid use. However, the review did highlight that one large RCT showed that the interactive multimedia videos (C2Hear) encouraged more people to wear their hearing aids (Ferguson, Brandreth, Brassington, & Wharrad, 2016). Furthermore, of all the 37 studies reported in the review, this study was shown to have the lowest risk of bias in terms of how it was conducted, therefore indicating a high-quality study.
Much of the relatively limited evidence looking at self-management relating to hearing loss is limited to adherence to interventions (e.g., hearing aid use), with relatively little focus on the more psychosocial aspects such as coping (Convery, Keidser, Hickson, & Meyer, 2019). A recent study by Convery et al. (2019) identified self-management of hearing loss as a multifactorial construct that includes three factors:
1. actions (e.g., shared decision-making, taking action);
2. psychosocial behaviors (e.g., coping); and
3. knowledge.
Independent variables associated with these factors and overall self-management of hearing loss were hearing aid self-efficacy, health literacy, hearing health care experience, and problem-solving skills. Convery et al. (2019) propose that although fixed factors such as age, gender, and health literacy may influence the self-management intervention, modifiable factors such as self-efficacy may be targeted to improve self-management. These findings, which bring together self-efficacy and behavior change as constructs underpinning self-management of hearing loss, fit well with the outcomes from the C2Hear research, discussed in a later section.
Development of C2Hear
The C2Hear RLOs were coproduced using a participatory approach involving hearing aid users and hearing health care professionals, who were core to the development process and were involved at all stages of design (Ferguson, Leighton, Brandreth, & Wharrad, 2018). At the time that C2Hear was being developed in 2011, there was relatively little in the scientific literature to describe what good-quality information for first-time hearing aid users looked like. To address this, a two-stage approach was taken.
Delphi Review
The first stage used a Delphi review method to reach a consensus amongst hearing health care professionals on the informational needs of first-time hearing aid recipients. This is an iterative process that refines opinions on a specific subject until a group of experts reaches an accepted degree of consensus. A Delphi review has four core characteristics: an expert panel, a number of iterations and controlled feedback, statistical feedback, and anonymity of responses (Diamond et al., 2014). The expert panel comprised 33 U.K. hearing health care professionals including National Health Service (NHS) audiologists, hearing therapists, hearing researchers, hearing charity representatives, hearing aid company representatives, and independent hearing aid dispensers.
An anonymized three-round Delphi review was conducted by email. In round 1, 10 open-ended questions sought to establish the ideal information for first-time hearing aid users and reasons for non-use of hearing aids. Thematic analysis of responses resulted in a bank of 67 statements on information needs. These statements formed the basis of rounds 2 and 3, and participants scored the statements on a 5-point Likert scale (strongly agree to strongly disagree). In round 3, the statements were presented alongside the summary statistics from round 2. Consensus on a statement was reached when ≥90% of the expert panel “agreed” or “strongly agreed” with the statement. To provide general topic areas for the RLOs, the panel was asked to rank order the 15 proposed topics that arose from round 1.
At the end of round 3, 100% agreement was reached for 21 statements (31.3%), and between 90% and 99% agreement for a further 21 statements (31.3%). There was less than 50% agreement for nine statements (13.4%). The final top 10 ranked topics were: hearing aid insertion; hearing aid controls; hearing aid maintenance; getting used to hearing aids; communication tactics; hearing aid benefits and limitations; information for communication partners; listening in different situations; expectations of hearing aids; and telephones and assistive listening devices.
Workshops
The second stage involved hearing aid users and audiologists in the development of the RLO content through the coproduction of A0 (841 × 1189 mm) storyboards (Figure 15–1). This provided an opportunity for participants to conceptualize their personal experiences of hearing aids and hearing loss. A total of 32 hearing aid users and 11 audiologists participated in three 1-day workshops. The top 10 topics of ideal information from the Delphi review were discussed by the participants, and their views and perspectives of these topics were captured on the storyboards that provided visual representations of their personal thoughts and experiences around these topics. Each group developed two or three storyboards, and a total of 23 storyboards were generated, with at least two storyboards per topic.
Development and Production of the RLOs
The Delphi statements that reached consensus (≥90% agreement) and key points from the storyboards were mapped and integrated onto the relevant RLO title derived from the top 10 topics. Written specifications for the RLOs were developed, which included key pedagogical components: learning goals; detailed description of visual imagery and sounds, such as illustrations, video clips, static and dynamic animations, and photographs; transcripts of the text to accompany the media, which formed subtitles; and a two- or three-question multiplechoice quiz with additional feedback. The specifications were iteratively developed and peer reviewed with input from the project-specific patient and public involvement (PPI) panel that consisted of hearing aid users. This ensured that the RLOs were meaningful and relevant, and clearly explained the concepts in a language that could be easily understood by the future end user (i.e., first-time hearing aid users). In addition, there was also iterative peer review from a panel of audiologists to ensure the RLOs had clinical validity. Each RLO specification was reviewed two to three times.
Figure 15–1. Example of a storyboard developed by hearing aid users.
The written specifications were then developed into the multimedia RLOs with subtitles. At the time the RLOs were developed in 2011 to 2012, the use of PCs and internet in the typical first-time hearing aid user age group (70 to 74 years) in Nottingham, U.K., was quite low, at 36% and 17%, respectively (Henshaw, Clark, Kang, & Ferguson, 2012). Although the interactivity potential for RLOs delivered online was greater, in order to maximize accessibility for the typical first-time hearing aid user population, a DVD delivery platform was chosen. This meant the RLOs could be delivered through DVD for TV or computer, as well as online through the internet via a custom-made, password-protected portal.
Initially, there were a total of seven RLOs plus an introductory RLO, some of which were developed for both slim open-fit tubes and custom earmolds (e.g., How to Insert Hearing Aids). The duration of the RLOs ranged from 4 minutes and 34 seconds to 11 minutes and 35 seconds (Mean = 9 min, 25s) (Ferguson, Brandreth, Brassington, & Wharrad, 2015). Participants had the freedom to choose which RLO to watch, and when, and for as many times as they liked, with the option to fast forward, rewind, and pause. Additional interactivity was achieved through the interactive multiple-choice quiz. The aim of this participatory approach to the development of the RLOs was to ensure that as many hearing aid users would find them relevant and useful. However, the ultimate aim of the research was that the C2Hear RLOs would provide benefits to hearing aid users.
Evaluation of C2Hear in Patients, Partners and Professionals
First-Time Hearing Aid Users
Following development of the RLOs, their effectiveness was evaluated in a registered RCT of 203 first-time adult hearing aid users (ISRCTN11486888) (Ferguson, Brandreth, Brassington, & Wharrad, 2016). The RCT aimed to (a) establish the accessibility, uptake, acceptability, and adherence of the RLOs, and (b) assess the benefits and cost-effectiveness of the RLOs. Patients were prospectively recruited and remotely randomized by the Nottingham Clinical Trials Unit into either the intervention group (RLO+, n = 103) that received the RLOs, or the waitlist control group (RLO−, n = 100) that received standard care. Those allocated to the RLO+ group were able to choose their preferred RLO delivery method. The most common delivery format was DVD for TV (50.6%), followed by internet delivery (32.9%) and DVD for TV (15.2%). One person used a DVD with autoplay.
The primary outcome measure was hearing aid use from the Glasgow Hearing Aid Benefit Profile (GHABP) (Gatehouse, 1999), and the study was powered to show a 12.5% difference between the RLO+ and RLO− groups. Allowing for a 15% attrition rate, 200 patients needed to be recruited. The RLO+ group received the RLOs at the hearing aid fitting appointment, and both groups were seen for a follow-up evaluation at 6 to 7 weeks postfitting (Mean = 6.8 weeks). The research audiologists were blinded as to the group allocation, and at the end of the follow-up session the RLO- control group were offered the RLOs.
Secondary outcome measures included: GHABP part 2, International Outcome Inventory for Hearing Aids (IOI-HA) (Cox & Alexander, 2002), Hearing Handicap Inventory for the Elderly (HHIE) (Ventry & Weinstein, 1982), Satisfaction with Amplification in Daily Life (SADL) (Cox & Alexander, 1999), Practical Hearing Aid Skills Test (PHAST) (Desjardins & Doherty, 2009), Hearing Health Care Intervention Readiness (HHCIR) (Weinstein, 2012), Hearing Aid and Communication Knowledge (HACK) (Ferguson et al., 2015), and the Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983). In addition, a video diary was used to record use and usefulness of the RLOs. Patient feedback on the RLOs was obtained based on 20 statements, such as “I found the videos enjoyable,” using a 5-point Likert scale (strongly agree to strongly disagree). To gain a deeper understanding of the benefits of the RLOs, three focus groups were held that included both the research participants (n = 20) and communication partners (n = 5).
Uptake and Adherence Was High; Feedback Was Positive
Uptake and adherence of the RLOs was high (78.4% and 97.4%, respectively). The average number of views was 13 per participant, and around half (49.2%) watched the RLOs more than once, with 22% watching at least three times. The multiple use of the RLOs suggests that they were used to self-manage their hearing loss, and this was confirmed in the focus groups and open-ended questions from the feedback questionnaire. The RLOs were rated as highly useful on average (Mean = 8.9, where 0 = not useful, 10 = extremely useful), and 78.4% said they would recommend the RLOs to other people. Patient feedback was favorable. For content, the vast majority (92%) agreed the illustrations and videos aided their understanding. For activity and engagement, 91% agreed the quiz gave a clear message, and 88% would refer back to the RLOs if they had a problem. Finally, participants reported they preferred the RLOs to written information (82.9%), and felt more confident in discussing hearing aid and communication with others (81.3%).
This positive feedback was reflected in the responses from the open-ended feedback questions and the focus groups. Participants reported that the RLOs:
■ provided useful and helpful advice;
■ were easy to understand and reliable;
■ reinforced their knowledge and confidence;
■ provided reassurance and helped perseverance with hearing aids;
■ were a helpful resource to refer back to if needed; and
■ helped with coping in difficult situations.
Focus groups confirmed that the RLOs were generally very well received, with key themes being repeated watching, sharing RLOs, providing reassurance, and helping people to remember, reflected in the following statements:
“. . . I found that I had missed something, so I went back and looked again.”
“I have passed my DVD onto an old couple who both have hearing aids . . . I kept telling her, play that DVD and you will know why . . .”
“The DVD explained how we have to relearn to rehear things. That was not an aspect that I was aware of, to re-educate your brain to interpret what you hear.”
Not all the comments were positive, however. Some people reported that the RLOs were either too long or could have delivered the key messages in a more concise way. Others thought the RLOs were too simple. A surprising finding was that some participants thought that the hearing aid users who appeared in the RLOs and were the age of typical first-time hearing aid users were sometimes perceived to be too old. Even though they were broadly the same age as those participating in the study, this was seen as a negative and off-putting. Future development of interventions that depict hearing aid users should take into account these views to minimize negative perceptions.
RLOs Benefited Patients
There were significant improvements in outcome measures for the RLO+ group compared to the control RLO− groups for:
■ knowledge of hearing aids (HACK, p < .001), with a large clinical effect size (d = 0.95);
■ practical handling skills (PHASI, p < .001); and
■ hearing aid use (GHABP) in those who did not wear their hearing aids all the time (<70%) (p = .03), with a large clinical effect size (d = 0.83).
There was no difference in overall hearing aid use for the whole sample (median RLO+ = 100%, RLO− = 96.7%, p = 0.48), in part because many participants reported 100% use, indicating ceiling effects. For other outcomes, there were no group differences. Finally, a health economic analysis showed that the RLOs in DVD format were highly cost-effective.
To summarize, the results from this RCT of the C2Hear educational intervention showed key benefits of knowledge improvement, hearing aid handling skills, and hearing aid use, as well as providing reassurance and increasing confidence with hearing aids and communication. RLO uptake and adherence was high, and C2Hear was rated as highly useful.
Through the mixed-methods approach using both quantitative and qualitative methods, the study demonstrated that C2Hear was effective in providing a range of benefits for first-time hearing aid users. However, it was also relevant to find out why this intervention was effective, and to establish what these underlying effects were. To do this, the Medical Research Council process evaluation framework was used that aims to examine causal mechanisms and contextual factors (Moore et al., 2015). Causal mechanisms, also known as mechanisms of impact, refer to how an intervention works, highlighting where future improvements can be made. Contextual factors are those that are external to the intervention, which can strengthen or impede its effects, and can be used to inform why an intervention does or does not work. Based on these principles, General Linear Model (GLM) analyses were conducted to gain some insights about how and why C2Hear provides benefits to hearing aid users.
After the RCT was completed, further feedback obtained from research participants was reviewed and the RLOs were revised. The end result was nine RLOs plus an introductory RLO. Changes included patient testimonials being removed from the main body of the RLOs, removing aspects that were considered negative such as the use of black-and-white photos that compounded the older age of people who appeared in the RLOs, and the total time was reduced from 1 hour to 45 minutes (Figure 15–2).
Early Delivery of C2Hear
The RCT provided C2Hear at the fitting appointment, but increasing patient’s knowledge prior to receiving hearing aids has obvious advantages, such as enhancing self-efficacy for hearing aids and readiness to take action. To investigate this, an RCT of 47 first-time hearing aid users was conducted where C2Hear was delivered earlier in the patient journey, at the hearing assessment. First-time hearing aid users received either C2Hear (n = 24, intervention group) or the standard clinic booklet (n = 23, control group) (Gomez & Ferguson, 2019). Outcomes were assessed 4 weeks later, prior to the fitting of the hearing aids. The primary outcome measure was the Measure of Audiologic Rehabilitation for Self-Efficacy for Hearing Aids (MARS-HA) (West & Smith, 2007). Other outcome measures were the Ida Institute motivation line tools that measure readiness and self-efficacy (Ferguson, Maidment, Russell, Gregory, & Nicholson, 2016), and the HACK that measured knowledge of hearing aids and communication.
Figure 15–2. C2Hear RLOs made publicly available online following further patient input.
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