as social cognitive theory that explains human functioning (Bandura, 1977, 1986). Social cognitive theory describes human functioning as a triadic interaction among personal factors (cognition, affect, and biological events), environmental factors, and behavior (Bandura, 1986). Each component of the triad influences the other components, and a person can exert control over each component to achieve a desired outcome. For example, individuals are not solely products of their environment, but have the capability to exert control over their environment through their personal factors (e.g., self-regulation, forethought, etc.) and behavior. Individuals’ beliefs about themselves influence their environment and are critical to how they behave. Self-efficacy beliefs are core to social cognitive theory and thus human functioning. Individuals need to believe that they can produce a desired outcome or accomplishment; otherwise, there is little motivation to do so.
It cannot be overemphasized that self-efficacy beliefs are domain specific and pertinent to a particular behavior or task. With each task or behavior, certain knowledge and requisite skills must be organized and executed to achieve the desired outcome successfully. Consider the knowledge and skills associated with successful computer use versus public speaking. They are quite different. Therefore, an individual may be highly confident in their abilities to use a computer (i.e., computer self-efficacy) while at the same time completely lack confidence in their public speaking abilities (i.e., public speaking self-efficacy). In the context of AR behaviors, for example, a patient may be highly confident in their hearing aid use skills (i.e., hearing aid self-efficacy) but at the same time have low confidence in their ability to execute assertiveness in demanding communication situations (i.e., assertiveness self-efficacy) with unfamiliar communication partners.
Self-efficacy beliefs are thought to influence individual functioning in several ways including but not limited to the choices people make about the tasks or behaviors they pursue; the amount of effort they will put forth to succeed; how long they will persevere when tasks or behaviors become difficult or failure is experienced; and their ability to mobilize motivation to set goals and commit to them (Bandura, 1992, 1997, 1998; Pajares, 2002; Stajkovic & Luthans, 2002). In the context of AR, these influences should be carefully considered, as patients have to make decisions regarding which AR intervention option(s) they pursue and the effort involved with each option. Individuals tend to choose to engage in tasks that they believe they can confidently execute to achieve the desired outcomes. Patients may lack the knowledge about the requisite skills and behaviors involved in a particular AR intervention, which highlights the importance of carefully reviewing the details associated with a desirable outcome and the support the clinician can provide as the patient implements new skills and behaviors. The good news is that self-efficacy is a key and modifiable mediator involved with behavioral change, including those associated with adopting and maintaining health behaviors (Bandura, 1997, 1998; Schwarzer & Fuchs, 1996; Shortridge-Baggett, 2001). Data from the larger health literature clearly show that patients who have high self-efficacy for managing a chronic condition have higher treatment outcomes, better adherence to treatment plans, better resilience when adversity is encountered, and a better outlook on their health in general (Bandura, 1992, 1997, 1998, 2004; Holden, 1991; Marks et al., 2005; Schwarzer & Fuchs, 1996). Later in this chapter, techniques clinicians can use to increase self-efficacy in their patients will be reviewed.
Role of Self-Efficacy in Audiologic Rehabilitation Domains
Help-Seeking
Self-efficacy beliefs influence the choices people make regarding whether or not to adopt a new behavior. In the context of AR, a primary treatment option is the adoption of amplification options such as hearing aids, cochlear implants, or other assistive technologies. Previous research has posited that individuals with hearing loss may not seek amplification options if they have low self-efficacy regarding their abilities to manage a hearing aid (Kricos, 2000; Smith & West, 2006a; Weinstein, 2000). Meyer and colleagues (2014) conducted a study and confirmed that individuals who had high self-efficacy for handling a hearing aid were more likely to seek professional help and adopt hearing aids. Laplante-Lévesque et al. (2011) examined the factors that predicted choice for an AR intervention (hearing aids, individual or group communication programs, or no intervention) adopted by a group of 139 adult participants. Communication self-efficacy, or how confidently an individual can plan and execute actions to successfully manage a communication situation, was one predictor variable used in the study. The study showed that participants who had higher levels of communication self-efficacy were less likely to choose hearing aid adoption, suggesting these patients with hearing loss may rely on other resources for communicating. Ferguson et al. (2016a) showed that a group of first-time hearing aid users who participated in motivational engagement during a prefitting assessment had higher self-efficacy for following health care recommendations than those participants who engaged in a standard of care approach without motivational engagement. Finally, the role of self-efficacy has been examined in the context of multifaceted health behavior change models for which self-efficacy is a factor. Saunders and colleagues (2013, 2016) showed that self-efficacy plays a small role in where the patient is in their hearing health care help-seeking journey, whereas Pronk and colleagues failed to show that self-efficacy was a significant predictor in help-seeking behaviors of older patients with hearing loss. Overall, however, the results of these studies demonstrate that self-efficacy plays a role in help-seeking behaviors in patients with hearing loss. Therefore, counseling that incorporates self-efficacy (among other factors) might help patients promote help-seeking behaviors or take action regarding the treatment of their hearing loss (Saunders et al., 2016).
Associations Among Self-Efficacy and Other Measures Related to AR
The relations between self-efficacy and other measures associated with hearing have been evaluated in an effort to understand better its role in the context of AR domains, including audiometric data and self-reported measures. For example, Smith and West (2006b) evaluated hearing aid self-efficacy as a function of degree of hearing loss. They found that hearing aid users with mild hearing loss had higher aided listening self-efficacy than those with greater degrees of hearing loss. Kelly-Campbell and McMillan (2015) made a similar finding. Confidence levels in following conversations with a variety of auditory communication skills were found to be significantly correlated with degree of unaided hearing loss, word recognition abilities in quiet and in noise, and self-perceived handicap (Sweetow & Sabes, 2010). Consistent with other research, Sweetow and Sabes showed that poorer performance on behavioral and self-reported measures is associated with lower levels of confidence in following conversations in various listening conditions. Jennings et al. (2013) found that although communication self-efficacy was not associated with degree of hearing loss or age, it was associated with hearing attitudes and handicap. Those who reported that they were more affected by their hearing loss and who had more negative attitudes towards hearing loss also reported less confidence in managing various listening situations. Taken together, these results suggest that listeners with more significant degrees of hearing loss, greater speech perception difficulties, or more negative perceptions regarding their hearing need additional counseling to improve their abilities to confidently engage in challenging listening conditions whether they wear hearing aids or not.
Kelly-Campbell and McMillan (2015) explored the relation between hearing aid self-efficacy and hearing aid satisfaction in a group of 47 new and experienced users who completed the outcome measures 12 weeks following their hearing aid fitting. Their data showed that, in general, users who exhibited high hearing aid self-efficacy were more satisfied with their hearing aids. Ferguson et al. (2016b) showed that hearing aid self-efficacy, when measured prior to the hearing aid fitting, is predictive of hearing aid satisfaction, but not other domains of hearing aid outcomes used in their study (e.g., data logging, Glasgow Hearing Aid Benefit Profile [Gatehouse, 1999]), whereas Dullard and Cienkowski (2014) showed that hearing aid self-efficacy was correlated with hours of use.
Johnson and colleagues (2018) examined outcomes in domains related to benefit, satisfaction, and hearing aid self-efficacy for advanced digital hearing aids in listeners with mild hearing (n = 153) who underwent best practice hearing aid fitting procedures. They found their sample had positive outcomes in all domains in general and was equivalent to published data. They did note, however, that some users lacked confidence in their advanced hearing aid skills (e.g., troubleshooting) and in using their hearing aids in difficult listening situations. These were the same users who had moderate levels of satisfaction for some items related to negative features of hearing aids (e.g., picked up sounds that prevented them from hearing the target). This finding, as the authors indicated, suggests that close follow-up and counseling are crucial for patients to optimize hearing aid use in challenging situations (i.e., noise) confidently.
Smith and Fagelson (2011) examined associations between self-efficacy for managing chronic tinnitus and self-reported tinnitus ratings. They found that patients with tinnitus who had high confidence in their abilities to manage their tinnitus tended to report being significantly less aware of their tinnitus while awake and less distressed and handicapped by their tinnitus compared to those who had lower confidence in their abilities to manage their tinnitus. In addition, tinnitus self-efficacy was found to be significantly lower in patients who had both tinnitus and post-traumatic stress disorder (PTSD) than those patients with tinnitus who did not have PTSD (Fagelson & Smith, 2016). These data suggest that self-efficacy plays a role in tinnitus management and even more so in patients who exhibit additional comorbidities. Although AR interventions tend to place emphasis on communication, patients may also present with goals associated with reducing the effects of tinnitus and thus it is not uncommon that tinnitus is part of an AR approach in patients with hearing loss and is the focus of Chapter 22.
Changes in Self-Efficacy Through AR Intervention
Consistent with the self-efficacy concept, individuals’ confidence in their abilities should improve with education to increase knowledge, practice, or training to teach new skills, and experience with using those skills in a variety of situations. Studies that have evaluated changes in self-efficacy levels through an AR intervention will be illustrated in this section.
West and Smith (2007) developed a hearing aid self-efficacy measure called the Measure of Audiologic Rehabilitation Self-Efficacy for Hearing Aids (MARS-HA). To demonstrate criterion validity of the measure, or to validate that experience with hearing aids leads to greater confidence in hearing aid skills, they reported on data examining hearing aid self-efficacy levels in 29 first-time hearing aid users preintervention and 1 month postintervention. Each participant received a standard hearing aid orientation that also highlighted the skills assessed on the measure (basic and advanced handling, adjustment, and aided listening). A subsample of these participants received enhanced counseling that incorporated self-efficacy enhancing techniques during the orientation (this will be described later in this chapter, but a detailed description can be found in Smith & West, 2006a, and Smith, 2014). The data showed a 30% increase in hearing aid self-efficacy levels when comparing prefitting self-efficacy levels to 1 month postfitting self-efficacy levels. These data support that training and experience lead to increased self-efficacy.
Sweetow and Sabes (2010) carried out a similar study in 51 patients receiving hearing aids for the first time. They showed that, on their measure of self-efficacy, the Communication Confidence Profile (CCP), nearly all of the patients reported improvements in self-efficacy following 2 to 4 weeks of hearing aid use. Their measure focused on self-efficacy for a variety of auditory communication skills such as understanding conversation when talking with one to two individuals while at home or understanding an unfamiliar talker in a noisy environment.
In a somewhat different approach, McMullan and colleagues (2018) evaluated whether or not enhanced education materials would affect self-efficacy levels. In their study, they developed an enhanced hearing aid user guide (HAUG) by improving its readability and suitability. In addition, they made a video to accompany the revised HAUG. The use of education materials in written and video form is a technique suggested to increase hearing aid self-efficacy (Smith & West 2006a, Smith, 2014). They randomized 16 adults to a group that used the original HAUG (OG group) and 15 adults to the experimental group, which used the revised HAUG and video (RG group). Minimal counseling was provided by the examiner and both groups were allowed to review their assigned materials and practice their skills with a hearing aid without a time limit. Both groups completed a practical skills test along with the MARS-HA. The results revealed that the RG group had significantly higher self-efficacy for hearing aid skills compared to the control group (OG). These findings support that the use of enhanced written materials and videos results in higher hearing aid confidence in adults with no prior hearing aid experience.
In summary, self-efficacy plays a role in all aspects of human behavior, including those behaviors in the context of audiologic rehabilitation. Emerging data in our field show that self-efficacy is an important factor in hearing health care help-seeking behaviors. An individual’s self-efficacy level for hearing aids, if low, may prevent them from seeking help regarding hearing aid adoption or from advancing through the steps in the patient journey. On the other hand, if communication self-efficacy is high, individuals may not pursue amplification because they are confident they can manage in their current situation. Taken together, these findings highlight the importance of examining self-efficacy in the target domain or context of interest. In addition, self-efficacy levels have been shown to be associated with attitudes and perceptions about hearing loss and also with hearing aid outcomes. These associations are good in the sense that they are modifiable through additional intervention or counseling. In addition, there are strategies that will be reviewed later to increase self-efficacy levels of patients in the context of AR. Finally, through AR intervention and experience, AR self-efficacy levels have been shown to increase. In the next sections, how an individual formulates their self-efficacy beliefs will be discussed, followed by a review on how clinicians can use targeted techniques to help patients increase their self-efficacy levels.
Making Self-Efficacy Judgments
Individuals make judgments or appraisals about their self-efficacy levels by interpreting information from four sources. These sources of information include the following: (a) mastery experience, (b) vicarious experience, (c) verbal persuasion, and (d) physiologic and affective states (Bandura, 1986, 1977). For the purposes of illustrating these sources of information in action, we will consider some skills and behaviors associated with successful hearing aid use.
Mastery Experience
The strongest source of information from which individuals make self-efficacy judgments is through mastery experience or enactive attainment. This refers to the judgments made by acting out the skill or skill set associated with achieving the behavior of interest or judgments based on past experiences. Simply stated, if the skill was performed successfully, then self-efficacy often is judged as being high for that skill, whereas failures to perform the skill successfully often result in low self-efficacy judgments (Bandura, 1997).
The ability to adjust manual programs on a hearing aid, for example, often is needed to optimize hearing aid use in different listening situations. If a patient successfully identifies when to use a given program and navigates to the desired program correctly for a given listening situation, then they will likely judge their self-efficacy via mastery experience as high for this skill. In the future, they likely will attempt to use a manual program when the need arises and persevere with its use if difficulties are encountered. In contrast, an individual who cannot determine or navigate to the proper manual program for a given listening situation will likely judge their ability as being low, thus forming a low self-efficacy belief via lack of mastery experience. In this latter case of low self-efficacy, the patient is at risk for avoiding future attempts of using manual programs with their hearing aid or may simply give up after a feeble attempt.
Vicarious Experience
The old adage, “if they can do it, then I can do it,” represents judgments based on vicarious experience. By observing others, or models, perform tasks or behaviors, individuals form beliefs about their own abilities. If the model successfully performs the skills needed to achieve a behavior, then a person will likely judge their own self-efficacy beliefs about their abilities as high. On the other hand, if a person observes a model struggling with achieving a behavior, then they will likely have low self-efficacy beliefs in their own abilities for accomplishing that behavior (Bandura, 1997).
It is not uncommon for older patients, particularly first-time hearing aid users, to struggle with inserting their batteries into their hearing aids. If the model successfully identifies and opens the battery door, removes the tab on the battery, orients the battery correctly, and inserts the battery into the door without dropping it, then the patient may judge their ability for battery insertion as high via vicarious experience. They may think “if they can do it, then so can I” and then be motivated to attempt battery insertion on their own and more eager to try again if failures occur along the way. If the model’s ability for their battery insertion skills is less than ideal, then the patient may judge their own abilities for the same skills as low. When the time comes for the patient to try out their skills for battery insertion, they may find that they face uncertainty in their ability.
The relationship between the patient and the model also is an important factor. Judgments based on vicarious experience are more effective when the model is viewed as a peer compared to when the model is viewed as a significant upward or downward social comparison. For example, new golfers are more likely to judge their self-efficacy levels more realistically when observing fellow new golfers who are similar in social comparison rather than observing a golf professional.
Verbal Persuasion
Individuals make judgments about their self-efficacy levels based on the feedback of others. Most commonly, verbal persuasion comes in the form of feedback one expresses about the abilities of the person, which can be very influential, particularly if the source is considered credible and when the feedback immediately follows the behavior. Positive verbal persuasion tends to boost the self-efficacy beliefs of the person, whereas negative verbal persuasion can undermine self-efficacy judgments (Bandura, 1997). Furthermore, feedback is more effective if it is specifically related to the ability or effort put into the skill rather than general in nature. For example, telling a new hearing aid patient “You can do it” may not be as effective as “You were able to change the programs in your hearing aid correctly. You will be able to change the volume too.” The latter feedback is more specific and more likely to be motivating compared to the former statement that is more general in nature. The patient can provide verbal persuasion via self-talk, or say to himself that he believes he can do the task. Other sources such as viewing videos or reading materials about the subject matter may also serve as verbal persuasion (Smith & West, 2006a), especially if they are provided in an enhanced format (McMullan et al., 2018).
Physiologic and Affective States
The final source of information regarding self-efficacy judgments is how individuals feel emotionally and physically when performing behaviors. For example, if individuals are stressed or frustrated, or have sweaty palms or increased heart rate when performing skills, then they likely will interpret those states and judge their self-efficacy as low. Individuals with high self-efficacy for their abilities will likely have positive physiologic and affective states when performing behaviors.
It is not uncommon for first-time hearing aid users to have uncertainty about inserting hearing aids into their ears correctly. They may drop the hearing aid or have repeated unsuccessful insertion attempts. For these patients, they may express feelings of frustration or develop anxiety during these unsuccessful attempts. In this instance, their self-efficacy beliefs related to hearing aid insertion are likely to be judged as low. On the other hand, a patient who is able to insert the hearing aid into their ear with ease will have neutral or positive physiologic and affective states and judge their ability for this skill as high.
Techniques to Enhance Self-Efficacy
There are several techniques that clinicians can use to help their patients increase self-efficacy. These techniques can specifically target self-efficacy for a given source of information that was described previously. In other words, there are different techniques available for a clinician to use with the patient depending on whether or not the clinician wants to increase self-efficacy through sources of information related to mastery experience, vicarious experience, verbal persuasion, or physiologic and affective states. Regardless of the AR intervention being targeted, the clinician can incorporate self-efficacy-enhancing techniques.
Recall that mastery experience is the strongest source of information by which individuals make self-efficacy judgments. Clinicians thus may focus on techniques to increase self-efficacy for mastery experience, although tapping into all four sources of information is most effective (Bandura, 1997; Maddux & Lewis, 1995). Extensive practice is a primary way to increase self-efficacy with mastery experience. The clinician can offer the patient several opportunities to practice the skills they are learning during the session and encourage them to practice at home to reinforce what has been learned. To ensure the task is successful while the patient is in the clinic, simpler skills can be introduced before moving to more advanced skills. Role play can be used to help the patient learn to execute the skill or behavior. Goals can be set for at-home practice and future follow up for skills or behaviors that posed some challenge or uncertainty.
Clinicians can use modeling as a means to increase self-efficacy through vicarious experience; however, they may not be viewed as a peer. The patient’s communication partner may serve as a better model and can learn and practice the skills along with the patient. The use of a family-centered AR approach can be helpful in this area. A group setting for the AR intervention may be a venue to elicit vicarious experiences. In addition, videoing can be used so that the patient can serve as their own model (i.e., self-modeling). By watching oneself perform the skills, the patient can identify what is being done correctly or incorrectly and use that information to reinforce or alter performance for that skill or behavior. If videotaping is unreasonable for the clinical setting, the patient can watch an instructional film of the skill or behavior in action. Ideally that instructional video would include star performers who would be considered peers by the patient. Cognitive rehearsal, which is a mental visualization of oneself executing the skills or behavior, can be used to increase self-efficacy for vicarious experience.
Clinicians can increase self-efficacy through verbal persuasion. One way to do this is to provide realistic feedback immediately following the patient performing the skill. This feedback should focus on the patient’s capabilities or effort and be specific in nature. If the communication partner is involved in the AR, then the clinician can encourage the partner to provide positive feedback about the patient’s capabilities and efforts. Verbal persuasion also can come in the form of educational materials. The more knowledge a patient has about the AR skill or behavior of interest, the higher their self-efficacy may be for that skill.
Increasing self-efficacy for the source of information related to physiologic and affective states is accomplished primarily by reducing any negative emotional and/or physical stressors. For example, the clinician should provide a calm environment with ample time to practice skills so as to not rush the patient. If time is limited, then the skills associated with the AR behavior can be broken down into subsets and taught over multiple sessions. Another technique is to take a break from the skill that may be causing heightened negative states and work on a different, possibly easier, skill. The clinician can inquire about why the patient is having these negative states when performing the skill and counsel them accordingly.
The above are examples of techniques that can be used to increase self-efficacy for a given source of information. There can be some overlap in the techniques across these areas. For example, the communication partner can be included in the AR and used as a source of vicarious experience and also encouraged to provide supportive feedback to increase self-efficacy through verbal persuasion. In short, these self-efficacy enhancing techniques add to the armamentarium available to clinicians engaged in AR services and are summarized in Table 13–1 (also see Smith, 2014). Smith and West (2006a) provide a comprehensive tutorial on self-efficacy and a detailed example of an interaction between an audiologist and patient during a hearing aid orientation session in which the audiologist is utilizing these self-efficacy-enhancing techniques.
Measuring Self-Efficacy for AR Behaviors
Given that self-efficacy beliefs are one’s perceptions, measuring one’s self-efficacy levels is done formally through the use of questionnaires. Consistent with the domain-specific nature of self-efficacy, an important characteristic of these measures is that the questionnaire targets the context of interest. Therefore, an all-purpose self-efficacy measure is unsuitable. Rather, self-efficacy questionnaires in AR need to focus on the skills and behaviors that the clinician is addressing during the particular AR intervention. Furthermore, the items should target skills over which the patient can exhibit some control that will foster behavior change. Bandura (2006), who pioneered the self-efficacy theory, also recommends that self-efficacy questionnaires have certain characteristics so self-efficacy is being measured accurately. First, the items should be worded to inquire about current abilities (e.g., “I can . . .”) rather than intentions (e.g., “I will be able to . . .”). Second, each item should inquire about one skill or task at a time as individuals may have different levels of self-efficacy for different skills or tasks. Third, items should have gradations of challenge so that the measure contains skills that vary degree of difficulty. Fourth, the response scale should be positive and unidirectional (i.e., no negative values); it is best if there is a 0 to 100 response scale in 10-unit intervals (i.e., 0, 10, 20, . . . 100). Figure 13–1 illustrates an example of a response scale on self-efficacy measures. As seen in Figure 13–1, 0% represents complete uncertainty in the respondent’s ability to accomplish the task in question, 50% represents moderate certainty, and 100% represents complete certainty. Finally, Bandura recommends that self-efficacy measures contain practice items not related to the domain of interest so that the respondent can become familiar with the scale. For example, the following two practice items have been used in self-efficacy questionnaires developed within the authors’ laboratory:
1. I can lift a 10-pound object with ease.
2. I easily can tell the weight difference between a 19-pound object and a 20-pound object (West & Smith, 2007; Smith, Pichora-Fuller, Watts, & La More, 2011; Smith & Fagelson, 2011).
Table 13–1. Summary of Techniques to Increase Self-Efficacy
Note. This table summarizes the techniques that clinicians can use to increase self-efficacy based on the four sources of information.
Source: Adapted from Smith and West (2006a).
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