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Applying the Stages of Change to Audiologic Rehabilitation

Laplante-Lévesque, Ariane PhD

doi: 10.1097/01.HJ.0000466872.90185.34
Special Series

This article continues The Hearing Journal’s special series on revolutionizing audiologic rehabilitation through health and social psychology approaches, which is guest edited by M. Kathleen Pichora-Fuller, PhD.

Dr. Laplante-Lévesque is research project manager at the Eriksholm Research Center in Denmark and adjunct associate professor at Linköping University in Sweden.

Figure 1.

Figure 1.

“Why on earth are people so reluctant to come and see me in the first place?”

“Some days, it feels as if all clients who come through the door are not motivated. They aren't ready to take the next step for their hearing.”

“I know when clients don't feel the need for hearing aids. I can just sense their reluctance from the start.”



These observations are all too familiar to the seasoned audiologist. Wouldn't it be great if we could understand more about why these situations are so common? And wouldn't it be even better if we could eliminate the root of these observations?

People's intentions and behaviors provide insights into how to overcome barriers to help seeking and action taking for hearing problems.

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Health psychology is the study of intentions and behaviors in health, illness, and healthcare. Health psychologists map how attitude, knowledge, behavior, and context influence health. Lifestyle-related diseases share four behavior-based risk factors: physical inactivity, unhealthy diet, alcohol, and tobacco, according to the World Health Organization (

Given the global epidemic of lifestyle-related diseases, health psychologists are busier than ever trying to prevent chronic health conditions or help people manage and live with a chronic health condition.

Joining a gym class—and going to it—is easier said than done. The same goes for making an audiology appointment—and attending it. These tasks involve channeling motivation and readiness into intentions and behaviors. They require changing or modifying a current behavior, or perhaps acquiring a new behavior, to achieve a healthier lifestyle and maintain optimal health. Health psychologists describe this process as health behavior change.

Many models and theories describe what it takes for a person to adopt a healthy behavior. This article focuses on the stages of change part of the Transtheoretical Model, which pictures people going through steps or stages of readiness. The other parts of the Transtheoretical Model are processes of change, decisional balance, and self-efficacy.

The Transtheoretical Model is far from the only model of health behavior change. Alternative models include the Health Belief Model and the Theory of Planned Behavior. The next article in this special series, written by Gabrielle Saunders, PhD, is a great primer for the Health Belief Model.

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James O. Prochaska, PhD, and Carlo C. DiClemente, PhD, developed the Transtheoretical Model while working with people who were attempting to quit smoking in the early 1980s ( J Consult Clin Psychol 1983;51[3]:390-395 They proposed that people go through the stages of precontemplation (denial), contemplation (ambivalence), action (behavior change), and maintenance (relapse prevention).

Some newer versions of the stages of change have added the preparation stage between the contemplation and action stages, and the termination stage after maintenance (see figure 1). (Prochaska JO, Johnson S, Lee P. The Transtheoretical Model of behavior change. In: Shumaker SA, Ockene JK, Riekert KA, eds. The Handbook of Health Behavior Change. 3rd ed. New York, NY: Springer Publishing Company; 2009:59-83.)

According to the model, people progress from one stage to another, moving toward health behavior change, but regression to an earlier stage can occur. In the past 30 years, the stages of change have been applied to populations ranging from diabetics to Internet addicts.

Until recently, however, little evidence was available for audiologic rehabilitation. One notable exception is a study by Doron Milstein, PhD, and Barbara E. Weinstein, PhD, that mapped the stages of change in older adults who had failed a hearing screening ( J Acad Rehabil Audiol 2002;35:43-58,%20%20JARA,%20%202002.pdf).



The present article reports on two recent studies examining stages of change in audiologic rehabilitation. Both studies used the University of Rhode Island Change Assessment (URICA) questionnaire to map stages of change ( Psychother: Theory Res Pract 1983;20[3]:368-375

The URICA is a 32-item questionnaire, with eight items for each of the four stages of change initially proposed ( Psychother: Theory Res Pract 1983;20[3]:368-375; see the table). “Problem” is replaced with “hearing problem,” and respondents state their agreement with each item.

In both studies, the maintenance items were omitted from the URICA, as they were not relevant. You can find out more about the URICA here:

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Longitudinal studies generally point to low rates of help seeking, hearing aid uptake, and successful rehabilitation after hearing screening failure. Health psychology can map the readiness of people who have failed a hearing screening to seek help.

Study A yielded the profile of the stages of change in 224 adults who had failed an online hearing screening ( Ear Hear 2015;36[1]:92-101 Swedish adults age 18 and older visited the online screening website from the location of their choice after coming across an advertisement in the newspaper, on the radio, or on the Internet.

People were screened with a validated measure of speech-in-noise recognition played via the headphones or loudspeakers of their own computer or mobile device. Those who failed the screening—indicating a high likelihood that they had a pure-tone average threshold in the better ear of at least 35 dB HL at 0.25 kHz, 0.5 kHz, 1 kHz, 2 kHz, 3 kHz, 4 kHz, and 6 kHz if the screening was conducted over loudspeakers—completed the URICA online.

Figure 2.

Figure 2.

A factor analysis showed that the stages of change relevant for adults who have failed an online hearing screening are: precontemplation, contemplation, preparation, and action. Participants did not agree as much with the items representing the action stage as with the items representing contemplation and preparation (see figure 2).

That preparation was identified as a relevant stage highlights the importance of adequate guidance for adults who have yet to seek help for their hearing problems. Screening alone is unlikely to be enough to improve help-seeking and rehabilitation rates.

Study A supports the importance of a carefully planned pathway from failure of a hearing screening to successful rehabilitation ( Int J Audiol 2011;50[9]:594-609

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It takes an average of 10 years from the time that people notice they have hearing difficulties to when they first seek hearing help ( Health Technol Assess 2007;11[42]:1-294 Note that this number is an average—some people take less than 10 years—but the fact that some people take more than 10 years makes the figure even more alarming.

Clearly, all people who seek help are not equally ready to do something about their hearing problems. Health psychology can map the readiness of people who seek help for the first time, as well as relate their readiness to the taking up of an intervention and the reporting of good outcomes as a result of that intervention.

Study B yielded the profile of the stages of change in153 participants with acquired hearing impairment who were seeking help for the first time ( Ear Hear 2013;34[4]:447-457 Australian adults age 50 and older came to an audiology clinic, completed the URICA with the audiologist, and were offered hearing aids and communication rehabilitation programs. Those who took up hearing aids or communication programs reported outcomes three months after completing their intervention appointments.

Just like in Study A, a factor analysis showed that the stages relevant for adults who seek hearing help for the first time are: precontemplation, contemplation, preparation, and action. Again, preparation was identified as a stage, highlighting the importance of adequate guidance for adults who seek help for the first time. Importantly, participants agreed most with the items representing action (see figure 2).

In Study B, 43 percent of the 153 participants took up hearing aids, and 18 percent of the 153 participants took up communication programs. These two groups of participants had a more advanced stage of change than their peers who decided not to take up hearing aids or communication programs.

Of even greater importance, those with a more advanced stage of change had an increased likelihood of reporting good outcomes with hearing aids or communication programs. In other words, the stages-of-change profile at the first appointment is a significant predictor of hearing aid and communication program outcomes in the long term.

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These two studies show that the stages of change are relevant to mapping the intentions and behaviors of candidates for audiologic rehabilitation. The clear advancement in stages-of-change profiles from the time of failing a hearing screening (Study A) to coming to the audiology clinic (Study B) supports the use of these stages to understand behavior change in audiologic rehabilitation better.

As found in Study B, stages of change serve as a marker for those who do well with hearing aids and communication programs. This relationship shows the power of psychology for understanding hearing health intentions and behaviors.

Despite these encouraging results, much more must be uncovered about health psychology. Colleagues at the Eriksholm Research Center in Denmark, Linköping University in Sweden, the National Center for Rehabilitative Auditory Research in the United States, and other research centers around the world are furthering our understanding of the stages of change in audiology and how new types of services could remove barriers to help seeking and action taking for hearing problems.

For example, a Linköping University study is testing a shorter measure of stages of change for quicker clinical use. Two other studies are testing approaches to help people with hearing problems advance through the stages of change.

But why wait? You can start using health psychology now in planning interventions and promoting healthy intentions and behaviors in the clients you see in your practice.

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Here are some tips to help you use health psychology in audiology:

  • Identify the behavior you would like to see clients change. A behavior change could be a move from not seeking help or using hearing aids to seeking help or using hearing aids, respectively. Think about baby steps that might be considered, taken, and successfully achieved even by the most reluctant individuals.
  • Map the general profile of stages of change for your caseload. Map the specific profile of stages of change for individual clients. At an individual level, you can ask for a rating of readiness to change or adopt the new behavior from zero to 10. You can also involve significant others in this exercise.
  • Consider how to promote behavior change, either at a caseload or individual level. We all know that information is power, but beware; information is not sufficient to change health behaviors. For example, the information that smoking has severe negative consequences is widely available, yet tobacco companies still make billions of dollars in profits every year. Above and beyond factual information, give clients food for thought and exercises for self-reflection. You can ask them to describe how their hearing is affecting them or what kind of person they would like to become if their hearing problems were addressed.
  • Probe clients on their values and lifestyle, perceived pros and cons, and ambivalence. While many see ambivalence as an enemy, see it as a friend. Ambivalence denotes some willingness, rather than an outright refusal, to consider change. Successful behavior change depends on self-efficacy—the belief that one can make the targeted change. Ask clients about their own self-confidence for changing behavior.
  • Embrace personalization to facilitate behavior change. Listen to the client and relate behavior change benefits to the client's life. Focus on goals that are important to patients: this approach unlocks behavior change.
  • Invest in good, collaborative, long-term relationships with clients and their families. Behavior change is seldom instantaneous. Remember, most people don't quit smoking overnight. Establishing realistic timelines and engaging the support of significant others will increase chances for success as changes in behavior are made.
  • Look for inspiration in the work of John Greer Clark, PhD; Michael Harvey, PhD; Gabrielle Saunders, PhD; Donald Schum, PhD; Barbara E. Weinstein, PhD; the Ida Institute; and others. Don't fear: you are not the first audiologist to apply health psychology to your daily work.
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In the next installment of this special series, Gabrielle Saunders, PhD, describes how the Health Belief Model and its constructs are significant predictors of help seeking for hearing loss and hearing aid uptake.

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