Hearing healthcare professionals have heard the statistics before: About 80 percent of individuals who suspect they have a hearing loss do not seek treatment during the initial five to 10 years after its detection. And this: Fewer than 20 percent of individuals who would benefit from a hearing intervention actually seek treatment.
What they may not know, however, is that this reluctance to seek help is not unique to hearing loss. It turns out that that there are similar statistics for many other chronic health conditions. Kuramoto et al. found that only 11 percent of 4,027 individuals with symptoms of alcohol abuse had sought help in the previous year.1
Gresset and Baumgarten also reported that only 20 percent of individuals over 65 with correctible vision impairment used rehabilitation services,2 and Perera et al. reported that only 12 (13%) of 93 women with at least daily episodes of urinary incontinence sought treatment.3 The factors that influence whether someone seeks help for their hearing loss show considerable overlap with the reasons associated with help-seeking for other chronic health conditions (Table 1).
HEALTH BEHAVIOR CHANGE
People are notoriously resistant to changing health behaviors, even when they know that they can lessen the effects of a chronic health condition by doing something fairly straightforward, such as changing their diet or exercising more.4 Data show that more than one-third of deaths in the United States in 2000 were attributed to lifestyle choices.5
In fact, 18.1 percent of deaths were associated with tobacco use, 15.2 percent with poor diet/physical inactivity, 3.5 percent with alcohol consumption, 0.8 percent with sexual behaviors, and 0.7 percent with illicit drug use. Health psychologists have been aware of this resistance to behavior change for many years. This has led to theories that try to explain why people do and do not take health-related actions and to develop strategies to change those behaviors so more people engage in health-promoting behaviors and fewer health-compromising behaviors.
Two of the most widely used health behavior theories are the transtheoretical model (TTM), also known as the stages of change model, and the health belief model (HBM).6,7,8 Health behavior theory has been applied to understanding motivations around hearing loss prevention and in developing hearing loss prevention programs.9,10,11 This was applied to rehabilitative audiology by a few researchers decades ago.12,13 Investigators are showing renewed interest in the topic now, specifically with applying health behavior theories to understanding help-seeking for hearing problems and hearing aid uptake.
HBM was developed in the 1950s to explain why people in the United States were not taking the opportunity to receive free tuberculosis screenings. Since then it has been applied to understand and predict many other health-related behaviors. HBM holds that the likelihood that someone will engage in a health behavior is determined by his perceived threat from a condition and the balance between the perceived benefits of adopting the behavior and the perceived barriers for doing so.
The perceived threat is influenced by the individual's assessment of the risk of getting the condition (perceived susceptibility), the seriousness of the consequences of the condition (perceived severity), confidence in the ability to adopt a behavior successfully (perceived self-efficacy), and external influences that promote the behavior, such as symptoms, the media, and information from a healthcare provider (cues to action). The balance among these factors determines whether a health behavior occurs (Figure 1).
These constructs make a lot of sense in understanding help-seeking for hearing loss. Individuals who think they are immune to hearing loss (low perceived susceptibility) would not be likely to attribute hearing difficulties to hearing loss and would not get a hearing test. Those who do not consider hearing impairment to be a problem (low perceived severity) would be unlikely to see the need to get help.
And individuals who think they would be unable to manage hearing aids or who think hearing aids wouldn't work for them (low perceived self-efficacy) would not be likely to seek help, nor would individuals who consider that seeking help for hearing has more disadvantages (high perceived barriers) than advantages (low perceived benefits). Finally, individuals who have heard positive things about hearing aids or who feel their family supports their getting help (high cues to action) would be more likely to seek help than those who have heard the opposite (low cues to action).
HEARING HEALTH BEHAVIORS
At the National Center for Rehabilitative Auditory Research in Portland, we developed a questionnaire to assess the constructs of the HBM as they apply to hearing.14 We used the Hearing Beliefs Questionnaire (HBQ) in one completed study and one ongoing study. A total of 223 individuals in a primary care clinic waiting area of a VA hospital completed the HBQ in the first study. We showed that scores on the HBQ distinguished among individuals with different hearing-related behaviors. Individuals who reported having had their hearing tested recently thought they were more likely to lose their hearing (higher perceived susceptibility scores), saw fewer negatives to taking action (lower perceived barrier scores), and had encountered more prompts from others about their hearing (higher cues to action scores) than those who had not had a recent hearing test.
Those who had taken up hearing aids perceived themselves to be more susceptible to hearing loss, perceived more benefits and fewer barriers to taking action, and had encountered more cues to action than those who had not taken up hearing aids. Finally, the hearing aid owners who used their hearing aids regularly perceived hearing loss to be more problematic (perceived severity), perceived fewer barriers, had greater perceived self-efficacy, and had encountered more cues to action than individuals who did not regularly use their hearing aids.
In our ongoing collaborative study with the Eriksholm Research Centre in Denmark, we are examining the attitudes and beliefs of individuals who have recently had a hearing test. We are following them for six months to find out who goes on to get hearing aids (if appropriate) and whether they become successful hearing aid users (See Figure 2 for the study design).
Participants completed the HBQ, among other questionnaires. Preliminary data from 71 participants replicated our earlier results, and found a significant difference in the HBQ scores of individuals who did or did not get hearing aids (F=6.4, p=0.020). Those who did take up hearing aids perceived hearing loss to be more problematic (p=0.012), perceived more benefits to taking action (p=0.059), and had encountered more cues to action (p=0.061) than those who had not taken up hearing aids.
Preliminary data from 52 individuals who had taken up hearing aids show better hearing aid outcome (assessed with the International Outcome Inventory for Hearing Aids [IOI-HA]) was associated with their perceiving hearing loss to be more problematic, perceiving more benefits from hearing aids, and having encountered more external prompts to take action.
THEORY AND PRACTICE
How can information like this be used by hearing health practitioners in clinical practice? One approach would be to develop counseling strategies to address the attitudes and beliefs that underlie an individual's hesitancy to take action. Problematic attitudes and beliefs could be identified by having the patient complete a short and simple questionnaire prior to meeting with the clinician. These attitudes and beliefs can be approached within the constructs of the HBM. (Table 2.)
These intervention strategies could use videos, one-on-one conversations, and reading materials. They could be provided early in the consultation before making a decision about an intervention.
3. Perera J, Kirthinanda DS, Wijeratne S, Wickramarachchi TK. Descriptive cross sectional study on prevalence, perceptions, predisposing factors and health seeking behaviour of women with stress urinary incontinence BMC Womens Health. 2014;14:78 http://www.biomedcentral.com/1472-6874/14/78
4. Newsom JT, Huguet N, et al. Health behaviour changes after diagnosis of chronic illness among Canadians aged 50 or older Health Rep. 2012;23(4):49–53