“What brings you here today?” In many years of clinical practice, I often initiated my first conversation with a patient with this question. No, I wasn't interested in what mode of transit the patient took to reach my office, but I was interested in the journey: the patient's journey to seek help for hearing problems. Every hearing health professional is familiar with the statistics that show a delay of seven to 10 years or more between the time an older person first suspects a hearing loss and professional help is sought. After being assessed, many patients delay further action even when results confirm significant hearing loss. The failure of the hearing health care field over many years to influence prospective patients to seek out and use our services sooner rather than later behooves us to determine the underlying causes of such lengthy delays. Health psychology models and findings from other health domains offer hearing health professionals new insights into the causes of delays in help-seeking for hearing problems and may spark new ideas to reduce those delays. Some years back, I developed the Model of Self-Assessment in Help-Seeking, which was based on findings from a qualitative research study of older women with age-related hearing loss who had recently booked their first audiology assessment (Carson. J Aging Stud 2005;19:185-200http://www.sciencedirect.com/science/article/pii/S0890406504000702).
My model is compatible with models from health psychology, as described in this special series, and may inform the study of other chronic health conditions (Prochaska. Am J Health Promot 1997;12:38-48http://www.ajhpcontents.com/doi/abs/10.4278/0890-1171-12.1.38; Rosenstock. Health Educ Behav 1974;2:328-335http://heb.sagepub.com/content/2/4/328.extract). At the core of my model is the construct of “self-assessment.” What is meant by “self-assessment,” and why is it so important?
It is human nature to regularly monitor how we are doing in many areas of our lives. At a physiological level, our body has elaborate systems in place that monitor and take action to offset imbalances, such as in pH and sugar levels, without us being aware of how these imbalances are regulated. As self-aware, relational beings, monitoring our health may also include our conscious (and subconscious) appraisal of our functioning in the world. For example, if we notice something amiss with our health (e.g., an unusual mole on our skin or increasing difficulty understanding a family member who is talking to us), we pay close attention to the observed anomaly as we attempt to identify the problem and determine whether it is serious enough for us to seek professional help to deal with it.
Regarding hearing, self-assessment refers to the process that people engage in to evaluate, analyze, and make decisions concerning hearing challenges and their consequences. Questions that drive self-assessment include: How much of a problem is my hearing? Does it affect my life enough that I should seek help? If so, what exactly should I do, and when would be the best time to do it?
Self-assessment is the ongoing internal appraisal that a person who is hard of hearing engages in to find out what is going on with changes in his or her hearing. As shown in figure 1, there are three main components, or themes, that define self-assessment: contrasting/comparing, cost versus benefit, and control.
- Contrasting/comparing refers to the evaluation of one's hearing with reference to a number of yardsticks. People compare their hearing to internal referents, such as their vision or other health conditions, or in reference to how good their hearing used to be. They contrast their hearing with how they think others hear, most notably friends and spouses. This approach is analogous to the construct of “social comparison” in health psychology (Festinger. Human Relations 1954;7:117-140http://hum.sagepub.com/content/7/2/117.extract). Contrasting/comparing helps people put their hearing in context so they can prioritize hearing among all their life concerns. This is similar to the construct of “perceived severity” in the Health Belief Model (Maiman. Health Educ Behav 1974;2:336-353http://heb.sagepub.com/content/2/4/336.extract). Depending on the context, contrasting/comparing can either inhibit or promote help-seeking.
- Cost versus benefit refers to assessing the cost of an action in relation to the value of the resulting benefit. People who are hard of hearing adopt behaviors in conversation, such as asking for repetition (a cost) to increase their understanding (a benefit). Costs include the cognitive, physical, and emotional efforts involved in persevering in the face of a hearing problem. If such expenditures are successful, other benefits accrue, such as an improved sense of self-esteem. On the other hand, a strategy (such as asking for repetition) may be abandoned if it is not successful because with each attempt, the cost escalates relative to the benefit that may eventually be achieved.
The cost versus benefit analysis evolves as hearing loss worsens and/or awareness of hearing problems increases. When hearing challenges are infrequent, the cost of hearing difficulty (its consequences) is low enough that there may be no perceived need for action. As hearing challenges increase in frequency and severity, however, especially when issues of safety and security are involved, the perceived benefits of taking action may outweigh the rising cost of not taking action. It is also possible that people with little self-perceived hearing difficulty may find the “nagging” by family members to get a hearing test a greater cost than having the test itself. In a nutshell, help-seeking is triggered when the costs of a hearing problem are greater than one's resources to deal with the problem. Cost versus benefit is analogous to the construct of perceived barriers in the Health Belief Model (Maiman. Health Educ Behav 1974;2:336-353http://heb.sagepub.com/content/2/4/336.extract).
Control: The third component refers to people's perception of the power they have to direct aspects of their lives. No one likes to relinquish control. Unfortunately, hearing loss creates many situations in which control is lost, with consequences such as failures in ability to communicate effectively or hear important safety signals. With hearing loss, there comes a loss of control in how one presents oneself to the world. Hearing loss represents not only loss of hearing but also loss of other important aspects of life: security, intimacy, spontaneity, and confidence. It can result in a sense of an overall lessening of control over one's life. Control may also be an interpersonal issue, especially among family members. For example, a person who is hard of hearing may perceive that a spouse is imposing control by urging that a hearing test or hearing aid be obtained. Significant others may also take over communicating and decision making in many domains, as the partner who is hard of hearing seems to become less competent in communicating in important situations, such as those involving finances, legal matters, or even other health decisions. One can see parallels between control and the constructs of perceived self-efficacy and locus of control in health psychology (Bandura. Psychol Rev 1977;84:191-215http://psycnet.apa.org/psycinfo/1977-25733-001; Rotter. Social Learning and Clinical Psychology. Englewood Cliffs, NJ: Prentice Hall, 1954).
SELF-ASSESSMENT MEETS HEARING
The three components of self-assessment factor into decision making regarding help-seeking for hearing loss. A big step in help-seeking is taken by making an appointment with a hearing health professional. However, we fool ourselves if we frame help-seeking by those who are hard of hearing only in relation to our own services. These people may take many help-seeking steps before booking a hearing test. As noted earlier, they may seek help to achieve better understanding from a conversation partner by asking the partner to repeat a comment, they may seek the opinions of friends about their experiences with hearing aids or other hearing health care options, and they may conduct online research on hearing loss and possible solutions. The outcomes of such steps are routed back into subsequent rounds of self-assessment in the quest to decide whether further action is needed.
THE SPIRAL OF DECISION MAKING
I coined the term “spiral of decision making” around hearing loss to illustrate that self-assessing and decision making do not proceed in a linear, or even circular, fashion. Although some people may persevere in the same thought patterns about their hearing loss after they seek help, it is more accurate to view the process as a slow evolution in thinking about one's hearing loss, rather than a revolving door of repeatedly voicing the same concerns and opinions. People take the information they have assembled over time about their hearing loss and apply it anew to another round of self-assessment. However, when they go through this next round of self-assessment, they are at a new place of understanding, further along the trajectory or upward spiral of coming to terms with their hearing challenges. An illustration of this aspect of my model is shown in figure 2.
What does this all mean for clinicians who are testing and counseling new patients? It means that we must recognize that the hearing assessment is but one point along a patient's trajectory of self-assessment. We expect patients to want information about their hearing, and they certainly do. More important, however, is that patients seek validation of their real-world experience of hearing loss. This goal is not easily achieved within audiology's current biomedical paradigm of practice. Clinicians do not have much time to hear a patient's story before soliciting case history details that only provide a snapshot view of the patient. From here, the clinician jumps into test procedures to document impairment. All too often, not enough information is gathered about how hearing loss affects the person's activities and participation in everyday life. After the initial assessment, a heavily quantitative, often overly technical description of test results is provided before the clinician moves on to discuss hearing aids or other technical solutions.
In contrast to the information that is the focus of the hearing health professional, the patient's focus, beyond the degree of impairment, is on his or her quality of life and experiences with hearing challenges that reflect participation restrictions and activity limitations. These divergent perspectives of the professional and the patient often result in the patient being unable to find meaning in the test results or reconcile test results with his or her own daily experiences of hearing challenges. It is difficult for patients to gain a sense of closure and move forward with the next steps with such disjuncture or mismatch. Self-assessment does not end with the diagnosis or confirmation of hearing loss. The person who is hard of hearing will incorporate this assessment experience, including the test results and his or her interaction with the practitioner, and return to self-assessing once the appointment is over. He or she will compare and contrast the testing experience with real-world experience, weigh the cost versus the benefit of getting hearing aids or returning to the professional for other services, and assess the degree of control maintained or lost in the process.
TOWARD A NEW CLINICAL PROGRAM?
Is there a need to change our clinical culture? If so, how may we shift to a new practice paradigm? These are huge questions that are worth more space than is available here. However, in terms of the spiral of decision making in self-assessing hearing, here is one question to get you started: In your interaction with patients, to what extent do you feel that you increase their sense of control (increase perceived self-efficacy), tip their cost/benefit analysis more favorably toward taking action (reduce perceived barriers), and help move hearing higher on their contrast/compare list of health and quality of life priorities (increase perceived severity)?
There has been much discussion in recent years about moving toward more patient-centered care and shared decision making, whereby practitioners are encouraged to empower their patients to be more active participants in the decisions regarding their health. Although this is a positive step, it may be putting the cart before the horse. Before shared decision making between patient and practitioner can succeed, there must first be shared understanding. As Keller and Carroll advise clinicians, “Most patients make a self-diagnosis. It is human nature to do so. If your diagnosis and the patient's differ, the patient will act based upon his or her own diagnosis. Consequently it is imperative that you understand and discuss the patient's (self-) diagnosis.” (Keller. Patient Educ Couns 1994;23:131-140http://www.pec-journal.com/article/0738-3991(94)90051-5/abstract).
Hearing health practitioners could learn much from the growing field of health communication, in which research highlights the importance of quality communication between clinician and patient as key to improving patient outcomes and satisfaction.
The evolution of the field of audiology seems to be mimicking the evolution of society more generally: there have been great research investments and successes in advancing technology but not enough investment in advancing our understanding of factors that influence behavior change (or lack of change). As a result, instead of seeing “early adopters” flock to our clinics to embrace technology, we continue to see a proliferation of “early adapters” who have been struggling, while working in relative isolation, to adapt to and cope with hearing challenges. It is time to allocate more attention and resources to examining the psychology of help-seeking and decision making in relation to hearing loss, especially in older adults. We need to gain a more thorough understanding of the answers to the question, “What brings you here today?”