“Alone: Bad. Friend: Good!”
-The Monster, Bride of Frankenstein
Two traditions have strongly influenced Western views on health and illness. The original view (the biomedical tradition) attempted to understand health and illness by focussing on the body and emphasizing pathological development, biochemical changes, and physiological processes associated with disease. The second view (the biopsychosocial tradition), championed in part by George Engel proposed a reconceptualization of health (Science 1977;196: 129-136http://www.lumsa.it/sites/default/files/UTENTI/u668/PSIC_HANDICAP_Engel1977_modello_biopsicosociale.pdf). Rather than focussing solely on the body, the biopsychosocial model posits that to understand health and illness, there also needs to be a consideration of one's psychological state and social environment.
Health psychology focuses on how the mind (psychological factors), the body (biological factors), and social forces (lifestyle factors including behavior) interact to influence health, disease, and healthcare decision-making. Biological determinants include a person's genetic makeup and predispositions, including inherited personality traits. Psychological determinants include a myriad of mental processes such as perception, cognition, emotion, intelligence, and motivation, to name just a few. Social determinants of health include the presence (actual or imagined) of others in our social world, environmental factors, and cultural context.
To date, hearing research has tended to focus more on understanding how the auditory system works, with an emphasis on conducting perceptual studies and psychophysical experiments, and/or focusing on how impaired biological processes (e.g., hair cell damage, cochlear nerve degeneration, etc.) influence auditory perception. These efforts have significantly increased our understanding of the auditory system and how it works. Knowledge about the auditory system has undoubtedly informed audiologic practice, resulting in improvements to the quality of life of people who are hard-of-hearing.
In contrast, relatively less emphasis has been placed on research to understand how social forces contribute to a person's hearing health (See Figure). To some extent, this is surprising because social forces, most notably social support, have been found to exert powerful influences on a wide range of health outcomes. Social support refers to those behaviors that lead one to believe that she (or he) is cared for and loved, can receive assistance from other people, and is a member of a supportive social network (Broadhead. Medical Care 1988;26: 709-723http://www.jstor.org/stable/3765493?seq=1#page_scan_tab_contents; Cohen. American Psychologist 2004;59:676-684http://www.psy.cmu.edu/~scohen/AmerPsycholpaper.pdf).
Lisa F. Berkman, PhD, and S. Leonard Syme, PhD, provide compelling evidence that first linked the availability of social support with mortality (Am J Epidemiol 1979;109:186-204http://aje.oxfordjournals.org/content/109/2/186.abstract). Subsequent—and particularly striking—demonstrations found that the risk of mortality associated with a lack of social support is as strong as that of other well-known risk factors, including cigarette smoking (House. Science 1988;241:540-5http://www.jstor.org/stable/1701736?origin=JSTOR-pdf&seq=1#page_scan_tab_contents). Moreover, a lack of social support is an even stronger risk factor than both excessive drinking and obesity (Pantell. Am J Public Health 2013;103:2056-62http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2013.301261). Typically, positive health outcomes are associated with the availability of social support in the form of emotional support (empathy, love, etc.), instrumental support (tangible aid, money, service), and/or informational support (advice, suggestions, information, etc.).
Although less research has investigated the role of social support in audiology, several articles have attempted to understand how the availability of social support can potentially benefit listeners with impaired hearing.* For example, there is evidence that significant others can help motivate individuals who are hard-of-hearing to have their hearing tested and to seek help for hearing problems (Mahoney. Br J Audiol 1996;30:153-158http://www.tandfonline.com/doi/abs/10.3109/03005369609079037?journalCode=ijap20; van den Brink. Br J Audiol 1996;30:313-324http://www.tandfonline.com/doi/abs/10.3109/03005369609076779?journalCode=ijap20), particularly when the significant other exerts mild social pressure (Duijvestijn. Acta Otolaryngol 2003;123:846-850https://www.researchgate.net/publication/9041711_Help-seeking_Behaviour_of_Hearing-impaired_Persons_Aged_55_Years_Effect_of_Complaints_Significant_Others_and_Hearing_Aid_Image). Moreover, when patients pursue hearing assessments, the involvement of significant others can assist clinicians to understand the communication difficulties of the patient (Newman. J Acad Rehabil Audiol 1986;19:109-115http://www.audrehab.org/jara/1986/NewmanWeinstein,JARA,1986.pdf; Lormore. Br J Audiol 1994;28:81-89http://www.tandfonline.com/doi/abs/10.3109/03005369409077918?journalCode=ijap20).
There is also new evidence to suggest that the availability of social support is associated with greater satisfaction with hearing aids. I co-authored two studies in which we found the availability of social support was the single best predictor of satisfaction with hearing aids (Singh. Ear Hear 2015; 36:664-676http://journals.lww.com/ear-hearing/Fulltext/2015/11000/Social_Support_Predicts_Hearing_Aid_Satisfaction.4.aspx). In our first study, 173 users of hearing aids completed a survey assessing attitudes toward health, hearing, and hearing aids, as well as a questionnaire assessing personality factors. Social support was found to be significantly correlated (r = 0.34, p < 0.001) with satisfaction with hearing aids. In a follow-up study of 161 different users of hearing aids, participants completed similar measures via the internet. Again, the availability of social support was found to be significantly correlated with satisfaction with hearing aid (r = 0.51, p < 0.001). Interestingly, when all correlates of hearing aid satisfaction were entered into regression analyses, in both studies, social support was observed to be the best predictor of satisfaction with hearing aids (accounting for 22% and 43% of the variance in hearing aid satisfaction, respectively). To our surprise, social support was observed to be a much stronger predictor of hearing aid satisfaction than more traditional indices of hearing aid satisfaction such as perceived hearing aid benefit, the number of hours/day a participant wore their hearing aid(s), satisfaction with the hearing healthcare practitioner, style of hearing aid, or personality. Furthermore, the study implemented statistical controls to minimize the possibility that the relationship between social support and hearing aid satisfaction was due to a response bias arising from a participant's tendency to respond positively on self-report measures (i.e., an acquiescence bias). The results from both studies found little support for the claim that response bias accounts for the relationship between satisfaction with hearing aids and social support.
SOCIAL SUPPORT, SATISFACTION
So how might the availability of social support contribute to a person's experience and satisfaction with hearing aids? There are several possibilities. First, the relationship between social support and satisfaction with hearing aids could be boosted if the significant other provides encouragement and motivation that reinforces ongoing use of the devices (Lockey. Int J Audiol 2010;49:542-549https://www.researchgate.net/publication/43097636_Exploring_hearing_aid_use_in_older_women_through_narratives). As a person shifts from unaided to aided listening, first-time users of hearing aids may experience doubt regarding the benefit of hearing aids and consider abandoning the device. Positive reinforcement by significant others can potential alleviate some of this uncertainty and help build self-efficacy (Smith. Am J Audiol 2006;15:46-56http://aja.pubs.asha.org/article.aspx?articleid=1737135). A second possibility is that significant others may contribute to satisfaction with hearing aids by helping with handling and caring for the devices (e.g., changing batteries, assistance with insertion and removal, or cleaning of the devices). A third possibility is that significant others may adopt beneficial communication strategies to promote optimal listening performance when hearing devices are used (e.g., being mindful about positioning themselves so as to optimize attention, the use of visual cues during communication, and the performance of directional microphone technologies). Finally, it could be that social support in the form of emotional support may help the new user to adjust to their hearing aids.
In addition to evidence suggesting that the availability of social support may promote satisfaction with hearing aids, there is evidence to suggest that the availability of social support can distinguish successful users of hearing aids from unsuccessful users. In such studies, “success” is typically defined as adhering to treatment (i.e., continued and regular use of hearing aids) as well as experiencing at least some benefit. The authors of one study compared non-matched groups of hearing-impaired older adults who either accepted or rejected a hearing healthcare practitioner's advice to obtain and use amplification (Garstecki. J Speech Lang Hear Res 1998;41:527-537https://www.researchgate.net/publication/13645563_Hearing_Loss_Control_and_Demographic_Factors_Influencing_Hearing_Aid_Use_Among_Older_Adults). They found that the availability of social support was one of several factors that were positively associated with hearing aid use. More recently, L. Hickson and colleagues identified factors associated with success with hearing aids in a retrospective study of 160 older adult users of hearing aids (Int J Audiol 2014;53[Suppl 1]:S18-27https://www.researchgate.net/publication/259845607_Factors_associated_with_success_with_hearing_aids_in_older_adults). The factor that was most strongly associated with membership in the “successful” hearing aid users group was positive support from significant others.
In conclusion, there is increasing evidence to suggest that the availability of positive social support is strongly associated with successful hearing aid outcomes. At this point, it is prudent to provide a note of caution regarding the interpretation of these findings. Although there are several possible explanations for why social support may lead to successful hearing aid outcomes, there is very little experimental evidence that demonstrates audiological benefit arising from social support. Although correlations have been observed in a number of studies, it is as yet too early to conclude that there is a causal relationship between the two variables, let alone the direction of causality. Future research should address this gap.
In the meantime, in addition to assessing a client's hearing loss, it is important for hearing health care professionals to assess the availability of social support and how to involve significant others to advantage in the planning and implementation of interventions, including but not limited to the provision of hearing aids.
*Importantly, there are also a number of social costs associated with impaired hearing, but they are not the focus of the current article (Mick. Otolaryngol Head Neck Surg 2014;150:378-384http://oto.sagepub.com/content/150/3/378.abstract; Scarinci. Int J Audiol 2009;48:671-683http://www.tandfonline.com/doi/full/10.1080/14992020902998409).