It is well established that people with hearing disability are at risk for experiencing poor health-related quality of life across a variety of domains, including elevated cardiovascular risks (diabetes and high blood pressure), increased all-cause mortality, reduced physical activity levels, increased functional dependence, increased risk of incident dementia, and social and emotional loneliness. There is considerable speculation, however, regarding the mechanism(s) through which the linkage is mediated. Hogan et al. proposed that the Person environment (P-E) fit model might explain the connection between hearing status and poor health outcomes (Hogan. Disabil Rehabil 2015;37:2070-2075http://www.tandfonline.com/doi/abs/10.3109/09638288.2014.996675?journalCode=idre20). In the P-E fit model of stress and well-being, stress arises from a misfit between the characteristics of the person and dimensions of the environment (Caplan. Job Demands and Worker Health: Main Effects and Occupational Differences. Ann Arbor, MI: Institute for Social Research, 1980http://deepblue.lib.umich.edu/handle/2027.42/99283). The theory posits that a key determinant of stress is the fit between the individual's characteristics (e.g., social ability to manage hearing loss) and the perceived and objective demands of the environment in which one is communicating. Stress is higher and well-being lower when the match between the person's coping capacity and environmental demands is poor. Hogan et al. tested this hypothesis on a small sample of adults, most with moderate hearing loss, which reportedly affected them psychosocially in a variety of ways, as shown in Table 1.
In their sample, hearing loss severity, as measured audiometrically, was not correlated with perceived physical or mental health reactions. However, a link between fasting blood glucose levels, systolic blood pressure, and feeling stressed and tired because of hearing loss did emerge.
Hogan et al. found that self-rated quality of life (i.e., “How would you rate your quality of life?”) was positively associated with the capacity to self-manage hearing and listening environments (i.e., “How would you rate your ability to manage your hearing and listening impairments overall?”). Furthermore, higher anxiety levels and reduced self confidence due to hearing impairment were associated with a decreasing ability to successfully manage hearing and listening impairments. Hogan et al. underscored the importance of attending to the social and health impacts of residual hearing disability, which often exist among persons with moderate to moderately severe hearing loss who are using hearing aids.
WHAT CAN WE DO?
How can we reduce the stress and anxiety associated with hearing loss and, in so doing, affect patient well-being? In answering this question, I will step outside the box and draw an analogy to the professions of psychiatry and psychology. Their professional area is the mind and the way it affects behavior and well-being; our professional area is the ear and the brain and how breakdowns affect communication, behavior, and well-being.
In psychiatry, medication management is often not enough to treat a given condition; counseling is also indicated, yielding a synergistic effect. Similarly, in audiology, a technocentric approach is often not sufficient; we must adopt a patient-centric therapeutic approach, with counseling as an important part of our solutions toolkit. Designed to help individuals address particular problems, such as communication breakdowns and the attendant stress reaction, the focus of counseling is on problem solving or on teaching specific techniques for coping with or avoiding problem areas. With hearing aids in our patient's ears (similar to medication in the mouth), we must devote more of our professional time to restoring the patient's participation in activities that have been limited as a result of inability to self-manage hearing loss. By providing strategies aimed at optimizing interpersonal encounters and helping persons with hearing loss to more actively engage, we will be carrying out our mission as audiologists interested in promoting the well-being of the people we serve (Tye-Murray. Foundations of Aural Rehabilitation: Children, Adults, and Their Family Members (3rd ed.). Clifton Park, NY: Delmar, Cengage Learning, 2009).
Verbrugge has proposed the following two premises:
- The extent of the stress and anxiety experienced by persons with hearing loss is determined by the intersection of their capacity, resources, and behaviors, and the demands of their social and physical environment.
- At the point at which the demands of the environment exceed the individual's ability to meet those demands, disablement, stress, and anxiety will set in (Verbrugge. Soc Sci Med 1994;38:1-14http://deepblue.lib.umich.edu/bitstream/handle/2027.42/31841/0000788.pdf;jsessio).
If we accept these premises, then our role is a straightforward one. We must focus on helping to improve our patients’ ability to cope with environmental demands and provide solutions our patients must adopt to self-manage in these situations. Because the intersection is a dynamic one, we must constantly reevaluate our patients’ residual disability, functional status, self-efficacy, and adherence (Lawton. Environment and Aging. Albany, NY: Center for the Study of Aging, 1986). Let's now look at the steps you may wish to ponder, and perhaps even adopt or adapt.
STEPS TO TAKE
- Have your patient identify the environments that are especially challenging, both with and without hearing aids (dynamic process).
- Ask your patient to rate his or her competence in responding to the demands of each of these listening environments (e.g., solutions to challenges).
- Once you determine the patient's environments and competence levels, jointly outline environmental modifications that will serve as the basis for communication strategies training.
- Monitor the patient's competency at making the necessary adjustments or changes in each of these environments.
- Assess and reassess the patient's residual disability or the degree of disablement that remains even when using hearing aids or assistive technology, as this will inform the steps necessary to optimize communication (Agree. Soc Sci Med 1999;48:427–443http://www.sciencedirect.com/science/article/pii/S0277953698003694).
According to the P-E fit theory, the misfit between the person and the environment leads to psychological, physiological, and behavioral strains, which may ultimately increase morbidity and mortality. It is incumbent on audiologists to help ensure that our patients have the skill set necessary to manage the demands and requirements of the environments in which communication takes place. By improving the match between their communicative strategies and environmental barriers, we will hopefully alleviate stress and improve quality of life (Iwarsson. Gerontologist 2005;45:327-336http://gerontologist.oxfordjournals.org/content/45/3/327.full). Of utmost importance throughout the process is monitoring a patient's residual disability. This construct is an important, albeit underassessed, variable in clinical practice. We must also make sure to minimize negative coping strategies (avoidance of a situation, reduced frequency of partaking in an activity) and promote positive compensation strategies (use of hearing aids, assistive technology, and communication strategies). I have modified the Hearing Handicap Inventory so that responses could easily be used to guide in individualized counseling about communication strategies (examples shown in Table 2).
By addressing patient responses, clinicians could improve the match between environmental constraints and communication competence. I also include a log developed by a patient of mine (Table 3), which we have used successfully with information gleaned from the hearing aid data logs to individualize and personalize communication strategies counseling.