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The Noncompliance Challenge: How to Improve Hearing Aid Use

Shaw, Gina

doi: 10.1097/01.HJ.0000508360.58676.a6
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You have the patient come into your office. You conduct your standard battery of testing, diagnose their hearing loss, and help them select an appropriate hearing aid, which you dispense and fit. Now comes the hard part: getting the patient to use it.

Hearing aid noncompliance is a persistent challenge for audiologists. A number of studies have found that a significant percentage of people who have been prescribed and issued hearing aids do not use them consistently.

  • Nearly one-third of responders to a 2015 UK survey used their hearing aids less than four hours per day (Int J Audiol. 2015;54[3]:152
  • Six months post-fitting, 68 percent of Korean adults who agreed to “try” a hearing aid continued to use it regularly—meaning that about 32 percent did not (Int J Audiol. 2015;54[9]:613
  • A 2013 Finnish study found that only 55.4 percent of people with hearing aids used their aids daily, and just 27.3 percent used them for more than six hours per day (B-ENT. 2013;9[1]:23

Other studies have had similar results; a 2014 review of interventions to improve hearing aid use for the Cochrane Collaboration noted that up to 40 percent of people fitted with at least one hearing aid either fail to use it, or do not gain optimal benefit from it (Cochrane Database Syst Rev. 2014;12[7]:CD010342

But while it's clear that hearing aids are not being effectively used by a substantial segment of the patient population, research has been less clear on what can be done to change that behavior.

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The same Cochrane review examined 32 trials of interventions designed to improve or promote hearing aid use in adults with acquired hearing loss, compared with usual care or another intervention. They found that there was some evidence (although it was low quality) to support the use of “self-management support”—helping individuals manage their hearing loss and hearing aids by giving information, practice, and experience at listening and communicating, or by asking them to practice tasks at home. Other low-quality evidence also supported combining self-management support with “delivery system design” to change how hearing aid and auditory rehabilitation services were delivered. “However, effect sizes are small and the range of interventions that have been tested is relatively limited,” the authors noted.

Researchers at the NIHR Nottingham Hearing Biomedical Research Unit in the UK, suggest that one type of intervention in need of more study is the concept of motivational engagement—a type of patient-centered communication that has been successfully used in areas like smoking cessation, alcohol addiction and drug rehabilitation (Int J Aud. 2016. 55:S23).



Melanie Ferguson PhD, Consultant Clinical Scientist in Audiology and Honorary Associate Professor, and her audiology colleagues undertook a feasibility study on the use of motivational tools for hearing aid users developed by Denmark's Ida Institute. The tools are designed to help audiologists better engage patients in the rehabilitation process.

“By better understanding the patient's motivations for help-seeking and where the patient is at in the stages of change, the audiologist can work collaboratively with the patient,” says Dr. Ferguson.

Audiologists in the study were trained in the use of tools called “The Line, The Box, and The Circle.”

  • The Line asks two questions: “How important is it for you to improve your hearing right now?” aims to help patients assess their own motivations and readiness to improve their hearing. “How much do you believe in your ability to use a hearing aid?” aims to help patients assess their self-efficacy for hearing aids and identify any fears or lack of confidence. Patients select answers on a line from 0 to 10.
  • The Box asks the patient to assess the costs and benefits of taking action to improve their hearing versus the costs and benefits of inaction.
  • The Circle “provides a visual representation of patients’ readiness to receive hearing care recommendations, derived from a combination of self-assessment from the patient and the audiologist's own observations.” (This is completed by the audiologist and may or may not be shared with the patient.)

The intervention arm of 32 first-time hearing aid users received this motivational counseling at the assessment appointment, while the control arm of 36 hearing aid users received usual care. At the hearing aid fitting, the group receiving motivational engagement had significantly greater self-efficacy and reduced anxiety levels compared to the standard clinical care control group. However, by the 10-week post-fitting follow-up, there were no significant differences between groups for any of the outcome measures.

“Although there were no reported longer-term benefits at the 10-week point, there could be multiple reasons for that. However we found evidence showing increased readiness for hearing aids resulted in greater hearing aid use longer term,” says Dr. Ferguson. “The audiologists in the study indicated to us that they felt the tools helped them to get their patients to open up more and think about what their individual day-to-day issues were, rather than just standard questions. They felt it encouraged a more collaborative relationship.”

In another recently published study involving a group of 30 first-time hearing aid users, Dr. Ferguson and her colleagues also found that perceived self-efficacy (confidence in the ability to perform a set of skills needed to achieve a certain behavior), along with positive expectations for hearing aids and readiness to improve hearing, predicted satisfaction with hearing aids but not hearing aid use (Int J Audiol. 2016;55 Suppl 3:S34

Dr. Ferguson also recently published a high-quality randomized controlled trial on the effectiveness of a series of interactive, multimedia videos for hearing aid users, now freely available online known as “C2Hear Online.” Hearing aid use six weeks after fitting in those patients who did not wear their hearing aids all the time was significantly higher in the patients who viewed the videos compared to those who did not, with a large effect size. In the whole sample (n=203) those in the video group exhibited significantly better knowledge of practical and psychosocial issues, and significantly better practical hearing aid skills, again with large effect sizes. C2Hear Online is currently being ‘americanized’ for a US study. In summary, by enhancing patient's motivations and readiness to wear hearing aids, and ensuring patients have good knowledge of hearing aids and communication, the chances of success for hearing aid users can be improved.

Several prominent audiologists who spoke with The Hearing Journal agreed that the level of audiologists’ involvement and engagement with their patients throughout the process of assessing and managing hearing loss plays an important role in whether patients will effectively use their hearing aids.

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Stephanie Sjoblad, AuD, clinic director for the University of North Carolina Hearing and Communication Center, teaches her audiology students to talk to their patients not about getting their hearing aids, but about their “treatment plan,” instilling the idea that getting and using hearing aids is just one part of an overall program to improve their hearing.

“We begin by making sure that we assess the patient's functional communication issues before we choose hearing aids,” she says. “When we do that well, I think compliance is much better. We take the emphasis off the product, because patients need to understand that hearing aids are not going to cure their hearing loss.”

Her patients begin by filling out several self-assessments, such as the 10-question Characteristics of Amplification Tool (COAT) developed at the Cleveland Clinic, which assesses the issues a patient is interested in resolving, their motivation, and cost concerns; the Abbreviated Profile of Hearing Aid Benefit (APHAB), a 24-item self-assessment in which patients report the amount of trouble they are having hearing and communicating in various everyday situations; and the Expected Consequences of Hearing Aid Ownership (ECHO) survey, which measures pre-fit expectations of hearing aid use. “Doing a thorough needs assessment allows you to develop a treatment plan that is customized and narrow in on things the patient is trying to solve,” she says.



“Audiologists must prequalify their patients about their listening needs,” agrees Kenneth Smith, PhD, vice president and director of operations for the Hearing Center of Castro Valley in California. “That is really important in determining the level of technology you recommend for someone. If it's too low, they're eventually going to put it in a drawer and do nothing with it at all.”

Dr. Sjoblad's group also uses Real-Ear measurements on every fitting, something she says only about a quarter of audiologists in practice do. “I think one of the biggest problems we have in our profession is the lack of using these research-based methods that have been documented for 30 years,” she says. “With patients who come to me from other clinics, when I run Real-Ear, I often see that the fitting they have is nowhere close to what they need to have optimal access to speech.”

Words Dr. Sjoblad rarely uses are “trial period” and “demo.” She prefers to say “evaluation and adjustment.” “We don't want the patient to think they're ‘just trying it out,’ and treat the treatment process too casually,” she says. “I've seen data suggesting that 60 percent of providers ‘demo’ hearing aids to convince their patients to purchase them, but I don't think it pulls them in the same way as getting an assessment of their lifestyle.”

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Drs. Sjoblad and Smith both stress the importance of “better hearing workshops” to improve hearing aid use. “As part of any hearing aid fitting we do a no-cost class which involves two one-hour sessions in our conference room, usually about eight to ten people,” Dr. Smith says. “These classes focus on their individual hearing loss, what their priorities are, and how to make life at home a lot easier. We find taking that class correlates very highly with the successful adoption of hearing aids, as measured by data logging.”

“We as audiologists can say something ten times, but when they're talking with peers about how to solve the difficult communication problems they encounter, it hits home much more,” Dr. Sjoblad says. “I wish we could mandate this, but we presently cannot bill Medicare and most insurances for this service.”



Audiologists must also develop more of a “culture of follow-up,” building a long-term relationship with their patients, says Barbara Weinstein, PhD, professor and founding executive officer of the Doctor of Audiology Program at the Graduate Center of the City University of New York. “I haven't done any formal surveys on this, but I ask people all the time, ‘What's the name of your audiologist?’ and they have no idea. People who see an audiologist and get hearing aids from an audiologist should know them. Everybody knows the name of their dentist and their doctor!”

She notes that there are many frequent updates to hearing aid technologies, and audiologists need to have a regular means of reaching out to their patients to inform them. “There are so many advances and aids that can often be retro-fitted to address residual issues, but we have to reach out with things like patient newsletters and social media. That will keep the relationship going—remember, you could have these patients for 30 years!”

Dr. Smith has a rigorous follow-up schedule with his patients. “After the diagnostic visit and fitting, we see the patient two weeks later, assuming there are no problems beforehand,” he says. “At that two-week visit, we do Real-Ear measurements and data logging, and see how things are going. Assuming everything is fine, we see that patient every six months for the rest of the life of their device.”

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