Effective communication is an important consideration for any clinician when interacting with a patient. Experts in many fields can find it challenging to communicate with non-experts;1 it requires effort to avoid field-specific terminology commonly used among peers but is impenetrable jargon to a layperson. Existing evidence for audiology suggests that hearing specialists are not immune to this difficulty, with clinicians and other experts communicating using a vocabulary that is at a much higher reading level than that of their patients.2,3 Moreover, it has been shown that the more complex the audiologists’ language, the lower the likelihood of hearing aid uptake by the patient.4 Missing from our understanding is the relationship between the patients’ ability to understand health-related information and their use of hearing health care.
Evidence from other domains in health care strongly supports the potential role of a patient's comfort and competence with health information in determining their health care choices and outcomes. The commonly used phrase is “health literacy,” meaning the broad scope of skills necessary to interact with materials and communicate in a health-related context.5 In chronic conditions such as diabetes and hypertension, low levels of health literacy have been associated with poor outcomes.6 This is likely due, in part, to differences in self-management and differences in utilization. For example, reliance on emergency services is materially influenced by real and perceived barriers to non-emergent ambulatory care.7 Low health literacy is also correlated with poor understanding of prescriptions and self-management plans, resulting in the unnecessary exacerbation of chronic conditions.5
The possible mechanism for a role of health literacy in hearing health care is straightforward: Low levels of health literacy in patients met with high reading level communication from clinicians could result in poor understanding of options for care, possible consequences of different choices, and ultimately lower utilization of hearing care and strategies.
EXPLORING HEALTH LITERACY & HEARING AID USE
To explore the potential relationship between health literacy and hearing aid use, we turned to the Health and Retirement Study (HRS),9 which is a biennial, longitudinal survey of retired American households that covers a variety of topics, including demographics, financial information, health care utilization, and hearing aid use. While the core surveys are relatively consistent, additional components are sometimes added. Over the past decade, this has included some measures for health literacy. A single question, “How confident are you filling out medical forms by yourself?” has been successfully tested against other health literacy measures in a different population.10,11 In 2009, 2010, 2011, and 2013, this question was combined with questions drawn from the Rapid Estimate of Adult Literacy in Medicine (REALM)12 and the Short Test of Functional Health Literacy in Adults (S-TOFHLA)13 in the HRS.
These measures allowed us to investigate whether there was an association between different health literacy measures and hearing aid use while controlling for some variables that have been associated with hearing aid use or uptake, such as age, demographics, net worth, and hearing ability. In our initial exploration of the data, we found that hearing aid use by one member of a household was not independent of hearing aid use by another member, so we limited subsequent analyses to just one member per household. We constructed four different discrete-time survival models based on the availability of different health literacy measures in the HRS; an overall ‘subjective’ health literacy model using the single question screener and respondents from all four years, and three separate ‘objective’ health literacy models using respondents with answers to the S-TOFHLA and REALM questions in 2009 and 2010. Discrete-time survival analysis, a type of survival analysis that models the probability of an event, was used to predict hearing aid use over time. It allowed us to determine if the different factors we included in the analysis significantly changed the likelihood a respondent would report starting to use a hearing aid in any given HRS response period.
STUDY FINDINGS & CLINICAL IMPLICATIONS
Our findings paint a mixed picture of the relationship between health literacy and hearing aid use in HRS participants. The models including ‘objective’ health literacy measures did not support a relationship between the participants’ responses and self-reported hearing aid use, with confidence intervals for the odds ratios overlapping 1, and the ratios themselves very close to 1 (OR = 0.97, 0.98, 1.02). This is despite having fairly large sample sizes (n = 1240, 1586, and 2412). However, the analysis using the single-question screener (n = 8632) did find a relationship (OR = 0.94, CI 0.88-0.99, p = 0.02), which represents a six percent lower likelihood of using a hearing aid for every step lower a participant rated their ability to fill out medical forms. Other variables in the models broadly agreed with the existing literature.14
Complicated results do not tend to lead to simple conclusions beyond the need for further study. It is possible that the objective analyses were underpowered, that the objective measures were insufficient, or that unmeasured variables obscured a relationship. It is likewise possible that the subjective analysis found a spurious relationship that won't be borne out by subsequent studies or analyses. It is also possible that both findings bear out in further investigations, and that differences between subjective and objective health literacy measures capture something essential to understanding hearing health care use in the United States.
It's important to consider any results within the broader context of health literacy and hearing health care. The evidence of the role of health literacy in the larger scope of health care is robust,5 and should encourage further consideration by clinicians and researchers in hearing. Barriers to hearing health care in the United States were manifold and multifaceted even before a global pandemic shifted priorities for in-person care.15 The potential gain of communicating with patients in a way that they can understand and make use of a clinician's expertise seems to far outweigh the minimal costs. Written information, whether paper or electronic, can be assessed for the appropriate reading level using widely available tools, including common word processing software.16 In conversations with patients, clinicians can focus on interactive communication in a patient-centered setting,17 or more formally lean on methods such as teach-back.18 Audiology researchers and clinicians have ample opportunities to learn from existing health care research and to expand and explore how those findings fit into the niche of hearing health care.