Throughout the years there has been considerable disagreement among scientists regarding how best to conceptualize health literacy. Yet, most agree it is a modifiable determinant of health, critical to decision making regarding both disease prevention and health promotion. 1 Health literacy is multidimensional and incorporates a skill set that includes competencies ranging from the ability to obtain, access, and understand health information to appraising and applying health information to make decisions about one’s personal health care. 1,2 As noted in Table 1, health literacy can be conceptualized as having multiple levels. The skill set includes functional health literacy, communicative health literacy, critical health literacy and I will include health numeracy as a health literacy skill set. 2
For persons with difficulty hearing and communicating, critical health literacy, communicative health literacy (CHL), and health numeracy literacy are essential to individuals feeling empowered to navigate the health care continuum and to take control over their general health and hearing health. 1 In the case of persons with hearing loss, personal and societal factors impact one’s motivation and decision to take action regarding hearing health.
PERSONAL AND SOCIETAL INFLUENCES
While the burdens of hearing loss are growing, and the reach of hearing goes far beyond the ears, the sense of hearing remains undervalued, and hearing loss underrecognized and under treated. 3 In fact, as recently as 2021, the U.S. Preventive Services Task Force reaffirmed their conclusion that current evidence is insufficient to assess the balance of benefits and harms of screening for hearing impairment in asymptomatic older adults. 4 Regarding the personal, attitudes toward hearing health care and health care seeking behavior are both influenced by health literacy variables. Negative stigma about hearing aids signaling the presence of a disability is a powerful deterrent. Further, our study of activation levels and hearing status revealed that persons who reported “a lot of trouble hearing” were at risk for having low rather than high patient activation levels. Compared to individuals with low activation levels, persons with high activation levels reported greater use of preventive care, less delay in seeking needed care, and greater medication adherence. In addition, they were more likely to follow through on recommendations. 5 Our findings relating to activation may in part explain why persons with hearing loss tend not to engage in preventative care and wait close to nine years between the time they first notice hearing loss as an issue and decide to seek treatment. 6 Postponing a decision to seek treatment can of course lead to serious downstream consequences. Confirming our findings, Lin, et al. 7 reported that Medicare beneficiaries who reported a lot of trouble hearing were significantly more likely to indicate that they would do anything they could to avoid seeing a physician. In addition, respondents with difficulty hearing were reportedly less likely to say they would go to a doctor when they began to feel ill. These findings clearly confirm a connection between low health literacy and help seeking.
While overall sensory status is integral to each component of health literacy, hearing status is at the heart of communicative health literacy (CHL). CHL includes a set of three competencies, namely the ability to:
- access or seek, find and obtain health information;
- understand/comprehend and utilize basic health information; and
- appraise, interpret, filter, judge, and evaluate the health information that has been provided. The ability to obtain information is as important as the ability to comprehend it.
Low CHL red flags to which audiologists should be alert range from lack of follow-through on hearing tests, referrals, and frequently missed appointments to the sense that there was little a doctor could do about an individual’s hearing/communicative challenges.
WHAT IS AN AUDIOLOGIST TO DO?
Existing along a continuum ranging from low/limited/basic to proficiency, there is a generative aspect to health literacy that we can impact through our efforts in the realm of advocacy, accomodations, inclusivity, and education. With respect to patient education, we must ally with persons with hearing loss and their family members and empower them to take control of their health care. From the outset we must provide our patients with the communicative skill set they will need to participate actively in their health care. They must understand the principles and relevance of shared decision making and patient centered care when communicating with health care professionals and that hearing is essential. We must underscore that by maximizing hearing status, they will be best positioned to obtain, comprehend, and share information from health care professionals. 2 To this end, our patients must be encouraged to self-advocate and inform their health care providers how best to communicate with them so that they can share in decision making. As shown in Figure 1, hearing status (HS) is integral to shared decision making (SDM) and patient centered care (PCC). In fact, according to Wells, et al. (2020), low health literacy is associated with older age, male gender, lower income, a number of health conditions, and hearing loss, especially among those who do not use hearing aids.
In sum, according to the National Academy of Medicine, 8 health literacy is multidimensional and complex. Malleable and impacting health outcomes in a variety of ways, correlates of low health literacy in health care range from less satisfaction with health care communication, to poor self-rated health, higher medical costs, and difficulty making informed decisions, especially when it comes to accessing Medicare information. 9 Listed in Table 2 are a series of recommendations from the National Academy regarding how to optimize health literacy levels. Since hearing loss and health illiteracy are costly in terms of health care expenditures, health outcomes, and hearing aid/cochlear implant uptake, audiologists should make every effort to optimize competencies of persons with hearing loss in terms of health communication processes in clinical and community settings using some of the tips listed in the communication toolkit outlined in Table 3.
1. Sorenson K, Broucke S, Fullam ■, et al. 2012 Health literacy and public health: A systematic review and integration of definitions and models BMC Public Health 12 80
2. Muscat D, Shepherd H, Nutbeam D, et al. 2020 Health Literacy and Shared Decision-making: Exploring the Relationship to Enable Meaningful Patient Engagement in Healthcare J Gen Intern Med 36 521 4 10.1007/s11606-020-05912-0
3. Wilson B, Tucci D, Merson M, O’Donoghue G 2017 Global hearing health care: new findings and perspectives The Lancet 390 2503 2515
4. Feltner C, Wallace IF, Kistler CE, Coker-Schwimmer M, Jonas DE 2021 Screening for hearing loss in older adults: updated evidence report and systematic review for the US Preventive Services Task Force JAMA 325 1202 1215
5. Chang Weinstein, Chodosh ■, et al. 2019 J Am Geriatr Soc 67 1423 1429 10.1111/jgs.15833 Epub 2019 Apr 2.
6. Simpson A, Matthews L, Cassarly C, Dubno J 2019 Time from hearing-aid candidacy to hearing-aid adoption: a longitudinal cohort study Ear Hear 40 468 476
7. Lin H Y H, Willink A, Jilla A M, Weinreich H M, Oh E S, Robertson M, Reed N S 2021 Healthcare-seeking behaviors among medicare beneficiaries by functional hearing status Journal of Aging and Health 33 764 771
8. Pleasant A, Rudd R E, O’Leary C, Paasche-Orlow M K, Allen M P, Alvarado-Little W, Myers L, Parson K, Rosen S 2016 Considerations for a New Definition of Health Literacy NAM Perspectives Discussion Paper, National Academy of Medicine Washington, DC https://doi.org/10.31478/201604a
9. Willink A, Reed N S 2020 Understanding Medicare: hearing loss and health literacy Journal of the American Geriatrics Society 68 2336 2342