By Sophie Brice, PhD, GradCert, Msc, BMedSci (Hons), and Elaine
Saunders, PhD, MAudSci, BSc
holds great value in achieving improved clinical outcomes of people with
chronic conditions including hearing loss. With hearing health care branching
out of clinic-based services and into blended and online models of hearing care
delivery including app-based services, the importance of successful
self-management has become even more evident. Here, we review the evidence and
opportunities in modern hearing health care support to effectively use the
principles of self-management.
SELF-MANAGEMENT IN HEARING
The most recent MarkeTrak
X report—a highly regarded market
analysis and consumer trends survey in hearing health care—released in 2019
showed an estimated hearing aid adoption rate of 34 percent among individuals
who would benefit from hearing care.1 While the reason for such low
adoption rate remains unclear, it has been postulated that the clinician-centric
model of hearing care delivery may be a factor.2-5
care in medicine was discussed in chronic health literature by Clark6 and Wagner7 in the early 90s, culminating in the
development of the Chronic Care Model along with the adoption of Bandura’s
ideas behind self-efficacy. Initially applied to education and learning, the
ideas of self-efficacy were soon applied to health behavior.8 The Chronic Care Model is a strong
model to adopt in improving audiological care, whereby self-management is
valued and supported.9 Wagner, et al., showed that self-management
and behavior change support improved outcomes across chronic health. Four
elements were consistently seen in successful care programs, thereby shaping
the consequently proposed Chronic Care Model7, 10: (1) Collaborative problem defining,
(2) Goal setting, (3) Continuum of self-management training and support
services, and (4) Active and sustained follow-up.
In this article,
we propose an adaptation to support effective rehabilitation in hearing care:
(1) Control: Client controlled hearing aid fitting
(2) Adjustments: Ability to adjust hearing aid
(3) Rehabilitation: Tools to assist
Do clients really
want to be in control? Interpreting the work of Goldstein and Stephens on
rehabilitation types, the answer is unlikely to be consistent across the
current and potential client population. In a client-centered model, the control or decision
making is shared with or owned by the client, as supported by audiological
literature.9, 11, 12 The tools for the client are
generally offered via software or an app that is easy to use. Control has been
listed as one of nine vital factors needed for clients to more likely accept
telemedicine applications,13 as a sense of safety comes from a
sense of control over a situation. This is consistent with evidence in
telepsychiatry that online interactions with a health professional allow
greater engagement, which is thought to be due to the notion of control by the technology
user over the interaction.14 For example, it is by far easier to
end a call than to remove someone else from the room. Dario, et a.,l15 reported a high level of
acceptability of user-driven telehealth technology, as well as high user satisfaction
that increased over time.15
hearing aid fitting software by the client offered with an option for a follow-up
appointment to be conducted online or in the clinic has shown a positive skew
in client choice toward remote support appointments.16 One concern could be that first time
hearing users have unidentified needs due to lack of prior experience with
hearing aids. Brannstrom, et al.,17 have shown that overall satisfaction
and positive hearing aid outcomes among first time hearing aid users actually
improved when post-fitting support was delivered via teleaudiology. Furthermore,
Amlani, et al.,18 very recently showed that an app-based
interface for hearing support led to improvement in perceived benefits and
reduction of perceived barriers of wearing hearing aids. It is encouraging to
see research findings that suggest greater user control may in turn enable
greater user satisfaction.
devices are becoming a reality in the United States. Direct-to-consumer (DTC)
hearing aids are available globally, and all major hearing aid manufacturers are
now offering user apps to manage various aspects of their hearing care. The idea of a client in control is gaining
traction, partly, and importantly, driven by the consumers.
of user control are provided in the apps supplied to adjust the hearing aids.
The range of control varies from simple controls such as volume levels to customizable
programs, daily experience surveys to direct communication with a clinician, clinician-altered
settings, and self-fitting of hearing aids in some cases. These capabilities
have also allowed data logging that can be reviewed remotely in individual and big
data sets. There are two key aspects of the value and benefit of client
1. Will clients be happier with their own
Strong evidence supports
the answer to be positive. Perceived benefit and hearing aid satisfaction are
positively associated with hearing aid self-adjustments (self-efficacy).19-24 A valuable tool in assessing satisfaction is the use of
third-party feedback surveys. A blended service model offers online and
traditional clinic based services, equally and interchangebly supported by
teleaudiology. A 2018 study found that online users gave higher satisfaction
ratings to a blended model of self-fit hearing aid products and services than
their clinic based counterparts.25 These ratings may be due to several interacting factors that merit
further investigatation, but other studies point to factors such as convenience
and user control26 as well as a sense of empowerment.27
2. Should self-fittings be a concern for
question relates to the client not choosing one of the common fitting formulae
targets, and potentially negatively impacting the audibility benefit from
hearing aids and devices. Recent studies have shown that client-based
adjustments show consistently reproducible preferences, with variations
according to the listening environment and potentially according to the type of
hearing loss.24, 28, 29 Of note, these studies also showed speech
intelligibility scores equivalent to those obtained with pure-tone audiometry
and prescription fittings. In a true client-centered model, client preferences
of the auditory experience are of paramount importance. Such client preferences
can even be used to identify improvements to fitting prescriptions.30
Satisfaction is a
significant factor in compliance for chronic disease management31 that is likely also observed in the modern
provision of hearing aid and devices. Should the impact of allowing clients to
make their own adjustments, in turn, be directed to providing effective support
and intervention such as counseling and adjustments (guided or clinician-controlled)
by the clinician instead?
Kramer describe auditory rehabilitation as a dynamic problem-solving process that
should optimize participation and feedback from the client.32 They aptly use the term enablement to
better describe this process. The IDA Institute has developed, and shared,
tools for audiology professionals to use with clients in assisting clients to
achieve successful outcomes with hearing aids. They are predominantly designed for
face to face interactions though many are transferable to an online setting.
rehabilitation programs delivered online have been shown to improve quality of
life for experienced hearing aid users.33, 34 Hearing aid users with self-efficacy
values below normative values may require additional training from their audiologist.20 Counseling is a highly valued skill
in audiological care, has been shown to impact the likely success of fitting
and auditory rehabilitation with hearing devices,35, 36 and can be designed to operate as
part of app-based support. Successful results of this already have been seen.27, 37
the benefit of appropriate counseling and client-centered communication in
improving adherence and improved outcomes with hearing aids.36, 38, 39 Services and communication may differ
between service models, and so different metrics of success, failure, and
outcome measurements may be required. Replicating a clinic-based model onto an
online delivery is not necessarily a solutions based-approach, nor may it be
best practice. A clinician in a client-led hearing service model will use the
most appropriate tools to deliver the support and outcome that the client seeks
developments offer an opportunity to address and improve aspects of current
care practices. In hearing care, a relatively low uptake, and clinician centric
practices have been problems to solve. Incorporation of apps, self-fitting
hearing aids, internet-based interventions, and support can expand ways to
deliver high-quality and effective hearing care by supporting self-management
in a variety of ways.
ABOUT THE AUTHORS: Sophie Brice, PhD, GradCert, Msc, BMedSci (Hons), is an adjunct faculty, a teleaudiology consultant, and a lead researcher in digital health specializing in teleaudiology at Swinburne University in Melbourne, Australia. Elaine Saunders, PhD, MAudSci, BSc, has pioneered a client-centered, blended teleaudiology and face to face service of hearing health care. She is an adjunct professor at Swinburne University of Technology.
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