Motivational interviewing (MI) is a collaborative approach to having a conversation about making a behavior change (Miller and Rollnick, 2013). While originally used to address problematic drinking, it has been used successfully with regard to other behavior changes, such as medication adherence (Palacio et al, 2016). The reaer is referred to Rollnick et al (2008) for an overview of applications in health-care settings. It seems logical that MI also might be a beneficial approach for audiologists to use when speaking to their patients about the behavior changes associated with using hearing aids.

A recent pilot investigation (Aazh, 2016) explored the potential benefits of MI for individuals who were not making regular use of their hearing aids. The group of subjects who received the standard of care plus MI had a greater increase in hearing aid use than the group who only received the standard of care. While this was only a pilot investigation, these results are encouraging and suggest that MI may facilitate hearing aid use. In fact, this benefit was partially supported by another recent pilot study (Solheim et al, 2018). 

While Ferguson et al (2016a) did not use MI, these authors explored the effectiveness of using the Ida Institute’s motivational tools (http://idainstitute.com/toolbox/motivation_tools) with patients who were about to get hearing aids for the first time. Two of their tools help facilitate a collaborative conversation about behavior change. 

As compared to the control group, Ferguson et al (2016a) reported that the subjects who were in the motivational-tools group showed lower anxiety and higher self-efficacy at the end of the evaluation appointment. They reported feeling more involved in the decision-making process and getting understandable answers to their questions at the hearing aid fitting (HAF) appointment. 

FIGURE 2
FIGURE 2. NUMBER OF RESPONDENTS FROM EACH VISN Number of respondents from each VISN pictorially represented by their geographic region. Areas that are non-contiguous to the mainland continental United States are grouped with their associated mainland counterpart. 
Note: Nine respondents skipped this question and one answered that they were not sure. 

Finally, Zarenoe and colleagues (2016) compared outcomes between patients with both tinnitus and hearing loss who received MI and those who did not at the HAF appointment. While there were no significant differences in hearing aid outcomes between the two groups, these authors found a greater reduction in tinnitus handicap by the group of patients who received MI. 

The Veterans Benefits Administration has long reported that hearing loss and tinnitus are among the most prevalent service-connected disabilities (U.S. Department of Veterans Affairs, 2015). To address the majority of the hearing losses seen in Department of Veterans Affairs (VA) clinics—noise-induced hearing loss and presbycusis—audiologists often recommend hearing aids (U.S. Department of Veterans Affairs, 2015). In fact, the VA accounts for almost one-fifth of all hearing aids dispensed in the United States (Amlani, 2018). 

While additional studies are still needed regarding the effectiveness of using motivational-based approaches  with patients who have or who are about to get hearing aids, the aforementioned studies suggest that such an approach may have promise as an adjunct to audiologic clinical care. 

Prior to the publication of the aforementioned articles, our research group was exploring factors that affect hearing aid outcomes and considering new clinical tools/methodologies, including MI. Our study team created a 12-item survey (see FIGURE 1) to assess current clinical practice in the VA Audiology and Speech Pathology Service, as well as clinician interest and likelihood of use of some developing materials. This article considers the forenamed articles and reviews the findings of the related audiological counseling questions in this survey. 

Methods

Administration of our survey was approved by the VA Portland Health Care System Institutional Review Board (#2151) using a Waiver of Informed Consent Process and Waiver of Authorization.

FIGURE 3
FIGURE 3. TYPE OF COUNSELING PROVIDED Type of counseling, beyond the use and care of hearing aids, typically provided to patients. 
Note: No respondents skipped this item.

FIGURE 4
FIGURE 4. ASSESSMENT OF MOTIVATION TOWARD USING HEARING AIDS How often motivation toward using hearing aids is assessed. 
Note: One respondent skipped this item.

FIGURE 5
FIGURE 5. ASSESSMENT OF CONFIDENCE OF HEARING AID USE How often confidence regarding hearing aid use is assessed before the fitting of hearing aids. 
Note: Two respondents skipped this item.

Analyses

We filtered the results to include only responses from individuals who indicated that they were both an audiologist and currently dispensing hearing aids. To keep with the focus of this article, we report only the results from items 6–10 and 12, as well as provide details regarding respondent characteristics. Items with missing responses are marked accordingly. 

Results

Subjects

Of the 234 responses, 228 responded “yes” to being an audiologist and “yes” to currently dispensing hearing aids. FIGURE 2 illustrates the number of respondents according to their Veterans Integrated Service Network (VISN)1

FIGURE 6
FIGURE 6. Bubble plot comparing frequency of assessment of motivation versus confidence.

Counseling Content

Question #6 of the survey queried respondents about the type of counseling, beyond the use and care of hearing aids, they usually provided to their patients. Free-field responses for the “other” category in this question were reviewed to determine if any of the responses could be added to the closed-set response options or were already covered by “use and care of the hearing aids.” FIGURE 3 shows the number of respondents for each response option, after these adjustments. 

The following categories were selected for the remaining “other” responses: (1) tinnitus-related topics (n=4); (2) hearing conservation (n=4); (3) handouts (n=4); (4) acclimatization (n=4); (5) VA policies and procedures (n=3); (6) hearing loss and communication (n=2); (7) group auditory rehabilitation/hearing aid orientation class (n=2); (8) motivational tools (n=1); (9) incorporation of the significant other (n=1); (10) teleaudiology (n=1); and (11) dependent on patient’s needs/questions (n=1). 

Note that the number of responses marked for each of these categories does not add up to the total number of responses in the “other” category provided in FIGURE 3. This is because some respondents had more than one category identified in their free-field response. For example, “handouts to order supplies from DALC2” was categorized into “handouts” and into “VA policies and procedures.”

Question #9 (FIGURE 4) queries clinicians on how often they assess their patients’ motivation toward using hearing aids, while Question #10 (FIGURE 5) pertains to the assessment of self-efficacy. Three-quarters of the respondents reported assessing the motivation of their patients about using hearing aids “always” or “very frequently.” This percentage is smaller, however, when it comes to assessing self-efficacy. FIGURE 6 is a bubble plot illustrating the differences. Respondents above the diagonal line assessed self-efficacy more frequently, whereas respondents below the diagonal assessed motivation more frequently.

FIGURE 7
FIGURE 7.COUNSELING TIME PRIOR TO THE HAF APPOINTMENT The amount of time spent on counseling prior to the HAF appointment. 
Note: Three respondents skipped this item.

FIGURE 8
FIGURE 8. COUNSELING TIME AT THE HAF APPOINTMENT The amount of time spent on counseling at the HAF appointment. 
Note: No respondents skipped this item.

Timing-Related Issues

The amount of counseling time spent prior to the HAF appointment and during the HAF appointment are provided in FIGURES 7 (Question #7) and 8 (Question #8), respectively. For over half of these audiologists, no more than 10 minutes typically was spent on counseling prior to the HAF appointment. Additional counseling time typically occurred at the HAF appointment. A bubble plot of the “time spent during the HAF appointment” against “time spent prior to the HAF appointment,” with the diameter of each bubble proportional to the number of respondents is provided in FIGURE 9.

Most of the respondents (to Question #12) would be willing to dedicate at least 10 extra minutes of clinical time to a new counseling methodology if it helped improve patient outcomes and potentially reduced the need for follow-up appointments (see FIGURE 10). 

FIGURE 9
FIGURE 9. Bubble plot comparing time spent prior to the HAF appointment versus at the HAF appointment.

Discussion

These results demonstrated that VA dispensing audiologists spend more time on counseling activities during the HAF appointment rather than prior to the HAF. Beyond the use and care of hearing aids, almost all counseled their patients on realistic expectations and communication strategies. Fewer usually discussed hearing-assistive technology and the psychosocial consequences of hearing loss. More VA audiologists reported counseling on communication strategies than was reported in a recent online survey of American Academy of Audiology members (Clark et al, 2017), where only 72 percent of respondents “often” or “always” discussed communication strategies. Differences between these two surveys may be a result in the timing of the survey administration, the difference in wording of the questions, and/or practice locations. Future work should examine this in more detail. 

Our results are consistent, however, with the findings of Clark et al (2017) regarding discussing hearing-assistive technology. Clark et al (2017) reported that 51 percent of Academy members discussed this “often” or “always.” 

Additionally, it is not surprising that fewer audiologists discussed the psychosocial consequences of hearing loss with their patients. Greness et al (2015) and Eckberg et al (2014), in a review of patient-audiologist interactions at the patient’s first appointment, found that audiologists asked fewer questions related to psychosocial issues and often did not adequately address these types of concerns when raised by the patient. As suggested by Meibos et al (2017), this may be because audiologists feel less prepared to have these types of conversations. 

The majority of respondents regularly assessed their patients’ motivation toward using hearing aids. Autonomous motivation has been associated with the decision to get hearing aids (Ridgway et al, 2016)and with hearing aid outcomes (Hickson et al, 1999; Ridgway et al, 2016). As mentioned previously, MI and the use of the Ida Institute’s tools can facilitate a discussion regarding a patient’s motivation about using hearing aids. The results regarding patient outcomes using these approaches are limited, however, and we need more data regarding the efficacy of using these strategies in hearing health care. 

Fewer audiologists regularly assessed hearing aid self-efficacy prior to fitting hearing aids. Hearing aid self-efficacy is the confidence that one has in their ability  to use and take care of hearing aids (Smith and West, 2006). Hearing aid self-efficacy has been associated with seeking help with one’s hearing (Meyer et al, 2014), successful hearing aid use (Hickson et al, 2014; Meyer et al, 2014), and hearing-aid satisfaction (Ferguson et al, 2016b; Kelly-Campbell and McMillan, 2015). 

MI and the Ida Institute’s motivational tools also can address self-efficacy. Another method for measuring hearing aid self-efficacy is the Measure of Audiologic Rehabilitation Self-Efficacy for Hearing Aids (MARS-HA; West and Smith, 2007). Smith and West (2006) also provide strategies for raising hearing aid self-efficacy. 

The majority of our respondents reported a willingness to add clinical time for counseling if it improved outcomes and potentially reduced the need for follow-up appointments. Aazh (2016) reported that the average amount of time spent on counseling alone (not including technical modifications) at the initial hearing aid follow-up/review appointment for those that received MI was 41 minutes. This resulted in an average total appointment time that was 15 minutes longer than the control group. More of the subjects in the MI group, however, came back for an additional appointment. It is interesting to note that the subjects who had MI in the Zarenoe et al (2016) study had significantly fewer appointments. These timing-related factors require further exploration.

FIGURE 10
FIGURE 10. ADDITIONAL COUNSELING TIME Amount of additional clinical time respondents willing to spend on new counseling methodology. 
Note: No respondents skipped this item.

Limitations

Finally, we must acknowledge the limitations of the findings from this survey. We disseminated the survey link in 2012 and only to the VA e-mail community. The results, therefore, may not be reflective of current clinical practice or practice in other arenas. Additionally, the wording of the questions and the amount of information provided may have influenced the responses given by the audiologists. Despite these limitations, we believe these results can provide some insight for researchers developing new audiological counseling methodologies and considering their implementation in the clinical environment.