Behavior Change in the Context of Hearing Health Care: Interview with Fiona Barker, MSc
Douglas L. Beck, AuD, spoke with Dr. Barker about The Cochrane Review on Interventions to Improve Hearing Aid Use, the behaviors of patients and health-care professionals, outcome goals versus behavioral goals, and more.
Academy: Hi, Fiona. Thanks for your time this morning. I know you're very busy re-writing and publishing the 2016 Cochrane Update on Interventions to Improve Hearing Aid Use….and I hope you'll be able to tell us a little about that?
Barker: Hi, Doug. Well, as it's currently in peer-review, we can't say much, but we can discuss the general trends. We've added in a few more studies with additional random controlled trials, and so the Cochrane Report is now based on more than 40 randomized controlled studies.
Academy: That's great. And so in those reports, the original and the one to be released in 2016, you looked at factors above and beyond the hearing aid itself?
Barker: Right. We looked at any intervention which might help some people use their hearing aids including self-management protocols. So we were interested in hearing aid use post fitting rather than hearing aid uptake.
Academy: And your timing is perfect as I just published (November 2015) my thoughts in an op-ed, which addressed the importance of the quality of the conversation, and the importance of the words chosen, and the fact that success and failure with amplification often pivots on the professional—arguably more so—than the specific equipment selected.
Barker: Yes, that seems to be generally true. I have read that op-ed, and I agree with your points. In theory, many things could contribute to the success of a hearing aid fitting some of which have been tested in randomized controlled trials and some of which haven't.
Academy: And given all these factors, many of which can be controlled and some which cannot be controlled, what's the most important factor?
Barker: We don't actually know which is the most important factor based on the data but personally I would say the face-to-face interaction appears to be a primary issue most of the time. But again, there are many other powerful factors in motion.
Academy: That makes intuitive sense….and what about the other factors?
Barker: There are many other intervening factors which impact the way people manage their hearing loss, such as the support and encouragement of significant others, and of course, how much help are they truly seeking, how much of a hearing disability do they actually demonstrate, versus how much hearing loss do they have on an audiogram.
Academy: Sure…We've all seen many people with high-frequency hearing loss who are doing fine without amplification, and others with the exact same hearing loss who cannot get by without amplification…and that's why it is so important to measure their hearing handicap, or hearing disability, rather than just measuring audiograms. Did you find any factors which related to increased hours of hearing aid use?
Barker: We didn't find anything which increased self-reported daily hours of hearing aid use. In fact, we question whether "hours of use" is an appropriate metric to measure hearing aid success. In our 2014 review, we found very few studies which examine the effect of interventions on 'adherence' or whether or not people wear their hearing aids. And as you know, there's even less information revealing the pattern of use rather than simple quantity of use in hours per day.
Academy: Good point. I suspect one could be a successful hearing aid user if he or she wore their hearing aids at the most appropriate times (for him or her) and received substantial benefit during those times. That is, rather than using hearing aids all day, every day, perhaps someone with a mild high frequency hearing loss would use them on an "as needed" basis, much like folks older than 50 years of age using reading glasses?
Barker: Exactly, the definition of "successful hearing aid use" varies with the exact perception and needs of the patient, not the professional!
Academy: So then, moving on from the review, what are the key points to successful behavior change for the hearing aid user?
Barker: Well, there are many. The model and method I use proposes one needs to develop a thorough understanding of how the patient's behavior interacts with other people's behaviors. That is, behaviors never occur in isolation in any context. And so to effectively intervene, we need to know when and where to intervene, and that starts with understanding how behaviors interact. One key issue is to develop a map of hearing aid use for the individual, and then to see how the behaviors of the patient, the professional, the system and even the manufacturers interact.
Therefore, so when we map these behaviors, we see the points of interaction, which dictate the staring points. In my research, I've taken the decision that the most effective place to intervene is with the professional's behavior, as that usually has the potential to impact on the patient's behavior. From there we create an analysis to see if the professional has the opportunity, capability and motivation to engage in the behavior you're interested in, or the behavior you'd like to change. In my research this would be to engage in collaborative behavioral goal-setting.
Academy: And so behavioral-based goal setting with the professional is the actual task that you would embark upon?
Barker: Yes. To be clear, these are different from outcome goals (such as might be identified using the COSI), these are behavioral goals. So the professional might discuss and collaborate with the patient to develop goals for how they will behave differently going forward such as the specifics of when, where and how they are going to wear their hearing aids. This is not to replace outcome goals relating to which situations where the patient might like to hear better but provides a behavioral plan for how to get there. Successful hearing aid fittings may be about setting behavior and outcome goals.
Academy: And I recall you use the COM-B model. Can you define that for me?
Barker: Sure, in essence, the COM-B model (Michie et al, 2014) is used to analyze behavior as a starting point for intervention development. The model proposes that for a behavior (B) to occur, people need to have the physical and psychological capability (C), the physical and social opportunity (O) and the motivation (M) to do it at any given moment. My hypothesis is that if hearing healthcare professionals engage in collaborative behavioral goal setting with their patients when hearing aid are fitted then patients are more likely to become successful hearing aid users. So I need to start by analyzing whether audiologists have the capability, opportunity and motivation to do this behavior.
Academy: Yes—have you enacted the protocol, and do you have results?
Barker: Excellent question! Unfortunately, not yet. This is the project I am working on to complete my PhD. One of the key benefits of this model is that it includes automatic motivational processes. This means I can use it to include an assessment of how important habit is to professionals and patients. This is important because both hearing aid use and collaborative goal-setting are behaviors that you want people to repeat in consistent contexts and so habit formation could be an important determinant of these behaviors.
Academy: Fantastic! I'm interested to see how this pans out. It would be amazing if we could motivate professionals and patients to examine and modify behaviors, and if we could motivate clinicians to address behavioral goals, that might be a whole new ballgame.
Barker: Right. If we embedded goal setting behaviors into the clinical protocol, we might get a very different clinical protocol and a different result.
Academy: Thanks for your time and your insight, Fiona. This is a fascinating concept and I wish you a speedy and positive result!
Barker: Thanks, Doug. I appreciate your interest!
Fiona Barker, MSc, is a clinical Scientist in audiology and PhD student at University at Surrey, England.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor with the American Academy of Audiology.
For More Information, References, and Recommendations
Beck DL. (2015) Professionals, Placebo and Curative Discussions. Op-Ed. November. Available at www.audiology.org.
Barker F, Munro KJ, de Lusignan S. (2015) Supporting living well with hearing loss: a Delphi review of self-management support. International Journal of Audiology May 4:1-9.
Barker F, Mackenzie E, Elliott L, de Lusignan S.(2015) Outcome measurement in adult auditory rehabilitation: A scoping review of measures used in randomized controlled trials. Ear and Hearing. April 27.
Barker F, Mackenzie E, Elliott L, Jones S, de Lusignan S. (2014) Interventions to improve hearing aid use in adult auditory rehabilitation. Cochrane Database of Systematic Reviews 2014 Issue 7.
Barker F, de Lusignan S, Baguley D, Gagne JP. An evaluation of audiology service improvement documentation in England using the chronic care model and content analysis. International Journal of Audiology 2014 53(6), 377-82.
Michie S, Atkins L, West R. (2014) The Behavior Change Wheel: A Guide to Designing Interventions (1st ed) Silverback: London.