Encouraging Patients to Become Better Self-Managers

An Interview with Michelle Arnold, Au.D.

One of the central ironies associated with modern hearing aid use is that as amplification technology becomes more automated and sophisticated, it adds more time and complexity to the fitting process. Anyone who has fitted a pair of hearing aids with direct Bluetooth streaming, near field magnetic induction (NFMI) and user-controlled, smartphone-enabled apps, knows exactly how cutting-edge technology, designed to provide improved patient outcomes, sometimes makes the patient more reliant on the audiologist to “get it right.” One antidote to this dilemma could be the use of self-management skills training.

Hearing loss self-management skills refer to the knowledge and skills people use to manage – as independently as possible – the effects of hearing loss on all aspects of their lives. Moving beyond device mastery skills, teaching individuals to actively identify challenges and solve problems associated with their hearing loss best describes the term self-management. For audiologists, providing self-management skills training could be an opportunity to offer a tangible service that adds value to the traditional bundled service model, or self-management skills training could stand apart from the delivery of a device. Given the likely movement toward more over-the-counter purchases of hearing devices, it’s imperative audiologists offer some type self-management skills training that can be provided to patients who purchased devices elsewhere but are in need of optimizing their use. In addition to a service provision for those buying devices elsewhere, as you will read in this interview with a self-management skills expert, Michelle Arnold, AuD of the University of South Florida, these types of skills should be provided to all patients, regardless of where they may have bought their hearing aids.

To set the stage for Dr. Arnold, let’s get up to speed on some of the essential elements of teaching patients how to be successful self-managers of their condition. Beyond successfully using hearing aids, hearing loss self-management skills encompass maintaining physical and emotional well-being, active monitoring of changes in hearing loss or hearing device effectiveness and taking an active role in long term care and decision making. In a paradigm that focuses on improving self-management skills, it is the responsibility of the audiologist to help patients acquire these skills.

Self-management skills for adults with hearing loss is defined as the patient independently demonstrating the following behaviors: (1.) Active participation in the goal setting and treatment planning process, (2.) Adherence to an agreed upon treatment plan, (3.) Ability to recognize and manage changes in condition or treatment plan, and (4.) Use of proactive coping strategies when communication becomes challenging or treatment plan falls short of expectations.

When audiologists improve the self-management skills of adults with hearing loss, several benefits are likely to occur: Individuals, who can effectively self-manage their condition, are less likely to show up unannounced in the clinic looking for additional help, they are more likely to keep their scheduled appointments and to experience improved outcomes. All of which help a practice operate more efficiently. To learn more about hearing loss self-management skills and how they can be fostered in your patient, let’s turn to my interview with Dr. Arnold.

BT: Tell us a little about your background and how you became interested in issues related to encouraging persons with hearing loss to be better self-managers of their condition?

MA: I am an audiologist and I also have a PhD in Aging Sciences. During my education and training for my AuD, I didn’t think a lot about the value of fostering self-efficacy or self-management skills, and those things weren’t highlighted in any of my courses. It was my clinical experiences that helped me to realize that self-management is an integral component for success with hearing aids. My research interests are focused on increasing hearing loss awareness and treatment for people from vulnerable populations (i.e., people from low SES backgrounds, people with limited English proficiency, older adults on fixed incomes). I began to look for resources that promoted hearing loss self-management, but the majority of resources weren’t suitable from a health literacy standpoint – a concept I was introduced to by delving into the Ida Institute website. At the time I was also tasked with working on self-management materials for a clinical trial planning grant, and I wasn’t satisfied with what was available, which led to the development of the Hearing Loss Toolkit for Self-Management©.

BT: Maybe we should step back and look at this issue of hearing loss self-management. Describe for our readers the concept of self-managing a chronic condition and how those principles may apply to work in an audiology clinic?

MA: I think of self-management skills as a reflection of a person’s individual self-efficacy. In other words, if a person has high self-efficacy, they feel confident and able to complete tasks or overcome obstacles they perceive as difficult. Self-efficacy is impacted by 4 main learning experiences: (1) mastery experiences, (2) vicarious experiences; (3) persuasive experiences; and (4) emotional arousal experiences. In a clinic setting, self-efficacy can be fostered by providing clients with the different experiences as they relate to the treatment plan. For example, if a person is receiving hearing aids for the first time, providing them opportunities to master hearing aid skills, such as charging the batteries, syncing devices to a smart phone, or cleaning a wax guard, as opposed to simply showing them or demonstrating these skills; these are all mastery experiences. Vicarious experiences can be provided through introducing clients to others who have hearing loss and similar treatment paths – I have a colleague who makes it a point to pair cochlear implant candidates with recent successful recipients so they can observe and learn how they were able to manage the surgery, activation, and follow-up. I think clinicians are probably already providing persuasive experiences, simply by introducing treatment options to clients and telling them that they can be successful. Finally, emotional arousal is impacted by the environment. A rushed, disorganized clinic can trigger negative emotions that will be conveyed then to the intervention, whereas an organized clinic with a calm and empathetic provider will be more likely to foster positive emotions in the client.

BT: What are your thoughts on audiologists offering an unbundled service package that involves helping patients hone their self-management skills? What might that service look like and do you think that type of service package would be valued in a market where people can self-direct their care and buy hearing aids over-the-counter?

MA: I believe that providing clients with the tools to successfully manage their hearing loss shouldn’t be de-coupled from the device in an unbundled service package, for several reasons. First, in a rapidly changing professional landscape, where state-of-the-art devices are now available to people with hearing loss at drastically reduced prices compared to what they find in a private practice, the value the clinician will bring to the table is this type of service. I don’t believe that private practice will be able to compete with the per-unit prices or manpower of an OTC or big box store anytime soon. What happens when Apple releases an OTC device, and includes the Genius Bar services and classes? Currently, any owner of an Apple device can walk into nearly any mall in the US and attend a Genius Bar course that teaches them how to manage and use their device in a hands-on session – for free. And they hold these sessions EVERY DAY. What about companies like Listen Lively, where a person can receive top of the line technology and follow-up rehabilitation services (including counseling on device use and self-management) for two years – from a licensed AuD – all included in the cost? Pretty much on-demand! Why will a patient want to pay the private practitioner an additional fee on top of an already high ticket price for hearing aids to receive these services when the competitors will be offering them as part of the device cost?

Second, I think that some of the primary obstacles to learning self-management skills are due to a lack of understanding about (1) the negative impacts of untreated hearing loss and (2) a lack of education resources that meet the needs of those with low health literacy. While anyone can have low health literacy, you are much more likely to see this in people from low socio-economic backgrounds. There are already so many cost and access barriers to hearing loss treatment, and these barriers tend to impact those who are probably the most likely to need help with self-management. I find something fundamentally wrong with offering services that I consider necessary for successful hearing loss treatment only to those that can afford to pay for them.

BT: What tools have you developed that a clinician could adapt and potentially use as part of a sell-management service package?

MA: Our lab, the Auditory Rehabilitation and Clinical Trials lab (ARCT) developed the Hearing Loss Toolkit for Self-Management©, which is a modular hearing loss education program that can be tailored to the needs of the individual patient. The Toolkit is based on the most current health literacy and patient learning guidelines. Readers can learn more about it in the February 2019 edition of Seminars in Hearing.

BT: Turning to your work on help-seeking behavior models, could you familiarize our readers on some of the frameworks used to explain the help seeking behaviors of persons with hearing loss?

MA: I have been lucky enough to have had the opportunity to work with one of the foremost experts in the field in the area of help-seeking for hearing loss, Gabrielle Saunders. Her work (which I collaborate on) encompasses investigating several health behavior models and how they relate to persons with hearing loss. Some of the models include the theory of planned behavior, the health belief model, and the transtheoretical model of behavioral change. The various models seek to predict and explain behaviors related to decisions and actions people make to manage their health, particularly chronic conditions. I highly suggest any readers interested in learning more about the value of applying health behavior models to explaining decisions about hearing loss help-seeking to check out some of her work.

BT: Let’s look more closely at the model where you have conducted some research, the Theory of Planned Behavior, tell us about the questionnaire you developed and what it measures?

MA: This questionnaire was developed as part of a larger NIH-funded study where individuals with probably hearing loss are identified at a hearing screening and then followed for 3 years to see what they do (in a nutshell). Do they have a hearing test as recommended? If they have the test, do they follow-up with hearing aids if recommended? Why or why not? Specifically, the theory of planned behavior questionnaire looks at 4 main constructs: intentions to get a hearing test, attitudes about getting a hearing test, how social norms impact the decision to get a hearing test, and a person’s confidence that they have the resources and wherewithal to get a hearing test should they want one. We found that the questionnaire reliably differentiates between those who received a hearing test, as recommended, and those that didn’t. A measure such as this might be used to tell who might need more counseling or information regarding the negative impacts of untreated hearing loss, or perhaps some motivational interviewing to get at the bottom of why they might not follow through with treatment recommendations.

BT: How might a clinician apply your insights to their own work with patients?

MA: I think overall that shifting focus away from tests and devices and concentrating clinical efforts on meeting the needs of the people sitting in front of you is a great start. Whether it’s through providing the best self-management skills training or homing in on addressing the client’s individual listening goals, the value of the AuD in the near future will be in providing services – not just diagnostics or devices.

BT: You mentioned your recent publication in Seminars in Hearing, what other work would you recommend to audiologists interested in honing their ability to deliver hearing loss self-management training?

MA: Sure. Here are some places to start. I was the guest editor of that issues of Seminars in Hearing, Novel Approaches to Fostering Hearing Loss Self-Management in Adults. It was published earlier this year and you can find it here.

Also, my colleagues in Australia, led by Elizabeth Convery, PhD, recently published a terrific paper in the American Journal of Audiology that looked at the relationship between hearing loss self-management skills and hearing aid benefit. I encourage everyone to read it, as one of the main take-aways is that audiologists can make hearing aid fitting outcomes even better by addressing the psycho-social components of hearing loss. You can find that paper here at this gated site.    
Michelle Arnold, Au.D., Ph.D., is an assistant professor in the department of communication sciences and disorders at the University of South Florida in Tampa, FL. She can be reached at mlarnold@usf.edu.