Stages of Change: A Unique Perspective

Author: Katie Ekberg, Ph.D.

Over the past few years, there has been considerable research conducted on the underlying behaviours and attitudes exhibited by individuals with gradual hearing loss of adult onset. Stemming from research conducted with other chronic medical conditions, the Transtheoretical Model and the Health Belief Model are two nomenclatures that have been used to help us better understand why some people with a seemingly challenging communication problem oftentimes wait years to seek help. These models have received a lot of recent attention from research audiologists around the world. To date, the research in this area has indicated that the combination of perceiving fewer benefits and more barriers, having lower self-efficacy, and encountering fewer cues to action is associated with lower likelihood of seeking help for hearing difficulties. Counselling-based interventions targeting the attitudes that reduce help seeking behaviour is the likely outcome of much of this research. In an attempt to help us make sense of this vein of important clinically relevant research, we have enlisted the guidance of Dr. Katie Ekberg from the University of Queensland in Brisbane, Australia. Katie is not an audiologist, so she brings a totally unique perspective to helping us better understand the behaviours and attitudes of our adult patients. She has co-authored several papers, many of them published by the International Journal of Audiology, that provide tremendous insight on how to counsel patients through the process of behaviour change. In deference to Katie’s Australian heritage, we have not altered her grammar in this interview. She refers to people who seek help from us as clients, so we will too!

AP: Tell us about yourself, your clinical experience and your university.

Katie Ekberg: My background is in Psychology - I did my undergraduate and Ph.D. in Psychology at the University of Adelaide, Australia. My research interests involve communication in client-clinician healthcare interactions, addressing psychosocial issues in healthcare consultations, patient-centred care, and family-centred care. I am currently a Postdoctoral Research Fellow at The University of Queensland in Brisbane, Australia, within Professor Louise Hickson’s team. Part of our recent research has involved examining communication in audiology consultations with older clients with hearing impairment.

AP: There have been quite a few papers published on the Stages of Change model. Please share with us from your perspective the value of this model for clinicians working with adults with hearing loss.

KE: Audiologists will be aware that not all clients who attend an initial appointment to have their hearing tested go on to obtain hearing aids. In order for clients to decide to go ahead with hearing rehabilitation, they need to feel ready to make a change. If clients do not yet feel ready to pursue hearing rehabilitation, they are unlikely to have much long-term success incorporating changes into their daily life. It is thus important for audiologists, during their first appointment with clients, to try to gauge how ready they feel to improve their hearing.

The Stages of Change (or transtheoretical) model is a health behavior change model that can be useful for audiologists to explore clients’ readiness for change. It views behavioural change as a process that occurs across 5 key stages: (1) pre-contemplation (problem denial or lack of awareness); (2) contemplation (awareness of problem); (3) preparation (intention to change behaviour); (4) action (overt behaviour modification); and (5) maintenance (sustained behaviour change). The model suggests that individuals who are in the later stages of change are more likely to succeed at help-seeking, intervention uptake, and adherence.

This model has been found to have validity in the audiology setting. However, the questionnaires typically used to measure clients’ stage-of-change are too long to be used in time-pressured clinical settings. This led us to consider whether clients’ readiness for change could be identified through their interactions with their audiologist within standard initial appointments, rather than using questionnaires.
Figure 1. The Stages of Change Model

AP: Your recent article in the International Journal of Audiology (published online in June 2016) was quite interesting. In the study, you analyzed several appointments between patients and audiologists. Can you elaborate on how you conducted the research and what you found?

KE: This study was part of a larger project that was developed by Dr Caitlin Grenness for her Ph.D. research. The project involved video recording 63 real-life, initial audiology appointments with older adults with age-related hearing impairment. Across a series of studies, the interaction between audiologists, older adult clients, and family members (when present) was profiled and analysed in detail using two different methods: Roter Interaction Analysis System (RIAS) and Conversation Analysis (CA). In this particular study, we used CA to examine: (1) how clients’ readiness for change can be observed within the history-taking phase of the appointment; and (2) whether this perceived readiness has consequences for their rehabilitation decisions in the management phase of the appointment.

The study found that clients’ stage-of-change could be identified through their responses to history-taking questions within the initial minutes of the appointment. Further, the findings indicated that clients’ stage-of-change can have important consequences for how they respond to rehabilitation recommendations. In particular, the study found that 80% of clients who were identified as being in ‘pre-contemplation’ went on to reject a recommendation of hearing aids in the appointment.

AP: Wow, that’s a big difference in patients in the pre-contemplation stage and the other stages with respect to willingness to accept the recommendation. How can the typical busy clinician identify a patient in the pre-contemplation stage?

KE: There are 5 key features of clients’ talk that audiologists can look for during history-taking to identify a client in a pre-contemplation stage-of-change. In particular, the client may:
  1. play down the impact of their hearing difficulties on their everyday life;
  2. display low concern for their hearing difficulties;
  3. provide self-initiated examples of situations where they can hear well;
  4. attribute blame for hearing difficulties to third parties (e.g., family members mumbling, or speaking softly), or situational factors (e.g., background noise);
  5. utilize interactional devices for displaying a preferred response when responding to history-taking questions, including delaying devices (e.g., “um”, turn-initial “well”, intra-turn pauses, cut-offs, and re-starts).
Using a motivation tool, such as the Ida Institute line tool, may also help audiologists identify clients’ readiness for change.
Figure 2. Option Grid for Educating Patients
Patients Often Want to Know Hearing Aids Assistive Devices or PSAP Managing without Technology
What is involved in it? Usually a pair of hearing aids are fitted and 2-3 follow-up appointments are needed over 3 to 6 months.

Patients who wear their hearing aids more than 8 hours per day often do well.
These are devices that are designed to help you hear in specific places, like watching TV or using the phone.

Some are worn on your ear like hearing aids.
You may learn some ways to cope with hearing in noisy places if you choose to wait to get hearing aids. You may also learn some strategies for becoming a better lipreader.
How will it help my hearing? With some initial professional guidance you should experience improved hearing in many situations, especially listening in quiet. It will improve your hearing in very specific places only, like the TV or phone. They are not intended to be used all day long like hearing aids. You may expect some limited improvement if you learn some of the hearing loss coping and management skills our clinic provides.
What should I expect? It may take you about a month to fully adjusted to hearing aids. Your audiologist will provide guidance on this. You can purchase these devices from our clinic and we can show you how to use it. Follow-up service is usually not included. Your hearing difficulties may continue to cause you and others around you to be frustrated.
Are there listening situations where this option may fall short of my expectations? There may be some noisy places that you find challenging. Your audiologist will provide guidance to you. These devices will only provide help in specific places and many are not portable. N/A
Do I have to pay for it? Your insurance may provide some coverage; otherwise hearing aids are often an out-of-pocket expense. This is an out-of-pocket expense. N/A
What maintenance and service are involved? You usually need to have your hearing aids cleaned and checked two times per year. Our clinic does not provide service to these devices. You need to contact the manufacturer directly. N/A
Will this option work with other options? Hearing aids can be used alone or with various types of ALDs. Some of these devices work in combination with hearing aids. N/A

AP: Once the clinician recognizes a “pre-contemplator” what are some ways they can address them without losing the patient’s trust?

KE: Our findings suggest that, for clients in the pre-contemplation stage-of-change, it may not be the most effective strategy for audiologists to immediately progress to a recommendation of hearing aids. Instead the following strategies may be more effective for these clients:
  • Be more flexible in the management phase of the appointment – focus more broadly on awareness-raising and broader discussions about age-related hearing loss.
  • Individualize information provision and rehabilitation planning – provide information relevant to the client and meaningful rationales for change, without applying pressure.
  • Offer options (using a decision aid may help) – these clients are likely to respond well to being offered options, including other devices, participating in communication programs, or even pursuing no intervention at this stage. Taking a patient-centred approach to the decision-making process with these clients will facilitate the building of a long-term relationship with their audiologist. See the example in Figure 2 of a patient decision aid.
  • Invite a family member to attend appointments – having a family member within the appointment may help facilitate a broader discussion of the client’s potential hearing difficulties in everyday life and how these could be addressed.

AP: Looking into the future, what do clinical audiologists need to do differently? What skills do they need in order to compete with automated testing and self-fitting, direct to consumer hearing aids?

KE: Audiologists have a fantastic opportunity to provide clients with holistic hearing rehabilitation to meet clients’ individual communication needs. This requires audiologists to think beyond the hearing aids, and instead focus on helping to improve communication difficulties for both clients and their family members in their daily life. In doing so, audiologists will be providing a service that cannot be obtained from direct-to-consumer hearing aids sales. A large part of the way audiologists can provide holistic hearing rehabilitation is through adopting a patient- and family-centered approach to care. By listening to clients’ individual communication needs and taking a shared decision making approach to rehabilitation, audiologists can empower clients to live well with their hearing loss. This type of approach can help build long-term relationships between clients and their audiologists (that do not end at the hearing aid fitting), and encourage clients to be active in their hearing rehabilitation choices (so hopefully no more hearing aids being left in the drawer at home!).

AP: What are 3 additional articles from your research team you would encourage clinicians to read and what can they apply from them?

KE: The following 3 articles from our team examine other aspects of clinical interaction in the audiology clinic, with a focus on patient- and family-centered practice:
  1. Grenness, C., Hickson, L., Laplante-Lévesque, A., Meyer, C., & Davidson, B. (2015). The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultations. Journal of the American Academy of Audiology, 26, 36–50. doi: 10.3766/jaaa.26.1.5
  2. Ekberg, K., Grenness, C., & Hickson, L. (2014). Addressing patients’ psychosocial concerns regarding hearing aids within audiology appointments for older adults. American Journal of Audiology, 23, 337-350.
  3. Ekberg, K., Meyer, C., Scarinci, N., Grenness, C., & Hickson, L. (2015). Family member involvement in audiology appointments with older people with hearing impairment. International Journal of Audiology, 54, 70-76. doi: 10.3109/14992027.2014.948218.