Stop Trying to Convince and Focus on the Person: Using Frameworks in Holistic Care

Author: Brian Taylor, Au.D.

Hearing loss is a multifaceted condition that obliges the audiologist examine the person not simply their hearing loss or the type of hearing aids that might be most beneficial. Clearly, the simple act of conducting a hearing test and recommending hearing aids falls far short of effective long-term intervention for many individuals with hearing difficulties. Overcoming the gap between hearing loss prevalence and consistent use of hearing aids requires audiologists to rethink how they interact with persons with hearing loss. To better address the needs of adults with hearing loss, audiologists must be more holistic in their approach to patient care. In many ways, however, technology gets in the way of this humanistic interaction.
The Tyranny of Ever-Improving Technology
For the past 30 years, hearing aids have experienced incremental technology improvements. This means that about every 12 to 24 months hearing aid manufacturers bring a new product or feature to market that, at least on paper, is more sophisticated than the product or feature that preceded it. During the early to mid-1990’s multiple channels of wide dynamic range compression, multiple memories and high quality directional microphones revolutionized the performance of hearing aids. In the late 1990s and early 2000s digital signal processing enabled a wide range of noise reduction features to be added to digital hearing devices that contributed to improved performance in background noise. Similar to smartphones and personal computers, audiologists and consumers alike have come to expect hearing aid technology launched today to be incrementally more sophisticated (and beneficial to wearers) than preceding generations. Although these incremental improvements in hearing aid technology are often useful (not to mention fun for audiologists to talk about), they do not always translate into improved patient outcomes.

One recent study illustrates this point. Wu et al (2018) evaluated differences in patient outcome for advanced hearing aids compared to basic hearing aid technology. The researchers compared advanced noise reduction/directional microphone technology (NR/DM) to basic noise reduction/directional microphone (NR/DM) circuitry in both laboratory and real-world listening situations. Fifty-four older adults with mild to moderate, medically uncomplicated hearing loss were fitted with the following four different hearing aid configurations: 1.) Advanced circuitry, NR/DM Features ON, 2.) Advanced circuitry NR/DM Features OFF. 3.) Basic circuitry, NR/DM Features ON, and 4.) Basic circuitry, DNR/DM Features OFF. Each study participant, as well as the researchers, were blinded to the exact configuration they were wearing and each of the four configurations of circuitry was worn by each of the participants for five weeks.

Results show that all 54 participants had better results with NR/DM turned ON for both levels of circuitry. Laboratory results indicated that advanced circuitry outperformed basic technology in speech understanding and localization measures. Interestingly, these differences disappeared in real world measures, as no differences between basic and advanced circuitry were found. These findings suggest that NR/DM strategies are effective in both basic and advanced models, and optimizing audibility by carefully matching and verifying a scientifically validated prescription gain target (a key components of the design of this study) trumps the level of technology found inside the hearing aid.

Further, the results of this study underscore the limitations of incrementally improving hearing aid technology as a panacea for improving all facets of patient outcomes. Yes, hearing aids work, but as this one important study reminds us, hearing aids alone do not solve all of the communication problems of persons with hearing loss: A dedicated audiologist who understands the motivations, values and beliefs of persons with hearing loss is necessary to improve the probability of outcomes for most patients.

The challenge, of course, is that understanding the underlying attitudes, motivations and behaviors of individuals with hearing loss is complicated. The process of behavior change, moving from indifference to action, takes time and effort by both the person with hearing loss and the clinician. Every help seeking individual presents with unique demands that are time-consuming for the audiologist. After all, most audiologists have a limited number of hours to spend with any given patient. Therefore, to be more holistic, to focus on the person more than the product, demands that we adopt different behavioral frameworks that allow audiologists to cut through the complexity of hearing loss and its effect on the individual’s attitude, motivations and behaviors. There are two frameworks that help audiologists focus on the person with hearing difficulties, rather than simply trying to convince that patient to wear hearing aids.
The COM-B model, given its simple framework, is a useful way for understanding how to guide behavior change in individuals with hearing loss. The COM-B model, originally created by Mitchie et al (2011), defines capability, opportunity and motivation as the influencing factors that shape a patient’s behavior. For persons with hearing loss, when we talk about shaping behavior or behavior change we are usually referring to a patient’s ability to accept treatment or to consistent use of hearing aids. The COM-B model, summarized in Figure 1, can be used as a basis for developing interventions and strategies that shape the behavior of persons with hearing loss.
Figure 1. The four components of the COM-B

Let’s examine the COM-B model through the lens of the person with hearing loss. Capability is defined as the power or ability to do something that contributes to increased motivation that in turn can drive behavior change. In the COM-B model, capability is best described as the psychological and physical factors that affect an individual’s ability to consistently wear hearing aids and communicate effectively in day-to-day listening situations. Physical issues include limited cognitive ability, which may preclude a person from remembering to wear their hearing aids every day. Another physical issue that is a capability factor would be dexterity problems that prevent a person from properly inserting hearing aids onto her ears. Psychological reasons that impact consistent hearing aid use and effective communication include a lack of knowledge, confidence, and an external locus of control. Capabilities are factors that need to be addressed by the audiologist through the provision of clear and understandable information and teaching the person with hearing loss to become a more successful communicator. In short, audiologists improve a patient’s capabilities through teaching.

Opportunity is defined as the external factors that influence a person’s ability to be a consistent hearing aid wearer and effective communicator. These external factors can be divided into environmental factors and social factors. Lack of family support, social stigma and high costs of hearing aids are considered social reasons. In contrast, environmental factors include the inability to access the clinic and online accessibility. Opportunities are factors that can be barriers to successful use of hearing aids and are often addressed through the application of technology that might be novel or engaging. Recent innovations in hearing aids such as smartphone apps that enable individuals to connect with the audiologist remotely or fine-tune their hearing aids, in the context of the COM-B model are tools that create opportunities to become a more consistent or more successful hearing aid wearer. In short, audiologists improve a patient’s opportunities through technological innovations that make the experience of using hearing aids more interactive or engaging.

Let’s examine the third component of the COM-B model. Motivation is a person’s inclination or willingness to engage in the process of behavior change. Motivation can be divided into two primary types. 1.) Automatic motivations that are impulsive or instinctive. They are often activated quickly by the individual. 2.) Reflective motivation that require evaluation and planning by the individual. With respect to behavior change associated with hearing loss and treatment, both types of motivations are at work.

Automatic motivations related to not wearing hearing aids include embarrassment and stigma associated with using one. Reflective motivations associated with persons with hearing difficulties include the belief that the hearing loss is not bad enough to warrant the use of hearing aids. Reflective motivations also include skepticism that hearing aids will be worth the money, or that it simply not worth the trouble to go through the process of getting a hearing test and acquiring hearing aids. A careful look at the COM-B model in Figure 1 tells us that audiologists can shape a patient’s motivation by focusing on opportunities and capabilities.

The COM-B model is helpful for understanding the factors associated with seeking help, acquiring hearing aids and then wearing them consistently. Through the lens of the COM-B model, audiologists can focus on improving capabilities and providing opportunities that, in turn, motivate the wearer to modify or change a behavior. Rather than giving the proverbial pep talk to patients who are not successful with their devices, a largely ineffective method of external motivation intended to inspire a patient into action, the COM-B model reminds us that when we focus on boosting capabilities through education and training, and creating new opportunities by introducing new tools to the patient, we can influence internal motivation, which in turns drives new behaviors. Table 1 summarizes several of the essential tasks to be completed by the audiologist associated with the four components of the COM-B model. Audiologists can think of opportunity and capability as levers that they can pull to motivate and empower the patient to take action.
Table 1. A summary of key tasks conducted by the audiologist using the COM-B framework
Capability Opportunity Motivation Behavior
  • Provide information that is clear and understandable
  • Provide training that is useful and targets the need of the individual
  • Identify and account for factors that could be barriers to successful treatment
  • Provide easy to use or engaging tools such as a smartphone app that empower the wearer to think or act in a new way about their condition
  • Recognize barriers to success
  • Collaborate on a plan that accounts for opportunities and focuses on capabilities of the individual
  • Empower the patient to take action
  • Encourage the patient to maintain a sense of control

The four boxes in Table 1, along with the accompanying arrows of the COM-B framework, as shown in Figure 1, remind audiologists that not only can the capability, opportunity and motivation factors affect behavior, but each of these individual factors influence each other. There are numerous examples of how capabilities, opportunities and motivation spur behavior change. When we lower the out of pocket cost of hearing aids, say with a third-party insurance benefit it can influence the motivation of the person with hearing loss to pursue hearing aids. When we provide skills training on hearing aid insertion into the ear or teach the patient how to recognize and better manage a noisy listening situation, we influence capability. When we provide our patients with an interactive smartphone app that makes hearing aid adjustments easy to do without visiting the clinic for an appointment, we are systematically pulling the levers of the COM-B model and influencing behavior change. Improving a patient’s capability or opportunity, in turn, motivates the person with hearing loss to wear their devices more regularly.

Think of the capability and opportunity factors of the COM-B model as two sides of an accordion squeezing in on the center factor, motivation. For example, when audiologists engage in the act of teaching a hearing aid wearer to be a better listener in noisy places or demonstrate how to use a new smartphone app that provides better ability to tailor sound quality in a wide range of listening places, those actions can influence both motivation and behavior change.
The 5As
The ‘5As’ model of behavior change counseling is an evidence-based approach appropriate for a broad range of different behaviors and health conditions, including hearing loss. The 5As are: assessing patient level of behavior, beliefs and motivation; advising the patient based upon personal health risks; agreeing with the patient on a realistic set of goals; assisting to anticipate barriers and develop a specific action plan; and arranging follow-up support. The 5As originates from a tobacco cessation guide for physicians developed by the National Cancer Institute. Whitlock et al. (2002) revised the construct to include “Agree” based upon the evident need to include shared decision making in the delivery of patient-centered care. The 5As model, as outlined in Figure 2, contains at its core the patient-driven factor of behavior change. It culminates in an individual action plan for each help seeking patient. This action plan is a document that changes over time and serves as a sort of canvas where new treatment goals are targeted in partnership with the patient and their communication partners. According to Gilligan (2016), the 5As model can be applied to hearing care and audiology by providing services summarized below:

  1. Audiologist Assesses
    • Patient Needs and Preferences
    • Health Literacy
    • Health Beliefs & Behaviors
    • Functional Communication Ability
    • Hearing Handicap
  2. Audiologist Advises
    • Educate about hearing loss
    • Options for treatment, including non-device treatment options
    • Offer the pros and cons of treatment using a patient decision aid
    • Provide health-literate information and counseling
  3. Audiologist Agrees to
    • Engage the patient in shared decision making - work in a partnership with the person with hearing loss
    • Explore the patient’s story to uncover motivation toward behavior change
    • Agree on goals and expectations
  4. Audiologist Assists in
    • Helping the patient adjust to treatment
    • Identify and overcome barriers to treatment
    • Foster self-efficacy and independent self-management of hearing loss
  5. Audiologist Arranges to
    • Organize and facilitate follow-up with the patient over time
    • Monitor provision of patient centered communication
Figure 2- The 5As Self-Management Model

Both the COM-B and 5As model provide audiologists with a systematic approach to the provision of holistic care. By putting either model into clinical practice, an audiologist avoids the common habit of trying to convince help seeking individuals to wear hearing aids and places the focus squarely on the behaviors, attitudes, and motivation of the person. In an age of over-the-counter hearing aids in which persons with hearing loss can opt to self-directed their care, the ability to provide holistic hearing care, using one of these frameworks, can become a competitive advantage.    
Gilligan, J. (2016) Development of a Patient-Centered Health Literacy Toolkit for Audiology and Hearing Loss (The ‘HH Lit Kit’). City University of New York CUNY Academic Works. AuD Capstone

Michie, S.,van Stralen,M., & West, R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Sci, vol. 6 (1). doi:10.1186/1748-5908-6-42.

Whitlock EP, Orleans CT, Pender N, Allan J. (2002). Evaluating primary care behavioural counseling interventions: an evidence-based approach. American Journal of Preventative Medicine. 22(4):267-84.

Wu, Y. H., Stangl, E., Chipara, O., Hasan, S. S., DeVries, S., & Oleson, J. (2019). Efficacy and Effectiveness of Advanced Hearing Aid Directional and Noise Reduction Technologies for Older Adults With Mild to Moderate Hearing Loss. Ear and hearing, 40(4), 805–822.