Trigger Happy Hearing: Using Social Triggers to Promote Regular Hearing Checks



Author: by Curtis Alcock

Let us imagine we are ordinary members of the public with no exposure to hearing healthcare or its messages. Now ask yourself this question: Why would we consider having our hearing checked? What’s the trigger?
The Four Challenges of Hearing Awareness
The first challenge is that if a sound falls outside our hearing range it simply ceases to exist. Think of a “silent” dog whistle: just because we can’t hear it, doesn’t mean there’s no sound. If we hadn’t seen someone blow it, there would be nothing to indicate there was something to be heard. Likewise, if any speech sounds fall outside our hearing range, how would we know? We probably wouldn’t, not unless we had some other indication, such as a visual cue (“I can see their lips move, but there’s no sound.”)

The second challenge is that even if we have the world’s best hearing there will be people and situations we encounter where even our hearing will struggle. If we’ve experienced “good” hearing most of our lives then the default way for us to interpret a difficult-to-hear person or situation is to assume the problem lies not with ourselves, but with the signal.

Should our hearing change, this default interpretation remains in place. Why wouldn’t it? We have no indication to the contrary. If we subsequently encounter people or situations we find difficult, but with a now reduced hearing range, how is this perceptibly different from our lifelong experience?

The third challenge is that our hearing works seamlessly in partnership with a number of other systems: visual, cognitive, and social. When any one of these systems is unable to fully “pull its weight”, the other systems “lend a hand”. Consider lip-reading (visual), top-down processing (cognitive) and friends raising their voice (social).

This seamless blending between all available systems happens, for the most part, unconsciously and adaptively, and comes with a high degree of built-in tolerance which allows us to “get by” no matter what situation we find ourselves in. The drawback is that it makes it virtually impossible to detect when one system has become increasingly reliant on the others – unless a threshold has been reached, which means we can no longer meet the challenge.

The final challenge is that most changes occur gradually over a number of years, so people have no practical comparison they can contrast their present hearing against. If we woke one morning to find we could suddenly no longer hear the radio, we have the immediacy of our memory the day before to compare with. But spread that same change across several years and our memory of how the world sounded the previous month—let alone yesterday—would be perceptibly identical to how it is this morning. Each of these factors conspire with one another to make it almost impossible for a person to detect a change in their own hearing. What, then, is the trigger for having our hearing checked? If we assume our hearing is “normal”, what is the point of having it checked?

A Clash of Perceptions
That’s why changes in our hearing are normally detected by others long before we suspect it ourselves, which puts family and friends in the awkward position of having to debate whether to risk offending us by politely suggesting our hearing is not as it should be. It can feel as socially awkward as hinting that someone might like to consider experimenting with deodorant. If someone does pluck up the courage to tell us, we have no reason to believe him. Say you have blue eyes. You’ve always known it: not only have you seen them for yourself but other occasions have confirmed this for you, such as the flattery of a would-be suitor perhaps. One day someone announces you have brown eyes. What’s your reaction?

First, you’ll compare this “new information” to your pre-existing belief. Second, you’ll look for evidence to disprove this new information, particularly as we have a bias towards confirming our currently held “knowledge”.1 You won’t actually put too much effort into this because you know they’re wrong anyway; you’ll probably just accept the first example that springs to mind that confirms your belief.

Apply this to hearing, and we see the same process at work. Someone suggests our hearing is not all it should be and we think, “But I’ve always had good hearing! If something had changed, surely I would have noticed.”

Secondly, we look for evidence to disprove his “preposterous assertion” by calling to mind all those sounds we can hear. Since “we only hear what we hear”, we won’t have any examples of sounds we can’t hear. We’ll recall how we can hear people speaking, and the noise of traffic, even when our partner can’t.

The very fact that someone has challenged our hearing and we have successfully confirmed to ourselves their assertion is mistaken, actually strengthens our pre-existing belief that our hearing’s fine. It now becomes even harder for us to accept any other possibility; we become resistant to any suggestions to the contrary.2

It is only when our hearing reduces further that we begin encountering what may be possible evidence, such as getting “the wrong end of the stick”. But there have to be enough occasions when this happens before we will suspect it’s our hearing, and not the situation.3

If we do, we have a dilemma: we have been adamantly holding to the belief that we have good hearing. And if there’s one thing we humans don’t much like, it’s being wrong. So what do we do? Do we stick to the story? Or do we change our thoughts and behavior?

If only someone could offer us an out – otherwise we’ll lose face. Because the very act of having our hearing checked would now be tantamount to a declaration that we were wrong.
Whose Hearing is it Anyway?
Unfortunately our family’s patience has worn out. As we’ve been decreasing our “effort”, they’ve been increasing theirs to compensate. They’ve been tolerating a louder TV, saying everything more than once, reducing their socializing, and they have even started apologizing for us! They’ve watched as we’ve become increasingly dependent on them, seeing us drift more and more into our own little world, sparking fears of dementia. It’s been a strain.4

So, in their desperation they’ve finally coerced us into attending a hearing healthcare practice. It’s not our choice; we’re there either because our family want to prove a point or because they feel sorry for us. Neither reason is good for our self-esteem. And so the first hearing assessment we ever have becomes a symbol of just how far we have fallen, that our best days are behind us.
Changing the destiny
Let’s now return to our role as hearing healthcare professionals and see whether we can’t change this soul-destroying destiny. We must begin by putting ourselves in the patient’s shoes:
  1. What looks to us like “denial” is often nothing more than a patient’s observation. We must therefore learn to see this from their perspective rather than ours. If we don’t, we risk engineering the very denial we accuse them of as they build resistance to what clearly—to them—is a preposterous assertion.
  2. The difficulty in recognizing—then acknowledging—changes in one’s own hearing is arguably the biggest contributor to the delay between onset of a hearing loss and seeking professional advice (“My hearing’s good enough”). If we can address this, and correctly manage the process—from change, to recognition, to action—we should also be able to accelerate the rate of acceptance of hearing technology.
  3. If people are the first to know about their hearing problem, it puts them in the position of “problem solver” as they seek to restore their status quo—getting them back to how they believe they should be. But if others are the first to notice the problem, they find themselves in the position of “defender” as they seek to maintain their status quo—defending how they believe they are. So how a person is introduced to a potential change in their hearing is a crucial motivational factor. The closer it is to “self discovery” the more it puts them in control.5,6
Making the Imperceptible Perceptible
Our challenge is that we have to get people to detect the absence of something that is actually outside of their perceptible experience, like seeing ultraviolet. How can we possibly do that? Fortunately we have three models we can turn to for instruction: ghosts, germs and plaque. A strange combination perhaps, but they share something in common: they each link something imperceptible to something easily perceptible.

According to those who claim to have experienced such things, we would recognize the presence of a ghost from the strange chill in the room and because the dog is barking at the corner of the room for no apparent reason. Regardless of our own personal opinions about the existence of the paranormal there’s a valuable lesson to be learned here: if we want to render the imperceptible perceptible, we must first draw attention to an occurrence that is easily perceptible (e.g. chill, barking dog) and then assign a meaning to it. It’s obviously an effective strategy: 37% of Americans believe houses can be haunted.7

For those more comfortable with health-based examples, consider hygiene. Today, the idea of washing hands before meals and after using the toilet to “wash away the germs” is considered common-sense. But the idea that something you can’t see could be responsible for causing so much sickness and death throughout history was understandably met with ridicule when first posited.8 Most of us have never even seen a germ, but it’s rendered perceptible (in our minds) by the act of washing our hands: we believe because we act.9 Notice also the implied risk of not washing our hands? Even if you’re uncertain germs spread illness, wouldn’t you rather be safe than sorry?

The final example we’ll consider is the social norm of tooth-brushing. It’s hard to believe that only seven percent of Americans used to brush their teeth, a tiny minority. But following an advertising campaign by the toothpaste manufacturer Pepsodent in the 1920s and 1930s, toothbrushing increased to a majority of 65%. Other campaigns had tried and failed. Why this one succeeded was thanks to an adman called Claude Hopkins, who rendered the imperceptible perceptible.10, 11

He came across mention in a scientific volume of something called the pellicle membrane, a natural film that coats our teeth and can be removed by rubbing (and therefore brushing). He used his campaign to draw attention to this “dingy film” which you could feel (i.e. it’s perceptible), and then assigned a meaning to it – that it was evidence of something hiding your beautiful, glistening teeth and smile, and providing a platform for all the nasties that grow on your teeth and cause decay (the imperceptible). As with our hand-washing example above, we’re being shown a risk that can be avoided, in this case by using Pepsodent which “curdles the film and removes it”.
Constructing Our Trigger
Pulling these examples together we now have a formula for creating our own trigger:
  1. Draw attention to a perceptible occurrence that people can relate to.
  2. Assign meaning to this occurrence in order to link it to the imperceptible.
  3. Highlight the hidden risk.
  4. Offer a solution that minimizes that risk by promoting an action that is easy to perform.
  5. Increase self-esteem through taking that action.
Let’s work this through step-by-step…

Step 1: Draw Attention (the 3 Triggers)
First, what should we draw attention to? It needs to be an occurrence that people encounter regularly enough to increase the likelihood of creating a trigger for having their hearing checked.

Here we have no better inspiration than the situations our patients commonly report to us. These almost always include: 1) finding background noise difficult, 2) needing the TV volume up higher, 3) asking others to repeat themselves. These are the 3Rs of hearing: Restaurant, Remote [control, for TV], Repeat.

We might develop triggers for them thus:
  1. “Noise interfering?
    –> Check how you’re hearing.”
  2. “Raising the volume raising the tension?
    –> Checking your hearing’s the greatest prevention.”
  3. “If you ask to repeat?
    –> Check your hearing’s complete.”
We’ve linked each situation to having your hearing checked by means of a rhyming mnemonic.12 (Even better, try setting them to music and repeatedly playing them on the TV or radio. It’s the quickest way to get people repeating them to themselves.)13

By focusing on situational triggers we maintain the widest possible relevance—and frequency—to ensure we’re including those who, perhaps incorrectly, assume their hearing is fine. From time to time, most of us will ask others to repeat, or find noise interferes, or need the volume up higher.

Our job as hearing healthcare professionals is to get society automatically thinking that whenever these occurrences take place, it’s a reminder to have hearing checked regularly. How do we achieve this? The same way toothbrushing and the use of deodorant caught on: advertising and marketing.14 It will only become part of society’s “common knowledge” through repetition and awareness. We must each consider how we might incorporate these triggers into our own communications, perhaps joining forces with others in our area to get this shared message out there.

Step 2: Assign Meaning
What does it mean when you ask others to repeat, or you find noise interfering, or you need to raise the volume? It means there are sounds outside your hearing range that you weren’t aware of. It’s evidence of the imperceptible, and you’ve just been given the means to recognize it before someone else does.

Our meaning must not be: “You’re losing your hearing.” Such a meaning would be damaging. Think about it from their perspective: if they’ve lost their hearing, there’s nothing they can do to get it back. It’s gone forever; even a hearing aid won’t restore it, it would only remind them of what they’ve lost. What a bleak outlook! People instinctively avoid such messages. So if we avoid them, they won’t have to.

Instead, our message is one of empowerment – now that they know sounds are falling outside their range, they can potentially bring them back. But first we must give them a reason for doing so by highlighting the risk of inaction. Step 3: Highlight the hidden risk
You are mishearing and everyone knows it but you. That’s the hidden risk.

Instead of saying “1 in X people have a hearing loss; it could be you,” we are saying:
“If you haven’t had your hearing professionally checked within the last 5 years, you are increasing your risk of mishearing to around 23%”.15

Nobody likes social embarrassment or causing frustration for others. It makes us feel uncomfortable and we are driven to address that discomfort. Every time we ask to repeat, or struggle in a restaurant, or need the volume up higher, is a reminder of that discomfort: that we cannot trust our own judgement of how we hear. We want to be liked by others and accepted, so we want to avoid mishearing.

Notice we’re focusing on “mishearing”, rather than “hearing loss”? Hearing loss, for the most part, is unavoidable—there are so many contributory factors that there’s little people can practically do to avoid it. Mishearing, on the other hand, is preventable. And this is the solution we are offering…

Step 4: Offer a solution
Having a hearing check must not be about “detecting a hearing loss” – who wants to know that? It’s about the means to avoid the social embarrassment, frustration to others, and the “strain on the brain” that comes from mishearing. It’s about being confident your hearing is ready for whatever life throws at it, so you can always be yourself.

Such an approach prepares the way for hearing technology to be presented as a solution to reducing the risk of mishearing. Think of it this way, if you wear hearing aids, does it stop you being hearing impaired? No; if anything it confirms you are impaired, which changes how you see yourself. But when hearing technology is the means to prevent you mishearing, that puts you in the same social category as someone who hears well; it becomes a tool for empowerment.

Step 5: Increase self-esteem
If you are having your hearing checked to find out if you are impaired, it will lowers your self-esteem. Conversely, when it’s to prevent mishearing:
  • It empowers you to fulfil the unwritten social agreement to “hear others first time, accurately”, so society is more inclined to like and accept you.
  • You maintain your status quo as someone who hears well.
  • You retain control over your life because you know what’s going on and don’t find yourself in a position where others know something about you that you don’t. No more coercion!
  • You are more confident socially.
  • You keep yourself ready for whatever life throws at you, so you can always be yourself, grasping the opportunities of life.
  • You are keeping your brain healthy.
Conclusion
Hearing is one of the most important connections a human has to the world around him, and particularly to other people. Yet society finds hearing healthcare largely irrelevant because the default assumption that our own hearing is performing as expected is based on the limitations of human perception.

Our task is to change this by linking easily perceptible situational triggers to the imperceptible (sounds outside a patient’s hearing range). We must then instil motivation to act by presenting an avoidable risk (unknowingly mishearing) that they can reduce through regular professional hearing checks. This article provides a framework for accomplishing this.    
Curtis Alcock is the Founder of Audira – Think Tank for Hearing. He can be contacted at curtis.alcock@audira.info.
References
1 Nickerson, R. S. (1998). Confirmation Bias: A Ubiquitous Phenomenon In Many Guises. Review of General Psychology, 2(2), 175.

2 Festinger, L. (1957). A Theory of Cognitive Dissonance. Evanston, IL: Row, Peterson.

Jones, E. E., & Nisbett, R. E. (1972). The actor and the observer: Divergent perceptions of the causes of behavior. In E. E. Jones, D. E. Kanouse, H. H. Kelley, R. E. Nisbett, S. Valins, & B. Weiner (Eds.), Attribution: Perceiving the causes of behavior (pp. 79-94). Morristown, NJ: General Learning Press.

3 Wallhagen, M. I., Strawbridge, W. J., Shema, S. J., & Kaplan, G. A. (2004). Impact of self-assessed hearing loss on a spouse: A longitudinal analysis of couples. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 59(3), S190-S196.

4 Higgins, E. T. (1987). Self-discrepancy: A theory relating self and affect. Psychological Review, 94, 319–340.

5 Kahneman, D., Knetsch, J. L., Thaler, R. H., (1991). The Endowment Effect, Loss Aversion, and Status Quo Bias. The Journal of Economic Perspectives, Vol. 5, No. 1. (Winter, 1991), pp. 193-206.

6 Three in Four Americans Believe in Paranormal, http://www.gallup.com/poll/16915/Three-Four-Americans-Believe-Paranormal.aspx Accessed 02.02.2014

7 Case, C. L., Handwashing. http://www.accessexcellence.org/AE/AEC/CC/hand_background.php Accessed 02.02.2014

8 Bem, D.J. (1972). Self-Perception Theory. In L. Berkowitz (Ed.), Advances in experimental social psychology (Vol. 6, pp. 1-62). San Diego, CA: Academic Press.

9 Duhigg, C., (2012). The Power of Habit. Chapter 2, p. 35. Published by William Heinemann 2012

10 Twitchell, J. B. (2000). Twenty Ads that Shook the World. Published by Three Rivers Press (New York).

11 McGlone, M.S. & Tofighbakhsh, J. (2000). Birds of a feather flock conjointly (?): rhyme as reason in aphorisms. Psychological 12 Science, Vol. 11, No. 5, September 2000.

13 Cone, S. (2008). Powerlines. Bloomsberg, pp. 150-153.

14 Twitchell, J. B. (2000). Twenty Ads that Shook the World. Published by Three Rivers Press (New York).

Figure 1


15 The figure of 23% is taken by plotting the prevalence rate of hearing loss by age (decades) using the figures of Davis (1989)16 and Agrawal et al (2008)17, working out what the age is for the overall prevalence rate of 16% (both sets of data), then cross-referencing the prevalence rate for five years later. Based on the idea that if we had a random adult audiogram in front of us there is a 16% chance it would show a hearing loss. If that same person was retested 5 years later, this would increase to a 23% chance. See also Cruickshanks et al. (2003)18 where the 5 year incidence rate is high (around 45%) due to the use of an older population (48-92 years). Note how we are not framing in terms of “23% risk of having a hearing loss”, because having your hearing checked would not reduce this risk.

16Davis, A. C. (1989). The prevalence of hearing impairment and reported hearing disability among adults in Great Britain. International Journal of Epidemiology, 18(4), 911-917

17 Agrawal, Y., Platz, E. A., & Niparko, J. K. (2008). Prevalence of hearing loss and differences by demographic characteristics among US adults: data from the National Health and Nutrition Examination Survey, 1999-2004. Archives of Internal Medicine, 168(14), 1522.

18 Cruickshanks, K. J., Tweed, T. S., Wiley, T. L., Klein, B. E., Klein, R., Chappell, R., ... & Dalt, D. S. (2003). The 5-year incidence and progression of hearing loss: the epidemiology of hearing loss study. Archives of Otolaryngology—Head & Neck Surgery, 129(10), 1041.