Melissa T. Frederick

Application of the health belief model: Development of the hearing beliefs questionnaire (HBQ) and its associations with hearing health behaviors

Abstract Objective: To develop a hearing beliefs questionnaire (HBQ) that assesses hearing beliefs within the constructs of the health belief model, and to investigate whether HBQ scores are associated with hearing health behaviors. Design: A 60-item version of the questionnaire was developed and completed by 223 participants who also provided information about their hearing health behaviors (help seeking, hearing-aid acquisition, and hearing-aid use). Study sample: Individuals aged between 22 and 90 years recruited from a primary care waiting area at a Veterans hospital. Seventy-six percent were male, 80% were Veterans. Results: A 26-item version of the HBQ with six scales was derived using factor analysis and reliability analyses. The scales measured: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, and cues to action. HBQ scores differed significantly between individuals with different hearing health behaviors. Logistic regression analyses resulted in robust models of hearing health behaviors that correctly classified between 59% and 100% of participant hearing health behaviors. Conclusions: The HBM appears to be an appropriate framework for examining hearing health behaviors, and the HBQ is a valuable tool for assessing hearing health beliefs and predicting hearing health behaviors.

Validation of a novel combination hearing aid and tinnitus therapy device.

Objectives: Most patients with tinnitus also have hearing loss. Hearing aids have been well-documented to provide amelioration for both hearing and tinnitus problems. Some hearing aids have built-in noise/sound generators that are intended to provide added benefit to patients with tinnitus. It has not been proven, however, whether these “combination instruments” are more effective for tinnitus management than hearing aids alone. The purpose of this study was to collect initial data addressing this question. Design: Thirty individuals meeting study requirements (bothersome tinnitus, hearing aid candidate, and no use of hearing aids for the previous 12 months) were enrolled. All participants initially completed the primary outcome questionnaire (Tinnitus Functional Index [TFI]) and then returned to be fitted with combination instruments. The hearing aid portion of the devices was adjusted to optimize hearing ability. Participants were then randomized to either the experimental group (n = 15) or the control group (n = 15). The experimental group had the noise feature of the instruments activated and adjusted to achieve optimal relief from tinnitus. The control group did not have the noise portion activated. Following the hearing aid fitting, all study participants also received brief tinnitus counseling. Participants returned 1 to 2 weeks later for a follow-up appointment to confirm proper fit of the instruments and to make any necessary programming adjustments. Additionally, they returned 3 months after the fitting to complete the TFI, which also concluded their participation in the study. Results: Both groups revealed significant improvement, as indicated by reductions in mean TFI index scores. Differences between groups at 3 months were not statistically significant. However, the experimental group showed a mean reduction in the TFI score that was 6.4 points greater than that for the control group. The difference approached significance (p = 0.09), suggesting that a larger group of participants may have resulted in a significant difference between groups. This possibility is tempered by the fact that effect sizes, which control for variation, were very similar between groups. Conclusions: Results of this study suggest that the use of hearing aids alone or hearing aids plus the use of sound generators both provide significant benefit with respect to alleviating effects of tinnitus. A larger controlled clinical trial is needed to obtain more definitive results regarding the two configurations of hearing aids.

Description of Adults Seeking Hearing Help for the First Time According to Two Health Behavior Change Approaches: Transtheoretical Model (stages of Change) and Health Belief Model

Objectives: Several models of health behavior change are commonly used in health psychology. This study applied the constructs delineated by two models—the transtheoretical model (in which readiness for health behavior change can be described with the stages of precontemplation, contemplation and action) and the health belief model (in which susceptibility, severity, benefits, barriers, self-efficacy, and cues to action are thought to determine likelihood of health behavior change)—to adults seeking hearing help for the first time. Design: One hundred eighty-two participants (mean age: 69.5 years) were recruited following an initial hearing assessment by an audiologist. Participants’ mean four-frequency pure-tone average was 35.4 dB HL, with 25.8% having no hearing impairment, 50.5% having a slight impairment, and 23.1% having a moderate or severe impairment using the World Health Organization definition of hearing loss. Participants’ hearing-related attitudes and beliefs toward hearing health behaviors were examined using the University of Rhode Island Change Assessment (URICA) and the health beliefs questionnaire (HBQ), which assess the constructs of the transtheoretical model and the health belief model, respectively. Participants also provided demographic information, and completed the hearing handicap inventory (HHI) to assess participation restrictions, and the psychosocial impact of hearing loss (PIHL) to assess the extent to which hearing impacts competence, self-esteem, and adaptability. Results: Degree of hearing impairment was associated with participation restrictions, perceived competence, self-esteem and adaptability, and attitudes and beliefs measured by the URICA and the HBQ. As degree of impairment increased, participation restrictions measured by the HHI, and impacts of hearing loss, as measured by the PIHL, increased. The majority of first-time help seekers in this study were in the action stage of change. Furthermore, relative to individuals with less hearing impairment, individuals with more hearing impairment were at more advanced stages of change as measured by the URICA (i.e., higher contemplation and action scores relative to their precontemplation score), and they perceived fewer barriers and more susceptibility, severity, benefits and cues to action as measured by the HBQ. Multiple regression analyses showed participation restrictions (HHI scores) to be a highly significant predictor of stages of change explaining 30% to 37% of the variance, as were duration of hearing difficulty, and perceived benefits, severity, self-efficacy and cues to action assessed by the HBQ. Conclusions: The main predictors of stages of change in first-time help seekers were reported participation restrictions and duration of hearing difficulty, with constructs from the health belief model also explaining some of the variance in stages of change scores. The transtheoretical model and the health belief model are valuable for understanding hearing health behaviors and can be applied when developing interventions to promote help seeking.

A Randomized Control Trial: Supplementing Hearing Aid Use with Listening and Communication Enhancement (LACE) Auditory Training.

Objective: To examine the effectiveness of the Listening and Communication Enhancement (LACE) program as a supplement to standard-of-care hearing aid intervention in a Veteran population. Design: A multisite randomized controlled trial was conducted to compare outcomes following standard-of-care hearing aid intervention supplemented with (1) LACE training using the 10-session DVD format, (2) LACE training using the 20-session computer-based format, (3) placebo auditory training (AT) consisting of actively listening to 10 hr of digitized books on a computer, and (4) educational counseling—the control group. The study involved 3 VA sites and enrolled 279 veterans. Both new and experienced hearing aid users participated to determine if outcomes differed as a function of hearing aid user status. Data for five behavioral and two self-report measures were collected during three research visits: baseline, immediately following the intervention period, and at 6 months postintervention. The five behavioral measures were selected to determine whether the perceptual and cognitive skills targeted in LACE training generalized to untrained tasks that required similar underlying skills. The two self-report measures were completed to determine whether the training resulted in a lessening of activity limitations and participation restrictions. Outcomes were obtained from 263 participants immediately following the intervention period and from 243 participants 6 months postintervention. Analyses of covariance comparing performance on each outcome measure separately were conducted using intervention and hearing aid user status as between-subject factors, visit as a within-subject factor, and baseline performance as a covariate. Results: No statistically significant main effects or interactions were found for the use of LACE on any outcome measure. Conclusions: Findings from this randomized controlled trial show that LACE training does not result in improved outcomes over standard-of-care hearing aid intervention alone. Potential benefits of AT may be different than those assessed by the performance and self-report measures utilized here. Individual differences not assessed in this study should be examined to evaluate whether AT with LACE has any benefits for particular individuals. Clinically, these findings suggest that audiologists may want to temper the expectations of their patients who embark on LACE training.

Development and evaluation of a questionnaire to assess knowledge, attitudes, and behaviors towards hearing loss prevention

Abstract Objective: To develop and evaluate a questionnaire assessing knowledge, attitudes, and behaviors (KAB) as they pertain to hearing conservation, using the constructs of the health belief model (HBM). Design: The KAB was completed by 235 participants. Relationships between knowledge and attitudes about hearing and hearing conservation, participation in noisy activities, and use of hearing protection were examined. Study sample: 117 males and 118 females aged between 18 and 80 years (mean = 42.3, SD = 4.1) recruited from the Portland VA Medical Center, local universities, and a community college. Results: Knowledge scores ranged from 15.6% to 93.8%. Factor analyses revealed six attitude factors, interpreted as measuring perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, and cues to action. Over 95% of participants routinely participated in at least one noisy activity but few used hearing protection while doing so. The attitude scores of individuals who used hearing protection differed significantly from the scores of those who did not. Conclusions: Significant relationships between use of hearing protection and scores on the KAB provide validation that the HBM is a valuable framework for understanding hearing health behaviors, and evidence that the KAB is a valid tool for assessing these attitudes and behaviors.

Health behavior theories as predictors of hearing-aid uptake and outcomes

Abstract Objective: To understand hearing behaviors of adults seeking help for the first time through the application of two models of health behavior change: the transtheoretical model and the health belief model. Design: The relationships between attitudes and beliefs were examined relative to hearing-aid uptake and outcomes six months later. Study sample: One hundred and sixty adults completed the University of Rhode Island change assessment (targeting the transtheoretical model), and the hearing beliefs questionnaire (targeting the health belief model), as well as the hearing handicap inventory and the psychosocial impact of hearing loss scale, within two months of an initial hearing assessment. Six months later, participants completed these same questionnaires, while those who had taken up hearing aids also completed hearing-aid outcome questionnaires. Results: (1) Attitudes and beliefs were associated with future hearing-aid uptake, and were effective at modeling this behavior; (2) attitudes and beliefs changed following behavior change, and (3) attitudes and beliefs following behavior change were better predictors of hearing-aid outcomes than pre-behavior change attitudes and beliefs. Conclusion: A counseling-based intervention targeting the attitudes and beliefs assessed by the transtheoretical model and the health belief model has the potential to increase uptake of hearing health care.

Development and pilot evaluation of a novel theory-based intervention to encourage help-seeking for adult hearing loss

Background: Health behavior theories can provide an understanding of hearing health behaviors and, more importantly, can be used to develop theoretically based strategies to change these health behaviors. Purpose: To develop a theory‐based brief intervention to increase help‐seeking for adult hearing loss and to conduct a pilot study to evaluate its feasibility, effectiveness, and impact on hearing beliefs and behaviors. Research Design: An intervention was designed that could be easily administered by a health‐care provider who does not have expertise in audiology—such as a primary care physician, community nurse, or social worker. The intervention aims to alter perceived benefit, severity, cues to action, and self‐efficacy for seeking help by providing experiential/affective messaging and simultaneously providing intrinsic motivation for the recipient to seek hearing help. To first determine whether this intervention changed beliefs and increased help‐seeking behavior, this study was conducted in a hearing research laboratory setting. Study Sample: A total of 101 adults aged 50–89 yr were recruited within 6 months of having attended an appointment at a primary care clinic at the VA Portland Health Care System. All were sent a letter inviting them to participate in a study if they had trouble with their hearing but had not had a scheduled hearing test or worn hearing aids in the prior 5 yr and also had functional oral and written English. Data from 87 individuals were available for analysis. Intervention: The intervention is designed for use in any health‐care setting in which a health‐care provider can facilitate a conversation about hearing. On arrival at a health‐care facility, recipients are provided with nine emotionally evocative color photographs to prompt reflection on ways in which hearing difficulties impact them. A discussion with a health‐care provider (facilitator) follows, during which recipients may identify the negative impacts of their hearing loss. If the recipient identifies negative impacts, the facilitator suggests that he or she consider having a hearing test and provides a list of local hearing‐health professionals. Data Collection and Analysis: Participants completed baseline questionnaires assessing hearing beliefs and attitudes. They were then randomly assigned either to the group receiving the study intervention or to a control group. Six months after study enrollment, participants reported whether they had sought help for their hearing and completed a second set of questionnaires. Results: Twelve of 41 individuals (29.3%) in the intervention group and 7 of 46 individuals (15.2%) in the control group sought help within the 6‐month follow‐up period. A χ2 test showed these numbers did not differ significantly; however, the odds ratio of having had a hearing test were 2.3 times greater for those who received the intervention than for those who did not. Conclusions: Despite not reaching statistical significance, the odds ratio suggests that the theory‐based brief intervention is worthy of additional examination. We intend to work with health‐care providers to conduct a larger study to investigate whether the intervention has value in the real world.

A randomized controlled trial to evaluate approaches to auditory rehabilitation for blast-exposed veterans with normal or near-normal hearing who report hearing problems in difficult listening situations

Background: Blast exposure is a major source of injury among Service members in the Iraq and Afghanistan conflicts. Many of these blast‐exposed veterans report hearing‐related problems such as difficulties understanding speech in noise and rapid speech, and following instructions and long conversations that are disproportionate to their measured peripheral hearing sensitivity. Evidence is mounting that these complaints result from damage to the central auditory processing system. Purpose: To evaluate the effectiveness of audiological rehabilitative interventions for blast‐exposed veterans with normal or near‐normal peripheral hearing and functional hearing difficulties. Research Design: A randomized controlled trial with four intervention arms. Study Sample: Ninety‐nine blast‐exposed veterans with normal or near‐normal peripheral hearing who reported functional hearing difficulties. Intervention: Four interventions were compared: compensatory communication strategies (CCS) education, CCS and use of a personal frequency modulation system (FM + CCS), CCS and use of an auditory training program (AT + CCS), and use of all three interventions combined (FM + AT + CCS). Data Collection and Analysis: All participants tested before, and immediately following an 8‐week intervention period. The primary outcome measures upon which the study was powered assessed speech understanding in noise and self‐reported psychosocial impacts of the intervention. In addition, auditory temporal processing, auditory working memory, allocation of attention, and hearing and cognitive self‐report outcomes were assessed. Results: Use of FM + CCS resulted in significant benefit for speech understanding in noise and self‐reported hearing benefits, and FM + AT + CCS provided more self‐reported cognitive benefits than FM + CCS, AT + CCS, or CCS. Further, individuals liked and reported using the FM system, but there was poor adherence to and high attrition among individuals assigned to receive AT. Conclusions: It is concluded that a FM system (or remote microphone via Bluetooth system) is an effective intervention for blast‐exposed veterans with normal or near‐normal hearing and functional hearing difficulties and should be routinely considered as an intervention approach for this population when possible.

Impact of hearing loss and amplification on performance on a cognitive screening test

BACKGROUND There have been numerous recent reports on the association between hearing impairment and cognitive function, such that the cognition of adults with hearing loss is poorer relative to the cognition of adults with normal hearing (NH), even when amplification is used. However, it is not clear the extent to which this is testing artifact due to the individual with hearing loss being unable to accurately hear the test stimuli. PURPOSE The primary purpose of this study was to examine whether use of amplification during cognitive screening with the Montreal Cognitive Assessment (MoCA) improves performance on the MoCA. Secondarily, we investigated the effects of hearing ability on MoCA performance, by comparing the performance of individuals with and without hearing impairment. STUDY SAMPLE Participants were 42 individuals with hearing impairment and 19 individuals with NH. Of the individuals with hearing impairment, 22 routinely used hearing aids; 20 did not use hearing aids. DATA COLLECTION AND ANALYSIS Following a written informec consent process, all participants completed pure tone audiometry, speech testing in quiet (Maryland consonant-nucleus-consonant [CNC] words) and in noise (Quick Speech in Noise [QuickSIN] test), and the MoCA. The speech testing and MoCA were completed twice. Individuals with hearing impairment completed testing once unaided and once with amplification, whereas individuals with NH completed unaided testing twice. RESULTS The individuals with hearing impairment performed significantly less well on the MoCA than those without hearing impairment for unaided testing, and the use of amplification did not significantly change performance. This is despite the finding that amplification significantly improved the performance of the hearing aid users on the measures of speech in quiet and speech in noise. Furthermore, there were strong correlations between MoCA score and the four frequency pure tone average, Maryland CNC score and QuickSIN, which remain moderate to strong when the analyses were adjusted for age. CONCLUSIONS It is concluded that the individuals with hearing loss here performed less well on the MoCA than individuals with NH and that the use of amplification did not compensate for this performance deficit. Nonetheless, this should not be taken to suggest the use of amplification during testing is unnecessary because it might be that other unmeasured factors, such as effort required to perform or fatigue, were decreased with the use of amplification.