Changing the narrative for hearing health in the broader context of healthy living: a call to action

Abstract

Objective

To discuss the steps necessary to facilitate hearing health care in the context of well-being and healthy living

Design

Common themes among the articles in this special supplement of the International Journal of Audiology were used to identify issues that must be addressed if audiology is to move from being hearing-focussed to taking a holistic perspective of hearing care in the context of healthy aging. These are discussed within the context of other published literature.

Results and conclusions

Three needs were identified: (i) Increased interdisciplinary education to raise awareness of the interplay between hearing and health. (ii) Increased emphasis on counselling education in audiology programs so that audiologists are equipped with the knowledge, competence and confidence to provide counselling and emotional support to their patients, beyond care. (iii) Redefinition of therapeutic goal setting and hearing outcomes to include aspects of well-being, so that audiologists can capture and patients realise that that good hearing outcomes can have a direct positive impact on a person’s quality of life that extends beyond their improved ability to hear. It was emphasised that each of these needs to be considered within the context of the audiologists’ scope of practice and audiologists’ well-being.

Keywords:

• Hearing loss
• Well-being
• Hearing health
• Scope of practice
• Audiology
• Interdisciplinary education
• Counselling

In this year of disruption, social distancing, and anxiety, a focus on hearing health in the broader context of healthy living is timelier than we could have imagined when we began working on this special issue back in 2019. The hours we have spent at home have probably underscored to all of us the importance of social connection for quality of life and well-being. It is therefore all the more apposite that the field of audiology contemplates how to address hearing health in the broad context of well-being and healthy living. In this paper we use common themes that arose from articles in this special issue to illustrate the steps we think are necessary to bring about this change in approach.

Interdisciplinary education to raise awareness of the interplay between hearing and health

Interdisciplinary education and awareness is a two-way street. Not only do audiologists need to be mindful of the interactions between hearing, tinnitus, vestibular disorders and other health conditions (see Wallhagen, Strawbridge, and Tremblay 2021, this issue), but other healthcare professionals also need to be cognisant of how hearing (loss), tinnitus and vestibular disorders might impact the outcomes of care they are providing. Our hope is that interdisciplinary education will foster interprofessional care, so that unique disciplinary knowledge will be used when making patient care decisions (Rizzo Parse 2015). Indeed, interprofessional practice can result in improved patient outcomes and satisfaction (Fewster-Thuente and Velsor-Friedrich 2008, World Health Organization 2010; Reeves et al. 2013; Youngwerth and Twaddle 2011), while its absence is a recognised threat to patient safety and quality of care (Institute of Medicine (US) 2001). Interprofessional care is needed because vast numbers of older individuals have multiple chronic conditions that can require complex interventions, and because many of today’s interventions, technologies, devices, and drugs require coordination between disciplines. Further, without an awareness and understanding of other disciplines, we are limiting the ways in which information technology can be used to combine information from multiple sources to contribute to improved care (Institute of Medicine (US) 2001).

Even at a relatively simple level, the absence of interdisciplinary awareness can lead to patients receiving interventions they can’t manage, while its presence can result in positive outcomes. For instance, Dullard and Saunders (2016) in their review of the electronic medical records of 20 Veterans with dual sensory (hearing and vision) impairment reported two case studies. In one, the individual was provided with an intervention for his vision loss (a talking watch) but was unable to use it because of his hearing loss. Conversely, in the second reported case, an individual was provided with a vision assistive technology during his hearing aid orientation appointment. These individuals would have had very different impressions about the care they received.

Wallhagen, Strawbridge, and Tremblay (2021, this issue) propose that audiology should be working within the ‘4M’s framework’ used by the Age-Friendly Health Systems movement. The 4M’s are ‘what Matters (or person-centred care), Medication (i.e. being mindful of ototoxicity, other medication-hearing interactions, and the impacts of hearing loss when communicating about medication and other health care), Mentation (meaning prevention and early intervention for changes in cognition/mental health), and Mobility (to maintain overall function). They argue this framework is applicable to audiology because there are established links between hearing and each ‘M’ and thus an interprofessional coordinated approach is a must. Moreover, because people with untreated hearing loss incur significantly greater annual medical costs than those without hearing loss (Wells et al. 2019), it is evident that hearing loss is not independent of other health conditions, and thus should not be treated as such. In a similar manner, Bott and Saunders (2021, this issue) discuss bi-directional aspects of interprofessional care. They note that not only should hearing care professionals work collaboratively with other care professionals (e.g. geriatricians, general practitioners, allied health professionals) to address well-being in older adults, but that other healthcare professionals should be aware that hearing loss contributes to the well-being of older adults and that they should refer people for hearing care if they think hearing loss is present. The study of Nuesse et al. (2021, this issue) also illustrates that there are interrelationships between general health and hearing. They show that frailty (computed from health questionnaires) and mental well-being explain variance in reported hearing handicap over and above hearing thresholds and speech recognition in noise performance.

It can thus be argued that general health factors should be taken into consideration when managing hearing loss – perhaps through managing expectations, providing ongoing support, ensuring carers are involved in auditory rehabilitation, or through collaborating with, and making referrals to, other health care providers (Pichora-Fuller et al. 2013). Again, in this special issue, Clark, English, and Montano (2020, this issue) make the point that audiologists need to be vigilant about patient well-being when they encounter patients who need care, support, or intervention beyond the hearing loss. They provide examples of scenarios in which collaboration with professionals from other health disciplines is critical to patient well-being and safety. Of course, interdisciplinary care is not without its complications, one of which is the need to ensure that within any interdisciplinary team, someone must be responsible for monitoring the patient’s care process from start to finish and facilitate communication among professionals and with the patient (Kramer 2008). Without this, there is a risk that no one takes responsibility for overseeing the patient’s care as a whole.

Interprofessional care must begin with interprofessional education. The World Health Organization (2010) proposed a Framework for Action on Interprofessional Education & Collaborative that provides ideas and strategies to assist in policy-making that will allow for implementation of interprofessional education and practice, while also acknowledging that because every health system is different, the specific policies and steps to achieving it will differ. For audiology training programs, interprofessional education could start with the incorporation of modules associated with optometry, occupational therapy, psychology/counselling, and rehabilitation, because individuals with conditions addressed by these disciplines often have conditions that impact hearing rehabilitation and/or vice versa. Unfortunately, interprofessional education is not yet widespread in audiology programs. A survey conducted in 2008 by the WHO Study Group on global Interprofessional Education and Collaborative Practice indicated that just 2.2% of audiologists received interprofessional education at their educational institution. This is considerably lower than the 16% of nurses/midwives and 9.3% of social workers who received interprofessional education, but similar to the <5% of community health workers, speech pathologists and physician assistances receiving the same (World Health Organization 2010). There are indications, however, that interprofessional education is being gradually introduced into audiology programs across the world. For example, in Canada some universities require all health sciences students, including those studying audiology, to take interdisciplinary courses; in Australia, the Audiology program curricula include courses that educate on both theory, and practice of interdisciplinary care by having audiology students team up and work with students in different specialties; while in the UK, there exist programs such as the UK Scientist Training Programme (STP) Master’s degree in which students employed by the UK National health Service, spend time in a variety of different clinical settings and take courses in healthcare science, before focussing on a speciality area, such as audiology, vision sciences, genomics, etc. The fact that many Au.D. and Audiology programs are located at institutions that also award degrees in other health service disciplines, should facilitate the inclusion of interdisciplinary education in audiology degrees. It would seem that individuals trained in such programs would be well equipped to recognise the interplay between hearing loss, hearing rehabilitation and other medical health conditions.

Increased emphasis on counselling education in audiology programs

As noted by Clark, English, and Montano (2020, this issue), audiologists have an ethical responsibility for the health and well-being of patients and should watch attentively for concerns and situations, whether stated or not in the audiology encounter, that might necessitate the need for professional outside referral or mental health support. Clark et al. remind us that outside referral may be necessary because audiologists are neither professionally prepared nor licensed to provide the type of care that some situations require.

On a routine basis, patients seeking care for hearing and tinnitus are encouraged to share personal experiences so that the audiologist can gain a good understanding of their hearing-related communication problems. This can lead to revelations of personal situations beyond those associated directly with hearing which can leave the audiologist in the position of needing to manage a situation that they are not formally trained to handle. It is essential then, that audiologists are able to differentiate between those situations that can be managed through audiological care and rehabilitation, from those that cannot. If the former, the audiologist needs to know how to provide support and feel confident about doing so.

Unfortunately, counselling education and training is often missing from the curricula of audiology programs (Whicker et al. 2017), despite the fact that it is considered to be a critical component of audiological care (Meibos et al. 2017). As with interprofessional education, the inclusion of counselling in audiology degrees is becoming more common (English 2005; Whicker et al. 2017), nonetheless studies indicate that many audiologists feel unprepared to provide emotional counselling and support because they feel they do not have the necessary skills, confidence, or time to do this, and they are uncertain as to how it fits within their scope of practice (Bennett, Meyer, et al. 2020). This probably explains why emotion-based concerns raised by patients often go unaddressed, and instead are dealt with via information-based or technology-based responses (Ekberg, Grenness, and Hickson 2014; Muñoz et al. 2017), or are avoided entirely (Grenness et al. 2015, Bennett, Meyer, et al. 2020). The study of Bennett, Barr, et al. (2020, this issue) highlights this. Bennett and colleagues learned that clients and audiologists consider that ‘providing emotional support’ is beneficial for helping people adjust to the psychosocial impacts of hearing loss, but that audiologists rate its importance and likelihood of use more highly than do adults with hearing loss. They hypothesise that this is because the audiologists do not have a full understanding of their client’s needs and wants, and thus do not provide the support that their clients actually hope for and/or require. Ekberg et al. (2020, this issue) recognised that audiologists need additional support and education around counselling-related care and thus developed a program to train audiologists in the use of family-centred care in their everyday practice. Using the Behaviour Change Wheel that arose from the COM-B model of behaviour (Michie, van Stralen, and West 2011), their program aims to increase audiologists’ psychological capability, opportunity, and motivation around supporting attendance and involvement of family members at audiological appointments. The program highlights an awareness of the need for broadening audiology education around providing programs of care that go beyond technological management of hearing loss.

Until counselling education that focuses on hearing loss within the broader context of mental well-being is incorporated into audiology programs, it is unreasonable to expect the next generation of audiologists to feel equipped to provide counselling and emotional support to their patients. While ultimately audiology programs should assume responsibility for this, identifying gaps and recommending change is a place to start. For those audiologists already practicing, it would be of value for professional clinical bodies and organisations to facilitate access to additional training.

Redefine therapeutic goal setting and hearing outcomes to include aspects of well-being

According to Boothroyd (2007), adult aural rehabilitation aims to restore quality of life by eliminating, reducing, or circumventing hearing-loss-induced deficits of function, activity, participation, and quality of life (Boothroyd 2007). It is a definition that specifies quality of life as the end goal. This makes sense because, as is illustrated by several articles in this special issue, hearing loss negatively impacts multiple life domains such as employment (Granberg & Gustafsson, 2021; Holman et al. 2021, this issue), social and physical activity (Holman et al. 2021, this issue), social engagement (Bott and Saunders 2021, this issue), and mental well-being (Nuesse et al. 2021, this issue). Assessment of the outcome of hearing rehabilitation however, is typically limited to measuring hearing function – behaviourally or via self-report. We propose that more distal outcomes related to well-being (i.e. long term goals), should also be assessed. In this respect, it is important to mention the International Classification of Functioning, Disability and Health (ICF) framework which was endorsed by the World Health Organization Assembly (2001). The framework provides a standard language for the description of health and health-related states and covers multiple domains of life and environmental factors that may influence health and performance. To make the ICF more applicable for everyday use, ICF Core Sets were developed. These provide lists of essential categories that are relevant for specific health conditions and health care contexts. In 2015, the ICF Core Sets for hearing loss were developed (Granberg 2015) which have since been validated (Alfakir et al. 2019) and operationalised (van Leeuwen et al. 2020) for broader clinical implementation in an intake instrument. While the sensitivity of the Core Sets for Hearing Loss as an outcome measure still need to be established, there is the potential that they will be more sensitive to hearing-related interventions than the generic quality of life measures reviewed by Chisolm et al. (2007) because they were developed with hearing in loss in mind.

Other approaches to evaluating distal outcomes could include assessment of dimensions such as listening effort, fatigue, stress, social engagement, psychosocial outcomes, and work satisfaction. However, objective methods for assessing these dimensions (e.g. pupillometry, EEG, and skin conductance) are not yet ready for broad clinical implementation (Moore and Picou 2018; Alhanbali et al. 2019) and questionnaire measures are subject to recall bias and lack can contextual resolution (Shiffman, Stone, and Hufford 2008). A solution to this is use of Ecological Momentary Assessment (EMA), in which data are collected in real time in real-world environments on repeated occasions. EMA has been found to be a reliable indicator of listening experiences (Jenstad et al. 2019) and can provide a more detailed picture of real life experiences and thus provide a deeper understanding of real-world communication (Timmer, Launer, and Hickson 2020). EMA has been used as a research tool for rating speech understanding, listening difficulties in different soundscapes, user satisfaction and preferences for different hearing aid settings, and to compare outcomes measured using EMA versus standard self-report questionnaires (see Holube, von Gablenz, and Bitzer 2020 for review), and to assess well-being concepts such as listening enjoyment and the extent to which individuals feel hampered by their hearing difficulties (Timmer, Hickson, and Launer 2018).

Technology now allows us to combine data from multiple sources including EMA, sensors in hearing aids, smartphones, and wearables. These data open up the possibility of assessing a vast array of outcomes over time and across different listening situations. To date, work of this type has been limited to research (Caduff et al. 2020; Christensen et al. 2021). Data are promising but from a clinical perspective, EMA adds considerable patient burden and data analysis is very intensive. However, with ever increasing technological literacy and access to smart phones, and sophisticated data analysis techniques, the clinical use of these tools is becoming more feasible. This is attractive because they have the potential to provide a deeper understanding of real-world communication, social engagement, stress, and emotional state, thus providing ways to document the impacts of auditory rehabilitation on the whole person.

Scope of practice

Any conversation about broadening audiological care necessitates a discussion about scope of practice. From a legal perspective, scope of practice guidelines define precisely what procedures, actions, and processes a healthcare provider is permitted to undertake while remaining within the terms of their professional licence, and which has been permitted based upon specific education and experience, and demonstrated competency. Scope of practice is complex to navigate because guidelines vary across the globe, and because the delineation between legal boundaries and discipline-appropriate boundaries is somewhat imprecise.

For example, some have proposed that audiologists should administer cognitive screening tests to identify undiagnosed cognitive impairment in order to provide timely referral and to optimise the outcomes of auditory rehabilitation (e.g. Shen et al. 2016; Weinstein 2017; Raymond et al. 2020), while others have highlighted that such screening tools have not been validated with, or are invalid for, people with hearing loss (Raymond et al. 2021). The Gerontological Society of America supports the notion of cognitive screening by providers, as long as the guidelines are carefully followed. They state that non-physician care providers can help increase detection of cognitive impairment and encourage diagnostic evaluation by (a) making information available to their clients and families, (b) knowing the signs and symptoms of cognitive impairment, (c) listening for a client’s concerns about cognition and being observant about signs, and (d) maintaining a list of organisations to refer to. They state that a brief mental status evaluation should be conducted by a non-physician only if the provider (1) has been trained to use the test, (2) such testing is within their scope of practice, (3) they know and use the required consent procedures, and (4) there is an established procedure to refer individuals who score below a pre-determined score on the test to a physician for a diagnostic evaluation (Maslow and Fortinsky 2018). On the other hand, the Canadian Task Force on Preventive Health Care recommends against screening for cognitive impairment among older asymptomatic adults (Canadian Task Force on Preventive Health Care, et al. 2016) and the US Preventive Services Task Force et al. (2020) notes that there is insufficient evidence to assess the balance of benefits and harms of screening for cognitive impairment in older adults.

An approach that audiologists could take that would not encroach upon scope of practice issues would be to adapt the care they provide to ensure it is accessible to all clients – regardless of their cognitive status. Adaptations could include allowing extra time for counselling and education, giving short, simple instructions, demonstrating with examples, recommending a communication partner attend the appointment, supplementing verbal instruction with gestures and plain language written instructions and/or multimedia tools such as videos and smart phone applications, and/or using teach-back to confirm an individual can recall and has understood the information provided (Pichora-Fuller et al. 2013; Saunders et al. in press). Of course, this approach should also include referral to primary care, neurology or other, if warranted.

Similar dilemmas associated with scope of practice arise in respect of how to use data collected from hearing aid sensors that purport to monitor cognitive health, wellness, motion, and cardiovascular function. These sensors can monitor vital signs with high precision (Caduff et al. 2020), and as such could be used for long-term ongoing health monitoring. However, again this requires care and deliberation about how such monitoring would be integrated into the audiologist’s scope of practice, the assurance of interprofessional support, agreements about liability for patients’ health, and ownership and privacy of health data. It is important that these issues are considered before audiologists embrace the collection of health data from hearing aids

We do not want to be prescriptive in specifying what is or is not an appropriate activity for audiology but are raising the issue in the hope that individuals and professional bodies will carefully consider how they balance the role of the audiologist with that of providing care in the context of well-being and healthy living.

Audiologist well-being

In a conversation about hearing health in the broader context of healthy living, the health and well-being of audiologists must not be forgotten. While there is no research published on the impacts of audiologist well-being on patient outcomes, a systematic review of the general medical literature, indicates that physicians’ occupational well-being can contribute to better patient satisfaction and interpersonal aspects of care (Scheepers et al. 2015). More specifically, studies showed higher occupational well-being in the provider to be associated with greater patient satisfaction (Szecsenyi et al. 2011) and higher levels of adherence to interventions (DiMatteo et al. 1993).

Job satisfaction among audiologists is generally high (Saccone and Steiger 2012) and has remained so since 1997 (Martin, Champlin, and Streetman 1997). Job interest, autonomy, the opportunity to feel competent, working with competent others in pleasant surroundings, and receiving an appropriate salary being significant predictors of overall satisfaction (Saccone and Steiger 2012). Audiology is of course not without stress. One study showed that about 20% of audiologists were at a high risk of burnout and that this increased with age of the audiologist (Severn, Searchfield, and Huggard 2012). In that study, the sources of stress were primarily associated with time and administrative demands, staffing, and patients’ unrealistic expectations. This being the case, the audiology profession needs to be aware that if the role of the audiologist is to be broadened, it could lead to additional job stress, decreased satisfaction and well-being, and in turn poorer patient outcomes. Thus, any changes to the practice of audiology need to be managed with care and introduced in a supportive environment.

Summary and conclusion

We propose several steps and considerations that can move audiology from being hearing focussed to taking a holistic perspective of hearing care in the context of healthy aging (Campos and Launer 2020). This approach will require strong interprofessional collaboration between audiologists and other health care professionals, and deliberation over how changes should be integrated into the audiologist’s scope of practice. It will necessitate that audiologists shift their focus when treating and counselling their clients with a view to emphasising that good hearing outcomes can have a direct positive impact on a person’s quality of life that extends beyond their improved ability to hear. We also note that with more and more sensors being integrated into hearing aids. They might morph into multi-functional health care devices that could be for ongoing health monitoring. This again this will require careful navigation if it is to be integrated into audiological care.

In conclusion, the papers in this special issue of the International Journal of Audiology provide strong evidence that hearing loss has impacts on health that go far beyond hearing and that therefore hearing rehabilitation care must encompass approaches that look to distal outcomes related to well-being and use these to assess outcome.

Acknowledgements

This paper arose following a conference sponsored by Sonova AG, Switzerland. Five authors are employees of Sonova (CV, BHBT, GS, AP, SL) and one is an employee of GN Hearing (AB).

There was no funding directly associated with the writing of this paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).