Transtheoretical Model as an Audiological Counseling Approach

Transtheoretical Model as an Audiological Counseling Approach

Abstract

This paper explores five current publications on the transtheoretical model (TTM), supplementary articles, and the model’s application in audiological counseling. Patients who seek help from an audiologist for their condition are not always ready to purchase or to utilize them in their daily life. Consequently, an audiologist should not expect their patients to be psychologically ready for hearing aids upon conclusion of their initial evaluation; an attitude shift must occur in order for successful adoption to occur.  The TTM can be applied in audiological counseling in order to gauge the patient’s readiness for hearing aid acceptance based on the patient’s attitudes and beliefs.  The transtheoretical model identifies the stage-of-change the patient is in and if it has a particular influence on whether or not they choose to purchase amplification. This model has proven successful in audiological rehabilitation as it provides audiologists a way to personalize their treatment approach for their geriatric patients as it can work alongside other noted patient needs and their readiness for amplification in order to improve their patient’s success with amplification.  Clinically, utilizing the transtheoretical model can potentially increase the acceptance of hearing aids following use and can lead to better utilization and outcomes in the patient.

Main Body

The transtheoretical model (TTM) describes the attitude and behavior change in a patient as a process that occurs over time rather than a distinct occurrence and provides a structure for understanding how patients accept and sustain behaviors that improve their health (Saunders, Frederick, Silverman, Nielsen, & Laplante-Lévesque, 2016).  There are four distinct stages of change that outline this model: 1) precontemplation or problem denial; 2) contemplation (aware of the problem and thinking about the pros and cons of the change); 3) action (healthy behavior acquired); 4) maintenance (maintenance of healthy behavior (Laplante-Lévesque, Hickson, & Worrall, 2013).  A patient’s progress through the stages-of-change is, in fact, nonlinear and they commonly retrogress to a previous stage (Laplante-Lévesque et al., 2013).  Those patients in the later stages of change in this model are thought to demonstrate to the audiologist that they will have successful acceptance of the proposed treatment, sustain the behavior, and have more successful outcomes as a result of the treatment (Laplante-Lévesque et al., 2013).   One of the most important factor to patients regarding acceptance of hearing aids is the communication method of the audiologist (Poost-Foroosh, Jennings, & Cheesman, 2015).  Therefore, this model can be directly applied clinically in the audiology field and has shown to be successful in audiological counseling when in direct conjunction with the administration of the University of Rhode Island Change Assessment (URICA) to the patient.

Typically, psychosocial concerns of patients are not addressed by their audiologist and therefore, don’t receive the best patient-centered care (Elkberg, Grenness, & Hickson, 2014).  The TTM is an important avenue to explore in order to increase patient-centered care and successful rehabilitation in adults who are pursuing amplification.  By identifying the attitudes and beliefs of the patient, the audiologist can use this model to predict the psychological readiness of their patient to pursue, utilize and sustain the use of amplification.  Identification can occur by providing the URICA or simply through observation/active listening during initial case history.  Applied clinically, the audiologist can use this model to first identify if the patient is in the precontemplation stage of the model, which would indicate that they are not aware of a potential hearing loss and believe that amplification is unnecessary to pursue.  80% of those in this stage were found to have declined hearing aids (Ekberg, Grenness, & Hickson, 2016).  If an audiologist identifies the patient in the contemplation stage of the model, then they can assume they are help-seeking individuals with an openness toward hearing aids or other hearing rehabilitation (Ekberg et al., 2016).  For those who are at the action phase of the model, these are patients who will likely purchase hearing aids and who can potentially move on to the final stage in the cycle, maintenance, where they will use their hearing aids consistently (Ekberg et al., 2016).  Therefore, patients who score highly on the precontemplation stage are less likely to have favorable rehabilitation outcomes than patients who scored higher on the action stage indication they will have successful adoption of hearing aids (Ekberg et al., 2016).  Knowing the patient’s stage of change can offer insight into who might need a different counseling approach (Ekberg et al., 2016).

The article, “Application of the Transtheoretical Model of Behaviour Change for Identifying Older Clients’ Readiness for Hearing Rehabilitation During History-Taking in Audiology Appointments”, provides key points that other audiologists can use as a resource to aid in figuring out what stage they are in.   For example, if a patient is in the precontemplation phase, then the patient may play down the actual impact of their hearing loss on different aspects of their life (Ekberg et al., 2016).  They may also attribute blame on their family members citing that they are mumbling to softly.  If an audiologist identifies someone in the precontemplation phase, it is their obligation to try to change their attitudes and behaviors in order to get them to move to accept their hearing loss and make an action (Ekberg et al., 2016).  This article highlights that taking a thorough case history is of the utmost importance during an initial appointment.

Discovering the patient’s stage in the TTM during case history will not expose itself utilizing a close-ended question; it will only reveal itself during open-ended questions because the patient needs to lead the case history discussion (Ekberg et al., 2016).  Utilizing open-ended questions will allow the audiologist to tailor the treatment to the patient’s specific needs.  The audiologist should be flexible during counseling and direct their counseling more to raising awareness about hearing loss and options for treatment for those on the fence of pursing amplification (Ekberg et al., 2016).  Therefore, audiologists should investigate why their patient is so resistant to change or treatment (Ekberg et al., 2016).

It’s worth noting the limitations that require further research. One such limitation of the TTM its often viewed in terms of jumping from stage to stage in a linear fashion, however, research has noted that it should be viewed in terms of on a continuum (Saunders et al., 2016). However, any stage can be entered anytime similar to the stages of grief.  In addition, another limitation of the TTM is that it typically focuses on the initial appointment, but even current research has not delved into the maintenance stage; the articles addressed in this paper only focus on the stages from precontemplation to action (Saunders et al., 2016). One final limitation is that the TTM often takes a while to do when in conjunction with the URICA.  In busy clinics, this could make it not feasible to do with an intake form and therefore must be done orally during case history.

Knowing where people fall on the continuum, versus assuming they are traveling through the stages linearly, is important for future research.  This will aid the audiologist in understanding their patient’s chance of success when utilizing hearing aids or other audiological rehabilitation technique.   This fact directly ties in with the second limitation to the TTM mentioned above.  If an audiologist were able to predict their patient’s continued use of the hearing aids based on this model, then hearing aid sales may potentially increase due to increased acceptance of hearing aids.  Although data logging does exist, prediction of maintaining their use of hearing aids is just as important as predicting if they will pursue amplification or not.  The goal for audiologists is to treat the patient, not the audiogram.  The patient being pleased with their hearing aids and their perception of how it improves their quality of life is very important to the practice in general and personally to the audiologist.  It can improve the referral source and it can also be motivating for the audiologist.

In addition to the aforementioned further research topic ideas, it should also be noted that the TTM does not give any indication as to what the target behavior for change should be (Saunders et al., 2016). For example, target behavior for change would be for those who have never purchased amplification before to actually purchase hearing aids or being successful with their hearing aids.  Further research should be conducted on this area to perhaps educate audiologists about the model so they can incorporate it successfully in their audiological rehabilitation sessions. This can be especially useful for new audiologists or for those needing a different approach for a patient as it can serve as a quick reference to perform the model correctly.

Perhaps the most need for further research arises from the fact that the TTM is one that occurs over time and take a lot of time during appointments if done with a questionnaire or orally through case history.  A simplified measure should be developed so that even the busiest of clinics can still use this model on their patients.

Summary

The TTM has proven to have application in audiological counseling and rehabilitation.   The TTM can be applied in audiological rehabilitation in order to assess their readiness for hearing aid acceptance based on the patient’s attitudes and beliefs.  It can be conducted during case history or through written materials that are distributed before the appointment. Limitations of the model such as the length of time it takes should be explored in further research in order to create a simplified measure for use is busier clinics.

References

Ekberg, K., Grenness, C., & Hickson, L. (2016). Application of the transtheoretical model of behaviour change for identifying older clients’ readiness for hearing rehabilitation during history-taking in audiology appointments. International Journal of Audiology, 55(December), S42–S51. https://doi.org/10.3109/14992027.2015.1136080

Elkberg, K., Grenness, C., & Hickson, L. (2014). Addressing Patients’ Psychosocial Concerns Regarding Hearing Aids Within Audiology Appointments for Older Adults. American Journal of Audiology, 23(September), 337–350. https://doi.org/10.1044/2014

Laplante-Lévesque, A., Hickson, L., & Worrall, L. (2013). Stages of change in adults with acquired hearing impairment seeking help for the first time: Application of the transtheoretical model in audiologic rehabilitation. Ear and Hearing, 34(4), 447–457. https://doi.org/10.1097/AUD.0b013e3182772c49

Poost-Foroosh, L., Jennings, M. B., & Cheesman, M. F. (2015). Comparisons of Client and Clinician Views of the Importance of Factors in Client-Clinician Interaction in Hearing Aid Purchase Decisions. Journal of the American Academy of Audiology, 26(3), 247–259. https://doi.org/10.3766/jaaa.26.3.5

Saunders, G. H., Frederick, M. T., Silverman, S. P. C., Nielsen, C., & Laplante-Lévesque, A. (2016). Health behavior theories as predictors of hearing-aid uptake and outcomes. International Journal of Audiology, 55(December), S59–S68. https://doi.org/10.3109/14992027.2016.1144240