Hearing loss can lead to isolation and loneliness from communication loss and disconnection. Holistic hearing rehabilitation is gaining traction as the ‘gold standard’ in hearing healthcare, integrating social and emotional wellbeing to improve outcomes. Attendees at The Sound Exchange ’24 were among the world’s first to experience hands-on learning of a 5-step plan to support implementation of this approach into clinical practice. Speakers included plan co-authors.
When it comes to tackling hearing loss, it is increasingly clear that rehabilitation is a team sport. Those supported through their hearing care journey by family or friends have been found to experience better results from devices including hearing aids than patients who are isolated and lack support.
Lead developer of the 5-step plan for holistic hearing rehabilitation, researcher and Audiology Australia (AudA) president Dr Barbra Timmer, who was in Melbourne for the Sound Exchange, said audiologists in her team wanted to drive change in thinking as most audiologists were still more likely to ask a patient about their hearing than how they were feeling. Outside Australia, the story is different with the importance of asking a patient not just about what they can hear but how they are coping socially and their emotional wellbeing becoming so well understood it is being written into clinical software.
In Germany these indicators are included in software used by audiologists to record improvements in hearing after hearing aids have been prescribed. Patients’ social and wellbeing needs and goals have been incorporated into management plans in the NHS in Wales and are embedded in CRM software across the UK to align supports to goals, and to measure that treatment outcomes meet patients’ needs.
Dr Timmer’s message to audiologists including in the packed room at The Sound Exchange ’24 is clear: “Don’t just ask ‘how’s your hearing?’ also ask, “how do you feel about your hearing?”
Before their hearing loss is addressed and treated, people often feel increasingly isolated, lonely, embarrassed, even ashamed because they miss parts of the conversation, they can’t join in jokes, they don’t know the full story at home or work, and often find it easier to retreat and isolate, Dr Timmer said. Even at home, relatives can become angry and short with them due to having to constantly repeat themselves. Research showed it took on average seven years before hard of hearing patients asked for professional help yet they rarely discussed these feelings with their audiologist.
“Some patients who were surveyed said their audiologist never discussed feelings of isolation or asked about loneliness or how they were feeling emotionally,” Dr Timmer explained.
Social integration and support is key
A senior lecturer, scientist and research academic at The University of Queensland, Dr Timmer is helping spearhead change globally as the lead author of the 5-step plan for holistic hearing rehabilitation, a project she masterminded with several co-authors of the plan during the 2019 Phonak “Hearing well and being well – a strong scientific connection” conference in Frankfurt. The co-authhors agreed to team up to develop the model.
Grounded in evidence-based research the resulting paper on their 5-step plan made a splash in the International Journal of Audiology as the most read paper of 2023.
Watching her talk at The Sound Exchange ’24, her passion for driving the change is clear. Speaking at the AudA masterclass, Dr Timmer told the 100 delegates lack of social integration was a key factor in mortality and morbidity. She said recent studies had found this was the most important predictor of mortality behind the number two risk factor, lack of social support. Loneliness and lack of support were more important risk factors for death and disease than obesity, smoking, diabetes, hypertension or any of the other well known risk factors, she added.
“Many people are not aware of this but we are starting to see research increasingly show this,” she told delegates. “This is why we want to make sure we practise the 5-step plan for holistic hearing rehabilitation. Look at the holistic and wellbeing needs of our patients. Everything is interconnected – cognitive, physical, social, emotional,” she told the audience.
“Audiologists are communication specialists. It’s important to involve family because the number two predictor of morbidity and mortality is lack of social contact. Once family know how to help, they’re willing to do it.”
Change the narrative
Although they may not discuss these topics with clients, Dr Timmer says audiologists do realise the importance of wellbeing in their clients and are starting to embrace methods to incorporate rehabilitation plans and measures into their practise. This is supported by the fact the top two downloaded papers in the International Journal of Audiology in 2023 were on wellbeing, including research by Dr Timmer and colleagues.
“Wellbeing is a hot topic – wellbeing of patients and clinicians too. There’s lots of interest and research,” she added. “The next five years I expect there will be an upswing in research and evidence on effects in audiology about generalised wellbeing. It will change the narrative in clinics – it won’t just be about hearing loss, it will be about wellbeing too.
“The 5-step plan says it is important we address a patient’s social and emotional wellbeing because in identifying this we feel we add value and we have better outcomes in hearing rehabilitation.”
And while hearing aids improve social and emotional wellbeing, there are other ways it can be improved too, she added.
Perception of hearing loss remains a challenge.
“There is still a lot of stigma associated with hearing loss. The University of Queensland touched on the topic in recently conducted research about how stigma impacts use and uptake of hearing aids in an international survey of over 300 Australians, Brits and Americans with hearing loss who were hearing aid wearers, non-users and past-users,” Dr Timmer said.
“One-third of those who were not wearing hearing-aids, and 8% who were, said they would never disclose their hearing loss in any situation. What can we do? Start talking about hearing loss to make people more comfortable about telling others about their hearing difficulties and help them realise the benefits of hearing rehabilitation. The research also showed that hearing aids were seen to be discreet, beneficial and high-tech, even by those not wearing them.”
The survey also asked 300 family members why their relatives were not using hearing aids.
“A common response was – ‘no-one has ever suggested using hearing aids’ which ties in with that figure of many waiting seven years before seeing us,” she said.
Although it was good to give people time and space to decide to seek help, leaving people without help for so long could mean deterioration in their social and emotional wellbeing.
The 5-step plan comprises:
- Identifying the social and emotional wellbeing of the patient.
- Involving and inviting family members – (see tips box).
- Including social and emotional wellbeing goals in the management plan.
- Relating needs and goals to interventions such as hearing aids and communication strategies.
- Using counselling skills in the hearing loss rehabilitation process.
Another co-founder of the plan, The University of Queensland Executive Dean, Faculty of Health and Behavioural Sciences, audiologist Professor Louise Hickson PhD AM, expanded at Sound Exchange on the importance of including loved ones in the hearing health journey.
“Family-centred care is about including family members in all aspects of rehabilitation and is not limited to biological family but can be anyone who the client feels comfortable with – close friends or relatives can be included in the appointments virtually with platforms like Zoom. You can call them beforehand to offer to include them virtually,” she said.
“Why include family? Because family care, they will do what they can to help their relative or friend, and evidence is very strong that family involvement improves outcomes. If family is involved, the person with hearing loss is more likely to seek help so please engage with family. Think of the family as the client.
“Families help with decisions the patient makes including cost and style of devices and whether to get hearing aids now or later. Hearing aids are a major financial decision and families are an important part of this decision.”
Prof Hickson said wearers of hearing aids were more successful using them if they had support from the community around them.
“People whose partners have (untreated) hearing loss can experience third party disability because it can also limit them attending family gatherings and limit their social interactions too but rehabilitation can reduce this disability,” she added.
Involving family not only led to better clinical outcomes, but also improved outcomes for businesses because happy clients told others, Prof Hickson reminded delegates.
Unfortunately, research shows that only about 30% of adults attending audiology appointments in Australia bring a significant other, she said. The study found certain tips worked (see tip box) and increased in-person family attendance from 26% to 48%.
Dr Timmer advised creating an individual management plan and relating social and emotional needs and goals to audiology rehabilitation recommendation, such as hearing devices, communication and auditory training and social prescribing.
“Use counselling skills and technology to explore and monitor social and emotional wellbeing. You’re not just providing a path in audiology care but are providing added value to the therapeutic alliance with your patients. Monitor and document these new social and emotional goals regularly.”
She said holistic hearing care was the foundation of the audiology competency standards in Australia. Essential to this was addressing the social and emotional wellbeing of clients and The Sound Exchange stream taught how social and emotional wellbeing could be addressed in audiology appointments by using the plan.
“Some audiologists say they don’t have the time or a structured approach to this and I understand the time pressures on audiologists and the pressure to optimise their appointment times are very real but if we do not screen our clients’ social and emotional wellbeing, and make sure we address this during their hearing care journey, how do we know that we are adding real value to their hearing care?” Dr Timmer told Hearing Practitioner Australia (HPA).
“No client comes to us for hearing devices, they come to improve their communication, feel more connected to others, not be a burden on family, for a host of reasons which are all related to the impact from their hearing loss. Hearing devices are one tool in the range of services we provide but if that is the only thing we provide, then we are too device-centric and are forgetting the comprehensive nature of the role of an audiologist.”
The 5-step plan has skills and techniques that audiologists can use for counselling and suggests questionnaires for social and emotional wellbeing and holistic hearing care, including resources to set rehabilitation goals or expected outcomes.
“These goals often relate to an improvement in speech understanding or audibility as a result of hearing devices. What the individual management plan tries to incorporate is a more holistic approach. This means discussing hearing goals and social and emotional goals,” Dr Timmer explained.
“Feeling less embarrassed or less fatigued by my hearing loss”, for example, or “being more connected with family and friends” are great goals and can be achieved with a range of options from auditory and communication training, the use of hearing technologies, social prescribing and counselling. These goals are as important as those that address a change in hearing.
“I’d love to see the plan profiled in the audiology university programs. All institutions teach the links between hearing and wellbeing and the core of person-centred care but perhaps the 5-step plan is a good model to bring these teachings together,” Dr Timmer told HPA.