Self-determination theory and hearing rehabilitation: The role of motivation in help-seeking, hearing aid adoption and hearing aid fitting outcomes

Abstract

Adults with hearing impairment do not always seek help for their hearing or adopt hearingaids and some people who adopt hearing aids do not use or gain benefit from them.Psychosocial factors that influence help-seeking, hearing aid adoption and outcomesillustrate the importance of addressing client experiences and motivation. Although modelsof health behaviour have been recommended to understand client behaviour, motivationhas not been explored in detail. To investigate motivation in hearing rehabilitation, theresearch in this thesis applied self-determination theory (SDT) as the guiding theoreticalframework.The research comprised three quantitative studies and one qualitative study, whichtogether followed an explanatory sequential mixed methods design. The thesis researchaims were to (1) identify motivational characteristics of first time hearing help-seekersand determine relationships between these characteristics and the decision whether ornot to adopt hearing aids; (2) identify whether or not motivational characteristics influencehearing aid fitting outcomes, and if so, in what ways; (3) determine associations betweenpersonal characteristics and motivation in first time hearing help-seekers; (4) identify firsttime hearing help-seekers’ perceptions of their interactions with practitioners; and (5)explore practitioner influence on relationships between motivation, help-seeking andhearing aid adoption. The first three aims were addressed by each of the quantitativestudies. The fourth and fifth aims were addressed in multiple studies.For the quantitative studies, a total of 253 participants completed a series ofquestionnaires adapted from SDT. In the first study, associations between autonomousand controlled motivation, personal and audiometric variables and hearing aid adoptionwere explored with multivariate regression analysis. Three factors were positivelyassociated with increased hearing aid adoption: autonomous motivation, perceivedhearing difficulty and poorer hearing. Controlled motivation was not associated withhearing aid adoption.The second study reported outcomes for 216 of the 253 participants with respect toautonomy support. Multivariate regression models were formed that examinedassociations between autonomous and controlled motivation, personal and audiometricvariables, autonomy support and hearing aid fitting outcomes. Autonomy support was notassociated with increased hearing aid adoption, but was associated with three outcomes:increased perceived competence for hearing aids, reduced activity limitations and increased hearing aid satisfaction. Autonomous motivation was positively associated withone outcome, hearing aid satisfaction.The patterns of effect of autonomous and controlled motivation on hearing aid adoptionand hearing aid fitting outcomes prompted the third quantitative study, which sought toexamine personal characteristics associated with motivation. Multivariate regressionindicated that, in the 253 participants, those who were younger, wanted hearing aids moreand reported greater hearing difficulty also reported higher autonomous motivation.Participants with higher controlled motivation were more often referred by others andwanted hearing aids more than those reporting lower controlled motivation.Together, the three quantitative studies revealed a variety of motivational processes thatunderlie behaviours and actions of participants. Practitioners may benefit from evaluatingmotivation in order to better understand how help-seekers engage with hearing servicesand to identify how hearing aid adoption is internalised. Using autonomy support as aguiding principle, practitioners may provide hearing aid adopters with skills to masterchallenges associated with hearing aid adoption. The lack of association betweenautonomy support and hearing aid adoption raised questions about the practitioner’s rolein hearing aid adoption.To explore these relationships in greater detail among first time hearing help seekers, 13participants not previously engaged in this research project and who either adopted or didnot adopt hearing aids were interviewed about their motivations for seeking help andexperiences in the clinic. Transcripts were analysed using thematic analysis. The mostimportant motivational processes for seeking help were (1) Communication experiences,which encompassed conversation difficulties, impact on family, participation andparticipants’ emotional response, and (2) My story, which comprised preconceptions abouthearing aids, perceived difficulties, self-image, encouragement from family and promotionof service. There was evidence also that practitioners supported participants’ hearing aidadoption decisions reflected in the theme Clinical experiences, which included generalcomments about the service, discussions about the audiogram, supportive and nondirectivepractitioners, choice and cost. When SDT principles were applied to the interviewdata, participants’ comments were seen to fall along the internalisation continuum andreflect need satisfaction in terms of autonomy, competence and relatedness. Autonomysupport was less evident when practitioners minimised or dismissed self-reportedcommunication difficulties, when rehabilitation options did not include communication strategies, and when family members were not involved in hearing aid adoption decisions.In summary, this research provides evidence to support application of SDT in hearingrehabilitation involving hearing aids. A variety of motives were evident in people seekingservices, and autonomy was important throughout rehabilitation. Autonomy supportivepractitioners have the potential to reduce activity limitations, facilitate competence withhearing aids and improve hearing aid satisfaction for adults with hearing impairmentseeking help for the first time.