Beyond the Streetlight in Hearing Aid Research

Examining the socio-cultural effects of smartphone-connected hearing aids

Stella Ng, Ph.D.

Imagine it’s late at night, you’re walking in a potential effects of this innovation. For example, parking lot and you drop your keys as you might the features and functions born of approach your car. In the distance you see a smartphone connectivity influence the social streetlight, so you move away from your car acceptability of hearing aids? Might there be toward the light to search for your keys. It’s concerns about privacy, given that many hearing easier to see over there. health providers are bound by health information laws, and smartphone connectivity involves Seems silly, right? The streetlight effect describes information tracking? Might the demographic an observational bias that finds people searching for interested in hearing aids shift? Under the that which they seek only where it is easiest to look. streetlight, we might not ask all of these In audiology, a crucial opportunity exists to move questions, or we might try to answer them beyond the streetlight effect to broaden our using familiar theories and methods. research questions and approaches. In this current study, we shift our gaze into the hard-to- Smartphone-connected hearing aids have see, and thus often overlooked area of introduced a range of new capabilities, including: sociocultural effects of technology. stereo audio transmission directly to hearing aids, real-time internet connectivity, graphical user interfaces, and real-time access to coordinates “Sociocultural refers to behaviors, values and from global positioning systems. With no relay practices common within a particular context or device, hearing aid users can control their hearing population within a given time frame. Technology aids and make location-specific program interacts with, and thus influences, the adjustments by using the iPhone® interface. For sociocultural milieu in complex ways.” example, through the mobile device feature of (Ng, Phelan, Leonard, & Galster, 2016; Orlikowski, ‘‘geotagging’’ (attaching a geographic location to a 2007; Joyce & Loe, 2010; Lehouxet al., 2014; particular media object on one’s phone), hearing Phelan, Gibson, & Wright, 2015) aid program preferences can be associated with and automatically activated at specific geotagged locations This article summarizes the Journal of the American Academy of Audiology article: “A qualitative case study of smartphone-connected Beyond the streetlight, we can dig deeper, though hearing aids: Influences on patients, clinicians, we need to draw from other scientific concepts and patient–clinician interactions.” and disciplines to do so. Technology itself may often be seen as value-neutral — only as beneficial Consider the innovation of smartphone-connected or harmful as intended by its creators and users. hearing aids. As the innovation grows, studies in Hearing healthcare as we know it could not exist this domain will likely focus on the usual suspects: without technology, which the field continually important outcomes like speech recognition, advances through research and development. quality of life, psychoacoustics. Meanwhile, However, rarely do we pause to examine the popular hearing health websites and magazines underlying assumptions of the field’s intents, reveal many fascinating assertions about other instead operating safely under the assumption

Beyond the Streetlight in Hearing Aid Research 1 that our field aims to help people hear, and theory analytic techniques, (Ng, Lingard, & therefore innovations in the field are born of these Kennedy, 2013; Meston & Ng, 2012) was most intents and are inherently positive. But as a appropriate to answer these research questions. scientific field, hearing health research has an For a detailed description of this rigorous, imperative to test its assumptions, all of its sociological methodology, see the full version of assumptions! While we often test assumptions Ng and colleagues’ (2016) paper. Data collection about the behavior of digital signal processing entailed semi-structured interviews with 19 (DSP) innovations, we rarely test assumptions people, framed as two cases – 11 patients (the about the social and cultural effects of an patient case) and eight clinicians (the clinician innovation on individuals and society. case) – and identification of 10 “grey literature” documents – news and popular media articles – related to the study topic and published during the Research questions study time frame. All but one of the patient and one of the clinician participants had tried Halo This study thus used sociological theories and hearing aids; these two participants were research methods to pose and answer two considering, but had not yet tried, smartphone- research questions: connected hearing aids. The constant comparative method (Ng, Lingard, & Kennedy, 2013; Meston & 1. How do patients and clinicians experience Ng, 2012) was conducted within and between smartphone-connected hearing aids? individual interview transcripts, and within, between, and across the clinicians and patients. 2. What are some of the sociocultural and Therefore, we are able to present findings in ethical implications of smartphone- terms of: connected hearing aids?

• Clinician experiences with smartphone- The smartphone-connected hearing aids in this connected hearing aids study were Starkey Halo™ and the associated TruLink® application, although some participants • Patient experiences with smartphone- also had experience with other manufacturers’ connected hearing aids connected devices. • Differential experiences of the same Methodology sociocultural effects, between clinicians and patients A qualitative research design, specifically collective case study drawing upon grounded • Pervasive experiences of sociocultural effects, across clinicians and patients Findings

Between-Case Findings Within-Case Findings Within-Case Findings (compare between CLINICIANS PATIENTS columns, within rows) (look within column) (look within column)

Candidacy profiles (and thus caseloads) shifted and Patients reflected upon their technological competence clinicians developed and used heuristics to determine and defined their identity as a technology user and who might benefit from these devices. learner.

Longer appointments meant increased time spent Increased workload as a technology user and Changes to the clinical getting to know the patient, necessary to best fit and “troubleshooter,” which was met with both positivity encounter/experience educate around the device. and frustration.

Across-Case Findings: The smartphone-connected hearing aids were perceived as “normal” technology, privacy concerns were acknowledged with resignation/ dismissal, and opportunities for meaningful activities were perceived as increased.

Beyond the Streetlight in Hearing Aid Research 2 Clinicians used heuristics to make The clinician-patient relationship and candidacy decisions roles changed; but this change was experienced differently Clinicians described heuristic-based judgments when deciding which patients would be good A common effect – greater effort and time spent candidates to try the smartphone-connected working with the smartphone-connected hearing hearing aids. These judgements were labelled aids relative to non-connected hearing aids “heuristic-based” to contrast them from – resulted in different experiences between evidence-based protocols. Heuristics, in clinical clinicians and patients. Clinicians identified decision-making, derive from experiential increased time spent talking to patients, about knowledge, forming quick “rules of thumb” that their lives and teaching them how to use the practitioners run through to make a clinical device and app, as an implication of the decision (Wieringa & Greenhalgh, 2015; Marewski smartphone-connected hearing aids. Clinicians & Gigerenzer, 2012). Remarkably similar across valued the increased time and effort they spent practitioners in our study, elements of these ‘‘getting to know’’ their patients. Patients also heuristics included: identified considerable effort related to using and troubleshooting the smartphone-connected • Patient experience with and usage of hearing aids. Many were frustrated by this smartphone technology, as gathered from additional effort, while the more technologically- the clinician’s observation of the patient, and savvy patients seemed more willing to adopt a case history “troubleshooter” identity with one even joining online discussion forums to take matters into his • Patient lifestyle (i.e. activity level and type) and own hands. goals (e.g. being able to hear better on the phone) as determined both informally and through more formal assessment The smartphone-connected hearing aids had a ‘normalizing’ effect • Cost versus patient budget Across patients and clinicians, there was a resounding theme of ‘‘normalization’’ of hearing Patients described themselves in terms aids via their integration with a ‘‘normal’’ of technological (in)competence technology (mobile phones). Participants appreciated the inconspicuous nature of the Patients’ described themselves in terms of connected devices, allowing discreet volume technologically competent or incompetent. control. One patient specifically remarked on how Those who perceived themselves as tech-savvy much “cooler” his hearing aids were than his tended to take pride in being able to use the mother’s, and specifically noted that he was glad smartphone-connected hearing aids. Those who his hearing aids did not resemble hers. One perceived themselves as technological clinician remarked on how the link to the neophytes tended to see the smartphone- smartphone meant that Halo users would not connected hearing aids as a learning “look old” while controlling a device from a opportunity. Importantly here, technological smartphone, whereas another specifically competence was tied to participants’ sense of promoted Halo based on how discreet they are. identity, with one patient even “studying” the Along with this normalization trend was a smartphone application prior to his perception of an expanded caseload. Both patients appointment, for fear of presenting an and clinicians suggested that this innovation incompetent image of himself. would result in younger demographics and skeptical patients increasing their willingness to

Beyond the Streetlight in Hearing Aid Research 3 try hearing aids. Some clinicians perceived this The Clinical Encounter as a trend in their practice. As one clinician said, “They have completely changed the way that we fit Clinicians may wish to consider two ways in which hearing aids, and honestly, they’ve helped change a smartphone-connected hearing aid may shift my entire client database.” the nature of the patient-clinician relationship.

1. Patients who adopt smartphone-connected Information privacy was considered a hearing aids may take on more responsibility lost cause in terms of usage effort and technological learning. Some patients may feel a sense of Clinicians and patients alike seemed indifferent insecurity regarding their technological regarding the geotagging and other forms of competence. Therefore, patient education and surveillance embedded in the smartphone counseling may need to address the greater application. Overall, participants in our study expectations of patient “workload” related to seemed resigned to a loss of control with respect the technology – learning how to use the to digital data in general. Perhaps since all but application for example – and to keep in mind one clinician and one patient participant had that patients may need support as they already adopted Halo hearing aids, our develop their identity as a technology user. participants were generally unconcerned about the details or implications of sharing their data. 2. Candidacy profiles for smartphone-connected hearing aids may look different than those for The connected hearing aids supported non-connected hearing aids. Clinicians may participation in meaningful activities wish to attend to potential assumptions about who might benefit from smartphone Particular to the connectivity aspect, participants connectivity, in light of some of our attributed opportunities to enjoy activities of participants telling us about their willingness meaning to their Halo hearing aids. Specifically, to try new technology or to learn new more enjoyable music listening, and conversing in technology, even if they didn’t start out as the car, on the phone, and at work were smartphone-savvy. While heuristics have highlighted by our participants. actually shown promise to be just as, or more, effective than protocols, (Wieringa & Greenhalgh, 2015) they do have some pitfalls Implications and Conclusions (Norman & Eva, 2010). Clinicians should ask themselves who they might be inappropriately The implications of these findings will be ruling out by applying their heuristics. discussed in terms of what we have learned in this move away from the streetlight, and where we still need to look: Normalization and Stigma: Critical questions for our field • Considerations for integrating the innovation into our clinical encounters A paradox presents itself in our findings. On the one hand, patients’ experiences of stigma may • Critical views on taken-for-granted decrease by way of connecting a formerly assumptions in our field stigmatized assistive device (the hearing aid) with a popular, everyday technology (the smartphone). • New research directions, beyond the This outcome is, in many respects, positive. streetlight However, on the other hand, to make a hearing aid more discreet and “cool” may also feed into

Beyond the Streetlight in Hearing Aid Research 4 societal stigma, as our field implicitly tries to hide considers the range of listening situations and hearing loss by blending it into everyday life. In this demands people encounter, and their relative sense, stigma itself is not being decreased, but importance to people, (Gatehouse, Naylor, & rather hearing aid wearers are blending in more Elberling, 2003) research in this realm may be effectively, hiding that which is still stigmatized. expanded by an occupational science lens.

Therefore, a crucial practice point for all of us in As innovations open up new possibilities for the hearing aid industry must be made: while we patients, the patient-clinician encounter may need develop and dispense these technologies to help to be informed by new science to shift most people, we must continue to critically challenge optimally. This “new” science may require a move society to accept hearing loss as an aspect of life away from the streetlight. Clinical decision- that many will experience. A range of choices is making research is an exciting field stemming available to those with hearing loss, and this from the cognitive and social sciences (Wieringa range will likely continue to grow. But rather than & Greenhalgh, 2015; Norman & Eva, 2010; pushing discreet or “cool” technological Mamede, Schmidt, & Rikers, 2007). This study’s innovations as the sole answer, we have an findings about clinicians’ use of heuristics open up ethical imperative to continue to push society many research questions that we will pursue. toward genuine acceptance and inclusion. Everyday practices that may help achieve this Summary goal include being mindful of the language we use in practice and in promoting hearing aids. We Every field has its focus, and hearing healthcare should attend to and query language that implies has long focused where it certainly should. Yet this hearing loss should be hidden, keeping in mind study opens up new avenues of research, which that we may be influencing people’s sense of are also important to the field. As clinicians, identity as an individual with hearing loss. engineers, scientists, and hearing aid users, we do Therefore, we must continually engage in critical not only exact our influence on future hearing analysis of our own practices and the language innovations, we are also influenced by technologies we use to talk about options and opportunities, (e.g. smartphones), and the new social possibilities lest we hurt those we are aiming to help (Phelan, they produce. These effects require continued Wright, & Gibson, 2014). interdisciplinary inquiry and critically conscious practices. Exciting new research directions, beyond the streetlight

Further research could help articulate some considerations for candidacy decision-making, perhaps taking into account concepts from occupational science and auditory ecology. Occupational science looks at activities of meaning, toward enabling meaningful participation in society (Phelan & Kinsella, 2009). Given the substantial role of individual’s lifestyles and meaningful activity in connected hearing aid candidacy decision-making, an occupational science lens may help us attend to questions beyond the reach of our current theories in hearing science. While auditory ecology already

Beyond the Streetlight in Hearing Aid Research 5 References

Gatehouse, S., Naylor, G., & Elberling, C. (2003). Benefits from hearing aids in relation to the interaction between the user and the environment.International Journal of Audiology, 42 (sup1), 77-85.

Joyce, K. & Loe, M. (2010). A sociological approach to ageing, technology and health. Sociology of Health & Illness. 32(2):171–80. 10.1111/j.1467-9566.2009.01219.x

Lehoux, P., Gauthier, P., Williams-Jones, B., Miller, F. A., Fishman, J. R., Hivon, M., & Vachon, P. (2014). Examining the ethical and social issues of health technology design through the public appraisal of prospective scenarios: A study protocol describing a multimedia-based deliberative method. Implementation Science. 9(1):81. 10.1186/1748-5908-9-81

Mamede, S., Schmidt, H. G., & Rikers, R. (2007, February). Diagnostic errors and reflective practice in medicine. Journal of Evaluation in Clinical Practice. 13(1):138–45. 10.1111/j.1365-2753.2006.00638.x

Marewski, J. N. & Gigerenzer, G. (2012). Heuristic decision making in medicine. Dialogues in Clinical Neuroscience. 14(1):77–89.

Meston, C. N. & Ng, S. L. (2012). A grounded theory primer for audiology. Seminars in Hearing. 33(2):135–46. 10.1055/s-0032-1311674

Ng, S., Lingard, L., & Kennedy, T. (2013). Qualitative research in medical education: Methodologies and methods. In: Swanwick, T., editor. Understanding Medical Education: Evidence, Theory and Practice. 2nd ed. Oxford, UK: John Wiley & Sons, Ltd; 2013. p. 371–84. 10.1002/9781118472361. ch26

Ng, S. L., Phelan, S. K., Leonard, M., & Galster, J. (2016). A qualitative case study of smartphone-connected hearing aids: Influences on patients, clinicians, and patient–clinician interactions. Journal of the American Academy of Audiology. 0:1–16. http://dx.doi.org/10.3766/jaaa.15153

Norman, G. R. & Eva, K. W. (2010, January). Diagnostic error and clinical reasoning. International Journal of Medical Education. 44(1):94–100. 10.1111/j.1365-2923.2009.03507.x

Orlikowski, W. J. (2007, September 1). Sociomaterial practices: Exploring technology at work. Organizational Studies. 28(9):1435–48. 10.1177/0170840607081138

Phelan, S. K., Gibson, B. E., & Wright, V. (2015). What is it like to walk with the help of a robot? Children’s perspectives on robotic gait training technology. Disability and Rehabilitation. 1–10. doi:10.3109/09638288.2015.1019648Title

Phelan, S. & Kinsella, E. A. (2009). Occupational identity: Engaging sociocultural perspectives. Journal of Occupational Science. 16(2):85–91. DOI:10.108 0/14427591.2009.9686647

Phelan, S. K., Wright, V., & Gibson, B. E. (2014, February 25). Representations of disability and normality in rehabilitation technology promotional materials. Disability and Rehabilitation.1–8. 10.3109/09638288.2014.891055

Wieringa, S. & Greenhalgh, T. (2015, April 9). 10 years of mindlines: A systematic review and commentary. Implementation Science. 10(1):45. 10.1186/s13012-015-0229-x

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