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.