NIHR Nottingham Hearing Biomedical Research Unit

1. Note: unpublished data have been removed to prevent future publishing conflicts “If it wasn’t for the DVD I’d have stopped wearing my hearing aids” Interactive videos for hearing aid users NIHR Nottingham Hearing Biomedical Research Unit Mel Ferguson

2. The unmet need in the UK • An estimated people with hearing loss • No. of hearing aid users = • Average age of first-fit = yearsold • Significant problems years 10 million 2 million 4 million Estimate of nos benefitting from a hearing aid= 74 10+ Access to hearing services is not optimal Davis 1995; ONS 2010; Davis et al. 2007

3. Non-use of hearing aids 350,000 • 2010/11: NHS England n= first time users • Non-use of hearing aids = • Costs of non-hearing aid use • To NHS: Annual = • To person with hearing loss = communication difficulties   • HA use and benefit for many is not optimal • HA fitting occurs too late or not at all ~20% ~£25-30m reduced social interaction reduced quality of life Hearing aids alone are not the only option

4. Non-use of hearing aids 350,000 • 2010/11: NHS England n= first time users • Non-use of hearing aids = • Costs of non-hearing aid use • To NHS: Annual = • To person with hearing loss = communication difficulties   • HA use and benefit for many is not optimal • HA fitting occurs too late or not at all ~20% ~£25-30m reduced social interaction reduced quality of life Hearing aids alone are not the only option

5. Habilitation for Hearing Loss • Evaluate interventions • based on scientific principles of: • brain plasticity • learning theory • patient centred care

6. Brain plasticity Auditory and cognitive training

7. Brain plasticity • Does auditory training work? • See systematic review in people with hearing loss • Henshaw and Ferguson, PLoS One, 2013 • Improvements shown for the trained task • Some evidence of generalisation to measures of speech intelligibility, cognition & communication • Auditory training on phonemes (mild HL) results in • - significant training on the task • - significant improvement in challenging listening situations • - improvements in complex, but not simple cognition • - no improvement in speech in noise • (Ferguson et al, in review)

8. Brain plasticity So what about training cognition directly? Study of 54 hearing aid users See Poster “Holding back the ears – auditory and working memory training in people with hearing loss” Henshaw & Ferguson

9. Patient centred care Motivational engagement

10. Motivational engagement See poster “Feasibility of using motivational tools in an audiology clinic” Offers useful tips and advice to aid clinical practice • 30 minute ethnographic video • (clinician training) • Available online: • http://hearing.nihr.ac.uk

11. Learning theory Interactive patient education

12. Delivery and retention of information Lots of information Some questions for you: How many see clients on a regular basis? How many give (i) verbal info (ii) written info (iii) some other media How many are fully satisfied that the client gets all the info they need? How much information is remembered 6 weeks after the final appt with you?

13. Delivery and retention of information “You get a lot of information …by the time you get home, you’ve forgotten most of it.” 51% found difficulties using aid at first (RNID Hear Me Out, 2011) Retention of information in first-time HA users after 6 weeks Overall = 49.6% Practical = 62.9% Psychosocial = 34.3% (El-Molla, Smith, Henshaw, Ferguson)

14. Supplementary delivery of information • Information booklets, as standard • Internet • Constructivist learning theory • the learners construct an internal representation by taking an active role • higher interactivity with learning materials promotes learning (Zhang et al, 2006) • Re-usable Learning Objects (RLOs)

15. Re-usable learning objects (RLOs)(or interactive video tutorials to you and me) Interactive multimedia clips • Commonly used in elearning environments • Participatory approach - high quality materials aligned to the user’s needs • Improve motivation and compliance with health treatments Highly visual illustration of concepts support learning goal Self-assessment – a test of mastery of content Activity and engagement with the content

16. HEAR IT study Q: Do video tutorials supplement advice and information provided by audiologists and result in enhanced benefit and use for hearing aid users? • To develop a series of reusable learning objects (RLOs) • range of auditory rehabilitation subjects • accessible to hearing aid users and their families 2. To evaluate the benefits and cost-effectiveness of the RLOs Randomised controlled trial (CTU) RLO+ or RLO+

17. RLO development – participatory design Storyboard Workshops HA users Storyboard Workshops HA users Storyboard Workshops NAS audiologists Spec Review Develop Review Pilot Use & evaluation

18. Delivery of RLOs 1hour duration Introduction HA Controls Earmould insertion Expectations Adaptation Communicn tactics Phones and ALDs Trouble-shooting 50-54 yo 70-74 yo PC use = 85% = 36% Internet use = 66% = 17% Henshaw, Clark, Kang, Ferguson, J Int Med Res 2012

19. Based on educational principles Each reusable learning object (RLO) has: • Learning outcomes • Subtitles • Reinforcement and consequences • Variety of images • Photos, animations, videos (including testimonials) • Interactive quiz • Problems? Go back to Audiology

20. Troubleshooting“the earmould may not be inserted correctly”” Video clips are not available through this ppt but sample clips can be seen on the NHBRU website http://www.hearing.nihr.ac.uk/public/interactive-video-tutorials-for-hearing-aid-users-hear-it So please do take a look.

21. Based on educational principles Each reusable learning object (RLO) has: • Learning outcomes • Subtitles • Reinforcement and consequences • Variety of images • Photos, animations, videos (including testimonials) • Interactive quiz • Problems? Go back to Audiology

22. Acclimatisation“gradually our brain adapts” Video clips are not available through this ppt but sample clips can be seen on the NHBRU website http://www.hearing.nihr.ac.uk/public/interactive-video-tutorials-for-hearing-aid-users-hear-it So please do take a look.

23. Communication partners“hearing loss is not visible” Video clips are not available through this ppt but sample clips can be seen on the NHBRU website http://www.hearing.nihr.ac.uk/public/interactive-video-tutorials-for-hearing-aid-users-hear-it So please do take a look.

24. Based on educational principles Each reusable learning object (RLO) has: • Learning outcomes • Subtitles • Reinforcement and consequences • Variety of images • Photos, animations, videos (including testimonials) • Interactive quiz • Problems? Go back to Audiology

25. Interactive Quiz

26. Interactive Quiz

27. Based on educational principles Each reusable learning object (RLO) has: • Learning outcomes • Subtitles • Reinforcement and consequences • Variety of images • Photos, animations, video (including testimonials) • Interactive quiz • Problems? Go back to Audiology

28. To date, recruited n=203evaluated n=152planned total n=170Today: results from n=100 Interim results

29. How do we measure success?

30. RLO access and compliance Barriers to RLO access n=675 (49.5% fit criteria) **No access to DVD, PC or internet = 32% Poor understanding of English = 9% Inability to use RLOs due to cognitive decline = 15% These barriers have implications for implementation into clinical practice. • RLO uptake and compliance • Expressed interest in RLOs and participating in study = 78% • Compliance was high • 92% watched all the RLOs more than once • 8% watched at least half • There is high interest and compliance with the RLO concept.

31. RLO re-use suggestsself-management

32. Internet use was higher than initially expected Henshaw et al (2012) 70-74y=17% 65-69y=36% 37% opted for internet; 63% opted for DVD Age: mean 67.7y (range 42-94y) (age not interested = 74.8y, 50-92y)

33. V+ group: better knowledgeof HAs and communication 20 item questionnaire; free recall 6 weeks post-fitting Highly significant effect of video group - total (p<.001) - practical (p<.001) - psychosocial (p<.001) Error bars = mean +/- 95% CI

34. V+ group: better knowledgeof HAs and communication Highly significant difference evident for both practical and psychosocial scores (p<.001) Error bars = mean +/- 95% CI

35. V+ group: better practicalHA maintenance skills Practical Hearing Aid Skill Tasks; 18 items Highly significant effect of video group (p<. 001) - but only for HA/EM clean and phone use (p<.001) Error bars = mean +/- 95% CI

36. HA outcome measures:limited benefits of V+ Glasgow Hearing Aid Benefit Profile Satisfaction with amplification in daily life No significant difference between groups HA non-use V+ n= 0 V- n= 5 (10%) Significant effect of group overall p=.50 V+ more satisfied re negative effects (b/g noise, feedback, phone), p<.01 Error bars = mean +/- 95% CI

37. RLOs were rated as highly useful • Quantitative and qualitative methods On a scale form 0-10, where was highly useful Range 8.6-9.3, average 9.0

38. Positive feedback on RLOs • 5 point scale (strongly agree to strongly disagree) • Gave me confidence to use HAs and communicate • Gave me additional advice to the audiologist • If I had a problem I would refer back to RLOs • Quiz was valuable to show me what I’d learned • Prefer RLOs to written information • More likely to contact audiology agree disagree

39. The users voice: seemed to like them Insertion For more sample clips go to http://hearing.nihr.ac.uk/

40. Users voice: post-evaluation focus groups • 3 groups, mix of V+ and V-, n=7-10 • Main themes • RLOs aligned to people’s experience • Content supported by the majority • Repeated watching • … I found that I had missed something. So I went back and looked at it again • Sharing of videos with others (family, friends, neighbours) • I have passed my DVD on to on old couple who both have hearing aids …" I kept telling her. "Play that DVD and you will know why," because you have got to get used to it, haven't you?”

41. Post-evaluation focus groups • Provided reassurance, helped remember things • Improved awareness and confidence • it explained how we have to learn to rehear things. That is not an aspect that I [was aware of], to re-educate the brain to interpret what you hear. • Communication partners were involved • “Well, I went through them, right the way through. I begged my wife to watch them as well which I thought was important” • “I sat my husband down. I said, "I would like you to watch this." Well, "What do I need to watch this for? I am not deaf," but I said, “It will help you to understand me.” So he did…. But yes, I did find it very, very useful for that”

42. Summary • Series of 7 RLOs or interactive video tutorials developed • Using tried and tested educational principles • Views and perspectives embedded from over 35 HA users • RLOs • uptake and compliance is high • patients are referring back to them • There are barriers due to accessibility and English not main language • Outcomes for video tutorial users • Better knowledge of HAs and psychosocial related issues • Better practical skills (e.g. maintenance and phone) • No difference in reported use, but more satisfied on ‘negative aspects’ • RLOs rated as highly useful • Positive feedback e.g. confidence, helping to remind, reassurance, CPs

43. Slide from 2010 When will they become available? Delivery across NHS • If beneficial • Vision – part of standard patient management for PHL to supplement information • Implementation within Audiology • concept is simple • benefits are readily recognised • demands on Audiologist’s time will be low • intervention accessible to many • cost of intervention is low

44. Would you be interested in these RLOs for your clinical practice?

45. Million dollar question How much would you pay per DVD/internet access?

46. Slide from 2010 When will they become available? Delivery across NHS • If beneficial • Vision – part of standard patient management for PHL to supplement information • Implementation within Audiology • concept is simple • benefits are readily recognised • demands on Audiologist’s time will be low • intervention accessible to many • cost of intervention is low

47. Further research • Develop an RLO specifically for CPs • Hi-tech, hi-interactivity RLOs for internet use • Low-tech option i.e. interactive booklet • Address expectations prior to HA fitting • Training • Basic hearing aid use, communication tactics • Nursing homes – training for care assistants • Hospitals – training for nurses • GPs

48. Thanks to.... NHBRU team Marian Brandreth Holly Thomas Helen Henshaw Ashana Tittle Research funded by NIHR RfPB grant Nottingham Audiology Service Will Brassington Karen Goodrum-Clarke Julie Brady Leena Kapilla Alissa Baguley Joanne Rowe Annie Jones Helen Bastow BAA Team of the year Patient panel Anne Darby Tina Wales Rachel Ravenlock Patricia Barnes Video stars (Pat, Chris, David, Tina, Caroline and Clive) University of Nottm Heather Wharrad UoN HELM Paul Leighton EM RDS James Henderson UoN HELM Mike Taylor UoN HELM

49. Summary ? • Series of 7 RLOs or interactive video tutorials developed • Using tried and tested educational principles • Views and perspectives embedded from over 35 HA users • RLOs • uptake and compliance is high • patients are referring back to them • There are barriers due to accessibility and English not main language • Outcomes for video tutorial users • Better knowledge of HAs and psychosocial related issues • Better practical skills (e.g. maintenance and phone) • No difference in reported use, but more satisfied on ‘negative aspects’ • RLOs rated as highly useful • Positive feedback e.g. confidence, helping to remind, reassurance, CPs