20Q: Positive Focus - An Innovative Way to Improve Hearing Aid Use, Benefit, and Satisfaction

From the Desk of Gus Mueller

Am I excited!  I can hardly wait to get to work today!  It’s going to be so fun.  Sit on hold for 30 minutes or more waiting to talk to my favorite hearing aid manufacturer, clean out gunk from a really nasty plugged receiver, and maybe do a little masking for a bilateral 40 dB A/B gap!  Did you know that positive thinking, and a general positive view on life, can result in: Increased life span, lower rates of depression, lower levels of distress and pain, greater resistance to illnesses, better psychologic and physical well-being, and a reduced risk of death from cardiovascular disease and stroke?

In the world of sports, research has shown that acting on “intrinsic motivation” is the most effective way to motivate oneself to obtain the highest levels of performance and is a source of personal satisfaction.  Hmm.  What if we applied this notion of a positive focus to the world of hearing aid benefit and satisfaction?

In this month’s 20Q, we’re going beyond the technical aspects of the selection and fitting of hearing aids, and talking about some of the psychological factors influencing patient outcomes. More specifically, we'll be exploring what is often called “positive focus intervention,” which suggests that how patients perceive and reflect on their hearing aid experiences can significantly impact their success.

Our guest author is Dina Lelic, PhD, Principal Scientist at the ORCA Labs, WSAudiology in Denmark. If you’ve checked out the audiology literature over the past few years, you know that she has authored numerous peer-reviewed papers, with a commitment to advancing evidence-based approaches in hearing healthcare.  In general, her work focuses on understanding real-life needs and behaviors of people living with hearing loss and hearing aid users, with the goal of developing meaningful interventions that improve their quality of life. 

At ORCA Labs, she leads clinical research activities and supports development and evaluation of hearing solutions that deliver optimal outcomes. Dr. Lelic collaborates closely with academic institutions and hearing clinics to ensure that research insights translate into practical benefits for users—which is evidenced in this 20Q article. 

It is well known that a substantial proportion of hearing aid owners do not use their devices consistently.  We also know that a perceived lack of benefit is a leading reason for this.  As pointed out by Dina in her excellent article, understanding these non-audiologic factors and how they can be applied could be a game-changer for your clinical practice.

Gus Mueller, PhD
Contributing Editor

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

Note: The information in this article was accurate at the time of writing. Proposed changes to the federal budget may impact the ongoing funding of newborn hearing screening and intervention services.

20Q: Positive Focus - An Innovative Way to Improve Hearing Aid Use, Benefit, and Satisfaction

Learning Outcomes 

After reading this article, professionals will be able to:

• Define the core idea underlying Positive Focus.
• List at least three outcomes of using Positive Focus that have been identified in research studies.
• Identify one way to incorporate Positive Focus in clinical practice.

Dina Lelic

1. Can you begin by explaining what the Positive Focus intervention is? 

My personal interest in the Positive Focus intervention approach simply involves asking hearing aid users to focus on their positive listening experiences in everyday life and reflect on them via, for example, an app or a text message. That’s all there is to it.   

2. Sounds pretty simple.  What is the core idea behind this intervention?

The core idea is to counteract what's known as "negativity bias," a psychological phenomenon where negative events are perceived as more potent and salient than positive ones. For hearing aid users, this means difficult experiences might overshadow the benefits, leading to dissatisfaction. The Positive Focus intervention asks hearing aid users to actively focus on, identify, and reflect upon their positive listening experiences in everyday life. Repeatedly focusing on beneficial experiences can help overcome this negativity bias, leading to increased appreciation, satisfaction, and ultimately, more consistent use of their hearing aids.  

3. Where did the idea for Positive Focus come from? Is there research that supports this approach?

The Positive Focus approach has been applied in the field of positive psychology. Research has shown that a consistent focus on emotionally positive experiences can enhance self-reported cognitive and emotional abilities, as well as happiness. In the world of audiology and the fitting of hearing aids, the concept builds on a growing body of evidence indicating that the intervention and counselling process itself can significantly influence hearing aid benefits, independent of the device's technical capabilities. Previous positive framing studies showed that simply describing hearing aids as "digital" versus "analog," or "new" versus "conventional," or conveying a positive narrative before fitting, led to better subjective and even objective outcomes like speech-in-noise performance. What sets the Positive Focus intervention apart is its shift from externally delivered narratives to internally generated ones. Instead of being told a positive story, users are encouraged to construct their own by actively reflecting on positive listening experiences. This approach draws from positive psychology research, which shows that internalizing positive experiences enhances life satisfaction and happiness. So, we asked: what if we applied this to audiology? Could encouraging hearing aid users to reflect on positive listening moments improve hearing aid outcomes? That question became the foundation for three different Positive Focus studies.

• Study #1:  Lelic, D., Parker, D., Herrlin, P., Wolters, F., & Smeds, K. (2023). Focusing on positive listening experiences improves hearing aid outcomes in experienced hearing aid users. International Journal of Audiology.
• Study #2:  Lelic, D., Herrlin, P., Wolters, F., Nielsen, L. L. A., Tuncer, C., & Smeds, K. (2024). Focusing on positive listening experiences improves hearing aid outcomes in first-time hearing aid users: a randomized controlled trial. International Journal of Audiology.
• Study #3:  Lelic, D., Nielsen, L. L. A., Pedersen, A. K., & Neher, T. (2024). Focusing on Positive Listening Experiences Improves Speech Intelligibility in Experienced Hearing Aid Users. Trends in Hearing.

4. All very interesting. I’d like to hear a little more about the design of your studies? It sounds like you studied both first-time and experienced hearing aid users?

Yes, the research spanned both of those groups. In Study 1, we focused on experienced users and investigated subjective outcomes after 2-3 weeks of reporting positive listening experiences. In Study 3, we also focused on experienced users to assess measured speech intelligibility after two weeks of reporting positive listening experiences. In Study 2, on the other hand, we specifically investigated first-time hearing aid users to see both short- and long-term effects of the Positive Focus intervention. We followed first-time users for six months, and self-report assessments were taken at weeks 2, 4, 8, 12, 16, 20, and 24.
In all three studies, study participants were randomized to either a Positive Focus group or a control group. The two groups were comparable in terms of age, gender, degree of hearing loss, personality, hearing-related lifestyle characteristics, and hearing aid expectations. All participants were fitted with the same brand and model of hearing aids by the same audiologist and followed the same study protocol. The only difference between the groups was that the Positive Focus group was exposed to the Positive Focus intervention. 

5. How was this Positive Focus intervention implemented in your studies? 

Participants in the Positive Focus group were instructed to focus on good listening experiences with their new hearing aids and report them via an app (Study 1 and 2) or text message (Study 3). They were told that a good experience could be anything from hearing birds or dripping water to understanding speech in noisy environments. They could compile experiences at the end of the day or report in the moment, and they were encouraged to keep reporting even if repeating themselves. Importantly, all positive reports were self-initiated. 

6. What specific types of positive listening experiences did participants report? 

Participants reported a diverse range of positive listening experiences, which highlights how the intervention effectively drew attention to the benefits of their hearing aids. For instance, they noted hearing nature sounds like birds singing, rustling leaves, or falling rain. Many reported improved speech communication, such as understanding conversations at parties, family dinners, or being able to focus throughout meetings. There was also increased awareness of environmental sounds, like traffic noise or the sounds within a shopping center. For first-time hearing aid users, reported experiences broadly categorized into speech communication (44%), monitoring surroundings (33%), and focused listening (e.g., when watching TV or listening to a lecture) (21%). Other reports included general improvement and enjoyment of the devices, comfort, and even tinnitus reduction. 
By consistently focusing on and reflecting upon these personally relevant experiences, the intervention helped users realize the true benefits of their hearing aids. This self-generated awareness and appreciation directly contributed to increased hearing aid satisfaction, which was observed in our studies.

7. You mention that you observed increased satisfaction in your studies. Can you speak, more specifically, to what were the key findings? 

The Positive Focus group showed significantly better hearing aid outcome ratings compared to the control group who did not focus on and report their good listening experiences. This was evidenced across multiple self-report measures:

• International Outcome Inventory for Hearing Aids (IOI-HA): Significantly higher scores in the Positive Focus group (Study 1 and Study 2).
• Hearing-Related Lifestyle Questionnaire (HEARLI-Q): Significantly higher hearing aid satisfaction scores (Study 1 and Study 2).
• Ecological Momentary Assessment (EMA): Significantly higher satisfaction scores on the EMA scale (Study 1).
• Client-Oriented Scale of Improvement (COSI): Both the "degree of change" and "final ability" ratings were significantly higher in the Positive Focus group (Study 1 and Study 2).

8. Was it a short-term or long-term effect?

The effects were both short-term and long-term.
Based on the results of IOI-HA, HEARLI-Q, and COSI, hearing aid satisfaction and benefit scores were significantly better in the Positive Focus group as early as two weeks after fitting. Crucially, the improved outcomes persisted throughout the entire six-month trial period even though the number of positive reports tapered off after about five weeks (Study 2). This indicates that as long as the new hearing aid user focuses on and reports on positive listening experiences during the critical initial period after the hearing aid fitting, it’s enough to sustain a long-term effect of the Positive Focus intervention. 

9. Beyond subjective satisfaction, did Positive Focus influence objective hearing aid performance, like speech intelligibility?

Yes, somewhat remarkably, it did.  The Positive Focus intervention improved objective speech-in-noise performance in experienced hearing aid users (Study 3). These participants were fitted with new hearing aids and their speech-in-noise abilities were measured on the Danish Hearing in Noise Test (HINT) and the Danish Dagmar, Asta & Tine (DAT) corpus. Then, they went home and wore the hearing aids for two weeks in their everyday environments. After two weeks, speech-in-noise performance was measured again. For the Positive Focus group, performance significantly improved on both speech intelligibility tests. No significant change was observed in the control group.

10. How significant were these improvements in speech intelligibility?

On the HINT test, the control group demonstrated average speech recognition thresholds of -2.8 dB SNR immediately after fitting and -2.4 dB SNR two weeks later. In comparison, the Positive Focus group showed thresholds of -2.5 dB SNR immediately after fitting and improved to -3.8 dB SNR after two weeks, following reflection on positive listening experiences. For the DAT test, the control group had average thresholds of 10.3 dB SNR immediately after fitting and 9.8 dB SNR after two weeks. The Positive Focus group, however, started at 11 dB SNR and improved to 8.5 dB SNR after two weeks of reflecting on positive listening experiences.

These gains in speech intelligibility for the Positive Focus group were statistically significant. Notably, the 2.5 dB SNR improvement on the DAT test can be considered clinically meaningful. Furthermore, 47% of participants in the Positive Focus group experienced improvements exceeding 2.5 dB SNR.

11. What's the proposed psychological mechanism behind why this works?

The primary mechanism is the reduction of negativity bias. By actively seeking out and reflecting on positive listening experiences, users become more aware of situations where their hearing aids genuinely help them. This increased awareness and appreciation for the benefits can overshadow challenging experiences, leading to greater overall satisfaction and a better user experience. There could also be a link to "gain/loss framing," where focusing on positive experiences highlights the benefits (gain) of wearing hearing aids and what might be missed (loss) if they are not used. 

12. Did the number of positive reports influence the outcomes?

It seems so. There was a significant positive relationship between the number of submitted positive reports and certain hearing aid outcome ratings.

In experienced users, COSI degree of change was positively correlated with the number of reports (Study 1). In first-time users, a significant positive relationship was found between the number of submitted reports and overall hearing aid satisfaction, IOI-HA total score, hearing aid satisfaction measured on the HEARLI-Q scale, and COSI degree of change (Study 2). While causality isn't established, it indicates a positive relationship between the number of positive experiences participants reflected on and hearing aid outcomes.

13. Did Positive Focus affect how much people used their hearing aids?

In Study 2 involving first-time users, the Positive Focus group tended to use their hearing aids more than the control group. At the one-month follow-up, hearing aid log data showed that participants in the Positive Focus group used their hearing aids for an average of 10.3 hours per day, compared to 7.7 hours per day in the control group. This trend of increased usage could potentially lead to higher hearing aid acceptance.

14. Did the participants' reflections at the end of the studies differ between the Positive Focus and control groups?

They did.  We conducted exit interviews at the end of our studies, and we observed a notable difference in the way participants in the Positive Focus and control groups talked about their experiences. 

In Study 1, the control group typically discussed the experiment itself, the app, prompts, and questionnaires, with no mention of the hearing aids. In contrast, the majority of participants in the Positive Focus group talked about their pleasant experiences with the hearing aids. This indicates that the Positive Focus intervention primed the users to think and talk about their positive experiences. 

In Study 3, when asked if they became more aware of helpful or problematic situations, most participants in the Positive Focus group said "yes," compared to only one in the control group. And when asked if they could recall some positive and negative listening experiences that they’ve had during the two-week trial period, the Positive Focus group, on average, named 2.8 good listening experiences and 1 difficult listening experience. Conversely, participants in the control group could recall, on average, 1.5 good listening experiences and 1.1 difficult experiences. This means the Positive Focus group recalled more everyday positive listening experiences compared to the control group, while the number of difficult listening experiences was comparable between the two groups. The positive-to-negative ratio in the Positive Focus group aligns broadly with the "3-to-1 positivity ratio" proposed by Fredrickson (2013), which suggests that three positive experiences are needed to offset one negative one. This indicates that the larger number of positive experiences may have mitigated negativity bias by making difficult experiences less relevant.

15. That’s really interesting! So, in other words, the Positive Focus intervention made the positive listening experiences more present or bigger in the hearing aid user’s mind which is what led to improved hearing aid outcomes?

Yes, that seems to be the case. So, all in all, the Positive Focus intervention did not eliminate the negative experiences, as participants in the Positive Focus group still encountered some challenges. However, it diminished the impact of those negative experiences on the overall hearing aid experience. This is really important to say because I am in no way advocating that negative experiences do not exist or that we should ignore those negative experiences  - some people will still need extra fine-tuning of the hearing aids, guidance, and counselling. But, by asking patients to focus on positive listening experiences and reflect on them, users will realize that there are many situations in which hearing aids are truly helping them, and this will lead to greater overall hearing aid experience. 

16. What are the direct clinical implications of these findings for audiologists?

The findings strongly point to the importance of asking hearing aid users to focus on positive listening experiences and to reflect and talk about them. This can lead to increased hearing aid benefit and satisfaction, potentially encouraging more consistent use of devices. For first-time users, this intervention could be a potent tool to augment the effectiveness of hearing aids and encourage their adoption, especially during the crucial initial weeks after fitting. Notably, recall that there even was a small improvement in speech-in-noise understanding,  highlighting the power of this non-audiological intervention. Moreover, satisfied users are more likely to recommend hearing aids to others, potentially increasing uptake.

17. I have a pretty busy practice.  Is this intervention going to be burdensome for me?

No, the implementation of the Positive Focus intervention is not expected to be burdensome for clinicians. In our studies, audiologists did not discuss the incoming positive reports with participants, nor was there expectation from participants to discuss them at follow-up visits. Your primary role would be to instruct the patient on the task and encourage adherence.

18. How does this align with broader counselling goals?

The audiologist's role in the Positive Focus intervention is primarily to initiate and support the patient's engagement with the task. This involves instructing the patient to focus on and report positive listening experiences. 

While the audiologist does not need to actively discuss individual positive reports with patients, they could monitor compliance. If a patient doesn't report any positive listening experiences for a set period, the audiologist may follow up with a gentle reminder to encourage attention to and reporting of positive listening experiences. This intervention is designed to facilitate the patient's own internal reflection and narrative construction of how hearing aids are truly helping them, shifting from a third-party narrative to self-discovery of benefits. This self-discovery is crucial for increasing satisfaction and consistent use.

This approach aligns with broader counselling goals by encouraging patients to actively reflect on and talk about their successful listening moments. This fosters a positive feedback loop, enhances awareness of hearing aid benefits, and can ultimately lead to greater hearing aid acceptance. 

19. Are there any practical considerations for implementing Positive Focus in a clinic? 

One thing you’ll want to think about is if you want your patients to reflect via an app, text message, e-mail, paper-pen diary, or another format. In our studies, participants reported their experiences either through a smartphone app or by sending a daily text message - both methods proved effective. Although we used digital tools, a basic paper-and-pen diary could serve the same purpose. Importantly, summarizing experiences at the end of the day was just as beneficial as reporting in real time, and may be more practical, as users are not required to engage with the process during potentially inconvenient moments. Notably, the positive effects observed in first-time users continued even after the frequency of reporting decreased, suggesting that a brief initial reporting period post-fitting may be sufficient to create lasting benefits. That said, the approach may not be suitable for everyone - two participants in Study 2 withdrew due to the demands of regular reporting. Still, for those who are motivated, the benefits are clear. 

20. So, do you have an overarching take-home message for audiologists?

I do!  My overarching message is clear: Focusing on positive listening experiences is a powerful and practical intervention that can significantly improve perceived hearing aid benefit and satisfaction in both experienced and first-time hearing aid users and can even enhance objective speech intelligibility. By guiding patients to actively reflect on their successful listening experiences, clinicians can create a reinforcing cycle of positive feedback that mitigates negativity bias, increases awareness of hearing aid benefits, and supports long-term acceptance and consistent use, complementing the technical aspects of fitting. This simple, patient-centered approach can be a valuable addition to routine clinical counselling practices, especially during the initial onboarding period.

References

Fredrickson, B. L. (2013). Updated thinking on positivity ratios. American Psychologist, 68(9), 814–822. DOI: https://doi.org/10.1037/a0033584

Lelic, D., Parker, D., Herrlin, P., Wolters, F., & Smeds, K. (2023). Focusing on positive listening experiences improves hearing aid outcomes in experienced hearing aid users. International Journal of Audiology, 63(6), 420-430. DOI: https://doi.org/10.1080/14992027.2023.2190006

Lelic, D., Herrlin, P., Wolters, F., Nielsen, L. L. A., Tuncer, C., & Smeds, K. (2024). Focusing on positive listening experiences improves hearing aid outcomes in first-time hearing aid users: a randomized controlled trial. International Journal of Audiology, 64(5), 498–508. DOI: https://doi.org/10.1080/14992027.2024.2379533

Lelic, D., Nielsen, L. L. A., Pedersen, A. K., & Neher, T. (2024). Focusing on Positive Listening Experiences Improves Speech Intelligibility in Experienced Hearing Aid Users. Trends in Hearing, 28, 1–1, DOI: https://doi.org/10.1177/23312165241246616