International Journal of Audiology

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Exploring the influence of culture on hearing helpseeking and hearing-aid uptake Fei Zhao, Vinaya Manchaiah, Lindsay St. Claire, Berth Danermark, Lesley Jones, Marian Brandreth, Rajalakshmi Krishna & Robin Goodwin To cite this article: Fei Zhao, Vinaya Manchaiah, Lindsay St. Claire, Berth Danermark, Lesley Jones, Marian Brandreth, Rajalakshmi Krishna & Robin Goodwin (2015) Exploring the influence of culture on hearing help-seeking and hearing-aid uptake, International Journal of Audiology, 54:7, 435-443 To link to this article: http://dx.doi.org/10.3109/14992027.2015.1005848

Published online: 11 Mar 2015.

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International Journal of Audiology 2015; 54: 435–443

Discussion Paper

Exploring the influence of culture on hearing help-seeking and hearing-aid uptake

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Fei Zhao*, Vinaya Manchaiah†,‡,#, Lindsay St. Claire$, Berth Danermark^, Lesley Jones⫹, Marian Brandreth¶, Rajalakshmi Krishna§ & Robin Goodwin** *Department of Hearing and Speech Science, Xinhua College, Sun Yat-Sen University, Guangzhou, China, †Department of Speech and Hearing Sciences, Lamar University, Beaumont, Texas, USA, ‡Linnaeus Centre HEAD, Department of Behavioral Sciences and Learning, The Swedish Institute for Disability Research, Linköping University, Linköping, Sweden, #Audiology India, Mysore, India, $Department of Psychology, University of Bristol, Bristol, UK, ^Swedish Institute for Disability Research, Örebro University, Örebro, Sweden, ⫹Hull-York Medical School, University of York, York, UK, ¶National Institute for Health Research, National Hearing Biomedical Research Unit, University of Nottingham, Nottingham, UK, §All India Institute of Speech and Hearing, University of Mysore, Mysore, India, and **School of Social Sciences, Brunel University, Uxbridge, Middlesex, UK

Abstract Objective: The purpose of this paper was to highlight the importance of cultural influence in understanding hearing-help seeking and hearing-aid uptake. Design: Information on audiological services in different countries and ‘theories related to cross-culture’ is presented, followed by a general discussion. Study sample: Twenty-seven relevant literature reviews on hearing impairment, cross-cultural studies, and the health psychology model and others as secondary resources. Results: Despite the adverse consequences of hearing impairment and the significant potential benefits of audiological rehabilitation, only a small number of those with hearing impairment seek professional help and take up appropriate rehabilitation. Therefore, hearing help-seeking and hearing-aid uptake has recently become the hot topic for clinicians and researchers. Previous research has identified many contributing factors for hearing help-seeking with self-reported hearing disability being one of the main factors. Although significant differences in help-seeking and hearing-aid adoption rates have been reported across countries in population studies, limited literature on the influence of cross-cultural factors in this area calls for an immediate need for research. Conclusions: This paper highlights the importance of psychological models and cross-cultural research in the area of hearing help-seeking and hearing-aid uptake, and consequently some directions for future research are proposed.

Key Words: Culture; cross-cultural communication; hearing loss; hearing help-seeking; hearing aids Hearing impairment is the most frequent sensory impairment and is one of the most common difficulties experienced by people as they grow older. The World Health Organization (2013) estimates there are 360 million people throughout the world who have moderate to profound hearing impairment. Numerous studies have shown that, in addition to the deleterious impact on communication ability, individuals with hearing impairment often also experience difficulties in both the psychological and social domains (e.g. Arlinger, 2003; Fook & Morgan, 2000). Audiological rehabilitation services and procedures (e.g. hearingaid fitting) facilitate the ability to communicate in people with hearing impairment, and are thus most likely to improve health-related quality of life by reducing the psychological, social, and emotional effects of hearing loss (Chisolm et al, 2007). The World Health Organization (2013) suggests that 90% of people with hearing impairment could benefit from wearing a hearing aid. Notwithstanding this, only a small percentage of people with hearing impairment choose to seek

professional help and take up appropriate rehabilitation (Kochkin, 2009). Therefore, hearing help-seeking, and hearing-aid uptake and use have become an important topic for clinicians and researchers (see Knudsen et al, 2010; Jensted & Moon, 2011; Saunders et al, 2012; Meyer & Hickson, 2012 for recent reviews). Evidence from the aforementioned reviews indicates that hearing help-seeking behaviors and hearing-aid uptake can be attributed to a variety of external (e.g. healthcare system, hearing devices, counselling) and internal factors (e.g. self-reported hearing disability, degree of hearing loss, gender, socioeconomic status). Of the main factors, self-reported hearing disability is the primary motive for seeking aural rehabilitation (Chang et al, 2008; Garstecki & Erler, 1998; Helvik et al, 2008; Humes et al, 2003; Meister et al, 2008; Palmer et al, 2009; Chao & Chen, 2008; Knudsen et al, 2010). In addition, the following factors (and their interactions) contribute to hearing-aid uptake: demographic factors (age, gender, socioeconomic status [SES], and educational background); psychological

Correspondence: Fei Zhao, Department of Hearing and Speech Science, Xinhua College, Sun Yat-Sen University, Guangzhou, China. E-mail: [email protected] (Received 8 December 2013; accepted 5 January 2015) ISSN 1499-2027 print/ISSN 1708-8186 online © 2015 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.3109/14992027.2015.1005848

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Abbreviation

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ICF

International Classification for Functioning, Disability and Health

variables (attitude towards hearing aids, personality, and coping strategies), as well as other factors external to the help-seeker (such as features of the healthcare system, the relevant hearing devices, and the professionals’ skills) have also been identified as influencing hearing-aid uptake (Cox et al, 2005; Garstecki & Erler, 1998; Helvik et al, 2008). Furthermore, studies have also shown differences between countries in the percentages of people seeking help, and taking up and using hearing aids (Kochkin, 2009; Hougaard et al, 2011; Davies et al, 2007; National Sample Survey Organization, 2003; Wong & McPherson, 2008). For example, in western countries such as the United Kingdom (UK) and the United States of America (USA) the hearing-aid adoption rates are reported to be about 20 to 25% of hearing-impaired people whereas in developing countries such as China and India they are reported to be 1 to 8%. Cultural diversity might be associated with such differences in hearing help-seeking and hearing-aid uptake, because the International Classification for Functioning, Disability and Health (ICF) proposed by the World Health Organization (2001) has acknowledged the role of cultural factors, such as societal attitudes (i.e. e460) in brief sets, and many such factors in comprehensive core sets (e.g. e410 - Individual attitudes of immediate family members; e425 - Individual attitude of friends; e460 - Societal attitudes; e465 - Social norms, practices, and ideologies) (ICF Research Branch, 2012; Danermark et al, 2013). In order to test the value of the World Health Organization’s ICF in the classification of problems experienced by elderly hearing-impaired people, Stephens and colleagues (2001) identified several of the factors listed previously, e.g. e410 and e425. This study highlights the importance of cultural influence in terms of how hearing loss is perceived and managed. Although evidence has shown the cultural influences on patients’ health beliefs in the nature of disease and their subsequent behaviors (Triandis, 1994; Campinha-Bacote, 2002), the relevant literature is limited in the areas of help and hearing-aid uptake, and to our knowledge, further research is needed. We therefore convened a seminar in Bristol in 2013, composed of delegates from the UK, Sweden, China, and India. These four countries were chosen to ensure variation in the individualism-collectivism dimension suggested by Hofstade (2010) (see General Discussion section for further details). They also represented an opportunistic sample of researchers committed to further and wider collaboration in order to explore relevant cross-cultural similarities and differences in attitudes towards hearing help-seeking and hearing-aid uptake in four countries, i.e. the UK, Sweden, China, and India. On the basis of presentations and group discussion, this paper describes the health-care systems, audiological services and their uses in order to identify similarities and differences between countries. In addition, theoretical approaches of potential relevance are highlighted in order to understand how culture might impact on hearing-related behaviors. Such information will provide the foundation for developing ideas on the future cross-cultural research of hearing help-seeking and hearing-aid uptake, as well as facilitating a wide collaboration by including more countries across the world.

Section 1: Health care systems, audiological services, and their uses in the UK, Sweden, China, and India This section provides a synopsis of the current situation of hearing-help seeking, hearing-aid uptake, and use in the UK, Sweden, China, and India. Attempts have also been made to highlight different dimensions across the four countries, including health-care systems, prevalence of hearing loss, and accessibility to audiological services, together with some important influencing factors which might be associated with differences in hearing help-seeking, hearing-aid uptake and use (see Table 1 for a summary).

The situation in the UK In the UK the National Health Service (NHS) provides primary health care (including medical general practices, dental practices, pharmacies, and opticians), secondary care (hospital and ambulance services), tertiary care (specialist hospitals treating diseases such as cancer), and community care (care provided in partnership with social services). Equitable, timely, and effective access to these services, maintaining their high quality and ensuring good patient satisfaction are key priorities for the government and local health authorities (Department of Health, 1998; Iezzoni et al, 2002). The NHS provides a full range of audiological services free of charge to all UK residents. Approximately 200 predominantly hospital-based audiology departments (approximately 2250 audiologists) care for a population of 26 334 residents per audiologist (Goulios & Patuzzi, 2008). Provision of discreet behind-the-ear (BTE) digital hearing aids with custom mould or open fittings is typical, with batteries and maintenance included; although other services, such as cochlear implants are also provided where appropriate. Access to NHS audiological services is most usually through a general practitioner (GP) referral but following Department of Health initiatives to improve the quality of service, efficiency and accessibility (such as Modernizing hearing-aid services, 18-week pathway, and Any qualified provider), an additional 1600 ‘private’ hearing-aid dispensers, now provide NHS services in the community. In the UK, there are more than 10 million people with hearing loss (approximately 16.1% of the total population). In spite of readily accessible and cost-free audiological services, approximately six million of these are yet to benefit from amplification, long-term audiological rehabilitation, and/or other related services (Action on Hearing Loss, 2011). Several studies of adults with acquired hearing loss in the UK indicate that a series of stages must be negotiated on the patient journey to audiology services (Manchaiah et al, 2011). Various factors or barriers may affect each stage in the patient journey, and consequently attrition occurs. For example, only about 75% of a sample of older British hearingimpaired people was aware that they had a hearing problem; of these, between 65 and 75% had sought help from their doctor for the problem, and of these, fewer than 50% owned a hearing aid (Gilhome Herbst et al, 1990). Moreover, other UK studies indicate that 45% of people who reported hearing problems to their GP were not referred on to audiology services (Davis et al, 2007; Hougaard et al, 2011) and Action on Hearing Loss (2011) estimated that 20% of hearing aids dispensed were never, or rarely used. Such studies suggest that attrition accumulates at each stage and that many, and varied factors are likely to contribute to it (Knudsen et al, 2010; Meyer & Hickson, 2012).

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Table 1. A summary of the population, prevalence of hearing loss, hearing-aid uptake estimates, and information about healthcare in the UK, Sweden, China, and India.

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UK

Sweden

China

India

Population Estimated number of people with hearing loss Estimated hearing-aid adoption rate Main healthcare service provision

62 million 10 million (16.1%)

9.6 million 1.3 million (13.5%)

1.4 billion 27.8 million (2.0%)

1.2 billion 63 million (5.3%)

20 to 25% Public healthcare (NHS)

25 to 30% Public healthcare

1 to 2% Private healthcare

Hearing-aid provision by the government

Free BTE hearing aids

Free or subsidized BTE/ITE hearing aids depending on the region

1 to 8% A combination of basic medical insurance and rural co-operative medical schemes No free hearing aids in general

The situation in Sweden In Sweden, The Ministry of Health and Social Affairs provides policy and guidelines for health and medical care at the national level, while county councils determine how services are to be delivered at regional level, based on local conditions and priorities. As a result, the organization of primary care health centers and hospitals varies at the local level. In addition, local authorities are responsible for maintaining post-discharge care and social welfare services for the disabled and elderly. County councils provide a full range of audiological services, including diagnosis and rehabilitation for residents with hearingrelated problems. In most county councils, medical- related audiological services are organized together with ENT care. In addition, neighbourhood medical care and company health schemes run outreach and preventive audiological health-care schemes. There are approximately 1200 audiologists in Sweden, who graduated from the universities authorized by the Ministry of Social Affairs. The audiological services provide hearing aids either free of charge or with a degree of subsidization, largely depending on the region. Residents with hearing impairment access audiological services either through a physician’s referral at a local health centre, or through self-referral (i.e. by making direct contact with hospitals or private specialists contracted by county councils). In Sweden, according to the annual report from Swedish Association for Hard-of-hearing people, in 2009, there were more than 1.3 million people with acquired hearing loss, which was approximately 13.5% of the total population (equivalent to 17.2% of the adult population) (Swedish Association for Hard-of-Hearing People, 2009). Of these, it was estimated that about 600 000 people with hearing loss among the working age population between the ages of 18 and 69 years, require audiological rehabilitation (Arlinger et al, 2008). It is noteworthy that the prevalence figure is significantly higher (i.e. 44 to 56%) in the older population (Central Bureau of Statistics, 2007; Karlsson & Rosenhall, 1998). In the study by Rosenhall and Karlsson-Espmark (2003), out of 559 older people (70–91 years old) who were offered audiological and otological services (including hearing-aid fitting), 15% of them had requested audiological services; 6% of the participants had severe hearing loss, and the majority of these were fitted with hearing aids. However, a high percentage of people with mild to moderate hearing loss (i.e. 10 to 22%) had contemplated purchasing a hearing aid but did not do so. These results indicated that degree of hearing loss and self-reported hearing disability were likely to play an important role in help-seeking and hearing aid uptake.

Free body-worn hearing aids only provided in national institutes

A more recent study investigated self-reported hearing difficulties, hearing-aid uptake and its outcomes in relation to demographic, cognitive, psychosocial, and health variables in 85 year olds (Öberg et al, 2012). In this study, 55% of people admitted having hearing difficulties, and 59% of them owned and used hearing aids. The most frequent reason for not owning hearing aids was that participants did not perceive their hearing difficulties as a significant problem for communication under both quiet and noisy conditions.

The situation in China In China, the current healthcare system is the result of China’s dramatic economic and social welfare reforms since the 1980s. It has been transformed from a centralized public system of financial support for health services into local taxation systems such as the Urban Residents’ basic medical insurance for urban residents and the New Cooperative Medical Scheme for rural residents. Although health-care system reform has made significant progress in many aspects of public health, there are still a number of challenges. For example, economic differences between richer urban coastal regions and poorer rural regions have led to inequalities between available health services (Hougaard et al, 2011). In addition, because of the lack of an effective primary care system, patients in rural areas often find it difficult to get access to health care. Audiology is a relatively new profession in China, with a history of only 10 to 15 years. Currently, there are about 1200 audiologists in China, who graduated from either undergraduate or postgraduate audiology programs. They are working in ENT/Audiology departments in public hospitals, private clinics, or hearing-aid shops/clinics to provide audiological services, primarily in urban areas. Although it is much easier to access private clinics or hearingaid shops/clinics, residents with hearing impairment usually choose to access the ENT/Audiology departments in large public hospitals which provide a variety of audiological services, including a full range of diagnostic tests, together with hearing-aid fitting and cochlear implantation. However, residents have to pay all the costs themselves, including the cost of hearing aids or cochlear implants. Prices of hearing aids range from 3000 CNY to 30 000 CNY (between approximately $470 and $4700). For comparison, the average annual family income in urban areas is about $2600, while it is $1600 in rural areas, the cost of hearing aids is simply too expensive for many Chinese families. Therefore, McPherson (2008) suggests that affordability is an important external factor, and people in China may have concerns about the cost of these devices when

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they seek help for hearing loss and uptake of a hearing-aid (Wong & McPherson, 2008). In China, there are approximately 27.8 million people with hearing loss (2.0% of the total population) (Sun et al, 2008), which is thought to be the largest hearing-impaired population in the world. Due to an enormous unmet need for highly trained audiologists, together with a lack of provision of hearing-aid services in China, as Wong and McPherson (2008) point out, fewer than 2% of people with hearing impairment in China have received an appropriate audiological service (i.e. appropriate audiological assessment and aural rehabilitation given by a qualified audiologist). Furthermore, a recent survey of seventy-two participants with hearing impairment showed that one-third did not think that they needed to consult on their hearing problem (Li & Zhao, submitted). For those who thought they did need a consultation because of their hearing problem, more than 50% did not know where to go or whom to ask for help. The other influencing factor is likely to be associated with cultural attitudes to ageing. Elderly people believe that age-related hearing loss is an inevitable part of the ageing process, and instead of seeking help they expect others to adapt to their needs. Leaflet/newspaper/purchasing experiences appear to have a bigger influence on hearing-aid adoption than the influence of family members. Moreover, a good knowledge of hearing aids gave hearing-impaired people more realistic expectations (Li & Zhao, submitted).

The situation in India In India, a universal public healthcare service is provided by each state or territory at primary, secondary, and tertiary levels. The national health policy is to ensure equal access to high quality health services for all Indian residents regardless of socio-economic status, gender, caste, or religion. However, in India, private healthcare remains the primary choice for about 70% of urban and 63% of rural households because of differences in quality and accessibility (e.g. distance, waiting times, and operating hours) (National Family Health Survey, 2007). These differences are the main reason for preferring the private health care system at the national level. Audiological services are available at all levels, although there is limited access to such services in rural areas (Manchaiah et al, 2009, 2010). They include diagnostic hearing assessment and aural rehabilitation. Access to audiological services usually begins with seeking help from GPs in primary care settings. Meanwhile, people with hearing impairment may directly access secondary and tertiary services by seeing an audiologist and/or otolaryngologist. Most residents who visit government-funded hearing institutions receive body-worn hearing aids, which are issued free of charge, or at 50% cost, dependent on income. However, patients whose income exceeds a threshold determined by the government usually buy low cost digital or other high-end hearing aids. These choices may be influenced by listening needs, professional recommendations, and affordability, although relevant evidence is limited. In India the prevalence of hearing difficulty was estimated at 5.3 to 16.6% (of a population of 1.2 billion) (World Health Organization, 1999; National Sample Survey Organization, 2003). There are no relevant studies on hearing help-seeking and hearing-aid adoption rates in people with hearing impairment in India, although some estimates suggest around 1 to 2% (National Sample Survey Organization, 2003). Furthermore, studies on the adult population have shown the gender effect on hearing-aid adoption in India, with a larger proportion of elderly male hearing-aid users than female. In addition,

studies suggest that there are fewer female hearing-aid users who choose technologically advanced hearing aids (Maya, 1987; Suresh, 1990; Stella Mary, 1992).

Summary Although the facts and figures are derived from independent sources, with different methodologies and reliabilities, there are enormous differences in health-care system structure, nature of audiological services, and its accessibility in the UK, Sweden, China, and India. While a lack of provision of audiological services in rural areas of China and India is one of the obvious hindrances to seeking help for hearing loss, affordability of audiological services and hearing aids are likely to be the other important influencing factors on hearing help-seeking and hearing-aid uptake (McPherson, 2008; Wong & McPherson, 2008). Since the evidence from the UK and Sweden suggests that accessibility and affordability are unlikely to explain the low percentages of hearing help-seeking and hearing-aid uptake in these countries, psychological factors may play a major role in association with hearing-related behaviors. Therefore, in the next section, potentially relevant theoretical perspectives are highlighted in order to facilitate understanding of cross-cultural influences on hearing help-seeking and hearing-aid uptake behaviors.

Section 2: Theoretical perspectives related to cultural influence on health behaviours At present, four theoretical approaches have been used or can be used in analysing cross-cultural influences on health behaviour and/or non-compliance with health interventions, which include: (1) Theory of social recognition; (2) Theory of stigma; (3) Theory of social representation; and (4) Theory of planned behavior.

Theory of social recognition The theory of social recognition, proposed by Honneth (1995), focuses on mechanisms that both hinder and facilitate the processes involved in gaining recognition as a human being. This highlights the fundamental role of social relations and social bonding. Honneth describes this by focusing on three different types of processes. The first process is centered on the individual and his/her concrete needs and emotions. Recognition evolves in primary relationships between child and child carer, lovers, family members, friends, etc., and is crucial to the individual’s basic ‘self-confidence’. Lack of recognition affects an individual’s physical integrity. The second process is centered on a person’s position as a legal subject in the law and is expressed as rights crucial to obtaining a sense of possessing a universal dignity as a human being and thereby to acquire ‘selfrespect’. Lack of recognition is accordingly expressed as denial of rights, exclusion, etc. The third process of recognition is centered on the subject, and his/her individual particularity, traits, and abilities. As human beings we need to be recognized through each of the three processes and modes of relations of recognition and establish positive relations to ourselves in terms of ‘self-confidence’ and ‘selfrespect’.

Theory of stigma This theory has some similarities with the third process of recognition discussed previously in the theory of social recognition

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Influence of culture on help-seeking and hearing-aid uptake when focusing on stigmatization proposed by Goffman (1963). Stigmatization is precisely a process where negative valuation of a characteristic within a ‘local moral order’ causes people with this characteristic to, for instance, develop strategies in order to protect their sense of self, or ‘self-esteem’. In the context of this paper, for people with hearing loss, their hearing help-seeking and hearing-aid uptake behaviors can be viewed as stigmatizing reactions to their problems, such as misunderstanding what is being said, communication breakdowns. In all local moral orders there are stigmatizing reactions. Some reactions are generic (i.e. exist in all types of local moral orders), but some are specific for certain local moral orders (e.g. using a hearing aid in the local moral order of older male industrial workers is quite different to being a young female hearing-aid user working as a teacher). In addition, stereotyping is a part of stigmatization. When a disability becomes the dominant characteristic attributed to a person it is called master status. According to Barnartt (2001) a master status is given to a person by society and she/he usually does not have a choice in the assignment of this master status.

Theory of social representation At the group level of analysis, a social representation is ‘a set of concepts, statements, explanations originating in daily life in the course of inter-individual communications. They are the equivalent, in our society, of the myths and belief systems in traditional societies. They might even be the contemporary version of commonsense’ (Moscovici, 1981, pp. 181). Two processes underpin the development and function of social representations. First, ‘anchoring’, which emphasizes conceptual aspects, refers to a process whereby members of a society build new representations by aligning them with frameworks of meanings that are already familiar to them. Second, ‘objectification’, which emphasizes perceptual aspects, refers to a process whereby members of a society match abstract representations with known physical objects or visual images. In the context of this paper, these two processes could help in understanding how hearing loss could be anchored and represented, which is largely based on its pre-existing images and beliefs in a society. Furthermore, the theory of social representations appears a useful approach for exploring cross-cultural perceptions of, and reactions to, a given hearing loss.

Theory of planned behavior Primarily at the intra individual level of analysis, the theory of planned behavior focuses on predicting the extent to which an individual intends to carry out a given behavior (Ajzen, 1991). It means that the theory aims to predict behavior intention rather than actual behavior from a combination of the person’s attitude to performing the act and the relevant ‘social norm’, which captures the person’s understanding of what people who matter to him or her think about the act. In the context of this paper, whether or not an individual intends to wear his or her hearing aid will depend not only on his or her attitude to wearing the hearing aid but also on his/ her understanding of his or her spouse’s (or other important others’) views. Many studies have found the theory of planned behavior effective in predicting health-related behavior intentions, including cessation of smoking, weight loss, reducing alcohol consumption, healthy eating, and hearing health care (Conner & Norman, 2005; Meister et al, 2014).

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Section 3: General Discussion Research has noted that there are culturally-related determinants of health related behaviours (Triandis, 1994). In this context, culture refers to socially shared ideas, accumulated attitudes, beliefs, values, and practices which influence how people view the world in terms of their choices, actions, and behavioural preferences (Smith et al, 2006). Therefore, it could be important to have a better understanding of cultural influence and its interactions with psychological factors on hearing-related behavior.

Psychological models for better understanding of hearing-related behavior Various studies have been conducted to develop theoretical frameworks to facilitate understanding and prediction of social cognition models of health behavior (e.g. Conner & Norman, 2005). These models and/or theories are used to explain the role of personal control on behavior and behavior changes by incorporating attitude and social/cultural influences. Using these models, the central assumption is that thinking processes drive human behavior, which fits the finding that self-reported hearing loss is consistently related to hearing-related behaviors rather than hearing loss per se in the context of hearing help-seeking and hearing-aid uptake behaviors. A recent study by Meister et al (2014) investigated the intention of hearing-aid uptake using the theory of planned behavior. Their results showed that the intention of hearing-aid uptake could be modelled on the basis of the constructs ‘attitude toward the behavior’, ‘subjective norm’, and ‘behavioral control’, depending on the individual’s stage of hearing help-seeking. This study provides a better understanding of the influence of attitude and behavioral control on the trajectory of audiological rehabilitation, which may contribute directly to audiological service (e.g. counselling, public hearing health awareness campaigns). However, early studies using the theory of planned behavior have proved unsuccessful in predicting behavior directly from attitudes because the measures of predictor variables and target behaviors needs to be compatible in terms of action, context, and time (e.g. Fishbein & Ajzen, 1975; Ajzen, 1991). For example, the attitude towards hearing loss will not be equally–if at all–successful in predicting different classes of behaviors, such as help-seeking for hearing loss or hearing-aid uptake, nor in predicting different behaviors within a given class of behavior, such as hearing-aid use. The latter is because individual behaviors vary according to the specifics of action (e.g. is hearing-aid use needed to facilitate employment as a sound engineer, for example, or for conversations over coffee after church?), context (e.g. to what extent is the hearing-aid provider respectful?), and time (e.g. is the hearing-aid wanted for a family wedding in a month or sometime after the person retires?) (Clucas et al, 2012; Clucas & St. Claire, 2010, 2011). Furthermore, the theory of planned behavior has been criticized because of its mathematical complexity and because the demands of compatibility dictate that predictor variables specific to, and compatible with, the behavior of interest as opposed to general attitudes need to be measured (Stainton-Rogers, 1991). On the other hand, because the theory of planned behavior changes the focus from objective circumstances surrounding hearing loss and service provision to the person’s understanding of these issues, it offers multiple loci for interventions. This change of focus might enhance the wellbeing of people with hearing loss, without the necessity of practice alterations such as mass audiometric screening of older adults

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(Davis et al, 2007; Stephens et al, 1990), which are likely to require costly political or service changes, and have no assurance of success.

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Cultural differences and cross-cultural research Cultural difference refers to the ways in which individuals within differing nations vary in terms of their cultural value systems, which are socially shared ideas that influence how people view the world in terms of their choices, actions, and behavioral preferences (Knafo et al, 2011). According to Knafo et al (2011), values can be conceptualized at the individual level, whereby they affect the way that people interpret behavioral choices, preferences, and actions. At the national level, values reflect the assumptions that societal groups make about social and organizational processes; these can be used to make comparisons between national cultures. To facilitate crosscultural comparisons Hofstede (2010) surveyed the values of representative samples from 53 countries and regions, and subsequently identified individualism-collectivism as the most important construct for understanding differences between national cultural orientations. This refers to the degree to which people within a society are interdependent, or whether there is greater concern for individuals’ rights and well-being (Hofstede, 2010). He conceptualized individualism as a preference for social frameworks in which individuals are expected to take care of only themselves and their immediate families, and collectivism as a preference for more tightly-knit social frameworks in which individuals are expected to take care of relatives or other group members. As a result, on the dimension of individualism measured by using individualism index (IDV) values, Guatemala had the lowest score of 6, while the USA has the highest score of 91. This score reflects the level of cultural difference between countries, i.e. the country that has a low score is a collectivism society and the country that has a high score is an individualism society. On the basis of Hofstede’s theory, people that belong to an individualism society give priority to the individual’s needs as these are regarded as more important than the group’s needs, while people that belong to a collectivist society value the importance of the group (such as family and close friends) over the needs of the individual. Therefore, the individualism-collectivism dimension reflects cultural differences in terms of people’s position and self-image within society. For example, China scores 20 and is categorized as a collectivist society, ranking lower than most of the other Asian countries in terms of individualism-collectivism, India has a score of 48 on the individualism-collectivism scale indicating a greater tendency for people to be characterized by individual achievements, while Sweden and the UK score 71 and 89 respectively, indicating that both countries are strongly characterized by their focus on individual achievements rather than group concerns (Figure 1). Studies have suggested that there are cross-cultural differences in the way that these culturally-related factors moderate perceptions of health, disability, and disease, which implies that individuals within differing nations or geographic locations may have different ways of perceiving and interpreting situations related to hearing loss and hearing-aid use. For example, Devins et al (2010) looked at cultural values and attitudes as moderators of the relationship between illness, emotional distress, and subsequent lifestyle changes forced by the onset of rheumatoid arthritis, a chronic, debilitating autoimmune disease. The authors found that those persons characterized by higher levels of horizontal individualism, or the aspect of individualism that is associated with group equality and autonomy, were more flexible in dealing with the effects and constraints of the disease. The

Individualism

UK

89

Sweden

71

Spain

51

(Examples of European countries)

48

India

26

Malaysia

20

China

18

South Korea

Indonesia

14

(Examples of Asian countries)

Collectivism

Figure 1. Comparison across the UK, Sweden, India, and China in terms of the cultural value dimension Individualism versus Collectivism using Hofstede’s model (higher scores indicating more individualism and vice versa). authors suggested that people high in individualism were better able to adapt to changing circumstances created by ill health or disability by viewing the disease as an opportunity to adopt new coping strategies and tactics, and it was found that this ability resulted in lower levels of stress. On the other hand, Chen et al (2008) examined the link between cultural beliefs and the propensity to seek help from mental health professionals. These authors found that culture shapes attitudes towards help-seeking behaviors for those experiencing mental health problems, as well as the beliefs that people have about their illness. For example, people in collectivist cultures are more likely to associate their mental health issues to internal causes, while people in individualistic cultures assume that the problems arise from the interaction of environmental and personal factors. Chen and colleagues concluded that those people who are influenced by individualism are more likely to seek help for their illness, than those characterized by collectivism, thus suggesting that there are cultural variations in people’s perceptions of their illness and the likelihood that they will seek treatment. Although cross-cultural studies have been assessed in other areas of illness and disease, to our knowledge, there is no study on the influence of culture, particularly the individualism and collectivism dimension, on whether or not individuals’ attitudes toward hearing loss and hearing-aid use has an impact on the failure to seek and use hearing aids. Studies have suggested that there may be culturally-related differences in the way that people interpret situations related to disability

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Influence of culture on help-seeking and hearing-aid uptake and disease. There are also indications to suggest that there are cultural differences in the perceptions of ageing, and these perceptions may be linked to attitudes to hearing loss and the uptake of hearing aids (e.g. Knudsen et al, 2010). Pointing to the link between culture and perceptions of ageing, the theory of social representation suggests that the views of ageing are socially constructed and form part of the shared value systems of a cultural group (Moscovici, 2000). Subsequent research focusing on attitudes towards health and ageing has suggested there are cross-cultural variations in these perceptions. For example, Wong and McPherson (2008) have looked at the relationship between cultural attitudes to ageing and hearing-aid uptake. They suggested that cultural attitudes to ageing may affect whether or not people seek help for their hearing loss. The authors concluded that elderly Chinese people appear to believe that hearing loss is an inevitable part of the ageing process, and instead of seeking help they expect others to adapt to their needs. Subsequent research has supported the view that there are culturally-determined attitudes to ageing. For example, in a questionnaire study involving 26 cultures on six continents, Lockenhoff et al (2009) found that there was cross-cultural consensus in the perceptions of ageing related to the biological changes associated with ageing (i.e. physical attractiveness, ability to perform everyday tasks, and ability to learn new things). However, Lockenhoff and colleagues found the effects of culture on the views and perceptions of ageing were strongest in the context of social and emotional factors (e.g. family relations, emotional contentment, satisfaction with life, and in the societal views or stereotypes of ageing). Generally, it was found that there were cultural differences in participants’ perceptions of society’s stereotypical views on ageing, with Asian cultures having more positive societal views of ageing associated with socio-emotional factors, than in Western societies. Using Hofstede’s uncertainty avoidance value construct, Lockenhoff et al (2009) found that those countries high in uncertainty avoidance tended to have less positive beliefs and expectations about the ageing process, and less positive expectations and beliefs about age-related changes in family structures and life satisfaction. It is noteworthy that only four countries (two European countries and two Asian countries) were included for comparison and discussion in the present paper. A recent Euro Trak survey showed different aspects of stigmatization between different European countries (Hougaard et al, 2013), which was most likely due to differences in healthcare systems and reimbursement systems, as well as social and cultural aspects. Therefore, it is important to include more European countries as well as other Western, South American, and African countries when exploring the differences and similarities in attitudes towards hearing loss and also on hearing help-seeking and hearing-aid uptake. In addition, the hearing-aid market (e.g. USA nonregulated market compared to countries where the hearing-aid market is regulated) may have a considerable impact on hearing help-seeking and hearing-aid uptake. These and other similar factors need to be taken into account when studying cross-cultural aspects related to hearing help-seeking and hearing-aid uptake.

Further research Although cross-cultural studies have been assessed in other areas of illness and disease, further research is needed to collect prospective data on cultural influences on attitudes toward hearing loss and the use of hearing aids, by including a wide range of nations from across the world. The theoretical models discussed in this paper would be helpful in establishing a structured framework for interna-

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tional multi-center studies. The specific areas of research could be: (1) understanding the stigmatization of people with a hearing disability across countries using the theory of social recognition and the stigma theory; (2) understanding how society thinks about hearing disability and also the views of people with hearing loss about hearing disability and audiological rehabilitation using the theory of social representation; (3) studying the attitudes, beliefs, intentions, and actions of people with hearing loss in terms of hearing helpseeking, hearing-aid uptake and hearing-aid use across countries using the theory of planned behavior; (4) research on views concerning the provision of audiological services, cost implications, and issues related to the hearing devices themselves. Professionals’ preferences for service delivery models is another important area for further exploration, focusing on how they influence hearing help-seeking and hearing-aid uptake in the context of cultural differences.

Conclusions In summary, studies have suggested that individuals within diverse cultural value systems have different ways of perceiving and interpreting situations related to ageing, disability, hearing loss, and hearing-aid use. Also, studies have highlighted that the underuse of hearing aids may be related to negative stereotypes about ageing, and that the perceptions of ageing appear to vary cross-culturally. Although various dimensions in terms of political, social, educational, and cultural diversity suggest that people in countries such as the UK, Sweden, China, and India differ in terms of their attitudes towards disability, disease, ageing, and hearing-aid use, little research has been done to explore these views. Future studies are needed to identify the dimensions of attitude and barriers towards hearing-aid uptake and access to audiological services for people with hearing loss in the cultural context. Significant outcomes will provide the foundation for better understanding of cultural influence on hearing-aid uptake and help-seeking behaviour within China and India, compared to experiences in the West. It will lead to the establishment of strategies and solutions in the cultural context to improve quality and management of hearing-aid uptake and satisfaction among hearing-aids users.

Acknowledgements The inspiration for this paper came from a seminar on ‘Cross-cultural communication: Exploring cross-cultural differences and similarities in attitudes towards hearing help-seeking and uptake of hearing-aids’ held in Bristol during February 2013, jointly organized by the University of Bristol and Swansea University. The seminar was partially funded by the Oticon Foundation. Declaration of interest: The authors report no conflicts of interest.

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