Key Words
auditory rehabilitation - counseling - hearing aids and assistive listening devices
- photo voice
Photovoice is a participatory action research method in which people take photographs
to represent real-world experiences that are under study, so that issues of interest/concern
can be documented and discussed. Individuals or a group of individuals are tasked
with photographing objects, places, and situations that represent the question of
interest. The photographs are briefly annotated by the individual and later discussed
with the facilitator to explain why the photograph was taken and what it represents.
Data are then compiled and used to provide insight into the individual’s or the group’s
real-world experiences.
Photovoice has been applied to health research in a variety of ways. It has been used
to document the experiences of people living with chronic pain ([Baker and Wang, 2006]), prostate cancer ([Oliffe and Bottorff, 2007]), and mental illness ([Clements, 2012]), for exploring health-care access and use ([Rosen et al, 2011]; [Kowitt et al, 2015]; [True et al, 2015]), and for documenting health-care needs ([Angelo and Egan, 2015]; [Gill et al, 2016]). The purposes of these studies were to promote community awareness of issues, implement
programs to address needs, and/or change public policy.
Other researchers have adapted photovoice methodology and used photographic images
in clinical care. For example, [Baker and Wang (2006)] examined the potential use of photovoice to assess the pain experience by having
participants photograph objects that reflected their experiences with chronic pain
and objects that reflected what they would like their lives to be like without chronic
pain. Participants attended a one-on-one exit interview during which they were asked
about their participation in the study, their experience as a photographer, and their
overall experience with pain. The authors reported that the technique helped participants
share their experiences of living with chronic pain and suggested it could assist
individuals who work with populations who experience chronic pain to better understand
and assess the way chronic pain impacts the patient’s life. In another study, [Linz et al (2016)] used patient videos (instead of photographs) as a form of support during recovery
from mental illness. They found that individuals in their video intervention group
were better able to think about day-to-day changes in the emotional state, feelings
of isolation, and their hopes for the future. Furthermore, the participants reported
that the videos could help others by educating potential viewers about the impacts
of mental illness. [Ginicola et al (2012)] described why photovoice, or as they referred to it—phototherapy, can be beneficial
for counseling. They used specific case examples to illustrate how photographs helped
build rapport with a client by allowing the counselor to learn about the individual
on a personal level such as their hobbies, likes, and dislikes, and noted that by
looking for themes within the photographs, it could be used to assist with choosing
types of intervention strategies. [Guerra et al (2013)] used photovoice as an outcome measure to identify the positive and negative impacts
of a program that supports families caring for a relative with dementia. The participants
were instructed to take photographs over a three-month period and to then select photographs
that represented positive and negative impacts of the program. Participants reported
that although they initially had concerns about translating ideas into photographs,
it was actually easier than expected. They said the process helped them reflect on
their caregiving situation and the implications that it had for their family. They
also reported that photovoice facilitated communication about their situation with
others, reported that it allowed them to explore and interpret their own feelings,
and reported it to be more proactive in how they chose to represent themselves and
others. Finally, [Sackett and Jenkins (2015)] provided a hypothetical case example in which they proposed photovoice could be
used as a tool for individual counseling sessions. Although hypothetical, the case
illustrated how personal photographs could potentially facilitate emotionally charged
discussions.
To our knowledge, there are no published studies in which photovoice has been used
as a tool in audiological rehabilitation (AR), although [Saunders et al (2017)] used preselected, emotionally evocative photographs as a tool to encourage reflection
about the impacts of hearing difficulties. The IDA Institute (https://idainstitute.com), an organization that works with hearing care professionals from around the world
to develop and integrate person-centered care in hearing rehabilitation, has developed
AR tools that use photographs. Specifically, the photographs are used as talking points
to develop strategies for improving communication (Living Well tool), to help individuals
prepare for an initial clinical visit at which hearing difficulties and management
strategies are discussed, and to prompt reflection on how improving hearing and communication
would affect their daily life (Ida Telecare tools). Whereas the former tool uses only
preselected photographs, the latter allows individuals to provide their own photographs
as well. [Saunders et al (2017)] showed promising outcomes; however, there are no published data on the effectiveness
of the IDA tools.
There are many reasons why an adaptation of photovoice could have potential value
in audiology practice. Photographs could provide the audiologist with insight about
an individual’s lifestyle, communication priorities, and the specific environments
in which they communicate. Photographs could also be used to assist with making rehabilitation
recommendations, or when providing highly tailored communication strategies for specific
listening situations. Photographs also have the potential to facilitate self-reflection
and increase the patient’s awareness of his/her successes and difficulties with hearing
aids and/or specific listening situations. Finally, photographs could play a role
in providing perspective for communication partners about the impacts hearing loss
has on the dyad. With the recent recommendations to include a family member in adult
AR ([Grenness et al, 2016]; [Singh et al, 2016]), this could have considerable value.
Another potentially valuable aspect of photovoice is that, by its very nature, it
facilitates patient-centered communication ([Lorenz and Chilingerian, 2011]). Although audiologists and patients report a preference for patient-centered care
([Laplante-Lévesque et al, 2014]; [Poost-Foroosh et al, 2015]), the style of communication used by audiologists is often not consistent with such
an approach ([Ekberg et al, 2014a]; [Grenness et al, 2015]; [Pryce et al, 2016]; [Sciacca et al, 2017]). As such, discussion of a patient’s photographs could facilitate patient-centered
communication during clinical encounters by opening up personal conversations about
hearing and communication.
Because photovoice has not been used before as a clinical tool in AR, is it is appropriate
to conduct a feasibility study to assess whether it is a novel intervention and is
worthy of further testing in a full-scale trial. This is because feasibility studies
are relatively cost and time efficient and the methodology can be flexible and iterative
(i.e., the methods can be adapted as new information is learned); furthermore, it
is acceptable to use a convenience sample with limited statistical power for the testing
([Bowen et al, 2009]; [Orsmond and Cohn, 2015]). Typically, and as is the case here, feasibility studies are used to examine factors
such as recruitment capacity, that is, “Are people willing to take part?”; procedures
and measures, that is, “How should the intervention be used and what outcomes should
be measured?”; intervention acceptability, that is, “Do recipients find the intervention
acceptable?”; resources required for implementation, that is, “How much time, etc.,
is needed for implementation?”; and preliminary outcomes, that is, “Does the intervention
appear to indicate positive outcomes?” ([Orsmond and Cohn, 2015]).
The purpose of this study, therefore, was to examine the feasibility of adapting photovoice
by using patient photographs as an audiological counseling tool. Given the widespread
presence of cellphone cameras, photovoice would appear to be a feasible and timely
way to improve the provision of AR. To this end, a feasibility study was designed
to determine whether photovoice could be applied to four aspects of AR: (a) to facilitate
provision of tailored communication strategy counseling, (b) as a post–hearing aid
fitting counseling tool, (c) to enhance communication between partners regarding hearing
loss, and (d) to provide an understanding of the emotional impacts of hearing loss.
METHODS
Study Synopsis
The feasibility of using photovoice for four aspects of AR was examined in which participants
attended two study visits. During visit 1, participants were instructed in the photovoice
methodology and were given a specific photographic task, dependent on the AR application.
During visit 2, the photographs taken by each participant were discussed during a
debriefing session.
This work was approved by the Institutional Review Board and the Research and Development
Committee at the VA Portland Health Care System.
Study Design
The study examined the feasibility of applying photovoice to four aspects of AR as
follows:
-
To determine whether it is feasible to use photovoice as a tool to facilitate provision
of tailored communication strategy counseling, five individuals with hearing loss
were instructed to take photographs of situations in which they had encountered hearing
difficulties.
-
To determine whether it is feasible to use photovoice as a post–hearing aid fitting
counseling tool, four individuals who had been fitted with their first pair of hearing
aids within the prior three months were asked to take photographs of typical daily
activities in which they found their hearing aids either particularly helpful or particularly
problematic.
-
To determine whether it is feasible to use photovoice to enhance communication between
partners regarding hearing loss, five individuals with hearing loss and a partner
were asked to take photographs that represented the typical shared daily activities
in which communication was a problem. Partners were asked to take photographs independently
so that the perspective of both individuals would be represented.
-
To determine whether it is feasible to use photovoice to provide insight into the
emotional impacts of hearing loss, five individuals with hearing loss were instructed
to take photographs that showed what having a hearing loss meant to them.
Participants
Participants were individuals recruited from a data repository at the National Center
for Rehabilitative Auditory Research. The data repository holds contact information
and audiometric data of prior study participants who agreed to be contacted for future
studies. Audiometric thresholds stored in the database were used to find individuals
with 1 kHz thresholds ≥40 dB HL in both ears. In addition, participants were required
to own a smart phone with a camera and be comfortable using it to take photographs.
Demographic and audiometric data, including age, gender, and pure-tone thresholds,
were not extracted from the database nor were they collected for this feasibility
study. To determine the feasibility of using photovoice to enhance communication between
partners, potential participants were required to have a partner who was also willing
to take part. [Table 1] provides all available information about the participants.
Table 1
Participant Information
|
Aspect of AR Investigated
|
Participants (n)
|
Participants with Hearing Aids (n)
|
Eligibility Criteria
|
|
Use of photovoice to facilitate tailored communication strategy counseling
|
5
|
3
|
Hearing impairment[*]
|
|
Use of photovoice as a post–hearing aid fitting counseling tool
|
4
|
4
|
Received first pair of hearing aids within prior 6 months
|
|
Use of photovoice to enhance communication between partners
|
5 communication dyads
|
5
|
Hearing impairment and a communication partner[†] willing to participate
|
|
Use of photovoice to understand the emotional impacts of hearing loss
|
5
|
4
|
Hearing impairment
|
* Hearing impairment defined as 1-kHz thresholds ≥40-dB HL in both ears.
† Hearing status of the communication partner was not assessed nor collected via self-report.
Payment
Participants received $25 for attending study visit 1 and $75 for attending study
visit 2.
Procedures
Study Visit 1: Instruction
Participants underwent a written informed consent process to confirm that they understood
the study purpose and procedures. They were then instructed in the photovoice procedure
which was supplemented with a take-home booklet (see Supplemental Material S1, available
with the online version of this article). The booklet described the photovoice methodology,
provided study-specific goals and instructions, and stressed the need to maintain
the privacy of individuals who might be photographed. To assist with this, the booklet
specified strategies for taking photographs in which a person could not be identified,
such as taking photographs from the neck down, from behind the person, and from far
away. The training curriculum and supplemental booklet were developed based on the
training used by Ono (personal communication) for an ongoing VA Health Services Research
and Development study.
Key components of the instructions were as follows:
-
Take 20–25 photographs over a one-week period with a smartphone. Note: After testing
about 15 participants, the number of photographs individuals were instructed to take
was decreased to 10–15, for two reasons: (a) many participants reported it was stressful
to find content for 20–25 different photographs and (b) the investigators observed
that after discussing 10–15 photographs; no further information was being learned
and no new advice was being given.
-
Write a sentence or two about each photograph describing what it represents and why
it was taken.
-
Email the photographs to the study team at the end of the week.
-
Avoid taking photographs of people’s faces or have the individual sign a photo release
form.
-
Avoid taking photographs on the VA Portland Health Care System campus because it is
not permitted by federal regulations.
To confirm whether participants understood the study instructions, they were asked
to give one or two examples of photographs they might take and how they might annotate
them. At the end of the instruction process, participants were given a copy of the
instruction booklet and 20 photo release forms to take home.
Reminder Phone Call
One to two weeks later, participants received a reminder call to email their photographs
to the study team. If a participant sent any images that included an individual who
could be identified, the photograph was immediately edited by placing a colored circle
over the identifiable face. Of the 189 photographs received, just 12 included identifiable
content.
Study Visit 2: Debriefing
Two or three members of the research team attended each debriefing session. The research
team consisted of a clinical audiologist (M.T.F.), an Au.D. student completing her
4th year clinical placement (L.K.D.), a sociologist (S.C.S.), and an AR researcher (G.H.S.).
M.T.F. and/or L.K.D. were present during all debriefing sessions, and G.H.S. was present
for all but three debriefing sessions. All present were given a printed copy of the
participant’s photographs on which to take written notes. Although previously agreed
to via informed consent, the research team confirmed participants were comfortable
with the discussion being audio recorded. A discussion of each photograph was then
led by a member of the research team. In general, participants were asked to describe
what each photograph represented and why they had taken it. However, depending on
the AR application being examined, there were some differences in the follow-up questions
and advice provided, as follows.
When examining the feasibility of using photovoice for counseling regarding communication
strategies, follow-up questions included asking participants what they had done when
they encountered a specific communication problem and whether it had helped. The research
team suggested situation-specific communication strategies as appropriate.
When examining the feasibility of using photovoice for post–hearing aid fitting counseling,
follow-up questions included asking participants how they typically coped in the problematic
situations they had identified, and to think about ways in which the problematic listening
situations differed from the ones in which their hearing aids helped them. This was
performed so they could identify for themselves how they might manage better. Advice
regarding hearing aid accessories and communication strategies for the photograph-specific
listening situations was also provided.
When examining the feasibility of using photovoice for enhancing communication between
partners about hearing-related matters, communication partners were asked to comment
on one another’s photographs and commentary. They were asked how they viewed each
other’s perspective on a situation and were prompted to request suggestions from one
another that might help in problematic listening conditions. The research team also
provided recommendations for solving communication problems.
When examining the feasibility of using photovoice to provide an understanding of
how it feels to live with hearing loss, the research team asked follow-up questions
only; they did not provide advice or input. Follow-up questions included “how did
that make you feel” and “what emotion or adjective would you use to describe your
feelings at the time.”
Once each photograph had been discussed, the research team asked all participants
the following questions:
-
Did you capture in a photograph everything you wanted to represent, and if not, what
else would you like to have photographed?
-
Was the week during which you took the photographs a typical week and if not, how
did it differ?
-
What did you think about taking the photographs?
-
Did you learn anything from taking part in the study?
After completing several debriefing sessions, an additional question was asked of
individuals to determine whether participants would consider the method clinically
acceptable:
Note: Individuals tasked with taking photographs that depicted how it feels to live
with hearing loss were not asked this final question because the photographic task
did not have immediate clinical application; thus, just 12 of the 24 participants
responded to this question.
Data Analysis
Descriptive statistics were used to document the number of photographs taken and the
duration of the debriefing sessions; qualitative description ([Sandelowski, 2000]) was used to describe the qualitative findings.
RESULTS
Quantitative Data
[Table 2] provides information about the number of photographs and duration of the debriefing
sessions. Based on the many photographs received and the duration of the debriefing
sessions, it seems that the photovoice procedure was acceptable to participants. All
20 participants who were asked whether the prior week had been a typical week, agreed
it has been, and all but four reported they had captured everything they wanted to
represent in a photograph. Of those who did not capture everything, two said that
taking a photograph in the missing situation would have been inappropriate (in a church,
on the bus, and at a store checkout), one said it would have been dangerous (while
driving the car), and one said the situation was not encountered that week (going
to a restaurant).
Table 2
Number of Photographs Taken and the Duration of Debriefing Session for Each Aspect
of AR Investigated
|
Aspect of AR Investigated
|
No. of Photographs
|
Duration of Debriefing Session (min:sec)
|
|
Mean (SD)
|
Mean (SD)
|
|
Range
|
Range
|
|
Use of photovoice to facilitate tailored communication strategy counseling
|
16.6 (9.2)
|
43:55 (16:19)
|
|
4–29
|
23:25–64:26
|
|
Use of photovoice as a post–hearing aid fitting counseling tool
|
15.0 (8.1)
|
39:07 (7:50)
|
|
5–23
|
31:35–50:04
|
|
Use of photovoice to enhance communication between partners
|
11.3 (3.7)
|
54:40 (9:44)
|
|
7–17
|
43:48–66:22
|
|
Use of photovoice to understand the emotional impacts of hearing loss
|
9.2[*] (3.1)
|
24:37 (11.32)
|
|
6–14
|
14:30–39:00
|
* After testing about 15 participants, the number of photographs requested was decreased
to 10–15. SD = Standard deviation.
Qualitative Data: Patient Perspectives
Opinions about the study were generally positive. Some participants stated that taking
the photographs was enjoyable, interesting, informative, and fun. Others, however,
said it had been challenging to avoid taking photographs of people’s faces, burdensome
to remember to take photographs, and a little harder than expected to find a variety
of subject matter. When asked what they thought about the study and what, if anything,
they had learned, participants said that participation had made them think more about
their hearing problems, appreciate their hearing aids more, and became aware of the
situations in which their hearing aids were and were not helpful. Some also said the
exercise had been a learning tool, and one noted it had facilitated conversations
with others about hearing problems. Specifically, the individual shared that during
a barbeque at a friend’s house, she had explained to the other guests why she was
taking photographs which led to a conversation about her hearing difficulties and
the hearing difficulties that others in the group were also experiencing at the gathering.
The group then discussed how they could best communicate with one another. The participant
said she had never discussed her hearing loss with this group of friends before and
that doing so was helpful to her, as well as to them. The communication dyads said
that the exercise had made them think about problems and find ways to solve them together,
that it allowed them to get problems out into the open, and that it gave them insight
into the perspective of their partner. [Table 3] provides quotes from participants that illustrate these points.
Table 3
Illustrative Quotes from Participants
|
Qualitative Description
|
Quote
|
|
Sharing with others
|
I enjoyed doing this and because I eventually told people what I was doing, I brought
it up in conversation and then it helped create understanding and create also people’s
willingness to bring something up that they might not have brought up…
|
|
Learning and problem-solving
|
It made me think about what areas do I have problems hearing and what things could
be done to help them out.
|
|
It’s made me think concretely about specific things- specific losses- but that hasn’t
depressed me… it’s made me adapt. I think it made me more aware and pay more attention.
You know, speak up, tell people.
|
|
…and it was interesting to me to reflect- where exactly do I have challenges and where
don’t I?
|
|
It made you think a bit more… What the real challenges are, instead of just living
those challenges, thinking of the challenges.
|
|
When someone is first exploring their hearing loss, this activity is to get a picture
of where the problem areas are… [it] may be very helpful in figuring out what are
those options for hearing, whether it’s devices or settings.
|
|
Facilitating conversation
|
It did force us to think about more of the situations… it was positive because it
gives us an opportunity to be more aware of what’s going on and get some of our frustrations
out in the open.
|
|
Hearing aid use
|
I wore the hearing aids, which is something I was avoiding before.
|
|
But then I decided, look, you got the hearing aids to help you hear so now I try to
wear them every day.
|
|
…so it made me realize that I had to wear them all the time, instead of like wear
them three days and then don’t wear them two days, and then wear them one day and
then don’t wear them two days. You know, that’s what I was doing.
|
|
Appreciation of hearing aids
|
It made me appreciate wearing my hearing aids more. There was a period where I was
like- oh, I don’t need them…
|
|
I never really thought about my hearing aids in the way that they worked for me or
didn’t work for me, I just did ‘em and went “maybe I don’t like these and maybe I’m
not going to be able to wear them” and I’ve had them adjusted like 2 or maybe 3 times.
What I found was that the sounds that were pleasant to me and that I enjoyed were
mostly outside and that surprised me.
|
|
It made me appreciate them because it made me feel safer…
|
|
Empathy for others
|
…it gives me a little bit more insight into people that are fully deaf
|
|
I think the idea of having the couples come in and share like this is really good
because it does give the hearing partner a better appreciation as to why [my partner]
isn’t paying attention to me.
|
[Table 4] shows the emotions assigned to photographs by participants in use case 4 (understanding
how it feels to live with hearing loss). In addition to those in the table, the emotions
of handicapped, humility, empathy, hesitance, neutrality, and skepticism were assigned
by just one participant to a single photograph. It is noteworthy that participants
identified both positive and negative emotions during this task.
Table 4
Emotions Assigned to Photographs by Participants Describing the Emotional Impacts
of Living with Hearing Loss
|
Emotion
|
No. of Participants who Assigned Emotion to ≥1 Photograph (max = 5)
|
No. of Photographs to Which Word Was Assigned
|
|
Frustration, annoyance, irritation, and stress
|
4
|
23
|
|
Sad and depressed
|
4
|
12
|
|
Left out, isolation, missing out, and hard to be there
|
3
|
9
|
|
Peace, relaxation, joy, comfort, and relief
|
2
|
13
|
|
Anger
|
2
|
2
|
|
Fear
|
1
|
3
|
|
Gratefulness
|
1
|
3
|
|
Embarrassment
|
1
|
2
|
Qualitative Data: Research Team Perspectives
The research team noted several outcomes that could positively benefit AR, as follows.
Highly Tailored Counseling
Using photographs as the basis for conversation facilitated the provision of highly
tailored counseling, and it seemed that having a concrete situation to discuss enabled
participants to better identify with the information than had it been provided without
the aid of the photographs. For example, one participant shared a photograph of his
partner (wife) sitting directly in front of a window at the kitchen table. The participant
described that he often had trouble hearing her during meals. The research team suggested
changing the seating arrangement so the wife’s face was not backlit would likely make
it easier for him to gain information from his wife’s face and lips. Because the photograph
was taken in the kitchen, the research team also asked whether there was a nearby
stove with a fan and suggested ensuring the stove fan is off during mealtimes. Although
this advice is fairly standard, being able to provide it in the context of a photograph
of participant’s home is likely to result in better recall and application, as illustrated
by numerous studies showing that the use of pictures or pictographs increases recall
and understanding of health education information, particularly among those with low
literacy (see [Houts et al, 2006], for review).
Enhanced Interaction between Communication Partners
The photovoice process seemed to facilitate interactions between communication partners
that may have been more difficult to initiate without the photographs, and these interactions
appeared to lead to mutual understanding between partners. For example, a communication
partner shared a photograph of a restaurant. She described that it represented her
being the go-between for her hearing-impaired husband and the wait staff. She said
that although she understood it was a problem for her husband to hear and wanted to
help him, she was uncomfortable being the go-between and never knew when she should
intervene. When asked for his perspective, the hearing-impaired husband said he relied
on his wife because he did not want to impose on wait staff to repeat things. Both
partners said they were uncomfortable with the present approach, and noted they had
not known their partner was also uncomfortable with it. The research team raised the
notion with the hearing-impaired partner that polite self-advocacy was completely
acceptable, and suggested that asking wait staff to speak more slowly, move closer,
and look directly at him was completely appropriate. Both partners responded positively
to this advice. In another case, a hearing-impaired partner showed a photograph of
his tablet computer. He said it represented him not hearing his wife when he was using
the tablet. He noted that she would begin talking without first getting his attention,
and that he, therefore, missed much of the content. His wife responded that this was
the case, and added that she found it frustrating because he was almost always using
some form of technology (tablet, cellphone) and/or also watching the television, so
there was never a suitable time to converse. This led to a discussion about making
dedicated time for conversation during which all distractions were removed. The wife
noted that an appropriate time for this would be just before going to sleep while
in bed but mentioned that currently it was not possible because her partner removed
his hearing aids before getting into bed. Without being prompted, the couple then
discussed the possibility that the husband wears his hearing aids in bed for a few
minutes each night so that they could have a conversation.
Evidence-Based Recommendations for Hearing Assistive Technology
The photographs enabled the research team to give recommendations for hearing technology
that was highly specific to individual needs. For example, a participant who was a
cab driver shared a photograph taken from the back seat of his taxi cab that he said
represented his inability to hear passengers seated in the back seat of the cab. He
said he was distressed at not hearing the passengers because he was concerned that
they thought him rude when he did not reply. The research team suggested he consider
purchasing a remote microphone for his hearing aids that could be attached to the
back of his seat. The photograph was used to illustrate possible placement of the
remote microphone.
Insight into Participants’ Lifestyle and Communication Needs
A brief examination of a participant’s photographs provided considerable insight into
his/her lifestyle, and as a group, the range of activities they engaged in. It was
clear that some participants were highly social, sharing photographs of gatherings
with friends and in restaurants, others engaged primarily in outdoor activities, sharing
photographs of a walk in the countryside or out jogging, whereas others primarily
shared photographs taken within their home.
Rapport and Trust
As seen from [Table 2], participants were willing to spend time discussing their photographs. The content
of the discussion was often very personal and involved the sharing of feelings both
about hearing loss/communication, and sometimes other unrelated matters. Although
the latter is not applicable to AR, we interpret this to indicate that the participants
trusted the research team and that a positive rapport was generated, and based on
the extremely personal nature of the content shared, we suggest that the photographs
might have helped with this.
Hearing Aid Appreciation
When examining the feasibility of using photovoice as a post–hearing aid fitting counseling
tool, participants were instructed to document both positive and negative hearing
aid experiences. Being asked to reflect on the positive and the negative experiences
seemed to result in increased appreciation of the hearing aids. Although this cannot
be attributed to photovoice per se, it is nonetheless an important observation. For
instance, one individual shared a photograph of leaves on the ground. She noted that
because she was thinking about the positive impacts of her hearing aids, she became
aware of how much she enjoys the sound of walking through crackling leaves and other
outdoor sounds—something she could not appreciate without her hearing aids. She said
that although she originally obtained the hearing aids to assist with indoor conversation,
the instruction had made her realize how enjoyable it was for her to hear outside
and that as a result, she was now using her hearing aids more consistently. Another
individual noted that having spent time trying to understand where his hearing aids
were and were not helpful, he came to the realization that he should wear them all
the time, rather than sporadically as he had been before participating in the study.
DISCUSSION
This study assessed the feasibility of adapting photovoice methodology for use in
audiological practice. The data showed that participants were willing to take and
discuss photographs, that the photographs they provided depicted various aspects of
hearing and communication, and that, for the most part, reflected the content we expected
based on the instructions provided. In fact, participants were so willing to discuss
their photographs that the duration of the debriefing visits was long—too long to
be clinically practical. However, for the study, the research team encouraged in-depth
debriefing, and did not attempt to limit the discussion. In a clinical setting, the
debriefing session could be considerably shortened by requesting fewer photographs
and encouraging patients to focus their discussion on directly relevant content. Based
on the comments from some participants, who said it was challenging to take photographs
in multiple unique situations, limiting the number of photographs might be advantageous.
If photovoice is to be used as a clinical tool, patients must understand its value
because adherence to clinical recommendations is impacted by whether the patient agrees
with those recommendations ([Davis et al, 2002]). It is, therefore, reassuring that just three of the 24 participants were skeptical
of the process; the remainder could see its potential value as a clinical tool. Of
course, we do not know whether patients attending a clinical appointment would be
willing to participate in a photovoice activity. Of the nine participants who were
asked what they would think about bringing photographs to a clinical appointment if
their audiologist requested it of them, six said they would be willing to do so if
the audiologist thought it would be helpful, two did not have an opinion on the matter,
and one said he/she would be suspicious of the audiologist’s motives. Thus, although
clinical use of photovoice might not be acceptable to all patients, it would likely
be acceptable to many. In instances in which the patient was unwilling to share personal
photographs, one could provide the patient with preselected photographs to discuss
in the manner used by the IDA Institute. This would limit the extent to which the
conversation could be highly tailored but nonetheless, it could prove valuable.
Another consideration if photovoice is to be used as a clinical tool is maintaining
the privacy of the individuals in photographs that are shared with a clinician. It
is critical to ensure that the photographer is aware of the need for this. In this
study, it seems that most participants understood the importance of privacy, in that
just 12 of the 189 photographs received had identifiable content. It suggests that
the instructions and supplemental take-home booklet provided were effective in transmitting
the intended message. However, it would presumably be possible to develop an app that
automatically detects and hides facial features (through blurring or other means)
of all photographs taken using the app. This would have the dual benefit of ensuring
privacy while also broadening the subject matter available to the participants—thus
allowing more natural and ecologically valid photographs to be used in the clinical
or research setting.
The study illustrated the value of including a communication partner in the AR process.
The communication partners reported learning a lot about their hearing-impaired partner’s
hearing and hearing aids, they felt it gave them the opportunity to share their perspective
about communication, and that it gave them greater insight into their partner’s hearing
difficulties. These are some of the factors that underlie the value of family-centered
audiological care ([Hallberg and Barrenäs, 1994]; [Habanec and Kelly-Campbell, 2015]; [Singh et al, 2016]). Audiologists rarely involve family members in audiological care, being present
at less than 30% of appointments, and then only being involved in 12% of the total
interaction time ([Ekberg et al, 2015]). Often-cited reasons for not implementing family-centered care in audiological
practice are concerns about the complexities of family dynamics, uncertainty as to
what to do when there is a mismatch between the needs and priorities of the client
and the family member, and being unsure about how to involve family members in the
conversation ([Ekberg et al, 2014b]; [2015]; [Meyer et al, 2015]). Use of photovoice would seem to be a simple and effective way to involve both
partners in conversation, in a safe environment in which mismatches in opinion can
be discussed.
The personal nature of the debriefing sessions suggested that participants trusted
the research team. High trust and good patient–provider communication are associated
with greater satisfaction with health care, better adherence to treatment recommendations,
and better self-management ([Safran et al, 1998]; [Clark, 2003]; [Wanzer et al, 2004]; [Bendapudi et al, 2006]). Based on the nature of photovoice, it is perhaps not surprising this is the case,
but nonetheless it can be postulated that using photovoice as a clinical counseling
tool would enhance satisfaction, adherence, and self-management.
The instruction to document both positive and negative hearing aid experiences is
atypical of data collected in most clinical appointments and research protocols. Typically,
individuals are only queried about residual problems and problematic circumstances.
The data here illustrate the value of having individuals document both positive and
negative hearing aid experiences, regardless of whether photovoice is used as a tool.
This is well illustrated by the case described previously in which the participant
began using her hearing aids more because she had become aware that the hearing aids
were beneficial in situations that she had not previously thought about. Had she been
instructed to only focus on problematic listening situations, it is quite likely that
her hearing aid use would not have changed. We, therefore, encourage clinicians and
researchers alike to document positive hearing aid outcome because it can motivate
hearing aid use.
In general, the counseling advice focusing on communication strategies and rehabilitation
devices was fairly standard. However, the fact that it could be highly tailored to
the participant’s experiences using their own photographs seemed to make the advice
understandable to participants and, thus, likely easy to apply and retain. The differences
in patient lifestyle, needs, and preferences were evident when looking at and discussing
photographs. This kind of insight could be very useful for audiologists when selecting
assistive technology, and while empirical evidence is needed, our observation suggests
that obtaining the information from photographs was more efficient and targeted than
obtaining the information from an interview. Furthermore, the individual differences
in lifestyle demonstrate the need for patient- and family-centered interventions and
counseling. Photovoice can be used to guide selection of rehabilitation recommendations,
and for postfitting counseling.
Recall that our goal was to examine the feasibility of using an adapted version of
photovoice as a clinical tool; we did not aim to identify thematic content in the
interviews nor did we apply a formal qualitative analytical approach. Furthermore,
because we are interested in the application of photovoice methodology in clinical
audiology, we did not provide the research team with training in qualitative interviewing.
This was an intentional decision that was made in order that clinical utility could
be evaluated.
Being a feasibility study, there are limitations regarding the extent to which the
findings can be applied to a clinical sample. First, participants consisted of a convenience
sample of 24 individuals recruited from a database of prior volunteers who received
payment for taking part; thus, they were possibly more motivated to adhere to the
study protocol of taking photographs than a clinical sample might be. Second, formal
outcome measures were not included in the study design. This was because our goal
was to answer questions, such as “are people willing to use photovoice,” “is it considered
acceptable,” and “how much time might it take if it is implemented as a clinical tool,”
rather than to assess its impact on AR outcomes. In the future, the impact of photovoice
in clinical outcomes will be examined in a controlled, statistically powered research
study using standardized outcome measures. Third, we only asked 12 participants what
they would think if they were asked to bring photographs to a clinical appointment;
thus, we have little data from which to draw conclusions about this issue. Clearly,
patient acceptance of the method would be critical if it were to be used clinically.
As with many clinical procedures, it is likely that a proportion of individuals would
object to doing this. In such cases, as noted previously, using preselected photographs
could in part address this.
In summary, this feasibility study suggests that an adapted form of photovoice methodology
could be a highly promising tool for AR when used to facilitate provision of tailored
communication strategy counseling, as a post–hearing aid fitting counseling tool,
to enhance communication between partners regarding hearing loss, and to provide insight
into the emotional impacts of hearing loss. In the future, a statistically powered,
controlled research study using standardized outcome measures and a broader clinical
population will be conducted.
Abbreviations
app:
application
AR:
audiological rehabilitation
