Application of the Consumer Decision-Making Model to Hearing Aid Adoption in First-Time Users

Abstract

Since 1980, hearing aid adoption rates have remained essentially the same, increasing at a rate equal to the organic growth of the population. Researchers have used theoretical models from psychology and sociology to determine those factors or constructs that lead to the adoption of hearing aids by first-time impaired listeners entering the market. In this article, a theoretical model, the Consumer Decision-Making Model (CDM), premised on the neobehavioral approach that considers an individual's psychological and cognitive emphasis toward a product or service, is described. Three theoretical models (i.e., transtheoretical, social model of disability, Health Belief Model), and their relevant findings to the hearing aid market, are initially described. The CDM is then presented, along with supporting evidence of the model's various factors from the hearing aid literature. Future applications of the CDM to hearing health care also are discussed.

Learning Outcomes: As a result of this activity, the participant will be able to (1) discuss hearing aid adoption rates in first-time users, (2) state reasons for the slow growth in hearing aid adoption of first-time users, (3) explain the theoretical models used to understand the hearing aid adoption process in first-time listeners, and (4) discuss various constructs that influence purchase intent.

In 2015, an estimated 10% of the world's population, or greater than 700 million individuals, experienced some form of reduced hearing sensitivity (e.g., sensorineural loss, losses demonstrating a conductive component, single-sided deafness). Reduced hearing was defined as thresholds exceeding 25-dB hearing loss according to the British Medical Research Council.¹ Of these individuals, 215 million reside in the developed world.

In the United States, an estimated 35.8 million Americans experience some form of decreased hearing sensitivity.² Over the next three decades, estimates indicate that the number of persons with hearing loss will increase to 50.9 million, or by an additional 15.1 million Americans. Mathematically, these data suggest an organic growth of 0.5 million impaired listeners annually, based on an annual U.S. population increase of 1.1%. Estimates further suggest that between 17.5 and 24.6% of newly identified impaired listeners in the United States,² or ∼0.12 million annually (i.e., 0.5 million × 24.6%), at best, adopt amplification technology. In 2015, an estimated 8.81 million Americans (i.e., 35.8 million impaired listeners × 24.6% adoption rate) will have adopted amplification technology, compared with an estimated 8.57 million Americans in 2014.³ The market growth between 2014 and 2015 is estimated at 2.7%—that is, 1–(8.57 million/8.81 million) × 100—which is consistent with the long-standing average of 3 to 5% annual growth rate in this market.⁴ Furthermore, the 2015 estimate indicates that ∼26.99 million potential first-time American hearing aid users (i.e., 35.8 million impaired listeners – 8.81 million hearing aid users) will not adopt amplification technology. From an economic standpoint, it could be argued that not all 26.99 million potential hearing aid users want or need amplification. Using a model from Amlani and De Silva,⁵ the estimated number of potential first-time hearing aid users in the United States is 8.37 million.

Historically, the market has shown a long-term supply of individuals with decreased auditory sensitivity, rendering it a viable and ecological market, with an increased growth potential because of the world's marked increase in individuals aged 65 years and older.⁶ This population is expected to experience an increase in life expectancy, given improvements in occupational health conditions, medicine, and reduced tobacco use.^{7 8 9} Furthermore, this population is more likely to be obese and to have diabetes, hypertension, and hearing difficulties compared with the previous generation at similar ages.^{9 10} Recent research, on the contrary, suggests that the severity of hearing difficulties in the this population is milder than previously anticipated.^{10 11} Thus, one might postulate an increased likelihood of noncompliance to provider recommendations and adopting amplification in this population, stemming from a perception that their decreased hearing sensitivity is not sufficient to warrant assistance.^{12 13} This noncompliance to provider recommendations in this population is further constrained, in part, by terms such as mild and hearing loss that negatively impact consumer behavior toward hearing health care services and technology,¹⁴ and by technology that fails to provide the listener with user-adjustable controls.¹⁵

Over time, data indicate that the percentage of devices adopted by first-time users has declined,² but not because of the retail cost of hearing aids.^{5 16} In 1989, for instance, hearing aids adopted by first-time users comprised an estimated 53.4% of the market.² Since then, hearing aids adopted by this subpopulation have averaged an estimated 36%, ranging between 29% in 1994 and 40.5% in 1991. These data are complicated by the fact that the average first-time hearing aid user waits between 6.5 and 12 years to adopt amplification, after being diagnosed with impaired hearing.^{3 17} These estimates also suggest that 64% of hearing aids purchased in the United States stem from experienced users readopting this technology. Interestingly, less than one-half of experienced hearing aid users readopt their previous brand.^{2 3} A primary reason(s) for these behaviors has yet to be identified.^{18 19 20}

The long-standing purchase behaviors in the hearing aid market may stem from a lack of understanding of how listeners with reduced hearing sensitivity perceive information regarding amplification technology and act positively so that their behavior translates into purchase intent. This article provides a theoretical framework of the hearing aid uptake process from the first-time listener's perspective using the Consumer Decision-Making Model (CDM).

Theoretical Models To Explain Hearing Health Behavior

Treating decreased hearing sensitivity depends in large part on a listener's perception about hearing disability and hearing aids.¹⁹ Historically, there have been attempts to quantify this perception in impaired listeners using models from psychology and sociology.^{21 22 23 24} In this section, we report on three models applied to audiologic rehabilitation of first-time hearing aid users: (1) transtheoretical model, (2) social model of disability, and (3) Health Belief Model.

Transtheoretical Model

The transtheoretical model of intentional behavior change is premised on an individual's stages of change and the accompanying processes of change toward a healthy behavior.²⁵ The model quantifies changes in an individual's attitudes, actions, and intentions as they cycle through the decision-making process toward an intentional behavior change. This model has been successful in addressing issues related to depression, tobacco use, and obesity.^{26 27 28}

The model conceptualizes various stages: stages of change, decisional balance, self-efficacy, and temptation.²⁹ In audiology, the stages of change concept are the most widely reported. As shown in Fig. 1, the process of change involves five stages: (1) precontemplation (i.e., no thoughts or plans to change a behavior), (2) contemplation (aware of the problem that the behavior creates), (3) preparation (intended action to be taken), (4) action (behavior modification), and (5) maintenance (sustained healthy behavior). The findings from the model aid the clinician in determining an individual's stage of readiness to change, as well as a basis for counseling and intervention (for a review of interventions, see Table 1 in Babeu et al²¹). The individual's stage of readiness to change is determined by asking an individual to indicate which one of five statements best represents their attitude toward hearing aid use³⁰:

Figure 1.

Diagram of the stages of change processes within the transtheoretical model of intentional behavior.

1. I am not ready for hearing aids at this time. (Precontemplation)

2. I have been thinking that I might need hearing aids. (Contemplation)

3. I have started to seek information about hearing aids. (Preparation)

4. I am ready to get hearing aids if they are recommended. (Action)

5. I am comfortable with the idea of wearing hearing aids. (Maintenance)

For example, for an individual who indicates an initial stage of preparation—by responding favorably to “I have started to seek information about hearing aids”—the provider would intervene by, say, discussing the advantages and disadvantages of hearing aids and providing the impaired listener with additional information (e.g., pamphlets, Web sites) about amplification technology.²¹

Laplante-Lévesque and colleagues reported on the application of the transtheoretical model in audiologic rehabilitation.³¹ One hundred fifty-three adults with impaired hearing were asked to provide their (1) initial stage of change to four stages (i.e., precontemplation, contemplation, action, maintenance), and (2) completed the University of Rhode Island Change Assessment (URICA).²⁹ The URICA is a 32-item questionnaire, with 8 items designated to each of the four stages of change. Participants were offered three intervention options: (1) hearing aids, (2) communication programs, or (3) no intervention. Intervention utilization and compliance were assessed 6 months later, and their intervention outcomes were assessed 3 months after intervention completion. Overall, results revealed that participants who reported a lower stage of change (i.e., precontemplation) were those with milder hearing losses, and these individuals were less likely to use intervention and report successful outcomes.

The transtheoretical model also has been evaluated in listeners with decreased hearing sensitivity who have failed hearing screenings. When Milstein and Weinstein,³² for example, obtained hearing screening results and stage of change responses in 147 older adults prior to the screening, 76% of the participants rated themselves as either precontemplative or contemplative. Respondents then provided stage of change responses after participating in a hearing screening, with no significant change in stage response. Likewise, Laplante-Lévesque and colleagues evaluated the stage of change in 224 adults who failed an online hearing screening.³³ Results revealed that 88% of the participants were either in the preparation or contemplation stages of change, whereas 12% reported being in the preparation or action stage. Together, these studies suggest that the transtheoretical model provides a basis for an individual's present stage with respect to audiologic rehabilitation, but falls short in providing evidence of the cognitive and psychological processes that lead to future uptake intervention for a given individual.

Medical and Social Models of Disability

Prior to the 18th century, many cultures around the world considered people with physical, sensory, and mental impairments as being possessed by witchcraft or by demons or as sinners being punished by God. In the 18th century, a sense of confidence was born in medical science's ability to rehabilitate individuals with impairments. A pseudosignificant notion of normality was created within the sciences that assessed performance compared with normative data. Individuals with abnormal performance were labeled as disabled. This ideology is referred to as the medical model, or individual model, and pejoratively viewed the disabled individual as the problem.³⁴ In this model, the disabled individual was deemed a passive receiver of services dictated by the medical and associated professions. In other words, an individual with an impairment could plausibly or reasonably be asked to forgo control of one's own life.

A disability rights movement began in the 1950s, emphasizing the individuals' remaining capabilities and how they can be best supported to permit full economic and social participation (for a review of the historical legislation, the reader is referred to Winter³⁵). This led to the development of the social model of disability, which created a paradigm shift in how disability was perceived and the manner in which disability policy is to be developed and implemented. The crowning achievement of the social movement in the United States, one could argue, was the Americans with Disabilities Act (P.L. 101-336).³⁶ This act empowered people with disabilities with equal rights toward employment, communication, and public transportation. At the international level, the social model approach also modified the World Health Organization's attempt to account fully for interactions between the individual and the physical and social environment of an individual with a disability.³⁷

The social model recognizes that measured hearing sensitivity does not predict the degree of an individual's disability or handicap. However, it does elucidate that increasingly severe hearing loss impairs the likelihood of the listener's ability to carry out activities associated with their social, economic, and self-well-being.

Health Belief Model

The Health Belief Model is a sociopsychological model of health behavior change developed to explain and predict the adoption of health services.³⁸ Specifically, the Health Belief Model assumes that changes in health behavior stem from three stages: (1) an individual's perception about the health issue, (2) modifying factors that promote a change, (3) the likelihood of action (Fig. 2). The initial stage (i.e., individual's perception) consists of four constructs: (1) perceived susceptibility (i.e., the degree to which an individual feels vulnerable to a condition and the extent to which the individual believes that they are at risk of acquiring the condition); (2) perceived severity (i.e., the extent to which the condition affects the individual medically and socially); (3) perceived benefits (i.e., the belief that intervention will yield a desired outcome); and (4) perceived barriers (i.e., the barriers that an individual needs to overcome to achieve the desired outcome).

Figure 2.

Diagram of the stages and constructs of the Health Belief Model.

The second stage of the model is highlighted by the construct perceived threat. Perceived threat is an individual's risk assessment of the health problem, stemming primarily from the perceived severity and perceived susceptibility. Secondary constructs, such as demographic factors (e.g., age, sex, culture, ethnicity), psychosocial factors (e.g., personality, social class), knowledge of the health disorder, and adherence to treatment (e.g., severity of health issue, health status) influence perceived threat. Individuals who believe they are at low risk for developing decreased hearing sensitivity are more likely to engage in risky behaviors, whereas individuals who believe they are at high risk for developing decreased hearing sensitivity are more likely to decrease risky behaviors.

Once the individual has assessed the risk, it is necessary to prompt, or cue, the individual to take action. One example of a cue to action is setting an appointment with a primary care physician to identify hearing deficits as a part of a routine, multimorbidity, preventive wellness program (i.e., interventional audiology). Such a partnership program may lead to earlier intervention for age-related hearing loss while fostering the impaired listener's active participation in their hearing health care needs. (For a detailed description of this program, see Taylor's article in this issue.) Other examples of cues to action include appointment reminder postcards and product warning labels.

Likelihood of action is the third stage and is predicated on the perceived benefits of the intervention compared to the perceived barriers. The construct of perceived benefits is an individual's opinion of the usefulness of a new behavior in decreasing the risk of developing a disease. In an occupational setting, for example, the adoption of earplugs (i.e., preventative behavior) and hearing screenings is likely to increase as individuals strive to reduce the risk of noise-induced hearing loss. The construct of perceived barriers is challenged by change, and change is a difficult undertaking for most people. Research suggests that perceived barriers are the most important construct in determining whether behavioral changes will occur.⁴¹

Self-efficacy is the final construct of the third stage and was added to the model in 1988.⁴² Self-efficacy is the individual's perception that they can successfully perform a behavior. When an action is being performed, self-efficacy determines the amount of effort invested and the perseverance. Individuals with self-doubts are more inclined to anticipate failure scenarios, worry about possible performance deficiencies, and prematurely abort their attempts. Individuals with an optimistic sense of self-efficacy, however, visualize success scenarios that guide the action and let them persevere in the face of obstacles. Recent laboratory research found that listeners with higher self-efficacy scores were more likely to adopt amplification technology than those with lower self-efficacy scores, and postpurchase satisfaction was higher despite similar aided perceptual difficulties.⁴³

Few studies have used the Health Belief Model to assess hearing health behaviors. Van de Brink and colleagues examined the relationship between attitudes and help-seeking behaviors of 624 older adult impaired hearing participants of the Groningen longitudinal study.⁴⁴ At the study onset, 41% of participants had adopted hearing aids, 26% of participants had sought out intervention for decreased hearing sensitivity and had not adopted amplification technology, and 27% of participants had yet to seek out intervention for decreased hearing sensitivity. During the study, participants completed a questionnaire that assessed (1) perceived severity of decreased audibility, (2) perceived benefits of hearing aids, (3) perceived barriers related to cost, and (4) cues to action stemming from perceived social norms. Results revealed categorical groupings of data as a function of participant group. Specifically, participants who had adopted hearing aids reported higher scores on perceived severity, perceived benefits, and cues to action. Intermediate scores for these constructs were reported for those who had sought out intervention for decreased hearing sensitivity and had not adopted amplification technology, with the lowest scores reported by participants who had yet to seek out intervention for decreased hearing sensitivity.

Recently, Saunders and colleagues developed the hearing beliefs questionnaire (HBQ), within the constructs of the Health Belief Model, and then investigated whether HBQ scores were associated with hearing health behaviors.⁴⁵ A 60-item questionnaire was developed and completed by 223 participants across six constructs: (1) perceived susceptibility to acquiring hearing loss, (2) perceived severity of hearing loss both medically and socially, (3) perceived benefits from intervention, (4) perceived barriers to overcome for intervention to be successful, (5) perceived self-efficacy, and (6) internal (e.g., symptoms of a health problem) and external (e.g., mass media information) cues to action. These six constructs were then measured against the hearing health behaviors of (1) help seeking, (2) hearing aid adoption, and (3) hearing aid use. Of the 60 items in the HBQ, 26 items across the six constructs were salient for analysis. Data showed that help seekers demonstrated higher perceived susceptibility, lower perceived barriers, and higher cues to action than non–help seekers. Hearing aid adopters were found to perceive themselves as more susceptible to hearing loss, while perceiving more benefits and fewer barriers to action, and were provided more cues to action compared to those who had not adopted amplification technology. Finally, hearing aid users perceived an increase in severity of the health condition, perceived fewer barriers, increased self-efficacy, and had encountered more cues to action than participants who did not use hearing aids regularly. Despite these findings, the six constructs explained only 36% of the variance in participant responses.

Historically, the Health Belief Model has been labeled as being more descriptive than explanatory, and as a result, is not sufficiently able to provide strategies for changing health-related actions.⁴⁶ In addition, the model does not account for individual's attitudes, beliefs, or other individual determinants that dictate a person's acceptance of a health behavior. Recent research suggests that listeners diagnosed with impaired hearing, especially those with milder degrees of decreased auditory sensitivity, exert more effort in redefining their new self-identity rather than attempting to restore communication ability.⁴⁷

Consumer Decision-Making Model

The profession is still attempting to understand the consumer decision-making process as it relates to amplification adoption in first-time users. Many consumer-decision models, such as the three described earlier in this article, are premised on static assumptions that the consumer is rational and adaptive.⁴⁸ That is, these models assume a goal-oriented approach to decision-making, as an individual moves from awareness and knowledge, to liking and preference, to conviction, and, ultimately, purchase.⁴⁹

The CDM, developed by Blackwell, Miniard, and Engel,⁵⁰ also assumes a sequence approach to decision-making, but further considers individual differences by including internal factors (e.g., self-esteem, emotions, expectations, attitude, motivations) and external (e.g., hearing health care professional, service delivery method, counseling) factors. In the hearing aid literature, many of these factors have been found not to yield statistical differences.^{19 51} Cox and colleagues elucidate, “a different questionnaire approach might be optimal for evaluating intervention effectiveness in a clinical context.”^{51 (p.141)} At the University of North Texas, believe the CDM provides a different approach to assessing an individual's psychological and cognitive processes toward hearing aid adoption.

The CDM stems from the neobehavioral approach that attempts to describe an individual's psychological and cognitive emphasis toward a stimulus, called a stimulus-organism-response approach.⁵⁰ In this approach, the stimulus represents, for example, a product characteristic or a packing or advertising action. The stimulus is presented to the individual, or organism, where psychological and cognitive processes play a prominent role in guiding consumer behavior, with influences from internal (e.g., attitude, emotions, motivation) and external (e.g., culture, family, advertisements) variables. The output reaction, or response, by the organism yields either a positive (e.g., purchase) or a negative (e.g., nonpurchase) outcome. Similarities and differences in outcomes among individuals having similar needs helps explain how information is processed. The CDM is illustrated in Fig. 3.

Figure 3.

Diagram of the Consumer Decision-Making Model.

Need Recognition

The initial, and most important, stage for the consumer in the decision-making process is need recognition. As shown in Fig. 4, need recognition depends on (1) the perceived discrepancy between the individual's desired lifestyle—termed the desired state—and the individual's current situation—termed the actual state—for a given characteristic, and (2) the relative importance of the problem. For a need to be recognized, the magnitude of discrepancy for the desired state must exceed that individual's psychological threshold for the actual state. Conversely, when the magnitude for the desired state is less than or equal to the individual's psychological threshold for the actual state, satisfaction supersedes need recognition. In the latter condition, the individual does not foresee the need to continue with the decision-making process.

Figure 4.

Diagram and decision-making process associated with the need recognition stage of the Consumer Decision-Making Model.

Motivation, ability, and opportunity to make the acquisition are the key constructs of need recognition that affect whether an individual will pay attention to and perceive information, the next stage in the decision-making process (Fig. 4). Motivation reflects an inner state of arousal that directs the individual to engage in goal-relevant behaviors, effortful information processing, and detailed decision-making.⁵² Most motivated consumer experiences involve affect or cognition, and the degree of involvement may be either long-term or situational (i.e., lasting only until the goal has been met). An individual's motivation is greatest when they regard a goal (1) as personally relevant (i.e., relates to the individual's self-concepts, values, needs, goals), (2) as entailing considerable risk, or (3) as moderately inconsistent with their prior attitudes. From an audiological standpoint, the following factors fall into this category: self-efficacy, motivation, and expectations. Knudsen and colleagues,¹⁹ who provide an excellent review on hearing aid adoption, found only one published study (on expectations and adoption⁵³) from the three categories. A recent study from our laboratory found that perceived self-efficacy increases the likelihood of hearing aid adoption in first-time adopters by a factor of 2:1 in listeners with hearing impairment when hearing screening results are provided through a self-administered smartphone-based hearing test application compared with the traditional screening approach.⁴³

Motivation alone does not result in an increased likelihood of decision-making. Decision-making requires the ability of the individual to process information, make decisions, and engage in behaviors. Ability is defined as the extent to which consumers have the necessary environmental (e.g., culture, social, family, financial) and individual (e.g., cognitive, emotional, attitudes, personality) resources to make the outcome happen. The cost of amplification, emotions, and stigma are often cited deterrents to hearing aid adoption.

From an economic standpoint, the demand function for adopting amplification is inelastic.^{5 16} This simply means that consumers' purchasing behavior is essentially constant, regardless of increases or decreases in the price of a product or service. This theory is supported by behavioral research, where Gussekloo and colleagues found that elderly listeners from varying economic backgrounds were equally likely to adopt amplification as a function of price.⁵⁴

Emotions, or affect, also influence the decision-making process. Zajonc proposed that emotion has indirect effects on our behavior through implicitly shaping our attitudes and judgments (i.e., cognitive representations of the world).⁵⁵ Individuals with reduced hearing sensitivity demonstrate high levels of anxiety,⁵⁶ potentially precluding their ability to interpret meaningful situations and information.⁵⁷ In the context of health-related decisions, affect has been found to be an important predictor of engaging in health-protective behaviors (e.g., safer sex practices, exercise, healthy diet) through its effects on self-efficacy (i.e., perceived ability to manage one's health).⁵⁸ In the case of hearing aid adoption, the lack of self-efficacy hinders health-protective behaviors in first-time listeners. As noted previously, improved self-efficacy increases hearing adoption by a factor of 2:1 in first-time adopters of amplification. Results further revealed greater satisfaction with provider services and with the same technology between participants having higher perceived self-efficacy than those with lower perceived self-efficacy, despite statistically similar perceptual difficulties among participants while listening to aided speech-in-noise, and with hearing aid feedback.⁴³

Negative attitude, termed stigma or the hearing aid effect, is another common deterrent to individuals adopting hearing aid technology.¹⁸ Wallhagen purports that marketing efforts of hearing aids should feature the cosmetic aspects of hearing aid use, rather than the functional benefit, through advertisements that focus on reduced visibility and vanity.⁵⁹ Research suggests that stigma is considerably higher in individuals who do not experience hearing loss,^{60 61} and it is similar in groups having hearing loss. However, stigma alone did not preclude whether an individual adopts the technology.⁶² Given the proliferation in young individuals wearing headphones coupled to their smartphones, research also suggests a decrease in the hearing aid effect by college-aged observers.⁶¹ The implication of this research bodes well for young impaired listeners needing amplification as attitudes are learned behavior. Whether this decrease in hearing aid effect is seen in the older population is not yet clear. Research further indicates that once an attitude is predisposed, resulting from direct experience with the product, word-of-mouth information acquired from others, or exposure to mass-media advertising or the Internet, changing the predisposition is difficult. Wilson and colleagues hypothesize that new attitudes can override predisposed attitudes, but the initial predisposed attitudes are never replaced, resulting in dual attitudes.⁶³ Dual attitudes are a cognitive assessment of the same object that can result in differing attitudes.

Information processing is another construct that influences an individual's opportunity factor. An impaired listener, for example, may be highly motivated and have sufficient financial resources to adopt hearing aid technology. However, their inability to attend follow-up visits during the fitting process may preclude success in everyday listening environments. Two important opportunity factors that influence need recognition, despite high motivation and ability, are time and information.

Time is an important construct in the decision-making process. Individuals spend time and financial resources to acquire products and services and must expend time prior to and after the consumption and utilization of their acquisition. Research has shown that time influences consumer purchasing behavior.⁶⁴ Individuals who have insufficient time to attend to product and service information are less likely to problem solve. In this case, the individual who elects to adopt a product will either select the well-known brand because they do not take the time to consider alternatives, or they will select the least expensive product and risk buyer's remorse (i.e., cognitive dissonance). Product demonstrations are one means to enhance the individual decision process while reducing buyer's remorse. Furthermore, research indicates that individuals are less likely to adopt a service or product once they leave the premises.⁶⁴ For individuals who are time-constrained, on the other hand, additional time to process the information may beneficial.

The amount and type of information presented also can affect the individual's processing ability. Individuals view messages containing a picture without words, often seen in trade journals, as ambiguous and difficult to process. Furthermore, large amounts of information that require sorting are viewed as complex. Most importantly, information that is technical or quantitative is more difficult for individuals to process than information that is nontechnical or qualitative. As an example, Amlani et al assessed the perceived value of pricing and advertising strategy on hearing aid adoption in experienced and first-time users of amplification technology.⁶⁵ Perceived value was quantified as the mean amount respondents were willing to pay as a function of whether pricing was bundled, partially unbundled, and completely unbundled for the same technology and professional service. The technology and professional service was framed in three different ways: using vague terms (e.g., 100% digital), using industry terms (e.g., adaptive directionality, multichannel), and using layman's terms (e.g., improves listening effort, automatically adjusts volume) based on empirical evidence.

Overall, results revealed that willingness to pay (i.e., perceived value) increased significantly (p < 0.05) when the attribute of amplification technology (i.e., perceived quality) was framed using nontechnical language and demonstrated evidence-based benefit, compared with attributes of the same technology that were framed using vague and technical language. Likewise, perceived value increased significantly (p < 0.05), as a function of perceived price, when an unbundled pricing strategy was employed.

Search for Information

Following need recognition, the next step is the individual's internal search into memory to determine whether enough is known about available options to allow a choice to be made without further information (Fig. 5). This search is a scan for decision-relevant knowledge stored in memory and may include product knowledge, brand awareness, image analysis, price awareness, purchase knowledge, and usage knowledge.

Figure 5.

Diagram of the search for information stage of the Consumer Decision-Making Model.

Whether individuals rely solely on internal search information depends on the adequacy of their existing knowledge. Most first-time buyers lack the knowledge for decision-making. Reasons for this lack of knowledge, according to Amlani and Taylor,⁶⁶ stem from (1) a market that has failed and continues to fail would-be users with evidence-based benefits of the technology in a meaningful way, (2) a lack of emphasis on the service aspect of rehabilitation related to the hearing aid fitting, and (3) a lack of distribution of over-the-counter devices that allow for increased self-efficacy and hearing health awareness and reduced stigma.

When the internal search proves inadequate, the individual may decide to collect additional information from the environment. Most individuals today begin their search online. Data from the Pew Institute suggests that 53% of American adults aged 65 years and older use the Internet or e-mail, with 70% of the 53% using the Internet on a daily basis.⁶⁷ In addition, 69% of adults aged 65 years and older own a mobile phone. Research suggests that for older adults, Internet information influences the attitudes of ease of use, usefulness, and trust on purchase behavior.⁶⁸ Amlani assessed the influence of mass media on hearing aid adoption of nonusers of amplification.⁵⁶ Results revealed negative mean responses to media stemming from the respondents' perception that marketing tactics focus primarily on technology and price, not benefit and value.

As noted earlier, terms such as mild and hearing loss also negatively impact consumer behavior toward hearing health care services and technology.¹³ Evidence supports the notion that adopting amplification is influenced positively in first-time users when a family member/friend participates in the acquisition process.⁵⁶ Conversely, nonadoption of amplification also is influenced by health care providers, family members, and friends who are in denial of the consumer's hearing problems.⁵⁹

A barrier to the supply of individuals needing audiological services and technology is further evident in the percentage of hearing screenings performed by general practitioners. In the United States, Kochkin reported that a mere 13.9 and 16% of adults aged between 65 and 74 years, and 74 years and older, respectively, were screened by their general practitioner for decreased hearing sensitivity.² In Denmark, only 7% of general practitioners ask their patients about their ability to hear.⁶⁹ In addition, when Danish patients who demonstrate decreased hearing sensitivity are referred, in 45% of cases the referral was made to an otolaryngologist compared with 17% of cases referred directly to an audiologist.

Individuals who understand their emotional ability can make higher-quality consumption decisions such as health decisions and product choice.⁷⁰ Blocker further suggests that the influence of emotional ability is mediated by the interaction between the seller and the buyer.⁷¹ Specifically, Blocker investigated the emotional communication that occurs between real estate agents and clients; that is, an emotionally competent agent interacting with a client having great difficulty recognizing and expressing their emotions, and vice versa. To assess this interaction, he used the Consumer Emotional Intelligence Scale (CEIS),⁷⁰ an 18-item questionnaire that assesses a person's ability to perceive, understand, and manage human emotions. A high score, closest to 1, on the CEIS indicates a positive impact to adopt or sell, whereas a low score, closer to 0, indicates a negative impact to adopt or sell. Blocker found that when real estate agents and their clients scored similarly, the outcome resulted in a positive emotional communication relationship, which increased the likelihood of a sale. When scores were asymmetrical between agent and client, the relationship deteriorated, resulting in an increased likelihood that no sale would occur.

In a recent doctoral capstone project,⁷² we borrowed Blocker's experimental design in an attempt to assess the emotional intelligence of audiologists and their patients. Data were collected for 60 audiologists paired with 60 patients. Twenty of the patients were nonusers of amplification, 20 patients had purchased hearing aids and returned the devices for credit, and 20 patients had successfully adopted amplification (i.e., daily use of device, minimum 8 hours daily, for >1 year). Mean CEIS results across groups revealed that audiologists scored significantly lower (p < 0.05) on the CEIS compared with all three groups of impaired listeners (Fig. 6). This finding suggests that audiologists are falling short in creating a positive emotional communication relationship, which might be a factor in why impaired listeners are not adopting audiologic services and technology.

Figure 6.

Mean Consumer Emotional Intelligence Scale (CEIS) responses from impaired listeners who are nonadopters of hearing aids (First-Time), impaired listeners who adopted then returned hearing aids (Ret HA), impaired listeners who adopted and use hearing aids (Exp HA), and audiologists (Aud).

Information Processing

Once an individual is exposed to information, that information is processed in a series of steps. As shown in Fig. 7, exposure is the initial step, where one or more of the senses are activated based on information received via a stimulus. The stimulus provided must be informative and persuasive, exceeding that individual's absolute threshold for a sensation to occur. Multisensory input increases the chances of exceeding the absolute threshold of sensation.⁷³ An example of exposure is the smell of perfumes and colognes, the visual message displays, and the visual and tactile ability to see and hold the product as one passes by the fragrance counter at the local department store. For hearing aids, exposure should include the patient's handling of the device while listening to amplified speech during an in-office product demonstration, which can further be associated with the smell and sight of peppermint candy from a container, placed strategically on the counter in the testing area.

Figure 7.

Diagram of the information-processing stage of the Consumer Decision-Making Model.

The second stage of information processing is attention (Fig. 7). The individual's cognitive system must allocate information-processing capacity to store the incoming information. Attention is heightened when content is multisensory and matches the individual's motivations and needs, especially through advertising messages in the exposure stage.⁷³ An individual's attitude also is known to influence attention. A patient having strong negative stigma regarding hearing aid benefit will be less attentive to professional recommendations during an auditory-only counseling session but may be more attentive during counseling that is enhanced through an in-office product demonstration. If attention is heightened, the message is further analyzed against categories of meaning stored in memory.

Comprehension, the third stage in information processing, is influenced by many stimuli and personal factors. Motivation also influences comprehension. During a hearing aid product demonstration, as attention is increased, motivation is increased, resulting in greater comprehension of the benefits provided by amplification. Conversely, decreased motivation results in decreased attention and, ultimately, decreased comprehension. Comprehension is also dependent on knowledge stored in the individual's memory. Thus, it is important that the message provided by hearing health care providers to the impaired listener is at a level that they can comprehend. Thus, using terms such as multichannel compression and adaptive directionality reduce comprehension and decrease the likelihood of adoption. Use of terminology in layman's terms is critical.⁶⁵

The fourth stage, acceptance, occurs when the individual's existing beliefs and attitudes are modified by the persuasive effect of the stimulus. Assume that a patient, who has experienced an in-office product demonstration and been counseled using layman's terminology, comprehends the benefits of amplification technology. Is this comprehension sufficient for persuasion to occur? Not necessarily. The patient may understand the message being communicated but may disagree with the message as it conflicts with their existing beliefs, ideas, or values (i.e., cognitive dissonance). Cognitive dissonance may be reduced by eliciting feelings and emotions from the stimulus.^{74 75} For instance, messages that show contrasts in quality of life—an impaired listener seated alone in an assisted facility versus the same individual socializing during a board game—increase positive attitudes, comprehension, and acceptance. Finally, product claims of superiority are, on average, accepted by less than 30% of individuals.

The final stage of information processing is retention, shown in Fig. 7, and involves the transfer of stimulus interpretation into long-term memory. (The topic of memory is beyond the scope of this article. The reader is referred to Solomon for additional information.⁷⁶) From a practical standpoint, information retention involves the consumer's ability to retrieve and recall information when choosing among product alternatives.

Prepurchase Alternative Evaluation and Purchase Intent

The third and fourth steps in the CDM are termed evaluation and purchase intent, respectively. The prepurchase alternative evaluation step denotes the process by which a choice alternative is evaluated and selected to meet a consumer's needs. In the hearing aid literature, the prepurchase decision by the participant has been quantified using unidimensional self-measures, for example, of hearing aid use, satisfaction, and benefit.^{18 19 20} Findings are then concluded from small study samples and generalized to the impaired listening population.

A more robust and inferential methodology is needed to understand consumer decision-making. In our previous work, we have assessed the prepurchase alternative evaluation through the construct of perceived value. Perceived value predicts an individual's perception between the price and quality of a product or service and how that perception meets their needs or requirements, resulting in purchase intent (Fig. 8). Purchase and repurchase intent is predicated on perceived price, perceived quality, and, most importantly, perceived value.^{77 78}

Figure 8.

Illustration of the prepurchase alternative decision stage of the Consumer Decision-Making Model.

To illustrate the concept of perceived value, assume a nonadopter of amplification is in the market for a hearing aid. This individual will determine a perception of price for a product based on the retail (i.e., actual) price and the reference price stemming from external sources. Perceived quality also is determined by the individual's perception of the superiority of the product to its intended purpose, relative to alternatives. Perceived price and perceived quality, together, result in a formation of value perceptions, which is the key variable to influencing choice. Perceived value is the individual's overall assessment of the utility of a product and depends on the relationship between what is received and the price paid (i.e., higher-quality products are associated with higher retail prices).

Assume that an adult listener with impaired hearing is having difficulty communicating in family and social situations and has decided to investigate hearing aids as a treatment option. This individual begins the potential adoption process by searching the Internet. Here, perceptions are formed regarding price and quality. In the event that this individual notes no differences in quality—for example, no differences in services provided among different businesses and no difference in the quality of the product—then price perception influences perceived value. This scenario is the primary reason for the success of big-box retailers. Now, because this individual paid substantially less for the same product and similar services, there is a lower perceived value toward the technology. This creates a predisposed attitude toward amplification, and that attitude is amplified—either positively or negatively—based on degree of success the individual perceives from their daily experiences.

For the same individual, assume that the perception of price shows no marked differences. In this case, perceived quality influences perceived value. Here, the individual may assess such factors as services, standard of care, and accessibility provided by the hearing health care provider, as well as the functional usability (i.e., controls) and benefits to lessen their communication difficulties provided by the product. In cases where perceived value becomes obfuscated by the potential hearing aid user, use of a smartphone or personal sound amplification product may be useful in changing their attitude.

Summary

Hearing aid growth has remained stagnate over the past 35 years. We conjecture that this growth is hindered by a lack of understanding of how first-time users of amplification technology perceive attributes and price information of products and, ultimately, how these perceptions translate into purchase intent. Researchers have attempted to gain a better perspective of this behavior using various models adopted form psychology and sociology. Although these models do provide some insight into consumer behavior, they are limited in their availability to provide sufficient clarity of the purchase intent in the impaired-listener population. Although the CDM has not been utilized in the hearing aid literature, at least not to our knowledge, it is believed that the proposed model can provide greater insights into the consumer behavior of this population. Such information would allow the profession to serve better this population, while improving market growth.