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Objectives: This study investigated the application of the transtheoreti-cal (stages-of-change) model in audiologic rehabilitation. More specifi-cally, it described the University of Rhode Island Change Assessment (URICA) scores of adults with acquired hearing impairment. It reported the psychometric properties (construct, concurrent, and predictive valid-ity) of the stages-of-change model in this population.

Design: At baseline, 153 adults with acquired hearing impairment seeking help for the first time completed the URICA as well as mea-sures of degree of hearing impairment, self-reported hearing disability, and years since hearing impairment onset. Participants were subse-quently offered intervention options: hearing aids, communication pro-grams, and no intervention. Their intervention uptake and adherence were assessed 6 months later and their intervention outcomes were assessed 3 months after intervention completion. First, the stages-of-change construct validity was evaluated by investigating the URICA fac-tor structure (principal component analysis), internal consistency, and correlations between stage scores. The URICA scores were reported in terms of the scores for each stage of change, composite scores, stages with highest scores, and stage clusters (cluster analysis). Second, the concurrent validity was assessed by examining associations between stages of change and degree of hearing impairment, self-reported hear-ing disability, and years since hearing impairment onset. Third, the predictive validity was evaluated by investigating associations between stages of change and intervention uptake, adherence, and outcomes.

Results: First, in terms of construct validity, the principal component analysis identified four instead of three stages (precontemplation, con-templation, preparation, and action) for which the internal consistency was good. Most of the sample was in the action stage. Correlations between stage scores supported the model. Cluster analysis identified four stages-of-change clusters, which the authors named active change, initiation, disengagement, and ambivalence. In terms of concurrent validity, participants who reported a more advanced stage of change had a more severe hearing impairment, reported greater hearing disability, and had a hearing impairment for a longer period of time. In terms of predictive validity, participants who reported a more advanced stage of change were more likely to take up an intervention and to report suc-cessful intervention outcomes. However, stages of change did not pre-dict intervention adherence.

Conclusions: The majority of the sample was in the action stage. The construct, concurrent, and predictive validity of the stages-of-change model were good. The stages-of-change model has some validity in the rehabilitation of adults with hearing impairment. The data support that change might be better represented on a continuum rather than by movement from one step to the next. Of all the measures, the precon-templation stage score had the best concurrent and predictive validity. Therefore, further research should focus on addressing the precontem-plation stage with a measure suitable for clinical use.

(Ear & Hearing 2013;XX;0–0)

INTRODUCTION

Successful rehabilitation of adults with acquired hearing impairment requires changes in cognitions and behaviors, for example, in acknowledging a hearing disability, in seeking pro-fessional help, and in completing rehabilitation interventions. For this reason, theories of health behavior change have fre-quently been discussed in audiology (Erdman et al. 1994; Noh et al. 1994; van den Brink et al. 1996; Babeu et al. 2004; Carson 2005; Manchaiah 2012).

Transtheoretical (Stages-of-Change) ModelModels and theories of health behavior change abound

(for reviews, see Nieuwenhuijsen et al. 2006; Clark & Houle 2009; Ravensloot et al. 2011). The transtheoretical model of behavior change (Prochaska & DiClemente 1983) focuses on a person’s readiness to change in adopting and maintaining healthy behaviors. It has been widely influential for a number of behaviors, such as tobacco cessation or dieting (Prochaska et al. 2009). As the transtheoretical model depicts health behavior change as progress through discrete stage steps, it is often described as the stages-of-change model. Although the transtheoretical model includes other concepts such as processes of change, decisional balance, self-efficacy, and temptation (Prochaska et al. 2009), this article focuses on the stages of change.

Stages of ChangeThe authors of the transtheoretical model have proposed dif-

ferent versions of the stages of change throughout the years; however, four stages are most often described (McConnaughy et al. 1983): (1) precontemplation (problem denial); (2) contem-plation (problem awareness and ambivalence regarding the pros and cons of change); (3) action (healthy behavior acquisition or modification); and (4) maintenance (sustained healthy behav-ior and relapse prevention). Preparation or decision making has been proposed as a stage between contemplation and action where change is imminent (Prochaska et al. 2009). Progress through the stages is understood to be nonlinear with regression to an earlier stage common.

Model proponents argue that people in the later stages of change are most likely to display help seeking, intervention uptake, adherence, and successful outcomes (Prochaska et al. 2009). Motivational interviewing proposes that a person’s stage of change can inform intervention and counseling needs (Miller & Rollnick 2002). A meta-analysis of 72 randomized controlled trials showed that motivational interviewing achieves better treatment outcomes than traditional advice for both physiologi-cal and psychological health conditions (Rubak et al. 2005).

Stages of Change in Adults With Acquired Hearing Impairment Seeking Help for the First Time: Application of the Transtheoretical Model in Audiologic Rehabilitation

Ariane Laplante-Lévesque,1,2 Louise Hickson,1 and Linda Worrall1

1School of Health and Rehabilitation Sciences, University of Queensland, Australia; and 2Eriksholm Research Centre, Oticon, Denmark.

LWW

0196-0202

Hagerstown, MD

10.1097/AUD.0b013e3182772c49

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Audiologists can address the typical reluctance, rebellion, res-ignation, or rationalization precontemplators exhibit with active listening, which can raise problem awareness and encourage-ment to improve self-efficacy toward behavior change. Con-templators can benefit from evidence-based information highlighting the pros and cons of intervention uptake, therefore reducing ambivalence and instilling hope that change is pos-sible. Audiologists can meet the needs of preparators by helping set realistic intervention goals and proposing concrete treatment plans. Nevertheless, sound stages-of-change measures are cen-tral to the application of the stages-of-change model.

Stages-of-Change MeasuresSome stages-of-change measures have been developed for

specific population groups but two measures are generic and can be applied to all populations.

The first generic measure is the staging algorithm, where each stage of change is represented by one statement (e.g., Prochaska et al. 1994). The statements are mutually exclusive and respon-dents identify the statement that best represents their situation: I do not intend to change in the next 6 months (precontemplation stage); I intend to change in the next 6 months (contemplation stage); I have changed in the last 6 months (action stage); and I have changed over 6 months ago (maintenance stage). The authors note that the 6-month time criteria might be revised to a more relevant time estimate in some populations. For example, 12 months has been used for mammography screening (Pro-chaska et al. 1994). The staging algorithm was used in adults with hearing impairment in one previous report (Milstein & Weinstein 2002). No association was found between stages of change and hearing assessment attendance in adults aged 65 years and older who had failed hearing screening.

The second generic measure is the University of Rhode Island Change Assessment (URICA; McConnaughy et al. 1983). The URICA has 32 items, with 8 items for each of the stages of change: precontemplation (e.g., As far as I’m con-cerned, I don’t have any problems that need changing), contem-plation (e.g., It might be worthwhile to work on my problem), action (e.g., I am actively working on my problem), and main-tenance (e.g., I have been successful in working on my prob-lem but I am not sure I can keep up the effort on my own). The five response options are: (1) strongly disagree, (2) dis-agree, (3) undecided, (4) agree, and (5) strongly agree. Total stage scores range from 8 to 40, with higher scores indicative of greater endorsement of the relevant stage of change. The URICA has a four factor structure consistent with the four stages of change (e.g., McConnaughy et al. 1983; Carney & Kivlahan 1995) and good test–retest reliability (Abellanas & McLellan 1993). However, some inconsistencies in the item loadings and stage definitions have emerged in controlled stud-ies, pointing to some issues with the construct validity of the stages of changes (e.g., Pantalon & Swanson 2003; Dozois et al. 2004). To our knowledge, the URICA has not been used with adults with hearing impairment. Stages-of-change descriptions (construct validity) as well as relationships between stages of change and other similar measures (concur-rent validity) and behavior change (predictive validity) have been extensively studied in a range of populations but are unknown in the context of audiologic rehabilitation.

More recently, we studied the relationship between stages of change (continuous scores for precontemplation, contempla-tion, and action stages) and intervention decisions, uptake, and outcomes (predictive validity). We demonstrated that stages-of-change scores were not associated with intervention decisions in adults with hearing impairment seeking help for the first time (Laplante-Lévesque et al. 2011) but that they were associated with intervention uptake and outcomes in the same sample (Laplante-Lévesque et al. 2012). The present article focuses on the psychometric properties of the URICA. It reports on con-struct and concurrent validity of the model in audiology, which has not been published before. Moreover, as described in the next section, stages of change can be expressed in a number of different ways, which have yet to be explored in adults with hearing impairment. The present article therefore also reports on previously unpublished in-depth analyses of the stages-of-change data collected as part of a large research project of adults with acquired hearing impairment seeking help for the first time.

Research AimsThis analysis explored the application of the stages-of-

change model in audiologic rehabilitation. More specifically, the psychometric properties (construct, concurrent, and pre-dictive validity) of the URICA were assessed in adults with acquired hearing impairment seeking help for the first time.

PATIENTS AND METHODS

ParticipantsPeople aged 50 years and older seeking hearing help for the

first time were recruited in Brisbane, Queensland, Australia. All potential participants completed a hearing assessment (otoscopy and air conduction pure-tone audiometry) with the first author who is a certified audiologist. Eligibility was restricted to those who presented with a hearing impairment (average of air conduction thresholds at 0.5, 1, 2, and 4 kHz greater than 25 dB HL in at least 1 ear). Potential participants who had received previous hearing rehabilitation services were excluded. The study received ethical clearance from The University of Queensland’s Behavioural and Social Sciences Ethical Review Committee and the Australian government’s Department of Health and Ageing Ethics Review Committee.

MeasuresStages of change, self-reported hearing disability, and inter-

vention outcomes were assessed with questionnaires.

Stages of Change • Each of the URICA (McConnaughy et al. 1983) statements includes the phrase “the problem,” which was replaced here by “the hearing problem,” as the URICA authors recommended. Because the participants were seeking help for the first time and had never completed an intervention for their hearing impairment, the eight URICA items relevant to the main-tenance stage were excluded as they were considered irrelevant. This report therefore focuses on the precontemplation, contem-plation, and action stages of change as measured by the 24-item version of the URICA, which has previously been used in clinical populations (e.g., Lam et al. 1988; Treasure et al. 1999). As sum-marized in Table 1, the URICA scores can be reported in at least four different ways to represent the respondent’s health behavior

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change profile: (1) stage scores; (2) composite scores; (3) stage with the highest score; and (4) stages-of-change clusters. First, stage scores (i.e., total scores for each of the stages) can be used as a measure of stage endorsement (e.g., Amodei & Lamb 2004; Dozois et al. 2004). With the stage scores, respondents can score high on more than one stage of change.

Second, some simple arithmetic on the stage scores can provide two composite scores (i.e., readiness and committed action). Adding the URICA’s average contemplation, action, and maintenance stage scores and subtracting the average pre-contemplation stage score provides the readiness score (e.g., Velasquez et al. 1999; Pantalon & Swanson 2003). Subtract-ing the contemplation stage score from the action stage score provides the committed action score (e.g., Pantalon et al. 2002; Field et al. 2007). The higher these two scores, the further the respondents are along the stages of change.

Third, the stage with the highest score can be used to describe a respondent’s stage of change (e.g., Etter et al. 1997; Treasure et al. 1999). If two stages have an equal score, the stage furthest from precontemplation in the model is considered to have the highest score. This measure implies that a respondent can be in only one stage at any point in time.

Fourth, cluster analysis of the URICA scores can generate stages-of-change clusters (e.g., McConnaughy et al. 1983; Keefe et al. 2000). Cluster analysis is a statistical analysis technique that assigns participants into subgroups (called clusters) based on the similarity of their results (Everitt et al. 2001). Cluster analysis groups participants with similar permutations of scores on questionnaire subscales, whereas principal component analy-sis groups similar questions based on questionnaire scores. For example, cluster analysis could reveal a cluster of participants who rate high on the precontemplation and contemplation stages but low on the action and maintenance stages. Evaluation of the cluster results is typically done with visual inspection of the cluster analysis dendogram and with comparisons of the Eucle-dian distance (measure of dissimilarity) between clusters.

In the present study, the URICA results were described in terms of scores for each stage, composite scores (readiness and committed action), stage with highest score, and stages-of-change clusters (see Table 1).

Self-Reported Hearing Disability • The Hearing Handicap Questionnaire (HHQ; Gatehouse & Noble 2004) contains 12 items (e.g., How often do you feel tense or tired because of your hearing difficulty?) measuring self-reported hearing disability. The five response options are (1) never, (2) rarely, (3) some-times, (4) often, and (5) almost always. Total scores range from 12 to 60, with higher scores indicative of greater disability. The HHQ has a one-factor structure accounting for a large amount of the variance in scores (58.24%) and good internal consis-tency (Cronbach’s alpha of 0.93) in 178 older adults with hear-ing impairment (Hickson et al. 2007b). The first administration of the HHQ was completed in an interview format. The later administration of the HHQ, as an intervention outcome mea-sure, was completed at home in a pen-and-paper format.

International Outcomes Inventory • The International Outcome Inventory (IOI: Cox et al. 2000; Noble 2002) is a questionnaire measuring seven dimensions of hearing interven-tion outcomes: (1) daily use; (2) benefit; (3) residual activity limitations; (4) satisfaction; (5) residual participation restric-tions; (6) effect on others; and (7) quality of life. There are TA

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4 LAPLANTE-LÉVESQUE ET AL. / EAR & HEARING, VOL. XX, NO. XX, XX–XX

several forms of interventions and the IOI versions used in the present study addressed hearing aid outcomes (IOI-HA; Cox et al. 2000) and communication program outcomes (IOI-AI; Noble 2002). The IOI questionnaire contains seven items (one item for each of the seven aforementioned dimensions), with five response options scored from 1 to 5. IOI scores for each item are averaged and total scores therefore range from 1 to 5, with higher scores indicative of more successful outcomes. Evidence points toward a two-factor structure for both the IOI-HA and the IOI-AI, but as they are slightly different (Cox & Alexander 2002; Stephens 2002; Hickson et al. 2006), factor scores were not compiled in this study.

ProcedureAt the initial help seeking, participants first had their hearing

assessed and discussed the results with the audiologist. They then completed the URICA and the HHQ, both in an interview format, before being offered intervention options (i.e., hear-ing aids, communication programs, or no intervention) with the support of a decision aid. Participants had at least 1 week to consider the intervention options before making their inter-vention decision in collaboration with the audiologist (shared decision making). Participants who obtained hearing aids were provided with them by their preferred clinic. Approximately 73% of participants were eligible for subsidized hearing ser-vices. Participants who completed a communication program could choose between the Active Communication Education program (Hickson et al. 2007a) and the Individual-Active Communication Education program, an adaptation of Active Communication Education program suitable for at-home indi-vidual sessions instead of group sessions. Both programs were provided by an audiologist from the Audiology Clinic of the University of Queensland, for free. Topics included communi-cation strategies and hearing assistive technology. Finally, the option of no intervention acknowledges that some participants, after considering their condition and the benefits and barriers to intervention, choose not to pursue an intervention for their hearing impairment. Participants were asked to choose only one intervention. They were invited to consider another interven-tion after completion of a first intervention and the associated outcome measures. Participants completed the intervention out-come measures at home in a pen-and-paper format.

Data AnalysisData were analyzed with Stata 10.1. The following statistical

tests were used: χ2 test, t test, and Pearson’s correlation coeffi-cient. To evaluate the construct validity of the stages of change, principal component analysis with varimax orthogonal rotation determined the URICA factor structure. Internal consistency was assessed with Cronbach’s alpha. Furthermore, cluster analysis was performed to investigate stages-of-change clusters. For this purpose, stage scores were standardized according to the z dis-tribution to approximate a mean of 0 and a standard deviation of 1. Without standardization, values that vary most from the mean can greatly influence the outcomes of cluster analysis. In this study the hierarchical agglomerative method of cluster analysis with complete-linkage clustering (Everitt et al. 2001) was used. Evaluation of the cluster results was done with visual inspection of the cluster analysis dendogram and with comparisons of the Eucledian distance (measure of dissimilarity) between clusters.

Where relevant, assumptions of normality and equality of variance were tested before statistical analysis. An alpha level of 0.05 determined significance for all statistical analyses.

RESULTS

Sample DescriptionIn total, 153 participants met the eligibility criteria and par-

ticipated in the study (see Table 2 and Fig. 1 for sample char-acteristics). On average, participants were 70 years of age and reported 10 years since onset of hearing impairment. According to the World Health Organization grades of hearing impairment, participants had on average a slight to moderate bilateral hear-ing impairment. However, the sample encompassed a variety of audiometric profiles typical of adults with acquired hearing impairment seeking help for the first time: the better-ear pure-tone average of the participants varied from 11.25 (participant with unilateral hearing impairment) to 65 dB HL (participant with severe bilateral hearing impairment). Of the 153 partici-pants, 82 (53%) initially decided to obtain hearing aids, 41 (27%) decided to complete communication programs, and 30 (20%) decided to not complete an intervention. For participants who intended to complete an intervention (n = 123), intervention uptake was assessed 6 months later. Six months after making their intervention decision, 94 participants (61%) had obtained

TABLE 2. Sample characteristics

Characteristic

Age, yrs (M ± SD) 70.74 ± 7.45Gender (% female) 30.72Education (%) None or primary school 15.03 High school or technical school 51.63 University 33.33Degree of hearing impairment (0.5, 1, 2, and 4 kHz average in better ear, in db HL) (M ± SD) 32.25 ± 8.56Self-reported hearing disability (HHQ) at baseline (M ± SD) 25.68 ± 7.92Years since hearing impairment onset (yrs) (M ± SD) 10.06 ± 10.89Intervention uptake 6 months after entry in the study (%) 61.44Intervention adherence 6 months after entry in the study (%) (n = 123) 75.61Intervention outcomes 3 months after intervention completion (IOI) (M ± SD) (n = 91) 3.65 ± 0.61Intervention outcomes 3 months after intervention completion (reduction in HHQ scores) (M ± SD) (n = 91) 3.74 ± 7.87

n = 153, except where specified.HHQ, Hearing Handicap Questionnaire; IOI, International Outcome Inventory.

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hearing aids or had completed a communication program and 59 participants (39%) had not completed an intervention. The intervention adherence of participants who had initially decided to complete an intervention (n = 123) was defined as dichoto-mous: the 94 participants (76%) who completed an intervention as intended had adhered and the 29 participants (24%) who did not complete an intervention even though they had intended to had not adhered. For participants who completed an interven-tion (hearing aids or communication programs; n = 94), inter-vention outcomes were measured 3 months after intervention completion. Of the 94 participants who obtained hearing aids or

completed communication programs, 91 (97%) reported their outcomes 3 months after intervention completion.

Factor Structure • The URICA principal component analy-sis yielded four components with eigenvalues greater than 1, which explained 64% of the total variance in URICA scores. Table 3 shows each URICA item, the component on which it loaded in this study, the original component (precontemplation, contemplation, or action) it represents, and the amount of vari-ance each component explains.As seen in Table 3, the URICA items were designed to represent three stages of change (pre-contemplation, contemplation, and action). However the prin-cipal component analysis identified these three stages plus an extra fourth stage. Five of the eight items originally represent-ing contemplation loaded on a fourth component in this sample of 153 adults with hearing impairment. The five items primarily target information seeking and need for professional guidance toward behavior change and, as a result, we named this new fourth component preparation. Therefore, four stages of change were identified in adults with hearing impairment: precontem-plation, contemplation, preparation, and action. All other analy-ses were run in accordance with this four-stage model.

Description of URICA ScoresStages-of-Change and Composite Scores • Table 4 reports the means and standard deviations of stages-of-change and composite scores. In our sample of adults with acquired hearing

Fig. 1. Median air conduction thresholds of the sample (n = 153) with 25th to 75th percentile.

TABLE 3. University of Rhode Island Change Assessment principal component analysis (n = 153)

StageFactor

LoadingOriginal

Component

Precontemplation stage (7.86% of total variance) (α = 0.89) 1. As far as I’m concerned, I don’t have any hearing problems that need changing. 0.04 P 5. I’m not the problem one. It doesn’t make much sense for me to be here. 0.29 P 9. Being here is pretty much a waste of time for me because the hearing problem doesn’t have to do with me. 0.38 P 11. I guess I have faults, but there’s nothing that I really need to change. 0.14 P 18. I may be part of the hearing problem, but I don’t really think I am. 0.25 P 21. All this talk about psychology is boring. Why can’t people just forget about their hearing problems? 0.88 P 22. I have worries but so does the next guy. Why spend time thinking about them? 0.64 P 24. I would rather cope with my faults than try to change them. 0.26 PContemplation stage (24.81% of total variance) (α = 0.79) 2. I think I might be ready for some self-improvement. 0.79 C 4. It might be worthwhile to work on my hearing problem. 0.79 C 13. I have a hearing problem and I really think I should work at it. 0.67 CPreparation stage (11.19% of total variance) (α = 0.76) 7. I’ve been thinking that I might want to change something about myself. 0.48 C 10. I’m hoping this place will help me to better understand myself. 0.81 C 15. I wish I had more ideas on how to solve the hearing problem. 0.49 C 17. Maybe this place will be able to help me. 0.69 C 19. I hope that someone here will have some good advice for me. 0.74 CAction stage (20.41% of total variance) (α = 0.90) 3. I am doing something about the hearing problems that had been bothering me. 0.61 A 6. I am finally doing some work on my hearing problem. 0.69 A 8. At times my hearing problem is difficult, but I’m working on it. 0.65 A 12. I am really working hard to change. 0.71 A 14. Even though I’m not always successful in changing, I am at least working on my hearing problem. 0.80 A 16. I have started working on my hearing problems but I would like help. 0.72 A 20. Anyone can talk about changing; I’m actually doing something about it. 0.70 A 23. I am actively working on my hearing problem. 0.68 A

P, Precontemplation; C, Contemplation; A, Action.

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6 LAPLANTE-LÉVESQUE ET AL. / EAR & HEARING, VOL. XX, NO. XX, XX–XX

impairment seeking help for the first time, the action stage obtained the highest mean score, whereas the precontemplation stage obtained the lowest mean score.

Stage of Change With the Highest Score • Table 4 reports the proportion of the sample that scored highest on the stages of precontemplation, contemplation, preparation, and action. Most participants (80%) scored highest on the action stage of change. The second most common stage was contemplation (10%) whereas participants seldom rated the stages of prepara-tion (8%) or precontemplation (2%) the highest.

Stages-of-Change Clusters • To identify stages-of-change clusters in the sample of participants, cluster analysis was per-formed on the standardized z scores. Inspection of the dendo-gram identified four clusters. For each of the clusters, Figure 2 depicts the mean stage scores. Based on the profiles they repre-sent, we named the four clusters active change, initiation, disen-gagement, and ambivalence. The active change cluster includes participants who scored low on precontemplation and high on action. It was the most common cluster, representing 58% of the sample. The initiation cluster includes participants who scored low on precontemplation compared with the three other stages (contemplation, preparation, and action). It represented 35% of the sample. The disengagement cluster includes partici-pants who scored low on action compared with the three other stages (precontemplation, contemplation, and preparation). It represented 4% of the sample. Finally, the ambivalence cluster includes participants who scored high on both precontempla-tion and action, which represented only 3% of the sample.

Construct ValidityInternal Consistency • Table 3 reports Cronbach’s alpha for each of the four stages of change. It ranged from 0.76 to 0.90, indicative that each stage’s items are highly intercorrelated and measure the same construct.

Correlations Among URICA Stage Scores and Compos-ite Scores • Table 5 reports the correlations among the URICA stage scores (precontemplation, contemplation, preparation, and action) and the composite scores. As described in the Introduc-tion, the readiness composite score was obtained by adding the URICA’s average contemplation and action stage scores and subtracting the average precontemplation stage score (mainte-nance stage score is usually added as well but was not relevant to this sample of people seeking help for the first time). The committed action score composite was obtained by subtracting the contemplation stage score from the action stage score. As expected, the precontemplation stage score was negatively cor-related with the action stage score and the readiness composite score. The contemplation stage score was positively correlated with the preparation stage score. The action stage score was pos-itively correlated with the readiness and the committed action composite scores. The readiness composite score was also posi-tively correlated with the committed action composite score. Overall, adjacent stages were positively correlated whereas non-adjacent stages were negatively correlated. The results support the stages-of-change model.

Concurrent ValidityRelationships among the different ways to report URICA

scores and degree of hearing impairment, self-reported hear-ing disability, and years since hearing impairment onset were investigated.

Degree of Hearing Impairment • Hearing impairment was defined as the average of pure-tone thresholds at the frequencies 0.5, 1, 2, and 4 kHz in the better ear. Participants with greater hearing impairment (worse pure-tone thresholds) scored sig-nificantly lower on the precontemplation stage: the correlation was weak but statistically significant, r(151) = −0.19, p = 0.02. Better-ear pure-tone averages generally increased with the stages with the highest score from precontemplation to action (see Table 6), but those differences did not reach statistical significance.

Self-Reported Hearing Disability • Participants with greater self-reported hearing disability on the HHQ scored sig-nificantly lower on the precontemplation stage r(151) = −0.48, p < 0.01 and higher on the action stage r(151) = 0.30, p < 0.01 as well as the readiness composite score r(151) = 0.44, p < 0.01. Mean self-reported hearing disability as expressed with the HHQ increased with the stages with the highest score from pre-contemplation to action (see Table 6). Those differences were statistically significant: participants who scored highest on the action stage reported more hearing disability than participants who scored highest on precontemplation t(123) = −2.40, p = 0.02, contemplation t(136) = −3.01, p < 0.01, or preparation t(132) = −2.01, p = 0.04. Self-reported hearing disability also differed according to stages-of-change clusters. Those who were in the disengagement cluster reported significantly less hearing disability than their peers in the active change cluster t(93) = 3.01, p < 0.01 and in the initiation cluster t(58) = 2.83, p < 0.01.

TABLE 4. University of Rhode Island Change Assessment results: stages-of-change scores, composite scores, and stage with the highest score (n = 153)

Scores

Stages-of-change Precontemplation 15.01 ± 4.88 Contemplation 24.35 ± 5.71 Preparation 24.35 ± 4.00 Action 30.10 ± 5.37Readiness composite score 47.44 ± 12.84Committed action score −2.24 ± 3.92Participants with highest score in each stage (%) Precontemplation 1.96 Contemplation 10.46 Preparation 7.84 Action 79.74

TABLE 5. Pearson’s correlations between University of Rhode Island Change Assessment stage scores and composite scores (n = 153)

1 2 3 4 5 6

1 1.002 0.11 1.003 −0.04 0.62* 1.004 −0.62* −0.12 −0.08 1.005 −0.89* −0.14 −0.03 0.89* 1.006 −0.03 −0.02 −0.09 0.641* 0.24* 1.00

*Significant correlation with α = 0.05.

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Years Since Hearing Impairment Onset • Participants reported at baseline how long it had been since they had first noticed their hearing impairment. Those who reported more years since hearing impairment onset scored significantly lower on the precontemplation stage r(151) = −0.17, p = 0.04. Years since hearing impairment onset increased with the stages with the highest score from precontemplation to action (see Table 6), but those differences did not reach statistical significance.

All the associations that were uncovered support the concur-rent validity of the stages-of-change model. People with less severe hearing impairment, who report less hearing disability, and who have had their hearing impairment for a shorter period of time tend to be in the early stages of change.

Predictive ValidityThe following relationships among the different ways to

report URICA scores were investigated: (1) intervention uptake 6 months after entry in the study; (2) intervention adherence 6 months after entry in the study; and (3) intervention outcomes 3 months after intervention completion. Information on other predictors of intervention uptake, adherence, and outcomes in the sample has been published elsewhere (Laplante-Lévesque et al. 2012).

Intervention Uptake 6 Months After Entry in the Study • As noted previously, intervention uptake 6 months after entry in the study was measured for all participants (n = 153). Par-ticipants who had obtained hearing aids or who had completed a communication program were deemed to have taken up an intervention. Participants who took up an intervention scored lower on the precomtemplation stage, t(151) = −2.54, p = 0.01 and higher on the action stage, t(151) = 3.09, p < 0.01 and the readiness composite, t(151) = 3.41, p < 0.01 6 months earlier. Intervention uptake 6 months after entry in the study is also sig-nificantly different according to participants’ stage with highest score (see Table 6). More specifically, 67% of the participants who scored highest on action had taken up an intervention 6 months later, compared with 33% of those who had scored highest on preparation, and this difference was statistically

significant χ2(1, n = 134) = 5.45, p = 0.02. However, stages-of-change clusters did not predict intervention uptake.

Intervention Adherence 6 Months After Entry in the Study • Intervention adherence 6 months after entry in the study was measured for all participants who had intended to pursue an intervention (n = 123). All measures of stages of change failed to predict intervention adherence.

Intervention Outcomes 3 Months After Intervention Completion • Intervention outcomes 3 months after intervention completion were measured on 97% of the par-ticipants who completed an intervention (n = 91) using the IOI-HA or the IOI-AI and the HHQ (reduction compared with baseline HHQ scores). IOI scores were significantly associated with precontemplation r(151) = −0.28, p < 0.01 and action stage score r(151) = 0.23, p = 0.03 as well as readiness composite score r(151) =0.26, p = 0.01. As pre-dicted, participants who scored higher on precontemplation reported less favorable intervention outcomes 3 months after intervention completion. Inversely, participants who scored higher on action or on the readiness composition score reported more favorable intervention outcomes 3 months after intervention completion. This was also true of reduction in HHQ scores, which was significantly asso-ciated with precontemplation r(151) = −0.38, p < 0.01 and action stage score r(151) = 0.32, p < 0.01 as well as readiness r(151) = 0.36, p = 0.01 and action r(151) = 0.36, p = 0.01 composite score. Stage of change with highest score and stages-of-change clusters did not predict intervention outcomes, both measured with the IOI and the HHQ.

DISCUSSION

This study collected several relevant measures to compare against the URICA scores. Degree of hearing impairment, self-reported hearing disability, and years since hearing impairment onset were available for all 153 participants. Furthermore, the longitudinal aspect of the study allowed investigation of rela-tionships between initial stage of change and intervention

TABLE 6. Degree of impairment, self-reported hearing disability, years since hearing impairment onset, intervention uptake 6 months after entry in the study, intervention adherence 6 months after entry in the study, and intervention outcomes 3 months after intervention completion (IOI and HHQ) according to stage with highest score

Stage With Highest Score Precontemplation Contemplation Preparation Action

Degree of hearing impairment (0.5, 1, 2, and 4 kHz average in better ear, in db HL) (M ± SD) 29.17 ± 0.72 31.80 ± 7.92 32.40 ± 9.50 32.38 ± 8.70

Self-reported hearing disability (HHQ) (M ± SD) 16.33 ± 6.66 20.81 ± 7.88 22.25 ± 8.34 26.89 ± 7.55Years since hearing impairment onset (M ± SD) 1.94 ± 2.65 7.78 ± 8.69 8.88 ± 11.48 10.68 ± 11.16Intervention uptake 6 mos after entry in the study Hearing aids or communication programs (%) 33.33 43.75 33.33 67.21 No intervention (%) 66.67 56.25 66.67 32.79Intervention adherence 6 mos after entry in the study Yes (%) 100.00 70.00 57.14 78.10 No (%) 0.00 30.00 42.86 21.90Intervention outcomes 3 mos after intervention completion

(IOI) (M ± SD) 3.00* 3.43 ± 0.69 3.29 ± 0.62 3.69 ± 0.60Intervention outcomes 3 mos after intervention completion

(reduction in HHQ scores) (M ± SD) 2.00* −7 ± 6.16 −2 ± 8.19 4.96 ± 7.26

*Standard deviation not applicable, as n = 1.HHQ, Hearing Handicap Questionnaire; IOI, International Outcome Inventory.

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8 LAPLANTE-LÉVESQUE ET AL. / EAR & HEARING, VOL. XX, NO. XX, XX–XX

uptake, adherence, and outcomes. Despite following up each participant for at least 6 months, the retention rate was very high, with all 153 participants reporting their intervention uptake and adherence 6 months after entry in the study and with 97% of participants who obtained hearing aids or completed communication programs reporting their outcomes on the IOI-HA or the IOI-AI 3 months after intervention completion. Nonresponse bias is therefore unlikely to have influenced this study’s findings, which are subsequently discussed.

Construct ValidityThe principal component analysis of the URICA scores

of 153 adults with hearing impairment seeking help for the first time supports two stages between precontemplation and action. Therefore, for this sample of adults with hearing impairment there were four stages from preawareness of their hearing impairment to successful rehabilitation: (1) precon-templation; (2) contemplation; (3) preparation; and (4) action. This finding is also consistent with reports arising from other populations. For example, a preparation stage was also uncov-ered in smoking cessation (DiClemente et al. 1991), where it successfully predicted smoking cessation 6 months later. In adults with acquired hearing impairment seeking help for the first time, the preparation stage was characterized by partici-pants having a clearer idea of a plan of action or of their need for rehabilitation. Information and counseling specifically tar-geting this stage of change could be relevant for adults with hearing impairment.

The internal consistency of the stages was similar to that of previous reports (McConnaughy et al. 1983; Pantalon et al. 2002). In this study of adults with acquired hearing impairment, the internal consistency varied from 0.76 to 0.90.

Adjacent stage scores were positively correlated whereas nonadjacent stages were negatively correlated. These correla-tions between the URICA stage scores and the composite scores support the construct validity of the stages-of-change model in adults with hearing impairment.

URICA ScoresMost of the participants in this sample scored highest on the

action stage. This is not surprising given that they had made an initial help-seeking step by participating in the study. Different findings would be expected in adults with hearing impairment who have not yet sought help. For example, the vast majority of smokers are in the precontemplation stage (Etter et al. 1997). In audiology, 72% of 147 older adults attending a hearing screening were in the precontemplation or contemplation stages (Milstein & Weinstein 2002). Given that adults with hearing impairment typically wait for 10 years between noticing their first hearing difficulties and seeking hearing help (Davis et al. 2007), it is most likely that results similar to those of Milstein and Weinstein (2002) would emerge if people with hearing impairment had been recruited from the general population. The present sample was composed of adults with acquired hearing impairment seeking help for the first time, but different stages-of-change profiles could be uncovered in other audiology samples.

Cluster analysis identified four distinct stages-of-change clusters (see Fig. 2). Most of the participants were in the active change cluster (low precontemplation scores and high action scores) whereas approximately one third of the participants

were in the initiation cluster (low precontemplation scores com-pared with contemplation, preparation, and action scores). Only a small proportion of the sample was in the disengagement (low action scores compared with precontemplation, contemplation, and preparation scores) and in the ambivalence clusters (high precontemplation and action scores). One could argue that these two latter clusters are so uncommon in a sample of adults with hearing impairment seeking help for the first time that they should be omitted. However, visual inspection of the cluster analysis dendogram showed that the disengagement and ambiv-alence clusters were very different (large Eucledian distance) to the active change and initiation clusters. It is most likely that the disengagement and ambivalence clusters are more prevalent in adults with hearing impairment who have yet to seek help. This is not the first report of cluster analysis of URICA scores. For example, the clusters identified in this study were different to those obtained with adults engaged in psychotherapy (McCon-naughy et al. 1983) but had similarities with the clusters identi-fied in people with arthritis (Keefe et al. 2000). Further cluster analyses of URICA scores in people with various chronic health conditions could identify similarities and differences in health behavior change and effective interventional approaches in these subpopulations.

Concurrent ValidityStages-of-change measures were associated with aspects of

hearing. Participants who scored low on precontemplation had a more severe hearing impairment, reported greater hearing dis-ability, and had their hearing impairment for longer than their peers who scored high on precontemplation. Degree of hear-ing impairment, self-reported hearing disability as expressed with the HHQ, and years since hearing impairment onset all increased with the stages from precontemplation to contempla-tion, preparation, and action, although these patterns did not always reach statistical significance. The uneven distribution of participants in the stages, with most of the participants in the action stage and few in the other stages, could explain why the statistical analyses failed to confirm perfect concurrent validity. Participants in the disengagement cluster also reported signifi-cantly less hearing disability than their peers. This is consistent with the stages-of-change model where more readiness toward change is associated with more severe hearing impairment

Fig. 2. Stages-of-change clusters according to cluster analysis (n = 153).

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(problem severity), more self-reported hearing disability (prob-lem awareness), and more years since hearing impairment onset (problem duration).

Predictive ValidityAs argued by the proponents of the stages-of-change model,

participants in the later stages of change were most likely to dis-play intervention uptake and successful intervention outcomes. Some stages-of-change results were associated with interven-tion uptake 6 months later. More specifically, those who scored low on precontemplation and high on action were more likely to have taken up an intervention (hearing aids or communication programs) 6 months later. However, the predictive validity of the stages-of-change clusters was poor: these clusters were not associated with intervention uptake.

Furthermore, this study failed to identify a relationship between stages-of-change measures and intervention adherence defined dichotomously as having completed an intervention as intended (adherence) or not having completed an interven-tion even though it was intended (nonadherence). The evidence available to date on stages of change and dichotomous adher-ence is inconclusive, with some reports of an association (Bro-gan et al. 1999; Edens & Willoughby 2000). However, some reports also found no association (Treasure et al. 1999) and at least one study reported an inverse relationship (Pantalon & Swanson 2003). Reasons for lack of adherence are complex, vary widely from one individual to the other, and most likely interact. For this reason, research in this area often fails to iden-tify statistically significant group trends.

Precontemplation and action scores as well as readiness composite scores were associated with intervention outcomes. Participants who scored high on precontemplation reported less successful intervention outcomes. Inversely, participants who scored high on action and on the readiness composite reported more successful intervention outcomes. The ability of stages to inform intervention outcomes has been confirmed in other stud-ies (Pantalon et al. 2002; Prochaska et al. 2004). However, other methods of reporting URICA scores, namely stages of change with highest score and stages-of-change clusters, failed to pre-dict intervention outcomes in the present study. It is impossible to ascertain whether other outcome measures could have yielded significant relationships with stages with highest score or with stages-of-change clusters. However, it is clear that stages-of-change scores have better predictive validity than stages of change with highest score and stages-of-change clusters.

Clinical ImplicationsThe URICA identified four stages of change in adults

with hearing impairment seeking help for the first time. The preparation stage, which this study identified, should be taken in account. Preparation stage was characterized by participants having a clearer idea of a plan of action or of their need for rehabilitation. As proposed by motivational interviewing (Miller & Rollnick 2002), information and counseling can target stages. Some of the URICA scores successfully predicted intervention uptake and outcomes. The precontemplation stage score seems to be the measure with the best concurrent and predictive validity. High precontemplation scores were significantly associated with milder hearing impairment, less self-reported hearing disability, and a more recent hearing impairment onset.

High precontemplation scores were also significantly associated with lower intervention uptake and less successful intervention outcomes. These highlight the central role of precontemplation in adults with acquired hearing impairment seeking help for the first time. Using measures of stages of change, and targeting precontemplation more specifically, could inform candidacy for audiologic rehabilitation and help identify a priori clients likely to require more clinical attention.

Research ImplicationsThe findings of this study propose that a continuous rather

than a discrete model of change may be more appropriate. Inspection of the cluster analysis results supports the idea that respondents are not in a single stage of change at a given point in time. Discrete stages might be useful to understand change, but change might be better represented on a continuum rather than by movement from one step to the next. Measures such as the URICA, which yield continuous scores for each of the stages, are more clinically useful than measures such as the staging algorithm, which assign a respondent to one discrete stage. For example, continuous scores for the different stages were better predictors of intervention uptake and outcomes than were stages with highest score. However, stages with highest score were not equally distributed in this study sample (80% of the sample scored highest on action versus only 2% of the sample scored highest on precontemplation), which sig-nificantly reduced statistical power. Still, Milstein and Wein-stein (2002) also did not find any association between discrete stages of change (as measured by the staging algorithm) and hearing assessment attendance in people who had failed hear-ing screening.

Despite this study’s encouraging results for the clinical relevance of stages of change in audiologic rehabilitation, the concurrent and predictive validity of the model was not perfect. The model failed to account for several of expected associa-tions. For example, none of the stages-of-change measures were associated with intervention adherence. This is unfortunate, as a tool that is able to identify future adherence problems would be most useful for clinicians. Other ways to predict adherence in audiologic rehabilitation should be tested. Several other stages-of-change shortcomings have been discussed in the literature (Sutton 2001) and should be considered when plan-ning future research efforts. For example, in previous research URICA stage scores did not correlate with stage membership as determined by the stages-of-change algorithm (DiClemente et al. 1991). The relevance of this issue to people with hear-ing impairment needs to be addressed as it is unlikely that the URICA in its current form (32 items) is suitable for clinical use. Shorter measures of stages of change are required. For example, item reduction of the URICA could yield a screening questionnaire to assist clinicians in targeting interventions to an individual’s stage. The concurrent and predictive validity of the stages-of-change algorithm also needs to be better under-stood. Relationships between the URICA, the stages-of-change algorithm, or any other stages-of-change measure should be investigated before they can successfully be applied in clinical practice in audiology.

Progress through the stages of change is understood to be cyclical and regression to an earlier stage to be common. Fur-ther longitudinal studies of adults with acquired hearing impair-ment could determine the relationship between how people’s

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10 LAPLANTE-LÉVESQUE ET AL. / EAR & HEARING, VOL. XX, NO. XX, XX–XX

cognitions and behaviors progress and regress over time and how this affects stages of change. This is especially important if stages-of-change interventional approaches such as motiva-tional interviewing are to be implemented to reduce the lengthy delays between first hearing impairment symptoms and suc-cessful rehabilitation (Beck et al. 2007). This is also relevant as screening programs for adults with acquired hearing impair-ment are increasingly being made available and aim to result in earlier help seeking (Pronk et al. 2011).

This study only investigated the stages of change spanning from precontemplation to action. As all participants were seek-ing help for the first time, the maintenance stage was not relevant to the study population. Future studies should take into account the full spectrum of stages of change, including maintenance and relapse prevention. In hearing rehabilitation, this could, for example, help explain why some hearing aids are not worn.

The pros and cons of behavior change (termed decisional balance) are also an important part of the transtheoretical model. We have explored and reported on how intervention beliefs (e.g., intervention barriers and facilitators) relate to interven-tion decisions, uptake, and outcomes (Laplante-Lévesque et al. 2010, 2011, 2012). However, further research on interven-tion beliefs would help understand the full picture of stages of change in adults with hearing impairment and their relation-ship to cognitive (e.g., motivation) and behavioral (e.g., help seeking) processes. This could help determine whether tackling intervention beliefs can help move people along the stages of change and result in improved intervention uptake, adherence, and outcomes. Similarly, measures of self-efficacy, such as those devised for communication and hearing aid use (Reference Note 1; West & Smith 2007; Smith et al. 2011) may help pro-mote behavior change.

All future stages-of-change research in audiologic rehabili-tation should provide a clear criterion for the target behavior change and, consequently, for the action stage. For adults with acquired hearing impairment who have no previous experience of rehabilitation, the target behavior could be help seeking, intervention uptake (e.g., obtaining hearing aids or attending a communication program), or successful intervention outcomes (e.g., using hearing aids or communication strategies).

Of all the stages-of-change measures in this study, the precontemplation stage score had the best concurrent and predictive validity. Therefore, further research should focus on addressing the precontemplation stage with a measure suitable for clinical use. Developing and testing a short continuous measure of stages of change, which focuses on the precontemplation stage should be a research priority. Alternatively, a new stage-of-change measure specific to hearing impairment could be proposed to achieve better concurrent and predictive validity for all stages.

CONCLUSIONS

This study investigated the application of the stages-of-change model in audiologic rehabilitation. The majority of this sample of adults with hearing impairment seeking help for the first time were in the action stage. The construct, concur-rent, and predictive validity of the stages-of-change model in this population were rather good. The data support that change might be better represented on a continuum rather than by movement from one step to the next. The stages of change can

help support people with hearing impairment, from help seek-ing to successful rehabilitation outcomes.

ACKNOWLEDGMENTS

The authors sincerely thank the Office of Hearing Services of the Australian government’s Department of Health and Ageing for their recruitment assis-tance and the study participants for their enthusiasm. Asad Khan provided statistical advice, Michelle Nicholls and Tamar Philp assisted with data collection, Martin Rune Andersen assisted with figure preparation, and Thomas Lunner provided input to an earlier version of this article.

The first author acknowledges the financial support of the Australian Department of Education, Science, and Training.

The authors declare no conflict of interest.

Address for correspondence: Ariane Laplante-Lévesque, Eriksholm Research Centre, Oticon A/S, Rørtangvej 20, Snekkersten, 3070, Denmark. E-mail: arl@eriksholm.com

Received February 15, 2012; accepted September 23, 2012.

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REFERENCE NOTE

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