Table 1 Components of the AIMER intervention, a multifaceted intervention addressing the three target behaviours: (i) asking clients about their mental wellbeing, (ii) providing general information on the mental wellbeing impacts of hearing loss, and (iii) providing personalised information on managing the mental wellbeing impacts of hearing loss
Intervention functions | COM-B components served by intervention functions | Target behavioura | Behaviour change techniques to deliver intervention functions | Operationalisation of the behaviour change technique | Mode of delivery/implementation strategy |
|---|---|---|---|---|---|
Arm 1. Training, education, enablement and persuasion | |||||
Training | Psychological capability. Audiologists require knowledge of how to detect signs and symptoms for emotional and psychological distress | Ask | 4.1 Instruction on how to perform behaviour | We provided information on the signs and symptoms of emotional and psychological distress in adults with hearing loss | In-person workshop. Information was provided as part of the online in-person workshop Self-directed learning. The workshop recording was made available after the training session |
Training | Psychological capability. Audiologists require knowledge of how to ask about emotional well-being | Ask | 4.1 Instruction on how to perform behaviour | We provided information on how to ask about emotional wellbeing and provided with examples of language and sentence structure | In-person workshop. Information was provided as part of the online in-person workshop Self-directed learning. The workshop recording was made available after the training session |
Training | Psychological capability. Audiologists require knowledge of treatment/management options for emotional and psychological distress, and how to provide reliable information regarding funding and access for psychological services | Manage | 4.1 Instruction on how to perform behaviour | We recorded a video of a local clinical psychologist describing various treatment/management options and pathways for emotional and psychological distress | In-person workshop. Information was provided as part of the online in-person workshop Self-directed learning. The workshop recording was made available after the training session |
Training | Psychological capability. Audiologists require knowledge of how to refer for mental wellbeing support | Manage | 4.1 Instruction on how to perform behaviour 6.1 Demonstration of the behaviour | We developed two videos recorded by (i) a local clinical psychologist and (ii) a local GP describing referral processes for psychological support in Australia We developed referral report templates to provide structure and language to help audiologists report on mental wellbeing needs. Audiologists were shown how to use the newly developed report templates and asked to practice generating reports with the new templates in their own time | In-person workshop. The videos were incorporated into the pre-workshop recorded material and also played during the in-person workshop The electronic referral templates were embedded into the patient management system used so that they could be accessed in the same way as the other report templates used by the clinicians. As part of the in-person workshop. audiologists were shown how to use the newly developed report templates. The importance of aligning wording in reports with the exact wording used by clients was emphasised Audiologists were asked to practice generating reports with the new templates in their own time |
Training | Psychological capability. Audiologists require language skills for discussing mental health-related topics | Inform and manage | 4.1 Instruction on how to perform behaviour 6.1 Demonstration of the behaviour | Prior to the training, audiologists were asked to put forward phrases that their clients have said that they found difficult to respond to (e.g. “All my friends are dead now”, “I've got no one left”). In partnership with clinical psychologists and audiologists, we developed a deck of training flashcards, each stating one of the "difficult" client statements followed by a few suggested responses that demonstrate empathy and understanding | In-person workshop. Audiologists were given a set of flashcards in their workshop packs. The flashcards and how to use them to promote development of language skills for discussion mental wellbeing was discussed within the in-person workshop Self-directed learning. Audiologists were encouraged to use the flashcards in their own time to continue practicing using language to discuss mental wellbeing |
Ask, inform, and manage | 6.1 Demonstration of the behaviour 9.2 pros and cons | We demonstrated how one might (i) ask about mental wellbeing, (ii) provide information on the mental wellbeing impacts of hearing loss, and (iii) provide information on mental wellbeing treatment/management strategies. We invited the audiologists to discuss what was good and bad about the examples provided, and to devise their own scripts for how they would feel most comfortable asking these questions and providing this information in the future | In-person workshop. We demonstrated how to perform the three behaviours using role play. We also provided a list of possible wording for asking about mental wellbeing and provided purposefully developed clinical resources to assist with information provision Self-directed learning. The workshop recording was made available after the training session | ||
Training | Reflective motivation. Audiologists need to develop confidence in their ability to ask about mental wellbeing and respond with empathy when clients describe their challenges | Ask and inform | 8.1 Behavioural practice/rehearsal | We provided instruction on how to respond with empathy, and opportunity to practice responding to difficult statements put forward by clients | In-person workshop. We provided information on the definition of empathy, the benefits of using empathy and examples of how empathy can be expressed within audiological interactions. We delivered an activity wherein we listed common statements made by clients and had the audiologists work in small groups to discuss and document how they might respond empathetically. The audiologists spent time reading the flashcards to reinforce how they might respond with empathy in challenging situations Self-directed learning. The workshop recording was made available after the training session. Audiologists were encouraged to use the flashcards in their own time to continue developing their confidence in responding with empathy |
Education | Psychological capability. Audiologists require knowledge of who to refer to for mental wellbeing support | Manage | 4.1 Instruction on how to perform behaviour | We developed a list of local referral partners, including identification of those who specialise in psychological support for people with hearing loss | In-person workshop. Audiologists were presented with the list of local referral partners generated and how to locate the list from within the organisations document storage systems Self-directed learning. The workshop recording was made available after the training session. The clinical resources and where to locate them were included in one of the post-workshop videos |
Education and persuasion | Reflective motivation. Audiologists need reassurance that clients are open to receiving information on the mental wellbeing impacts of hearing loss | Inform | 6.3 Information about others’ approval | We developed an educational resource wherein adults with hearing loss described how they cope with the mental wellbeing impacts of hearing loss and how grateful they were to receive this information and support from their audiologist (https://www.youtube.com/watch?v=rmu4e4hNlKs) | In-person workshop. Audiologists viewed the video within the training session and then reflected as a group on how receptive clients are to these conversations within general clinical appointments Self-directed learning. The recording was emailed to staff after the training session |
Education | Reflective motivation. Audiologists need reassurance that asking about and providing mental wellbeing support is within their scope of practice | Ask and manage | 6.3 Information about others’ approval | We provided information on the Australian Scope of Practice guidelines, as well as the USA guidelines to emphasise that provision of wellbeing support is within current practice guidelines | In-person workshop. Information on Scope of Practice guidelines were provided Self-directed learning. The recording was emailed to staff after the training session |
Enablement | Social opportunity. Audiologists require reassurance from their managers that provision of mental wellbeing support is a vital part of their service provision despite it not being a claimable service | Ask, inform, and manage | 3.2 Social support (practical) | The Chief Operating Officer and clinical managers demonstrated their support for focussing clinical time on clients’ mental wellbeing needs | In-person workshop. The Chief Operating Officer and clinical managers attended the training workshop and stated their support for the research program and the benefits of addressing mental wellbeing needs within routine audiological care |
Persuasion | Reflective motivation. Audiologists need to feel responsible for (i) asking about mental wellbeing, (ii) providing information on the mental wellbeing impacts of hearing loss, and (iii) providing information on mental wellbeing treatment/management strategies | Ask, inform, and manage | 5.1 Information about health consequences | We developed a persuasive resource wherein adults with hearing loss described their personal experiences of living with hearing loss, how this impacted on their mental wellbeing and how they wish their audiologist had helped them to better understand and address these mental wellbeing impacts of hearing loss (https://www.youtube.com/watch?v=zQbM2NPmU_Y) | In-person workshop. Audiologists viewed the video within the training session and then reflected individually on how often they provide mental wellbeing support to their clients Self-directed learning. The workshop recording was emailed to staff after the training session |
Persuasion | Reflective motivation. Audiologists require reassurance that clients are open to receiving information on mental wellbeing treatment/management options during audiological appointments | Inform and manage | 9.1 Credible sources | To address audiologists’ insecurities regarding how clients would react to being given information on mental wellbeing, we developed a video of clients describing positive stories of how their audiologists helped them to gain an understanding of how wellbeing is impacted by hearing loss, how they are interested to learn more about psychological treatment/management options during audiological appointments, and that management strategies are effective | Pre-workshop videos. The persuasive video was incorporated into the pre-workshop video content In-person workshop. Audiologists viewed the video within the training session and then reflected as a group on how receptive clients are to these conversations within general clinical appointments. Self-directed learning. The workshop recording was emailed to staff after the training session |
Persuasion | Reflective motivation. Audiologists need reassurance that GPs would react positively to receiving a referral from an audiologist regarding concerns for a client’s mental wellbeing | Manage | 9.1 Credible sources | We developed a video interviewing three local GPs on their views regarding the role of the audiologist in detecting the mental wellbeing impacts of hearing loss, and how GPs and audiologists can work together to provide multidisciplinary care. Within these videos the GPs explicitly stated how they would be pleased to accept referrals from audiologists regarding the mental wellbeing needs of their clients | In-person workshop. Audiologists viewed the video within the training session Self-directed learning. The recording was emailed to staff after the training session |
Persuasion | Reflective motivation. Audiologists need reassurance that psychologists have the skills required to address the psychological needs of adults with hearing loss seeking psychological support | Manage | 9.1 Credible sources | We developed a video interviewing a local clinical psychologist describing the many ways that psychologists can support the mental wellbeing needs of adults with hearing loss | In-person workshop. Audiologists viewed the video within the training session Self-directed learning. The recording was emailed to staff after the training session |
Persuasion | Reflective motivation. Audiologists need reassurance that psychologists are open to receiving referrals from them | Manage | 9.1 Credible sources | We developed a video interviewing a local clinical psychologist, wherein the psychologist described the referral process and explained how audiologists’ referrals promote holistic and multidisciplinary care for adults with hearing loss We also generated a list of local psychologists with experience in working with adults with hearing loss and who had indicated that they were willing to accept referrals from audiologists so that our audiologists could confidently refer | In-person workshop. Audiologists viewed the video within the training session Self-directed learning. The recording was emailed to staff after the training session |
Arm 2. Environmental restructuring | |||||
Environmental restructuring | Psychological capability. Audiologists require knowledge of who to refer to and how to refer for mental wellbeing support | Manage | 12.5 Adding objects to the environment | We developed a list of local psychological services, specifically those who indicated that they would accept referrals from audiologists, and that they had experience working with older adults and'/or adults with hearing loss. We also developed lists of local community groups and a list of local mental health support groups | In-person workshop. Audiologists were presented with the lists and shown how to locate the lists from within the organisations document storage systems Self-directed learning. The workshop recording was made available after the training session. A copy of the lists and where to locate them were included in one of the post-workshop videos |
Environmental restructuring | Social opportunity. Audiologists require reassurance that clients will be receptive to them asking about mental wellbeing | Ask | 12.5 Adding objects to the environment | We developed a clinical resource, an animated explainer video, wherein an adult with hearing loss describes his experience of hearing loss and how it impacts on his mental wellbeing. The purpose of the video was to help clients realise the link between hearing loss nd mental wellbeing, prime them in that audiologists are likely to ask about mental wellbeing, and encourage them to think about how their hearing loss might be affecting them (preparing them for the mental wellbeing conversation with the audiologist). By making the audiologists aware of the video and dissemination plan, we hoped audiologists would be reassured that clients were anticipating and prepared for being asked about mental wellbeing within audiology appointments | The video is disseminated to clients via (i) emailed to all clients prior to their hearing assessment, (ii) posted on the clinic’s social media pages, and (iii) played on the clinic’s waiting room TVs In-person workshop. Audiologists viewed the video within the training session and then reflected as a group on how clients might respond to the video and what they might now be expecting from their first appointment |
Environmental restructuring | Physical opportunity. Audiologists require clinical resources to assist with (i) asking about wellbeing, (ii) providing information on the wellbeing impacts of hearing loss, and (iii) providing information on wellbeing treatment/management strategies | Ask, inform, and manage | 12.5 Adding objects to the environment | In partnership with the target audiologists, we developed a series of clinical tools, including (i) two discussion tools incorporated into the existing flip chart used to aid client discussion (one facilitating asking about and discussing wellbeing in relation to hearing loss; one facilitating discussion on the stepped care approach to mental wellbeing management); (ii) a series of three client information sheets (describing the “Emotional impacts of hearing loss”, “Social impacts of hearing loss”, and how “Hearing loss affects relationships”); and (iii) a client brochure to assist discussion and information provision relating to mental wellbeing management options (including what the management options entail, access and funding) | To embed the factsheets within the audiologists’ workflow, we altered the customer management software used by the clinic staff to set up an automated factsheet printing system. As the audiologists enter their case notes, they can select which factsheets they want printed (including these three new ones as well as all of the existing factsheets previously used by audiologists, but manually printed or photocopied) In-person workshop. Audiologists were presented with the lists and shown how to locate the lists from within the organisations document storage systems Self-directed learning. The workshop recording was made available after the training session. A copy of the lists and where to locate them were included in one of the post-workshop follow up videos Ongoing support. The organisations clinical protocols were updated to reflect incorporation of the new clinical resources into routine practice |
Environmental restructuring | Social opportunity. Audiologists require reassurance from their managers that provision of mental wellbeing support is a vital part of their service provision despite it not being a claimable service | Ask, inform, and manage | 12.2 Restructuring the social environment | The management team demonstrated their commitment to supporting the wellbeing needs of clients, by allowing us to update their (i) Clinical Procedures Documentation to describe the use of these new resources, emphasising the importance of considering client’s mental wellbeing needs within appoints, and (ii) internal training procedures | In-person workshop. To reinforce this message, the clinical managers addressed the staff highlighting that provision of mental wellbeing support is a vital part of their service provision despite it not being a claimable service, noting that the Clinical Procedures Documentation and internal training procedures had been updated to reflect this new way of working |
Environmental restructuring | Automatic motivation. Audiologists need reminders/prompts to help them remember to ask clients about mental wellbeing | Ask | 7.1 Prompts/cues 6.1 Demonstration of the behaviour | To improve remembering and habit forming for asking clients about their mental wellbeing, we added a question on wellbeing to the electronic client case history form and in the clinical case notes (1st appointment and annual recall appointment templates) We also modified the client goals template to promote inclusion of goals relating to mental wellbeing impacts of hearing loss. To embed the new goal setting template within the audiologists’ workflow, we altered the customer management software used by the clinic staff to set up an automated printing system. After the audiologist completes the goals within the data management system, they can now easily print the goals to assist discussion with the client | In-person workshop. We showed audiologists where the changes had been made, and demonstrated how to use the new questions within the regular work flow Ongoing support. Audiologists were sent bimonthly emails promoting specific aspects of the intervention, including how to use the new questions in the case history forms and the goals template |
Environmental restructuring | Social opportunity. Audiologists need to feel supported by peers in their workplace | Ask, inform, and manage | 3.2 Social support (practical) | Senior audiologists with advanced skills in providing mental wellbeing support were identified as mental wellbeing champions | Three members of the clinical team were identified as mental wellbeing champions In-person workshop. We advised the audiologists as to who the champions were nd how to contact them should they need support. The members of the research team with dual research and clinical expertise also made themselves available to answer any question throughout the duration of the project |
Arm 3. modelling | |||||
Modelling | Social opportunity. Audiologists need to see their managers and senior staff role modelling provision of mental wellbeing support | Ask, inform, and manage | 9.1 Credible sources | After the in-person training day, senior and well-respected audiologists (including the mental wellbeing champions) from the partner clinic were engaged to record themselves describing which of the new clinical resources were their favourite to use and why, as well as providing a demonstration of how they use the resource(s) within their routine workflow | Ongoing support. Videos were distributed to audiologists in the months following the in-person workshop |