Development of a Multimedia Educational Programme for First-time Hearing Aid Users: A Participatory Design

23 Objective: To develop content for a series of interactive video tutorials (or reusable learning 24 objects, RLOs) for first-time adult hearing aid users, to enhance knowledge of hearing aids 25 and communication. 26 Design: RLO content was based on an electronically-delivered Delphi review, workshops, 27 and iterative peer-review and feedback using a mixed-methods participatory approach. 28 Study sample: An expert panel of 33 hearing healthcare professionals, and workshops 29 involving 32 hearing aid users and 11 audiologists. This ensured that social, emotional and 30 practical experiences of the end-user alongside clinical validity were captured. 31 Results: Content for evidence-based, self-contained RLOs based on pedagogical principles 32 were developed for delivery via DVD for television, PC or internet. Content was developed 33 based on Delphi review statements about essential information that reached consensus 34 (≥90%), visual representations of relevant concepts relating to hearing aids and 35 communication, with iterative peer-review and feedback of content. 36 Conclusions: This participatory approach recognises and involves key stakeholders in the 37 design process to create content for a user-friendly multimedia educational intervention, to 38 supplement the clinical management of first-time hearing aid users. We propose participatory 39 methodologies are used in the development of content for e-learning interventions in hearing- 40 related research and clinical practice. 41 42 43 44 45


Introduction
exchange and patient education have been proposed as core aspects of patient-centred care Operationalising stakeholder participation in the form of a design workshop represents a 120 participatory, community of practice approach that involves end-users and provides a forum 121 for inclusive debate around the content creation, leading to relevant and high-quality   The main objective of this paper is to describe the participatory approach used to develop the 169 content for a series of evidence-based multimedia, interactive RLOs for first-time HA users.

170
HA users and hearing healthcare professionals were core to the development process that 171 integrated methods of a Delphi review, workshops and peer-review process. In particular, to 172 ensure the RLOs were aligned to the end-users needs, we aimed for the content to have a 173 substantial input from HA users. The aims of the participatory approach were to: obtain a consensus on essential information for first-time HA users using a Delphi   Initially, participants were sometimes uncertain as to how they might 'draw' their experience 253 on the storyboard. The key was to ensure the participants had hold of the pens, and that they 254 were fully aware that this was about their own personal perspectives, and there were no right-255 wrong answers. Typically, once started, the thoughts and drawings followed easily. The

293
(1) Obtaining consensus on essential information 294 Response rates for the Delphi review were high for round 1 (n=33, 100%), round 2 (n=32, 295 n=97.0%), and round 3 (n=31, 93.9%).  (2) Generating and defining content 330 For the workshops, each group generated two or three storyboards with one storyboard per 331 topic (for example, see Figure 1). In total, 23 storyboards were generated, with at least two storyboards per topic, generated with input from both HA users and audiologists. The  Table 3 shows the key topics of information for first-time HA users ranked by the HA users.

340
The top four categories identified by the expert panel are broadly similar to those of the HA 341 users. The most striking difference is in the relative ranking of 'Expectations of HAs'.

342
Whereas the expert panel rated this as the 9 th important topic, the users rated this as second 343 highest, after HA controls. The ten topics in Table 3  Three versions of the DVD were produced to tailor to the individual's delivery requirements.    Table 5, Ferguson et al, 2016b).

462
For example, 97% agreed the illustrations and videos helped their understanding of topics.

463
Ratings for RLO usefulness averaged 8.9/10 on a scale where 0=not useful to 10=highly 464 useful, and 78% said they would recommend the RLOs to other people. Finally, around 50% 465 reported using the RLOs two or more times, and 88% of HA users agreed that they would was not cost-neutral, and we found that even a low cost of £1-2/DVD to cover manufacturer 492 costs for the commercial partner was prohibitive for publicly-funded audiology services (only 493 350 DVDs were ordered in a 9 month period).

494
The ultimate aim of this research was always to make the RLOs available to as many people Future plans 506 We are currently developing and evaluating a theoretically-driven, patient-centred, mobile-    o Getting a hearing aid is the first step in addressing their hearing difficulties and is not the only solution to their hearing and communication difficulties o The patient's listening environment, including familiar surroundings, will sound different (i.e. the world is a noisy place) o Using a hearing aid regularly allows the brain to adapt to everyday sounds o The benefit they will get in different listening situations will vary (e.g. in quiet and in noise)  Information to the patient should include communication skills (e.g. lip reading), hearing tactics (e.g. asking the speaker to speak louder/clearer) and strategies (e.g. managing their environment).
 It is essential that the individual lifestyle needs and the abilities of the patient are understood by the audiologist.
 Effective self-management should be encouraged by working together with the patient rather than treating them as a passive recipient of information.
 Communication partners (e.g. spouse, friend) should be made aware that: o effective communication depends on communicating and listening strategies being used by both themselves and the hearing aid user. o hearing aid has limitations (e.g. it may be less effective in some listening environments compared to others).

On DVD:
 A DVD consisting of several short videos each considering a separate issue or topic (e.g. 10 x 2 minutes) will be more usable and effective than a single video which covers multiple topics.
 Video content should be informal and patient-focused. On hearing aid non-use:  Audiological factors, such as distortion arising from sensorineural hearing loss and acoustical characteristics of hearing aids are significant causes of non-use.  Service delivery factors, such as clinical experience, location, time allowed and the availability of having a follow up appointment, are significant causes of non-use  The amount of information given at the fitting appointment is too much for patients to remember and is a barrier to effective use.  Hearing aids are often set up (i.e. programmes and volume control) in a way that is too complex for the patient's needs and so the hearing aid is not used.  A failure to agree clear and realistic goals within a patient management plan leads to patients giving up.  Patients who o feel removed from the decision making process relating to their treatment are more likely to give up wearing their hearing aid(s). o perceive a lack of empathy from the audiologist during their fitting appointments are less inclined to wear their hearing aid(s). o experience practical problems early on are more likely to reject their hearing aid(s).