J Am Acad Audiol 2019; 30(05): 417-430
DOI: 10.3766/jaaa.18061
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Applying the COM-B Model to Assess the Usability of Smartphone-Connected Listening Devices in Adults with Hearing Loss

David W. Maidment
*   National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham, UK
†   Hearing Sciences Section, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
Yasmin H. K. Ali
*   National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham, UK
†   Hearing Sciences Section, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
Melanie A. Ferguson
*   National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham, UK
†   Hearing Sciences Section, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
‡   Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
› Author Affiliations
Further Information

Publication History

12 November 2018

27 December 2018

Publication Date:
26 May 2020 (online)



Unlike conventional hearing aids, smartphone-connected listening devices may require limited or no input from a trained audiologist in terms of device programming and adjustment. However, there is a lack of peer-reviewed evidence assessing the real-world perspectives of people living with hearing loss toward such technological innovations.


This study assessed the everyday experiences of adults living with hearing loss toward a range of smartphone-connected listening devices using the Capability, Opportunity, Motivation, Behaviour (COM-B) model as a theoretical framework.

Research Design:

A qualitative study where participants trialed one of the following smartphone-connected listening devices for two weeks in their everyday lives: made-for-smartphone hearing aid, personal sound amplification product, and smartphone “hearing aid” app with wired earphones or wireless hearable. Individual semistructured interviews were conducted.

Study Sample:

Twenty adults (13 male and 7 female; mean age = 62.25 years, SD = 11.59) with mild-to-moderate hearing loss (mean better ear pure-tone average = 30.49 dB HL, SD = 17.51) were recruited using a convenience sampling strategy. All participants owned conventional hearing aids.

Data Analysis:

The data were analyzed using an established deductive thematic analysis procedure within the context of the COM-B model. The model stipulates that for individuals to engage in a particular behavior (B), they must have sufficient capability (C), opportunity (O), and motivation (M).


Capability: One of the key advantages facilitating use and adherence of smartphone-connected listening devices was the ability for participants to make fine-tune adjustments in any listening situation. Opportunity: Participants commented that these devices could address issues surrounding stigma as smartphones are ubiquitous in everyday life. Motivation: Participants consistently reported that the ability to make adjustments via a smartphone provided them with a greater sense of autonomy and empowerment. As a result, they felt more in control of their hearing loss.


This study lays the foundation for further high-quality research to explore whether smartphone-connected technologies have the potential to yield optimum benefits for people living with hearing loss.

This paper presents independent research funded by the NIHR Nottingham Biomedical Research Centre and carried out at the NIHR Nottingham Clinical Research Facilities. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.


  • Amlani AM. 2015; Improving patient compliance to hearing healthcare services and treatment through self-efficacy and smartphone applications. Hearing Rev 22: 16-20
  • Amlani AM, Taylor B, Levy C, Robbins R. 2013; Utility of smartphone-based hearing aid applications as a substitute to traditional hearing aids. Hearing Rev 20: 16-18
  • Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, Foy R, Duncan EM, Colquhoun H, Grimshaw JM. 2017; A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci 12: 1-18
  • Barker A, Leighton P, Ferguson M. 2017; Coping together with hearing loss: a qualitative meta-synthesis of the psychosocial experiences of people with hearing loss and their communication partners. Int J Audiol 56: 297-305
  • Barker F, Atkins L, de Lusignan S. 2016; Applying the COM-B behaviour model and behaviour change wheel to develop an intervention to improve hearing aid use in adult auditory rehabilitation. Int J Audiol 55: S90-S98
  • Braun V, Clarke V. 2006; Using thematic analysis in psychology. Qual Res Psychol 3: 77-101
  • British Society of Audiology 2011. Recommended Procedure: Pure-Tone Air-Conduction and Bone-Conduction Threshold Audiometry with and without Masking. Reading, United Kingdom:
  • Callaway SL, Punch JL. 2008; An electroacoustic analysis of over-the-counter hearing aids. Am J Audiol 17: 14-24
  • Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, Tyrer P. 2000; Framework for design and evaluation of complex interventions to improve health. BMJ 321: 694-696
  • Cane J, O’Connor D, Michie S. 2012; Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci 7: 37
  • Chien W, Lin FR. 2012; Prevalence of hearing aid use among older adults in the United States. Arch Intern Med 172: 292-293
  • Coulson N, Ferguson MA, Henshaw H, Heffernan E. 2016; Applying theories of health behaviour and change to hearing health research: time for a new approach. Int J Audiol 55: S99-S104
  • Cox RM, Alexander GC, Rivera IM. 1991; Comparison of objective and subjective measures of speech intelligibility in elderly hearing-impaired listeners. J Speech Lang Hear Res 34: 904-915
  • Cox RM, Johnson JA, Xu J. 2016; Impact of hearing aid technology on outcomes in daily life I: the patients’ perspective. Ear Hear 37: e224-e237
  • Davis A, Smith P, Ferguson M, Stephens D, Gianopoulos I. 2007; Acceptability, benefit and costs of early screening for hearing disability: a study of potential screening tests and models. Health Technol Assess 11: 1-294
  • Deloitte 2017. State of the Smart: Seventh Annual Mobile Consumer Survey. Deloitte Limited Liability Partnership (LLP):; London, United Kingdom:
  • Dillon H, Zakis JA, McDermott H, Keidser G, Dreschler W, Convery E. 2006; The trainable hearing aid: what will it do for clients and clinicians?. Hearing J 59: 30-36
  • Ferguson MA, Coulson NS, Henshaw H, Heffernan E. 2016; Application of health behaviour theory to hearing healthcare research: the state of play and beyond. Int J Audiol 55: S1-S2
  • Ferguson MA, Kitterick P, Chong L, Edmondson-Jones M, Barker F, Hoare D. 2017; Hearing aids for mild to moderate hearing loss in adults. Cochrane Database Syst Rev 9: CD012023
  • Ferguson MA, Maidment DW, Henshaw H, Gomez R. 2019; Knowledge is power: improving outcomes for patients, partners, and professionals in the digital age. Perspect ASHA Spec Interest Groups 4: 140-148
  • Fishbein M, Ajzen I. 1977. Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley;
  • Gopinath B, Schneider J, Hartley D, Teber E, McMahon CM, Leeder SR, Mitchell P. 2011; Incidence and predictors of hearing aid use and ownership among older adults with hearing loss. Ann Epidemiol 21: 497-506
  • Heffernan E, Coulson N, Henshaw H, Barry JG, Ferguson MA. 2016; Understanding the psychosocial experiences of adults with mild-moderate hearing loss: a qualitative study applying Leventhal’s self-regulatory model. Int J Audiol 55: S3-S12
  • Henshaw H, Clark D, Kang S, Ferguson MA. 2012; Computer skills and Internet use in adults aged 50–74 years: influence of hearing difficulties. J Med Internet Res 14: e113
  • Humes LE, Rogers SE, Quigley TM, Main AK, Kinney DL, Herring C. 2017; The effects of service-delivery model and purchase price on hearing-aid outcomes in older adults: a randomized double-blind placebo-controlled clinical trial. Am J Audiol 26: 53-79
  • Johnson JA, Xu J, Cox RM. 2016; Impact of hearing aid technology on outcomes in daily life II: speech understanding and listening effort. Ear Hear 37: 529-540
  • Kamil RJ, Lin FR. 2015; The effects of hearing impairment in older adults on communication partners: a systematic review. J Am Acad Audiol 26: 155-182
  • Keidser G, Brew C, Brewer S, Dillon H, Grant F, Storey L. 2005; The preferred response slopes and two-channel compression ratios in twenty listening conditions by hearing-impaired and normal-hearing listeners and their relationship to the acoustic input. Int J Audiol 44: 656-670
  • Laplante-Lévesque A, Hickson L, Worrall L. 2013; Stages of change in adults with acquired hearing impairment seeking help for the first time: application of the transtheoretical model in audiologic rehabilitation. Ear Hear 34: 447-457
  • Lin FR, Hazzard WR, Blazer DG. 2016; Priorities for improving hearing health care for adults: a report from the national academies of sciences, engineering, and medicine. JAMA 316: 819-820
  • Maidment DW, Barker AB, Xia J, Ferguson MA. 2018; A systematic review and meta-analysis assessing the effectiveness of alternative listening devices to conventional hearing aids in adults with hearing loss. Int J Audiol 57: 721-729
  • McCormack A, Fortnum H. 2013; Why do people fitted with hearing aids not wear them?. Int J Audiol 52: 360-368
  • Medical Research Council 2006. Developing and Evaluating Complex Interventions: New Guidance. London, United Kingdom:
  • Meister H, Grugel L, Meis M. 2014; Intention to use hearing aids: a survey based on the theory of planned behavior. Patient Prefer Adherence 8: 1265-1275
  • Michie S, Atkins L, West R. 2014. The Behaviour Change Wheel: A Guide to Designing Interventions. London, United Kingdom: Silverback;
  • Michie S, van Stralen M, West R. 2011; The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 6: 42
  • National Institute for Health and Care Excellence 2018. Hearing Loss in Adults: Assessment and Management. London, United Kingdom:
  • Ng SL, Phelan S, Leonard M, Galster JA. 2017; A qualitative case study of smartphone-connected hearing aids: influences on patients, clinicians, and patient–clinician interactions. J Am Acad Audiol 28: 506-521
  • Patton MQ. 1990. Qualitative Evaluation and Research Methods. Newbury Park, CA: SAGE Publications;
  • Pew Research Center 2018. Mobile Fact Sheet. Washington, DC:
  • Prochaska JO, DiClemente CC. 1983; Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol 51: 390-395
  • Reed NS, Betz J, Kendig N, Korczak M, Lin FR. 2017; a Personal sound amplification products vs a conventional hearing aid for speech understanding in noise. JAMA 318: 89-90
  • Reed NS, Betz J, Lin FR, Mamo SK. 2017; b Pilot electroacoustic analyses of a sample of direct-to-consumer amplification products. Otol Neurotol 38: 804-808
  • Rosenstock IM. 1966; Why people use health services. Milbank Mem Fund Q 44: 94-127
  • Saunders GH, Frederick MT, Silverman S, Papesh M. 2013; Application of the health belief model: development of the hearing beliefs questionnaire (HBQ) and its associations with hearing health behaviors. Int J Audiol 52: 558-567
  • Southall K, Gagne JP, Jennings MB. 2010; Stigma: a negative and a positive influence on help-seeking for adults with acquired hearing loss. Int J Audiol 49: 804-814
  • The National Academies of Sciences Engineering & Medicine 2016. Hearing Healthcare for Adults: Priorities for Improving Access and Affordability. Washington, DC:
  • Thorén ES, Öberg M, Wänström G, Andersson G, Lunner T. 2013; Internet access and use in adults with hearing loss. J Med Internet Res 15: e91
  • Timmer BH, Hickson L, Launer S. 2018; Do hearing aids address real-world hearing difficulties for adults with mild hearing impairment? Results from a pilot study using ecological momentary assessment. Trends Hear 22: 1-15
  • Vas V, Akeroyd MA, Hall DA. 2017; A data-driven synthesis of research evidence for domains of hearing loss, as reported by adults with hearing loss and their communication partners. Trends Hear 21: 1-25
  • Ventry IM, Weinstein BE. 1982; The hearing handicap inventory for the elderly: a new tool. Ear Hear 3: 128-134
  • Wallhagen MI. 2010; The stigma of hearing loss. Gerontologist 50: 66-75
  • Yardley L. 2008. Demonstrating validity in qualitative psychology. In: Smith JA. Qualitative Psychology: A Practical Guide to Research Methods. London, United Kingdom: SAGE Publications;