Editor’s note: Ear to the Ground is a monthly column from Dr. Brian Taylor, offering timely reflections on research, technology, clinical practice, and emerging trends in hearing care. You can read last month’s column here.
The NASEM Meaningful Outcome Report identifies which patient-related outcomes to measure but offers limited guidance on how to improve them. One way to improve those NASEM hearing health outcomes is to focus on patient empowerment, which is the topic of this month’s Ear to the Ground.
Patient empowerment is an understudied concept that can help patients more readily accept treatment and achieve better outcomes. An added benefit of focusing on patient empowerment is this: it provides clinicians with a practical way to put patient-centered care into action.
Drawing on recent research, this month’s ETTG explores three key questions:
- What does it mean when a patient is empowered?
- How can greater levels of empowerment benefit patients?
- How can audiologists help patients become more empowered?
Empowerment: What it looks like in the clinic
The following clinical scenario compares two hypothetical patients to illustrate the potential link between empowerment, the lived experience of hearing loss, and treatment outcomes.
John, 62, struggles to follow conversations in busy restaurants. He assumes his hearing aids should solve the problem, but when they do not, he feels frustrated and embarrassed. He rarely tells his audiologist about these difficulties, believing that he must simply get used to the devices. Gradually, he begins avoiding social gatherings. Eventually, his hearing aids end up in the drawer. This is an example of a disempowered patient.
Margaret, 67, faces similar difficulties. She understands that hearing aids can improve communication but may not eliminate every listening challenge. She discusses her concerns with her audiologist, explores different settings and communication strategies, and learns to ask friends to face her when speaking. She feels more confident participating in social activities because she knows she has options that can influence her success with hearing aids. Margaret illustrates what it means to be an empowered patient.
The key difference between John and Margaret: Both experience hearing difficulties, but Margaret feels informed, involved, and capable of taking action. Margaret demonstrates empowerment, while John struggles to feel that same sense of agency.
In reality, most clinicians would probably ask both patients the same thing during a routine hearing aid re-check appointment: “How do you like your hearing aids?” Although there is nothing wrong with this question, it doesn’t help us understand how empowered the patient might be or if we can influence their current state of empowerment so that he experiences higher levels of outcome.
Being empowered does not mean “liking your hearing aids” or overcoming every hearing difficulty; instead, it means having the knowledge, confidence, and support to manage those challenges. Too often, clinicians assume that empowerment is something patients either naturally bring to the clinic or lack. Some arrive with the skills and confidence to take an active role in their care, while others do not.
This view implies clinicians can do little to help patients become more empowered. Research is emerging, however, that says otherwise: clinicians can take an active role in shaping the patient’s level of empowerment. Intentional efforts to strengthen patient empowerment may indeed support treatment acceptance and better outcomes.
Five Components of Empowerment
For an adult experiencing hearing loss, empowerment means developing the knowledge, confidence, skills, and decision-making ability to manage hearing difficulties in ways that fit their own life. For clinicians, the practical takeaway is this: assessing and supporting empowerment requires attention to several interconnected elements, rather than a single skill or attitude.
Gotowiec, et al (2022) outlined five intertwined components of empowerment. They are summarized below along with an example of each.
1. Knowledge
Understanding the nature of hearing loss, the results of a hearing assessment, the limitations and benefits of hearing aids, and the available management options.
Example: Being able to explain why hearing speech in a noisy restaurant is difficult, even when one can hear quiet sounds.
2. Skills and Strategies
Learning how to manage hearing aids, troubleshoot common problems, use assistive listening technology, and adopt communication strategies.
Example: Knowing how to ask a conversation partner to rephrase a sentence rather than simply speaking louder.
3. Participation
Having a meaningful voice in consultations and decisions about treatment, rehabilitation, and communication goals.
Example: Explaining to the clinician or caregiver that understanding colleagues in meetings matters more than hearing every environmental sound equally well
4. Self-efficacy
In simple terms, confidence. Believing that one can take effective action to address hearing difficulties, including when situations are challenging.
Example: Feeling confident enough to request communication accommodations at work or during family gatherings.
5. Control
A sense of agency. Feeling able to influence hearing healthcare, use hearing solutions effectively, and make choices about participation in daily life.
Example: Deciding when to use hearing aids or additional listening devices and knowing how to seek help when needs change.
Gotowiec, et al (2022) concluded that these five dimensions operate throughout the hearing health journey rather than appearing at separate, fixed stages. Empowerment begins when someone first recognizes hearing difficulties and continues through assessment, fitting, adjustment, and longer-term use. In other words, empowerment is fluid and has several dimensions.
Empowerment as a Noun and a Verb
One of the most compelling insights from this vein of research is that empowerment has two complementary meanings: 1. It is a state or outcome (a noun) and 2.) it is a process in which the individual is becoming empowered (a verb).
When empowerment is used as a noun, it refers to a condition, experience, or sense of being empowered at a single point in time. In this sense, empowerment describes how a person feels or what they can do because of having the necessary knowledge, skills, confidence, and support.
For example, an empowered person with hearing loss may:
- Feel confident discussing their hearing difficulties with an audiologist.
- Understand the different hearing aid options available to them.
- Feel that they have control over decisions about their hearing care.
- Feel confident they can participate in conversations and social activities.
When used as a noun, empowerment describes the person’s sense of confidence, participation, and control when they walk in the door for the first time seeking help. The emphasis is on the patient’s own experience at a single point in time.
In contrast, describing empowerment as a verb highlights its active, ongoing, and fluid nature. In this sense, empowerment is not simply something a person has. It is something that develops as they gain knowledge, practice skills, make decisions, participate in care, and learn to manage challenges. Supportive interactions with an audiologist can help them become more empowered (we hope).
For example, an empowered person with hearing loss may:
- Learn about the effects of hearing loss on communication.
- Develop strategies to manage difficult listening situations.
- Ask questions and express preferences during follow-up appointments.
- Experiment with hearing aid settings and learn how to use them.
- Gradually become more confident in making decisions about their hearing health.
Understanding empowerment as both a noun and a verb has practical implications for clinicians. If empowerment is understood only as an outcome, a professional might focus on whether a patient feels confident or capable. If empowerment is understood as a process, the professional also considers what opportunities, resources, information, and support help the patient develop that confidence and capability.
For example, an audiologist should not assume that providing a patient with information automatically empowers them. The patient may also need opportunities to ask questions, practice using hearing aids, express concerns, and participate in decisions.
This shifts the emphasis from simply giving patients power to supporting patients to develop and exercise their own knowledge, skills, confidence, and control. It also recognizes that empowerment is dynamic: a person may feel confident in one aspect of their hearing care but need additional support in another.
Promoting Empowerment in the Clinic: Where to Begin?
Some well-crafted clinical guidelines from the UK called the NICE Guideline Hearing loss in Adults: Assessment and Management help us understand how empowerment might fit into the larger picture of holistic care.
The NICE guideline recommends assessing the person’s communication needs, expectations, motivations, and psychosocial difficulties. It also recommends discussing management options and agreeing on a personalized care plan that reflects the person’s goals and preferences, using the five stages listed below. Through the lens of these guidelines, we can begin to see how empowerment fits into the broader patient journey.
Stage 1 — Explore the person’s experience
Ask about the situations in which hearing is difficult, how the person has adapted, what prompted them to seek help, and what they hope will change.
Empowerment focus: The patient feels he is being heard and having his individual needs recognized.
Stage 2 — Build understanding
Explain the hearing assessment results, how hearing loss affects the ability to participate in their daily communication, the likely benefits and limitations of hearing aids, and other available support. Provide written or visual information the person can revisit.
Empowerment focus: knowledge and informed decision-making.
Stage 3 — Make decisions together
Discuss suitable hearing aids, assistive listening devices, communication strategies, and rehabilitation options. Invite questions and concerns and agree on meaningful goals.
Empowerment focus: participation, choice, and control.
Stage 4 — Develop practical skills
Practice fitting and removing the devices, care and maintenance, controls, troubleshooting, and communication strategies. Check that the person can perform tasks independently or has the support they want.
Empowerment focus: competence and self-efficacy.
Stage 5 — Review and adapt
Follow up on the person’s own goals, listen to feedback, address discomfort or unmet expectations, adjust the devices when appropriate, and revisit the plan as needs change.
Empowerment focus: sustained agency and ongoing self-management.
Assessing Empowerment in the Clinic
Recent research provides further support for treating empowerment as an outcome that can be assessed, rather than simply a general principle of good care. In a study of 693 adults with hearing loss, Ferguson et al (2026) examined patient empowerment using the 15-item Empowerment in Audiology Questionnaire (EmpAQ-15). They found hearing aid use, social satisfaction, and emotional and cognitive measures were among the factors most strongly associated with empowerment. Hearing aid wearers had higher empowerment scores than non-wearers. However, the study was cross-sectional, so it cannot establish whether hearing aid use increases empowerment, or whether more empowered people are more likely to wear hearing aids.
Another study, published online in September 2026, assessed the EmpAQ-15 and its five-item short form in adults with hearing difficulties, the EmpAQ-5. In a group of 51 first-time hearing aid wearers, average empowerment scores increased three months post-fitting, with improvements maintained at six months. Only about 22% of participants showed individual changes exceeding the study’s threshold for change beyond measurement error. This suggests that average improvements do not necessarily mean every individual experiences a measurable improvement.
Together, these recently published studies suggest:
- Empowerment can be measured using hearing-specific questionnaires.
- Empowerment may change during the adjustment to hearing aids.
- Hearing aid provision and empowerment are related, but the relationship is not necessarily causal.
- Assessment should consider the person’s experience and confidence, not just hearing thresholds or device use.
How can we tell whether a patient is more empowered after our intervention?
Empowerment-oriented assessments complement self-report measures of hearing disability, perceived benefit, and hearing aid satisfaction. They go beyond asking whether patients like their hearing aids or how many hours they wear them.
Developed primarily as a research tool, the EmpAQ-15 assesses five dimensions of empowerment. Administering it before and after hearing aid fitting can show changes in empowerment over time, but those changes alone do not establish how much improvement was caused by the clinician’s involvement.
While the EmpAQ-15 has been validated for research, the shorter EmpAQ-5 can be used clinically to better understand how empowered the patient is on the day of the fitting, and how much your counseling and other interventions may have improved their empowerment over time. Taken directly from the EmpAQ-15, here is the shorter EmpAQ-5. Note that each question assesses one of the five dimensions of empowerment (shown in paratheses):
Q1. (Knowledge) I know how to get help if I have any problems with my hearing:
- 1 = Strongly Disagree
- 2 = Disagree
- 3 = Agree
- 4 = Strongly Agree
- NA = Not Applicable
Q2. (Skills & Strategies) I use tactics to help me communicate in challenging situations (e.g., move to a quieter location)
- 1 = Strongly Disagree
- 2 = Disagree
- 3 = Agree
- 4 = Strongly Agree
- NA = Not Applicable
Q3. (Participation) My hearing loss doesn’t stop me from participating in social activities
- 1 = Strongly Disagree
- 2 = Disagree
- 3 = Agree
- 4 = Strongly Agree
- NA = Not Applicable
Q4. (Control) I can control how I respond to the challenges I experience resulting from my hearing loss.
- 1 = Strongly Disagree
- 2 = Disagree
- 3 = Agree
- 4 = Strongly Agree
- NA = Not Applicable
Q5. (Confident) I am confident about my ability to manage problems caused by my hearing loss.
- 1 = Strongly Disagree
- 2 = Disagree
- 3 = Agree
- 4 = Strongly Agree
- NA = Not Applicable
Rapid Scoring of the EmpaAQ-5
If the patient answers all five items, use Chart 1 to find their percentile rank:
| Total Points (Sum of 5 items) | Final EmpAQ-5 Score (Percentile Rank) |
|---|---|
| 5 points | 0% |
| 6 points | 6.7% |
| 7 points | 13.3% |
| 8 points | 20.0% |
| 9 points | 26.7% |
| 10 points | 33.3% |
| 11 points | 40.0% |
| 12 points | 46.7% |
| 13 points | 53.3% |
| 14 points | 60.0% |
| 15 points | 66.7% |
| 16 points | 73.3% |
| 17 points | 80.0% |
| 18 points | 86.7% |
| 19 points | 93.3% |
| 20 points | 100% |
Chart 1.
Using the Score During the Initial Visit
The percentile rank in Chart 1 can be used to determine the individual’s initial empowerment profile. Chart 2 shows three different empowerment profiles with corresponding clinical recommendations.
| Score Range | Empowerment Profile | Clinical Recommendation |
|---|---|---|
| High Rank (75% – 100%) | Highly Empowered Patient
Possesses strong self-efficacy, effective coping strategies, and high participation confidence. |
Focus on shared decision-making. These patients are excellent candidates for advanced, wearer-controlled hearing aid technologies, other forms of rehab, and proactive self-management. |
| Moderate Rank (40% – 74%) | Developing Self-Management
The patient understands their condition but may lack execution strategies or struggle in specific noisy social environments. |
Target specific gaps. Use individual item responses to see if they need more educational knowledge or actionable communication strategies. |
| Low Rank (0% – 39%) | Vulnerable / Low Self-Efficacy
High feelings of helplessness, poor participation, or significant perceived hearing handicap. |
Provide high-support care including the use of remote care option (e.g. apps). Prioritize counseling, involving communication partners/family members, and scheduling structured, gradual follow-ups to build basic operational skills. |
Chart 2.
Tracking Progress
Clinical validation data (Bennett et al 2026) shows that the EmpAQ-5 is responsive to audiological interventions. Following a successful hearing aid fitting or rehabilitation program, clinicians should look for a mean change score of approximately 10-11% at follow-up appointments to indicate a true, meaningful shift in patient empowerment. A net shift of ~10% occurs when a patient improves their rating on two distinct items by one step each (for example, moving from “Disagree” to “Agree” on two questions).
Beyond Measurable Score Improvements
You don’t have to meticulously measure EmpAQ-5 scores pre- and post-treatment to get value from using it. Ferguson et al (2025) integrated the EmpAQ-5 into ten clinics and 19 staff. They found it to be feasible, appropriate, and acceptable in real-world audiology settings and a catalyst for “empowerment-focused care.” Their qualitative analysis of feedback from clinicians who incorporated it into their workflow was that the EmpAQ-5 allowed them to have a deeper empowerment-based dialogue with patients.
Putting the EmpAQ-5 into Practice
The EmpAQ-5 can help audiologists look beyond hearing aid satisfaction (“Do you like your hearing aids?”) to explore patients’ knowledge, communication strategies, participation, control, and confidence.
Use it to start a patient-centered conversation, identify support needs, and review empowerment over time. Scores complement—they don’t replace—the patient’s own account of what matters and what remains difficult.
References
Bennett, R. J., Larsson, J., Gotowiec, S., & Ferguson, M. (2024). Refinement and Validation of the Empowerment Audiology Questionnaire: Rasch Analysis and Traditional Psychometric Evaluation. Ear and Hearing, 45(3), 583–599. https://doi.org/10.1097/AUD.0000000000001449
Bennett, R., Incerti, P., Larsson, J., Engelund, G., Bothe, E., & Ferguson, M. (2026). Measuring empowerment with the EmpAQ-15 and EmpAQ-5: test-retest reliability and responsiveness in a clinical population. International Journal of Audiology, 1–14. Advance online publication. https://doi.org/10.1080/14992027.2026.2732708
Ferguson, M., Gavrilis, J., Larsson, J., Bennett, R., Incerti, P., & Engelund, G. (2026). Understanding the correlates of hearing-specific empowerment in a clinical hearing loss population. International Journal of Audiology, 1–12. Advance online publication. https://doi.org/10.1080/14992027.2026.2619591
Ferguson, M. et al (2025) Implementing the EmpAQ-5 and Empowerment Clinical Tools to Enhance Client Empowerment in Clinical Practice: A Multi-Site Study. Poster presented at the British Academy of Audiology. Accessed at: British Academy of Audiology poster (PDF)
Gotowiec, S., Larsson, J., Incerti, P., Young, T., Smeds, K., Wolters, F., Herrlin, P., & Ferguson, M. (2022). Understanding patient empowerment along the hearing health journey. International Journal of Audiology, 61(2), 148–158. https://doi.org/10.1080/14992027.2021.1915509
Gotowiec, S., Bennett, R., Larsson, J., & Ferguson, M. (2024). Development of a self-report measure of empowerment along the hearing health journey: a content evaluation study. International Journal of Audiology, 63(4), 275–285. https://doi.org/10.1080/14992027.2023.2174456
Hearing loss in adults: assessment and management. London: National Institute for Health and Care Excellence (NICE); 2023 Oct 2. (NICE Clinical Guidelines, No. 98.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK616103/
Yngve, M., Larsson, J., & Karlsson, E. (2026). Measurement Properties of the Swedish Empowerment Audiology Questionnaire: A Rasch Analysis. Journal of Speech, Language, and Hearing Research, 69(5), 2355–2364. https://doi.org/10.1044/2026_JSLHR-25-00821
About the Author
Brian Taylor, AuD, has served as the editor of Audiology Practices since 2009 and is an adjunct instructor at the University of Wisconsin. He brings more than three decades of experience as an audiologist, educator, clinical researcher, and author across a wide range of professional topics. He received ADA’s prestigious Joel Wernick Award for outstanding educational contribution within the fields of audiology and hearing science in 2024.
