Psychological, Marketing, Physical, and Sociological Factors Affecting Attitudes and Behavioral Intentions For Customers Resisting the Purchase of an Embarrassing Product

ABSTRACT - In this research, we examine hearing impaired consumers’ attitudes and behavioral intentions regarding hearing aids. We measured attitudes prior and subsequent to exposure to marketing communications which attempt to persuade consumers to purchase hearing aids and perceive them more favorably. We consider the hearing aid patient/consumer holistically, and include predictors for their psychological and physical states, as well as explanatory factors such as the environmental, sociological pressures that the patient/consumer is experiencing which help to induce the hearing aid purchase. In this context, we test the marketing effect of the advertising exposure.


Dawn Iacobucci, Bobby J. Calder, Edward C. Malthouse, and Adam Duhachek (2003) ,"Psychological, Marketing, Physical, and Sociological Factors Affecting Attitudes and Behavioral Intentions For Customers Resisting the Purchase of an Embarrassing Product", in NA - Advances in Consumer Research Volume 30, eds. Punam Anand Keller and Dennis W. Rook, Valdosta, GA : Association for Consumer Research, Pages: 236-240.

Advances in Consumer Research Volume 30, 2003     Pages 236-240


Dawn Iacobucci, Northwestern University

Bobby J. Calder, Northwestern University

Edward C. Malthouse, Northwestern University

Adam Duhachek, Northwestern University

[We are grateful to Sergei Kochkin of Knowles Electronics, MarketFacts Inc., and Colle-McVoy Advertising Agency for their assistance in this research.]


In this research, we examine hearing impaired consumers’ attitudes and behavioral intentions regarding hearing aids. We measured attitudes prior and subsequent to exposure to marketing communications which attempt to persuade consumers to purchase hearing aids and perceive them more favorably. We consider the hearing aid patient/consumer holistically, and include predictors for their psychological and physical states, as well as explanatory factors such as the environmental, sociological pressures that the patient/consumer is experiencing which help to induce the hearing aid purchase. In this context, we test the marketing effect of the advertising exposure.

This study is predominately a psychological profile of the consumer who needs to buy and wear a hearing aid, but as yet has not done so. We believe the psychological processes that we consider may have broader implications, in that the class of embarrassing products is large, e.g., AIDS-testing, adult undergarments, etc., and our findings should therefore have wide-ranging implications. The marketer attempting to persuade consumers to make any of these kinds of purchases has to overcome similar levels of resistance and denial in the purchase of these embarrassing products. We also sought representative sampling of our study participants and real-world execution of advertisements to also enhance the generalizability of this research.

Nevertheless, this particular study focuses on hearing aids and consumers’ attitudes toward people who wear them, including the psychological stigma attached to the wearer, which in turn begins to explain the state of denial in which a hearing impaired consumer lives. Denying the need for an embarrassing product creates greater resistance to the purchase of that product, from not paying attention to the targeted marketing communications efforts, to holding rather unfavorable attitudes toward the product, regardless of the consumer’s (or patient’s) physical realities, namely, having a hearing incapacity that would be benefitted from the wearing of the hearing aid product.

We shall begin by describing data that demonstrate our claim that hearing aids are a purchase that involve no small amount of consumer embarrassment. Accordingly, the marketer’s task, typically to induce more favorable product attitudes and greater purchase intentions, is quite challenging. Still, as we will demonstrate in our data, such attitudes and behavioral intentions are indeed mutableCthey can be enhanced, as long as the psychological complexities of the consumer are acknowledged, and several classes of predictor variables incorporated into the modeling.

We will test our hypotheses in a data set gathered from a large field experiment. The respondents comprise a sample of "real" people, contacted by a real field marketing research firm, and the advertisements in all their varying media forms were created by a real advertising agency; hence we have attempted to maximize external validity to the extent possible, on both the dimensions of the sampling of respondents and the creation of the advertising stimuli. We will describe our study shortly, but first, given that we expect few readers to be familiar with this particular product and its sales difficulties, we describe the nature of the typical hearing impaired consumer.

Consumers Who Need Hearing Aids

Many people who would benefit from wearing hearing aids do not use them. Of adults 18 years old and older with impaired hearing, 78% do not own a hearing aid. As we age, the need for hearing instrument assistance becomes nearly universal (Datan, Rodeheaver, and Hughes 1987; Garstecki and Erler 1998), but even among the hearing impaired who are 65 years and older, 61% do not wear hearing aids (Garstecki and Erler 1998; Kochkin 1998; National Center for Health Statistics 1994).

The process of buying a hearing aid can be initiated by self-discovery that one’s hearing is not as effective as it had been formerly, or through prompting by members in one’s social environmentCfriends, or co-workers, but usually a spouse or family member whose own quality of life has been affected by the focal person’s hearing loss. The consumer/patient may discuss with his or her physician their hearing disability and proceed to an audiologist or hearing instrument specialist to have their hearing tested, with the intention to buy a hearing aid, and so forth. Most people who have been identified as at least somewhat hearing impaired, and who should initiate this process fail to follow-through doing so.

Patient conformity (e.g., making an appointment to see an audiologist upon recommendation by a family physician) is important and challenging to achieve in many areas of health promotion. In our study, we seek to understand possible reasons for resistance to the particular intervention of buying and wearing a hearing aid.

Respondents (in our sample, to be described shortly) were asked to explain their unwillingness to speak to a doctor about their possibly needing a hearing aid. As illustrated in Figure 1, the primary reason stated was that "my current hearing ability is okay." This response reflects a sense of denial because, as we shall describe in greater detail shortly, all of the participants had been included in our sample only if they had been previously identified by a physician as hearing impaired. The remaining reasons offered in Figure 1 include: the cost of visiting the health professional, lack of interest (presumably driven by thoughts that a hearing aid was unnecessary). Relatively fewer people rejected hearing aids as a function of past failures with the electronic products.

Figure 2 gives an impression regarding the level of avoidance toward hearing aids. People reported that they would readily wear eyeglasses to help correct their vision (M=6.40 of 7). Respondents also would have no problem taking pain relievers to alleviate aches (5.24). They would not even mind terribly having to circumambulate with a cane (4.98). However, the thought of wearing a hearing aid is a far less positive prospect (3.46). Why?

There is a hypothesis in the hearing and speech communications literature that wearing a hearing aid carries a bit of a stigma that the wearer is old, feeble, and incompetent. An article in the American Psychological Association’s Monitor described the denial and depression people associate with hearing loss (Seppa 1997). People do not want to admit their hearing loss to themselves, because it connotes aging, nor do they want to admit it to others, for fear of being viewed as incompetent.





Given all these concerns, it is perhaps not surprising that when Business Week features a hearing aid manufacturer in its "Annual Design Awards," the product receiving acclaim is tiny and is said to "nestle discreetly in the ear canal"; i.e., no one will know you’re wearing it (Baker 1998). Anecdotally, hearing aids saw a surge in sales after President Clinton’s public acknowledgment of beginning to wear one (Cowley, Breslau and Kalb 1997; Rivera 1997); perhaps the devices were seen as more acceptable when rather than being associated with the old and feeble, they were associated with the relatively young and purportedly virile.

In addition, hearing loss, if not assisted with hearing aids, can lead to greater dependence upon a spouse, or withdrawal from social events (Garstecki and Erler 1998). It is often due to the stress experienced by family members or co-workers, i.e., those who are secondarily affected by the focal person’s hearing loss, who first diagnose the problem and recommend they seek help (Kochkin 1998). Feelings of isolation and loss of control of one’s environment can in turn contribute to states of depression, anxiety and related illnesses (Garstecki and Erler 1998; Miller, Shoda, and Hurley 1996).

Some people console themselves with social comparisons, e.g., that their hearing is at least as good as others’ of comparable age (Collins 1996). In general, there are many coping strategies with hearing impairment, including denial (cf. Rodin and Salovey 1989).

Thus, varied psychological contributors may affect attitudes toward hearing aids and intentions to purchase hearing aids. We now present our particular hypotheses about how these factors are inter-related.

We begin simply, by explicating benchmark hypotheses that had better be supported, given decades of research on the relationships among attitudes and behavioral intentions (e.g., Chaffee and Roser 1986; Kim and Hunter 1993). Specifically, we predict that prior states (attitudes or behavioral intentions) ought to be reflected in current states:

H1: Attitudes measured prior to the advertising interventions will contribute to the prediction of attitudes measured following the advertising exposure, A(t-1) ->A(t).

H2: Buying intentions measured prior to the advertising interventions will contribute to the prediction of buying intentions measured following the advertising exposure, BI(t-1) -> BI(t).

In addition, if we have captured consumer attitudes, these indicators should contribute to our understanding of the consumers’ behavioral intentions:

H3: Consumer attitudes will help predict consumer buying intentions and intentions to contact a medical professional, A(t) -> BI(t).

H4: Consumer intentions toward buying hearing aids will in turn propel greater reported likelihood of visiting a hearing professional to begin the hearing aid purchase process, BIaid(t) -> Bidoc(t).

We are also interested in unique precursors to the attitudes and behavioral intentions. Given the psychological nature of an attitude, we predict that other psychological measures should also give rise to one’s reactions to the product. For the class of embarrassing products, relevant psychological indicators are likely to include such predictors as: a) the extent to which a stigma is attached to the product (i.e., the degree of embarrassment associated with the product, the perceptions of self-efficacy with and without the hearing aid, e.g., Fine and Asch 1988; Kochkin 1998; Lee and Bobko 1994); b) denial of one’s own need of the product associated with the stigma (a la Kubler-Ross, cf. p.528 of Demorest and Erdman 1986); and c) the extent to which a person has salient needs for self-presentation, e.g., as may be measured by a self-consciousness scale (e.g., Fenigstein, Scheier, and Buss 1975). Thus, psychological factors should impact the consumer attitudes:

H5: Psychological factors (denial, self-consciousness, and concern about a stigma) will contribute to the formation of the attitudes toward hearing aids, y ->A(t).

Marketers have long claimed that advertisements presumably make more favorable attitudes toward featured products, thus:

H6: Marketing interventions (advertisements) will enhance the attitude toward the product, Ad -> A(t).

By comparison, behavioral intentions may be impacted less by perceptual factors and more by physical ones, such as the consumer’s hearing competency and the pressures they are experiencing to make the purchase, such as word-of-mouth from their family or physician (Coleman 1993; Kochkin 1998). Whether one likes hearing aids or not (i.e., one’s attitude is positive or negative), one may be driven to buy a hearing aid when the need becomes sufficiently great, as becomes obvious either to the focal consumer or to those around him or her. Thus:

H7: Physical factors (the extent of hearing impairment) will heighten a respondent’s intention to purchase a hearing aid, O -> BI(t).

H8: Social factors (pressures from medical professions) will also enhance a person’s intention to buy the recommended hearing aid, Soc -> BI(t).

Altogether, our predicted nomological network (illustrated in Figure 3) may be described as follows: the prior-attitudes and prior-behavioral intentions should assist the prediction of the current attitudes and intentions, and the attitudes ought to contribute to our understanding of the intentions themselves. The attitudes, in turn, should be affected by the psychological and marketing factors, and the intentions, in turn, should be impacted by the physical and sociological factors.

In sum, a product with such a negative image as hearing aids clearly presents a challenge to the marketer interested in stimulating their sales. Due to the complexities of the entire circumstances, initial advertising exposure may be judged successful if it simply prompts the consumer to begin to think of the extended process involved toward deciding to purchase a hearing aid. While our study is not extensively longitudinal, we made efforts to obtain data at multiple points in time. We now describe our study and findings.


Market Facts Inc. surveyed a U.S. national panel of 80,000 adults in September 1995 with a screener to identify respondents who had been previously diagnosed by their general practice physician or a hearing specialist as having some hearing impairment, in one or both ears, and who were between the ages of 30 and 75. Of the 59,828 cards returned (for a 74.8% response rate), 7955 respondents qualified (this near 10% rate approximates the prevalence of hearing difficulties in the population). Those qualifying were sent an 8-page questionnaire (Wave 1) in March 1996. Usable questionnaires were returned by 4824 persons, for a 60.6% response rate. This survey provided baseline data on attitudes toward hearing aids, intentions to visit a physician to discuss them, intentions to purchase a hearing aid, and several individual difference covariates.

Media exposures were conducted in August and September 1996. A random sample of 4344 participants (of the 4824) received advertising messages attempting to enhance their attitudes toward hearing aids, persuade them to visit their physicians to discuss hearing aids, and eventually to purchase a hearing aid. The advertising stimuli were created by the Colle-McVoy advertising agency based on their previous research to convey the idea that a hearing aid would enhance the wearer’s interactions with his or her work and family environments. These advertising messages were delivered via multiple and varied media vehicles, to simulate a real-world advertising campaign. These media included print ads, television ads (on video tape), telemarketing phone calls and direct marketing mailings. The messages were consistent across the media in an effort to produce integrated marketing communications (Edell and Keller 1989).

Participants were mailed another 8-page survey (Wave 2) to measure short-term change in attitudes and reactions to the advertisements. Returns came in from 3351 persons, resulting in a 77.1% response rate. A briefer (4-page) follow-up questionnaire (Wave 3) was sent to the 3351 parties in November 1996 to obtain indices of moderately longer-term attitude change; 3049 surveys were completed, for a 91.0% response rate. All surveys complied with human subjects requirements.

In sum, this test market was conducted over a nine-month period. The panel of respondents was contacted at t1, prior to the exposure to any marketing communications; their attitudes were measured upon exposure to the persuasive materials, t2; as well as t3, two to three months after the marketing efforts.

Sample Characteristics

In an attempt to be in the position to generalize our findings to the greater U.S. population, we sought a random, representative sample of respondents from across the country, who varied on any properties except the two screeners (i.e., they must have been previously diagnosed as hearing impaired, and they were between 30 and 75 years old). As a result, descriptive statistics on our sample offer a rough profile of the cross-section of the general public who have an identified hearing problem. Their mean age is 54.2 years, but the standard deviation is large (12.6 years), confirming that hearing loss problems are not entirely concentrated among the elderly. Our sample was comprised of slightly more men than women (53.5%), but not so disproportionately as to be unrepresentative. Very few people in this sample, who are known to have hearing losses, have tried to use a hearing aid (5.1%), although more (45.9%) state their willingness to discuss the possibility of getting one. Finally, socioeconomic indicators suggest that these persons could probably afford a hearing aid if they wished to own one; specifically, most own homes (81.8%), most are employed (68.3%), many are professional workers (30.4%).


Respondents’ behavioral intentions were measured both with respect to their anticipating seeing a doctor to discuss hearing aids, and with respect to their intentions to buy a hearing aid. (We are happy to make available to interested readers the items we used to measure our constructs and those scales’ Cronbach’s coefficient alphas to indicate their estimated reliabilities.) Attitudes toward the product and attitude toward the advertisement were measured. Items measuring attitudes toward the product included several classic, semantic differential scales, as well as several items about the respondents’ beliefs about hearing aids, e.g., their usefulness in different situations. The items tapping "attitude toward the ad" were drawn from the advertising measurement literature, to capture dimensions of the Viewer Response Profile and other popular Aad scales (cf. Beltramini and Evans 1985; Schlinger 1979).



The items measuring the psychological factors of denial, self-consciousness, and the perceptions of stigma are also available from the authors, and again, where scales existed in the literature, we implemented the extant items (e.g., the self-consciousness scale of Fenigstein, Scheier and Buss, 1975). The physical impairment scale has been extensively studied and established in the speech and communications disorders literature. Accordingly, we borrowed the CPHI items (the Communication Profile for the Hearing Impaired; Demorest and Erdman 1986; Garstecki and Erler 1998). Finally, we also used measured the extent of sociological pressures from one’s medical service providers.


We fit our model via Lisrel. The results are displayed in Figure 3. All coefficients are significant (p<.01) except for the "self-conscious -> attitude" path that is labeled "n.s."

As anticipated in H1 and H2, pre-attitudes significantly predicted post-attitudes (.42) and pre-buying intentions predicted post-advertising buying intentions (.52). As per H3, attitudes predicted buying intentions (.34), and attitudes predicted intentions to contact medical professionals (.19). H4 was also supported in that consumer buying intentions (.35) begin the hearing aid purchase process by increasing the consumers’ intention to visit their physicians to discuss hearing aids. These first results are not surprising, given the extensive psychological literature on the relationships among attitudes and behavioral intentions; essentially that prior-attitudes should affect current attitudes, and attitudes should affect behavioral intentions.

H5 had stated that the psychological factors of denial, self-consciousness, and perceptions of stigma would contribute to the consumers’ attitudes about hearing aids. The parameter estimates for the first and third of these factors were significant (-.14 and -.23, respectively; as denial or perceptions of stigma increase, one’s attitudes towards hearing aids becomes more negative). Self-consciousness was not a significant contributor. We expected self-consciousness to be important, if consumers are so sensitive to the "stigma" of hearing aid that they are in "denial" f their own state of hearing impairment.

In hypothesis H6, as per the extensive literature on advertising and its effects on attitudes, we posited that an effective marketing intervention should enhance the consumer’s attitude toward the product, and we did indeed find this to be true (.22). H7 and H8 suggested that the physical need due to the extent of hearing impairment, and social pressures, such as a physician recommending the use of a hearing aid would both encourage the respondent’s intention to purchase a hearing aid. These paths were also significant (.16 and .11, respectively). Thus, aside from one’s attitude about hearing aids and people who wear them, consumers were more inclined to be considering the purchase of a hearing aid if their physical need was greater or if they were being implored to do so by a medical professional.

The model in Figure 3 fits well: X216=31.27 (p=.012, presumably due to our large sample size); CFI=0.97; RMR=0.071; AGFI=0.93. Nevertheless, for some theoretical and empirical comparison, we explored a competing model.

Specifically, we explored whether adding paths indicative of greater advertising effectiveness would further enhance the model. Thus, we modified Figure 3 to also include effects of "advertising"Abuying intentions" and "advertising"Aplan to see doctor." Neither of these paths were significant (t=1.25 and t=1.71), nor was there a significant improvement in fit: X214=28.87 (so DX2=2.40 on Ddf=2) and AGFI=0.77. These results suggest that, at least for hearing aids, the advertising enhanced a consumer’s attitudes about the product, but it did not directly impact behavioral intentions. Having fit an alternative model and found it lacking, we conclude with somewhat greater confidence that the model depicted in Figure 3 is a reasonably useful approximation of the complex world of the consumer who is resisting hearing aids.


We have explored one particular sensitive product, hearing aids, but our findings should speak to the broader class of embarrassing products that would carry negative associations and stigma. While our study has focused on how consumers with hearing loss can be convinced to consult a physician and buy a hearing aid, the principles we explored are more generalCthere is resistance and denial in many kinds of behavioral solutions to medical and social ills, and this study suggests it is possible to identify those discriminatory variables that lend some compliance.

We were able to demonstrate distinct precursors of attitudesCpsychological and marketing factors, and of behavioral intentionsCphysical and sociological factors. We do not claim that these classes of predictors will always align themselves with these consequence constructsCthe particular relationships are likely to depend on the product category. Rather, the general principal is that we can indeed find categories of predictors that can assist our understanding and predictions of these key psychological constructsCattitudes and intentions.


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Dawn Iacobucci, Northwestern University
Bobby J. Calder, Northwestern University
Edward C. Malthouse, Northwestern University
Adam Duhachek, Northwestern University


NA - Advances in Consumer Research Volume 30 | 2003

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