Adopting a Client-Centered Approach for the Hearing Aid Uptake Process



Author: Laya Poost-Foroosh, Ph.D., Mary-Beth Jennings, Ph.D., and Margaret. F. CheesMan, Ph.D.

 

Abstract

Hearing aids are the most common intervention for reducing the negative consequences of hearing impairment, however, only a small fraction of people who could benefit from hearing aids own one. A recent study has highlighted the perceived influence of the client-centered approach to care in hearing aid adoption decisions. Factors that were perceived to influence hearing aid adoption have informed the development of a preliminary model of client-centered care for the hearing aid uptake process. The model has one pre-requisite element of client-centered traits and actions of the clinician and five interactive components: acknowledging and understanding the client as an individual, ensuring client comfort, provision of information, facilitating shared decision making, and considering client motivation and readiness. The six components of the preliminary client-centered model of care for the hearing aid uptake process and ways in which to incorporate the client-centered model into clinical practice are discussed.

Hearing is a key element in the ability to communicate and a decline in hearing may limit an individual’s ability to fully engage in social and productive activities or even lead to withdrawal from social engagements (Hawthorne, 2008; Strawbridge, Wallhagen, Shema, & Kaplan, 2000). Hearing aids and aural rehabilitation (AR) are viable non-medical interventions for rehabilitation of hearing impairment (Jennings, 2005; Kricos, Erdman, Bratt, & Williams, 2007; Weinstein, 1996). Hearing aid use improves communication and reduces some of the adverse effects of hearing impairment (Mulrow et al., 1990; Newman & Weinstein, 1988; Stark & Hickson, 2004), however, evidence show that only a small proportion of older persons with age-related hearing loss use hearing aids (Kochkin, 1996; Popelka et al., 1998). The low rate of hearing aid ownership among adults with age-related hearing loss is a problem that needs to be addressed (Fischer et al., 2011). Raising levels of ownership and use of hearing aids in adults are major challenges for hearing health care professionals (Fischer et al., 2011; Humes, Wilson, Barlow, & Garner, 2002). Fischer and colleagues (2011) followed adults with age-related hearing loss for 10 years and reported that only one third of those who were recommended hearing aids acquired one within 10 years of detection of the hearing loss. Non-adherence to health care recommendations in chronic conditions is often attributed to client-related factors by researchers and health care providers. However, factors including those related to the health care professional and/or the health service delivery system also influence adherence to treatment recommendation (Sabaté, 2003). For example, first time hearing aid candidates consistently report their declining hearing ability, the request of family members, and hearing health care professional recommendations as the top three factors that influence their decision to purchase hearing aids (Kochkin, 2009). In a qualitative study of barriers and facilitators to hearing aid uptake, women with age-related hearing loss reported that the personal qualities of the hearing health care professional such as professionalism, understanding, and ability to trust the clinician had an impact on their decision to purchase hearing aids (Winsor, 2011).

A client-centered approach to the client-clinician interaction in which the clients’ perspectives are elicited by the clinician is positively associated with treatment adherence in chronic illness (Bartlett et al., 1984; Gavin, Wamboldt, Sorokin, Levy, & Wamboldt, 1999; Hovell et al., 1986; Lo, 1999). Client-centered care is suggested as the preferred approach in client-clinician interactions when rehabilitation decisions are made (Laplante-Lévesque, Hickson, & Worrall, 2010a). A recent study that identified factors in the client-clinician interaction that were perceived to influence hearing aid adoption promoted use of a clientcentered approach to care in hearing aid adoption encounters (Poost-Foroosh, Jennings, Shaw, Meston, & Cheesman, 2011). This paper provides a summary of the study by Poost-Foroosh and colleagues (2011) and presents a preliminary model of client-centered care for the hearing aid uptake process that was developed from the influential factors identified in the client-clinician interaction. This article also provides a few suggestions as how to incorporate the client-centered model of care into clinical audiology practice.

Client-Clinician Factors Perceived to Influence Hearing Aid Adoption

In a study investigating the factors in client-clinician interactions that influence hearing aid adoption, a concept mapping approach was used to identify eight concepts that were perceived to influence hearing aid purchase decisions (Poost-Foroosh et al., 2011). Ten audiologists who prescribed hearing aids and 13 clients who had recently received their first hearing aid recommendation participated in different stages of the study. Participants attended separate focus groups for clients and clinicians and generated 122 statements that described factors in the client-clinician interaction that they perceived to influence hearing aid purchase decisions in first time hearing aid candidates. The statements were individually sorted by participants into groups based on how similar in meaning they were to one another. Multidimensional scaling and hierarchical cluster analysis was used to group the individual sorts of the statements into eight clusters with common themes. The result was a concept map with eight clusters including (Figure 1): (1) Understanding and meeting client needs, (2) Acknowledging client as an individual, (3) Client-centered traits and actions, (4) Ensuring client comfort, (5) Factors in client readiness, (6) Imposing undue pressure and discomfort, (7) Supporting choices and shared decision making, and (8) Conveying device information by clinician. Two overarching themes of client-centered interaction and client-empowerment were identified in the concept map. Empowerment is a complex experience of personal change which can be facilitated by adopting a client-centered approach to care (Aujoulat, d’Hoore, & Deccache, 2007). The concepts highlighted empowerment as a combination of an interactive and a personal process in which the power is not simply given by the clinician to the client, nor is it solely created within the client, but empowerment is facilitated by the client-clinician relationship. (McWilliam et al., 1997). The concepts highlighted the perceived influence of the client-clinician interaction in hearing aid adoption. Table 1 provides examples of the statements in each of the eight concepts.

Client-Centered Interaction in Audiological Encounters

Client-centeredness is regarded as the gold standard approach to care in most health care domains. A clientcentered approach to care improves client adherence and health outcomes (Robinson, Callister, Berry, & Dearing, 2008) and has been promoted and advocated as the preferred model of care in the delivery of audiological rehabilitation (Duchan, 2004; Erdman, 2009; Gagné & Jennings, 2011). Client-centered care is an enabling process that focuses on the client (Law, Polatajko, Baptiste, & Townsend, 1997). The health care professional acts as a facilitator who enables the client to implement solutions to their health problems. In an audiological encounter, the focus is often on the diagnosis and management of the hearing impairment (Erdman, Wark, & Montano, 1994; Stephens & Hétu, 1991). Focusing on the impairment alone and assessing and interpreting the test results reduces the client’s problems to a set of signs and symptoms which fits with a biomedical approach to care (Mead & Bower, 2000). Focusing on the management of the hearing loss instead of the person with hearing impairment can create tension because hearing aids are both a consumer and a health care product. This approach to care may cause the client to be unable to distinguish audiological services from other sales activities. To this end, clinicians should be conscious of their relationship with the client and become aware of the need for flexibility in their approach to care. In order to distinguish the hearing aid uptake process from a sales approach, audiologists can foster a client-centered approach to care. In the next section an overview of a preliminary client-centered model of care for hearing aid uptake process is presented with suggestions on how to adopt or to become more aware of client-centered care in audiological encounters in which hearing aids are recommended and fitted.

Figure 1. Concept map of client-clinician interaction depicting eight clusters. Each dot represents one brainstormed statement.

Table 1. Eight concepts in client-clinician interaction perceived to influence hearing aid adoption and examples of the statements in each concept.
Concept Sample Statements
Ensuring client comfort
  • The client feels that the clinician is sincere in his/her intentions.
  • The client doesn’t feel pressured.
  • The physical environment is comfortable and welcoming.
Understanding and meeting client needs
  • The clinician asks what situations are difficult for the client.
  • The clinician relates the assessment results to the difficulty they are having.
  • The clinician considers the client’s life style and/or work requirements
Client-centered traits and actions
  • The clinician is upfront and honest.
  • The clinician does not appear hurried.
  • The client and clinician communicate easily.
Acknowledging client as an individual
  • The clinician values what is important to the client.
  • The clinician provides an opportunity for the client to express his/her concerns.
  • The clinician is able to explain things to the client at the wappropriate level.
Imposing undue pressure and discomfort
  • The client feels some pressure to purchase.
  • The client has the impression audiologist is “up-selling”.
  • The client is given too many choices.
Conveying device information by clinician
  • The clinician explains why a particular hearing aid is recommended.
  • The clinician explains the pros and cons of each hearing aid.
  • The clinician provides pamphlets with information for different hearing aids.
Supporting choices and shared decision making
  • The client feels that he/she is part of the process.
  • The client feels he/she is allowed to make choices.
  • The client is given time to think about the hearing aid purchase.
Factors in client readiness
  • The client accepts there is a need for hearing aids.
  • The client is referred by a friend.
  • The client’s experience with friends or family that have hearing aids.
The Preliminary Model of Client-Centered Care for Hearing Aid Uptake Process

The eight concepts identified in Poost-Foroosh and colleagues’ (2011) study were used as a framework to develop a preliminary model of client-centered care in the audiological encounter for the hearing aid uptake process. This preliminary client-centered model has common elements with several client-centered frameworks (for example, Law, Baptiste, & Mills, 1995; Law & Mills, 1998; Stewart, 2003). The proposed model has six constructs, including one prerequisite element and five interactive components (Figure 2). The pre-requisite element is Client-centered traits and actions of the clinician which is a requirement for providing client-centered care. The five interactive components of the model include: 1) Acknowledging and understanding the client as an individual, 2) Ensuring client comfort 3) Provision of information, 4) Facilitating shared decision making, and 5) Considering client motivation and readiness.These components are interactive and cannot be considered in isolation from the other elements. A client-centered interaction should include all the components. Each of the components of the preliminary model of client-centered care for the hearing aid uptake process are reviewed in the next section and examples of how each element could be incorporated into practice are provided.

Figure 2. The preliminary model of client-centered care for the hearing aid uptake process.

Acknowledging and Understanding the Client as an Individual

According to the World Health Organization’s International Classification of Functioning, Disability and Health (ICF: WHO, 2001), impairment and disability are different concepts. Impairment is a problem in the function of a body part. Disability includes limitation and restriction in participation in daily activities and not simply dysfunction at the body level. According to the ICF, contextual factors (personal and environmental factors) also influence the functioning and disability domains of health. As a consequence, clinicians must not rely on the hearing assessment results alone to evaluate the impact of the hearing impairment on the client. Knowledge of the negative consequences of untreated hearing loss does not necessarily enable clinicians to understand the extent to which a hearing loss may impact a particular individual’s life. Two individuals with similar audiograms may perceive different degrees of disability because of their different lifestyle and limitations in activities that they participated in prior to acquiring the impairment or limitations in engaging in new activities. The impact of the hearing loss on the individual can only be understood if the clinician enters the person’s world and evaluates the hearing impairment in the realm of the client rather than solely of the basis of clinical knowledge and from a clinical point of view.

The first component of the client-centered model of care which is acknowledging and understanding the client as an individualimplies the need for a holistic approach to the hearing assessment process in which clients are enabled to become more aware of and to evaluate their communication abilities and difficulties. The commonly used case history questions and a hearing assessment, which often includes pure tone and speech audiometry, are not sufficient to assess clients using the ICF framework. Self-assessment tools can be of great value for exploring a client’s individual communication concerns. For example, the Hearing Handicap Inventory for the Elderly (HHIE: Ventry & Weinstein, 1982) can be used to assess the perceived disability caused by hearing impairment for each individual. Explaining the assessment results should also be individualized. Clinicians should provide the information at appropriate level for each individual and avoid use of technical jargon. Many clients may not find the audiogram meaningful when it is explained in terms of frequency/pitch and loudness. Clinicians can explain the audiogram in a more meaningful way for the clients by relating the graph to the clients’ experienced communication abilities and difficulties. The self-assessment tool can also be useful in explaining and linking the assessment results to the experiences of the individual.

Ensuring Client Comfort

Creating an environment in which clients feel comfortable to express their views and preferences is fundamental in utilizing shared decision making (Charles, Gafni, & Whelan, 1999). Physical comfort is reported as a common element in six client-centered models (Law & Mills, 1998). In the current preliminary model, the physical comfort element is expanded and includes client comfort in both physical and emotional domains. In addition, client comfort implies the need for avoiding undue pressure and discomfort for clients. Emotional comfort in the interaction can be achieved by establishing a trusting relationship in which the client feels comfortable communicating with the clinician. For example, client comfort can be ensured by providing enough time in the appointment, being patient with the client during the entire process, making sure the client understands what the clinician is saying, not giving the client too few or too many choices, and avoiding a sales approach when recommending hearing aids. An authentic client-centered approach to care inherently encompasses client comfort in the interaction. In a client-centered approach to care, a clinician will spend enough time with the client to understand the client’s views and experiences of hearing impairment and its impact on his/her life. An interaction in which the client is rushed or pressured to make a decision to purchase hearing aids before the client understands and appreciates the potential benefits and limitations of hearing aids, or an interaction in which the clinician insists on hearing aids that are beyond a client’s need, do not fit with a client-centered model.

Provision of Information

An important element in both client-centered care and client empowerment concepts is the provision of information about diagnosis and treatment/intervention (Holmström & Röing, 2010). Adequate information empowers clients and supports them in shared decision making. To provide adequate information, clinicians need to consider the content, amount and format of the information. The content and the format of the information are important in the processing of the information by clients (Feldman-Stewart, Brundage, McConnell, & Mackillop, 2000; van Dulmen, 2002). The information clients consider important varies widely. Clinicians need to be mindful of these variations and be flexible in the provision of information (Feldman-Stewart et al., 2000). In a recent study, clients who were in the process of hearing aid acquisition perceived device-related information more important than did clinicians (Poost-Foroosh, 2012). However it should be noted that information overload may reduce the ability of clients to make a rational decision or even hinder their active participation in decision making (McCaul, Peters, Nelson, & Stefanek, 2005). Clients who seek hearing health care for the first time are often presented with an overwhelming amount of information such as hearing assessment results, hearing aid candidacy information, and hearing aid related information. While clinicians should provide all necessary information for each client, they should not overwhelm clients with too much information in one session. Another consideration in provision of information is the format in which the information is presented. Information in alternative formats such as written material and diagrams can be helpful in the processing of the information by the client. By engaging clients in the discussion, the one-way transfer of the information from clinician to client can be changed to an information exchange between the client and clinician. Thus, the client’s input can be used to tailor the information according to individual clients’ particular needs, wishes, and knowledge of the concept under discussion. Poor transmission of information, poor understanding of the information by the client, and low level of recall of the information by the client are associated with dissatisfaction with communication and lack of adherence to recommendations (Ley, 1982). Clinicians rarely assess the client’s understanding of information (Silberman, Tentler, Ramgopal, & Epstein, 2008). Clients who visited family physicians in a community practice recalled less than 50% of the information they received (Flocke & Stange, 2004). Flocke and Stange (2004) reported that recall of information is strongly associated with the duration of the visit. Improved provision of information in a client-centered way can be achieved by allotting adequate time for clients, prioritizing and providing information over the course of several visits, verifying with clients how much of the information they have understood, assessing clients’ recall of information in the follow up visits, and reviewing important and relevant information.

Facilitating Shared Decision Making

A fundamental requirement in client-centered care is the provision of opportunities for shared decision making (Charles, Gafni, & Whelan, 1999). Shared decision making is described as a process in which client and clinician exchange information, express their preferences of intervention, make intervention decisions together, and finally the client agrees to implement the decision (Charles, Gafni, & Whelan, 1997). To facilitate the exchange of information, clinicians need to engage clients in the conversation. This can be achieved by creating a comfortable space and place for the clients to express their views. Most often the initial audiologic encounters in the hearing aid adoption process are spent on hearing assessment and technical aspects of the hearing aid evaluation while clients remain mostly passive (Doyle, 1994). A more active role of the clients in the interaction can be created by information transfer, development of personal expertise, and a good relationship with the health care professional (Say, Murtagh, & Thomson, 2006). As mentioned earlier, the components of this preliminary model of client-centered care are interactive; as a result, shared decision making cannot be facilitated unless all other elements are utilized. For example, in order to facilitate clients’ participation in decision making, the clients need to have adequate information. Adequate information varies widely among individuals. An individual who presents to a hearing clinic only to placate his/her spouse or children may need different information than a person who feels the hearing impairment is causing him/her to miss out on social activities. Both these individuals need to feel comfortable in the interaction in order to express their motivation for seeking help, experiences with hearing impairment and intervention preferences. Shared decision making cannot be facilitated unless all other elements of the client-centered care are utilized.

Considering Client Motivation and Readiness

The audiologist must have an understanding of client’s motivation for hearing help seeking and their readiness for the intervention in order to tailor the interaction for each individual client. For example, the client who presents to the clinic in order to placate his/her family may not be ready to have discussions of the styles and models of hearing aids in the first appointment. Recommending interventions without taking into account the clients’ motivation and intentions for seeking hearing health care may sometimes create a negative image of the clinician. In this example, discussions of hearing aids may project the image of a sales person- rather than a hearing health care professional. In a client-centered approach to care, clinicians need to actively elicit and then modify the interaction based on the client’s attitude and readiness toward acknowledging hearing loss and the need for hearing aids.

Client-Centered Traits and Actions of the Clinician

The pre-requisite element of the client-centered model of care focuses on clinician attributes and includes traits such as being honest, caring, and pleasant and interpersonal skills and professional competence. To communicate easily with clients, clinicians require well developed interpersonal skills. Professional competence focuses on attributes such as being knowledgeable and development of professionalism and clinical expertise. Possession of client-centered attributes supports clinicians in communicating with clients, eliciting and understanding clients’ experiences with hearing impairment, creating a comfortable environment for interaction, and facilitating the exchange of information and shared decision making.

Incorporating client-Centered Care Into Practice

Implementing client-centered care into clinical practice may be challenging and requires changes to practice. Clinicians need to be aware of and willing to apply a model of care that meets the exigencies of differing client situations. In a client-centered framework clients’ perspectives and experiences define what is best for them. Health care professionals’ sincere desire to do what they think is best for clients, may become a barrier to practicing in a client-centered way (Stern, Restall, & Ripat, 2000). For example, focusing on the impairment may suggest that amplification is the best option for an individual while the individual may not perceive enough disability to see reasons to adopt hearing aids. In order to incorporate client-centered care into clinical practice, the focus needs to be shifted to the person and the hearing impairment should be viewed from the perspective of the client.

There are several tools that can support clinicians to implement client-centered care into practice. As mentioned earlier in this paper, self-assessment instruments can help both clients and clinicians to evaluate the clients’ perception of their disability. Goal Attainment Scaling (Kiresuk & Sherman, 1968) has been used to set personal goals for audiological rehabilitation (Jennings, 2009) and to provide valuable information about clients’ preferences of what they would like to achieve in rehabilitation. Clinicians can also use decision aids to facilitate decision making for clients (LaplanteLévesque et al., 2010b). Decision aids are evidence based tools that improve clients’ knowledge of the options and outcome, and support clients in making choices consistent with their personal values (Stacey et al., 2011). Reflection can be used as a tool by clinicians to evaluate the client-centeredness of the interaction. Reflection is a way of bridging the gap between theory and practice by identifying discrepancies between what clinicians would like to do and what they actually do in practice (Schön,1987). Ng (2012) reported that reflection can inform and inspire client-centered care in audiology students and novices. Clinicians are encouraged to reflect on their actions and behavior in practice and the extent to which their actions have been client-centered. Among multiple factors that are reported to influence hearing aid adoption and use (e.g., perceived severity of the hearing problem, a person’s attitude toward hearing loss and hearing aids, stigma, and cost of hearing aids), one factor that can be modified by clinicians to increase hearing aid uptake is the way clinicians interact with the clients. In addition, in order to change the focus of the audiological services from the hearing impairment to the person and to distinguish hearing aid uptake process from a sales approach, audiologists need to be cognizant of the model of care they adopt to interact with their clients and consider adopting a client-centered model of care in their practices.    

 

Laya Poost-Foroosh, PhD, is a lecturer at the School of Communication Sciences and Disorders at Western University, London, Canada. Her doctoral research was focused on client-clinician communication and its impact on hearing aid uptake. Dr. Poost-Foroosh has been a certified audiologist for over 15 years and works part time as a clinical audiologist.

Mary Beth Jennings, PhD, is an Associate Professor in the School of Communication Sciences and Disorders (CSD) and is the Principle Investigator of the Robert B. Johnston Aural Rehabilitation Laboratory within the National Centre for Audiology (NCA) at Western University. She worked clinically for 13 years prior to beginning her academic career. Dr. Jennings has been a certified Audiologist for 25 years.

Margaret F. Cheesman, PhD, is an Associate Professor in the School of Communication Sciences and Disorders at Western University, London, Canada.  Dr. Cheesman is a founding researcher at the National Centre for Audiology and director of the Cobban Hearing Science Laboratory.

Acknowledgements

The Authors gratefully acknowledge Canada Foundation for Innovation, Ontario Research Fund, Unitron, Ontario Neurotrauma Foundation, and Ontario Graduate Scholarship in Science and Technology for their support.

References

Aujoulat, I., d’Hoore, W., & Deccache, A. (2007). Patient empowerment in theory and practice: Polysemy or cacophony? Patient Education and Counseling, 66(1), 13-20.

Bartlett, E. E., Grayson, M., Barker, R., Levine, D. M., Golden, A., & Libber, S. (1984). The effects of physician communications skills on patient satisfaction; recall, and adherence. Journal of Chronic Diseases, 37(9-10), 755-764.

Charles, C., Gafni, A., & Whelan, T. (1999). Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Social science & medicine, 49(5), 651-661.

Charles, C., Gafni, A., & Whelan, T. (1997). Shared decisionmaking in the medical encounter: What does it mean?(or it takes at least two to tango). Social science & medicine, 44(5), 681-692.

Doyle, J. (1994). Initial consultations in hearing aid clinics in Australia. Journal of American Academy of Audiology, 5(3), 216- 225.

Duchan, J. F. (2004). Maybe audiologists are too attached to the medical model. Seminars in Hearing, 25(4), 347-354.

Erdman, S. A. (2009). Audiologic counseling: A biopsychosocial approach. In J. J. Motano & J. B. Spitzer (Eds.), Adult audiologic rehabilitation (pp. 171-215). San Diego, CA: Plural Publishing.

Erdman, S. A., Wark, D. J., & Montano, J. J. (1994). Implications of service delivery models in audiology. Journal of the Academy of Rehabilitative Audiology, 27, 45-60.

Feldman-Stewart, D., Brundage, M. D., McConnell, B. A., & Mackillop, W. J. (2000). Practical issues in assisting shared decision‐ making. Health Expectations, 3(1), 46-54.

Fischer, M. E., Cruickshanks, K. J., Wiley, T. L., Klein, B. E. K., Klein, R., & Tweed, T. S. (2011). Determinants of Hearing Aid Acquisition in Older Adults. American Journal of Public Health, 101(8), 1449.

Flocke, S. A., & Stange, K. C. (2004). Direct observation and patient recall of health behavior advice. Preventive Medicine, 38(3), 343-349.

Gagné, J. P., & Jennings, M. B. (2011). Incorporating a ClientCentered Approach to Audiologic Rehabilitation. The ASHA Leader.

Gavin, L. A., Wamboldt, M. Z., Sorokin, N., Levy, S. Y., & Wamboldt, F. S. (1999). Treatment alliance and its association with family functioning, adherence, and medical outcome in adolescents with severe, chronic asthma. Journal of Pediatric Psychology, 24(4), 355. doi: 10.1093/jpepsy/24.4.355

Hawthorne, G. (2008). Perceived social isolation in a community sample: its prevalence and correlates with aspects of peoples’ lives. Social Psychiatry and Psychiatric Epidemiology, 43(2), 140-150.

Holmström, I., & Röing, M. (2010). The relation between patientcenteredness and patient empowerment: A discussion on concepts. Patient education and counseling, 79(2), 167-172.

Hovell, M. F., Black, D. R., Mewborn, C. R., Geary, D., Agras, W. S., Kamachi, K., et al. (1986). Personalized versus usual care of previously uncontrolled hypertensive patients: an exploratory analysis. Preventive medicine, 15(6), 673-684.

Humes, L. E., Wilson, D. L., Barlow, N. N., & Garner, C. (2002). Changes in hearing-aid benefit following 1 or 2 years of hearingaid use by older adults. Journal of Speech, Language, and Hearing Research 45(4), 772-782.

Jennings, M.B. (2009). Clinical report: Evaluating the efficacy of a group audiologic rehabilitation program for adults with hearing loss using a Goal Attainment Scaling approach. Canadian Journal of Speech-Language Pathology and Audiology, 33(3), (Fall), 146-153.

Jennings, M. (2005). Audiologic rehabilitation needs of older adults with hearing loss: Views on assistive technology uptake and appropriate support services. Canadian Journal of Speech-Language Pathology and Audiology, 29(3), 112-124.

Kiresuk, T.J., & Sherman, R. (1968). Goal attainment scaling: A general method of evaluating comprehensive mental health programmes. Community Mental Health Journal, 4, 443-453.

Kochkin, S. (2009). MarkeTrak VIII: 25-Year trends in the hearing health market. Hearing Review, 16(10), 12-31.

Kochkin, S. (1996). MarkeTrak IV: 10-year trends in the hearing aid market--has anything changed. The Hearing Journal 49(1), 23-34.

Kricos, P. B., Erdman, S., Bratt, G. W., & Williams, D. W. (2007). Psychosocial correlates of hearing aid adjustment. Journal of the American Academy of Audiology, 18(4), 304-322.

Laplante-Lévesque, A., Hickson, L., & Worrall, L. (2010a). Factors influencing rehabilitation decisions of adults with acquired hearing impairment. International Journal of Audiology, 49(7), 497-507.

Laplante-Lévesque, A., Hickson, L., & Worrall, L. (2010b). A qualitative study of shared decision making in rehabilitative audiology. Journal of the Academy of Rehabilitative Audiology, 43, 27-43.

Law, M., Baptiste, S., & Mills, J. (1995). Client-Centred Practice: What Does It Mean and Does It Make a Difference? Canadian Journal of Occupational Therapy, 62(5), 250-257.

Law, M., & Mills, J. (1998). Client-centered occupational therapy. In M. Law (Ed.), Client-centered occupational therapy (pp. 1-18).

Law, M., Polatajko, H., Baptiste, S., & Townsend, E. (1997). Core concepts of occupational therapy (pp. 29–56): CAOT Publications ACE.

Ley, P. (1982). Satisfaction, compliance and communication. British Journal of Clinical Psychology, 21(4), 241-254.

Lo, R. (1999). Correlates of expected success at adherence to health regimen of people with IDDM. Journal of advanced nursing, 30(2), 418-424.

McCaul, K. D., Peters, E., Nelson, W., & Stefanek, M. (2005). Linking decision-making research and cancer prevention and control: important themes. Health Psychology 24(4S), S106.

McWilliam, C. L., Stewart, M., Del Maestro, N., Pittman, B. J., Brown, J. B., McNair, S., et al. (1997). Creating empowering meaning: an interactive process of promoting health with chronically ill older Canadians. Health promotion international, 12(2), 111-123.

Mead, N., & Bower, P. (2000). Patient-centredness: a conceptual framework and review of the empirical literature. Social science & medicine, 51(7), 1087-1110.

Mulrow, C., Aguilar, C., Endicott, J., Tuley, M., Velez, R., Charlip, W., et al. (1990). Quality-of-life changes and hearing impairment. A randomized trial. Annals of Internal Medicine, 113(3), 188-194.

Newman, C. W., & Weinstein, B. E. (1988). The Hearing Handicap Inventory for the Elderly as a measure of hearing aid benefit. Ear and Hearing, 9(2), 81-85.

Ng, S. L., Bartlett, D., & Lucy, S. D. (2012). Reflection as a Tool for Audiology Student and Novice Practitioner Learning, Development, and Self-Care. Seminars in Hearing, 33(02), 163-176.

Poost-Foroosh, L. (2012) Factors in the client-clinician interaction that are perceived to influence hearing aid adoption in first time hearing aid candidates and their rated importance by clients and clinicians. Doctoral dissertation, Western University, Canada. Retrieved from http://ir.lib.uwo.ca/cgi/viewcontent. cgi?article=1783&context=etd

Poost-Foroosh, L., Jennings, M. B., Shaw, L., Meston, C. N., & Cheesman, M. F. (2011). Factors in Client–Clinician Interaction That Influence Hearing Aid Adoption. Trends in Amplification, 15(3), 127-139.

Popelka, M., Cruikshanks, K., Wiley, T., Tweed, T., Klein, B., & Klein, R. (1998). Low prevalence of hearing aid use among older adults with hearing loss: the Epidemiology of Hearing Loss Study. Journal of the American Geriatrics Society, 46(9), 1075-1078.

Robinson, J. H., Callister, L. C., Berry, J. A., & Dearing, K. A. (2008). Patient-centered care and adherence: definitions and applications to improve outcomes. Journal of the American Academy of Nurse Practitioners, 20(12), 600-607.

Sabaté, E. (2003). Adherence to long-term therapies: evidence for action. Geneva, Switzerland: World Health Organization.

Say, R., Murtagh, M., & Thomson, R. (2006). Patients’ preference for involvement in medical decision making: a narrative review. Patient education and counseling, 60(2), 102-114.

Schön, D. A. (1987). Educating the reflective practitioner:Toward a new design for teaching and learning in the professions. San Francisco, CA: Jossey-Bass Inc.

Silberman, J., Tentler, A., Ramgopal, R., & Epstein, R. M. (2008). Recall-promoting physician behaviors in primary care. Journal of general internal medicine, 23(9), 1487-1490.

Stacey, D., Bennett, C. L., Barry, M. J., Col, N. F., Eden, K. B., Holmes-Rovner, M., et al. (2011). Decision aids for people facing health treatment or screening decisions. The Cochrane library(10).

Stark, P., & Hickson, L. (2004). Outcomes of hearing aid fitting for older people with hearing impairment and their significant others. International Journal of Audiology, 43(7), 390.

Stephens, D., & Hétu, R. (1991). Impairment, disability and handicap in audiology: towards a consensus. International Journal of Audiology, 30(4), 185-200.

Stern, M., Restall, M., & Ripat, J. (2000). The Use of Self-Reflection to Improve Client-Centered Processes. . In V. G. Fearing & J. Clark. (Eds.), Individuals in context : a practical guide to client-centered practice. Thorofare, NJ: SLACK Incorporated.

Stewart, M. (2003). Patient-centered medicine :transforming the clinical method (Vol. 2nd). Abingdon: Radcliffe Medical Press Ltd. Strawbridge, W., Wallhagen, M., Shema, S., & Kaplan, G. (2000).

Negative consequences of hearing impairment in old age: a longitudinal analysis. The Gerontologist, 40(3), 320-326.

van Dulmen, S. (2002). The key to good healthcare communication. Patient education and counseling, 46(4), 233-234.

Ventry, I. M., & Weinstein, B. E. (1982). The hearing handicap inventory for the elderly: a new tool. Ear and Hearing, 3(3), 128.

Weinstein, B. E. (1996). Treatment efficacy: hearing aids in the management of hearing loss in adults. Journal of speech and hearing research, 39(5), S37.

Winsor, D. A. (2011). Barriers and facilitators to hearing aid uptake in older females : a qualitative report. Unpublished MSc Thesis, University of British Columbia, Vancouver. Retrieved from http:// hdl.handle.net/2429/34892

World Health Organization. (2001). International classification of functioning, disability and health (ICF). Geneva. Retrieved from http://www.who.int/classifications/icf/en/