Promoting the Participation of Adults With Acquired Hearing Impairment in Their Rehabilitation

Abstract

The aim of this tutorial is to review approaches that promote client participation in health care. More specifically, client-centeredness, joint goal setting, and shared decision making are defined; their applications to the management of people with chronic health conditions, and more specifically acquired hearing impairment, are outlined; and the evidence for their effectiveness is described. Future directions in audiology clinical practice and research are proposed to re-solve whether such approaches can improve outcomes for people with acquired hearing impairment.

Full text

CONTRIBUTED PAPERS
Promoting the Participation of Adults
With Acquired Hearing Impairment
in Their Rehabilitation
Ariane Laplante-Lévesque, Louise Hickson, and Linda Worrall
University of Queensland
The aim of this tutorial is to review approaches that promote client participation
in health care. More specifically, client-centeredness, joint goal setting, and
shared decision making are defined; their applications to the management of
people with chronic health conditions, and more specifically acquired hearing
impairment, are outlined; and the evidence for their effectiveness is described.
Future directions in audiology clinical practice and research are proposed to re-
solve whether such approaches can improve outcomes for people with acquired
hearing impairment.
Chronic health conditions have reached “epidemic proportions” (Daar et al.,
2007, p. 494). They are of long duration, of slow progression, and include car-
diovascular diseases, chronic respiratory diseases, diabetes, and vision and hear-
ing impairments (World Health Organization, 2005). Although chronic health
conditions cannot be cured, their consequences can be minimized with self-man-
agement, that is, the adoption, modification, and/or maintenance of healthy be-
haviors (Lawn & Schoo, 2010; Newman, Steed, & Mulligan, 2004). Self-man-
agement refers to “the individual’s ability to manage the symptoms, treatment,
physical and psychosocial consequences and life style changes that are inherent
in living with a chronic condition” (Barlow, Wright, Sheasby, Turner, &
Hainsworth, 2002, p. 178). Client participation is central to the success of self-
management. Just as a person with diabetes can increase physical activity and
Ariane Laplante-Lévesque, Louise Hickson, and Linda Worrall, Communication Disability Cen-
tre, School of Health and Rehabilitation Sciences, University of Queensland.
Correspondence concerning this article should be addressed to Ariane Laplante-Lévesque, Com-
munication Disability Centre, School of Health and Rehabilitation Sciences, University of Queens-
land, Brisbane, Queensland, Australia 4072. Telephone: +61 7 3346 7453. Fax: +61 7 3365 1877.
E-mail: ariane@uq.edu.au
11
CONTRIBUTED PAPERS

12 JARA©XLIII 11-26 2010
decrease caloric intake to reduce diabetic complications, a person with hearing
impairment can use hearing aids, hearing assistance technology, and apply
knowledge obtained through a communication program to reduce hearing-related
activity limitations and participation restrictions (for a review, see Laplante-
Lévesque, Hickson, & Worrall, 2010c).
This article describes approaches that promote client participation, specifically,
client-centeredness, joint goal setting, and shared decision making. These ap-
proaches are defined and their applications to the management of people with
chronic health conditions, and more specifically acquired hearing impairment, are
outlined. Finally, clinical and research future directions are highlighted.
CLIENT-CENTEREDNESS
The terms client-centeredness, family-centeredness, patient-centeredness, per-
son-centeredness, and relationship-centeredness are commonly used to describe
health centeredness. In an effort to better understand the similarities and differ-
ences in the above terminologies, a review of their definitions, key elements, and
components revealed many common themes (Hughes, Bamford, & May, 2008).
As the different terms are very similar, a decision was made to use client-cen-
teredness here as an umbrella term to include all types of health centeredness.
Historically, client-centeredness was first used in psychotherapy (Rogers,
1946). It has been described as the clinician understanding the client as a unique
human being (Balint, 1969), as health professionals recognizing that client psy-
chology influences their practice (Tait, 1974), and as an alternative to disease-
centeredness or clinician-centeredness (Levenstein, McCracken, McWhinney,
Stewart, & Brown, 1986). It has strong roots in a biopsychosocial view of health
(Engel, 1977) and three major schools of ethical thought (consequentialist moral
theory, deontological theory, and virtue-based theory) all concluded that client-
centeredness is morally right (Duggan, Geller, Cooper, & Beach, 2006).
Although client-centeredness lacks a universal definition, the paradigm is typ-
ically described according to five dimensions: biopsychosocial perspective, client
as a person, shared power and responsibility, therapeutic alliance, and clinician as
a person (Mead & Bower, 2000). Client-centeredness takes a biopsychosocial
perspective, acknowledging that combined biological, psychological, and social
perspectives are required to understand health. The World Health Organization’s
International Classification of Functioning, Disability, and Health (2001) adopts
a biopsychosocial perspective. Seeing the client as a person refers to the impor-
tance of understanding his or her unique illness experience. Sharing power and
responsibility promotes an egalitarian client-clinician relationship and respects
the client’s expertise and autonomy. The therapeutic alliance refers to the funda-
mental importance of a good clinician-client relationship. Finally, the clinician as
a person recognizes the humanity of the clinician and its inherent influence on the
client-clinician relationship. According to a systematic review, interventions for

clinicians that aim to promote client-centeredness in consultations can success-
fully increase client-centeredness (Lewin, Skea, Entwistle, Zwarenstein, & Dick,
2009). But what do clients think of client-centeredness?
Clients value client-centeredness: general practice clients mentioned wanting
their clinicians to listen to them, communicate effectively, find common grounds,
and provide information on disease prevention and health promotion (Little et al.,
2001). When presented with two videos of medical consultations, one using a
biomedical approach (i.e., with a focus on the disease and clinician-driven deci-
sion making) and one using a client-centered approach, more clients preferred the
latter approach (Swenson, Zettler, & Lo, 2006). They described the client-cen-
tered clinician in the video as working with the clients, respecting them, and ex-
ploring their needs. Krupat and colleagues (2000) assessed dyads of clients and
clinicians’ preferences for client-centeredness and client satisfaction towards
their clinicians. Clients were satisfied with clinicians that either gave the same
amount of importance to client-centeredness as them or that gave more impor-
tance to client-centeredness than them. Similarly, Brody and colleagues (1989)
asked clients to complete questionnaires before and after a visit to the general
practitioner. Clients were most satisfied when their general practitioner valued
their perspectives and provided education and counseling. More importantly, this
finding was independent of the clients’ stated preference prior to the visit for a
general practitioner that values their perspectives and provides education and
counseling; both the clients who valued and those who did not value client-cen-
teredness beforehand reported greater satisfaction when their clinician used a
client-centered approach during the visit.
Client-Centeredness and Chronic Health Conditions
A review of the literature on client-centeredness with people with chronic
health conditions identified two particularly relevant components. First, eliciting
and discussing clients’ beliefs can promote intervention adherence and client sat-
isfaction (Michie, Miles, & Weinman, 2003). Prompting clients to discuss their
perspectives and being genuinely interested in their individual experiences of liv-
ing with chronic health conditions is essential. Second, facilitating client en-
gagement in the clinical encounter can promote long term self-management of the
health condition (Michie et al., 2003). Engaging the clients in actively taking
control of their health condition, for example by encouraging them to ask ques-
tions or take part in decisions, is also paramount. The clinician must recognize
the expertise of the clients living with chronic health conditions in order to
achieve this (Wilson, 1999).
Client-Centeredness and the Rehabilitation of Adults With Acquired Hearing
Impairment
Researchers, clinicians, and policy-makers involved in the rehabilitation of
adults with acquired hearing impairment have integrated aspects of the five di-
LAPLANTE-LÉVESQUE ET AL.: Promoting Client Participation 13

mensions of client-centeredness discussed by Mead and Bower (2000). For ex-
ample, Stephens provided much support for the use of a biopsychosocial ap-
proach in hearing rehabilitation (Stephens, 1996; Stephens & Hétu, 1991). The
biopsychosocial model of the World Health Organization (2001) and its earlier
versions are commonly applied in rehabilitative audiology (e.g., Abrams, McAr-
dle, & Chisolm, 2005; Chisolm, Abrams, & McArdle, 2004; Gagné, 1998; Gate-
house, 1994, 2001; Hickson & Scarinci, 2007; Hickson, Worrall, & Scarinci,
2007; Kramer, Allessie, Dondorp, Zekveld, & Kapteyn, 2005; Saunders,
Chisolm, & Abrams, 2005). The exploration of the client’s experience of hearing
impairment has been discussed to some extent in the rehabilitation of people with
hearing impairment, for example through the use of open ended questionnaires
(Barcham & Stephens, 1980) or through the discussion of the stigma attached to
hearing impairment (Hétu, 1996). The Ida Institute, a non-profit educational
Danish body, builds on this and provides audiologists with information and sup-
port to help guide people with hearing impairment towards successful rehabilita-
tion (Kirkwood, 2008). However, the literature on the other aspects of client-cen-
teredness described by Mead and Bower (2000), for example the sharing of
power and responsibility, the therapeutic alliance, and the clinician as person is
rather scarce.
Many authors have advocated for client-centeredness in audiology (see, e.g.,
Duchan, 2004; Erdman, Wark, & Montano, 1994) and the term client-centered-
ness has been used in several audiology publications. For example, rehabilitative
audiology was said to be “profoundly client-centered; the client reveals the
predicament, helps to evolve the management plan, and ideally, drives its imple-
mentation” (Hyde & Riko, 1994, p. 356) and to be a “client-oriented problem
solving process” (Danermark, 1998, p. 125). Wilkerson described a “person-cen-
tered analytic framework for outcome measurement” in rehabilitative audiology
(2000, p. 81) whilst Sweetow (1999) contrasted a professional-centered approach
to a client-centered approach when counseling hearing aid users. Borrowing
from Carl Rogers’ humanist perspective to psychology, Sweetow advocated that
the audiologist working in the client-centered approach should listen with con-
cern and empathy, provide unconditional positive regard, and counselor congru-
ence (genuineness). Furthermore, the client was described as “empowered to
make decisions (and) held responsible for decisions and outcomes” (Sweetow,
1999, p. 4).
The terminology of client-centeredness was also used in rehabilitative audiol-
ogy to describe an “approach to patient care, which openly recognizes the desires
of the patient and asks each of us to examine how these desires may best be hon-
ored as treatment is planned, initiated, and carried out” (Clark, 2007, p. 164). The
benefits of motivational interviewing with hearing aid candidates, described as “a
focused, goal-directed, patient-centered approach and counseling tool,” were
seen as reducing their ambivalence and increasing their willingness to obtain
14 JARA XLIII 11-26 2010

hearing aids (Beck, Harvey, & Schum, 2007). The potential application of rela-
tionship-centeredness to audiology, with its focus on the client-audiologist inter-
action, has also been raised (English, 2005).
JOINT GOAL SETTING
Joint goal setting refers to the client and the clinician sharing the power and re-
sponsibility by elaborating together meaningful objectives or desired outcomes,
events, or processes, either specifically relevant to the client’s current health sta-
tus or life goals (Austin & Vancouver, 1996; Naik, Schulman-Green, McCorkle,
Bradley, & Bogardus, 2005). The aims of rehabilitation goal setting identified in
the healthcare literature are to: (a) enhance the client’s autonomy; (b) improve re-
habilitation outcomes; (c) assess individualized rehabilitation outcomes; and (d)
provide information to stakeholders such as health service funders, quality audi-
tors, accreditation agencies, and professional bodies (Levack, Dean, Siegert, &
McPherson, 2006).
Goal setting can affect behaviors (Locke & Latham, 2002) and therefore joint
goal setting can enhance quality of care (Bogardus et al., 2004). However, focus
groups highlight that not all clients and clinicians wish to participate in goal set-
ting (Schulman-Green, Naik, Bradley, McCorkle, & Bogardus, 2006). Major rea-
sons clients and clinicians gave for not wanting to participate in goal setting in-
cluded limited time, health encounters focused on symptoms, perception of dis-
interest by the other party (clinicians believing that clients are not interested in
goal setting and vice-versa), and the view that all clients’ goals are similar.
Joint Goal Setting and Chronic Health Conditions
Joint goal setting has been used successfully in the management of chronic
health conditions, for example when helping diabetic clients achieve healthy be-
haviors (DeWalt et al., 2009). Clients with chronic health conditions naturally
develop goals but joint goal setting with clinicians can improve the likelihood of
these goals supporting effective self-management (Brown, Bartholomew, &
Naik, 2007). After setting goals, rehabilitation clients reported greater perceived
confidence in self-management (Wressle, Eeg-Olofsson, Marcusson, & Henriks-
son, 2002). Clients attending neurological rehabilitation who actively partici-
pated in goal setting also reported increased satisfaction with the rehabilitation
process (Holliday, Cano, Freeman, & Playford, 2007).
Joint Goal Setting and the Rehabilitation of Adults With Acquired Hearing
Impairment
Historically, the potential benefits of goal setting in rehabilitative audiology
were highlighted over 20 years ago (McKenna, 1987). Roberts and Bryant
(1992) identified three functions of goal setting in rehabilitative audiology: (a)
motivate the client to take an active role in their rehabilitation, (b) educate the
client to continue seeking information, and (c) evaluate progress towards goal
LAPLANTE-LÉVESQUE ET AL.: Promoting Client Participation 15

achievement. Later, research reports on behavioral intervention for adults with
acquired hearing impairment mentioned the use of individualized intervention
goals (Andersson, Melin, Scott, & Lindberg, 1995; Lindberg, Scott, Andersson,
& Melin, 1993). Stephens (1996) also described how goal setting could be used
in rehabilitative audiology. Subsequently, the importance of tailoring both the re-
habilitation interventions and the outcome measures according to goals achieved
prominence in the audiology literature (Cox et al., 2000; Gagné, 1998; Gagné,
Hétu, Getty, & McDuff, 1995; Gagné, McDuff, & Getty, 1999; Schow, 2001;
Stephens, Jaworski, Kerr, & Zhao, 1998).
Joint goal setting has since been used successfully in rehabilitative audiology.
The Client-Oriented Scale of Improvement (COSI; Dillon, Birtles, & Lovegrove,
1999; Dillon, James, & Ginis, 1997) asks clients to nominate up to five rehabili-
tation goals and to rate their perceived reduction in disability and resulting abil-
ity to communicate in these specific situations at the conclusion of rehabilitation.
It was the first goal setting tool that clinicians working with people with hearing
impairment widely integrated in their practices. The individualized nature of the
COSI has been generally appreciated by clients, as described by an audiologist:
“it gives the client some ownership over the rehabilitation program” (Dillon &
So, 2000, p. 3). Although designed more specifically as an outcome measure
tool, the Glasgow Hearing Aid Benefit Profile (GHABP; Gatehouse, 1999, 2000,
2001) can also be used for goal setting. More recently, Jennings (2009) success-
fully used Goal Attainment Scaling (goal set along with quantifiable attainment
levels) with 46 adults with hearing impairment participating in a group-based re-
habilitation program. The goals were set individually prior to rehabilitation. The
participants described each of their goals in terms of the environment in which
they occurred, the people involved, and how participants currently addressed
them. Participants also identified the extent to which they would like the goals
improved. Goal attainment was reviewed after rehabilitation completion and
6 months later. The use of the COSI is well established for joint hearing aid goal
setting and it has also been used for audiological interventions other than hearing
aids (see, e.g., Hickson et al., 2007). Jennings provides an in-depth description
of how joint goal setting can be applied to audiological interventions other than
hearing aids.
SHARED DECISION MAKING
Like joint goal setting, shared decision making is a component of client-cen-
teredness (Mead & Bower, 2000). Some of the other terms used to describe client
participation in intervention decision are informed decision making, client-clini-
cian partnership, concordance, evidence-based client choice, client autonomy,
client self-determination, active client participation, and client participation.
Decision making is best represented on a continuum, from sole clinician par-
ticipation at one end to total client participation at the other end. Three main ap-
16 JARA XLIII 11-26 2010

proaches to intervention decision making have been identified on this continuum:
paternalistic, shared, and informed (Charles, Gafni, & Whelan, 1997, 1999).
Shared decision making occupies the middle of the decision making continuum:
paternalistic decision making (clinician making the decision with little client par-
ticipation) is at one end and informed decision making (client making the deci-
sion with little clinician participation) is at the other end. In shared decision mak-
ing, or the middle position on the continuum, the information exchange, deliber-
ation, decision making, and intervention action are performed together by the
client and the clinician (Charles et al., 1997, 1999). It signifies involving clients
in decision making “to the extent that they desire” (Edwards & Elwyn, 2006,
p. 317).
Client participation in intervention decisions has two main advantages. First,
it respects the client’s right to autonomy and informed consent (Emanuel &
Emanuel, 1992; Lidz, Appelbaum, & Meisel, 1988). Second, it achieves better
intervention adherence and outcomes. A systematic review reported shared deci-
sion making to be particularly suitable for people with chronic health conditions,
when more than one intervention is available, and when the interventions require
more than one session (Joosten et al., 2008). Despite this, many barriers to shared
decision making exist.
Clinicians report barriers to shared decision making such as health system fac-
tors (e.g., time constraints), clinician factors (e.g., insufficient availability of in-
formation), and client factors (e.g., misconceptions about the health condition or
the intervention, high level of anxiety, or poor understanding of the information
conveyed by the clinician; Gravel, Légaré, & Graham, 2006). From the client’s
perspective, 52% of Americans reported preferring paternalistic decision making
(Levinson, Kao, Kuby, & Thisted, 2005) whilst 96% of Swedes reported prefer-
ring shared decision making (Rosén, Anell, & Hjortsberg, 2001). Such dispari-
ties in client preferences across studies may be attributed to methodological dif-
ferences. The former study surveyed the general population whilst the latter
study surveyed clients just after a medical visit when they may have been more
inclined to reflect on their preferences. Decision making preferences were deter-
mined differently in the two studies as well. The American study asked the par-
ticipants to rate their agreement with the statement ‘‘I prefer to leave decisions
about my medical care up to my doctor’’ and those who strongly agreed, moder-
ately agreed, or slightly agreed were deemed as preferring paternalistic decision
making. The Swedish study asked participants to complete the statement “If
there are alternative therapies, the choice of treatment should be made by . . .” and
those who answered “myself and the doctor who treats me but the doctor has the
deciding vote” or “myself and the doctor who treats me but I have the deciding
vote” were deemed as preferring shared decision making. The disparity in these
surveys’ results shows how preferences for shared decision making are influ-
enced by contextual factors such as recent experience with health care. Cultural
LAPLANTE-LÉVESQUE ET AL.: Promoting Client Participation 17

aspects may also come into play and demographic differences also exist in client
preferences for shared decision making. In general, younger clients, clients with
more years of formal education, and female clients are more likely to prefer par-
ticipation in health decisions (for a review, see Say, Murtagh, & Thomson, 2006).
It is still unclear whether the influence of age is indeed an age effect or rather a
cohort effect, with the new generation of older adults expected to prefer more par-
ticipation than their predecessors.
Understandably, clients want to be adequately prepared before participating in
health decision making. Prerequisites to shared decision making include knowl-
edge, explicit encouragement of client participation by the clinician, appreciation
of the client’s rights and responsibilities to play an active role in decision mak-
ing, awareness of choice, and sufficient time (Fraenkel & McGraw, 2007).
Client’s access to information is a fundamental part of shared decision making
and decision aids can provide information on the intervention options and their
benefits and limitations. Decision aids are “evidence-based tools designed to pre-
pare clients to participate in making specific and deliberated choices among
healthcare options in ways they prefer. Patient decision aids supplement (rather
than replace) clinician’s counseling about options” (O’Connor et al., 2009, p. 3).
A decision aid can take various forms such as a leaflet, a board, a poster, an audio
or audiovisual recording, or an interactive computer-based presentation. Deci-
sion aids are used by the client and the clinician to enable a systematic, consis-
tent, and unbiased presentation of the intervention options. They provide infor-
mation on the benefits and limitations of the available interventions and help
clients clarify their goals and values relevant to the health condition and the in-
tervention options so that their intervention decision is compatible with those.
Decision aids are important as inconsistencies in the presentation of intervention
options (e.g., introducing a bias in the option presentation or omitting the option
of no intervention or of deferring the decision) can intentionally or unintention-
ally direct the client towards a specific intervention (Ashcroft, Hope, & Parker,
2001; Elwyn, Edwards, Gwyn, & Grol, 1999; Wills & Holmes-Rovner, 2003).
Decision aids should provide accurate yet parsimonious information and individ-
ualized decision aids that adapt to each client’s situation have been advocated. A
systematic literature review on decision aid outcomes revealed that they improve
client knowledge of intervention options, facilitate decisions, and increase client
participation in decision making (O’Connor et al., 2009). The quality of decision
aids fluctuates greatly but decision aid standards are now available (Elwyn et al.,
2009). The standards can assist clinicians and researchers wishing to develop
their own decision aids.
Shared Decision Making and Chronic Health Conditions
Shared decision making appears particularly relevant to people with chronic
health conditions as these conditions require self-management through sustained
18 JARA XLIII 11-26 2010

behavior modifications (Paterson, Russell, & Thorne, 2001; Thorne, 2006). In
contrast with a person with an acute health condition, someone with chronic
health conditions does not make one single decision, but rather has recurrent de-
cisions to make (Garfield, Smith, Francis, & Chalmers, 2007; Montori, Gafni, &
Charles, 2006). Clients prefer participation in decisions pertaining to non-life
threatening health conditions and to behavioral decisions (Deber, Kraetschmer, &
Irvine, 1996; Say et al., 2006).
In terms of shared decision making outcomes for people with chronic health
conditions, clients with myocardial infarction who chose between group cardiac
rehabilitation and individual cardiac rehabilitation were more likely to complete
their rehabilitation program than clients who were randomly assigned to one of
the two rehabilitation programs (Wingham, Dalal, Sweeney, & Evans, 2006).
Similarly, clinically depressed clients who chose to pursue counseling achieved
better outcomes than their counterparts who were randomized to the same inter-
vention (Chilvers et al., 2001). The literature on diabetes also signals favorable
outcomes when clients are offered their preferred decision making role (Michie
et al., 2003; van Dam, van der Horst, van den Borne, Ryckman, & Crebolder,
2003). Similarly, if shared decision making was to be used with adults with ac-
quired hearing impairment, intervention adherence and outcomes may benefit.
Shared Decision Making and the Rehabilitation of Adults With Acquired
Hearing Impairment
Rehabilitative audiology has been described as a sequence of decisions (Hyde
& Riko, 1994). A person with hearing impairment faces many decisions on the
road to successful rehabilitation. The person decides to seek help, to pursue an
intervention, and to follow all the steps to successful implementation and main-
tenance of the intervention (Milhinch & Doyle, 1990). Little empirical evidence
on rehabilitative audiology decision making is currently available. A paternalis-
tic approach to decision making (clinician making the decision) has dominated
historically, however for Stephens, the decision making step is “a vital stage in
the rehabilitative process in which key decisions are made jointly between the
professionals and the hearing impaired people together with an input from Sig-
nificant Others (author’s own capitalization)” (1996, p. 61).
Shared decision making achieves particularly good outcomes with people with
chronic health conditions and when several interventions requiring more than one
session are available (Joosten et al., 2008). This is the case for adults with ac-
quired hearing impairment who have many possible audiological intervention op-
tions such as hearing aid fitting, other technological interventions, and commu-
nication programs. Meta-analyses and systematic reviews have confirmed the ef-
fectiveness of hearing aids as well as group and individual communication pro-
grams in reducing activity limitations and participation restrictions and increas-
ing quality of life (Chisolm et al., 2007; Hawkins, 2005; Sweetow & Palmer,
LAPLANTE-LÉVESQUE ET AL.: Promoting Client Participation 19

2005). Thus, better outcomes may be achieved if clients are made aware of all
intervention options, receive quality information in the form of decision aids that
highlight those, and are involved in shared decision making.
FUTURE DIRECTIONS
This article described approaches that promote client participation, specifi-
cally, client-centeredness, joint goal setting, and shared decision making. Re-
search evidence indicates that these approaches result in improved adherence and
outcomes for people with chronic health conditions. It is suggested here that
client participation may also be integrated in the rehabilitation process for adults
with acquired hearing impairment. Like other people with chronic health condi-
tions, people with hearing impairment require self-management through sus-
tained behavior modifications. For example, people with hearing impairment
constantly decide whether they will or will not use technical aids and communi-
cation strategies. Intervention adherence and successful intervention outcomes is
unlikely unless clients become active partners in their management program. Re-
habilitative audiologists should recognize the expertise of their clients and seek
to open their approaches to promote self-management. Borrowing approaches
from other disciplines that promote the participation of people with chronic
health conditions in the management of their conditions could enrich the services
offered to people with hearing impairment.
Research also needs to be undertaken to better understand how the various
components of client participation are currently being used by rehabilitative au-
diologists. Their acceptability, both by clients and clinicians, benefits, and limi-
tations must be formally investigated. For example, very little is currently known
about the client-audiologist relationship. Studies performed in other fields of
health, such as asking clients to describe and express their preferences for bio-
medical or client-centered consultations after viewing videos of clinical scenar-
ios using both approaches, should be conducted in rehabilitative audiology. How
client participation can be used to enhance the rehabilitation of adults with ac-
quired hearing impairment remains to be determined. For example, what are the
factors that clients take into account when making hearing rehabilitation deci-
sions? What information should rehabilitative audiology decision aids include?
What is the effect of client participation on rehabilitation outcomes?
A clinical trial currently underway at the University of Queensland in Bris-
bane, Australia, seeks to provide answers to some of these questions. The litera-
ture on intervention options for people with acquired hearing was reviewed (La-
plante-Lévesque, Hickson, & Worrall, 2010c) to inform the development of a de-
cision aid. The decision aid was used in a clinical trial of shared decision mak-
ing in rehabilitative audiology. A companion article in this journal describes the
shared decision making experiences of adults with acquired impairment in the
shared decision making clinical trial (Laplante-Lévesque, Hickson, & Worrall,
20 JARA XLIII 11-26 2010

2010b) whilst the factors influencing rehabilitation decisions of adults with ac-
quired hearing impairment has been published elsewhere (Laplante-Lévesque,
Hickson, & Worrall, 2010a). This latter publication also includes a copy of the
decision aid used.
CONCLUSION
Approaches that promote clients’ participation in their health such as client-
centeredness, joint goal setting, and shared decision making hold promise for the
rehabilitation of people with acquired hearing impairment. During an initial
client-audiologist encounter, most of the time is typically devoted to instrumen-
tal assessment and intervention implementation, at the expense of history taking
and discussion of assessment results and intervention options (Doyle, 1994). Al-
though the importance of the hearing impairment assessment should not be over-
looked, increased client participation, for example via client-centeredness, joint
goal setting, and shared decision making, constitutes a more holistic approach
that respects the client as a person and that may hold promise to improve the qual-
ity of life of these people. Successful client participation calls for an evolution of
the client-clinician relationship from a paternalistic to a collaborative association.
ACKNOWLEDGEMENTS
The first author acknowledges the financial support of the Australian Department of Education,
Science, and Training.
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