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International Journal of Audiology

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Application of the transtheoretical model of behaviour change for identifying older clients’ readiness for hearing rehabilitation during history- taking in audiology appointments

Katie Ekberg, Caitlin Grenness & Louise Hickson

To cite this article: Katie Ekberg, Caitlin Grenness & Louise Hickson (2016) Application of the transtheoretical model of behaviour change for identifying older clients’ readiness for hearing rehabilitation during history-taking in audiology appointments, International Journal of Audiology, 55:sup3, S42-S51, DOI: 10.3109/14992027.2015.1136080

To link to this article: http://dx.doi.org/10.3109/14992027.2015.1136080

© 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

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International Journal of Audiology 2016; 55: S42–S51

Original Article

Application of the transtheoretical model of behaviour change for identifying older clients’ readiness for hearing rehabilitation during history-taking in audiology appointments

Katie Ekberg1, Caitlin Grenness2,3 & Louise Hickson1,2

1School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia, 2HEARing Cooperative Research Centre, and 3Department of Audiology and Speech Pathology, The University of Melbourne, Melbourne, Australia

Abstract Objectives: The transtheoretical model (TTM) of behaviour change focuses on clients’ readiness for adopting new health behaviours. This

study explores how clients’ readiness for change can be identified through their interactions with audiologists during history-taking in

initial appointments; and whether clients’ readiness has consequences for the rehabilitation decisions they make within the initial

appointment. Design: Conversation analysis (CA) was used to examine video-recorded initial audiology appointments with older adults

with hearing impairment. Study sample: The data corpus involved 62 recorded appointments with 26 audiologists and their older adult

clients (aged 55+ years). Companions were present in 17 appointments. Results: Clients’ readiness for change could be observed through

their interaction with the audiologist. Analysis demonstrated that the way clients described their hearing in the history-taking phase had

systematic consequences for how they responded to rehabilitation recommendations (in particular, hearing aids) in the management phase

of the appointment. In particular, clients identified as being in a pre-contemplation stage-of-change were more likely to display resistance to

a recommendation of hearing aids (80% declined). Conclusions: The transtheoretical model of behaviour change can be useful for helping

audiologists individualize management planning to be congruent with individual clients’ needs, attitudes, desires, and psychological

readiness for action in order to optimize clients’ hearing outcomes.

Key Words: Audiology; hearing rehabilitation; behaviour change; transtheoretical model;

clinician-client communication; patient-centred care; conversation analysis

Introduction

Despite the increasing incidence of hearing impairment (HI) among

the older population, as compared to younger adults, audiologists

often encounter reluctance to seek professional help (Meyer &

Hickson, 2012). Further, many older adults who do have their

hearing tested do not subsequently go on to obtain hearing aids

(Meyer et al, 2011). A recent study found that only just over half of

clients who were recommended hearing aids within an initial

audiology appointment made a commitment to obtain them within

that appointment (Grenness et al, 2015a). There is also an under-

utilization of hearing aids among those who have been fitted with

them (Chien & Lin, 2012; Gopinath et al, 2011; Hartley et al, 2010).

These findings highlight that help-seeking is not synonymous with a

readiness for obtaining and using hearing aids. Older adults who

attend audiology appointments to have their hearing tested cannot

universally be assumed to be psychologically ready for hearing aids

(Claesen & Pryce, 2012). They may be attending only to appease

others, may not have considered hearing aids as a treatment option,

or may consider hearing aids an undesirable option. For such

clients, the decision to go ahead with hearing rehabilitation,

particularly acquiring hearing aids, requires a major shift in

attitudes and behaviour.

Models of health behaviour change can be useful for exploring

how people make decisions to change health-related behaviours.

One particular model, the transtheoretical model (TTM), views

behavioural change as a process that occurs across a number of

stages, rather than being a discrete event (Prochaska et al, 2009). In

viewing behaviour change as a process, the model focusses on an

individual’s current attitudes, behaviours, and intentions to assess

his/her readiness for change. This model can thus be useful for

Correspondence: Katie Ekberg, Communication Disability Centre, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Queensland, 4072,

Australia. E-mail: k.ekberg@uq.edu.au

(Received 14 July 2015; revised 8 December 2015; accepted 21 December 2015)

ISSN 1499-2027 print/ISSN 1708-8186 online � 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article

distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and

reproduction in any medium, provided the original work is properly cited.

DOI: 10.3109/14992027.2015.1136080

examining the psychological readiness of clients for hearing

rehabilitation when they attend an initial audiology appointment.

The model has identified five key stages that an individual will

move through in changing their behaviour (although not necessarily

occurring in a linear manner). These stages include: (1) pre-

contemplation (problem denial or lack of awareness); (2) contem-

plation (awareness of problem); (3) preparation (intention to change

behaviour); (4) action (overt behaviour modification); and (5)

maintenance (sustained behaviour change). The model purports that

individuals who are in the later stages of change are more likely to

succeed at help-seeking, intervention uptake, and adherence. There

are three other key constructs in the model, including: decisional

balance (the pros and cons of changing); self-efficacy; and

processes of change. However, the current paper is focused on

identifying clients’ stage-of-change. This model has successfully

been applied to various health behaviours including smoking

cessation, dieting, depression and anxiety, HIV prevention, sun

exposure, and medication compliance (for reviews see Hall &

Rossi, 2008; Prochaska et al, 2009).

The TTM has also been applied within audiology as a way of

exploring clients’ readiness for hearing rehabilitation (e.g. Babeu et

al, 2004; Laplante-Lévesque et al, 2012, 2013, 2015; Milstein &

Weinstein, 2002; Raymond & Lusk, 2006; van den Brink et al, 1996).

Babeu et al (2004) described how the different stages of readiness for

change can be applied to the audiological rehabilitation setting. For

example, a client in the pre-contemplation stage would be unaware,

or not yet concerned about, problems with hearing loss (Babeu et al,

2004). They may feel that their hearing is fine or that they only have

mild difficulties in some situations. Any hearing difficulties they may

have might be attributed to environmental factors or third parties (e.g.

people who mumble or speak too softly). They would, therefore, be

likely to believe that audiological assistance is unnecessary. In the

contemplation stage, clients would be aware of a hearing loss and be

beginning to have concerns. They would be open to considering

options towards hearing rehabilitation. At the preparation stage the

client would indicate a readiness to make changes. These clients

would be likely to have sought help for their hearing and already

thought about hearing rehabilitation options. Then clients at the

action stage would take the actual steps toward a commitment to

hearing rehabilitation (e.g. purchasing hearing aids and/or agreeing

to adopt new communication strategies). In the last stage, mainten-

ance, the client would have integrated their hearing rehabilitation

into their life (e.g. sustained use of hearing aids / assistive listening

devices, applying self-advocacy strategies).

This model has been shown to have validity in the audiology

setting (Laplante-Lévesque et al, 2012, 2013, 2015). In particular,

measurement of the pre-contemplation stage has been shown to

have the best concurrent and predictive validity of intervention

uptake and outcomes. In a study by Laplante-Lévesque et al (2012),

participants who scored highly on pre-contemplation reported less

successful intervention outcomes, whereas those who scored highly

on action were more likely to have taken up hearing intervention at

six months follow-up. The study concluded that measuring clients’

stage-of-change could help audiologists identify clients that are

likely to require a different clinical approach. However, they also

concluded that the 24-item University of Rhode Island Change

Assessment (URICA) used in the study was unlikely to be useful for

application in clinical settings because of its length. Thus, while

previous studies have demonstrated that a client’s readiness for

hearing rehabilitation is an important aspect for consideration

during initial audiology appointments, testing their stage-of-change

may be difficult in the time-pressured clinic environment. These

findings raise the question as to whether clients’ readiness for

change can be identified through standard clinical interactions with

audiologists within their initial appointments rather than under-

taking additional tasks. That is, whether clients’ stage-of-change be

recognized through clients’ verbal and nonverbal communication.

This study explores the aforementioned question through an

analysis of 62 video-recorded initial audiology appointments with

older adults. The paper aims to examine: (1) how clients’ readiness

for change can be observed within the history-taking phase of the

appointment; and (2) whether this perceived readiness has conse-

quences for their rehabilitation decisions in the management phase

of the appointment.

Materials and methods

Participants and procedure

The current study is part of a broader project that used two types of

interaction analysis (Roter Interaction Analysis System (RIAS) and

Conversation Analysis (CA)) to profile and examine video-recorded

audiology appointments with older adults with age-related hearing

impairment. The data for this study involved a corpus of 62 video-

recorded initial hearing assessment audiology appointments, col-

lected during 2011–2013. In this data set, participants are both

audiologists (n ¼ 26) and adult clients, aged 55 years and over

(n¼ 62). The age bracket of 55 years or older was a pragmatic cut

off for recruitment reasons. In addition, in Australia, those over the

age of 55 are more likely to be retired, or semi-retired and therefore

potentially have differing motivations and readiness of younger and

middle-aged adults. Audiologists who worked in adult hearing

rehabilitation settings were invited to participate in this study. After

audiologist consent was obtained, clients who fitted the inclusion

criteria (over the age of 55 and attending this audiologist for the first

time) were also invited to participate by having their audiological

consultation filmed. All participants provided signed consent with

no form of reimbursement. Participating audiologists had clinical

experience ranging from 1 to 40 years and 61% were female; clients

were 71.6 years of age, on average (SD 8.9) and 58% were male

(Grenness et al, 2015a,b).

Filmed appointments were restricted to those that involved a

hearing assessment and a discussion about hearing rehabilitation

options; or a follow-up appointment where results and rehabilitation

options had not been discussed during the first appointment (that is,

where the first appointment involved hearing screening or diagnos-

tic testing only). Filming was conducted using an Apple iPhone 4 or

iPod touch on a mini tripod without the researcher in the room.

After filming, the consultation was uploaded onto a computer. For

the analysis reported in this study, consultations were transcribed

verbatim with additional notations (as discussed below in analysis).

Consultations had an average duration of 57.8 minutes (SD 20.3)

wherein the history-taking phase took 8.8 minutes (SD 4.3) on

average and 29.0 minutes (SD 18.6) were spent discussing results

and management planning (Grenness et al, 2015a,b). Audiologists

Abbreviations

URICA University of Rhode Island Change Assessment

CA Conversation analysis

HI Hearing impairment

SDT Self-determination theory

TTM Transtheoretical model of behaviour change

Older clients‘ readiness for hearing rehabilitation 43

recommended rehabilitation in 83% of consultations where the

presence of hearing loss was identified during the appointment

(based on audiometric thresholds or presence of significant hearing-

related impairment), and all of these recommendations included

discussion of hearing aids. Alternative rehabilitation options (e.g.

hearing-assistive technology, group or individual communication

classes) were recommended in 8% of consultations, and only if the

client had already decided against hearing aids (Grenness et al,

2015a). Further information regarding participants’ characteristics

and the procedure for data collection can be found in Grenness et al

(2015a,b). This study was approved by the Royal Victorian Eye and

Ear Hospital, The University of Queensland Behavioural and Social

Sciences Ethical Review Committee, and Australian Hearing

Human Research Ethics Committee, and adhered to the principles

of the National Health and Medical Research Statement on

Research Involving Human Subjects.

Data analysis

The video data were transcribed using the Jeffersonian transcription

system (Jefferson, 2004) to include micro-details of the interaction

which have been found to be consequential for how participants

understand conversation (see Appendix 1 for transcription nota-

tions). The data were analysed using conversation analysis (CA).

CA focuses on, and provides conventions for, the analysis of talk as

a vehicle for social action (Drew et al, 2001; Drew & Heritage,

1992; Heritage & Maynard, 2006). CA is a well-established

approach for studying communication in a range of healthcare

settings (Pilnick et al, 2009). Studies of healthcare interaction have

revealed the ways in which clinicians and clients accomplish

interactional tasks such as diagnosing, recommending, and respond-

ing to treatment, and address various interactional issues and

dilemmas that arise as they undertake these tasks (Pilnick et al,

2009). This method has also been used in previous research of

communication in audiology appointments, including family

involvement in appointments, and how audiologists address clients’

concerns regarding hearing aids (Ekberg et al, 2014a,b, 2015).

During the history-taking phase of the appointment, clients’

responses to audiologists’ questions were analysed for how they

described their hearing difficulties. It was identified that clients’

responses during history-taking clearly matched the key descrip-

tions of one of the stages-of-change. Further systematic analysis of

the whole corpus was conducted by the lead author (KE) to code

each client into a stage-of-change based on the descriptions of their

hearing difficulties during history-taking. At the beginning of the

audiology appointment, during history-taking, clients could poten-

tially be in one of three stages-of-change according to the TTM:

pre-contemplation, contemplation, or preparation (clients may

progress to the action stage by the end of the appointment if they

decide to obtain hearing aids). Analysis of clients’ responses during

history-taking demonstrated that their stage-of-change could be

observed through the way they described their hearing difficulties.

Some clients displayed an awareness of their hearing difficulties

and attributed their problems to a decline in their own hearing.

Across the history-taking interaction, these clients could be

identified as being at the ‘contemplation’ stage-of-change. Some

clients additionally mentioned an intention to obtain hearing aids,

and could be identified as being in the ‘preparation’ stage-of-

change. Other clients tended to deny or play down their problems,

and attributed any difficulties they were having to third parties or

environmental factors. From the responses of these clients, they

could be identified as being in a ‘pre-contemplation’ stage-of-

change. Once the history-taking phase of each appointment had

been coded, the management phase of the appointment was

analysed for how clients’ responded to rehabilitation recommenda-

tions. Transcript fragments are presented in the results section

(‘A’¼ audiologist; ‘C’¼ client; and ‘F’¼ family member).

Results

Of the 62 video-recorded appointments, hearing aids were formally

recommended in 79% (n¼ 49) of the assessment appointments. Of

these appointments, 61% (n¼ 30) of clients made a commitment

within the appointment to obtain hearing aids and 39% (n¼ 19)

declined hearing aids or decided they needed more time to think

about them. In the remaining 21% of consultations, no recommen-

dation of hearing aids was made as clients experienced no self-

reported hearing impairment; no hearing loss was diagnosed; or the

level of hearing loss was not deemed appropriate for hearing-aid

fitting (according to the minimum loss threshold criteria of a three

frequency average�23 dB).

Conversation analysis of the history-taking phase of the

appointments identified 27% of clients to be in a pre-contemplation

stage-of-change (n¼ 17), 65% of clients to be in a contemplation

stage-of-change (n¼ 40), and 8% (n¼ 5) of clients to be in a

preparation stage-of-change.

Analysis also demonstrated that how clients described their

hearing in the history-taking phase had systematic consequences for

how they responded to rehabilitation recommendations (in particu-

lar, hearing aids) in the management phase of the appointment.

‘Pre-contemplation’ clients were much more likely to display

resistance to a recommendation of hearing aids. In particular, of

those clients who were identified as being in ‘pre-contemplation’

and were subsequently recommended hearing aids, 80% declined

(n¼ 8/10). The two clients who did go ahead with hearing aids

agreed to ‘‘trial’’ the fully-subsidized, Government-funded devices.

Conversely, 71% (n¼ 24/34) of clients identified as being in the

contemplation stage, and 80% (n¼ 4/5) of clients identified as

being in the preparation stage agreed to obtain hearing aids when

offered them. These clients thus successfully transitioned to the

action stage across their appointment. These results are presented in

Table 1.

The following three sections will analyse, in detail, five

examples that were typical of the corpus for how clients displayed

their readiness for change, and the consequences it had for the

management phase of the appointment.

Client displays ‘pre-contemplation for change’

There were appointments where clients revealed that they were

unaware of, or not concerned about any hearing difficulties, and this

had consequences for their responses to rehabilitation recommen-

dations later on. Fragments (1a) and (1b) provide an example:

44 K. Ekberg et al.

In Fragment (1a), in response to the audiologist’s history-taking

question, the client denies noticing any hearing difficulties. She

states that her husband thinks she has hearing loss (line 4), which is

confirmed by her husband in overlap (lines 5 and 7). The client’s

turn is marked with several indications of providing a dispreferred

response to the audiologist’s question: it is slightly delayed, and

contains a turn-initial ‘well’, followed by a sentential response to a

yes/no question (Heritage & Raymond, 2010; Pomerantz, 1984).

Later, when asked directly whether she has noticed hearing loss

herself, the client shakes her head (line 10). This lack of awareness

or concern about her hearing problem would suggest that perhaps

the client may still be in the pre-contemplation stage-of-change.

These displayed beliefs about her hearing have consequences for the

management phase of the appointment, when hearing aids are

recommended:

In Fragment (1b), after providing a diagnosis of mild hearing

loss, the audiologist suggests hearing aids to the client at lines 1–3.

The client responds that ‘no’ she does not really see hearing aids as

an option for her (lines 4 and 6). The client’s rejection of the

recommendation is produced as an immediate, flat ‘no’ response.

When the audiologist begins to take another turn, the client again

responds with a ‘no’ (line 6). Following this response from the

client, the interaction soon comes to a close and the client leaves

without taking any action toward hearing rehabilitation. Fragment

(1b) demonstrates how clients reserve themselves the right to reject

hearing aids when they do not feel ready for them. Fragments (2a)

and (2b) provide another example from another client:

In Fragment (2a), during the history-taking phase, the client

expresses that she is not too concerned with her hearing (line 3),

launching her turn with an emphatic ‘no not a lot’. As in Fragment

(1a), her response is marked with interactional indications of

dispreference (Pomerantz, 1984). She provides an elongated

hesitancy marker ‘mmm::::::’ followed by a ‘no’ response and an

account for her low concern. She mentions a mild difficulty in

situations of background noise (lines 4–5), playing down her

difficulty with the minimizer ‘a bit’. She also attributes troubles

with hearing to her granddaughter mumbling and talking ‘very low’

(lines 6–7), but follows on to describe it as ‘not a big problem’. To

authenticate her account, the client then provides an example of a

situation where she can hear very well (lines 14–17). The client’s

responses here display low concern about her hearing difficulties,

thus suggesting that she may be in the pre-contemplation stage-of-

change. Again, the client’s opinions displayed during the history-

taking phase can be seen to be consequential for how she responds

to recommended treatment in the management phase (Fragment

(2b) below):

Fragment (2b) follows a diagnosis of mild-moderate hearing

loss. Across lines 1–7, the audiologist suggests hearing aids would

be beneficial and asks the client if this is something she has

thought about doing. The client responds that hearing aids are not

something she has thought about (line 6), and not something

she’s interested in unless ‘she really has to’ (line 8). The audiologist

progresses to provide some further information about hearing

aids and suggests the client do a trial (omitted from transcript).

She then asks the client again if that’s something she would like to do.

The client provides several further resistive responses across lines

15–22, stating that she is not keen, does not feel she needs one, and

that she can hear. It is interesting that she repeats the phrase ‘I can

hear’ which she had originally said to the audiologist during the

history-taking phase (see line 19 of Fragment (2a)). The client’s turns

are littered with interactional indications of resistance as

well: delaying devices such as elongated ‘u:::m’s, intra-turn pauses,

cut-offs, and re-starts. Again, in this example, the client leaves

Table 1. Results of coding clients according to stage-of-change.

Stage-of-change Total number of clients Clients offered no rehab Clients offered hearing aids Clients who accepted hearing aids

Pre-contemplation 17 27% 7 41% 10 59% 2 20%

Contemplation 40 65% 6 15% 34 85% 24 71%

Preparation 5 8% 0 0% 5 100% 4 80%

Total 62 100% 13 21% 49 79% 30 61%

Older clients‘ readiness for hearing rehabilitation 45

without hearing aids or without taking up any other hearing

rehabilitation.

Fragments (3a) and (3b) provide another example of a client

displaying an awareness of some possible hearing difficulties but

playing them down and attributing blame to others for the

difficulties they tend to experience.

In Fragment (3a), the client’s account of her hearing difficulties

here is similar to the one seen in Fragment (2a). In response to the

audiologist’s history-taking question (lines 1–2), the client provides

one situation in which she is having difficulty - hearing movies on

the TV. Her turn has markers of a dispreferred response, however.

She begins her turn with ‘well’, followed by an ‘um’, and an intra-

turn pause, which all act to delay her response (Pomerantz, 1984).

She then follows this admission by stating that she typically blames

her troubles on the actors muttering and mumbling. She continues

to explain that her family members point out her hearing difficulties,

but again she feels they are not speaking clearly (lines 7–10). In

a similar way to Fragment (2a), the client authenticates her account

that her difficulties are due to people mumbling by proclaiming that

there are some movies she ‘can hear well’ (lines 12 and 14). So again,

here we can see the client attributing her hearing difficulties to

a particular situation and blaming third parties for her troubles.

The client’s account here thus suggests she may still be at the

pre-contemplation stage-of-change. And again, in this appointment,

the client’s attitude towards her hearing has consequences for

how she responds to a recommendation for hearing aids. Fragment

(3b) occurs after testing and a diagnosis of mild-moderate hearing

loss.

At lines 1–2 of Fragment (3b), the audiologist asks the client

how she feels about hearing aids. After a lengthy 1.5 second gap in

the interaction, the client responds ‘not much’ followed by a sigh

(line 4). Both the content and the construction of her turn indicate

resistance to the recommendation. She then goes on to account for

her resistance towards them with a recollection that her husband

always fiddled with his, and she’d not heard anyone speak highly of

their benefits. In this appointment, after further discussion about

hearing aids and further resistance from the client, she agrees to go

away and think about hearing aids but does not commit to any

hearing rehabilitation at this stage.

Client displays ‘contemplation for change’

Fragment (4a) provides an example of a client displaying awareness

of her hearing loss:

The audiologist delivers an opening question to the client, asking

what has brought her into the clinic (line 1). The client makes an

explicit disclosure of ‘being deaf’ (line 2). In this opening sequence,

the client, therefore, appears to be aware of her hearing difficulties,

and attributes the problem to her own hearing rather than any

environmental factors. Following Fragment (4a), the client provides

some details of the difficulties she is having, including with hearing

the TV and hearing people when they are not looking at her.

Fragment (4b) occurs 2 minutes later:

Here, at lines 1–2, the client concludes that she has attended

the appointment to see if anything can be done about her hearing.

She also reasserts her awareness of her hearing loss at lines 10 and

12, with emphatic ‘Oh yes’ and ‘Yes definitely’ responses to the

audiologist. Within this opening history-taking sequence, the client

has thus indicated that she is: (1) aware of her problems with

hearing; and (2) open to exploring what options might be available

to help her hearing. The interaction here suggests that the client

would be at the contemplation stage-of-change. She does not

mention an explicit intention to go ahead with hearing rehabili-

tation in the appointment (suggesting she is not quite yet in the

preparation stage), but does display a desire to explore ‘whether

anything can be done’. The opening interaction thus suggests that

she would be open to being offered hearing rehabilitation options

if her tests showed that she did indeed have hearing loss.

Fragment (4c), below, follows the client’s testing and diagnosis of

mild-moderate hearing loss, with the audiologist making a

recommendation for hearing aids:

Across the audiologist’s recommendation for hearing aids, the

client provides ongoing acknowledgements (‘mmhm’). Then, in

46 K. Ekberg et al.

response to the audiologist’s question about whether she would like

to talk further about the types of hearing aids available, the client

provides a clear ‘Yes’ response (line 13). Following this sequence,

the interaction progresses into the discussion about hearing-aid

options, and the client leaves the appointment having ordered two

hearing aids and booking her fitting appointment. These three

fragments provide an example of a client who has displayed, within

her interaction with the audiologist, both an awareness of her hearing

difficulties and an openness to explore options for change, who then

takes action toward hearing rehabilitation within the appointment.

Client displays ‘preparation for change’

Clients identified in the preparation stage-of-change displayed an

explicit intention to take action towards hearing rehabilitation

within the history-taking phase of the appointment. Fragment (5a)

provides an example:

In response to the audiologist’s initial history-taking question

(lines 1–2), the client explicitly orients to an intention to take action

toward hearing rehabilitation, in this case obtain hearing aids

(line 3). She also expresses that she has been aware of hearing

difficulties for a long period (‘five to six years’, line 8). The client’s

responses to these two questions suggest that she would be in the

‘preparation’ stage-of-change, and would, therefore, be open to

being offered hearing rehabilitation options if diagnosed with a

hearing loss. Analysis of the ‘management’ phase of this appoint-

ment can shed light on whether this was the case. Fragment (5b)

occurs after the completion of audiometric testing where the client

is diagnosed with a mild hearing loss:

The audiologist provides an explanation of the client’s hearing

loss across lines 1–11. Rather than just acknowledging the diagnosis

in response, the client provides an assessment that she must,

therefore, need some kind of hearing rehabilitation. The client thus

displays her readiness to take action by initiating a discussion about

rehabilitation before the audiologist has even made a recommen-

dation. The interaction progresses to a discussion about hearing

options for the client, and the client chooses to obtain hearing aids

within the appointment. Fragment (5b) thus provides an example of

a client who displayed an intention to take action toward hearing

rehabilitation in the history-taking phase, and subsequently made

the decision to obtain hearing aids in the management phase of the

appointment.

Discussion

Previous studies have demonstrated that a client’s readiness for

hearing rehabilitation is an important aspect for consideration

during initial audiology appointments (Babeu et al, 2004; Laplante-

Lévesque et al, 2013, 2015). However, testing clients’ stage-of-

change in time-pressured appointments may not always be achiev-

able (Laplante-Lévesque et al, 2013). Analysis of these videoed

appointments has demonstrated how clients’ stage-of-change can be

observed through their responses to history-taking questions within

the initial minutes of the appointment.

Application of the TTM to audiologist-client interactions

The audiology appointments in this study were the first time that

rehabilitation options had been discussed between the audiologist

and adult client; that is, clients were yet to take any overt or recent

action towards hearing rehabilitation prior to the appointment. As

the action stage-of-change typically refers to the point where overt

behaviour modification occurs, all of the clients were thus identified

as being in one of the first three stages-of-change at the beginning

of the appointment: pre-contemplation; contemplation; or prepar-

ation. Within the corpus, a small number of clients displayed an

explicit intention to take action toward hearing rehabilitation within

the history-taking phase. These clients could be identified as being

in the preparation stage-of-change (this intention to take action at

the beginning of the appointment is distinguished from the actual

commitment to order hearing aids at the end of the appointment,

hence clients being categorized as in ‘preparation’ at this point,

rather than ‘action’). Other clients displayed an awareness of their

hearing difficulties, and attributed these problems as being due to a

decline in their own hearing. These clients could be identified as

being at the contemplation stage-of-change. Another group of

clients tended to deny or minimize their problems, displayed low

concern, and attributed any difficulties they were having to third

parties or environmental factors. The way these clients described

their hearing loss was indicative of the pre-contemplation stage-of-

change. Systematic analysis of the corpus showed that clients’

displayed attitudes toward their hearing (observed during history-

taking) have consequences for how they respond to rehabilitation

recommendations in the management phase of the appointments. In

particular, it appears that the recommendation of hearing aids to

clients in the pre-contemplation stage is likely to be received with

resistance. This was the case even when clients were eligible for

fully-subsidized, Government-funded devices. On the other hand,

those clients identified as being in the contemplation or preparation

stages-of-change were much more likely to transition to the action

stage by the end of the appointment and commit to obtaining

hearing aids.

Practical implications for identifying clients’ stage-of-

change during history-taking

Based on the findings from this study, there are some key features

of clients’ talk that can indicate that they are still in a pre-

contemplation stage-of-change in regards to hearing rehabilitation.

In particular, the client may:

� play down the impact of their hearing difficulties on their

everyday life;

� display low concern for their hearing difficulties;

Older clients‘ readiness for hearing rehabilitation 47

� provide self-initiated examples of situations where they can

hear well;

� attribute blame for hearing difficulties to third parties (e.g.

family members mumbling, or speaking softly), or situational

factors (e.g. background noise);

� utilize interactional devices for displaying a dispreferred

response when responding to history-taking questions, includ-

ing delaying devices (e.g. ‘um’, turn-initial ‘well’, intra-turn

pauses, cut-offs, and re-starts).

The results from this study emphasize the importance of

audiologists building a full and complete history with their clients.

As described by Grenness et al, (2015b), many audiologists

commonly commence the history with a closed-ended question,

interrupt clients’ response and give few opportunities for clients’ to

lead the direction of the discussion. This history-taking strategy is

unlikely to reveal clients’ stage-of-change to the audiologist. Thus,

an opportunity is missed for the audiologist to tailor their

management to the client’s individual needs. Audiologists may be

able to more readily identify a client’s readiness for change by using

open history-taking questions that allow the client to describe their

hearing difficulties in their own words. An open history-taking style

is also in line with principles of patient-centred care (Grenness et al,

2014a,b).

Clinical implications for optimizing clients’ hearing

rehabilitation

The findings also suggest that, for clients who appear to be in the

pre-contemplation stage-of-change, it may not be the most effective

strategy for audiologists to immediately progress to a recommen-

dation of hearing aids. Clients in a pre-contemplation stage-of-

change overwhelmingly resisted a recommendation of hearing aids.

The TTM describes the ‘processes of change’ that people engage in

to progress through the stages of change. The model suggests that,

for clients at the pre-contemplation stage-of-change, health practi-

tioners should focus on making changes to how the individual

thinks and feels about the health behaviour (i.e. cognitive-affective

processes) (Babeu et al, 2004). Thus, in order for these clients to

take steps toward hearing rehabilitation, it might be more effective

for the audiologist to be more flexible in the management phase of

the appointment, and focus more broadly on awareness-raising and

broader discussions about age-related hearing loss and other forms

of communication assistance. Further, it may be particularly

important to individualize information provision for these clients

(Grenness et al, 2014a). Along similar lines, self-determination

theory (SDT) would suggest that clients are more likely to adopt and

adhere to new health treatments if they have a sense of autonomous

motivation to do so (Ng et al, 2012; Ryan et al, 2008). In support of

this theory, a recent study found that autonomous motivation was

associated with hearing-aid adoption (Ridgway et al, 2015).

Clinicians can facilitate client autonomy by providing relevant

information and meaningful rationales for change, without applying

external pressures that detract from a sense of client choice and

agency (Ryan et al, 2008). This means that clinicians are

encouraged to support clients as they explore resistances and

barriers to change.

The use of a decision aid (see Laplante-Lévesque et al, 2010a) can

be beneficial for further exploring clients’ feelings about different

rehabilitation options, including pursuing no intervention, and thus

help audiologists to tailor interventions to suit clients’ degree of

readiness for change. These clients may value being offered a choice

of rehabilitation options, including participating in individual or

group communication programs (Laplante-Lévesque et al, 2012).

Motivation tools such as those developed by the Ida Institute may

also help clients to reflect on their degree of readiness for change

(Clark, 2010). Clients who feel pressured or distrustful of the

audiologist’s agenda within an appointment may be hesitant to return

in the future (Grenness et al, 2014a). They would also be unlikely to

recommend audiologists to others in their network. On the other

hand, taking a patient-centred approach with these clients may

facilitate the building of a long-term relationship with their

audiologist, and clients may be more willing to return for rehabili-

tation when they are ready to take that step. If clients do commit to

hearing aids when they are ready and motivated to help their hearing,

they are more likely to utilize them and fully integrate their hearing

rehabilitation into their life (Laplante-Lévesque et al, 2012).

In addition, the presence of a family member may be helpful in

these appointments to facilitate a broader discussion of the client’s

potential hearing difficulties in everyday life. In many of these

appointments, clients reported that family members had concerns

about their hearing, even when they did not have concerns

themselves. Having a family member in attendance may help

audiologists to explicate communication problems within the

family. Previous research has found that family members who

attend appointments display a desire to have an active involvement

in the interaction (Ekberg et al, 2014b, 2015; Meyer et al, 2015;

Preminger, 2003).

The findings from this study also show support for optimizing

communication and counselling education in audiology training.

Teaching students how to build a history with the client, and to be

more aware of clients’ responses to history questions in the initial

stage of the appointment may help them better tailor rehabilitation

recommendations for clients, increase clinical efficiency, and

increase long-term adherence to their rehabilitation goals. While

little published literature explores current practice in teaching

communication and patient-centred practice, academics have

flagged that such skills are either taught via the hidden curriculum,

or are poorly represented relative to other audiology topics in

postgraduate degrees (Atkins, 2007; English et al, 2007). Despite

this, the expectation that audiologists possess mastery of counsel-

ling skills is observed in Scope Of Practice documents found in

many countries (e.g. AAA, 2004; ASHA, 2006; Audiology

Australia, 2013; BSA, 2012). Much can be learnt by exploring

recent developments and empirical findings relating to teaching

quality patient-practitioner communication in medical training

and other allied health degrees (Hatem et al, 2007; Kalet et al,

2004).

A limitation of this study was that, within the corpus, there were

no examples of audiologists using an awareness-raising approach

with clients identified as being at a pre-contemplation stage-of-

change. Future research might examine how clients respond to such

approaches, and whether this can better help clients progress

towards some kind of hearing rehabilitation. Future research may

also seek to directly compare clients’ responses to history-taking

questions during the appointment, with their responses on ques-

tionnaires such as the URICA and the Ida Institute motivation tools.

Limitations of the TTM have been documented, and the validity of

the model has been questioned by some researchers (e.g. Bridle et

al, 2005). Some of the previous studies investigating the TTM have

been methodologically weak, and there have been ambiguous

results relating to its effectiveness. It has been suggested that the

48 K. Ekberg et al.

model needs further specification of which, and how, different

processes relate to particular stages of change (Bridle et al, 2005).

However recent studies conducted in audiology, particularly

focussing on stages-of-change, have demonstrated support for the

use of this model (e.g. Laplante-Lévesque et al, 2010b, 2012; 2013,

2015).

Conclusion

Clients’ readiness for hearing rehabilitation can be observed

within their responses to history-taking questions in initial

audiology appointments. Clients’ stage-of-change can have import-

ant consequences for how they respond to a recommendation of

hearing aids in the management phase of the appointment. In

particular, clients who appear to be in a pre-contemplation stage-

of-change tended to resist a recommendation of hearing aids. The

transtheoretical model of behaviour change can be useful for

helping audiologists fit a rehabilitation plan to individual clients

based on their needs, attitudes, desires, and psychological

readiness for action.

Acknowledgements

This study was conducted under the HEARing Cooperative

Research Centre, established and supported under the Cooperative

Research Centres Program, an initiative of the Australian

Government.

Declaration of interest: The authors report no conflict of interest.

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Appendix 1

Jeffersonian transcription system This list represents the most widely-used transcription symbols used in this study. For a more comprehensive list, see Jefferson (2004).

Appendix 2

Table 1.

(.) Micro-pause: less than a tenth of a second

(0.2), (2.6) Examples of timed pauses

"word Onset of noticeable pitch rise

#word Onset of noticeable pitch fall

A: word [word

B: [word

Square brackets aligned across adjacent lines denote the start of overlapping talk.

. Falling vocal pitch

? Rising vocal pitch

.hhh In-breath

hhh Out-breath

wo(h)rd Within-speech aspirations

wor- A sharp cut-off

wo:rd Colons show that the speaker has stretched the preceding sound

(words) A guess at what might have been said if unclear

() Unclear talk

A: word¼ B: ¼word

The equals sign shows that there is no discernible pause between two speakers’ turns

word Vocal emphasis

WORD Talk pronounced loudly in comparison with surrounding talk �word� Talk between ?degree signs? is quieter than surrounding talk

4word word5 Talk between inward arrows is delivered faster than surrounding talk

5word word4 Talk between outward arrows is delivered slower than surrounding talk

! Analyst’s signal of a significant line

((sniff)) Transcriber’s effort at representing something difficult, or impossible, to write phonetically

£word£ Words spoken with smiley voice

Older clients‘ readiness for hearing rehabilitation 51

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