Article Analysis 1

AJA

Research Article

Family Involvement in Adult Hearing Evaluation Appointments:

Patient Perspectives Bailey Reynolds,a Sarah E. Yoho,a Karen Muñoz,a,b and Cache Pitta

Background: Many adults suffer from an array of consequences due to their hearing loss (e.g., self-efficacy, mastery, psychosocial challenges). Family involvement can help improve their outcomes. Purpose: This study aimed to determine audiology adult patients hearing experiences and inquired about their perspectives on family involvement in appointments. Research Design: A cross-sectional survey was completed. Descriptive statistics, item analyses, and quantitative analyses were used to examine patient’s characteristics and perspectives. Study Sample: Three hundred eighty-two adult audiology patients participated in the study. Data Collection and Analysis: A 15-item survey was created with 4 sections, including patient demographic information, general hearing questions, hearing experiences, and family interactions and involvement. Descriptive statistics were used to examine patient’s characteristics

and perspectives on family involvement in audiology appointments. Chronbach’s alpha was used to reveal good internal consistency of difficult feelings related to hearing and perceived negative family member reactions. Quantitative analyses were used to determine patient perspectives on family involvement. Results: Though patients reported difficulties due to their hearing loss, more than half reported that they did not want family involvement or they were unsure of the benefit that the involvement would provide. Patients who were interested in having family involved reported benefits such as educational opportunities and support. Few barriers of family involvement were reported by patients. Conclusions: Patients had a mixed desire about family involvement in their adult audiology appointments. Education of patients about the benefits of family involvement may need to happen for this shift in audiologic practice.

H earing loss prevalence increases as people age, and of those 75 years and older, 50% have a documented hearing loss (National Institute on Deafness and

Other Communication Disorders, 2016). Untreated hearing loss can lead to an array of negative consequences, interfering with quality of life (Piercy & Piercy, 2002; Preminger & Meeks, 2012; Scarinci, Worrall, & Hickson, 2009, 2012). Acknowledging the presence of a hearing loss and taking steps to address hearing problems can be difficult, and family involvement in the treatment process may offer benefits. In audiology, recent research suggests that family involvement

in adult services is minimal (Ekberg, Meyer, Scarinci, Grenness, & Hickson, 2015), and there have been recom- mendations to increase family involvement (Meyer, Scarinci, Ryan, & Hickson, 2015; Singh et al., 2016). Specifically, the approach of “family-centered care” involves individuals who play a large role in the patient’s life to be actively involved in the patient’s health care (Ekberg et al., 2015; Grenness, Meyer, Scarinci, Ekberg, & Hickson, 2016; Singh et al., 2016). It has been predicted that this involvement may result in positive outcomes for audiology patients (Ekberg, Meyer, Scarinci, Grenness, & Hickson, 2014; Grenness et al., 2016; Scarinci, Meyer, Ekberg, & Hickson, 2013). Understanding adult patient perspectives about involving family members in their hearing appointments may provide audiologists with insights about how to effectively engage family members while respecting the autonomy of their patients.

When adults acquire a hearing loss, they can experience a variety of consequences, and the impact of hearing loss can be exacerbated when treatment is delayed. Struggles can include emotional impacts such as social isolation, depression,

aDepartment of Communicative Disorders and Deaf Education, Utah State University, Logan bNational Center for Hearing Assessment and Management, Utah State University, Logan

Correspondence to Sarah E. Yoho: [email protected]

Editor-in-Chief: Sumitrajit Dhar Editor: Kathy Vander Werff

Received January 28, 2019 Revision received May 1, 2019 Accepted July 16, 2019 https://doi.org/10.1044/2019_AJA-19-0013

Disclosure: The authors have declared that no competing interests existed at the time of publication.

American Journal of Audiology • Vol. 28 • 857–865 • December 2019 • Copyright © 2019 American Speech-Language-Hearing Association 857

anxiety, and loneliness (Dalton et al., 2003; Kramer, Kapteyn, Kuik, & Deeg, 2002; Saunders, Chisolm, & Wallhagen, 2012). In general, older adults may exhibit lower self-efficacy (e.g., insecurity in abilities to problem solve, handle diffi- cult situations, cope) and mastery (e.g., control of their life and goal accomplishments), and their social networks may become more limited (Kramer et al., 2002). Such challenges can lead to a reduced quality of life, as well as stress and frustration that can result in individuals feeling unconnected to the people in their lives (Dalton et al., 2003). There are also personal and societal costs associated with hearing loss, such as lost wages (Jung & Bhattacharyya, 2012; Zimmer, 2019). Even with such negative impacts, less than half of those adults who could benefit from hearing aids (the primary treatment for most types of hearing loss) obtain them (KochKin, 2012). For adults who do obtain hearing aids, an estimated 22.9 million in the United States do not consis- tently wear them, and of those 50 years and older, only one in seven use their hearing aids regularly (Chien & Lin, 2012).

In addition to the impacts on the individual, hearing loss can also negatively impact family members (Kamil & Lin, 2015; Piercy & Piercy, 2002), resulting in a third-party disability (World Health Organization, 2001). Third-party disability can be described as the disability felt by family members or significant others due to another person’s health condition. The International Classification of Functioning, Disability and Health provides a framework for audiologists to gain a comprehensive understanding of a patient’s hearing- related challenges, which may include environmental and personal factors, as well as third-party disability (Grenness et al., 2016). Considering the impact of hearing loss on the family unit is essential as family members report having reduced relationship satisfaction and quality of life (Kamil & Lin, 2015). Their struggles often include carrying the communicative burden (e.g., answering the phone for their partner, filling in conversational gaps), problems socializing with others as a couple, feelings of anger or frustration related to adaptations they must make for their partner’s hearing loss, and feelings of concern for their partner (Scarinci et al., 2009). Communication requires effort from both communicative partners. Individuals with hearing loss, as well as their communication partners, recognize the challenges in communication (Scarinci, Worrall, & Hickson, 2008; Scarinci et al., 2009). Successful communication is an important part of relationship satisfaction. Family involvement in adult audiology appointments can aide in addressing the third-party disability that may be felt.

Family Involvement Involving family members in audiology appointments

can provide an opportunity for the audiologist to get a holistic view of communication challenges and may facilitate the ability to jointly create a more comprehensive interven- tion plan (American Speech-Language-Hearing Association, 2017; Meyer et al., 2015). Oftentimes during appointments, patients receive new information, learn new skills, and need to consider how to apply what they have learned to their

lives. This can be overwhelming and difficult to manage alone. In other areas of health care, for example, in diabetes management, families report being able to provide vigilance and support for the patient (e.g., assisting with insulin readings), and when the family was not involved in the care plan, patients reported they were more vulnerable in times of difficulty and crisis (Gunn, Seers, Posner, & Coates, 2012). During health care appointments, family members can help patients understand information and offer additional context to the patient’s concerns (Rosland & Piette, 2010; Schilling et al., 2002), as well as offer emotional support, share burdens, and help with daily management activities (Piette, 2010; Singh et al., 2016). Being involved in appoint- ments may also provide the family members an opportunity to share their perspectives, experiences, and challenges (Grenness et al., 2016; Scarinci et al., 2009, 2012). Many health care appointments include the presentation of a substantial amount of new or complex information for the patient, and the cognitive load required to process all of this information can be burdensome (Wilson & Wolf, 2009). Additionally, having support from family members or sig- nificant others may lead to greater hearing aid satisfaction (Singh, Lau, & Pichora-Fuller, 2015). Family members may provide an important secondary perspective and retain information that the patient does not after the appointment is over.

Although there is a body of evidence supporting the inclusion of family members in health care appointments generally, research related to family involvement in adult audiology care specifically is limited. In Ekberg et al.’s (2015) study, only 27% of audiology appointments had a family member of the patient present. When family members were present, they often self-initiated expansion on what the patient said and asked questions of the clinician. Although it appears from related research that family involvement in health care appointments offers multiple benefits, the feelings of audiology patients on including family members, includ- ing both concerns and perceived benefits, are not currently known. As the field of audiology begins to further emphasize a “whole-person” mindset of health care, practitioners may need to emphasize the potential benefits of including family members in patient care. Therefore, the purpose of the current study was to investigate patients’ recent hearing experiences and their perspectives on family involvement in their audiology appointments.

Research Questions The specific research questions for the current study

were as follows: Research Question 1. What percentage of patients

recruited for the current study brought family members to their audiology evaluation, and how many of these patients desired family members present at future appointments?

Research Question 2. What possible influencing factors may affect family involvement in audiology care? Specifically, what are patients’ perspectives of their family members’ feelings due to the patients’ hearing loss, and

858 American Journal of Audiology • Vol. 28 • 857–865 • December 2019

how does the patient feel about the functional impact of their hearing loss?

Method This study used a cross-sectional survey design. Sur-

veys were anonymous. Institutional review board approval at Utah State University was obtained prior to beginning the study, and participants provided written consent prior to the appointment.

Participants and Procedure Participants recruited to complete the survey were

English-speaking adults who wanted a hearing test to find out the status of their hearing sensitivity. Participants were recruited through flyers distributed in the community and social media and were told about the study when they con- tacted the clinic to schedule an appointment. As compensa- tion, participants received the hearing evaluation at no charge. A total of 382 patients completed the survey prior to their hearing evaluation appointment during a 15-month period.

Instrument A 15-item survey instrument was developed by the

research team (see the Appendix). The instrument had four sections: (a) demographic information, (b) general hearing items related to previous hearing testing and hearing aid experience, (c) hearing experiences during the previous 2 weeks, and (d) items related to family interactions and perceptions on family involvement in audiology appointments. The survey was piloted by discussing the questions with several audiology patients who volunteered their time to review the questionnaire prior to beginning the study to ensure all items were clear and no modifications were necessary.

Data Analysis Of the 382 individuals who completed the survey,

none was excluded. Statistical analyses were performed using Statistical Package for the Social Sciences (Version 25). Two individuals independently coded and then cross- checked all entered data. The sample size varies by ques- tion, as participants were allowed to skip any question they did not want to answer. Item analyses for two domains in- cluded in the survey (i.e., difficult feelings related to hear- ing, perceived negative family member reactions) revealed good internal consistency: difficult feelings (n = 344, items = 4, Cronbach’s α = .899) and perceived family member reactions (n = 330, items = 5, Cronbach’s α = .885). A chi- square analysis was completed to determine if there were significant differences between the functional impact of hearing loss on those who did or did not desire family at audiology appointments. Specifically, functional impact was measured by evaluating the amount of difficulty the patient experienced in certain listening situations during

the past 2 weeks, the patient’s feelings regarding the impact of their hearing loss over the past 2 weeks, and family re- actions related to the patient’s hearing loss over the past 2 weeks.1 A regression analysis was completed to determine if there were significant predictors (gender, age, duration of hearing loss, etc.) on whether an individual did or did not desire family at audiology appointments. Content analysis was completed for the open-ended questions to identify emergent themes. For the open-ended questions, one coder analyzed all entries and developed categories to group the responses. A second coder then refined the categories and verified the fit of each response into each category. Patient characteristics, preferences, and listening environment chal- lenges were summarized using descriptive statistics.

Results Demographics and Hearing History

Approximately half of participants were female (49%, n = 185), the mean age was 71 years, and the majority of participants were White (97%, n = 365). Over half of partici- pants had obtained a bachelor’s degree or higher (55%, n = 205). Approximately a quarter of participants (26%, n = 97) reported the appointment was their first appointment with an audiologist, and half reported owning or having owned hearing aids (54%, n = 204). A large majority reported experiencing hearing difficulty for at least a few years (82%, n = 308). Nearly half of patients had a companion at the current appointment (46%, n = 172), with the majority of those who brought a companion reporting that the person was a spouse/partner. Full demographic details can be found in Table 1.

Recent Hearing Experiences Patients were asked to report on their hearing expe-

riences during the previous 2 weeks. Table 2 shows the percentage of time the patients reported that they experi- enced difficulty hearing in different environments. More than half reported difficulty hearing the majority of the time during the previous 2 weeks when they were in noisy places (68%, n = 253) and large groups (58%, n = 212); fewer experienced difficulty in small groups (25%, n = 88) and quiet places (16%, n = 63). Table 3 shows the percentage of time patients reported that they felt certain negative emotions related to their hearing loss. Thirty percent (n = 110) reported that they felt uncertain about what others said the majority of the time during the previous 2 weeks. Approxi- mately 21%–25% reported that they felt isolated from conversations, embarrassed when they misunderstood, or tension when they tried to understand the majority of the time during the previous 2 weeks. Table 4 shows the percentage

1To quantify functional impact for each of these three categories (Questions 9, 10, and 12 of the survey), a composite score for each participant was calculated by taking the median of all responses in that category. These composite scores were used in the quantitative analysis.

Reynolds et al.: Family Involvement in Adult Hearing Evaluations 859

of time the patient’s family members expressed negative feel- ings or displayed a functional impact related to the patient’s hearing loss. Nearly 60% of patients reported that family members expressed one or more of these at least a quarter of the time during the previous 2 weeks.2

Factors Influencing Attitudes on Family Involvement

Patients were queried about their interest in having a family member attend future audiology appointments. Forty percent (n = 154) reported they did not want family to attend, 39% (n = 148) reported they did want family to attend, and 16% (n = 61) said that they were not sure (5% did not respond to this question). A chi-square test was conducted to determine whether there were significant differences between individuals who did or did not desire family at future appointments (with those saying “not sure” excluded from analysis). Results indicate there was no significant interaction between the desire to have family at future appointments and the percentage of time the patients reported that they experienced difficulty hearing in different environments. Additionally, no significant inter- action between the desire to have family at future appoint- ments and the percentage of time the patient’s family members expressed negative feelings or displayed a functional impact related to the patient’s hearing loss was shown (Questions 9 and 12 of the survey: χ2(6, N = 286) = 6.7, p = .46, and

χ2(6, N = 264) = 13.6, p =.06, respectively; see the Appendix). However, there was a significant interaction between the desire to have family at future appointments and the percent- age of time patients reported that they felt certain negative emotions related to their hearing loss (Question 10 of the survey: χ2(6, N = 281) = 30.7, p < .001. A regression analysis was conducted to determine if there were significant predic- tors on whether an individual desired family member at future appointments or not (again, those who indicated “not sure” were excluded from analysis). Possible predictors in- cluded age, gender, highest level of education, and length of hearing difficulty. No significant predictors were identified.

Of those who responded to the question of whether they wanted family at future appointments, 35% (n = 133) described their reasoning. Of the patients who responded, many who wanted family involved (38%, n = 51) described that it would be helpful for their family to gain an under- standing of the hearing loss, to help them remember infor- mation, and for additional support. One patient reported that having a family member at appointments would be beneficial so her family member “understands what steps and procedures are being taken.” Another patient responded

2Patients were queried on the percentage of time family members or significant others expressed certain negative emotions during the past 2 weeks because of the patient’s hearing loss. Fifty-six percent of patients reported that family members needed to repeat what they said to me more than 25% of the time.

Table 1. Participant demographic information.

Participant characteristics % n M (SD)

Gender (female) 49 185 Age 71 yrs (14.28) Race White 97 365 Other 1.1 4 Prefer not to answer 2 8

Education Less than high school 2 8 High school diploma/GED 27 100 Professional degree 9 32 Associate degree 8 29 Bachelor’s degree 29 107 Graduate degree/PhD 26 98 Prefer not to answer 0.5 2

First appointment with an audiologist (yes) 26 97 Previous hearing loss diagnosed (yes) 75 285 Own/previously owned hearing aids (yes) 54 204 Length of hearing difficulty Less than a year (few days/weeks, several months) 5 19 A few years 41 154 Many years 41 154 Not noticing difficulty/not sure 13 51

Family member at appointment (yes) 46 172

Table 2. Percentage of time hearing difficulty was experienced during the previous 2 weeks.

Environment Not

applicable

% (n) time difficulty was experienced

0%–25% 26%–50% > 50%

Quiet places 17 (57) 52 (176) 15 (50) 16 (63) Small groups 11 (37) 34 (119) 31 (110) 25 (88) Large groups 7 (27) 17 (61) 18 (66) 58 (212) Noisy places 5 (18) 14 (50) 14 (50) 68 (253)

860 American Journal of Audiology • Vol. 28 • 857–865 • December 2019

that their family member “may be able to express how my hearing loss is affecting them and they would be able to get information on how to deal with their concerns.” Of the patients who reported they did not want family there, many (36%, n = 48) described that they did not feel it was necessary or that family lived far away or were busy, making it difficult for them to attend. Answers included “no immediate family now,” “time and distance,” and “not necessary.” Some patients (11%, n = 15) indicated it did not matter to them whether or not family attended. Responses included “Fine either way” and “I’d be fine with it, but there is no need.” Several patients (14%, n = 19) provided miscellaneous re- sponses, including “have done this before,” “until I can hear better,” and “don’t need to be told what to do.”

Patients also responded to two queries exploring their perspectives on what would be helpful about having a family member attend and what they thought would be barriers to family member attendance; 62% (n = 237) and 68% (n = 259) responded to these two questions, respectively (see Table 5). The most prevalent reason for having family members involved was related to the educational benefits (increased understanding of hearing loss, increased understanding of recommendations, etc.), and the second most common reason was patients indicated the support would be helpful (e.g., moral support). When asked about the barriers to having family members involved, the majority of patients reported that there were no barriers keeping them from having family with them in their audiology appointments. For those who did indicate a barrier, some patients reported scheduling con- flicts, inconvenience, or feelings of embarrassment.

Discussion The current study examined adult patients’ recent

hearing experiences and their perspectives on involving their family in audiology appointments. While patients’ experiences

and preferences varied, some patients did recognize the im- portance of family involvement in audiology appointments, including how the additional involvement may address the third-party disability that their family members are experienc- ing. However, it is important to note that over half of the respondents reported they either did not want family at future appointments or were not sure if they wanted family at future appointments. This demonstrates a potential lack of understanding that some patients may have on the im- portance of family involvement in health care, particularly in audiology rehabilitation. Past literature has discussed an array of benefits that are possible when family members are involved in audiology appointments, including shared understanding, additional support, opportunities for a more comprehensive intervention plan, and a more holistic view of the patient (American Speech-Language-Hearing Association, 2017; Grenness et al., 2016; Meyer et al., 2015; Singh et al., 2016). Given that these benefits of family involvement have been demonstrated in other areas of health care (Piette, 2010; Rosland & Piette, 2010; Schilling et al., 2002), these issues should be further explored and emphasized in audiology.

Several impacts of hearing loss on both the individual and the family have been previously reported, such as difficulty listening in various environments (Dalton et al., 2003), experiencing difficult emotions related to communica- tion (Dalton et al., 2003; Grenness et al., 2016; Meyer et al., 2015), and third-party disability (Kamil & Lin, 2015). This study similarly found that patients experienced difficulty listening in noise and in large groups, and approximately one quarter of the participants expressed difficulty in small groups and quiet environments. Participants also perceived family member burden (e.g., need to repeat themselves, feeling impatient or angry, discontinuing conversations) and reported experiencing psychosocial challenges (e.g., feelings of uncertainty, isolation, embarrassment) related

Table 3. Percentage of time the patient felt the following during the previous 2 weeks.

Emotion felt Not

applicable

% (n) time difficulty was experienced

0%–25% 26%–50% > 50%

Uncertain about what others said 6 (21) 37 (134) 28 (102) 30 (110) Embarrassed when I misunderstood 26 (90) 37 (131) 16 (58) 21 (73) Isolated from conversations 23 (83) 32 (114) 20 (73) 25 (87) Tension when trying to understand 21 (76) 33 (116) 21 (76) 25 (89)

Table 4. Percentage of time family/significant other expressed the following during the previous 2 weeks.

Emotion expressed Not

applicable

% (n) time difficulty was experienced

0%–25% 26%–50% > 50%

Angry when I misunderstood 45 (156) 37 (128) 9 (30) 10 (33) Impatient when I misunderstood 31 (109) 41 (147) 17 (59) 12 (42) Said volume on TV/radio was too loud 40 (138) 31 (106) 14 (47) 16 (55) Needed to repeat what they said to me 11 (39) 30 (109) 24 (88) 35 (127) Discontinued conversation due to misunderstanding 39 (137) 39 (136) 12 (43) 10 (33)

Reynolds et al.: Family Involvement in Adult Hearing Evaluations 861

to communication. Participants who reported more frequent negative emotions related to their hearing loss were more likely to report that they desired family at future appoint- ments. Negative emotions can be a barrier to action reducing adherence and satisfaction, highlighting the important role of family support. Offering to include family members at appointments provides an opportunity for broader patient and family benefits.

Although over half of patients in the current study did not want or were not sure they want family at future appointments, many patients did acknowledge benefits of having family involved in their audiology consultations. Benefits, such as having a shared understanding of the hearing problem, support for addressing communication, and an opportunity to learn together how to improve communication are similar benefits to those who have been raised in the literature recommending that audiologists increase their efforts to provide family-centered care for adult audiology consultations (Kramer et al., 2002; Meyer et al., 2015; Scarinci et al., 2009; Singh et al., 2016).

The benefits of family involvement have been demon- strated in other areas of health care (Piette, 2010; Rosland & Piette, 2010; Schilling et al., 2002), and these findings can provide important insight into how this issue may impact audiology. The family member or companion often contrib- utes the most to the appointment during the case history and feedback/counseling portions (Beisecker, 1989), and they can often provide important insight such as communi- cating concerns of the patient, communicating their own concerns about the patient’s health or the impacts on the

family member, and assisting in decision making about treatment options (Schilling et al., 2002). The involvement of the family member or companion in the case history of counseling portions of the appointments also seem to be more common in elderly patients than in middle-age patients (Beisecker, 1989), and many audiology patients are older (e.g., the average age in the current study was 71 years). In several studies in other health care fields, majority of pa- tients had a companion at appointments with them. These patients recognized benefits of family involvement such as emotional support and an increased shared understanding, similar to the respondents in favor of family involvement in the current study (Beisecker, Brecheisen, Ashworth, & Hayes, 1996; Prohaska & Glasser, 1996). There is the poten- tial for negative consequences of family or companion in- volvement in health care appointments, such as the patient and companion not sharing goals or agenda for the appoint- ment (Beisecker, 1989), a hesitance of the patient for discussing sensitive concerns (Laidsaar-Powell et al., 2013), or disagreements between patient and family members about hearing difficulty and rehabilitation (Ekberg et al., 2014). However, the benefits appear to outweigh the harm, with many physicians reporting that the involvement of a family member or other companion generally plays a positive role in the appointment (Brown, Brett, Stewart, & Marshall, 1998).

Unfortunately, recent research exploring family in- volvement in audiology consultations has shown minimal family engagement. Ekberg et al. (2015) found that only 17 of 62 initial hearing evaluation appointments had family

Table 5. Patients’ responses to open-ended questions on benefits and barriers of family involvement.

Responses, % (n) Main themes, % (n) Quotes

Benefits of having family involved, 62% (247)

Educational benefits, 59% (139) “Remember something that I missed” “Understand hearing problem” “Understand, learn methods to improve communication” “Better understanding of amount of hearing loss”

Support, 16% (38) “Moral support” “Having a second listener”

Not helpful, 13% (30) “I don’t think it would be necessary” “It wouldn’t be helpful”

No preference, 7% (17) “I don’t need it, but it could be helpful for people with severe hearing”

“I would not mind having her here” No barriers, 66% (174) “None. Just didn’t think they needed to come”

“No barriers” “None”

Barriers of having family involved, 68% (262)

Schedule conflicts, 13% (33) “Few, if any, since we’ve both retired. Perhaps time conflict with another commitment”

“None—just their time and availability” No family in the area, 7% (18) “They live away”

“No one very close by” Embarrassment/family reactions, 5% (13) “Small bits of embarrassment”

“Some are impatient or rude” “If they are not hard of hearing, they don’t understand

as well” Inconvenience, 3% (9) “Inconvenience” Inconvenience, 3% (9) “None other than inconveniencing them when there was

no need for their presence”

862 American Journal of Audiology • Vol. 28 • 857–865 • December 2019

members present. In another study looking at the partner- ship between the audiologist, the patient, and family members, the audiologists reported an estimate of less than 30% of appointments had family involvement (Meyer et al., 2015). In the current study, less than half of the patients had a family member at the appointment, although it is not known if the family member joined the patient during the encounter or stayed in the waiting room. Even though patient responses were mixed about their desire to have family members involved in their audiology appoint- ments, they identified benefits to family involvement and expressed few barriers. When barriers were expressed, nega- tive family reactions and embarrassment were concerns raised.

There were a few important limitations of the current study, as a large majority of participants were White, many had at least some college education and all were patients at one university clinic; thus, the current results reflect a relatively narrow demographic for understanding patient perspectives. Participants who called the clinic for a hearing evaluation were offered a free hearing test for their participation, and this may have affected the responses received. Additionally, patients were asked if they have, or previously had worn, hearing aids; they were not asked if they currently use their hearing aids. Furthermore, patients were asked if the family member was with them at the clinic; it is not known how often family members went into the appointment with the patient or if they stayed in the waiting room. Future studies should expand on these findings to explore these issues more broadly and how family involvement in audiologic care can be better appreciated and emphasized.

Audiologists have a role in helping patients recognize benefits of including their communication partners in their care. Audiologists can invite their patients to include family and talk with patients about how their hearing concerns are impacting their lives and the lives of those around them. By addressing the whole patient, not just the hearing loss, audiologists have an opportunity to positively impact the lives of their patients. When an alliance between the audiol- ogist, the patient, and the family member is formed, shared responsibility, understanding, and expectations can be achieved, which provides an avenue of support for the patient, as well as the family member (Meyer et al., 2015). Utilizing a family-centered approach in practice may lead to more successful communication for the patient, family members, and the audiologist, as well as improved outcomes for the patient (Ekberg et al., 2014; Grenness et al., 2016; Scarinci et al., 2013). Audiologists, however, may not recog- nize the importance of family-centered care with adult populations. In a recent study (Ekberg et al., 2015), it was found that audiologists did not encourage family members to be actively involved in appointments. For a shift to family- centered service delivery in adult audiology health care to occur, audiologists may need to gain a better understand- ing of the benefits and how they can orchestrate a compre- hensive approach to care. Further research, including more in-depth qualitative studies, to understand audiolo- gists’ perspectives on including family in adult audiology

consultations, as well as family member perspectives, could further assist in shaping practice.

Conclusion Adults with hearing loss experience a range of

challenges, and family involvement in adult audiology con- sultations is a recommended practice. This study found that patients were mixed in their desire to have a family member present at appointments, although patients identified multi- ple benefits to involving family members and few barriers. Further research on perspectives of family members and audiologists would provide important insights to shape prac- tice patterns.

References American Speech-Language-Hearing Association. (2017). Hearing

aids for adults. Practice portal. Retrieved from http://www.asha. org/PRPSpecificTopic.aspx?folderid=8589935381&section=Key_ Issues

Beisecker, A. E. (1989). The influence of a companion on the doctor–elderly patient interaction. Health Communication, 1(1), 55–70.

Beisecker, A. E., Brecheisen, M. A., Ashworth, J., & Hayes, J. (1996). Perceptions of the role of cancer patients’ companions during medical appointments. Journal of Psychosocial Oncology, 14(4), 29–45. https://doi.org/10.1300/J077v14n04_03

Brown, J. B., Brett, P., Stewart, M., & Marshall, J. N. (1998). Roles and influence of people who accompany patients on visits to the doctor. Canadian Family Physician, 44, 1644.

Chien, W., & Lin, F. R. (2012). Prevalence of hearing aid use among older adults in the United States. Archives of Internal Medicine, 172(3), 292–293. https://doi.org/10.1001/archinternmed. 2011.1408

Dalton, D. S., Cruickshanks, K. J., Klein, B. E., Klein, R., Wiley, T. L., & Nondahl, D. M. (2003). The impact of hearing loss on quality of life in older adults. The Gerontologist, 43(5), 661–668. https://doi.org/10.1093/geront/43.5.661

Ekberg, K., Meyer, C., Scarinci, N., Grenness, C., & Hickson, L. (2014). Disagreements between clients and family members regarding clients’ hearing and rehabilitation within audiology appointments for older adults. Journal of Interactional Research in Communication Disorders, 5(2), 217–244. https://doi.org/ 10.1558/jircd.v5i2.217

Ekberg, K., Meyer, C., Scarinci, N., Grenness, C., & Hickson, L. (2015). Family member involvement in audiology appointments with older people with hearing impairment. International Journal of Audiology, 54(2), 70–76. https://doi.org/10.3109/14992027. 2014.948218

Grenness, C., Meyer, C., Scarinci, N., Ekberg, K., & Hickson, L. (2016). The international classification of functioning, disability and health as a framework for providing patient-and family- centered audiological care for older adults and their significant others. Seminars in Hearing, 37(3), 187–199. https://doi.org/ 10.1055/s-0036-1584411

Gunn, K. L., Seers, K., Posner, N., & Coates, V. (2012). “Somebody there to watch over you”: The role of the family in everyday and emergency diabetes care. Health and Social Care in the Community, 20(6), 591–598. https://doi.org/10.1111/j.1365- 2524.2012.01073.x

Reynolds et al.: Family Involvement in Adult Hearing Evaluations 863

Jung, D., & Bhattacharyya, N. (2012). Association of hearing loss with decreased employment and income among adults in the United States. Annals of Otology, Rhinology & Laryngology, 121(12), 771–775. https://doi.org/10.1177/000348941212101201

Kamil, R. J., & Lin, F. R. (2015). The effects of hearing impairment in older adults on communication partners: A systematic review. Journal of the American Academy of Audiology, 26(2), 155–182. https://doi.org/10.3766/jaaa.26.2.6

KochKin, S. (2012). MarkeTrak VIII: The key influencing factors in hearing aid purchase intent. Hearing Review, 19(3), 12–25.

Kramer, S. E., Kapteyn, T. S., Kuik, D. J., & Deeg, D. J. (2002). The association of hearing impairment and chronic diseases with psychosocial health status in older age. Journal of Aging and Health, 14(1), 122–137.

Laidsaar-Powell, R. C., Butow, P. N., Bu, S., Charles, C., Gafni, A., Lam, W. W. T., . . . Juraskova, I. (2013). Physician–patient– companion communication and decision-making: A systematic review of triadic medical consultations. Patient Education and Counseling, 91(1), 3–13.

Meyer, C., Scarinci, N., Ryan, B., & Hickson, L. (2015). “This is a partnership between all of us”: Audiologists’ perceptions of family member involvement in hearing rehabilitation. American Journal of Audiology, 24(4), 536–548. https://doi.org/10.1044/ 2015_AJA-15-0026

National Institute on Deafness and Other Communication Disorders. (2016). Quick statistics about hearing. U.S. Department of Health & Human Services. Retrieved from https://www.nidcd.nih.gov/ health/statistics/quick-statistics-hearing

Piercy, S. K., & Piercy, F. P. (2002). Couple dynamics and attribu- tions when one partner has an acquired hearing loss: Implica- tions for couple therapy. Journal of Marital and Family Therapy, 28(3), 315–326. https://doi.org/10.1111/j.1752-0606.2002.tb01189.x

Piette, J. D. (2010). Moving beyond the notion of “self” care. Chronic Illness, 6, 3–6. https://doi.org/10.1177/1742395309359092

Preminger, J. E., & Meeks, S. (2012). The Hearing Impairment Impact–Significant Other Profile (HII-SOP): A tool to measure hearing loss-related quality of life in spouses of people with hearing loss. Journal of the American Academy of Audiology, 23(10), 807–823. https://doi.org/10.3766/jaaa.23.10.6

Prohaska, T. R., & Glasser, M. (1996). Patients’ views of family involvement in medical care decisions and encounters. Research on Aging, 18(1), 52–69. https://doi.org/10.1177/0164027596181004

Rosland, A.-M., & Piette, J. D. (2010). Emerging models for mobilizing family support for chronic disease management:

A structured review. Chronic Illness, 6, 7–21. https://doi.org/ 10.1177/1742395309352254

Saunders, G. H., Chisolm, T. H., & Wallhagen, M. I. (2012). Older adults and hearing help-seeking behaviors. American Journal of Audiology, 21(2), 331–337. https://doi.org/10.1044/ 1059-0889(2012/12-0028)

Scarinci, N., Meyer, C., Ekberg, K., & Hickson, L. (2013). Using a family-centered care approach in audiologic rehabilitation for adults with hearing impairment. Perspectives on Aural Re- habilitation and Its Instrumentation, 20(3), 83–90.

Scarinci, N., Worrall, L., & Hickson, L. (2008). The effect of hearing impairment in older people on the spouse. International Journal of Audiology, 47(3), 141–151. https://doi.org/10.1080/ 14992020701689696

Scarinci, N., Worrall, L., & Hickson, L. (2009). The effect of hearing impairment in older people on the spouse: Development and psychometric testing of the Significant Other Scale for Hearing Disability (SOS-HEAR). International Journal of Audiology, 48(10), 671–683. https://doi.org/10.1080/14992020902998409

Scarinci, N., Worrall, L., & Hickson, L. (2012). Factors associated with third-party disability in spouses of older people with hearing impairment. Ear and Hearing, 33(6), 698–708. https://doi.org/ 10.1097/AUD.0b013e31825aab39

Schilling, L. M., Scatena, L., Steiner, J. F., Albertson, G. A., Lin, C. T., Cyran, L., . . . Anderson, R. J. (2002). The third person in the room: Frequency, role, and influence of companions during primary care medical encounters. Journal of Family Practice, 51(8), 685–692.

Singh, G., Hickson, L., English, K., Scherpiet, S., Lemke, U., Timmer, B., & Launer, S. (2016). Family-centered adult audiologic care: A Phonak position statement. Hearing Review, 23(4), 16.

Singh, G., Lau, S.-T., & Pichora-Fuller, M. K. (2015). Social sup- port predicts hearing aid satisfaction. Ear and Hearing, 36(6), 664–676.

Wilson, E. A., & Wolf, M. S. (2009). Working memory and the design of health materials: A cognitive factors perspective. Patient Education and Counseling, 74(3), 318–322. Retrieved from. https://www.sciencedirect.com/science/article/pii/ S0738399108005879#aep-bibliography-id24

World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.

Zimmer, D. M. (2019). The effect of hearing impairments on wage earnings: Evidence from a copula-based spline selection model. Labour, 33(2), 147–161. https://doi.org/10.1111/labr.12142

864 American Journal of Audiology • Vol. 28 • 857–865 • December 2019

Appendix

Patient Experiences and Perspectives About Their Hearing

This survey will help us understand your experiences and how you feel about including your family, or other important people in your life, in your audiology appointment. Completing the survey should take less than 5 minutes. Your perspectives are important!

Information About You

Your Hearing

Your Family/Significant Other 11. Is a family member/significant other with you/coming to your audiology appointment? □ No □ Yes What is their relationship to you? ______________________________________

12. Indicate approximately how often your family/significant other expressed the following during the past two weeks:

13. Would you want a family/significant other to attend future audiology appointment with you? □ No □ Yes □ I’m not sure Describe why: ____________________________________________________________ 14. What would be helpful about having a family member/significant other with you at your appointment? ____________________________________________________________________________________________________ 15. What are the barriers to having a family member/significant other with you at your appointment? ____________________________________________________________________________________________________

1. How old are you? ____ □ I prefer not to answer 2. What is your gender? □ M □ F □ I prefer not to answer 3. What is your race? □ American Indian or Alaska Native □ Asian □ Black or African America □ Native Hawaiian/Pacific Islander □ White □ I prefer not to answer

Ethnicity: □ Hispanic or Latino □ Not Hispanic or Latino □ Prefer not to answer 4. What is your highest level of education? □ Less than high school □ High school diploma/GED □ Professional degree □ Associate’s degree □ Bachelor’s degree □ Graduate degree/PhD □ I prefer not to answer

5. Is this your first appointment with an audiologist? □ No □ Yes 6. Have you been previously diagnosed with a hearing loss? □ No □ Yes 7. How long have you had difficulty with your hearing?

□ a few days/weeks □ several months □ a few years □ many years □ I am not noticing difficulties □ I’m not sure

8. Do you currently or have you ever worn hearing aids? □ No □ Yes

Your Experiences 9. Indicate approximately how often you had difficulty understanding conversations in each of the following situations during the

past two weeks: During the past two weeks, it was difficult to understand in… Not applicable 0%–25% 26%–50% 51%–75% More than 75% a. Quiet places 1 2 3 4 5 b. Small groups 1 2 3 4 5 c. Large groups 1 2 3 4 5 d. Noisy places 1 2 3 4 5 10. Indicate approximately how often you felt each of the following during the past two weeks: During the past two weeks, I felt … Not applicable 0%–25% 26%–50% 51%–75% More than 75% a. Uncertain about what others said to me 1 2 3 4 5 b. Embarrassed when I misunderstood 1 2 3 4 5 c. Isolated from conversations 1 2 3 4 5 d. Tension when trying to understand 1 2 3 4 5

During the past two weeks my family/significant other… Not applicable 0%–25% 26%–50% 51%–75% More than 75% a. was angry when I misunderstood 1 2 3 4 5 b. was impatient when I misunderstood 1 2 3 4 5 c. said volume on the TV/radio was too loud 1 2 3 4 5 d. needed to repeat what they had said to me 1 2 3 4 5 e. discontinued conversation due to misunderstanding 1 2 3 4 5

Reynolds et al.: Family Involvement in Adult Hearing Evaluations 865

Copyright of American Journal of Audiology is the property of American Speech-Language- Hearing Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Copyright of American Journal of Audiology is the property of American Speech-Language- Hearing Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.