Evaluation of audiological rehabilitation services for adults with hearing impairment in Malaysia

Abstract

The effects of hearing impairment on adult patients and their families have been extensively reported (e.g. communication difficulties, emotional distress and social engagement restrictions, and decreased quality of life). Therefore, audiologists have a responsibility to help patients and their families manage activity limitations and participant restrictions that arise from hearing impairment in the context of the International Classification of Functioning, Disability and Health (ICF). This approach is very much in line with the principles of patient-centred care (PCC) that have been extensively promoted as best practice for the healthcare management of older adults. Despite reports of the benefits of PCC for adult patients in Western countries, including adherence to management plans and reduced recovery time, it is not known whether this approach is incorporated into audiological services for adult patients in Malaysia. The aims of this thesis were to investigate (i) the nature of audiological rehabilitation services for adults with hearing impairment in Malaysia, and (ii) the extent of patient-centredness exhibited by audiologists in Malaysia. To address these aims, a mixed methods approach was used. The quantitative measures were utilised to explore the current practice of audiologists in managing adult patients and to identify the preferences for PCC in audiological management from the perspectives of audiologists and adult patients, while the qualitative measures provided an in-depth view of the implementation of PCC in audiological management. The types of methods utilised were online and paper based surveys, individual semi-structured in-depth interviews, and video observation. Chapter 1 describes Malaysia briefly, with a focus on the field of audiology and the services offered. The ICF framework, which structures this thesis, and the PCC approach, which is the focus of this thesis, is presented in this chapter. Chapter 2 describes the audiological management for adults with hearing impairment and their significant others in the context of the ICF, as recommended by established audiology professional associations. Chapter 2 also includes background on PCC in more detail. Chapter 3 explored the nature of audiological services for adults with hearing impairment in Malaysia, with an emphasis on whether current services addressed patients’ overall functioning described in the ICF. In general, the audiologists in Malaysia addressed the hearing impairment and its associated activity limitations and participation restrictions in their management of adult patients. However, gaps were identified with there being a strong emphasis on addressing impairment-level impacts. Inadequate infrastructure, resources and facilities in the workplace may have contributed to the gaps in service provision and influenced the current practice of audiological management for patients in Malaysia. Chapter 4 identified the preferences of adult patients for PCC and the level of PCC they received from audiologists. Although the patients expressed a desire to be more involved in their audiological management, they preferred the information sharing and decision-making processes to be clinician-centred. A high variability in patients’ preferences for PCC highlights the need for audiologists to identify patients’ expectations prior to the commencement of rehabilitation in order to ensure patients’ individual needs are addressed. Despite patients reporting that they received a moderate level of patient-centred hearing care from audiologists, our findings showed that audiologists were rated higher for being courteous and respectful to patients, compared to providing general information related to patients’ audiological conditions. Although adult patients recommended improvements on various aspect of the audiological services, one third of the adult patients were satisfied with service provision. Chapter 5 investigated the preferences of audiologists towards PCC in audiological management and explored the implementation of elements of PCC in the management of their patients. This chapter incorporated findings from the Patient-Practitioner Orientation Scale (PPOS), which was part of the online survey distributed in Chapter 3. Semi-structured interviews were conducted to gain an in-depth understanding of the implementation of PCC by audiologists with their adult patients. The PPOS score showed that although audiologists reported a preference for PCC in general, they preferred to be in charge of deciding on the discussion topics. Chapter 6 explored the nature of communication between the audiologists and adult patients during initial audiological appointment sessions, with a focus on the shared-decision making (SDM) process. Although audiologists exhibited patient-centred communication behaviours to a moderate extent, there was a lack of evidence of SDM taking place. Audiologists put more emphasis on building relationship with patients and allowing patients opportunities to talk compared to providing rehabilitation options to the patients, which is one of the behaviours essential for SDM. The room setup and the length of appointment time may have also influenced communication, as observed during the audiological consultations.The overall findings of this thesis have implications for providing a better understanding of the audiological services in Malaysia as well as highlighting aspects of service provision that would need to improve in order to provide a holistic and individualistic audiological management for adult patients in Malaysia.