Audiology and Speech Pathology - Theses
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ItemAn evidence-based pathway to early cochlear implantation in infants: reducing the reliance on the behavioural audiogram( 2023-03)ABSTRACT Background and Aims Cochlear implantation has emerged as a leading hearing intervention for infants born with severe to profound hearing loss. Research has shown that early intervention with a cochlear implant (CI) can significantly improve speech perception and oral language development in infants, providing them with access to the sounds that are critical for language acquisition. However, studies investigating the relationship between initial electrophysiological hearing thresholds and subsequent behavioural thresholds have demonstrated uncertainty as to whether initial results are able to provide an accurate estimation of an infant’s functional hearing. This estimation must be accurate if a CI is to be considered before behavioural audiometry has been obtained, as CI surgery is likely to remove any remaining natural hearing. This study aims to explore the variance between initial electrophysiological thresholds and subsequent behavioural hearing thresholds in young infants with suspected severe to profound hearing loss in a clinical setting, to determine under which conditions initial electrophysiological results can be used to support a CI recommendation in the absence of behavioural audiology. It also aims to propose evidence-based recommendations for implementation of a paediatric CI candidacy pathway for cases in which reliance on behavioural audiometry can be reduced. Method A prospective cohort study of 63 infants with suspected severe to profound hearing loss, referred to the Cochlear Implant Clinic, Melbourne, before 12 months of age. Assessment protocol included auditory brainstem response, auditory steady-state response, otoacoustic emissions, tympanometry, cortical auditory evoked response, and behavioural audiometry. Data was explored using correlational analysis, linear regression, and clinical decision analysis. Results 90.8% of all individuals who met CI candidacy criteria with initial electrophysiological testing (3FAHL>85dB) also met criteria upon behavioural testing. This proportion increased to 95% once certain exclusion criteria were placed on the group, excluding children born prematurely and children with auditory neuropathy. This result indicates that, under certain conditions, initial electrophysiological thresholds may be reliable enough to form the basis of a CI recommendation. Sensitivity and specificity of diagnostic electrophysiological testing was also found to increase once exclusion criteria were applied. Conclusion For most infants undergoing CI candidacy evaluation, initial electrophysiological thresholds were an accurate reflection of their subsequent behavioural hearing thresholds. An alternative CI candidacy pathway is recommended for infants who show profound sensorineural hearing loss on initial electrophysiological testing in the absence of middle ear effusion or auditory neuropathy features, to provide CI recommendations before behavioural thresholds are obtained. This would lead to reduced timeframes between hearing loss identification, diagnosis, and implantation, which can improve oral speech and language outcomes.
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ItemPsychologically Informed Practice in Hearing Healthcare: Perspectives and Needs of Clients and Audiologists( 2022)For many people, the sense of hearing provides a connection with others and the world around them. Losing one’s hearing can have a deleterious impact on many psychological and social aspects of life. Hearing loss can compromise psychological wellbeing, resulting in an increase in loneliness or reduced self-esteem, and it can also increase the odds of experiencing psychological symptoms, such as depression and anxiety. Given this association, audiologists are likely to encounter clients with psychological concerns on a regular basis. Understanding how these clients experience audiological rehabilitation may be an important way for audiologists to provide relevant and optimal services. Psychological factors, including mental health and illness, can also significantly influence the initiation, adherence, and success of audiological rehabilitation. Despite this, psychological factors are not adequately considered within hearing healthcare, so the recommended approach of person-centred care may need to be further extended to better address these factors. Psychologically informed practice (PIP) may provide a suitable framework that can be used to extend upon person-centred care, especially for clients with comorbid psychological symptoms. A PIP framework recognises the role of psychological factors in chronic health conditions and addresses these using psychological theories and frameworks. PIP has shown success in other rehabilitation settings and may therefore provide benefits within hearing healthcare. The aim of this thesis was therefore to explore the nature of mental illness, mental health, and psychological symptoms within audiological rehabilitation, from the perspective of clients and audiologists, and to provide a foundation of support for the implementation of PIP into hearing healthcare. Four studies were conducted to achieve the aims of this thesis. The first study included in-depth, semi-structured qualitative interviews to understand the experience of hearing loss and audiological rehabilitation for older adults with comorbid psychological symptoms. A novel theme found in this study was the bi-directional and cumulative relationship between hearing loss and psychological symptoms. Given the relationship between hearing loss and psychological symptoms, the second study included a systematic review and meta-analysis to determine the effect of interventions targeted at hearing loss on psychological symptom outcomes in adult clients. The meta-analysis showed that hearing aids, cochlear implants, and communication and education programs resulted in a small decrease in depression and anxiety symptoms. A mixed-method survey of audiologists working in adult audiological rehabilitation in Australia was then conducted to understand the nature of client-audiologist discussions about client mental health within audiological rehabilitation. This study found that audiologists occasionally discuss mental health, and clients are more likely than clinicians to initiate these conversations. The final study aimed to determine the barriers and facilitators to audiologists discussing and addressing client mental health, and to determine audiologists’ preparedness and willingness to implement aspects of PIP in audiological rehabilitation. Audiologists were generally motivated to incorporate PIP into audiological rehabilitation; however, a lack of knowledge about mental health and organisational barriers, such as time and resources, would need to be overcome. Overall, the studies in this thesis provide an understanding of how psychological symptoms are experienced, recognised, discussed, and addressed within audiological rehabilitation and suggested that the current way of delivering audiological rehabilitation is insufficient to achieve optimal outcomes for clients with psychological symptoms. These studies form an evidence-based foundation and rationale for the implementation of PIP within hearing healthcare.
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ItemPreventing hearing injury in the music industry( 2019)Sound levels in the live music industry have been demonstrated to reach levels capable of causing harm to the auditory system. The body of work presented here aimed to explore ways in which hearing injury can be prevented in the Australian music industry. To do so, multiple stakeholders were engaged, including venue owners, live-music sound engineers, audiologists and manufacturers of hearing protectors for musicians. Four discrete, mixed-methodology studies were conducted to address the topic. Study 1 aimed to investigate the clinical provision of musicians’ hearing protectors (MHPs) by audiologists and manufacturers of MHPs in Australia. Method. Audiologists and manufacturers were asked to complete one of two surveys, investigating the delivery of clinical care for musicians, and recommended processes relating to the manufacture of earplugs. Results. Inconsistencies in the clinical procedures were noted in both the practice of audiological care for musicians, and the recommendations made by manufacturers of MHPs. Study 2 aimed to investigate whether the use of, and satisfaction with, MHPs is influenced by the specific treatment delivered to musicians by audiologists. Method. Musicians rated their satisfaction with the services as delivered across the four treatment conditions. Results. No statistically significant differences across conditions were observed, however, certain aspects of care were perceived positively by musicians, such as the provision of a hearing test. Study 3 aimed to assess the hearing of live music sound engineers and their risk of hearing injury. Method. Participants completed a questionnaire on their hearing health as well as a hearing assessment. Results. Ninety-six percent of sound engineers reported having experienced at least one symptom of hearing injury during or after a work shift in music. Use of hearing protection was low, however, individuals who frequently wore hearing protection had significantly better hearing, particularly in the extended high frequencies. Study 4 aimed to investigate if the use of sound level management software can assist in reducing exposure levels in indoor live music venues. Method. Use of a commercial sound level management system in six indoor live-music venues of Melbourne was trialled. Results. Overall, there was no reduction in mean sound level (LAeq,T), however the number of nights on which extreme volume levels were recorded was reduced. Subjective questionnaires indicated that one-fifth of patrons would prefer lower sound levels than experienced. Overall, the results indicate there is a significant risk of hearing injury to individuals working within and attending live music venues in Australia. Findings indicated that there is a need for greater hearing awareness across all stakeholders. Audiologists would benefit from the development of best-practice guidelines for the care of musicians’ ears, while more broadly, the inclusion of EHF hearing thresholds would benefit in early detection and monitoring of noise-induced hearing loss. Greater research focus and hearing conservation training is needed for both LMSEs and staff in live-music venues, who would benefit from the implementation of strategies to manage venue sound levels in a way that takes into account the sound level preferences of patrons, while minimising the risk of hearing injury for all.
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ItemPatient-centred communication in audiology education: an exploration of perspectives and practice( 2018)Patient-centred communication is recognised as the cornerstone to quality healthcare delivery and is associated with positive patient health outcomes. It is a core component of established healthcare disciplines, such as medicine and physiotherapy and is beginning to gain recognition and curriculum space in younger disciplines such as audiology. While there has been a growth in patient communication education in the audiology curricula, studies have reported that students feel ill-prepared when communicating with patients about their hearing impairment. Research remains sparse in exploring the current gaps in communication skills education in audiology. In addition, little is known about student-patient communication in a naturalistic setting such as clinical placements. Therefore, the overarching aim of the research was to explore patient-centred communication in audiology education in an Australian context. This research contains three studies. The first study aimed to examine the perspectives of audiology educators towards patient-centred communication. Semi-structured interviews were conducted with nine audiology program coordinators and key teaching staff to examine the barriers and facilitators to teaching patient-centred communication. Content analysis of the transcribed interviews revealed four emerging themes: professional culture and values, contextual factors, knowledge and understanding of patient-centred communication and individual factors. The findings shed light onto the competing tension between the teaching staff’s value towards patient-centred communication and the biomedically-driven professional culture that places a priority towards technical skills. The aim of the second study was to explore audiology students’ perception of their own clinical communication and learning in the audiology program. In a semi-structured interview using video reflexivity, fifteen students were asked to co-view their own filmed clinical appointment and discuss areas that were most salient to them. Thematic analysis revealed the themes of striving to be patient-centred, assessment shapes behaviour, and power relations to have the biggest influence on students’ own clinical communication. The final theme of what students want uncovered students’ perception towards different teaching methods. These findings showed students’ motivation to demonstrate patient-centred communication can be hindered by conflicting educational standards. The final study examined two interrelated research questions: i) how do audiology students co-construct the communicative tasks in a supervised hearing assessment appointment?; and ii) how does students’ communication align with the principles of patient-centred communication? Final year audiology students from two Australian universities were video-recorded during one of their university-based clinical placements. Two analytical procedures were performed using genre analysis and the development of The Patient-Centred Analytical Framework for Audiology to map students’ patient-centred communication. Findings showed clear communication patterns in how students structured the appointment in the presence of the clinical educator. Students also demonstrated patient-centred communication skills in fostering the relationship and gathering patient information. However, shared decision-making, enablement and responding to patients’ emotional concerns were rarely observed. A significant relationship was found between the clinical educators’ interjection and students’ patient-centred communication patterns. Collectively, these findings identified strengths and gaps in students’ patient-centred communication, and raised questions about the clinical educator’s role in the provision of learning opportunities during the clinical placement. This body of work demonstrated the complexities in teaching and learning patient-centred communication and highlighted the tension between existing barriers and enablers to the implementation of clinical communication education. Irrespective of external barriers, teaching and learning relies on educators’ knowledge and understanding of patient-centred communication. This may include training educators and providing clear guidelines to strengthen the alignment between educational content required for practice, as well as skills to optimise student feedback. To change the technical and biomedical focus within the audiological culture, the development of a unified teaching framework for communication could inform teaching content and assessment rubrics. Ultimately, communication is a skill that requires the opportunity for development. This can be facilitated by integrating communication education longitudinally into the audiology curriculum. Continual reinforcement of communication skills over the course of the program will sustain students’ communication learning and promote skilled communicators.
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ItemPatient-practitioner interactions: older adults and their audiologists( 2014)Hearing impairment increases in prevalence with ageing. If left untreated, hearing impairment can be a barrier to successful ageing and can cause a variety of negative consequences. Recent investigations of factors associated with hearing aid uptake and use by older adults revealed a paucity of research examining the value and influence of patient-audiologist interactions. Within the health professions, there is a growing interest in patient-practitioner interactions and in particular the quality of professional exchanges termed “patient-centred”. Philosophical and clinical definitions of the term are reported throughout literature where decades of research illustrate relationships between patient-centred care and improved patient outcomes. Before such relationships can be examined in audiological rehabilitation for older adults, the term needed first be defined and the existence of patient-centred interactions explored. This research utilised a mixed-methods design to triangulate patient-centred care in audiological rehabilitation as defined by older adults with hearing impairment with observed patient/companion-audiologist communication in audiology consultations. A sequential exploratory design was used across two studies. Firstly, a qualitative descriptive study was conducted with a purposively sampled group of older adults who owned hearing aids. This study explored participants’ experiences with audiologists and their definition of patient-centred audiological rehabilitation. The findings of this study are represented visually in two models. The first model describes the people, behaviours and processes required to provide patient-centred audiological rehabilitation: a therapeutic relationship was seen as central to patient-centred audiology interactions; the audiologist and patient were seen as key players; and the way two processes occurred (information exchange and decision-making) was considered instrumental in whether audiological rehabilitation was patient-centred. The second model provided an operationalised description of how patient-centred care can be clinically implemented. In this model, there were four dimensions: 1) therapeutic relationship, 2) informed patients, 3) involved patients and 4) individualised care. Results from Study 1 provided a rationale and focus for the examination of patient-audiologist communication in initial consultations and thus informed the second study. In Study 2, 63 initial consultations between audiologists and older adults (and companions in 17 cases) were filmed and analysed using the Roter Interaction Analysis System (RIAS). This method was used to examine the presence and nature of patient-centred communication. Analyses were conducted in two phases: Study 2a focussed on the history-taking phase of initial consultations and Study 2b focussed on the counselling phase. Taken together, the results revealed a dearth of patient-centred communication in initial consultations. That is, little communication was invested in developing a therapeutic relationship; patients were primarily informed only about hearing aids and audiologists asked closed-ended, biomedical questions thus limiting information received about patients’ needs. Little patient and companion involvement was observed. Audiologists rarely sought input from those accompanying the client and, in the presence of a companion, asked fewer psychosocial and lifestyle questions and offered less psychosocial and lifestyle education than when a companion was not present. Limited individualisation of information and options was observed. At the conclusion of this thesis, the results of Study 2 were juxtaposed with the results of Study 1. The overall findings present an imperative to value and promote the quality of patient-audiologist interactions, beyond technical skills, in the provision of “patient-centred” audiological rehabilitation for older adults and in the education of students of audiology.
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ItemCentral auditory processing in schizophrenia patients who experience auditory hallucinations( 2013)Central Auditory Processing can be conceptualised as how the brain interprets auditory stimuli. Disordered auditory processing may lead to difficulties interpreting complex auditory signals such as speech, even where normal sound detection thresholds are recorded. Auditory verbal hallucinations are the perception of hearing voices “in the head” in the absence of auditory stimuli, and occur in over 70% of patients with schizophrenia. Impaired central auditory processing in schizophrenia patients with a history of auditory hallucinations has been reported, and evidence suggests possible dysfunction of interhemispheric transfer in auditory circuits in this group. This thesis investigated the hypothesis that connectivity between left and right auditory cortical regions may be reduced in schizophrenia patients who experience auditory hallucinations, compared with both non-hallucinating patients and healthy controls. Experiments 1 and 2 used electrophysiological techniques to investigate the hypothesis. EEG was recorded continuously while subjects listened passively to pure tones and single-syllable words, presented monaurally to each ear. Experiment 1 used temporal information obtained from latency measures of the auditory N1 evoked potential to examine interhemispheric connectivity between auditory cortical regions. The Interhemispheric Transfer Time (IHTT) was calculated by comparing latencies of the auditory N1 potentials recorded contralaterally and ipsilaterally to the ear of stimulation, for each stimulus type. No between-group differences of IHTT were found for pure tone stimuli. For word stimuli however, significant between-group differences were found: the IHTT was highest in the hallucinating patient group, close to zero in the control participants, and was negative (shorter latencies ipsilaterally) in the non-hallucinating patients. Experiment 2 used the technique of EEG spectral coherence to examine interhemispheric functional connectivity between cortical areas known to be important in the processing of auditory information. Upper alpha and upper beta band interhemispheric coherence was calculated from six pairs of electrodes located over homologous auditory areas in the left and right cerebral hemispheres. In the upper alpha band, significant between-group differences were found on four electrode pairs (C3-C4, C5-C6, Ft7-Ft8 and Cp5-Cp6). Of the three groups, coherence was lowest in the hallucinating patient group, consistent with the hypothesis that interhemispheric connectivity may be reduced in these patients. Experiment 3 used two behavioural auditory tasks which are thought to be sensitive to interhemispheric transfer difficulties – the Staggered Spondaic Words (SSW) and the Frequency Pattern Test (FPT) – to assess interhemispheric transfer function and dysfunction in schizophrenia patients. Although a wide range of abilities were found in both patient groups, overall group results from the behavioural data suggest reduced interhemispheric connectivity in auditory hallucinating patients. These behavioural results were correlated with coherence data from Experiment 2, and significant correlations were found. In conclusion, this thesis provides evidence which supports the hypothesis that, in schizophrenia patients who experience auditory hallucinations, the transfer of auditory information between the left and right auditory cortices via the corpus callosum is less efficient than in healthy people.