HECS3077 200574013

Word Count: 5730
Student number 200574013
The view of
audiologists on
medicalisation and
its desirability
within NHS
services
HECS 3077 Research Project
Submission date
4/29/2015

HECS 3077 Research Project StudentNo.200574013
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Abstract
Key Message: Medicalisation and its effect on stigma and hearing aid (HA) uptake
is complex, further study is required to gain clarity as well as an insight into the
effects of the patient journey on HA uptake.
Objectives: A qualitative and quantitative approach was used to explore the views of
National Health Service (NHS) audiologists regarding medicalisation, its desirability
and its effect on stigmatisation and HA uptake. Additionally there was an opportunity
to gain awareness on how NHS services are medicalised across Yorkshire and
Humber.
Methods: An online scoping survey was developed for NHS audiologists; enrolment
was conducted via a snowball recruitment process. 26 responses were collected
aged 22-51 (mean age 34 years). Questions were grouped into themes of
medicalisation, desirability and ratings on how highly departments are medicalised.
Within these themes audiologists rated statements on treatment, visual information,
environment, HA technology and treatment. A model of medicalisation, stigma and
HA uptake was presented with an opportunity for participants to pass comment.
Results: Various components were considered more medicalised than others, such
as anatomical charts, disease information, atmosphere, hearing technology choice
and treatment of conditions. Desirability was varied between these medicalised
components. Departments on the whole were moderately medicalised.
Conclusion: Moderate medicalisation is already occurring within NHS audiology
departments; however the link between stigma and HA uptake is unclear.
Additionally, audiologists rate medicalisation as both desirable and undesirable.

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Further study is needed to clarify themes and gain further insights into how working-
aged adults view medicalisation regarding stigma and HA uptake.
Key words:- Medicalisation, Stigma, Hearing aid uptake.
Introduction
Age related hearing loss (ARHL) is a common sensory impairment affecting
adults. It has been estimated that 1 in 10 adults aged between 40-69 years have
some degree of hearing loss with prevalence increasing with age (Dawes et al.,
2014; Smits et al., 2006; Wilson and Strouse, 2002). This impairment goes beyond a
physical deficit of the auditory system; it impedes psychosocial elements such as
behaviour, cognitive reactions, and quality of life of significant others (Arlinger, 2003;
Brooks et al., 2001; Hogan, 2001; Scarinci et al., 2008). There are negative
associations with ARHL, for example social isolation, depression, anxiety, reduced
quality of life and decreased physical wellbeing (Morgan-Jones, 2001; Hetu, 1996;
Hogan, 2001). These associations have a significant burden on society however;
reports have suggested that HA usages can reduce these effects and may help
reduce the likelihood of developing dementia, or impeding the development of
dementia (Mathers et al., 2006; Lin et al., 2013; Brooks et al., 2001; Dawes et al.,
2014; Chisolm et al., 2007).
Despite these benefits HA use remains low; Dawes et al. (2014) noted only
2% of adults aged 40-69 years regularly used HAs, this finding was similar to
previous studies (Davis et al., 2007; Davis, 1995). Numerous factors have been
proposed to explain this level of HA uptake for instance, perceived lack of benefit,
appearance and comfort plus denial and stigma (Wallhagen, 2010; McCormack and
Fortnum, 2013; Hetu, 1996).

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Stigmatisation is the process when individuals believe that an attribute or
characteristic devalues a person’s identity (Crocker, 1999). Stigmatisation can
impact on a person’s behaviour, from denial of hearing impairment to dismissing
advice from significant others and professionals (Garstecki and Erler, 1998; Hallberg
and Carlsson, 1991). Studies have suggested that HA uptake is adversely affected
by this social construct, conversely, other studies have suggested that stigma
towards has little or no effect on HA uptake (Franks and Beckmann, 1985; Garstecki
and Erler, 1998; Wallhagen, 2010; Meister et al., 2008; Knudsen et al., 2010; Hallam
and Brooks, 1996). Nevertheless reducing stigmatisation may positively impact on
ab individuals acknowledgment of their hearing loss and may enable them to
understand what the hearing care specialists and their significant others are
proposing (Wallhagen, 2010).
Wallhagen (2010) discussed three inter-related experiences related to stigma;
vanity, ageism and self-perception. These aspects can combine to make service
users feel disabled, or older than their perceived selves. Therefore stigmatisation
may endanger an individual’s identity, potentially leading to denial of their hearing
impairment and impacting on HA uptake negatively. Nonetheless, acceptance of
ARHL does not guarantee HA uptake, it only offers a greater possibility of uptake
(Hetu, 1996; Wallhagen, 2010; Wänström et al., 2014).
Today, HA wearers have a different digital experience to wearers of previous
analogue designs; HAs are smaller in design, offering a variety of discreet fittings
with improved feedback control, multiple listening programs and dynamic
amplification (Dillon, 2012; McCormack and Fortnum, 2013). These, discrete digital
designs may help reduce stigma associated with vanity however, there are other
factors to take into account, for instance the current healthcare setting may

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unwittingly reinforce stigma from hearing professionals and hospital set up
(Wallhagen, 2010). Audiology departments are typically hospital based, and are
treated similarly with medically focused areas for example surgery, and accident and
emergency. Because of this departments make considerations for infection control
regarding the display and use of hand gel dispensers, easily cleaned flooring and
seating (Loveday et al., 2014). From personal experience, waiting areas have neutral
colour schemes with information on diseases unrelated to ARHL displayed on walls.
Additionally clinic rooms have anatomical posters on display and clinicians may use
medical terminology. These medicalised components may contribute to the
impression of illness and therefore increase stigmatisation for working-aged adults
and may affect HA uptake.
Medicalisation is the process of treating human disorders and conditions as
illnesses or sickness (Morrall, 2009; Conrad, 2007). Currently the NHS model of HA
provision is originated from a general practitioner (GP) referring patients to audiology
services. This biomedical approach may reinforce stigmatisation and the belief that
ARHL is an illness or disease, rather than a natural occurring degradation of the
auditory system (Katz, 2009; Wallhagen, 2010). Therefore, to encourage HA uptake,
departments may benefit from de-medicalising their approach, which may reduce
stigma (Katz, 2009; Brooke et al., 2015; International Longevity Centre-UK, 2014).
Medicalisation however, may be a positive force for individuals to access
treatment, and rehabilitation; for example treating alcoholism as a disease can help
reduce society’s propensity to blame drinkers thus, enabling a reduction in shame
allowing individuals to seek help (Conrad and Schneider, 1992). Additionally, family
members may need medical authority to confirm a person’s limitations due to

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scepticism about the effect a condition has on an individual (Broom and Woodward,
1996).
Conversely, medical terminology and medicalisation may increase
stigmatisation potentially allowing individuals to withdraw from their own
responsibilities or seek blame elsewhere (Mann and Himelein, 2004). As such there
have been calls for mental health services to de-medicalise the treatment of human
misery in an attempt to reduce stigma (Kvaale et al., 2013). As categories of human
misery have expanded, the increased usage of medication may place individuals at
greater risk of iatrogenic harm, when management of certain conditions may be
better suited to social intervention (Conrad and Potter, 2000). However the impact of
medicalisation is dependent on each condition (Broom and Woodward, 1996).
Recently there have been calls for de-medicalisation or moderate medicalisation
within ARHL services however, these reports have not been based on empirical
evidence and the views of audiologists have not been taken into consideration
(Brooke et al., 2014; Brooke et al., 2015; International Longevity Centre-UK, 2014).
Therefore, study is needed to understand the extent medicalisation is occurring
within ARHL and how this impacts on stigma and HA uptake.
Earlier intervention of ARHL within the age group of fifty to sixty years has
been encouraged in an attempt to overcome the aforementioned consequences and
is seen as important to help working-aged adults stay within their careers (Dawes et
al., 2014; Wallhagen, 2010; International Longevity Centre-UK, 2014). Equally
studies have indicated that younger adults gain greater satisfaction from HAs
(Hosford-Dunn et al., 2008; Mulrow et al., 1992). However the average length of time
adults live with ARHL is about 10 years, this length of time may allow maladaptive
behaviours to form, such as denial which could affect HA uptake negatively (Helvik

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et al., 2008; Davis et al., 2007). Nonetheless working-aged adults might fear
discrimination and feel stigma more so than older adults, therefore reducing stigma
may improve HA uptake (Brooke et al., 2015; Hetu, 1996).
Some parallels can be drawn from vision care, the wearing of spectacles did
have some degree of stigmatisation, however, today they are seen as fashion
statements, with designer endorsements and celebrities wearing them in public
(Lewis, 2001 cited in Bichard et al. 2007 page 623; Pullin, 2009). It could be argued
that de-medicalisation of optometry services aided this shift from stigma to fashion,
for instance Shickle et al. (2014) reported that the most important feature of eyewear
was that individuals could choose designer glasses, this was universal across all
ages and gender.
The treatment of age related vision issues with spectacles is very successful,
as the affected muscles that control the lens gain support from corrective lens
(Foster and Jiang, 2014). However, ARHL affects the sensory cells not the muscles
within the middle ear and although HAs offer benefits they cannot correct the
damage of sensory cells. This is where the parallel with vision care ceases, and can
produce a misunderstanding that HAs will bring back perfect hearing.
Aim of study
The intention of this study is to gain evidence on the views of audiologists
regarding what is considered medicalised, what is desirable and how medicalised
departments are. This survey will also offer some insight into the willingness of
audiologist to accept change.

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Method
No studies to date have conducted surveys that gather audiologists’ views on
medicalisation hence, a new survey was developed.
Ethical considerations
Ethical approval was obtained from the School of Healthcare Research Ethics
committee, University of Leeds with reference number RP455 and the date of
approval 07/10/14. This process of gaining ethical approval ensured that the survey
was morally acceptable. Informed consent was implied by participants completing
and submitting the survey, as the information sheet at the beginning informed the
participants of the objectives and that continuing onward from this page constituted
consent. An email address was accessible as a point of contact if participants
wanted further information. Anonymising data allowed individuals to respond without
fear of reprisal; in addition to this participants could exit the survey at any stage
without giving a reason. No element of deception occurred within this survey and any
data collected, was kept confidential and protected by a password that was only
accessible to the researchers involved in this study.
Participants
Anonymous data was collected via Survey Monkey; any participants who
volunteered for the survey could exit at any stage and were selected by an iterative
process using a snowball recruitment strategy.
Purposive sampling was conducted to recruit participants from clinical
partners in the Yorkshire and Humber region, with a request of help to encourage
other audiologists to participate, due to this process a power calculation cannot be

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given. Although emails were sent initially from the survey group, forwarding email
details were unknown and because demographic information collected contained no
personal details, anonymity was protected.
Survey
An online scoping survey was designed via an iterative process, comprising
demographic data and six questions requiring rated responses on medicalisation and
old aged focus, however for the purpose of this paper discussion will focus on the
responses from the medicalisation components. Survey availability was from
12/11/14 to 01/03/15 and both quantitative and qualitative date was collected.
Demographic data collected was age, place of work, job title, time qualification
held for and time spent providing adult hearing services. Development of questions
was based on personal clinical experiences and the article by Brooke et al. (2014).
Participants were asked to rated statements that were grouped under three headings
of what audiologists viewed as medicalised, what they considered as desirable or
undesirable and how medicalised their departments were after a definition was given
(See below).
“Medicalisation
In general, ‘medicalisation’ describes the phenomenon of describing and treating
human conditions (which can be natural and commonplace) as medical
problems/diseases which require medical intervention.
Within Audiology, the assessment, diagnosis and treatment of age-related hearing
loss within a typical hospital setting (comprising of wipe-clean floors/chairs and
practitioners wearing white tunics) is an example of a medicalised approach”.

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Statements requiring evaluation were neutral in wording, for example “Hand
sanitiser stations on the wall” and “Smells such as disinfectant and alcohol-based
sanitisers”. Other statements comprised of imagery, literature, technology choice and
customisation, audiologists attire, how ARHL was discussed, practitioner relationship
and décor. Empty text boxes were placed after each question allowing participants
to make further comments, a full question list is available (Appendix One). At the end
of the survey, a proposed model of medicalisation and its effect on hearing aid
uptake was given; from this audiologists were encouraged to pass comment on this
model.
Four members of the research group developed questions with a further two
reviewing them, discussion was encouraged and where necessary the questions
amended. A pilot study was conducted on audiology students at the University of
Leeds. Based on their responses, questions were reviewed and amended before
completion of the survey.
Each question had to be answered before moving on to the next, and a forced
choice method was used with statements that could not be perceived as positive or
negative to avoid bias. At the mid-point, participants’ numbers were reviewed and
clinical partners reminded.
Data analysis
Descriptive statistics determined using Excel.

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Theory
Medicalisation is an undesirable component of audiology and NHS audiology
departments are highly medicalised. Medicalisation of HA services increases stigma
and negatively affects HA uptake
Results
26 participants responded with an age range 22 to 51 years, average 34.3
years, standard deviation (SD) 9.1 years (Table 1). Job title ranged from student
audiologist to head of audiology. The average hours spent within adult setting was
29.2 SD 10.6.
Table 1: Demographic data of participants
Job title (% of total participants), mean and standard deviation (SD) is given
for age, hours worked within adult setting and time qualification was held for.
Demographic Information Participants n=26
Age in years (mean±SD) 34.3 ± 9.1
Age range in years 22 - 51
Job title %
Head of Audiology 3.8
Chief audiologist 3.8
Senior paediatric audiologist 3.8
Senior audiologist 30.8
Audiologist 46.2
Associate audiologist 7.7
Student audiologist 3.8
Hours worked with adult setting (mean±SD) 29.2 ± 10.6
Time qualification held in years (mean±SD) 9.9 ± 8.1

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Within question two audiologists were asked their views on how medicalised
certain components of audiology was (Figure 1). Components considered highly
medicalised were, hand sanitiser on the wall great extent (GE) 80.8%, some extent
(SE) 11.5% and no extent (NE) 7.7%). Reading material concerning diseases was
second highest (GE 69.2%, SE 19.2%, NE 11.5%), then anatomical charts or
posters (GE 69.2%, SE 19.2%, NE 11.5%) and wipe-clean floors and chairs (GE
61.5%, SE 30.8%, NE 7.7%).
Conversely comfortable, modern décor was weighted towards not medicalised
(GE 15.4, SE 38.5%, NE 46.2%). Typical NHS colour schemes results were spread
somewhat evenly across the three categories (GE 26.9%, SE 42.3%, NE 30.8%).
With the treatment of naturally occurring age-related conditions as a disease (GE
42.3%, SE 46.2%, NE 11.5%) and an equal client and practitioner relationship (GE
30.8%, SE 46.2%, NE 23.1%) were considered more towards to some extent
medicalised.

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Question three asked participants to state whether these components were
desirable or undesirable (Figure 2). Areas of greatest desirability were equal client
and practitioner relationship and hand sanitisers on the wall, both at 96.2%, followed
Hand sanitiser stations on the wall
Reading materials concerning diseases
Anatomical charts or anatomy posters
Wipe-clean floors and chairs
Smells such as disinfectants and alcohol-based
sanitisers
White tunics or uniforms
The treatment of naturally occuring, age-related
conditions as a disease
An equal client and practitioner relationship
Typical NHS colour Schemes (e.g. magnolia,
cream, pastel blue)
Professional but personal attire
Comfortable, modern decor
Bright, economic, effcient lighting
Abscence of music or radio in waiting rooms
0.0 20.0 40.0 60.0 80.0 100.0
Componentsofinterest
Percentage
To whatextentdo you associate the following with the term
'medicalistion'?
Great extent Some extent No extent
Figure 1. Clinician’s views on the extent components within audiology are considered
medicalised

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by bright economic efficient lighting 92.3%, anatomical charts or posters 88.5%, and
wipe-clean floors and chairs 84.6%. Conversely limited range of HA choice or
customisation was undesirable at 80.8%. Areas that were marginally undesirable
included typical NHS colour scheme (57.7%) and treatment of naturally occurring
diseases (46.2%) with an equal split between desirable and undesirable regarding
reading materials concerning diseases.
0.0 20.0 40.0 60.0 80.0 100.0
Limited range of hearing aid…
Smells such as disinfectants and alcohol-…
Typical NHS colour Schemes (e.g. magnolia,…
The treatment of naturally occuring, age-…
Abscence of music or radio in waiting rooms
Bright, economic, effcient lighting
Percentage
Areaswithintheworkplace
Do you think that the following are desirable or undesirable in an
audiologyworkplace?
Undesirable Desirable
Figure 2. Percentage of desirability of components within audiology

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Prior to question three a definition of medicalisation was given; three
respondents exited the survey at this stage indicating a dropout rate of 11.5%, this
question asked audiologists to rate how medicalised their workplace was (Figure 3).
Many areas were considered moderately medicalised components. Overall
atmosphere of waiting area highly medicalised (HM) 8.7%, moderately medicalised
(MM) 65.2%, slightly medicalised (SM) 17.4%, not medicalised (NM) 4.3%), posters
or advertisements on the walls (HM 4.3%, MM 65.2%, SM 26.1, NM 4.3%),
information offered in leaflets (HM 13.0%, MM 60.9%, SM 26.1%, NM 4.3%) and
Hearing technology choice available (HM 13.0%, MM 56.5%, SM 26.1%, NM 4.3% .
Other components were weighted towards MM however to a lesser extent, use of
colour in department décor was considered (HM 17.4%, MM 39.1%, SM 30.4%, NM
8.7%), an equal client/practitioner relationship (HM 17.4%, MM 39.1%, SM 34.8%,
NM 8.7%). Finally how age related loss is discussed with client/family members (HM
.4%, MM 30.4%, SM 43.5%, M 4.3%).

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At the end of the study respondents were asked to comment on the proposed
model of medicalisation and its effect on HA uptake. Twelve comments were
recorded some are included below a full listing is in appendix one.
Some audiologists agreed partially with this model with these statements
“I agree that a higher rate of stigma would lead to a lower HA uptake, but not sure if
medicalised HA services would lead to increased stigma.”
Figure 3. Clinicians views on how medicalised components are within their departments

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“I agree that traditional beige BTE aids discourage some users (including older
patients) from wearing NHS hearing aids. Patients still see hearing loss as a problem
mainly relating to old age.”
“yes, the more options/colours/styles available to the pt [sic] the better, they may
accept aids more.”
“I think there is some merit to it, but at the same time a hospital has to cater for
people who are incontinent, not very mobile, partially sighted as well as hip young
things…?”
Whilst others disagreed with the model with the statements below.
“It represents a dated model of hospital sevices [sic]……”
“I don't agree that medicalising something automatically gives it an old-age focus.
But putting an old-age focus can then increase stigma”
“Stigma may not be entirely due to medicalisation of services.
Discussion
Reading and visual information
Audiologists viewed reading materials about diseases as greatly medicalised,
and regarded its desirability at 50%, this implies that this approach could argued as
the wrong approach, while others think it is the right approach. The desirable opinion
may have developed from the belief that health promotion is the responsibility of the
NHS and that prevention is better than cure, therefore contact with health
professionals it is seen as an opportunity to educate patients (Mulrow et al., 1992).
Equally some may argue that raising awareness of diseases helps drug companies

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to sell more products and allows passive medical influence into everyday life
(Moynihan, 2002; Conrad and Potter, 2000). Audiologists rated information within
their departments as moderately medicalised, this result may imply there is other
information offered within departmental literature on offer, but what this is, is
unknown.
It is unclear whether this approach is suitable, however, as medicalisation is
the process of expanding medical practice into everyday life and that ARHL is not an
illness, these results suggest that disease awareness is encroaching into audiology
departments (Morrall, 2009).This may be due to waiting areas being shared with
medical departments, thus medicalisation is occurring with unknown effects on
patients’ views of service and HA stigmatisation.
Anatomical charts and posters were considered highly desirable and greatly
medicalised; this may be due to the desirability in offering a visual tool to discuss
ARHL. Visual information, and disease awareness within the surveyed departments
is medicalised, these results may imply that medical information can be desirable
and may be useful when explaining ARHL, or promoting the expertise of the
audiologist. However, how this impacts on a working adult’s perception of self is
unclear. This visual information may be desirable but it could be argued that it does
not necessarily need to be in plain view as some patients may feel overwhelmed
amongst this visual input. A suggestion would be to remove medical imagery and
disease information from clinics, and waiting rooms, yet keep it accessible for
audiologists as and when needed.
Environment

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Overall atmosphere of surveyed waiting rooms was viewed as moderately
medicalised, this generalised term has numerous components, therefore harder to
analyse. However, aspects of, décor and colour may influence this opinion, therefore
these aspects will be discussed regarding desirability and their medicalised nature.
Wipe-clean floors and chairs were considered greatly medicalised, and highly
desirable. Because audiology is predominantly hospital based, departments are
influenced by infection control measures hence, the need for easily cleaned seating
and a view held by one audiologist within this survey (Loveday et al., 2014; Hosford-
Dunn et al., 2008).
Audiologist: “… a hospital has to cater for people who are incontinent….”
Audiology has close working links with Ear Nose and Throat departments and
may share waiting rooms, which may lead to a potentially increased risk of infection.
Despite this some hospital departments do have softer furnishings in a bid to
improve the environment for patients, for example within cancer treatment wards
(Dalke et al., 2006). As ARHL is not the result of an infectious process it could be
argued that clinical procedures such as using single use specula will minimise any
potential risk of infection (Hosford-Dunn et al., 2008). This survey suggests medical
concerns over infection infringes upon ARHL patients, therefore medicalisation has
encroached into audiology waiting rooms. How affects stigma for working-aged
adults and HA uptake is undecided, nonetheless anecdotal evidence suggests that
patients and staff may prefer a relaxed domestic environment (Dalke et al., 2006).
Colour use within departments can help promote well-being and if used
incorrectly could be visually disturbing, several studies have shown that wall colour
can affect mood and behaviour greatly equally, others have reported only modest

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effects on attitude (Dijkstra et al., 2008; Mattila and Wirtz, 2001; Kuller et al., 2006;
Dalke et al., 2006). NHS colour schemes were considered medicalisation to some
extent, with slightly greater undesirability, yet the weighting of medicalisation was
close to an equal split between great, some and no extent. These results may imply
mixed views over whether traditional NHS colour schemes can be considered
medicalised or not. When clinicians rated their workplace, departments were
weighted towards moderate then slightly medicalised. This suggests that colour use
within departments may vary between traditional and non-traditional but may also
reflect the personal opinions of respondents. It’s undecided if colour can be
considered a form of medicalisation, and whether it can negatively impact HA uptake
however, to enable a positive experience for working-aged adults a modern décor
may be beneficial, equally it was reported as being less medicalised than typical
NHS colour schemes.
Audiology departments are some distance from designer decor, soft
furnishings, carpets and bold colouring. Nonetheless these results potential indicate
that departments are varied within their use of undesirable NHS colour schemes,
with some desirable medicalised components such as hand sanitiser and easily
cleaned seating. The results support previous suggestions that hospitals are
preferred to be modern, up to date and clean in line with commercial environments
(Dalke et al., 2006; Loveday et al., 2014). Again how this affects working-aged
adults, stigma and HA uptake is unknown
Technology
Audiologists considered a limited range of hearing aids as undesirable and rated
departmental choice of hearing technology available as moderately medicalised.

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These results suggest that audiologists prefer offering a greater choice, as one
audiologist commented.
Audiologist: “…the more options/colours/styles available to the pt [sic] the better,
they may accept aids more.”
Equally these findings indicated that some departments are offering choice.
Audiologist: “…we offer a wide range of hearing aids including in-the-ear aids and in
a choice of colours…”
Yet, it is unclear what elements of hearing technology was viewed as moderately
medicalised, for example was it style of HAs, colour, or assistive technology, equally
it was undetermined whether this medicalisation impacted on stigma and HA uptake.
This issue may have a limited impact on stigma with recent studies suggesting that
HA wearers are seen as more respect worthy, potentially indicating that HA
stigmatisation has reduced, indeed one study suggested there was greater stigma
associated with hearing loss than HAs (Erler and Garstecki, 2002; Rauterkus and
Palmer, 2014; Clucas et al., 2012). This positive trend is reflected in evidence stating
that 4% of adults disliked the look of HAs, and where cosmetic appearance was
linked more so with satisfaction over non-uptake (Eurotrak, 2012; Mulrow et al.,
1992; Hosford-Dunn and Halpern, 2001). Nevertheless, the effect of HA design on
uptake may affect one individual more so than another, potentially from
preconceptions based on negative experiences of older HA designs. Nonetheless,
adults need to accept that this stigma is reducing with regard to wearing HAs for it to
positively impact HA uptake (Rauterkus and Palmer, 2014). Therefore further
detailed study with clearer questioning is required to better understand this issue.

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Clinician contact
How hearing loss is treated as a naturally occurring, age related condition as
a disease was seen as greatly and to some extent medicalised with divided
desirability. When asked to rate departments how ARHL was discussed it was
considered slightly medicalised. These results may indicate the variety of opinions or
styles that clinicians take when dealing with ARHL, inferring that the management of
ARHL has medicalised elements dependent on the audiologist.
Medicalisation is the treatment of human conditions as a disease; therefore
they come under medical study and are likely to be described using medical
terminology (Conrad and Schneider, 1992).The use of medical terminology may lead
patients to consider their condition more severely, which may potentially increase
emotional distress (Young et al., 2008). A recent study suggested that narratives
during appointments may affect satisfaction of HA fittings; however, this study was
unable to suggest what narrative is preferred, advocating a patient centred approach
to gain the best outcomes (Naylor et al., 2015).
Within this survey audiologists considered an equal practitioner client
relationship as to some extent medicalised and was seen as a desirable component
yet, within departments it was considered moderately medicalised. This may again
infer that how this relationship develops is dependent on the audiologist; Bentler et al
(2003) suggested that patients trusted the clinician over their own ears. This agrees
with previous research that suggested patient partnerships affect disease outcomes
(Stewart, 1995; Di Blasi et al., 2001). Therefore audiologists need to be wary of their

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impact on patient outcomes, in regards to how they build a rapport, how ARHL is
discussed and how management of the condition is conducted.
These studies have highlighted the impact medical language may have on a
patient’s decision to try HAs. Nevertheless, because the patient has had to discuss
their hearing with a GP before a referral is made how ARHL is discussed at this point
may be more influential to HA uptake than during audiology assessments (Humphrey
et al., 1981).
A recent report highlighting dropout rates of patients during their journey to
HA provision, indicated a 23% dropout rate occurred from visiting a GP to audiology,
while out of the 46% referred to audiology the percentage of patients taking up HAs
dropped by five percentage points to 41% (Eurotrak, 2012). This suggests that
language used before entering audiology may be more significant than within a
hearing assessment appointment. Yet further study is needed to understand
language and its impact during the patient journey.
Finally the proposed model of medicalisation increasing stigma and therefore
reducing HA uptake had limited agreement. Thus presently, we cannot assume that
medicalisation within audiology departments is solely responsible for increasing
stigma and negatively affecting HA uptake.
Despite testing before implementation there are some limits within this survey.
The response rate was indeterminate, therefore survey design success cannot be
assessed, yet, the dropout rate of 11.5% could indicate that the survey was too long,
or that audiologist found it too difficult to answer. Wording of statements were at
times ambiguous, for example “hearing aid technology choice” was meant to infer
assistive devices as well as HAs, but it’s unclear whether this statement was taken

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as such. Additionally several statements were not repeated across the three
question areas, this made it hard to compare areas directly, from opinion to
desirability to reality. Future surveys may benefit from consistent statements across
all questions with greater depth and clarity.
Furthermore the survey did not ask where the participants worked in order to
protect their identity, therefore it is unclear how many departments were rated,
making it hard to generalise these results. The views of audiologists are important
equally as the NHS strives for patient centred care and that the patient journey starts
before audiology, a larger study looking at current pathways and their impact on
stigmatisation would offer a more rounded insight into service provision.
Conclusion
This survey has highlighted elements within audiology that are highly
medicalised and desirable, for example infection control measures, as well as
moderately medicalised and desirable, such as how ARHL is treated and finally
minimally medicalised and undesirable regarding NHS colour schemes. This Implies
that medicalisation in its various forms has positive and negative associations. These
results suggest that audiologists may be open to change within some areas
however, how these changes affect stigma and HA uptake is unclear. The model
proposed had minimal agreement, suggesting the surveyed elements are more
complicated than initially thought therefore; it is difficult to make an association of
medicalisation and its impact on HA uptake. Indeed some participants suggested the
patient journey contributed to stigma and HA uptake more so than audiology
departments.

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Surveyed departments were considered moderately medicalised more than
any other classification, despite this, HA uptake still remains low. This may infer that
moderate medicalisation may still negatively affect HA uptake, equally it could be
deduced that components outside the remit of this study contribute more so but
could not be assessed, therefore further investigation to understand the impact of the
patient journey is needed. Nonetheless if departments make changes in an attempt
to appeal to working-aged adults, the requirements of all patient groups will need to
be preserved, as the NHS caters for all people of all ages, ranging from the unwell to
the well.
This study has gained insight from a small group of audiologists from an
uncertain number of NHS departments. It was unsuccessfully linking medicalisation
with stigma and HA uptake. Nevertheless, as a scoping survey it has offered an
insight into audiologists understanding of what medicalisation is, its desirability and
an awareness of how departments approach HA provision.

Page 25
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(Bichard et al., 2007; Shickle et al., 2014; Pullin, 2009; Arlinger, 2003; Bentler et
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1992)
Appendix one
Question one: Please tell us the following information
How old are you?
Do you work within the NHS, Private Non-independent (e.g. Boots, Specsavers) or
Private Independent?
What is your current job title?
How many hours per week do you spend providing adult hearing services?
How long have you been qualified?
Question two: To what extent do you associate the following with the term
'medicalisation'?
Audiologists rated below as: Great extent, Some extent, No extent
Bright, economic, efficient lighting
Typical NHS colour schemes (e.g. magnolia-cream, pastel-blue)
Absence of music or radio in waiting rooms
Smells such as disinfectants and alcohol-based sanitisers
The treatment of naturally occurring, age-related conditions as a disease
Professional but personal attire
Comfortable, modern decor

Page 29
Question three: Do you think that the following are desirable or undesirable in
an Audiology workplace?
Audiologist rated below as: Desirable, Undesirable
Brightly, economic, efficient lighting
Hand sanitiser stations on walls
Absence of music or radio in waiting rooms
Limited range of hearing aid choice/customisation
Smells such as disinfectant and alcohol-based sanitisers
The treatment of naturally occurring, age-related conditions as a disease
We will be asking you questions about this.
Medicalisation
In general, ‘medicalisation’ describes the phenomenon of describing and treating
human conditions (which can be natural and commonplace) as medical
problems/diseases which require medical intervention.
Within Audiology, the assessment, diagnosis and treatment of age-related hearing
loss within a typical hospital setting (comprising of wipe-clean floors/chairs and
practitioners wearing white tunics) is an example of a medicalised approach.ng white
tunics) is an example of a medicalised approach.

Page 30
Question four: After reading our definition, please rate how ‘medicalised’ your
workplace is in the following areas.
Audiologists rated below as: Highly medicalised, Moderately medicalised, Slightly
medicalised, Not at all medicalised, N/A
Use of colour in department decorations
Information offered in leaflets
Posters or advertisements on the walls
Auditory environment (e.g. telephones, alarms, patient/practitioner conversations)
Hearing technology choice available
Selection of magazines available
How age-related hearing loss is discussed with clients/family members
Smell (such as disinfectant)
Overall atmosphere of waiting area
Old-age focus definition
In general, the term ‘old-age focus’ is used to describe an approach or environment
that is targeted towards an elderly demographic.
Within an Audiology setting, many aspects are arguably old-age focused. This
includes the provision of leaflets targeted towards an older readership (e.g. leaflets
regarding mobility scooters) and upright chairs within waiting rooms.

Page 31
Question five: What age group do you MOST associate the following with? (We
appreciate your opinions may overlap on some choices).
Audiologists rated below as: Under 45 year-olds, 45-65 year-olds, 70-80 year-
olds,80+ year-olds.
Plastic, easily cleaned, upright chairs
Information leaflets about diseases
Contemporary music
Contemporary fixtures and furnishings
"Daytime TV"
Electronic appointment systems
After reading our definition, please rate how ‘old-age focused’ your workplace
is in the following areas:
Audiologist rated below as: Highly, Moderately, Slightly, Not at all, N/A
Style of seating in the waiting room
Selection of reading materials (e.g. magazines or books)
Advertisements & information on walls (e.g. posters or leaflets)
Style and colours of hearing aids available
Hearing technology choice available
How age-related hearing loss is discussed with clients/family members
Music/radio/TV programmes playing in waiting area
Artworks, wall graphics and wall decorations
Overall atmosphere of waiting area
Comments
“I work within paediatrics”
“we offer a wide range of hearing aids including in-ear aids and in a choice of
colours. I've struggled to answer these questions!”

Page 32
On the final page we displayed the model below
The above model proposes that increased medicalisation can lead to increased
stigma, which reduces the uptake and usage of hearing aids.
Please tell us what you think about this model...
Below are the comments we received
“Model implies 'problem', as opposed to natural ageing process. People with hearing
loss much more likely to walk in to store in town than make decision to visit a
hospital
“i agree that a higher rate of stigma would lead to a lower HA uptake, but not sure if
medicalised HA services would lead to increased stigma.”
“I agree that traditional beige BTE aids discourage some users (including older
patients) from wearing NHS hearing aids. Patients still see hearing loss as a problem
mainly relating to old age.”
“Nonsence [sic]”
“most patients who come to our department are just happy to be given a professional
and free services and i feel that the surrounds they receive this in is not their main
prority [sic]”
“yes, the more options/colours/styles available to the p [sic] the better, they may
accept aids more”
“Patients have had to identify that they have a problem/deficit in the first instance
before they even get to audiology (ie have to see their GP in a MEDICALISED
environment). I think that only a very tiny proportion of patients for which the model
will apply. The implication is that when the experience the medicailised environment
[sic], the choice of hearing aids, the general literature/TV programmes/waiting room
posters, that they will develop a greater stigma and will thus have decreased hearing
aid uptake. I think that the initial view of the patient regarding their hearing loss is of
far greater importance than the medicalisation of hearing loss/aids/departments. If
they already have negative associations, medicalised hearing aid services may have
MEDICALISED
HA SERVICES
STIGMA HA UPTAKE

Page 33
little to no effect. Or vice versa, the smell of the disinfectant may evoke feelings of
'being made better'. A 'new build, smart department' that is well thought out and
attractive but still 'medicalised' can have a very different effect compared with an old,
worn out, ill-fit for purpose department. The main problem with this model is the word
'stigma' as it can mean lots of different things to lots of different groups”
“It represents a dated model of hospital sevices [sic]. PT's have a increased
expectations of services provided that should [sic] be reflected in the environment”
“I feel that when the audiology department is based in a hospital we are limited in
terms of the environment as we have to abide by IP&C and Trust policies. However
this is just 1 aspect of the service and if audiologists talk to their patients in the right
way then there shouldn't be stigma associated with coming to the hospital and
getting hearing aids”
“I think there is some merit to it, but at the same time a hospital has to cater for
people who are incontinent, not very mobile, partially sighted as well as hip young
things. Would you like a softly furnished room for continent well washed younger
people only?”
“Not sure whether this is true as many patients will opt for a hospital setting over that
of a shop (eg going to an AQP provider) so I don't think that medicalised services as
always undesirable”
“ I don't agree that medicalising something automatically gives it an old-age focus.
But putting an old-age focus can then increase stigma
“Stigma may not be entirely due to medicalisation of services.”

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