April 2021 The Hearing Journal

What drives eligible adult patients to get a cochlear implant (CI), and what prevents others from choosing the same? A recent Australian study explored the perspectives of various stakeholders in the patient journey to map the specific drivers and barriers in patients’ decision-making on cochlear implantation. The resulting concept map shows that CI uptake decisions are heavily influenced by patient-related factors more than external ones, and that individualised care is pivotal in influencing clients’ decisions.


In the study, a mix of CI patients and professionals were asked to brainstorm on what influences people's decision-making regarding CIs. The participants generated statements and rated each one based on its impact on the decision. The researchers collected 110 unique statements from this brainstorming, which were clustered into six concepts: external influences; uncertainties, beliefs, and fears; health problems; hearing difficulties; implant professionals; and goals and support. These six concepts further showed two overarching domains: external and patient-driven.

Of the six concepts, four fell under the patient-driven domain: “Fears, belief and uncertainties,” “Health problems,” “Hearing difficulties,” and “Goals and support.”

“The magnitude of the generated statements in the client-driven domain emphasises the pivotal role of understanding client needs and expectations providing individualised care in clinical settings,” the paper stated. “This was an interesting finding as the majority of research in the field to date has emphasised external factors such as cost and inconvenience of travel,” lead author Azadeh Ebrahimi-Madiseh, AuD, PhD, said. “Some of the most prominent barriers identified in this study were Fear of surgery, Fear of unknown, Fear of losing the hearing they have, Hearing unsuccessful stories about CI, or Misinformation about CI’,” she said.

The most prominent drivers to CI uptake were patient-driven, explained Ebrahimi-Madiseh. “These included their unmet hearing and psychosocial needs. Statements such as Being able to communicate with kids and grandkids, Their desire to increase independence, or Confidence in cochlear implants to improve their hearing and communication.


To the researchers, the concept map underscores the need for individualised hearing health care, where professionals understand a patient's needs and expectations. “The magnitude and diversity of the statements in the client-driven domain suggest that understanding the clients’ needs and what matters most to them are the most important steps in having an efficient and effective CI service,” said Ebrahimi-Madiseh. “Providing patient-centred care is not a new concept; the theory has been extensively covered in the literature. In practice, this means focusing on clients’ underlying emotional components of decision making as the first step to address their needs,” she advised. “This includes building rapport and gaining the trust of the client, addressing the underlying fears and uncertainties before reasoning and rationalising the importance of intervening with their hearing loss. That means being less methodical and protocol-driven, being more compassionate, and having a greater focus on the outcome that matters to the patient. And yes, this may mean talking about how big it looks or what colours are available!”

The call to be more patient-oriented isn't exclusive to CI professionals. The study emphasises a collaborative multi-stakeholder approach in overcoming barriers in the patient journey.

“Surprisingly, the first point of decision-making to go ahead or not with a cochlear implant is not at an implant clinic, but the hearing aid clinics where clients receive hearing aid services,” Ebrahimi-Madiseh noted. “The important role of non-implant hearing care professionals, especially hearing aid audiologists, in the journey of a cochlear implant candidate was highlighted in this study.” She added: “Audiologists need to realise that cochlear implantation is not the last resort for when hearing aids are not enough.’ Hearing aids and cochlear implants are two effective pieces of technology that address different problems. Put simply, one amplifies sounds to compensate for the loss of outer hair cells while the other compensates for severe loss of inner hair cells and delivers the signal directly to the nerve endings. “Therefore, the hearing rehabilitation discussion has to be around the need of the person with hearing loss, and must include consideration of a wide range of solutions from the beginning.

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