International Journal of Audiology 2017; 56: 854–861

Original Article

Difficult conversations: talking about cost in audiology

consultations with older adults

Katie Ekberg1, Caitlin Barr2,3 & Louise Hickson1,2

1
School of Health and Rehabilitation Sciences, The University of Queensland, Queensland, Australia, 2HEARing Cooperative Research Centre,
Melbourne, Australia, and 3The University of Melbourne, Melbourne, Australia

Abstract
Objective: Financial cost is a barrier for many older adults in their decision to obtain hearing aids (HAs). This study aimed to examine
conversations about the cost of HAs in detail within initial audiology appointments. Design: Sixty-two initial audiology appointments were
video-recorded. The data were analysed using conversation analysis. Study sample: Participants included 26 audiologists, 62 older adults
and 17 companions. Results: Audiologists and clients displayed interactional difficulty during conversations about cost. Clients often had
emotional responses to the cost of HAs, which were not attended to by audiologists. It was typical for audiologists to present one HA cost
option at a time, which led to multiple rejections from clients which made the interactions difficult. Alternatively, when audiologists offered
multiple cost options at once this led to a smoother interaction. Conclusions: Audiologists and clients were observed to have difficulty
talking about HA costs. Offering clients multiple HA cost options at the same time can engage clients in the decision-making process and
lead to a smoother interaction between audiologist and client in the management phase of appointments.

Key Words: Audiology; hearing rehabilitation; clinician–client communication; cost; shared decision
making; conversation analysis

Introduction participants found HAs expensive to maintain (52%) or not worth

Many older adults who have their hearing tested do not subse-
quently go on to obtain hearing aids (HAs) (Meyer et al, 2011). In a
recent Australian study, Grenness et al (2015a) identified that only
just over half of clients who were recommended HAs within an
initial audiology appointment made a commitment to obtain them
within that appointment. For an individual to adopt HAs, they must
perceive more benefits than barriers to amplification. Several
barriers have been identified that influence older adults’ decision to
seek help and obtain HAs and one of these is financial cost (e.g.
Franks & Beckmann, 1985; Garstecki & Erler, 1998; Kricos et al,
1991; Kochkin, 2007; Fischer et al, 2011; Laplante-Lévesque et al,
2012b; Meyer & Hickson, 2012). For example, a population-based,
prospective study by Fischer et al (2011) found that cost was one of
the most-often reported reasons for not acquiring a HA. Similarly,
in the MarkeTrak VII study (Kochkin, 2007), 76% of participants
described financial constraints as a barrier to acquiring a HA, and
64% indicated that they could not afford HAs. In addition, some
the expense (45%).
In an interview study exploring the factors influencing rehabili-
tation decisions of older adults, financial cost was one of seven key
factors identified by clients as affecting their decision (Laplante-
Lévesque et al, 2010c). Another study by Laplante-Lévesque et al
(2012b) conducted interviews with older adults from four countries
(Australia, Denmark, UK and USA) about their perceptions of
hearing help-seeking and rehabilitation. The cost of HAs was
reported to influence hearing aid selection. Some participants did
not expect there to be such a large range of cost of HAs, and also
described having difficulty in understanding the differences
between the devices and why some cost more than others. The
cost of HAs to clients varies between countries.
To contextualise the current research, in Australia, adults who
receive a Government pension (e.g. old age, disability, war
veterans) are eligible for free hearing services (www.hearingservi-
ces.gov.au). They are provided with a voucher which allows them to
choose a hearing services provider, have a hearing assessment,

Correspondence: Katie Ekberg, Communication Disability Centre, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Queensland 4072,
Australia. Tel: +61 7 3365 8547. E-mail: k.ekberg@uq.edu.au

(Received 18 September 2016; revised 1 June 2017; accepted 2 June 2017)

ISSN 1499-2027 print/ISSN 1708-8186 online ß 2017 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society
DOI: 10.1080/14992027.2017.1339128

Abbreviations
HAs hearing aids
CA conversation analysis
receive advice and support about hearing loss, and if necessary, be
fitted with subsidised hearing device/s and receive a contribution to
the maintenance of the device/s. Using this voucher, a client can
choose fully subsidised hearing devices, partially subsidised hearing
devices or assistive listening devices. The fully subsidised (i.e. free
to the client) devices are digital HAs with the following minimum
specifications: automatic directional microphone (if fitted with
behind-the-ear hearing aids), feedback cancellation, adaptive noise
reduction, multi-channel compression, multi-memory and telecoil.
Clients who choose fully subsidised devices are also eligible for
additional rehabilitation to better manage their hearing loss, a
programme referred to as Rehab Plus. Some clients may choose
partially subsidised HAs in this case they are asked to contribute to
(‘‘top-up’’) the cost of their HAs and receive technological features
to suit individual lifestyles.
Those who are not eligible for public funding are responsible for
financing their own hearing devices and service and the cost of HAs
is typically bundled with other costs. This cost ranges from
AU$2000 to AU$12,000 (We’re All Ears, 2014). Some private
health insurers may contribute to the price of HAs, but this typically
is less than AU$1000 in total over a 5-year period. Additional
ongoing costs for batteries and maintenance are also a consider-
ation. To put this cost in perspective, the average range for an older
person’s household income is $20–40,000 per annum, compared to
$80–100,000 for all Australians (CEPAR, 2014). HAs, therefore,
come at a substantial cost to many older Australians whereas most
other health concerns would be covered under the Government
Medicare rebate system. Funding arrangements for HAs vary, but it
is common for cost conversations to occur and these can be complex
and take a substantial amount of time in audiology consultations
(Grenness et al, 2015a).
Previous research in other areas of healthcare has found that
doctors and clients are uncomfortable discussing costs in clinical
appointments (Alexander et al, 2003; Schrag & Hanger, 2007). A
recent study found that while 52% of clients with cancer expressed a
desire to talk to their doctors about cost, only 19% had this
discussion within appointments (Bestvina et al, 2014). This research
has led to a recent focus on clients’ ‘‘cost-related health literacy’’:
their ‘‘ability to obtain, process, communicate and use health-
related cost information to make informed treatment decisions’’
(Zafar et al, 2015: 171). A key component of health cost literacy
involves clients having the opportunity to discuss expenses with
their clinician(s) as part of treatment decision-making. Discussing
the costs of various treatment options with the client is necessary for
shared decision-making, a key component of client-centred care.
Within audiology, the value of a shared decision-making approach
to hearing rehabilitation planning has already been established in
previous research (Laplante-Lévesque et al, 2010a, 2012a). Clients
have been found to value being offered options (e.g. hearing aids,
hearing assistive technology, communication programs) (Laplante-
Lévesque et al, 2012a). Offering options and using a decision aid,
such as the Hearing Loss Option Grid (www.optiongrid.org), are
also now a recommended procedure by the British Society of
Audiology (Ferguson et al, 2016). However, recent research has
found that clients are not typically offered options for rehabilitation
Cost discussions in audiology appointments 855
within initial appointments (Grenness et al, 2015a). For those clients
who choose HAs, they then have to make decisions relating to
different styles and models of HAs, which have different levels of
cost. This study extends research on shared decision-making in
audiology consultations to explore the question as to whether, and
to what extent, the cost options for HAs are discussed within typical
initial appointments.
The quality of the physician–client relationship has also been
found to particularly influence clients’ treatment decisions when
they are under cost pressures. A study by Wilson et al (2005) found
that clients who reported the lowest quality physician relationship
were at higher risk of cost-related nonadherence. Similarly, Piette
et al (2005) found that clients who had low trust in their physician
were more likely to underuse medications in response to cost
pressures, than those who had greater trust in their physician (under
similar cost pressures). The strongest predictor of clients’ trust in
their physicians is communication style (Hall et al, 2002). Within
audiology, a recent study by Preminger et al (2015) found that the
absence of a ‘‘commercialised approach’’ in audiology appoint-
ments, focussing on comprehensive rehabilitation rather than just
hearing aid sales, was a key factor engendering clients’ trust in their
hearing care clinician. Participants in the study were wary of
clinicians who appeared to focus on hearing aid sales. Participants
had higher trust in clinicians who did not always recommend the
most expensive HAs. A positive communication style (e.g. laughed
at client’s jokes, answered client’s questions), promotion of shared
decision-making and empathy were also key factors in clients’ trust.
Participants had higher trust in clinicians who displayed relational
competence. It is, therefore, important to examine how clinicians
and clients communicate about the costs associated with treatment
within appointments.
Previous research in audiology has shown that aspects of the
client–clinician encounter can have implications for clients’
rehabilitation decisions. For example, Poost-Foroosh et al (2011)
found that factors related to client-centred interaction and client
empowerment influenced hearing aid adoption. However, other
recent research has shown that audiologists may not always
adequately address psychosocial issues that arise within appoint-
ments (Ekberg et al, 2014; Grenness et al, 2015a). Given that HAs
would be discussed in most initial audiology appointments where a
diagnosis of hearing loss has been made, the cost of HAs also
becomes an essential part of the interaction. However, we know
little about how audiologists approach these conversations within
appointments, and how they are typically responded to by clients.
This study aimed to address this gap in current research by
examining, in close detail, conversations about the cost of HAs
within 62 video-recorded initial audiology appointments with older
adult clients.
Method
Participants and procedure
The current study is part of a larger project that profiled and
examined 62 video-recorded audiology appointments with older
adults with age-related hearing impairment. Participants were
audiologists (n ¼ 26), adult clients aged 55 years and over
(n ¼ 62), and their significant others when present (n ¼ 17).
Audiologists had an average of 11.5 years’ experience (range ¼
1–40, SD 10.1), and 61% were female. Older adult clients had an
average age of 71.6 years (SD 8.9) and 58% were male. Within the
data corpus, 48% of the older adult clients were eligible for a
856 K. Ekberg et al.

Government-funded voucher for fully-subsidised, basic HAs
(n ¼ 30) or a subsidy towards more expensive HAs. The other
52% of clients would be required to pay the entire cost of HAs out
of their own pocket. All participants provided written informed
consent.
Recorded appointments contained a hearing assessment and
discussion about rehabilitation options (when relevant), or a follow-
up appointment if the rehabilitation options had not been discussed
in the initial appointment. Recordings were made on an Apple
iPhone or iPhone touch attached to a small tripod. The researchers
were not present in the room during the appointments. Consultations
had an average duration of 57.8 min (SD 20.3). Further details of
participant demographics and data collection procedures can be
found in Grenness et al (2015a, 2015b).
This study received ethical approval from the Royal Victorian
Eye and Ear Hospital, University of Queensland Behavioural and
Social Sciences Ethical Review Committee, and Australian Hearing
Human Research Ethics Committee.
Data analysis
The video data were transcribed using the Jeffersonian transcription
system, which is the standard system used in conversation analytic
research (2004) (see Supplementary Appendix 1 for transcription
notations).1 The data were analysed using conversation analysis
(CA). CA is a micro-analytical approach to systematically studying
clients’ talk.2 Across the data, audiologists and clients displayed
interactional difficulty during conversations about cost. Clients
often took a negative emotional stance in responding to the cost of
HAs. The emotional valence of clients’ responses was not typically
attended to by audiologists.
The second pattern relates to how audiologists typically
presented hearing aid cost options. It was typical for audiologists
to present one hearing aid cost option to the client at a time (it
varied whether they presented the price for either a low, mid or top
range device). Audiologists used this approach in 76% of appoint-
ments (n ¼ 35/46). This type of turn set up a next-turn from the
client to either accept or reject the cost option presented. Following
a rejection from the client regarding the cost of HAs, audiologists
would typically: (1) recommend another, cheaper hearing aid; or (2)
re-question the client about going ahead with HAs. Clients were,
therefore, in a position to potentially have to reject the cost again.
Cost discussions could be quite lengthy and led to difficulty in the
interaction between the audiologist and client.
These typical patterns will be discussed in detail across
Fragments (1)–(2) below. Fragment (1) provides the first example.
In this appointment, the client is still working and not eligible for
Government-funded HAs. She would, therefore, need to pay the full
cost of her HAs.
(1)[C04-3]

naturally-occurring interaction (Sacks et al, 1974; Stivers & Sidnell, 1 A: U::m (0.3) now they– (0.3) 4that–< (0.8) if- if we’re talking
2 about the full cost ra:nge of hearing aids, [they] start at
2012). It is a well-established method for studying healthcare
3 C: [ Mm. ]
interaction (Drew et al, 2001; Heritage & Maynard, 2006), and can
4 A: <about4three thousand dollars for two.
provide details for how participants organise the healthcare visit to 5 (0.4)
accomplish tasks such as history-taking, diagnosing and recommend- 6 C: "Oh: God.
ing treatment (Pilnick et al, 2009). This method has also previously 7 (0.9)
been used to examine interaction in audiology appointments (e.g. 8 C: hhuhh. ((C crying. Takes tissue out of box))
Ekberg et al, 2014). For the current analysis, sequences of talk 9 (0.4)
focussing on the cost of HAs were identified within the corpus and 10 A: And the:
analysed for how audiologists initiated these discussions (they were 11 C: Well no that’s not– that’s not an option. ((C wipes eyes))

always initiated by the audiologist in the current corpus), how clients 12 (1.3)



13 C: I’d rather just live with it. It’s-

That’s crazy.
responded and how these sequences progressed across the manage-
14 (0.4)
ment phase of the appointment. Transcript excerpts of the key
15 C: Especially if you can’t get it back through your health fund.
findings are presented in the Results section. Talk denoted as ‘‘A’’ 16 A: No.¼"Well .hh what– what people ah:: 4we don’t keep tabs on
originates from the audiologist; and ‘‘C’’ originates from the client. 17 every insurance fund < but usually they talk about a
18 figure of about six hundred dollars back.
19 C: Yeah.
Results
20 ((43 lines omitted – A checks about healthcare card))
A hearing aid was recommended to the client in 49 of the 62 21 A: So in terms of (.) hearing aids is that just out of the

appointments (79%). Of these, 46 appointments involved a discus- 22 question then? Do you think?
23 (3.0)
sion about the cost of various HAs and were included in the current
24 C: .tch [hhh]
analysis. In this corpus, discussions about the cost of different HAs
25 A: [ Or ] do you want to look "into that?
occurred even when the client was eligible for fully-subsidised,
26 We:ll I don’t– I don’t– I– I need to think about it.
Government-funded HAs (as they have the option of paying a top- 27 A: Yeah.
up to purchase higher level devices). Recurrent patterns in the way 28 (1.5)
discussions about cost progressed within the management phase of 29 C: U:m (3.2) I’ve got various- you know I’ve got seventy thousand
the appointments are presented below with exemplar extracts from 30 dollars left on my mortgage ¼ which I really want to get paid
the data. 31 off ¼ so I’m not leaving all that to my kids to deal with.
32 (4.5)
33 C: So you know there’s always something.

Typical cost discussions 34 A: Yeah.

35 (0.8)
Two notable communication patterns were observed within typ-
36 C: Two thousand for something to do with the car and now three
ical discussions about the cost of HAs within the appointments.
37 thousand for this y’know I’ll never get it paid off at
The first pattern relates to the emotional valence (Frijda, 1986; 38 this rate.
Ellsworth & Scherer, 2003) of both the audiologists and
 Cost discussions in audiology appointments 857

Within this fragment, a negative emotional valence is observable

within both the audiologist and client’s talk. The audiologist (2) [C07-4]
initiates talk about the cost of HAs in his turn across lines 1–4. He 1 A: #Oka:y, I’m th"inking of devices called the (1.0) ((brand))
displays difficulty in doing so, evidenced by the hesitations, intra- 2 (0.6) ((<number4))
turn pauses and cut-offs in his talk at the start of his turn (‘‘U::m 3 C: Yeah.

(0.3) now they– (0.3) 4that–< (0.8) if-’’, line 1) (Silverman & 4 (0.6)
5 A: because they have that feature that tries to reduce thee
Peräkylä, 1990; Schegloff, 2007). The client provides a negative
6 (0.8) four different background noises,
emotional response to the cost of HAs: ‘‘Oh God’’ (line 6). She also
7 C: Mm,
begins crying (line 8). In conjunction with this emotional response,
8 (0.7)
she makes it explicit that the aforementioned cost is not an option 9 A: <And that4 will allow you to hear be[tt]er¼but4as long as<you
for her (line 11). Again she uses emotional terms in describing the 10 C: [be]
cost as ‘‘crazy’’ (line 13). The audiologist offers the client a tissue 11 keep the noise (0.4) [beh]ind you,
when crying but otherwise does not attend to the emotional content 12 C: [Yep]
of the client’s talk, instead focussing the conversation on procedural 13 C: Yeah,
aspects of whether the client would be able to claim any cost of the 14 A: Normally they would be for a pair four thousand seven hundred

device from her health fund, concluding that it would be unlikely 15 and fifty dollars,
16 C: Yeah.
(some lines omitted here).
17 A: The s"enior’s card reduces that to four thousand two hundred
As was typical of these conversations, the audiologist can be
18 and eighty dollars.
seen to provide one cost option to the client within his initial turn at
19 C: #Uh: 4that’s a b-< tha(h)t’s ou(h)t of m(h)y ra(h)[nge heh heh]
lines 1–4 (the cheapest option of two HAs costing AU$3000). This 20 A: [ I’m out of ]
turn sets up a relevant next-turn from the client as being either an 21 your range?
acceptance or rejection of that cost. Across lines 6–15, the client 22 C: We’re well out of the range.
rejects this cost option. At lines 21–22, the audiologist then re- 23 (0.2)
issues a question about going ahead with HAs despite the client 24 A: There "is (0.8) the next level down in technology,[which] (0.6)
having stated it is not an option for her. His turn is structured as a 25 C: [ Mm. ]

yes/no interrogative (‘‘So in terms of (.) hearing aids is that just out 26 A: is similar but (.) what it does differently is that it (0.2)
27 looks to the strongest background noise [rather th’n–] rather
of the question then? Do you think?’’), thus again inviting the client
28 C: [ Yea:h. ]
to either accept or reject the proposed option. The client displays
29 A: than (.) the (0.3) four separate ones,
further resistance by responding that she would need to think about
30 C: Yeah.
it (line 26). A lengthy 1.5-s pause ensues where the audiologist does 31 (1.2)
not respond to accept the client’s rejection and move on. The client 32 A: In terms of investment (0.9) that normally would be three
then provides a personal account as to why she cannot afford the 33 thousand four hundred and twenty,
HAs. The multiple resistive (dispreferred) responses that the client 34 C: Mm:
provides over this sequence results in disconnect between the two 35 A: senior’s card that- brings that to three thousand and [eighty.]
participants at this point in the appointment. 36 C: [ But ]

Fragment (2) provides a similar example (with a different 37 still– .hh because I don’t get that- y’know a- a- al-
38 [although]
audiologist and client). In this case, the client is eligible for
39 A: [ () ]
Government-funded HAs. However, the audiologist, at lines 1–2,
40 C: I get compensation from thee Veteran’s Affair [ y’know ]
41 A: ["Oh they]
42 won’t? Oh that’s a bit of a nuisance in’t it?

43 C: Yeah,
44 (1.1)
offers a higher level device in the first instance, which would
45 C: No.
require the client to pay top-up costs.
46 (0.2)
47 C: Only get a certain am"ount you know what I [mean?]
Again, the audiologist and client’s talk across the sequence
48 A: [Yeah.]
displays a negative emotional stance. Across lines 1–18, the
49 (0.2) audiologist provides an extended turn recommending a particular
50 A: 4Well there’s< (.) another one where: (2.0) once again it tries hearing aid to the client that would cost AU$4000. He does not
51 to reduce the background noise,¼[not qu]ite as sophisticated as mention the cost of the hearing aid until the end of his extended
52 C: [
Mmhm
] turn, which is a common approach for initiating dispreferred actions
53 A: ones I’ve just mentioned¼.hh normally (1.1) one thousand four (Schegloff, 2007). The client provides a response with an emotional
54 hundred dollars, the voucher brings that down to one thou:sa:nd stance: he produces awkward laughter (Haakana, 2001) across his
55 two hundred and sixty doll[ars]
turn. The audiologist does not attend to the emotional valence of the
56 C: [ No ] still [out- still- 4b’cus<]
client’s turn but instead progresses the conversation about other
57 A: [ Still out?
heh heh
]
hearing aid cost options.
58 C: still out ah- ah–ah bec[ause] .hh I– I’ve got to pay fur– .hh
59 A: [ Mm. ]
As with Fragment (1), the audiologist only provides one cost
60 C: I’ve got to pay a yearly rate for– for rates and [things like–] option to the client. This turn design sets up the relevant next turn
61 A: [ "Oh right? ] from the client to be acceptance or rejection of the recommended
62 C: j- but things like that. hearing aid. The client rejects the hearing aid as ‘‘out of his
63 A: .hh well the– the fully funded ones are still quite good range’’ (line 19). The audiologist responds by offering another,
64 devices. slightly cheaper, hearing aid that would cost the client AU$3080
858 K. Ekberg et al.

(lines 24–35). The client is thus again positioned to accept/reject the
specific hearing aid cost being proposed. The client again rejects the
cost of that hearing aid, explaining that he does not get full
compensation from Veteran’s Affairs. The audiologist then offers a
third hearing aid that would still involve an out-of-pocket expense
from the client of AU$1260 (lines 49–54). The client is thus
positioned to respond to the cost on a third occasion. This time, the
client provides a personal account as to why he cannot afford to
purchase ‘‘top-up’’ HAs (he needs to be able to pay his yearly
rates). In response to this account, the audiologist settles on the
fully-funded HAs as an option. Across this lengthy sequence, the
client was positioned to provide resistive responses to the cost of
HAs on multiple occasions, resulting in escalating disconnection
between the two participants.
These two examples illustrate how (1) audiologists and clients
display a negative emotional stance in discussions about the cost of
HAs; and (2) audiologists typically provide one cost option to
clients within their initial turn, restricting the client’s possible
relevant response. These types of turns from audiologists did not
allow for any further client input in the decision making. Clients
rejected to these turns, whether they had been offered the cheapest
HAs available (as in Fragment (1)) or more expensive top-up HAs
(as in Fragment (2)).
A different approach: presenting options
It was less common for audiologists to provide different cost
pair of fully-subsidised HAs, and two pairs of HAs that would
involve a different level of top-up costs.
Some hesitations (intra-turn pauses and repetition) can be seen in
the audiologist’s talk across lines 1–9 when initiating the discussion
about cost options. There are, however, less of these conversational
markers than in Fragments (1) and (2). Importantly, in this
fragment, the client’s response to the audiologist is not marked
with a negative emotional stance.
In this case, unlike Fragments (1) and (2), the audiologist lists
three hearing aid cost options to the client across an extended turn: a
fully-subsidised, government-funded device, a mid-range top-up
device and a more expensive top-up device (lines 1–9). This type of
turn sets up a next-turn from the client to be a choice. The client’s
choice in the matter is also emphasised at the beginning of the
audiologist’s turn, ‘‘it’s entirely up to you what you want to
choo:se’’ (line 1), and again at the end of their turn, ‘‘it’s entirely up
to you’’ (line 9). In response, the client provides a rationale for only
needing a basic hearing aid for around the house. The audiologist
and client then co-jointly agree on the fully subsidised hearing aid
across lines 15–22. Following the audiologist’s list of options, the
interaction progresses smoothly with the audiologist and client
remaining aligned with each other across the sequence. Fragment
(4) provides another example within an appointment where the
client is not eligible for a pair of Government-funded HAs (and
would therefore need to pay for the full cost or at least the majority
(4) [C18-2]

options up-front, within their initial turn. Audiologists took this 1 A: We:ll I have to admit the technology these this- these days is
2 very very good.¼So even the- the basic model hearing aids
approach in 22% of appointments (n ¼ 10/46). However, when they
3 would do the job for you: .hh um I think given your workplace- uhm
did, this set up a different type of next-response for the client.
4 y’know you’re working on your own at the mome:nt, [ um ] and th-
Rather than being in a positon to accept/reject the cost of one 5 C: [Mm.]
recommended hearing aid, they were able to respond with a choice. 6 A: l::::: thee::situations where you do want the hearing aids .hh I
This approach allowed for more client input in the decision-making 7 think even the base models would be suitable for you, .hh the
about cost and typically led to a smoother progression of the 8 main differences between < base mid and4top of the range
interaction. Fragment (3) is an example of an audiologist providing 9 h"earing aids is the way it sou:nds, (0.5) so of course the ten
cost options to the client. This client is eligible for Government- 10 thousand dollars a pair hearing aids [will sound much-]
funded HAs, so the options provided by the audiologist involve a 11 C: [ I don’t think I ] want a
12 [ten thousand dollar one] thank [ you. ]
13 A: [ Heh heh heh heh heh heh ] [Yeah.] So that one s- y’know

(3) [C08-3] 14 sounds very very goo:d, it’s got Bluetooth capabilities, it
15 communicates with the other ear.
1 A: .hhh it’s "entirely up to you what you want to choo:se, so
16 C: No.¼
2 this is the one that’s no out of pocket ex[pense,] the government
17 A: ¼uhh: okay. .hh um mid range, we’re looking at about (.) f:ive
3 C: [ Yeah ]
4 A: supplies, .hh this one is about one thousand two hundred and 18 to seven th"ousand dollars a pair, and the base model, is
19 about three thousand dollars a pair,
5 sixty for two: and this is about three thousand [and] eighty ¼ You
20 C: Yea:h.
6 C: [ Mm ]
21 (0.5)
7 A: c"ertainly don’t have to spend the money if [ you ] don’t [wan]t
22 C: Yeah [I WAS hop-] thinking around four that’s [ what ] my friend
8 C: [
Yep
] [ Mm ]
23 A: [ () ] ["Okay]
9 A: but it’s entirely up to you.¼It really depends on: (0.2)
24 C: told me.
10 C: "Oh well () (1.7) at- at the moment I rea- really only
11 want it to be for at home, [th- th-] there e- e- there- I’m 25 Yea:h [I think you will] (.) definitely
26 C: [ They were a do- ]
12 A: [ Yeah ]
27 C: Mm:
13 C: m"anaging quite well oth[ erwise, i]t’s just that eh-
28 A: u:m benefit from
14 A: [otherwise]
15 A: Round the house?¼ [ Well ] this w’d be the sort of thing you 29 C: Mm:
30 A: even the base model [hear]ing aids okay?
16 C: [Yeah.]
31 C: [ Mm ]
17 A: [want, so] are you ha- saying the fully subsidised might be
18 C: [ Yep Mm ]
19 A: [where you’d like to go?]
20 C: [ Yeah we’ll- we’ll go ] with that one of the cost of HAs themselves).
21 A: Okay, There are some minor hesitations within the audiologist’s initial,
22 C: an’ s- see how that works.
extended turn, where she presents the various cost options to the

client. The client initially displays a negative emotional stance when
the AU$10,000 HAs are mentioned (‘‘I don’t think I want a ten
thousand dollar one thank you’’ (lines 11–12), and ‘‘no’’ (line 16)),
but this dissipates across the sequence as the other options are
presented.
Across the audiologist’s initial extended turn, she first mentions
that she thinks even basic HAs would be helpful for the client,
before beginning to describe the difference between different priced
HAs (lines 1–10). When the audiologist mentions AU$10,000 HAs,
the client interrupts her mid-turn to reject that possibility (lines
11–12). The audiologist continues her turn, describing some of the
capabilities of that model of hearing aid and the client again adds
another ‘‘no’’ response. In her next turn, the audiologist then
provides two other price options of HAs (mid-range costing
approximately AU$5000–7000, and base models costing around
AU$3000 a pair). This turn allows the client to choose a cost option
in her next turn, rather than accepting/rejecting one recommenda-
tion. The client responds with her own cost option: she was thinking
of spending around AU$4000. The audiologist aligns with the
client’s choice in her following turns and the interaction progresses
smoothly.
Fragments (3) and (4) have provided examples of how providing
different cost options for clients to choose from can lead to a
smoother progression of the ‘‘cost discussion’’ within the manage-
ment phase of appointments. Once all options had been presented to
clients, they made a choice without displaying a negative emotional
stance in their response. However, it should be noted that if
audiologists did not accept the client’s choice and subsequently
suggested a different option, this could lead to similar interactional
troubles as seen in Fragments (1) and (2).
Discussion
This study examined how hearing aid costs are discussed during
initial appointments with older adult clients. The findings demon-
strated that audiologists and clients often displayed interactional
difficulty during conversations about cost, evidenced by delays and
hesitations in their talk across this part of the interaction. Clients
often took an emotional stance in responding to the cost of HAs,
including using affective phrases (e.g. ‘‘Oh God’’, ‘‘Goodness
me’’), crying, and/or awkward laughter. These emotional displays
in clients’ responses were not typically attended to by the
audiologists, who focussed on technical/logistical aspects of
purchasing HAs.
Audiologists typically presented one cost option at a time which
set up the next-turn from the client to either accept or reject the
option. In addition, audiologists often pursued hearing aid recom-
mendations even after the client had displayed resistance to the cost
by either: (1) recommending another, cheaper hearing aid; or (2) re-
questioning the client about going ahead with HAs. Clients were,
therefore, in a position to potentially have to reject the cost again.
These secondary rejections would often prompt clients to produce a
personal account as to why they could not afford the HAs (e.g.
mortgage/rates costs, not working full-time). These responses from
clients caused disconnection between the audiologist and client at
that point in the interaction (potentially affecting the rapport
between the two parties).
An alternative approach to introducing the cost of HAs was
found to lead to a smoother interaction between the audiologist and
client during the management phase of the appointment. When
audiologists offered multiple cost options within their initial turn,
Cost discussions in audiology appointments 859
this allowed clients to make a choice in their responsive turn, rather
than acceptance/rejection. Previous CA research in healthcare
settings has identified that a recommendation for a course of
action can lead to different sequences of interaction than when
clients are provided an opportunity to choose their own action (e.g.
Pilnick, 2008; Ekberg & LeCouteur, 2015). Providing options for
hearing aid costs allowed clients to be more engaged in this phase of
the interaction, and avoided the need for clients to provide resistive
responses to the audiologist, which could potentially lead to poor
rapport.
No key differences were observed between appointments where
government subsidies were available to the client, and private
appointments in the corpus. Audiologists typically presented
hearing aid recommendations in similar ways in both types of
appointments. Clients responded with rejections even when the
cheapest HAs were being recommended (as seen in Fragment (1)).
Clients appeared to react more negatively to any cost of HAs when
they were not being provided with a choice. This finding highlights
the importance of the audiologist’s communication behaviour (e.g.
turn design) when introducing the cost of HAs, no matter which cost
level they are suggesting. Sometimes audiologists also initially
suggested a more expensive hearing aid to a client even when they
were eligible for fully-subsidised, Government-funded HAs (thus
requiring the client to pay a top-up amount), as seen in Fragment
(2). Audiologists may have done this because they assumed the
client already knew they could use their voucher to obtain free HAs,
however the analysis of Fragment (2) has shown that these
assumptions may not always be correct.
Given that cost has been identified as one key barrier to
hearing adoption (e.g. Franks & Beckmann, 1985; Kricos et al,
1991; Garstecki & Erler, 1998; Kochkin, 2007; Fischer et al,
2011; Laplante-Lévesque et al, 2012b; Meyer & Hickson, 2012),
and hearing aid costs are likely to remain relatively high, it may
be useful to explore ways in which discussing costs with clients
can be made easier for audiologists and clients. The findings of
this study show support for using a shared decision-making
approach to discussions around the cost of HAs. While the cost of
HAs may be viewed by audiologists as a simple, logistical element
of the overall discussion about HAs, the cost can be an emotional
decision for older clients. The expense may have a large impact on
their lifestyle. Previous research has shown that clients attend an
initial assessment for a number of reasons and may not be
expecting a hearing aid recommendation (Claesen & Pryce, 2012).
Further, they may not be fully aware of the high costs of HAs.
Thus, when clients are told about the costs of HAs within the
management phase of their initial appointment, it may raise
various emotions for them. It would, therefore, be beneficial for
audiologists to apply personal adjustment counselling skills to
their discussions about cost. Discussing different cost options in
relation to how they might help the client’s individual hearing
difficulties and lifestyle could further help the client in making a
choice. It was often the case in this corpus that audiologists
provided little explanation of how the recommended hearing aid
suited the client’s individual hearing needs (e.g. Fragment (2)) or
what additional features the more expensive HAs have over other
HAs. Again, individualising clients’ hearing aid recommendations
is a key part of providing client-centred care. If clients do have
emotional or psychosocial concerns in relation to the cost of HAs,
it is important for audiologists to try to attend to these concerns
within the appointment (Ekberg et al, 2014). If clients feel
pressured or distrustful of the audiologist’s agenda in
860 K. Ekberg et al.
recommending a costly hearing aid, they may decline rehabilita-
tion and be hesitant to return in the future (Piette et al, 2005;
Grenness et al, 2014).
Adopting a shared decision-making approach in discussions
about cost is a key way that audiologists can be more client
centred in their appointments (Mead & Bower, 2000; Laplante-
Lévesque et al, 2010a; Pryce & Hall, 2014; Pryce et al, 2016).
Shared decision-making involves information exchange, decision
making and intervention action to be performed together by client
and clinician, and is a key component of client-centred care
(Charles et al, 1997). Previous research, in other areas of
healthcare, has found that when options are not provided and/or
the client is not engaged in decision-making, this can lead to
reduced client adherence and an increased likelihood of clients
seeking a second opinion elsewhere (Charles et al, 1999). Offering
different rehabilitation cost options provides the client with a
choice. This might include a no-cost option, including fully
subsidised HAs (if eligible) or a communication programme, and
also, importantly, an option to not pursue any rehabilitation at this
stage. Taking this approach may help ease the difficulty of the
conversation for both audiologists and clients. Options other than
HAs were rarely offered in this corpus of appointments. This
complements other recent research by Pryce et al (2016), which
found that decision-making was clinician-led and other alternative
or additional forms of intervention were not offered to clients.
Previous research has demonstrated that clients value shared-
decision making within rehabilitative audiology appointments
(Laplante-Lévesque et al, 2010a, b, c, d). The use of a decision
aid, with different cost options included, may help audiologists in
adopting a shared decision-making approach and exploring clients’
feelings about different rehabilitation options (Laplante-Lévesque
et al, 2010a). The British Society of Audiology recommend the
use of a decision aid (e.g. the Hearing Loss Option Grid, available
at www.optiongrid.org) to ensure audiologists and clients are
making shared, informed decisions about their hearing rehabilita-
tion (Ferguson et al, 2016). Some barriers have been identified to
clinicians adopting a shared decision-making approach, including
lack of time (Pryce & Hall, 2014). Thus, support from managers
and business owners for audiologists to take up this approach is
also important.
Further to this, the findings support a focus on holistic
rehabilitation services, rather than merely hearing aid devices.
Preminger et al (2015) highlighted the device-focus in current
audiology practice as a key contributor to clients viewing the
hearing health care system in a commercialised manner.
Appointments that focus on service rather than sales are likely to
engender more client trust. For example, in an interview study
conducted with older adults who owned HAs, participants described
that they would happily pay more for hearing services if they
received care in a holistic manner and felt as if they were being
understood (Grenness et al, 2014).
Conclusion
Cost remains a significant barrier to hearing aid adoption for older
adults. The findings from this study have highlighted how
audiologists and clients find it difficult to talk about hearing aid
costs within initial appointments. However, audiologists can
overcome some of this difficulty when they approach cost
discussions by offering clients multiple cost options of HAs. This
approach engages clients in the decision-making process by
allowing them to choose an option most suited to them, and can
lead to a smoother interaction between audiologist and client in the
management phase of appointments.
Acknowledgements
This study was conducted under the HEARing Cooperative
Research Centre, established and supported under the Business
Australia Cooperative Research Centres Program.
Declaration of interest: The authors report no conflict of interest.
Notes
1. Where appropriate and necessary for the analysis, aspects of
multimodal interaction such as participants’ gaze and body
movements were also analysed. For brevity and clarity, these
multimodal actions have not been included in the transcripts in the
current manuscript unless crucial to the analytic point being made.
2. Emotional valence refers to the underlying ‘tone’ of an expressed
emotion, whether it is positive or negative.
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