What influences referral for mental health support in audiology clinics? A qualitative exploratory approach of barriers and facilitators

Figures & data

Table 1. Theme 1: beliefs about and the recognition of the need for referral.

Subtheme	B/F/M	Example quotes
Beliefs that mental health is related to hearing, therefore, addressing mental health is needed for hearing rehabilitation	F	People quite often find there's a lot of poor mental health associated with hearing loss and if we can help with the hearing aids provided and the rehabilitation you’re providing and there's more of a support network, I think they’ll feel like they were actually more successful with their hearing aid fitting and their actual long-term outcomes.
Beliefs that hearing aids will substantially improve mental health	B	We think they [hearing aids] do and say just put some hearing aids in and all these problems [isolation, depression, loneliness] are going to be solved.
HCPs’ beliefs about qualifications and scope of practice in relation to mental health discussion and referral	M	In a work context, it is our duty of care to refer our clients who are distressed. We’re not psychologists.
HCPs’ beliefs that they (or do not) have an important role to play in detecting clients’ need for help with their mental health	M	We are in the front line so we’re certainly ones that can help. I can't see myself handing my clients these forms, talking about this stuff and referring them on. No way. It's got nothing to do with ears.
HCPs awareness of clients’ need for help with their mental health	F	The struggle becomes the new normal and depression make things foggy at the best of times. So, people don't usually realise how bad they are, or that they are now at the point where support may be warranted.
Screening, diagnosis, and discussion tools and protocols to assist HCPs in detecting the need for mental health referral	M	We do have a question on the back of the page about a history of anxiety and that's really helpful. That definitely makes us think there could be more. It's called the ‘Hearing History form’. It is for the balance clinic. I think if you could have something to assess it clinically where it doesn't depend on each person's feelings or personality. It's almost like they do in tinnitus where if they have this score then you have to do something about it.
Management, staff, and organisational culture and support for mental health discussions in hearing healthcare setting	F	I think you guys [admin staff] have a really powerful role in helping them recognise it and they’ll probably be more honest with you guys compared to us so there's definitely a role there. I think there's a lot that we should be doing within our sessions that we already don't do and that's to do with hearing. I think that to add something else that's going to be one of those forms that we don't fill in like there's a lot of forms that we don't fill in because we don't have the time–Wax and things–there's a whole lot, and I think that's the way it may end up being unless management stand behind the need for it.
HCP's preferences and motivations for discussing and referring (or not) clients for mental health support	M	But then I’m happy to say ‘look, have you thought about seeing a psychologist?’ I can't see myself handing my clients these forms, talking about this stuff and referring them on.
Severity of clients’ presentation triggers the HCP towards a referral	F	Interviewer: So, if you did happen to find that someone was incredibly distressed would you refer them on? And who would you refer them to? Participants: Yep … Doctor … GP … I’d write a report … I’ve made a phone call in the past. I actually rang the GP myself.
Client disclosure of mental health concerns to audiologists	M	They might feel comfortable with you to share this with you, as a clinician professional, rather than a family member or friends where they might be ostracised. I find it easier being on the implant side of things as our clients have often been living with severe hearing loss for so long that they openly talk about their mental wellbeing.

Note: B: Barrier, F: Facilitator, M: mixed, HCP: Hearing Care Practitioner.

Table 2. Theme 2: knowledge, skills, and training for mental health referral.

Subtheme	B/F/M	Example quotes
HCPs’ knowledge and skills for detection and discussions of mental health problems	M	You might spend more time talking to the client building rapport leaving less time for doing a hearing test but at the end of the day the hearing test doesn't matter. I don't think that's something I’ve been taught … and I could very easily get out of my depth.
HCPs’ knowledge of what the next steps are	B	I think if there was a pathway, I mean in the past, I’ve actually rung the GP myself but if there was like a kind of case history thing that there was a standard question in there that was like a … . I don't know what it could be … like a quick screener, how are you feeling whatever, and then you had a clear pathway as to where you might go next, then you would feel more comfortable.
HCPs’ knowledge of when to refer clients for mental health support	M	Obviously, when you get to that point [suicide] we refer to the doctor and they take it from there. There really is no way of knowing [when clients’ condition is bad enough to refer them]
HCP's training for dealing with clients’ mental health problems	B	We’re finding that we counsel her as best we can but we’re not really trained to deal with that.
Knowledge of how to refer clients for mental health support (who, when, or where to refer clients to)	B	It is a shame really. We tell them [clients] exactly which ENT or speech therapist to go see. It would be nice to have a list of decent psychologists to refer to.
Privacy considerations in referring clients to GPs and psychologists	B	If my dentist rang my doctor and said that, I would not be happy. That's a breach of his privacy.
Time and resources for discussing the next steps and referral to mental health services	M	… an hour is a lot longer than a GP is ever going to [inaudible] you can go there, not because it's within our means and then we can always bring them back anyway, in about a week you’ve always got a follow-up. Do I have the equipment to then discuss what happens next?

Note: B: Barrier, F: Facilitator, M: mixed, HCP: Hearing Care Practitioner.

Table 3. Theme 3: outcomes and consequences of referring clients for mental health support.

Subtheme	B/F/M	Example quotes
HCPs’ awareness of the outcomes and consequences of (not) referring clients	M	From our point of view, we probably wouldn't find out about it. It doesn't come into our world.
HCPs’ beliefs about clients’ motivation to take the next steps, and access to mental health services	M	I think most people that suffer depression and anxiety, if they have the skills they’re going to do it anyway to help themselves; and it's those that can't help themselves, will they take on any help anyway? No motivation. Usually, people with emotional issues and that, are they heirs to a fortune, do they have big jobs? No. Some of them can have and so they’re financially secure but a lot of them, the demographics I would imagine would be, they don't have access to all these funds and so where are they going to go?
Beliefs about labelling clients by mental health referral	B	Yeah, I would feel like it is not my place to make that call that they actually need to see a psychologist. And a referral is very strong. It says, hey, you need help.
HCPs’ beliefs that they offend clients if they refer	B	My clients don't know that. They’ll be wondering why I am up in their private business.
HCPs’ beliefs and experiences about GPs and psychologists’ knowledge and response to referrals	M	So, I contacted the GP … I just went straight to the GP. Eventually, in the fullness of time, the son appeared, and we informed him too, and it ended up good. Yes, my client said that her psychologist told her she had to go out more and acclimatise to social settings, but when my client tried to explain that hearing loss made it hard in busy social settings the psych told her to go get a hearing aid … didn't seem to notice (nor ask about) the whopping cochlear implant on her head.
HCPs and admin staff are motivated to provide referrals but lack the clinical resources and organisational support to provide this type of care	M	I mean, how would I know whether it is mindfulness or CBT that is going to fix their problem. But I do think that we should be suggesting it to them and then letting them find their own preferred pathway. I think if we had a pamphlet that explained, as an audiologist, we care about how your hearing is influencing … I don't know if want to put mental health but … therefore, please fill out this questionnaire.

Note: B: Barrier, F: Facilitator, M: mixed, HCP: Hearing Care Practitioner.

Data availability statement

The datasets analysed during the current study are not publicly available due to ethical restrictions but are available from the corresponding author on reasonable request.