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

ABSTRACT Objective This study aimed to gain an in depth understanding of factors influencing mental health referrals for adults with hearing loss in the audiology setting. Method A semi-structured focus group with hearing care practitioners (HCPs) and reception staff (N = 12, Mage = 45 ± 12 years, 10 female) from a large hearing services provider in Western Australia in 2020. Results Three themes were identified: (1) beliefs about and the recognition of the need for referral, (2) knowledge, skills, and training for mental health referral, and (3) outcomes and consequences of referring clients for mental health support. Discussion This study identified a wide range of factors influencing referral of adults with hearing loss for mental health support. The findings of this research may be used to inform intervention development targeting mental health referral behaviours within the audiology setting.


Introduction
Untreated mental health concerns may result in chronic mental illness and a poor prognosis for complete recovery (Parmelee et al., 1989).Early diagnosis and intervention for mental health concerns are crucial for preventing illness progression and lowering the risk of suicide (Davison et al., 2009;Parmelee et al., 1989).However, mental health related stigma can prevent people from seeking help for their mental health problems (Clement et al., 2015).Health professionals, including child health nurses (Jones et al., 2012;Leigh & Milgrom, 2008), speech-language pathologists (Ryan et al., 2017), and hearing care practitioners (HCPs), are well placed to detect the need for mental health support.Although HCPs' primary role is prevention, detection, and treatment of hearing loss, audiology guidelines suggest a holistic approach, including using screening measures of mental health to assess and refer clients for mental health support if needed (American Speech-Language-Hearing Association, 2018).However, there is a lack of research exploring barriers and facilitators to referral to mental health support by HCPs.
The experiences of mental health problems can negatively influence subjective hearing ability and audiological rehabilitation (Laird et al., 2020).Anxiety, for example, may make hearing more difficult and hearing difficulties exacerbate people's anxiety (Laird et al., 2020).Adults with hearing loss are also more likely to experience poorer mental health outcomes than their counterparts with normative hearing (Bigelow et al., 2020;Jiang et al., 2020).Adults with hearing loss are at an increased odds for experiencing social isolation (OR 2.14; 95% CI, 1.29-3.57)(Mick et al., 2014), loneliness (women with mild hearing loss: OR 1.51, 95% CI, 1.35-1.68;men with mild hearing loss: OR 1.18, 95% CI, 1.03-1.35)(Wells et al., 2020), anxiety (OR = 1.50, 95% CI = 1.29-1.74)(Vancampfort et al., 2017), and depression (OR = 1.47, 95% CI = 1.31-1.65)(Lawrence et al., 2020), suggesting the important role that HCPs could play in early detection and referral to facilitate timely and appropriate mental health support.However, research suggests that HCPs are underskilled and lack confidence in providing mental health support to adults with hearing loss, including referral to mental health practitioners (Bennett, Meyer, Ryan, Barr, et al., 2020;Bennett, Meyer, Ryan, and Eikelboom, 2020;Bennett et al., 2023).When asked to describe their usual clinical behaviours in response to three case vignettes depicting severe grief or depression, approximately half of the HCPs surveyed reported some actions that only addressed the audiological symptoms of their clients, disregarding the psychological concerns raised (Bennett, Meyer, Ryan, & Eikelboom, 2020).Less than one-third of the HCPs described referral or recommendation that the clients seek additional help beyond the HCPs' services.The open text responses put forward by HCPs suggest that they have little understanding of referral pathways and services provided by professionals/groups.When asked to indicate the major barriers to referral for mental health support, HCPs most commonly indicated unawareness of who to refer to, when to refer someone, or how to make a referral (Bennett, Meyer, Ryan, Barr, et al., 2020).Importantly, the majority (96%) of HCPs reported an interest in developing their knowledge and skills associated with addressing their clients' mental health needs in the audiology setting (Bennett, Meyer, Ryan, Barr, et al., 2020).
HCPs are well positioned to identify the mental wellbeing needs of adults with hearing loss.However, providing psychotherapeutic intervention is outside of their scope of practice.So, referring clients to mental health practitioners is an important part of their role.Reception staff in audiology clinics can also play a supportive role for clients with mental health concerns (Bennett, Kelsall-Foreman, et al., 2021).Despite this, HCPs rarely refer their clients for mental health concerns (Bennett, Meyer, Ryan, Barr, et al., 2020), and there is a lack of detailed understanding about the referral process and related barriers and facilitators for mental health support by HCPs.We hypothesised that a qualitative study would help to provide a more detailed understanding of the barriers identified in the original survey of HCPs regarding barriers to referring clients to mental health practitioners (Bennett, Meyer, Ryan, Barr, et al., 2020).Qualitative research methods can provide rich and nuanced data that can shed light on the complexity of the issues and allow for a deeper exploration of the attitudes, beliefs, and experiences of HCPs related to this topic.One of the benefits of using qualitative research methods is that they can help to identify the underlying reasons behind the barriers identified in the survey.For example, a qualitative study could explore the specific knowledge gaps that HCPs may have regarding mental health referrals, or the specific challenges they face in finding the time to make these referrals.Through in-depth focus groups with HCPs, qualitative research can help to uncover these details and provide a more nuanced understanding of the barriers.In addition, a qualitative study can help to identify potential solutions or interventions that may be effective in addressing the barriers to mental health referrals.By exploring the experiences and perspectives of HCPs, researchers can gain insights into what types of interventions may be most effective in addressing the specific challenges they face.This information can be used to develop targeted interventions or educational programs to help overcome the identified barriers.This qualitative study, therefore, aimed to phenomenologically explore: (1) factors influencing mental health referrals for adults with hearing loss by HCPs in an audiology setting, and (2) the role of HCPs in improving access to mental health services to clients.

Study design
A qualitative descriptive approach with phenomenological aspects (Sandelowski, 2000) using a focus group was used to explore the beliefs and perspectives of the staff of audiology clinic (combined opinions of HCPs and reception staff) about referral for mental health support.A qualitative study was selected because it can help to complement the findings of a survey (Bennett, Meyer, Ryan, Barr, et al., 2020) by providing a more detailed and nuanced understanding of the barriers to mental health referrals among HCPs.By exploring the underlying reasons behind the barriers and identifying potential solutions, this type of research can help to inform the development of interventions and strategies to promote more effective and comprehensive care for clients.
A series of semi-structured questions related to the aims of the study was used for the focus group.The Human Research Ethics Office of The University of Western Australia granted ethical approval for this study (HREC RA.4.20.5873).The Standards for Reporting Qualitative Research guideline were used for reporting this study (O'Brien et al., 2014).

Participants
Convenience sampling was used to recruit HCPs and reception staff through a large hearing services provider to adults in Western Australia in February 2020.Although reception staff do not provide clinical care, we recruited them as they are: (1) part of the healthcare team and can sometimes detect mental health problems and alert the HCPs to this, (2) sometimes decision makers regarding what brochures go in the waiting room, and (3) often responsible for triaging activities and administration tasks such as typing up and sending referral letters (Bennett, Kelsall-Foreman, et al., 2021).
All staff received consent forms by email and provided written informed consent prior to the focus group session.Participation was voluntary.Participants (N = 12) ranged in age from 27 to 63 years (M age = 45 years, SD = 12), 10 were female, and included six HCPs (with a range of experience in hearing aids, cochlear implants, balance, and tinnitus) and six audiology reception staff.They were from different cultural backgrounds, including Australian (7; 58.3%),British (2; 16.7%), New Zealander (1; 8.3%), Indian (1; 8.3%), South African (1; 8.3%).Participants self-reported between 1 and 29 years (M = 12, SD = 9) of experience working in audiology clinics.All participants spoke fluent English and were over 18 years of age.

Procedure
An in-person focus group (1.5 h) with 12 participants was carried out in a large community hall in Western Australia.A hand-held Sony ICD-PX470 recorder was used to record the conversation.The session was moderated by RJB, a female clinical audiologist with experience in conducting qualitative research.RJB was a past colleague of the participants so they would have likely felt comfortable opening up to her.Participants were given the opportunity to ask any questions before the session started.Participants were asked semi-structured questions to get their perceptions about whose role is it to help audiology clinic clients with mental health concerns, when audiologists should refer their clients for mental health, what would audiologists need to have the equipment to discuss what happens following the referral to mental health support, how worthwhile is letting people talk about their mental health concerns, what happens if audiologists do not talk about mental health problems with clients, and what might the consequences be if audiologists choose to ignore the mental health symptoms.
The discussion continued until the session moderator felt they reached saturation of responses where no additional information provided when questions were repeated or rephrased.

Data analysis
Audio recordings were professionally transcribed and imported into NVivo (QSR International Pty Ltd.Version 12) for analysis.Inductive thematic analysis was performed in line with the six steps described by Braun and Clarke (2021).In the first step, data familiarisation, MN read the transcripts to familiarise herself with the data.In the second step, systematic data coding, she generated the initial codes related to the research question without any preconceived codes.MN, RJB, and AEM met regularly to review and discuss the codes (n = 203).In step three, generating the initial themes, MN, RJB and AEM grouped similar codes and sorted them into subthemes and themes.In step four, developing and reviewing themes, the team checked if the initial themes had enough support in the focus group data.Some subthemes were further combined at this step.In the fifth step, refining, defining, and naming themes, the whole team checked the themes to ensure they were relevant to the study question and their names captured the content of the theme.In the sixth step, writing the report, MN prepared the first draft of the manuscript, and all authors were actively involved in editing the manuscript.The authors met regularly for peer-checking, and discrepancies in each step of the thematic analysis were discussed until a consensus was reached.

Results
Twenty-three sub-themes were identified across three themes.A subset of quotes from each of the themes is presented to show examples of the content discussed.
Theme 1: beliefs about and the recognition of the need for referral The first theme identified in this study was recognising the need for referring audiology clients for mental health support and beliefs about the referrals.Theme 1 was comprised of 10 subthemes, many of which were internal factors of the participant such as beliefs, preferences, the qualifications, scope and role of HCPs in detecting and issues regarding discussing mental health signs and symptoms with adult clients.In addition, external factors such as tools/protocols and culture and support for referral were highlighted, as were factors related to the client such as severity of mental health problem and client openness to disclosure (Table 1).
Participants in this study expressed their beliefs that mental health is impacted by hearing loss, and therefore addressing mental health should be part of hearing rehabilitation services to decrease social isolation.However, some participants believed that hearing aids would improve clients' mental health problems, negating the need for referral: 'We think they [hearing aids] do [help to allow less social isolation] and say just put some hearing aids in and all these problems [isolation, depression, loneliness] are going to be solved'.
Besides, there were opposing beliefs about qualifications and scope of practice about mental health discussions and referrals for HCPs amongst participants.Although some believed that discussion and referral for mental health support are within the scope of audiology practice, and it is their duty of care to refer distressed clients, others disagreed.Some participants described uncertainty about their ability and qualifications for mental health discussions; and other participants assumed that they have an important role to play in detecting clients' mental health needs.Most participants were aware of clients' need for support as they saw clients who needed mental health support every week, and more specifically, more clients with mental health concerns and suicidal thoughts in the balance and tinnitus clinics.Participants were also aware that some clients do not realise how severe their mental health problems are, and they might live unhappily.
Participants also described a need for management, staff, and organisational culture and support for mental health discussions as well as screening, diagnosis, and discussion tools and protocols to assist participants in detecting the need for mental health referrals: 'I think it also comes with the culture of the place that you're working.And the culture of your team as well' and: 'There needs to be a protocol for the whole clinic on how to deal with it'.
The preferences and personal comfort of participants with discussing and referring clients for mental well-being also appeared to influence referral initiations.It appeared that some participants shut down mental health conversations, they do not hear the need for clients' mental health support and do not refer clients appropriately.Although some participants described being quite comfortable balancing the audiology appointment requirements and mental health discussion, others wanted to shut down the emotional conversation and focus only on the hearing aid appointment requirements. .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 thingsthere's a whole lot, and I think that's the way it may end up being unless management stand behind the need for it. (Continued) Theme 2: knowledge, skills, and training for mental health referral The second theme identified in this study was about the knowledge, skills, and training for referring clients for mental health support.Theme 2 was comprised of seven subthemes, including statements about knowledge and skills for detection/discussion of mental health and the next steps; knowledge of when and how to refer clients for support; training for dealing with clients' mental health problems, privacy and permission considerations for referrals; and having the time or resources for referral (Table 2).Some participants reported that they referred clients for mental health support and other participants did not.The factors that influenced referral behaviours varied.For example, participants' knowledge and skills for detection and discussion of mental health concerns and timing of referral were important factors identified in the current study influencing mental health referrals.Some participants reported knowing the importance of building rapport with clients, listening to them, and knowing how to validate experiences and comfort clients; however, they reported receiving little or no formal training on these skills and that described being get out of their depth during mental health discussions.Therefore, participants suggested online or in-person training for HCPs, as well as training for audiology students within university courses: 'I think it should be a part of the Audiology Masters.There should be a unit that should be used through the three years'.
Participants' knowledge of next steps and how to refer clients for mental health support was a barrier for referral; some participants needed to know who, when, or where to refer clients to: 'Say, someone does start using terminology that's a little bit scary, well what do we do, who do we tell?Where do we go from there?' 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.
Privacy considerations were raised by participants, believing that contacting family members or General Practitioners (GPs) of a client with mental health issues without client's permission is breaching the client's privacy.One participant reported not knowing if it was right or wrong to inform the GP and family members when clients present with mental health concerns.Some participants in this study also discussed the need for time and resources for discussing next steps and referral.A voucher for mental health services and a template for writing a quick structured report, for example, were suggested: 'I will often suggest it, won't write it in the report but I could write it in the report if I had something to base my knowledge on, rather than just being me reading into the situation'.Theme 3: outcomes and consequences of referring clients for mental health support Theme 3 was comprised of six subthemes, including statements regarding participants' awareness about the consequences of referring or not referring clients for mental health support, beliefs about clients' motivation to take next steps for mental health treatments, beliefs about labelling clients, beliefs and experiences of GPs and psychologists' knowledge and responses to mental health referrals from HCPs, and lack of clinical resources and organisational support to provide mental health care (Table 3).
Some participants reported that they were aware of the detrimental consequences of ignoring clients' mental health symptoms and the outcomes and consequences of referring or not referring clients for mental health support.Participants believed that if clients seek help, it can improve their mental health.A participant also mentioned the impact of mental health problems on the uptake of hearing aids: 'But then I think that if they're already feeling low, how committed are they going to be at wearing their hearing aids regularly and re-engaging themselves'.
However, in response to the interviewer who asked, 'What might the consequences be if we choose to ignore the mental health symptoms that our clients are presenting with?' one participant said: 'It's not our problem, so no consequence for us'.But another participant said: 'Human to human.If I met someone who was in distress, I'd tell them about the benefits of seeking professional help'.
Participants in this study also expressed their beliefs about clients' motivation to proceed with the recommendation to access mental health services.They believed that clients who are not motivated enough to take up HCPs' recommendations may not take on any help.Also, clients may not believe in the benefits of consulting with a psychologist: She [client] keeps saying, 'what good will a psychologist do me?'She was putting up her own barriers.
Cost and access to mental health services were reported as a barrier for some clients.Participants were conscious of the perception that they might be seen as labelling clients when recommending mental health referral.Some participants also expressed beliefs that clients may ask how the mental health questions/questionnaire are related to their hearing loss; and HCPs might offend clients by referring them to mental health services.Conversely, one participant reported that in their experience, there was less stigma around mental health problems than previously.
Experiences about GPs and psychologists' knowledge and response to referrals from audiology clinics were reported as important factors for mental health referrals.Some participants believed that psychologists could help clients in recognising the problems that are worth addressing.Others indicated that suggesting clients find a psychologist or a GP for discussing their mental health may not be helpful.Additionally, some participants reported negative experiences when referring clients to psychologists: Well, any of my clients who have seen a psychologist have had a bad experience.They say that the psychs don't ask about the hearing loss and don't know anything about hearing loss.Yes, my client said that her psychologist told her she had to go out more and acclimatize 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.Some participants interviewed in this study did not want to refer clients to GPs as they believed that GPs might dismiss mental health concerns or give medications before other interventions.Participants also reported that GPs and psychologists may or may not take HCPs' referrals seriously.There was a concern about the lack of knowledge amongst 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.
other professional groups: 'I don't think psychologists are taught anything about hearing loss in their course'.
Finally, some participants and reception staff expressed their motivation to provide referrals and 'hand out some flyers for local activities' as they thought being empathetic was part of their role, but cited a lack of clinical resources and organisational support to provide this type of care.

Discussion
Enlisting HCPs to assist in the detection and referral of the client's mental health issues may promote early intervention and improve mental healthcare.The barriers and facilitators to referring audiology clients for mental health support have not been well understood.From the perspectives of HCPs and audiology reception staff, this study explored factors influencing mental health referral behaviours for adults with hearing loss.The findings of this qualitative study builds upon and provides further understandings to a previous survey based study (Bennett, Meyer, Ryan, Barr, et al., 2020).
The current study found that recognising the need to refer clients for mental health support as well as beliefs about mental health referrals were the initial factors prompting HCPs to refer clients on to appropriate support.Others have identified several mental health problems associated with hearing loss, including psychological distress (Bigelow et al., 2020), anxiety disorders (Shoham et al., 2019), depression (Adigun, 2017;Lawrence et al., 2020), and psychosis (Almeida et al., 2019).The rates of psychological distress has been shown to higher for those with greater degrees of hearing loss and when communication is significantly affected by hearing difficulties (Bigelow et al., 2020).Therefore, HCPs' awareness about clients' possible mental health problems and their beliefs that mental health is related to hearing difficulties prompted referrals.
There are many mental health screening tools available for health professionals to use in identificaiton of mental health problems (Donley, 2013), however, the HCPs in this study did not appear to be aware of such tools.In addition, some barriers exist for applying mental health screening tools effectively.For example, audiologists may experience uncertainty about the appropriateness, usability, and acceptability of the tools as some tools are too long or cover one aspect of mental health problems (e.g.anxiety), or use inappropriate language (Bennett, Donaldson, et al., 2021); therefore, appropriate training would give the HCPs the resources and skills for identifying mental health problems in clients who present at audiology clinics.
Although the mental health of clients is every healthcare professional's responsibility (Donley, 2013), some HCPs in the current study were not sure if the discussion around mental health was within their scope of practice.Audiology guidelines stipulate the need for a holistic approach, including the need for referral to psychologists (Audiology Australia, 2013) and using 'screening measures of mental health' to 'assess, treat, and refer' clients for mental health support (American Speech-Language-Hearing Association, 2018).Similarly, others have called for the development of clinical guidelines to better inform HCPs in addressing their clients' mental health needs (Bennett, Meyer, Ryan, Barr, et al., 2020).
Other factors influencing HCPs referral practices related to knowledge, skills, and training for mental health referral.HCPs' lack of knowledge/skill deficits in identifying and discussing mental health concerns with clients were key barriers to supporting these clients.Likewise, HCPs indicated a lack of appropriate training in this field.These findings align with Bennett and colleagues, who found the need for training of HCPs to detect and refer for mental health problems in Australia (Bennett, Meyer, Ryan, & Eikelboom, 2020).Knowledge of how, who, where to, and when to refer clients were also identified as barriers to referring clients to mental health supports, resonating with recent quantitative self-report survey data from a national cohort of audiologists in Australia (Bennett, Meyer, Ryan, Barr, et al., 2020).Given that time constraints and lack of resources were identified as barriers for some HCPs, development of brief interventions facilitating mental health discussions could improve timely access to mental health care for clients at audiology clinics.
Finally, it was found that HCPs' awareness and beliefs about outcomes and the consequences of referring or not referring clients for mental health support could play an important role in referral decisions.HCPs in this study shared varied experiences about GPs and psychologists' knowledge and responses to referrals.Although some referrals to GPs led to positive outcomes, other referrals did not as some GPs and psychologists were not aware of hearing loss; and these experiences can impact HCPs' willingness to provide future referrals.HCPs wanted to refer clients to mental health clinicians who understood the needs of people with hearing loss.Providing information about the methods psychologists employ can make it more appealing for GPs to refer their clients to psychologists (Winefield et al., 2003) and similar could be provided to HCPs.Further, counselling clients with hearing loss may pose special challenges to psychologists, and psychologists may need to improve their knowledge and competencies when providing services to clients with hearing loss and be willing to adopt a range of treatments that reflect the diversity of people with hearing loss (Fusick, 2008).

Limitations and future directions
All participants were recruited from a single hearing services provider in Australia, and experiences may differ for staff in other geographical locations.In addition, this study explored the influencing factors for HCPs' mental health referrals in community hearing clinics only, and experiences may differ for staff in other hearing clinics (e.g.hospital or university clinics) or in other allied health professions.
In addition, no question about experience of working with clients with mental health problems was asked from the HCPs in this study.However, research indicates that HCPs may not ask about mental health problems due to barriers such as lack of counselling skills and knowledge of questions to ask about mental well-being that could be addressed by reducing stigma and normalising the discussions about emotional well-being (Nickbakht et al., 2023).Referral procedures play an important role in ensuring that clients receive the appropriate healthcare management.Referral pathways, often presented as algorithms or decision trees, are systematic processes consisting of an ordered sequence of steps with each of them depending on the outcome of the previous one (Kainberger et al., 2002).Appropriate and sensitive referral pathways can lead to appropriate diagnosis and treatment of mental health problems in medical and nursing practice (Adli et al., 2017;Waldrop et al., 2018).Developing such referral procedures could assist HCPs, working with groups at high risk of developing mental health concerns to support self-management of sub-clinical symptoms of low mental health and participate in making shared decision plans for client care.Future research could develop referral procedures for mental health specifically designed for audiology practice.
This study involved HCPs and reception staff to understand mental health referrals.Future research is encouraged to recruit GPs and psychologists to explore their insights about receiving referrals from HCPs and addressing these clients' mental health concerns.

Conclusion
Hearing loss can negatively impact mental wellbeing.HCPs potentially have a role in the early detection of mental health problems and timely referral for mental health support.This is the first study to report a wide range of factors influencing referral of audiology clients for mental health support.Factors included barriers and facilitators for recognising the need for and beliefs about the mental health referral by HCPs and knowledge, skills, and training for mental health referral as well as the HCPs' awareness and beliefs about the outcomes and consequences of referring clients for mental health support.Protocols and training in the field of mental health can improve the frequency and appropriateness of referrals for mental health concerns.

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

Table 1 .
Continued.I can't see myself handing my clients these forms, talking about this stuff and referring them on. .

Table 2 .
Theme 2: knowledge, skills, and training for mental health referral.
. 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. .That's a breach of his privacy.

Table 3 .
Theme 3: outcomes and consequences of referring clients for mental health support.From our point of view, we probably wouldn't find out about it.It doesn't come into our world.