What Is the International Classification of Functioning, Disability and Health and Why Is It Relevant to Audiology?

Abstract

The World Health Organization's International Classification of Functioning, Disability and Health (ICF) is widely used in disability and health sectors as a framework to describe the far-reaching effects of a range of health conditions on individuals. This biopsychosocial framework can be used to describe the experience of an individual in the components of body functions, body structures, and activities and participation, and it considers the influence of contextual factors (environmental and personal) on these components. Application of the ICF in audiology allows the use of a common language between health care professionals in both clinical and research settings. Furthermore, the ICF is promoted as a means of facilitating patient-centered care. In this article, the relevance and application of the ICF to audiology is described, along with clinical examples of its application in the assessment and management of children and adults with hearing loss. Importantly, the skills necessary for clinicians to apply the ICF effectively are discussed.

Learning Outcomes: As a result of this activity, the participant will be able to (1) describe the components of the World Health Organization's International Classification of Functioning, Disability and Health; (2) provide examples of impairments, activity limitations, participation restrictions, and contextual factors relevant to audiology; and (3) outline the advantages of applying the ICF to adults and children with hearing loss.

It is common for audiologists to encounter patients with similar degrees of hearing loss who experience different impacts and who respond differently to hearing rehabilitation. Why is this? It is because patients will experience hearing loss differently, depending on the types of activities they do, societal roles they have, who they are, and the environment in which they participate. Through the application of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework,¹ we are able to explore the impacts of hearing loss on all facets of an individual's life and identify factors that influence these impacts. Such exploration can guide both the audiological assessment and management of children and adults with hearing loss.

The ICF is an interactive, biopsychosocial framework that can be used to describe health and health-related states.¹ The ICF considers a person's health in two ways; first, through functioning and disability, and second, through contextual factors. Functioning and disability incorporates a description of body functions and structures, and activities and participation. The corresponding negative impacts of a health condition are described using the terms impairments (e.g., hearing loss), activity limitations (e.g., communication difficulties), and participation restrictions (e.g., difficulties forming relationships). Activities refer to the execution of a task or an action by an individual, and participation describes an individual's involvement in a life situation.¹ Contextual factors in the ICF include consideration of the impact of environmental factors (e.g., attitudes of family, friends, and health professionals; organizational policies) and personal factors (e.g., age, gender, personality) on a person's overall functioning and disability (see Fig. 1). The overall aim of the ICF is to provide a common language and framework for the description of health and health-related states.

Figure 1.

World Health Organization's International Classification of Functioning, Disability and Health.¹

The impact of hearing loss can be extensive. For children, loss or degradation in hearing is often associated with difficulties in speech and language development and educational attainment and literacy development.^{2 3 4 5 6} Furthermore, childhood hearing loss adversely affects future employment prospects and emotional well-being.^{7 8 9 10} Similarly, for adults, hearing loss may negatively impact communication (e.g., in group situations and on the telephone), work activities, interactions with family and friends, and participation in social activities (e.g., dining at restaurants, going to the theater).^{11 12 13 14} For these reasons, hearing loss can negatively affect the psychosocial well-being and quality of life of children and adults with hearing loss and sometimes, their families.^{9 10 11 15 16 17 18 19 20 21 22 23 24} Figs. 2 and 3 are two case examples demonstrating how each component of the ICF is relevant to children and adults with hearing loss. Fig. 2 depicts an 8-year-old boy named Luke who presents with chronic otitis media with effusion, and Fig. 3 depicts a 55-year-old woman named Mary who presents with a sensorineural hearing impairment.

Figure 2.

Pediatric case example: Luke.

Figure 3.

Adult case example: Mary.

ICF Core Sets for Hearing Loss

In addition to the framework in Fig. 1, the ICF applies a comprehensive categorization and coding system to describe a person's overall functioning with respect to body functions and structures, activities and participation, and environmental factors.¹ For each of these components there are different categories and within each category two to three levels of codes (assigned to subcategories) wherein each level is more specific than the previous. For example, for the activities and participation category of communication, it can be specified as conversation (d350) and more specifically, as conversing with one person (d3503).¹ Recently, Granberg and colleagues have established the ICF core sets for hearing loss (see Appendix).^{25 26 27 28 29} According to Granberg et al, “a core set is a set of the ICF categories of specific relevance to a target group, diagnosis, or target area.”29(p.498) This list of core sets was derived through a WHO-defined process, which began with several preparatory phases (e.g., systematic review, qualitative focus group interviews) followed by expert consensus.²⁵ The same process has been used to develop core sets for other health conditions such as low back pain, osteoarthritis, and obesity.⁷⁹ The comprehensive core set for hearing loss comprises 117 categories; however, the brief core set for hearing loss comprises only 27 of these categories.²⁵

Appendix: Brief ICF Core Set for Hearing Loss²⁵ .

BODY FUNCTIONS = physiological functions of body systems (including psychological functions)
b126	Temperament and personality functions
	General mental functions of constitutional disposition of the individual to react in a particular way to situations, including the set of mental characteristics that makes the individual distinct from others. Inclusions: functions of extraversion, introversion, agreeableness, conscientiousness, psychic and emotional stability, and openness to experience; optimism; novelty seeking; confidence; trustworthiness Exclusions: intellectual functions (b117); energy and drive functions (b130); psychomotor functions (b147); emotional functions (b152)
b140	Attention functions
	Specific mental functions of focusing on an external stimulus or internal experience for the required period of time. Inclusions: functions of sustaining attention, shifting attention, dividing attention, sharing attention; concentration; distractibility Exclusions: consciousness functions (b110); energy and drive functions (b130); sleep functions (b134); memory functions (b144); psychomotor functions (b147); perceptual functions (b156)
b144	Memory functions
	Specific mental functions of registering and storing information and retrieving it as needed. Inclusions: functions of short-term and long-term memory, immediate, recent and remote memory; memory span; retrieval of memory; remembering; functions used in recalling and learning, such as in nominal, selective and dissociative amnesia Exclusions: consciousness functions (b110); orientation functions (b114); intellectual functions (b117); attention functions (b140); perceptual functions (b156); thought functions (b160); higher-level cognitive functions (b164); mental functions of language (b167); calculation functions (b172)
b152	Emotional functions
	Specific mental functions related to the feeling and affective components of the processes of the mind. Inclusions: functions of appropriateness of emotion, regulation and range of emotion; affect; sadness, happiness, love, fear, anger, hate, tension, anxiety, joy, sorrow; lability of emotion; flattening of affect Exclusions: temperament and personality functions (b126); energy and drive functions (b130)
b210	Seeing functions
	Sensory functions relating to sensing the presence of light and sensing the form, size, shape and color of the visual stimuli. Inclusions: visual acuity functions; visual field functions; quality of vision; functions of sensing light and color, visual acuity of distant and near vision, monocular and binocular vision; visual picture quality; impairments such as myopia, hypermetropia, astigmatism, hemianopia, color-blindness, tunnel vision, central and peripheral scotoma, diplopia, night blindness and impaired adaptability to light Exclusion: perceptual functions (b156)
b230	Hearing functions
	Sensory functions relating to sensing the presence of sounds and discriminating the location, pitch, loudness and quality of sound. Inclusions: functions of hearing, auditory discrimination, localization of sound source, lateralization of sound, speech discrimination; impairments such as deafness, hearing impairment and hearing loss. Exclusion: perceptual functions (b156) and mental functions of language (b167)
b240	Sensations associated with hearing and vestibular functions
	Sensations of dizziness, falling, tinnitus and vertigo. Inclusions: sensations of ringing in ears, irritation in ear, aural pressure, nausea associated with dizziness or vertigo Exclusions: vestibular functions (b235); sensation of pain (b280)

BODY STRUCTURES = anatomical parts of the body such as organs, limbs and their components
s110	Structure of brain
S240	Structure of external ear
S250	Structure of middle ear
S260	Structure of inner ear

ACTIVITIES AND PARTICIPATION = execution of a task or action by an individual and involvement in a life situation
d115	Listening
	Using the sense of hearing intentionally to experience auditory stimuli, such as listening to a radio, music or a lecture.
d240	Handling stress and other psychological demands
	Carrying out simple or complex and coordinated actions to manage and control the psychological demands required to carry out tasks demanding significant responsibilities and involving stress, distraction, or crises, such as driving a vehicle during heavy traffic or taking care of many children. Inclusions: handling responsibilities; handling stress and crisis

d310	Communicating with - receiving - spoken messages
	Comprehending literal and implied meanings of messages in spoken language, such as understanding that a statement asserts a fact or is an idiomatic expression.
d350	Conversation
	Starting, sustaining and ending an interchange of thoughts and ideas, performed by means of spoken, written, sign or other forms of language, with one or more people one knows or who are strangers, in formal or casual settings. Inclusions: starting, sustaining and ending a conversation; conversing with one or many people
d360	Using communication devices and techniques
	Using devices, techniques and other means for the purposes of communicating, such as calling a friend on the telephone. Inclusions: using telecommunication devices, using writing machines and communication techniques
d760	Family relationships
	Creating and maintaining kinship relationships, such as with members of the nuclear family, extended family, foster and adopted family and step-relationships, more distant relationships such as second cousins, or legal guardians. Inclusions: parent-child and child-parent relationships, sibling and extended family relationships
d820	School education
	Gaining admission to school, engaging in all school-related responsibilities and privileges, and learning the course material, subjects and other curriculum requirements in a primary or secondary education program, including attending school regularly, working cooperatively with other students, taking direction from teachers, organizing, studying and completing assigned tasks and projects, and advancing to other stages of education.
d850	Remunerative employment
	Engaging in all aspects of work, as an occupation, trade, profession or other form of employment, for payment, as an employee, full or part time, or self-employed, such as seeking employment and getting a job, doing the required tasks of the job, attending work on time as required, supervising other workers or being supervised, and performing required tasks alone or in groups. Inclusions: self-employment, part-time and full-time employment
d910	Community life
	Engaging in all aspects of community social life, such as engaging in charitable organizations, service clubs or professional social organizations. Inclusions: informal and formal associations; ceremonies Exclusions: non-remunerative employment (d855); recreation and leisure (d920); religion and spirituality (d930); political life and citizenship (d950)

ENVIRONMENTAL FACTORS = make up the physical, social and attitudinal environment in which people live and conduct their lives
e125	Products and technology for communication
	Equipment, products and technologies used by people in activities of sending and receiving information, including those adapted or specially designed, located in, on or near the person using them. Inclusions: general and assistive products and technology for communication
e250	Sound
	A phenomenon that is or may be heard, such as banging, ringing, thumping, singing, whistling, yelling or buzzing, in any volume, timbre or tone, and that may provide useful or distracting information about the world. Inclusions: sound intensity; sound quality
e310	Immediate family
	Individuals related by birth, marriage or other relationship recognized by the culture as immediate family, such as spouses, partners, parents, siblings, children, foster parents, adoptive parents and grandparents. Exclusions: extended family (e315); personal care providers and personal assistants (e340)
e355	Health professionals
	All service providers working within the context of the health system, such as doctors, nurses, physiotherapists, occupational therapists, speech therapists, audiologists, orthotist-prosthetists, medical social workers. Exclusion: other professionals (e360)
e410	Individual attitudes of immediate family members
	General or specific opinions and beliefs of immediate family members about the person or about other matters (e.g., social, political and economic issues), that influence individual behavior and actions.
e460	Societal attitudes
	General or specific opinions and beliefs generally held by people of a culture, society, subcultural or other social group about other individuals or about other social, political and economic issues, that influence group or individual behavior and actions.
e580	Health services, systems and policies
	Services, systems and policies for preventing and treating health problems, providing medical rehabilitation and promoting a healthy lifestyle. Exclusion: general social support services, systems and policies (e575)

Appendix: Comprehensive ICF Core Set for Hearing Loss²⁵ .

BODY FUNCTIONS = physiological functions of body systems (including psychological functions)
b117	Intellectual functions
	General mental functions, required to understand and constructively integrate the various mental functions, including all cognitive functions and their development over the life span. Inclusions: functions of intellectual growth; intellectual retardation, mental retardation, dementia Exclusions: memory functions (b144); thought functions (b160); higher-level cognitive functions (b164)
b126	Temperament and personality functions
	General mental functions of constitutional disposition of the individual to react in a particular way to situations, including the set of mental characteristics that makes the individual distinct from others. Inclusions: functions of extraversion, introversion, agreeableness, conscientiousness, psychic and emotional stability, and openness to experience; optimism; novelty seeking; confidence; trustworthiness Exclusions: intellectual functions (b117); energy and drive functions (b130); psychomotor functions (b147); emotional functions (b152)
b1300	Energy level
	Mental functions that produce vigor and stamina.
b1301	Motivation
	Mental functions that produce the incentive to act; the conscious or unconscious driving force for action.
b140	Attention functions
	Specific mental functions of focusing on an external stimulus or internal experience for the required period of time. Inclusions: functions of sustaining attention, shifting attention, dividing attention, sharing attention; concentration; distractibility Exclusions: consciousness functions (b110); energy and drive functions (b130); sleep functions (b134); memory functions (b144); psychomotor functions (b147); perceptual functions (b156)
b144	Memory functions
	Specific mental functions of registering and storing information and retrieving it as needed. Inclusions: functions of short-term and long-term memory, immediate, recent and remote memory; memory span; retrieval of memory; remembering; functions used in recalling and learning, such as in nominal, selective and dissociative amnesia Exclusions: consciousness functions (b110); orientation functions (b114); intellectual functions (b117); attention functions (b140); perceptual functions (b156); thought functions (b160); higher-level cognitive functions (b164); mental functions of language (b167); calculation functions (b172)
b152	Emotional functions
	Specific mental functions related to the feeling and affective components of the processes of the mind. Inclusions: functions of appropriateness of emotion, regulation and range of emotion; affect; sadness, happiness, love, fear, anger, hate, tension, anxiety, joy, sorrow; lability of emotion; flattening of affect Exclusions: temperament and personality functions (b126); energy and drive functions (b130)
b1560	Auditory perception
	Mental functions involved in discriminating sounds, tones, pitches and other acoustic stimuli.
b1561	Visual perception
	Mental functions involved in discriminating shape, size, color and other ocular stimuli.
b164	Higher-level cognitive functions
	Specific mental functions especially dependent on the frontal lobes of the brain, including complex goal- directed behaviors such as decision-making, abstract thinking, planning and carrying out plans, mental flexibility, and deciding which behaviors are appropriate under what circumstances; often called executive functions. Inclusions: functions of abstraction and organization of ideas; time management, insight and judgement; concept formation, categorization and cognitive flexibility Exclusions: memory functions (b144); thought functions (b160); mental functions of language (b167); calculation functions (b172)
b167	Mental functions of language
	Specific mental functions of recognizing and using signs, symbols and other components of a language. Inclusions: functions of reception and decryption of spoken, written or other forms of language such as sign language; functions of expression of spoken, written or other forms of language; integrative language functions, spoken and written, such as involved in receptive, expressive, Broca's, Wernicke's and conduction aphasia Exclusions: attention functions (b140); memory functions (b144); perceptual functions (b156); thought functions (b160); higher-level cognitive functions (b164); calculation functions (b172); mental functions of complex movements (b176); Chapter 2 Sensory Functions and Pain; Chapter 3 Voice and Speech Functions
b210	Seeing functions
	Sensory functions relating to sensing the presence of light and sensing the form, size, shape and color of the visual stimuli. Inclusions: visual acuity functions; visual field functions; quality of vision; functions of sensing light and color, visual acuity of distant and near vision, monocular and binocular vision; visual picture quality; impairments such as myopia, hypermetropia, astigmatism, hemianopia, color-blindness, tunnel vision, central and peripheral scotoma, diplopia, night blindness and impaired adaptability to light Exclusion: perceptual functions (b156)

b2300	Sound detection
	Sensory functions relating to sensing the presence of sounds.
b2301	Sound discrimination
	Sensory functions relating to sensing the presence of sound involving the differentiation of ground and binaural synthesis, separation and blending.
b2302	Localization of sound source
	Sensory functions relating to determining the location of the source of sound.
b2304	Speech discrimination
	Sensory functions relating to determining spoken language and distinguishing it from other sounds.
b235	Vestibular functions
	Sensory functions of the inner ear related to position, balance and movement. Inclusions: functions of position and positional sense; functions of balance of the body and movement Exclusion: sensations associated with hearing and vestibular functions (b240)
b240	Sensations associated with hearing and vestibular functions
	Sensations of dizziness, falling, tinnitus and vertigo. Inclusions: sensations of ringing in ears, irritation in ear, aural pressure, nausea associated with dizziness or vertigo Exclusions: vestibular functions (b235); sensation of pain (b280)
b280	Sensation of pain
	Sensation of unpleasant feeling indicating potential or actual damage to some body structure. Inclusions: sensations of generalized or localized pain in one or more body part, pain in a dermatome, stabbing pain, burning pain, dull pain, aching pain; impairments such as myalgia, analgesia and hyperalgesia
b310	Voice functions
	Functions of the production of various sounds by the passage of air through the larynx. Inclusions: functions of production and quality of voice; functions of phonation, pitch, loudness and other qualities of voice; impairments such as aphonia, dysphonia, hoarseness, hypernasality and hyponasality Exclusions: mental functions of language (b167); articulation functions (b320)
b320	Articulation functions
	Functions of the production of speech sounds. Inclusions: functions of enunciation, articulation of phonemes; spastic, ataxic, flaccid dysarthria; anarthria Exclusions: mental functions of language (b167); voice functions (b310)
b330	Fluency and rhythm of speech functions
	Functions of the production of flow and tempo of speech. Inclusions: functions of fluency, rhythm, speed and melody of speech; prosody and intonation; impairments such as stuttering, stammering, cluttering, bradylalia and tachylalia Exclusions: mental functions of language (b167); voice functions (b310); articulation functions (b320)

BODY STRUCTURES = anatomical parts of the body such as organs, limbs and their components
s110	Structure of brain
S240	Structure of external ear
S250	Structure of middle ear
S260	Structure of inner ear
s710	Structure of head and neck region

ACTIVITIES AND PARTICIPATION = execution of a task or action by an individual and involvement in a life situation
d110	Watching
	Using the sense of seeing intentionally to experience visual stimuli, such as watching a sporting event or children playing.
d115	Listening
	Using the sense of hearing intentionally to experience auditory stimuli, such as listening to a radio, music or a lecture.
d140	Learning to read
	Developing the competence to read written material (including Braille) with fluency and accuracy, such as recognizing characters and alphabets, sounding out words with correct pronunciation, and understanding words and phrases.
d155	Acquiring skills
	Developing basic and complex competencies in integrated sets of actions or tasks so as to initiate and follow through with the acquisition of a skill, such as manipulating tools or playing games like chess. Inclusion: acquiring basic and complex skills

d160	Focusing attention
	Intentionally focusing on specific stimuli, such as by filtering out distracting noises.
d175	Solving problems
	Finding solutions to questions or situations by identifying and analyzing issues, developing options and solutions, evaluating potential effects of solutions, and executing a chosen solution, such as in resolving a dispute between two people. Inclusions: solving simple and complex problems Exclusions: thinking (d163); making decisions (d177)
d220	Undertaking multiple tasks
	Carrying out simple or complex and coordinated actions as components of multiple, integrated and complex tasks in sequence or simultaneously. Inclusions: undertaking multiple tasks; completing multiple tasks; undertaking multiple tasks independently and in a group Exclusions: acquiring skills (d155); solving problems (d175); making decisions (d177); undertaking a single task (d210)
d240	Handling stress and other psychological demands
	Carrying out simple or complex and coordinated actions to manage and control the psychological demands required to carry out tasks demanding significant responsibilities and involving stress, distraction, or crises, such as driving a vehicle during heavy traffic or taking care of many children. Inclusions: handling responsibilities; handling stress and crisis
d310	Communicating with - receiving - spoken messages
	Comprehending literal and implied meanings of messages in spoken language, such as understanding that a statement asserts a fact or is an idiomatic expression.
d315	Communicating with - receiving - nonverbal messages
	Comprehending the literal and implied meanings of messages conveyed by gestures, symbols and drawings, such as realizing that a child is tired when she rubs her eyes or that a warning bell means that there is a fire. Inclusions: communicating with - receiving - body gestures, general signs and symbols, drawings and photographs
d330	Speaking
	Producing words, phrases and longer passages in spoken messages with literal and implied meaning, such as expressing a fact or telling a story in oral language
d3503	Conversing with one person
	Initiating, maintaining, shaping and terminating a dialogue or interchange with one person, such as in discussing the weather with a friend.
d3504	Conversing with many people
	Initiating, maintaining, shaping and terminating a dialogue or interchange with more than one individual, such as in starting and participating in a group interchange.
d355	Discussion
	Starting, sustaining and ending an examination of a matter, with arguments for or against, or debate performed by means of spoken, written, sign or other forms of language, with one or more people one knows or who are strangers, in formal or casual settings. Inclusion: discussion with one person or many people
d360	Using communication devices and techniques
	Using devices, techniques and other means for the purposes of communicating, such as calling a friend on the telephone. Inclusions: using telecommunication devices, using writing machines and communication techniques
d440	Fine hand use
	Performing the coordinated actions of handling objects, picking up, manipulating and releasing them using one's hand, fingers and thumb, such as required to lift coins off a table or turn a dial or knob. Inclusions: picking up, grasping, manipulating and releasing Exclusion: lifting and carrying objects (d430)
d470	Using transportation
	Using transportation to move around as a passenger, such as being driven in a car or on a bus, rickshaw, jitney, animal-powered vehicle, or private or public taxi, bus, train, tram, subway, boat or aircraft. Inclusions: using human-powered transportation; using private motorized or public transportation Exclusions: moving around using equipment (d465); driving (d475)

d475	Driving
	Being in control of and moving a vehicle or the animal that draws it, travelling under one's own direction or having at one's disposal any form of transportation, such as a car, bicycle, boat or animal-powered vehicle. Inclusions: driving human-powered transportation, motorized vehicles, animal-powered vehicles Exclusions: moving around using equipment (d465); using transportation (d470)
d620	Acquisition of goods and services
	Selecting, procuring and transporting all goods and services required for daily living, such as selecting, procuring, transporting and storing food, drink, clothing, cleaning materials, fuel, household items, utensils, cooking ware, domestic appliances and tools; procuring utilities and other household services. Inclusions: shopping and gathering daily necessities Exclusion: acquiring a place to live ( d610 )
d660	Assisting others
	Assisting household members and others with their learning, communicating, self-care, movement, within the house or outside; being concerned about the well-being of household members and others. Inclusions: assisting others with self-care, movement, communication, interpersonal relations, nutrition and health maintenance Exclusion: remunerative employment (d850)
d710	Basic interpersonal interactions
	Interacting with people in a contextually and socially appropriate manner, such as by showing consideration and esteem when appropriate, or responding to the feelings of others. Inclusions: showing respect, warmth, appreciation, and tolerance in relationships; responding to criticism and social cues in relationships; and using appropriate physical contact in relationships
d720	Complex interpersonal interactions
	Maintaining and managing interactions with other people, in a contextually and socially appropriate manner, such as by regulating emotions and impulses, controlling verbal and physical aggression, acting independently in social interactions, and acting in accordance with social rules and conventions. Inclusions: forming and terminating relationships; regulating behaviors within interactions; interacting according to social rules; and maintaining social space
d730	Relating with strangers
	Engaging in temporary contacts and links with strangers for specific purposes, such as when asking for directions or making a purchase.
d740	Formal relationships
	Creating and maintaining specific relationships in formal settings, such as with employers, professionals or service providers. Inclusions: relating with persons in authority, with subordinates and with equals
d750	Informal social relationships
	Entering into relationships with others, such as casual relationships with people living in the same community or residence, or with coworkers, students, playmates or people with similar backgrounds or professions. Inclusions: informal relationships with friends, neighbors, acquaintances, co-inhabitants and peers
d760	Family relationships
	Creating and maintaining kinship relationships, such as with members of the nuclear family, extended family, foster and adopted family and step-relationships, more distant relationships such as second cousins, or legal guardians. Inclusions: parent-child and child-parent relationships, sibling and extended family relationships
d770	Intimate relationships
	Creating and maintaining close or romantic relationships between individuals, such as husband and wife, lovers or sexual partners. Inclusions: romantic, spousal and sexual relationships
d810	Informal training
	Learning at home or in some other non-institutional setting, such as learning crafts and other skills from parents or family members, or home schooling.
d820	School education
	Gaining admission to school, engaging in all school-related responsibilities and privileges, and learning the course material, subjects and other curriculum requirements in a primary or secondary education programs, including attending school regularly, working cooperatively with other students, taking direction from teachers, organizing, studying and completing assigned tasks and projects, and advancing to other stages of education.
d825	Vocational training
	Engaging in all activities of a vocational program and learning the curriculum material in preparation for employment in a trade, job or profession.

d830	Higher education
	Engaging in the activities of advanced educational programs in universities, colleges and professional schools and learning all aspects of the curriculum required for degrees, diplomas, certificates and other accreditations, such as completing a university bachelor's or master's course of study, medical school or other professional school.
d840	Apprenticeship (work preparation)
	Engaging in programs related to preparation for employment, such as performing the tasks required of an apprenticeship, internship, articling and in-service training. Exclusion: vocational training (d825)
d845	Acquiring, keeping and terminating a job
	Seeking, finding and choosing employment, being hired and accepting employment, maintaining and advancing through a job, trade, occupation or profession, and leaving a job in an appropriate manner. Inclusions: seeking employment; preparing a resume or curriculum vitae; contacting employers and preparing interviews; maintaining a job; monitoring one's own work performance; giving notice; and terminating a job
d850	Remunerative employment
	Engaging in all aspects of work, as an occupation, trade, profession or other form of employment, for payment, as an employee, full or part time, or self-employed, such as seeking employment and getting a job, doing the required tasks of the job, attending work on time as required, supervising other workers or being supervised, and performing required tasks alone or in groups. Inclusions: self-employment, part-time and full-time employment
d855	Non-remunerative employment
	Engaging in all aspects of work in which pay is not provided, full-time or part-time, including organized work activities, doing the required tasks of the job, attending work on time as required, supervising other workers or being supervised, and performing required tasks alone or in groups, such as volunteer work, charity work, working for a community or religious group without remuneration, working around the home without remuneration. Exclusion: Chapter 6 Domestic Life
d860	Basic economic transactions
	Engaging in any form of simple economic transaction, such as using money to purchase food or bartering, exchanging goods or services; or saving money.
d870	Economic self-sufficiency
	Having command over economic resources, from private or public sources, to ensure economic security for present and future needs. Inclusions: personal economic resources and public economic entitlements
d910	Community life
	Engaging in all aspects of community social life, such as engaging in charitable organizations, service clubs or professional social organizations. Inclusions: informal and formal associations; ceremonies Exclusions: non-remunerative employment (d855); recreation and leisure (d920); religion and spirituality (d930); political life and citizenship (d950)
d920	Recreation and leisure
	Engaging in any form of play, recreational or leisure activity, such as informal or organized play and sports, programs of physical fitness, relaxation, amusement or diversion, going to art galleries, museums, cinemas or theaters; engaging in crafts or hobbies, reading for enjoyment, playing musical instruments; sightseeing, tourism and travelling for pleasure. Inclusions: play, sports, arts and culture, crafts, hobbies and socializing Exclusions: riding animals for transportation (d480); remunerative and non-remunerative work (d850 and d855); religion and spirituality (d930); political life and citizenship (d950)
d930	Religion and spirituality
	Engaging in religious or spiritual activities, organizations and practices for self-fulfillment, finding meaning, religious or spiritual value and establishing connection with a divine power, such as is involved in attending a church, temple, mosque or synagogue, praying or chanting for a religious purpose, and spiritual contemplation. Inclusions: organized religion and spirituality
d940	Human rights
	Enjoying all nationally and internationally recognized rights that are accorded to people by virtue of their humanity alone, such as human rights as recognized by the United Nations Universal Declaration of Human Rights (1948) and the United Nations Standard Rules for the Equalization of Opportunities for Persons with Disabilities (1993); the right to self-determination or autonomy; and the right to control over one's destiny. Exclusion: Political life and citizenship (d950)

d950

Political life and citizenship

Engaging in the social, political and governmental life of a citizen, having legal status as a citizen and enjoying the rights, protections, privileges and duties associated with that role, such as the right to vote and run for political office, to form political associations; enjoying the rights and freedoms associated with citizenship (e.g., the rights of freedom of speech, association, religion, protection against unreasonable search and seizure, the right to counsel, to a trial and other legal rights and protection against discrimination); having legal standing as a citizen. Exclusion: human rights (d940)

ENVIRONMENTAL FACTORS = make up the physical, social and attitudinal environment in which people live and conduct their lives
e115	Products and technology for personal use in daily living
	Equipment, products and technologies used by people in daily activities, including those adapted or specially designed, located in, on or near the person using them. Inclusions: general and assistive products and technology for personal use
e120	Products and technology for personal indoor and outdoor mobility and transportation
	Equipment, products and technologies used by people in activities of moving inside and outside buildings, including those adapted or specially designed, located in, on or near the person using them. Inclusions: general and assistive products and technology for personal indoor and outdoor mobility and transportation
e125	Products and technology for communication
	Equipment, products and technologies used by people in activities of sending and receiving information, including those adapted or specially designed, located in, on or near the person using them. Inclusions: general and assistive products and technology for communication
e130	Products and technology for education
	Equipment, products, processes, methods and technology used for acquisition of knowledge, expertise or skill, including those adapted or specially designed. Inclusion: general and assistive products and technology for education
e135	Products and technology for employment
	Equipment, products and technology used for employment to facilitate work activities. Inclusion: general and assistive products and technology for employment
e140	Products and technology for culture, recreation and sport
	Equipment, products and technology used for the conduct and enhancement of cultural, recreational and sporting activities, including those adapted or specially designed. Inclusion: general and assistive products and technology for culture, recreation and sport
e145	Products and technology for the practice of religion and spirituality
	Products and technology, unique or mass-produced that are given or take on a symbolic meaning in the context of the practice of religion or spirituality, including those adapted or specially designed. Inclusion: general and assistive products and technology for the practice of religion and spirituality.
e150	Design, construction and building products and technology of buildings for public use
	Products and technology that constitute an individual's indoor and outdoor human-made environment that is planned, designed and constructed for public use, including those adapted or specially designed. Inclusions: design, construction and building products and technology of entrances and exits, facilities and routing
e155	Design, construction and building products and technology of buildings for private use
	Products and technology that constitute an individual's indoor and outdoor human-made environment that is planned, designed and constructed for private use, including those adapted or specially designed. Inclusions: design, construction and building products and technology of entrances and exits, facilities and routing
e225	Climate
	Meteorological features and events, such as the weather. Inclusions: temperature, humidity, atmospheric pressure, precipitation, wind and seasonal variations
e240	Light
	Electromagnetic radiation by which things are made visible by either sunlight or artificial lighting (e.g., candles, oil or paraffin lamps, fires and electricity), and which may provide useful or distracting information about the world. Inclusions: light intensity; light quality; color contrasts
e2500	Sound intensity
	Level or volume of auditory phenomenon determined by the amount of energy being generated, where high energy levels are perceived as loud sounds and low energy levels as soft sounds.
e2501	Sound quality
	Nature of a sound as determined by the wavelength and wave pattern of the sound and perceived as the timbre and tone, such as harshness or melodiousness, and which may provide useful information about the world (e.g., sound of dog barking versus a cat meowing) or distractions (e.g., background noise).

e310	Immediate family
	Individuals related by birth, marriage or other relationship recognized by the culture as immediate family, such as spouses, partners, parents, siblings, children, foster parents, adoptive parents and grandparents. Exclusions: extended family (e315); personal care providers and personal assistants (e340)
e315	Extended family
	Individuals related through family or marriage or other relationships recognized by the culture as extended family, such as aunts, uncles, nephews and nieces. Exclusion: immediate family (e310)
e320	Friends
	Individuals who are close and ongoing participants in relationships characterized by trust and mutual support.
e325	Acquaintances, peers, colleagues, neighbors and community members
	Individuals who are familiar to each other as acquaintances, peers, colleagues, neighbors, and community members, in situations of work, school, recreation, or other aspects of life, and who share demographic features such as age, gender, religious creed or ethnicity or pursue common interests. Exclusions: associations and organizational services (e5550)
e330	People in position of authority
	Individuals who have decision-making responsibilities for others and who have socially defined influence or power based on their social, economic, cultural or religious roles in society, such as teachers, employers, supervisors, religious leaders, substitute decision-makers, guardians or trustees.
e335	People in subordinate positions
	Individuals whose day-to-day life is influenced by people in positions of authority in work, school or other settings, such as students, workers and members of a religious group. Exclusion: immediate family (e310)
e340	Personal care providers and personal assistants
	Individuals who provide services as required to support individuals in their daily activities and maintenance of performance at work, education or other life situation, provided either through public or private funds, or else on a voluntary basis, such as providers of support for home-making and maintenance, personal assistants, transport assistants, paid help, nannies and others who function as primary caregivers. Exclusions: immediate family (e310); extended family (e315); friends (e320); general social support services (e5750); health professionals (e355)
e345	Strangers
	Individuals who are unfamiliar and unrelated, or those who have not yet established a relationship or association, including persons unknown to the individual but who are sharing a life situation with them, such as substitute teachers, coworkers or care providers.
e350	Domesticated animals
	Animals that provide physical, emotional, or psychological support, such as pets (dogs, cats, birds, fish, etc.) and animals for personal mobility and transportation. Exclusions: animals (e2201); assets (e165)
e355	Health professionals
	All service providers working within the context of the health system, such as doctors, nurses, physiotherapists, occupational therapists, speech therapists, audiologists, orthotist-prosthetists, medical social workers. Exclusion: other professionals (e360)
e360	Other professionals
	All service providers working outside the health system, including lawyers, social workers, teachers, architects and designers. Exclusion: health professionals (e355)
e410	Individual attitudes of immediate family members
	General or specific opinions and beliefs of immediate family members about the person or about other matters (e.g., social, political and economic issues), that influence individual behavior and actions.
e415	Individual attitudes of extended family members
	General or specific opinions and beliefs of extended family members about the person or about other matters (e.g., social, political and economic issues), that influence individual behavior and actions.
e420	Individual attitude of friends
	General or specific opinions and beliefs of friends about the person or about other matters (e.g., social, political and economic issues), that influence individual behavior and actions.
e425	Individual attitudes of acquaintances, peers, colleagues, neighbors and community members
	General or specific opinions and beliefs of acquaintances, peers, colleagues, neighbors and community members about the person or about other matters (e.g., social, political and economic issues), that influence individual behavior and actions.
e430	Individual attitudes of people in position of authority
	General or specific opinions and beliefs of people in positions of authority about the person or about other matters (e.g., social, political and economic issues), that influence individual behavior and actions.
e440	Individual attitudes of personal care providers and personal assistants
	General or specific opinions and beliefs of personal care providers and personal assistants about the person or about other matters (e.g., social, political and economic issues), that influence individual behavior and actions.
e445	Individual attitudes of strangers
	General or specific opinions and beliefs of strangers about the person or about other matters (e.g., social, political and economic issues), that influence individual behavior and actions.
e450	Individual attitudes of health professionals

	General or specific opinions and beliefs of health professionals about the person or about other matters (e.g., social, political and economic issues), that influence individual behavior and actions.
e455	Individual attitude of other professionals
	General or specific opinions and beliefs of health-related professionals about the person or about other matters (e.g., social, political and economic issues), that influence individual behavior and actions.
e460	Societal attitudes
	General or specific opinions and beliefs generally held by people of a culture, society, subcultural or other social group about other individuals or about other social, political and economic issues, that influence group or individual behavior and actions.
e465	Social norms, practices and ideologies
	Customs, practices, rules and abstract systems of values and normative beliefs (e.g., ideologies, normative world views and moral philosophies) that arise within social contexts and that affect or create societal and individual practices and behaviors, such as social norms of moral and religious behavior or etiquette; religious doctrine and resulting norms and practices; norms governing rituals or social gatherings.
e515	Architecture and construction services, systems and policies
	Services, systems and policies for the design and construction of buildings, public and private. Exclusion: open space planning services, systems and policies (e520)
e525	Housing services, systems and policies
	Services, systems and policies for the provision of shelters, dwellings or lodging for people.
e535	Communication services, systems and policies
	Services, systems and policies for the transmission and exchange of information.
e540	Transportation services, systems and policies
	Services, systems and policies for enabling people or goods to move or be moved from one location to another.
e545	Civil protection services, systems and policies
	Services, systems and policies aimed at safeguarding people and property.
e550	Legal services, systems and policies
	Services, systems and policies concerning the legislation and other law of a country.
e555	Associations and organizational services, systems and policies
	Services, systems and policies relating to groups of people who have joined together in the pursuit of common, noncommercial interests, often with an associated membership structure.
e560	Media services, systems and policies
	Services, systems and policies for the provision of mass communication through radio, television, newspapers and internet.
e570	Social security services, systems and policies
	Services, systems and policies aimed at providing income support to people who, because of age, poverty, unemployment, health condition or disability, require public assistance that is funded either by general tax revenues or contributory schemes. Exclusion: economic services, systems and policies (e565)
e575	General social support services, systems and policies
	Services, systems and policies aimed at providing support to those requiring assistance in areas such as shopping, housework, transport, self-care and care of others, to function more fully in society. Exclusions: personal care providers and personal assistants (e340); social security services, systems and policies (e570); health services, systems and policies (e580)
e580	Health services, systems and policies
	Services, systems and policies for preventing and treating health problems, providing medical rehabilitation and promoting a healthy lifestyle. Exclusion: general social support services, systems and policies (e575)
e585	Education and training services, systems and policies
	Services, systems and policies for the acquisition, maintenance and improvement of knowledge, expertise and vocational or artistic skills. See UNESCO's International Standard Classification of Education (ISCED-1997).
e590	Labor and employment services, systems and policies
	Services, systems and policies related to finding suitable work for persons who are unemployed or looking for different work, or to support individuals already employed who are seeking promotion. Exclusion: economic services, systems and policies (e565)

The comprehensive ICF core set for hearing loss emphasizes the impact of hearing loss on a person's overall functioning, beyond body function and structure. Of the 117 categories included in the core set, 36% pertained to activities and participation (e.g., acquiring skills, speaking, interpersonal interactions), whereas only 19% pertained to body functions (e.g., sound discrimination) and only 3% pertained to body structures (e.g., structure of inner ear).²⁵ The core set also acknowledges a large number of contextual factors that can influence the way in which hearing loss is experienced. Of the 117 categories, 41% related to environmental factors (e.g., individual attitudes of immediate family members, health services, systems, and policies).²⁵

Seemingly, the ICF codes implicated in a person's overall functioning will differ for every patient with hearing loss. For example, with respect to activities and participation, codes d115 (listening), d310 (communicating with—receiving—spoken messages), d330 (speaking), d750 (informal social relationships), d760 (family relationships), d820 (school education), and d920 (recreation and leisure) would be relevant for 8-year-old Luke, whereas codes d115 (listening), d310 (communicating with—receiving—spoken messages), d3504 (conversing with many people), d750 (informal social relationships), d845 (acquiring, keeping, and terminating a job), and d920 (recreation and leisure) would be relevant for 55-year-old Mary.

Applying the ICF to Audiological Management

The application of the ICF model to audiological management can help facilitate patient-centered care by focusing on the individual needs of the patient and relevant contextual factors. This is important for two reasons. First, adults with hearing loss frequently emphasize the importance of individualized hearing health care in qualitative research studies,^{30 31 32} and the implementation of patient- and family-centered practices for children with hearing loss have long been advocated in the literature.³³ Second, there is strong evidence that activity limitations (e.g., perceived communication difficulties), participation restrictions (e.g., perceived hearing handicap), and personal factors (e.g., attitudes toward hearing devices, confidence in hearing device use, family support) have a greater impact on hearing rehabilitation outcomes for both adults and children with hearing loss than measured hearing loss alone.^{34 35 36 37 38 39} Next, we will describe, in detail, how audiologists might be able to apply the ICF framework to the assessment and management of people with hearing loss.

Assessment

In light of what is known about the broad ranging effects of hearing loss, it is apparent that audiological management should begin with assessments of all the components within the ICF framework. For example, it is recommended that the case history incorporate open-ended questions about a person's lifestyle, in addition to the typical biomedical questions related to hearing function and structure. For example, you may ask a parent “Tell me how the hearing loss is affecting your child in the classroom” or your patient “Tell me how hearing loss is affecting the activities you like to do.” It is important that audiologists invest time in the case history to ensure they have a comprehensive understanding of the patient's needs, which should ultimately inform management planning. In addition, by seeking information about the person's lifestyle and the impact of hearing loss on his or her psychosocial well-being, the audiologist is likely to build better rapport and trust with the patient.^{30 40} There is growing research in audiology and other areas of health care that an effective patient-clinician relationship is fundamental to patient-centered care.^{30 32 40 41 42 43} In primary health care, patient-centered care has been found to be associated with improved patient outcomes such as greater satisfaction with care and better treatment adherence.^{42 43 44}

Following a comprehensive case history, it is standard practice for audiologists to conduct otoscopy, pure tone audiometry, speech perception testing, and impedance testing. These assessments, and others that may be deemed necessary, are important to aid audiologists' understanding of changes to body function and structure. To evaluate the other components within the ICF, however, audiologists also need to seek information about the impact of hearing loss on communication, daily activities (e.g., watching television, using the phone), and participation in education/work and social settings. In addition, clinicians should enquire about contextual factors that may impact management, for example, the parent's or patient's attitude toward hearing devices, confidence in ability to use hearing devices (hearing device self-efficacy), and family support and the impact of the hearing loss on significant others (also referred to as third-party hearing disability). Such information can be elicited by a conversation between the audiologist and parent/patient; however, there is also a variety of parental/teacher report or self-report measures that can assist audiologists in their evaluation of activity limitations, participation restrictions, and contextual factors for children (see Table 1) and adults (see Table 2) with hearing loss. We will illustrate how these might apply to our two case examples.

Table 1. Example Parent/Teacher/Self-Report Measures That Can Evaluate the Impact of Hearing Loss and Relevant Contextual Factors in Children with Hearing Loss.

Component	Instrument
Activities and participation	Infant-Toddler Meaningful Auditory Integration Scale60
	Meaningful Auditory Integration Scale61
	Meaningful Use of Speech Scale62
	Parent's Evaluation of Aural/Oral Performance of Children63
	Speech, Spatial, and Qualities of Hearing Scale for Parents of Children with Impaired Hearing64
	Auditory Behavior in Everyday Life65
	Little Ears66
	Teachers' Evaluation of Aural/Oral Performance of Children67
Contextual factors	Pediatric Abbreviated Profile of Hearing Aid Benefit68
	Listening Inventory for Education-Revised69
	Listening Situations Questionnaire70

Table 2. Example Self-Report Measures That Can Evaluate the Impact of Hearing Loss and Relevant Contextual Factors in Adults with Hearing Loss.

Component	Instrument
Activities and participation	Hearing Handicap Questionnaire71
	The Hearing Handicap Inventory for the Elderly, shortened version72
	Self-Assessment of Communication73
	Communication Profile for the Hearing Impaired74
	Self-Efficacy for Situational Communication Management Questionnaire75
Contextual factors	University of Rhode Island Change Assessment76
	Attitude toward Hearing Aids Questionnaire77
	Hearing Beliefs Questionnaire39
	Measure of Audiologic Rehabilitation Self-Efficacy for Hearing Aids45
	Intervention Questionnaire36
	Significant Other Scale for Hearing Disability18
	Hearing Impairment Impact-Significant Other Profile78

Luke

Luke presented to the hearing clinic with chronic otitis media with effusion accompanied by his mother. By way of a comprehensive case history with Luke's mother, Luke's audiologist identified several activity limitations and participation restrictions (see Fig. 2). For example, Luke's mother commented that her son's speech development had plateaued, he was not participating in classroom activities, and his relationships with family and peers were negatively affected. Audiometric testing revealed a mild to moderate conductive loss, and speech perception testing identified impaired spatial listening and a restricted ability to hear consonant sounds. Further discussion with Luke's mother revealed that he had good eyesight, he was the youngest of three children, and he had recently changed schools. These latter factors are important contextual factors that would need to be considered in Luke's management planning.

Mary

Mary presented to the clinic on her own and reported a hearing loss. A comprehensive case history revealed several activity limitations and participation restrictions (see Fig. 3). For example, Mary reported trouble understanding speech over the phone and difficulties following conversations in group situations. Ultimately, this has resulted in her withdrawing from social activities and resigning from her job as a secretary. A standard audiometric test battery confirmed the presence of a moderate to severe bilateral sensory/neural hearing loss. A short discussion with Mary revealed that she was unmarried and lived alone, had type 1 diabetes, and was not financially ready to retire. The audiologist felt that Mary would benefit from hearing aids and asked Mary how she felt about this prospect. Mary commented that she had heard mixed reports about hearing aids but that she was happy to try them; the audiologist noted in Mary's chart that she felt Mary had a positive attitude toward hearing aids. Because Mary lived alone, the audiologist wanted to check if Mary would be confident in using hearing aids and administered the Measure of Audiologic Rehabilitation Self-Efficacy for Hearing Aids (MARS-HA).⁴⁵ The results from the MARS-HA indicated that Mary was confident she could do basic tasks such as inserting a battery, but she was less confident that she could do more complex tasks such as hearing aid troubleshooting. The audiologist made a note of this to assist in Mary's management planning.

Rehabilitation/Habilitation

After identifying how hearing loss is impacting a particular person, it is important to address or consider each component of the ICF framework in creating a hearing management plan. For example, the audiogram might inform which type of hearing device is suitable; however, patients' activity limitations and participation restrictions might dictate that an assistive device is more appropriate. Thus, it is time to revisit the information collected from the case history and parent/teacher/self-report questionnaires and apply this information to intervention planning. First, audiologists can draw on this information to help establish meaningful goals for patients and their family members. Goal setting should be done in a collaborative manner, and tools such as the Client Oriented Scale of Improvement (COSI) and the Goal Sharing for Partners Strategy can be used to support this process.^{46 47 48} Essentially, both tools allow for the individualization of hearing rehabilitation/habilitation programs by encouraging a conversation about how the patient (and his or her family) would like to cope better.

Second, after identifying meaningful goals for the person with hearing loss and his or her family, audiologists should present patients with a choice of intervention options to address these goals. Intervention options may include (but are not limited to) hearing aids, cochlear implants, assistive listening devices, communication training, and/or listening training. One way to present a patient with hearing rehabilitation/habilitation options is by way of a decision aid.^{36 49 50} A decision aid outlines what is involved in each option and the advantages and disadvantages of each. The format is simple and is meant as a supplement to a verbal explanation of each option, which is also provided to the patient. Recently, Laplante-Lévesque et al used a decision aid to present four hearing rehabilitation options to older adults with hearing loss (e.g., hearing aids, group/individual communication training, and no intervention).⁵⁰ When multiple options were provided to patients, hearing aids were only taken up on 54% of occasions. Therefore, audiologists must be mindful that not all patients (in particular, adult patients) with hearing loss are seeking amplification when they present to a hearing clinic, and hearing aids do not necessarily address patients' activity limitations and participation restrictions when used in isolation.

Finally, it is important to consider additional support that people with hearing loss and/or their family may require. For example, a young patient may need the audiologist to liaise with his or her classroom teacher to ensure the classroom environment is conducive to learning, an adult patient who reports low hearing aid self-efficacy may require additional hearing aid training, and a patient who reports or shows signs he or she is suffering depression and/or anxiety may benefit from a referral to a psychologist.

Next, we will illustrate how the ICF framework can be applied to the management of a child and adult with hearing loss using the two case examples.

Luke

In consultation with Luke and his mother, the following COSI goals were decided upon: (1) improve Luke's hearing levels; (2) improve Luke's listening in the classroom environment; (3) improve Luke's ability to follow directions at home and in the classroom; and (4) increase Luke's confidence in his ability to interact with peers. Together, these goals address body function and structure, and activities and participation. To address goal 1, Luke's audiologist recommended that he be referred to an ear, nose, and throat specialist for further assessment and Luke's mother agreed. To address goals 2 and 3, the audiologist presented Luke and his mother with a couple of options, including communication training and a frequency-modulated system for Luke's classroom teacher. Luke's mother felt that she and her husband would benefit from communication training to improve their communication with Luke at home. She also decided to speak to Luke's classroom teacher about the possibility of using a frequency-modulated system to support Luke's understanding of verbal information in the classroom. To address goal 4, Luke's mother, Luke, and the audiologist agreed to provide information and support to Luke's classmates at school to educate them about Luke's hearing loss and the implication of that for interactions with his classmates.

It is clear, in this example, to reduce Luke's activity limitations and participation restrictions that Luke's family and classroom teacher will need to be engaged in his rehabilitation program. Luke's mother is busy with her three children and with part-time work but appears committed to support Luke with his hearing rehabilitation. She is still establishing her relationship with Luke's classroom teacher but understands that Luke's teacher will have less capacity to be engaged given that Luke is 1 of 25 children in her classroom. Luke's mother has asked that the audiologist prepare a report to give the classroom teacher, detailing several listening and communication strategies that could be applied in the classroom to support Luke's learning. The audiologist also will schedule an appointment with Luke's parents (at a time when Luke's father is available) to focus on how to improve communication with Luke around the home. To determine the impact of Luke's hearing loss on his speech development, Luke's audiologist recommended that Luke be referred to a speech-language pathologist for further assessment.

Mary

Mary attended the appointment alone. Together with her audiologist, she decided on the following COSI goals: (1) increase her hearing levels; (2) improve her understanding of speech in group settings; and (3) gain paid employment. Mary was presented with a decision aid that described the benefits and disadvantages associated with hearing aids, communication training, assistive listening devices, and no intervention. Following discussion with her audiologist, Mary decided that it would be best in her situation to try hearing aids and simultaneously receive communication training. She felt that hearing aids alone would not improve her communication in noisy, group situations and at work. With respect to goal 3, Mary's audiologist informed her of modifications that could be made to the work environment to support Mary in her role as a secretary (e.g., use of a telecoil for telephone communication, moving the printer away from her desk to decrease background noise). Given that Mary lives in a rural center, Mary decided to get in touch with her previous employer to see if they could accommodate her hearing loss. In light of Mary's reported low hearing aid self-efficacy, her audiologist has scheduled a follow-up appointment to focus on hearing aid training, prior to fitting her with a hearing aid. Communication training will begin after Mary has had a chance to adjust to hearing aids.

Reflection on Current Practice

Recent research suggests that audiologists can better integrate the ICF framework into their management of children and adults with hearing loss. For example, with respect to assessment and early intervention, studies of parents' perceptions of the diagnostic and early intervention period have revealed inconsistencies in the level of psychosocial support provided by audiologists, with some parents reporting that they did not receive adequate information about the hearing loss and associated activity limitations and participation restrictions.^{51 52} Furthermore, video observations of initial audiology assessment appointments with older adult patients revealed that slightly more than half of the questions (57%) asked by audiologists during the history taking phase of appointments were biomedical in nature and in most cases, closed-ended (e.g., “Have you ever had an ear infection?”).⁵³ Similarly, during the diagnostic and management planning phases of appointments, 83% of audiologist talk devoted to education and counseling was focused on the medical condition (e.g., “Hearing loss can happen gradually”) or hearing aids (e.g., “There are many styles of hearing aids”), not on the patient's lifestyle or psychosocial topics.⁵⁴ Alternative rehabilitation options (e.g., assistive listening devices, communication training) were rarely offered to patients.⁵⁴ Further to the predominance of biomedical talk, audiologists often missed opportunities for psychosocial talk (i.e., talk that relates to activities, participation, and contextual factors). That is, patients raised concerns about hearing aids in 80% of filmed consultations. Despite these concerns having psychosocial undertones, in all but one instance, the audiologist did not address the concern or inappropriately addressed the concern by redirecting the conversation back toward hearing aids.⁵⁵ If patients are not ready to pursue hearing aid fitting, it may be more appropriate to revisit patients' needs across all components of the ICF and consider alternative rehabilitation options to address these needs.

Overall, the results from these clinical interaction studies indicate that, despite three-quarters of the codes in the ICF core set for hearing loss pertaining to the activities and participation and environmental components,²⁵ there appears to be a disproportionate focus in hearing assessment appointments on body function and structure. A focus on body function and structure alone is not considered patient-centered. Thus, to improve outcomes for children and adults with hearing loss, we encourage audiologists to reflect on their current practice to see if there are opportunities to better understand and address patients' needs in hearing health care. For example, audiologists may wish to reflect on their opening question in a case history with a child or adult patient (i.e., is it sufficiently open and encouraging?) or ask themselves if they know what activities their patient enjoys and participates in when considering rehabilitation/habilitation options. In addition, consideration of contextual factors, in particular, environmental factors that may influence outcomes, is especially important in providing true patient-centered care.

The key skill needed by clinicians to facilitate patient-centered care and thereby address each of the components within the ICF is effective communication.⁵⁶ Indeed, in a recent qualitative study, older adults with hearing loss reported that they value good communication skills when interacting with their audiologists, namely that they wanted their needs to be understood and valued.³⁰ Effective patient–clinician communication requires a multitude of skills and can be observed across three areas: relationship building, information exchange, and decision-making.⁵⁷ For example, in developing a relationship, practitioners should seek and be responsive to patients' psychosocial concerns and invest in social talk. Additionally, information should be exchanged in a two-way, meaningful, and individualized manner. Such communication can impact the success of a consultation.^{43 58 59} For example, Street et al found that patients were more likely to participate in medical consultations if the clinician used partnership building (e.g., asked patient's preferences) and supportive (e.g., reassurance, comfort) talk.⁵⁹

In addition to the potential advantages for patients if audiologists were to adopt the ICF in patient assessment and management, there are other potentially broader advantages to its adoption. First, and most importantly, the ICF establishes a common language for the exchange of information with other health care professionals. The ICF has been widely applied in speech pathology, physiotherapy, occupational therapy, social work, medicine, and more, and it could therefore be expected that meaningful interprofessional discussions could occur in light of this. One way to think of the importance of this is to consider that participation for a person with hearing loss is not likely to be influenced solely by changes to the auditory system (body function and structure). An older adult may not be able to attend social gatherings because of hearing loss and mobility issues and lack of family support. Thus, an interprofessional approach to patient management is needed. Second, if the ICF is used in research and clinical practice as a means to describe the impacts of a health condition, it will be possible to compare data across different health conditions, services, and countries.

Conclusion

Following in the footsteps of other health professions, the ICF framework can and should be used to guide audiology services for children and adults with hearing loss. It allows for individualized services that address not only each patient's body function and structure, but also relevant activity limitations and participation restrictions in the context of environmental and personal factors. In this way, the ICF framework can be adopted by audiologists to support their implementation of patient-centered care and ultimately improve patient outcomes.