Impact of Sociodemographic Disparities on Language Outcomes After Cochlear Implantation in a Diverse Pediatric Cohort

Disparities in Adult Otolaryngology Patients with Limited English Proficiency: A Systematic Review

OBJECTIVE

Limited English proficiency (LEP) has become increasingly recognized as an independent predictor of adverse health outcomes in the United States. We aim to examine trends and summarize current insights into LEP-related disparities in adult otolaryngology.

DATA SOURCES

Web of Science, PubMed, and Scopus.

METHODS

A systematic review of US-based, peer-reviewed literature evaluating outcomes in adult otolaryngology across primary language or varying levels of English proficiency; results were analyzed for study design, subspecialty, cohort demographics, and outcomes; findings were further assessed with the Kilbourne conceptual framework for health care disparities.

RESULTS

An initial search yielded 3886 articles. After removal of duplicates, 2906 articles were screened and 31 studies were included after full-text analysis. Head and Neck Oncology (25.8%) and Otology (16.1%) were the most highly represented subspecialty topics. Patients with LEP represented an average of 21.71% (Range 2.21% - 51%) of the study populations. Definitions of LEP were variable. Furthermore, studies specifying patient-reported LEP status reported significant findings more often than those using electronic health record-derived data (p < 0.01). Under the Kilbourne framework, all studies were "detecting" (N = 21, 67.7%) and "understanding" (N = 10, 32.3%) disparities. In outcomes-focused studies, patients with LEP presented with a higher burden of oncologic disease, more severe hearing loss, and disparities in treatment access/implementation.

CONCLUSION

Patients with LEP are adversely impacted across various otolaryngology subspecialties. Defining these inequities is vital to provide more targeted and comprehensive care for patients with LEP.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:1248-1258, 2025.

Understanding and Improving Pediatric Hearing Care Navigation: A Human-Centered Design Approach

OBJECTIVE

Explore the experiences of stakeholders within hearing care pathways using a human-centered design process to design a patient navigator (PN) to improve hearing health equity for deaf or hard-of-hearing children.

STUDY DESIGN

A qualitative, prospective, observational study utilizing the Empathize, Define, and Ideate phases of Human-Centered Design.

SETTING

Academic tertiary children's hospital with interviews over Zoom.

METHODS

We interviewed 12 hearing care providers, diverse in role and education across the United States, and 10 parents of deaf or hard-of-hearing children, diverse in preferred language and delays in care (mean age at diagnosis of 4.7 months, mean age at intervention of 10.5 months). The main outcomes were themes and subsequent insights that arose from the thematic analysis of interviews, which were used within a design synthesis session.

RESULTS

Qualitative analysis revealed 3 themes: Intrinsic Barriers, Extrinsic Barriers, and Areas of Opportunity. Within Intrinsic Barriers, a majority of providers and parents described a grieving process that led to delays. Within Extrinsic Barriers, interviewees expressed challenges navigating multiple deaf or hard-of-hearing care pathways. Within Areas of Opportunity, providers and parents agreed on connecting parents of new hearing loss diagnoses with mentor families to improve the care-seeking experience. Intercoder reliability was achieved (Cohen's κ = 0.73). Findings from the qualitative analysis were incorporated in a synthesis session with diverse stakeholders to design a PN role.

CONCLUSION

Providers and parents agree that the deaf or hard-of-hearing care pathway is difficult to navigate at baseline with delays in accessing care further exacerbated by barriers intrinsic to the family unit.

Social Determinants of Health and Language and Academic Outcomes in Pediatric Cochlear Implantation: A Systematic Review and Meta-Analysis

Importance

Cochlear implants can restore sound and enable speech and language development for children with severe to profound sensorineural hearing loss. Long-term outcomes of pediatric cochlear implant recipients are variable. Although the association between social determinants of health (SDH) and pediatric cochlear implant outcomes has been explored, the strength of this association has not been quantitatively synthesized in the literature.

Objective

To determine the association of SDH with language and academic outcomes in pediatric cochlear implant recipients.

Data Sources

In August 2023, the following databases were searched: Embase.com, Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, Cumulated Index to Nursing and Allied Health Literature Plus, APA PsycINFO, and ClinicalTrials.gov. Following duplicate exclusion of 8687 results, 5326 records were finalized.

Study Selection

Abstract screening, full-text review, and risk of bias assessment was performed by 1 to 2 reviewers. Articles were included if an effect size for an SDH variable that was associated with measures of language, communication, reading, academics, and quality of life was reported.

Main Outcomes and Measures

A random-effects meta-analysis was performed, with standardized regression coefficients measuring the relative direction and magnitude of a variable association with the outcome of interest.

Results

Of 5326 articles, 40 articles that included a total of 3809 children were included in the systematic review; 20 articles that included a total of 1905 children were included in the meta-analysis. Parental involvement, education level, and low socioeconomic status were moderately to strongly associated with language outcomes (β = 0.30; 95% CI, 0.13-0.48; β = 0.45; 95% CI, 0.29-0.62; β = -0.47; 95% CI, -0.83 to -0.10, respectively). Known determinants of language outcomes, such as the age of cochlear implantation and duration of cochlear implant use, demonstrated moderate to no associations with language outcomes (β = -0.30; 95% CI, -0.43 to -0.17; β = 0.19; 95% CI, -0.26 to 0.63, respectively).

Conclusions and Relevance

The results of this systematic review and meta-analysis suggest that SDH are associated with childhood language development and academic achievement. In addition to efforts to expedite cochlear implant placement in eligible children, optimal outcomes may be achieved with interventions centered on the child's home, primary medical care, and school environment.

Associated factors and outcomes for quality of life in children receiving cochlear implantation before seven years of age

PURPOSE

To evaluate the relationship of cochlear implant-related factors with quality of life (QOL) outcomes in pediatric cochlear implantation (CI) recipients.

METHOD

In this cross-sectional study, data from 146 children who received CI before 7 years of age were collected. QOL was measured using the Children using Hearing Implants Quality of Life (CuHI-QoL) questionnaire. Auditory and language abilities were measured using categories of auditory performance II(CAP-II) scale and speech intelligibility rating (SIR) scale. The reliability and validity of the CuHI-QOL scale were tested using internal consistency tests and correlation analysis, respectively. Bivariate correlations were used to compare CuHI-QOL scores and educational placements to cochlear implant-related factors. QOL scores were further compared using ANOVA in different groups based on age at CI with different durations of implant use.

RESULTS

The mean total CuHI-QOL scores was 60.13 (SD 8.97). The Cronbach's alpha of overall CuHI-QOL scale was 0.820. The CuHI-QOL total score was strongly to moderately correlated with CAP score (r = 0.542), SIR score (r = 0.545), duration of implant use (r = 0.403), and educational placement (r = 0.478). ANOVA showed the CuHI-QOL scores after 5 years post-CI were higher than those less than 2 years post-CI in children implanted ≤ 3 years of age.

CONCLUSIONS

Good QOL could be obtained for children with CI and were significantly associated with young age at implantation, good auditory and speech abilities, speech rehabilitation training pre-CI, long duration of cochlear implant use, and mainstream educational placement.

Geographic, Sociodemographic, and Clinical Factors Associated With Parental Self-Efficacy in Pediatric Patients With Hearing Loss

OBJECTIVE

To identify geographic, sociodemographic, and clinical factors associated with parental self-efficacy in a diverse cohort of deaf or hard-of-hearing (DHH) children.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary children's hospital.

METHODS

Four hundred forty parents of DHH children aged 0 to 17 completed the 25-item Scale of Parental Involvement and Self-Efficacy (SPISE) survey from 2014 to 2022. Residential addresses were geocoded and assigned Area Deprivation Index and Social Vulnerability Index rankings, and univariable and multivariable analyses were conducted using sociodemographic and clinical variables, including sex, race/ethnicity, insurance type, survey language, age at the survey, comorbidities, newborn hearing screening results, and hearing loss laterality and severity.

RESULTS

Compared to English and Spanish-speaking parents, Chinese-speaking parents were associated with overall lower parental self-efficacy and involvement (regression coefficient = -0.518, [-0.929, -0.106]), Cohen's d = 0.606) and lower scores on items related to their ability to affect multiple aspects of their child's development and expression of thoughts as well as competency in checking and putting on their child's sensory device. Across univariable and multivariable analyses, besides Chinese language, all other sociodemographic, clinical, and geographic variables were not associated with SPISE score.

CONCLUSION

To achieve the best patient outcomes, care teams can use the SPISE to evaluate parental self-efficacy and provide targeted support to parents at risk for having lower knowledge and confidence scores about critical skills necessary to facilitate their child's auditory access and language development. Notably, this study found similar reports of parental efficacy across various sociodemographic, clinical, and geographic variables but significantly lower SPISE scores in Chinese-speaking families.

Hearing Loss and Autism Spectrum Disorder

CASE

Gretta is a 3.5-year-old girl with a history of congenital cytomegalovirus, congenital bilateral profound sensorineural hearing loss (SNHL), and bilateral vestibular dysfunction, resulting in frequent falls. She underwent cochlear implantation at 12 months of age and was diagnosed with autism spectrum disorder at 2.5 years of age.On presentation for follow-up in the developmental-behavioral pediatrics (DBP) clinic, Gretta's mother reports that Gretta has refused to wear her cochlear implants for the past 5 months. Before that, she seemed to enjoy having access to sound and like dancing to music, and her receptive and expressive language skills, including speech, were progressing. Initially, the rejection of her devices occurred only at preschool. When frustrated or overwhelmed, she would close her eyes and remove her devices for up to 5 minutes before allowing them to be reapplied. Over time, this progressed to a complete refusal to wear her devices at school and then at home, rendering her without access to sound and spoken language.Gretta's mood has become sullen, and she is now having tantrums at school. She physically startles when attempts are made to reintroduce her devices. Her ability to participate in classroom learning or interact with her classmates is limited, as she attends a spoken-language-focused preschool program. A board-certified behavioral analyst, hired by the family, recommended that Gretta not be allowed to participate in classroom activities unless she wears her devices. She now becomes visibly anxious even when in the same room as her devices and repetitively states "no implant, no implant." Her mother is worried about her inability to communicate and has "no idea" what may have changed or sparked her initial refusal to wear the devices.What factors would you consider when determining the cause and function of Gretta's refusal to wear the cochlear implants? How would you guide her parents, teachers, and clinicians to ensure the best developmental and behavioral outcomes for her?

Use of Socioeconomic Demographic Data in Studies on Pediatric Unilateral Hearing Loss: A Scoping Review

OBJECTIVES

Social determinants of health (SDOH) (healthcare access and quality, education access and quality, socioeconomic status, social and cultural context, neighborhood and built environment) ( Healthy People 2030 ) have been shown to impact a wide range of health-related outcomes and access to care. Given the medical and nonmedical costs associated with children with unilateral hearing loss (UHL), the varied insurance coverage for hearing healthcare services, and the differences in hearing aid utilization rates between children of different sociodemographic classes, the sociodemographic information of children with UHL enrolled in research studies should be collected to ensure the generalizability of hearing healthcare interventions. Therefore, the objective of this scoping review is to assess the reporting of SDOH data for participants in studies of pediatric UHL and its comparison to population trends.

DESIGN

Two searches of published literature were conducted by a qualified medical librarian. Two reviewers then evaluated all candidate articles. Study inclusion parameters were from 2010 to present, peer-reviewed studies with prospective study design, and participant population including children (age 0 to 18 years old) with UHL.

RESULTS

Two literature searches using PubMed Medline and Embase found 442 and 3058 studies each for review. After abstract and paper review, 87 studies were included in final qualitative review, with 22 of these studies reporting race distribution of participants, 15 reporting insurance status or family income, and 12 reporting the maternal education level.

CONCLUSIONS

Sociodemographic data are not commonly reported in research studies of children with UHL. In reported samples, research participants are more likely to have private insurance and higher family income compared with overall population distribution. These demographic biases may affect the generalizability of study results to all children with UHL. Further evaluation is warranted to evaluate whether participant recruitment affects outcomes that reflect the overall population.