Geographic Distribution of the Hearing Aid Dispensing Workforce: A Teleaudiology Planning Assessment for Arizona

An overview of World Health Organization guidance aiming to increase global access to critical hearing aid services

OBJECTIVE

Equitable access to hearing aids and related services remains a global health challenge, particularly in resource-limited settings. A major barrier to access is the lack of diagnostic and rehabilitative services, which is substantially attributable to the persistent shortage of ear and hearing care specialists. This discussion article provides an overview of limitations in the ear and hearing care workforce, the relevance of task sharing to ear and hearing care, and a new, evidence-based World Health Organization (WHO) technical resource aimed at improving access to hearing aids worldwide.

DESIGN AND STUDY SAMPLE

A synthesis of current research and expert opinion.

RESULTS

First, this article describes the global shortage of qualified ear and hearing care specialists. Next, it describes how community-based care, supported by task sharing among trained non-specialist providers and qualified ear and hearing care providers, could overcome these workforce limitations, and describes the critical role of qualified ear and hearing care providers in task sharing. Finally, this article provides an overview of a WHO resource which provides practical information for hearing aid service provision in resource-limited settings.

CONCLUSION

Innovative strategies to expand the ear and hearing care workforce are essential to advance efforts towards equitable access to hearing aids and related services.

School-Based Enhanced Hearing Screening and Specialty Telehealth Follow-Up for Hearing Loss Among Children in Rural Alaska: Study Protocol for a Hybrid Effectiveness-Implementation Stepped Wedge, Cluster-Randomized Controlled Trial (North STAR Trial)

Background

Childhood hearing loss has well-known profound implications for language development, school achievement, and future employment opportunities. School-based health programs can provide hearing screening, but access to specialists for follow-up care is limited in rural areas. This is especially problematic for children in rural Alaska who experience a disproportionately high burden of preventable childhood hearing loss. The purpose of this study will be to develop and test the effectiveness and implementation of school-based specialty telehealth follow-up to improve timely access to specialty care after school hearing screening in rural Alaska.

Methods

This will be a hybrid type 1 effectiveness-implementation stepped wedge, cluster-randomized trial in three representative regions of Alaska. The trial will evaluate the STAR model, which consists of three core components: 1) enhanced school hearing screening, 2) school-based specialty telehealth follow-up, and 3) streamlined communication between schools, healthcare providers, and parents/caregivers. The trial will begin with a formative phase in the first two years, when qualitative data on community preferences and perspectives will be gathered to systematically adapt the STAR model and develop an implementation plan for participating regions. The adapted STAR model will be evaluated with a stepped wedge, cluster-randomized design in approximately 25 schools in three regions of rural Alaska. The primary effectiveness outcome will be the proportion of referrals resulting in specialty follow-up within 60 days of school hearing screening, measured using queries of electronic health records from the healthcare systems serving each region. Generalized estimating equations (GEE) will be used to model these cluster-period school-level proportions to obtain population-averaged intervention effects that are of public health relevance and therefore of interest in implementation trials. Secondary implementation outcomes will include fidelity, reach, acceptability, feasibility, and appropriateness. Sustainability of the STAR model will be evaluated through iterative meetings with state leaders and policymakers.

Discussion

This trial will evaluate school-based specialty telehealth follow-up in diverse regions of Alaska, addressing preventable childhood hearing loss with a model that could be translated to other underserved rural and marginalized groups to bring high-value services into rural schools and alter the paradigm of prevention nationwide.

Trial registration

NCT05593484 - https://clinicaltrials.gov/study/NCT05593484.

Longitudinal Insights from Blended Hearing Care: Service Modality Choices, Support Received, and Satisfaction Ratings

Background/Objectives: Sensorineural hearing loss (HL) is a highly prevalent chronic health condition. It can be managed through hearing care, including the use of hearing aids (HAs). Still, a majority of individuals with HL remain undiagnosed or untreated. Virtual care delivery may support uptake and adherence to interventions. In blended care, individuals can choose interchangeably between in-person and virtual services. This study aimed to investigate how real-world individuals accessed blended hearing care (through in-person, virtual, or hybrid services), the amount of support they received, and their satisfaction with services and products. Methods: An exploratory, retrospective analysis was performed on longitudinal observational data collected through Australia's longest-running blended hearing care model. A total of 25,058 appointment records were available, matched to HA purchase records and clinical notes where possible, as well as 916 satisfaction ratings. Results: The majority of individuals attended in-person appointments (75%); 25% were virtual or hybrid appointments. The number of appointments attended depended on how HAs were purchased (in-person, virtually, or hybrid), but all modalities were complemented by ample unscheduled email and telephone support. Of those who purchased HAs repeatedly, 49% changed preferred sales channel (in-person versus virtual) over time. Satisfaction ratings were highest for virtual services. Conclusions: This first report of real-world, longitudinal evidence on blended hearing care showed strong attendance of in-person appointments, while hybrid services-including informal; unscheduled support-may have responded to individuals' changing needs and preferences over time. The findings offer practice-based evidence for blended care models and recommendations for further research.

Health disparities and health literacy challenges experienced by individuals with hearing loss: A scoping review

OBJECTIVE

The purpose of this scoping review is to explore health disparities and health literacy challenges encountered by U.S. adults with hearing loss when trying to seek specialized care and access to medical devices such as hearing aids.

METHODS

The Arksey and O'Malley (2005) York methodology was used for this review: (1) identifying research questions; (2) searching for relevant studies; (3) selecting studies relevant to the research questions; (4) charting the data; (5) collating, summarizing, and reporting results.

RESULTS

A total of 52 articles were retained for analysis. Significant associations were reported between health literacy and health disparities when assessing the relationship between health literacy and poor health outcomes, social support surrounding health, communication with health professionals, accessibility of health information, immediacy of care, income, healthcare costs, age, and gender.

CONCLUSION

Findings will inform evidence-based strategies to increase equitable access to affordable and quality care among patients with hearing loss.

Demographic Disparities in Drive Times to the Nearest Audiologist in the United States

PURPOSE

Audiological services are underused, possibly because patients need to drive long distances to see a provider. In this study, we measured the association of drive times to the nearest audiologist with population density, income, ethnicity, race, and distance to the nearest audiology graduate program.

METHOD

Drive times for each census block group to the nearest audiologist were measured using census data, the National Provider Identifier Registry, and a geographic analyzing tool called ArcGIS for all block groups within the United States. The association between drive times and population density, income, ethnicity, race, and audiology program distance was evaluated with a population density-matched case-control study and multiple linear regression analyses.

RESULTS

Approximately 5.29 million Americans need to drive at least 1 hr to visit their closest audiologist. The 10% most rural-dwelling Americans drive an average of 33.8 min. The population density-matched case-control study demonstrated that percent below poverty, percent identifying as Hispanic, and travel times to the nearest audiology program were all significantly higher in census block groups with high drive times to the nearest audiologist. An average of 7.96% of individuals in census block groups with low drive times identified as Hispanic, but 18.8% identified as Hispanic in high drive time groups. The multiple linear regression showed that the effect of demographics and distance to the nearest audiology program was highest in rural areas. In both analyses, adjusting for poverty did not drastically change the effect of percent identifying as Hispanic on drive times.

CONCLUSIONS

Long drive times restrict access to audiological care for those who live in rural areas. This restriction disproportionately affects those in rural areas who identify as Hispanic or have low income.

"Close to My Community": A Qualitative Study of Community Health Worker-Supported Teleaudiology Hearing Aid Services

OBJECTIVES

Given well-documented disparities in rural and minority communities, alternative service delivery models that help improve access to hearing care are needed. This article reports on a study of older Latino adults with hearing loss who received hearing aid services with Community Health Workers (CHWs) providing support via teleaudiology. The present study used qualitative data to explore perceptions of this novel service delivery model.

DESIGN

Participants completed semistructured interviews related to their experiences in the intervention approximately 17 weeks after the hearing aid fitting appointment. Two coders independently coded the data, using an iterative deductive and inductive thematic analysis approach. Inter-rater reliability was good (κ = 0.80).

RESULTS

Of the 28 participants, 19 were interviewed (CHW group: n = 9, 8 females; non-CHW group: n = 10, 9 females). Both groups of participants reported experiencing barriers in access to care and reported positive experiences with teleaudiology and with hearing aids as part of the trial. CHW group participants reported interactions with patient-site facilitators that were indicative of patient-centeredness.

CONCLUSIONS

Results demonstrate the feasibility and potential effectiveness of trained CHWs as patient-site facilitators in teleaudiology-delivered hearing aid services for adults.

Personal experience with the remote check telehealth in cochlear implant users: from COVID-19 emergency to routine service

PURPOSE

To critically illustrate the personal experience with using the "Remote Check" application which remotely monitors the hearing rehabilitation level of cochlear implant users at home and further allows clinicians to schedule in-clinic sessions according to the patients' needs.

METHODS

12-month prospective study. Eighty adult cochlear implant users (females n = 37, males n = 43; age range 20-77 years) with ≥ 36 months of cochlear implant experience and ≥ 12 months of stable auditory and speech recognition level volunteered for this 12-month long prospective study. For each patient, at the beginning of the study during the in-clinic session to assess the stable aided hearing thresholds and the cochlear implant integrity and patient's usage, the "Remote Check" assessment baseline values were obtained. "Remote Check" outcomes were collected at different times in the subsequent at-home sessions, to identify the patients that had to reach the Center. Chi-square test has been used for statistical analysis of the comparison of the "Remote Check" outcomes and in-clinic session results.

RESULTS

"Remote Check" application outcomes demonstrated minimal or no differences between all sessions. The at-home Remote Check application reached the same clinical outcomes as the in-clinic sessions in 79 out 80 of participants (99%) with high statistical significance (p < 0.05).

CONCLUSIONS

"Remote Check" application supported hearing monitoring in cochlear implant users that were not able to attend the in-clinic review during COVID-19 pandemic time. This study demonstrates that the application can be a useful routine tool also for clinical follow-up of cochlear implant users with stable aided hearing.

Modeling Lost to Intervention in Early Hearing Detection and Intervention: A Modified eDelphi Study

PURPOSE

The purpose of this study was to develop a functional model of the drivers behind why families may decline early intervention services following the identification of a child as D/deaf or hard of hearing.

METHOD

This model was developed using a modified eDelphi method. Invited experts (N = 155) were provided proposed models of why families may decline early intervention services in accordance with current literature. In the first phase of feedback, participants (n = 23) provided changes they would make to the model to be more in line with their perceptions of lost to intervention. These changes were implemented, and a second phase of feedback with participants (n = 25) moved to accept the model as presented.

RESULTS

Agreement was reached on five main barriers to early intervention access for children who have been identified as D/deaf or hard of hearing (family experience, family culture, perceived vulnerability, perceived benefits, and perceived barriers). Each of these main barriers has associated examples of how they may manifest across different early intervention programs and situations.

CONCLUSIONS

This is the first theoretical model of why loss to intervention happens within early hearing detection and intervention. Having a model provides the opportunity for future work to implement novel approaches to support families during the early intervention enrollment process.

An Assessment of Hearing Health Care Needs in Rural West Central and South Alabama

PURPOSE

Hearing loss has become a significant public health concern because of its association with physical health, cognition, and emotional well-being. Age-related hearing loss is the third leading cause of global years lived with disability after lower back pain and migraine. Among other sensory disorders, hearing loss is ranked first. To help mitigate these health concerns, access to affordable hearing health care across rural and urban communities will be necessary.

METHOD

For this study, the needs of rural communities and their residents with hearing loss were explored. Individual interviews and focus group discussions with 26 adults with hearing loss, 14 friends and family of those with hearing loss, and 25 community members who worked and lived in rural communities were conducted.

RESULTS

Collectively, four themes emerged from qualitative analysis of the comments from all three groups, including Communication and Other Related Hearing Loss Issues, Social and Emotional Issues, Dealing with Hearing Loss, and Addressing Hearing Loss in the Community. Factors associated with the themes were mapped onto the Meikirch Model of Health to determine potential areas of intervention within the individual, society, and environment components of the model.

CONCLUSION

Future care mitigating health concerns for adults with hearing loss living in rural communities will involve interprofessional collaboration and increased access to hearing health care.

The cost-effectiveness of targeted screening for congenital cytomegalovirus in newborns compared to clinical diagnosis in the US

OBJECTIVE

Congenital cytomegalovirus (cCMV) is the leading environmental cause of hearing loss (HL) among children, affecting four in one thousand newborns. cCMV testing in the US is currently based on clinical diagnosis which does not consistently identify cCMV cases and precludes early intervention to prevent and reduce the severity of HL. We estimated the cost-effectiveness of targeted newborn screening and cCMV testing among newborns compared to clinical diagnosis.

METHODS

We use a decision-analytic model to estimate the costs of preventing HL progression, of additional cases of severe HL, of identifying a case of HL one year earlier, and of identifying an additional case of cCMV, through targeted screening and cCMV testing for infants failing two newborn hearing screens with follow-up to age five. We also estimate the costs of nationwide implementation of a newborn screening and testing program. Model pathways were based on best practices for screening, testing, and treatment. Probabilities were drawn from the published literature; costs were estimated based on Medicare reimbursement rates. Probabilistic and scenario analyses were conducted to determine the robustness of results.

RESULTS

Targeted testing and cCMV screening, compared to standard of care, cost an additional $2.96 (±2.26) per infant screened and identified 0.00038 (±0.00022) cases of HL, 3.8 in 10000 children, at a cost of $8197 (±4217) per case of HL identified. Implementing targeted screening for all children in the US was estimated to cost $193,229.

CONCLUSIONS

Although cases numbers are small, our model shows that targeted newborn screening and cCMV testing reduced cases of HL progression. Adoption of newborn targeted screening as standard of care should be considered given it may prevent disability at very low cost.

Core Values in the Traditional Provision of Hearing Health Care

PURPOSE

Untreated hearing loss is a significant public health issue affecting the quality of life of millions of Americans. Barriers to treatment invite novel and innovation solutions, but as these solutions create new treatment delivery models, they also may-purposefully or accidentally-challenge the values of the field.

METHOD

Value-sensitive design methodology is used in this study to identify the values in current hearing health care service delivery. We performed qualitative content analysis of questionnaires, clinical practice guidelines, and professional ethics documents that represent the intended and enacted values in audiology.

RESULTS

The result is a comprehensive list of values that can be used as a structured codebook for systematic textual analysis of materials representing current best practices in the provision of hearing health care services. A secondary result is an analysis of the relative importance of values in audiology, inferred from the frequency of references to each value.

CONCLUSIONS

Subjective benefit, professional duties, and self-efficacy were the core values identified in the current provision of audiologic care, and these values should be central to considerations for new hearing health care models and technologies.

Community Health Workers as Patient-Site Facilitators in Adult Hearing Aid Services via Synchronous Teleaudiology: Feasibility Results from the Conexiones Randomized Controlled Trial

OBJECTIVES

The purpose of this study was to investigate the feasibility of Community Health Workers (CHWs) as patient-site facilitators in teleaudiology-facilitated hearing aid services to improve hearing aid rehabilitation outcomes for older Hispanic/Latino adults in a medically underserved, rural, US-Mexico border community.

DESIGN

A total of 28 adults (aged 55 to 89) with bilateral hearing loss participated in this study. Individuals were randomized to one of two teleaudiology intervention arms that differed at the level of the patient-site facilitator. Participants in the experimental group were assisted locally by trained CHW facilitators. Participants in the control group were assisted locally by trained university student facilitators. Synchronous (real-time) teleaudiology hearing aid services took place with participants located at a rural community health center and the clinician located a university 70 miles away. The results of this feasibility study are presented within the reach, effectiveness, adoption, implementation fidelity, and maintenance implementation framework.

RESULTS

Regarding reach, the participants in this study population are historically under-represented in research (primarily low-income Hispanic/Latino older adults). A total of 57 individuals were recruited, 47 were consented and assessed for eligibility and 28 individuals met inclusion criteria and were randomized. The average age of participants was 73.9 years, (range: 55 to 89 years) and most individuals were female (75%). Most participants (86%) reported having incomes less than $20,000 annually. Effectiveness results (via the Self Efficacy for Situational Communication Management Questionnaire) showed that both groups (CHW and control) significantly improved listening self-efficacy from pre-fitting baseline and no difference between groups was observed. Regarding datalogging, at the short-term follow-up, participants in the CHW group wore their hearing aids for more hours/day on average compared with participants in the control group. Implementation fidelity was high for both groups. Long-term maintenance of CHW-supported teleaudiology appears feasible given that training and institutional support is in place.

CONCLUSIONS

Teleaudiology-delivered hearing aid services were feasible when facilitated locally by trained CHWs. Future efficacy and effectiveness research is warranted with CHWs and teleaudiology, potentially leading to a significant reduction in barriers for rural and medically under-resourced communities.

Socioeconomic position and hearing loss: current understanding and recent advances

PURPOSE OF REVIEW

The purpose of this review is to describe recent literature examining the relationship between socioeconomic position (SEP) and hearing loss, including the impact of hearing loss on several socioeconomic outcomes over the life course. Additionally, we highlight current policy advances in recent years and review alternative models of hearing care that aim to address disparities related to SEP and hearing healthcare.

RECENT FINDINGS

Applying a social epidemiologic lens to hearing health gives insight into the role of material and social contexts in understanding and improving hearing health outcomes. Recent studies investigating the intersection of SEP and hearing health highlight the disparities that exist for individuals with low SEP as well as the influence of hearing loss on SEP. Individuals with hearing loss are more likely to be unemployed, have lower educational attainment, lower income, and are less likely to use hearing aids and access hearing care. Legislation addressing cost and access to hearing care as well as transforming the current landscape of hearing care, is essential to creating equitable care for individuals, especially older adults, with low SEP.

SUMMARY

With the expected rise in prevalence of hearing loss over the next 40 years, hearing care that is affordable and accessible is a public health priority. As hearing loss is associated with negative outcomes for individuals with low SEP, advances in legislation and care delivery models are necessary in order to include populations traditionally unserved by current hearing healthcare.

Describing the Rehabilitation Workforce Capacity in the Public Sector of Three Rural Provinces in South Africa: A Cross-Sectional Study

The World Health Organisation emphasises the importance of addressing gaps in health systems where rehabilitation services are poorly integrated. In South Africa, regions with the largest disability rates are usually the areas where rehabilitation is least accessible, due to inadequate workforce capacity. The first step towards addressing workforce capacity is to determine current capacity. This paper presents a cross-sectional study to describe rehabilitation workforce data in the public sector of three rural South African provinces. A web-based therapist survey and a telephonic facility survey was conducted. Data were collected regarding total number of therapists per province, age, years employed, qualifications, salary level, profession type, level of care, and rural/urban distribution. Descriptive statistics were conducted, while Chi-squared tests compared professions regarding highest qualification and salary level. Population-adjusted ratios were calculated using national uninsured population statistics. The web-based survey had 639 responses while the telephonic survey reported on 1166 therapists. Results indicated that the mean age of therapists across the respective provinces was 28, 35 and 31 years of age, and the mean employment years in the respective provinces were three, eight and five years. Most of the workforce (n = 574) had a bachelor's degree as their highest qualification. A total of 27% of the workforce were community service therapists and 61% of therapists earned a production-level salary. Occupational therapy was best (40%) and speech and audiology therapy least (7%) represented. Three percent of therapists worked at primary level, versus eighty percent at secondary level. Forty percent of therapists worked in rural areas. Workforce density per province ranged from 0.71-0.98 per 10,000 population. Overall, results show that the rehabilitation workforce density is low, and that the distribution of therapists between rural and urban settings, and levels of care, is inequitable. Considering the rise in rehabilitation need, prioritisation and strengthening of the rehabilitation workforce capacity is vital to ensure integration across all levels of care and service.

Rehabilitation workforce descriptors: a scoping review

BACKGROUND

A comprehensive, accurate description of workforce capacity is important for health service planning, to ensure that health services meet local needs. In many low- to middle-income countries, the government's service planning ability is barred by the lack of accurate and/or comprehensively-described workforce data. In these low-resource settings, lack of appropriate planning leads to limited or no access to rehabilitation services. Variability in the definitions and scope of rehabilitation professionals further complicates the understanding of rehabilitation services and how it should be planned and delivered. Another challenge to describing the primary rehabilitation workforce capacity, is the lack of standardised and agreed-upon global metrics. These inconsistencies highlight the need for a comprehensive understanding of current practices, which can offer guidance to countries wishing to describe their rehabilitation workforce. This study aimed to scope the range of descriptors and metrics used to describe the rehabilitation workforce and to compare the workforce across countries that used similar descriptors in published reports.

METHODS

A scoping review was conducted according to the five-step framework first developed by Arksey and O'Malley. The review included a broad search of literature regarding the rehabilitation workforce and how countries quantify and describe the rehabilitation workforce.

RESULTS

Nineteen studies on rehabilitation workforce capacity were identified. All but one (a cross-sectional study) were database reviews. The main descriptors and indicators used to describe the rehabilitation workforce capacity were profession type, age, gender, distributions between urban/rural, level of care, and private/public sectors, absolute count totals, and population-adjusted ratios.

CONCLUSION

This scoping review provided an overview of descriptors and indicators used to describe the rehabilitation workforce capacity internationally. The study is a first step towards developing standardised descriptors and metrics to quantify the rehabilitation workforce capacity, that will allow for comparison between different settings.

TRIAL REGISTRATION

This scoping review protocol has been registered with the Open Science Framework (http://osf.10/7h6xz).

Telehealth solutions for assessing auditory outcomes related to noise and ototoxic exposures in clinic and research

Nearly 1.5 billion people globally have some decline in hearing ability throughout their lifetime. Many causes for hearing loss are preventable, such as that from exposure to noise and chemicals. According to the World Health Organization, nearly 50% of individuals 12-25 years old are at risk of hearing loss due to recreational noise exposure. In the occupational setting, an estimated 16% of disabling hearing loss is related to occupational noise exposure, highest in developing countries. Ototoxicity is another cause of acquired hearing loss. Audiologic assessment is essential for monitoring hearing health and for the diagnosis and management of hearing loss and related disorders (e.g., tinnitus). However, 44% of the world's population is considered rural and, consequently, lacks access to quality hearing healthcare. Therefore, serving individuals living in rural and under-resourced areas requires creative solutions. Conducting hearing assessments via telehealth is one such solution. Telehealth can be used in a variety of contexts, including noise and ototoxic exposure monitoring, field testing in rural and low-resource settings, and evaluating auditory outcomes in large-scale clinical trials. This overview summarizes current telehealth applications and practices for the audiometric assessment, identification, and monitoring of hearing loss.

How the Past Shapes the Future and What to Do About It: A Discussion at CI 2021 Virtual With Panelists: Teresa Caraway, Ph.D., C.C.C.-S.L.P.; Cliff Megerian, M.D.; Debara Tucci, M.D., M.S., M.B.A.; Peter Thomas, J.D.; Jason Wigand, Au.D

ABSTRACT

This report summarizes the highlights of a lively discussion between leaders in the cochlear implant (CI) field who also bring significant leadership experience at the practice and health system levels, as well as policy and research perspectives. The discussion revealed several areas in which established patterns of practice should be reconsidered to facilitate wider acceptance of the CI as part of an integrated continuum of hearing healthcare. The importance of continued innovation to advance outcomes, lower cost, and increase access was emphasized. Trends in healthcare funding, which increasingly reward quality at lower cost, will also challenge longstanding assumptions that have influenced program design. Proactive efforts that pursue consistent value in the episode of surgical care while establishing innovative delivery models for audiological and rehabilitation services are the best hope for a future of equitable access and expanding impact.

Masked-Speech Recognition for Linguistically Diverse Populations: A Focused Review and Suggestions for the Future

PURPOSE

Twenty years ago, von Hapsburg and Peña (2002) wrote a tutorial that reviewed the literature on speech audiometry and bilingualism and outlined valuable recommendations to increase the rigor of the evidence base. This review article returns to that seminal tutorial to reflect on how that advice was applied over the last 20 years and to provide updated recommendations for future inquiry.

METHOD

We conducted a focused review of the literature on masked-speech recognition for bilingual children and adults. First, we evaluated how studies published since 2002 described bilingual participants. Second, we reviewed the literature on native language masked-speech recognition. Third, we discussed theoretically motivated experimental work. Fourth, we outlined how recent research in bilingual speech recognition can be used to improve clinical practice.

RESULTS

Research conducted since 2002 commonly describes bilingual samples in terms of their language status, competency, and history. Bilingualism was not consistently associated with poor masked-speech recognition. For example, bilinguals who were exposed to English prior to age 7 years and who were dominant in English performed comparably to monolinguals for masked-sentence recognition tasks. To the best of our knowledge, there are no data to document the masked-speech recognition ability of these bilinguals in their other language compared to a second monolingual group, which is an important next step. Nonetheless, individual factors that commonly vary within bilingual populations were associated with masked-speech recognition and included language dominance, competency, and age of acquisition. We identified methodological issues in sampling strategies that could, in part, be responsible for inconsistent findings between studies. For instance, disparities in socioeconomic status (SES) between recruited bilingual and monolingual groups could cause confounding bias within the research design.

CONCLUSIONS

Dimensions of the bilingual linguistic profile should be considered in clinical practice to inform counseling and (re)habilitation strategies since susceptibility to masking is elevated in at least one language for most bilinguals. Future research should continue to report language status, competency, and history but should also report language stability and demand for use data. In addition, potential confounds (e.g., SES, educational attainment) when making group comparisons between monolinguals and bilinguals must be considered.

Barriers to Equity in Pediatric Hearing Health Care: A Review of the Evidence

Purpose

We review the evidence regarding barriers to hearing health care for children who are deaf or hard of hearing.

Background

There are considerable data to suggest that hearing health care disparities constitute a major factor in loss to follow-up or documentation for children going through the Early Hearing Detection and Intervention process. Families are affected by a combination of factors underlying these disparities, resulting in delayed care and suboptimal developmental outcomes for children who are deaf or hard of hearing.

Conclusions

To address the socioeconomic, cultural, and linguistic inequities seen in the diagnosis and management of childhood hearing loss, pediatric audiologists and speech-language pathologists have a responsibility to provide culturally responsive practice to their individual clients and their families, as well as advocate for substantive changes at the policy level that impact their clients' daily lives.

Foundational Approaches to Advancing Hearing Health Equity: A Primer in Social Epidemiology

Hearing health is inextricably linked to factors beyond biology. Social, demographic, environmental, geographic, and historical influences affect hearing health, but these factors are often unmeasured within traditional biological, clinical, and epidemiological studies of hearing health. With increasing recognition of hearing health over the life course as a public health priority, there is also a growing understanding of existing hearing health inequities at the individual, community, national, and global levels. To make progress in addressing these inequities, public health disciplines, such as social epidemiology, can provide valuable frameworks. With a focus on integrating the biological and functional with social and structural factors influencing health, social epidemiology provides key concepts and approaches for filling existing research and practice gaps. In this review, we introduce the discipline of social epidemiology and its associated concepts to inspire greater cross-disciplinary collaboration for the ultimate goal of advancing hearing health equity.

Relating Suprathreshold Auditory Processing Abilities to Speech Understanding in Competition

(1) Background: Difficulty hearing in noise is exacerbated in older adults. Older adults are more likely to have audiometric hearing loss, although some individuals with normal pure-tone audiograms also have difficulty perceiving speech in noise. Additional variables also likely account for speech understanding in noise. It has been suggested that one important class of variables is the ability to process auditory information once it has been detected. Here, we tested a set of these “suprathreshold” auditory processing abilities and related them to performance on a two-part test of speech understanding in competition with and without spatial separation of the target and masking speech. Testing was administered in the Portable Automated Rapid Testing (PART) application developed by our team; PART facilitates psychoacoustic assessments of auditory processing. (2) Methods: Forty-one individuals (average age 51 years), completed assessments of sensitivity to temporal fine structure (TFS) and spectrotemporal modulation (STM) detection via an iPad running the PART application. Statistical models were used to evaluate the strength of associations between performance on the auditory processing tasks and speech understanding in competition. Age and pure-tone-average (PTA) were also included as potential predictors. (3) Results: The model providing the best fit also included age and a measure of diotic frequency modulation (FM) detection but none of the other potential predictors. However, even the best fitting models accounted for 31% or less of the variance, supporting work suggesting that other variables (e.g., cognitive processing abilities) also contribute significantly to speech understanding in noise. (4) Conclusions: The results of the current study do not provide strong support for previous suggestions that suprathreshold processing abilities alone can be used to explain difficulties in speech understanding in competition among older adults. This discrepancy could be due to the speech tests used, the listeners tested, or the suprathreshold tests chosen. Future work with larger numbers of participants is warranted, including a range of cognitive tests and additional assessments of suprathreshold auditory processing abilities.

Evaluation of Remote Check: A Clinical Tool for Asynchronous Monitoring and Triage of Cochlear Implant Recipients

BACKGROUND

A new Remote Check App permits remote self-testing of hearing function for Nucleus cochlear implant (CI) recipients and enables asynchronous review by their clinician to support patient-management decisions.

OBJECTIVES

To evaluate the Remote Check App for: (1) ease of use; (2) overall acceptance of the test battery by CI recipient or their carer in the home setting; (3) test-retest reliability of audiological threshold and speech recognition measures via wireless streaming; and (4) to compare outcomes from patient-driven measures with conventional clinician-driven measurements of aided-hearing function.

DESIGN

Single-site, prospective, repeated-measures cohort study with 32 experienced CI users (28 adults and 4 children).

METHODS

Participants completed self-testing using the Remote Check app at home and in the clinic. Measures include audiological, objective and subjective tests. Self-administered speech recognition in noise, via the digit triplets test (DTT) and aided thresholds, via the aided threshold test (ATT) were reassessed in free-field and by clinicians following conventional clinical protocols. Results of ATT and DTT were compared across test conditions. Completion time and perceived ease of self-driven assessments were documented. Insights from subsequent real-world experience with Remote Check are summarized and compared to the study findings.

RESULTS

Remote Check was rated as easy to use by the majority (87%) of subjects. Mean group test-retest score differences for self-administered testing within the clinic versus at-home environments were nonsignificant (p > 0.05): 1.4 dB (SD = 1.97) for ATT and 1.6 dB (SD = 1.54) for DTT. Mean group test-retest score difference for patient-driven DTT in streamed versus the free-field condition was 1.8 dB (SD = 2.02). Self-administered, streamed, ATT via Remote Check, resulted in significantly lower thresholds compared to clinician-driven warble-tone thresholds in the free-field by 6.7 dB (SD = 6.8) (p < 0.001). ATT thresholds via Remote Check were not significantly different from predicted thresholds based on the Threshold Sound Pressure Level of the sound processor.

CONCLUSION

Remote Check is the first CI telehealth assessment tool that uses wireless streaming to enable comprehensive, easy and reliable self-testing of hearing function by the CI recipient or their carer, in the comfort of their home. Asynchronous access to test results can assist clinicians in monitoring and triaging individuals for appropriate patient-management based on their needs. Use of remote monitoring may also help to reduce the burden of unnecessary clinic visits on clinic resources, patient travel time and associated costs. Remote Check is an important step toward addressing the current growing need for asynchronous audiological telepractice to support long-term care of CI recipients.

Feasibility of community health workers as teleaudiology patient-site facilitators: a multilevel training study

OBJECTIVE

We evaluated the feasibility of a multi-level teleaudiology patient-site facilitator training program for Community Health Workers (CHWs) at a partnering health centre in southern Arizona.

DESIGN

Three levels were offered: Introductory, with basic information on hearing loss and teleaudiology; Intermediate, on technology, team roles, and access issues; and Facilitator, on further knowledge and hands-on skills to serve as patient-site facilitators in synchronous hearing aid service delivery. Six domains of feasibility were addressed using a mixed-methods design. Quantitative data included survey responses and observation of hands-on skills. Qualitative data included field notes from group discussion and open-ended survey questions, and were analysed using CHW core competencies.

STUDY SAMPLE

Twelve CHWs participated in the introductory training, ten moved on to intermediate, and three continued to the facilitator.

RESULTS

Quantitative outcomes indicated that the trainings were feasible according to each of the six domains. CHWs in the facilitator training passed the practical hands-on skill assessment. Qualitative analyses revealed CHWs comments addressed eight of the ten possible CHW core competencies, and focussed on service coordination/navigation, and capacity building.

CONCLUSIONS

Teleaudiology trainings for CHWs were feasible, increasing service capacity for a potential pathway to improve access to hearing health care in low-resource areas.

Accessibility to Hearing Healthcare in Rural and Urban Populations of Alabama: Perspectives and A Preliminary Roadmap for Addressing Inequalities

Hearing loss is a growing public health concern and has been associated with poor cardiovascular health, diabetes, increased social isolation and poor cognitive functioning. Addressing this issue, especially in rural communities, will require increased awareness of hearing loss and its link to emotional and physical well-being. The purpose of this study was to understand the challenges that those with hearing loss living in rural and urban communities experience and to examine the feasibility of using primary care physicians to assist with improving access to hearing healthcare in rural communities. One hundred thirty-four participants were recruited from rural and urban counties in West Central and South Alabama. All participants completed a hearing evaluation and a Healthcare and Hearing Healthcare Accessibility Questionnaire. Over half of the adults in the study with hearing loss did not have access to hearing healthcare because of distance to a hearing healthcare professional. Other reasons for participants not having access to hearing healthcare included financial constraints, lack of awareness of having a hearing loss, lack of time to see a hearing healthcare provider, and not knowing how to access a provider. Results, however, revealed that most adults in the study had access to a primary care professional. The primary care provider, therefore, could be a valuable resource for the dissemination of information related to hearing healthcare. Collaborative work with primary care providers will help to develop and expand hearing healthcare awareness, research and services provided through the Here Hear Alabama project, a rural outreach initiative in West Central and South Alabama.

The Role of Patient-Site Facilitators in Teleaudiology: A Scoping Review

Purpose Teleaudiology helps improve access to hearing health care by overcoming the geographic gap between providers and patients. In many teleaudiology encounters, a facilitator is needed at the patient site to help with hands-on aspects of procedures. The aim of this study was to review the scope and nature of research around patient-site facilitators in teleaudiology. We focused on identifying the facilitators' background, training, and responsibilities. Method To conduct this scoping review, we searched PubMed, CINAHL, and Embase. To be included, studies needed to address teleaudiology; be experimental/quasi-experimental, correlational/predictive, or descriptive; be published in English; and include the use of a facilitator at the patient location. Results A total of 82 studies met the inclusion criteria. The available literature described a number of different individuals in the role of the patient-site facilitator, including audiologists, students, and local aides. Fifty-seven unique tasks were identified, including orienting the client to the space, assisting with technology, and assisting with audiology procedures. The largest number of studies (n = 42) did not describe the facilitators' training. When reported, the facilitators' training was heterogenous in terms of who delivered the training, the length of the training, and the training content. Conclusions Across studies, the range of duties performed by patient-site facilitators indicates they may have an important role in teleaudiology. However, details are still needed surrounding their background, responsibilities, and training. Future research is warranted exploring the role of the patient-site facilitator, including their impact on teleaudiology service delivery. Supplemental Material https://doi.org/10.23641/asha.12475796.

Sensitivity and Specificity of Pure-Tone and Subjective Hearing Screenings Using Spanish-Language Questions

Purpose The purpose of this study is to determine the sensitivities and specificities of different audiometric hearing screening criteria and single-item and multi-item hearing disability questionnaires among a group of Spanish-speaking adults in a rural community. Method Participants were 131 predominantly older (77% 65+ years) Hispanic/Latinx adults (98%). A structured Spanish-language interview and pure-tone threshold test data were analyzed for each participant. The sensitivities and specificities of three single questions and the Hearing Handicap Index for the Elderly-Screening (HHIE-S; Ventry & Weinstein, 1983) in Spanish, as well as three audiometric screening criteria, were evaluated in relation to the pure-tone threshold test for detecting hearing loss. Results Sensitivity and specificity of audiometric screening criteria varied, but the highest sensitivity was found for the criterion of > 25 dB HL at 1-4 kHz in either ear. The single self-perception question, "¿Cree usted que tiene pérdida de audición? (Do you think you have a hearing loss?)," was shown to be the most sensitive self-report screening compared to other single-item questions and the HHIE-S. This single question was as sensitive as an audiometric screening to detect a moderate hearing loss (> 40 dB HL in either ear). Results from the Spanish HHIE-S indicated poor performance to detect hearing loss in this population, consistent with previous research. Conclusions Among older Spanish-speaking adults, self-reported hearing status had varying sensitivities depending on the question asked. However, of the tools evaluated, the self-perception question proved to be a more sensitive and specific tool than a multi-item screen. Objective audiometric testing (> 25 dB HL) resulted in the highest sensitivity to detect a mild hearing loss.

Qualitative research methods to investigate communication within a group aural rehabilitation intervention

Objective: Aural Rehabilitation (AR) aims to minimise negative effects of hearing loss. However, there has been limited study of the lived experience of clients receiving Aural Rehabilitation services, particularly for disparity populations. The purpose of this study is to demonstrate the use of an innovative qualitative approach to investigating communication in an AR setting among Hispanic/Latino older adult dyads. Design: We developed a qualitative phenomenology approach using observation methods to document and analyse how individuals experience living with acquired hearing loss within group AR. Trained observers collected systematic, detailed notes on observations of participants over the course of a 5-week community-based AR intervention. In partnership with audiologists, Community Health Workers facilitated the intervention, which focussed on decreasing negative communication impacts of hearing loss for families. Audiometric data and subjective hearing disability results, using the HHIE-S Spanish version, are presented as additional context for observation outcomes. Study sample: Participants were older Hispanic/Latino adults with hearing loss and their frequent communication partners (five dyads). Results: Four themes related to the experience of communication emerged among dyads in the intervention: (i) emotions related to hearing loss (ii) communication dynamics, (iii) self-management of hearing loss, and (iv) hearing health advocacy. Conclusions: A mixed methods approach that includes group observation would contribute substantially to comprehensively evaluating group AR interventions.

Internet and Audiology: A Review of the Third International Meeting

PURPOSE

In this introduction, the four members of the scientific committee for the Third International Meeting on Internet and Audiology describe the meeting that took place at the University of Louisville on July 27-28, 2017.

METHOD

This special issue, with a decidedly clinical focus, includes 14 articles that arose from presentations given at the Third International Meeting on Internet and Audiology. All touch upon the theme of innovation as it pertains to teleaudiology and mobile health (mHealth), application of Big Data to audiology, and ethics of internet and telemedicine.

CONCLUSION

Innovations in teleaudiology, mHealth, and Internet-based audiology are developing at a rapid pace and thus research in the field must continue. We invite readers to the next International Meeting on Internet and Audiology that will take place in Southampton, England, June 17-18, 2019.