Hearing Norton Sound: a community randomised trial protocol to address childhood hearing loss in rural Alaska

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.

Telemedicine Referral to Improve Access to Specialty Care for Preschool Children in Rural Alaska: A Cluster-Randomized Controlled Trial

OBJECTIVES

Preschool programs provide essential preventive services, such as hearing screening, but in rural regions, limited access to specialists and loss to follow-up compound rural health disparities. We conducted a parallel-arm cluster-randomized controlled trial to evaluate telemedicine specialty referral for preschool hearing screening. The goal of this trial was to improve timely identification and treatment of early childhood infection-related hearing loss, a preventable condition with lifelong implications. We hypothesized that telemedicine specialty referral would improve time to follow-up and the number of children receiving follow-up compared with the standard primary care referral.

DESIGN

We conducted a cluster-randomized controlled trial in K-12 schools in 15 communities over two academic years. Community randomization occurred within four strata using location and school size. In the second academic year (2018-2019), an ancillary trial was performed in the 14 communities that had preschools to compare telemedicine specialty referral (intervention) to standard primary care referral (comparison) for preschool hearing screening. Randomization of communities from the main trial was used for this ancillary trial. All children enrolled in preschool were eligible. Masking was not possible because of timing in the second year of the main trial, but referral assignment was not openly disclosed. Study team members and school staff were masked throughout data collection, and statisticians were blinded to allocation during analysis. Preschool screening occurred once, and children who were referred for possible hearing loss or ear disease were monitored for follow-up for 9 months from the screening date. The primary outcome was time to ear/hearing-related follow-up from the date of screening. The secondary outcome was any ear/hearing follow-up from screening to 9 months. Analyses were conducted using an intention-to-treat approach.

RESULTS

A total of 153 children were screened between September 2018 and March 2019. Of the 14 communities, 8 were assigned to the telemedicine specialty referral pathway (90 children), and 6 to the standard primary care referral pathway (63 children). Seventy-one children (46.4%) were referred for follow-up: 39 (43.3%) in the telemedicine specialty referral communities and 32 (50.8%) in the standard primary care referral communities. Of children referred, 30 (76.9%) children in telemedicine specialty referral communities and 16 (50.0%) children in standard primary care referral communities received follow-up within 9 months (Risk Ratio = 1.57; 95% confidence interval [CI], 1.22 to 2.01). Among children who received follow-up, median time to follow-up was 28 days (interquartile range [IQR]: 15 to 71) in telemedicine specialty referral communities compared with 85 days (IQR: 26 to 129) in standard primary care referral communities. Mean time to follow-up for all referred children was 4.5 (event time ratio = 4.5; 95% CI, 1.8 to 11.4; p = 0.045) times faster in telemedicine specialty referral communities compared with standard primary care referral communities in the 9-month follow-up time frame.

CONCLUSIONS

Telemedicine specialty referral significantly improved follow-up and reduced time to follow-up after preschool hearing screening in rural Alaska. Telemedicine referrals could extend to other preventive school-based services to improve access to specialty care for rural preschool children.

Implementation factors influencing the sustained provision of tele-audiology services: insights from a combined methodology of scoping review and qualitative semistructured interviews

OBJECTIVES

The objectives of the current study were to (a) identify long-term tele-audiology services reported to be implemented beyond the research phase and determine whether they are sustained, (b) map the implementation process to Standards for Reporting Implementation Studies guidelines and (c) map the factors that influenced its sustainability to the Implementation Outcomes Framework (IOF) to understand the gaps from an implementation research perspective.

STUDY DESIGN, SETTING AND PARTICIPANTS

This cross-sectional study included a scoping review of articles describing long-term tele-audiology services from around the world to determine the factors influencing the implementation. Six electronic databases (PubMed, Cochrane Library, Web of Science, Scopus, Google Scholar and ProQuest) were searched for literature published between 2010 and 2023. This was followed by semistructured interviews (SSIs), which were guided by the IOF. Six project implementers were interviewed to obtain an in-depth understanding of factors that influenced sustainability of these tele-audiology services. Thematic analysis of the interview transcripts was carried out using a hybrid inductive-deductive approach.

RESULTS

Data were extracted from 32 tele-audiology studies included in the review, which were then mapped to 21 projects. The findings of the scoping review reveal that tele-audiology services were predominantly provided using synchronous telepractice methods. The 'professional-facilitator-patient' model was most commonly used. None of the studies reported the use of implementation research and/or outcome frameworks. Factors that influenced sustainability of tele-audiology services were identified from the combined results of the scoping review and the SSIs. These factors could be mapped to implementation outcomes of acceptability, adoption, feasibility, implementation cost and sustainability.

CONCLUSION

Implementation research and/or outcome framework should be used to guide the implementation processes, its evaluation and measurement of outcomes systematically in tele-audiology service delivery. When such frameworks are used, gaps in information regarding the context influencing implementation, reporting of fidelity and adaptability measures can be addressed.

Community Perspectives on Hearing Loss in Rural Alaska

OBJECTIVES

The aim of this study is to present an explanatory model of hearing loss in the Bering Strait region of Alaska in order to contextualize the results of a cluster randomized trial and propose implications for regional hearing-related health care.

DESIGN

To promote ecological validity, or the generalizability of trial findings to real world experiences, qualitative methods (focus groups and interviews) were used within a mixed methods cluster randomized trial evaluating school hearing screening and follow-up processes in 15 communities in the Bering Strait region of Alaska. Focus groups were held between April and August 2017, and semistructured interviews were conducted between December 2018 and August 2019. Convenience sampling was used for six of the 11 focus groups to capture broad community feedback. Purposive sampling was used for the remaining five focus groups and for all interviews to capture a variety of experiences with hearing loss. Audio recordings of focus groups and interviews were transcribed, and both notes and transcripts were deidentified. All notes and transcripts were included in the analysis. The constant comparative method was used to develop a codebook by iteratively moving between transcripts and preliminary themes. Researchers then used this codebook to code data from all focus groups and interviews using qualitative analysis software (NVIVO 12, QSR International) and conducted thematic analyses to distill the findings presented in this article.

RESULTS

Participants in focus groups (n = 116) and interviews (n = 101) shared perspectives in three domains: etiology, impact, and treatment of hearing loss. Regarding etiology, participants emphasized noise-induced hearing loss but also discussed infection-related hearing loss and various causes of ear infections. Participants described the impact of hearing loss on subsistence activities, while also detailing social, academic, and economic consequences. Participants described burdensome treatment pathways that are repetitive and often travel and time intensive. Communication breakdowns within these pathways were also described. Some participants spoke positively of increased access via onsite hearing health care services in "field clinics" as well as via telemedicine services. Others described weaknesses in these processes (infrequent field clinics and communication delays in telemedicine care pathways). Participants also described home remedies and stigma surrounding the treatment for hearing loss.

CONCLUSIONS

Patient-centered health care requires an understanding of context. Explanatory models of illness are context-specific ways in which patients and their networks perceive and describe the experience of an illness or disability. In this study, we documented explanatory models of hearing loss to foster ecological validity and better understand the relevance of research findings to real-life hearing-related experiences. These findings suggest several areas that should be addressed in future implementation of hearing health care interventions elsewhere in rural Alaska, including management of repetitious treatments, awareness of infection-mediated hearing loss, mistrust, and communication breakdowns. For hearing-related health care in this region, these findings suggest localized recommendations for approaches for prevention and treatment. For community-based hearing research, this study offers an example of how qualitative methods can be used to generate ecologically valid (i.e., contextually grounded) findings.

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.

Environmental Factors for Hearing Loss and Middle Ear Disease in Alaska Native Children and Adolescents: A Cross-Sectional Analysis from a Cluster Randomized Trial

OBJECTIVES

Infection-related childhood hearing loss is one of the few preventable chronic health conditions that can affect a child's lifelong trajectory. This study sought to quantify relationships between infection-mediated hearing loss and middle ear disease and environmental factors, such as exposure to wood smoke, cigarette smoke, household crowding, and lack of access to plumbed (running) water, in a northwest region of rural Alaska.

DESIGN

This study is a cross-sectional analysis to estimate environmental factors of infection-related hearing loss in children aged 3 to 21 years. School hearing screenings were performed as part of two cluster randomized trials in rural Alaska over two academic years (2017-2018 and 2018-2019). The first available screening for each child was used for this analysis. Sociodemographic questionnaires were completed by parents/guardians upon entry into the study. Multivariable regression was performed to estimate prevalence differences and prevalence ratios (PR). A priori knowledge about the prevalence of middle ear disease and the difficulty inherent in obtaining objective hearing loss data in younger children led to analysis of children by age (3 to 6 years versus 7 years and older) and a separate multiple imputation sensitivity analysis for pure-tone average (PTA)-based infection-related hearing loss measures.

RESULTS

A total of 1634 children participated. Hearing loss was present in 11.1% of children sampled based on otoacoustic emission as the primary indicator of hearing loss and was not associated with exposure to cigarette smoke (PR = 1.07; 95% confidence interval [CI], 0.48 to 2.38), use of a wood-burning stove (PR = 0.85; 95% CI, 0.55 to 1.32), number of persons living in the household (PR = 1.06; 95% CI, 0.97 to 1.16), or lack of access to running water (PR = 1.38; 95% CI, 0.80 to 2.39). Using PTA as a secondary indicator of hearing loss also showed no association with environmental factors. Middle ear disease was present in 17.4% of children. There was a higher prevalence of middle ear disease in homes without running water versus those with access to running water (PR = 1.53; 95% CI, 1.03 to 2.27). There was little evidence to support any cumulative effects of environmental factors. Heterogeneity of effect models by age found sample prevalence of hearing loss higher for children aged 3 to 6 years (12.2%; 95% CI, 9.3 to 15.7) compared to children 7 years and older (10.6%; 95% CI, 8.9 to 2.6), as well as for sample prevalence of middle ear disease (22.7%; 95% CI, 18.9 to 26.9 and 15.3%; 95% CI, 13.3 to 17.5, respectively).

CONCLUSIONS

Lack of access to running water in the home was associated with increased prevalence of middle ear disease in this rural, Alaska Native population, particularly among younger children (aged 3 to 6 years). There was little evidence in this study that cigarette smoke, wood-burning stoves, and greater numbers of persons in the household were associated with infection-mediated hearing loss or middle ear disease. Future research with larger sample sizes and more sensitive measures of environmental exposure is necessary to further evaluate these relationships. Children who live in homes without access to running water may benefit from earlier and more frequent hearing health visits.

Hearing-related quality of life in children and adolescents in rural Alaska

Objective

This study evaluated the Hearing Environments and Reflection on Quality of Life (HEAR-QL) questionnaire in rural Alaska, including an addendum crafted through community feedback to reflect the local context. The objectives were to assess whether HEAR-QL score was inversely correlated with hearing loss and middle ear disease in an Alaska Native population.

Methods

The HEAR-QL questionnaires for children and adolescents were administered as part of a cluster randomized trial in rural Alaska from 2017 to 2019. Enrolled students completed an audiometric evaluation and HEAR-QL questionnaire on the same day. A cross-sectional evaluation of questionnaire data was utilized.

Results

A total of 733 children (ages 7-12 years) and 440 adolescents (ages ≥13 years) completed the questionnaire. Median HEAR-QL scores were similar among children with and without hearing loss (Kruskal-Wallis, p = .39); however, adolescent HEAR-QL scores significantly decreased with increasing hearing loss (p < .001). Median HEAR-QL scores were significantly lower in both children (p = .02) and adolescents (p < .001) with middle ear disease compared with those without. In both children and adolescents, the addendum scores were strongly correlated with total HEAR-QL score (ρ_Spearman = 0.72 and 0.69, respectively).

Conclusions

The expected negative association between hearing loss and HEAR-QL score was observed in adolescents. However, there was significant variability that could not be explained by hearing loss, and further investigation is warranted. The expected negative association was not observed in children. HEAR-QL scores were associated with middle ear disease in both children and adolescents, making it potentially valuable in populations where the prevalence of ear infections is high.

Level of Evidence

Level 2 Clinicaltrials.gov registration numbers: NCT03309553.

School Hearing Screening With a Portable, Tablet-Based, Noise-Attenuating Audiometric Headset in Rural Nicaragua

OBJECTIVE

To investigate the utility and effectiveness of a noise-attenuating, tablet-based mobile health system combined with asynchronous telehealth evaluations for screening rural Nicaraguan schoolchildren for hearing loss.

STUDY DESIGN

Prospective population-based survey.

SETTING

Rural Nicaraguan communities.

PATIENTS

There were 3,398 school children 7 to 9 years of age.

INTERVENTIONS

Diagnostic automated and manual audiometry, detailed asynchronous telehealth evaluations.

MAIN OUTCOME MEASURES

Referral rates, ambient noise levels, and audiometric results as well as hearing loss prevalence, types, and risk factors.

RESULTS

Despite high ambient noise levels during screening (46.7 dBA), no effect of noise on referral rates on automated audiometry or confirmatory manual audiometry in those who failed automated testing was seen. The overall audiometric referral rate was 2.6%. Idiopathic sensorineural hearing loss (SNHL) and cerumen impaction were the most common types of hearing loss in this population with an estimated prevalence of hearing loss (all types) of 18.3 per 1,000 children. SNHL was associated with both drug exposure during pregnancy (p = 0.04) and pesticide exposure in the home (p = 0.03).

CONCLUSION

Hearing screening using a tablet-based, noise-attenuating wireless headset audiometer is feasible and effective in rural low-resource environments with moderately elevated ambient noise levels. The referral rate with noise-attenuating headsets was much lower than that previous reports on this population. In addition, manual audiometry resulted in much lower referral rates than automated audiometry. The confirmed hearing loss rate in this study is comparable to reports from other low-income countries that use some form of noise attenuation during screening. Pesticide exposure and drug exposure during pregnancy are potential causes of SNHL in this population.

Expanding Clinical Trials Designs to Extend Equitable Hearing Care

Clinical trials are critically important to translate scientific innovations into clinical practice. Hearing healthcare depends on this translational approach to improve outcomes and quality of life. Across the spectrum of healthcare, there is a lack of diverse participation in clinical trials, a failure to recruit and retain underrepresented and underserved populations, and an absence of rigorous dissemination and implementation of novel research to broader populations. The field of hearing healthcare research would benefit from expanding the types and designs of clinical trials that extend hearing healthcare and novel interventions to diverse populations, as well as emphasizing trials that evaluate factors influencing how that care can be delivered effectively. This article explores the following: (1) the role, value, and design types of clinical trials (randomized controlled, cluster randomized, stepped wedge, and mixed methods) to address health equity; (2) the importance of integrating community and stakeholder involvement; and (3) dissemination and implementation frameworks and designs for clinical trials (hybrid trial designs). By adopting a broader range of clinical trial designs, hearing healthcare researchers may be able to extend scientific discoveries to a more diverse population.

Prevalence and characteristics of hearing and vision loss in preschool children from low income South African communities: results of a screening program of 10,390 children

BACKGROUND

The majority of children with sensory impairments live in low- and middle-income countries. More studies of hearing and vision impairment prevalence are needed, in order to generate more accurate estimates of trends in sensory impairments. This study aimed to estimate the prevalence and describe the characteristics of hearing and vision loss among preschool children (4-7 years) in an underserved South African community following community-based mobile health (mHealth) supported hearing and vision services.

METHODS

A screening program of sensory impairments was undertaken of children attending preschools in the communities of Khayelitsha and Mitchell's Plain, Cape Town, from September 2017 until June 2019. Hearing and vision screening were done by trained community health workers using mHealth technology. Children who failed hearing and vision screening were seen for follow-up assessments at their preschools. Follow-up assessments were conducted using smartphones that host point-of-care validated and calibrated hearing and vision testing applications (hearTest app, hearX Group, South Africa and PeekAcuity app, Peek Vision, United Kingdom). Descriptive statistical analysis and logistic regression analysis were conducted after extracting data from a secure cloud-based server (mHealth Studio, hearX Group) to Microsoft Excel (2016).

RESULTS

A total of 10,390 children were screened at 298 preschools over 22 months. Of the children screened, 5.6 and 4.4% of children failed hearing and vision screening respectively. Community-based follow-up hearing tests were done at the preschools on 88.5% (514) of children of whom 240 children (54.2% female) presented with hearing loss. A preschool-based follow-up vision test was done on 400 children (88.1%). A total of 232 children (46.1% female) had a vision impairment, and a further 32 children passed the test but had obvious signs of ocular morbidity. Logistic regression analysis found that age was a significant predictor of vision loss (p < 0.05), but not for hearing loss (p = 0.06). Gender was not a significant predictor of hearing (p = 0.22) or vision loss (p = 0.20).

CONCLUSIONS

Hearing loss is prevalent in at least 22 per 1000 and vision loss in at least 23 per 1000 preschool children in an underserved South African community. Timely identification of sensory losses can be facilitated through community-based hearing and vision services supported by mHealth technology.

Early Patient-Centered Outcomes Research Experience With the Use of Telehealth to Address Disparities: Scoping Review

BACKGROUND

Health systems and providers across America are increasingly employing telehealth technologies to better serve medically underserved low-income, minority, and rural populations at the highest risk for health disparities. The Patient-Centered Outcomes Research Institute (PCORI) has invested US $386 million in comparative effectiveness research in telehealth, yet little is known about the key early lessons garnered from this research regarding the best practices in using telehealth to address disparities.

OBJECTIVE

This paper describes preliminary lessons from the body of research using study findings and case studies drawn from PCORI seminal patient-centered outcomes research (PCOR) initiatives. The primary purpose was to identify common barriers and facilitators to implementing telehealth technologies in populations at risk for disparities.

METHODS

A systematic scoping review of telehealth studies addressing disparities was performed. It was guided by the Arksey and O'Malley Scoping Review Framework and focused on PCORI's active portfolio of telehealth studies and key PCOR identified by study investigators. We drew on this broad literature using illustrative examples from early PCOR experience and published literature to assess barriers and facilitators to implementing telehealth in populations at risk for disparities, using the active implementation framework to extract data. Major themes regarding how telehealth interventions can overcome barriers to telehealth adoption and implementation were identified through this review using an iterative Delphi process to achieve consensus among the PCORI investigators participating in the study.

RESULTS

PCORI has funded 89 comparative effectiveness studies in telehealth, of which 41 assessed the use of telehealth to improve outcomes for populations at risk for health disparities. These 41 studies employed various overlapping modalities including mobile devices (29/41, 71%), web-based interventions (30/41, 73%), real-time videoconferencing (15/41, 37%), remote patient monitoring (8/41, 20%), and store-and-forward (ie, asynchronous electronic transmission) interventions (4/41, 10%). The studies targeted one or more of PCORI's priority populations, including racial and ethnic minorities (31/41, 41%), people living in rural areas, and those with low income/low socioeconomic status, low health literacy, or disabilities. Major themes identified across these studies included the importance of patient-centered design, cultural tailoring of telehealth solutions, delivering telehealth through trusted intermediaries, partnering with payers to expand telehealth reimbursement, and ensuring confidential sharing of private information.

CONCLUSIONS

Early PCOR evidence suggests that the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by the patients themselves to meet the needs of specific communities and populations. Further, this evidence shows that the best practices in telehealth implementation include delivery of telehealth through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and safeguards to ensure patient-guided confidential sharing of personal health information.

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.

Hearing Norton Sound: community involvement in the design of a mixed methods community randomized trial in 15 Alaska Native communities

Community involvement is important in good research practice. We led a community-based study to improve early detection and treatment of childhood hearing loss in rural Alaska. This study evaluated a cell phone-based hearing screening process and compared a new telemedicine specialty referral pathway to the standard primary care referral pathway. The study included community involvement, engagement, and participation from the very beginning to inform how to best design the trial. We obtained insight and feedback from community members through involvement of a core stakeholder team and through community engagement and participation in focus groups and community events. Feedback received through community involvement and participation influenced the design of the trial at key decision points. Community member guidance shaped the research question, the outcomes to be measured, and the procedures for completing the project, such as participant recruitment. This study offers an example of community involvement, engagement and participation that could be mirrored in future research to maintain the interests of participating communities. Background Effective systems for early identification and treatment of childhood hearing loss are essential in rural Alaska, where data indicate a high prevalence of childhood ear infections and hearing loss. However, loss to follow-up from school hearing screening programs is pervasive. The Hearing Norton Sound study was a mixed methods community randomized controlled trial that was developed to address this gap. The study engaged community members and participants in the design of the trial, including involvement of stakeholders as collaborators. Methods Community engagement and participation in research design occurred through focus groups and through the integration of stakeholders into the study team. Representation was cross-sectoral, involving individuals from multiple levels of the school and health system, as well as community members from each of the 15 communities. Feedback obtained between April 2017 and August 2017 informed the final design of the randomized trial, which began enrollment of children in October 2017 and concluded in March 2019. Results Stakeholder involvement and community participation shaped the design of specific trial elements (research question; comparators; outcomes and measures; telemedicine protocols; and recruitment and retention). Community involvement was strengthened by the use of multiple modalities of involvement and by the positionality of lead stakeholders on the study team. Conclusions This study highlights the effectiveness of multifaceted stakeholder involvement and participation in the design of health research conducted within Alaska Native communities. It offers an example of involvement and reporting that could be mirrored in future research in order to protect and further the interests of the participating community. Trial registration ClinicalTrials.gov, NCT03309553 , First registered 10/9/2017.

Hearing Norton Sound: mixed methods protocol of a community randomised trial to address childhood hearing loss in rural Alaska

INTRODUCTION

Childhood hearing loss has implications for school achievement, economic outcomes and quality of life. This study will engage rural Alaska communities in research to improve the school hearing screening and referral process, partnering with stakeholders to develop a locally derived, evidence-based solution to improve timely identification and treatment of childhood hearing loss.

METHODS AND ANALYSIS

Mixed methods community randomised trial in 15 communities in the Norton Sound region of northwest Alaska. Data collection will span from April 2017 until February 2020. Qualitative and mixed methods components are described in this protocol and the community randomised trial in the companion protocol. Focus groups and community events will be held leading up to the randomised trial to obtain community perspectives on childhood hearing loss in Alaska and elicit community input during trial protocol refinement (exploratory sequential stage). Stakeholder groups, including parents, children, teachers, school administrators and community health aides, will participate, along with community leaders, tribal leaders and community members. The randomised trial will be combined with qualitative, semi-structured interviews to elicit stakeholder perspectives on the intervention (explanatory sequential stage). The five stakeholder groups described above will participate in interviews. The study will conclude with additional focus groups and community events to discuss results and provide community insight for future implementation. Concluding focus groups will include policymakers, healthcare administrators, and tribal and community leaders in addition to the stakeholder groups. Informed consent and child assent will be required. Recordings will be transcribed and deidentified, with only stakeholder group recorded. Analyses will include categorical coding as well as narrative and thematic analysis.

ETHICS AND DISSEMINATION

The Hearing Norton Sound study has been approved by the Institutional Review Boards of Alaska Area, Norton Sound, and Duke University, with trial registration on clinicaltrials.gov. Study results will be distributed with equal emphasis on scientific and community dissemination.

TRIAL REGISTRATION NUMBER

NCT03309553; Results.