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Inglis-Jenson M, Robler SK, Gallo JJ, Ivanoff P, Ryan S, Hofstetter P, Emmett SD. Community Perspectives on Hearing Loss in Rural Alaska. Ear Hear 2023; 44:1078-1087. [PMID: 36939709 PMCID: PMC10426783 DOI: 10.1097/aud.0000000000001348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/11/2023] [Indexed: 03/21/2023]
Abstract
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.
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Affiliation(s)
- Meade Inglis-Jenson
- Center for Health Policy and Inequalities Research, Duke University, Durham, North Carolina, USA
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Norton Sound Health Corporation, Nome, Alaska, USA
- These authors contributed equally to this work
| | - Samantha Kleindienst Robler
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Norton Sound Health Corporation, Nome, Alaska, USA
- These authors contributed equally to this work
| | - Joseph J. Gallo
- Mixed Methods Research Training Program, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Paul Ivanoff
- Lead Parent Stakeholder, Hearing Norton Sound, Unalakleet, Alaska, USA
| | - Stephanie Ryan
- Lead Patient Partner, Hearing Norton Sound, Anchorage, Alaska, USA
| | | | - Susan D. Emmett
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Duke Global Health Institute, Durham, North Carolina, USA
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Arkansas for Medical Sciences, Arkansas, USA
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Arkansas, USA
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Robler SK, Inglis-Jenson M, Gallo JJ, Ivanoff P, Ryan S, Hofstetter P, Emmett SD. Mobile Health School Screening and Telemedicine Referral to Improve Access to Specialty Care in Rural Alaska: Integrating Mixed Methods Data to Contextualize Trial Outcomes. Ear Hear 2023; 44:1271-1281. [PMID: 37594255 PMCID: PMC10426779 DOI: 10.1097/aud.0000000000001394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/04/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVES To understand factors associated with outcomes in a cluster-randomized controlled trial that evaluated a telemedicine specialty referral intervention for school hearing screenings in 15 rural Alaskan communities. DESIGN Hearing Norton Sound was a mixed methods cluster-randomized controlled trial that compared a telemedicine specialty referral pathway (intervention) to a standard primary care referral pathway (control) for school hearing screenings. As a mixed methods trial, both quantitative and qualitative data were collected, analyzed, and integrated. Main trial results are published elsewhere, but integration of community-specific quantitative outcomes and qualitative results have not yet been reported. The constant comparative method was used to analyze qualitative data from semistructured interviews with six stakeholder groups across all 15 communities. Descriptive statistics were used to describe community-specific proportions of follow-up in both trial years. Qualitative and quantitative results were integrated to reveal relationships between contextual factors and follow-up outcomes across communities. RESULTS The Hearing Norton Sound trial enrolled 1481 children from October 2017 to March 2019, with a total of 790 children requiring referral. Of the children who referred in the telemedicine specialty referral pathway communities (intervention), 68.5% received follow-up (268/391), compared to 32.1% (128/399) in primary care referral communities (control)(previously reported). When broken down by community, the mean proportion receiving follow-up was 75.26% (SD 22.5) and 37.9% (SD 11.4) for the telemedicine specialty referral communities and primary care referral communities, respectively. For qualitative data collection, semistructured interviews were conducted with 101 individuals between December 2018 and August 2019. Six stakeholder groups participated: elders (n = 14), parents (n = 25), children (n = 11), teachers/school staff (n = 18), principals (n = 6), and healthcare providers/clinic staff (n = 27). Six overall factors related to the outcomes of the telemedicine specialty referral pathway emerged during analysis: clinic capacity, personnel ownership and engagement, scheduling, telemedicine equipment/processes, communication, and awareness of the need for follow-up. We integrated these factors with the community-specific follow-up percentages and found associations for four of the six qualitative factors: clinic capacity, personnel ownership and engagement, communication, and awareness. An association was not seen for scheduling and telemedicine equipment/processes, which had variable relationships with the follow-up outcome. CONCLUSIONS The Hearing Norton Sound trial demonstrated that a telemedicine specialty referral pathway can close the gap on children lost to follow up after school hearing screening. As a whole, the intervention profoundly increased the proportion of children receiving follow-up, but there was variability in outcomes within and between communities. To understand this variability, we analyzed community-specific intervention outcomes alongside community member feedback on factors related to the intervention. We identified four key factors that contributed to the success of the intervention. Attention to these factors will be essential to successful adaptation and implementation of this telemedicine specialty referral intervention and other similar interventions in future work in rural Alaska and beyond.
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Affiliation(s)
- Samantha Kleindienst Robler
- Norton Sound Health Corporation, Nome, Alaska, USA
- Center for Hearing Health Equity, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- These authors are co-first authors who contributed equally to this work
| | - Meade Inglis-Jenson
- Norton Sound Health Corporation, Nome, Alaska, USA
- Center for Hearing Health Equity, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Center for Health Policy and Inequalities Research, Duke University, Durham, North Carolina, USA
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- These authors are co-first authors who contributed equally to this work
| | - Joseph J. Gallo
- Mixed Methods Research Training Program, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul Ivanoff
- Lead Parent Stakeholder, Hearing Norton Sound, Unalakleet, Alaska, USA
| | - Stephanie Ryan
- Lead Patient Partner, Hearing Norton Sound, Anchorage, Alaska, USA
| | | | - Susan D. Emmett
- Center for Hearing Health Equity, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Duke Global Health Institute, Durham, North Carolina, USA
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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