Investigating the Feasibility of Community Health Workers as Teleaudiology Patient-Site Facilitators: A Strategy to Improve Access to Hearing Aid Services for Older Adults

Abstract

BACKGROUND: Hearing loss is highly prevalent among older adults, and, when unaddressed, its impacts include social isolation, depression, and cognitive decline. Hearing aids are typically recommended to help manage hearing loss. However, there are significant disparities in the use of hearing aids by race/ethnicity, rural/urban status, and income, representing underlying access barriers. The prevailing model of hearing aid service delivery is clinic-based and private-pay, posing multiple obstacles for potentially millions of Americans. Teleaudiology is a strategy that can improve geographic access to services, yet there is a lack of research demonstrating the implementation and feasibility of this service delivery model in real-world practice settings, particularly among diverse and rural populations who may benefit most. Community Health Workers (CHWs) are non-medical public health workers from their community who help improve patient access, including by connecting patients to services and by improving the cultural-relevance of health information. CHWs may be uniquely positioned as the local, hands-on facilitators in teleaudiology to help improve patients’ access to hearing aid services, and therefore help improve their health outcomes. OBJECTIVES: The work in this dissertation addresses the following three aims: 1) synthesize past teleaudiology literature focusing on the role of patient-site facilitators; 2) describe the development and evaluation of a training program to prepare CHWs as patient-site facilitators in teleaudiology; and 3) investigate the feasibility of CHWs as patient-site facilitators in a teleaudiology intervention to improve hearing aid rehabilitation outcomes for older adults in a medically underserved, rural, US-Mexico border community. METHODS: To address Aim 1, a scoping literature review of the teleaudiology literature was conducted, in which patient-site facilitator roles, responsibilities, and background were described. Next, Aim 2 was a multi-level training study offered to CHW volunteers on teleaudiology. At the most advanced level, CHW participants were evaluated to determine their preparedness prior to engaging in a role as patient-site facilitators in hearing aid service delivery. Next, to address Aim 3, we conducted a Randomized Controlled Trial (Conexiones) to evaluate the feasibility of Community Health Workers as patient-site facilitators in teleaudiology service delivery compared to a study control (non-CHWs). Participants (28 adults with hearing loss over 50 years of age in a rural, US-Mexico border town in Arizona) were randomized to one of two teleaudiology intervention arms that differed at the level of the facilitator (CHW or non-CHW). Both groups received hearing aid fittings and follow-up care via teleaudiology from a remote audiologist. Mixed-methods data included surveys on self-efficacy for communication, hearing aid use, and satisfaction, as well as semi-structured interviews. RESULTS: Regarding Aim 1, a total of 82 studies met the criteria for the scoping review. Across the teleaudiology literature reviewed, patient-site facilitators performed a variety of tasks, including managing local technology and performing hands-on aspects of testing, yet most studies lacked a description of the facilitators’ training. Results from Aim 2 indicated that a multi-level training for CHWs on teleaudiology can prepare individuals for a role as patient-site facilitators. At the advanced level, all CHWs fulfilled the benchmark score required to demonstrate adequate knowledge and skills on trained outcomes, and qualitative comments indicated they found the training useful. Lastly, results from Aim 3 (Conexiones trial) indicated the feasibility of delivering hearing aid services via synchronous teleaudiology for older, rural, Hispanic/Latino adults, and that there may be benefits when the facilitator is a CHW vs. a non-CHW, as indicated by quantitative and qualitative outcomes. CONCLUSIONS: Taken together, the findings from the three studies reported here indicate that trained CHWs are well-positioned to help improve hearing care access, including by facilitating hands-on aspects of teleaudiology in their community when appropriate training is provided. Given the feasibility of teleaudiology-delivered hearing aid services among groups who face disparities in access, future efficacy and effectiveness research is warranted on CHWs and teleaudiology, potentially leading to significant reduction in barriers for rural and medically under-resourced communities.