Hearing loss is a common problem affecting approximately 20 percent of people over 12 years old and at least 40 percent of adults over 70 (Arch Intern Med. 2011;171:1851 http://bit.ly/2w0L1LK). The prevalence of hearing is higher among adults living in rural communities compared with those in urban settings, which may have a link with pressing public health factors facing rural communities–poor overall health, poverty, low-levels of education, and high exposure to occupational noise (Am J Epidemiol. 1998;148:879 http://bit.ly/2w0p8fS; Am J Public Health. 2015;105:1262 http://bit.ly/2w0Y5B2, Chou 2015). Diagnosis and treatment of rural children and adults with severe forms of hearing loss are often delayed (Laryngoscope. 2014;124:1713 http://bit.ly/2w0fQjH; Otol Neurotol. 2016t;37:1320 http://bit.ly/2w0seAn). Such delays may lead to communication impairment, profoundly affecting education and employment. The lifetime medical, educational, and occupational costs of hearing loss are substantial. Adults with hearing loss often face significant obstacles in employment and may have lower wages than their normal-hearing peers (Ann Otol Rhinol Laryngol. 2012;121:771 http://bit.ly/2w088pT). Additionally, hearing loss has been linked to depression, poorer quality of life, and dementia. The effects of untreated hearing loss may be compounded when combined with existing medical and socioeconomic disparities affecting rural communities.
INVESTIGATING THE DISPARITY
Access to hearing health care is complicated by a lack of screening in most primary care settings, limited number of hearing professionals, and lack of patient motivation and facilitating influences to pursue evaluation and treatment. On average, adults with hearing loss may delay seeking care for 10 years after the onset of symptoms (Health Technol Assess. 2007;11:1). Hearing aids are an effective treatment option for most patients but only around 25 percent of adults who would be candidates use these devices (Hearing Rev. 2009;16:12). Patients in rural areas face unmitigated limitations in local resources and lack of specialized providers. This disparity calls for a closer look—a challenge recently braved by Chan and colleagues in their investigation of (1) the timing of hearing aid fitting between adults with hearing loss in rural and urban communities and (2) the impact of hearing loss on employment and education for these participants (Laryngoscope. 2017 http://bit.ly/2w09cdn).
This study used a 25-item questionnaire to investigate the socioeconomic status, timing of hearing aid fitting after diagnosis of hearing loss, impact of hearing loss, and hearing aid benefits among adults with hearing loss. Of the 336 participants, 273 were from urban communities and 63 were from rural communities. The primary outcome measure recorded was the age of onset of their hearing loss and the time (in years) between onset of hearing loss and fitting of their hearing aids. Additional data included travel time to their audiologist, impact of hearing loss on their education and employment, and quality of life related to hearing loss treatment.
On average, the rural participants had significantly lower household income and greater travel time to their audiologists. They also had lower levels of education and were more likely to have Medicaid insurance compared with the urban participants. A significantly longer period between onset of hearing loss and hearing aid fitting was identified in the rural participants compared with the urban participants. Among those with hearing loss for at least eight years, over 25 years elapsed before hearing aid fitting among the rural participants, compared with 19 years among the urban participants. Notably, participants who began experiencing hearing loss early in life (under age 50) waited significantly longer before obtaining hearing aids than those who developed hearing loss later in life (over age 50; Fig. 1).
Another factor that affected the timing of hearing aid acquisition was the patient's travel time to the audiologist. Those who resided farthest from an audiologist reported the longest period before getting treatment for their hearing loss. Rural participants reported an average of one hour travel time to their audiologists compared with urban participants who travelled an average of 32 minutes. There was an inverse relationship between the time to obtain hearing aids and the impact of hearing loss on job performance, with the shortest period to hearing aid fitting reported among participants with the greatest amount of job performance impairment. The impact of hearing loss on educational attainment and employment was also reflected in the study results. A larger percentage of rural adults reported that their hearing loss prevented them from obtaining higher levels of education compared with urban adults. All participants reported receiving benefit from their hearing aids and noticing improved quality of life.
BRIDGING THE GAP
These study results are important as we face an aging population with over 20 percent of the U.S. population living in rural communities (FHWA, 2017 http://bit.ly/2w0NOVe). Similar health care disparities have been reported in other countries and have been demonstrated in other areas of health care (Aust J Rural Health. 2016;24:130 http://bit.ly/2w0RaaI). Adults with hearing loss are facing a shortage of audiologists, which can restrict access to care (J Am Acad Audiol. 2013;24:407 http://bit.ly/2w0ujfr). The lack of financial resources to cover the cost of hearing aids along with inadequate insurance coverage can also contribute to delays in hearing aid acquisition. Rural adults often have poorer health, in general, when compared with urban adults, and this can negatively affect hearing health care utilization (Int J Audiol. 2012;51:108 http://bit.ly/2w0Jeq4). They direct more effort and resources to other health problems, leaving little or no reserve to address hearing loss treatment.
To address these geographic differences and disparities, community-based models of delivery of care have been investigated in other areas of health care like optometry (Optometry. 2008;79:724 http://bit.ly/2wkXo7Y). This requires a partnership between specialists outside of the area of care delivery and local health care or civic organizations to provide diagnostic services. This type of model could be utilized in hearing health care to educate people about hearing loss in adults and facilitate timely screening. Remote delivery of hearing health care services through telemedicine has also been widely explored. Telemedicine refers to the delivery of health services through audiovisual telecommunication technology. There is solid evidence to suggest that hearing loss can be treated by audiologists who remotely fit and program hearing aids and/or cochlear implants; however, limited local resources at the point of care (internet connectivity and local infrastructure) and lack of cost-effectiveness data could limit the feasibility of remote care delivery (Otol Neurotol. 2016;37:1466 http://bit.ly/2wkYwsB). Additional research is needed to further understand the unique characteristics and needs of adults in rural communities and to explore ways to expedite hearing loss treatment and maximize its benefits.
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