One-third of Americans age 65 to 74 and about half of those older than 75 have hearing loss, but only 20 percent of people who might benefit from treatment seek help. As a result, the need for innovative solutions to untreated hearing loss represents an urgent public health problem.
“We know that there's approximately a seven-year gap between a person becoming aware of a problem with hearing and taking action,” said David Citron, PhD, of the South Shore Hearing Center in Weymouth, MA. “One wonders why, and I suspect awareness and access to screening have a lot to do with it.”
But who is going to identify this population, screen its members for hearing loss, and help implement aural rehabilitation strategies when, in many cases, people with hearing loss are attributing their condition to normal aging, and projections predict a growing shortage of audiologists?
One innovative strategy that is just beginning to be tested in the United States is the use of trained community health workers (CHWs). According to the Community Health Worker Network of New York City, CHWs are “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community they serve. This trusting relationship enables CHWs to serve as a liaison/link/ intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.”
Research projects are now examining the potential role of community healthcare workers in hearing healthcare.
“While CHWs cannot provide true audiologic care, they may be able to provide essential services for certain populations who might otherwise have no access to the hearing healthcare system at all,” Dr. Citron said.
BEHIND THE DEVELOPING WORLD
They may have no formal professional education, but whether they're called promotoras (as in Hispanic communities), anganwadi workers (as in India), or CHWs, community health workers have been acting as a critical bridge between their communities and the formal health system in many aspects of public health for at least 50 years. They are found everywhere from Zimbabwe to Appalachia. Some are specialists, with training in maternal and child health, malaria, or HIV, while others are generalists.
CHWs have long been deployed in the United States to address chronic diseases such as diabetes and screening for cancer and mental health. They're particularly useful for common health issues that significantly affect hard-to-reach populations because community health workers know the values and attitudes of the communities they represent.
But hearing healthcare hasn't taken advantage of community health workers until very recently. In fact, the use of CHWs in this specialty is one area in which the developing world is moving ahead of the United States.
In nations such as Mozambique, Malawi, and Zambia, there may be no or very few audiologists and sometimes only one otolaryngologist to serve a large and widely spread population, said Jackie Clark, PhD, a member of The Hearing Journal Editorial Advisory Board, a clinical associate professor at the University of Texas at Dallas School of Brain and Behavioral Sciences, and an expert in humanitarian audiology who collaborates with programs in Africa and Asia.
In these countries, “hearing health techs” or “hearing health assistants” are receiving training in particular interventions to offer in their communities, she said.
“They would do very basic things like performing a pure-tone audiogram or instructing a mother in how to wick a child's draining ears to reduce the propensity to infection. They are not making clinical decisions. They have specific criteria that define what they can handle, and if the situation doesn't meet those criteria, they bump to the next level of care.”
Community health workers could be very effective for audiology care in the United States, Dr. Clark said.
“They would be particularly helpful for teleaudiology and telehealth practices. For example, in parts of western Texas, there are no permanent audiologists. There are audiologists who travel from town to town, but they don't live and practice there. Their time could be used more effectively if they stayed in the office and had trained CHW-type assistants in the towns they now travel to, working with them through video conferencing.”
PROMOTORA PARTNERSHIP IN ARIZONA
Three fledgling programs will be testing the feasibility of CHWs in audiology over the coming months and years.
At the University of Arizona, Nicole Marrone, PhD, assistant professor and the James S. and Dyan Pignatelli/Unisource Clinical Chair in Audiologic Rehabilitation for Adults, focuses on increasing access to hearing healthcare in rural communities. In partnership with the Mariposa Community Health Center in Nogales, AZ, she is training a group of experienced promotoras in basic hearing health outreach.
“We have a program called Living Well with Hearing Loss, which provides group audiologic rehabilitation here on campus,” she said. “Working with the Mariposa Community Health Center, we are taking that program into the community through the promotoras.”
The idea to work with the community health workers first came to Dr. Marrone when she participated in a service learning workshop with them and faculty members from the Mel and Enid Zuckerman College of Public Health.
“They were telling me about facilitating peer support groups on cancer and diabetes, and the link immediately struck me because of diabetes-related hearing loss,” she said. “I asked them what they were doing about hearing, and they said, ‘We do nothing. We don't know about that.’ And I thought, here's a group of people who likely have hearing issues but nothing really to connect people back to hearing services.”
And so Dr. Marrone's project began. To date, she has trained about half of the center's 49 promotoras in basic hearing health outreach, and one project manager and three promotoras have undergone more extensive training on facilitating peer support and health education about hearing.
With funding from a National Institutes of Health (NIH) and National Institute on Deafness and Other Communication Disorders (NIDCD) phased innovation grant, Dr. Marrone and her team have conducted a community needs assessment, are preparing a training curriculum that can be used elsewhere, and are launching the pilot study of the program.
“We did a series of interactive workshops about how we hear and the effects of hearing loss on communication and quality of life,” she said. “What the promotoras are ultimately doing is not substituting for the hearing healthcare system but acting as a bridge and a link to that system.”
The promotoras facilitated the first five-week hearing health support program, with a group of 10 participants recruited following hearing screening in the community.
“Quite a few people have talked to me about how helpful the group has been for them,” said research specialist and incoming doctor of audiology student Adriana Sanchez, who's a member of Dr. Marrone's team.
“They have been feeling embarrassed about having to ask people to repeat what they're saying because they can't hear or responding incorrectly because they heard something wrong. They say it isn't talked about much in the community, so it's all new, even for the promotoras, and they're really excited to be doing this because they see how important it is.”
HELPING BALTIMORE HEAR
On the other side of the country, Johns Hopkins otolaryngologist Frank Lin, MD, PhD, whose research has highlighted the many ways in which hearing loss affects the health and functioning of older adults, is launching another pilot project using CHWs in hearing care, inspired in part by Dr. Marrone's work.
“My postdoc Carrie Niemann and I have been working for the last year-and-a-half to develop a program called HEARS: Hearing Healthcare Equality through Accessible Research and Solutions,” he said.
Drs. Lin and Niemann have developed a standardized intervention manual to hire CHWs who can act as a point of community contact and provide basic services, including a personal sound amplification product (PSAP), all in a two-hour visit.
“The beauty of this approach is that it is very affordable and accessible, and can be directly delivered in the community by the CHW at an average cost of $223, including the cost of the device,” Dr. Lin said.
In preparation for the project, Dr. Lin's research staff has been doing pilot projects in three community settings: a Korean-American church where the staff has taught the pastor the intervention, a subsidized housing community for low- to moderate-income older African-Americans, and a partnership with several assisted living facilities and memory clinics.
“These pilots have helped us build the foundation to develop protocols to take community health workers and train them with accurate fidelity to do this intervention,” he said. The group recently submitted a large grant to the NIH to recruit and train CHWs for the next phase of Baltimore HEARS.
The pilot program involving CHWs will have three primary components:
- A hearing screening, with caveats from the CHW about its limitations: “They will make sure that the person knows that this is not a complete hearing exam but just basic services,” Dr. Lin said. Those services will include audiometry, as well as otoscopy for ear abnormalities using CellScope, an iPhone-based otoscope that can send the image to Dr. Lin for review in real time.
- Direct provision of a PSAP. For people who have dexterity limitations or prefer no device in their ear, a pocket talker will be provided.
- Counseling and education about how to use the device, and communication about repair and rehabilitation strategies.
This approach clearly is not gold-standard hearing healthcare, Dr. Lin acknowledged.
“But is it better than nothing?” he said. “You bet. There's a huge gap between gold standard and nothing.”
INTEGRATED SERVICE ON NORTH SHORE
A third program using CHWs in hearing healthcare will launch this summer on the North Shore of Boston. David Bergeron, who cofounded the pilot that promoted Massachusetts healthcare reform in the mid-1990s, the Fishing Partnership Health Plan, also developed and headed the project's CHW program for about 15 years. With his wife, Judi Bergeron, who is a hearing instrument specialist and legally deaf, he has launched the Hearing Partnership.
“If we hadn't had CHWs involved at the beginning of our demonstration for healthcare reform in Massachusetts, we wouldn't have been able to get anyone to sign up,” Mr. Bergeron said. “Our target for the demonstration was the fishing community, so we hired fishermen's wives to do outreach and get people to sign up.” A study showed that after the CHW program launched, the uninsured rate in the target population dropped from 43 percent to 13 percent ( Hum Ecol Rev 2008; 15:213-226 http://www.humanecologyreview.org/pastissues/her152/hartleyetal.pdf).
The Hearing Partnership is working closely with the Massachusetts Commission for the Deaf and Hard of Hearing and interested researchers from the Boston University School of Public Health to evaluate its intervention, which the Bergerons began testing with some of Ms. Bergeron's patients last spring.
“We're aiming for an integrated service delivery model,” Mr. Bergeron said. “We'll help patients who are eligible for amplification through that process, make them aware of other services and connect them with those, and help them address the social and financial barriers that are inhibiting their progress. CHWs offer a tremendous opportunity to improve the hearing care delivery model and how people access treatment.”