Transforming Access to Hearing Care: Community Perspectives on School-Based Telehealth in Rural Appalachia

Abstract

Objectives:

School-based hearing screening serves as a critical resource for children in rural areas to be screened and connected to hearing healthcare. Telemedicine interventions in schools have shown promise in connecting children to providers; however, there is limited research on systematic adaptation and deployment of telemedicine in rural schools. Obtaining community perspectives and preferences on school-based telemedicine hearing evaluation is essential to ensure such interventions are deployable in a rural context. Grounded in the ADAPT-ITT framework, this research focused on assessing community perspectives and preferences regarding school-based telemedicine hearing screening to inform adaptation of a school-based telemedicine intervention. This analysis represents the first step of the ADAPT-ITT framework (Assessment of community perspectives).

Design:

We completed 21 semi-structured interviews of 3 informant groups: parents of children in elementary school, school staff, and regional care providers from 14 rural Appalachian counties. We analyzed data from informant groups using qualitative methods across two a priori domains: (1) experience with childhood hearing loss, screening, and follow-up process, (2) components of childhood hearing screening (school-based screening, exchange of information with educators/parents/providers, integration of technology and telemedicine).

Results:

Important implications and opportunities drawn from these data include the need for an adapted hearing screening intervention that can integrate care coordination into the screening process, provide clear yet secure communication to parents, educational staff, and regional healthcare providers, and facilitate comprehensive and timely collection of screening data.

Conclusions:

Rural school-based hearing screening programs face a pervasive lack of communication and coordination of care following screening. By gaining community perspectives on hearing screening, communication, and care coordination, this study presents a model for how to initiate intervention adaptation when it will be studied in another context.

INTRODUCTION

Childhood hearing loss is a global hearing health concern that impacts language, cognitive, and social development, along with educational attainment and employment potential (Wake et al. 2016; Ching et al. 2017). Of particular concern are delays in identification and treatment for childhood hearing loss, as these delays often lead to poor language development, decreased academic performance, diminished economic outcomes, poorer cognition, and delays in psychosocial development (Singh et al. 2017; Emmett et al. 2019; Yong et al. 2020). Hearing loss and these negative consequences disproportionately affect children in underserved communities, such as rural regions (Mehra et al. 2009; Emmett et al. 2023). The World Health Organization estimates that 60% of childhood hearing loss globally is preventable, and this estimate rises to 75% in underserved communities (Krug et al. 2016). From the time they are born, children from rural communities face significant challenges in accessing hearing healthcare and are often delayed in the diagnosis and treatment of hearing loss (Bush et al. 2013; Bush et al. 2014a, 2014b). Factors attributed to rural pediatric hearing health and healthcare disparities include greater travel distances, lower levels of parental education, lower socioeconomic status, and poorer insurance coverage of services (Bush, Osetinsky, et al. 2014; Kingsbury et al. 2022; Nicholson et al. 2022).

Poverty is an additional barrier to pediatric hearing healthcare in Appalachia, as significantly higher rates of children in this region experience financial insecurity than national averages (Benson 2023). Further compounding these challenges, rural primary care providers may lack confidence and key diagnostic information necessary to direct pediatric hearing healthcare (Bush et al. 2015; Jesudass et al. 2024a). The pervasive and persistent disparities of rural pediatric hearing healthcare access and utilization are a result of the different domains of the social determinants of health and the interplay between them (Schuh & Bush 2021, 2022). Yet, early identification and treatment of childhood hearing loss has the potential to minimize rural children’s developmental delays pertaining to communication and socioeconomic status (Schuh & Bush 2022). Improving hearing screening and follow-up through innovative solutions has important long-term implications for mediating childhood development and communication outcomes.

Public schools are currently a vital source for preventive hearing screening in many rural communities across the United States and, in some instances, one of the only feasible locations for healthcare delivery. However, making advancements in healthcare delivery and connections between schools and regional healthcare providers is challenging (Rodriguez et al. 2018). These challenges include logistical barriers to secure communication, frequent miscommunications, and the importance of timeliness (Schmalzried et al. 2015). In addition, hearing screening protocols vary widely across different counties and different states (Bush et al. 2017). When hearing screening does occur, there are inconsistent protocols and programs to ensure timely follow-up with a health care provider (Yong et al. 2020). There is a need for clear, consistent, and coordinated school-based hearing screening.

Telemedicine approaches that connect children in remote schools to specialty care are promising solutions. For example, in rural Alaska, where rates of preventable childhood hearing loss are high, a cluster randomized trial (Hearing Norton Sound trial) evaluating a telemedicine-facilitated hearing healthcare delivery model demonstrated that telemedicine can significantly increase the proportion of children receiving follow-up and expedite the time to follow-up compared with the standard of care (Emmett et al. 2022). This intervention, which was developed using existing telemedicine infrastructure in Alaskan tribal health clinics and in partnership with local community stakeholders, involved in-school mobile health hearing screening, communication with parents, and clinic-based telemedicine consultations with audiologists or otolaryngologists (Emmett et al. 2022). The audiology evaluation in this trial was conducted in a local village health clinic by health aide or telemedicine practitioner and the information was sent to an audiologist for evaluation and determination of whether an in person appointment or Otolaryngologist evaluation was needed while the standard of care comparison for this study required children to leave the local village and travel a regional hospital to be evaluated by an audiologist in person for evaluation and subsequent referral. This type of program is unique in the research literature and represents a promising approach to connect children in rural schools with specialists of multiple types.

Research interventions are often studied in a specific context and may lack generalizability to other populations. The school-based hearing screening intervention in rural Alaska is intimately linked to the tribal health system (Emmett et al. 2022) and has yet to be studied in broader rural contexts. This evidence-based intervention has immense potential to strengthen school-based hearing healthcare amongst other rural communities; however, implementation requires adaptation and subsequent evaluation in new contexts. An effective program for school-based enhanced hearing screening and telehealth specialty follow-up needs to incorporate the perspectives of key stakeholders, such as parents, educational staff, and regional healthcare providers (Ramkumar et al. 2016; Govender 2022). Systematic adaptation of research interventions that incorporate local perspectives, practices, and policies has the potential to increase uptake, ensure sustainability, and expand the public health impact of an evidence-based intervention (Glasgow et al. 1999; Glasgow & Chambers 2012; Jesudass et al. 2024b). One such systematic adaptation approach is outlined by the ADAPT-ITT model, which is intended to guide the adaptation of an evidence-based intervention into a new social or geographic context (Wingood & DiClemente 2008). ADAPT-ITT represents Assessment, Decision, Adaptation, Production, Topical experts, Integration, Training, and Testing. This ideologic framework for systematic adaptation was formed through the HIV/AIDS epidemic and has been utilized globally to guide adoption of evidence-based HIV/AIDS interventions into novel environments.

Adaptation of existing interventions can reduce the cost of new intervention development and can expedite the translation of scientific discoveries to marginalized populations (Crooks et al. 2023). Furthermore, through this process, communities are engaged in the research and with the research team early, which can build trust and the sustainability of the proposed intervention (Crooks et al. 2021). Collecting data regarding the status of regional hearing screening, including audiologic technology and on-the-ground screening protocols, informs community leaders on specific targets for improving follow-up and referral processes. The purpose of this qualitative study is to describe the initial step of the Assessment required for systematic adaptation of an enhanced hearing screening and telehealth specialty follow-up intervention, specifically the Hearing Norton Sound trial intervention, for implementation in rural school systems by involving the community stakeholders in the process to make the intervention relevant to the population of interest. The ADAPT-ITT model is a multi-stepped and structured methodology to facilitate adaptation of an evidence-based intervention into a new context, in this case from the Hearing Norton Sound trial in rural Alaska to a rural Appalachian environment (Fig. 1). This study was designed to explore the initial Assessment phase of ADAPT-ITT and assess key stakeholder (educational staff, parents, and regional healthcare providers) experiences with childhood hearing loss and school-based hearing screening and obtain perspectives and preferences of the current screening program and future integration of technology and telemedicine within a rural Appalachian context.

Fig. 1.

ADAPT-ITT model phases of the ADAPT-ITT model are to be utilized for adaptation of a comprehensive hearing screening and tele-audiology referral intervention from rural Alaska to Appalachia.

MATERIALS AND METHODS

Study Design

The protocol received institutional review board approval, and this manuscript reports on the first study component for contextualizing an evidence-based hearing screening intervention. ADAPT-ITT is a model that contains eight main components, including: Assessment, Decision, Administration, Production, Topical experts, Integration, Training, and Testing (Fig. 1) (Wingood & DiClemente 2008). To complete the first step (i.e., Assessment) of the ADAPT-ITT model, we designed this study to determine preferences and perspectives of educational staff, parents, and regional healthcare providers regarding school-based hearing screening, communication of screening results, specialty care follow-up after screening, and telemedicine-based hearing screening within schools. A 16-member Community Advisory Board (CAB), consisting of regional educational staff (N = 10), healthcare providers (N = 5), and parents (N = 1), provided guidance on study design and recruitment methods. The CAB supported this project by suggesting and reviewing questions utilized for the semi-structured interviews, along with recommendations of potential study participants.

Setting

Appalachia is a region of the United States with a population of approximately 26.4 million, encompassing portions of 13 states, with 20.6% of residents being people of color (Srygley et al. 2024). The Appalachian region of Kentucky was selected to develop a generalizable model that could be translated to other rural regions of the United States. Of the 120 counties in the state of Kentucky, 54 are within Appalachia (Clark et al. 2021). A total of 14 Appalachian Kentucky counties (Carter, Clay, Harlan, Whitley, Elliott, Rockcastle, Laurel, Lawrence, Fleming, Lewis, Menifee, Morgan, Robertson, and Montgomery County) were selected to participate based on limited audiological care in those counties, yet each having access to a state-funded pediatric hearing healthcare clinic in an adjacent county where comprehensive hearing healthcare is accessible (Fig. 2). Within the participating counties, district-wide leaders were interviewed for each county, as well as individuals from 11 elementary schools. Public schools were recruited to participate due to their preexisting, although limited, relationships with state-funded hearing healthcare and to increase generalizability to other rural communities.

Fig. 2.

Intervention sites and regional hearing healthcare clinics in Appalachian counties (shaded in blue) enrolled in the study (n = 14) and geographic proximity to regional hearing healthcare clinics (star).

Study Participants

Interview participants included educational staff, parents, and healthcare stakeholders in the participating counties that were recruited through snowball sampling. Educational staff (elementary school teachers, speech language pathologists, school nurses, and administrative staff members) who are either involved in school hearing screening or willing to provide insights regarding hearing screening were recruited using purposive sampling procedures and a network of referrals within each school district. Participants were identified by participating county educators, school board members, and our healthcare co-investigator at a state-funded regional clinic. The number of staff to be recruited was based on the goal of obtaining a diverse representation of different types of staff, counties across the region, and various school sizes. Recruitment was to be concluded when data saturation was met, with a goal of 25 interviewees. Informed consent procedures and study enrollment were conducted by trained research assistants. The inclusion criteria required participants to be 18 years or older, English-speaking, and a staff member at one of the elementary schools within participating counties.

Parents of early elementary-aged children were also recruited using snowball sampling. The team sought participants residing in different counties across the region with varied perspectives regarding hearing loss (Corbin & Strauss 2008). Participants were identified by participating county educational staff and our regional specialty clinic personnel. Inclusion criteria included age 18 years or older, custodial caregiver of child, child living full-time in the caregiver’s home, able to read English, and English-speaking. Exclusion criteria were residence outside the 14 counties involved in this research.

Healthcare stakeholders were recruited based on direct suggestion or referral from our professional networks of CAB members. The goal was to ascertain perspectives from different types of providers who work directly with children and their families. Participants in this group included audiologists from the region (private and public-funded clinic settings) and private practice pediatricians in the region. While speech language pathologists are healthcare providers, our interviewees’ practices were entirely within public school systems, thus they were considered amongst educational staff.

Procedures and Measures

Once consent was obtained, interviews were conducted via Zoom by a trained interviewer for over 60 to 90 min. The primary interviewer was experienced with conducting qualitative interviews and focus groups and was guided by co-investigators with expertise in qualitative methodology and implementation science. Participants were given $25 to compensate them for their time away from work.

Interview guides were developed to capture insight into the status of hearing screening in each school district, as well as the processes for communicating results to parents and medical personnel. The interview guide addressed two primary domains: (1) experience with the field of childhood hearing loss, screening, and follow-up process, (2) knowledge on current components of the hearing screening processes in the school/county (school-based screening, exchange of information with educational staff/parents/providers, integration of new technology and telemedicine), as well as desired adaptations (Appendices 1–4 in Supplemental Digital Content, https://links.lww.com/EANDH/B749). The current practices in each county were assessed through queries such as, “Can you walk me through from start to finish the follow-up process for children who have been referred from their school hearing screenings?” Additional topics included: effectiveness of hearing screening in their institutions, effectiveness of the referral process after school hearing screening, preferences regarding school-based enhanced hearing screening and telehealth specialty follow-up, referral process content and delivery, and perceptions of existing hearing healthcare resources in the community. Qualitative data collection and analyses followed an iterative process, with the study team meeting biweekly to evaluate recruitment, review interview content, and modify interview guides as needed. These meetings led to modifications of the interview guides to maximize saturation on the primary domains of interest. Following 21 interviews, the research team felt that saturation was met due to recurring information and a lack of appreciable gaps in the Assessment.

Rapid Qualitative Analysis

Digital recordings of key informant interviews were transcribed, and the data were analyzed using a rapid qualitative analysis approach (Hamilton 2013; Vindrola-Padros & Johnson 2020; Nevedal et al. 2021; Schexnayder et al. 2023). The CFIR model was utilized to guide qualitative analysis. The transcript of each interview was recorded through an automated feature in Zoom’s software, then manually reviewed and transcribed to ensure accuracy. An interview summary was created from each interview by the primary interviewer and aligned with interview question domains. The summaries were reviewed by additional research staff, and the summary data were transferred to a larger summary matrix for coding. The research team met weekly to adjudicate differences and highlight recurring themes. The research team created reports of quotations attributed to each code. Summary reports were reviewed by staff members, who identified themes and corresponding quotations for each code. Themes were compiled from the summary matrix describing the overall findings from the interviews.

RESULTS

Participants included educational staff, healthcare professionals, and parents. Educational staff (n = 11) were an average age of 46 years old, 100% white, and 91% female (n = 10). Within this group, 55% (n = 6) had previously held their current position for more than 10 years. Of the remaining educational staff, one participant had held their position for less than 1 year, two participants for 2 to 5 years, and two participants for 6 to 10 years. Interviewees were leaders involved in overseeing school health screening programs or speech language pathologists directly administering hearing screening. Healthcare professionals (n = 5) were an average age of 45 years old, 80% white (n = 4), and 80% female (n = 4). Healthcare participants included 3 audiologists and 2 pediatricians. Parents (n = 5) were an average age of 39 years old, 100% white, 100% female, with 50% attaining higher education, including either trade school or a bachelor’s degree. One parental figure was a grandmother, while the remaining interviewees were mothers. Of note, only 50% of parents received information from their child’s school regarding the hearing screening results. Most parents (80%, n = 4) had previously taken their child to the doctor for ear or hearing concerns. The content of the domains explored during the qualitative interview is summarized in Table 1.

TABLE 1.

Summary of major themes and implications for intervention adaptation stakeholder perspectives on current hearing screening, potential changes, elements of the intervention in Alaska, and subsequent adaptations

Themes Related to School-Based Hearing Screening Programs	Stakeholders Perspectives of Current School Hearing Screening Challenges, Barriers, Facilitators	Stakeholders’ Perspectives on a Potential Telehealth Hearing Screening Program	Core Elements of Successful Intervention in Rural Alaska	Proposed Intervention Design in Kentucky
Coordination	Time-consuming county-wide coordination Labor-intensive administration	Embrace best practices across all counties. Well-trained staff Efficient training and ample support	Coordination of educational screening program with tribal health system Coordinated screening of children upon school entry	Coordination of educational screening program with state-funded health system Cloud-based integration of enrollment data and screening results
Testing techniques and protocols	Variation of testing techniques Variation of testing protocols Time-consuming	Time-efficient testing Thoughtful design and protocols Comprehensive tests	OAE evaluation of hearing with tympanometry User-friendly design	Automated tablet-based testing Clarity of results Cloud-based storage of results
Communication	Challenges in communication of screening results to parents Challenges in counseling	Telehealth is viewed as a strength. Use of school-based communication methods (texts)	Communication of results with follow-up plan with tribal health clinic Communication of results in writing to parents	Infinite Campus communication of test results to parents and to the Department of Education Tracking system of screening results
Follow-up with healthcare professional	Schools do not arrange referrals Some children lack PCP’s Lack of audiologists Uncertain where to pursue care	Privacy concerns Coordination of recommendations and results between parents, schools, and providers Referrals made to the appropriate providers	School coordination of telehealth visit with hearing specialist in tribal health clinic Recommendations for further care based on telehealth visit	Enhanced screening options within the school Asynchronous review of screening data by regional audiologist School facilitated audiology appointments

Domain 1—Experience With Childhood Hearing Loss and School-Based Hearing Screening in Rural Communities

Each interview represented a distinct viewpoint pertaining to exposure to and experience with childhood hearing loss and the evaluation and management of hearing loss. Themes and quotations are described earlier by the informant group.

Educational Staff •

While some participants knew only a few children in their district with hearing loss and were unfamiliar with hearing loss treatment, in general, participants acknowledged the value and importance of early screening and management in their rural communities to avoid long-term impacts. Most participants were aware of the challenges faced by children with hearing loss in their school system or had personal experiences with hearing loss.

“You really going to need to get this checked out, because if we don’t they could have hearing loss down the road.”

(Educator #18)

It was clear from informants that current protocols for hearing processes varied, although most described mass screening of students in pre-kindergarten and kindergarten using a portable audiometer before or just after the start of the school year. There was more variation in the time frame and protocols for repeat screens and referrals. One informant described doing a more thorough evaluation if students failed the screen rather than repeating or referring right away:

“If I have a child that has a hearing deficit that’s never had one before, then I get my otoscope and look in their ears, look for impacted, wax, look and see if they have an ear infection. Look and see if they have fluid, things like that, things that would interfere with a normal hearing tone.”

(Educator #19)

The lack of local hearing health care professionals creates a number of challenges for educators. The educational staff does not have clarity on where to refer students and what type of information would be useful to hearing health care professionals. One educational staff participant was concerned about the ability of children to obtain timely follow-up:

“We, first we don’t have an audiologist close. Our closest audiologists would probably be…like 45 minutes from here. And they are…not there every day.”

(Educator #10)

Parents •

All parents who participated reported having hearing loss themselves or a child with hearing loss. While two of the five parents/guardians were unfamiliar with hearing screening within the school system, the other three described the process of detecting and diagnosing hearing loss for their children as “very time consuming and very stressful.” One parent described the desire to stay involved and engaged in hearing-related care within the school system.

“I still want to be a part of what’s going on and I still wanna know what’s being done with my child. What’s being found out, what’s being said and what’s the game plan.”

(Parent #4)

Regional Healthcare Providers •

Audiologist informants revealed that in their practices, they generally receive most hearing screening referrals from pediatricians rather than from schools, with many children being diagnosed with hearing loss at a significant delay from the time of onset. Audiologists expressed that many referrals were chronic, rather than acute in nature by the time children were receiving diagnostic evaluation. Audiologists also noted a frequent lack of clinical information and the screening results among referred patients, as well as a high no-show rate.

“But I would say that’s the biggest thing is getting them to the appointments, no shows because you know our pediatric no-show rate is higher than our adult no show rate.”

(Healthcare provider #6)

Audiologist noted that the Medicaid requirement for pediatrician referrals created a substantial barrier to school-based audiology care. One noted previously conducting hearing screening at local elementary schools, however the audiologist’s services were suspended because it was not a billable service for the regional hearing clinic.

The pediatrician participants reported that they do not hear from schools directly but are made aware of screening results from families.

“The referrals have become very far and in between…the referral through the patient to me – so if they don’t show up, I don’t know about it.”

(Healthcare provider #16)

There was concern raised that the school hearing screening system has been inconsistent in recent years. Pediatricians also reported that follow-up for hearing care is poor, mostly due to transportation issues. Furthermore, one of the pediatricians stated that they were unaware of any audiologists or otolaryngologists in their local area.

Domain 2—Preferences and Perspectives on Core Components of Childhood Hearing Screening

Each interview represented a distinct viewpoint pertaining to each of the components of screening, which include school-based testing, communication of information with educational staff/parents/providers, and integration of new technology and telemedicine. Themes and quotations are described below. A summary of barriers facing the coordination of follow-up care after failed screening is depicted in Figure 3.

Fig. 3.

Barriers to hearing evaluation and diagnosis barriers to diagnostic evaluation following a “refer” result from annual hearing screening, with the goal being timely evaluation by a regional audiologist for comprehensive testing and diagnosis.

School-Based Testing •

Educational staff.

Screenings were challenging due to limited staff, time, and quiet space to conduct the screening tests. In addition, many staff noted using “ancient” and outdated screening equipment with no budgetary plan for equipment updates.

“I think probably just, you know, the time to do everything and having, you know, staff available to do everything. Last year we had we had a staffing shortage, we didn’t have substitutes or anything like that, so it was difficult…”

(Educator #10)

Parents.

Parents also described various experiences with limitations of staff time for hearing screenings in their schools, which limited their trust in the school to properly screen and manage hearing loss.

“I think it’s kind of just a drive-through screening, you know. “You could hear, move on’.”

(Parent #1)

In terms of changes to the current systems, parents were concerned that making big changes when the current screening program was so under-resourced would be challenging. Importantly, some parents perceived a general lack of concern for hearing loss among staff in their child’s school, which may also limit the successful implementation of a new program.

“I don’t think it it’s the lack of responsibility or whatever, but I think it’s the knowledge they just don’t understand that there’s a need for that. You know that there may be fluid behind the ears and it’s not selective hearing that they’re just ignoring what they’re saying, that kids just actually may not be able to hear no more.”

(Parent #5)

Regional healthcare providers.

Similar to parents, healthcare participants also perceived that hearing screening was not prioritized or consistently performed by school staff, and that equipment and training procedures were outdated and did not appropriately identify middle ear disease:

“Well, I guess the first of them [my concerns] is to work through and enlisting the support of the school… I don’t know how open they [school nurses] are to take on additional things to do.”

(Healthcare provider #16)

Communication of Screening Results and Referrals Between Schools, Parents, Primary Providers, and Specialists •

Educational staff.

The participants reported significant challenges in communicating screening results and recommendations. Educational staff were concerned that the screening results were sent out, but there was doubt as to whether the parents understood the results or the next steps. Letters were the primary means of communication for “pass” results.

“We just send a letter home after we contact them by phone and then it’s kind of up to the parent to take them wherever they want to go.”

(Educator #1)

“[the] report for the test would be sent home but they didn’t really understand the details of it, so I think that would be one of the challenges is just breaking it down for the parents… I mean a lot of times messages don’t get relayed. They kind of get lost in the transmission.”

(Educator #18)

Several educator participants expressed frustrations in trying to communicate results with parents and educating them on the importance of hearing.

“But for me it’s getting parents on board to check. You know, because a lot of times they will be like, “Oh they just have selective hearing loss” or “they hear what they want to hear.”

(Educator #10)

In addition, participants expressed their desire for an integrated communication method or protocol.

“I would like to see a way that we could easily connect the kid with [a hearing clinic] or an audiologist, and not have a bunch of go-betweens with the parents. But just get permission and let us roll with it. And just, you know, integrating processes.”

(Educator #5)

However, limitations in information exchange complicate communications.

“We can’t share any information with anyone unless the parent gives us permission to share that… if the parent wants us to share things we or if they want to take something to their medical provider, we make copies available of any reports or tests we have done. We very rarely speak in person to a physician.”

(Educator #1)

Parents.

While parents expressed a desire to stay informed on health-related information of their child, they expressed their dislike for letters as a means of communication.

“To me, a letter is not the best way. I feel like stuff can be really miscommunicated in letters, as far as you know, you can’t ask a question back in a letter, you know.”

(Parent #1)

One parent recommended using an electronic application as the platform to communicate health-related information.

“For me personally, text or through the Remind app, because it also comes through as a text. That is the best way, because that way if I am at work I can check it quickly and know what’s going on. Sometimes, especially when I’m at work, I can’t answer my phone. But they allow me to keep my phone on me so, and I keep a smart watch. So of course, if you know if something comes through, then I at least can click on it and read it real quick, and that way if I need to get ahold of them, or if I need to call them or something I can, you know, let my boss know and step off the floor for a minute and go see what’s going on.”

(Parent #3)

Regional healthcare providers.

Audiologists reported having direct communication with educational staff (mostly teachers of the deaf and hard of hearing) and phone contact or e-mails with families of children who had been previously referred and evaluated. There was some concern expressed regarding the security and consistency of communication through these means.

“I mean, I guess the biggest thing you need to think of is like consistency. You need contact information that’s going to be consistent right. So if the phone number is going to change consistently, Obviously, you don’t want to be trying to communicate via phone, email is best always. So, if they if they will give an email or make it, you know, kind of a requirement because everybody has an email. And if they say they don’t then you can ask them well, do you have Facebook and they’re like, yeah. Like, then you have an email, address. But it’s, you know, email is that I think one of the best ways.”

(Healthcare provider #6)

Pediatricians reported a desire to have the school lead the communication efforts but want to lead in monitoring of subsequent follow-up appointments.

“The school has the most recent contact details of the parents, because we also live in an environment where phone numbers and addresses that change very rapidly, but usually the school is the one that has it because each time the child is going to school, they have more current information”

(Healthcare provider #16)

Integration of New Technology and Telemedicine Into the Screening Program •

Educational staff.

Informants reported that connecting children with specialists would be very helpful. Some educational staff reported prior use of telemedicine services in their schools (e.g., to provide mental health services and speech therapy). Educational staff suggested that health information regarding hearing screening could be stored and mobilized through a cloud-based repository and information exchange and messaging system called Infinite Campus (Blaine, MN), which is currently being used throughout the country.

“When I think of the dashboard, I think of that being between the school system and maybe the [specialty clinic] where the referral process… I think they definitely need to be provided information and help us in planning care and services.”

(Educator #11)

The major concerns raised by educational staff were centered around time constraints of any additional testing, limited available staff and expertise, the need for parental consent prior to additional testing, and the ability of a parent to participate in a live telemedicine encounter.

“We can’t share any information with anyone unless the parent gives us permission to share that… I think that you will have a difficult time getting parents to answer the phone, they will have a difficult time getting parents to log on to a telehealth, visit, even from home to participate.”

(Educator #1)

One educator suggested that additional consents for enhanced screening and telemedicine information exchange could be included with enrollment packets that parents receive and sign at the beginning of the year.

“If you want something signed [it] definitely needs to be in enrollment packets… parents and grandparents are just so resistant to anything new, which is why, you know, I stress the importance of, you know, if you all have a form just kind of getting it in that enrollment.”

(Educator #2)

Parents.

Incorporation of new components of hearing screening data that could be captured in schools and communicated with healthcare providers was viewed favorably by parents. Parents face significant travel distances to take their child to an audiologist, which typically involves missing school for their child and work for the parent. If new technology is used in hearing screening, parents expressed a desire to stay informed about the process, interpretation of the results, and the next steps. The types and purposes of new technology incorporated into schools are not always communicated well with parents, and there is some skepticism regarding technology.

“But technology in the school, the school system seems to think that everybody is on board with that and they’re not.”

(Parent #5)

Parents requested that enhanced screening data and communication be shared through an existing program with the schools. Considering the potential of live interaction of a student with an audiologist, one parent stated their desire to be present.

“I would just like to be present for the telehealth communication and to give me the option to join the Zoom. [I] would like to actually like attend the appointment and interact with the audiologist.”

(Parent #4)

Regional healthcare providers.

Incorporation of new technology in schools to capture health-related data and communicate those results was viewed favorably by the healthcare participants. There was an expressed desire for technology to improve health information by making “the process be as automated as possible” (Healthcare provider #16). The use of app-based health information exchange and technology-driven care delivery is increasing among this rural population.

“The health portal is still, it’s a growing phenomenon”

(Healthcare provider #16).

Providers reported that while telemedicine with patients in their homes is complicated by lack of understanding and the lack of internet connectivity, the school would be an optimal location for telemedicine healthcare information exchange. According to one audiologist, using newer technology and communicating those results to an audiologist for review could improve the efficiency of care and ensure that children are referred to the right specialist.

“I think the more you can [improve] the screening at the school, the better because you have some kids who aren’t going to participate. And some kids who might not pass their screening, but they have flat tymps [tympanogram]. So maybe, and that is a different referral, right? That’s not a referral to an audiologist, that’s a referral to an ENT. So, and that can save time, because we get those referrals too, where they didn’t pass the screening, and then we’re seeing them, and they’ve got super red eardrums and flat tymps [tympanogram].”

(Healthcare provider #6)

For an audiologist to review hearing screening data captured and transmitted through new technology and telemedicine, it could take a considerable amount of time and could cause delays in care.

“I mean, I guess depending on the volume of kids that it would be, would be my biggest concern… you might have 20 kids that don’t pass the screening, for whatever reason. And then, you know, making sure that you get [to them], because you don’t want them waiting on services, or anything… you would have to have like your outside clinics agree to setting aside a dedicated amount of time every week to just reviewing these results.”

(Healthcare provider #6)

DISCUSSION

Pragmatic community-based research to address disparities in access to hearing healthcare is limited. The overall goal of this research is to address pediatric hearing healthcare inequities in rural communities by adapting an evidence-based telemedicine hearing screening intervention (Emmett et al. 2022) using the ADAPT-ITT model. As the first phase of the ADAPT-ITT model, this study focused on assessing perspectives and preferences of educational staff, parents, and regional healthcare providers on the problem of hearing healthcare disparities for elementary-aged families in rural Kentucky, and the proposed intervention. Across the informant groups, constructed themes suggest a clear need to improve the context under which hearing healthcare is addressed in rural schools.

Consistent themes arose across the perspectives that were shared throughout the interview process. There is a clear need for improvements in school-based hearing screening to facilitate efficient, comprehensive, and accurate data collection. This health information must then be consistently communicated to parents and hearing healthcare specialists. Appropriate staffing and time for proper screening were widely expressed needs, which are necessary for the consistent delivery of screening results to healthcare professionals and parents. Staffing and time constraints likely represent root causes for the deprioritization of hearing screening in elementary schools across Kentucky. Modifications are needed to improve the referral process from rural school screening programs to regional audiology clinics through access to telehealth-based audiology (Govender 2022). The referral process should ensure that children who are referred from screening see the correct provider in a timely manner and that the recommendations from a specialist are communicated back to both educational staff and primary care providers.

Systematic adaptation of an evidence-based intervention is important for both successful implementation and health equity. Without understanding and accommodating regional needs, resources could potentially be wasted and exacerbate existing disparities. These findings, as defined by the Assessment ADAPT-ITT phase, will inform adaptations of a program for school-based enhanced hearing screening and telehealth specialty follow-up for deployment in rural Kentucky schools. Pragmatic clinical trials are uncommon in hearing research, and stakeholder-driven intervention adaptation is underutilized. While the use application of the ADAPT-ITT model is novel in this field, this model has been successfully utilized to adapt a variety of public health interventions in the HIV and substance use fields, to improve the acceptability, appropriateness, and the feasibility of the intervention in new delivery contexts and populations across the world (Escoffery et al. 2019; Giang et al. 2023). Like other applications of the ADAPT-ITT model, we engaged community members in the Assessment phase, and will continue to elicit their perspectives to guide adaptations to intervention protocols throughout the course of this study (Cavanaugh & Wismar 2022).

Innovative opportunities and potential challenges lie ahead for the adaptation of a school-based enhanced hearing screening and telehealth specialty follow-up program based on these perspectives and preferences of community members (Ramkumar et al. 2023). Educational health programs have evolved over time to focus on community health, health education, and coordination of care (North & Dooley 2020), thus, school-based hearing screening has immense potential to promote hearing health. Changes to school health programs require multi-level engagement through the student, parent, educational staff, county superintendent, school board, and state leadership. Proposed changes must also consider the specific population needs, community partnerships, functional and financial sustainability, and impacts on health and healthcare utilization (Akilan et al. 2014). Based on our research findings, it is essential to prioritize improving communication in hearing screening and subsequent follow-up care. Innovative development and adaptation of a central communication method and platform of the screening program (prescreening schedule and education, screening results, and follow-up recommendations) could help bridge the gaps in care. A school-based enhanced hearing screening and telehealth specialty follow-up program may facilitate data sharing and communication between school personnel, regional healthcare providers, and parents. Multiple adaptations of the Hearing Norton Sound trial will be necessary, based on this research. Instead of using a tribal health system, it will be necessary to coordinate screening between the school system and a state-funded health system with sharing of the information across health and educational systems. Based on the perspectives of the Appalachian participants, it will be necessary to change testing techniques and protocols to capture data on hearing screening electronically and store this data in a cloud-based system. Regarding communication preferences, the Appalachian participants suggested using the existing educational platform, Infinite Campus (Blaine, MN), to store and share information, which is different from the Tribal health system. Lastly, this study identified an expressed preference and desire for enhanced screening, testing, and appointment coordination with audiology to occur within the school setting and not within a healthcare facility, which the Hearing Norton Sound trial utilized. These adaptations will proceed using the ADAPT-ITT model.

In spite of the value of these data, this study has some limitations that are worth considering. This study is limited by the subjectivity and bias of the research team in collecting and interpreting the data from stakeholders’ perspectives. The snowball sample method may have overlooked other perspectives of other members of the community. The use of the CAB was helpful in assisting us in identifying and recruiting key stakeholders from across the 14 counties involved in the study. While a larger sample size may have afforded a wider range of input, we concluded saturation was reached based on the recurrent themes presented by participants. Regardless of the focus on rural educational-based hearing screening programs, these findings may not be widely generalizable to rural regions in other states or to urban regions. In addition, we note that the participants were largely white and do not necessarily represent the perspectives of Appalachians of color. However, this study can benefit the broader hearing research field as it represents a model for how to initiate community-engaged intervention adaptation when it is studied in another context or population.

CONCLUSION

This study represents utilization of the ADAPT-ITT model to assess the perspectives and preferences of key stakeholders (Assessment phase) regarding: (1) experience with childhood hearing loss, screening, and follow-up process, and (2) components of childhood hearing screening (school-based screening, exchange of information with educational staff/parents/providers, and integration of new technology and telemedicine). This Assessment was conducted to identify the status of school-based hearing screening and potential barriers to implementation of an evidence-based telemedicine hearing screening in elementary schools of the Appalachian region. The participants reported concerns about the pervasive lack of communication from all perspectives regarding hearing screening, along with the lack of coordination and access to care following screening. Furthermore, there is a need for time-efficient, clinically useful, and accurate data collection during the screening process. Important implications and opportunities drawn from these data will be to adapt a school-based enhanced hearing screening and telehealth specialty follow-up program that can integrate care coordination into the screening process, provide clear yet secure communication to parents, educational staff, and regional healthcare providers, and collect comprehensive and timely collection of screening data. The ADAPT-ITT model is a valuable framework that engages key community stakeholders early in the process in order to guide culturally grounded adaptations of research interventions.

Supplementary Material

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