Interventional Audiology to Address Hearing Health Care Disparities: Oyendo Bien Pilot Study

Abstract

Interventional audiology, specifically community-based outreach, can connect people with the hearing health care system. Community-based participatory research methods were applied in two phases of research to: (1) investigate the needs of families affected by hearing loss in a rural Arizona community on the U.S.–Mexico border; and (2) evaluate an outreach program on hearing health. The needs assessment included interviews with persons with hearing loss and focus groups with family members and the greater community. The needs assessment revealed that despite perceived severity of hearing loss, help-seeking for audiologic care was limited due to barriers, stigma, and low self-efficacy. Results informed development of a community-based pilot study conducted as part of an academic-community partnership between audiology, public health, and community health workers of a federally qualified health center. An outreach program, Oyendo Bien (hearing wellness), a 5-week, Spanish-language health education program for older adults (n = 21) incorporated communication strategies and behavioral change techniques. Postprogram focus groups revealed increased self-efficacy and decreased stigma. After 1 year, 7 of 9 participants with hearing loss contacted for follow-up had sought some form of hearing-related health care. Future research should further investigate interventional audiology approaches to address health disparities.

Learning Outcomes: As a result of this activity, the participant will be able to (1) apply the Health Belief Model in assessing community needs related to hearing loss and; (2) describe the potential contribution of community health workers (promotoras) to health promotion and interventional audiology outreach.

Managing hearing loss is important for the well-being of older adults, and there is increasing understanding of its potential connections to health.¹ However, only a small proportion of the adults with hearing loss living in the United States access hearing health care.^{1 2 3} An interventional audiology approach to educating communities through outreach and community-based health promotion programs could raise general awareness of hearing health care, potentially decreasing the time between recognition of hearing loss and seeking audiologic care.^{4 5} The main contribution of the current study is to develop and evaluate an interventional audiology approach that could also support achieving goals in health equity and reducing disparities in access to hearing health care.

Among adults over the age of 50 years, the prevalence of hearing loss doubles with each age decade, yet utilization of hearing health care services lags at a much slower rate.^{1 2} There are multiple and complex potential reasons why there is currently such a large disconnect between the number of people with hearing loss and the number seeking care.^{1 5 6 7 8 9 10} Epidemiologic research has demonstrated that health care disparities related to race/ethnicity and socioeconomic factors contribute to disparities in access to care.^{3 11 12 13 14} For example, there are lower estimates of hearing aid use among Hispanic/Latino and African American older adults as compared with non-Hispanic white older adults.^{11 12} The influences of disparities-related socioeconomic variables such as education and poverty-to-income ratio, are also associated with access to care and in some studies have been confounded with race/ethnicity.^{12 13} More research is needed to better understand the unique needs and concerns of underserved adults for hearing health care.

One effective public health approach for reaching underserved populations is to conduct health promotion and health education outreach. Community health workers (CHWs), or promotoras de salud in the Hispanic/Latino community, are members of the public health workforce who develop linkages between the health care system and the community.¹⁵ In other areas of health promotion, CHW interventions have been successful in improving health care access and management of chronic health conditions.^{16 17 18 19} CHWs have served as outreach liaisons targeting underserved or disadvantaged populations to facilitate access to services and improve the quality and cultural competence of service delivery.^{16 17 18 19} Since the 1980s, CHWs in the U.S.–Mexico border region have helped to increase access to health care and health education, encouraged community empowerment, improved quality of care and compliance with care, reduced costs, improved health status, promoted behavior change, and helped people manage chronic diseases.¹⁸

Culture is another important influence on health and help-seeking, though study in relation to hearing health care is more limited.^{8 20} Cultural, situational, and interpersonal factors all may shape the beliefs that contribute to health-related behaviors. The Health Belief Model provides a framework for studying the level of individual factors that impact health behavior that has been recently applied within audiology.²¹ Saunders and colleagues have proposed that the multiple factors that contribute to the uptake of hearing rehabilitation fit within the conceptual framework of the Health Belief Model.²² These health belief areas include one's definition of health and perceived-health status, perceived susceptibility to hearing loss (or other health conditions), perceived benefits of seeking health care, perceived barriers to health care, and perceived self-efficacy in managing health, which interact with cues to action that lead to behavior change or seeking health care. However, to date there has been limited research on the influence of culture on health beliefs related to help-seeking and management of hearing loss.

The current study was an evolution of an academic-community collaboration between audiology, public health, and a rural federally qualified health center (FQHC) to increase community engagement on hearing and to develop a culturally relevant hearing health education outreach program for Hispanic/Latino older adults.²³ The CHWs involved in health promotion activities at the FQHC received specialized training about hearing loss and communicating effectively with individuals and families with hearing loss.²⁴ In the current research, CHWs served as cultural brokers and community health educators. Their role was inspired in part by the Peer Mentor Training Certificate Program for aural rehabilitation developed at Gallaudet University.²⁵ However, unlike the Peer Mentor Training Program, the CHWs did not themselves have hearing loss. Instead, their knowledge of their border community informed the development and cultural adaptation of a hearing health outreach program to be culturally and linguistically relevant for Spanish-speaking Hispanic/Latino older adults. Some CHWs may differ from other lay community members by having prior work-related experience in facilitating support groups and health education classes in the community.

To achieve the goal of developing a culturally relevant hearing health outreach program, we conducted a needs assessment around the Health Belief Model to gain understanding of health beliefs related to hearing loss and access to care in a rural, predominantly Hispanic/Latino community. This knowledge was then applied to the development of an outreach program to educate community members on hearing health and promote self-efficacy to manage hearing loss. The research described here is part of a larger, ongoing 5-year study funded by the National Institute on Deafness and Communication Disorders to evaluate the effectiveness of an interventional audiology CHW outreach program on hearing loss to reduce disparities and improve quality of life outcomes. In this study, we report on community-based participatory research conducted in two phases:

• Phase 1: Community needs assessment to investigate the unmet needs of families affected by hearing loss in a U.S.–Mexico border community.

• Phase 2: Qualitative analysis of focus groups following a community-based program on hearing health (Oyendo Bien, “hearing wellness”).

Methods

Community-Based Participatory Research Design

Community-based participatory research (CBPR) is a colearning process that engages researchers and community members in the development of knowledge related to an issue of concern to the community.²⁶ Involvement of community in the initial stages of research ensures that the issue under study is relevant to the community, and the investment of community members in the research question in turn contributes to the quality of data collection and interpretation.²⁷ In this study, the rural FQHC had a long-standing relationship with the research institution, thus increasing the opportunity for research findings to be sustained through community-based programming. Initial conversations with the FQHC revealed that within the clinical setting, age-related hearing loss was viewed more as a predetermined condition, rather than a problem with the potential for intervention. A community needs assessment was essential as a first step to develop an understanding of the extent of hearing loss and how it affected people's lives in the community, as well as to determine community interest in an interventional audiology program. Fig. 1 provides an overview of the two phases of the CBPR process. Phase 1 included the community needs assessment around the issues of hearing loss, communication, health and well-being, and the iterative development of the pilot outreach program (March 2014 to January 2015). Phase 2 included implementation of two pilot hearing health education and peer support groups in the community (February to May 2015) and subsequent qualitative evaluation by focus groups. One-year postprogram outcomes also were gathered via phone interview (June 2016). The research procedures were approved by the Institutional Review Board at The University of Arizona and all participants provided informed consent for the study procedures.

Figure 1.

Flow diagram illustrating the phased development and implementation of the pilot Oyendo Bien community-based program conducted in collaboration between audiology, public health, and bilingual (English-Spanish) community health worker (or Promotora) staff of the Health and Wellness department of a federally qualified community health center in rural Arizona.

Setting

Santa Cruz County is located on the U.S.–Mexico border between Arizona and the Mexican State of Sonora. With a population that is 95% Hispanic, the culture is highly influenced by their Mexican neighbors. Approximately 14.9% of the population is over the age of 65 years.²⁸ The FQHC and research partner is the major health care organization in the county, providing medical, dental, and preventive care to more than 22,000 patients. The Health and Wellness Department has 49 staff members, the majority of whom are Mexican American (93%) and bilingual in English and Spanish (95%). The CHWs are the foundation of the health promotion programming at the health center. As members of the community who are trained in a set of core competencies focused on providing community health outreach, support, and education, the CHWs were also uniquely positioned to engage community members in research efforts. At the time of the project, there were no audiologists who lived and worked in the community.

Procedures

As a first step in developing relationships within the community around hearing loss, the research project provided free hearing screenings on two separate occasions. The CHWs invited individuals to the screenings from their health promotion and diabetes self-management classes as well as by word of mouth in the community and health center. The screenings were held in the Mexican consulate where the CHWs had already established a presence in health promotion. Those identified with hearing loss based on results from the screening were referred to their primary care physician and audiology for follow-up.

Phase 1: Community Needs Assessment

We used the hearing screenings as a springboard to recruit participants for the needs assessment (April to June 2014), which included five focus groups with community members (n = 47), interviews with people with hearing loss (n = 20), and three focus groups with family members (n = 29). The questions in the focus groups and the interviews were complementary and sought to explore perceptions and experiences of hearing loss within the specific context of the community and the domains of the Health Belief Model. The community assessment yielded a rich dataset in which both experiences and perceptions of hearing loss were expressed from a variety of perspectives; these have also been previously explored within the Socio-ecological Model and reported elsewhere.²³

Intervention Development

The Oyendo Bien program used a group intervention model that was a Spanish-language, Mexican American cultural adaptation of an ongoing group audiologic rehabilitation program based in Tucson, Arizona (“Living WELL with Hearing Loss” at The University of Arizona Hearing Clinic²⁹). Intervention development followed an iterative process shaped by knowledge gained from the needs assessment, the CHWs, and a focus group of program participants held between the first and second pilot groups. The Oyendo Bien program prioritized two intervention targets. The first objective was to improve empowerment to manage hearing loss as evidenced by an increase in self-efficacy and advocacy behaviors to address its chronic effects on communication and quality of life. The second program objective was to improve family communication behaviors to create a more supportive communication environment for the person with hearing loss and communication partner. The content developed for the program included information drawn from and inspired by didactic materials for audiologic rehabilitation.^{30 31 32 33} The group intervention model allowed for incorporating behavior change techniques as classified using the behavior change taxonomy v1³⁴ and specific to addressing development of self-efficacy.^{35 36} The language, activities, and examples were tailored for appropriateness in the cultural, rural, and FQHC contexts based on input from the community partners. Program content was adapted for facilitation by nonclinical health educators (trained CHWs²⁴).

Phase 2: Program Delivery

The CHWs recruited 21 people to participate in the pilot Oyendo Bien groups held in February to May, 2015 (pilot 1: n = 10; 5 persons with hearing loss, 5 communication partners; pilot 2: n = 11; 5 persons with hearing loss, 6 communication partners). The CHWs had previously made contact with the participants through other health promotion programs offered at the FQHC. Individuals who self-reported hearing loss were recruited to attend the program with a frequent communication partner (e.g., spouse, family member, or friend). Members of the research team conducted an intake assessment with each participant 1 week prior to the program by face-to-face interview in Spanish. Audiologists or supervised Doctor of Audiology graduate students conducted hearing testing and provided individualized counseling on assessment results and recommendations in Spanish, including whether the individual qualified for enrollment in the study. Hearing tests were completed using a screening audiometer.³⁷ Following a brief case history and otoscopy, the testing was completed in a quiet room with environmental noise levels not exceeding American National Standards Institute recommendations for testing as verified with a sound level meter.³⁸

Hearing loss for the purpose of eligibility and enrollment into the study was defined as an average of air conduction thresholds at 1, 2, and 4 kHz greater than 25-dB hearing loss. The group mean audiogram of participants in the pilot programs is shown in Fig. 2. All participants who self-identified as having hearing loss during recruitment to the programs met this audiometric definition bilaterally. Among the 11 communication partners who enrolled, 8 individuals were available for hearing testing, and they also met the criteria for definition of hearing loss in both ears (though on average, had a milder degree of loss, and most did not self-report hearing loss).

Figure 2.

Average audiogram of participants in the pilot Oyendo Bien community-based outreach programs held in Santa Cruz County, Arizona from March to May, 2015. The solid lines correspond to the average audiogram for clients (±1 standard deviation in gray solid lines) and the dashed lines correspond to the average audiogram for communication partners (±1 standard deviation in gray dashed lines).

In the 5-week Oyendo Bien programs, CHWs facilitated interactive group sessions on basic hearing health education and facilitated interactive discussions among group members to promote peer support. Training for the CHWs addressed specific health promotion content on hearing loss and its management as well as specific skills in group facilitation and communication access for persons with hearing loss.²⁴ To enhance communication access in the group setting, the facilitators each used microphones and a pass-around microphone for participants connected to a linked sound field and individual FM headsets. For the purpose of monitoring the feasibility and fidelity of the pilot programs reported here, audiologists were also present at all sessions. The audiology staff conducted a debriefing with the CHWs after each session where they provided feedback and guidance to the CHWs on communicating effectively with adults with hearing loss.

Postprogram Evaluation

Focus groups were held with participants (those with hearing loss and their communication partners) after each pilot program, 2 weeks following the last class. Focus group questions explored changes that had occurred in the lives of participants since attending the program, what they felt had been the most impactful information or activity in the program, and specifically how communication had been affected by their participation in the program. Open-ended questions also were asked of program participants on the immediate and longitudinal outcomes questionnaires. One year following the pilot programs, the participants were contacted for short interviews addressing similar questions on how their communication and quality of life had been affected by program participation as well as a question on follow-up utilization of health care related to hearing loss. The follow-up interviews were conducted either in person or by phone, depending on the participant's preference.

Analysis

Audio recordings of the interviews and focus groups were transcribed verbatim in Spanish. Two members of the research team coded the qualitative data from both the needs assessment and postprogram focus groups in Spanish based on the constructs of the Health Belief Model using N Vivo (QSR International, Melbourne) software. The full research team reviewed the data and came to consensus regarding the definitions of each construct within the experiences of hearing loss in this population. As an example, previous research on the Health Belief Model predefined the construct “severity” as the extent to which respondents perceived that hearing loss negatively impacted daily activities, personal relationships, and job performance.²² In the focus groups, participants expressed severity in terms of the physical and emotional impact of hearing loss, as isolation, desperation, or anger. Using the refined definitions, the original researchers recoded the data to achieve an interrater reliability, or a percentage of common agreement, of at least 80%. Translations to English were completed for the purpose of disseminating the results.

Results

Phase 1: Community Needs Assessment

Perceived Severity

Participants described the severity of living with hearing loss as extensive, from gradual social withdrawal to ensuing emotional impact. Participants said they preferred to spend time alone, explaining that “it is embarrassing to misunderstand people” and that they “don't like being called sordo (deaf).” They also felt that the hearing loss had impacted their personality and their self-esteem. Family and friends agreed that people with hearing loss isolate themselves and become depressed. In some cases, they felt their loved ones had become irritable, and that “having to depend on others changes their character.” Participants also expressed severity in terms of how others respond to their hearing loss, which directly impacts their relationships with others. One participant had trouble relating to his grandchildren because “kids have no patience with me” and another said that “people think I am angry because I talk loudly.” Those communicating with people with hearing loss reflected these difficulties, saying, “I don't like it when he yells at me” and “It's hard to live with people with hearing loss, you have to talk to them face to face and repeat yourself all the time.” Other specific concerns of family and friends related to hearing loss severity included concerns about safety in crossing the street or driving, as well as in understanding medical information in a medical doctor's appointment (“They tell the doctor they understand when in reality they didn't hear anything”).

Self-Efficacy

One interviewee with hearing loss described having felt glad to have had hearing testing to find out they have hearing loss so they could address it with their family (“Someday I will find a solution to this”). However, most others reported feeling ashamed or without a solution. One participant described not feeling confident to discuss hearing loss with the primary care physician (“Well, I did not tell the doctor because of course I feel the loss” and going on to describe its emotional impacts). Other participants with hearing loss reported acknowledging their hearing loss but not knowing what they can do about it. This lack of knowledge in some cases was viewed with resignation, (“What am I going to do?” and going on to explain there is not much they can do). From the perspective of family members, concepts related to self-efficacy included perceptions of confidence that treating hearing loss earlier would be better and confidence in the importance of prevention.

Perceived Barriers

Those with hearing loss felt that hearing aids were too expensive and unattainable because you have to pay cash. Family members and friends were more candid regarding the perceived barriers of hearing loss on their communication partner than those persons with hearing loss self-reporting the condition. However, the ways in which communication partners were more forthright and open about issues related to hearing loss were in their observations on behalf of their family members or friends rather than about how the issues affected them as individuals. Family members and friends pointed out that there is little in the way of community resources for hearing loss and that the price drives people to buy cheaper hearing aids or devices, which they reported then do not work. Family also expressed suspicion of dispensers of hearing aids and their desire to sell them a product. Although those with hearing loss described aging as a problem with no solution, communication partners felt that it operated as a barrier, saying that people are also reluctant to admit to hearing loss because it is a sign that they are getting older. Further, family and community members described that older people are less likely to seek help in general and the age of those with hearing loss makes it difficult to address the hearing loss directly with them. Family members saw stigma as a barrier; for women, vanity was identified as an issue (“Especially women don't want to be seen wearing hearing aids”), whereas among men as a point of pride (“not wanting to be seen with a weakness”). Other gender differences also emerged in discussion of emotional responses to hearing loss, with men expressing themselves through frustration and anger and women expressing themselves through sadness. The experience of shame and stigma then caused by hearing loss was specifically described as a barrier in that people would reportedly pretend they do not have a hearing loss or choose not to seek hearing health care advice from a doctor or specialist.

Culture

In addressing concepts such as perceived severity, self-efficacy, and barriers, culture is another important consideration in development of a community-based intervention. Several cultural considerations emerged in the needs assessment related to self-management of hearing loss. Persons with hearing loss and family members expressed the importance of Mexican cultural values related to the development and implementation of a potential hearing health program. The centrality of family in the Mexican culture was emphasized, including that “families are united, with many traditions.” A representative example of familismo, or placing the family's needs over the individual's needs, included many family members pitching in to buy a hearing aid. Likewise, the larger family's needs also could outweigh the needs of the individual with hearing loss. The involvement of extended families was important and common, with multiple family members attending medical and hearing care appointments together. Neighbors and friends took on the role of family for those individuals separated by great distances or widowed. Family cohesion, respect for older persons, and an expectation of closeness in personal relationships were also expressed as strong cultural values.

Additional examples of the interaction between socioeconomics, culture, and hearing health included the use of home remedies to address issues with hearing and “because there are no resources (for intervention), we have denial that there is a problem or not paying attention to it.” Others referred to hearing loss as an achievement of aging, representative of survival despite the odds and making it to a later stage of life. Hearing loss was viewed as a situation for which there was no improvement when other needs for food and shelter must be taken care of before hearing health care's out-of-pocket costs. The impact of the community's geographic location in rural Arizona on the border between the United States and Mexico also emerged through comments such as “the community is a mixture of two countries. People from Mexico think that their buying things in the United States is more reliable.” Others reported “(The community) is behind in technology,” and “(The community) is the point of reference and we don't look beyond it,” in discussion of seeking access to hearing health care.

Phase 2: Qualitative Analysis of Pilot Program Focus Groups

The postprogram focus group data were analyzed around the constructs of self-efficacy for individuals and communication partners as the cornerstone of the pilot program approach. Given that the questions directly addressed application of communication strategies, it is not surprising that most responses related to an increase in self-efficacy. What is notable, however, is how participants described their experiences in terms of mastery, modeling, and social persuasion, all factors related to self-efficacy. The three emergent themes were: (1) use of communication strategies; (2) increased confidence in managing hearing loss; and (3) social support engendered by participation in a group setting.

Theme 1. Communication Strategies

Both those with hearing loss and their communication partners reported that they were regularly implementing the communication strategies between themselves and with others. The most common strategy reported was to take steps to ensure that they were speaking face-to-face, either by touching the person on the shoulder or waiting until they came from the other room. Speechreading and using key words in asking clarifying questions also were reported as strategies, although less frequently. In the phase 1 needs assessment, respondents described using negative coping strategies to manage hearing loss that required the involvement of the communication partner. After the classes, they reported also directly telling people that they had hearing loss and instructing others to speak to them more slowly and loudly. Both those with hearing loss and their partners took ownership for informing and reminding other family members to use the communication strategies.

Theme 2. Increased Confidence

Overcoming embarrassment connected to having hearing loss was a major influence of the strategies on participants' expressed ability to manage hearing loss. One participant described the relief that was echoed by several other participants in saying: “One of the most important things for me was not being ashamed because of a little detail (hearing loss) that had us chained up.” This sentiment was also expressed as increased confidence to manage hearing loss, or mastery over the communication strategies. “It gives me more and more confidence talking with my friend and my neighbors. I started to use key words, look at them in the face, and, if they don't hear me, to touch them. At first, if I did it, it was timidly, thinking that the person was going to be annoyed or become inhibited, but now I have used this tool 100%.”

The relationship between mastering the communication strategies and self-confidence appeared to be symbiotic. Over the course of the classes, participants increased their confidence to practice the strategies, and as they practiced the strategies their self-confidence grew.

Theme 3. Group Identity and Social Support

The third theme can be understood as social persuasion, another factor associated with self-efficacy. Several members of the groups expressed the value of not only talking to other people who were challenged by hearing loss, but also collectively practicing and reporting back to the group on their use of the strategies. The groups appeared to have created a safe space in which individuals could express their feelings of stigma, shame, anger, and frustration, which then allowed them to more constructively engage in the communication strategies outside of the classes. One individual described his participation in the group as “the most meaningful thing in my life, learning to live with all these people with hearing loss, it is magnificent.” The extent of gratitude expressed by participants was clearly related to improvements in the quality of their relationships with others. One communication partner described the benefit this way:

“What's worked for me is when we go to a restaurant because we understand each other really well. Before we were fighting and I thought of leaving because he couldn't hear. But not anymore because I get his attention and don't talk to him until he is looking me in the face and I say, “You go to the buffet first.” We peacefully arrange things.”

Overall, the social support of others with hearing loss and feeling a sense of group identity emerged as an important change experienced following participation in the pilot group program. One of the participants with hearing loss described this as: “having more confidence with people . . . I have shared with them in these 5 weeks and now I feel very comfortable; we all learned from one another and now we are not ashamed that we can't hear. On the contrary, when we see each other in the street, I say look my friend with hearing loss that I met in that group.”

Health Care Utilization

Participants also reported having increased their skills in self-management for coping with the chronic effects of hearing loss and taking actions related to managing its effects on communication and health. At the time of the Oyendo Bien program, only 2 of 21 participants used hearing aids. The CHWs contacted participants ∼1 year after the end of the pilot groups (June, 2016) for brief phone interviews about their progress after the program. Outcomes were evaluated for 18 of 21 participants (1 deceased, 1 ill, 1 traveling) 1 year after the end of the pilot groups. The actions taken by participants in managing their hearing loss at 1 year following the program are summarized in Table 1. Overall, 11 of the 18 participants reported having taken some form of action in managing hearing loss, ranging from talking with family members (n = 10), to communicating with their primary care physician (n = 6), seeing an audiologist or otolaryngologist for specialty care (n = 5), as well as continuing use of amplification and increasing hours of daily use (n = 2) or obtaining amplification (n = 4). A greater number of individuals who self-reported hearing loss at the beginning of the program took next actions (n = 7) as compared with communication partners who took actions by follow-up at 1 year (n = 4).

Table 1. Summary of Actions Taken on Hearing Health by Participants at 1 Year after the Oyendo Bien Community-based Hearing Health Promotion Program^* .

Actions Taken†	1-y Outcomes
	Participants with Hearing Loss (n = 9)	Communication Partners (n = 9)
Did nothing	2	5
Talked to family	7	3
Discussed with primary care physician	5	1
Had an appointment with a specialist	3	2
Had a hearing test (not related to the program)	3	1
Continued use of hearing aid amplification‡	2	0
Obtained a new hearing aid or assistive device	4	0

^*Of those who self-identified with hearing loss, 9 of 10 participants were able to be contacted at 1 year (1 was deceased).

^†Note: participants could indicate having taken more than one action.

^‡Two participants wore hearing aids at the time of the Oyendo Bien program.

Discussion

This study aimed to develop an interventional audiology approach to address hearing health care disparities among Hispanic/Latino older adults living with hearing loss in a rural Arizona community on the U.S.–Mexico border. Interventional audiology has been proposed as an innovative way to bring audiology into community settings, where public health and personal adjustment counseling can be combined in a targeted way to meet the unmet needs of the population.^{4 39} In the program reported here, interventional audiology outreach was conducted through collaboration with CHWs within the health and wellness department of a rural FQHC. The overarching goals of the research were to address the lack of culture- and language-specific interventions for hearing loss among Hispanic/Latino adults and to contribute to a more accessible entry point to audiology care for families facing health disparities.

The first phase of research used a community-based participatory research design to understand the needs, resources, and concerns of rural, Spanish-speaking elders and their families, as well as the community strengths and barriers to help-seeking related to hearing loss. The community-engaged process illuminated factors that would potentially influence program delivery, including unmet needs and strengths, to tailor a program for health education and peer support in a format that would be accessible and acceptable to the community. Although devastating in terms of the negative emotional impacts of living with hearing loss without resources for intervention that were expressed in the interviews and focus groups, the perceived severity and barriers to help-seeking created clear opportunities in the development of the Oyendo Bien intervention program. Importantly, the starting point in this community was not to raise awareness of the presence of hearing loss and importance of hearing. Rather, it was to begin with acknowledgment of this issue and its value to the community, which shifted the focus of program content toward self-management and access to care opportunities. Incorporating these qualitative findings allowed for a client-centered approach in aligning the program to the perspectives of community members on help-seeking and rehabilitation.⁴⁰ In terms of theoretical implications, we found that the perception of severity of hearing loss was not enough to lead to help seeking in the face of not having resources, and perceptions of efficacy mitigated these perceptions of severity. Other researchers have observed that the component of severity alone in the Health Belief Model is not consistently predictive of behavior.⁴¹

Several key themes derived from the needs assessment informed the intervention development; specifically, needs around issues of low self- and family efficacy, community and family resources, as well as barriers in access to care. Existing perceptions in the community of the costs and limited options for care for hearing loss, including that cost of care would interact with quality of care, were important to recognize about the context of bringing interventional audiology into the community, particularly because the program was not focused on direct care related to providing amplification. However, all participants experienced the use of individual FM headsets during the program, which may have provided a form of mastery experience according to Bandura's social cognitive theory.^{35 36}

To increase the cultural relevance of the intervention, the qualitative data and the cultural expertise of the bilingual-bicultural CHWs then informed the selection of theory-based and practical strategies for the pilot program. Analogous to a growing body of community-based participatory research on health promotion, the CHWs facilitated a bridge between the researchers and community, which improved communication and contact with underserved families.^{42 43 44 45 46} With the input of the partners and community members, the program could thus be culturally and linguistically tailored for the rural population served by the health center.

The second phase of this study was to qualitatively evaluate the outcomes of the pilot Oyendo Bien program. Overall, the community was receptive to this interventional audiology program. The preliminary qualitative results underscore the importance of addressing family communication and quality of life within this population. In the short span of the 5-week program, participants transformed how they viewed communication in their relationships and life experiences with hearing loss, feeling greater confianza, or empowerment, to manage their hearing loss as individuals, families, and community members. Importantly, self-efficacy beliefs are theorized to be among the most important determinants of how much people will persevere when they face challenges or obstacles to behavioral change.³⁵ Our data are consistent with previous research on the positive contributions of social support and incorporating consideration of communication partners into audiologic interventions.^{47 48 49 50} Recognition of the severity of hearing loss accompanied by the availability of an actual resource for hearing loss seems to be an important step toward help-seeking and subsequent increased confidence and adjustment to disability, or self-efficacy. The pilot study outcomes are promising on the issue of access to care and reducing disparities in demonstrating that, out of this sample, a majority of clients reported improvements in communication and well-being as well as accessing the hearing health care system through primary care, specialty care, and self-management. Thus, the initial results of this interventional audiology approach warrant further research as a new entry point to the hearing health care system.

The results of this study fit within the literature showing beneficial effects of group aural rehabilitation programs.^{47 48 49 50 51 52} As characteristic of group intervention formats, participants identified the collaborative environment and opportunities to learn from peers with hearing loss as important components of the program. Gaining social support from their communication partners and other group members also contributed positively toward building participants' efficacy in managing hearing loss. Evidence from a community-based group aural rehabilitation program developed in Australia suggested that ∼10% of participants took actions such as getting a hearing aid, or wearing the aids they already had more often, after an education and peer support aural rehabilitation program.⁵² Within the health care utilization outcomes for the Oyendo Bien pilot study, it is interesting to note that help-seeking was relatively less among communication partners, who also had objective hearing loss but to a lesser degree than the clients. Reflecting back to the Health Belief Model (HBM), greater self-efficacy in the absence of perceived severity did not lead to help-seeking but rather the combination of perceived severity and self-efficacy catalyzed action among many clients. Current evidence suggests similar positive outcomes from hearing aids, hearing assistance technology, and communication programs as an initial form of management of hearing loss among adults.⁵³ Taken together with the present research among rural Mexican Americans, group audiologic rehabilitation programs show promise as a format for interventional audiology via community-based outreach.

As an interventional audiology approach, the program also benefitted from interprofessional collaborative practice and training opportunities for the Doctor of Audiology students to work with professionals in public health, community health and wellness, and translation studies. Based on research from other health care disciplines, these opportunities for professional development in communication, decision making, and collaborative competencies may positively impact students and build capacity for patient-centered and family-centered interprofessional collaboration within their future practice contexts.^{54 55 56 57} Training interprofessional collaborative practice is an emerging area of research within audiology with further study needed in evaluation of collaborative practice.^{58 59}

Our program development process may be relevant to other communities seeking to develop an interventional audiology approach that includes community-based outreach, interprofessional practice, and evaluation research. In terms of scale, the project as a pilot study was an intentionally small, yet imperative, step toward building trust and capacity for a health education program in a topic area (hearing) that was viewed as highly new to the health center.²³ Based on the outcomes of this research, we propose that an important aspect of future program development and training within community-based interventional audiology should be a process to define the community-clinical linkages between public health and audiology. Such a process would involve identifying local resources (both community based and within health care institutions), defining roles, and establishing collaborations between CHWs/promotoras and appropriate health care providers for referral, such as audiologists, primary care physicians, as well as other specialists.

To build a bridge between the community and the health care system requires both engineering and supports, identifying where to connect community members with appropriate services. Recent case studies and reviews of implementation science literature have suggested that a potential barrier to success for new CHW programs can be inadequate connections to clinicians/health care delivery and poorly defined roles.^{60 61 62} Future efforts in sustaining this program and others in interventional audiology will rely on expanding training opportunities, interprofessional collaboration, and identifying mechanisms for financial support.