Feasibility of Community Health Workers as Teleaudiology Patient-site Facilitators: A Multilevel Training Study

Abstract

Objective:

We evaluated the feasibility of a multi-level teleaudiology patient-site facilitator training program for Community Health Workers (CHWs) at a partnering health center in southern Arizona.

Design:

Three levels were offered: Introductory, with basic information on hearing loss and teleaudiology; Intermediate, on technology, team roles, and access issues; and Facilitator, on further knowledge and hands-on skills to serve as patient-site facilitators in synchronous hearing aid service delivery. Six domains of feasibility were addressed using a mixed-methods design. Quantitative data included survey responses and observation of hands-on skills. Qualitative data included field notes from group discussion and open-ended survey questions, and were analyzed using CHW core competencies.

Study sample:

Twelve CHWs participated in the introductory training, ten moved on to intermediate, and three continued to the facilitator.

Results:

Quantitative outcomes indicated that the trainings were feasible according to each of the six domains. CHWs in the facilitator training passed the practical hands-on skill assessment. Qualitative analyses revealed CHWs comments addressed eight of the ten possible CHW core competencies, and focused on service coordination/navigation, and capacity building.

Conclusions:

Teleaudiology trainings for CHWs were feasible, increasing service capacity for a potential pathway to improve access to hearing health care in low-resource areas.

INTRODUCTION

Globally, disabling hearing loss affects an estimated 466 million adults, the majority of whom live in areas with limited resources for hearing health care (WHO, 2020). In the United States and in countries around the world, providers tend to be located in urban areas, creating access barriers and delays in care for rural patients with transportation issues (Chan, Hixon, Adkins, Shinn, & Bush, 2017; Coco, Sorlie Titlow, & Marrone, 2018; Hixon, Chan, Adkins, Shinn, & Bush, 2016; Noblitt, Alfonso, Adkins, & Bush, 2018; Powell, Jacobs, Noble, Bush, & Snell-Rood, 2019).Teleaudiology is a service delivery model that can help improve access to hearing health care for rural communities (Swanepoel et al., 2010). In teleaudiology, computers, mobile devices, or other technology is used to connect patients and providers who are physically distanced from one another. Research has demonstrated the feasibility and validity of teleaudiology in a number of areas, including pure-tone audiometric testing, hearing aid fitting, and auditory rehabilitation (see reviews: Bush, Thompson, Irungu, & Ayugi, 2016; Muñoz, Nagaraj, & Nichols, 2020; Tao et al., 2018). Despite evidence supporting teleaudiology in research, widespread and sustained implementation of the service delivery model has been slow. A survey conducted in 2016 revealed that among 269 audiologists across 37 countries, respondents had a positive view of teleaudiology, yet most had never engaged in it (Eikelboom & Swanepoel, 2016). However, with the Coronavirus (COVID-19) pandemic, providers have been increasingly moving towards adopting aspects of teleaudiology for service continuity (Saunders & Roughley, 2020).

In teleaudiology service delivery, patients and clinicians connect from two separate sites, and a trained facilitator may be needed at the patient site to assist with hands-on tasks. The clinician’s site is typically within a hospital or clinic, and the patient’s site may be located at a local community clinic, a mobile clinic, or even within the patient’s own home. Communication between sites either occurs in real-time (synchronous), or patient data is collected and sent to the clinician site at a later time (asynchronous). The facilitator’s duties will vary depending on the services provided, and may include audiology-specific tasks such as capturing video otoscopic images and placing audiometry transducers on the patient (Coco, Davidson, & Marrone, 2020). Despite their range of duties, and potentially significant role on the service delivery team, there is a lack of systematic training opportunities to prepare individuals to serve as patient-site facilitators in teleaudiology. There are a small number of general telehealth training programs available, yet none includes audiology-specific components. In this project, we address the lack of training opportunities for teleaudiology for Community Health Workers (CHW) as patient-site facilitators for synchronous hearing aid fitting and verification as part of a teleaudiology clinical trial.

Community Health Workers – An Overview

CHWs have important roles in the public health workforce, and therefore were engaged in this feasibility study because of their role in enhancing access to health services and improving health outcomes through culturally-relevant social support. CHWs are non-medical, frontline public health agents who share sociocultural characteristics with the communities they serve (Katigbak, Van Devanter, Islam, & Trinh-Shevrin, 2015). According to a review commissioned by the World Health Organization, CHWs “should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily part of its organization, and have shorter training than professional workers” (Lhemann & Sanders, 2007, p. 5). By addressing the social factors that impact health and wellness, CHWs take a holistic approach as a link between vulnerable populations and the formal health care system.

There are an estimated 1.3 million CHWs globally, and 123,000 in the United States (WHO, 2011; U.S. Bureau of Labor and Statistics, 2018). CHWs’ roles and responsibilities are tailored to fit the unique needs of the community served, and therefore their activities vary by region. Generally, in the US, CHWs’ help clients understand the health care system, provide culturally-relevant outreach and patient advocacy, deliver health education, and provide some limited direct health services, such as basic first aid, informal medication counseling, and health screenings (APHA, 2020). According to the most recent CHW National Workforce Study by the Health Resources and Services Administration’s (HRSA’s) Bureau of Health Professions, nearly three-fourths of CHWs in the US work in paid positions, and one-fourth are volunteers (HRSA, 2007). CHWs may be financed through community-based non-profit organizations, schools, universities, physician’s offices, hospitals, and short-term grant funding (HRSA, 2007). Research on US-based interventions shows that CHWs have contributed to health improvements in patients with chronic diseases and conditions, including diabetes (Allen, Brownstein, Satsangi, & Escoffery, 2016), hypertension (Balcázar et al., 2010), and asthma (Coutinho, Subzwari, McQuaid, & Koinis-Mitchell, 2020).

Community Health Workers and Hearing Health Care

CHWs have also been identified for their potential role in extending the reach of hearing health care within underserved and vulnerable communities. A systematic scoping review of CHWs and hearing health services showed that CHWs across the globe are beginning to be involved in a variety of capacities of hearing health, from community outreach and patient education to more direct services such as screening or supervised community-based services (O’Donovan, Verkerk, Winters, Chadha, & Bhutta, 2019). Authors of the review identified that the majority of included studies involved screening for hearing loss (e.g., Akilan, Vidya, & Roopa, 2014; Olusanya & Akinyemi, 2009), although researchers have also demonstrated CHWs’ involvement in motivating community members to attend screenings (e.g., Shrestha, Baral, & Weir, 2001) and in delivering basic treatment (ear washing and antibiotics) for ear disease (e.g., Couzos, Lea, Mueller, Murray, & Culbong, 2003). Notably, out of 38 identified studies, the majority came from South Asia, and only four were US-based (Ingram et al., 2016; Kokesh et al., 2008; Marrone et al., 2017; Sánchez et al., 2017).

Among the few US-based studies reviewed, in Southern Arizona, CHWs on staff at a community health center were engaged around hearing through the Oyendo Bien (Hearing Wellness) clinical trial (Ingram et al., 2016; Marrone et al., 2017). Additional training was provided on how to identify signs of hearing loss in their community, use of communication strategies, and how to facilitate peer-support groups for community members with hearing loss (Sánchez et al., 2017). Results from a mixed-methods analysis showed that, following training, CHWs (n = 12) had improved knowledge on basic information on hearing loss, and improved confidence in communicating with clients with hearing loss, and in providing hearing loss peer-support groups.

Additionally, in Alaska, Kokesh et al. (2008) examined the extent to which video-otoscopic images taken by trained Community Health Aides/Practitioners (CHA/Ps) in remote village clinics were comparable to images taken by an otolaryngologist at an in-person clinic. Results indicated that agreement between groups was high (up to 97%), similar to when two otolaryngologists examine the same patient in person (Kokesh et al., 2008). In Alaska, CHA/Ps have an established role in the state’s Tribal Health System, where they receive two years of on-the-job training on a broad range of health issues, and complete 48 hours of continuing education every two years (Golnick et al., 2012). In Kokesh et al. (2008) partnering CHA/Ps also received additional specialized training to prepare them to conduct video otoscopy. Alaska CHA/Ps’ involvement in teleaudiology is further described in the following section.

Community Health Workers and Teleaudiology

A small but growing body of evidence shows that CHWs have engaged in different aspects of teleaudiology to improve health in their communities. For example, in India, Gupta et al. (2017) describes a program to screen children for hearing loss and ear disease involving local CHWs. In this study, trained CHWs used a smartphone-enabled otoscope to capture images of the patients’ ears, and, using store-and-forward teleaudiology, the images were sent to an off-site specialist for review (Gupta, Chawla, Gupta, Dhawan, & Janaki, 2017). CHWs received three months of training on topics including anatomy and physiology of the ear, hands-on otoscopic examination, and how to conduct patient case history, as well as use of the teleaudiology equipment. Five trained CHWs screened a total of 3,000 children over six months, 58% of whom were referred for specialist follow-up. Additional studies from India have involved trained Village Health Workers (VHWs) assisting with synchronous tele-Auditory Brainstem Response testing to help detect infant hearing loss (Ramkumar, Hall, Nagarajan, Shankarnarayan, & Kumaravelu, 2013; Ramkumar, John, Selvakumar, Vanaja, Nagarajan, Hall, et al., 2018; Ramkumar, Nagarajan, Shankarnarayan, Kumaravelu, & Hall, 2019).

Researchers from South Africa demonstrated the feasibility of CHWs using mobile phones to conduct child and adult hearing screenings in low-resource communities (Kinkel, Marcus, Memon, Bam, & Hugo, 2013; Mahomed-Asmail, Swanepoel, Eikelboom, Myburgh, & Hall, 2016; Yousuf Hussein et al., 2016; Yousuf Hussein, Swanepoel, Mahomed, & Biagio de Jager, 2018). For example, in Yousuf Hussein et al. (2018), CHWs conducted preschool-based hearing screenings using a smartphone application, hearScreen^™. Prior to initiating the program, CHWs were trained on the basics of ear and hearing health, its importance, how to use the smartphone device and application, and how to map the preschool sites. After one year, five CHWs had screened 6,424 children, with a referral rate of 24.9% (Yousuf Hussein et al., 2018).

As discussed, in Alaska, CHA/Ps have been trained to use video otoscopy to transmit images of the ear via store-and-forward teleaudiology. Additionally, in a currently ongoing, multi-site, randomized controlled trial, Hearing Norton Sound, researchers aim to address childhood hearing loss in rural and remote areas of Alaska by testing the effectiveness of an improved pathway for screening and referral (Emmett, Robler, Gallo, et al., 2019; Emmett, Robler, Wang, et al., 2019; Robler et al., 2020). The improved pathway involves cell phone-based screening (hearScreen^™) and tympanometry facilitated by local CHA/Ps, with referrals forwarded to specialists for offline review (see protocols: Emmett, Robler, Gallo, et al., 2019; Emmett, Robler, Wang, et al., 2019). The rural population in Alaska experiences a high prevalence of middle ear disease and hearing loss. This new pathway coordinates local support by CHA/Ps with expedited referral to remote providers via teleaudiology, and is expected to help minimize barriers to care and improve hearing health outcomes for children in this state (Robler et al., 2020).

As these examples illustrate, the use of teleaudiology with support from local CHWs can help improve access to care for rural, remote, and resource-limited communities. However, no studies have explicitly investigated their training, and research is lacking in the area of synchronous hearing aid services. Such gaps in information limit our ability to implement evidence-based strategies that improve access to hearing health care services. The purpose of the current study is to evaluate the feasibility of a series of teleaudiology trainings for CHWs in the Southwestern United States. This work builds capacity for a pilot cohort of CHW patient-site facilitators for teleaudiology. Future publications will describe results from a longitudinal mixed-methods randomized controlled trial investigating the effect of trained CHWs assisting locally in hearing aid services delivered via synchronous teleaudiology by a remote audiologist (ClinicalTrials.gov: NCT03864003).

METHODS

Feasibility Framework

This was a non-randomized feasibility study of CHWs in teleaudiology trainings. A feasibility study refers to research that is done in preparation for a main study, often a full-scale randomized controlled trial (Eldridge et al., 2016). For this research, a feasibility study was warranted because there are few published studies or existing data on training programs among CHW to support teleaudiology, and none originate in the United States. The term feasibility study is a broad term that can refer to multiple areas of focus. To support feasibility study design, Bowen and colleagues (2009) constructed a framework with eight potential general areas of focus addressed in feasibility studies. This study examined six of the eight areas (demand, implementation, integration, acceptability, practicality, and limited-efficacy). The two remaining areas (adaptation, or modifying aspects of the intervention for implementation in a new population or context, and expansion, or the extent to which the current intervention is effective in a new population or setting) are outside of the scope of the current project, and will be addressed in future research. Table 1 provides descriptions of the feasibility areas of focus from Bowen et al. (2009), and the aspects of feasibility specifically examined in this study.

Table 1.

Description of Bowen et al. (2009) areas of focus for feasibility, aspects of feasibility examined in the current study, and data collection methods by level of training.

Areas of focus for feasibility in Bowen et al. (2009)	Aspects of feasibility examined in the current study	Methods for Data Collection by Level of Training
		Introductory	Intermediate	Facilitator	Follow-up
Acceptability To what extent is the intervention suitable, satisfying, or attractive to participants?	Satisfaction with the training series.	Likert-type survey item: I would recommend this training to others. Open-ended survey item: Why would (or wouldn’t) you recommend this training to others?	Likert-type survey item: I would recommend this training to others. Open-ended survey item: Why would (or wouldn’t) you recommend this training to others?	---	---
Demand To what extent is the new idea, program, or intervention likely to be used?	Intent to use knowledge gained in trainings.	Likert-type survey items: I will use what I learned outside of work. I will use what I learned in my daily work.	---	---	---
Implementation To what extent can a new intervention be successfully delivered to the appropriate individuals?	Perceptions of what is needed to successfully carry out trainings.	Open-ended survey item: Are there other topics or information we should have included in the training?	Open-ended survey item: Are there other topics or information we should have included in the training?	---	---
Practicality To what extent can the participants carry out new activities without outside assistance?	Assessment of trained skills; and aptitude to carry out future intervention activities.		Knowledge-based survey and Computer Proficiency Questionnaire.	Practical assessment, scored by observation of hands-on skills	---
Integration To what extent can a new intervention be integrated within an existing system?	Perceptions of how intervention fits within community.	Likert-type survey item: Telehealth is an acceptable way of delivering health care to members of my community.	---	Group discussion prompt: What would be important to keep in mind when implementing teleaudiology in your community?	---
Limited-efficacy Does the new intervention show promise of being successful?	Long-term application of knowledge gained.	---	---	---	Open-ended survey item: If applicable, how have you used what you learned? Likert-type survey item: Since you participated in the training, how often have you used what you learned?

Setting

The partnering community center was a Federally Qualified Health Center (FQHC) in Santa Cruz County, Arizona. An FQHC receives federal funding to deliver health care services in underserved regions or populations, regardless of an individual’s ability to pay (HRSA, 2018). Santa Cruz County has a population of approximately 47,000, and is located in Southern Arizona bordering the Mexican state of Sonora. According to the US Census, most residents in Santa Cruz County report their ethnicity as Hispanic/Latino (94.6%), and most individuals (89.8%) speak a language other than English at home (US Census, 2010). When comparing Santa Cruz County to the State of Arizona, the county has a higher percentage of unemployed individuals (18.3% county vs 8.1% state) and more people below the poverty level (24.5% county vs 16.2% state). The county is also a health provider shortage area for primary care providers and specialists (HRSA, 2020). In Arizona, there is one primary care provider for every 424 individuals, while in Santa Cruz County, the ratio is one primary care provider for every 1,198 individuals (Carondolet Health Network, 2018). In addition, previous research identified this county as having limited resources for hearing health care (Ingram et al., 2016; Coco et al, 2018).

Community-Based Participatory Research (CBPR)

This project built on a longstanding partnership between the research team and the FQHC using a CBPR approach. Defining characteristics of CBPR include co-learning, collaborating, and sharing expertise between researchers and the individuals who are affected by the issue being studied (Israel, Schulz, Parker, & Becker, 2001). CBPR also emphasizes long-term partnerships between community members and academic researchers (Israel et al., 2001). This collaborative approach leads to better design and implementation of interventions, and translation from research findings into practice (Springett, 2003). Examples of how CBPR principles were applied in this study include: (1) Study researchers and CHW managers met throughout the study timeline to discuss aspects of the research, and ensure the training series was appropriate; (2) CHWs and their managers were engaged for their input in developing training curricula; and (3) group discussions occurred between CHW participants during training sessions at each level of the training series, and were opportunities for co-learning and capacity building. Discussions were specific and purposeful to engage CHWs on how to address disparities from within their community and helped inform the upcoming clinical trial as partners on the study team (Coulter, Ingram, McClelland, & Lohr, 2020). Further, these discussions were also a critical element of the CBPR approach where some of the CHWs trained also have roles as partners on the study team. Prior engagement with community members, including through a qualitative community study (e.g., Ingram et al., 2016), informed the development of this training, and is part of ongoing research within these partnerships.

Participants

Volunteer participants were CHW employees at the partnering health center. Recruitment of CHWs was done by flyer and word-of-mouth. Training sessions were delivered during work hours. Individuals were asked to attend the introductory training before enrolling in the intermediate training. The facilitator training was offered to a subset of CHWs who had completed the introductory and intermediate trainings, and were recommended by their manager based on the CHWs’ interest and availability. Study approval was obtained from the University of Arizona Institutional Review Board. Consent was obtained prior to participation in the research.

Training Delivery

Community partner members of the research team reported that training opportunities should be offered for all CHWs, beyond those who would ultimately be the facilitators in the clinical trial. The purpose was so that other CHWs from the staff could learn topic areas relevant to clients that they work with in their community, the topic was viewed as new to some CHW staff, and their teamwork as a staff relies on sharing knowledge with one another. Therefore, three levels of a training series were offered: introductory, intermediate, and facilitator, allowing individual CHWs to tailor the level of training to their level of interest and workload. Trainings were delivered by one of the authors (LC), who is a multilingual audiologist and researcher with over four years of experience delivering trainings on hearing loss and teleaudiology, including to CHWs. Trainings were delivered in Spanish or English, according to participants’ preference. Paper copies of the presentations were provided in both languages. Introductory and intermediate training sessions were offered on three separate days to accommodate CHWs’ work schedules. Group sizes ranged between two to eight individuals per session. Introductory and intermediate trainings took place in a conference room at the Federally Qualified Health Center, and the facilitator training took place at the University of Arizona in Tucson, Arizona, USA. Trainings were delivered in August, 2019.

Training Content

To develop training content, we consulted the WHO’s Primary Ear and Hearing Care Training Resource, the WHO guide to community-based ear and hearing rehabilitation, as well as a literature review (Coco et al., 2020; WHO, 2006; WHO, 2012) and our research group’s prior trainings for CHWs (Sánchez et al., 2017). We also took into account training recommendations from the WHO’s Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes (Cometto et al., 2018). Materials were first developed in Spanish and subsequently translated to English. To ensure linguistic and cultural accuracy of the materials, the content was reviewed by a native Spanish speaker with translation and linguistics expertise, a native Spanish speaker who was from the target community, and the CHWs’ manager (Colina, Marrone, Ingram, & Sánchez, 2016). Training sessions took place in an active learning environment, in which individuals participate in the learning process by thinking critically about the material, rather than passively receiving information (Freeman et al., 2014). Active learning techniques include problem solving, decision-making, and collaborative group work (Bonwell & Eison, 1991). A description of each level of training is provided below.

Introductory

The introductory training sessions were one hour in duration, and were guided by instructional PowerPoint-delivered presentations and group discussion, facilitated by the trainer. Key topics included basic information on the most common causes and effects of hearing loss, its prevalence, common interventions to mitigate its negative effects, strategies on how to communicate with those who have hearing loss, the basics of teleaudiology and who can benefit from its use. Topics for group discussion included: How hearing loss has affected CHWs themselves, their clients, and their community; experiences with access to hearing care and discussion of barriers and facilitators; and how CHWs can support clients with hearing loss and their families. In addition to group discussion, active learning elements included asking the students to apply the learning materials to their own lives, game-based learning, and problem-solving using a case study.

Intermediate

The intermediate training sessions lasted 1.5 hours, and, like the introductory trainings, the facilitator presented a mixture of instructional content using PowerPoint presentation and group discussion, facilitated by the trainer. Topics included a review on the prevalence, common causes, and effects of hearing loss; roles on the teleaudiology service delivery team; teleaudiology technology; and patient safety and confidentiality in teleaudiology. Group discussion topics included access issues in the participants’ own community, and integrated ways in which teleaudiology can improve access for their clients, as well as situations in which teleaudiology may not be safe or appropriate. Active learning components included reviewing a case study, as well as paired and whole-group discussion, during which participants were asked to think critically about the learning material and share personal insights.

Facilitator

The facilitator training lasted a total of 12 hours and was delivered over the course of two consecutive days. The training included a combination of instructional presentations and active learning components, including role-play, demonstrations, hands-on practice, and group discussion, facilitated by the trainer. The session was focused on preparing participants with the knowledge and hands-on skills to assist a remote audiologist in facilitating hearing aid fitting services using synchronous teleaudiology. Topics included detailed description and hands-on demonstration of teleaudiology duties, team roles, and technology. We also presented information on patient safety, confidentiality, and ethics. This information on teleaudiology expanded on participants’ foundation of prior knowledge on hearing loss gained through their employment at the health center and their collaboration with the research team on a clinical trial of a CHW intervention for hearing loss, the Oyendo Bien clinical trial (Clinicaltrials.gov NCT03255161). Hands-on practice included positioning the client in front of the video camera, and assisting with manual aspects of video otoscopy, pure-tone audiometry, and hearing aid verification. In addition, participants engaged in a simulation of remote care delivery. The facilitator training also included a four-hour in-person observation at a university-based adult audiology clinic, which included hearing tests, hearing aid consultations, initial hearing aid fittings, and follow-up care for troubleshooting appointments. Following the observation, the trainer engaged participants in a debriefing discussion about their experiences.

Training Evaluations

A mixed-methods approach was used to explore feasibility. The quantitative component included closed-ended questions with true/false and Likert-type scale response options and, at the facilitator level, an observation of skills using a structured form. The qualitative component included participants’ written answers to open-ended survey questions (in which case direct quotations are given). Single-word responses (e.g. “N/A”) were omitted from analyses. Direct quotes were translated to English, as applicable, for the purpose of reporting. In some instances, grammar was modified slightly for readability, but the intent of the message was preserved. Additionally, we analyzed field notes taken during group discussion. Field notes are a summary or paraphrasing of dialogue and interactions, documented by the observer (LC), during group discussion (Crabtree & Miller, 1992). Consenting documents and survey data were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools, hosted at the University of Arizona (Harris et al., 2019, 2009). Using the REDCap interface, survey responses were collected anonymously. Below is a description of how each level of training was evaluated. Table 1 shows domains of feasibility, and the survey questions, group discussion prompts, and assessment tools that addressed each domain.

Introductory

Immediately following the introductory training, participants received an email via the REDCap interface with directions and a secure link to self-administer a survey. Two weeks were given to complete and return the survey. Questions included demographics, education, and work history. Quantitatively, data was collected using Likert-type survey questions. Participants were asked to report their opinion on hearing care in their community (e.g. “How important do you think the issue of hearing health care is to the community you serve?”). We also asked participants about their potential collaboration on a remote service delivery team (e.g. “I would feel comfortable as a member of the telehealth team”), and if they will use the training knowledge (e.g. “I will use what I learned in my daily work”). We also probed acceptability (e.g. “Overall, would you recommend this training to others?”).

Qualitatively, data was collected from participant’s written responses to the open-ended survey questions: “Why would (or wouldn’t) you recommend this training to others?” and “Are there any other topics or information that we should make sure to include in the training next time?”. We also analyzed field notes from group discussion, gathered from the prompt: “What have been your experiences with hearing loss and hearing health care?”.

Intermediate

As in the introductory training, participants received an email immediately following the training, prompting them to self-administer a REDCap survey. Two weeks were given to complete and return the survey. The quantitative data component of the survey included a 14 question multiple-choice and true/false knowledge-based assessment on key concepts that participants had learned in the training. The questions can be summarized under three sub-domains: 1) recall of information from the introductory training; 2) patient privacy rules; and 3) roles on the teleaudiology team. Additional survey items probed for the potential demand for teleaudiology and teleaudiology trainings, and response were on a Likert-type scale.

The survey also included the Computer Proficiency Questionnaire (CPQ-12), a validated 12-question multiple choice evaluation of basic computer skills (Boot et al., 2015). The CPQ-12 covers six sub-domains: computer basics, printing, communication, Internet, scheduling, and multimedia use. Questionnaire items include topics such as, “I can use a keyboard to type” and “I can fix the printer when paper jams”. Responses are provided on a five-point Likert scale with one point for “never tried” and five points for “very easily”. The overall score is calculated by averaging responses within each sub-domain, and summing the total. Overall scores range from six to 30, with higher scores representing better technical and computer proficiency.

The qualitative component of data collection included participants’ written responses to open-ended survey questions, probing acceptability (“Why would (or wouldn’t) you recommend this teleaudiology training to others?”) and implementation (“Are there other topics or information we should have included in the training?”).

Facilitator

Participants underwent a performance-based assessment immediately following the conclusion of the training to measure to what extent the trained facilitators can carry out the duties they were trained on. Evaluations were conducted by two individuals, the first author (LC) and a bilingual undergraduate student researcher in the department of Speech, Language, and Hearing Sciences. The assessment included 17 hands-on tasks, under five categories (preparing for the client, otoscopy, assistance with Real Ear Measures, assistance with testing, and assistance with hearing aid fitting). Researchers observed the participants’ performance of each of the 17 tasks. If participants were unable to complete a task on the first attempt, they were reinstructed and encouraged to try again. Researchers rated participants’ aptitude on a four-point scale: completed on first attempt, completed on second attempt with re-instruction, completed on third attempt with re-instruction, or unable to perform. Participants were also asked to report their understanding of privacy and confidentiality in teleaudiology. To pass the privacy and confidentiality competency, participants needed to describe at least two ways to ensure client safety and security in a teleaudiology encounter. Responses to this question were rated as either complete or incomplete. The qualitative component included analysis of field notes from group discussion, in which participants were asked to consider “What would be important to keep in mind when implementing teleaudiology in your community”?

Follow-up

Six months following the training, all study participants (n = 12) were sent an email prompting them to self-administer a REDCap survey. The goal of the follow-up survey was to evaluate the extent to which CHWs’ used what they had learned in the training. Two weeks were given to complete and return the survey. The quantitative component included Likert-type scale survey questions (“ Since you participated in the training, how often have you used what you learned?”, 1 = never, 4 = very often). The qualitative component included an open-ended question (“If applicable, how have you used what you learned in the trainings?”).

Data Analysis

Quantitative data was summarized using means and standard deviations. To analyze written quotes (answers to open-ended survey questions) and the researchers’ observations (field notes from group discussion), we used a hybrid approach of inductive and deductive coding and thematic analysis (Fereday & Muir-Cochrane, 2006). First, written quotes and field notes were entered as separate data nodes into a word processing matrix. We used the CHW Core Consensus (C3) core competencies as a framework for analysis (Rosenthal, Rush, & Allen, 2016). These core competencies are part of a national effort to help define the workforce’s scope of practice and establish quality standards for statewide training and certification programs. They include: communication, interpersonal and relationship building, service coordination and navigation, capacity building, advocacy, education and facilitation, individual and community assessment, outreach, professional skills and conduct, and evaluation and research. Each C3 core skill served as a possible code category. A chart defining the C3 core competency skills and corresponding sub-skills served as the codebook for analysis, and is available publicly (Rosenthal et al., 2016, p. 23–24).

An inductive, data-driven approach was then used to test the appropriateness of the code categories (Fereday & Muir-Cochrane, 2006). Two authors (LC & NM) reviewed the first five nodes using the code categories, and determined that the code categories were appropriate, and that no changes were needed before analysis proceeded. Then, using a deductive analytic technique (Crabtree & Miller, 1992), each node was matched to an appropriate code category, or was assigned multiple code categories. Each of the authors assigned codes independently before coming together to reconcile potential differences.

RESULTS

Participant characteristics are shown in Table 2. A total of 14 CHWs participated in the introductory training (12 completed surveys), ten CHWs moved on to the intermediate training (all completed surveys), and three CHWs advanced to the facilitator training and completed the performance-based assessment. The expected enrollment was 24 individuals, based on the number of CHWs working at the FQHC. CHW participants were females between the ages of 35 and 75 years, and most reported their ethnicity as Hispanic/Latino. Participants had a variety of educational backgrounds, but most individuals reported that they had some University or technical school education. Participants worked in a variety of areas, although the most common areas were elder/senior health, women’s health, children and adolescents with special health care needs, and weight control/diabetes. Below we describe mixed-methods outcomes for each of the three levels of teleaudiology training, along with six-month follow-up data.

Table 2.

Characteristics of Study Participants (n = 12)

Characteristic	% (n)
Age in years
30–49	17% (2)
50–69	8% (5)
70–79	17% (2)
Not reported	12% (3)
Gender
Female	100% (12)
Highest level of education
High School graduate	12% (3)
Some University or technical school	50% (6)
University graduate	17% (2)
Prefer not to respond	8% (1)
Ethnic Category
Hispanic/Latino	92% (11)
Not Hispanic/Latino	8% (1)
Area(s) of work within the past year 1
Prenatal health	12% (3)
Adolescent health	8% (1)
Women’s health	33% (4)
Behavioral/mental health	33% (4)
Children with special health needs	8% (1)
Diabetes	33% (4)
Weight control	33% (4)
Tuberculosis	8% (1)
Immunizations	17% (2)
Does hearing loss affect quality of life?
The issue of hearing loss affects QOL for people in my community.	100% (12)

Note. QOL = Quality of Life

¹Participants may be represented in more than one area.

Quantitative component

Introductory (n = 12).

Participants reported that the issue of hearing loss is important to their community (M = 3.92, scale 1–4). On average, participants reported that telehealth would be an acceptable means of delivering health care to members of their community (M = 4.33, scale 1–5) and that they would feel comfortable receiving services via telehealth if they were a patient (M = 4.42, scale 1–5). Participants reported they would feel comfortable as a member of the telehealth team (M = 4.00, scale 1–5). Participants also indicated that they will use information from the training in their daily work (M = 4.42, scale 1–5), and outside of their work (M = 4.75, scale 1–5). All participants reported they would recommend the training to others (M = 4.92, scale 1–5). Table 3 shows quantitative outcomes.

Table 3.

Results from post-training quantitative outcome measures by training level

Data collection/Survey item	M (SD)
Introductory survey (n = 12)
How important is the issue of hearing health care to the community you serve?	3.92 (.29)a
I will use what I learned in my daily work.	4.42 (.79)b
I will use what I learned outside of work.	4.75 (.62)b
I would feel comfortable receiving services via telehealth if I were a patient.	4.42 (.67)b
I would feel comfortable as a member of a telehealth team.	4.00 (.74)b
Telehealth is an acceptable way of delivering health care to members of my community.	4.33 (.65)b
I would recommend this training to others.	4.92 (.29)b
Intermediate survey (n = 10)
Knowledge-based assessment sub-domains:
i. Recall of information from intro. level	100% (0)
ii. Patient privacy rules	90% (16.10)
iii. Roles on the teleaudiology team	87% (23.31)
Average across sub-domains	87% (11.87)
Computer Proficiency Questionnaire (CPQ-12)	28.25 (2.29)
Teleaudiology can help the community I serve.	4.60 (.70)b
Telehealth (any health care field) can help the community I serve.	4.40 (.70)b
I would recommend this training to others.	4.60 (.70)b
Six-month follow-up survey (n = 10)
Since you participated in the training, how often have you used what you learned?	2.40 (.97)d

Note. M = Mean; SD = Standard Deviation;

^aResponse items were on a four-point scale: 1 = not important, 4 = very important.

^bResponse items were on a five-point scale: 1 = strongly disagree, 5 = strongly agree.

^dResponse items were on a four-point scale: 1 = never, 4 = very often. Computer Proficiency Questionnaire scale ranges from six to 30, with higher scores representing better technical and computer proficiency (Boot et al., 2015).

Intermediate (n = 10).

Nine of ten participants achieved the benchmark passing score (80%) on the knowledge-based assessment. The average score was 87% (range: 60%−100%). Participants agreed with the statement: “Teleaudiology can help the community I serve” (M = 4.6, scale 1–5), as well as the statement “Telehealth (any field) can help the community I serve”, (M = 4.40, scale 1–5). Average CPQ-12 scores indicated high computer proficiency (M = 28.25, scale 6–30). All participants reported they would recommend the training to others (M = 4.6, scale 1–5).

Facilitator (n = 3).

All participants passed the practical assessment related to assisting with teleaudiology. Fourteen of 17 tasks were completed on the first attempt, and three required reorientation by test administrators, and were subsequently completed on the second attempt. Two participants required reinstruction to place the audiometer transducers on the participant, and to open software from computer desktop allowing for remote hearing aid programming. One participant required two attempts to insert and remove a probe mic in the ear correctly. None of the participants required more than two attempts to complete any of the tasks. All participants fulfilled the safety, privacy, and confidentiality competency. Table 4 shows quantitative outcomes for the facilitator training.

Table 4.

Facilitator Training Practical Assessment Results

Competency category and item	1st attempt	2nd attempt
	% (n)	% (n)
(i) Prepare for client
Measure and document sound level in room	100% (3)	-
Share desktop with remote site	100% (3)	-
Open fitting software from computer desktop, allowing for remote hearing aid programming	33% (1)	67% (2)
Position client seats in front of video camera	100% (3)	-
Connect with remote site	100% (3)	-
(ii) Assist with otoscopy
Use new tip (specula) on otoscope	100% (3)	-
Brace hand on client’s head	100% (3)	-
Capture photo and/or video of ear drum	100% (3)	-
(iii) Assist with Real Ear Measures
Use new or clean probe microphone tube	100% (3)	-
Place probe microphone tube on equipment	100% (3)	-
Calibrate probe microphones	100% (3)	-
Insert and remove probe mic in ear	67% (2)	33% (1)
(iv) Assist with diagnostic testing
Set up audiometer equipment	100% (3)	-
Place audiometer transducers on participant	33% (1)	67% (2)
(v) Assist with hearing aid (HA) fitting
Demonstrate insertion/removal of HA	100% (3)	-
Demonstrate use of HA battery	100% (3)	-
Demonstrate use of cleaning brush	100% (3)	-
(vi) Privacy, confidentiality, safety and ethics	Complete	Incomplete
Describe how to protect clients’ privacy, confidentiality, and safety in teleaudiology	100% (3)	-

Note. Participants were given three attempts to complete each task. If they were unable to perform the task on the first attempt, they were reinstructed by the test administrator, and asked to try again. Additional rating categories (performed on 3^rd attempt, and unable to perform) are not shown.

Follow-up (n = 10).

All study participants were contacted for the follow-up survey (n = 12). Ten responded, yielding a response rate of 80%. Of these ten participants, eight had attended both the introductory and intermediate trainings, and two had attended all three levels of training sessions. Most participants (n = 8) reported they had used what they learned since the training sessions, and two had not. Table 3 shows quantitative outcomes for the follow-up survey.

Qualitative component

Table 5 shows results of the coded qualitative data. Interrater reliability between coauthors (LC & NM) was good (85%) using Cohen’s Kappa (McHugh, 2012). After discussion between coders, agreement reached 100%. Eight out of ten possible core competencies were addressed: communication, interpersonal and relationship building, service coordination and navigation, capacity building, advocacy, education and facilitation, individual and community assessment, and professional skills and conduct. The majority of nodes were coded as service coordination and navigation skills (coordinating care, follow-up, and track referral outcomes), and capacity building skills (teaching self-advocacy skills, helping others develop to their fullest potential). Among the ten possible core competencies, two were not covered: evaluation and research skills (participating in the evaluation and research process) and outreach skills (conducting case finding, recruitment, and follow-up, and disseminating materials).

TABLE 5.

Qualitative Data and Coding, Training Series for CHWs on Teleaudiology

Intervention question	Participant quote or field note / Thematic code1
Introductory (n = 12)
Open-ended survey question: Are there other topics or information we should have included in the training?	Education: “How to notice signs of hearing loss in myself and others.” “How ear wax can affect hearing.” “Information on hearing aid fittings.” Advocacy: “I would like to know how patients using teleaudiology feel about it.” Service Coordination: “How can I approach someone who I suspect may have hearing loss and how to encourage them to seek clinical help?”
Group discussion: What have been your experiences with hearing loss and hearing care?	Education: Participants asked the trainer about topics such as childhood ear infection and potential hearing damage caused by loud music. Participants asked the trainer about the behaviors of clients and family members who they suspect have hearing loss. Service Coordination: Participants discussed the high cost of hearing aids as a potential reason clients do not address hearing issues. An individual shared that they drove a family member to appointments with an ear specialist that was over one hour’s drive away.
Open-ended survey question: Why would (or wouldn’t) you recommend this training to others?	Capacity Building: “Many of us do not know about this topic.” “Because hearing loss is so prevalent and the more info one has about it, the better.” “I received very good information that would benefit others.” “With this training, more people understand the importance of knowing how to treat or take care of people who do not hear well, and to let them know that there is help and hope for them.” Knowledge: “There are many people who have hearing loss and do not accept having it.” “For the patient, [teleaudiology] is much more convenient for different situations.” “It is very important that people know what hearing loss is and that they are not alone.”
Intermediate (n = 10)
Open-ended survey question: Are there other topics or information we should have included in the training?	Education: “More information on hearing loss and more information on the hearing aids.” Advocacy: “It is very important to give information to clients before they use their hearing aids.” Capacity Building: “This area is very new to me. I have 23 years of experience as a Community Health Worker, but I can’t say I know everything. We always have to be learning more.”
Open-ended survey question: Why would (or wouldn’t) you recommend this teleaudiology training to others?	Capacity Building: “We are learning something that is not very well-known.” “With this knowledge, we can see better results and more acceptance from people with hearing loss” “It is necessary for the community to know more about hearing loss. With more trained people, there is more opportunity for the community to be more informed.” “It is good for the people of the community or agencies to be aware of these new opportunities to be able to receive care available to them without having to travel very far.” “I believe [teleaudiology] will be a great benefit for people who are elderly and have problems with transportation.” “These trainings are helpful because the Community Health Worker is the bridge between the patient and audiologist.”
Facilitator (n = 3)
Group discussion prompt: What would be important to keep in mind when implementing teleaudiology in your community?	Advocacy / Professional Conduct Participants commented on the need to inform clients of the security measures that have been put in place, particularly if it is their first experience seeing a provider via telehealth. Participants discussed the importance of informing clients that the videoconferencing connection is secure, and that the provider site is in a private location. A participant suggested assuring clients that their video image was only visible to the remote site participants, and that the videoconferencing session was not being broadcast on a public platform, such as YouTube. Participants emphasized the need to discuss with clients why teleaudiology is being used in lieu of face-to-face services, and to assure client that quality of care will be maintained with remote service delivery.
Six-month follow-up (n = 10)
Open-ended survey question: If applicable, how have you used what you learned in the trainings?	Communication skills: “I observe the person, and sometimes they answer a different thing than the questions you ask, or raise their tone of voice, or simply answer yes, and they do not pay attention. So I try to speak slowly and face them, so they can see my lips and learn to read them or understand me better.” Advocacy: “I share interesting information about hearing loss with people that I know who I think would benefit.” “[I used what I learned] with my son. He has hearing aids, and my mother as well.” “I also put [what I learned] into practice with my mother who suffers from hearing loss and also for myself because I have been having a bit of a hard time hearing clearly out of my right ear.”

Note.

¹Thematic codes are from the Arizona CHW training and education framework (Arizona Community Health Workers’ Association (https://www.azchow.org/), adopted from the national Community Health Worker Core Consensus (C3) Project (https://www.c3project.org/).

DISCUSSION

This project demonstrated the interest and capacity of CHWs to become familiar with topics on hearing loss and teleaudiology as well as to be trained to perform the hands-on aspects of assisting with teleaudiology service delivery. Given the millions of individuals with hearing loss who lack access to treatment, there is a crucial need for strategies that improve access to care (NASEM, 2016). As others have shown, integrating CHWs with hearing health care is a viable strategy for improving patients’ access to services in limited-resource areas across the globe (Emerson, Job, & Abraham, 2013; Mulwafu, Kuper, Viste, & Goplen, 2017; Sánchez et al., 2017), including with teleaudiology (Kokesh et al., 2008; Ramkumar, John, Selvakumar, Vanaja, Nagarajan, & Hall, 2018; Yousuf Hussein et al., 2018). However, this is the first study to systematically investigate multi-level trainings to prepare CHWs to serve as patient-site facilitators in synchronous teleaudiology hearing aid service delivery, serving as a pathway to expand their role in improving access to hearing health care.

Collaboration between CHWs and audiology

The research community, like many rural areas in the United States, has a relatively limited number of audiology providers locally (Coco et al., 2018; Planey, 2019). In LMIC across the world, provider shortages are more severe. Some countries report one audiologist or fewer per one million people (WHO, 2013). Findings from a WHO multi-country assessment of capacity to provide hearing care showed that the availability of audiologists varies by a country’s income level (WHO, 2013). However, even within high-income countries, communities and populations experience barriers that impact their ability to access care. In this study, CHW participants reported that hearing health care is an important issue in their community, and discussed barriers that exist in their community, such as the high cost of hearing aids and long travel distances to reach a provider. CHWs reported that teleaudiology could help their community, and that they would be willing to serve on a telehealth team, indicating the trainings are feasible in terms of demand and implementation. As mentioned, CHWs have been a part of the US public health workforce since the 1960s. However, their collaboration with audiology, particularly in a remote service delivery context, is an emerging area of study.

Trained CHWs can also promote hearing health awareness in their communities, even outside of the teleaudiology patient-site facilitator role. Some CHW participants asked questions that indicated the information would be used in their daily work, including how to connect clients with hearing health care services, and how to approach someone who has hearing loss. This study’s six-month follow-up data showed that many individuals used what they learned in the training to talk to community members and family members about hearing health, and to improve communication with clients. As seen in Table 2, CHWs worked in a variety of different areas, including elder health, adolescent health, diabetes management, and weight control. These communities are particularly important targets for promoting healthy hearing. With additional evidence in dissemination and implementation in this area, there will be support to sustain CHWs in clinical practice.

Following training, CHWs in this study reported that they were willing to engage in teleaudiology, and many participants commented on its potential for positive benefits. It is notable that, on average, participants were in stronger agreement with the statement “Teleaudiology can help the community I serve” compared to “Telehealth (any health care field) can help the community I serve”. It is possible that participants had more positive attitudes toward teleaudiology specifically after having training and gaining familiarity with it, whereas they may not have felt as comfortable commenting on the acceptability of telehealth in general without training in this topic. Previous research has shown that individuals rate telehealth as more acceptable if they have experience with it (Hanson, Calhoun, & Smith, 2009; Singh, Pichora-Fuller, Malkowski, Boretzki, & Launer, 2014). Certainly future research in this area could be influenced by the increase in the use of telehealth during the world’s response to the COVID-19 global pandemic.

In synchronous hearing aid service delivery, a patient-site facilitator may be responsible for more than the manual, hands-on tasks related to assisting with testing. The individual may also operate, manage, and troubleshoot local technology, such as video conferencing software (Coco et al., 2020). We evaluated participants’ technology skills, using the CPQ-12 (Boot et al., 2015), because the practical success of a telehealth training or intervention may be affected by the technical abilities of the individuals assisting with service delivery. The CPQ-12 is highly correlated with general technology experience (r = 0.72), and has been recommended as a measure of an individual’s skill level prior to trainings involving technology (Boot et al., 2015). Compared with a previous study using the CPQ-12, our cohort’s average scores were similar to older adults with high levels of computer proficiency, versus older adults with low computer proficiency (Boot et al., 2015). Additionally, previous research found a significant correlation between participant age and CPQ-12 scores, with older individuals less proficient (r = −.23, p < .001). In our sample, although observation of the data suggested there may be the same relationship between CPQ-12 scores and age, we did not measure a significant correlation (r = −.48, p > 0.2). However it should be noted that the correlation analysis was under-powered due to sample size (Faul, Erdfelder, Buchner, & Lang, 2009). This study’s participants’ computer proficiency may be related to their work role as CHWs, although this was not directly asked of them in this study. By assessing technology skills at baseline, such as through a validated measure like the CPQ-12, useful information can be obtained about a potential patient-site facilitator’s strengths and training needs.

CHW Competency and Workforce Framework

CHW core competencies represent the fundamental knowledge and skills needed by all CHWs to fulfill their role. The C3 core competencies have been adopted by at least 18 US statewide agencies as part of curricula for training and certification processes (ASTHO, 2018). The current study used this framework to investigate how CHW participants’ experiences in the trainings applied within the core competencies. According to qualitative analysis, the training was a venue to discuss service coordination and navigation, including barriers that limit access to hearing services in their community, and how to connect clients with services. Additionally, participants discussed building capacity in themselves and their community around hearing loss. Notably, although the core competency evaluation and research skills (ability to participate in research, including identifying priority issues and research questions) was not identified in the qualitative coding, as a CBPR project, the CHW participants were engaged in the research process, and therefore this skill was addressed more broadly. The core competency outreach (ability to conduct case-finding, recruitment, follow-up, and disseminate materials) was not coded, and may be a relevant skill following additional training.

Recently, as the US CHW workforce has become more formally integrated in some health systems, many states are moving towards adopting voluntary or required certification processes for CHWs that include establishing standards for education, training, experience and qualifications, and continuing education (Connecticut Health Foundation, 2016). In the future, we will investigate aligning training curricula with the CHW core competencies, potentially allowing for increased dissemination. For example, core competency-based trainings on supporting clients with hearing loss, including assisting with teleaudiology may be adopted by state-level CHW training programs. The current study may be a first step toward a potentially scalable model.

In Covert et al. (2019), an expert panel developed a framework focusing on CHW workforce development. The framework organizes CHWs into three categories, with increasing specialization in terms of their training, work setting, and scope of practice (Covert, Sherman, Miner, & Lichtveld, 2019). Category three corresponds with the most specialized CHWs. At this level, CHWs focus on a specific health condition or disease, such as diabetes or asthma. Category three CHWs undergo core competency training, as well as specialty training, and work in a community clinic or ambulatory care setting. Their work involves coordinating care, providing disease and treatment-specific information to clients, and facilitating access to care. The current study’s multilevel training approach aligns with the Covert et al. (2019) framework. A CHW who completed the introductory or intermediate trainings would correspond with categories one or two (entry or midlevel), while a CHW who also fulfilled the facilitator trainings and competencies would be considered a category three (specialized) CHW. With this multilevel approach, more CHWs can receive basic training on content that may affect their clients and aid in facilitating access to care, while those engaging in specialized work can advance through the series and receive additional training in hands-on tasks, if appropriate. Additionally, aligning teleaudiology trainings with a CHW workforce framework may lead to easier adoption and implementation of this training series in other geographic regions or clinics where CHWs work.

Ensuring Quality Care in Teleaudiology Service Delivery

This project is a step towards understanding the training needs for patient-site facilitators in teleaudiology. Research in this area may lead to development of curricula, metrics, and recommendations, helping to ensure quality of care is upheld in teleaudiology service delivery. Audiology is regulated differently by region throughout the world, and many countries lack guidance on teleaudiology. To date, there are no known recommended qualifications or licensure requirements for individuals in the patient-site facilitator role. In the US, audiology licensure is regulated at the state level. We conducted an exploratory review of US state licensing laws to summarize the regulation of teleaudiology patient-site facilitators. Our search revealed that only 13 states’ regulations referenced facilitators. As an example, the regulating board in West Virginia provides guidance for the use of facilitators, including that they may set up and maintain the video conferencing connection, position the client in front of the camera, set up therapy materials, and serve as the interpreter, when needed (W.V. 2017). Training was mentioned in five states’ regulations (Alabama, Massachusetts, New Mexico, West Virginia, Montana). In these states, the licensed audiologist is responsible for ensuring that the patient-site facilitator has been properly trained, or must provide the training themselves. However, no states’ regulations provided specific requirements or recommendations for the facilitator’s training.

Given that the majority of audiologists have lacked experience in teleaudiology (Eikelboom & Swanepoel, 2016), clinicians may not be prepared to train patient-site facilitators themselves. Another option may be for individuals to receive training at a University or community college, some of which offer general telehealth education or even facilitator training certificate courses (Australian College of Rural & Remote Medicine, n.d.; Hazard Community & Technical College, n.d.; Thomas Jefferson University, 2019; Heath, 2018). Such courses are designed for health care providers and students from all disciplines, and cover fundamentals in telehealth service delivery, including on-screen presence, patient safety, and equipment. However, to our knowledge, none offered audiology-specific content.

Patient-site facilitators in teleaudiology assist audiologists with tasks related to the hearing health care service being provided, and therefore, there may be some overlap with the role of an audiology assistant. According to a position statement by the American Academy of Audiology, audiology assistants perform routine tasks that do not require professional judgement, such as preparing a patient for testing and maintaining the equipment (American Academy of Audiology, 2010). As with patient-site facilitators, audiology assistants are regulated by state licensure laws and professional associations, although most state laws do not mention audiology assistants. Recently, the American Speech-Language-Hearing Association (ASHA) created certification standards for audiology assistants, and established a training program to prepare individuals for this role. ASHA-certified audiology assistants must meet eligibility requirements, including a minimum education level, a minimum number of hours of supervised clinical experience, and a passing score on a national exam (ASHA, 2020).

It is important to recognize that audiology assistants, general telehealth facilitators, and Community Health Workers are considered three distinct jobs. However, it is also possible in some workplace settings for the same individual to fill multiple roles, provided that training is in place. Neither audiology assistants nor general telehealth facilitators necessarily share the qualities that are unique and characteristic of CHWs, which, as discussed previously, include shared culture, deep trust with the population served, and an understanding of local barriers and resources.

In this project, the training series combined both audiology-specific and telehealth-general content. Telehealth concepts, such as patient safety and confidentiality, were taught within an audiology context, while audiology-related topics were tailored for the role of a patient-site facilitator. This synchronized approach may also be implemented in health specialties other than audiology. Instructors who are qualified in both areas (telehealth and the health care specialty), such as facilitated by an audiologist with teleaudiology experience, can provide expertise and respond to context-specific questions. There are also advantages to the development of systematic trainings, including the ability to measure performance outcomes relative to learning objectives, identify gaps in knowledge, and measure consistency in skills between patient-site facilitators and across locations. Although little is known about the training of patient-site facilitators in other health fields, this project could encourage such research.

Limitations and Future Directions

This study introduced and demonstrated the feasibility of a multi-level training program for CHWs on teleaudiology. While it is beyond the scope of the current paper to have assessed outcomes of teleaudiology service delivery, there is evidence from the training evaluations that CHWs perceive teleaudiology as relevant to their community and could achieve the hands-on skills necessary for fulfilling the role of a local patient-site facilitator for hearing aid fittings within this amount of training. Forthcoming work describes outcomes from a clinical trial in which the trained CHW patient-site facilitators from the current study engaged in research and teleaudiology service delivery with older adults in a rural, underserved community. The trial is important in terms of long-term goals related to this study, including interpreting the training program’s efficacy, monitoring fidelity, and informing the selection of CHWs as patient-site facilitators in other interested clinics. Additionally, although such trainings have not yet reached the stage of widespread implementation and adoption, this feasibility study helps set the ground for important future stages of intervention development (Onken, Carroll, Shoham, Cuthbert, & Riddle, 2014).

This study involved a cohort of CHWs employed by one health organization in southern Arizona who were experienced and employed by a community organization. Their work experience and the system-level support of their position by the health center may have contributed to their preparation and availability for training within the current research on teleaudiology hearing aid service delivery. Additionally, the cohort of CHWs demonstrated prior proficiency with technology, as evidenced by high scores on the computer proficiency questionnaire. Congruent with a CBPR approach, aspects of the trainings were adapted to the cultural and linguistic context of the research community. Conclusions drawn from this data cannot be decontextualized from the community where the research took place. It is unknown whether the results from this study would also be a found in among CHWs in different context. An area for future study would be in testing the training series in groups of CHWs with shared characteristics, as well as among CHWs in different areas serving different populations and geographic regions across the globe, including among CHWs with less technology familiarity, and within other health systems.

Future work will also include teleaudiology patient-site facilitator trainings among groups of non-CHWs, to explore how training evaluation outcomes differ among individuals with different demographic characteristics and employment backgrounds. Although each community is unique, the insights provided in the current study may be particularly relevant for other CHWs, including those working in rural areas, low-resource areas, on the US-Mexico border, and Spanish-speaking CHWs. CHWs in these groups may have shared experiences with the current cohort, including their job functions, and the health and socioeconomic characteristics of structurally vulnerable communities served.

In this study, rich insights were yielded from qualitative information. However, data collection methods may have limited the amount of data available for analysis. For example, participants’ written answers to open-ended survey questions were sometimes brief, and they may have been able to elaborate more in a different format, such as an interview or focus group. Future research will include additional steps to collect qualitative data, such as audio recordings of trainings and group discussions, and engaging participants in focus groups and/or structured interviews. Enhancing qualitative data collection will help contextualize quantitative outcomes, and frame our understanding of the training needs and health disparities in the target community.

The research presented in this paper was conducted prior to the COVID-19 pandemic. Now, at a time when many in-person clinics across the world have temporary suspended or limited face-to-face services, more clinicians have begun adopting teleaudiology (Saunders & Roughley, 2020). Teleaudiology with a patient-site facilitator involves direct contact with a patient. However, the training series could be adapted to accommodate a remote work environment. Trainings could be conducted online, either asynchronously, in real-time, or through a hybrid approach. Though not impossible, additional consideration would be needed for adapting the in-clinic observations and hands-on practice of practical skills. Virtual trainings may also help extend opportunities to individuals who experience barriers to accessing in-person trainings, such as those who live far from the training location, or individuals with time constraints. Additionally, given that more providers may continue offering teleaudiology services even after the pandemic, research in this area is increasingly vital.

CONCLUSION

Teleaudiology trainings for CHWs were feasible according to the areas of focus within the framework examined: demand, implementation, integration, acceptability, practicality, and limited efficacy. Engaging CHWs in core competency-based trainings on teleaudiology may serve as a potential pathway to improve access to hearing health care in low-resource areas. Given the increasing demand for teleaudiology, particularly in light of the COVID-19 pandemic, research in this area is needed to explore efficacy, effectiveness, adoption, and implementation.