Evaluating Equity through the Social Determinants of Hearing Health

Abstract

Hearing loss in adults is a significant public health problem throughout the world. Undiagnosed and untreated hearing loss causes a measurable impact on health and social, occupational, and emotional well-being of those affected. In spite of a wide array of health care resources to identify and manage hearing loss, there exist vast disparities in outcomes, as well as access to and utilization of hearing healthcare. Hearing rehabilitation outcomes may vary widely among different populations and there is a pressing need to understand, in a broader sense, the factors, that influence equitable outcomes, access, and utilization. These factors can be categorized according to the widely accepted framework of social determinants of health, which is defined by the World Health Organization as “the conditions in which people are born, grow, work, live, and age.” According to HealthyPeople2030, these determinants can be broken into the following domains: healthcare access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment. This article defines these domains and examines the published research and the gaps in research of each of these domains, as it pertains to hearing health and healthcare. Herein, we review foundational sources on the social determinants of health and hearing-related research focused on the topic. Further consideration is given to how these factors can be evaluated in a systematic fashion and be incorporated into translational research and hearing health care.

INTRODUCTION

Current events have drawn attention to and amplified long-standing inequities in health and healthcare. Being witness to the global strain on healthcare capacity and the indwelling systemic racism in health and healthcare, we are compelled to evaluate equity in hearing healthcare. Resources and technology to address hearing loss are available, yet significant discrepancies persist in the equitable access to and utilization of health care. Clinical outcomes may vary widely among different populations and there is a pressing need to understand and address, in a broader sense, the factors that influence equity in hearing health and healthcare. Our pursuit of equity in hearing healthcare will require broader perspectives and deeper investigations into the domains of social determinants of health. This information will be foundational to develop culturally intelligent and inclusive interventions to promote hearing health equity for all.

Social determinants of health (SDH) are factors of one’s environment both within and outside the home that influence health and quality-of-life outcomes (Centers for Disease Control and Prevention, 2021). These social determinants of health not only directly impact one’s health but also play a role in the severity and the distribution of health disparities and delivery of healthcare (Braveman, 2011). The World Health Organization (WHO) also recognizes the impact of the social determinants of health in which they state that research shows these factors account for 30–55% of health outcomes among the population (World Health Organization, 2021b). In fact, they established the Department of Social Determinants of Health to lead the efforts to address the social determinants of health in order to reduce health disparities globally (World Health Organization, 2021b). Furthermore, there is a clear link between race and the social determinants of health in which the various physical, social, and economic factors affected by discrimination lead to health disparities among minorities (Walker et al., 2016).

The Centers for Disease Control and Prevention (2021) divides the factors of social determinants of health into five categories: healthcare access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment (Figure 1). The healthcare access and quality domain concentrates on people’s access and utilization of healthcare services as well as the understanding of their own health. Some factors that reside under this domain include insurance coverage, provider availability, health literacy, and healthcare quality. The second area concentrates on the quality and access to education and its relation to health outcomes. This category includes high school graduation rates, enrollment in higher education or vocational training, general language and literacy, and early childhood education. Social and community context domain focuses on the social conditions and connections where people live, learn, work and play and how it impacts their overall health and wellbeing. This category includes topics such as support systems, community engagement, and social integration. Discrimination based on race, ethnicity, gender, sexual orientation or other stereotype also falls within the social and community context. Discrimination is the unfair and prejudicial treatment of individuals or communities based on explicit or innate differences. This is a critical area to address since discrimination significantly predicts poorer physical and mental health outcomes (Cohen et al., 2007). The fourth domain is economic stability which focuses on the relationship between people’s financial resources and their health. Some issues include employment, income, poverty, debt or expenses, as well as secure housing and food. The last domain of this framework is the neighborhood and built environment, which focuses on the connection of where people live and how it affects their health and wellbeing. Topics under this category include the safety and quality of housing, transportation access and utilization, water and air quality, neighborhood crime, and rurality.

Figure 1.

Social Determinants of Health Schematic

The social determinants of health have been studied and described in wide range of medical fields, including Otolaryngology (Bergmark, 2017). Although on a surface level it may seem that some of these domains are unrelated to hearing and hearing healthcare, these factors profoundly influence health and healthy behaviors, whether directly or indirectly. Despite current efforts and campaigns to address SDH and health disparities led by hearing healthcare professionals and associations (Curhan, 2019), continued emphasis on robust research of these topics, integration of this information into clinical practice, and dissemination of these efforts across a wide range of stakeholders in hearing health is warranted. Knowing how these factors impact hearing health can determine how we develop and allocate resources to improve health outcomes as well as promote health equity. This article examines and defines each of the SDH domains and how they influence hearing health and healthcare. Some of the domains have been studied in depth within hearing-related research while others have very limited research.

SOCIAL DETERMINANTS OF HEALTH

A. Health Care Access and Quality

In a general sense, utilization of healthcare is linked to health and the lack of access to quality healthcare can affect hearing and speech outcomes. Globally, the WHO estimates that 60% of pediatric hearing loss is preventable and public health interventions (i.e. - immunizations, maternal health, primary care services, access to antibiotics, education regarding risk factors for hearing loss) could greatly reduce this disease burden (World Health Organization, 2021a). Access to these types of general healthcare interventions could potentially reduce hearing loss incidence across the life span. Access to specialty hearing healthcare also plays a crucial role in timely identification and treatment of hearing loss in order to maximize hearing and communication abilities. These hearing healthcare services could include hearing screenings, diagnostic testing and evaluation, treatment options, auditory rehabilitation, counseling, or even speech therapy (National Academies of Sciences, Engineering, and Medicine, 2016). Patients throughout the world in need of those services do not have access to them or have difficulty accessing them in a timely manner (World Health Organization; 2021c). Another facet of hearing healthcare access is the relative paucity of novel hearing loss treatments compared to other chronic diseases. While surgical procedures, cochlear implants, and hearing aids can provide much needed benefit for patients with hearing loss, there is a need for discovery in the medical management options which could expand access to hearing healthcare.

The barriers to high-quality hearing healthcare access on a global level, with developing countries in view, are significant and have been linked to low governmental prioritization of hearing health, lack of providers, lack of access to affordable assistive technology, and patient perceptions/misperceptions of hearing loss (McMahon, 2021) The vast majority of the 1.5 billion people who experience hearing loss live in low- or middle-income countries (World Health Organization; 2021c). Historically, hearing loss has not been a public health priority among many developing nations (WHO, 2013). Infant hearing screening programs are not available to 38% of the global population (Neumann, 2020). Among these low-to-middle-income countries, hearing healthcare services are either limited or unavailable (World Health Organization, 2021). The World Health Organization (2021c) found that 78% of low-income countries have less than 1 ENT specialist per 1 million people and 76% of lower-middle income countries have less than 1 audiologist per 1 million people. Similar disparities were also noted among speech therapists and teachers of the deaf (World Health Organization, 2021c). Additionally, the prevalence of hearing aid use among adult patients with hearing loss continues to remain low (less than 15%) throughout the world even though there are hearing aids and devices available (Yong et al., 2019; World Health Organization, 2021c). This reduced access is due to the lack of providers, high cost and low awareness & stigma surrounding hearing loss (World Health Organization, 2021c). Overall, there are significant low ratios of population to hearing healthcare service providers globally demonstrating disparities in both access and services.

Disparities in healthcare access not only affect developing nations, but also developed ones, based on a number of sociodemographic factors. In developed nations, public hearing health initiatives such as universal newborn screening programs function to provide diagnostic and intervention services for all patients; however, these services may not be utilized equitably among different populations. In the U.S., timely adherence to universal newborn hearing diagnostic and early intervention timepoints for children with congenital hearing loss results in children receiving cochlear implants 15.1 months earlier than those who do not meet recommended timepoints and also directly influences pediatric receptive and expressive language development (Yoshinaga-Itano 2017, Yoshinaga-Itano 2018). In spite of the availability of the hearing healthcare, it becomes critically important to determine the factors affecting if and when patient utilize hearing healthcare. One such factor is the geographic location of one’s household. Location of residence, such as metropolitan versus rural, has an impact on both access to, utilization of, and quality of care. Considering congenital hearing loss, there is evidence that children from rural areas are at a significantly higher risk of being delayed in diagnosis and treatment of hearing loss within universal hearing screening programs compared with children from urban areas. One such study comparing rural and urban children in the U.S. found a higher no-show rate after referred newborn hearing screen in rural children (27% versus 15%) and delayed diagnosis of hearing loss in rural children (7 months versus 4 months) (Bush et al., 2014a). Furthermore, in the United States, rural children with congenital hearing loss are significantly delayed in cochlear implantation than urban children (Bush et al., 2014b). Interestingly, the same study demonstrated that implementation of the universal newborn hearing screening program decreased the average age of implantation in rural children from average of 7.73 years of age to an average 3.06 years of age, yet still lagged behind urban children who were implanted at an average age of 2.43 years of age (Bush et al., 2014b). This delay in care is complicated by a variety of factors; however, the lack of local specialists is a consistently identified barrier in rural America (Elpers et al., 2015). In children with congenital hearing loss, the distance to hearing healthcare services is directly associated with the timing of hearing aid fitting and the timing of cochlear implantation. Furthermore, children with hearing loss from rural regions in developed countries have greater difficulty in accessing speech therapy and other rehabilitative services (Noblitt et al., 2018; Barr et al., 2019). Similarly, the location of residence impacts adult hearing healthcare. The World Health Organization reports that, globally, there is a greater burden of age-related hearing loss in rural areas than urban areas, due to the lack of resources available for hearing healthcare (Yong et al., 2019). Rural adults residing in the United States with hearing loss may face a multi-decade journey before receiving hearing aids or cochlear implants and are consistently delayed in receiving care compared with urban adults (Hixon et al., 2016; Chan et al., 2017; Planey, 2019). Planey (2019) found vast inequalities in the availability of audiologists among U.S. urban and rural counties with rural counties being two times less likely to have audiologists. Furthermore, the limited access to hearing services in rural communities in the US can affect an individual’s quality of life (Hay-McCutcheon et al., 2020).

Beyond geographic barriers to care, the availability, accessibility, and quality of healthcare access can also be influenced by race and ethnicity. While the racial and ethnic health disparities may be influenced by a variety of SDH domains, there is clear evidence on a broad spectrum that indicates access to healthcare services continues to differ based on race among older adults living in the U.S. (Anderson & Bulatao, 2004; Bergmark & Sedaghat, 2017). Moreover, in the U.S. patients from racially and ethnically diverse backgrounds are less likely to receive care for any type of healthcare specialist and experience lesser quality of care compared to White patients (Anderson & Bulatao, 2004; Bergmark & Sedaghat, 2017). For example, the utilization of pediatric cochlear implantation in the United States differs based on race and ethnicity as Black, Indigenous, and Persons of Color (BIPOC) pediatric patients with hearing loss who are candidates for cochlear implantation are half as likely to actual receive a cochlear implant compared with White patients (Tolisano et al., 2019). Additionally, timing of implantation differs based on race and ethnicity as demonstrated in a U.S.-based study that reported that, Black children were 56% less likely and Hispanic children were 30% less likely to be implanted prior to the age of 2 compared with White children and regardless of insurance status (Liu et al., 2020). This racial hearing healthcare utilization inequity also extend to hearing aid use as BIPOC patients are less likely to use hearing aids compared to White patients with similar hearing loss in the U.S. (Nieman 2016). Race and ethnicity also influence where patients choose to seek and obtain services. In the U.S., African Americans as well as Hispanic adults are more likely to receive services from urgent care centers or emergency rooms and are less likely to pursue preventive healthcare services compared to White adults (Anderson & Bulatao, 2004). BIPOC populations in the U.S. are more likely to receive specialty care at safety-net hospitals or less-experienced lower-volume centers and may receive lower quality care and face poorer outcomes (McKee et al., 2018; Rezaii et al., 2019; Tang et al., 2020). Unconscious bias or discrimination on behalf of medical professionals as well as cultural barriers may contribute to inequalities of care and can affect the quality of care (Anderson & Bulatao, 2004; Bergmark & Sedaghat, 2017).

Even when access is available in the form of provider and treatment availability, the lack of insurance coverage and out of pocket costs represent significant barriers to care for some patients. While lack of insurance coverage is a global concern, this section will focus on how insurance coverage affects a patient’s accessibility and affordability of care in the United States. Insurance coverage in the US is funded in a variety of ways, including employer-provided or supplemented, federally funded (e.g. Veteran’s Administration, Medicare), state funded (e.g. Medicaid, CHIP), and privately funded (personal or family health insurance plans paid for out of pocket). The amount and type of insurance coverage one has is affected by various factors including income, employment, or race and ethnicity. In the US, many BIPOC patients have poorer health insurance coverage compared to White patients (Institute of Medicine, 2003; Bergmark & Sedaghat, 2017). Hispanic patients also experience greater barriers to health insurance coverage and are less likely to have a regular source of health care (Timmins, 2002; Anderson & Bulatao, 2004). This trend of poorer health insurance coverage extends to other vulnerable populations as well, such as Native Americans and Alaska Natives (Cobb, 2014). Additionally, African American and Hispanics patients are more likely to have public health insurance coverage instead of employer-provided or supplemented insurance coverage compared to White patients (Anderson & Bulatao, 2004; Bergmark & Sedaghat, 2017). African American patients enrolled in federal- or state-funded insurance programs, such as Medicare or Medicaid, are more likely to receive poorer care (such as lack of specialty referrals, lack of indicated surgical procedures) than White patients with the same insurance coverage (Anderson & Bulatao, 2004; Bergmark & Sedaghat, 2017). Medicaid patients may have lower quality care than those with Medicare or private insurance (Hasan, 2010). The quality of care is an important consideration since deaf or hard of hearing patients face communication challenges with healthcare providers and have reported low satisfaction with healthcare quality and services, specifically these patients have expressed concerns regarding safety, patient-centeredness, timeliness and equity of the care they receive (Iezzoni et al., 2004). Lack of insurance coverage and cost of healthcare issues play a major role in the access to hearing healthcare in hearing aids (Powell et al., 2019; Yong et al., 2019). The lack of insurance coverage for hearing aids plays a major role in the lower utilization of hearing aids among Hispanic/Latino adults (Arnold et al., 2019). This SDH domain will continue to be critical for researchers in the future as we study how, when, why, and where patients access hearing healthcare and strive to expand access to equitable high-quality care.

B. Education Access and Quality

An individual’s access to and obtainment of education impacts healthcare access and health outcomes in a variety of ways. An individual’s education informs basic knowledge of health and self-care and influences regulation of emotion, reason, and behavior (Hahn & Truman, 2015). Education is simultaneously an element of health as well as an influencer of health throughout the lifespan (Hahn & Truman, 2015). Early childhood education creates life-long positive impact on health outcomes which intersects with other social determinants of health (Williams & Cooper, 2019). Additionally, it is well-known that higher educational attainment is associated with better health outcomes and that lower educational attainment, especially among racial and ethnic minorities, is strong predictor of poor health outcomes. This is troubling since BIPOC populations in the U.S. are less likely to have a high school or college degree and more likely to live in poverty compared to individuals who are White (Anderson & Bulatao, 2004; Bergmark & Sedaghat, 2017). Similarly, Native American and Native Alaska populations in the U.S. have lower levels of education than White individuals, which represents a risk factor for chronic disease development and adverse health behaviors (Cobb et al., 2014). Academic achievement is also associated with health-related risk and protective behaviors (Hahn & Truman, 2015). Again, there are significant intersections between SDH domains as high educational attainment leads to higher wages and income, which increases access to health-related resources such as healthy food, safe environment, and healthcare coverage (Hahn & Truman, 2015). Within hearing healthcare, lower levels of educational attainment have been linked to poorer compliance with hearing aid use and poorer outcomes with cochlear implants among adults living in the U.S. (Mulrow et al., 1992; Francis et al., 2014; Barnett et al., 2016). Additionally, there is a body of evidence that demonstrates that parental education is directly correlated with utilization of hearing healthcare and hearing and speech outcomes in children with hearing loss in both developing and developed countries. Cavalcanti and Guerra (2012) reported that in Brazil maternal education of 4^th grade or less results in a 2.7 odds ratio (95% CI 1.6–4.5) of non-adherence to infant hearing diagnostic testing. Deng et al (2020) found that in the United States maternal education of at least a bachelor’s degree is associated with nearly 4 times higher odds (OR 3.58, 95% CI 2.98–4.29) of receiving infant hearing testing and earlier diagnosis of infant hearing loss (−3.4 weeks, p=0.01) than with those with maternal education less than a high school diploma. Noblitt et al (2018) evaluated factors influencing pediatric cochlear implant rehabilitation services in the U.S. and found that higher levels of parental education had a positive effect on access to speech therapy services with those beyond a high school degree having lower odds of being in an area with no speech therapists (OR 0.17, 95% CI 0.03–0.97) was associated with more advanced speech expression. Yoshinaga-Itano et al (2020) examined the speech development of children with bilateral hearing loss in the U.S. and found a direct association between years of maternal education and pragmatic language skills (0.23 increase in pragmatics score per year of maternal education, p=0.017, 95%CI 0.04–0.42).

Educational attainment directly influences personal health literacy, which affects a patient’s capability to seek and obtain healthcare services and treatment (Berkman et al., 2011). Personal health literacy is defined by the CDC (2020) as “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.” Low health literacy (LHL), reduced capacity or ability to understand health-related information, is associated with not only lower socioeconomic status, but also poorer health outcomes and utilization of health care services (Berkman et al., 2011; Bergmark & Sedaghat, 2017). From a primary care perspective and based on subjective data, patients with low health literacy were more likely to delay or forgo necessary care and to report greater difficulty in finding a provider compared to those with normal health literacy in the U.S. (Paasche-Orlow & Wolf, 2007; White, Chen, & Atchison, 2008; Berkman et al., 2011; Levy & Janke, 2016). These challenges prevent patients from being seen by medical professionals in a timely manner (Levy & Janke, 2016). Among U.S. patients with hearing loss, patients with LHL are more likely to present with a higher pure tone average (5.38 dB, 95% CI 2–75-8.01) (Wells et al., 2020) and more likely to be unaided (OR 1.80, 95% CI 1.51–2.15) (Tran et al., 2020). Patients with both hearing loss and LHL are more likely to have higher medical costs in the U.S. (Wells et al., 2020). In addition to health literacy, an individual’s native language can play a role in access to healthcare services and health outcomes. Language barriers and discordance are linked to lower patient satisfaction, perceived worse quality of care, and poor outcomes among non-English or limited English proficiency patients (Timmins, 2002; Flores et al. 2005; Bergmark & Sedaghat, 2017; Diamond et al. 2019). Additionally, language barriers may prevent patients in the U.S. from seeking or accessing prevention services, such as hearing screenings (de Brey et al., 2019). Diamond et al. (2019) found that language concordance, when a provider is fluent in a patient’s native language, resulted in more positive health outcomes for limited English patients. This finding could help inform healthcare practice to better fit needs of non-native English-speaking patients. The relationships between language diversity/fluency, health literacy, and hearing healthcare access/utilization/outcomes are certainly complex but has not been deeply studied at this point. This SDH also deserves further research attention as we consider the role of hearing loss on one’s educational attainment and then how individual education influences hearing-related and general health outcomes.

C. Social and Community Context

Social identity, relationships, and interactions also influence health outcomes. Supportive reciprocal relationships can improve one’s health and decrease mortality (Holt-lunstad & Smith, 2010). Conversely, the lack of social support and connections can negatively impact health outcomes (Holt-lunstad & Smith, 2010). Within hearing healthcare, a robust social support structure influences how and when adults seek hearing healthcare services and may lead to compliance with hearing aid usage (Mahoney et al., 1996; Duijvestijn et al., 2003; Abdellaoui & Tran Ba Huy, 2013; Hickson et al., 2014). Pipp-Siegel (2002) found that social support systems can assist parents in the U.S. in managing stress related to caring for a child with hearing loss. Social identity within a community may influence hearing healthcare decisions and the community perspectives may produce cultural norms in how individual deal with certain medical conditions. Adults with hearing loss from rural communities in the U.S. report being marginalized and may have significantly poorer social interactions than their urban peers which may result in more pronounced social isolation and depression (Hay-McCutcheon et al., 2018a, b). There are vast cultural differences regarding experiences with hearing healthcare and the community perspectives have a powerful effect on decision making of individuals with hearing loss (Laplante-Lévesque et al., 2010). Stigma related to hearing loss, which stems from one’s social and cultural identity, also has a strong influence on hearing healthcare usage and outcomes but is also associated with depression, anxiety and overall quality of life (Meister et al., 2008; Mousley & Chaudoir, 2018; Dreyzehner & Goldberg, 2019; World Health Organization, 2021c).

Implicit racial and ethnic bias are deeply rooted within all of the SDH domains, explicit manifestations of bias based on sociodemographic identity and how that influences health are classified under this domain. Implicit bias refers to attitudes or beliefs one has towards people or populations that unconsciously affects decisions and actions such as clinical assessments or provider-patient relationships (National Center for Cultural Competence). Discriminatory practices and policies in the U.S. affect education, employment, housing, along with access to and quality of healthcare (Anderson & Bulatao, 2004; Bergmark & Sedaghat, 2017). While there is evidence of racial disparity and inequity in hearing healthcare regarding the management of a variety of clinical conditions such as vestibular schwannoma, otogenic brain abscess, and hearing loss in the U.S., there is a gap within hearing healthcare research regarding this important domain of social and community context both domestically and globally (Babu et al., 2013; Burton et al., 2019; Dornhoffer et al., 2020; Qian et al., 2021).

D. Economic Stability

Economic stability or socioeconomic position (SEP) directly impacts a person’s health by intersecting with other SDH domains. Socioeconomic position (SEP) comprises of a patient’s household income, employment status, educational attainment, and perceived social status that attributes to one’s quality of life and afforded opportunities. Employment plays a crucial role in maintaining economic stability by providing a source of income and the potential for insurance coverage. Exposure to dangerous conditions, risk factors or environments, such as noise pollution, is more common among those with lower SEP (based on neighborhood block level data of a variety of economic factors) and BIPOC communities in the U.S. (Anderson & Bulatao, 2004; Casey et al. 2017). Individuals or families of lower SEP have limited resources to manage significant health-related situations. Although social policies and programs can assist those of lower SEP, these resources are often underutilized in the U.S. (Williams & Cooper, 2019). Many individuals who live close to the poverty line tend to experience food insecurity and reduced access to healthy foods (Bergmark & Sedaghat, 2017; Hernandez et al., 2017). Approximately 16 million adults in the United States experience food insecurity and this is more likely to occur among Black and/or Hispanic households (Hernandez et al., 2017). Economic instability and food insecurity are more common among deaf and hard of hearing populations in the U.S. (Kushalnagar et al., 2018; Engelman et al., 2020). U.S. adults with a lower SEP are less likely to seek out hearing healthcare and are less compliant in hearing loss treatment options such as hearing aid uses (Bergmark & Sedaghat, 2017). Overall, an individual’s economic stability or instability impacts his or her health outcomes and susceptibility to disease.

E. Neighborhood and Built Environment

The physical environment where a person lives influences that individual’s healthcare access and overall health outcomes. One of the pivotal ways to improve health and reduce health disparities is by improving the quality of neighborhoods and homes where people reside (Williams & Cooper, 2019). Poor housing conditions such as mold, pests, poor drinking water, lead-exposure, second-hand smoke, and inadequate heating or cooling can adversely affect individuals’ health (National Low Income Housing Coalition, 2021). Homelessness can negatively impact one’s health and is more prevalent among racial and ethnic minorities: recent data from the National Low Income Housing Coalition (2021) demonstrated that African Americans represent 40% of the people experiencing homelessness in the U.S. Based on a study examining a large database of individuals utilizing behavioral health services, Crowe (2020) reported that individuals classified as “deaf” in the U.S.-based database were more likely to experience homelessness compared to those who did not have that classification. Conditions within neighborhoods and communities, such as consistent employment options, school access and quality, crime, healthcare infrastructure, and food access differ substantially. Racial and ethnic minorities in the U.S. tend to reside in neighborhoods that have unfavorable conditions or do not have local conveniences, such as grocery stores or gas stations, for their residents (National Low Income Housing Coalition, 2021). Limited personal or public transportation is more common among BIPOC populations in the U.S., which directly affects health and healthcare utilization (Powell et al., 2019; D’Agostino et al., 2020). Communities gripped by violence and crime have direct impacts on health but also have indirect effects. Unsafe neighborhoods in the U.S. have less usage of outdoor parks and recreation centers which result in adverse health outcomes related to physical inactivity (Han et al., 2018). The physical location and conditions of neighborhoods differ based on race and ethnicity but the underlying connection to healthcare and communication with healthcare providers differs as well. Based on pilot research investigating relationships between BIPOC communities and a cochlear implant center in the U.S., the lack of a physical presence in the neighborhood and direct engagement between clinical teams and community members represent critical obstacles to cochlear implantation (Sims et al., 2017). Along with the other domains, this SDH domain needs much more research attention moving forward to understand these factors and mitigate disparities based on neighborhood differences.

FUTURE DIRECTIONS AND RECOMMENDATIONS

This overview of the social determinants of health is not meant to be a comprehensive description of all factors influencing health, but this review should serve to increase awareness of these factors and how they influence hearing and hearing healthcare. In order to promote equity, it is crucial for clinicians and researchers to have a clear understanding of these domains. Recognition of disparities in hearing outcomes and hearing healthcare, in a general sense, is an important step but awareness must lead to active assessment of specific SDH within our field. A deeper understanding of these factors and will only come through concentrated efforts to collect this data in research and quality improvement fields.

A variety of SDH assessment tools could be utilized in our field within clinical practice and research to collect data on these diverse domains; thereby providing a more holistic picture of patients thus facilitating well-informed analyses and informing culturally inclusive intervention development. One such assessment tool is the Protocol for Responding to and Assessing Patients’ Assets, Risk, and Experiences (PRAPARE) created by the National Association of Communication Health Centers (2016). PRAPARE helps researchers, clinicians, and clinic administrators collect and apply data on their patients’ social determinants of health in order to improve health outcomes and reduce healthcare costs. Some advantages to PRAPARE include the ability to be integrated into electronic health record systems, it takes about 5 to 10 minutes to administer, it can be adapted to align with other data collection efforts, and it has been translated into 26 different languages. One disadvantage is that it is tailored to adult populations only. Additionally, the free toolkit provides resources on how to act on the various social determinants of health. While this toolkit has been used in quality improvement, it could readily be translated to research activities. A second tool is the Health-Related Social Needs Screening Tool from the Centers for Medicare and Medicaid Services Accountable Health Communities (2017). This short questionnaire systematically collects data on the health-related social needs related to the SDH domains and has been used in Medicare and Medicaid recipients to evaluate effects on healthcare costs and overall health outcomes. One advantage of this tool is that it can be used in a variety of clinical settings; however, it is only designed for use with adults. Lastly, the American Academy of Family Physicians (2017) developed a social determinants of health screening tool as part of their EveryONE Project designed to promote health equity throughout communities. This tool comes in both short and long forms for easy integration into clinics and can be either self-administered or by a health professional. Similar to the first two tools, this screening tool also only targets adult patients. These tools and resources could be used in hearing healthcare to evaluate SDH in a quantitative way. The factors influencing health equity are complex and interrelated, thus systematic quantitative evaluation of these SDH should be paired with qualitative assessment to gain a broader perspective of health outcomes.

The SDH are much more than just sociodemographic data as each of these domains has core areas that influence every aspect of health, healthcare, and health-related research. Aspects of SDH can and should be considered during every phase of research spanning from descriptive analytical studies to interventional clinical trials. Contemporary clinical trial designs can and should facilitate simultaneous collection of SDH data along with primary outcomes data. Researchers are also encouraged to consider trial research designs promote equity, not only in “who” they recruit but “what” they collect. Diverse and inclusive recruitment of participants is essential in obtaining meaningful and well-informed SDH evidence. These initiatives are mirrored the National Institutes of Health’s All of Us Research Program that seeks to improve health care by creating a diverse database that includes a breadth of personalized health information. This national initiative emphasizes that healthcare research should include data on a person’s environment, lifestyle, family history, genetic makeup and other individual characteristics (U.S. Department of Health and Human Services, 2021). Regardless of the methodology, it is imperative that hearing healthcare leaders seek to understand SDH and how they influencer equity. A commitment from clinicians and researchers to incorporate SDH into their work could positively influence equity in hearing healthcare by increasing awareness, stimulating scientific innovation, and promoting community partnerships. Based on the underlying current events and long-standing complicated disparities, there is a need to take an active stance to evaluate equity through the SDH lens and take positive steps forward to maximize hearing health along with access to and utilization of hearing healthcare.

CONCLUSION

The social determinants of health encompass 5 domains that impact hearing health and hearing healthcare. Each of these domains may interact in complex ways to profoundly impact equity. There is much work to be done in hearing-related research to understand these complex interactions and develop and implement innovative solutions to bridge disparity gaps in hearing health. Leaders in hearing-related field are encouraged to actively assess aspects of the SDH in hearing-related research and then use that information to promote equity in hearing health and healthcare in their research and the care that they provide.