Barriers to Equity in Pediatric Hearing Health Care: A Review of the Evidence

Abstract

Purpose:

We review the evidence regarding barriers to hearing health care for children who are deaf or hard of hearing.

Background:

There are considerable data to suggest that hearing health care disparities constitute a major factor in loss to follow-up or documentation for children going through the Early Hearing Detection and Intervention process. Families are affected by a combination of factors underlying these disparities, resulting in delayed care and suboptimal developmental outcomes for children who are deaf or hard of hearing.

Conclusions:

To address the socioeconomic, cultural, and linguistic inequities seen in the diagnosis and management of childhood hearing loss, pediatric audiologists and speech-language pathologists have a responsibility to provide culturally responsive practice to their individual clients and their families, as well as advocate for substantive changes at the policy level that impact their clients’ daily lives.

Hearing loss is the most common congenital sensory condition that can be screened for at birth (Dedhia et al., 2018). Approximately three in 1,000 newborns have a congenital hearing loss. The prevalence of hearing loss increases during the school-age years, with 19.5% of adolescents between 12 and 19 years of age receiving a diagnosis of unilateral or bilateral hearing loss (Shargorodsky et al., 2010). Childhood hearing loss of any degree can have significant long-term repercussions for educational, vocational, and social achievement (Idstad & Engdahl, 2019).

Since universal newborn hearing screening (UNHS) programs were first implemented in the United States in the early year 2000s, national screening coverage rates have risen above 98.5% (Centers for Disease Control and Prevention, 2020). Recent international coverage rates are consistent with U.S. rates, with a pooled rate of 97.9% (Mackey et al., 2021). Currently, the goal of state-run Early Hearing Detection and Intervention (EHDI) programs is to screen all infants for hearing loss by 1 month of age, confirm hearing loss with a formal diagnostic evaluation by 3 months of age, and enroll children in early intervention by 6 months of age (The Joint Committee on Infant Hearing [JCIH], 2019). These goals of early identification and intervention are emphasized in the wake of accumulating evidence pointing to advantages of early intervention for language and cognition (Butcher et al., 2019; Ching et al., 2013; Moeller, 2000; Yoshinaga-Itano et al., 2021).

Failure to help children and their families move through the EHDI system at the appropriate rate increases the risk of adverse developmental outcomes for children who are deaf/hard of hearing (D/HH; Yoshinaga-Itano et al., 2017). Common delays in the process stem from professionals not following recommended guidelines for screening and diagnostic procedures (Sapp et al., 2021). Another source of delay is when children are lost to follow up/documentation (LTFU/D). LTFU/D occurs when an infant requires further medical care (e.g., diagnostic exam or intervention) but does not receive it or follow-up is not documented by state EHDI programs. With the implementation of state EHDI programs, nationwide LTFU/D rates for diagnosis of children who are D/HH have decreased from 64% to 27.5% between 2005 and 2019. Internationally, however, recent LTFU/D rates are lower at 14.3% for countries with high screening coverage (i.e., greater than 85% of infants screened; Neumann et al., 2020). This difference in rates between the United States and other developed nations raises questions about the effectiveness of the U.S. health care system and is an impetus for further research and efforts for improvement (Bussé et al., 2020; Subbiah et al., 2018).

As we discuss in this article, there is considerable evidence that hearing health care disparities constitute a major factor in LTFU/D for children going through the EHDI process. Moreover, it is common that families are affected by a combination of these disparities resulting in delayed care. Health care disparities are defined as differences between groups in health coverage, access to care, and quality of care that may be closely linked with social, economic, and environmental disadvantages (Jabbour et al., 2018). These disparities have a proximal impact on access to hearing services, including diagnosis, early intervention, and selection and use of hearing devices (i.e., hearing aids, cochlear implants, remote microphones). There is also a distal impact on developmental outcomes (Boss et al., 2011; Jabbour et al., 2018).

The purpose of this article is to review and evaluate the evidence for five major barriers to equity in pediatric hearing health care, as well as identify potential strategies to overcome these barriers. These barriers include (a) socioeconomic status (SES), poverty, and caregiver education level; (b) rurality and distance to diagnostic centers; (c) private or public health insurance coverage; (d) availability of qualified professionals; and (e) cultural and linguistic differences between professionals and clients. Though we review these factors independently, we also recognize that these barriers are highly intertwined and influence one another due to their intersectional nature. Systems that lead to disparities are connected, stemming from a common root cause, and manifesting in different outcomes for children who are D/HH and their families. The literature review is followed by a discussion of future areas of research related to pediatric hearing health care disparities. We conclude with a recognition of the root causes of these inequities in the systems built over time in the United States. Our conclusion is intended to serve as a starting point for a conversation on how we can advocate for policy changes to help the children and families we serve.

Barrier #1: SES, Poverty, and Caregiver Education Levels

There has been extensive research on the effects of SES on health care disparities. SES is a complex, layered social construct that is defined by a collection of economic, geographic, and educational variables, complicated by privilege and power (Oakes & Rossi, 2003). Because of the complicated nature of SES, caregiver education level and/or family income level are often reported as proxies for SES (Diemer et al., 2013). In a systematic review of factors related to LTFU/D, caregiver education level was the most frequently reported variable contributing to the likelihood of children being LTFU/D (Ravi et al., 2016). Bush et al. (2015) conducted surveys with parents of children who had been diagnosed as D/HH. The authors reported that parents with lower educational levels (e.g., high school diploma, General Educational Development) were more likely to indicate that they had no knowledge of their child’s newborn hearing screening (NHS) results at the time of hospital discharge and more likely to believe that nothing could be done to intervene with childhood hearing loss compared with parents with higher educational levels (e.g., undergraduate or graduate degrees). Families with lower educational levels were also less likely to have heard of cochlear implants, relative to families with higher educational levels.

Maternal education level is closely linked to poverty levels, with higher percentages of adults without high school diplomas living in poverty compared with adults with at least a bachelor’s degree (29% compared with 5%, respectively; DeNavas-Walt & Proctor, 2015). Researchers often focus specifically on maternal education level rather than paternal education level because most children (approximately 96%) live in two-parent families or mother-only families, as opposed to father-only homes (Hernandez & Napierala, 2014). Holte et al. (2012) found that higher maternal education level was the only factor significantly associated with younger age at first diagnostic hearing evaluation, hearing loss confirmation, and hearing aid fitting, after also examining degree of hearing loss, sex, and site of testing. Infants whose mothers held graduate degrees had their hearing loss confirmed on average 7 months earlier than infants whose mothers’ education levels were at or below a high school level. In a study of compliance rates with outpatient NHS programs in Brazil (Griz et al., 2009), maternal education level and family income level were significantly associated with likelihood of attending a scheduled NHS, whereas maternal age and marital status were not.

Although much of the focus on SES and hearing health care involves children with permanent hearing loss, it is worth noting that transient hearing loss is prevalent in children, particularly hearing loss associated with otitis media (i.e., inflammation or infection of the middle ear space). Otitis media affects approximately 90% of children before the age of 2 years in the United States alone (Brennan-Jones et al., 2015; Paradise et al., 1997), and a conductive, transient hearing loss results from persistent episodes of otitis media (Hydén et al., 2006). Low SES (measured via a combined index of maternal educational level and health insurance status) has been identified as one of the major risk factors for the occurrence of otitis media (Paradise et al., 1997). Some of the manifestations of low SES that can contribute to a child experiencing more episodes of otitis media include infant feeding technique and access to prenatal training, participation in group child care, and poor air quality (Smith & Boss, 2010; Uhari et al., 1996). For example, supine feeding position (i.e., feeding the infant while they are lying down rather than in an upright position) is associated with earlier onset of otitis media with effusion because it increases the likelihood of reflux of milk into the middle ear via the eustachian tube (Owen et al., 1993; Swamy et al., 2017). Feeding strategies are part of prenatal classes that are only accessible to those mothers who have the time and finances to take part in this education.

In addition to the prevalence of otitis media, SES is also related to the treatment of otitis media (e.g., watchful waiting, broad-spectrum antibiotic use, or surgical placement of tympanostomy tubes [TT]). Nieman et al. (2016) conducted a retrospective chart review of children who had undergone placement of TT at an urban tertiary care facility. Their major finding was that SES was associated with indications for when children received TT. Children from higher SES areas were more likely to receive TT for recurrent acute otitis media (i.e., inflammation of the middle ear due to bacterial infection, with three or more separate episodes over 6 months or four episodes over 12 months), whereas children from lower SES areas were more likely to receive TT for chronic otitis media with effusion (i.e., the occurrence of fluid in the middle ear space persisting for 3 months or longer from date of onset or diagnosis). These results suggest that poverty levels may be related to differential rates of treatment for otitis media, with children from more affluent backgrounds having greater utilization and referrals to specialty care from ear, nose, and throat physicians than children from less affluent backgrounds. Additional research is needed to explore the cultural and economic factors, as well as the possible role of provider bias, that may be mediating the associations between SES and health care in cases of middle ear issues.

Potential Strategies for Overcoming Barriers Related to SES

To mitigate the role of SES on hearing health care disparities, we need to recognize the processes that mediate this relationship. Poor communication by professionals about NHS results, difficulty with scheduling follow-up appointments due to high demands of working-class jobs, and lack of information about childhood hearing loss are all underlying factors driving SES disparities for pediatric hearing health care (Elpers et al., 2016). Some of these issues may be ameliorated through improved public health education and communication between families and professionals. Education about NHS and childhood hearing loss can occur even prior to birth. Krishnan et al. (2019) showed that having an obstetrics and gynecology nurse provide expectant mothers with written information about NHS during the third trimester of pregnancy resulted in higher satisfaction with the NHS process, compared with mothers who did not receive information prior to giving birth.

After a newborn fails an NHS, education about the importance of follow-up and communication with the infant’s primary care physician are critical to reducing LTFU/D. In a retrospective study of infants born in Colorado hospitals between 2007 and 2012, Cunningham et al. (2018) found that while most facilities recorded NHS results in the discharge summary, counseled parents, and scheduled rescreens before discharge, less than half provided written information about the results or directly communicated with the primary care physician if the infant did not pass the screening. Zeitlin et al. (2017) found that LTFU/D rates were reduced when families believed they had health care professionals to consult. Upon a failed NHS, families should be connected with a support professional such as a social worker, patient navigator, or community health worker who will guide them in the steps necessary for timely diagnosis and intervention.

Barrier #2: Rurality and Distance to Diagnostic Centers

Families with children who are D/HH from rural areas are at higher risk for LTFU/D and delays in receiving appropriate audiology health care services compared with children from urban settings (Ravi et al., 2016). States with higher percentages of geographically rural communities have documented increased rates of LTFU/D and appropriate health care access (Bush, Bianchi, et al., 2014; Bush, Osetinsky, et al., 2014; Shulman et al., 2010). Barr et al. (2018, 2019, 2020) investigated the impact of living in rural and remote areas of the United States, Canada, and Australia on hearing health care services for children who are D/HH. A consistent theme was that families of children who are D/HH in rural areas experienced challenges accessing hearing health care services, which resulted in delays in hearing loss confirmation, hearing aid fitting, and enrollment in early intervention. In a survey of 55 state and territorial EHDI programs, Shulman et al. (2010) reported that underlying factors related to rurality include a lack of transportation, increased travel time, and costs of travel. Bush, Bianchi, et al. (2014); Bush et al. (2015); and Bush, Osetinsky, et al. (2014) focused more specifically on pediatric hearing health care services in the rural Appalachian region in the United States. They found that children from rural settings were more likely to be categorized as LTFU/D compared with children from urban settings. For those children who did receive follow-up, the children from rural settings were diagnosed at 20 months of age, on average, which is over 6 times later than the JCIH recommendation of 3 months of age at diagnosis. Even after controlling for the implementation of UNHS after the year 2000, children from rural settings still demonstrated a significantly later age at diagnosis compared with children from urban settings. These same patterns held for average age at cochlear implantation.

Qualitative research supports the need for improved hearing health care service access for rural children and their families. Elpers et al. (2016) conducted semistructured interviews with 40 caregivers of children who were D/HH. The interviews were designed to assess barriers to diagnostic and intervention services for children in rural locations. Over 50% of caregivers indicated that distance to audiology clinics was the biggest single challenge to receiving hearing health care for their child. Families reported that they would have to drive up to 4 hr for an unsedated diagnostic hearing test; upon arrival at the diagnostic center, they would be unable to complete the hearing test because their newborn was awake and alert (having slept during the long car ride). Families also noted the difficulty in obtaining transportation for the frequent follow-up appointments required as part of intervention services (e.g., hearing aid verification and earmold fittings).

Potential Strategies for Overcoming Barriers Related to Rurality and Distance

Lack of transportation and cost of transportation are major limitations to accessing care for people in rural communities. Developing free public transportation across the country has the potential to help both people in rural and urban communities access care more frequently and conveniently. Other more immediately viable options are to increase the use of telepractice and mobile audiology clinics (Bush & Sprang, 2019; Coco et al., 2018; Fletcher et al., 2019; for a review on teleaudiology, see Kim et al., 2021). While we have clear evidence for the effectiveness of these nontraditional service delivery models in the geriatric population, there is a need for more research to support their use for families and children who have hearing health concerns. Expanding the role of educational audiologists, who typically identify and treat school-age children with hearing loss, is another possibility to overcoming barriers related to distance. A recent quality-improvement study demonstrated the feasibility and effectiveness of training educational audiologists to perform unsedated diagnostic hearing evaluations for infants who fail the NHS (Sapp et al., 2021).

It is also imperative that medical providers engage in outreach and community building with their patients. Outreach clinics in rural communities would be a way to provide audiological services and build trust with families (Hay-McCutcheon et al., 2020). Additionally, medical providers must be sensitive to cultural differences that may be present in rural communities and adequately practice culturally responsive care to build therapeutic alliances and regain trust.

Barrier #3: Private or Public Insurance Coverage for Hearing Health Care Services

As UNHS programs have expanded, the need to pay for hearing-related services has also expanded. Unfortunately, there is a long history of poor coverage for necessary pediatric hearing services in the United States, for both private and public health insurances (Shulman et al., 2010). McManus et al. (2010) examined Medicaid reimbursement rates for children from 15 states from year 2000 to 2005. On average, Medicaid reimbursement rates for the same audiology services were 38% of private insurance reimbursement rates. Furthermore, Medicaid rates decreased between 2000 and 2005. Many states did not have billing codes for a significant number of hearing-related services needed by infants and their families. These results suggest that disparities in insurance coverage may contribute to higher LTFU/D rates in combination with the SES and location-based barriers described above.

Barriers related to health insurance are seen in children living in rural or urban settings. Zhang et al. (2020) conducted a retrospective study of 90 children from the ages of 1–15 years who were referred to a tertiary care academic medical facility for diagnostic hearing testing to identify socioeconomic, demographic, and clinical factors that hamper children from being fit with amplification. Participants were from both urban and rural areas of Maryland. This study found that insurance type and whether the family spoke English as a first language (described later in this review) were significant barriers to a child receiving a timely diagnostic hearing evaluation, but ZIP code did not play a role after controlling for these other factors. The lack of an effect of ZIP code (as a proxy measure of rural vs. urban neighborhoods) could be considered as counter-evidence of the negative impact of rurality on timeliness of hearing health care services; however, Zhang et al. acknowledged that they may have had an insufficient sample size to detect an effect of ZIP codes on delay in diagnostic hearing evaluations, given that they had 90 participants in the study and the state of Maryland has 467 active ZIP codes. Children who had Medicaid insurance received their first diagnostic hearing evaluation 13 months after their NHS, on average, whereas children on private insurance received their first diagnostic test an average of 7 months after their NHS.

Su et al. (2017) collected survey responses from parents of children who were seen at a multidisciplinary hearing loss clinic located within a major metropolitan area in California. They documented that parents of children who have Medicaid insurance were less likely to receive hearing aids or cochlear implants compared with children who have private insurance. Insurance status was also associated with auditory development; children who had Medicaid insurance demonstrated significantly lower scores on a parent report measure of functional listening skills compared with children who had private insurance, though insurance status did not have a significant effect on parent report of hearing-related quality of life for their children. Similar to the factors related to SES and rural disparities, a lack of knowledge regarding hearing loss and the implications of permanent hearing loss also pertains to differences related to health insurance status. Su et al. (2017) reported that there was a knowledge gap between parents of children who had public versus private health insurance: Parents of children who had Medicaid were less likely to know what their child’s type or degree of hearing loss was than parents of children who had private insurance.

It should also be pointed out that private insurance does not guarantee full and appropriate coverage for pediatric hearing health care. Even if families can afford or are provided private insurance by their employer, many private insurance companies refer to hearing aids as “cosmetic devices” and do not cover their costs, leaving families to pay for devices out of pocket (Limb et al., 2010). Furthermore, many private plans often exclude academic centers (Schleicher et al., 2016), where many Speech-Language-Hearing clinics reside. The large variability in insurance coverage between different private insurance company policies leaves audiologists having to acquire extensive knowledge regarding individual insurances, which takes away from time and energy that could be used to directly serve patients.

Potential Strategies for Overcoming Barriers Related to Insurance

The findings described above should not be interpreted as an indication that Medicaid itself promotes health disparities. Investment in the Medicaid program is a crucial factor contributing to access and health literacy related disparities (Dickman et al., 2017). Although Medicaid improves access to care, specialist care is often not covered because Medicaid funding is not sufficient to pay specialists who may choose to turn away patients who have Medicaid insurance (Dickman et al., 2017; Rosenbaum, 2014). Thus, the reason for the disparity in hearing health coverage between private insurance and Medicaid may be largely attributed to Medicaid underfunding combined with private health insurance being tied to a caregiver’s employment, creating wealth-related disparities in hearing health care outcomes. Su et al. also highlight the intersectionality between insurance status and SES, as children qualify for Medicaid coverage when the parents’ income level is 100%–200% below the federal poverty level (depending on the state and age of the child). As a result, having public health insurance is intertwined with living in poverty. These compounding factors place an increased burden on caregivers and make it more difficult to obtain the tools and information necessary to effectively advocate for their children.

Stabilizing Medicaid reimbursement rates across the country and ensuring coverage of appropriate hearing assistive devices and related therapy services under Medicaid ensures that all Medicaid recipients will qualify for equal and appropriate access to necessary equipment and care. Increasing the speed of Medicaid reimbursement will allow more clinics to serve Medicaid recipients. This increase will allow many Medicaid recipients to find more conveniently located and accessible clinics to receive treatment.

Currently, 24 states have passed legislation requiring insurance companies to pay a certain amount toward hearing aids for children in their health benefit plans in their state. Although these legislative requirements are a step in the right direction, they vary greatly in amount of coverage, the benefit period, provider qualifications, and ages covered. Coverage ranges from $700 to $4,000 with benefit periods ranging between 12 months and 5 years depending on the state’s statute. A federal statute mandating full coverage for appropriate hearing devices and related therapy services from private insurance companies, without exemptions, could be a potential strategy to address variations in coverage. Federal legislation would ensure that people across all 50 states will qualify for required devices and services regardless of their specific private insurance plan and without having to pay out of pocket. Furthermore, such legislation will relieve the burden from audiologists and speech pathologists who currently spend valuable time working out specific insurance coverage for their clients, rather than providing direct patient care.

Barrier #4: Access to Qualified Professionals

As efforts to improve screening rates and timeliness of diagnostic evaluation in infants have increased, there is a growing concern regarding the number of qualified and experienced pediatric audiologists. Audiology clinical training programs tend to have a low emphasis on pediatrics and intervention (Muñoz et al., 2011; Oyler & Gross, 2000; Richburg & Smiley, 2009; Shaw, 2013), instead focusing more on the geriatric population. Students often must indicate that they are exclusively interested in working with pediatrics to receive pediatric training or outplacements because of the wide range of knowledge and skills necessary for graduation from AuD programs. Because pediatric audiology is viewed as a specialized area within general audiology, the practicum and continuing education is minimally prescribed by current accreditation, leading to a lack of qualified pediatric audiologists (Roush, 2010). Furthermore, few AuD programs provide preparation in competencies for interdisciplinary practice (Beckrow & Nerbonne, 2002). While some specialized training programs exist in the United States (e.g., Vanderbilt, Tennessee, Utah State), a review of the American Speech-Language-Hearing Association (ASHA) Ed Find indicates that most graduate-level programs do not offer specialized training focused on pediatric audiology.

Further research indicates that infants and families face obstacles in accessing appropriate resources due to a lack of access to qualified professionals (Oyler & Gross, 2000; Shulman et al., 2010; White et al., 2010). Shulman et al. (2010) surveyed NHS program coordinators from 50 states and five territories. Nearly half of the program coordinators indicated that a lack of pediatric audiologists is a major hindrance in conducting diagnostic hearing tests. More recent research suggests that access to qualified pediatric audiologists and diagnostic facilities continues to be a challenge in many states. Nagaraj et al. (2019) examined pediatric audiologist access patterns using the EHDI-PALS (Pediatric Audiology Links to Services) web-based diagnostic audiologist directory. They found large variability in the density of audiology facilities equipped to perform diagnostic auditory brainstem response (ABR) testing across states. For example, there was a 15-fold difference between the state with the highest density (Maine, 1.3 diagnostic facilities/1,000 births) and the lowest density (California, 0.09 facilities/1,000 births). Additionally, the authors highlighted a discrepancy between pediatric audiologists who are reportedly able to provide infant diagnostic services. Less than 70% of those facilities reported having the necessary equipment for diagnosing hearing loss in infants (i.e., diagnostic ABR equipment). This mismatch suggests the possibility that infants are repeatedly having their hearing screened with otoacoustic emissions or automated ABRs when they require a true diagnostic hearing evaluation to confirm the presence of hearing loss (Holte et al., 2012; Sapp et al., 2021). This trend of repeated hearing screenings represents care that is off guideline from recommendations laid out in the 2019 JCIH position statement.

Potential Strategies for Overcoming Barriers Related to Access to Qualified Professionals

With rising cost of tuition at universities and the necessity of a 3-year postgraduate program with an additional externship year, a clinical audiology doctoral degree is out of reach for many individuals. Creating scholarship funds for individuals to become pediatric audiologists may allow more qualified individuals to enter the field. Incentivizing pediatric audiologists, especially those in areas with higher need, is another important action that may be undertaken by the ASHA or the American Academy of Audiology. Additionally, funding is needed to fully equip facilities to allow them to conduct appropriate diagnostic services in accordance with recommendations.

Barrier #5: Cultural and Linguistic Differences

Though health disparities are in large part a direct consequence of the macrolevel factors described above (e.g., poverty, insurance), social determinants of health are also affected by culture (e.g., differences in family dynamics, perceived trustworthiness in Western medicine). Indeed, culture influences the experience and expression of health problems, ways of coping with health problems, and the outcomes of treatment (Alegria et al., 2010; Chaze et al., 2015). Bush et al. (2015) speculated that while geographic isolation and limited public transportation lead to delays in accessing hearing health care, there are cultural factors in rural regions that intersect with the distance and transportation issues. These cultural factors may result in a reluctance for parents to travel to unfamiliar locations for diagnostic testing and therapy. For example, families living in rural areas may have a strong sense of self-reliance, which feeds into the perceived untrustworthiness of medical professionals from urban regions. A lack of trust with medical professionals also arises within communities who have been harmed historically by medical professionals and continue to experience lower health outcomes (Brandon et al., 2005; Warren et al., 2020). This lack of trust leads into a decreased willingness to access health care outside of their familiar surroundings (Statz & Evers, 2020).

Language differences have also been noted to impede diagnosis and intervention for childhood hearing loss. Su et al. (2017) found that children who are D/HH where English is not the primary language in either their home or community have unmet hearing needs; their parents reported having more difficulty obtaining educational accommodations for their children, compared with parents who spoke English as their first language. Zhang et al. (2020) reported that caregivers who used English as their first language experienced much shorter periods of time between NHS and ABR testing for their infants than caregivers who used a first language other than English (mean interval between NHS and ABR of 9 months vs. 15 months, respectively). However, the association between primary language group and timeliness of diagnostic hearing tests was not significant when insurance status was accounted for, as most families in the study who had private insurance spoke English as their first language. Thus, primary language and insurance type are highly interconnected and both factors may disrupt the process of navigating health care systems to receive the specialized care that is integral to achieving optimal outcomes for children with hearing loss.

Potential Strategies for Overcoming Barriers Related to Cultural and Linguistic Differences

Reaching the highest level of hearing health for everyone requires interpersonal steps on the part of the clinician. One evidence-based strategy is actively engaging in culturally responsive practice, defined as the specific delivery of health care and information in ways that are sensitive, creative, and meaningful to people from other cultures (Leininger, 2002). Culturally responsive practices are crucial to achieving health equity (Kirmayer & Jarvis, 2019). An example of a culturally responsive practice in the medical field is understanding the familial structure of the patient being treated and to whom results should be communicated (Brooks et al., 2019). The idea of the “nuclear family” being solely the parents and maybe siblings of a child is a stereotypically White structure that does not reflect the diverse nature of family structures in America (Irvin et al., 2018). Culturally responsive practice is more than a fleeting buzzword in medicine, especially in speech and hearing; in fields linked intrinsically to communication and language, professionals cannot afford to be complacent about properly serving patients of many different cultures and languages.

Participating in culturally responsive practice is especially important for current and future practice because the demographics of the United States are rapidly changing (Clayton, 2011). In the United States, there is an especially high rate of immigration from countries with higher rates of hearing loss (McPherson & Swart, 1997; Stevens et al., 2013). It is more likely today clinicians will have patients with a cultural background different than their own compared with clinicians from 20 years ago. The direct patient experiences that these clinicians have with their patients will impact the services and treatment received. Thus, clinicians need to partake in culturally responsive practices to foster health equity at the microlevel, or interactions that are between individuals (e.g., health care provider and patient).

There are practical ways that clinicians can be culturally responsive when interacting with families from different cultures. First, if the clinician knows that the family is bilingual, they can request that a medical interpreter be present for appointments. Gutierrez et al. (2019) used discourse analysis to see how Spanish interpreters aided in genomic counseling and noted that they used contextualization, comprehension checking, and encouraging phrases to communicate complicated medical information. This use of empathetic linguistic tools can make patients and their families more open to provider recommendations. In large health care settings, like a hospital, the process of requesting medical interpreters is more straightforward than for audiologists working in outpatient clinics or private practice, but the Centers for Medicare and Medicaid Services states that “all providers who receive federal funds from the Department of Health and Human Services for the provision of Medicaid/Children’s Health Insurance Program services are obligated to make language services available to those with Limited English Proficiency under Title VI of the Civil Rights Act and Section 504 of the Rehab Act of 1973” (2021).

Interpreters make up a subset of cultural brokers, or those individuals who act as a “go-between” for two parties with different cultural backgrounds (Pang et al., 2020). Note that these two parties do not have to speak different languages for a cultural broker to be of service to their interactions. Cultural brokers can include outreach and lay health workers, peer mentors, therapists, social workers, program managers, or even family members (Georgetown University Center for Child and Human Development, n.d.). In the age of COVID-19, it can be challenging to allow more than one person attend an appointment, but if clinicians can establish ahead of time with the patient the need for a cultural broker, safe accommodations (e.g., larger treatment spaces, masks required) can be organized to allow for the most effective appointments. For those audiologists involved in clinical research, considering ethnographic interviewing, or asking their participants subjective questions about their experiences with audiologists, is a qualitative way to informally collect data about the attitudes, perceptions, and impressions surrounding their care. Ethnographic interviewing is an effective way to learn about the individual and family’s beliefs, values, and goals. This may help clinicians tailor their therapeutic approach to best fit each individual family’s culture and preferences to result in more effective and understanding care.

In addition to traditional factors that are components of culturally responsive practice in hearing assessment and intervention (e.g., use of interpreters, cultural brokers, ethnographic interviews; Douglas, 2011a, 2011b; Kohnert & Derr, 2004; Lonka et al., 2011; Rhoades et al., 2008; Soman et al., 2012; Wallhagen, 2010), Hyter and Salas-Provance (2018) suggest several factors that should be considered when providing hearing services to individuals and families from cultural and linguistic backgrounds that differ from one’s own: (a) environmental and personal factors (e.g., student’s home or school environment, or access to services; Howe, 2008; Manchaiah et al., 2015; Rhoades et al., 2004), (b) stigmas toward hearing loss (Harris et al., 2012; Knudsen et al., 2010; Manchaiah et al., 2015), and (c) health literacy (Hasselkus & Moxley, 2009). Hyter and Salas-Provance (2018) suggest adopting a model for clinicians to inform themselves about how their clients and their families might perceive the client’s communication disorder. One such model is the Health Beliefs Model (Glanz et al., 2002), which aids clinicians in examining an individual’s understanding of their communication disorder, their beliefs about or toward the communication disorder, and identifying factors that influence an individual’s decisions about accessing and utilizing services (Harris et al., 2012). Efforts toward understanding the inherent beliefs families and clients could have about hearing loss and related services can allow the clinician to address their unique concerns instead of using a blanket approach of counseling that could be grounded in patriarchal, ethnocentric norms.

Future Research Needs

To move toward reducing disparities in childhood hearing loss, we need to continue to pursue rigorous investigations of the issues surrounding access to hearing health care. Though the current research suggests that there are differences in hearing health outcomes based on race, ethnicity, and SES (Boss et al., 2011; Zeitlin et al., 2017), little is understood about the underlying causes of these differences or how they intersect with one another. Examining these underlying causes within an intersectional framework provides a tool to analyze the interconnectedness of various social categorizations (e.g., race, gender, class, culture) and how they build off one another (Crenshaw, 1989). Furthermore, pediatric hearing health care within communities of color is severely underresearched (Nieman et al., 2016). In addition to supporting more studies about intersectionality and diverse populations, qualitative or mixed method studies should be implemented to accommodate participant groups that are largely underrepresented or perhaps alienated by the construction of present studies (Elpers et al., 2016). Ethnographic interviews, or conversations and interactions between researcher and participant that take place in naturalistic settings, are valuable because they aim to provide a cogent, multifaceted perspective on a participant and their culture. In instances where a questionnaire is not ecologically valid for a family or client population (e.g., asks about a nuclear family structure that eliminates grandparents, disregards bilingualism, or misses a foundational client experience), ethnographic interviews conducted before administering the questionnaire can make it more inclusive and applicable (Bauman & Adair, 1992).

There is also a pressing need for more research in how to provide culturally appropriate practice for families of children who are D/HH. As noted above, knowledge gaps constitute a significant problem in obtaining timely and effective services for children who are D/HH. Though many of these knowledge gaps arise due to inadequacies in health coverage, they are also the result of communication breakdowns that occur when providers are not implementing appropriate tools (i.e., culturally responsive practice) when working with clients who speak a different language or come from a different culture. A literature search of a university’s library holdings between 1990 and 2017 showed that publications related to culturally responsive practice in audiology appear to trail publications in speech-language pathology (Hyter & Salas-Provance, 2018), indicating that this is an area of need in audiology. As language is highly intertwined with culture, audiologists can provide support by discussing test results and amplification management in ways that are considerate of a client’s background and values (Caballero et al., 2017).

Conclusions: Addressing the Root Cause

The possible strategies presented in this article are responses to a root cause but do not directly address the root cause itself. These strategies are merely band-aids in response to wounds created by the larger scale inequality rampant across America. In addition to becoming culturally responsive clinicians in everyday clinical interactions, it is the responsibility of clinicians to advocate for concrete, long-term changes at the policy level that impact clients. The barriers discussed in this article are manifestations of structural policy that has maintained these inequalities.

Clinicians must realize there are deep root causes for health care inequities among children who are D/HH. Operating within a system that ties wealth and employment to health care opportunity will inevitably result in unequal access to care, prioritizing the more advantaged over the less advantaged. There are many potential causes underlying this complex power dynamic, but we highlight the privatized health care system and systemic racism as two speculative reasons for inequities. We recognize that these are assumptions that would benefit from being further researched by sociologists, anthropologists, and economists. To generate productive conversation surrounding our own profession, we would like to consider these causes. Offering Medicaid for those without private, premium insurance maintains a difference in care and furthers the divide between the advantaged and disadvantaged. Enabling a privatized health care system results in corporations focused on extracting maximum profit rather than focusing on care. Removing profit from the equation results in the ability to cover a greater amount of services and necessary medical devices. Eliminating privatized health care and offering a nationalized health care system in its place is an appropriate first step to ensuring more equitable access to care for all people in this country, regardless of employment or financial status (Zieff et al., 2020). Finally, we cannot fully address poverty, SES, maternal education, or disparities in culturally sensitive care without acknowledging that all systems in the United States were built upon White supremacy. As health care professionals, we must actively work to dismantle these systems that are harming our clients and contributing to unequal care and health outcomes. Future studies should drive changes at the policy level to guarantee universal access to high-quality health care, including pediatric hearing health care.