Audiology, Medicine, and Pharmacy Interprofessional Preliminary Interviews and Discussions: Improving Hearing Health Care in Rural Alabama

Abstract

Purpose:

Access and affordability of hearing health care varies depending on residency and individual financial means. Those living in rural areas have limited health care resources and experience higher levels of poverty compared to those living in urban regions. The purpose of this study was to determine the feasibility of interprofessional collaboration among physicians and audiologists and pharmacists and audiologists to improve access and affordability of hearing health care in rural communities.

Method:

Sixteen family physicians and medicine residents and 15 community pharmacists participated in the study. Physicians and residents completed an online survey to assess education regarding hearing health care and their understanding of hearing loss intervention. They also participated in small virtual focus group discussions. Pharmacists participated in virtual discussions based on guided questions.

Results:

The discussions with both physicians and pharmacists highlighted the need for more education, resources, and awareness of the negative impact of hearing loss on overall quality of life. Comments from these discussions were placed within the socio-ecological model of health behavior to increase understanding of hearing health behavior.

Conclusions:

Increased collaboration among medical professionals has the potential to improve access to hearing health care for those living in audiologically underserved regions of the country. Further research will identify how to increase effective and sustainable hearing health care resources in rural communities.

Hearing loss is a chronic condition that affects roughly 38 million people aged 18 years and older in the United States (National Institutes of Health, 2021). It has been associated with physical and emotional health issues including poorer cardiovascular health, diabetes, social isolation, and diminished cognitive functioning (Austin et al., 2009; Bainbridge et al., 2008; Dalton et al., 2003; Fischer et al., 2015; Hay-McCutcheon et al., 2018; Helzner et al., 2011; Lin et al., 2013). If hearing loss is left untreated, health concerns can become exacerbated, and individuals are more likely to incur higher health care costs (Arlinger, 2003; Reed et al., 2019). Unfortunately, only 34.1% of those diagnosed with hearing loss obtain hearing aids (Powers & Rogin, 2019). While most individuals with hearing loss would benefit from intervention, including hearing aids, personal sound amplification devices, or assistive listening devices, access and affordability of hearing health care vary for many. Access and affordability are dependent on where people live in relation to the location of audiological services and on individual means to cover the cost of hearing health care (Hay-McCutcheon et al., 2020).

Based on current U.S. Census data, 46 million Americans live in rural areas, including a substantial number of older adults (Centers for Disease Control and Prevention, 2017). Not surprisingly, older adults experience higher rates of hearing loss compared to younger adults (National Institute on Deafness and Other Communication Disorders, 2017). However, due to limited health care resources in rural areas, residents have limited medical care and may have to travel long distances to specialists, including those addressing hearing-related disorders (Centers for Disease Control and Prevention, 2017). In addition to an older population, residents in rural areas experience higher levels of poverty compared to those living in urban regions (Mohr et al., 2000; U.S. Department of Agriculture, 2021). In 2019, the average price of one digital hearing aid ranged from $1000 to $4000, and medical insurance companies in the United States generally do not cover the cost of hearing aids (Mroz, 2021; Rains, 2021). Typically, individuals with hearing loss are prescribed two hearing aids, thereby doubling the financial burden. The cost of these devices is prohibitive for many people who would benefit from them, especially for older adults with limited incomes living in rural regions of the United States. To improve access and affordability of hearing health care, the National Academies of Sciences, Engineering, and Medicine has recommended further research using interdisciplinary models to address this issue in rural communities (National Academies of Sciences Engineering Medicine, 2016).

To provide hearing health care in rural areas, it will be necessary to consider other nontraditional methods of delivery. Other models such as telehealth through video interface or mobile phone technology as well as mobile audiology clinics may allow for improvement in the access and affordability of hearing health care. In addition, interprofessional models of care need to be explored. Although otolaryngologists and audiologists are the primary providers of hearing health care, other medical professionals such as primary care physicians, physician assistants, nurse practitioners, pharmacists, and community health workers could become involved in hearing health care in impoverished communities (National Academies of Sciences Engineering Medicine, 2016). In fact, recent findings demonstrated that community health workers in low-income countries who received training can successfully identify hearing loss, suggesting that their responsibilities can be shifted (Bright et al., 2019; Dawood et al., 2021). Due to the limited number of audiologists across the country, especially in rural areas, utilizing other professionals who are established and trusted sources providing health care in the rural communities could benefit those in need of hearing health care (Planey, 2019).

Primary care physicians are general practitioners of medicine that usually serve as the first contact for patients and are responsible for comprehensive medical care (American Academy of Family Physicians, 2021). Evidence has suggested that patients who discuss hearing loss with their primary care physician are more likely to be referred for a hearing evaluation, an important first step in addressing hearing loss (Nash et al., 2013). Investigators have explored the feasibility of providing hearing screenings in a primary care physician's office to determine potential hearing loss and the need for further diagnostic testing, but staffing and equipment considerations might make this approach untenable (Cohen et al., 2005; Crowson et al., 2016). Further exploration, therefore, is needed to determine how primary care physician offices in rural communities could be involved in hearing health care. To begin, it might be appropriate to consider the inclusion of brief courses and training for family medicine residents to enhance their awareness and understanding of patients with untreated hearing loss.

Another avenue for the provision of hearing health care in rural communities could be the local community pharmacy. Although pharmacists are primarily viewed as dispensers of medications, their education and scope of practice allow them to provide many additional services including lab interpretation, disease screening, patient assessment and counseling, continuity of care, and referral source (American Pharmacists Association Foundation and American Pharmacists Association, 2013; Kent et al., 2006). Pharmacists are one of the most easily accessible health care institutions compared to other professions. In fact, 89% of residents in the United States live within 5 miles of a pharmacy (National Association of Chain Drug Stores, 2017). Due to their frequent interaction and proximity to patients, pharmacists have strived to expand their services to the full extent of their capability and have developed collaborations with other professionals (Ciardulli & Goode, 2003; Harmon et al., 2014; Kent et al., 2006; Miller et al., 2010). There is the potential for pharmacists and audiologists to work collaboratively to help those with hearing loss, especially in underserved regions of the United States. Although there is uncertainty for how the audiology and pharmacy professions might work together to improve access to hearing health care (Alhusein & Watson, 2019), initial discussions between the two professions have occurred to create an initial framework for this new collaboration (Berenbrok et al., 2021).

The purpose of this initial study, therefore, was to conduct separate focus group discussions and interviews with physicians and pharmacists to develop a greater understanding of how these professions could collaborate with audiologists to help improve access and affordability of hearing health care. The findings of these discussions were applied to a socio-ecological model (SEM) of health behavior. The SEM was originally proposed by Urie Bronfenbrenner in the late 1970s to demonstrate that individuals are affected not only by their own actions but also by social and environmental influences (Bronfenbrenner, 1979). Previously, the SEM has been applied to violence prevention and mental health, to name two, for the increased understanding of health behaviors (Centers for Disease Control and Prevention, 2021; University of Minnesota, 2021). It has also been used to describe overlapping factors of the individual, relationship, community, and society for adults with hearing loss (Ingram et al., 2016). Ultimately, an increased theoretical understanding of how medical professionals, including physicians, pharmacists, and audiologists, can effectively collaborate will allow for the development of a sustainable model for improving access and affordability of hearing health care.

Method

Participant Recruitment

Two groups of participants were included in this study. The first group included 16 physicians and family medicine residents (13 women and three men) at The University of Alabama's College of Community Health Science. Twelve of these physicians and residents were invited to participate in a focus group discussion following one of their regularly scheduled virtual monthly seminars. The seminar presented information on the association of hearing loss with physical health and emotional well-being along with information on hearing health care disparities in the state. The presentation provided physicians with general information related to hearing health and was not directly used for the group discussion that followed. Verbal informed consent was obtained prior to participation in the focus group discussion. Physicians and residents were informed that participation was voluntary, and they could contribute to the conversation as much or as little as they chose. Four additional physicians and residents were recruited through word of mouth. Three of these physicians and residents participated in a separate virtual group discussion, and one physician participated in an individual conversation with the second author. Discussions with family physicians and medicine residents were completed between March and April 2021.

During our conversations with physicians, it was suggested that audiologists could collaborate with other health professionals, including pharmacists or nurse practitioners. Consequently, we performed interviews and focus group discussions with 15 community pharmacists (seven women and eight men) who worked in independently owned community pharmacies in Alabama. Using Convenience Sampling (i.e., pharmacists who were familiar to the researchers), participants were contacted via e-mail using addresses obtained from the American Pharmacy Cooperative, Inc. (APCI), a professional trade group for pharmacists. Due to busy schedules during the COVID-19 pandemic, it was not possible to arrange large group discussions with the pharmacists. Consequently, eight pharmacists were interviewed individually by the second and third authors in a virtual setting. Additionally, two discussions with two pharmacists and one discussion with three pharmacists were held, also with the second and third authors in a virtual setting. Verbal consent was obtained by the pharmacists prior to each interview or discussion. These sessions took place from May to June 2021.

Materials and Procedure

To understand the extent of educational training that physicians received about hearing and hearing loss, an online survey using Qualtrics XM software was developed by the second and fourth authors. Information from this survey provided an initial guide for the degree to which physicians were able to address hearing loss with their patients. The seven-item survey consisted of questions that assessed physician education regarding hearing health care and their understanding of hearing loss intervention (see Table 1). Participants selected one response from multiple-choice options that most closely aligned with their views. The survey was completed before the group discussion and responses to the survey were not referenced during the group discussion. It was assumed that pharmacists received no training related to hearing loss in their professional degree program, and consequently, no preliminary survey for this group of participants was developed.

Table 1.

Physician survey questions and responses.

Total participants (N = 16)
Question 1
I agree to participate in the study and to the audio and/or video recordings (n = 16).
I do not agree to participate in the study (n = 0).
Question 2
How much classroom training related to hearing loss have you had? Responses: A great deal (n = 0); a lot (n = 0); a moderate amount (n = 1); a little (n = 7); none at all (n = 5); no response (n = 3).
Question 3
How comfortable do you feel providing information related to hearing health care to your patients? Responses: Extremely comfortable (n = 0); somewhat comfortable (n = 2); neither comfortable nor uncomfortable (n = 4); somewhat uncomfortable (n = 5); extremely uncomfortable (n = 2); no response (n = 3).
Question 4
How comfortable do you feel referring patients to an audiologist? Responses: Extremely comfortable (n = 6); somewhat comfortable (n = 4); neither comfortable nor uncomfortable (n = 2); somewhat uncomfortable (n = 1); extremely uncomfortable (n = 0); no response (n = 3).
Question 5
Audiologists always present patients with their percentage of hearing loss and not their degree of hearing loss. Responses: True (n = 0); false (n = 4); not sure (n = 9); no response (n = 3).
Question 6
How comfortable are you interpreting an audiogram? Responses: Extremely comfortable (n = 0); somewhat comfortable (n = 3); neither comfortable nor uncomfortable (n = 1); somewhat uncomfortable (n = 4); extremely uncomfortable (n = 5); no response (n = 3).
Question 7
Hearing aids are appropriate for all types and degrees of hearing loss. Responses: True (n = 2); false (n = 9); not sure (n = 2); no response (n = 3).
Question 8
Cochlear implants are appropriate for all types and degrees of hearing loss. Responses: True (n = 1); false (n = 10); not sure (n = 2); no response (n = 3).

To generate conversations during the group and individual discussions, physicians were asked two questions, and pharmacists were asked seven questions, as provided in Table 2. Focus group sessions were conducted and recorded using webinar technology, Zoom Version 5.7.4. Again, prior to the online discussions, physicians completed the online Qualtrics consent document, and pharmacists provided verbal consent. Participants were not given a time limit for their responses and were encouraged to provide their opinion and ask questions throughout the discussion.

Table 2.

Discussion questions for physicians and pharmacists.

Questions for physicians:
1. How comfortable are you talking about hearing health care with your patients?
2. Do you think we need to increase physician understanding of the importance of hearing health care; if so, how?
Questions for pharmacists:
1. In your pharmacies, what proportion of adult patients would you loosely estimate have hearing loss?
2. What cues (verbal/nonverbal) do you look for that let you know that a patient has hearing loss?
3. What difficulties do you experience when interacting with patients with hearing loss?
4. What strategies do you or members of your pharmacy team use to support communication with patients who have hearing loss?
5. How has COVID-19 affected your interactions with patients with hearing loss?
6. What tools or resources could you benefit from to assist you and members of your pharmacy team in community with patients with hearing loss?
7. Would you be willing to collaborate with audiologists or other hearing health care professionals to help increase access to hearing health care in your community, and if so, what suggestion for conducting this collaboration do you have?

All focus group discussions and interviews were later transcribed verbatim using the transcription feature of Microsoft Word. The first and second authors reviewed the transcriptions, and if needed, edits were made while comparing them to the audio recordings. The first and second authors also independently evaluated the transcripts for common themes and met over a 2-month period to review and refine placement of comments within the themes. Most comments did not overlap across themes, and consequently, the interrater agreement was high. However, for the comments from the physicians, the raters discussed and then agreed upon placement of comments for “education” as opposed to “awareness.” Notes for these comments are provided in the codebook (see Appendix). Codes for comments from discussions with physicians included, education, logistics and infrastructure, awareness, and ease of referral. Separate codes for the comments from pharmacists included number of people with hearing loss, difficulties and strategies, suggested resources, collaboration with audiology, and challenges with collaboration. These codes are defined in the Appendix. The codes were then expanded into themes. Placement of comments into the themes occurred through the use of NVivo 12 software.

Together, the first and second authors also reviewed the comments from each discussion and categorized them within the framework of the SEM. Definitions for the SEM factors included the “individual” or the person with hearing loss, “relationship” or the personal connections the individual has with relatives and friends, “community” were the professionals involved with hearing health care, and finally, “society” comprised the general population's role in the promotion and provision of hearing health care.

Compliance With Ethical Standards

This study was approved by the institutional review board of the university (Protocol #20-03-3429 and #21-02-4384). Collected data were de-identified and stored in a password-encrypted computer file. The anonymity and confidentiality of participants were ensured.

Results

Physician Survey Outcomes

The online survey questions and responses are displayed in Table 1. Sixteen family physicians and medicine residents completed the online survey. All participants answered the first question to consent to the study. However, three did not respond to the remaining seven questions related to hearing health care. With respect to the outcomes, most physicians believed their training in medical school related to hearing loss was not sufficient (Question 2), and they were not very comfortable providing information about hearing loss to their patients (Question 3). Generally, though, responding physicians were comfortable referring patients to an audiologist (Question 4). Many physicians were unsure if audiologists presented patients with their percentage of hearing loss, and four responded that the statement was false (Question 5). Although three physicians stated that they were comfortable interpreting an audiogram, the remaining physicians were not all that comfortable doing this task (Question 6). However, the majority of physicians were aware that hearing aids were not appropriate for all types and degrees of hearing loss (Question 7). Finally, most responding physicians believed that cochlear implants were not appropriate for all types and degrees of hearing loss (Question 8).

Physician Focus Group Discussion Outcomes

After transcribing and reviewing the comments as outlined in the methodology, three themes emerged, one with a subtheme. The themes were as follows: “Education for family medicine students and residents,” “physician awareness of issues associated with hearing loss,” and “ease of access for referral.” The codebook for the development of these themes is provided in the Appendix. Comments associated with each theme are provided below along with a de-identified participant number to indicate the variety of responses.

Education for Medicine Students and Residents

The majority of the physicians and residents who contributed to the discussions stated that their knowledge of hearing health care could be improved through education. The participants suggested that information regarding hearing loss and hearing health care could be included in undergraduate courses, graduate coursework, clinical rotations, and guest lecturer sessions for residents and physicians. Thirteen comments were found related to this theme, and below are a few examples.

I think the absence, I wouldn't even say the lack, of education on hearing is just beyond disgraceful in medical curriculum. (Physician 1)

We talk a lot about interprofessional education, but I've never seen an otolaryngologist and an audiologist co-present or co-teach. We may refer to them in each other's presentations, but, you know, maybe there should be a little bit more role modeling of, you know, clinical teaching together. (Physician 2)

I would argue that we will understand audiologists better if we interface with them directly in patient care. (Physician 2)

Subtheme: Logistics and Infrastructure

Within the theme of education, a subtheme regarding logistics and infrastructure comments emerged. It was discussed that family medicine students could complete elective courses, and potentially, a course related to hearing health care could be offered. Four comments were made within this subtheme, with one example below.

In the medical school curriculum, we've got these special topics courses, so I actually can get a third-year student…. They come and do a week with me on that topic. (Physician 3)

Physician Awareness of Issues Associated With Hearing Loss

Although many of the physicians and residents felt that their education was limited regarding hearing loss, they also stated that they desired further understanding of hearing health care beyond anatomy and amplification technology. Seven comments were made from physicians related to the need for increased awareness of hearing loss. One physician provided several comments suggesting that students and medicine residents need a greater understanding of the experiences people with hearing loss have regularly.

…being introduced to hearing loss from the understanding of the personal experience of hearing loss has to go on early in medical education, early in residency education…. (Physician 1)

Brief guides for hearing loss and treatment options were also recommended as a reference if they were unable to easily recall information about hearing health care.

Lectures are great, but I don't know how much I can take in from it and remember it. But if I have something tangible and a reference guide, I can always look back at it and talk to my patients with it together and make it a shared decision. (Physician 4)

Some physicians and residents were interested in providing hearing screenings in their own offices, but some participants were not sure of the relevancy of screening based on published task force recommendations.

I just checked [online], and currently there is no evidence suggesting that there needs to be any regular hearing screen that needs to be conducted [with regard to the U.S. Preventative Services Task Force]. (Physician 5)

Ease of Access for Referral (Comfort in Referring)

Although the physicians and medicine residents discussed a need for further education and awareness of issues associated with hearing loss, many felt comfortable referring to an audiologist. However, if patients required more specific information regarding hearing health care, physicians and residents did not believe they had enough knowledge to answer further questions. Study personnel determined that five comments were related to this theme, and two examples are below.

So, in my older adult population, people will bring it [hearing loss] up to me. I feel relatively comfortable discussing it with them. Yes, this is something that can happen, but then moving forward from there is where I'm a bit limited. (Physician 6)

I feel very comfortable referring to an audiologist…but as far as specifics about hearing aids, the options, don't know a lot about it other than they're very expensive. (Physician 7)

Focus Group Discussions and Interviews With Pharmacists

The comments from these discussions revealed four primary themes after evaluating the transcriptions: “Approximate percentage of people with hearing loss in pharmacy,” “difficulties and strategies for helping people with hearing loss,” “suggested resources to help pharmacists when interacting with people with hearing loss,” and “thoughts on audiology collaboration.” The fourth theme, “thoughts on audiology collaboration,” contained a subtheme, “challenges with collaboration.” The Appendix displays the codes developed for comments from this group of participants. All comments provided below for each theme were from different pharmacists.

Approximate Percentage of People With Hearing Loss in Pharmacy

Pharmacists were likely to have interactions with individuals who had some degree hearing loss in their pharmacies daily, but the number of patients with hearing difficulty that they saw varied. Thirteen comments referenced this theme.

I would say several people each day ‘cause I know we had people come in with hearing aids each day.

I mean, on a daily basis, it varies widely. We have multiple, and sometimes we have none.

At some level of hearing loss, I'd probably say, per month, I'd probably say maybe 100 or so. Maybe 150.

Difficulties and Strategies for Helping People With Hearing Loss

Pharmacists commented that those with hearing loss would sometimes share that they had difficulty hearing. However, if patients did not disclose a hearing loss, the pharmacist might not be aware of it for some time unless they saw a hearing device or recognized signs of hearing loss. Thirty-six comments related to these difficulties and strategies for helping people with hearing loss were provided.

A lot of times they'll tell us, like if we say something and they didn't hear us…. Some of them have a hearing aid, so you can visually see the hearing aid.

I can kind of tell the difference now with someone, you know, actually really upset at us or actually just trying to communicate to us, but only in a way that they can understand.

When interacting with patients who had hearing loss, pharmacists have had to adopt strategies to communicate more effectively including speaking louder and moving closer to the person. Some pharmacists have also utilized visual aids such as written instructions and symbols to assist their patients with understanding appropriate medication adherence.

We'll come down from the pharmacy and go closer to the patient.

Once I've identified that person as someone with hearing loss, I will sort of be prepared when I need to speak with them about their medications. I'll generally have something like the prescription label maybe written out to use it as a visual aid…. I already know to speak loudly and try to articulate it as well as possible what I'm saying.

I have color coded things for patients before especially when it comes to the medicines. You know, this is morning or try to draw a sun on the bottle or a moon.

Although many pharmacists spoke louder to their customers, there were situations when this technique was not effective and could disrupt other patients in the pharmacy.

With six or seven people in the store, people thought I was screaming at this lady which was kind of embarrassing for me that I would be screaming at an old lady.

I've had patients ask real oddball questions that they've just seen on the news, and I hate to answer so loudly because somebody might hear it in the store and then that just alarms everybody.

Suggested Resources to Help Pharmacists When Interacting With People With Hearing Loss

Pharmacists acknowledged that improvements could be made to interact with patients with hearing loss in their stores and recommended various resources. Participants in the discussions suggested handouts for the patients to review from their visit. Pharmacists could also encourage phone calls if patients had questions or needed any information repeated at home. A couple of pharmacists recommended a device that could transcribe their verbal discussion with the patient to a typed message instantaneously in the pharmacy. Pharmacists would also benefit from education regarding hearing health, and training resources were suggested for both pharmacists and staff. Suggestions to include pharmacy technicians in the care of adults with hearing loss also were provided. Eleven statements were associated with this theme.

A little bit better printable material to hand them….

If there was some sort of tablet thing that I could, you know, speak into, and it printed out immediately in an understandable format.

I would love a resource to help, you know, maybe more formally train my staff to accommodate these patients.

Thoughts on Audiology Collaboration

Some pharmacists responded positively to collaborating with audiologists and other hearing health care professionals. Forty statements were determined to be related to this theme.

I think it would be a welcome addition, and pharmacists working with other health care professionals no matter what setting to improve health care is, no matter how it's done, if it's improving health care, then yeah, absolutely you do whatever it takes.

We live in a very, very rural county, you know. And I mean anything basically west of our store, there's not a whole lot, so I don't know that anybody offers any kind of auditory specialty or anything. So I mean, I'd be interested to see what road that would go down for sure.

Subtheme: Challenges With Collaboration

Although most responses were positive, some pharmacists raised concerns regarding the feasibility of incorporating hearing health care into their stores. In total, there were six comments related to this subtheme. It was suggested that pharmacists have many responsibilities and limited time for offering further services. In addition, pharmacists were unsure if their patients would be able to afford the much lower-priced over-the-counter hearing aids.

Pharmacists and pharmacies are busy enough currently. We don't really need to add to that workload, and that's my biggest concern…. While I do see the need and I would love to help with that, I know that my pharmacy is not in a place to provide that consistently at this point in time.

We know there's a significant cost savings with the over-the-counter product…. That's one of the things I looked at before, but even at the time, in our area, the income demographics in the area really wouldn't support it.

Mapping Comments Onto the SEM of Hearing Health Behavior

In addition to organizing the comments into themes, they were assessed for their inclusion within the SEM (Bronfenbrenner, 1979). Within this framework, four domains of the SEM included the individual, relationship, community, and society. The results for this study were obtained from family physicians, medicine residents, and community pharmacists, as opposed to individuals with hearing loss. Consequently, the overall concepts associated with community and society will be highlighted and not the individual or relationship domains.

Findings within the context of the SEM framework are demonstrated in Figure 1. Within the community domain, the general concepts were a lack of health screenings in primary care settings, reference materials for medical professionals, knowledge regarding hearing care professionals and their scope of practice, evidence-based hearing screening recommendations by governing bodies and institutional experts, and educational resources focused on hearing health. In addition, limited time and resources for additional testing in primary care settings as well as a need for interprofessional collaboration were highlighted. Statements regarding society were related to negative stigma associated with hearing loss, poor image associated with hearing aids, and limited insurance coverage for hearing health care expenses.

Figure 1.

The socio-ecological model of hearing health care behavior including features of the Community and Society domains obtained from focus group discussions of the study.

Discussion

The purpose of the study was to understand how access and affordability of hearing health care in rural communities could be increased through collaboration with physicians and pharmacists. Due to the fact that 13% of individuals 12 years of age and older have hearing loss in the United States (National Institutes of Health, 2021), it would not be uncommon for physicians and pharmacists to regularly interact with patients who have some degree of hearing difficulty. Potentially, therefore, hearing health care can be improved through collaborative efforts among audiologists, primary care physicians, and pharmacists. Generally, the results from this study suggested that physicians and community pharmacists could benefit from more education and resources related to hearing health care. Primary care physicians, family medicine residents, and community pharmacists have had very limited interactions with hearing health care professionals, and consequently, there is potential for these professionals to work collaboratively with audiologists to increase access to hearing health care in rural communities. As noted in the focus group discussions though, there are challenges that need to be addressed before an interprofessional model of hearing health care can be developed.

Challenges for Interprofessional Collaboration With Physicians

One of the main hurdles to overcome is the lack of evidence for hearing screenings as outlined by the U.S. Preventive Services Task Force (USPSTF). The USPSTF is a national panel that consists of medical experts representing internal medicine, family medicine, pediatrics, behavioral health, obstetrics and gynecology, and nursing (U.S. Preventive Services Task Force, 1984). A systematic review by this agency determined that hearing screenings did not benefit hearing-related function for adults 50 years of age and older, and that more research is needed to address hearing screening outcomes (Feltner et al., 2021). Because the USPSTF has stated that there is insufficient evidence to recommend hearing screenings, primary care physicians will be reluctant to provide these screenings. In contrast to the USPSTF guidelines, the World Health Organization stated in the document, Hearing Screening: Considerations for Implementation, that the lack of evidence for the importance of conducting hearing screenings underlines the importance of conducting further research across the globe so that the negative effects of hearing loss can be mitigated (World Health Organization, 2021). It was recommended that the hearing screenings be conducted in clinical facilities, including primary care offices, as well as community or home settings.

Areas of Collaboration for Audiology and Medicine

The physicians and residents who participated in this study commented and reported that more education and awareness of hearing health care was needed to increase their involvement in this type of care. The outcomes from the discussions and survey suggested that medicine residents and primary care physicians believed they did not have adequate training in hearing health care. Potential options to increase training included the offering of targeted workshops or short courses about hearing loss and the development of pocket guides to be used when interacting with people who are suspected of having hearing loss.

This lack of education related to hearing health care has been noted by other professionals (Cohen et al., 2005; Smith et al., 2016). Smith et al. (2016) conducted a survey with palliative care professionals, including physicians, nurse practitioners, nurses, social workers, and chaplains and found that 87% of the participants did not conduct hearing screenings of any sort despite believing that hearing loss affected quality of life. It was reported that these professionals did not know how to screen for hearing loss, believed that it would take too long, and that a hearing loss could be detected through conversation (Smith et al., 2016). Similarly, Cohen et al. (2005) reported that 40% of primary care physicians who responded to a survey (N = 85) did not screen for hearing during clinical visits. The top reasons for not screening included the lack of time, more pressing issues to address, and uncertainty of how to screen. Potentially, through short courses or workshops, physician knowledge of hearing loss could be improved so that referrals to hearing specialists would be easily accomplished.

Along with increased education, physicians in the group discussions suggested that more resources could help assuage their reluctance to address hearing loss during wellness visits. Specifically, it was noted that through access to a pocket guide addressing hearing loss, physicians would be more comfortable knowing when and where to refer a patient for hearing health care. Previous literature has suggested that access to informational brochures could improve access to hearing health care. Wallhagen and Strawbridge (2017) used an informational brochure in combination with hearing screenings administered by a nurse in two busy medical clinics to explore means for improving access to hearing health care. They found that roughly half of the physicians referred patients for hearing health care. Generally, the results suggested that with a brochure and hearing screenings conducted at medical clinics, improved access to hearing health care was possible.

Areas of Collaboration for Audiology and Pharmacy

The Food and Drug Administration (FDA) established a new category of hearing aids to be available over the counter (OTC) in 2017 (Berenbrok et al., 2021). In the fall of 2021, the FDA proposed to define OTC hearing aids in a more formal manner (Food and Drug Administration, 2021). It is possible, therefore, that pharmacies will supply these hearing devices to the general public in the near future. However, it will be necessary for pharmacists to have some understanding of hearing health care to successfully provide these devices to their customers. Berenbrok et al. (2021) outlined 26 competency statements to encourage the adequate provision of OTC hearing aids. These statements were divided into six headings, including collect, assess, plan and implement, follow-up, collaborate, and communicate. More specific examples included the identification of ototoxic medications, knowledge of hearing health care interventions, assisting customers with OTC hearing aid selection, managing expectations of OTC hearing aids, explaining the effects of untreated hearing loss, and working collaboratively with audiologists (Berenbrok et al., 2021). The outcomes from our focus group discussions with pharmacists highlighted the need for increased interprofessional collaboration between audiology and pharmacy to address these competency areas.

During the discussions, pharmacists reported various strategies to assist patients with hearing loss, some more successful than others, suggesting that informational workshops or more training could improve interactions with their patients with hearing loss. Pharmacists reported increasing the loudness of their voices, moving closer to the individuals, and writing information for the patient to assist with understanding. Erber (1993) demonstrated that simply speaking louder with a person with hearing loss can cause speech distortion. In addition, the COVID-19 pandemic and mask-wearing have hampered the ability to use visual cues, and consequently, moving closer to an individual with hearing loss might not improve communication. Finally, for those who struggle with literacy issues in rural communities, writing notes might not always be effective. Much of these challenges could be addressed through intervention, including the use of hearing aids, personal sound amplification products, or assistive listening devices.

Pharmacists have very limited, if any, experience with hearing health care. Education regarding hearing loss could improve pharmacists' interactions with patients who have hearing difficulty. Pharmacists suggested resources that would benefit them in their stores for those with hearing loss, including visual aids or speech-to-text technologies. However, it was interesting to note that no amplification products, such as portable sound amplifiers, were considered. Portable sound amplifiers would allow for easier communication between pharmacists and their patients and prevent potential misunderstandings. These devices would also prevent pharmacists from having to raise their voices to be heard, thereby maintaining patient privacy and avoiding personal information being overheard by other customers. Providing pharmacists with greater understanding of hearing loss and how it can be addressed would ultimately improve patient care.

Encouraging to note was that most pharmacists who were interviewed were interested in collaborating with audiologists and other hearing health care professionals to increase access to hearing health care. A few pharmacists, though, had concerns about working with hearing health care professionals. It was noted that with limited time and staff available, an additional service may not be feasible in certain pharmacies. A few pharmacists also expressed concern regarding patient cost associated with treatment options for hearing loss. Traditional hearing aids have typically been cost prohibitive for patients with a restricted income, so the introduction of OTC hearing devices would be a lower cost option for patients. However, as noted by a few pharmacists, some patients may still not be able to afford the lower-cost OTC hearing aids, suggesting that other options for payment would be required. Overall, pharmacists seemed to welcome the opportunity to expand their services and meet the additional of their patients.

SEM of Health Behavior

Applying the general findings of the discussions with physicians and pharmacists to a framework can provide a guide to recognize issues within a given topic, develop appropriate interventions, and evaluate outcomes (U.S. Department of Health and Human Services, 2005). For this study, the SEM was used to organize concepts that arose during discussions. As outlined by Bronfenbrenner (1979), individuals' health behaviors are influenced by their relationships with others, the community where they live, and society in general. For this study, individuals with hearing loss were not interviewed and, therefore, only those features associated with the community and society components that emerged during our discussions were reported. Not surprisingly, more education, resources, and awareness related to hearing loss would benefit health care professionals so that the 26 competencies areas outlined by Berenbrok et al. (2021) can be established. In addition, the general population should have an increased awareness of hearing loss to reduce stigma associated with it.

Limitations

A few limitations of the study bare mentioning. Specifically, although the discussions with 31 participants provided insight to the perception of hearing health care by family medicine residents, family physicians, and community pharmacists, it would be beneficial to continue the discussions with more professionals to further support the current themes, establish themes at the individual and relationship levels by interviewing adults with hearing loss and their impressions of receiving hearing health care through medical facilities and pharmacies, and create additional features to enhance our growing SEM framework. The discussions were also completed virtually instead of meeting in person due to the COVID-19 pandemic. Although participants were encouraged to speak and ask questions, the online format of the discussions could have prevented the free-flowing conversations that in-person meetings may have provided.

Conclusions

Findings from this preliminary research indicate a need for increased education and awareness about hearing health care for medical professionals. Having a greater understanding of hearing loss would increase awareness of issues faced by those who have difficulty hearing, and additional knowledge could decrease stigma associated with hearing loss. However, research is needed to determine how education and resources can be provided effectively to create a sustainable model. It is encouraging to have physicians, residents, and pharmacists support a need for change and a desire to be involved with hearing health care. Outcomes from future planned studies will confirm and solidify the findings presented here related to interprofessional collaborations among audiologists, pharmacists, and physicians.

Author Contributions

Emma B. Brothers: Formal analysis (Equal), Visualization (Equal), Writing – original draft (Lead). Marcia J. Hay-McCutcheon: Conceptualization (Equal), Formal analysis (Equal), Funding acquisition (Lead), Investigation (Equal), Methodology (Equal), Project administration (Lead), Resources (Equal), Visualization (Equal), Writing – review & editing (Lead). Peter J. Hughes: Conceptualization (Equal), Investigation (Equal), Methodology (Equal), Resources (Equal), Writing – review & editing (Supporting). M. Louanne Friend: Conceptualization (Equal), Methodology (Equal), Resources (Equal), Writing – review & editing (Supporting).

Appendix

Codebook

Physician themes	Comments
CODE: Education Definition: The term “education” was coded in relation to enhancing training for students and medicine residents. When to use: Code was applied when participants referenced enhancing education or training for students and residents. NOTE: This code was not used for comments related to improving understanding of how hearing loss might affect individuals (i.e., awareness).	13
SUBCODE: Logistics and Infrastructure Definition: The terms “logistics and infrastructure” were associated with how to enhance education for students and residents. When to use: This subcode was applied to comments that specifically addressed how to improve educational training for students and residents.	4
CODE: Awareness Definition: The code “awareness” was coded for comments associated with physician awareness of hearing loss issues. When to use: Code was applied to comments related to understanding complications associated with hearing loss. NOTE: This code was not used for comments related to enhancing education related to knowledge of hearing loss.	7
CODE: Ease of Referral Definition: This term was associated with how comfortable physicians or how easy it was for physicians to refer their patients for audiological services. When to Use: The code was used for comments about how comfortable or how easy it was for physicians to refer their patients for audiological services and included comments related to what physicians were and were not able to provide to their patients about hearing loss issues.	5
Pharmacy themes
CODE: Number of People With Hearing Loss Definition: The approximate number of people with hearing loss who were regular customers at individual pharmacies. When to Use: Used for comments related to the number of pharmacy customers with hearing loss.	13
CODE: Difficulties and Strategies Definition: This code included comments related to difficulties interacting with people with hearing loss in the pharmacy and strategies that were used to help alleviate communication issues. When to Use: This code was used for comments associated with communication difficulties that occurred when communicating with people with hearing loss. Strategies that helped address the difficult interactions due to hearing loss were also included. Comments related to complicated interactions with someone with hearing loss and mask-wearing were also included in this code.	36
CODE: Suggested Resources Definition: Pharmacists commented on resources or techniques audiologists could provide to help them interact with people who had hearing loss. When to use: This code was used for all comments related to how audiologists could assist pharmacists when interacting with people with hearing loss.	11
CODE: Collaboration With Audiology Definition: The willingness of pharmacists to collaborate with audiologists to improve hearing health care in underserved communities. When to use: Used for comments related to interest or ease of collaborating with audiologists.	40
SUBCODE: Challenges With Collaboration Definition: Financial or logistical complications that would prevent potential collaborations with audiologists. When to use: Comments suggesting that collaboration between pharmacists and audiologists would be challenging or not possible due to financial or practical concerns.	6

Funding Statement

Funding for this study was provided by a grant from the National Institute on Deafness and other Communication Disorders (Grant R21 DC019073) awarded to Marcia J. Hay-McCutcheon. We are indebted to the physicians and pharmacists who provided insightful comments for the advancement of hearing health care in rural communities of the United States.