An Over-the-Counter Hearing Aid Clinical Trial in Rural Alabama: Project Design and Potential Implications for Pharmacy and Audiology Interprofessional Collaborations.

Over-the-counter hearing aids (OTC HAs) have the potential to help adults with perceived mild-to-moderate hearing loss across the US, especially in rural communities, where access to hearing healthcare is extremely limited or non-existent. The purpose of this study was to describe an OTC HA clinical trial being conducted in five rural counties of Alabama and to provide preliminary anecdotal data related to the use and care of these hearing aids by the participants. In brief, for this clinical trial, adults with hearing loss were randomly placed in one of three groups where they received varying levels of support for setting, using, and maintaining their OTC HAs. Listening tests and surveys were administered to assess the extent to which they benefitted from the hearing aids as related to word understanding, communication with others in natural settings, and hearing aid use and care. Currently, anecdotal findings suggested that, although some participants required very little support to successfully use their hearing aids, others had difficulty setting and caring for their devices and could have benefitted from individualized guidance. Future quantitative studies will assess the extent of support needed for successful hearing aid benefit and use. Potentially, collaborations among pharmacy and audiology professionals could lead to increased access to hearing healthcare by supporting the use and purchase of OTC HAs in rural pharmacy settings.

Church Leaders Share and Implement Solution-Focused Health Strategies During the COVID-19 Pandemic in Rural Alabama.

Bridging the healthcare access gap and addressing COVID-19 vaccine hesitancy among rural-dwelling Black American adults residing in the Deep South require involvement of faith-based leaders in the community. This study explored perceived barriers and resources to meeting community needs, including vaccination, during the COVID-19 pandemic as reported by 17 Black American church leaders in the rural West Alabama Black Belt geographic region in May 2022. The main themes that emerged included (1) attending to community impact of COVID-19 illness and death; (2) maximizing health literacy and diminishing vaccine hesitancy through engaging in preventive health practices and sharing public health information; (3) addressing challenges created or exacerbated by COVID-19, including reduction in in-person attendance (particularly among adolescents and young adults), limited access to and literacy with technology, and political perceptions influencing engagement in preventive health behaviors; (4) maximizing technological solutions to increase attendance in the church; and (5) engaging in solution-focused and innovative initiatives to meet the identified needs in the congregation and community. Church leaders in West Alabama rural areas facing economic, health, and technological disparities identified "silver linings" as well as challenges created or exacerbated during the pandemic. As the need for COVID-19 vaccination and booster vaccination continues, Black American church leaders play pivotal roles in meeting rural community needs.

An Assessment of Hearing Health Care Needs in Rural West Central and South Alabama.

PURPOSE: Hearing loss has become a significant public health concern because of its association with physical health, cognition, and emotional well-being. Age-related hearing loss is the third leading cause of global years lived with disability after lower back pain and migraine. Among other sensory disorders, hearing loss is ranked first. To help mitigate these health concerns, access to affordable hearing health care across rural and urban communities will be necessary. METHOD: For this study, the needs of rural communities and their residents with hearing loss were explored. Individual interviews and focus group discussions with 26 adults with hearing loss, 14 friends and family of those with hearing loss, and 25 community members who worked and lived in rural communities were conducted. RESULTS: Collectively, four themes emerged from qualitative analysis of the comments from all three groups, including Communication and Other Related Hearing Loss Issues, Social and Emotional Issues, Dealing with Hearing Loss, and Addressing Hearing Loss in the Community. Factors associated with the themes were mapped onto the Meikirch Model of Health to determine potential areas of intervention within the individual, society, and environment components of the model. CONCLUSION: Future care mitigating health concerns for adults with hearing loss living in rural communities will involve interprofessional collaboration and increased access to hearing health care.

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

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.

Accessibility to Hearing Healthcare in Rural and Urban Populations of Alabama: Perspectives and A Preliminary Roadmap for Addressing Inequalities.

Hearing loss is a growing public health concern and has been associated with poor cardiovascular health, diabetes, increased social isolation and poor cognitive functioning. Addressing this issue, especially in rural communities, will require increased awareness of hearing loss and its link to emotional and physical well-being. The purpose of this study was to understand the challenges that those with hearing loss living in rural and urban communities experience and to examine the feasibility of using primary care physicians to assist with improving access to hearing healthcare in rural communities. One hundred thirty-four participants were recruited from rural and urban counties in West Central and South Alabama. All participants completed a hearing evaluation and a Healthcare and Hearing Healthcare Accessibility Questionnaire. Over half of the adults in the study with hearing loss did not have access to hearing healthcare because of distance to a hearing healthcare professional. Other reasons for participants not having access to hearing healthcare included financial constraints, lack of awareness of having a hearing loss, lack of time to see a hearing healthcare provider, and not knowing how to access a provider. Results, however, revealed that most adults in the study had access to a primary care professional. The primary care provider, therefore, could be a valuable resource for the dissemination of information related to hearing healthcare. Collaborative work with primary care providers will help to develop and expand hearing healthcare awareness, research and services provided through the Here Hear Alabama project, a rural outreach initiative in West Central and South Alabama.

Access to Hearing Health Care, Geographical Residency, and Quality of Life in Adults with and without Hearing Loss.

BACKGROUND: There is an increased interest in the impact that hearing loss has on general well-being, including overall quality of life (QOL), to improve and expand care that is provided to individuals with hearing loss. PURPOSE: To evaluate QOL in adults with and without access to hearing health care (HHC). RESEARCH DESIGN: A cross-sectional study examined QOL across groups of individuals with and without hearing loss. STUDY SAMPLE: One hundred eight participants from West Central and South Alabama received pure-tone hearing evaluations. Thirty-two adults had hearing within normal limits and 76 had at least a mild hearing loss in one ear. DATA COLLECTION AND ANALYSIS: The Quality of Life Inventory (QOLI), the Charlson Comorbidity Index, and an Accessibility to Health Care questionnaire were administered to all participants. The QOLI outcomes were used as the dependent variable for the analysis of covariance (ANCOVA) statistical procedures. RESULTS: For adults with hearing loss who did not have access to HHC, lower QOL scores were reported compared with those with access to HHC, but this finding was not significant. Although ANCOVA results did not suggest QOL differences across geographical regions, effect size calculations indicated that adults with hearing loss who lived in the most rural regions of Alabama had lower reported QOL scores than their counterparts who had hearing within normal limits. Finally, those with higher incomes, who were older, and who had fewer physical disorders reported higher QOL than those with lower incomes, who were younger, and who had more physical ailments. CONCLUSIONS: Adults with hearing loss who live in regions without access to HHC might be at risk for decreased QOL. A number of models for improving access to HHC will be necessary to decrease this potential risk.

Positive Social Interaction and Hearing Loss in Older Adults Living in Rural and Urban Communities.

Purpose: This study explored the extent to which hearing loss affected positive social interactions in older adults living in rural and urban communities. Method: Pure-tone behavioral hearing assessments were administered to 80 adults 60 years of age or older. In addition, all participants completed 2 questionnaires, the Medical Outcomes Study Social Support Survey (Sherbourne & Stewart, 1991) and the Patient Health Questionnaire-Ninth Edition (Kroenke, Spitzer, & Williams, 2001). Results: The preliminary findings suggested that adults with hearing loss living in rural towns had poorer positive social interactions compared with their urban counterparts with hearing loss. Also, adults with hearing loss living in rural towns had more symptoms of depression than adults with normal hearing who lived in these same geographical regions. Conclusions: These preliminary findings could indicate that older adults with hearing loss living in rural communities will face more isolation than adults with hearing loss living in urban settings. Increasing our understanding of the extent of social isolation in adults with hearing loss living in rural and urban populations will be necessary.

Hearing loss and social support in urban and rural communities.

OBJECTIVE: Perceived social support and hearing handicap were assessed in adults with and without hearing loss who lived in different geographical regions of Alabama. DESIGN: The Hearing Handicap Inventory for Adults (HHIA) assessed emotional and social consequences of hearing loss. The Medical Outcomes Study (MOS) Social Support Survey and the Social Functioning, Role Emotional and Mental Health scales of the SF-36 were administered. STUDY SAMPLE: Data were collected from 71 study participants with hearing loss and from 45 adults without hearing loss. RESULTS: Degree of hearing loss and outcomes from the HHIA did not differ between adults who lived in rural or urban settings. Tangible support was poorer for adults with hearing loss who lived in rural settings compared to those who lived in urban settings. For adults without hearing loss, residency was not associated with tangible support. For these adults, income was associated with other types of social support (i.e. informational support, affection, positive social interaction). CONCLUSIONS: Adults with hearing loss living in rural areas had poor perceived tangible support. The provision of support to address a hearing loss could be worse for these adults compared to adults who lived in urban settings.

Performance variability on perceptual discrimination tasks in profoundly deaf adults with cochlear implants.

OBJECTIVES: The purpose of this study was to evaluate performance on two challenging listening tasks, talker and regional accent discrimination, and to assess variables that could have affected the outcomes. STUDY DESIGN: A prospective study using 35 adults with one cochlear implant (CI) or a CI and a contralateral hearing aid (bimodal hearing) was conducted. Adults completed talker and regional accent discrimination tasks. METHODS: Two-alternative forced-choice tasks were used to assess talker and accent discrimination in a group of adults who ranged in age from 30 years old to 81 years old. RESULTS: A large amount of performance variability was observed across listeners for both discrimination tasks. Three listeners successfully discriminated between talkers for both listening tasks, 14 participants successfully completed one discrimination task and 18 participants were not able to discriminate between talkers for either listening task. Some adults who used bimodal hearing benefitted from the addition of acoustic cues provided through a HA but for others the HA did not help with discrimination abilities. Acoustic speech feature analysis of the test signals indicated that both the talker speaking rate and the fundamental frequency (F0) helped with talker discrimination. For accent discrimination, findings suggested that access to more salient spectral cues was important for better discrimination performance. CONCLUSIONS: The ability to perform challenging discrimination tasks successfully likely involves a number of complex interactions between auditory and non-auditory pre- and post-implant factors. To understand why some adults with CIs perform similarly to adults with normal hearing and others experience difficulty discriminating between talkers, further research will be required with larger populations of adults who use unilateral CIs, bilateral CIs and bimodal hearing.

An Exploration of the Associations Among Hearing Loss, Physical Health, and Visual Memory in Adults From West Central Alabama.

Purpose: The purpose of this preliminary study was to explore the associations among hearing loss, physical health, and visual memory in adults living in rural areas, urban clusters, and an urban city in west Central Alabama. Method: Two hundred ninety-seven adults (182 women, 115 men) from rural areas, urban clusters, and an urban city of west Central Alabama completed a hearing assessment, a physical health questionnaire, a hearing handicap measure, and a visual memory test. Results: A greater number of adults with hearing loss lived in rural areas and urban clusters than in an urban area. In addition, poorer physical health was significantly associated with hearing loss. A greater number of individuals with poor physical health who lived in rural towns and urban clusters had hearing loss compared with the adults with other physical health issues who lived in an urban city. Poorer hearing sensitivity resulted in poorer outcomes on the Emotional and Social subscales of the Hearing Handicap Inventory for Adults. And last, visual memory, a working-memory task, was not associated with hearing loss but was associated with educational level. Conclusions: The outcomes suggest that hearing loss is associated with poor physical and emotional health but not with visual-memory skills. A greater number of adults living in rural areas experienced hearing loss compared with adults living in an urban city, and consequently, further research will be necessary to confirm this relationship and to explore the reasons behind it. Also, further exploration of the relationship between cognition and hearing loss in adults living in rural and urban areas will be needed.

Identification of acoustically similar and dissimilar vowels in profoundly deaf adults who use hearing aids and/or cochlear implants: some preliminary findings.

PURPOSE: In this study, the authors examined the effects of aging and residual hearing on the identification of acoustically similar and dissimilar vowels in adults with postlingual deafness who use hearing aids (HAs) and/or cochlear implants (CIs). METHOD: The authors used two groups of acoustically similar and dissimilar vowels to assess vowel identification. Also, the Consonant-Nucleus-Consonant Word Recognition Test (Peterson & Lehiste, 1962) and sentences from the Hearing in Noise Test (Nilsson, Soli, & Sullivan, 1994) were administered. Forty CI recipients with postlingual deafness (ages 31-81 years) participated in the study. RESULTS: Acoustically similar vowels were more difficult to identify than acoustically dissimilar vowels. With increasing age, performance deteriorated when identifying acoustically similar vowels. Vowel identification was also affected by the use of a contralateral HA and the degree of residual hearing prior to implantation. Moderate correlations were found between speech perception and vowel identification performance. CONCLUSIONS: Identification performance was affected by the acoustic similarity of the vowels. Older adults experienced more difficulty identifying acoustically similar confusable vowels than did younger adults. The findings might lend support to the ease of language understanding model (Ronnberg, Rudner, Foo, & Lunner, 2008), which proposes that the quality and perceptual robustness of acoustic input affects speech perception.

Audiovisual asynchrony detection and speech perception in hearing-impaired listeners with cochlear implants: a preliminary analysis.

This preliminary study examined the effects of hearing loss and aging on the detection of AV asynchrony in hearing-impaired listeners with cochlear implants. Additionally, the relationship between AV asynchrony detection skills and speech perception was assessed. Individuals with normal-hearing and cochlear implant recipients were asked to make judgments about the synchrony of AV speech. The cochlear implant recipients also completed three speech perception tests, the CUNY, HINT sentences, and the CNC test. No significant differences were observed in the detection of AV asynchronous speech between the normal-hearing listeners and the cochlear implant recipients. Older adults in both groups displayed wider timing windows, over which they identified AV asynchronous speech as being synchronous, than younger adults. For the cochlear implant recipients, no relationship between the size of the temporal asynchrony window and speech perception performance was observed. The findings from this preliminary experiment suggest that aging has a greater effect on the detection of AV asynchronous speech than the use of a cochlear implant. Additionally, the temporal width of the AV asynchrony function was not correlated with speech perception skills for hearing-impaired individuals who use cochlear implants.

Using early language outcomes to predict later language ability in children with cochlear implants.

The increased access to sound that cochlear implants have provided to profoundly deaf children has allowed them to develop English speech and language skills more successfully than using hearing aids alone. The purpose of this study was to determine how well early postimplant language skills were able to predict later language ability. Thirty children who received a cochlear implant between the years 1991 and 2000 were study participants. The Reynell Developmental Language Scales (RDLS) and the Clinical Evaluation of Language Fundamentals (CELF) were used as language measures. Results revealed that early receptive language skills as measured using the RDLS were good predictors of later core language ability assessed by the CELF. Alternatively, early expressive language skills were not found to be good predictors of later language performance. The age at which a child received an implant was found to have a significant impact on the early language measures, but not the later language measure, or on the ability of the RDLS to predict performance on the CELF measure.

Language skills of profoundly deaf children who received cochlear implants under 12 months of age: a preliminary study.

CONCLUSION: This study demonstrated that children who receive a cochlear implant below the age of 2 years obtain higher mean receptive and expressive language scores than children implanted over the age of 2 years. OBJECTIVE: The purpose of this study was to compare the receptive and expressive language skills of children who received a cochlear implant before 1 year of age to the language skills of children who received an implant between 1 and 3 years of age. SUBJECTS AND METHODS: Standardized language measures, the Reynell Developmental Language Scale (RDLS) and the Preschool Language Scale (PLS), were used to assess the receptive and expressive language skills of 91 children who received an implant before their third birthday. RESULTS: The mean receptive and expressive language scores for the RDLS and the PLS were slightly higher for the children who were implanted below the age of 2 years compared with the children who were implanted over 2 years old. For the PLS, both the receptive and expressive mean standard scores decreased with increasing age at implantation.

Audiovisual Spoken Word Recognition by Children with Cochlear Implants.

This study examined how prelingually deafened children with cochlear implants combine visual information from lipreading with auditory cues in an open-set speech perception task. A secondary aim was to examine lexical effects on the recognition of words in isolation and in sentences. Fifteen children with cochlear implants served as participants in this study. Participants were administered two tests of spoken word recognition. The LNT assessed isolated word recognition in an auditory-only format. The AV-LNST assessed recognition of key words in sentences in a visual-only, auditory-only and audiovisual presentation format. On each test, lexical characteristics of the stimulus items were controlled to assess the effects of lexical competition. The children also were administered a test of receptive vocabulary knowledge. The results revealed that recognition of key words was significantly influenced by presentation format. Audiovisual speech perception was best, followed by auditory-only and visual-only presentation, respectively. Lexical effects on spoken word recognition were evident for isolated words, but not when words were presented in sentences. Finally, there was a significant relationship between auditory-only and audiovisual word recognition and language knowledge. The results demonstrate that children with cochlear implants obtain significant benefit from audiovisual speech integration, and suggest such tests should be included in test batteries intended to evaluate cochlear implant outcomes.

An analysis of the impact of auditory-nerve adaptation on behavioral measures of temporal integration in cochlear implant recipients.

The objective of this study was to determine the impact that auditory-nerve adaptation has on behavioral measures of temporal integration in Nucleus 24 cochlear implant recipients. It was expected that, because the auditory nerve serves as the input to central temporal integrator, a large degree of auditory-nerve adaptation would reduce the amount of temporal integration. Neural adaptation was measured by tracking amplitude changes of the electrically evoked compound action potential (ECAP) in response to 1000-pps biphasic pulse trains of varying durations. Temporal integration was measured at both suprathreshold and threshold levels by an adaptive procedure. Although varying degrees of neural adaptation and temporal integration were observed across individuals, results of this investigation revealed no correlation between the degree of neural adaptation and psychophysical measures of temporal integration.

Audiovisual speech perception in elderly cochlear implant recipients.

OBJECTIVES/HYPOTHESIS: This study examined the speech perception skills of a younger and older group of cochlear implant recipients to determine the benefit that auditory and visual information provides for speech understanding. STUDY DESIGN: Retrospective review. METHODS: Pre- and postimplantation speech perception scores from the Consonant-Nucleus-Consonant (CNC), the Hearing In Noise sentence Test (HINT), and the City University of New York (CUNY) tests were analyzed for 34 postlingually deafened adult cochlear implant recipients. Half were elderly (i.e., >65 y old) and other half were middle aged (i.e., 39-53 y old). The CNC and HINT tests were administered using auditory-only presentation; the CUNY test was administered using auditory-only, vision-only, and audiovisual presentation conditions RESULTS: No differences were observed between the two age groups on the CNC and HINT tests. For a subset of individuals tested with the CUNY sentences, we found that the preimplantation speechreading scores of the younger group correlated negatively with auditory-only postimplant performance. Additionally, older individuals demonstrated a greater reliance on the integration of auditory and visual information to understand sentences than did the younger group CONCLUSIONS: On average, the auditory-only speech perception performance of older cochlear implant recipients was similar to the performance of younger adults. However, variability in speech perception abilities was observed within and between both age groups. Differences in speechreading skills between the younger and older individuals suggest that visual speech information is processed in a different manner for elderly individuals than it is for younger adult cochlear implant recipients.

Intracochlear and extracochlear ECAPs suggest antidromic action potentials.

With experimental animals, the electrically evoked compound action potential (ECAP) can be recorded from multiple sites (e.g., round window, intracranial and intracochlear sites). However, human ECAPs are typically recorded from intracochlear electrodes of the implanted array. To bridge this difference, we obtained ECAPs from cats using both intracochlear and nerve-trunk recording sites. We also sought to determine how recording the site influences the acquired evoked potential and how those differences may provide insight into basic excitation properties. In the main experiment, ECAPs were recorded from four acutely deafened cats after implanting a Nucleus-style banded electrode array. Potentials were recorded from an electrode positioned on the nerve trunk and an intracochlear electrode. We manipulated stimulus level, electrode configuration (monopolar vs bipolar) and stimulus polarity, variables that influence the site of excitation. Intracochlear ECAPs were found to be an order of magnitude greater than those obtained with the nerve-trunk electrode. Also, compared with the nerve-trunk potentials, the intracochlear ECAPs more closely resembled those obtained from humans in that latencies were shorter and the waveform morphology was typically biphasic (a negative peak followed by a positive peak). With anodic monophasic stimuli, the ECAP had a unique positive-to-negative morphology which we attributed to antidromic action potentials resulting from a relatively central site of excitation. We also collected intracochlear ECAPs from twenty Nucleus 24 implant users. Compared with the feline ECAPs, the human potentials had smaller amplitudes and longer latencies. It is not clear what underlies these differences, although several factors are considered.

Comparison of electrically evoked whole-nerve action potential and electrically evoked auditory brainstem response thresholds in nucleus CI24R cochlear implant recipients.

In this study, differences between electrically evoked whole-nerve action potential (EAP) and electrically evoked auditory brainstem response (EABR) measurements within Nucleus CI24R cochlear implant recipients were evaluated. Precurved modiolus-hugging internal electrode arrays, such as the CI24R, are designed to provide more direct stimulation of neural elements of the modiolus. If the electrode array is closer to the modiolus, electrically evoked and behavioral levels might be lower than were previously recorded for the straight electrode array, the CI24M. EAP and EABR growth functions and behavioral levels were obtained for 10 postlingually deafened adults. Results revealed no significant differences between EAP and EABR threshold levels, and these levels were not significantly lower than those obtained using the CI24M.