The prevalence of bilateral hearing loss in the United States in 2019: a small area estimation modelling approach for obtaining national, state, and county level estimates by demographic subgroup.

Background: The goal of this study was to re-estimate rates of bilateral hearing loss Nationally, and create new estimates of hearing loss prevalence at the U.S. State and County levels. Methods: We developed small area estimation models of mild, and moderate or worse bilateral hearing loss in the U.S. using data from the National Health and Nutrition Examination Survey (2001-2012, 2015-2018), the American Community Survey (2019), Census County Business Patterns (2019); Social Security Administration Data (2019); Medicare Fee-for-Service and Advantage claims data (2019); the Area Health Resources File (2019), and other sources. We defined hearing loss as mild (>25 dB through 40 dB), moderate or worse (>40 dB), or any (>25 dB) in the better hearing ear based on a 4-frequency pure-tone-average threshold, and created estimates by age group (0-4, 5-17, 18-34, 35-64, 65-74, 75+), gender, race and ethnicity, state, and county. Findings: We estimated that 37.9 million (95% Uncertainty Interval [U.I.] 36.6-39.1) Americans experienced any bilateral hearing loss; 24.9 million (95% U.I. 23.6-26.0) with mild and 13.0 million (95% U.I. 12.1-13.9) with moderate or worse. The prevalence rate of any hearing loss was 11.6% (95% U.I. 11.2%-12.0%). Hearing loss increased with age. Men were more likely to have hearing loss than women after age 35, and non-Hispanic Whites had higher rates of hearing loss than other races and ethnicities. Higher hearing loss prevalence was associated with smaller population size. West Virginia, Alaska, Wyoming, Oklahoma, and Arkansas had the highest standardised rate of bilateral hearing loss, and Washington D.C., New Jersey, New York, Maryland, and Connecticut had the lowest. Interpretation: Bilateral Hearing loss varies by State and County, with variation associated with population age, race and ethnicity, and population size. Geographic estimates can be used to raise local awareness of hearing loss as a problem, to prioritize areas for hearing loss prevention, identification, and treatment, and to guide future research on the hearing loss risk factors that contribute to these differences. Funding: CDC's National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health.

Newborn Hearing Screening Benefits Children, but Global Disparities Persist.

There is substantial evidence that newborn hearing screening (NHS) reduces the negative sequelae of permanent childhood hearing loss (PCHL) if performed in programs that aim to screen all newborns in a region or nation (often referred to as Universal Newborn Hearing Screening or UNHS). The World Health Organization (WHO) has called in two resolutions for the implementation of such programs and for the collection of large-scale data. To assess the global status of NHS programs we surveyed individuals potentially involved with newborn and infant hearing screening (NIHS) in 196 countries/territories (in the following text referred to as countries). Replies were returned from 158 countries. The results indicated that 38% of the world's newborns and infants had no or minimal hearing screening and 33% screened at least 85% of the babies (hereafter referred to as UNHS). Hearing screening programs varied considerably in quality, data acquisition, and accessibility of services for children with PCHL. In this article, we summarize the main results of the survey in the context of several recent WHO publications, particularly the World Report on Hearing, which defined advances in the implementation of NHS programs in the Member States as one of three key indicators of worldwide progress in ear and hearing care (EHC).

Hearing care and management priority among parents of children with Down syndrome: a grounded theory.

OBJECTIVE: This study qualitatively explored the factors that influence how parents of children who are Deaf or hard-of-hearing with Down syndrome prioritise hearing care and management and developed an associated theory to explain that priority. DESIGN: Grounded theory was used for the purposes of this qualitative study. Data were collected using in-depth interviews which were analysed using a three-tiered qualitative coding process. STUDY SAMPLE: Eighteen mothers of children who are Deaf or hard-of-hearing with Down syndrome participated in this study. RESULTS: The higher the extent of engaged professional support, perception of benefit for child, parent activation, and family engagement, the higher the priority for hearing care and management will likely be among parents of children who are Deaf or hard-of-hearing with Down syndrome. CONCLUSIONS: Understanding how parents of children who are Deaf or hard-of-hearing with Down syndrome decide to prioritise hearing care and management has implications for how hearing health providers and others provide care to parents to enhance priority for hearing-related needs.

Newborn and Infant Hearing Screening Facing Globally Growing Numbers of People Suffering from Disabling Hearing Loss.

Recent prevalence estimates indicate that in 2015 almost half a billion people-about 6.8% of the world's population-had disabling hearing loss and that prevalence numbers will further increase. The World Health Organization (WHO) currently estimates that at least 34 million children under the age of 15 have disabling hearing loss. Based on a 2012 WHO report, approximately 7.5 million of these children were under the age of 5 years. This review article focuses on the importance of high-quality newborn and infant hearing screening (NIHS) programs as one strategy to ameliorate disabling hearing loss as a global health problem. Two WHO resolutions regarding the prevention of deafness and hearing loss have been adopted urging member states to implement screening programs for early identification of ear diseases and hearing loss in babies and young children. The effectiveness of these programs depends on factors such as governmental mandates and guidance; presence of a national committee with involvement of professionals, industries, and stakeholders; central oversight of hearing screening; clear definition of target parameters; presence of tracking systems with bi-directional data transfer from screening devices to screening centers; accessibility of pediatric audiological services and rehabilitation programs; using telemedicine where connectivity is available; and the opportunity for case discussions in professional excellence circles with boards of experts. There is a lack of such programs in middle- and low-income countries, but even in high-income countries there is potential for improvement. Facing the still growing burden of disabling hearing loss around the world, there is a need to invest in national, high-quality NIHS programs.

What Contribution Did Economic Evidence Make to the Adoption of Universal Newborn Hearing Screening Policies in the United States?

Universal newborn hearing screening (UNHS), when accompanied by timely access to intervention services, can improve language outcomes for children born deaf or hard of hearing (D/HH) and result in economic benefits to society. Early Hearing Detection and Intervention (EHDI) programs promote UNHS and using information systems support access to follow-up diagnostic and early intervention services so that infants can be screened no later than 1 month of age, with those who do not pass their screen receiving diagnostic evaluation no later than 3 months of age, and those with diagnosed hearing loss receiving intervention services no later than 6 months of age. In this paper, we first document the rapid roll-out of UNHS/EHDI policies and programs at the national and state/territorial levels in the United States between 1997 and 2005. We then review cost analyses and economic arguments that were made in advancing those policies in the United States. Finally, we examine evidence on language and educational outcomes that pertain to the economic benefits of UNHS/EHDI. In conclusion, although formal cost-effectiveness analyses do not appear to have played a decisive role, informal economic assessments of costs and benefits appear to have contributed to the adoption of UNHS policies in the United States.

Trends in Hearing Loss Among Adolescents.

OBJECTIVES: Our aim with this article is to evaluate whether the prevalence of hearing loss is increasing among adolescents living in the United States. METHODS: All available data about hearing loss among adolescents from the large, federally funded National Health and Nutrition Examination Survey (NHANES) were analyzed. By using the 4 data releases between 1994 and 2010 (a total of 6891 adolescents), the prevalence of adolescent hearing loss >15 and ≥25 dB at low frequencies (0.5, 1, and 2 kHz) and high frequencies (3, 4, 6, and 8 kHz) for bilateral, unilateral, and any loss were calculated. RESULTS: Only 13 of 90 comparisons of prevalence across combinations of degree, frequency, and laterality of hearing loss revealed a statistically significant increase at P < .05. Among the 18 subgroups of degree, frequency, and laterality, 61% had a lower prevalence of hearing loss in 2010 than in 1994, and 100% of the subgroups had a lower prevalence in 2010 than in 2006. CONCLUSIONS: With previous analyses of NHANES data from 1994 to 2006, researchers showed that hearing loss among US adolescents was increasing. Based on the NHANES data from 1994 to 2010 that are now available, there is no consistent evidence that hearing loss among adolescents in the United States is increasing. Results reveal that conclusions about trends using data from 2 time points can be misleading. NHANES should resume collecting audiometric data as part of their data collection protocol so that trends in the prevalence of childhood hearing loss can be documented.

Parent perceptions of their child's communication and academic experiences with cochlear implants.

OBJECTIVE: To explore parent perceptions of communication and academic experiences of cochlear implant (CI) recipients under the age of 18. DESIGN: Cross-sectional survey design. Two surveys (K-12, birth-5) queried parent perceptions of the impact of CI on communication, listening in various environments and academic achievement. Surveys contained 16-23 multiple choice and/or Likert ratings, plus four open-ended questions to assess reasons for obtaining a CI, satisfaction with CI and suggestions for professionals. STUDY SAMPLE: Surveys were sent to 156 parents of CI recipients; 81 surveys returned; response rate 52%. RESULTS: According to parent report, 95% of K-12 children and 100% of preschool children used spoken language as their primary mode of communication; majority of K-12 children performed same as or better than peers across academic subjects; 99% of respondents were pleased with their decision to obtain a CI. The most important reasons reported for choosing CIs were for their child to use the same language as their families and to effectively communicate in hearing society. Satisfaction with CI was better in quiet than in noise. Respondents stressed the importance of audiologists having excellent skills in CI management and programming. CONCLUSIONS: Respondents were positive about the benefits of obtaining CI for their child.

The effectiveness of commercial desiccants and uncooked rice in removing moisture from hearing aids.

OBJECTIVE: In many low- and middle-income countries, the availability of hearing technology is limited, with few options for hearing aid repairs. Minimising moisture damage to hearing aid electronics improves function and longevity; however, desiccants that absorb moisture from hearing aid components are unavailable in many regions. This study compared the effectiveness of uncooked white rice and seven commercial silica gel desiccants in removing moisture from hearing aids. DESIGN: Relative humidity measurements in a test chamber were obtained from a water-saturated BTE hearing aid prior to and after placement in uncooked white rice and seven different silica gel desiccants. STUDY SAMPLE: Two BTE hearing aids, seven silica gel desiccants and white rice comprised the study sample. RESULTS: All desiccants and the white rice were effective in removing moisture from hearing aids, with Hal Hen Super Dri Aid showing the largest mean reduction in relative humidity. Based on analysis of covariance results, white rice was statistically similar to several of the commercial desiccants. CONCLUSIONS: White rice shows promise as an effective alternative to commercial desiccants in reducing moisture in hearing aids when silica gel products are unavailable. As this study was conducted in a relatively dry region, additional research may be needed.

Pediatric Hearing Aid Management: Parent-Reported Needs for Learning Support.

OBJECTIVES: The aim of this study was to investigate parent learning and support needs related to hearing aid management for young children, and factors that influence parent-reported hours of hearing aid use. DESIGN: A cross-sectional survey design was used to collect survey data in seven states. The child's primary caregiver completed a demographic form, a questionnaire to explore parent learning and support needs as well as their challenges with hearing aid use, and the patient health questionnaire to identify symptoms of depression. Three hundred and eighteen parents completed the questionnaires. RESULTS: Responses were analyzed for 318 parents of children (M = 23.15 months; SD = 10.43; range: 3 to 51) who had been wearing hearing aids (M = 15.52; SD = 10.11; range: <1 to 50 months). Even though the majority of parents reported receiving the educational support queried, approximately one-third wanted more information on a variety of topics such as loaner hearing aids, what their child can/cannot hear, financial assistance, how to meet other parents, how to do basic hearing aid maintenance, and how to keep the hearing aids on their child. The most frequently reported challenges that interfered with hearing aid use (rated often or always) were child activities, child not wanting to wear the hearing aids, and fear of losing or damaging the hearing aids. Forty-two percent of parents reported that, on good days, their child used hearing aids all waking hours. Multiple regression was used to compare the effect on parent-reported typical hours of hearing aid use based on good days for the variables of (1) presence of depressive symptoms for the parent, (2) child age, (3) family income, (4) primary caregiver education level, (5) presence of additional disabilities for the child, (6) degree of hearing loss, and (7) length of time since the child was fitted with hearing aids. There were statistically significantly fewer hours of reported hearing aid use when parents reported mild to severe symptoms of depression, lower income, less education level, and when children had mild hearing loss or additional disabilities. CONCLUSION: Although parents reported overall that their needs for hearing aid education and support had generally been met, there were important suggestions for how audiologists and other service providers could better meet parent needs. Hearing aid use for young children was variable and influenced by a variety of factors. Understanding parent experiences and challenges can help audiologists more effectively focus support. Audiologists are more likely to meet the needs of families if they take care to provide access to thorough and comprehensive education and ongoing support that is tailored to address the unique needs of individual families.

Pediatric hearing aid use: parent-reported challenges.

OBJECTIVES: The aim of this study was to investigate parent-reported challenges related to hearing aid management and parental psychosocial characteristics during the first 3 years of the child's life. DESIGN: Using a cross-sectional survey design, surveys were distributed to parents of children with hearing loss via state Early Intervention programs in Utah and Indiana. Packets contained one family demographic form and two sets of three questionnaires to obtain responses from mothers and fathers separately: the Parent Hearing Aid Management Inventory explored parent access to information, parent confidence in performing skills, expectations, communication with the audiologist, and hearing aid use challenges. The Acceptance and Action Questionnaire measured psychological flexibility, experiential avoidance, and internal thought processes that can affect problem-solving ability and decrease an individual's ability to take value-based actions. The Patient Health Questionnaire identified symptoms of depression. Thirty-seven families completed questionnaires (35 mothers and 20 fathers). RESULTS: Most responses were parents of toddlers (M = 22 months) who had been wearing binaural hearing aids for an average of 15 months. Both mothers and fathers reported that even though the amount of information they received was overwhelming, most (84%) preferred to have all the information at the beginning, rather than to receive it over an extended time period. Parents reported an array of challenges related to hearing aid management, with the majority related to daily management, hearing aid use, and emotional adjustment. Sixty-six percent of parents reported an audiologist taught them how to complete a listening check using a stethoscope, however, only one-third reported doing a daily hearing aid listening check. Both mothers and fathers reported a wide range of variability in their confidence in performing activities related to hearing aid management, and most reported minimal confidence in their ability to troubleshoot hearing aid problems. More than half of the parents reported child behavior and activities, such as playing outside, as a major hearing aid use challenge. Parents reported hearing aids were worn all waking hours by 35% of children and less than 5 hr/day by 31%. Almost half of the parents (47%) did not feel that they had enough time to talk about their emotions when speaking with their audiologist(s), 69% reported the audiologist did not help them know what to expect related to emotions about their child's hearing loss, and 22% reported symptoms of depression. CONCLUSIONS: Parents reported an array of challenges, even after their child had been wearing hearing aids for a prolonged time, revealing critical implications for how to provide audiological care. Audiologists have an important role in partnering with parents to identify and jointly problem-solving challenges related to their child's hearing aid use. Supporting parents includes not only addressing technical aspects of hearing testing and hearing aid function but also addressing parent thoughts, feelings, and emotions.

Measuring Costs and Outcomes of Tele-Intervention When Serving Families of Children who are Deaf/Hard-of-Hearing.

BACKGROUND: Optimal outcomes for children who are deaf/hard-of-hearing (DHH) depend on access to high quality, specialized early intervention services. Tele-intervention (TI), the delivery of early intervention services via telehealth technology, has the potential to meet this need in a cost-effective manner. METHOD: Twenty-seven families of infants and toddlers with varying degrees of hearing loss participated in a randomized study, receiving their services primarily through TI or via traditional in-person home visits. Pre- and post-test measures of child outcomes, family and provider satisfaction, and costs were collected. RESULTS: The TI group scored statistically significantly higher on the expressive language measure than the in-person group (p =.03). A measure of home visit quality revealed that the TI group scored statistically significantly better on the Parent Engagement subscale of the Home Visit Rating Scales-Adapted & Extended (HOVRS-A+; Roggman et al., 2012). Cost savings associated with providing services via TI increased as the intensity of service delivery increased. Although most providers and families were positive about TI, there was great variability in their perceptions. CONCLUSIONS: Tele-intervention is a promising cost-effective method for delivering high quality early intervention services to families of children who are DHH.

Midwives' knowledge, attitudes, and practices related to newborn hearing screening.

INTRODUCTION: Hearing loss is the most common congenital condition screened for at birth in the United States, and more than 95% of newborns are currently screened for hearing. Newborn hearing screening is most effective when infants receive timely and effective interventions. Unfortunately, follow-up rates for newborns not passing their initial hearing screenings are as low as 50% in some states. Midwives are well-positioned to encourage families to follow-up with their neonatal providers when newborns are referred for further testing. Newborn hearing screening is a relatively new practice in the United States and, to date, there has been no research regarding the informational needs and practices of certified nurse-midwives or certified midwives related to hearing screening. This study examined the knowledge, attitudes, and follow-up practices of midwives related to newborn hearing screening and intervention. METHODS: A survey instrument was developed and sent to 5255 American College of Nurse-Midwives members in 50 states and 2 territories. RESULTS: Five hundred and eighteen surveys were returned, yielding a response rate of 9.9%. Only 68% of respondents said it was very important to screen all newborns for hearing loss. Respondents reported significant gaps in their knowledge about screening procedures, steps for referral, and the availability of resources when newborns did not pass the test. Midwives also reported the need for information about hearing loss conditions and genetics, screening guidelines, protocols for follow-up, referral networks, and therapies available. DISCUSSION: Current practices in newborn hearing screening and intervention programs can be enhanced by strengthening the basic midwifery knowledge of and rationale for follow-up when newborns fail their hearing screenings. Midwives can play an integral role in optimizing hearing, speech, and family interaction by assuring that each newborn has access to the best hearing screening and referrals.

Evaluation of the universal newborn hearing screening and intervention program.

During the last 20 years, the number of infants evaluated for permanent hearing loss at birth has increased dramatically with universal newborn hearing screening and intervention (UNHSI) programs operating in all US states and many territories. One of the most urgent challenges of UNHSI programs involves loss to follow-up among families whose infants screen positive for hearing loss. We surveyed 55 state and territorial UNHSI programs and conducted site visits with 8 state programs to evaluate progress in reaching program goals and to identify barriers to successful follow-up. We conclude that programs have made great strides in screening infants for hearing loss, but barriers to linking families of infants who do not pass the screening to further follow-up remain. We identified 4 areas in which there were barriers to follow-up (lack of service-system capacity, lack of provider knowledge, challenges to families in obtaining services, and information gaps), as well as successful strategies used by some states to address barriers within each of these areas. We also identified 5 key areas for future program improvements: (1) improving data systems to support surveillance and follow-up activities; (2) ensuring that all infants have a medical home; (3) building capacity beyond identified providers; (4) developing family support services; and (5) promoting the importance of early detection.

Federal privacy regulations and the provision of Early Hearing Detection and Intervention programs.

To be successful, Early Hearing Detection and Intervention (EHDI) programs require individually identifiable information about children to be shared among people who are responsible for screening, diagnosis, early intervention, family support, and medical home services. Pediatricians and other stakeholders in the EHDI process often point to federal laws that were passed to ensure privacy and confidentiality in health care and educational programs as major obstacles to achieving efficient and effective EHDI programs. In this article we summarize the provisions of 3 federal laws (the Health Insurance Portability and Accountability Act [HIPAA], the Family Education Rights and Privacy Act [FERPA], and Part C privacy regulations of the Individuals With Disabilities Education Act [IDEA]) that most directly affect information-sharing in EHDI programs. We suggest strategies for sharing the information needed to operate successful EHDI programs while remaining in compliance with these laws, including obtaining signed parental consent to share information between providers, including an option on the individual family services plan for parents to permit sharing of the plan with pediatricians and other providers, and giving copies of all relevant test results to parents to share with providers as they wish.

Medicaid reimbursement of hearing services for infants and young children.

As newborn hearing-screening programs have expanded, more and more infants and young children need hearing services. Medicaid is one of the primary sources of funding for such services and, by law, must establish payment rates that are sufficient to enlist enough providers to provide services. In this study we compared 2005 Medicaid reimbursement rates for hearing services for infants and young children in 15 states with the payment rates for the same services by Medicare and commercially available health insurance. On average, Medicaid rates for the same services were only 67 as high as Medicare and only 38 as high as commercial fees. Furthermore, most Medicaid rates declined from 2000 to 2005, and many states did not have billing codes for a significant number of the hearing services needed by infants and young children. These factors likely contribute to infants and young children with hearing loss not being able to get the hearing services they need to benefit from early identification of hearing loss. These data also raise questions about the extent to which states are meeting the federal requirement that Medicaid payments be sufficient to enlist enough providers so that care and services are adequately available to the general population in the geographic area.

Teleintervention for infants and young children who are deaf or hard-of-hearing.

Advancements in videoconferencing equipment and Internet-based tools for sharing information have resulted in widespread use of telemedicine for providing health care to people who live in remote areas. Given the limited supply of people trained to provide early-intervention services to infants and young children who are deaf or hard-of-hearing, and the fact that many families who need such services live significant distances from each other and from metropolitan areas, such "teleintervention" strategies hold promise for providing early-intervention services to children who are deaf or hard-of-hearing. Unfortunately, little is known about the cost-effectiveness of such teleintervention services. In this article we outline the rationale for using teleintervention services for children who are deaf or hard-of-hearing, describe a teleintervention program that has been serving relatively large numbers of children in Australia since 2002, and summarize what we know about the cost-effectiveness of such an approach. We conclude by summarizing the type of research needed to decide whether teleintervention should be used more frequently with children who are deaf or hard-of-hearing and the potential relevance of the teleintervention approach for the development of intervention systems in the United States.

Ensuring financial access to hearing AIDS for infants and young children.

Many young children with permanent hearing loss do not receive hearing aids and related professional services, in part because of public and private financing limitations. In 2006 the Children's Audiology Financing Workgroup was convened by the National Center for Hearing Assessment and Management to evaluate and make recommendations about public and private financing of hearing aids and related professional services for 0- to 3-year-old children. The workgroup recommended 4 possible strategies for ensuring that all infants and young children with hearing loss have access to appropriate hearing aids and professional services: (1) clarify that the definition of assistive technology, which is a required service under Part C of the Individuals With Disabilities Education Act (IDEA), includes not only analog hearing aids but also digital hearing aids with appropriate features as needed by young children with hearing loss; (2) clarify for both state Medicaid and Children's Health Insurance Programs that digital hearing aids are almost always the medically necessary type of hearing aid required for infants and young children and should be covered under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program; (3) encourage the passage of private health insurance legislative mandates to require coverage of appropriate digital hearing aids and related professional services for infants and young children; and (4) establish hearing-aid loaner programs in every state. The costs of providing hearing aids to all 0- to 3-year old children in the United States are estimated here.

The evolution of early hearing detection and intervention programs in the United States.

Identifying and treating children with congenital hearing loss during the first few months of life is a relatively new concept. To assist states in the development of statewide Early Hearing Detection and Intervention programs, the federal government provides grants and/or cooperative agreements to almost all states and has established "National Goals, Program Objectives and Performance Measures" to guide the development and implementation of those systems. This article reviews the history of newborn hearing screening programs in the United States, summarizes the content of legislation and regulations passed by states related to universal newborn hearing screening, and describes how well each National Goal has been addressed. Although substantial progress has been made in the percentage of infants screened for hearing loss before hospital discharge, significant improvement is needed with respect to the availability of pediatric audiologists, implementation of effective tracking and data management systems, program evaluation and quality assurance, availability of appropriate early intervention programs, and linkages with medical home providers.