Publications

This study examined state-level Medicaid hearing aid coverage for adults ages twenty-one and older across the United States. Using policy surveillance principles, we compiled a cross-sectional data set detailing hearing aid coverage policies from fifty states and Washington, D.C., as of December 31, 2023. We then merged these data with individual-level American Community Survey data to estimate national rates of Medicaid hearing aid coverage and identify how coverage varies according to demographic characteristics. We identified thirty-two states with Medicaid hearing aid coverage for adults, with substantial variability in policy features of that coverage. Approximately 70 percent of Medicaid beneficiaries ages twenty-one and older lived in a state with coverage. Women, working-age adults, and Black adults had slightly lower odds of coverage, whereas Hispanic and Latino and other or multiple race beneficiaries had higher odds of coverage. Expanding and standardizing Medicaid coverage of hearing aid benefits in line with best practices could improve access and utilization.

IMPORTANCE: Hearing loss is a significant public health issue, affecting 23% of individuals 12 years and older in the US. While hearing loss can be efficaciously treated in many cases, shortages in the supply of hearing health care (HHC) professionals may limit uptake.

OBJECTIVE: To quantify the US HHC professional workforce from 2012 to 2022 and identify areas experiencing HHC professional shortages in 2019.

DESIGN, SETTING, AND PARTICIPANTS: In this quality improvement study, raw data from the National Plan and Provider Enumeration System were transformed to create a state- and county-level database of HHC professionals, including audiologists and hearing instrument specialists from 2012 to 2022, to assess HHC workforce supply. To assess HHC workforce demand, 2019 state- and county-level hearing loss prevalence data from Sound Check and US Census population data were used. Shortage areas were determined by comparing these measures of supply and demand in 2019. The audiologists and hearing instrument specialists included possessed National Provider Identifiers, allowing them to bill public and private insurance in the US. The data were analyzed between August 2022 and December 2024.

MAIN OUTCOMES AND MEASURES: Potential-shortage areas were defined using a threshold of 1 or fewer audiologists per 3500 individuals with hearing loss, and shortage areas were defined using a threshold of 1 or fewer HHC professionals per 3500 individuals with hearing loss.

RESULTS: From 2012 to 2022, the number of HHC professionals in the US increased from 16 770 to 30 704, or more than 83%. By the end of 2022, 72.4% of the HHC workforce were audiologists, and 27.6% were hearing instrument specialists, compared to 82.6% and 17.4%, respectively, in 2012. In June 2019, 75.0% of US counties were identified as shortage counties, and these counties were disproportionately rural. Ten states, primarily in the South Census region, are identified as shortage states.

CONCLUSIONS AND RELEVANCE: This quality improvement study showed that despite workforce growth, many areas of the US continue to experience shortages of HHC professionals, disproportionately affecting rural populations. Addressing these shortages may improve access to care for individuals with hearing loss.

OBJECTIVES: Hearing loss is a highly prevalent condition; however, it is widely under-treated, and Black Americans have been found to have significantly lower rates of hearing aid utilization than other ethnic/racial groups. In this exploratory study, we aimed to identify hearing health beliefs among Black adults, guided by the Health Belief Model, with social determinants of health, and examine individual differences in these perspectives.

DESIGN: The Hearing Beliefs Questionnaire (HBQ) was administered online to measure constructs of the Health Belief Model among 200 Black adults aged 18 to 75 ( M = 39.14, SD = 14.24). Approximately 13% reported hearing difficulty. In addition, 11 social determinants of health questions were included. Participants were recruited from a university otolaryngology clinic and local Black congregations, meeting inclusion criteria of being 18 or older and Black/African American. Mean scores and SDs for HBQ subscales were calculated. Analysis included analysis of variance and t tests to explore relationships with demographic variables and social determinants of health. Multiple regression analyses predicted HBQ subscale scores from sociodemographic variables.

RESULTS: Mean HBQ subscale scores ranged from 3.88 (SD = 2.28) for Perceived Barriers to 6.76 (SD = 1.93) for Perceived Benefits. Positive correlations were observed between Perceived Severity, Perceived Benefits, and Perceived Self-Efficacy scores and participant educational attainment. Lower economic stability was correlated with poorer scores in Perceived Self-Efficacy, Perceived Severity, and Perceived Benefits. Black adults' willingness to purchase a hearing aid was heavily influenced by their Perceived Benefit, Perceived Severity, and Perceived Self-Efficacy scores, with lower scores correlating with unwillingness to purchase devices. Higher frequency of racism/discrimination and financial hardship correlated with increased Perceived Barriers scores for accessing hearing healthcare. In addition, hearing health beliefs between participants with self-reported hearing difficulty and those without trouble only exhibited differences in the Perceived Susceptibility subscale, with those experiencing hearing difficulty having higher scores in this subscale; no other distinctions were identified.

CONCLUSIONS: The Health Belief Model, used with social determinants of health, revealed associations, and variations, in the hearing health beliefs held by Black adults. The present investigation reveals heterogeneity within this group and pinpoints individuals at higher risk for untreated hearing loss, stemming from their negative perceptions about hearing healthcare. These beliefs are influenced by demographics and social determinants of health, underscoring areas ripe for intervention.

BACKGROUND AND OBJECTIVES: To better understand racial/ethnic disparities in hearing aid use, we examined racial differences in discrepancies between subjective hearing ratings and objective hearing tests as a potential source of this disparity.

RESEARCH DESIGN AND METHODS: A cross-sectional assessment was conducted using the data from the Health and Retirement Study (HRS). Our analytic sample included 2,568 participants aged 50 and older: 1,814 non-Hispanic White Americans and 754 non-Hispanic Black Americans. Discordant groups were identified based on self-ratings of hearing abilities (positive vs negative) and objective hearing test results (normal vs hearing loss).

RESULTS: Analysis of HRS data revealed that approximately 73% of participants with objectively measured hearing loss reported positive hearing ratings. False positive hearing rates were found to be 80% among Black older adults and 70% among their White counterparts. Odds for false positive hearing ratings were significantly greater for Black older adults, men, those with less than a high school education, more health conditions and depressive symptoms, and current smoking. Racial differences were maintained after adjustment for these covariates.

DISCUSSION AND IMPLICATIONS: While cost of hearing aids has been a predominant explanation of low hearing aid use in Black Americans, false positive perceptions of hearing abilities may also play a significant role as a psychosocial mechanism. Future studies examining racial/ethnic differences in possible psychosocial mechanisms for discrepancies between objective and subjective hearing could guide the development and evaluation of culturally appropriate educational interventions.

BACKGROUND: Age-related hearing loss is common among older adults and may influence physical activity and sedentary behaviors, such as TV viewing. This study examined whether a hearing intervention could affect these behaviors over 3 years.

METHODS: A total of 977 participants (mean age of 76.8, 53.5% female, 11.5% Black), recruited from the ARIC study (n = 238) and de novo (n = 739) with hearing loss (pure-tone average = 39.4 dB), were randomized to a hearing intervention or a health education control group. Physical activity, leisurely walking, and TV viewing were interrogated at baseline and 3-year follow-up. We used regression models adjusted for demographic and hearing loss severity to examine the impact of the intervention on the change in the frequency of engaging in these activities.

RESULTS: At baseline, 57.6% of participants engaged in moderate-to-vigorous physical activity (MVPA), 29.1% in high-frequency leisurely walking, and 46.8% in high-frequency TV viewing. Over 3 years, MVPA decreased to 48.8%, whereas leisurely walking and TV viewing increased. After 3 years, the hearing intervention group had similar odds of engaging in MVPA (ratio of odds ratios [ROR] = 1.03, 95% confidence interval [CI], 0.93-1.14), leisurely walking (ROR = 1.04, 95% CI, 0.93-1.17), and TV viewing (ROR = 0.95, 95% CI, 0.87-1.02) compared with the control group. Results were consistent across recruitment sources (ARIC and de novo).

CONCLUSION: A hearing intervention did not significantly influence physical activity, walking, or TV viewing behaviors in older adults over 3 years. Additional strategies may be needed to change physical and sedentary behaviors in this population.

BACKGROUND: Hearing loss is prevalent in older adults and is associated with reduced daily physical activity, but whether hearing intervention attenuates declines in physical activity is unknown. We investigated the 3-year effect of a hearing intervention versus a health education control on accelerometer-measured physical activity in older adults with hearing loss.

METHODS: This secondary analysis of the ACHIEVE randomized controlled trial included 977 adults aged 70-84 years with hearing loss. Participants were randomized to either a hearing intervention group or a health education control group. Physical activity was measured using wrist-worn accelerometers at baseline, 1, 2, and 3 years. Linear mixed models assessed the impact of the intervention on changes in total activity counts, active minutes per day, and activity fragmentation.

RESULTS: Among 847 participants in the final analysis (mean age 76.2 years; 440 [52%] women; 87 [10%] Black; 5 [0.8%] Hispanic), total activity counts declined by 2.7% annually, and active minutes/day declined by 2.1% annually over 3 years in both intervention and control groups. Activity patterns also became more fragmented over time. No appreciable differences were observed between hearing intervention and health education control in the 3-year change in accelerometry-measured physical activity measures.

CONCLUSIONS: Hearing intervention did not appreciably attenuate 3-year declines in physical activity compared to health education control in older adults with hearing loss. Alternative strategies beyond hearing treatment may be needed to enhance physical activity among older adults with hearing loss.

BACKGROUND: Hearing loss is highly prevalent among older adults and has been associated with an increased likelihood of falling. We aimed to examine the effect of a hearing intervention on falls over 3 years among older adults in a secondary analysis of the ACHIEVE study.

METHODS: The Aging and Cognitive Health Evaluation in Elders (ACHIEVE) study was a 3-year, unmasked, randomised controlled trial of adults aged 70-84 years at enrolment with untreated hearing loss and without substantial cognitive impairment. Participants were recruited at four US community-based field sites from two study populations: (1) an ongoing observational study of cardiovascular health (Atherosclerosis Risk in Communities [ARIC] study), and (2) de novo from the community. Participants were randomly assigned (1:1) to a hearing intervention (audiological counselling and provision of hearing aids) or a health education control (didactic education and enrichment activities covering chronic disease prevention topics). A prespecified exploratory outcome was falls. Self-reported falls in the past 12 months were assessed at baseline and annually for 3 years, and analysed by intention to treat with covariate adjustment. The study was registered with ClinicalTrials.gov, NCT03243422, and is completed.

FINDINGS: Between Nov 9, 2017, and Oct 25, 2019, 3004 individuals were screened for eligibility and 977 (238 [24%] from the ARIC study and 739 [76%] de novo) were randomly assigned, with 490 (50%) in the hearing intervention group and 487 (50%) in the health education control group. Overall mean age was 76·8 years (SD 4·0), 523 (54%) participants were female and 454 (46%) were male, and 112 (11%) were Black, 858 (88%) were White, and seven (1%) were other race. In adjusted analyses, the intervention group had a 27% reduction in the mean number of falls over 3 years compared with the control group (intervention group: 1·45 [95% CI 1·28 to 1·61]; control group: 1·98 [1·82 to 2·15]; mean difference: -0·54 [95% CI -0·77 to -0·31]). This 3-year effect of hearing intervention was consistent across both the ARIC and de novo study populations.

INTERPRETATION: Hearing intervention versus a health education control was associated with a reduction in the mean number of falls over 3 years in older adults. Ongoing follow-up of ACHIEVE participants in a separate follow-up study (NCT05532657) will enable examination of the longer term effects of hearing intervention on falls.

FUNDING: US National Institutes of Health.

INTRODUCTION: Results from the Aging and Cognitive Health Evaluation in Elders (ACHIEVE) trial suggest hearing intervention may not reduce 3-year cognitive decline in all older adults with hearing loss but may be beneficial in certain groups. This secondary analysis investigated if participants with multiple risk factors for cognitive decline received greater benefits.

METHODS: We used a sample of dementia-free participants (N = 2692) from the Atherosclerosis Risk in Communities (ARIC) cohort to develop a predictive model for cognitive decline. The model was applied to baseline measures of ACHIEVE participants (N = 977) to estimate predicted risk. We tested an interaction between predicted risk and randomization to hearing intervention or health education control.

RESULTS: Among ACHIEVE participants in the top quartile of predicted risk, 3-year cognitive decline in the hearing intervention was 61.6% (95% confidence interval [CI]: 33.7%-94.1%) slower than the control.

DISCUSSION: The effect of hearing intervention on reducing 3-year cognitive decline was greatest among individuals with multiple baseline risk factors associated with faster cognitive decline.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03243422 HIGHLIGHTS: The Aging and Cognitive Health Evaluation in Elders (ACHIEVE) trial tested the effect of hearing intervention on cognitive decline. Participants were recruited from the Atherosclerosis Risk in Communities (ARIC) cohort or de novo from the local community. A 48% reduction in cognitive decline was observed in ARIC cohort participants. In this secondary analysis, there was an interaction between hearing intervention and predicted risk of cognitive decline. Among participants in the top quartile of predicted risk of cognitive decline, hearing intervention slowed cognitive decline by 62%.

IMPORTANCE: Promoting social connection among older adults is a public health priority. Addressing hearing loss may reduce social isolation and loneliness among older adults.

OBJECTIVE: To describe the effect of a best-practice hearing intervention vs health education control on social isolation and loneliness over a 3-year period in the Aging and Cognitive Health Evaluation in Elders (ACHIEVE) study.

DESIGN, SETTING, AND PARTICIPANTS: This secondary analysis of a multicenter randomized controlled trial with 3-year follow-up was completed in 2022 and conducted at 4 field sites in the US (Forsyth County, North Carolina; Jackson, Mississippi; Minneapolis, Minnesota; Washington County, Maryland). Data were analyzed in 2024. Participants included 977 adults (aged 70-84 years who had untreated hearing loss without substantial cognitive impairment) recruited from the Atherosclerosis Risk in Communities study (238 [24.4%]) and newly recruited (de novo; 739 [75.6%]). Participants were randomized (1:1) to hearing intervention or health education control and followed up every 6 months.

INTERVENTIONS: Hearing intervention (4 sessions with certified study audiologist, hearing aids, counseling, and education) and health education control (4 sessions with a certified health educator on chronic disease, disability prevention).

MAIN OUTCOMES AND MEASURES: Social isolation (Cohen Social Network Index score) and loneliness (UCLA Loneliness Scale score) were exploratory outcomes measured at baseline and at 6 months and 1, 2, and 3 years postintervention. The intervention effect was estimated using a 2-level linear mixed-effects model under the intention-to-treat principle.

RESULTS: Among the 977 participants, the mean (SD) age was 76.3 (4.0) years; 523 (53.5%) were female, 112 (11.5%) were Black, 858 (87.8%) were White, and 521 (53.4%) had a Bachelor's degree or higher. The mean (SD) better-ear pure-tone average was 39.4 dB (6.9). Over 3 years, mean (SD) social network size reduced from 22.6 (11.1) to 21.3 (11.0) and 22.3 (10.2) to 19.8 (10.2) people over 2 weeks in the hearing intervention and health education control arms, respectively. In fully adjusted models, hearing intervention (vs health education control) reduced social isolation (social network size [difference, 1.05; 95% CI, 0.01-2.09], diversity [difference, 0.19; 95% CI, 0.02-0.36], embeddedness [difference, 0.27; 95% CI, 0.09-0.44], and reduced loneliness [difference, -0.94; 95% CI, -1.78 to -0.11]) over 3 years. Results were substantively unchanged in sensitivity analyses that incorporated models that were stratified by recruitment source, analyzed per protocol and complier average causal effect, or that varied covariate adjustment.

CONCLUSIONS AND RELEVANCE: This secondary analysis of a randomized clinical trial indicated that older adults with hearing loss retained 1 additional person in their social network relative to a health education control over 3 years. While statistically significant, it is unknown whether observed changes in social network are clinically meaningful, and loneliness measure changes do not represent clinically meaningful changes. Hearing intervention is a low-risk strategy that may help promote social connection among older adults.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03243422.