An estimated 1.5 billion people across the globe experience hearing loss and over
430 million are candidates for intervention.[1] Hearing loss has profound impacts on communication, education, socialization, cognition,
and overall well-being across the lifespan.[2] The prevalence of hearing loss and the need for hearing healthcare is expected to
continue to rise over the next quarter century. Underserved populations face an even
higher prevalence and impact of hearing loss.[3]
[4] Evidence-based treatments for hearing loss, such as cochlear implants, can significantly
improve hearing-related outcomes and overall quality of life[5]; however, access to and utilization of such devices is neither uniform nor equitable.
In spite of this expanding global public health problem, the utilization of hearing
devices, including cochlear implants, across the world is less than 15%[6] and there are significant discrepancies in equitable hearing healthcare access and
utilization among different populations. Biological and clinical differences involved
in the pathophysiology and manifestation of hearing loss certainly influence outcomes
following CI; however, a wide variety of social factors are at play as well. Even
when care is accessed, clinical outcomes of cochlear implant recipients may vary widely
among different populations[7] and there is a pressing need to understand and address, in a broader sense, the
social factors that influence equity in CI access, utilization, and outcomes. Pursuing
equity is an ethical priority as many inequities in healthcare are rooted in discriminatory
practices and racism.[8] Furthermore, promoting equity has economic implications, as health inequities result
in billions of lost dollars each year due to increased medical costs and lost productivity.[9]
Health-influencing social factors are categorized according to the widely accepted
framework of social determinants of health, which is defined by where people live,
work, and play that can either directly or indirectly influence their health and overall
quality of life.[10] Additionally, these factors play a role in the severity and the distribution of
health disparities. Defining, describing, and addressing the social determinants of
health is a priority area for the World Health Organization (WHO) to tackle health
inequities, such as CI access differences between different nations.[11]
[12] The social determinants of health framework can be divided into five domains which
include the following: healthcare access and quality, education access and quality,
social and community context, economic stability, and neighborhood and physical environment.[10]
[13] The first domain concentrates accessibility and utilization of healthcare services
among patients as well as their health knowledge. For example, this could include
type and amount of insurance coverage, provider availability and accessibility, health
literacy, and the quality of care. The second domain of the social determinants of
health focuses on the accessibility and quality of education and its effects on health
outcomes. Examples of factors from this domain include level of education, access
to vocational training, parental educational attainment, access to early childhood
education, and school-based rehabilitation services. The next domain, social and community
context, evaluates the social conditions and connections of individuals and how they
impact one's overall health and well-being. This domain incorporates social support
systems and networks, community engagement, social integration, and cultural/racial/ethnic
social identity. The impact of discrimination based on race, ethnicity, gender, or
sexual orientation would be assessed within this domain. Economic stability represents
the fourth domain and encompasses individual financial and material resources and
how they impact health. Some factors under this domain include employment, income,
poverty, debt, or expenses, as well as food and housing security. The final domain
of this framework is the neighborhood and physical environment, which involves the
relationship between where people live and the impact on their health and well-being.
For example, this domain would connect health with the safety and quality of housing,
accessibility and utilization of transportation, water and air quality, neighborhood
crime, and rurality of household location. These five domains represent a comprehensive
framework that can be used to evaluate inequities in any aspect of health or healthcare
and these factors, either positively or negatively, influence the health of every
single person who is eligible for or who receives a cochlear implant. The objective
of this article is to define disparities in CI through the lens of the social determinants
and identify targets and methods to promote equity in patients who would benefit from
CI.
Social Determinants of Health
Healthcare Access and Quality
Utilization of and access to quality hearing healthcare services influences overall
health and hearing-related outcomes for adults and children. Considering the global
underutilization of hearing devices, access to care is a critical issue for CI specialists
and researchers to evaluate and address. Access to CI care is inherently complex,
as it requires transdisciplinary long-term care which is provided by different types
of specialists potentially in different locations over the course of a patient's life.
A patient's access to any type of healthcare, along with CI care, can be restricted
by a variety of different geographic and socioeconomic position (SEP) factors. The
geographic location of a patient's household affects a patient's access to CI care.
Certainly, CI is not an accessible hearing loss treatment option for every country;
however, access to CI care can be exceedingly limited in rural or remote regions of
any country. Limitations in rural hearing healthcare access is a pressing issue, as
rural adults face a greater burden of age-related hearing loss compared with urban
areas.[14]
[15] Children residing in rural areas are also more likely to experience delays with
every aspect of hearing healthcare including diagnosis of hearing loss, hearing aid
amplification, and cochlear implantation.[16]
[17]
[18] Delays in cochlear implantation have negative impacts on speech and language development
in children.[19] Furthermore, children from rural areas face greater difficulty in accessing rehabilitation
services post-CI surgery due to a lack of local providers thereby increasing costs
and travel for families.[7] Similar findings in adult populations demonstrate that rural adults with hearing
loss are delayed in CI compared with their urban peers, which is also related to lack
of local access and greater travel distances to cochlear implant centers.[20]
Insurance coverage or lack thereof represents a key factor influencing if and where
healthcare is accessed across a wide range of medical disciplines. Insurance status
and type of insurance has been used as a proxy for SEP but may be influenced by various
factors including income, employment, or race and ethnicity. There is evidence that
non-white patients and minority ethnic groups are more likely to have public insurance
coverage instead of private insurance coverage compared with white patients.[21] While cochlear implantation is typically covered for children by Medicaid and most
private insurance carriers in the United States, the same is not true for adults.
Among adults who are insured through Medicaid, cochlear implant coverage is optional
depending on the state's criteria. Currently, only approximately 60% of the States
offer Medicaid coverage for cochlear implantation in adults.[22] Even if CI Medicaid coverage is available, the quality of care that is delivered
may be negatively impacted by barriers in obtaining upgraded or replacement equipment,
poor reimbursement, limitations in locations of care, limitations in the number of
covered appointments, and difficulty in authorization for care.[22] In some states, a patient who received a Medicaid-covered cochlear implant as a
child may grow out of service eligibility to receive necessary care once they transfer
to adult Medicaid coverage.[22] Furthermore, there is evidence that Medicaid patients are 50% less likely to receive
sequential bilateral cochlear implants compared with those who were privately insured.[23] Furthermore, patients covered by Medicaid were five times more likely to experience
post-surgery complications and less likely to comply with follow-up appointments compared
with privately insured patients.[7]
[23] From a clinic perspective, one major challenge of Medicaid coverage for CI is the
low reimbursement rate throughout the continuum of care from surgery to rehabilitation
and may lead to limiting access for these patients.[22]
While the racial and ethnic health disparities may be influenced by various determinants,
there are long-standing differences in access to and quality of healthcare services
in a wide range of health conditions based on race and ethnicity. This racial and
ethnic disparity has been demonstrated in adult CI research as patients of non-white
racial groups are less likely to undergo CI surgery for cochlear implants despite
being eligible candidates.[24] Similarly, children who are from non-white racial groups are delayed in CI regardless
of their insurance type and coverage and are less likely to be implanted before the
age of 2 years compared with white children.[25] This racial/ethnic inequity is critical to address considering the developmental
implications of early implantation among pediatric patients. In addition to access
to care, unconscious bias or discrimination based on race and/or ethnicity from medical
professionals may contribute and play a role in the quality of care that patients
receive.[21] Understanding how patients access and utilize hearing healthcare services and the
barriers to that care will provide insight and possible solutions on how to increase
equitable healthcare for hearing loss.
Education Access and Quality
Educational access and attainment influences health through various pathways. Education
attainment intersects with other social determinants of health through its impact
on income and higher wages which in turn affects access to healthy food, safe living
environments, and insurance coverage.[26] Therefore, it is not surprising that there is a correlation between educational
attainment and health outcomes in which lower education attainment is associated with
poorer health outcomes. Adult CI outcomes have been directly correlated with educational
attainment levels. In the area of pediatric CI, parent's educational level has been
associated with the utilization of hearing healthcare and with the speech development
outcomes of their child. Lower parental education attainment may predict underutilization
of speech therapy following pediatric CI.[27]
Health literacy is directly connected to educational attainment, which in concert
influences behaviors that can promote health. Individuals with lower health literacy
are less likely to obtain necessary care and may report more difficulty with finding
providers compared with those with greater health literacy.[28] This inability to understand the language and systems of healthcare plays a role
in hearing healthcare, as patients with low health literacy may not be aware of potential
treatments of hearing loss and may not seek out hearing healthcare services.[29] Consequently, the delay in pursuing hearing services and their duration of hearing
loss may influence their clinical outcomes.[29] Health literacy also influences the cost of care, as there is a strong correlation
with lower health literacy and higher medical expenses among patients with hearing
loss.[30]
[31] English-fluency, while not directly connected to health literacy, strongly influences
communication between patients and providers within the United States and may influence
overall health outcomes. There is a link between language barriers, patient satisfaction,
care adherence, and utilization of healthcare services.[32] The language barriers between parents of deaf or hard of hearing children may influence
the timing of hearing healthcare service delivery and therefore hearing outcomes of
that child. Addressing the educational needs for patients needing cochlear implantation
is a daunting issue; however, there are ample opportunities to promote health literacy
of individual patients and the public regarding hearing loss and the evidence-based
treatment options. This domain begs for innovation and intervention development.
Social and Community Context
Social support through systems and relationships as well as interactions with individuals
and community members can also impact health outcomes.[33] Relationship support enhances overall health and decreases mortality, while the
lack of social support and connectedness can precipitate adverse health outcomes.
In hearing healthcare, the presence of a strong social support system impacts the
timing and delivery of hearing healthcare.[34] Moreover, cultural differences and community perspectives on hearing loss can shape
how individuals perceive their own hearing loss and the choices they make regarding
treatment.[35] Social support systems also influence adherence with wearing hearing devices. Children
lacking support and behavioral reinforcement at school and within the home are less
adherent with wearing their cochlear implants.[36] Similarly, elderly adult patients who were nonadherent with cochlear implant usage
also lack social support.[37] Overall, social support systems can influence hearing healthcare from the onset
of the condition to the utilization of hearing devices and services. This social determinants
of health (SDH) domain forms the basis for comprehensive cochlear implant teams that
incorporate key social support members and systems into cochlear implant counseling
and care delivery.
In addition to support systems, social identity can affect how individuals seek and
utilize care, thereby affecting health outcomes. Social identify is defined as an
individual's sense of who they are in relation to their group or community.[38] Children and adults who are deaf or hard of hearing may experience dissonance in
defining their social identity when coexisting among hearing peers and family members.
School-aged children with cochlear implants may face challenges in developing close
relationships with their peers and this may predispose them to mental health problems.[39] Furthermore, adults with hearing loss report marginalization and social isolation
due to their hearing loss, which may influence the development of depression in these
individuals.[40]
[41] In some cases, cochlear implant users may face an identity crisis between the hearing
community and the deaf community.[42] Related to social identity, stigma around deafness and hearing loss heavily influences
hearing health behaviors and outcomes. Stigma regarding hearing loss stemming from
social contexts has been associated with poor mental health and overall decreased
quality of life.[42]
[43] Cochlear implant users who identify with the deaf community may perceive more discrimination
than those who identify with the hearing world.[44] In addition to the discrimination based on hearing status, cochlear implant users
from non-white racial and ethnic groups experience collateral discrimination.[44] Discriminatory policies and practices based on social contexts or identity influence
not only individual health and healthcare but also other public health due to the
impact on other social determinants of health, such as employment, housing, and education.[21]
Economic Stability
Economic stability can influence health outcomes both individually and within a household.
Elements of economic stability include employment and income, SEP, as well as food
and housing security. These elements can impact one's health through various avenues.
First, employment directly affects a household's economic stability by providing not
only income but also insurance coverage and other benefits. An employed individual
or household could still have a low SEP and thereby limited access and availability
of information and resources to manage health conditions, such as hearing loss. Patient
or families with significant economic instability may not prioritize health and healthcare
services. Even when financial resources are made available to lower SEP families,
those resources are often underutilized.[45] Families of deaf or hard of hearing children or adults who live closer to the poverty
line are less likely to utilize a wide range of medical services, including hearing
healthcare.[46]
[47] Children from lower-income households are less likely to receive a cochlear implant,
in spite of having a higher prevalence of hearing loss compared with those from higher-income
families.[48] Moreover, lower family SEP has been associated with delayed cochlear implantation
among children younger than 3 years.[49] Even after implantation, pervasive disparities remain for CI users of low-income
households. Patients from a lower SEP background are more likely to experience postoperative
complications, to be nonadherent with follow-up appointments, and to receive only
unilateral and not bilateral sequential CI.[23] Furthermore, those same patients experience poorer speech and language outcomes
post-CI compared with those of a higher SEP background.[50] Similarly, adult patients of lower SEP demonstrate poorer speech perception gains
after cochlear implantation.[47]
Families of low economic stability also face other challenges that affect health outcomes,
such as limited food and housing security. Families who live close to the poverty
line are more likely to face food insecurity and have limited access to healthy foods.
This is amplified for non-white racial and ethnic groups.[51] Food insecurity is also more prevalent among those with hearing loss than those
with normal hearing.[52] It is intuitive that individuals with lower incomes are also more likely to experience
homelessness; however, racial and/or ethnic status influences homeless as demonstrated
by the estimate that 40% of the homeless population are African American.[53] This is pertinent because homeless adults tend to have a higher prevalence of chronic
diseases, including hearing loss, and experience poorer access to care due to barriers
such as lack of health insurance, prioritization of other physical needs, and discriminatory
practices by the healthcare system toward this population.[54] Furthermore, awareness regarding the types and availability of hearing-related resources
is poor among homeless adults.[55] In spite of the availability of cutting edge technology, the hearing healthcare
field faces a great dilemma in engaging a diverse population with a wide range of
socioeconomic resources and delivering affordable care in a culturally acceptable
way.
Neighborhood and Physical Environment
While homelessness represents extreme challenges for health, the location and quality
of housing can also influence one's health either positively or negatively. There
is a direct relationship between home and neighborhood improvements and overall health
within a community.[56] Poor drinking water, mold, lead exposure, pests, environmental exposures, second-hand
smoke exposure, and inadequate heating/cooling are housing condition factors that
can negatively affect health. While this SDH domain may seem indirectly related to
cochlear implantation outcomes and care, it is feasible that environmental exposures,
such as high levels of noise, or overall poor living conditions could increase the
chances of developing chronic diseases or infectious diseases and could thereby influence
the development or progression of hearing loss. It is valuable to consider this domain
in relation to the other domains and the overall health and ability of cochlear implant
recipients to pursue a healthy lifestyle. The established neighborhood conditions
such as types and access to schools, employment opportunities, crime rates, food access,
and healthcare infrastructure are all aspects of neighborhoods where cochlear implant
recipients live and each of these factors impact the health of these patients. Again,
racial and ethnic inequities are long-standing persistent issues based on neighborhood
resources and stability as non-white racial ethnic groups make up a higher population
percentage in neighborhoods with lower resources that could promote health. Consequently,
there is a shortage of hearing healthcare specialists in these same resource-poor
neighborhoods. For example, transportation to healthcare clinics may be lacking in
resource-poor neighbors. This is significant as decreased access to personal or public
transportation, which is more common among non-white racial and ethnic groups, directly
affects utilization of healthcare and thereby overall health.[57]
[58] When hearing specialists neither live nor physically work within these neighborhoods,
those community members lack a sense of trust, connection, and engagement with overall
hearing healthcare. This physical neighborhood disconnect with cochlear implant centers
is difficult to overcome, but opportunities are present to proactively engage key
stakeholders and community members to be a part of making meaningful linkages with
hearing healthcare teams.[59]
Discussion
This review of the social determinants of health serves to promote awareness of how
these factors can influence cochlear implantation and complex hearing healthcare access,
utilization, and delivery. While this explanation and discussion of the factors within
each domain above is not exhaustive, it provides a framework to inform a more comprehensive
understanding of the factors beyond the cochlea and underlying biology that influence
hearing health and healthcare. It is critical for providers and researchers to recognize
how the social determinants of health influence equity within hearing healthcare and
explore unstudied aspects of this framework. Furthermore, this framework can provide
mechanistic explanations for variations in outcomes following cochlear implantation.
The social determinants of health can provide critical information and insight into
the factors that influence hearing health outcomes and each of these domains can be
targeted to promote optimal CI-related outcomes for all.
It is difficult to address SDH-rooted disparities without measuring SDH factors and
these measures are not part of cochlear implant candidacy evaluations. Although it
may not be a part of traditional evaluation of hearing healthcare specialists, providers
can utilize a wide array of validated assessment tools to collect social determinant
health data on cochlear implant candidates and users. For example, the Centers for
Medicare and Medicaid Services Accountable Health Communities created the Health-Related
Social Needs Screening Tool.[60] This 10-item questionnaire gathers data on Medicare and Medicaid patients' social
needs related to the different five social determinants of health domains to inform
clinical decision-making and potentially impact health outcomes and healthcare costs.
The National Association of Communication Health Centers also developed a tool called
the “Protocol for Responding to and Assessing Patients' Assets, Risk and Experiences
(PRAPARE).”[61] This 21-item tool is a much more comprehensive set of measures that are rooted in
public health research and informed by stakeholder input. This inventory focuses on
areas where action can be taken to address inequities from a public health perspective.
This measure could easily be incorporated into CI candidacy evaluations and could
inform CI teams about potential factors that could influence outcomes. A third tool
that is publicly available is the Social Needs Screening Tool designed by the American
Academy of Family Physicians as part of their EveryOne Project.[62] This 15-item tool is rooted in clinical practice and has been used to identify basic
barriers to care and underlying social needs facing patients. This information can
be used to mobilize resources to address those needs in a timely fashion. Further
study is needed in this area regarding the value and utility of this information for
CI teams and how these data may correlate with cochlear implantation outcomes and
if targeting these SDH domains will influence equity in cochlear implantation. In
addition to these different quantitative measures of social determinants of health,
hearing-related research would benefit from incorporation of mixed methodology which
utilizes qualitative methods to better define and describe the complex and interconnected
nature of these domains on health. To increase the equitable utilization of cochlear
implants and maximize hearing health for all, leaders in cochlear implantation are
encouraged to consider and measure factors from each domain of the social determinants
of health in their patients and develop informed targeted interventions and programs
that address those needs. Comprehensive CI care extends far beyond the cochlea and
incorporating social determinants of health information into how care is given and
to whom care is given will promote health equity for diverse populations and communities.
Conclusion
The five domains of the social determinants of health impact hearing health and healthcare
in a wide array of mechanisms over the lifespan. Factors from these domains influence
how and when patients receive cochlear implants and can be used in part to explain
varying outcomes following cochlear implantation. While collection of SDH data has
not been a core component of CI candidacy or postoperative outcome measures, there
is a need to better understand how these social determinants of health affect patients'
access and utilization of CI-related services. This information can be used by CI
teams to develop and implement interventions, programs, and policies that address
disparities affecting their patients. Several validated tools can be used to systematically
evaluate health-influencing factors from these five domains. Equity in cochlear implantation
access, utilization, and outcomes is dependent on whether this information is considered
and used.
