Family-Perceived Barriers and Facilitators Toward a Tele-Audiology Infant Diagnostic Testing Approach in Victoria,Australia

Abstract

Background:

Universal newborn hearing screening programs allow for early identification of congenital hearing loss. However, some families experience difficulties accessing diagnostic audiology services following a refer screen result.

Methods:

This study aimed to assess the opinions of families who had experienced infant diagnostic audiology assessments regarding a telehealth option for these appointments within Victoria, Australia. Families who attended in-person infant diagnostic audiology appointments were sent a questionnaire exploring their experiences of the service and their opinion regarding a proposed telehealth option for infant diagnostic audiology (50 responses received). These results were also compared to those of families who were surveyed following testing in 2020, where the audiologist conducted the appointment remotely to comply with COVID-19-related social distancing recommendations at the time (10 responses received).

Results:

There were not significant differences between the duration or number of appointments, perceived understanding of results, or concerns regarding a tele-audiology model between families who experienced face-to-face and tele-audiology infant diagnostic audiology appointments. Opinions of infant diagnostic audiology appointments utilizing telehealth technology were largely positive, and minimal technological difficulties were identified.

Conclusion:

Overall positive attitudes of many families with infant diagnostic appointment experiences toward a tele-audiology option of this service suggest that offering a telehealth model of appointments may be an appropriate model to improve service access for families requiring infant diagnostic audiology in Victoria.

Introduction

It is well established that early diagnosis and intervention of hearing loss results in significantly better language outcomes for children born with congenital hearing loss.^1,2 Within the state of Victoria, Australia, statewide coverage of infant hearing screening for babies has occurred since 2012. Following the screening, any baby who does not pass is referred for full diagnostic audiological assessment.³

According to the Joint Committee on Infant Hearing (2019) recommendations, infant diagnostic audiology appointments involve a battery of primarily electrophysiological assessments conducted while the infant sleeps to determine hearing levels.⁴ Infant diagnostic audiology requires specialized equipment and highly trained audiologists to deliver the assessment and interpret the results. Most infant diagnostic audiology within Australia is conducted in metropolitan areas or in a limited number of larger regional centers. Small clinics with low referral rates may not be able to justify the cost of equipment and resources or maintain sufficient skill sets and larger regional audiology centers often have difficulty recruiting audiologists skilled in infant diagnostic audiology. A potential solution to improve access to services in rural regions maybe provided by telehealth, which in the audiology profession (tele-audiology) has expanded significantly over recent years to encompass many models of service delivery.^5
–7

The COVID-19 pandemic highlighted additional telehealth advantages beyond improved access to services. Telehealth was initially utilized to enable social distancing to reduce viral transmission.⁸ Both clinicians and patients have now had much greater exposure to telehealth and virtual connectivity technologies,^9
–11 and audiologists are reporting increased use and perception of the importance of tele-audiology compared to before COVID-19.^12,13

Infant diagnostic appointments using tele-audiology technologies have been trialed globally in regions where families do not attend diagnostic appointments following a refer result on a hearing screen. This research has aimed to use tele-audiology, largely to improve large of loss-to-follow-up rates.^14

–17 No significant differences in infant electrophysiological results measured using tele-audiology technology compared to in-person assessment have been reported, demonstrating that conducting infant diagnostic audiology services using tele-audiology technology can be used to accurately assess hearing levels for infants.¹⁶

A vital aspect of infant diagnostic audiology is, however, the provision of psychosocial support to families when diagnosing a baby with hearing loss. Attending diagnostic audiology appointments with a newborn can be a confusing or an anxious experience for families.¹⁸ When a diagnosis of hearing loss occurs, families may experience confusion, grief, sadness, or denial.¹⁹

Previous research investigated parent opinions regarding tele-audiology testing for infants in British Columbia and demonstrated good parental satisfaction of a tele-audiology model.¹⁷ Similarly, Dharmar surveyed parents who underwent tele-audiology infant diagnostic services in California.²⁰ All families rated the service as “extremely important” and reported a positive overall experience of the service. There is, however, still a lack of research into the experiences of families when conducting these appointments via tele-audiology compared to those who experienced in-person testing. Given the need to support families, particularly when first diagnosing a permanent hearing loss of an infant, it is important to learn about the experiences of families who have undergone infant diagnostic audiology services and their attitudes toward an alternate remote service delivery model.

The state of Victoria has high rates of diagnostic follow-up to newborn hearing screening. Despite this, barriers still exist for some families who live at significant distances from diagnostic services, including travel expenses and time away from work, which may delay diagnosis of a hearing loss. The introduction of tele-audiology diagnostic services in Victoria and elsewhere may reduce the number of infants with delayed final diagnosis by providing more easily accessible and timely infant diagnostic audiology appointments.

This study aimed to determine the caregiver opinion of families who experienced in-person infant diagnostic audiology appointments regarding a possible tele-audiology experience of this service and to compare these opinions to those of families whose infant diagnostic audiology appointment utilized tele-audiology technology to adhere to COVID-19 social distancing recommendations in 2020. This study further aimed to determine whether both groups of caregivers viewed tele-audiology as a suitable method of service delivery for infant diagnostic audiology appointments within Victoria. This exploratory research will describe the opinions of caregivers who underwent either in-person or tele-audiology infant diagnostic audiology appointments, regarding a possible tele-audiology option for families requiring infant diagnostic services in Victoria.

Methods

This study was approved by the University of Melbourne Human Ethics Advisory Group (Ethics ID: 1853055 and 2057062).

Participants and recruitment

A purposive sampling approach was used to identify families who had recent experience of infant diagnostic testing at two audiology clinics. All families of infants who underwent electrophysiological infant diagnostic assessments following a refer result on their newborn hearing screen at either a metropolitan Melbourne audiology clinic (361 families) or an audiology clinic in a regional town (50 families) located ∼350 km from Melbourne over a 2-year period were invited to complete a questionnaire (Supplementary Appendix SA1). Families returned the completed questionnaires via either reply-paid envelope or a link to the online version of the questionnaire.

Families who attended infant diagnostic audiology appointments at the University of Melbourne Audiology Clinic from May to September 2020 were sent an amended version of Questionnaire 1 (Supplementary Appendix SA2). During this time, infant diagnostic appointments were performed utilizing tele-audiology technology, with the audiologist in another room to comply with social distancing recommendations during the COVID-19 pandemic. For these assessments, the audiologist was present initially for patient setup, but then observed the room and communicated with the families using Zoom teleconferencing software from another clinical room and controlled the equipment using remote access software. All other standard clinical protocols for testing were followed during this time. E-mails with links to questionnaire 2 were distributed to the 24 families seen under the tele-audiology assessment conditions. All questionnaire results were anonymous; therefore, demographic information was not collected beyond hearing levels and postcodes. Forty-eight responses to questionnaire 1 and 10 responses to questionnaire 2 were received.

Questionnaires

Questionnaire 1 was a self-administered questionnaire developed to explore families' perceived experiences of their infant diagnostic appointments and their opinion of an alternative tele-audiology option. Four experienced clinical audiologists rated and suggested amendments to the questionnaire. The opinion of two families of infants seen for diagnostic audiology at the University of Melbourne Audiology Clinic was also sought to ensure the questions could be easily comprehended.

The questionnaire included requests for opinions and recollections of experiences of in-person infant diagnostic audiology appointments, and questions regarding families' opinions of the acceptability of a tele-audiology option for infant diagnostic assessments. The description of a possible tele-audiology protocol within the questionnaire was purposefully nonspecific to explore only opinions of the concept of a tele-audiology option, rather than of specific assessment protocols. The questionnaire was then amended to create Questionnaire 2, to distribute to families seen using tele-audiology technology in 2020. Questionnaire 2 included further questions to explore these families' experiences of the tele-audiology aspects of their appointment/s and any impacts they believed this method of delivery had on their experiences/outcomes.

Data analysis

Descriptive statistics were used for closed-ended and demographic questions. Inductive qualitative content analysis based on Elo and Kyngäs was used to explore the open-ended questionnaire responses.^21,22 NVivo^® software was used to code participant responses to questions into meaning units before grouping these further into categories.²³ Categories were reported as frequency of responses. The qualitative analysis process was completed by the primary researcher. Throughout this process, the primary researcher met with other researchers with experience in qualitative analysis to discuss and validate the identified categories. For questions that requested similar information (marked on Table 1) only, responses from both questionnaires were compared, with the appointment type as the independent variable, to extract information to inform future considerations of how tele-audiology may be implemented in infant diagnostic audiology in Victoria.

Table 1.

Number of Responses to Questionnaire Questions

No.	QUESTIONNAIRE 1 (FACE-TO-FACE)	QUESTIONNAIRE 2 (TELE-AUDIOLOGY)	TOTAL
Hearing levels^a	48	10	58
No. of appointments^a	45	10	55
Time spent per appointment^a	46	10	56
Hesitation	48	—	48
Understanding diagnostic information^a	48	10	58
Travel time and issues with travel	47	—	47
Priorities to find out	47	—	47
Test location	45	—	45
Concern about tele-audiology practice	-	10	10
Is this model beneficial?^a	44	8	52
Would you have used tele-audiology service?	44	—	44
Confidence in results via tele-audiology technology	44	—	44
Confidence when results were tele-audiology	—	10	10
Technical difficulties	—	10	10
Opinion on external location	—	10	10
Who communicates with family?	43	—	43
Communication with senior audiologist	44	—	44
Concerns about model^a	45	8	53
Advantages to model^a	46	8	54

Marks questions where responses were compared between the questionnaires.

Results

Questionnaire results are reported using descriptive statistics. As some respondents did not answer all questions, the number of responses for all questions included in both questionnaires is listed in Table 1.

Hearing levels

Diagnostic outcomes of families' infant diagnostic appointments are shown in Table 2. A chi-square test of independence (which considers unequal sample sizes) demonstrated no significant difference in the reported hearing outcome (normal hearing or hearing loss) between the responses to the two questionnaires χ²(1, N = 58) = 0.12, p = 0.74.

Table 2.

Reported Hearing Status from Questionnaires

No.	QUESTIONNAIRE 1 (FACE-TO-FACE)	QUESTIONNAIRE 2 (TELE-AUDIOLOGY)
Normal hearing	22	6
Hearing loss
Permanent bilateral	17	3
Permanent unilateral	3	1
Temporary	6	0
Total	48	10

Appointments

Two-sample t-tests showed no significant difference between the reported number of appointments required for a diagnosis in questionnaires 1 and 2 [t(16) = 2.10, p = 0.052]. There was also no significant difference in the reported time required per appointment type for the two groups [t(12) = 1.29, p = 0.022].

Travel

The median distance traveled to reach diagnostic services for all families was 12.4 km. However, due to significant distances traveled by a small number of rural families, the mean distance was 41.8 km, with a maximum of 374 km reported. 27.7% of families reported that the travel to their diagnostic appointment caused difficulty or concerns.

Hesitation before tele-audiology appointment

No families who participated in tele-audiology assessments in 2020 reported being concerned about their audiologist conducting the assessments from another location and communicating via tele-conferencing software. When asked to elaborate, 28.6% of families reported that using tele-audiology ensured they could be seen by infant diagnostic audiology quickly, and 71.4% reported the communication via video was sufficient throughout the appointment. Participants noted that the audiologist “communicated effectively from [the] computer setup.” Others reported no concerns, but believed their opinion may have been different if results were not normal, stating “difficult conversations over the screen are not ideal.”

Understanding of information

When asked to rank their understanding of what the audiologist explained in the infant diagnostic appointment, 68.4% reported “totally” understanding the information, 28.1% selected “mostly,” and 3.5% said they “partly” understood the information. No respondents selected “not at all.”

A Kruskal–Wallis Test was performed to compare the reported levels of understanding of families in the face-to-face group to the responses from the tele-audiology group. Results showed no significant difference between the level of understanding for the two groups [H (1) = 0.43 p = 0.51].

Technical difficulties during tele-audiology appointments

A majority (80.0%) of families reported no technical difficulties throughout their tele-audiology infant diagnostic audiology appointment. Twenty percent reported some technical difficulties, but that these did not impact their experience of the testing.

Opinions of a remote practice option

Figures 1 and 2 show responses to questions about a tele-audiology infant diagnostic model, reported on a five-point Likert scale from “strongly disagree” to “strongly agree.” Kruskal–Wallis tests showed no significant difference between the responses from the two questionnaires regarding concerns [H (1) = 0.13 p = 0.72] or benefit [H (1) = 1.42 p = 0.23] of a tele-audiology service. A Kruskal–Wallis test comparing the perceived advantages, however, found that families in the face-to-face group (responding to questionnaire 1) perceived more advantages than those who experienced tele-audiology and completed questionnaire 2 [H (1) 9.77, p = 0.002].

Fig. 1.

Opinions of families from in-person assessments, regarding a possible telehealth option (questionnaire 1).

Fig. 2.

Opinions of families who underwent telehealth assessments in 2020 (questionnaire 2).

Testing location preferences

Responses to families' preferences for testing locations included mostly at home (60.0%), followed by in-clinic if within 2 hours of home (24.4%) and at a clinic, regardless of distance (15.6%). Six (13.3%) respondents listed “home” as their last preference of testing locations.

Confidence in tele-audiology results with off-site senior audiologist

When families who underwent traditional infant diagnostic audiology testing were asked about their confidence in results that could be obtained via tele-audiology technology, 2.3% reported being more confident than in-clinic, 25.0% just as confident as in a clinic, 70.5% somewhat confident, but less than in-clinic, and 2.3% were not at all confident. Reasons for these responses included trusting the professional's confidence in the testing outcomes and believing a controlled clinical environment would provide more accurate assessments. All families who experienced tele-audiology diagnostic testing reported being just as confident in the results as they would be with the audiologist in the room throughout the appointment. Only one respondent explained their reasoning, stating “the process and results were fully explained—before, during and after.”

Forty percent of families who completed the questionnaire following tele-audiology assessment in 2020 felt their confidence in results would be affected if the audiologist was in a different building with another professional coordinating the technical equipment; “it was really helpful to have met the audiologist before she went into the other room.” The remaining 60.0% reported that this would not influence their confidence in the results. One participant commented that “the testing, and therefore results, rely on the technology, so I don't see why the clinical conversation can't rely on technology too.”

Family preference for primary communicator

Most families indicated a preference to communicate directly with the most knowledgeable professional person throughout the testing. A majority (52.9%) indicated they would prefer to communicate primarily with the senior audiologist remotely, rather than the assistant present in the room. Having confidence in the result interpretation from the senior audiologist and having questions answered immediately were cited as the reasons for this preference. A small percentage of families (11.8%) selected a preference for the junior professional in the room with them to deliver results to assist ease of communication in person. The percentage of respondents that had no preference was 35.3%.

Overall opinion of remote assessments

Families were given an opportunity to provide additional comments regarding their opinions of a possible infant diagnostic tele-audiology model. While 31.6% of families who responded thought the model could provide benefit, particularly to allow earlier diagnosis, face-to-face appointments were preferred. A total of 21.1% responded that a tele-audiology model would be most useful in only some situations such as review appointments, and when used in combination with in-person assessments. A total of 10.5% of respondents believed tele-audiology would not provide sufficient support for families and should not be offered, but 15.8% of families thought the model would be an excellent option.

Discussion

Increased funding and demand have facilitated improvements in technology and infrastructure to support telehealth consultations, which are being continued beyond the COVID-19 pandemic due to the advantages they provide.²⁴ Questionnaire responses indicated no significant differences between the duration or number of appointments, perceived understanding of results, or concerns regarding a tele-audiology model between families who experienced face-to-face and tele-audiology infant diagnostic audiology appointments. This indicates that families can be well supported throughout the appointment utilizing tele-audiology technology. Most families who experienced face-to-face testing reported that they would be somewhat confident in the results, but less so than with those obtained in-person. Families did report, however, that their level of trust would depend on the clinician's confidence in the results. In contrast, all families who had experienced appointments using tele-audiology technology were just as confident in the results as if the audiologist were in the room with them.

These results are consistent with those of Mog et al., who reported that even when patients were skeptical about telehealth technology, their opinion improved after experiencing a telehealth appointment.¹¹ If families are confident in the results obtained and feel emotionally supported during tele-audiology testing, a tele-audiology option in Victoria may allow a similar service delivery without the need for traveling significant distances to access services. It must be noted, however, that the tele-audiology experience of families surveyed in this study would not exactly match that of a truly remote appointment, as the audiologist met the parents and set up the equipment in person.

The families in this study reported an overall positive attitude toward tele-audiology infant diagnostic assessments. Many believed there were advantages to offering a tele-audiology infant diagnostic audiology service, particularly for families in remote areas. There were, however, a small number of families who had very negative perceptions of tele-audiology services for infant hearing assessments. Similarly, mixed attitudes have been described in other areas of health care, for example, Ahmad et al. reported that despite telehealth appointments being liked by patients, many patients preferred in-person health care visits.²⁵

Respondents reported concerns regarding potential technical difficulties interfering with testing in tele-audiology infant diagnostic assessment. This is consistent with clinician and patient concerns regarding infrastructure and technological limitations for tele-audiology implementation within audiology and in health care generally.^26
–28 There were, however, only minor technical difficulties reported by a minority of families who had experienced appointments using tele-audiology technology. Responses were mixed regarding preferences for options such as location of testing and who the primary communication would be with during the appointment, highlighting the importance of identifying priorities for individual families.

Limitations

This study has the following limitations. Anonymous questionnaires were chosen to ensure respondents felt they could answer questions honestly; however, respondents could also not be followed up to complete missing data, resulting in variable numbers of responses to both questionnaires. The relatively short time for which infant diagnostic appointments were conducted via tele-audiology at the University of Melbourne (5 months) may also have limited the number of families recruited to answer the second questionnaire.

Another factor which may have influenced results was the viewpoint of respondents and the timing of questionnaire administration. The opinions of those who experienced face-to-face appointments and completed questionnaire 1 were possibly limited by their understanding of both telehealth and the information provided in the questionnaire. Conversely, those who completed Questionnaire 2 had experienced aspects of tele-audiology themselves. Future studies with longer periods of recruitment and larger sample sizes of families undergoing tele-audiology infant diagnostic appointments could provide more diverse opinions of families with experience of these appointments.

Conclusion

A tele-audiology model of infant diagnostic assessments in Victoria has the potential to improve accessibility for remote families, who may have difficulty traveling to multiple appointments. This study revealed overall positive attitudes of many families with infant diagnostic appointment experiences toward a tele-audiology option of this service. There were, however, negative perceptions of a tele-audiology option and concerns reported by some caregivers. If this service model were to be offered in future, it would therefore be vital to enable families to choose their preferred option. Further research is required to investigate the specific assessment protocols and to make certain that the professional in the room with families had sufficient skills to ensure the quality of the diagnostic information obtained remotely.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Appendix SA1

Supplementary Appendix SA2

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Supplementary Material

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