“The barriers are plentiful.” Speech-language pathologists’ perspectives of enablers and barriers to hearing assessment for children in metropolitan, regional, and rural Australia: A mixed methods study

Abstract

Purpose

Access to hearing assessment is important for children, as poor auditory information can lead to poor speech and oral language development. This study aims to identify enablers and barriers to accessing hearing assessments for Australian children from the perspective of speech-language pathologists (SLPs), comparing access in metropolitan, regional, and rural areas.

Method

This is a sequential, explanatory mixed-methods study. Forty-nine participants completed the quantitative survey and 14 participated in semi-structured interviews. The study was undertaken online and included participants from metropolitan, regional, and rural parts of Australian states and territories.

Result

Similar accessibility issues were experienced across geographic locations and access to hearing assessment was related to the complexity of individual contexts. Speech-language pathologists felt that awareness and knowledge of hearing loss was low in parents and health professionals. Participants discussed barriers such as long wait times, complex criteria, and inefficient services that lead to compromised outcomes for clients.

Conclusion

Barriers to hearing assessment are extensive and multifaceted. Future research might examine the accessibility of the health system in light of the barriers discussed in this research, and whether policies and procedures could be adapted to allow more easily accessible services.

Keywords:

• Hearing assessment
• speech pathology
• service delivery
• barriers
• regional
• rural

Introduction

It is well known that children with hearing loss experience delays in speech and language development (Ching et al., 2018; Tomblin et al., 2020). The ability to hear is crucial to speech and oral language development, because children learn to communicate in early childhood by imitating the sounds they hear (Williams & Jacobs, 2009). Hearing loss reduces access to high-quality auditory information, which may result in an underspecified and imprecise representation of sound (Nittrouer & Burton, 2005). This may lead to sound distortions, receptive vocabulary delays, delays in syntactic complexity, and reduced use of function words (McGuckian & Henry, 2007; Zussino et al., 2022a). Given that the presence of hearing loss may impact children’s speech and language development, speech-language pathologists (SLPs) should be considered key referral sources to audiologists. These referrals are necessary to identify whether medical intervention or hearing technology could assist in improving hearing acuity, or whether alternative or compensatory communication support is required to allow the child to have full access to communication. Importantly, these two allied health professionals should collaborate to support speech, language, and hearing outcomes for children (Goldberg, 2015). SLPs should receive information about the results of the hearing test, in order to inform their practice and further educate families about treatment options.

The need for allied health services is extensive, especially in regional, rural, and remote areas of Australia where a reduced number of services are available (O’Sullivan & Worley, 2020). Speech Pathology Australia reports over 13 000 registered members (Speech Pathology Australia 2023); however, there are not enough speech-language pathology services in Australia to meet demand, particularly in rural/remote areas (Parliament of Australia, 2014). Findings from a workforce analysis project confirmed these shortages (Speech Pathology Australia, 2023). Audiology Australia reports only 3411 members (Audiology Australia 2022). Both SLPs and audiologists appear on the Medium and Long-Term Strategic Skills List (MLTSSL), which is a list of occupations compiled by the Australian Government seeking skilled migrants for positions for which there are not enough Australian residents or citizens available (Australian Government, 2022). This highlights the skill shortage of SLPs and audiologists in Australia.

In addition to the skill shortage, there are numerous other considerations in regard to accessing allied health services in Australia. In their theory of access model, Penchansky and Thomas (1981) identified five dimensions to access (accessibility, availability, affordability, adequacy, and acceptability), to which Saurman (2016) added a sixth (awareness). Definitions of these dimensions and how each may enable (i.e. facilitate) access to service have been provided in Table I. If this facilitation does not occur, these dimensions can also act as barriers (i.e. obstacles) to service access. In previous research, SLPs and audiologists have identified many of these dimensions as impacting parents’ ability to attend appointments. For instance, long wait times have been associated with lack of availability of enough audiologists to serve the community in a timely manner (Pokorny et al., 2022). Living in a rural or remote location can further complicate access due to accessibility (e.g. travel to appointments) and affordability challenges (Fulcher et al., 2015). Adequacy of the advice provided by the service has also been identified as a barrier by clinicians who report parents were provided with conflicting advice from local health and education professionals, and their primary care provider (Fulcher et al., 2015). Many of these barriers were also reported by parents of children requiring hearing assessments in Australia (Zussino et al., 2022b).

Table I. Dimensions of access definitions as per Penchansky and Thomas (1981) and Saurman (2016).

Access dimension	Dimension definition and components
Accessibility	Location: The service is located within a reasonable travel time and distance.
Availability	Supply and demand: There are enough services and available appointment times to meet the needs of those in the community.
Acceptability	Perception from the consumer: The service promotes cultural awareness and is considered acceptable by the community.
Affordability	Financial and other costs: The service considers all costs including the cost of the appointment, as well as travel, transport, and incidentals.
Adequacy	Accommodation and organisation: Consumers are able to use the service as it considers hours of operation, appointment systems, and other consumer needs such as wheelchair access.
Awareness	Communication and available information: The service establishes and maintains effective communication strategies with stakeholders, and considers health literacy.

Another layer of complexity identified as impacting service access and children’s outcomes is the influence of cultural and linguistic diversity, which falls under the adequacy dimension of the theory of access (Ng et al., 2022). Adequacy encompasses the importance of services accommodating the needs of the consumers so that the service is utilised appropriately (Penchansky & Thomas, 1981). There is a need for culturally safe care, however, not all clinicians have been able to access training to provide this care. For example, clinicians reported difficulty building rapport, performing assessments, and monitoring children’s progress as a result of language differences because appropriate assessments and/or interpreters could not be accessed (Ng et al., 2022). Thus, language differences may influence adequacy if clinicians do not have access to resources and training to adapt and accommodate to the needs of the consumer (Penchansky & Thomas, 1981). Similarly, cultural differences may also impact adequacy. For instance, Ng et al. (2022) showed that differing perspectives regarding disability and gender roles in the family provider relationship influenced the nature of the service provided.

There is a large proportion of Aboriginal and Torres Strait Islander populations living in regional, rural, and remote Australia. We will be respectfully referring to these populations as First Nations Australians hereon in. Australia has diverse, resourceful, and dynamic Aboriginal and Torres Strait Islander communities, however, there are significant health disparities compared with other Australians. The interaction between geographic location and socioeconomic status is complex and can lead to even further health accessibility difficulties, resulting in less equitable health services (Australian Institute of Health and Welfare, 2020). First Nations Australians are also more likely to experience hearing loss (Australian Institute of Health and Welfare, 2022) with particularly high rates of conductive hearing loss. For instance, otitis media with effusion is prevalent in up to 58% more First Nations Australian children compared to non-Indigenous children (Jervis-Bardy et al., 2014). These rates are concerning given that otitis media, if frequently reoccurring and severe, can become chronic and lead to sensorineural hearing loss (Xia et al., 2022). The Closing the Gap initiative brings together state and federal governing bodies to address the significant disparities between outcomes for First Nations and non-Indigenous people in a way that is culturally safe and responsive (Department of the Prime Minister and Cabinet, 2022). One such culturally safe and responsive program is Deadly Ears, which has been operating since 2007. However, it is still important to acknowledge that general acceptability of health services by First Nations Australians may continue to be impacted by fear of government services and general mistrust of non-Indigenous health professionals, which stems from a history of institutional racism (Zingelman et al., 2021).

Children with hearing loss or suspected hearing loss benefit from early identification and early intervention, and should have access to services regardless of their geographic location (Ching & Leigh, 2020; Lai et al., 2014). SLPs working with First Nations Australian children need to be particularly vigilant about monitoring the child’s hearing status due to the increased prevalence of ear disease (Jervis-Bardy et al., 2014). Given the links between hearing and speech and language development (Ching et al., 2018), SLPs should establish the child’s hearing status as part of their assessment and goal-setting process (Goldberg, 2015). SLPs need to be sensitive to potential enablers and barriers in that referral process, to direct parents to appropriate audiology services (Zussino et al., 2022b). The objective of this study is to identify enablers and barriers to accessing hearing assessments for children as identified by SLPs in Australia and to compare identified enablers and barriers between regional and rural/remote areas with metropolitan areas.

Method

This explanatory sequential mixed-methods study with quantitative and qualitative data used a pragmatism paradigm. Phase one analysed quantitative survey data, and phase two qualitative interviews; a third phase included triangulation of both datasets. Interview data themes were analysed separately to survey data, then compared and merged resulting in expanded findings. Central Queensland University’s ethics committee approved all processes (approval number 0000023432).

Participants

Participants were recruited throughout 2021 and 2022 via relevant social media network pages (e.g. the Facebook page of the Speech Pathology Paediatric Indigenous Network [SPPIN]) and the Speech Pathology Australia newsletter. For the quantitative phase, Australian SLPs who had recommended children have their hearing assessed were eligible to participate in the survey. Eligibility was determined by a screening question at the start of the survey. Survey participants could self-select to participate in the qualitative phase. Interview participants were SLPs with a range of experience in different geographic locations across Australia.

Data collection

For the quantitative phase, the authors developed a 10 min online survey based on information available in the literature regarding enablers and barriers to service, with a specific focus on the six dimensions of the theory of access (Penchansky & Thomas, 1981; Saurman, 2016). The survey included 16 questions in total. In addition to demographic questions, SLPs were asked to describe their caseload and to provide information about the recommendations they make for hearing assessment. The remaining questions aimed to elicit responses related to SLPs’ perceptions of enablers and barriers to children’s hearing assessment. Survey questions were piloted prior to use. Consent was gained when participants selected “I agree” and proceeded with the survey after reading the information sheet. A copy of the final survey can be accessed in the Supplementary materials.

Following the explanatory design, a semi-structured interview guide was developed for the qualitative phase based on the analysis of survey results. Verbal consent was confirmed and recorded at the start of the interview. Interview questions have been provided in the Supplementary materials. Interviews were video recorded via Zoom software and were 20–40 min in duration.

Data analysis

Data from the survey were exported from Qualtrics to SPSS and then analysed descriptively to determine normality, variability, and central tendency. This analysis showed that data were not normally distributed. Given this and the small sample size, data were analysed using non-parametric tests. Kruskal–Wallis tests were conducted to evaluate the whole data set followed by Chi–square tests to compare metropolitan, regional, and rural groups.

The transcribed interviews were coded using an inductive analysis of codes and themes, in which raw data was condensed into a summary and then clear links between the research objectives and data were established (Thomas, 2006). Two authors completed blind coding for 30% of transcripts to ensure agreement, which included line-by-line coding, confirming coding, and meaning alignment via cross-checking and memoing. Ongoing consultation and cross-checking across authors took place for the remaining transcripts. Iterative thematic analysis (i.e. the continual development of themes during the entire analysis process) was used to group words and phrases with shared meaning into a codebook (Palmer & Coe, 2020). Codes and themes were then reviewed and finalised via ongoing review of the data and consultation across authors. Interview data themes were analysed separately to survey data, then compared and triangulated. Triangulation included comparing and contrasting quantitative and qualitative findings to determine whether findings from each phase agreed with one another, offered complimentary information, or appeared to contradict each other. This process resulted in expanded findings (O’Cathain et al., 2010), which are presented in a joint display via Supplementary Table 1.

Result

Phase one: Survey

Participants

Seventy-six SLPs responded to the survey, 49 (64.5%) of whom met eligibility criteria. The remaining respondents (n = 27; 35.5%) had not recommended hearing assessments for their paediatric clients so were excluded from data analysis. Table II outlines overall participant details. The primary language of all participants was English. The majority of participants who completed the survey were women (n = 47; 95.9%). The majority of participants identified as non-Indigenous (n = 36; 73.5%), one identified as Aboriginal (n = 1; 2%), and the remaining three (6%) did not specify. Three geographical groups were identified—metropolitan (n = 13), regional (n = 25), and rural (n = 7). The geographic location for the survey was classified using the modified monash model (MMM), in which “metropolitan” refers to MM1 and 2 classification, “regional” refers to MM3, and “rural” refers to MM4–7 (Department of Health, 2019).

Table II. Speech-language pathologist survey participant demographics.

	Metro (n = 13)	Regional (n = 25)	Rural (n = 7)	Total (n = 49)
Age, mean (SD)	36.17 (8.4)	30.68 (6.7)	37 (6.7)	33.24 (8.6)
Number of children seen per month whom SLP has concerns hearing loss is present, mean (SD)	6.54 (7.5)	4.15 (3.9)	11.71 (10.4)	5.78 (6.6)
Number of children seen per month whom SLP recommends hearing assessment, mean (SD)	8.15 (7.8)	4.3 (3.1)	8.29 (6.8)	5.8 (5.5)
Highest degree/ level of schooling, n (%)
Bachelor’s degree	10 (76.9)	25 (92.6)	5 (71.4)	41(83.7)
Master’s degree	3 (23.1)	2 (7.4)	1 (14.3)	7 (14.3)
Doctorate	–	–	1 (14.3)	1 (2.0)
Age of children on caseload, n (%)
Less than 3 years	7 (53.8)	5 (18.5)	2 (28.6)	15 (30.6)
3–5 years	9 (69.2)	21 (77.8)	7 (100)	39 (79.6)
6–8 years	4 (30.8)	12 (44.4)	3 (42.9)	19(38.8)
9–12 years	1 (7.7)	6 (22.2)	2 (28.6)	9 (18.4)
13–18 years	–	1 (3.7)	1 (14.3)	2(4.1)

Survey findings

On average, the number of children with hearing concerns seen by participants each month significantly differed between the regional (mean rank = 20.41), and rural (mean rank = 33.57) groups (U = 44.50, z = −2.15, p = .031, r = 0.31). This variable was not significantly different for the metropolitan group (mean rank = 26.31) compared to the other two groups. No other differences were found regarding factors related to caseload between metropolitan, regional, and rural areas (ps = > 0.05).

Participants rated statements targeting dimensions of access about the accessibility of hearing assessment services in their area (see Table III). Ratings were compared across metropolitan, regional, and rural groups showing no significant between groups differences (ps = > 0.05), indicating similar enablers and barriers across geographic locations. Though not statistically different, more SLPs working in rural areas (87.5%) identified that hearing assessment services had long wait times compared to participants in regional (40.7%) and metropolitan areas (38.5%). The majority of participants in the metropolitan (84.6%) group felt they had experienced professionals in their area to adequately assess children with hearing difficulties, compared to only 55.6% in the regional and 42.9% in the rural group; this difference was not significant. There were no other significant differences between metropolitan, regional, and rural areas in demographic or caseload details (ps = > 0.05).

Table III. Survey responses to rating questions.

Rating question: 1 = disagree, 2 = neutral, 3 = agree	n = 45
	Metro (n = 13), mean (SD)	Regional (n = 25) mean (SD)	Rural (n = 7) mean (SD)
I know where I can refer clients to for more information about hearing assessment services in my area.	2.85 (0.55)	2.52 (0.75)	2.29 (0.95)
I am able to refer children to hearing assessment services located in the same community in which I practice.	2.38 (0.96)	2.26 (0.90)	2.00 (1.00)
The quality of health care that my clients receive is the same regardless of their geographic location.	1.92 (0.95)	1.37 (0.68)	1.00 (0.00)
It is important for all children to have regular hearing tests before they start school.	2.92 (0.27)	2.89 (0.32)	3.00 (0.00)
The hearing assessment services in my area have a reasonably short wait time, and can accommodate client needs in their hours of operation.	2.08 (0.95)	1.81 (0.78)	1.29 (0.76)
The hearing assessment services in my area or surrounding areas are affordable.	2.00 (0.91)	1.81 (0.68)	2.57 (0.78)
Attending hearing assessment services is accepted in my community.	2.46 (0.52)	2.59 (0.57)	2.86 (0.38)
There are experienced professionals in my area who can assess children with hearing difficulties adequately.	2.77 (0.59)	2.37 (0.79)	2.14 (0.90)
The staff at the hearing assessment service treat clients with respect and in a culturally appropriate manner.	2.62 (0.51)	2.56 (0.50)	2.43 (0.79)

p = > .05 when comparing responses across metropolitan, regional, and rural locations.

Phase two: Interviews

Participants

Fourteen participants across different geographic locations participated in semi-structured interviews (see Table IV). Contact was attempted with all participants who indicated their interest in an interview. For participants who responded, the geographic location of their work was confirmed. The aim was to include no more than two participants from each geographic location (metropolitan, regional, rural) per Australian state. It was made clear in the information sheet for the survey that potentially not all participants who indicated their interest would be interviewed. Once that maximum was reached, potential participants were thanked for their interest but not included in interviews. Participants’ current role type (e.g government employed rural generalist) was also considered to allow diversity across practice settings.

Table IV. Interview participant characteristics.

Participant ID	Modified Monash category area	Number of years of experience	Current role type
P1	Rural/remote	20+	Tertiary education
P2	Regional	10–20	Private practice generalist, research
P3	Regional	10–20	Government generalist
P4	Rural/remote	0–5	Government generalist
P5	Rural	0–5	School based generalist
P6	Regional	5–10	Private practice generalist
P7	Rural/remote	0–5	Private practice generalist
P8	Rural/remote	5–10	Government generalist
P9	Metropolitan	5–10	School based generalist
P10	Regional	5–10	Private practice generalist
P11	Metropolitan	5–10	NGO specialist (hearing)
P12	Metropolitan	10–20	Government specialist (hearing)
P13	Regional	10–20	Private practice generalist
P14	Rural	0–5	School based generalist

Interview findings

Three main themes were identified from the data. The first theme, “Education is important”, centred around ensuring understanding of the importance of hearing to development, regular monitoring for hearing loss, and the need for education across a range of stakeholders, including parents, speech pathology students, and other health professionals. The second theme, “Settle yourself in”: Multifaceted service level barriers, reflects participants’ perspectives on the numerous service barriers that need to be addressed including: communication; wait times; complex pathways and criteria; and the complexity of the assessment itself. Participants also talked about the complexity of various family circumstances, resulting in the third theme, “There’s a lot going on for them”: Contextual complexity. Themes and subthemes have been listed in Table V.

Table V. Themes and subthemes.

Theme name	Subthemes
“Education is important”.	Education of stakeholders (SLPs, health professionals, and parents). Education about the relationship between hearing and speech and language. Vigilance in monitoring hearing loss.
“Settle yourself in”: Multifaceted service level barriers.	Long wait times. Complex pathways and criteria. Communication between services. Complexity of assessment.
“There’s a lot going on for them”: Contextual complexity.	Health literacy. Competing priorities. Language and culture. Family resources.

Theme 1. “Education is important”

SLPs suggested that they felt awareness and knowledge of hearing loss was low, but not just in parents, leading most of them to identify a need for increased education and awareness about hearing loss by three main stakeholders, namely speech-language pathology students, health professionals, and parents. SLPs particularly highlighted the need for education regarding the relationship between hearing and speech and language, especially for speech pathology students and health professionals, so they in turn can provide education to parents. Five interview participants identified that they felt speech pathology students are not taught about the importance of adequate hearing for speech and language development or the importance of hearing assessment being completed before commencing speech pathology intervention. One participant (P1) commented, “it’s quite upsetting, the low level of knowledge [about hearing loss] amongst some of them. The unis [universities] aren’t preparing them these days.”

The importance of professionals ensuring the link was also understood by parents was described by one participant (P12), who stated: “They [mothers] need to understand the link between hearing and language and literacy, and you’ve got to be able to understand that, so that kind of feeds into your health literacy, cognitive skills.” Another participant (P3) said, “I think giving the ‘why’ is really important.” P10 elaborated, “We can’t really start working on therapy and working towards their goals until we know that they can hear. Because if they can’t hear then speech therapy is not going to be effective.” Participants also described that they try to educate parents about the difference between behavioural responses to sound in their environment and being able to hear and process speech: “They’re turning to you and they are talking a little bit, but perhaps not hearing at the optimal level for them to be able to differentiate between sounds or to localise sounds” (P13). Providing this education to parents helps to justify the request for hearing testing as parents understand the importance of effective hearing, which may enable them to see the benefit of following through with a hearing assessment when it is recommended.

Participants felt that education to primary care health professionals (such as general practitioners [GPs]) was also needed to ensure that they, as well as parents, understood the difference between hearing frequencies for speech versus other sounds. P12 described their concerns as follows:

Parents will say to me, ‘I went to the GP and I was worried and the GP slammed the door or they banged on the desk and they said there’s no problem with the hearing, don’t worry’ rather than sending kids off [for a hearing test]. So even at that primary healthcare, um, [level] we just get GPs that repeatedly don’t understand the implications of conductive hearing loss on language development. So when parents come and say, ‘my kid’s not talking’ they don’t make the link that it can be because their ears are blocked.

Though SLPs highlighted the need for education to parents and professionals, they also expressed some concern that insufficient education could exacerbate misunderstandings. For instance, while the universal newborn hearing screening (UNHS) has raised awareness to some degree, three interview participants reported that they felt insufficient education was provided to health professionals, and thus parents, regarding how vigilantly hearing needs to be monitored. P3 stated, “I think our team does not understand hearing as well. So they’re like, ‘Yeah, the hearing was assessed at birth, and now they’re four. Everything’s okay’. And I'm like, ‘four years has gone past. A lot of things have happened.’” In addition, participants felt that many parents are not aware that, “just because they passed a hearing screen at birth doesn’t mean that they don’t have a loss now” (P11). One participant described the UNHS as a “blessing and a curse”, explaining that “it’s a case of like a little bit of knowledge is dangerous” (P12).

Six of the 14 participants discussed their perception that hearing assessment should be standard practice and should occur early in a child’s life. Two of those participants worked in specialist hearing clinics and elaborated further on the importance of “hypervigilance” (P11) in monitoring hearing. One participant discussed the importance of having a hearing assessment prior to commencing speech therapy, however, they also conceded that “everybody is just under pressure to see people faster, get them out the door. Do more with less” (P12).

Theme 2. “Settle yourself in”: Multifaceted service level barriers

Service level barriers discussed by participants were similar despite geographic location. When one participant was asked to describe barriers to accessing hearing assessment, her response of “settle yourself in” (P12) indicated that it would take a long time to list all the barriers. Long wait times, identified by 11 participants, was a source of frustration for participants, as some felt that their client’s motivation faded if their hearing wasn’t immediately assessed. Seven participants mentioned the COVID-19 pandemic as having an additional negative effect on wait times, leading to a “backlog” (P11) of children needing hearing assessments. The long waits caused compromised outcomes for clients: “But if you’re waiting like 12 [months], or more, that’s not okay. And that’s a whole year of a little person’s life. If they can’t hear properly then they’re not hearing. And they’re not learning” (P8). SLPs also indicated that the compounding waitlists for allied health and medical professionals further compromises outcomes for children. As P8 stated,

So it’s right now, you know, they wait for 6–9 months for me as a speechie [SLP]… And then we wait another 18 months for a paediatrician… 6–12 for ENT and hearing test. Um, you put all that together, the kid’s really 3.5 [years old] and about to go to Kindy [kindergarten/preschool] and still hasn’t been seen.

Participants were also frustrated by complex pathways and criteria, which they reported results in inefficient service. As one participant stated, “I find it hard to know which services are which, which goes where and what’s the criteria” (P1). Another participant acknowledged,

to have three separate services operating in three different places [within the same rural community] just seems difficult. It would be much better if there was one service that visited every like once a month for two days. That would be great, at the same place. So people knew. (P4)

SLPs explained that if pathways and criteria are not clear, it leads to a doubling up of services because professionals will refer to every government and/or non-government service, which may have further consequences for wait times: “the child would get two checks within a month and be fine on both. But we’ve kind of doubled up on our service, and the parents didn’t need to take their child to two appointments” (P4).

Another difficulty experienced in relation to complex pathways and criteria involves communication between services. If a number of services are involved, communication between services is more complicated. Participants discussed difficulties contacting audiologists to access hearing assessment reports and also schools not being provided with copies of hearing assessment reports. Communication and service access seems even more complicated in rural/remote areas. The transient nature of health professionals in these areas causes difficulties in adequately following up on children with chronic issues such as otitis media: “even the GPs. In most of the communities other than [rural town name] are all locums. So they don’t see the same kids twice. So then you don’t see that this is an ongoing issue” (P8). Participants in rural/remote communities reported difficulties contacting parents, as their details changed frequently. This also made it difficult to advise parents that an outreach hearing service was visiting with enough notice that they could attend:

[outreach] clinics were often organised less than a fortnight before the visiting service arrived. Which meant reminders would be sent to people’s PO Box [post office box] because there’s no physical post in people’s houses in [rural town] and the chances that a family has checked their PO box within a fortnight of the appointment, put it on a calendar and then has transport to get to the appointment on time is very, very slim. (P4)

Even if parents can be contacted to advise of hearing assessment appointments, they may have other commitments. As one participant reported,

visiting services miss so much of the population, such a transient population with only four weeks of the year being covered, it doesn’t take much for all of those four weeks to happen to be school holidays or sorry business time or whatever else is going on for a family’s life. (P4)

SLPs indicated that they found navigating these complex service pathways and criteria challenging; presumably it would be even more so for parents given the degree of health literacy required. “There was a lot of difficulties with even accessing MyGov [Australia Government portal for accessing government services such as income support payments]” (P11). If SLPs and/or parents do manage to navigate the processes well enough to attain an appointment, the complexity of the assessment itself can lead to inconclusive results. For example, one participant reported: “most generalist audiologists don’t have any paediatric experience, and they’re certainly not appropriate to be testing kids with [who are] cognitively delayed and impaired” (P12). Another participant explained, “the results are coming back inconclusive… just because the child is not able to do it, so they you know, they won’t wear the headphones. Perhaps they’re not turning, they’re not responding” (P13).

Theme 3. “There’s a lot going on for them”: Contextual complexity

As indicated, health literacy can impact a family’s capacity to access services. If families do not fully understand hearing loss and implications for their child, it can lead to non-attendance. Health literacy and the family’s understanding of the information provided to them at hearing assessment appointments may also impact the information that SLPs receive about results to inform treatment targets. One participant identified that,

the parent had to be health literate enough to take the child and communicate the results to me… I would ask the audiologist to explain to me what the results were, so I could then follow that up with the family and say, you know, ‘did you understand? What did you think about that? Do you know what it means?’ There’s also no interpreter service regularly accessed by the audiology clinic. (P4)

Poor health literacy and misunderstandings about the health service can also impact upon attendance rates. Two participants discussed the notion that non-attendance could also arise out of fear or previous negative experiences. As one participant discussed,

we get a lot of child safety [child protection reporting], so there’s avoidance of contacting services from the public system in that they don’t want more people knowing what’s going on in their life. It’s just another person who can notify on them. And, um, you know, potentially take their children away from them. (P12)

Another participant added, “I think there’s a lot of health fear, you know, that doctors poke and prod and he [the child] doesn’t like that. So we’re not going to go back to the doctors because that makes him [child] cry” (P8).

Competing priorities or family resources can also result in non-attendance. Participants recognised that, “most families instances where they’re not as compliant is there’s a lot of other social issues in play” (P3), including financial resources or capacity to take time from work. As one participant discussed, “if you don’t have a place to live and food to eat and a safe environment. We’ve got high level[s] of dysfunction and poverty and unemployment and violence, and hearing assessment is not really high on the priority” (P1). Competing priorities are not just due to socioeconomic status: “middle class educated families. It’s actually been the biggest shock, I think the biggest, not battle, but having to push a bit, was with parents who are GPs. Not having thought about it, not realised, been too busy” (P1). Complex service pathways may further impact busy parents’ engagement in hearing services, since the navigation of the system would create a further time burden. However, if families perceived that the appointment was important to gain information to support their child, they prioritised appointments despite competing demands. Three participants identified that,

if it’s a really high priority for parents. Like if the kids are quite deaf and it’s causing big problems, and parents have recognised that, they will often do everything in their power to make it there. Um, but, yeah, it’s really dependent on how much the parent values the service and the competing demands and their resources at the time to make it there. (P4)

Participants acknowledged that parents’ differing priorities regarding hearing assessment impacted their willingness to follow through with a hearing assessment.

Interconnected with health literacy and competing priorities, language and cultural differences may also impact family engagement with services due to barriers such as, “just not understanding the whole pathway and the system and support, how you fit into the big picture and not knowing your questions to ask, culturally not wanting to ask” (P12). Language differences may also impact understanding of hearing and health literacy. Even with an interpreter, messages can get “lost in translation” (P12): “And when it goes through a third person, and I don’t know what that third person is saying and exactly what they’re saying, the nuance is often lost” (P12).

Related to culture are family values including the perception of disability, which may impact upon willingness to attend appointments. For example, one participant discussed the belief that families may not want to accept the hearing loss diagnosis, which may or may not be related to the family’s culture:

a lot of our families don’t want to believe that there’s a hearing loss…They don’t want to be told that they need to put a hearing aid on their children. Dad refuses to give it to her because he said that, ‘she has that on her head. People think there’s something wrong with her and they won’t be able to marry her off. (P12)

Family resources (e.g. financial and time cost) also contributed to service access. One participant reported, “I would say at least, I'd say 95% of people that we see are public only. Don’t have private health, don’t have funds up their sleeve to be able to pay for things like that [hearing assessments]” (P8). However, one participant reported that, “it’s pretty easy to get into, like, a paid hearing clinic.” (P9) Thus, it seems that access to financial resources may reduce service barriers through a reduction in wait times.

Proposed solutions by participants

Although participants identified many barriers to hearing assessments, they also proposed a number of solutions. For education barriers, proposed solutions included providing education to general practitioners and nurses so that they can educate parents about signs of hearing loss,as well as more direct education to parents so that hearing assessment may become more of a priority to them. Education regarding the importance of monitoring hearing status was also identified as a solution. Participants also suggested having routine points in time where hearing is assessed in early childhood. For example, “attach[ing] it to public health in some way, whether or not it’s funded by Australian Hearing, having more availability for them to see non-[diagnosed hearing loss patients]” (P12). Other participants suggested using screening tests, such as the Sound Scouts app (Dillon et al., 2018), as justification that a full hearing assessment is warranted, so parents may be more likely to travel and pay the cost. Participants suggested that hearing screening could occur by other professionals, which would reduce the service barrier of long wait times. Participants suggested that, “at the very least, all public clinics should have access to the full schedule of nurse audiometry” (P12). They also stated that: “speechies [SLPs] or OTs [occupational therapists] could do it [hearing screening]” (P6). Participants stated that having “GPs checking ears at every child check-up as routine” (P5) and having “teachers trained up” (P1) would allow more children to have their hearing status regularly monitored. A suggestion to address the issue of inconclusive tests, which can then lead to longer wait times, was to have two audiologists present at all hearing assessments for young children (P12).

Other solutions were related to complex pathways and criteria. One solution was to “reduce their strict criteria” (P3) in audiology practices so that more children could attend. Another participant suggested having “clear pathways or, you know, structure—I’m this person, I fit these criteria, I go there. Flow charts, or clear criteria” (P1). Participants suggested that having a case manager and/or Indigenous Liaison Officer would help parents to navigate the complex medical system. Four participants discussed how outreach services could make changes to be more flexible to cater for the community’s needs and competing priorities by visiting more frequently, visiting smaller towns, giving more notice for when the outreach service would occur, or visiting on set days each time and at the same location. One participant conceded, “I do think it would be good to have someone locally—but that’s probably never going to happen” (P8).

Participants discussed some solutions to contextual complexities within families, mainly addressing family resources. Some solutions specifically addressed the transport barrier. For instance, some participants suggested having a bus that could drive to potential consumers’ locations, or setting up services where the families already are, such as at schools. Other proposed solutions were focussed on overcoming financial barriers, including more Medicare rebates and “having audiology assessments covered under the NDIS” (P12).

Discussion

Participants across metropolitan, regional, and rural locations experienced similar barriers related to the theory of access (Penchansky & Thomas, 1981; Saurman, 2016). Joint displays demonstrated that most survey and interview findings complemented and expanded upon each other. Data from the surveys and interviews both identified that barriers did not differ across geographic location. Interview participants identified that the education of a range of stakeholders is key to ensuring children with hearing loss are identified and provided access to treatment. Participants elaborated on service delivery barriers, specifying that long wait times and complex pathways and criteria lead to inefficient services. Participants also identified that a family’s contextual complexity exacerbated accessibility issues, especially if the family did not have the health literacy education to understand the importance of hearing for speech and oral language development. Although children may be able to hear some sounds, they may not be able to access the full range of speech sounds required for oral language development.

The findings from this study suggest that access to hearing assessments depends more upon parental education and family circumstances than geographic location. Previous studies were contradictory to these findings and identified rurality as a barrier to prompt and high-quality services (Fulcher et al., 2015; Lai et al., 2014). However, the identification of parental education and family circumstances as potential barriers to accessing services, especially for parents from culturally and linguistically diverse backgrounds, has been supported by previous studies (Ng et al., 2022; Pokorny et al., 2022; Zingelman et al., 2021). Although the current study took place in Australia, research in New Zealand also found that family circumstances can impact upon access to services, especially in Indigenous populations (Pokorny et al., 2022).

Participants discussed the importance of educating parents about the awareness that although children may be able to hear, they may not be hearing the frequencies required for speech and language development (Oxenham, 2018). Anecdotally, participants felt that this education allowed parents to prioritise the hearing assessment more highly. A number of participants indicated frustration that some parents were not prioritising the hearing assessment. It is possible that these participants did not consider all the barriers that may cause non-attendance by parents. SLPs need to also consider that parents may identify different priorities for themselves and their children compared to SLP priorities. For example, parents may prioritise their child attending school over taking them out of class to attend a hearing assessment (Zussino et al., 2022b).

The need for education and awareness extends beyond parents to include speech pathology students and clinicians. Challenges raised about the education of this stakeholder group could be related to the fact that hearing was not listed as a range of practice area in speech pathology in Australia until the release of new professional standards from Speech Pathology Australia (SPA) in 2020 (Speech Pathology Australia, 2020), which may have reduced the degree to which it was included in university training programs. Now that hearing is specifically identified as an area of communication in SPA’s professional standards, it will be expected to be included in accredited university programs. Changes to the curriculum for students could mean that there is a greater focus on the importance of hearing for speech and language development, which will support students and future clinicians to provide more education to parents about the importance of hearing assessment. It became clear that SLPs with more experience and knowledge about the implication of hearing on speech and language were more confidently able to impart their knowledge onto parents. It is also important that the same awareness education that is provided to parents is also provided to other professionals who engage with children, such as teachers, general practitioners, and allied health professionals to ensure that hearing loss is monitored vigilantly. The wait and see approach participants reported as recommended by some health professionals should be ceased in favour of recommending early identification and early intervention, as it has been established that this approach improves speech and language outcomes for children (Ching & Leigh, 2020).

Health literacy was an underlying challenge commonly raised by interview participants, though none referred to it as such. Limited health literacy has been linked to lower levels of participation in health related decision-making and difficulty making sense of health information (Calvasina et al., 2016; Mancuso & Rincon, 2006). Health literacy skills relate to the awareness dimension of access theory as they relate to how, when, and why to access hearing assessments. When cultural and language barriers are added to these difficulties, the adequacy of the service in accommodating the needs of each consumer can be decreased. Mullan et al. (2017) identified that many health professionals lack an understanding of the consequences of low health literacy for vulnerable populations, which impacts upon sharing of results. Therefore, collaboration between SLPs and audiologists is important for supporting families to understand why a hearing assessment may be required, and also in supporting families to understand the results and implications of these results for their child.

Quality (adequacy) and consistency of service (accessibility and availability) were identified as a barrier by most participants. Participants reported that services were not equitable in all communities. The complex pathways to enter into a service rendered the service more difficult to access, especially for those with lower health literacy skills and complex family situations. Participants identified that although there were a number of services (outreach and local), the services do not communicate with each other or consult the communities, compromising their accessibility.

Despite being specifically asked about enablers during the survey and in interviews, SLPs tended to focus their information on barriers. In interviews with 14 participants, a total of three enablers were discussed; these same enablers were the only enablers that had been identified by the survey participants. Identified enablers related to community-centred practice, which involves partnering with communities to set collaborative goals. Hyett et al. (2019) suggest that important steps towards setting collaborative goals include identifying important occupations within the community. Participants identified that working alongside another professional who is well known to the community, or working with Indigenous Liaison Officers, assists with acceptability of the service. Hyett et al. (2019) also suggest to identify community resources and how these can be used to overcome barriers to community participation. This suggestion was supported by interview participants, who indicated that working with services in the community to provide transport for consumers assists with the accessibility of the service.

Considerations and future directions

Findings from this study are unable to be generalised to the whole population due to the small sample size in surveys and interviews. The recruitment method for both phases meant that the sample had the potential to be biased towards SLPs who had had a negative experience, so were more motivated to share their perspective. It is also important to note that the survey included fewer respondents from rural and metropolitan areas compared to regional areas. The researchers attempted to rectify this by interviewing a more balanced proportion of participants across geographical areas. While the researchers were able to confirm whether interview participants worked in the same geographic location that they lived, this was unable to be completed with survey participants. The researchers were concerned that requesting such specific information on the survey, where participants had been assured anonymity, could potentially identify participants. A more diverse sample could have added an interesting perspective.

The interview guide did not address what happens after a hearing test, which could have been useful for identifying barriers to helping families understand the results of a hearing test. Investigation into health system barriers discussed by SLPs may be conducted to determine whether policies and procedures could be adapted to allow more easily accessible services, available to all Australians. Future research should aim to investigate barriers to hearing assessments across countries with similar remoteness levels, and on a larger scale, to determine whether the experience of professionals and parents is the same across healthcare systems. Further investigation into health literacy awareness in health professionals should be considered, to determine whether health professionals are adapting their language appropriately for parents (especially those in vulnerable populations) to be able to understand the health information being presented. Future research might also examine the feasibility of changes that have been proposed by SLPs in this study to overcome presented barriers. Surveys or interviews could be repeated in the future, when education about hearing is more embedded into the training of Australian SLPs, to see if education is still identified as such as a strong barrier to accessing hearing assessment services.

Conclusion

Children need access to high-quality auditory information for speech and oral language development. Geographic location was not found to be a key contributor to access to hearing assessments. Instead, SLPs identified that more education about hearing for speech and oral language development was needed to encourage attendance to appointments and ongoing monitoring of hearing status. SLPs also identified other barriers to accessing hearing assessment, including service delivery barriers such as long wait times and complex referral pathways. SLPs reported that the complexity of a family’s situation made accessing hearing assessment services more difficult, especially if the family had poor health literacy, language and cultural differences, and/or reduced family resources.

Ethics statement

Ethics approval was granted by Central Queensland University Ethics Committee, project number 0000023432.

Author contributions

JZ: Conceptualisation, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Writing—Original draft. BZ: Conceptualisation, Formal analysis, Writing—Review & editing. RP: Methodology, Formal analysis, Writing—Review & editing.

Disclosure statement

No potential conflict of interest was reported by the author(s).