RP204 - Process Evaluation: Barriers and Facilitators in the Implementation of Community Interventions

Abstract:
We developed an internet-based Decision Coaching Guide (DCG) to increase the percentage of adults (65 – 89 years) who visit an audiologist after failing a hearing screening. We conducted an effectiveness study to determine whether the hearing screening setting influenced the uptake of, and adherence to, the DCG in the “real world”. Due to low uptake of the DCG we conducted a process evaluation to determine the barriers and facilitators that prompted DCG completion. Socioeconomic status appears to influence the uptake of a hearing health promotion intervention that encourages hearing aid usage and requires access to an internet-based program.

Summary:
Rationale
Principles of implementation science are used to translate effective clinical treatments from the research lab into the community. Whereas the concomitant effects of unaddressed hearing impairment are well known, the majority of adults who fail a hearing screening take no action to evaluate or manage their hearing problems. We developed an internet-based Decision Coaching Guide (DCG) to increase the percentage of adults (65 – 89 years) who visit an audiologist after failing a hearing screening. In addition to evaluating the efficacy of this treatment, we are determining whether the hearing screening setting influenced the uptake of, and adherence to, the DCG.

We used the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to design an effectiveness study to determine the type of screening experience that triggers the take-up of the DCG. Participants have been recruited from four different screening settings that varied in terms of CUES TO ACTION, TRUSTWORTHINESS of the setting and ACCESSIBILITY to the DCG:

1) Transdisciplinary Optimal Aging Clinic
2) Primary Care Physician (PCPs) Offices
3) Informational Lectures in the Community
4) Advertising via Social Media

Despite 18 months of recruitment, we have fallen short of our goal of 40 subjects per arm. With recruitment about to end, we have begun a process evaluation to determine the factors that led to successful and unsuccessful uptake of the intervention. Because the effectiveness study was designed to be implemented in the “real world” without participant assistance by the research team, many different factors may have led to unsuccessful recruitment. Process evaluations are designed to determine why an intervention program does or does not work (Linnan & Steckler, 2002). Process evaluations are particularly important to evaluate public health interventions that are implemented in the community using existing systems. The results may be used to better understand how to design successful hearing loss related public health interventions (Butterfoss 2006).

Design
We designed procedures to understand the breakdown of recruitment for each arm of the study:
1) We interviewed community participants that helped recruit older adults into each arm of the study. This included, social workers, medical professionals, PCPs, nurses, Institutions that offer community lectures for older adults, and programmers with expertise in the ‘user experience’.
2) We interviewed older adults who signed up to participate, including those who did not complete their participation.
3) When possible, we calculated whether participants sought audiology care without completing the DCG.

Results
Preliminary findings indicate that:
1) Older adults seeking healthcare, are not interested in learning about the importance of hearing healthcare if they have existing health concerns.
2) Learning about the importance of hearing healthcare from a brochure or a discussion with a healthcare provider may be sufficient to encourage older adults to seek audiology care.
3) Many individuals who were interested in our marketing materials were already hearing aid users.

Conclusions
The results of this study will be useful in the design of future effectiveness studies and to identify barriers and facilitators to the implementation of hearing related interventions (such as screenings or lectures) in the community.