Hearing Loss in the Elderly: A Proposal for Intervention in Primary Health Care

To evaluate the performance of professionals regarding knowledge about hearing loss in the elderly, through theoretical and practical training by a speech therapist. An intervention study was carried out with 87 Primary Health Care professionals in a municipality of Brazil. A survey of the participants’ knowledge related to hearing loss was performed using a data collection instrument composed of items related to both sociodemographic conditions and specific questions concerning the topic. This instrument was applied in two stages: before training and after training. The participants’ performance in relation to knowledge about hearing health was estimated by subtracting the post-training score from that obtained in pre-training. Participants were classified in higher performance (≥4 points) and lower performance (<4 points) groups. Other variables were collected: sex, age, occupation, schooling level, and length of professional service in health. The performance comparison estimated mean and the 95% confidence interval were calculated by the aforementioned variables using Student’s t-test. A comparison of these variables with higher performance was conducted using the X2 test with a significance level of 5%. After training, there was an increase in the average performance of about 30% (p < .01). The highest performance was more frequent among professionals who reported having high school and below levels of education (p < .01) and who were community health agents (p = .01). The performance of the professionals regarding their knowledge about screening for hearing loss increased. The training showed low complexity and was feasible for health professionals.


Introduction
Hearing loss, known as presbycusis, compromises oral communication, reduces social well-being, and negatively impacts people's quality of life.This type of impairment occurs for several reasons, and it is particularly common with aging (Ribeiro et al., 2021), often interfering with an individual's relationships in their social environment.This disease is related to a number of other neuropsychic comorbidities, such as anxiety and depression, which may be associated with neurological disorders involving cognitive decline and dementia (Kim et al., 2021).By 2050, according to estimates by the World Health Organization (WHO), 2.5 billion people will have some degree of hearing loss and at least 700 million will require rehabilitation in health services (World Health Organization, 2021).These estimates may be even more critical in countries with difficult access to health services, and where early diagnosis is sometimes impossible, a condition that makes populations in underserved regions more vulnerable (GBD, 2021).
With the increase in life expectancy around the world, that is, the aging of the population, many preventive actions are essential to improve the quality of life of the elderly, such as the early diagnosis of presbyacusis (Sharma et al., 2020).Identification of the problem and its severity levels contributes to the definition of strategies aimed at overcoming difficulties and preventing associated comorbidities (Carniel et al., 2017).
In Brazil, there is a Ministry of Health determination for the diagnosis of presbyacusis in Primary Health Care, but health teams have little or no knowledge about the issues involved in that process (Cohen et al., 2005;Lopes & Bento, 2021;Newman & Sandridge, 2004;Wallhagen & Pettengill, 2008).For this reason, basic care professionals need to be prepared for the preliminary identification of hearing loss, through simplified strategies, such as the hearing screening test called the Whisper Test (Brasil, Ministe´rio da Sau´de, Secretaria de Atenc xa˜o Especializada a`Sau´de, Departamento de Atenc xa˜o Especializada e Tema´tica, 2021).
Performing the Whisper Test is indicated as a strategy that can be adopted by any previously trained healthcare professional, due to the simplicity of its execution and high sensitivity for the identification of sensory impairment (Labanca et al., 2017).In general, in the Whisper Test, the examiner should stay approximately 30 cm behind the elderly person to avoid lip reading.Each ear is tested individually, by emitting certain whispered words.The elderly person is considered to have passed the screening test if they correctly repeat all the words (McShefferty et al., 2013;Pirozzo et al., 2003;Purnami et al., 2022).
Strategies to identify hearing loss in the elderly with the use of quick, simple and low-cost tests, such as the one mentioned above, are necessary in primary care and relevant for early diagnosis.Thus, this study aimed to evaluate the performance of Primary Health Care professionals in screening for hearing loss in the elderly, before and after theoretical-practical training for applying the Whisper Test, an important diagnostic screening tool for hearing loss.

Study Type
This is an intervention study to evaluate the performance of Primary Health Care professionals in the municipality of Santo Antoˆnio de Jesus, Bahia, Brazil, after training for the Whisper Test and improving knowledge related to hearing loss in general.The study included 87 professionals, made up of nurses and community health agents.

Data Collection
The training of professionals was conducted in two meetings, with an average duration of 2 hr each, using the recommendations of the Brazilian Ministry of Health for the management of hearing loss screening in the elderly (Brasil, Ministe´rio da Sau´de, Secretaria de Atenc xa˜o a Sau´de, Departamento de Atenc xa˜o Ba´sica, 2006).The first meeting consisted of a pre-training, in which a survey of the participants' knowledge related to hearing loss was conducted (STEP I).A data collection instrument composed of items related to sociodemographic condition and specific questions concerning knowledge about hearing loss was used (Alvarenga et al., 2008).This instrument was applied in two stages: before training (STEP I) and after training (STEP II).
After the application of the instrument, the first session of the training was conducted by a speech therapist with experience in this area of activity who addressed the following themes: (1) Anatomophysiology of hearing, (2) Definition of hearing loss-presence and severity, and (3) Risk factors for hearing loss and presbyacusis.
In the second meeting, also conducted by the speech therapist and team, the topics addressed were: (1) Hearing health care, (2) Main elements of the National Auditory Health Policy, (3) Rehabilitation process, and (4) Whisper Test, and its proper application in the elderly.After training, the performance evaluation of Primary Health Care professionals was carried out through the reapplication (STEP II) of the same data collection instrument mentioned above, with the same specific questions related to hearing health.

Performance Evaluation
The instrument used to evaluate the performance of Primary Health Care professionals contained 14 questions regarding hearing health, totaling a score of 14 points.The difference in participants' performance between the two steps (STEP I and STEP II), in relation to knowledge about hearing health, was estimated using an indicator resulting from subtracting the score obtained in STEP II (post-training) from that obtained in STEP I (pre-training) for each participant.That is, PERFORMANCE = (SCORE Step II 2 SCORE Step I ).
According to the result of the PERFORMANCE variable, the participants were classified into two groups: (1) HIGHER PERFORMANCE ( ø 4 points) and (2) LOWER PERFORMANCE (\4 points).The cutoff point of 4 corresponded to a difference of approximately 30% of the total correct answers and was chosen according to the distribution of the performance indicator (mean).Therefore, the distribution of the following variables was estimated using central tendency measurements (mean and median) and dispersion (standard deviation and interquartile range): scores obtained pretraining (STEP I) and post-training (STEP II), and PERFORMANCE of professionals (resulting from the subtraction of the score obtained in the two STEPS).

Other Study Variables
Other study variables were also obtained from the data collection instrument and presented according to distribution in the study sample.The represented the sociodemographic characteristics: sex (female; male), age (in years), occupation (nurse; community health agent), schooling level (high school and below; higher education), and length of professional service in health (in years).

Statistical Analysis
The Stata 17 statistical package was used for data analysis, with the following license: 301709305247.The normality of the variable PERFORMANCE was also verified through the Shapiro-Francia test, and the assumption of normality was guaranteed.With the use of the Student's t-test, the PERFORMANCE comparison and the estimated mean and the 95% confidence interval were calculated by sex, age, occupation, schooling level, and length of professional service in health.Furthermore, a comparison of higher performance was conducted using the X 2 test, considering the categories of the variables mentioned above.The level of significance adopted was 5% for the whole study.

Ethical Considerations
The research was approved by the Ethics and Research Committee of the Federal University of Recoˆncavo da Bahia (CAAE 41064620.3.0000.0056),and received funding through the FAPESB/ No. 02/2020 notice-RESEARCH PROGRAM FOR THE SUS.All participants signed an informed consent form.

Results
The sample consisted of 87 professionals, of whom 74.7% were community health agents (74.7%).The majority (94.3%) identified as female, while the remaining minority (5.7%) identified as male.Regarding the age group, 25.3% of the individuals were between 51 and 65 years old, and the median age was 45 years (IQR 37; 51).Regarding schooling level, 57.5% of the professionals had high school and below qualifications and 42.5% had completed higher education (Table 1).
It was observed that the median value of the PERFORMANCE variable was four points (Table 2) and that 75% of the professionals had a score of up to six points (IQR 2; 6).It was also detected that the participants' average length of service in health was approximately 18 years and that only 25% of them had up to 12 years of service (IQR 12; 23), the others being more experienced.
A higher female mean performance was observed when compared to males (Table 3).Regarding occupation, community health agents had higher average performance (Mean performance of 4.25; 95% CI [4.86,5.44]).Concerning schooling level, the group that studied high school and below performed better when compared to the group with higher education.For the variable length of professional service in health, those who had 18 years or greater of health service experience were more benefited by training (4.19; 95% CI [3.50,4.87]).There was statistical significance only for the variables schooling level (p \ .01)and length of professional service in health (p = .04).
Table 4 presents a comparison of the proportions of HIGHER PERFORMANCE ( ø 4 points), by the variables sex, schooling level, occupation, length of professional service in health and age.The bivariate analysis showed that the highest performance was more frequent among professionals who reported having high school and below (p \ .01)and who were community health agents (p = .01),with statistical significance.The other did not present a statistically significant difference between the proportions.

Discussion
The main findings showed that theoretical-practical training to identify hearing loss in the elderly is a viable method to be implemented in Primary Health Care, since it presented low execution complexity for a gain of 30%, with statistical significance.Previous studies that investigated the effectiveness of training health professionals to screen for hearing loss in the elderly were not found, which made it impossible to compare the findings.Early identification of hearing loss in individuals with indications of alterations may increase the frequency of referrals to reference services and, consequently, may reduce damage related to both hearing loss and associated comorbidities (Meneses et al., 2010).
In addition, the results showed that there was a better performance among individuals who reported having studied high school and below and aged above 45 years, corroborating a study by Andrade et al. (2020) that evaluated community health agents from different age groups.
A possible reason for the better performance among these participants may be the fact that individuals who have not had the opportunity to take a higher education health course could be more motivated to reduce this training deficit through continuing education, such as the applied training in the present study.This may be a strategy to compensate for the absence of an undergraduate course when compared to nursing professionals: a group with higher education, but which may not have engaged in the training process with the same intensity, perhaps as a result of overestimating their previously acquired academic knowledge, limiting their learning (Castro et al., 2015;Gouveˆa et al., 2015;Jacob et al., 2020;Melo & Alvarenga, 2009;Nielsen, 2014).
The arguments mentioned above can also be used as a hypothesis for greater effectiveness of training in older individuals, since the participants aged over 45 years constituted 70% of those who had only studied high school and below.
A secondary, and extremely relevant, finding concerns the lack of knowledge, on the part of Primary Health Care professionals involved in the study, regarding the existence of a Ministry of Health determination that the Whisper Test should be applied.The professionals also reported that they had not received any previous type of guidance or training on hearing screening during their professional history.
It is important to ensure that hearing health care for the elderly, especially hearing loss screening, is indeed on the radar of Unified Health System (Sistema U ´nico de Sau´de-SUS, in Portuguese), the Brazilian Government Ministry of Health and permanent education initiatives, such as the SUS Open Network website (UNA-SUS).In a quick search of the 419 courses registered on their site, none addresses this theme.Considering that half of the public health network's users seek Primary Health Care services, the offer of a course on hearing loss screening for the elderly would have a wide impact on primary health care professionals and, consequently, on the population assisted by them.In Brazil, the aging population has accompanied by an increase in the prevalence of hearing loss in the elderly, negatively impacting their quality of life.Although the Unified Health System (SUS) offers hearing health services, the training of the professionals involved is not always adequate, which can hinder the early identification of hearing loss and the implementation of preventive measures.Additionally, there are regional inequalities in access to health services, which can result in inequalities in the detection and treatment of hearing loss in the elderly.Therefore, it is essential that strategies for training in hearing health care for the elderly be implemented in Brazil to improve the quality of life of this population.This lack of training, in addition to not aligning with the National Hearing Health Policy (Brasil, 2004), can potentially generate an overload at secondary and tertiary levels of hearing health care.The adequate qualification of Primary Health Care teams, as well as allowing for greater detection of the disease, may even create health education devices to prevent hearing loss: through information campaigns, health fairs and guidance to the community on the control of exposure to noise in their daily life or work environment (Andrade et al., 2020;Ribeiro et al., 2021).
Despite methodological efforts to make the findings more reliable, the sample size of the study may have influenced the results.It should be emphasized that the entire process of planning, authorization and on-line execution of training occurred in June 2021, the peak of the ''second wave'' of COVID-19 cases in the state of Bahia-Brazil (Brasil, Ministe´rio da Sau´de, Secretaria de Atenc xa˜o Especializada a`Sau´de, Departamento de Atenc xa˜o Especializada e Tema´tica, 2021).During this period Primary Health Care teams were focused on the identification and monitoring of suspected cases of COVID-19, which may have reduced participation in the theoretical practical training offered (Maciel et al., 2020).
Another limitation concerns the lack of monitoring of the level of information received by the participants.In the present study, there was no development of strategies to monitor professionals with the objective of mapping, over time, what knowledge became promoters of preventive and educational actions in the participants' daily professional activities.Such monitoring can contribute to the effectiveness of preventive and educational actions in each unit due to a decline in knowledge acquired over time, as reported in a study that performed the monitoring of post-training retention in children's hearing health (Arau´jo et al., 2015).Thus, the retention of knowledge about hearing health in the elderly obtained by the participants in the present study will also probably tend to decrease; however, this evaluation was not performed.
It is important to highlight that the questionnaire used in this study was not formally validated.However, a pilot study was conducted to assess its performance prior to the main data collection.The pilot study helped to identify any potential issues with the questionnaire and make necessary adjustments to improve its reliability and validity, facilitating its administration.
On the other, it is important to highlight that this study presents strengths.For example, there was a significant participation of community health agents (74.5%), indicating a receptivity on the part of this category to adhere to initiatives directed at auditory health education for older people.It is known that the community health agents are directly linked to the community, constituting a key element of mediation between the population and health services, since these professionals often live in the territory where they work and share the same reality as the service users of that coverage area.As such, this professional has the potential to improve the quality of hearing health care for older people by increasing dialog between the family and the health team (Assis & Castro-Silva, 2018).

Conclusion
In this study, it was shown that the training of Primary Health Care professionals for hearing loss screening in the elderly is a low-cost strategy suitable for municipalities that do not have many resources, as in the Recoˆncavo da Bahia/Brazil.In addition, it is an effective by which to equip the primary care professional, develop optimized prevention/health education activities, facilitate early diagnosis, and better manage referral and management of elderly people with hearing loss; thus, raising the quality of comprehensive health care for this population group.
Based on these findings, we recommend the implementation of specific training strategies for the early detection of hearing problems in elderly individuals within Primary Health Care in Brazil.One approach may involve the development of targeted training programs for healthcare professionals, including physicians, nurses, and speech therapists, which emphasize the importance of presbycusis screening in the elderly.These programs could include the use of screening tools such as the whisper test, basic hearing tests and information on appropriate referrals to specialized services when necessary.
In addition, an important strategy could be the use of distance education platforms, such as online courses and webinars, to reach a greater number of healthcare professionals across the country.These education platforms can be developed in partnership with academic and research institutions, such as universities and hearing study centers, to ensure that training is evidence based and regularly updated.
To ensure the effectiveness of these training strategies, it is important that the approaches are culturally sensitive and consider the barriers that limit access to healthcare services in different regions of the country.For example, training may include community engagement strategies, such as partnerships with community leaders and local organizations, to increase awareness about the importance of hearing screening in elderly individuals.With these training strategies in place, we believe that we can improve the early detection of hearing problems in the elderly and ensure that they receive the necessary treatment and care to improve their quality of life.

Author Contributions
De´bora Conceic xa˜o Santos de Oliveira, BSc: Substantial contributions to the conception or design of the work; Drafting the work or revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Isaac Suzart Gomes-Filho, PhD, MSc: Substantial contributions to the conception or design of the work; Drafting the work or revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Michelle de Santana Xavier Ramos, PhD, MSc: Substantial contributions to the conception or design of the work; Drafting the work or revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Ana Lucia Barreto da Fonseca, PhD, MSc 1 : Substantial contributions to the conception or design of the work; Drafting the work or revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Adan Arau´jo Marques, BSc: Substantial contributions to the conception or design of the work; Drafting the work or revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Alexandre Marcelo Hintz, MSc: Substantial contributions to the conception or design of the work; Drafting the work or revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Doris Firmino Rabelo, PhD, MSc: Substantial contributions to the conception or design of the work; Drafting the work or revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Ana Claudia Morais Godoy Figueiredo, PhD, MSc: Substantial contributions to the conception or design of the work; Drafting the work or revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Simone Seixas da Cruz, PhD, MSc, DDS 1 : Substantial contributions to the conception or design of the work; Drafting the work or revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research was funded by the Foundation for Research Support of the State of Bahia-Brazil (Fundac xa˜o de Amparo aP esquisa do Estado da Bahia-FAPESB) and by National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Cientı´fico e Tecnolo´gico-CNPq).

Table 1 .
Distribution of Some Characteristics of Primary Health Care Professionals From the Study Sample (N = 87).

Table 2 .
Central Tendency Measurements of the Variables Score Step I, Score Step II, and PERFORMANCE of Primary Health Care Professionals From the Study Sample (N = 87).

Table 3 .
Comparison of the Average PERFORMANCE and Its Respective 95% Confidence Interval, by Sex, Occupation, Schooling Level, Length of Professional Service in Health, and Age of Primary Health Care Professionals From the Study Sample (N = 87).

Table 4 .
HIGHER PERFORMANCE Distributed by Sex, Occupation, Schooling Level, and Professional Service Time in Health of Primary Health Care Professionals From the Study Sample (N = 87).