The prevalence of childhood hearing loss in rural Alaska is disproportionately high and
predominately infection-related. With preventive screenings and access to health care,
much of childhood hearing loss is preventable. Although state-mandated school screening
helps identify children with hearing loss, loss to follow-up is pervasive and exacerbated
by a scarcity of specialists in rural regions. A mixed methods cluster randomized trial
conducted in northwest Alaska demonstrated that telemedicine can significantly reduce
loss to follow-up. This stepped wedge trial, in partnership with Southcentral Foundation,
will build on this existing work to develop a model that can be scaled in diverse
environments.
We will adapt and implement a new telemedicine intervention called Specialty Telemedicine
Access for Referrals (STAR). This trial will be conducted in 3 regions in rural Alaska
that represent multiple healthcare systems. Based on stakeholder feedback and evidence
generated from the previous trial, an enhanced mobile health (mHealth) hearing screening
will be implemented in all participating schools prior to the STAR intervention, and the
telemedicine referral to specialty care (STAR intervention) will be moved from the clinic
directly into the school.
This stepped-wedge cluster randomized trial is part of a larger hybrid type 1
effectiveness-implementation trial. The stepped wedge trial will evaluate the
effectiveness of the STAR intervention in reducing loss to follow-up from referred school
hearing screening in 3 regions of Alaska: Kodiak, Petersburg and Lower Yukon (n=23
schools, ~2,015 K-12 students/year). The STAR Intervention will be compared to the
standard referral of a letter home to families. Cluster randomization at the level of
school will be performed, with schools (clusters) randomized to one of two sequences. The
effectiveness outcome (i.e., proportion of children who receive follow-up) will be
evaluated over three academic years (2023-2026), with STAR rolled out in a stepwise
manner for each of the two sequences (academic year 2024-2025 for sequence 1 and academic
year 2025-2026 for sequence 2). The control periods for each sequence will be academic
year 2023-2024 for sequence 1 and academic years 2023-2024 and 2024-2025 for sequence 2.
Enhanced screening will be rolled out to both sequences at the same time (i.e.,
non-randomized) beginning academic year 2023-2024. An implementation evaluation will be
conducted to refine and adapt the enhanced hearing screening and STAR intervention
throughout the trial. Implementation data will be collected starting academic year
2022-2023 and then annually for each of the subsequent years.