Implementation of a Hearing Loss Screening Intervention in Primary Care

Article Figures & Data

Table 1.

Operationalization of Normalization Process Theory for the Present Study

NPT Constructs	Definition and Examples³¹	Related Interview Questions
Coherence	Process of understanding the intervention Understand new practice and its purpose Understand roles and responsibilities Understand utility of intervention	Tell us about HL among your patients. What are your clinic’s goals with regard to HL for your patients? Walk us through how the HL prompt showed up in your clinic. How has your clinic’s approach to HL changed since this prompt launched?
Cognitive participation	Process of engaging team members in intervention Involve key participants Support teamwork and group engagement Develop ways to sustain teamwork	How do you interact with the prompt? To what degree is everyone on board with the prompt? Why, or why not?
Collective action	Process of carrying out the intervention Interact in real-life settings Build confidence in intervention and team Assign work to team members Manage resources and policies	How was the prompt launched? How did that go? What was changed, and how? How do you interact with the prompt? How do you, and your team, handle the prompt in your workflow?
Reflexive monitoring	Process of evaluating the intervention and how it impacts team members Determine effectiveness Assess value Evaluate effects on team members Adapt intervention practices	How do you balance the priority of HL against other patient needs? How were problems detected and addressed? What is your sense of how the prompt supports what needs to be done to care for patients with HL?

HL = hearing loss; NPT = Normalization Process Theory.
Note: Interview questions may relate to more than 1 NPT construct. Questions appear in the final interview guide in a different order than listed here.

Table 2.

Site Characteristics

Health System	Site	Practice Size^{^a}	Patient Size (Patients Aged 55+ Years)	Patients Aged 55+ Years in Medicare (%)	Access to Audiology
BH	1	Small	3,723 (714)	22.7	External
	2	Small	7,369 (3,454)	44.2	External
	3	Large	7,760 (1,452)	42.3	External
	4	Medium	6,385 (3,122)	60.6	External
	5	Small	1,516 (249)	33.3	External
MM	6	Large	11,932 (6,223)	59.0	External
	7	Medium	6,834 (2,941)	47.6	External
	8	Medium	7,741 (1,734)	49.9	MM
	9	Large	7,969 (3,026)	41.0	MM
	10	Large	7,322 (1,678)	53.8	MM

BH = Beaumont Health; MM = Michigan Medicine.
↵a Practice size was determined by the number of physicians: small (1–5); medium (6–16); large (16+).

Table 3.

Themes and Related NPT Construct

Theme	NPT Construct
Prompt overwhelmingly viewed as easy, simple to use, accurate	Coherence
Clinicians considered prompt as an effective way to increase awareness of HL and increase conversations with patients about HL
Clinician and staff buy-in played a vital role in implementation	Cognitive participation
Clinicians prioritized prompt during annual visits	Collective action
MA involvement in prompt workflow varied by health system, clinic, and clinician
Prompt resulted in more conversations about HL, but uncertain impact on patient outcomes	Reflexive monitoring

Table 4.

NPT Ratings by Site

NPT = Normalization Process Theory.
Note: “Low” corresponds to scores in the lower quartile (1.5–2.1); “medium-low” to the second quartile (2.2–2.8); “medium-high” to the third quartile (2.9–3.4); “high” to the upper quartile (3.5–3.9).
↵* Percentage of patients (among all patients aged 55 years or older) referred to an audiologist for testing were compared with rates from 1 year immediately prior (T₀) to the study period (T₁) using Pearson’s X₂ tests at each site.