Evaluation of General Practitioners' awareness of hearing screening in the elderly

Jianli Ge Zhongshan Hospital Shasha Geng Department of General Practice, Shanghai East Hospital, Tongji University School of Medicine Qingqing Li Department of General Practice, Shanghai East Hospital, Tongji University School of Medicine Hua Jiang Department of General Practice, Shanghai East Hospital, Tongji University School of Medicine Xiaoming Sun (  xm_sun2003@aliyun.com ) Zhongshan Hospital


Introduction
The aging of population is one of the most prominent demographic changes since the late twentieth century, becoming a severe challenge for many countries. The de nition of presbycusis refers to the decline of auditory function caused by aging, which is the third of most common health condition affecting older adults after heart disease and arthritis [1][2] . The 2nd WHO Cooperative Center for Deafness Prevention StrategicPlanConference disclosed that mild presbycusis could reduce communication and basic living abilities of the elderly and might even lead to depression or other psychological diseases in severe cases [3][4] . The prevalence of Alzheimer's disease in the elderly with mild, moderate, and severe hearing loss is twice, three, and ve times higher than that of the elderly with normal hearing ability. It may even increase the risk of all-cause death in the elderly [2] .
Presbycusis is characterized by symmetrical hearing loss in both ears at the initial stage, partly accompanied by tinnitus, which will ultimately lead to cognitive decline. Early screening and intervention for hearing loss in the elderly are expected to slow down the process, reduce the incidence of disability, and improve the quality of life [5][6] .
Hearing screening for newborns has been carried out by primary health service centers for more than 20 years, achieving satisfying clinical results, while hearing screening for the elderly is still in its infancy [7][8][9] . The clinical standard hearing test and intervention technology model cannot consider both accuracy and cost-effectiveness. General practitioners undertake the task of non-infectious chronic diseases (NCDs) management for the elderly in the community. The management of presbycusis can refer to NCDs. Therefore, we hope to further evaluate the feasibility of community screening by general practitioners.
At present, there are many studies on the screening methods of presbycusis [10][11][12] and the health beliefs of patients with hearing loss [13][14] , but there are few evaluations on the general practitioners' knowledge, beliefs, and practice of senile hearing screening. The purpose of our study is to evaluate the mastery of general practitioners in the knowledge of hearing screening for the elderly through a questionnaire survey and to provide basic guidance for the implementation and improvement of hearing screening in community.

Participants
Questionnaire was designed under the guidance of audiology experts. Thirty fth general practitioners (unlimited nature) from each one of 12 community health service centers in Pudong New District, Shanghai, with a total of 420, were recruited by convenience sampling method. Finally, 367 doctors provided effective questionnaires, and the response rate was 87.4%.

Questionnaire Design
The questionnaire was comprised by four sections of force-choice scales, possible responses were the following: complete, basic, general, little, and no agreement.
The rst section: general information Gender, age, educational background, occupation, length of service, whether receiving general practice continued training, etc.
The second section: knowledge related to presbycusis According to relevant books such as "Auditory rehabilitation of the elderly" [ 15 ] and "Basic and Clinical Audiology" [16 ] , assessment of knowledge related to presbycusis was made from ve aspects: de nition, morbidity, diagnosis, high-risk factors, and harmful consequences.
The third section: knowledge of hearing screening for the elderly Including detection and treatment of presbycusis, appropriate means in community, and methods of early intervention.
The fourth section: necessity of hearing screening for the elderly in community Including self-attitude and awareness of presbycusis, frequency of hearing screening, clinical bene ts of hearing screening, whether general practitioners need to receive specialist training in otolaryngology, and whether to organize continuing sub-specialty education and the general practitioners' attitude towards conducting hearing screening Data collection Two investigators from Shanghai East Hospital who had been trained before the survey were responsible for the uni ed interpretation of the contents and options of the questionnaire individually. If there was any dispute about the results, the designer of questionnaire would make the nal judgment. The unquali ed questionnaires, with more than 5% of the core data missing, were rejected. The nal questionnaire data was then extracted and doublechecked for the analysis.

Data analysis
The questionnaire is designed by Wenjuanxing software, and the data is analyzed by SPSS 25.0 statistical software. Continuous variables are represented by mean ± SD, and categorical variable are represented by frequency and rate.
Reliability and Validity of the questionnaire Reliability analysis refers to the degree of consistency of the results of repeated measurements of the same object using the same method. Reliability indicators are mostly expressed by correlation coe cient, which can be roughly divided into three categories: stability coe cient (consistency across time), equivalence coe cient (consistency across forms) and internal consistency coe cient (consistency across projects). The higher the reliability coe cient is, the more reliable the measurement is. Cronbachα is the most used reliability coe cient. Cronbach α coe cient greater than 0.60 is considered reliable [7]. In this study, Cronbach α coe cient is used to test the internal consistency of questionnaire setting.
The content validity of the questionnaire was evaluated by the four experts (audiologist from Shanghai East hospital and Punan hospital) according to the standard judgment method and the items with low content validity had been deleted [8] . The procedure includes three steps: (1) determine the number of experts (≥ 3). (2) Experts evaluate the scale setting and dimensions, that is, whether the evaluation setting is complete and accurate, whether the content is consistent with the research objectives, and whether the setting can fully re ect the research scope.

Evaluation of reliability and validity
The internal reliability was evaluated through Cronbach's alpha coe cient. As a result, it was calculated to be 0.7 (Table 1). The validity analysis was judged by four experts, and the scale and the content validity ratio were also calculated. In addition, the proportion of those who obtained the title of attending doctor or above was 67.8%. As whole, the selected practitioners covered different ages, work seniorities, and educational levels ( Table 2).  (Table 3-4). However, more than 80% of the general practitioners knew the adverse consequences of presbycusis ( Table 5). The correlation analysis had then conducted based on the above data, suggesting that the overall awareness was positively correlated with the title and the work seniority with the corresponding Pearson coe cient of 0.109-0.152. (Table 6). Among the ve screening methods in the questionnaire, the top three popular choices are the HIEE-s (94.55%), Selfauditory assessment (83.65%), and Pure-tone audiometry (77.66%), which are more recognized recently [9,17−19] ( Figure 1). As for the general practitioners' understandings of the treatment methods for hearing loss in the elderly, the major four methods selected were audiphones, installation of the electronic cochlea implants, hyperbaric oxygen therapy, and psychotherapy. The result (Figure 2) suggested that the general practitioners had general understandings of the diagnosis and treatment of hearing loss in the elderly and were able to make preliminary recommendations.

Assessment of Attitudes to Screening
The strati ed analysis of screening attitude evaluation was conducted, and the results show: 1) Only 7.36% of the general practitioners agreed that elderly residents had complete or at least basic knowledge of presbycusis, 18.53% of general practitioners considered that when hearing loss occurs, the elderly would go to community health service centers for help, while 32.15% of them believed they would go to comprehensive hospitals. 2) About 70% of the general practitioners thought hearing screening for the elderly certainly had clinical bene ts and 52.29% of them agreed that screening should be carried out in community. 3) HHIE-s and pure-tone audiometry were more recommended by the participating general practitioners than subjective faces scale, Whispered voice test, [17,20] . 4) As for the intervention methods towards hearing loss, hearing screening, health check-up, and health record management are the three common items suggested by general practitioners.5) "Would you suggest that general practitioners carry out continuing education and training in ENT at present", 32.24% of the general practitioners chose "complete agreement", 36.24% of them chose "basic agreement", 22.07% chose "general agreement",7.63% chose "little agreement", and 1.63% of them chose " no agreement". 6) Only 41.96% and 9.26% of general practitioners completely or basically agreed to implement sub professional training. As whole, more than 50% of the general practitioners agreed that hearing screening should be carried out at primary health centers. Therefore, they agreed that early intervention can be generally achieved through regular hearing screening, physical examination, and health record management. But both elderly and general practitioners were not fully aware of the demand for hearing screening, thus further training on basic understandings of presbycusis is highly required.
More than 50% of general practitioners agree to hearing screening in primary health care centers. They also recognized early intervention through regular hearing screening, physical examination, and health education.
However, the elderly and general practitioners are not fully aware of the importance of regular hearing screening at the grass-roots level, so it is necessary to further strengthen professional training and health education.

Discussion
Nowadays, hearing loss is associated with many co-morbidities, including poorer physical health, anxiety, depression, loneliness, and isolation [21][22][23][24] . Despite its high prevalence, which has a signi cant negative impact on the quality of life and social burden, hearing loss has not been adequately treated.
According to data from the Centers for Disease Control of (USA) in 2013, less than a quarter of the elderly received hearing screening. There is no uni ed data of the elderly in China [25] . In the United States, only one in seven adults aged 50 and older used hearing aids, with fewer than 1 in 20 working adults aged 50-70 years doing so [26] . The number of studies on hearing aid use and its related factors is extremely limited in developing countries [27] . Nearly one-third of the hearing loss patients believed they were in sub-health state, while only 9% of normal-hearing patients considered they might be in poor health [28] . Findings suggest that hearing loss has a negative impact on independence levels and thus quality of life in older people as they heavily rely on family and their community for support [29] . Perhaps earlier detection and diagnosis of hearing loss would allow for more successful treatment and rehabilitation to help retain independence and cognition which is vital in improving quality of life [30] Therefore, it is highly required for us to pay attention to presbycusis.
At present, most studies focus on the mechanism of hearing loss and the development of portable and simple hearing screening tools [31][32] . The existing hearing screening mode need to be further optimized in the aspects of human and material costs, professional requirements, object compliance, speci city, and sensitivity of screening. General practitioners can provide clinical care, prevention, treatment and decision-making between doctors and patients. They are the suitable people to implement technologies which can reduce medical costs and health system costs [33][34] . For the elderly, hearing screening by general practitioners in community is a good choice.
The questionnaire results showed that only 18.53% of general practitioners thought that community health service center should be the rst choice for hearing loss of the elderly. Although they basically agree with the signi cance and intervention value of hearing screening for the elderly, but their willingness to screen is not synchronous, and their views on the implementation strategy are not the same. We need to further explore the reasons and accessibility measures.
In 2020, World Organization of National Colleges (WONCA) applied post competency to the eld of general practice, and proposed "WONCA tree model", including 6 general practitioners' competency, which are as follows: primary care management, community orientation, Speci c problem-solving skills, comprehensive approach, personcentered care, holistic approach. By 2020, China had initially established a general practitioner system, and basically formed a uni ed and standardized general practitioner training mode and the service mode of rst visit at primary medicine. However, the training mode of general practitioners is not perfect. The training of general practitioners is mainly focused on internal medicine and health management, but the knowledge of Ophthalmology, pediatrics, ENT, gynecology, dermatology and so on is truly little. At the same time, our questionnaire also re ects that the self-con dence of general practitioners is not high, and only 41.96% have a strong desire to obtain all kinds of specialist training. Therefore, the implementation of multi-channel continuing medical education (CME) will improve the comprehensive ability of general practitioners and promote their self-con dence, which is an important foundation for the implementation of hierarchical diagnosis and treatment, the realization of chronic disease management and the promotion of healthy aging [35] .
In addition, we need to consider the following points so as to promote the general practitioners carrying out hearing screening for the elderly actively. First, we should establish a performance system to link the workload and income of hearing screening. Secondly, we need to evaluate the cost-effectiveness of hearing screening, including technical cost, labor cost, case cost, false-positive cost, etc. Therefore, the hearing screening of the elderly in the community depends on the further resources and nancial support of the government.

Strengths And Limitations
The questionnaire was designed by us.
The subjects were general practitioners.
The questionnaire involves three aspects: knowledge, attitude, and practice. Questionnaireforarticle.pdf