PUBH 6213 Week 4 Problem Narrative Example

One Hundred Sixty-Eight Referrals and Fifty-Four Visits: A Problem Narrative That Starts With the Children of Four Rural School Districts Before It Reaches the Nation, for a Composite School Hearing Follow-Up Grant

Student Name

Walden University

PUBH 6213: Public Health Grant Writing

Instructor Name

Month Day, Year

One Hundred Sixty-Eight Referrals and Fifty-Four Visits: A Problem Narrative That Starts With the Children of Four Rural School Districts Before It Reaches the Nation, for a Composite School Hearing Follow-Up Grant

The Children Behind the Referrals

Last school year, nurses in Tamarack County's four school districts screened the hearing of 2,140 children in kindergarten through eighth grade. Those who did not pass were screened again two weeks later. One hundred sixty-eight children did not pass the second screen and went home with a referral letter asking their families to arrange a hearing evaluation. By June, the nurses had records of a completed evaluation for 54 of them. For the other 114 children, nearly seven in ten of those referred, the school year ended without anyone learning whether they could hear their teachers.

The referral letters were not ignored by careless families. Nurses who called families in the spring heard the same answers again and again. The nearest pediatric audiologist practices at the regional children's hospital, about 110 miles from the county seat. Appointments there are booked six to ten weeks out. A visit means a day's lost wages for a parent and a day of missed school for the child. Some families were told by their primary care office that a child "probably just had fluid" and should wait. Others meant to call and did not, because nothing seemed wrong at home.

Why a Missed Evaluation Matters

School hearing screens are designed to find children who need a closer look, not to diagnose. A referral that never leads to an evaluation means the screen did its work for nothing. Some of the 114 children will have had a temporary problem that cleared. Others will have a lasting hearing loss that is mild or affects one ear, the kind that goes unnoticed at home because the child hears well enough in a quiet room with one speaker.

That kind of loss matters at school. In a study of 1,218 children in the third, sixth and ninth grades of one school district, 5.4% had minimal sensorineural hearing loss, and 37% of those children had repeated at least one grade (Bess et al., 1998). Third graders with minimal loss scored lower than their peers on several subtests of a standardized achievement test, and teachers rated their communication in class as poorer (Bess et al., 1998). A classroom is noisy and reverberant, and a child who misses the ends of words loses instruction quietly.

How Common Hearing Loss Is Among Children

National data show that the 168 referrals are not a fluke of local screening. Among 6,166 U.S. children aged 6 to 19 tested with pure-tone audiometry in a national health survey, 14.9% had a measurable loss in one or both ears, most of it slight and in one ear (Niskar et al., 1998). Only about one in ten of the children with measured loss had been reported as having a hearing problem at interview (Niskar et al., 1998). Hearing loss in school-age children is common and mostly invisible to families.

Why Rural Children Wait Longest

Loss to follow-up after school hearing screening is a problem in programs worldwide. A review of 65 studies of school hearing screening found that loss to follow-up was a consistent concern across settings and that few programs were accountable for what happened after a referral (Yong et al., 2020). In the United States, screening rules differ widely by state: in one review, 34 of 51 states and districts required school hearing screening, and only 20 of those required screening after sixth grade (Sekhar et al., 2013). Rules for what happens after a failed screen are thinner still.

Distance makes the gap wider in rural counties. Where the nearest specialist is a day trip away, follow-up depends on a family's ability to take that trip. In 15 rural Alaska communities, only 32.1% of children referred through standard primary care after a school hearing screen received follow-up within nine months (Emmett et al., 2022). Tamarack's rate, 54 of 168 or about 32%, is nearly identical.

The Gap This Grant Would Close

The documented gap is the distance between a failed rescreen and a completed evaluation. In Tamarack County, that gap swallowed 114 children last year. The same Alaska trial tested a different path: children who failed the school screen were seen at school through telemedicine, with a remote specialist reviewing results. Under that path, 68.5% of referred children were followed up within nine months, and those who were seen waited an average of 41.5 days rather than 92 (Emmett et al., 2022). A local version of that path, with a care coordinator, tablet-based audiometry at each school and a contracted audiologist reviewing results remotely, is what this application proposes.

Who Is Affected

The children affected are mostly young. Kindergarten through third grade accounts for most of the screens, because the state requires screening in those grades. One in four children in the county's districts lives in a household below the federal poverty line, and nearly half have public coverage through Medicaid or the state's CHIP plan, according to district nurse records. Families without insurance face the full cost of a specialist visit, and families with insurance still face the distance.

What Families Have Tried

Some families did find a way. Nurses' notes show that several children were evaluated only because a grandparent with a car and a free weekday drove them to the regional hospital, and a few were seen when an ear infection brought them to a primary care office that happened to have a screening audiometer. These stories show that follow-up depends today on luck and family resources, which is exactly the pattern a public program should replace with a routine that does not depend on who has a car. School nurses say the same thing in their own words: the screen works, the rescreen works, and the system ends at the backpack. Every step after the referral letter currently belongs to the family alone, and families with the fewest resources carry the longest odds.

Summary of Need

In one sentence: two in three Tamarack County children who fail a school hearing rescreen never receive the evaluation their referral asks for, because the evaluation is far away, hard to schedule and easy to postpone, and a proven way to bring it to the school has not yet been tried here.

References

Bess, F. H., Dodd-Murphy, J., & Parker, R. A. (1998). Children with minimal sensorineural hearing loss: Prevalence, educational performance, and functional status. Ear and Hearing, 19(5), 339-354. https://doi.org/10.1097/00003446-199810000-00001

Emmett, S. D., Platt, A., Turner, E. L., Gallo, J. J., Labrique, A. B., Inglis, S. M., Jenson, C. D., Parnell, H. E., Wang, N.-Y., Hicks, K. L., Egger, J. R., Halpin, P. F., Yong, M., Ballreich, J., & Robler, S. K. (2022). Mobile health school screening and telemedicine referral to improve access to specialty care in rural Alaska: A cluster-randomised controlled trial. The Lancet Global Health, 10(7), e1023-e1033. https://doi.org/10.1016/S2214-109X(22)00184-X

Niskar, A. S., Kieszak, S. M., Holmes, A., Esteban, E., Rubin, C., & Brody, D. J. (1998). Prevalence of hearing loss among children 6 to 19 years of age: The Third National Health and Nutrition Examination Survey. JAMA, 279(14), 1071-1075. https://doi.org/10.1001/jama.279.14.1071

Sekhar, D. L., Zalewski, T. R., & Paul, I. M. (2013). Variability of state school-based hearing screening protocols in the United States. Journal of Community Health, 38(3), 569-574. https://doi.org/10.1007/s10900-013-9652-6

Yong, M., Panth, N., McMahon, C. M., Thorne, P. R., & Emmett, S. D. (2020). How the world's children hear: A narrative review of school hearing screening programs globally. OTO Open, 4(2). https://doi.org/10.1177/2473974X20923580