Although numerous publications emphasize the significance of careful attention to vulnerable groups during emergency management, a few have valid and utilized guidelines and instructions on how to handle this population. Reference Khorram-Manesh, Phattharapornjaroen and Mortelmans1,Reference Khorram-Manesh, Yttermyr, Sörensson and Carlström2 In the context of emergencies, vulnerable groups may include individuals with disabilities, pregnant women, children, elderly persons, ethnic minorities, socioeconomically disadvantaged, underinsured, or those with certain medical conditions. Members of vulnerable populations often have health conditions that are exacerbated by unnecessarily inadequate health care. Reference Khorram-Manesh, Phattharapornjaroen and Mortelmans1,Reference Khorram-Manesh, Yttermyr, Sörensson and Carlström2
One major group within the vulnerable populations is people with hearing loss. In 2019, an estimated 1.57 billion people had hearing loss, of whom 403 million (26%) had moderate hearing loss to deafness in the better ear. Reference Haile, Kamenov and Briant3 Hearing loss affects people of all ages and can be caused by many different factors. The 3 basic categories of hearing loss are sensorineural hearing loss (most common type of hearing loss. It occurs when the inner ear nerves and hair cells are damaged—perhaps due to age, noise damage, or something else), conductive hearing loss (typically, the result of obstructions in the outer or middle ear—perhaps due to fluid, tumors, earwax, or even ear formation), and mixed hearing loss (a combination of sensorineural and conductive hearing loss). 4–Reference Banks6
It is approximated that there are currently 1.16 million individuals with mild hearing loss, more than 400 million people with moderate-to-severe hearing loss, and about 30 million people with profound or complete hearing loss in both ears. Reference Chadha, Kamenov and Cieza7 The World Health Organization 8 forecasts that in the next 10 years, there will be 630 million people living with hearing disorders, with that number expected to grow to over 900 million by the year 2050. All grades of hearing loss are estimated to increase in 2030-2050, whereas the largest number of people with moderate-to-complete hearing loss is in the Western Pacific, Southeast Asia, and the Americas. Reference Chadha, Kamenov and Cieza7 A maximum rise of hearing loss is estimated in the regions of Eastern Mediterranean and Africa. Reference Chadha, Kamenov and Cieza7
Hearing loss affects communication with others. Not being able to hear what is going on around them or hear other people speak can add to their confusion, and consequences can be social isolation, Reference Chadha, Kamenov and Cieza7 depression, and reduced quality of life. Reference Mick, Kawachi and Lin9 Communication difficulties related to hearing loss is negatively associated with mental health and psychosocial and physical functioning. Reference Strawbridge, Wallhagen, Shema and Kaplan10 The use of protective devices like face masks by health care personnel as in the current coronavirus disease (COVID-19) pandemic reduces lip reading, used by people with hearing loss and worsens their communication during emergencies. Reference Trecca, Gelardi and Cassano11
Although medical students in Saudi Arabia receive curriculum training in effective patient–provider communication, most of this training assumes patients have intact communication capabilities, leading to a lack of preparedness among health care providers when interacting with patients with communication disorders, including hearing impairment and speech stuttering. Reference Baylor, Burns and McDonough12 Communication disorders are defined as an impairment in the ability to receive, send, process, and comprehend concepts or verbal, nonverbal, and graphic symbol systems. 13
Emergency medical services (EMS) rely on well-established protocols based on the most frequent cases encountered by EMS providers in the field. This leads to the exclusion of special case procedures concerning individuals with disabilities (sensory, motor, or cognitive). Reference Chittaro, Carchietti, De Marco and Zampa14 In such cases, first responders might end up delivering suboptimal care or possibly wrong procedures that could harm the disabled person. Reference Chittaro, Carchietti, De Marco and Zampa14
Recent studies show that good clinician–patient communication has been associated with better health outcomes, Reference Prochaska, Gellman and Turner15 better quality, Reference Stewart16 and safer patient care. Reference Doyle, Lennox and Bell17
A systematic review quantified the extent to which hearing loss is mentioned in studies of physician–patient communication. The results showed that less than one-quarter of studies mentioned the impacts of hearing loss on physician-patient communication, indicating the lack of scientific research addressing the issue of the vulnerable population with disabling hearing and communication disorders. Reference Cohen, Blustein and Weinstein18
Since the lack of knowledge about hearing and communication disorders in emergencies worsens the quality of EMS service provision for this population, Reference Leggio19,Reference Alsadhan20 this study aimed to assess the level of knowledge of EMS students both before and after a translation workshop on how to deal with patients suffering from hearing and communication disorders during medical emergencies.
Materials and Methods
Location of the Study
The study was conducted in the city of Riyadh in King Saud University. Riyadh is the capital of Saudi Arabia and one of the largest cities on the Arabian Peninsula with a population of 6.5 million people living in an area of 3115 square kilometers. 21 Riyadh citizens represent one-sixth of the population of Saudi Arabia.
Design
A quasi-experimental design (pretest–posttest) was used. The study was conducted on September 6, 2021. Comparisons between pretest and posttest scores were examined to test the effectiveness of the translation workshop.
Participants
Recruited was a sample of 57 EMS students from Prince Sultan College for Emergency Medical Services in King Saud University in Riyadh. To be eligible for the study, participants had to be currently in the final year of the paramedic program and not have had knowledge translation lectures/workshops before. To verify the research tool, we tested it on a sample of 5 EMS students, to check whether respondents understood the test, and how respondents understand it. This group was then excluded from the study and their results were not included in the final analysis.
Workshop Settings
The workshop was conducted virtually via a web conferencing platform, Zoom, due to the COVID-19 pandemic.
Procedures
Students were notified about the workshop via an announcement on WhatsApp and invited to participate on a voluntary basis. The workshop was held on a Zoom meeting by a communication and swallowing clinician from the Rehabilitation Sciences Department at the College of Applied Medical Sciences of King Saud University. Once an initial introduction of the workshop was done, students were provided with an electronic information sheet and a written informed consent was obtained from all subjects. Following to that, a pretest composed of 10 multiple choice questions (see online Appendices 1, 2) was electronically handed to students before the initiation of training. The pretest’s main aim was to assess the participants’ general knowledge about the communication, swallowing, and hearing disorders that are secondary to medical problems. Therefore, the questions were designed to target all the disorders mentioned during the workshop. The workshop began with an introduction of the general knowledge about the communication and swallowing profession, the role of the communication and swallowing clinicians, the audiology and balance profession along with the role of the audiologists, and the disorders resulting in problems related to those professions, such as Down syndrome, hearing impairment, autism, attention deficiency and hyperactivity disorder, spina bifida, aphasia and traumatic brain injury, stuttering, and cognitive problems. Following that, steps, tips, and instructions on how to deal with individuals with disabilities and/or disorders (mentioned earlier) that negatively affect the communication abilities and skills of those individuals were explained, emphasized, and modeled. Once the workshop completed, the posttest was administered in the same format and way of the pretest. Effectiveness of workshop was assessed by the pretest and posttest scores. Feedback was taken from the students regarding their perception on introducing pre- and post-in learning the salient concepts by administering a questionnaire (Appendix 1). Students received instruction in a traditional learning setting and format by faculty from the Department of Emergency Medical Services who had not participated in the interdisciplinary teaching workshop. The information sheet for participants was attached as Appendix 2. Written informed consent was obtained from all subjects.
Data Analysis
All data analyses were conducted using Python 3.8 for Mac https://www.python.org/downloads/macos/. Continuous data were screened for outliers, and participants with a missing pretest or posttest were excluded from further analysis. Descriptive statistics are reported for demographic characteristics and pretest and posttest scores. Comparisons between pretest and posttest scores were examined using the Wilcoxon signed rank test. Statistical significance was set at P < 0.05.
Ethics
Ethics approval was granted through the King Saud University Institutional Review Board (KSU-IRB 017E).
Results
Univariate Analysis
According to Table 1, paramedic students’ average knowledge on how to communicate and provide emergency care to the hearing and communication disorders population before being given the workshop was 4.98. The lowest was 1, and the highest was 8. The median value was 5, with a standard deviation of 1.789. The average after being in the workshop was 5.74. The lowest was 1, and the highest was 9. The median value was 5, with a standard deviation of 2.083. There was a 0.763 increase in the average knowledge level score.
Distribution of pretest and posttest knowledge of respondents
Normality Test
The data normality test was conducted using Shapiro–Wilk with computer software (Python 3.8).
According to Table 2, based on the normality test data using Shapiro–Wilk, pretest and posttest scores have a significant P-value, which means each variable violates the assumption of normality. Because the data are not normally distributed, the Wilcoxon test was used to analyze the data. Reference Woolson22
Normality test results of paramedic students’ knowledge level about hearing and communication disorders
Wilcoxon Test
The workshop improved the level of knowledge significantly among the EMS students. Table 3 shows the results of the Wilcoxon t-test. It can be concluded that there is an influence of hearing and communication disorders workshops on the level of knowledge of EMS students about such disorders and how to deal with the population of hearing and communication disorders during emergencies at Prince Sultan bin Abdulaziz College for Emergency Medical Services.
The effect of workshops on paramedic students’ knowledge level about hearing and communication disorders at Prince Sultan bin Abdulaziz College for Emergency Medical Services in 2021
The level of knowledge scores was compared before and after the hearing and communication disorders awareness workshop. EMS students’ scores before the workshop were lower (M = 4.98 ± 1.78) compared with EMS students’ scores after the workshop (M = 5.74 ± 2.08). A Wilcoxon signed rank test indicated that this difference was statistically significant: z = −3.51726 and P < 0.001.
Discussion
The primary objective of this quasi-experimental study was to assess a group of final-year EMS students’ knowledge about communicating with patients with hearing and communication disorders both before and after receiving a knowledge translation workshop. The results showed that after participating in the workshop, Saudi EMS students demonstrated a significant improvement in knowledge to enhance their ability in communicating with this group of vulnerable population, whose conditions negatively impact their hearing and communication abilities and skills, such as Down syndrome, hearing impairment, autism, attention deficiency and hyperactivity disorder, spina bifida, aphasia and traumatic brain injury, stuttering, and cognitive problems.
The knowledge translation workshop in this study proved to be beneficial to the EMS students in filling the gap in their education by providing information related to communicating with individuals experiencing hearing and/or communication difficulties. The results of this study are promising and concordant with earlier reports. For instance, EMS providers reported that educational training helped them effectively communicate when encountering hearing loss patients. Reference Rotoli, Hancock and Park23 Similarly, training medical students to interact with communication disorder patients was shown to promote patient-provider communication, thus enhancing provided care. Reference Trecca, Gelardi and Cassano11,Reference Saladino, Algeri and Auriemma24–Reference Zraick26
This study, in addition, sheds light on patient–provider communication barriers in the prehospital setting, where time and rapid intervention are critical matters. Patient–provider communication in the prehospital setting is inherently challenging due to reasons associated with the prehospital environment, such as instability of the scene, weather conditions, crowded scenes, and interacting with patients having special needs in hectic times. Reference Eadie, Carlyon, Stephens and Wilson27–Reference Bastable and Dada29 EMS providers are required to act promptly, within a short time frame, to determine the nature of the illness, medical history, ask specific questions related to the chief complaint, and intervene properly based on the gathered information. Reference Eadie, Carlyon, Stephens and Wilson27 The lack of or ineffective EMS provider–patient communication in unstable conditions and limited time can lead to unwanted outcomes as the possibility of medical errors or delayed intervention increases. Reference Ratna30–Reference Campbell, Torrens, Pollock and Maxwell32 Poor communication with deaf patients can interfere with the quality of provided care and threaten patients’ safety. 33,Reference Pereira, da Silva Corrêa and Da Silva34
The global number of people with hearing loss will increase parallel with an increasing population age. Reference Chadha, Kamenov and Cieza7 Consequently, health care providers are faced with greater demands in terms of communicating with hearing impaired people, as demonstrated by the challenges caused by using face masks due to the COVID-19 pandemic, Reference Goniewicz, Khorram-Manesh and Hertelendy35,Reference Al-Wathinani, Hertelendy and Alhurishi36 preventing lip reading, which is used to communicate by this population. Such difficulties may be reduced by using transparent masks. Other measures and in-depth knowledge about the consequences of hearing loss are required to provide correct information in emergency contingency plans. Reference Goniewicz, Carlström and Hertelendy37
Patients with disabilities reserve the right to receive the same quality of health care provided to patients without disabilities. 38 EMS program directors and policy-makers can benefit from the present study results to develop programs and workshops to increase EMS providers’ knowledge, ability, and confidence when interacting with patients who have a compromised ability to communicate. Although training workshops seem helpful, it is only 1 step in the right direction. Further refinement is needed to ensure that the best quality of health care is offered to deaf patients in the prehospital environment and to save valuable time for patients and EMS providers. Reference Goniewicz, Burkle and Hall39 For instance, standard question sheets could be developed to guide EMS providers when dealing with patients with hearing loss, captioned videos, and awareness programs to educate deaf patients on interacting effectively with EMS providers. Such procedures can help ensure communication efficiency and patients’ safety. Still, they need to be tested scientifically to prove their effectiveness.
Limitations
Limitations of this study include the small sample size of EMS students who were recruited; moreover, the sample was only males because the program is for males only.
Pretests and posttests may not be the best tools to use for every type of training but still offer a good overview of the tested group’s advancement. It measures growth or value-added; helps identify student knowledge, cognitive learning, and skills, although less so for measuring values; can be easily scored; and relatively can be easily analyzed using statistical procedures. Wishing to understand what knowledge can be credited to the training itself, using a pretest and posttest methodology is essential. It has, however, some disadvantages. It offers little useful information about the student’s present knowledge and the subject of the program. There is also a risk that it should be so basic that any additional learning could be seen as “growth” or value added.
Despite these limitations, the findings from this study provide a rich source of data on this topic among the Saudi population. Due to the essence of the problem, further research must be conducted with a larger and diverse sample. Further research could explore and involve assessing EMS students during an emergency and as they interact with various patients with different hearing and communication disorders.
Conclusions
The contribution to the growing literature is novel, in regard to educating health care providers on the essential skills to deal with individuals with hearing and communication disorders. Our results show that such training workshops lead to a better performance. Communication is a vital element in a medical encounter between health care providers and patients at all levels of health care but specifically in the prehospital arena. Reference Matusitz and Spear40–Reference Ong, De Haes, Hoos and Lammes42 Insufficient or lack of communication with a vulnerable population, who may suffer from various disabilities, has a significant impact on the outcome of treatment or emergency management. Reference Van Rooy, Amadhila and Mufune43–Reference Caulfield, Richard and Rivera45 This is the first paper to outline EMS provider-patient communication barriers in the prehospital environment in Saudi Arabia. Knowledge translation workshops may fill a gap in EMS students’ education by offering the necessary information about how to interact with hearing and communication disabled patients in emergencies.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/dmp.2022.120
Acknowledgments
The authors would like to extend their appreciation to King Saud University for funding this work through the Researcher Supporting Project (RSP2022R481), King Saud University, Riyadh, Saudi Arabia.
Author contributions
AAW provided the main framework, identified primary materials, and collaborated on the writing of the paper. KG identified appropriate references and collaborated on the writing of the paper. The remaining authors collaborated on writing and editing paper. All authors have read and approved the manuscript.
Availability of data
Data sets used and analyzed during the current study are available from the corresponding author on a reasonable request.
Funding statement
The author (MA) received a fund from the Researcher Supporting Project number (RSP2022R481), King Saud University, Riyadh, Saudi Arabia, to support the publication of this article. The funding agency had no role in designing the study, conducting the analysis, interpreting the data, or writing the manuscript.
Conflict(s) of interest
AK is Deputy Editor (DE) at this journal and KG is Associate Editor (AE) but does not participate in any level of the evaluation process. The remaining authors declare no conflicts of interest.
Ethical standards
Ethics approval was granted through the King Saud University Institutional Review Board (KSU-IRB 017E).
