UC Irvine

IntroductionHearing loss is common and treatable, but many individuals with hearing loss do not receive appropriate care. Spatial accessibility, having enough healthcare providers close enough to populations who need their services, is essential for hearing loss treatment. Ear and hearing care (EHC) healthcare providers (HCPs), including audiologists and hearing instrument specialists (HISs), are unevenly distributed across the United States, but the social, geographic, socioeconomic, and policy factors shaping this distribution remain poorly understood. This dissertation examines how place-based factors influence the spatial accessibility of EHC HCPs in the United States. Methods This dissertation includes three related studies. Chapter 2 was guided by the research question: What factors influence where geographically EHC HCPs choose to live and work among audiologists who relocate during their career? Semi-structured interviews were conducted with 19 audiologists who had relocated across state lines during their professional careers. Chapter 3 was guided by the research question: Does census tract-level rurality or socioeconomic status predict the spatial accessibility of different classes of EHC HCPs in the contiguous United States? This study used geospatial methods and census tract-level linear mixed-effects models with rurality and socioeconomic data from 2017–2023. Chapter 4 was guided by the research question: Do variations in state-level reproductive healthcare or LGBTQ+ policies influence a state’s supply of audiologists? This study used longitudinal LME and GLMM models with data from 2017 – 2024 to evaluate the influence of reproductive healthcare and LGBTQ+ policy on audiologist movement and where newly graduating audiologists initially registered to work. Results Chapter 2 found that audiologist siting was shaped by three overarching themes: occupational considerations, including compensation and financial incentives; local social and economic environments, particularly employment opportunities and resources needed by spouses, children, and aging parents; and state-level policies, which did not typically determine participants’ practice locations but were potentially influential for some audiologists. Gender influenced these themes through household decision-making, spouse employment, and caregiving responsibilities. Chapter 3 found that spatial accessibility to EHC HCPs was lower in more rural areas, with rurality more strongly associated with audiologist accessibility than HIS accessibility. Socioeconomic patterns were mixed, but audiologist accessibility was generally greater in communities with higher income and educational attainment, while HISs were relatively more prevalent in rural and lower-income communities. Chapter 4 found that neither reproductive healthcare or LGBTQ+ policy was significantly associated with the proportion or number of established audiologists leaving or entering states or newly graduating audiologists initially registering in states in the following year. Additional analyses did not identify a consistent pattern of audiologists moving toward states with more supportive policy environments or consistent associations with selected individual policies. Conclusion Together, these findings show that EHC HCP spatial accessibility is shaped by interacting occupational, family, socioeconomic, geographic, and policy contexts. Rurality and socioeconomic characteristics were associated with EHC HCP spatial accessibility, while state reproductive healthcare and LGBTQ+ policy environments were not independently associated with audiologist siting. These findings support conceptualizing EHC HCP siting through the SEM as a process in which factors across ecological levels interact to make communities and states more or less feasible and desirable for HCPs to live and practice.