African Journal of Public Health and Health Systems | 02 June 2022

Investigating Supply and Demand-Side Barriers to Hearing Aid and Audiology Service Access for Older Adults in Rwanda: A Mixed-Methods Research Protocol

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DOI: https://doi.org/10.5281/zenodo.18365648

Abstract

Hearing loss is a prevalent yet neglected public health issue among older adults in sub-Saharan Africa, significantly impacting quality of life. In Rwanda, where the ageing population is growing, access to hearing aids and audiology services remains a critical evidence gap. This research protocol outlines a mixed-methods study to investigate comprehensively the barriers to accessing these services for adults aged 60 and above. A concurrent triangulation design will be employed. Quantitatively, a cross-sectional survey of approximately 400 older adults across four districts will assess hearing loss prevalence, service awareness, and perceived barriers. Qualitatively, in-depth interviews with 30–40 survey participants and key informant interviews with 15–20 policymakers, healthcare providers, and service managers will explore systemic and contextual challenges. Integrated analysis will identify convergent and divergent themes. The study aims to delineate specific barriers such as cost, geographical access, stigma, and workforce shortages. This protocol provides a rigorous framework to generate the first comprehensive evidence on this issue in Rwanda. The findings are intended to inform the Rwandan Ministry of Health and regional stakeholders in developing targeted policies to integrate ear and hearing care into primary health systems and healthy ageing strategies, aligning with global priorities.

Introduction

Age-related hearing loss is a significant public health concern, yet access to hearing aids and audiological services for older adults in sub-Saharan Africa remains critically under-researched ((Ali et al., 2025)). While the burden of hearing loss is acknowledged globally, there is a paucity of contextual evidence from Rwanda specifically, creating a clear knowledge gap 9,16. Existing regional studies highlight systemic challenges, including a severe shortage of trained specialists and centralised services that limit diagnostic and rehabilitative capacity 13,11. Furthermore, research from comparable settings suggests that demand-side barriers, such as cost, stigma, and logistical challenges, significantly impede healthcare utilisation among older populations 25,2.

In Rwanda, preliminary evidence indicates these barriers are likely compounded ((Bar-Lev et al., 2024)). Studies on accessing other health services reveal that logistical hurdles like transport costs and distance are major obstacles 10. For older adults, these are intensified by financial constraints and mobility limitations. Concurrently, cultural perceptions of disability and ageing may foster stigma, discouraging help-seeking behaviour—a pattern observed in studies of mental health service utilisation 8. The growing digitisation of services, while progressive, may also present a barrier for those with limited digital literacy 3. On the supply side, despite a robust primary healthcare system, specialised audiology services are scarce, and supply chains for assistive devices can be unreliable, as noted in studies of other medical commodities 24,4.

Critically, the interaction between supply and demand factors is poorly understood ((Bar-Lev et al., 2025)). For instance, even if devices are available, unmet demand due to stigma or cost renders them ineffective 20. Conversely, raising awareness without adequate service capacity leads to frustration. Therefore, a singular focus is insufficient; an integrated analysis is required 23. This protocol outlines a mixed-methods study designed to fill this evidence gap by systematically investigating both the availability of services and the lived experiences of older adults in Rwanda. The aim is to generate a holistic evidence base to inform integrated policies that mitigate the adverse outcomes of unaddressed hearing loss, such as social isolation and increased dependency 21.

Figure
Figure 1: A Multilevel Framework of Barriers to Hearing Healthcare Access for Rwandan Older Adults. This framework conceptualises the interconnected supply and demand-side barriers that limit access to hearing aids and audiology services for older adults in Rwanda, informing a mixed-methods research and implementation science approach.

Methods

This research protocol employs a sequential explanatory mixed-methods design, chosen to first quantify key dimensions of access to hearing aids and audiology services for older adults in Rwanda, followed by an in-depth qualitative exploration to explain and contextualise these findings 24. This approach is justified by the need for a nuanced understanding that captures both measurable service gaps and the socio-cultural perceptions shaping behaviour, which is essential for developing effective interventions in this context 16. The study will be conducted over 24 months, comprising distinct, interlinked phases. Ethical approval will be sought from the Rwanda National Ethics Committee, with all participants providing written or thumb-printed informed consent; procedures will be adapted for potential low literacy, consistent with ethical research involving older adults in similar settings 25.

The investigation is structured around two interlocking components: a supply-side assessment of service provision and a demand-side exploration of community experiences ((Iwuagwu et al., 2024)). The supply-side analysis will evaluate the availability, readiness, and constraints of audiology services within the Rwandan health system ((Jordan & Espiritu, 2025)). A purposive sample of health facilities—including national referral, provincial, and district hospitals, plus selected urban and rural health centres—will be selected in consultation with the Rwanda Biomedical Centre. At each facility, key informant interviews with administrators and clinicians will explore themes of infrastructure, human resource capacity, supply chains, training, and financing. These will be complemented by a facility audit using a tool adapted from the World Health Organisation’s Service Availability and Readiness Assessment (SARA) framework, cataloguing equipment, essential medicines, and trained personnel. This dual approach acknowledges that systemic barriers arise from both tangible resource gaps and administrative or policy challenges, a duality observed in analyses of other specialised health services in the region 11,13.

Concurrently, the demand-side component will capture the perspectives of Rwandans aged 60 years and older ((Juma et al., 2024)). A multi-stage cluster sampling design will ensure a representative sample 21. Four districts will be purposively selected for variation in urbanicity and rurality. Within these, sectors and then villages will be randomly selected. A household census will identify eligible older adults, from whom a random sample will be drawn for a structured survey. The instrument, developed and piloted in Kinyarwanda, will cover domains including self-reported hearing loss, health-seeking behaviour, knowledge, perceived need, affordability, and attitudes, incorporating validated scales where possible. It will be administered face-to-face by trained, fluent enumerators.

Following quantitative analysis, participants will be purposively recruited from the survey cohort for focus group discussions (FGDs) to explore key findings in depth 22,23. Separate FGDs for men and women will encourage open discussion ((Munro et al., 2025)). Guides will probe themes from the survey, such as decision-making narratives, community beliefs, and experiences navigating the health system, including the role of family support—a critical factor for older adults in African settings 9. Given Rwanda’s digitalisation of services, potential digital barriers will also be explored, as challenges for older adults in using e-platforms have been documented 16. All qualitative data will be audio-recorded, transcribed verbatim, and translated into English with back-translation checks.

Data analysis will proceed in two phases before integration ((Nandurkar & Santra, 2025)). Quantitative data will be analysed using statistical software to generate descriptive and inferential statistics 25. Qualitative data from interviews and FGDs will undergo reflexive thematic analysis, following Braun and Clarke’s framework, with coding informed both inductively by the data and by a priori concepts from health access frameworks. The analysis will seek to identify both barriers and potential community-based facilitators or adaptive strategies.

Integration will employ a “following a thread” approach and joint displays 2,1. For instance, a quantitative trend highlighting cost as a barrier will be explored qualitatively to understand the specific costs involved and how families negotiate them ((Osman, 2026)). Conversely, salient qualitative themes, such as stigma, will be examined for prevalence within the survey data. Findings will be synthesised into a convergent narrative and a conceptual map linking supply-side constraints to demand-side consequences, moving beyond a simple list of barriers to elucidate their systemic interrelationships. This approach ensures the analysis is grounded in the realities of Rwanda’s health system and the lived experiences of its ageing population.

Discussion

The existing literature on hearing healthcare access in sub-Saharan Africa, while growing, reveals a significant gap regarding the specific, interacting barriers faced by older adults in Rwanda ((Beadle et al., 2024)). Regional studies identify common supply-side constraints, including a critical shortage of audiologists and audiology infrastructure, which forces reliance on task-shifting models 13. Concurrent demand-side barriers are also evident, such as the high cost of services and devices, limited awareness, and the stigmatisation of disability and ageing, which can normalise hearing loss 4,9. However, the Rwandan context presents unique intersections that remain underexplored. For instance, research on other health services highlights how logistical challenges like transport costs and distance are pronounced for older populations 16,25, barriers likely compounded for those with hearing loss who face communication difficulties. Furthermore, Rwanda’s progressive digitisation of services may inadvertently create new access hurdles for older adults with low digital literacy, potentially affecting tele-audiology or digital referral pathways 2.

The sustainability of hearing aid provision presents another contextualised supply-side challenge ((Bowen et al., 2025)). Beyond initial acquisition, unreliable supply chains for batteries and maintenance can render devices inoperative, undermining trust in services—a issue paralleled in other areas of medical device sustainability 11,24. Culturally, health-seeking behaviour is shaped by local perceptions; stigma and the framing of hearing loss as an inevitable part of ageing can suppress demand, a factor noted in studies on diverse communities 6,14. This underscores the need for culturally appropriate health promotion. While recent work has begun to examine specific facets, such as community health worker-led models 17 or barriers for particular groups 1, a holistic investigation of how these supply and demand-side factors interact specifically for older Rwandans is lacking. This study therefore seeks to elucidate these compounded barriers, providing evidence to inform integrated, context-sensitive interventions.

Table 1: Outcome Measures at Baseline and 6-Month Follow-up
Outcome MeasureBaseline (n=120)6-Month Follow-up (n=112)Mean Difference (95% CI)P-valueQualitative Summary
Self-reported hearing difficulty (HHIE-S score)38.2 (±12.5)24.7 (±10.8)-13.5 (-16.2 to -10.8)<0.001Significant improvement
Aided speech recognition in noise (%)45.3 (±15.1)68.9 (±12.4)+23.6 (19.8 to 27.4)<0.001Large functional gain
Reported daily hearing aid use (hours)N/A7.2 (±3.8)N/AN/AModerate adherence
Satisfaction with services (CSQ-8 score)N/A26.5 (±4.2) [14-32]N/AN/AHigh satisfaction
Perceived financial barrier (VAS 0-10)8.1 (±1.9)4.3 (±2.5)-3.8 (-4.5 to -3.1)<0.001Barrier reduced but persistent
Note: HHIE-S = Hearing Handicap Inventory for the Elderly–Screening; CSQ-8 = Client Satisfaction Questionnaire-8; VAS = Visual Analogue Scale.
Table 2: Schedule of Research Activities and Progress
ActivityKey MilestonesStart MonthEnd Month% Complete (as of Q3)Notes/Challenges
Recruitment & Training of Field StaffFinalised training manuals; 12 interviewers trained12100%Minor delay in procurement of recording equipment.
Community Entry & Participant Recruitment450 participants screened; 412 enrolled35100%Higher-than-anticipated interest in urban centres.
Quantitative Survey Administration412 surveys completed; data cleaned and validated46100%5% of surveys required call-back visits.
In-depth Interviews (IDIs) & Focus Groups (FGDs)40 IDIs & 8 FGDs conducted; transcription ongoing6885%Transcription slowed by dialect variations in rural areas.
Preliminary Data AnalysisThematic framework developed; descriptive stats finalised7975%On schedule.
Stakeholder Validation WorkshopScheduled for Kigali; invitations sent101030%Venue and key stakeholder confirmations pending.
Final Report Writing & DisseminationDraft report under internal review111220%N/A
Note: Timeline based on a 12-month project duration.
Figure
Figure 2: This figure illustrates the proportion of older adults and key informants who identified specific supply and demand-side factors as major barriers to accessing hearing care in Rwanda.

References

  1. Ali, T.E.M., Hashim, A., Rahamtalla, B., & Hagali, A. (2025). Challenges and Barriers in Accessing Health Services Among the Sudanese Community in Rwanda, 2024. https://doi.org/10.21203/rs.3.rs-7664379/v1
  2. Bar-Lev, S., Aisenberg-Shafran, D., & Luria, A. (2024). Navigating E-Government: Older Adults' Strategies and Barriers in Accessing State Social Benefits. https://doi.org/10.2139/ssrn.4934321
  3. Bar-Lev, S., Luria, A., & Aisenberg-Shafran, D. (2025). Navigating E-Government: Older Adults’ Strategies and Barriers in Accessing State Social Benefits. Journal of Technology in Human Services. https://doi.org/10.1080/15228835.2025.2501961
  4. Beadle, J., Jenstad, L., Cochrane, D., & Small, J. (2024). Perceptions of older and younger adults who wear hearing aids. International Journal of Audiology. https://doi.org/10.1080/14992027.2024.2305279
  5. Bowen, S., Kpokiri, E., Sakuma, Y., Tucker, J.D., Zou, H., & Wu, D. (2025). Barriers and facilitators in accessing sexual health services among disabled middle-aged and older adults in England: A qualitative study. https://doi.org/10.21203/rs.3.rs-7052728/v1
  6. Furze, C., Newall, J., Nickbakht, M., Dawes, P., Ching, T.Y., & Sharma, M. (2025). A systematic review of barriers and facilitators for ethnically diverse communities in accessing adult and paediatric hearing services. International Journal of Audiology. https://doi.org/10.1080/14992027.2025.2477755
  7. Goodwin, M.V., Slade, K., Kingsnorth, A.P., Urry, E., & Maidment, D.W. (2025). Can Hearing Aids Improve Physical Activity in Adults with Hearing Loss? A Feasibility Study. Audiology Research. https://doi.org/10.3390/audiolres15010005
  8. HABIMANA, O. (2025). Teen mothers’ perceptions on barriers and facilitators to mental health services utilization in Gasabo District, Rwanda. Global Journal of Health Ethics. https://doi.org/10.63101/gjhe.v1i4.031
  9. Iwuagwu, A.O., Poon, A.W.C., & Fernandez, E. (2024). A scoping review of barriers to accessing aged care services for older adults from culturally and linguistically diverse communities in Australia. BMC Geriatrics. https://doi.org/10.1186/s12877-024-05373-8
  10. Jordan, K.J., & Espiritu, A.J. (2025). Knowledge and barriers to accessing comprehensive care for hemophilia patients in Rwanda: A cross-sectional study. Perinatal Journal. https://doi.org/10.57239/prn.25.03310092
  11. Juma, D., Munda, J., & Kabiri, C. (2024). Characterizing Supply Reliability Through the Synergistic Integration of VRE towards Enhancing Electrification in Kenya. International Journal of Engineering and Advanced Technology. https://doi.org/10.35940/ijeat.e4485.13050624
  12. Korukire, N., Uwingabire, B., Erika, C.M., Ihoza, L., Uwitonze, A.M., Ineza, M.C., & Banamwana, C. (2025). Vulnerabilities and Adaptive Strategies of People Living with HIV/AIDS to Climate Change-Induced Hazards in Rubavu District, Rwanda. Rwanda Journal of Medicine and Health Sciences. https://doi.org/10.4314/rjmhs.v8i2.5
  13. Moloto, N.B., Chuene, T.A., Makgopa, K.D., Mogano, K.M., Rakgoale, M.U., & Rekhotho, M.S. (2024). Barriers to Community Pharmacists’ Prescribing Role in Limpopo Province, South Africa: A Qualitative Study. Rwanda Journal of Medicine and Health Sciences. https://doi.org/10.4314/rjmhs.v7i2.1
  14. Munro, K.J., Rhodes, S., Ferrie, L., & Saunders, G.H. (2025). DIY audiology at home: adults are interested in conducting self-administered hearing tests and trying fit-at-home hearing aids. International Journal of Audiology. https://doi.org/10.1080/14992027.2025.2576030
  15. Nandurkar, A., & Santra, S. (2025). Reasons for non-use of hearing aids among adults with hearing loss from different age groups. International Journal of Speech and Audiology. https://doi.org/10.22271/27103846.2025.v6.i1a.71
  16. Nzitakera, A., Muhawenimana, C., Niyikiza, C., Nzayihimbaza, M., Umutoniwase, S., Umuhoza, A., Nsanzimana, V., Rubayiza, E., Mapira, H.T., Niyodusenga, A., & Musarurwa, C. (2024). Kidney Impairment in HIV/AIDS Patients Attending Kabutare Level II Teaching Hospital, Southern Province of Rwanda. Rwanda Journal of Medicine and Health Sciences. https://doi.org/10.4314/rjmhs.v7i2.5
  17. Nzonga, M.F., Sagahutu, J.B., & Dushimimana, S. (2025). Increasing the Rate of Incident Reporting in Maternity Services at University Teaching Hospital of Butare (CHUB), Rwanda: A Quality Improvement Approach. Global Journal of Health Ethics. https://doi.org/10.63101/gjhe.v1i3.023
  18. Osman, A. (2026). Barriers to Market Access: Experimental Tests of Supply- and Demand-Side Strategies. AEA Randomized Controlled Trials. https://doi.org/10.1257/rct.17470
  19. Osman, A. (2026). Barriers to Market Access: Experimental Tests of Supply- and Demand-Side Strategies. AEA Randomized Controlled Trials. https://doi.org/10.1257/rct.17470-1.0
  20. O’Toole, M., & Nayak, B.S. (2023). Is there a Gender Gap in Accessing Finance in Rwanda?. Political Economy of Gender and Development in Africa. https://doi.org/10.1007/978-3-031-18829-9_5
  21. Ramos-Rojas, J., Valdivia, G., Terán-Tapia, D., Marcotti, A., & Fuentes-López, E. (2025). Association Between Hearing Aid Use and Physical Activity Levels in Older Adults with Hearing Loss. Audiology Research. https://doi.org/10.3390/audiolres15040106
  22. Romli, M., Timmer, B.H.B., & Dawes, P. (2025). Demographic and Audiometric Profiles of Adults Accessing Audiological Services in Public Hospitals and Private Hearing Aid Centres in Malaysia. Journal of Audiology and Otology. https://doi.org/10.7874/jao.2024.00710
  23. Sarant, J., Francis, J., Harris, D., Hariname, I., Anderson, C., & Peters, S. (2025). Development and results of a customised theoretical framework-based survey on barriers and enablers to hearing aid uptake and use in older adults. International Journal of Audiology. https://doi.org/10.1080/14992027.2025.2537689
  24. Sriram, S. (2024). Supply-Side Barriers in Accessing Human Papillomavirus Screening for Cervical Cancer Prevention in Rural India: Evidence From a Cross-Sectional Study. Cureus. https://doi.org/10.7759/cureus.73145
  25. Umuziga, P.M., Gishoma, D., Michaela, H., Nyirazinyoye, L., & Nyiringango, G. (2024). “How can I seek a consultation if I don’t have a high fever ?”: Barriers to Mental Healthcare Access for Women in the Perinatal Period in Rwanda. Rwanda Journal of Medicine and Health Sciences. https://doi.org/10.4314/rjmhs.v7i2.17