Developing a capacity-building intervention for healthcare workers to improve communication skills and awareness of hard of hearing and D/deaf patients: results from a participatory action research study

Background Healthcare workers (HCWs) are commonly not prepared to properly communicate with D/deaf and hard of hearing (HoH) patients. The resulting communication challenges reinforce the existing barriers to accessing and benefiting from quality of care in these populations. In response, this study aimed to develop and evaluate a capacity-building intervention for HCWs to raise their awareness of D/deaf and HoH individuals’ experiences in healthcare and improve their capacity to communicate with these populations. Methods This study featured a participatory action research design using qualitative and quantitative methods. The intervention was developed and tested through 4 iterative phases. Reactions (i.e., satisfaction and perception of the intervention content, quality, appropriateness and usefulness) were assessed quantitatively and qualitatively after the intervention, whereas perceived knowledge and self-efficacy in communicating with D/deaf and HoH patients and organizational payoffs (use frequency of basic rules and tools improving communication) were quantitatively assessed before, after and 6-month post-intervention. Results Main qualitative and quantitative findings showed that the final version of the intervention reached high levels of satisfaction among participants. Next, perceived knowledge and self-efficacy scores obtained after receiving the intervention and 6 months later were significantly higher than those yielded in the initial assessment, although both scores significantly decreased at 6 months (compared to the scores obtained just after the intervention). Finally, findings showed no significant changes in organizational payoffs after receiving the intervention. Echoing these results, main qualitative findings documented that after receiving the intervention, participants felt more confident yet not more equipped to communicate with D/deaf and HoH patients. Conclusions Findings suggest that the capacity-building intervention is a promising means to sustainably increase HCWs’ perceived knowledge and self-efficacy on how communicating with D/deaf and HoH patients, although complementary approaches and follow-up intervention reminders may be necessary to enable practice changes in the working environment. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-024-10574-3.


Background
More than 430 million people experience disabling hearing loss worldwide and this number may reach 700 million by 2050 [1].People with disabling hearing loss include hard of hearing (HoH) and D/deaf individuals.According to the WHO, HoH refers to individuals with hearing loss ranging from mild to severe, whereas D/deaf individuals generally experience profound hearing loss.HoH and parts of D/deaf individuals usually communicate with spoken language with support from assistive devices (e.g., hearing aids, cochlear implants), whereas most D/deaf people use Sign Language-a language per sé-to communicate.Importantly, D/deaf individuals communicating with Sign Language often self-identify themselves as part of a linguistic and cultural community, in which hearing loss is considered as an identity instead of a disability requiring correction (i.e., Deaf ).
Access to and delivery of effective and quality healthcare among D/deaf and HoH individuals has remained a significant challenge for many years [2][3][4][5][6][7], which negatively impacts health outcomes in these populations [8].There is, indeed, evidence that D/deaf and HoH individuals are disproportionally affected by somatic and psychological health problems compared to hearing populations [9][10][11][12][13][14][15].The most significant barriers to quality healthcare stem from miscommunication issues commonly experienced by d/Deaf and HoH populations in healthcare settings [2,16,17].Previous qualitative findings highlighted several communication issues' examples, including difficulties when interacting at the desk and in waiting-rooms, conflicting representations of HoH and D/deafness between patients and healthcare workers (HCWs), communication issues during consultation and physical examination and different perspectives about how improving communication [16,18].Importantly, among adult Deaf from birth or early childhood, these communication issues may be reinforced by certain negative consequences of language deprivation.Language deprivation refers to the limited language acquisition opportunities in early childhood and typically results from the lack of access of visual language, such as sign language.Language deprivation can lead to negative outcomes, such as low health literacy (i.e., knowledge and skills to access, understand, process, evaluate and use health information to make decisions regarding healthcare, disease prevention and health promotion) [19][20][21].There is, indeed, evidence of inadequate health literacy among Deaf adult sign language users, resulting from a limited access to health information typically tailored to hearing populations [22,23].Notably, the latter can pose significant communication barriers during clinical encounters with HCWs who are generally unaware of these risks [23].As a result of these multiple encountered communication challenges, and because most often the healthcare setting is not adapted to the specific needs of D/deaf and HoH patients (e.g., providing sign language interpreting services [5]), they typically experience lack of trust and unsatisfactory patient-provider relationships [24][25][26] while being at risk of facing preventable adverse events [7,27].
There is also evidence that HCWs experience their own difficulties when providing healthcare to D/deaf and HoH patients, including feeling unprepared, dissatisfied and uncomfortable [18,26,28,29].HCWs are typically not trained to properly communicate with D/deaf and HoH patients, neither are they aware of the D/deaf culture, their risks of inadequate health literacy and the importance to address them and D/deaf and HoH experiences in healthcare and specific communication needs [17,18,25,30,31].Consequently, there have been calls to develop interventions to improve HCWs' awareness of D/deaf and HoH experiences and communication needs [2,6,32].
Despite these calls, there is still a paucity of research focused on the development and implementation of such interventions [7].Only a handful of studies conducted among pre-graduate students began to address these needs [26,27].A first study described an elective educational 3-hour workshop for medical students (N = 120) before their entry into clinical settings; the workshop included questionnaires, lectures, discussions, simulated patient's sessions and involved D/deaf speakers.A survey completed by 41% of the students after the workshop documented high levels of satisfaction [33].Two other studies involving 76 first-year pharmacy students and 99 first-year medical students aimed to develop role-reversal exercises in which students were the patients and D/deaf volunteers the medical staff.Findings documented that students perceived the program as educational, interesting and thought-provoking [26,27].Finally, a more recent study involving second-year medical students aimed to evaluate the impact of a D/deaf awareness and basic sign language training on students' attitudes to and knowledge of D/deafness (i.e., seventeen 3-hour sessions) [34].Findings revealed that compared to students who took another module (N = 30), students completing the module on D/deafness (N = 29) had a more positive attitude to D/deaf individuals and higher knowledge scores on Deafness.
Despite these promising findings, advances remain isolated and focus on pre-graduate training exclusively.To the best of the authors' knowledge, no previous research focused on postgraduate interventions.Further initiatives targeting broader audiences, such as postgraduate HCWs, are needed to help decrease communicational barriers encountered by D/deaf and HoH individuals in healthcare.In response, this study aimed to develop an intervention to raise HCWs' awareness of D/deaf and HoH experience and specific needs and improve their communication skills.Specifically, the study aimed to develop and implement a capacity-building intervention among HCWs in Switzerland; to evaluate quantitatively and qualitatively participants' satisfaction and perceptions of the intervention content, quality and appropriateness; to evaluate changes among participants on perceived knowledge and self-efficacy to communicate with the target population after receiving the intervention and 6 months later; to evaluate changes in organizational payoffs (i.e., use frequency of the skills taught during the intervention) 6 months after receiving the intervention.Considering the literature described above, we hypothesized that participants would evince higher scores on perceived knowledge, self-efficacy and organizational payoffs after receiving the intervention and 6 months later.

Setting
This study was conducted at the Center for Primary Care and Public Health in Lausanne (Unisanté) in collaboration with Lausanne University Hospital and several medical institutions involved with the target population in the Canton of Vaud (Vaud: 823'881 inhabitants, 3rd most populated Canton in Switzerland, 9.4% of Swiss inhabitants), including the primary-care ambulatory and the pharmacy units from the home institution; geriatric acute services and geriatric rehabilitation unit at Lausanne University Hospital, the local nursing home association (HévivA) and the local home support association (AVASAD) (hereafter referred as partner institutions).
The project was conducted between November 2019 and December 2021.More details are provided elsewhere [35].

Design
This was a participatory action research using qualitative and quantitative methods [36].Consistent with the action research design, the study followed four cyclical and iterative phases: (1) Problem identification (identify and define the problem); (2) Action planning (design the action based on phase 1 data); (3) Implementation of the action; and (4) Evaluation of the action [37].

Patient and public involvement
The study was conducted using a participatory method, equitably involving the target population, stakeholders and researchers [38].Consistent with participatory method, the research team who implemented the research project included hearing [7], two Deaf French Sign Language users and one HoH research staff.The establishment of the research project work was discussed within the research team to ensure maximizing strengths and resources from everyone.It was decided that D/deaf and HoH research staff would be in charge of developing the capacity-building intervention, with support from the hearing research staff, and that they would provide the intervention to the participants.It was also decided that the research-related tasks (e.g., research project coordination, data collection, data analysis, draft writing) would be firstly managed by the hearing research staff.All research staff are authors of the current manuscript.
Participatory research was also operationalized through establishing an advisory committee including D/deaf and HoH individuals, association representatives and involved stakeholders (see acknowledgement section for members' names, functions, and hearing status).Committee members provided ongoing feedback to the research team and were involved in the intervention development.

Procedures Phase 1: problem identification
This phase aimed to explore experience in healthcare, clarify the needs and gather advice on how developing the intervention among both HCWs and D/deaf and HoH individuals.Regarding HCWs, heads of partner institutions invited key staff to participate in semi-structured interviews.For D/deaf and HoH participants, recruitment was conducted with the support of D/deaf and HoH associations and within the participating nursing home.Furthermore, a video promoting study participation in French Sign Language was posted on the websites of D/deaf associations.When first getting in touch with interested participants, the research team asked them to indicate their preferred mode of communication for the interviews.When asked for, the research staff conducted the interviews with French sign language interpreters.

Phases 2-4: action planning, implementation and evaluation
The research team organized two half-day workshops with the committee to craft the prototype intervention.Then, the research team developed a first version of the intervention, based on qualitative findings from Phase 1 and ideas generating through workshops by the committee members.Next, the research team organized a first version of intervention (first round of testing).Heads of partner institutions invited available and interested staff to participate in the intervention.After the intervention, participants were asked to complete a questionnaire and parts of them (one per institution, randomly selected) took part in one-on-one semi-structured interview.A second improved version of the intervention was developed based on the findings of the first round of testing (second round of testing) and through discussions with the advisory committee.The resulting intervention was tested through a second round of interventions (involving new participants from the partner institutions).For the testing of the second intervention, participants were asked to complete a questionnaire at pre-intervention (T0), post-intervention (T1, just after the intervention) and at 6-month post-intervention (T2).Finally, parts of the participants (at least one per partner institution, randomly selected) took part in one-on-one semi-structured interviews at T1. Table 1 displays a summary of the measures by phases.

Ethics and consent to participate
This research project was deemed exempt by the Human Research Ethics Committee of Lausanne University Hospital, Vaud, Switzerland because it did not involve clinical data measurement.All procedures followed the

T1
Note. 1 Participants were asked to rate their satisfaction regarding the intervention and to evaluate its content, quality, and appropriateness using a 5-point Likert scale, ranging from 1 (not satisfied at all/improvement needed) to 5 (completely satisfied/very good) 2 Participants were asked to indicate the extent to which they agree with items using a 5-point Likert-scale ranging from 1 (strongly disagree) to 6 (strongly agree) ethical guidelines outlined in the Declaration of Helsinki.Informed consent was obtained from all participants.Specific methods and results are presented for each phase of the research project below.

Participants
Participants (N = 37) were D/deaf and HoH individuals (n = 19) and HCWs (n = 18).For HCWs, inclusion criteria included being ≥ 18 years and having cared for at least one D/deaf or a HoH patient in a healthcare work environment.A group characteristics sampling per quotas by functions (i.e., physicians, nurses, other) was selected as purposeful sampling.For D/deaf and HoH individuals, inclusion criteria included being ≥ 18 years and being d/ Deaf or HoH.A group characteristics sampling per quotas by hearing loss (i.e., d/Deaf vs. HoH) was selected as purposeful sampling.We added a group characteristics sampling per quotas by age (i.e., 18-64 vs. 65 and older) for HoH individuals to account for age-related HoH (i.e., around 65) vs. more precocious forms of HoH.Interviews were conducted until reaching data saturation.

Measures
Sociodemographic items assessed participants' age, gender and profession.We added two items from the surveillance survey questions on hearing loss among D/ deaf and HoH participants [39].These items were used to describe the sample.Semi-structured interviews were conducted using a grid that comprised open-ended questions about participants' experiences with healthcare and their recommendations regarding the objectives, content, and format of the intervention (see Appendixes 1 and 2).Interviews were conducted in person, by phone or by videoconference by research team members with experience in qualitative methods, with the presence of a French Sign Language interpreter when asked for.The mean duration of semi-structured interviews was 53 min.

Data analysis plan
Semi-structured interviews were audio recorded and transcribed verbatim.Personal identifiable information were removed from transcripts prior to data coding.Data yielded in this first phase followed the steps of thematic analytical method [40].Initial coding was conducted separately on a subset of data using line-by-line technique, whereby coders narrated the actions occurring in the data (allowing for inductive themes to emerge).Next, we created a codebook in consensus meetings, combing codes into themes, pooling incident-by-incident codes and removing collapsing idiosyncratic or redundant codes.Then, we used the codebook to independently doublecode 10% of the sessions.After reaching adequate intercoder consistency (80%), three research members coded the remaining sessions.Feedback from the advisory committee served as a means of assessing fit and resonance of findings.This process was conducted independently with data yielded among HCWs and administrative staff and with data collected in the target population.Altlas.tisoftware was used to code qualitative data.

Participants and qualitative findings
In total, 37  ), and HoH > 65 years (n = 5), > 65 years (n = 8).Among the D/deaf and HoH individuals, the average age was 50.8 years (SD = 20.9) and 55.6% were female.Among them, 15 (73.7%) reported using a hearing aid; when using the hearing aid, 1 reported having no difficulty hearing sounds like people voices or music, 9 reported some difficulty, 4 a lot of difficulty and 1 reported he.she cannot hear at all.Among the 4 participants using no hearing aid, 1 reported a lot of difficulty and 3 reported being unable to hear at all.
Two main themes emerged from the qualitative analysis: (1) The experience and difficulties encountered in the healthcare system with and among D/deaf and HoH patients; (2) The objectives, the form, and the content of the intervention to be developed: Opinions and recommendations.Consistent with the action research method, the first theme provides a description of the problematic in the perspective of the target populations.Main findings related to the two themes are synthetized below.

Theme 1: the experience and difficulties encountered in the healthcare system Ineffective communication and difficulties related to the attitude of professionals
Most HCWs mentioned facing difficulties when communicating with the target population.They typically mentioned a "lack of precision, " "superficial and indirect communication, " and an "inability to ensure patients' understanding." This echoes the comments of the D/deaf and HoH participants who reported difficulty communicating with HCWs, primarily in understanding what was being discussed.
Notably, almost all the D/deaf and HoH participants reported having experienced difficulties related to the attitude of certain HCWs.Participants perceived that HCWs "make little effort, " "quickly forget their communication needs" or that "they do not have the right reflexes to communicate with them".For example, participant ID264 (HoH) explained: "Half of what my gynecologist says is incomprehensible, he speaks too softly, plus he has a little accent, and he doesn't articulate." Some participants also explained perceiving annoyance or fatigue among HCWs, with some of them refusing to adapt: I went once to the [name of hospital], and there, there was no respect at all for D/deaf patients.It was catastrophic.I said: "I didn't understand, I'm sorry, can we use written language?",and it was always refused, rather curtly (ID175, D/deaf person).
Several HoH participants and one D/deaf participant noticed additional difficulties in relation to the use of the telephone.For example, participant ID122 (HoH) recalled an experience when she had to contact an ambulance for her son:

Lack of time and fear of disturbance
Almost half of the HCWs mentioned that the longer time required with a patient who is D/deaf or HoH represents a critical difficulty.Perceiving these difficulties, half of the D/deaf and HoH participants explained they are afraid to disturb HCWs, for example by asking them to repeat when they have not understood or by requiring special arrangements.A HoH participant explained: "I didn't dare say that I didn't understand.The lady was already stressed out" (ID61).

Experience
As noted by most HoH and D/deaf participants, this lack of understanding is not without consequence.Several participants expressed they felt anxious, depressed or irritated in these situations.In fact, most of HoH people and all the D/deaf participants mentioned at least one negative experience-often several, in the healthcare system healthcare:

In the operating room, the hearing aids must stay in the room, and they ask us questions with the mask on, it's like speaking Chinese. You hear, you see the lips moving, but you understand absolutely nothing, and that's scary (HoH, ID211).
As a result, several D/deaf and HoH participants reported apprehension about having to return to the hospital, especially when they must meet unfamiliar HCWs.However, most D/deaf and HoH participants also reported good experiences in the healthcare system, in particular when they encounter caring and supportive HCWs or when there are ways to improve communication (e.g., Sign Language interpreters).
Although less intense, HCWs mentioned negative experiences as well.Half participants explained they typically feel embarrassed or frustrated when caring a D/deaf or HoH patients because the understanding cannot be optimal.

Theme 2: objectives, content and form of the training: recommendations Raising awareness of the experiences and needs of D/deaf and HoH patients
All participants, HCWs and D/deaf or HoH confounded, mentioned that the intervention should aim at raising awareness among HCWs about D/deafness and HoH, and more specifically about the experiences and their communication needs in the healthcare system.

Teaching basic reflexes to improve communication and basic concepts in French sign language
Most HCWs and D/deaf and HoH participants emphasized the need to teach HCWs the basic rules for communicating with the target population, such as speaking slowly, making one's face and mouth visible, not overarticulating or shouting, etc.Furthermore, teaching basic concepts in French Sign Language was commonly suggested by both HCWs and D/deaf and HoH participants.

Presenting existing tools and resources
Several HCWs recommended to include a presentation of existing tools and resources to improve communication with the target population, as well as how accessing them (e.g., French Sign Language interpreter services; cued speech coders; magnetic loop).Relatedly, some HCWs and D/deaf and HoH participants suggested creating a toolbox that could be made available after the intervention.

Form of the training and trainers
According to most participants, the intervention should last about half a day, although some participants felt that a more extensive training would be necessary.Regarding the form, most participants mentioned that the training should include practical components, such as role-playing.Importantly, most participants felt that the training should be delivered by D/deaf and/or HoH trainers.

Phase 2: Action planning -round 1 of testing
Two 2.5-hour workshops were conducted with the advisory committee to develop ideas on the form and content of the intervention to be developed based on the results of Phase 1.The workshops were facilitated by the first author and 2 members of the research team, with French Sign Language interpreters.In total, 11 members participated in these workshops.Fig. 1 describes workshops' process.
Main findings from these workshops indicated that the intervention should include 3 parts addressing 3 objectives:

Phase 3: Action implementation -round 1 of testing
The research team developed and organized the intervention according to results from phase 1 and recommendations from the advisory committee during the workshops (phase 2).It was decided that the intervention would take place over half a day and that it would include theoretical parts, testimonies, situational and practical exercises.In addition, the research team decided to use existing videos and create new ones to increase awareness of the target population's experiences and reinforce the learning of good practices to improve communication.Finally, it was decided that the introduction of existing tools and good practices to improve communication would be achieved through the development of a toolbox that would be sent to participants prior to the training and introduced during the intervention.Table 2

Measures
The Integrated Model of Training Evaluation and Effectiveness (IMTEE) [41] guided the intervention evaluation [36].A quantitative questionnaire was developed to  • Visual documents reminding good practices.
• Visual document to be used with D/deaf and HoH patients for the choice of communication means.
• Documents explaining the different interpreting possibilities.
• Links and contacts of professionals in cued speech and French Sign Language.
• Documentation on the magnetic loop.
• Link to an Internet site offering a lexicon in French Sign Language.
• Links of the existing training possibilities (French Sign Language, cued speech, lip reading) • Summary document of the different degrees of hearing loss.Toolkit sent to participants before the intervention.Presented and discussed throughout the intervention.
fit intervention content and adapted from past research using the IMTEE framework [42,43].Once developed, it was pre-tested in 10 HCWs to ensure items' understanding.For the first round of testing, the questionnaire assessed reactions of participants regarding the intervention (i.e., satisfaction and perception of the intervention content, quality, appropriateness, and usefulness) after receiving the intervention.The quantitative evaluation was completed by a qualitative assessment exploring the same dimensions through one-on-one semi-structured interviews conducted by videoconference with an interview grid (see Appendix 3).

Quantitative and qualitative analysis
Descriptive statistics were used to summarize quantitative data.Similar to Phase 1, semi-structured interviews were conducted until reaching data saturation, audiorecorded and transcribed verbatim by research assistants.
Qualitative assessment was conducted based on findings from phase 1 and aimed to complement quantitative findings.Hence, we used a deductive thematic analysis consisting of analyzing data according to an existing framework (i.e., the themes of the interview grid) [44].

Results
Table 3 presents the descriptive statistics from the questionnaires.Over 90% agreed or strongly agreed that the intervention met their expectations and needs in the field.Next, most participants agreed or strongly agreed that the intervention would influence their practice, that it strengthened their understanding of the target population's experiences and specific needs, and that they knew the basic principles to apply to improve communication with these patients.However, more than 30% of the participants indicated that they felt only moderately equipped to receive the target population after the intervention.All parts of the intervention were judged as good or very good by most participants except for the part on the history of the Deaf, which was evaluated as average by most participants.
The mean duration of the interviews was 51 min.

Overall impression of the intervention
The intervention was consistently well perceived, often described as "interesting" and "rich." The most appreciated aspects of the intervention included learning about the experiences of D/deaf and HoH people and their different communication needs, the testimonies and exchanges with the trainers, and the fact that they were themselves Deaf and HoH: "Having… interlocutors… from the… hearing impaired community, it was very enriching; we felt that their experience went with the theory, it was really an added value" (ID 2).Finally, most participants mentioned appreciating the balance between theoretical and practical moments as well as the videos often perceived as reinforcing the learning.

Perceptions of the usefulness of the intervention
Most participants mentioned that the intervention was useful and that they intended to integrate the elements taught into their practice.Furthermore, participants commonly reported that they felt equipped to pass on certain elements acquired to their colleagues, even though some noticed that it could not replace the intervention itself, as participation was considered essential to raise awareness of the experiences of the target population.However, two participants reported feeling not more equipped to communicate with HoH elderly after receiving the intervention:

Suggested improvements related to the content of the intervention
All participants felt that the section on Deaf history was too long, whereas the length of the part related to the good practices was often perceived as too short.Participants commonly suggested to add role playing to reinforce this part.Regarding the introduction of the French Sign Language, half participants reported that they were unable to retain the words introduced and suggested either deleting this part or reducing the number of words to ensure learning.Finally, two participants suggested to add a section focusing on HoH elderly.

Suggested improvements related to the form of the intervention
Although the videoconference intervention was perceived as well organized and functional, most participants would have preferred to participate in person to favor interaction.The duration of the intervention was considered too short by half of the participants, who suggested that it should be given over a full day to increase the practical parts and reinforce the learning.According to the other participants, the intervention length was adapted (2 participants) or too long (1 participant).

Back to phase 2: Action planning -round 2 of testing
The next step was to adjust the intervention based on the results from the previous phase with input from the advisory committee, leading to the finale version of the intervention.This phase began with working sessions with the advisory committee, during which the research team presented the content and format of the intervention tested in the previous phase as well as the results from the evaluation.These sessions aimed to collect committee member's feedback on possible improvements to be made and were conducted with French Sign Language interpreters.Committee members recommended to clarify the differences between sign language interpreter, community interpreter and intermediary interpreter.They also suggested to shorten the theory, lengthen the practical parts, Rating. 1 1 = very bad, 2 = bad, 3 = average, 4 = good, 5 = very good; 2 1 = disagree, 2 = disagree, 3 = somewhat agree, 4 = agree, 5 = strongly agree; 3 1 = really too short, 2 = too short, 3 = good, 4 = too long, 5 = really too long and add an introduction on cued speech as well as a section on communication with HoH elderly people.Finally, regarding the toolbox, they recommended to add pictures illustrating how to sign basic words in French Sign Language as well as a document clarifying the functioning of the remote interpreting.

The finale intervention
According to both results from the evaluation and the advisory committee recommendations, the following modifications were made: 1. Less theory, more practice: Synthesis of the theoretical parts, focus on good practices, and addition of role playing.Reinforcement of the toolbox usefulness during the intervention.2. HoH elderly: Addition of a section dedicated on how to promote good communication with this population (theoretical part and role playing).3. Sign Language interpretation: Addition of a slide clarifying the interpretation process and the distinctions between interpreter, community interpreter and intermediary interpreter; addition of a document clarifying these roles and the functioning of the remote interpreting in the toolbox.4. Cued Speech: Addition of a practical introduction and cued-speech-related information's in the toolbox.5. French Sign Language introduction: Aim to teach 4 words (instead of 10) and addition (in the toolbox) of videos teaching how to interpret a few basic words in French Sign Language to welcome a Deaf patient.
The duration of the intervention was kept to half a day and the second version was organized face-to-face.It was given twice, in June 2021, to a total of 28 participants from the project's partner institutions who had not participated in the first test of the intervention.

Measures
Consistent with the Integrated Model of Training Evaluation and Effectiveness (IMTEE) [41] the quantitative questionnaire assessed the following dimensions:

Intervention content and design
Seven items assessed reactions of participants regarding the intervention after receiving the intervention (T1).

Changes in participants
Eight items measured perceived self-efficacy to apply the skills taught during the intervention (α = 77); 10 items assessed perceived acquisition of knowledge (α = 88) [42,43].These dimensions were assessed at T0, T1 and at T2 and were used as dependent variables in the main analysis.

Organizational payoffs
Four items measured use frequency of the newly acquired skills (α = 94) [42,43].A total score was computed, hereafter referred as "organizational payoffs".This dimension was assessed at T1 and T2 and was used as a dependent variable.
The quantitative evaluation was completed by a qualitative assessment exploring the same dimensions through one-on-one semi-structured interviews conducted by videoconference (see Appendix 4).

Quantitative and qualitative analysis
Quantitative data were screened for missing cases, outliers, and normality of distributions using descriptive statistics.Population-averaged estimating equation (GEE) modeling were used to test time as a predictor of the dependent variables (i.e., self-efficacy, knowledge and organizational payoffs) over the 6-month follow-up period [45].GEE are marginal models that can take into account nonindependence resulting from data clustering (e.g., longitudinal data).As the three dependent variables were normally distributed, we specified the Gaussian distribution.All models were adjusted for professions, age and gender.Analyses were conducted using STATA.The significance level was set at p =.05.Qualitative analysis mirrored the methods used in the first round of testing.

Attrition analysis
All participants (N = 28) completed the questionnaires at T0 and T1; at T2, 25 participants (89.3%) completed the questionnaire.We conducted attrition tests comparing participants who completed the questionnaire at T2 with those who did not to verify whether the data were missing at random, which revealed no significant differences in gender, age and professions.

Participants' reactions regarding the intervention content and design
As shown in Table 4, all participants rated the training as good or very good and agreed or strongly agreed that it met their expectations.According to most of them, the training met the needs of the field and was applicable and useful for practice.

Changes in participants
Table 5 displays descriptive statistics of items assessing participants' perceived knowledge and self-efficacy at T0, T1 and T2 as well as organizational payoffs at T1 and T2.Table 6 presents GEE model statistics and parameter estimates.Both models testing the associations of time with knowledge and self-efficacy were significant.Findings showed that associations of time with knowledge and self-efficacy were significant, such that knowledge and self-efficacy increased over time.In contrast, the model and the association of time with institutional payoffs were not significant, indicating that institutional payoffs did not change over time.

Participants
Ten participants took part in a semi-structured individual interview (90% women; 20% pharmacists; 20% community care assistants, 20% receptionists, 40% nurses).Findings yielded from the analysis are synthetized below.The mean duration of the interviews was 42 min.

The intervention is well received and raises awareness of the experience and communication needs of D/deaf and HoH patients
Positive perceptions of the intervention.The intervention was systematically well perceived by the participants who described it as "interesting, " "fascinating, " "instructive, " "useful" and "rewarding." In line with findings from round 1, according to all participants, the trainers, and in particular the fact that they were themselves Deaf and HoH was the main added value of the intervention: Rating. 1 1 = very bad, 2 = bad, 3 = average, 4 = good, 5 = very good; 2 1 = disagree, 2 = disagree, 3 = somewhat agree, 4 = agree, 5 = strongly agree; 3 1 = really too short, 2 = too short, 3 = good, 4 = too long, 5 = really too long than just theoretical (…).Because, if you want to talk to them, you have to… well, you have to find ways to raise your hand, take off your mask, speak before you get a translation (ID 4).

The way it is given is really the best of the training. Having HoH or Deaf people, who are there in front of us with interpreters who do it live (…) that really allows us to have an understanding a little more
The fact that the trainers talked about their life experiences was pointed as a crucial ingredient of the intervention.Participant 3 disclosed for instance: "The strength of the training was precisely that… they dared to talk about

The intervention improves perceived knowledge of how communicating with D/deaf and HoH patients
Participants commonly explained that they improved their knowledge of the existing tools and basic reflexes to improve communication with D/deaf and HoH patients: The fact of knowing how to look face to face, speak nicely, with gestures.After writing too, there are also videoconferences with [sign language] interpreters… There are certain telephone numbers, hotlines (…).There are many easy solutions now (ID 6).
Furthermore, several participants explained that they had never heard of cued speech and magnetic loops before, whereas others explained that they improved their understanding of the differences between Deaf, deaf and HoH.Finally, participants commonly reported they learnt the extent to which communication needs are diverse across D/deaf and HoH patients.

The perceived anticipated benefits of the intervention in the working environment
Feeling more self-confident and more at ease.Most participants explained that the intervention provided them with a basis enabling to feel more self-confident and more at ease with D/deaf and HoH patients in the working environment.Participant 47 disclosed for instance: "I wouldn't say I know everything, but perhaps compared to a colleague who didn't attend the training, I would be at ease." Consequently, participants commonly explained that after the intervention they would be "less shy" with D/deaf and HoH and they would dare trying different means to communicate with them.According to participant 73, engaging with the target population was considered a priority: "This is the main tool, you must not be shy, When asked to reflect on concrete changes they anticipate making in the working environment, participants commonly evoked the use of different communication tools introduced during the intervention.Participant 47 noticed for instance that she would "really use mimicry more, " that "she would lift the mask, try to articulate." Other participants commonly evoked that they would try diverse means to communicate: "Maybe it will be drawings.The small cards.And to mime (…).Afterwards it will be to go and look for a [sign language] interpreter.(…) We can write (…).Yeah, no there are quite a few tools." (ID 96).Corollary, participants often explained that they would start the interaction with D/deaf and HoH patients by identifying their own specific communication needs:

Before starting a conversation, (…) I would ask in some ways what wants to use the person. If he prefers to write… that's it. Or if they need a [sign language]
interpreter actually over the phone… that would be a step that I would change now (ID 70).

Feeling more at ease yet not more equipped to communication with D/deaf and HoH patients
Despite the perceived benefits described above, participants commonly nuanced the anticipated changes in the working environment.
Too much theory and not enough practice to consolidate learning and feel equipped.The intervention was often perceived as too theoretical.Participant 21 mentioned for instance: "Yes, on the theory level we got a lot of stuff.But I think I'm still as lost if I have someone in front of me." The intervention length and lack of practice were commonly perceived as preventing participants from consolidating learning and thereby feeling more equipped: I would have found very interesting to do more practice.We did some, and I was able to participate in a practical case.And it's true that hearing how to react is easy.But afterwards, when you find yourself in the situation, suddenly, you don't know what to do when you've just heard the theory 3 seconds before (ID 8).
In its format, the toolbox is difficult to use in the field.Some participants questioned the toolbox usefulness.Its format was perceived as suboptimal and the fact that it was provided on the USB key was perceived as unpractical.

Recommendations to improve the intervention
Participants suggested several ways to improve the intervention and favor learning consolidation over time, such as including more role playing.Relatedly, a few participants suggested to organize the intervention in two half days, providing additional time for practical exercises.Furthermore, some participants evoked the importance of repetition to consolidate learning.The idea to organize regular reminders in staff meetings to avoid forgetting over time was suggested by some of the participants, whereas others recommended to propose an intervention follow-up or to have a resource person within the institution.For some participants, this follow-up training would aim to teach French Sign Language, whereas others suggested to receive coaching directly in the field after the initial intervention.Finally, participants commonly recommended to improve the toolbox format, making it more practical and user-friendly.

Discussion
This study aimed to develop and evaluate a capacitybuilding intervention aimed at raising HCWs' D/deaf and HoH experience and specific needs in healthcare and improve their communication skills.Main findings revealed that perceived knowledge related to D/deafness and HoH and existing tools to improve communication and perceived self-efficacy regarding how to communicate with D/deaf and HoH patients significantly improved after receiving the final version of the intervention, whereas there were no significant changes in organizational payoffs in the working environment (i.e., use frequency of basic reflexes and communication tools).These quantitative findings were corroborated by qualitative results documenting that participants typically felt more self-confident yet not necessary more equipped to receive and interact with D/deaf and HoH patients after the intervention.

Co-developing interventions to improve communication with D/deaf and HoH patients together with members of the target populations meet needs in healthcare setting
Consistent with research action method, the study started with a qualitative exploration aiming to describe the problematic from the perspective of involved populations and gather recommendations regarding the intervention's content and form.In line with past research [2,16,17,46], findings documented that D/deaf, HoH patients and HCWs face individual and structural difficulties severely impeding communication and leading to negative experiences in healthcare settings.The latter were described as sustaining an often already-existing apprehension to seek care and ultimately reinforcing barriers in the target population.These findings confirm the relevance to develop and disseminate interventions aimed at improving HCWs' communication skills and ultimately help decrease barriers to healthcare among D/ deaf and HoH individuals.
Consistent with existing literature focused on pregraduate training [32][33][34]47], findings revealed that the intervention should aim at raising awareness of the experiences and diverse communication needs of the target population, teach the basic communication rules to improve communication, introduce the French Sign Language, the cued speech and the resources and existing tools to support communication (e.g., French sign Language interpreter and cued speech coders services, magnetic loop).Furthermore, participants consistently advised to involve D/deaf and HoH in the intervention development and delivery.This recommendation is consistent with past studies testing interventions among medical and pharmacy students that typically involved the target populations [33,48].Consistent with the community-based participatory research paradigm [49], involving members of the target populations in the development and delivery of the intervention is critical to ensure embracing insights and perspectives of involved people and ultimately develop an intervention tailored to meet the specific needs encountered in the field.Importantly, our qualitative findings among participants who received the intervention highlighted that having the intervention delivered by Deaf and HoH trainers was perceived as the added value and the main ingredient of the intervention effectiveness.Taken together, our findings coupled with past research suggest that future efforts aiming to develop and disseminate such interventions should systematically involve D/deaf and HoH individuals.
The intervention is promising to improve HCWs' perceived knowledge and self-confidence in communicating with D/deaf and HoH patients but additional components are needed to ensure sustainable changes in the working environment Consistent with the few previous studies conducted among pre-graduate students [33,48,50], our results showed high levels of satisfaction among the participants who attended one of the interventions provided in this research.These results attest to the interest of the HCWs in this problematic and are reinforced by the fact that the intervention was given entirely by D/deaf and HoH trainers.As mentioned earlier, this aspect was percived as the added value during the qualitative evaluations of the interventions.
As developed in this study, the capacity-building intervention aimed to have participants (1) understand the experiences and diverse communication needs of D/deaf and HoH patients, (2) understand the importance of the first contact and apply good practices to reassure D/deaf and HoH patients and promote good follow-up care, and (3) know the different tools available, the basic rules and when and how to use them.Meeting parts of these objectives and consistent with past studies [34,47], findings showed that participants evinced significant increases in perceived knowledge and self-efficacy in communicating with D/deaf and HoH patients after the intervention.These findings and the fact that increases in both scores remained significant 6 months after the intervention suggest that the intervention may be an effective means to reach sustainable improvements in perceived knowledge of D/deafness, HoH and existing tools to improve communication and in self-confidence in communicating with D/deaf and HoH patients, although future research using more robust design is needed to confirm these findings.
Additional quantitative findings revealed however significant decreases in perceived knowledge and self-efficacy to communicate with D/deaf and HoH patients over time.Consistently, Gilmore and colleagues, who found that medical students attending a workshop on D/deafness had higher score on attitude to D/deafness than their peers who did not attend the intervention, also found a negative association of attitudes to D/deafness with time after completion of the workshop [34].It may be that beneficial effects of such interventions reduce over time.Hence, as highlighted by our qualitative findings, developing refresher interventions may be necessary to ensure sustainable changes in knowledge and self-efficacy.These refresher interventions might be short, delivered during team meetings or in the form of podcasts.
Additional findings showed that frequency use of basic rules and tools to improve communication as well as colleagues' remindings of applying the latter did not significantly increase after receiving the intervention.To the best of the authors' knowledge, this was the first study to assess changes of these organizational payoffs.These findings suggest that alone, the intervention was not sufficient to induce a sustainable change of practices in the working environment.Our qualitative findings suggest a few ways to promote concrete changes of practice in the working environment, including inserting additional practical exercices and benefiting from a resource staff whithin the institution.This resource staff might be an expert or a D/deaf or HoH HCW who would be responsible for providing support to the teams on a day-to-day basis, proposing awareness training for new staff as well as ongoing refreshers for the teams.Combining training and continuous supervision in the field, these resource persons in the field might help to promote sustainable changes in practices, although future research is needed to test this model effectiveness and efficacy.

Limitations
The results of this study should be interpreted with caution.Firstly, the fact that a majority of participants in each phase of the ressearch project identified themselves as females could represent a bias, even though this prevalence mirrors the higher percentage of females in most professions targeted by the intervention (e.g., nurses, adminsitrative staff ).Secondly, whereas the sample in the initial qualitative assessment included 33.3% of physicians, the latter profession was not represented in the intervention test phases.This might indicate a feasibility issue to free half a day to attend the intervention among physicians.Furthermore, inpatient healthcare facilities were not included in the partner institutions.Future research efforts specifically targeting physicians and including inpatient facilities are needed to adapt and evaluate the intervention to these working contexts.Next, the quantitative data used to test the impact of the intervention were derived from self-reported questionnaires, which may be subject to social desirability bias.However, we took steps to mitigate this risk by ensuring the confidentiality of the data.Another limitation pertains to the sample size (N = 28; in the test of the finale intervention).In case of small sample (< 30), the GEE sandwich variance estimate may be biased to zero, which increases the risks of type I errors [51].Although findings from the paired sample t-tests confirmed the findings of the GEE, future larger research is needed to test the intervention effectiveness and efficacy in larger samples.

Conclusion
To the best of the authors' knowledge, this was the first quantitative and qualitative longitudinal study involving postgraduate HCWs that evaluated changes on perceived knowledge, self-efficacy in communicating with D/deaf and HoH patients and organizational payoffs after receiving a capacity-building intervention.Main findings revelead that the intervention was followed by significant and sustainable increases in perceived knowledge and self-efficacy in communicating with D/deaf and HoH patients, whereas no significant changes was found for organizational payoffs.Findings of this study open up important perspectives for future research developing and testing a broader intervention aimed at improving communication skills and creating sustainable changes in practice among HCWs and ultimatley improve access and quality of care among D/deaf and HoH individuals.

1 .
Raising awareness of the experiences and communication needs of D/deaf and HoH patients.2. Raising awareness of the importance of the first contact and teaching good practices to reassure D/ deaf and HoH patients to promote a good follow-up.3. Introducing existing tools and basic rules for improving communication with D/deaf and HoH patients.

Fig. 1
Fig.1Workshop process with members of the advisory committee Theoretical presentation Link to toolbox (part 3) Reminder of the legal basis Theoretical presentation Role-playing situations Situation with limited hearing (using earplugs and lowering the volume of the computer) Objective 2: To understand the importance of the first contact and apply good practices to reassure patients who are D/deaf or hard of hearing and to promote good follow-up care Good practices (desk, waiting room and clinical encounter) • Make an appointment (e.g., smart phone messages, email, online sign language interpreting services) • Reception attitude and ground rules for better communication • Identification of communication's needs (e.g., sign language interpreter, cued speech coder, magnetic loop) • How to behave in the waiting room and during the clinical encounter Theoretical presentation• Broadcast of 3 educational films reinforcing good practices • Reception • Waiting room • Consultation Rudimentary knowledge of French sign language Theoretical presentation Practice (learning some basic words) Introduction to lip reading Theoretical presentation Putting it into practice Objective 3: To know the different tools available and the basic rules for communication and how and when to use them: Toolbox Contents of the toolbox • Course material of the intervention (condensed version).

Table 1
Summary of measures by action research phase

Table 2
Content of the intervention by objective

Table 3
Descriptive statistics of participants' reaction regarding the intervention (first round of testing; N = 13)

Table 4
Descriptive statistics of participants' reactions regarding the intervention content and design (second round of testing; N = 28)

Table 5
Descriptive statistics of participants' perceived knowledge and self-efficacy at T0, T1 and T2 and organizational payoffs at T1 and T2 (second round of testing; N = 28)

Table 6
GEE Model Effects and Parameters Showing the Associations of Time with Knowledge, Self-efficacy and Organizational Payoffs (N = 28)

The intervention raises awareness of experience and communication needs of D/deaf and HoH patients
you must try to mime, no matter how and show that you want to communicate."