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Background Hearing loss is a leading contributor to the global burden of disease, with more than 80 per cent of affected persons residing in low- and middle-income countries, typically where hearing health services are unavailable. Objectives This article discusses the challenges to hearing care in remote and resource-limited settings, and describes recommended service delivery models, taking personnel and equipment requirements into consideration. The paper also considers the novel roles of telemedicine approaches in these contexts for improving access to preventative care. Finally, two case studies illustrate the challenges and strategies for service provision in remote and underserved settings.
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Review Article
Dr D Swanepoel takes responsibility for the
integrity of the content of the paper
Cite this article: Swanepoel D, Clark JL.
Hearing healthcare in remote or
resource-constrained environments. J Laryngol
Otol 2018;17. https://doi.org/10.1017/
S0022215118001159
Accepted: 2 February 2018
Key words:
Audiology; Telehealth; Audiometry;
Hearing Loss
Author for correspondence:
Dr De Wet Swanepoel,
Department of Speech-Language Pathology
and Audiology,
University of Pretoria,
Pretoria, South Africa
E-mail: dewet.swanepoel@up.ac.za
© JLO (1984) Limited, 2018
Hearing healthcare in remote or
resource-constrained environments
D Swanepoel1,2,3 and J L Clark4,5
1
Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa,
2
Ear Sciences
Centre, School of Surgery, University of Western Australia, Nedlands, Australia,
3
Ear Science Institute Australia,
Subiaco, Australia,
4
Callier Center for Communication Disorders, University of Texas, Dallas, USA and
5
Department
of Speech Pathology and Audiology, University of Witwatersrand, Johannesburg, South Africa
Abstract
Background. Hearing loss is a leading contributor to the global burden of disease, with more
than 80 per cent of affected persons residing in low- and middle-income countries, typically
where hearing health services are unavailable.
Objectives. This article discusses the challenges to hearing care in remote and resource-
limited settings, and describes recommended service delivery models, taking personnel and
equipment requirements into consideration. The paper also considers the novel roles of
telemedicine approaches in these contexts for improving access to preventative care. Finally,
two case studies illustrate the challenges and strategies for service provision in remote and
underserved settings.
Introduction
Hearing loss is a major global contributor to the burden of disease. In 2015, an estimated
1.33 billion people worldwide were affected, ranking it as the fourth leading contributor to
years lived with disability globally.
1
When considering only permanent bilateral hearing
losses of a disabling degree, an estimated 360 million are affected globally, constituting
more than 5 per cent of the worlds population.
2
The highest prevalence rates for hearing
loss in children and adults are in South Asia, Asia Pacific and sub-Saharan Africa. As
almost 50 per cent of hearing loss could be prevented, and most of the remaining losses
could be treated effectively,
3
making hearing health services accessible is a global priority.
4
This is especially important in low- and middle-income countries where more than 80 per
cent of persons with hearing loss reside.
5
Recent surveys on the availability of hearing healthcare providers globally indicate that
in low- and middle-income countries, these providers are often non-existent. An inter-
national survey by the World Health Organization (WHO) showed that there is an
inequitable distribution of hearing healthcare providers globally, with low- and middle-
income countries commonly reporting less than one otorhinolaryngologist or audiologist
per million persons.
6
In sub-Saharan Africa, a recent survey of hearing healthcare
providers indicated that there are between 0.1 and 4.6 otorhinolaryngologists per million
persons across the region.
7
Apart from South Africa, there is less than one audiologist for
every million persons in sub-Saharan African countries.
7
Over a 10-year period, between
2005 and 2015, there was no real increase in these ratios.
7,8
Challenges to hearing health services
The inaccessibility of hearing healthcare providers in the majority of the world is a major
hindrance to care. Other challenges include poor public and professional awareness,
limited resources, geographical barriers such as distance and difficult or remote terrains,
and natural barriers such as severe weather. These barriers are not limited to low- and
middle-income countries, and can occur in high-income countries where pockets of
underserved people reside; for example, remote rural regions (e.g. parts of Australia
and Alaska) or inner-city communities.
9,10
Against this backdrop, many challenges exist when seeking to provide objective audio-
metric assessments in under-resourced communities, which can be found in upper-,
middle- and, more prevalently, low-income countries. Often such challenges arise from
either the absence of audiologists or audiological physicians in or near the community
needing basic services. Even more concerning is the challenge of the inability to meet the
burgeoning volume of need while performing at capacity on a daily basis, and significant
budgetary constraints in acquiring essential equipment to conduct the specific measures
called for in the identification, diagnosis or remediation of hearing loss and disorders.
Unfortunately, an abundance of individuals who are more at risk for hearing loss due
to chronic conditions of the ear reside in under-resourced communities. Some of the
conditions may be exacerbated by the local environments and factors that include: high
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illiteracy; high humidity and temperatures; a densely popu-
lated area with frequent disease outbreaks; poor air quality;
poor hygiene and/or sanitation; sleeping on the ground; and
limited or no access to hearing loss prevention information
and products.
9
Models of care
When considering the various means of engaging with the
patient, one is often limited by innovation and imagination
for delivery of services. Ultimately, all delivery modes are
predicated upon patient- and family-centred best practices
throughout the lifespan. These practices include the founda-
tional components of bioethics with regard to engaging in
standardised evaluation and outcome processes. As such,
assessment and outcome processes are dependent upon and
sensitive to the broad needs of the populations being served.
Identifying the appropriate care model is also dependent
upon recognising that hearing loss cannot be cured, and
should be acknowledged as a chronic condition requiring a
lifelong engagement between the patient and professional
service provider. As well as patient lifespan, one also needs
to consider manageability, to improve quality of life through
early detection and ongoing remediation, despite the inability
to cure the chronic condition of hearing loss. The specific
model of care chosen for mode of delivery will be dependent
upon whether the recipients are infants and children or adults,
and their significant caregivers. Components that would be
found in the chronic condition model of care include: inclusive
patient- or family-centred care, team-based care, stepped care,
and accessibility.
Ensuring sustainability of services in under-resourced
settings is an important prerogative. This often requires a
decentralised community-based approach to hearing care,
which enables access to services in communities and strength-
ens hearing care across all levels within the system, especially
at the primary level.
11
The components of such a model and
the associated considerations can guide such an implementa-
tion (Table 1
12
).
Establishing an ongoing and sustainable service requires a
multidimensional approach that is sensitive to the realities of
the specific context. As hearing loss is a silent disability that
does not receive the necessary public health attention, much
initial work requires raising awareness and advocating
amongst stakeholders, including policy makers, healthcare
providers and community members.
4,13
Subsequent steps
include planning, training, development of infrastructure,
programmes and data management systems.
11
Adults
The incidence of hearing loss and balance problems continue to
increase as populations age.
3,13
In fact, 30 per cent of adults aged
6584 years, and more than half of adults aged 85 years and
older, will acquire a significant hearing loss.
5
Consequently,
there is an expectation that the demand for hearing health
professionals will equally continue to grow at a disproportionate
ratio of professionals to patients.
14,15
This must be addressed
through modifying and creating different models of hearing
healthcare.
An inclusive model of care for an adultpatient would take
into consideration those individuals with limited cognitive
function due to dementia or psychiatric conditions, as well
as those who have full capacity and the ability to engage
completely as a team member. It is expected that an adult
model of care would include identification, intervention and
monitoring hearing status, while simultaneously engaging
other health disciplines as needed (e.g. communicable disease
Table 1. A community-based hearing healthcare service delivery approach in
underserved contexts
Components Considerations
Planning &
provision of services
Existing resources (infrastructure, equipment,
personnel, etc.)
Opportunities within health system
(e.g. overlapping mandates)
Education, livelihood & social support to ensure
holistic services
Ethnic, cultural & political context
Evidence-based approaches
Involving stakeholders across the board
Raise awareness Policymakers
Health professionals
Community level healthcare providers
Parents
Teachers
Workers
Sensitisation &
training
Training master trainers (otorhinolaryngologists
& audiologists)
Obstetricians & paediatricians
General primary level physicians
Primary level health workers
Teachers & parents
Primary ear &
hearing care
training
Identify person to be trained
Define roles in provision of ear & hearing care
Develop a training protocol
WHO training manuals
Training
Quality control
Monitoring, feedback & evaluations
Infrastructure
development
Identify health facilities for services
Agree on services to be provided
Identify requirements for service provision
Acquire & install equipment
Development of
priority
programmes
Infant hearing screening
School screening
Screening in elderly
Hearing aid service, etc.
Data management,
monitoring &
evaluation
Develop indicators & monitoring tools
Who will collect, when & how
Decide periodicity of evaluation
Develop suitable tools for promoting hearing care
Strengthen multi-sectoral engagement &
effective partnerships
Research &
development
Epidemiological research
Operational research
Adapted from Wattamwar et al.
13
WHO = World Health Organization
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health professionals for patients diagnosed with human
immunodeficiency virus (HIV) or acquired immunodeficiency
syndrome (AIDS), or tuberculosis), empowering patients, and
promoting advocacy. In addition to the considerations for the
paediatric realm, there is a stronger emphasis for hearing loss
prevention in adults. As older adults likely have more than one
chronic condition to address, there is a need to co-ordinate
care with the multiple healthcare provider teams who may
be involved.
16
Within the environment of limited resources, it should be
anticipated that provision of care would include a stepped
care approach. That is to say, simpler interventions should
be considered first, followed by a progressively more advanced
intervention if the patient and resources are tolerated. Of
course, foundations of bioethics (i.e. autonomy, beneficence,
benevolence and non-maleficence) must also factor into the
decision matrix of which next step is appropriate for each
patient. One example in a stepped care provision of services
would be a trained community worker, responsible for
explaining to an adult in the local community the dangers
of untreated draining ears and describing how to wick the
drainage from the ear canal. If the self-treatment is unsuccess-
ful, the adult would go to the next step of interacting with a
healthcare assistant and ultimately to a professional to resolve
the condition.
Ultimately, to obtain successes in hearing health services
provision, it is important to have uniform ease of access to
services. Unfortunately, as pointed out previously, many
provinces and countries do not have any access to professional
hearing healthcare services, and any support is untenable to
many ministers of health. As a consequence, innovative
methods of providing personnel, equipment and methodology
have become urgently necessary.
Infants and children
Infants and children are difficult-to-test populations that
require special adaptations of conventional hearing assessment
and intervention strategies. This makes it particularly challen-
ging to provide services to these populations in underserved
contexts, where equipment is often scarce and very few hearing
healthcare providers are typically available. Within such
contexts, where no services exist, it may be best to initiate
services that are focused on a specific programme. For example,
a school-entry hearing screening programme could be devel-
oped as a first step towards early detection programmes. As a
service, the implementation should consider the entire care
pathway, from detection and referral to diagnosis and treat-
ment. Once services have been developed and demonstrated
to be effective and efficient, this can be scaled more easily to
other communities. Other programmes may include infant
hearing screening. In this case, innovative approaches to com-
bine services with existing platforms, such as immunisation
17
or maternal obstetric unit visits,
18
can reduce costs and
align services.
Personnel requirements
Licensed or credentialed professional
Each country, and even provinces within the same country, may
have specific regulations pertaining to the training and didactic
experience necessary to provide professional hearing care
services. For instance, in a low- or middle-income country, it
is not unusual for a professional to obtain credentialing after
completion of 4 to 8 years of matriculation, 400 to 1800
hours of practical training, and successfully passing a national
examination to earn a professional license.
19
As such regulatory
expectations are not realistic in most low- and middle-income
countries, it is not unusual to find educational training experi-
ences ranging from a one-month certificate course to a four-
year, formal, didactic university-based degree programme.
20
Optimally, once trained, the professional will be prepared
to diagnostically identify the degree of hearing loss, as well
as the possible aetiology, and potential sites of pathology or
condition. As such, their full scope of practice will include
using a variety of equipment, with screening and diagnostic
capability to enable interpretation of the diagnostic results.
However, the types of equipment are dependent upon the
professionals training and the resources within the region.
Without a doubt, a short-term certificate training course
will not equip an individual to provide the full-breadth and
scope of diagnostic hearing care adequately, nor ultimately
serve the wide span of the population that ranges from
newborn infants, through end-of-life patients and the elderly.
Though completion of a certificate programme has many lim-
itations, it improves the possibility of individuals having access
to affordable basic hearing care in a region that previously had
none.
21
Conversely, a professional who completed the max-
imum matriculation and training would be welcome in under-
resourced communities. However, the local economies would
likely force a higher prioritisation of hiring many personnel
with less education holding a certificate, or a general health
practitioner or physician, over one highly degreed specialised
professional in hearing healthcare. As a consequence, a
low-income country will likely only have 1 or 0 audiologist
or otolaryngology service to every 20 000 inhabitants.
8,19
Non-professional
As mentioned earlier, advanced objective and behavioural
hearing assessments require extensive and specialised training.
However, in the absence of a specialised trained practitioner,
some basic procedures can be conducted by concerned indivi-
duals (e.g. volunteers, parent or guardian, and teachers) or
trained individuals (e.g. community or health workers).
When considering the need to confirm or deny suspicions
about the hearing status of adults, it is wholly appropriate to
train and engage non-licensed or non-professional personnel,
which could include: community workers, healthcare assis-
tants or family members. It is possible to recruit such commu-
nity workers from the local communities by identifying and
engaging with local elders or leaders (political, faith-based
and social), who are willing to act as the community cultural
brokerto target appropriate potential team members.
Some of the benefits of engaging and possibly training
non-licensed individuals within the local community include:
raising awareness about risk factors and the negative conse-
quences of poor hearing health, and allowing the community
to see first-hand the significant medical and psychological
complications known to occur as a result of ignoring ear
and hearing conditions without early identification. Other
added benefits are community education regarding the
available remediation that dispels myths about hearing loss,
and the contributions that those with hearing problems can
make to the community.
In order to achieve optimal capacity within a country or
province, it is also possible for a minister of health to approve
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multi-layers of hearing health workers, starting with a large
number of community workers, fewer community health
workers, even fewer audiology or hearing assistants, to very
few audiologists and hearing health physicians. When working
in the context of a community village, it is of particular
importance to identify the cultural broker, who can negotiate
approval from the local community or village chief or
mayor. The influence that the chief or mayor wield over the
communitys acceptance and participation in any healthcare
programme can be the difference between tremendous success
or dismal failure, despite any financial investment made by a
minister of health.
Equipment and resource requirements
There are some readily available resources to accommodate
screening and diagnostic measures, ranging from simple
questionnaires and structured behavioural observations, to spe-
cialised equipment. In general, questionnaires and informal
observations, potentially integral to stepped care, provide an
entry level triage, which ultimately contributes a wealth of
information to the results of objective audiometric measures
that are eventually completed by the highly trained professional.
Many of the screening questionnaires (e.g. Early Listening
Function questionnaire
22
and Hearing Handicap Inventory
for Adults
23
) are printed in multiple languages, or can be easily
translated, to assess the patient informally and determine fam-
ily perceptions of hearing abilities together with handicapping
conditions perceived as due to hearing loss. Many question-
naires are readily viewable through a simple search on the
internet, and would require practice to imbue confidence on
the part of the examiner. When reviewing the resources for
community-based assessment, it is clear that one is limited
by their creativity. With minimal instruction, a literate parent
or community worker can easily utilise age-appropriate ques-
tionnaires in various languages that can provide informal
assessments of listening abilities, from infants through to
geriatric patients.
Behavioural observations and assessments specific to the
patients cognitive age can also be documented by community
workers, a parent or guardian, or teacher. Though potentially
considered grossly simplistic, some informal observations and
assessments, like the finger rub test, whispered voice test or the
distance test, conducted by a community worker or a trained
hearing health assistant, can provide fundamental information
about hearing status, which could result in a referral for
complete diagnostic audiometric evaluation.
24
Eventually, with the tiered personnel approach, more
advanced assessments, conducted by better qualified profes-
sionals, can be engaged (depending upon the results of the
first- and second-stage outcomes). As personal computing
systems are more portable, accessible and affordable, there has
been a proliferation of deployment into the audiology and hear-
ing health industry. Cloud computing has virtuallyreduced
the distance between the patient and professional. Data captur-
ing, sharing and management have become a reality thanks to
the integrated connectivity between hardware and software
systems throughout the world.
25
With the advent of digitisation
of audiometric equipment, it is now possible to monitor calibra-
tion of the specialised equipment, as well as compliance of the
test environment, while data are captured and seamlessly trans-
mitted into cloud storage. In fact, every piece of audiometric
equipment can be deployed for telepractice measures. This
makes screening and complete diagnostic evaluations possible
in any part of the world.
A significant challenge in providing hearing assessment
services revolves around the calibration of audiometric appar-
atus.
25
Low- and middle-income countries typically may not
have any certified calibration laboratories, which may require
expensive shipments of equipment for international calibra-
tion and results during downtime on site. While newer digital
audiometric devices may offer novel ways to swap calibrated
headphones to avoid downtime and reduce costs,
25
this
remains a significant cost and opportunity challenge.
Telehealth possibilities
Telehealth has been proposed as a service delivery model that
can uniquely address some of the barriers to access in under-
served or remote communities.
10
Telehealth is a way to which
existing healthcare needs, like hearing care, may be served by
using information and communication technology to link
healthcare expertise with patients and with other health
experts. The ultimate aim of telehealth is to provide improved
access, efficiency, cost-effectiveness and even quality to health
services like audiology.
26
Telehealth services can be classified into two broad categor-
ies that relate to the timing of the information exchange and
interaction between healthcare providers and patients, or
between healthcare providers themselves. The first involves
sharing pre-recorded clinical information from one location
to another, and is referred to as store-and-forwardor asyn-
chronous telehealth. Information may be sent from a remote
site to a healthcare provider site, or between healthcare provi-
ders. The advantage of this mode is that healthcare providers
do not need to interact with the information in real-time. A
simple example may be transmitting a pure tone audiogram
by e-mail to an expert colleague for a second opinion. In
many cases, a facilitator at the patients site is present to record
clinical information, which is sent back to a healthcare pro-
vider.
26
The second category of telehealth, called real-time
or synchronous services, requires that the healthcare provider
and patient, or the healthcare providers themselves, engage in
information exchange at the same time, through information
and communication technologies. A live consultation with a
patient using video conferencing is a simple example.
Clinical use cases may involve a hybrid of synchronous and
asynchronous services.
Interest around telehealth has increased significantly as a way
to improve the access, quality, efficiency and cost-effectiveness
of hearing health services, particularly for populations who
have traditionally been underserved.
5
Telehealth services have
the potential to bridge the general barriers often created by dis-
tance, poor travel infrastructure, severe weather and unequal
distribution of healthcare providers in urban and rural settings,
or even across world regions.
9
The advantages that telehealth
services offer are particularly appealing for hearing healthcare
in places where there is a dearth of hearing healthcare
providers.
6,7
Advances in mobile phone technologies, and increased
connectivity in low- and middle-income countries, are
opening up affordable access to the detection and diagnosis
of hearing loss and ear disorders.
2729
Recent mobile phone
technologies have been validated for hearing assessment,
with calibrated headphones on low-cost smartphones, using
automated testing, interpretation with an operator and envir-
onmental quality control features.
25,27,30,31
Employing a simple
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user interface with the aforementioned features allows minim-
ally trained persons to facilitate tests in communities, with
remote monitoring of test quality from a cloud-based data
management portal.
27,31
These types of technologies are
making decentralised community-based services much easier
to implement and monitor.
Case study examples
Examples of service delivery in underserved populations are
discussed in the following case studies of rural hearing screen-
ings for children and adults.
Case one
After gaining genuine acceptance from the local chief and pro-
vincial minister of health to begin offering hearing screenings
in the village, as part of an outreach programme in South
Africa, a variety of training sessions were scheduled with
the community workers and community health workers in
the area.
All of the community workers met with the trainer (the
audiologist) over three sessions. Using the WHO primary
ear and hearing care training manual (2006),
32
these sessions
covered: the importance of hearing, taking care of the ears
and hearing, ear deformities, signs of hearing loss, personal
hygiene and ear hygiene. The information would enable
community workers to identify those with potential hearing
problems within the community so that the community health
worker could see them.
All of the community health workers met with the trainer
(the audiologist) over six sessions. Again using the WHO pri-
mary ear and hearing care training manual,
32
these sessions
covered: recognition of ear infections; hearing loss, due to
meningitis, malaria and so on; understanding what a hearing
screening is; learning the hearing screening protocols for
children and adults; and understanding the pathway for
those who fail the hearing screenings.
Some radio announcements were made about hearing
screenings being scheduled in a rural area community centre.
Simultaneously, the community workers were able to identify
and encourage any local adults and school-aged students
they encountered in the community to attend the scheduled
hearing screenings. For the 5 scheduled days of hearing screen-
ings, five community workers, five trained community health
workers and two audiologists arrived with seven portable
battery-operated screening audiometers, three screening
tympanometers, patient perception questionnaires, otoscopes
and two diagnostic audiometers.
At testing station 1, the patients, as they arrived each day,
provided personal information (i.e. name, date of birth, mobile
phone number, location of home, any known conditions such
as HIV or AIDS, or tuberculosis). The information was
entered by community workers onto a hearing health input
form, to be carried through the subsequent stations by the
patient. The community workers described, in the local dialect
of the patients, what the testing stations are, and the tasks the
patients are expected to complete for each stage (e.g. sit quietly
and raise a hand when soft notes are heard through the ear-
phones). A brief questionnaire about each patients hearing
status was completed by the community worker.
At testing station 2, community health workers viewed the
ear canals through an otoscope, to identify any obstructions
that would negatively affect the screening results. Those
patients with obstructed ear canals proceeded to station 3. If
there was no substantial ear canal obstruction, the hearing
screening was completed. Those who passed the hearing
screening were informed of this by the community workers,
and were asked to contact the community workers or commu-
nity health workers if their hearing changed. These patients
did not continue further with the screening activities. If the
patient did not pass the hearing screening, they were referred
to testing station 4.
At testing station 3, ear canal clearance was completed by
the audiologist, using irrigation or manual removal through
loop curettes (Figure 1). When ear canal clearance was
achieved, the patient returned to station 2 for hearing screen-
ing. In cases where ear canal clearance was not successful, the
patient was sent home with instructions for using sweet oil for
2 days before returning for the community screening.
At testing station 4, tympanometry screening in those who
did not pass the hearing screening at station 2 was completed
by the community health workers. Regardless of the findings,
these patients then moved to station 5.
At testing station 5, diagnostic audiometry was completed
by the audiologist. The audiologist collated the findings and,
ultimately, made critical clinical decisions based upon the
findings obtained at station 5. Either the findings led to referral
for medical treatment for middle-ear problems, or referral
for a hearing aid fitting if the patient questionnaire results
suggested a handicapping condition due to hearing loss.
Depending on the number of patients that are screened, the
audiologist or programme director is able to determine the fre-
quency of screenings in the community. A successful screening
programme is dependent upon the local support from the
community chief or mayor, community workers, community
health workers, and audiologists.
Case two
Children in low- and middle-income countries typically do not
have access to hearing screening. As a result, hearing loss is
only identified when the child enters the schooling system.
A community-based project was therefore launched in an
underserved community in South Africa to offer screening
and referral services in early childhood development centres,
carried out by trained community members. The project uti-
lised novel smartphone-based hearing assessment technology
(hearScreen®application and calibrated headphones, by the
hearX group, Pretoria, South Africa) linked to a cloud-based
data management and referral service.
Fig. 1. Otoscopy before cerumen management.
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The following initial groundwork was undertaken to initiate
this project. (1) In partnership with a local community non-
governmental organisation, two community members were
identified. These persons were selected based on their avail-
ability, local knowledge of early childhood developments and
recommendation by the non-governmental organisation. (2)
These two individuals visited all early childhood development
facilities in the community, informing them of the services to
be offered and providing informed consent letters for parents.
The early childhood development facilities were also mapped
using the hearScreen smartphone applications facility func-
tion to geolocate the specific early childhood development
centre. (3) Referral clinics with ear and hearing services were
also mapped onto the cloud-based data management system.
These were consulted first to ensure they had the capacity
for the children that may be referred. (4) The two screeners
received training on how to test young children for hearing
loss using the hearScreen application. This technology has
been developed for use by minimally trained persons, and
therefore utilises automated test sequences and interpretation
of screening results. (5) Practice screening sessions, performed
under the supervision of the trainer, were conducted at a local
early childhood development facility.
Once the groundwork was completed, the service delivery
process included the following. (1) Screening was conducted
by screeners, using smartphones, the hearScreen application
and calibrated headphones, within early childhood develop-
ment facilities. (2) Test quality was monitored by tracking
uploaded data on the cloud-based data management portal.
The quality control indices include noise levels recorded by
the smartphone, and a test operator quality index based on a
random non-presentation of a stimulus which is flagged if
an operator indicates a response was present. (3) Based on
an initial low-quality index, retraining was initiated, after
which the quality index improved significantly. (4) If a child
failed the screening test, an automated text message was gen-
erated from the cloud-based data management portal and sent
to caregivers. Based on the geolocation, referral was made to
the closest primary healthcare facility for follow-up services.
(5) When children arrived at the clinic for a follow-up assess-
ment, the same hearScreen application was used to search for
the childs details, review the previous outcome and conduct a
rescreen (Figure 2). Hence, children returning for follow up
were identified on the cloud-based data management system.
(6) If the child failed the screening a second time, threshold
pure tone audiometry was conducted using the hearTest appli-
cation.
31
If there was a hearing loss and it was not due to med-
ically treatable conditions (conductive), an appointment with a
hearing care provider (servicing the primary healthcare clinics
on a rotation basis) was made.
Conclusion
Access to hearing health services in remote or resource-limited
settings is a pervasive global challenge. Innovative service
delivery models are required to develop sustainable services
in these settings. An emphasis on decentralised community-
based approaches that strengthen hearing care, especially at
the primary level, is necessary for sustainability and wide-
spread access to services. New affordable technologies that
leverage mobile phone technology and connectivity, and
which allow minimally trained persons to facilitate services,
are enabling community-based access and monitoring. As
awareness of hearing loss as a global health concern increases,
the development, implementation and sustainability of ser-
vices in low- and middle-income countries must drive research
and resources.
Competing interests. The first author has a relationship with the hearX
Group that includes equity, consulting and potential royalties.
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... Existing audiological services cannot address the global burden of hearing loss due to inherent barriers, including a dearth of trained professionals, equipment costs, and required expertise (Swanepoel & Clark 2019). New approaches that transcend current models of practice are essential to overcome global access challenges. ...
... Hearing health care is challenging to deliver in low-and middle-income countries (LMICs) because it currently requires specialized equipment and trained professionals. Smartphonemediated telehealth holds great promise to lower many of these barriers (Swanepoel & Clark 2019). Smartphone penetration now exceeds 80% in LMICs (Jonsson et al. 2019), and low-cost equipment and robust test procedures are becoming available to perform audiometric (Potgieter et al. 2018;Swanepoel & Clark 2019) and otologic (Chan et al. 2019) diagnostic measures with acceptable levels of quality and reproducibility. ...
... Smartphonemediated telehealth holds great promise to lower many of these barriers (Swanepoel & Clark 2019). Smartphone penetration now exceeds 80% in LMICs (Jonsson et al. 2019), and low-cost equipment and robust test procedures are becoming available to perform audiometric (Potgieter et al. 2018;Swanepoel & Clark 2019) and otologic (Chan et al. 2019) diagnostic measures with acceptable levels of quality and reproducibility. We foresee a *Based on Crum (2019). ...
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The global digital transformation enables computational audiology for advanced clinical applications that can reduce the global burden of hearing loss. In this article, we describe emerging hearing-related artificial intelligence applications and argue for their potential to improve access, precision, and efficiency of hearing health care services. Also, we raise awareness of risks that must be addressed to enable a safe digital transformation in audiology. We envision a future where computational audiology is implemented via interoperable systems using shared data and where health care providers adopt expanded roles within a network of distributed expertise. This effort should take place in a health care system where privacy, responsibility of each stakeholder, and patients' safety and autonomy are all guarded by design.
... These include variable protocols for testing and referral criteria, less than ideal test conditions, limited human and technology resources, competing national health priorities, and poorly integrated electronic data management systems (Bamford et al., 2007;Prieve et al., 2015;Stenfeldt, 2018). As a consequence, children in resource-constrained settings are rarely screened for hearing loss (Harris & Dodson, 2017;Levy et al., 2018;Mulwafu et al., 2016;Swanepoel & Clark, 2019;Wilson et al., 2017). Some of these challenges may be overcome by incorporating mobile health (mHealth) technologies and community-delivered hearing health care as these have the potential to decentralize and increase access to services in resource-constrained settings Jayawardena et al., 2020;Manus et al., 2021;Suen et al., 2019;Swanepoel, 2020;van Wyk et al., 2019;World Health Organization [WHO], 2021;Yancey et al., 2019). ...
... Some of these challenges may be overcome by incorporating mobile health (mHealth) technologies and community-delivered hearing health care as these have the potential to decentralize and increase access to services in resource-constrained settings Jayawardena et al., 2020;Manus et al., 2021;Suen et al., 2019;Swanepoel, 2020;van Wyk et al., 2019;World Health Organization [WHO], 2021;Yancey et al., 2019). mHealth technology, such as the validated hearScreen application (hearX Group), offers an inexpensive and mobile alternative to conventional evaluations by utilizing calibrated headphones on low-cost smartphones, employing a simple user interface (Mahomed-Asmail et al., 2016;Sandström et al., 2016;Swanepoel, 2020;Swanepoel & Clark, 2019;van Tonder et al., 2017;Yousuf Hussein et al., 2016. Key enabling factors in these mHealth supported screening models are the utilization of community health workers (CHWs) and automated screening applications with preset protocols and advanced quality control measures that enable CHWs with minimal training to undertake screening (Dawood et al., 2020;Eksteen et al., 2019;Manus et al., 2021;O'Donovan et al., 2019;Swanepoel, 2020;van Wyk et al., 2019;WHO, 2021). ...
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Purpose This study aimed to describe and compare the performance of two screening protocols used for preschool hearing screening in resource-constrained settings. Method Secondary data analysis was done to determine the performance of two protocols implemented during a preschool hearing screening program using mobile health technology in South Africa. Pure-tone audiometry screening at 25 dB HL for 1000, 2000, and 4000 Hz in each ear was used by both protocols. The fail criterion for the first protocol (2,147 children screened) constituted a no-response on one or more frequencies in either ear. The second protocol required two or more no-responses (5,782 children). Multivariate logistic regression models were used to investigate associations between outcomes and protocol, age, gender, and duration. Results Fail rates for the one-frequency fail protocol was 8.7% ( n = 186) and 4.3% ( n = 250) for the two-frequency fail protocol. Children screened with the two-frequency fail protocol were 52.9% less likely to fail ( p < .001; OR = 0.471; 95% confidence interval [0.385, 0.575]). Gender ( p = .251) and age ( p = .570) had no significant effect on screening outcome. A percentage of cases screened (44.7%) exceeded permissible noise levels in at least one ear at 1000 Hz across both protocols. True- and false-positive cases did not differ significantly between protocols. Protocol type ( p = .204), gender ( p = .314), and age ( p = .982) did not affect the odds of being a true-positive result. Average screening time was 72.8 s (78.66 SD ) and 64.9 s (55.78 SD ) for the one-frequency and two-frequency fail protocols, respectively. Conclusions A two-frequency fail criterion and immediate rescreen of failed frequencies significantly reduced referral rate for follow-up services that are often overburdened in resourced-constrained settings. Future protocol adaptations can also consider increasing the screening levels at 1000 Hz to minimize the influence of environmental noise.
... The utility of WAI in clinical practice may potentially improve early identification and reduce these challenges. With the current proposed model of service delivery in resourceconstrained environments, which involves the use of specialised technology (Swanepoel & Clark, 2018), wideband absorbance measure can be embedded in these programmes, increase access to hearing healthcare and thereby reduce costs associated with traveling long distances for treatment. Although there is a promising prospect of using WAI, especially for the identification of middle ear pathology in developing countries and can be carried out without otorhinolaryngologists and audiologists, it may not be considered because of its expense. ...
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... The size of this global health burden and the lack of access to hearing health care require radical health care delivery changes, as highlighted in the recent World Report on Hearing [1]. The emergence of digital health technologies has been identified as an important trend to support scalable hearing health delivery models that are sustainable [2,3]. Digital health technologies have already demonstrated use as powerful enablers of hearing healthcare [4,5]. ...
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... 17 Innovative service delivery models, with an emphasis on decentralisation, are required to develop sustainable services in these settings. 18 Decentralisation is the transfer of responsibility for planning, management and financing from central to peripheral levels of government and has been a key health sector reform in a wide range of LMICs over the past decade. 19 Despite being implemented as a strategy across many health systems, the impact of decentralisation on health equity is still unclear. ...
... 17 Innovative service delivery models, with an emphasis on decentralisation, are required to develop sustainable services in these settings. 18 Decentralisation is the transfer of responsibility for planning, management and financing from central to peripheral levels of government and has been a key health sector reform in a wide range of LMICs over the past decade. 19 Despite being implemented as a strategy across many health systems, the impact of decentralisation on health equity is still unclear. ...
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... There is a growing interest in remote testing, both in the context of basic research (Anwyl-Irvine et al., 2020;Backx et al., 2020;Hartshorne et al., 2019;Shapiro et al., 2020) and clinical screening (Paglialonga et al., 2020;Sevier et al., 2019;Shafiro et al., 2020;Sheikh Rashid et al., 2017;Swanepoel & Clark, 2019;Watson et al., 2012). The ability to conduct experiments online facilitates rapid data acquisition and provides access to a larger and more diverse subject pool than that available for lab-based investigations (Casey et al., 2017). ...
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Importance: There is a critical disparity in knowledge regarding the rate and nature of hearing loss in the older old (80 years and older). Objective: To determine if the rate of age-related hearing loss is constant in the older old. Design, setting, and participants: We performed a retrospective review that began on August 1, 2014, with audiometric evaluations at an academic medical center of 647 patients aged between 80 and 106 years, of whom 141 had multiple audiograms. Main outcomes and measures: From a population perspective, the degree of hearing loss was compared across the following age brackets: 80 to 84 years, 85 to 89 years, 90 to 94 years, and 95 years and older. From an individual perspective, the rate of hearing decrease between 2 audiograms was compared with age. Results: Changes in hearing among age brackets were higher during the 10th decade of life than the 9th decade at all frequencies (5.4-11.9 dB hearing level [dB HL]) for the 647 patients (mean [SD] age, 90 [5.5] years). Correspondingly, the annual rate of low-frequency hearing loss was faster during the 10th decade by the 3.8 dB HL per year at 0.25 kHz, 3.8 dB HL per year at 0.5 kHz, and 3.2 dB HL per year at 1 kHz. Despite the universal presence of hearing loss in our sample, 382 patients (59%) used hearing aids. Conclusions and relevance: There is a significant increase in the rate of hearing loss in patients during the 10th decade of life compared with the 9th decade that represents a fundamental change in the mechanistic process of presbycusis. Despite the potential benefit of hearing aids, they remain underused in the older old. Use may be improved by changing the method of hearing rehabilitation counseling from a patient-initiated model to a chronic disease example.
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Background: Otitis media is one of the most common childhood diseases worldwide, but because of lack of doctors and health personnel in developing countries it is often misdiagnosed or not diagnosed at all. This may lead to serious, and life-threatening complications. There is, thus a need for an automated computer based image-analyzing system that could assist in making accurate otitis media diagnoses anywhere. Methods: A method for automated diagnosis of otitis media is proposed. The method uses image-processing techniques to classify otitis media. The system is trained using high quality pre-assessed images of tympanic membranes, captured by digital video-otoscopes, and classifies undiagnosed images into five otitis media categories based on predefined signs. Several verification tests analyzed the classification capability of the method. Findings: An accuracy of 80.6% was achieved for images taken with commercial video-otoscopes, while an accuracy of 78.7% was achieved for images captured on-site with a low cost custom-made video-otoscope. Interpretation: The high accuracy of the proposed otitis media classification system compares well with the classification accuracy of general practitioners and pediatricians (~64% to 80%) using traditional otoscopes, and therefore holds promise for the future in making automated diagnosis of otitis media in medically underserved populations.
Article
Otitis media is one of the most common childhood illnesses. Access to ear specialists and specialist equipment is rudimentary in many third world countries, and general practitioners do not always have enough experience in diagnosing the different otitis medias. In this paper a system recently proposed by three of the authors for automated diagnosis of middle ear pathology, or otitis media, is extended to enable the use of the system on a smartphone with an Internet connection. In addition, a neural network is also proposed in the current system as a classifier, and compared to a decision tree similar to what was proposed before. The system is able to diagnose with high accuracy (1) a normal tympanic membrane, (2) obstructing wax or foreign bodies in the external ear canal (W/O), (3) acute otitis media (AOM), (4) otitis media with effusion (OME) and (5) chronic suppurative otitis media (CSOM). The average classification accuracy of the proposed system is 81.58% (decision tree) and 86.84% (neural network) for images captured with commercial video-otoscopes, using 80% of the 389 images for training, and 20% for testing and validation.
Article
In 2015, approximately half a billion people had disabling hearing loss, about 6·8% of the world's population. These numbers are substantially higher than estimates published before 2013, and point to the growing importance of hearing loss and global hearing health care. In this Review, we describe the burden of hearing loss and offer our and others' recommendations for halting and then reversing the continuing increases in this burden. Low-cost possibilities exist for prevention of hearing loss, as do unprecedented opportunities to reduce the generally high treatment costs. These possibilities and opportunities could and should be exploited. Additionally, a comprehensive worldwide initiative like VISION 2020 but for hearing could provide a focus for support and also enable and facilitate the increased efforts that are needed to reduce the burden. Success would produce major personal and societal gains, including gains that would help to fulfil the “healthy lives” and “disability inclusive” goals in the UN's new 2030 Agenda for Sustainable Development.
Article
Background: A 2009 survey of ENT, audiology, and speech therapy services and training opportunities in 18 Sub-Saharan African countries reported that the availability of services was extremely poor, the distribution of services was very inequitable, and training opportunities were limited. Objective: We conducted a new survey to determine the current status of ear, nose, and throat (ENT), audiology, and speech therapy services in sub-Saharan Africa. Method: This study is a cross-sectional study. A questionnaire was distributed by email to an ad hoc group of ENT surgeons and audiologists in 30 sub-Saharan African countries. Data from the current survey were compared to those of a 2009 survey. The numbers of ENT surgeons, audiologists, and speech therapists/100,000 people were compared to the ratios in the United Kingdom. Results: A total of 22 countries responded to the questionnaire. When data of the 15 countries that responded in both 2009 and 2015 are compared, the number of ENT surgeons had increased by 43%, audiologists had increased by 2.5%, and speech therapists by 30%. When the 23% population growth is taken into account, the numbers of ENT surgeons, audiologists, and speech therapists per 100,000 people had declined in four countries, and there remains a severe shortfall of ENT surgeons, audiologists, and speech therapists when compared to the UK Respondents cited lack of availability of basic equipment as the most frequent limitation in providing ENT services. Other important factors causing limitations in daily practice were: lack of ENT training facilities and audiological rehabilitation, low awareness of the burden of ENT pathology, as well as poor human resources management. Conclusions: There has been a lack of progress in ENT, audiology, and speech therapy services and training opportunities in sub-Saharan Africa between 2009 and 2015. There is a need to look at increased collaboration with developed countries and non-governmental organisations, establishing new and improving existing training centres in Africa, and task-shifting of some ENT services to primary health workers.
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At least 5.6 million to 8 million--nearly one in five--older adults in America have one or more mental health and substance use conditions, which present unique challenges for their care. With the number of adults age 65 and older projected to soar from 40.3 million in 2010 to 72.1 million by 2030, the aging of America holds profound consequences for the nation. For decades, policymakers have been warned that the nation's health care workforce is ill-equipped to care for a rapidly growing and increasingly diverse population. In the specific disciplines of mental health and substance use, there have been similar warnings about serious workforce shortages, insufficient workforce diversity, and lack of basic competence and core knowledge in key areas. Following its 2008 report highlighting the urgency of expanding and strengthening the geriatric health care workforce, the IOM was asked by the Department of Health and Human Services to undertake a complementary study on the geriatric mental health and substance use workforce. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? assesses the needs of this population and the workforce that serves it. The breadth and magnitude of inadequate workforce training and personnel shortages have grown to such proportions, says the committee, that no single approach, nor a few isolated changes in disparate federal agencies or programs, can adequately address the issue. Overcoming these challenges will require focused and coordinated action by all. © 2012 by the National Academy of Sciences. All rights reserved.
Article
Smartphone-based threshold audiometry with automated testing has the potential to provide affordable access to audiometry in underserved contexts. To validate the threshold version (hearTest) of the validated hearScreen™ smartphone-based application using inexpensive smartphones (Android operating system) and calibrated supra-aural headphones. A repeated measures within-participant study design was employed to compare air-conduction thresholds (0.5–8 kHz) obtained through automated smartphone audiometry to thresholds obtained through conventional audiometry. A total of 95 participants were included in the study. Of these, 30 were adults, who had known bilateral hearing losses of varying degrees (mean age = 59 yr, standard deviation [SD] = 21.8; 56.7% female), and 65 were adolescents (mean age = 16.5 yr, SD = 1.2; 70.8% female), of which 61 had normal hearing and the remaining 4 had mild hearing losses. Threshold comparisons were made between the two test procedures. The Wilcoxon signed-ranked test was used for comparison of threshold correspondence between manual and smartphone thresholds and the paired samples t test was used to compare test time. Within the adult sample, 94.4% of thresholds obtained through smartphone and conventional audiometry corresponded within 10 dB or less. There was no significant difference between smartphone (6.75-min average, SD = 1.5) and conventional audiometry test duration (6.65-min average, SD = 2.5). Within the adolescent sample, 84.7% of thresholds obtained at 0.5, 2, and 4 kHz with hearTest and conventional audiometry corresponded within ≤5 dB. At 1 kHz, 79.3% of the thresholds differed by ≤10 dB. There was a significant difference (p < 0.01) between smartphone (7.09 min, SD = 1.2) and conventional audiometry test duration (3.23 min, SD = 0.6). The hearTest application with calibrated supra-aural headphones provides a cost-effective option to determine valid air-conduction hearing thresholds.
Article
Objective: Postnatal visits at community-based midwife obstetric units (MOUs) have been proposed as an alternative primary healthcare screening platform in South Africa. This study evaluated the outcomes of distortion product otoacoustic emissions (DPOAEs) and automated auditory brainstem response (AABR) screening conducted by a dedicated non-professional screener at a community-based MOU in the Western Cape, South Africa. Methods: Universal newborn hearing screening (UNHS) at a community-based MOU was evaluated over a 16-month period. A dedicated non-professional screener was trained to follow a two-stage screening protocol targeting bilateral hearing loss. A two group comparative design was used alternating AABR (Maico MB11 BERAphone™()) and DPOAE (Bio-logic AuDX I) technology on a daily basis. Infants referring the initial screen received a follow-up appointment in two days' time and were rescreened with the same technology used at their first screen. Those referring the second stage were booked for diagnostic assessments. Results: 7452 infants were screened including 47.9% (n=3573) with DPOAE and 52.1% (n=3879) with AABR technology. Mean age at first stage screen was 6.1 days. The initial bilateral referral rate was significantly lower for AABR (4.6%) compared to DPOAE (7.0%) and dropped to 0.3% and 0.7% respectively following the second stage screenings. First rescreen and initial diagnostic follow-up rates of 90% and 92.3% were obtained for the DPOAE group and 86.6% and 90% for the AABR group. Follow-up rates showed no significant difference between technology groups. Diagnostic assessment revealed a higher prevalence rate for bilateral SNHL among the AABR group (1/1000) compared to the DPOAE group (0.3/1000). Screening technology had no significant influence on daily screening capacity (23 AABR/day; 24 DPOAE/day). Conclusions: Postnatal visits at community-based MOUs create a useful platform for hearing screening and follow-up. AABR technology with negligible disposable costs provides opportunity for AABR screening to be utilised in community-based programmes. AABR screening offers lower initial referral rates and a higher true positive rate compared to DPOAE.