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Abstract

Hearing loss is the most prevalent chronic disability and a major contributor to the global burden of disease. Its effects are far-reaching and can lead to severely restricted developmental outcomes for children and limited vocational prospects for adults. The benefits of intervention are dramatic and can significantly improve developmental outcomes, especially in infants identified early. Hearing health-care services in developing regions such as sub-Saharan Africa are however severely limited, leaving affected individuals without access to secondary and tertiary intervention. Tele-audiology has potential for improved access to specialist hearing health services including identification, diagnosis and intervention. There has been limited experience so far with tele-audiology in industrialized countries. In the sub-Saharan region, the continued growth in Internet connectivity and general technological advances make tele-audiology an important approach to consider in the management of hearing loss. Pilot studies are warranted to investigate the potential obstacles to the widespread implementation of telehealth in the delivery of hearing health care in poorly-resourced communities, in line with World Health Organization initiatives.
1
LEADER/Focus
Hearing healthcare delivery in sub-Saharan Africa a role for
tele-audiology
De Wet Swanepoel1,2, Bolajoko O Olusanya3,4 and Maurice Mars5
1. Department of Communication Pathology, University of Pretoria, Pretoria, South Africa
2. Callier Center for Communication Disorders, School of Behavioral & Brain Sciences,
University of Texas at Dallas, USA
3. Maternal and Child Health Unit, Institute of Child Health and Primary Care, College of
Medicine, University of Lagos, Lagos, Nigeria
4. Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust,
University College London, UK
5. Department of Telehealth, Nelson Mandela School of Medicine, University of KwaZulu-
Natal, South Africa
Correspondence:
De Wet Swanepoel,
Department of Communication Pathology,
University of Pretoria,
Pretoria 0002,
South Africa
(Fax +27 12 4203517; Email: dewet.swanepoel@up.ac.za)
Summary
Hearing loss is the most prevalent chronic disability and a major contributor to the global
burden of disease. Its effects are far-reaching and can lead to severely restricted
developmental outcomes for children and limited vocational prospects for adults. The
benefits of intervention are dramatic and can significantly improve developmental outcomes,
especially in infants identified early. Hearing health care services in developing regions such
as sub-Saharan Africa are however severely limited, leaving affected individuals without
access to secondary and tertiary intervention. Tele-audiology has potential for improved
access to specialist hearing health services including identification, diagnosis and
intervention. There has been limited experience so far with tele-audiology in industrialized
countries. In the sub-Saharan region, the continued growth in Internet connectivity and
general technological advances make tele-audiology an important approach to consider in the
management of hearing loss. Pilot studies are warranted to investigate the potential obstacles
to the widespread implementation of telehealth in the delivery of hearing health care in
poorly-resourced communities, in line with World Health Organization initiatives.
2
Introduction
Hearing loss is the most prevalent chronic disability, and is present in almost 10% of the
global population to a mild or greater degree.[1,2] More severe hearing loss (moderate to
profound) affects 4.3% of the world's population.[2] The effects of hearing loss are far-
reaching and apart from the negative consequences for socio-emotional well-being and
participation, also result in severely restricted developmental outcomes for children and
limited educational and vocational prospects for adults.[3] In developing regions such as
sub-Saharan Africa (SSA) these consequences may be even more serious due to a vicious
cycle where poverty predisposes to hearing loss and hearing loss predisposes to poverty.[4]
Not only are the consequences serious, but the prevalence of hearing loss is greater due to
increased environmental risk factors and poorer maternal health care. For example,
congenital or early-onset infant hearing loss in developing countries is estimated to be twice
as high at 6 per 1000 live births compared to 2-4 per 1000 for industrialised countries.[1,4,5]
Hearing loss ranks as the third largest global contributor to the loss of healthy life due to
disability and is one of only four non-fatal conditions among the leading 20 causes of the
global burden of disease on the Disability Adjusted Life-Years (DALY) index.[1] These
estimates only include adult-onset hearing loss, and the inclusion of childhood hearing loss
will significantly increase the global burden.[5]
Current approaches to hearing loss management
Interventions for hearing loss, such as the early detection of infants with hearing loss and the
provision of hearing devices, offer developmental outcomes that are similar to those in people
with normal hearing and integrated societal participation.[3] Unfortunately globally
coordinated initiatives are still quite limited, particularly in developing regions such as SSA,
which account for more than 80% of the hearing loss disease burden.[2] Global efforts to
address hearing loss in this region have mainly focused on primary prevention to reduce
preventable causes of hearing loss. As a result, most individuals with hearing loss remain
without secondary and tertiary intervention services.
A major hurdle to the development of the necessary intervention services is the limited access
to hearing health care professionals and associated support. In most of SSA, services are
either totally absent or extremely limited and constrained to specific areas. Hearing health
care professionals such as otolaryngologists and audiologists are in very short supply in SSA.
In contrast to Europe, where there is typically one otolaryngologist for every 10-30,000
people, in SSA there may be 250,000 to 7.1 million people per otolaryngologist.[6] The
number of audiologists may be even smaller: many countries in SSA have no audiologists
and only one of the 46 countries offers tertiary training for a professional audiology
qualification. Access to hearing health care, which is inextricably linked to the number of
professionals providing the services, is wholly inadequate. This has prompted a reappraisal
of the current approaches to the delivery of hearing health care services.
Potential role of tele-audiology
Tele-audiology has a potential role in improving access to services. Currently its use is
limited, despite initial reports of tele-audiology applications with test validity and accuracy
equivalent to face to face services, e.g. video-otoscopy; pure tone audiometry; tympanometry;
otoacoustic emissions; auditory brainstem responses; hearing aid verification and cochlear
implant mappings.[7,8,9,10,11] Hearing can be assessed at a distance with portable tele-
3
audiology devices and appropriate software, using low bandwidth telecommunication and
without the need for sound booths which are not commonly available in SSA. Test
compliance, during device set up and calibration and testing can be monitored remotely
through audio and/or video feedback and appropriate hardware and software. The need for
expensive sound booths, can be largely overcome by using tele-audiology devices that
integrate live monitoring of environmental noise, sound attenuation using insert and
circumaural earphones, and active noise cancellation.[11] Available intervention options such
as hearing aid fitting and verification can be performed remotely using appropriate software
and application sharing.[10] Counselling, follow-up and rehabilitation services can be
facilitated through videoconferencing facilities or interactive Internet-based programs.
With improving connectivity in developing countries, where service providers are rare and
hearing evaluations are primarily equipment based, the prospect of tele-audiology to provide
remote services for screening, early detection and intervention of hearing loss and education
is particularly appealing. Educational applications may include interactive online modules to
facilitate continued professional development and training of paraprofessionals, parents or
patients themselves. Support may also be provided remotely via online interactive or on-
demand training and second-opinion services. Tele-mentoring of local professionals or para-
professionals is another valuable application which may serve to develop local skills and
expertise.
System architecture for tele-audiology
The basic infrastructure for tele-audiology comprises both hardware and software with
Internet connectivity. A typical system architecture is illustrated in Figure 1. Clinical hearing
evaluation and intervention can be performed in real-time (i.e. synchronously) through
devices operated remotely, using computer application sharing combined with
videoconferencing. The software can be desktop- or laptop-based, utilizing voice-over-
Internet and webcam applications that are inexpensive and easily accessible.
In SSA, the use of store and forward applications with automated testing and calibration
procedures may be the most appropriate model for providing tele-audiology services. This
approach can enhance time- and cost-efficiency by reducing the requirement for face-to-face
health care service by a specialist and by reducing the requirement for costly Internet
bandwidth. For example, automated computer-based hearing screening and threshold tests,
facilitated by a paraprofessional, can be conducted at remote locations. This reserves the
need for real-time tests by a specialist, for difficult cases. Other clinical procedures, like an
otoscopic examination, can be performed by a trained paraprofessional using a video-
otoscope, with digital images referred to a specialist by email, for diagnosis. A combination
of both synchronous and asynchronous approaches may also be useful in some settings.
Potential drawbacks and challenges
Tele-audiology in SSA offers patients improved access to specialist hearing health services,
the general population and in particular children. It is likely to facilitate a greater awareness
and knowledge of hearing health care among primary care providers, most of whom will
never have a chance for formal training. However, tele-audiology is not a panacea, especially
in low income countries. For example, it may distract from the pursuit of expertise in
audiology through formal training, ultimately producing a group of uncertified audiologists or
ear care specialists who are only proficient in the use of the supporting technology.
4
Challenges for the widespread implementation of tele-audiology will be technical,
organizational/infrastructural and socio-cultural in nature. For example, connectivity may be
hampered by the lack of a reliable electricity supply, even in urban areas in some developing
countries. The economic implications and the cost-effectiveness of tele-audiology in
different settings are not yet known. Concerns about data security, patient privacy and
cultural inertia to modern gadgets or technology-driven care, even among health workers,
also need to be addressed. Internet penetration in SSA, although growing rapidly, remains
low, with only 3.5% of the population having access to the Internet.[12] Furthermore, very
few countries have any e-health policy, strategy or legislation. These challenges are not
limited to tele-audiology, of course. For example, one report on the World Health
Oorganization (WHO) African Region cited low school enrolment, high illiteracy rates, low
per capita incomes, widespread poverty and weak ICT connectivity as posing major
challenges to the effective utilization of e-health services.[13] The current efforts led by the
WHO to promote e-health globally, in collaboration with national governments, are likely to
benefit hearing health care delivery as well.
Conclusion
The increasing global burden of hearing loss, largely unaddressed by present global health
funders, NGOs and governments, demands a critical reappraisal of traditional approaches to
hearing health care delivery in developing countries. The global revolution in connectivity
and the continuing advances in technology mean that tele-audiology is becoming an
important approach to bring hearing health care to the underserved in SSA. Pilot studies are
warranted to investigate the potential obstacles to the widespread implementation of
telehealth in the delivery of hearing health care in poorly-resourced communities, in line with
WHO initiatives.
References
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... 12,13 The cost associated with conventional audiological equipment for screening, diagnosis, intervention, and amplification is a major prohibitive factor. 8,14 Typical audiological clinics employ expensive, stationary audiometric equipment with a sound booth or sound-treated environment that is often more expensive than the audiometer. In low-resource settings, the cost barrier is exacerbated by competing against infrastructure and operational budgets for acute and life-threatening conditions. ...
... Even with the goal to build human resource capacity, 8 the disparity is so overwhelming that it becomes clear that radical rethinking of existing service-delivery models is necessary for any real impact to be realized in the near future. 14 ...
... Convergence of the digital and connectivity revolutions is combining to enable new ways of delivering decentralized audiological services along the entire patient journey through integrated eHealth solutions. [14][15][16] Personal digital technologies, smartphones, in particular, have seen an exponential growth in terms of processing power and capabilities alongside penetration rates that are reaching above 80% for adults in developed and developing countries. 17 At the same time, with mobile networks now covering 99% of the global population, 18 these technologies provide a powerful and ubiquitous tool for point-of-care health services, surveillance, and remote synchronous and asynchronous telehealth support. ...
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Hearing loss is a pervasive global health care burden affecting up to one in every seven persons of whom 90% reside in low- and middle-income countries. Traditional service-delivery models are unable to support and promote accessible and affordable hearing care in these setting. Major barriers include a severe shortage of hearing health care professionals, costs associated with equipment, facilities and treatments, and centralized service-delivery models. Convergence of digital and connectivity revolutions are combining to enable new ways of delivering decentralized audiological services along the entire patient journey using integrated eHealth solutions. eHealth technologies are allowing nonprofessionals in communities (e.g., community health workers) to provide hearing services with point-of-care devices at reduced cost with remote surveillance and support by professionals. A growing body of recent evidence showcases community-based hearing care within an integrated eHealth framework that addresses some of the barriers of traditional service-delivery models at reduced cost. Future research, especially in low- and middle-income countries, must explore eHealth-supported hearing care services from detection through to treatment.
... Потребность в таких технологиях в аудиологии определяется тем, что 90% лиц с нарушениями слуха проживают в странах с низким уровнем дохода и/или не имеют доступа к качественному медицинскому обслуживанию [1,2]. Глобальному развитию телеаудиологии способствуют также дефицит квалифицированных аудиологических кадров и их географическая удаленность от пациентов [3][4][5]. ...
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... However, we found that baseline audiological evaluation was inconsistently performed, and only 52% of participants in this sample were screened for their baseline hearing capacity through audiometry. There has been a lack of progress in availability of audiological services in sub-Saharan Africa, as well as need for technological solutions that address low resources and lack of trained personnel, such as tele-audiology (Mulwafu et al., 2017;Swanepoel et al., 2010). Moreover, the availability of trained audiologists and well-functioning audiometers at TB hospitals should be audited on a regular basis to make early detection of AG-induced hearing loss possible in practical settings. ...
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... Tele-audiology and mobile technologies have been proposed as important strategies to reduce the shortfall of hearing health care. 7,21 The smartphone self-test audiometry in this study demonstrates potential to provide reliable air conduction audiometry in low-income settings. It is the first study evaluating the self-test outside a soundproof booth in community clinics in low-income settings with substantial ambient noise and surrounding disturbances. ...
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... Hearing Loss (HL) is a leading cause of disability worldwide and it is a significant public health problem in Sub-Saharan Africa and other developing countries. From 278 million people with HL worldwide, more than two thirds of them live in developing countries in whom, over 180,000 babies have a significant hearing loss are born annually [1,2]. Unilateral sensorineural hearing loss is defined as average pure-tone air conduction thresholds (0.5, 1, 2, 4 kHz) ≥30 dB in the impaired ear with an average air-bone gap no greater than 10 dB at the same frequencies and normal hearing (≤15 dB from 0.5 to 4 kHz) in the good ear [3]. ...
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Background Hearing loss is one of the most common disabilities worldwide and affects both individual and public health. Pure tone audiometry (PTA) is the gold standard for hearing assessment, but it is often not available in many settings, given its high cost and demand for human resources. Smartphone-based audiometry may be equally effective and can improve access to adequate hearing evaluations. Objective The aim of this systematic review is to synthesize the current evidence of the role of smartphone-based audiometry in hearing assessments and further explore the factors that influence its diagnostic accuracy. Methods Five databases—PubMed, Embase, Cochrane Library, Web of Science, and Scopus—were queried to identify original studies that examined the diagnostic accuracy of hearing loss measurement using smartphone-based devices with conventional PTA as a reference test. A bivariate random-effects meta-analysis was performed to estimate the pooled sensitivity and specificity. The factors associated with diagnostic accuracy were identified using a bivariate meta-regression model. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Results In all, 25 studies with a total of 4470 patients were included in the meta-analysis. The overall sensitivity, specificity, and area under the receiver operating characteristic curve for smartphone-based audiometry were 89% (95% CI 83%-93%), 93% (95% CI 87%-97%), and 0.96 (95% CI 0.93-0.97), respectively; the corresponding values for the smartphone-based speech recognition test were 91% (95% CI 86%-94%), 88% (95% CI 75%-94%), and 0.93 (95% CI 0.90-0.95), respectively. Meta-regression analysis revealed that patient age, equipment used, and the presence of soundproof booths were significantly related to diagnostic accuracy. Conclusions We have presented comprehensive evidence regarding the effectiveness of smartphone-based tests in diagnosing hearing loss. Smartphone-based audiometry may serve as an accurate and accessible approach to hearing evaluations, especially in settings where conventional PTA is unavailable.
Thesis
Health is a fundamental human right although more than one billion people are unreached in terms of quality healthcare services. Insufficient healthcare facilities and unavailability of medical experts in rural areas are the two major reasons that kept the rural people unreached to healthcare services in developing countries, like Bangladesh. According to the World Health Organization (WHO) statistics, the doctor to population ratio is 1: 1500 in urban areas and 1:15000 in rural areas of Bangladesh. This scenario can be dramatically changed if we can simply convey medical tips using ICT infrastructure to the targeted unreached community. Recent development of Information and Communication Technologies (ICT) of the digital divide has been reduced and these technologies have the great potential to address contemporary global health problems. Telemedicine refers to the use of information and communication technologies to distribute information and or expertise necessary for healthcare services provision, collaboration and or delivery among geographically separated participants including physicians and patients. Telemedicine can be the key for providing good health care facilities to the target unreached community especially low resource countries, like ours (Bangladesh). In this research work, we have developed an intelligent telemedicine system based on Smart phone. The price of smart phone has reduced drastically in recent time and the number of users is increasing in a rapid rate. Recent study shows that even the relatively poor populations at rural areas are using smart phones. Our Smartphone based telemedicine system, therefore has a great potential to deliver the health care services for rural population of Bangladesh at very reduced cost and less hassle, as it requires a very little movement or out of home town. DICOT (Digital Imaging and Communication for Telemedicine) is the name of the machine which has been built by telemedicine working group of Bangladesh, and in use at some telemedicine centers. One of the major problems of the DICOT users is long cumbersome registration process. In this thesis work we have developed android apps which will provide opportunity of health care at home. After logging in apps, user can update their basic medical records and can choose and get a confirmation of appointment of specialist doctors. 6 Different medical records can be updated like body temperature, glucometer, ECG, personal information and others. After updating with database then a confirmation message of assigned appointed day and time will be sent to the patient through android app. So, patients need not experience a long cumbersome process of registration. A website of database has been developed using HTML, CSS and PHP. We have also developed a Telecardiology system which has been designed and implemented in this work. The Raw analog type ECG signal is amplified and filtered by band pass filter. Analog signal is digitized using Arduino board and then, interface between Arduino and smart phone sends this signal to Smartphone. Digitized value of the filtered ECG signal is stored in SD storage card of Smart phone. Using Bluetooth or existing telecommunication network digitized ECG signal can be sent to other Smart phone or to Server. During transmission of signal it generally gets corrupted by random noise or white Gaussian noise of the existing telecommunication network(s) and even some data points may be lost. Adaptive filter with three different algorithms have been used in MATLAB platform for denosing i.e. removing noise from the ECG signal. In this research work we have used three algorithms named as LMS (Least Mean Square), NLMS (Normalized Mean Square), and RLS (Recursive Least Square) and tested their performances to reduce the noise from ECG signal. We have taken 250 mV amplitude ECG signal from MIT-BIH database and 5mV (2 % of original ECG signal), 10 mV (4% of original ECG) 15mV (6% of original ECG), 20 mV (8% of original ECG signal) and 25mV (10% of original ECG signal) of random noise and white Gaussian noise is added with ECG signal and Adaptive filter with three different algorithms have been tested to reduce the noise that is added during transmission through the telemedicine system. Normalized mean square error was calculated. For highest amplitude random noise, 25 mV (10% of original ECG signal) added ECG signal, we have got normalized mean square error for LMS, NLMS and RLS adaptive filters are respectively 3.5566×10-4, 2.8322×10-4, 1.5938×10-5.For the case of 25 mV amplitude Gaussian Noise we have found simulation result of normalized mean square error for LMS, NLMS and RLS adaptive filters respectively 4.2407×10-4, 2.459×10-4 and 7.0148×10-5. The errors are very less in all of the cases and we found RLS Filter performed 7 the best amongst the three FILTERS mentioned above in our MATLAB simulation for denosing the ECG signal. We have used Cubic Spline Interpolation for regaining missing data point of ECG signal. We have taken 5000 data points of ECG signal from MIT-BIH database. In our simulation 11 data points (From 689 to 699 of original data points of ECG), 201 data points (from 800 to 1000 of original data points of ECG), 300 data points (From 1600 to 1900 of original data points of ECG), 500 data points (From 2000 to 5000) and 6 data points (From 4095 to 5000) are made zero and cubic spline interpolation function was called and it could regain the original data points of ECG signal. The Normalized Mean Square Error was calculated and it was found respectively .0909, .0050, .0033, .0020 and .1667. In all of the cases normalized mean square error is very less and so Cubic Spline Interpolation could be a good solution for regaining missing data points of original ECG signal. DICOT (Digital Imaging and Communication for Telemedicine) machine is in use to send different medical report like X-ray, mammography, skin image and others, and Gray Scale image is sent without compression. To increase the efficiency and reduce the BANDWITH requirements, we have developed a DCT based image compression technique. We have used five medical gray scale images of File size 110 KB, 51.1 KB, 118 KB, 62.5KB and 62 KB and after using compression technique we have got 92.5 KB, 38.1 KB, 113 KB, 44kB and 39 kB size of compressed image file. The compression ratio of file sizes becomes 15.9%, 25.4%, 4.23%, 29.6% and 37.097% respectively. File sizes are reduced to maximum 37.097 % without significant loss in image quality or medical information contained in it. Our result suggests that file size can be reduced in an efficient way using DCT and image reconstruction is possible without any loss of medical information, though some not very important fine details are lost.
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Telehealth in audiology-reaching underserved communities globally
  • D Swanepoel
  • J L Clark
  • D Koekemoer
Swanepoel D, Clark JL, Koekemoer D, et al. Telehealth in audiology-reaching underserved communities globally. Int J Audiol (in review)