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Hearing health-care delivery in sub-Saharan Africa - a role for tele-audiology

DOI:10.1258/jtt.2009.009003
Authors:
DeWet Swanepoel at University of Pretoria
DeWet Swanepoel
Bolajoko O. Olusanya at Centre for Healthy Start Initiative
Bolajoko O. Olusanya
Maurice Mars at University of KwaZulu-Natal
Maurice Mars
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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.
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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. ...
EHealth Technologies Enable more Accessible Hearing Care
Article
  • May 2020
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]. ...
Telerehabilitation of hearing-impaired children during COVID-19 pandemic
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Full-text available
Objective: To evaluate advantages and effectiveness of remote rehabilitation services for hearing-impaired children at Center of Pediatric Audiology during COVID-19 pandemic. Material and methods: 181 children with different types and degrees of permanent hearing loss, their parents and 10 hearing care professionals (audiologists, speech-language therapists) were included in the study. 2115 rehabilitation services were provided during 3 months: video- and text consultations, video lessons with child, sending homework to parents, etc. Results: The results of questionnaires showed that, on specialists' and parents' opinion, remote rehabilitation care is effective tool for hearing impaired children during emergency situations. TeleCare allowed to improve parents' abilities to manage with children by themselves, their understanding goals and methods of rehabilitation, improving child's hearing and speech skills. 95% of parents were satisfied by remote rehabilitation. Advantages and problems of remote hearing rehabilitation were analyzed from the sides of professionals and parents. The most challenging activities for professionals during TeleCare were: evaluation of HA/CI effectiveness, diagnosis and developing of hearing and speech. Conclusions: The experience of remote hearing rehabilitation in emergency situation allows to conclude that this type of care could be useful in clinical practice after pandemic for parents consulting and for children with motor problems.
... 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. ...
Prevalence of Pre-Existing Hearing Loss Among Patients With Drug-Resistant Tuberculosis in South Africa
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  • Apr 2020
Purpose Hearing loss, resulting from aminoglycoside ototoxicity, is common among patients with drug-resistant tuberculosis (DR-TB). Those with pre-existing hearing loss are at particular risk of clinically important hearing loss with aminoglycoside-containing treatment than those with normal hearing at baseline. This study aimed to identify factors associated with pre-existing hearing loss among patients being treated for DR-TB in South Africa. Method Cross-sectional analysis nested within a cluster-randomized trial data across 10 South African TB hospitals. Patients ≥ 13 years old received clinical and audiological evaluations before DR-TB treatment initiation. Results Of 936 patients, average age was 35 years. One hundred forty-two (15%) reported pre-existing auditory symptoms. Of 482 patients tested by audiometry, 290 (60%) had pre-existing hearing loss. The prevalence of pre-existing hearing loss was highest among patients ≥ 50 years (adjusted prevalence ratio [aPrR] for symptoms 5.53, 95% confidence interval (CI) [3.63, 8.42]; aPrR for audiometric hearing loss 1.63, 95% CI [1.31, 2.03] compared to age 13–18 years) and among those with a prior history of second-line TB treatment (aPrR for symptoms 1.73, 95% CI [1.66, 1.80]; PrR for audiometric hearing loss 1.33, 95% CI [1.03, 1.73]). Having HIV with cluster of differentiation 4 cell count < 200 cells/mm ³ and malnutrition were risk factors but did not reach statistical significance in adjusted analyses. Conclusion Pre-existing hearing loss is common among patients presenting for DR-TB treatment in South Africa, and those older than the age of 50 years or who had prior second-line TB treatment history were at highest risk.
... 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. ...
Accuracy and Reliability of Smartphone Self-Test Audiometry in Community Clinics in Low Income Settings: A Comparative Study
Article
  • Jan 2020
Background There is a lack of hearing health care globally, and tele-audiology and mobile technologies have been proposed as important strategies to reduce the shortfall. Objectives To investigate the accuracy and reliability of smartphone self-test audiometry in adults, in community clinics in low-income settings. Methods A prospective, intra-individual, repeated measurements design was used. Sixty-three adult participants (mean age 52 years, range 20-88 years) were recruited from ENT and primary health care clinics in a low-income community in Tshwane, South Africa. Air conduction hearing thresholds for octave frequencies 0.5 to 8 kHz collected with the smartphone self-test in non-sound treated environments were compared to those obtained by reference audiometry. Results The overall mean difference between threshold seeking methods (ie, smartphone thresholds subtracted from reference) was −2.2 dB HL (n = 467 thresholds, P = 0.00). Agreement was within 10 dB HL for 80.1% (n = 467 thresholds) of all threshold comparisons. Sensitivity for detection hearing loss >40 dB HL in one ear was 90.6% (n = 84 ears), and specificity 94.2% (n = 84 ears). Conclusion Smartphone self-test audiometry can provide accurate and reliable air conduction hearing thresholds for adults in community clinics in low-income settings.
... 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]. ...
Associated Factors of Unilateral Sensorineural Hearing Loss among Sudanese Patients
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... There are numerous advantages associated with teleaudiology as a method of service delivery. Teleaudiology has the potential to reduce travel time for audiologists (Crowell, Givens, Jones, Brechtelsbauer, & Yao, 2011) and clients (Ramkumar et al., 2016;Wasowski et al., 2012), reduce the cost of travelling (Govender & Mars, 2017;Kokesh, Ferguson, Patricoski, & LeMaster, 2009), increase client access to services (Coco, Champlin, & Eikelboom, 2016;Edwards, Stredler-Brown, & Houston, 2012;Swanepoel, Olusanya, & Mars, 2010;Visagie, Swanepoel, & Eikelboom, 2015), become a medium for health professional collaboration (Gladden, Beck, & Chandler, 2015;Novak et al., 2016) and monitor hearing aid (HA) fitting (Campos & Ferrari, 2012;Novak et al., 2016). In addition, client satisfaction and comfort in receiving rehabilitation services via telepractice have been reported by previous studies (Grogan-Johnson, Alvares, Rowan, & Creaghead, 2010;Sharma, Ward, Burns, Theodoros, & Russell, 2013). ...
Are we ready for teleaudiology?: data from Malaysia
Article
Full-text available
  • May 2019
Purpose: The application of teleaudiology in the field of audiology has been regarded as a promising approach to improve the quality of services and access to healthcare. Ongoing studies are required to explore the willingness and attitudes of clinicians to use teleaudiology services in clinical practice. The objective of this study was to obtain preliminary data regarding audiologists’ perceptions of teleaudiology in Malaysia. Method: Forty-three audiologists in Malaysia participated in a survey to examine their views regarding teleaudiology. The survey was conducted by inviting the audiologists to complete the Malay version of ‘Attitudes toward Teleaudiology Scale for Practitioners (MyATS-P)’. MyATS-P consists of 41 items with four sections assessing the usage of information communication technology, perceived effect of teleaudiology, and willingness to use teleaudiology. Results: Approximately half of the respondents indicated that teleaudiology would have a positive effect on quality of care (54.41%), accessibility (62.79%), and professional practice (46.51%). The willingness of the respondents to use teleaudiology was dependent on the types of clinical tasks and client groups examined. Conclusion: This study confirmed that support for remote audiology testing in Malaysia was divided among the audiologists. Several measures were suggested to initiate teleaudiology practice in Malaysia and to encourage its use in the future.
Diagnostic Accuracy of Smartphone-Based Audiometry for Hearing Loss Detection: Meta-analysis
Article
  • Sep 2021
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.
Guest Editorial: Hearing Care for All-An Opportunity to Globally Unite to Address Inequities in Hearing Health
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  • Mar 2021
Smart Phone Based Intelligent Telemedicine System for Bangladesh Perspective
Thesis
  • Jan 2014
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.
Supporting hearing health in vulnerable populations through community care workers using mHealth technologies
Article
  • Aug 2019
Objective: Access to hearing care is challenging in low- and middle-income countries, where the burden of hearing loss is greatest. This study investigated a community-based hearing screening programme using smartphone testing by community care workers (CCWs) in vulnerable populations infected or affected by HIV. Experiences of CCWs were also surveyed. Design: The study comprised two phases. Phase one employed a cross-sectional research design to describe the community-based programme. Phase two was a survey design to describe CCW’s knowledge and experiences. Study Sample: Fifteen trained CCWs administered hearing screenings on 511 participants during home-based visits using a validated smartphone application (hearScreen™) during phase one. Diagnostic follow-up assessments included evaluation using the smartphone test (hearTest™), otoscopy and tympanometry. Phase two surveyed the 15 CCW screening experiences. Results: Referral rates for adults and children were 5.0% and 4.2%, respectively. 75.0% of referred participants returned for follow-up diagnostic assessments, 33.3% were diagnosed with hearing loss and referred for further intervention. All 15 CCWs agreed that communities needed hearing services and only 6.6% did not want to continue providing hearing screening. Conclusion: Trained CCWs can decentralise hearing services to vulnerable communities using smartphone screening incorporating automated testing and measures of quality control.
Use of telemedicine in the remote programming of cochlear implants
Article
Full-text available
Remote cochlear implant (CI) programming is a viable, safe, user-friendly and cost-effective procedure, equivalent to standard programming in terms of efficacy and user's perception, which can complement the standard procedures. The potential benefits of this technique are outlined. We assessed the technical viability, risks and difficulties of remote CI programming; and evaluated the benefits for the user comparing the standard on-site CI programming versus the remote CI programming. The Remote Programming System (RPS) basically consists of completing the habitual programming protocol in a regular CI centre, assisted by local staff, although guided by a remote expert, who programs the CI device using a remote programming station that takes control of the local station through the Internet. A randomized prospective study has been designed with the appropriate controls comparing RPS to the standard on-site CI programming. Study subjects were implanted adults with a HiRes 90K(R) CI with post-lingual onset of profound deafness and 4-12 weeks of device use. Subjects underwent two daily CI programming sessions either remote or standard, on 4 programming days separated by 3 month intervals. A total of 12 remote and 12 standard sessions were completed. To compare both CI programming modes we analysed: program parameters, subjects' auditory progress, subjects' perceptions of the CI programming sessions, and technical aspects, risks and difficulties of remote CI programming. Control of the local station from the remote station was carried out successfully and remote programming sessions were achieved completely and without incidents. Remote and standard program parameters were compared and no significant differences were found between the groups. The performance evaluated in subjects who had been using either standard or remote programs for 3 months showed no significant difference. Subjects were satisfied with both the remote and standard sessions. Safety was proven by checking emergency stops in different conditions. A very small delay was noticed that did not affect the ease of the fitting. The oral and video communication between the local and the remote equipment was established without difficulties and was of high quality.
Remote probe microphone measurement to verify hearing aid performance
Article
Full-text available
We assessed the feasibility of obtaining probe microphone measurements of hearing aids at a distance. Face-to-face and remote probe microphone measurements were carried out in 60 hearing aid users (mean age 67 yrs) with uni- or bilateral hearing losses (105 ears tested). The participant and a facilitator were located in a room equipped with a probe microphone system interfaced to a PC. Desktop videoconferencing and application sharing was used to allow an audiologist in another room to instruct the facilitator and control the equipment via the LAN. There were significant correlations between face-to-face and remote real ear unaided response (REUR), aided response (REAR) and insertion gain (REIG) at seven discrete frequencies from 250 to 6000 Hz. Differences between face-to-face and remote responses were within the reported variability for probe microphone measurements themselves. The results show that remote probe microphone measurements are feasible and might improve the quality of public hearing aid services and professional training in Brazil.
E-health: Determinants, opportunities, challenges and the way forward for countries in the WHO African Region
Article
Full-text available
The implementation of the 58th World Health Assembly resolution on e-health will pose a major challenge for the Member States of the World Health Organization (WHO) African Region due to lack of information and communications technology (ICT) and mass Internet connectivity, compounded by a paucity of ICT-related knowledge and skills. The key objectives of this article are to: (i) explore the key determinants of personal computers (PCs), telephone mainline and cellular and Internet penetration/connectivity in the African Region; and (ii) to propose actions needed to create an enabling environment for e-health services growth and utilization in the Region. The effects of school enrolment, per capita income and governance variables on the number of PCs, telephone mainlines, cellular phone subscribers and Internet users were estimated using a double-log regression model and cross-sectional data on various Member States in the African Region. The analysis was based on 45 of the 46 countries that comprise the Region. The data were obtained from the United Nations Development Programme (UNDP), the World Bank and the International Telecommunications Union (ITU) sources. There were a number of main findings: (i) the adult literacy and total number of Internet users had a statistically significant (at 5% level in a t-distribution test) positive effect on the number of PCs in a country; (ii) the combined school enrolment rate and per capita income had a statistically significant direct effect on the number of telephone mainlines and cellular telephone subscribers; (iii) the regulatory quality had statistically significant negative effect on the number of telephone mainlines; (iv) similarly, the combined school enrolment ratio and the number of telephone mainlines had a statistically significant positive relationship with Internet usage; and (v) there were major inequalities in ICT connectivity between upper-middle, lower-middle and low income countries in the Region. By focusing on the adoption of specific technologies we attempted to interpret correlates in terms of relationships instead of absolute "causals". In order to improve access to health care, especially for the majority of Africans living in remote rural areas, there is need to boost the availability and utilization of e-health services. Thus, universal access to e-health ought to be a vision for all countries in the African Region. Each country ought to develop a road map in a strategic e-health plan that will, over time, enable its citizens to realize that vision.
Reducing the Burden of Communication Disorders in the Developing World
Article
Full-text available
At the Millennium Summit in September 2000 in New York, leaders of 189 countries, including 147 heads of state and government, adopted the United Nations Millennium Declaration, committing their nations to a global partnership to work toward 8 development goals.1 This project has since emerged as the global priority for resource allocation to the developing world through 2015. Three of the 8 goals—“to reduce child mortality,” “improve maternal health,” and “combat HIV/AIDS, malaria and other diseases”—are directly related to health, while the others—“to eradicate extreme poverty and hunger,” “achieve universal primary education,” “promote sex equality and empower women,” “ensure environmental sustainability,” and “develop a global partnership for development”—are indirectly linked to health. Eight of the 18 targets and 18 of the 48 indicators are health related. However, given the myriad problems confronting most developing countries, it is not surprising that some conditions received less attention and others were overlooked or forgotten outright.
Providing bask hearing tests using remote computing technology
Article
Full-text available
  • Feb 2007
We administered pure tone and otoacoustic emissions testing to subjects in a distant community using remote computing technology. Fifteen men and 15 women ranging in age from 18-30 years were tested. An audiometer was used to measure subject pure tone thresholds. In addition, distortion product otoacoustic emissions (DPOAEs) data were recorded using a portable system. Both systems were interfaced to a PC which was connected to the local area network at Minot State University (MSU). An examiner at Utah State University, 1100 km away, could control both the DPOAE and the audiometer equipment at MSU. Overall, the pure tone means for the face-to-face and telemedicine trials were equivalent at each frequency. Moreover, DPOAE recordings exhibited equivalent results at each frequency for telemedicine and face-to-face trials. These results support the use of remote computing as a telemedicine method for providing pure tone audiometry and DPOAE testing to distant communities.
Audiology education and practice from an international perspective
Article
This paper describes the international education and practice of audiology with the broader aim of proposing possible cost-effective and sustainable education models to address the current situation. Major audiology organizations worldwide were surveyed from February 2005 to May 2007, and organizations from 62 countries (78% of the world population) returned a completed survey. Overall, the results suggested a wide range of professionals providing hearing health care, and 86% of the respondents reported a need for more audiologists. There was also considerable variation in the scope of practice among the different hearing health care professionals, and the minimum education levels of audiologists with similar scopes of practice. The countries surveyed fell into four broad categories in terms of professional resources, and the results highlighted the urgent need for forward planning at both national and international levels. The study highlights options for addressing some of the challenges in educating audiologists and the provision of hearing health care services globally.
Validation of tele-otology to diagnose ear disease in children
Article
To determine if digitised still eardrum images, with a clinical history, and audiometry and tympanometry data provide sufficient information to an ear specialist to make an assessment of a patient. 66 children (9 months to 16 years) from remote communities were assessed by an ear specialist by standard otoscopy, using a clinical history, audiometry and tympanometry. Up to five images of each ear were digitised. At a later date, the ear specialist made observations, diagnoses and recommendations for management from the images and clinical data. There was a significant correlation (p<0.01) between image quality and age of the subject. There were significant agreements for the clinically important observations of otorrhea, perforation, retracted tympanic membrane and atrophy of the tympanic membrane (p<0.05). There were significant agreements for the diagnoses of acute otitis media, chronic suppurative otitis media, otitis media with effusion and Eustachian tube dysfunction. The rate of recommendations for review or referral after a tele-otology assessment were between 4 and 16% higher than those in made in the field. The agreements between the various forms of advice or recommendations made in the field to those made by tele-otology were statistically significant (p<0.01). A tele-otology system that incorporates good quality digitised images of the tympanic membrane, audiological and tympanometric data, and a comprehensive clinical history provides the ear specialist with sufficient information to make a confident diagnose of existing middle ear disease, and provide management advice to the patients' primary care provider.
Global burden of childhood hearing impairment and disease control priorities in developing countries
Article
Current State of Knowledge: Language and Literacy of Children with Hearing Impairment
Article
The purpose of this paper is to provide a review of past and current research regarding language and literacy development in children with mild to severe hearing impairment. A related goal is to identify gaps in the empirical literature and suggest future research directions. Included in the language development review are studies of semantics (vocabulary, novel word learning, and conceptual categories), morphology, and syntax. The literacy section begins by considering dimensions of literacy and the ways in which hearing impairment may influence them. It is followed by a discussion of existing evidence on reading and writing, and highlights key constructs that need to be addressed for a comprehensive understanding of literacy in these children.
Telehealth in audiology-reaching underserved communities globally
  • Int J Audiol
  • 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)