Awareness of audiology and speech-language pathology services among healthcare professionals in Saudi Arabia.

BACKGROUND:  Healthcare professionals are required to work effectively together to deliver the best healthcare services. Without awareness of other healthcare professionals' roles and responsibilities, interprofessional practice (IPP) cannot be optimally achieved. OBJECTIVES:  This study aimed to investigate healthcare professionals' awareness of audiology and speech-language pathology (SLP) services in Saudi Arabia. METHOD:  This cross-sectional descriptive study consisted of two parts. The content of a 20-item paper questionnaire was firstly validated. The full-scale study addressed the aim through distributing questionnaire items among potential participants. Descriptive statistics and chi-square test were used. RESULTS:  A total of 403 participants completed the questionnaires for the main study. Most of the participants were Saudi citizens (84.1%), aged 18 years - 40 years (84.8%) years, and lived in Riyadh region (76.2%). Allied health professionals (40.2%), physicians (22.6%), nursing (15.4%) and dentistry (11.2%) were the main group of participants working mainly at governmental hospitals (69.2%). Of the total participants, 92.6% and 95.3% reported being fully aware of the services provided by audiologists and SLPs, respectively. No statistically significant association between the specialty of participants and their familiarity with the scope of practice for SLPs and audiologists was determined. CONCLUSION:  Our study examined healthcare professionals' awareness of audiology and SLP services and revealed a high level of awareness.Contribution: The existed level of awareness is expected to facilitate IPP and enhance the quality of care. Still, awareness campaigns about audiology and SLP services are needed to address the existing lack of knowledge among some healthcare professionals.

'[M]y own pace and space, without the pressures': Online learning experiences of audiology students.

BACKGROUND:  Online learning has been used to improve students' learning experiences and to allow students to engage with their own learning in various spaces. However, there is a dearth of literature on students' experiences with online learning in the field of audiology. OBJECTIVES:  This study aimed to describe the conditions of online learning, explore the challenges and benefits of online learning and determine strategies that students employ while engaging with online learning. METHOD:  An exploratory qualitative research design was employed. Audiology students from the second to the fourth year participated in the study. Qualitative data were collected online via MS Teams using a semi-structured interview schedule with the participants. Thematic analysis was used to analyse the participants' interviews. RESULTS:  Most of our participants were females in their fourth year of study. The students accessed the online learning platforms procured by the university from their homes, with reported benefits such as the flexibility and independence of learning, and time and cost-effectiveness. However, challenges such as limited internet connectivity, issues with time management and inconsistent power supply restricted positive experiences with online learning. CONCLUSION:  The online learning benefits that were reported by the students and the compensatory strategies they employed facilitated self-regulated learning. The study's findings highlighted the need for continuous checking-in with students regarding their experiences with the learning approaches intended to improve engagement with their courses. These results could be used as a guide for curriculum planning that is student-focused.Contribution: Students' experiences explored in our study provided a guide for online learning approaches that were suitable for audiology students. Student-centred and self-regulated learning practices were highlighted and future studies may further explore these frameworks and theories.

Discussing Patient Emotions in Audiology: Provider Experiences With the Implementation Process of Hearing Loss Psychological Inflexibility Screenings.

PURPOSE: This study aimed to investigate barriers and facilitators experienced by clinical educators and graduate students when talking with patients about difficult emotions and thoughts related to their hearing. METHOD: A longitudinal observational design was used and an Implementation Research Logic Model guided the process. Five clinical educators and five graduate students participated in the study. Participants completed pre- and postmeasures and attended individual debriefing sessions during the 8-month study period. RESULTS: Four themes emerged from the debriefing sessions: (a) learning process, (b) confidence, (c) barriers, and (d) supervision. Participants described that the Acceptance and Action Questionnaire-Managing Child Hearing Loss and Acceptance and Action Questionnaire-Adult Hearing Loss served as a reminder to ask about patients' internal barriers and increased awareness of their discomfort in talking about patient emotions. Participants also described barriers and struggles related to supporting students in gaining counseling skills. CONCLUSIONS: Screening for internal challenges helped clinicians remember to talk with patients about their difficult thoughts and emotions. Clinician hesitancy to engage in conversations with patients about their emotions can interfere with opportunities for patients to share their struggles and with training student in these skills.

Audiology Students' Clinical Communication During Simulated Peer Role Play Consultations: An Exploratory Study.

PURPOSE: The objectives of this study were to describe the clinical communication practices of student audiologists during case history taking and feedback giving using simulated peer role play consultations and to explore whether clinical communication skills outcomes can be achieved through simulated peer role play. METHOD: An exploratory, qualitative research design was used for this pilot study. A total of four simulated peer role play consultations were video-recorded, comprising two adult diagnostic audiology case scenarios. Eight online interviews were conducted with the student participants following the simulated audiological consultation. Analysis of the video-recorded sessions incorporated an interactional sociolinguistic focus, and interviews were analyzed using inductive thematic analysis. RESULTS: Findings from the video analysis and interviews were triangulated, with a specific focus on establishing commonalities in terms of communication skills of student clinicians, reflections of their own skills, and the simulated peer patient's reflections on the student clinician's skills. Although variation was noted in terms of case history taking skills, feedback giving was similar among all student clinicians. These communication practices are consistent with findings from related literature on consultations with real patients. Student clinicians reflected on feedback giving as more challenging than case history taking, with room for improvement suggested by the simulated peer patients. CONCLUSIONS: Our findings highlight key questions regarding the use of peer simulation in facilitating the development of communication skills for audiological consultations among student audiologists. We discuss some considerations for using this approach to clinical training more effectively. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.25492804.

Hyperacusis Diagnosis and Management in the United States: Clinical Audiology Practice Patterns.

PURPOSE: Hyperacusis often leads to debilitating psychosocial consequences, but there is no standard protocol for its diagnosis and management in the United States. In this study, we surveyed U.S. clinical audiologists to understand their education and clinical practices surrounding the evaluation and treatment of hyperacusis. METHOD: An online survey was distributed to clinical audiologists across the United States. Survey responses were quantified using descriptive statistics and inductive content analysis. RESULTS: Hyperacusis definitions and clinical practice patterns varied widely across the 102 respondents. Respondents cited a lack of education and training as the primary barrier to effective audiological diagnosis and management of hyperacusis, with most respondents reporting ≤ 5 hr of hyperacusis education. Other primary barriers to effective audiological management of hyperacusis included time constraints, reimbursement, poor sensitivity and specificity of available diagnostic tools, and poor efficacy of available treatments and management strategies. Most respondents (82.5%) agreed that audiologists are the primary professionals who are responsible for implementing hyperacusis interventions. However, 63.3% of respondents reported that their clinic does not have a hyperacusis management protocol, and 80.0% routinely recommend treatment that is outside their scope of practice to implement (cognitive behavioral therapy). CONCLUSIONS: Clinical audiologists in the United States do not receive uniform education on hyperacusis, and they report multiple barriers to its evidence-based diagnosis and management. Effective hyperacusis management necessitates a multidisciplinary approach. The information obtained via this survey will pave the way toward the refinement of interprofessional education programs and the development of systematic, evidence-based clinical protocols for hyperacusis. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24431188.

Perceptions of the Scope of Practice of Audiology.

PURPOSE: The primary purpose of this study was to determine which scope of practice roles and responsibilities are attributed to the profession of audiology (AUD) relative to other health care disciplines by a group of health and human services faculty and students. METHOD: An online survey inquiring about participant knowledge of different health professions' scopes of practice, and experience with and attitude toward the profession of AUD, was sent to faculty and students in the Western Michigan University College of Health and Human Services. Students also completed two subscales of the Interprofessional Attitudes Scale. Descriptive statistics and chi-square and Kruskal-Wallis analyses evaluating response differences between groups are presented. RESULTS: Thirty-six faculty and 118 students (48 graduate and 70 undergraduate) completed the survey. AUD was the profession most often associated with all hearing-related scope of practice activities. Speech-language pathology was often associated with hearing-related scope of practice activities. Audiologists were less commonly associated with vestibular, balance, and mobility scope of practice activities. Group was significant for four scope of practice activities. About half of respondents indicated they knew nothing or a little about AUD, and a majority had no or rare interactions with audiologists in class or clinic. Only about half of participants responded they were likely or very likely to refer patients to an audiologist. CONCLUSION: Increased knowledge of the scope of practice and exposure to the profession of AUD may benefit other health care professionals and patients, possibly leading to increased interprofessional practice and an increased number of appropriate referrals.

Experiences of Patient Bigotry Among Doctor of Audiology Graduate Clinicians: A Review and Recommendations.

PURPOSE: Students in audiology clinical doctorate programs in the United States are required to participate in direct patient care under the supervision of a licensed precepting audiologist during their schooling. Audiology student clinicians commonly rotate through a variety of clinical settings with their own organizational structure, policies, and precepting clinicians. Systemic prejudice and stigma cause many of these student clinicians to experience bigotry from the patients they work with. METHOD: This review discusses the populations of audiology students at highest risk of patient bigotry and discusses the intersectionality of students with several historically marginalized identities. RESULTS: Little scholarship exists in the field of audiology on the bigotry that graduate student clinicians experience. The effects of bigotry are reviewed, and practical guidance on preparing for and responding to bigotry from patients is provided. CONCLUSIONS: As health care workers, these students are essential workers contributing to the health and health care of the population, making their well-being a critical public health concern. Bigotry from others has been shown to contribute to mental illness, burnout, and poorer physical health among the people experiencing it.

E-Learning Simulations for Teaching Clinical Decision-Making in an Audiology Training Program.

PURPOSE: Clinical decision-making is an essential component of most clinical processes across the health sector and an ongoing challenge for clinical education programs to teach to students. The traditional methods of teaching these skills outside of lectures are mainly through clinical placements and problem-based learning (PBL) sessions, but availability and consistency can be variable and resource heavy. To address these challenges, an e-simulation module specific to pediatric infant diagnostic testing has been developed and implemented into the teaching program. We aimed to establish whether e-simulation resulted in student skill acquisition. METHOD: Academic performance measures for 67 audiology students who used a traditional PBL and 108 students who used the e-simulation module were collected and analyzed. Student survey results generated both quantitative and qualitative data, which were analyzed using a thematic analysis with an inductive approach. RESULTS: Findings indicated that the e-simulation platform introduced in this study yielded learning outcomes similar to the traditional PBL format previously used. Participants experienced a significant in situ increase in understanding of infant diagnostic testing concepts following the use of the e-simulation and evaluated the e-simulation platform positively. CONCLUSION: The data support that an e-simulation-based approach in clinical education presents pedagogical benefits and can provide a meaningful sustainable inclusion in today's clinical teaching programs.

Perceptions of Racism and White Privilege Among White Graduate Students in Audiology and Speech-Language Pathology.

PURPOSE: In the White-dominated fields of audiology and speech-language pathology, graduate students should demonstrate awareness of racism and racial privilege to begin developing cultural humility. A 2013 survey of graduate students in audiology and speech-language pathology indicated that White students demonstrated minimal awareness of White privilege (Ebert, 2013). This study builds on Ebert (2013) by investigating changes in White students' perceptions of White privilege over time and by adding characterization of their perceptions of systemic racism. METHOD: A web-based survey was distributed to graduate students in audiology and speech-language pathology programs across the country. The survey combined repeat questions from the work of Ebert (2013) with novel questions on systemic racism within the fields. For this study, only responses from White students were analyzed. RESULTS: The majority of White respondents (n = 104) acknowledged White privilege and systemic racism, though colorblindness and denial were still present among student responses. Significant increases in acknowledgment of White privilege from the Ebert (2013) results were observed across all questions. In qualitative analyses, the most common themes were the impact of White privilege and systemic racism on quality of services, access and opportunities, and clinician-client mismatch. CONCLUSIONS: Among White audiology and speech-language pathology graduate students, awareness of White privilege has increased over the past decade and most students acknowledge this privilege, as well as systemic racism. However, additional steps should be taken by students, graduate training programs, and practicing clinicians to continue confronting racial inequities in the fields. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22714222.

Student Perceptions of Learning Clinical Masking in Audiology: An Exploratory Survey Study.

PURPOSE: The audiology literature is rich with work in the area of clinical masking, yet there is a perception that learning how to mask is difficult. The purpose of this study was to explore the experiences of audiology doctoral students and recent graduates in learning clinical masking. METHOD: This exploratory study used a cross-sectional survey design, sampling doctor of audiology (AuD) students and recent graduates to probe the perceived effort required and challenges experienced in learning clinical masking. A total of 424 survey responses were included in the analysis. RESULTS: A large majority of respondents rated learning clinical masking as being challenging and effortful. Responses suggested that it took more than 6 months for confidence to develop. Qualitative analysis of the open-ended question uncovered four themes: "negative experience in the classroom"; "lack of consensus or variation in teaching"; "focus on content/rules"; and "positives, internal and external." CONCLUSIONS: Survey responses shed light on the perception that clinical masking is difficult to learn and highlight teaching and learning strategies that affect the development of this skill. Students reported a negative experience when significant emphasis was placed on formulas and theories and when encountering multiple masking methods in the clinic. On the other hand, students found clinic, simulations, lab-based classes, and some classroom instruction beneficial to learning. Students reported that their learning process included use of cheat sheets, practicing independently, and conceptualizing the process of masking to support their learning.

Transgender Health Care Primer for Clinical Audiologists.

PURPOSE: Transgender people have been increasingly visible in society. Recent research has indicated that millions of Americans, 0.7% of the total population, identify as transgender. Although transgender people experience all the same auditory and vestibular disorders as people who are not transgender, there is a dearth of information about transgender issues in audiology graduate education and continuing education. The author discusses their positionality as a transgender audiologist and provides guidance on working with transgender patients from their experience and from the published literature. CONCLUSION: This tutorial provides an overview of transgender identity for clinical audiologists and summarizes the social, legal, and medical landscape of transgender identity as it relates to audiology.

Practical and ethical considerations for neurodiversity inclusion in audiology education and practice.

BACKGROUND: . An increasing number of people who are neurodiverse (people who have conditions such as autism, ADHD, and dyslexia) are pursuing higher education, including education and employment in the field of audiology METHODS: . This conceptual article was written by neurodivergent professionals to promote a cultural shift of inclusion for students, clinicians, researchers, and professors who identify as neurodivergent. FINDINGS: . People with these conditions thrive with supportive accommodations in higher education and workplaces but little has been reported in the literature on neurodiversity accommodations in audiology education and practice CONCLUSIONS: . This article reviews the current literature on neurodiversity as it relates to audiology and discusses the practical and ethical considerations for neurodiversity inclusivity in the discipline of audiology.

Audiology Clinical Practice Patterns in Acoustic Reflex Testing.

PURPOSE: Periodic reports of audiology clinical practice patterns, including acoustic reflex threshold (ART) protocols, provide insights into trends and assist in clinical decision making. Therefore, the purpose of this study was to examine audiologists' ART protocols, factors influencing audiologists' decision to test, and considerations for mentoring Doctor of Audiology (AuD) students in ART testing. METHOD: This study used a paper survey distributed by mail to a random sample of audiologists. Participants were 102 audiologists, representing diversity across age, clinical experience, and work setting. The survey asked participants to provide (a) demographics, (b) ART protocols, (c) rationale for ART testing, and (d) perspectives on mentoring of ART testing. RESULTS: When ART testing is conducted, 100% of respondents conduct ipsilateral ART testing, compared to 75% for contralateral testing. Most use 500-, 1000-, and 2000-Hz stimulus frequencies, and 56% report 4000 Hz. Patient-related factors are the primary reason participants cite for conducting, or not conducting, ART tests. Most supervisor-participants encourage AuD students to conduct ART tests, based on patient-centered and student learning-centered reasons, and use a variety of strategies to guide students when ART findings are unusual. CONCLUSIONS: Fewer than half (43%) of participants conduct ART testing for all new patients, suggesting it is ancillary to the standard test battery for most participants. When ART testing is conducted, ipsilateral testing only or a combination of ipsilateral and contralateral testing is used. Ongoing trends in ART testing include continued popularity of 500-2000 Hz and ipsilateral-only or ipsilateral plus contralateral testing. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21513987.

Application of machine learning approaches to analyse student success for contact learning and emergency remote teaching and learning during the COVID-19 era in speech-language pathology and audiology.

BACKGROUND:  The onset of the COVID-19 pandemic across the globe resulted in countries taking several measures to curb the spread of the disease. One of the measures taken was the locking down of countries, which entailed restriction of movement both locally and internationally. To ensure continuation of the academic year, emergency remote teaching and learning (ERTL) was launched by several institutions of higher learning in South Africa, where the norm was previously face-to-face or contact teaching and learning. The impact of this change is not known for the speech-language pathology and audiology (SLPA) students. This motivated this study. OBJECTIVES:  This study aimed to evaluate the impact of the COVID-19 pandemic on SLPA undergraduate students during face-to-face teaching and learning, ERTL and transitioning towards hybrid teaching and learning. METHOD:  Using course marks for SLPA undergraduate students, K means clustering and Random Forest classification were used to analyse students' performance and to detect patterns between students' performance and the attributes that impact student performance. RESULTS:  Analysis of the data set indicated that funding is one of the main attributes that contributed significantly to students' performance; thus, it became one of the priority features in 2020 and 2021 during COVID-19. CONCLUSION:  The clusters of students obtained during the analysis and their attributes can be used in identification of students that are at risk of not completing their studies in the minimum required time and early interventions can be provided to the students.

Conducting clinical research in the era of the COVID-19 pandemic: Challenges and lessons for Speech-Language Pathology and Audiology research.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) presented new and unanticipated challenges to the academic training and performance of clinical research at undergraduate and postgraduate levels of training. This highlighted the need for reimagining research designs and methods to ensure continued generation of knowledge - a core function of a research-intensive university. Whilst adhering to government regulations geared towards protecting both the research participants and researchers, innovative research methods are required. OBJECTIVE: The purpose of this scoping review is to explore published evidence on innovative clinical research methods and processes employed during COVID-19 and to document challenges encountered and lessons that the fields of Speech-Language Pathology and Audiology can learn. METHODS: Electronic bibliographic databases including Science Direct, PubMed, Scopus, MEDLINE, ProQuest were searched to identify peer-reviewed publications, published in English, between 2019 and 2021, related to innovative clinical research methods and processes applied where in-person contact is regulated. RESULTS: Significant challenges with conducting research in the COVID-19 era were identified, with important lessons learned and numerous opportunities that have relevance for this pandemic era and beyond. These findings are presented under 10 themes that emerged that highlight important considerations for research methods and processes during a pandemic and beyond. The findings of this study also raise implications for telehealth from which low- and middle-income countries (LMICs), where resource challenges exist, can benefit. CONCLUSION: Challenges and opportunities identified in this review have relevance for the field of Speech-Language Pathology and Audiology as far as current and future (beyond COVID-19) clinical research planning is concerned.

Virtual audiology education tools: A survey of faculty, graduate students, and undergraduate students.

Due to global shifts at educational institutions from in-person courses to online formats caused by the COVID-19 pandemic, the current study aimed to estimate whether currently available virtual audiology education tools are helpful for acquiring necessary audiology skills and knowledge from the perspective of both educators and students. Therefore, a remote survey was developed and distributed to faculty and students in undergraduate communication sciences disorders and graduate audiology programs. Although participation was somewhat limited, the trends observed in the survey results suggested that the majority of both educators and students found the subset of virtual tools easy to use, that these tools improved teaching methods and learning outcomes, and that these tools would likely be used again.

Audiology, Medicine, and Pharmacy Interprofessional Preliminary Interviews and Discussions: Improving Hearing Health Care in Rural Alabama.

PURPOSE: Access and affordability of hearing health care varies depending on residency and individual financial means. Those living in rural areas have limited health care resources and experience higher levels of poverty compared to those living in urban regions. The purpose of this study was to determine the feasibility of interprofessional collaboration among physicians and audiologists and pharmacists and audiologists to improve access and affordability of hearing health care in rural communities. METHOD: Sixteen family physicians and medicine residents and 15 community pharmacists participated in the study. Physicians and residents completed an online survey to assess education regarding hearing health care and their understanding of hearing loss intervention. They also participated in small virtual focus group discussions. Pharmacists participated in virtual discussions based on guided questions. RESULTS: The discussions with both physicians and pharmacists highlighted the need for more education, resources, and awareness of the negative impact of hearing loss on overall quality of life. Comments from these discussions were placed within the socio-ecological model of health behavior to increase understanding of hearing health behavior. CONCLUSIONS: Increased collaboration among medical professionals has the potential to improve access to hearing health care for those living in audiologically underserved regions of the country. Further research will identify how to increase effective and sustainable hearing health care resources in rural communities.

'I had nothing. It's just life experience that helped me through that situation': Australian audiologists' perspectives on audiological clinical practice for traumatic brain injury and rehabilitation.

OBJECTIVE: Australian Audiologists' perspectives on standard non-specialized clinical practice in the context of Traumatic Brain Injury (TBI) were examined, including the perceived barriers to optimal service provision. DESIGN: A qualitative research design utilizing semi-structured interviews was conducted using purposive sampling. Nine participants were interviewed about their understanding of the impact of TBI on hearing and balance; identification, diagnosis and management of auditory and vestibular dysfunction following TBI; barriers to service delivery; training relating to complex clients (i.e., TBI); and awareness of referral pathways. RESULTS: Three major themes, each with subthemes, were evident in the data. The major themes reflected general considerations of audiological professional culture and specific issues related to knowledge of TBI and clinical practice with patients. Analysis revealed that professional culture seemed to act as a contextual barrier and interacted with the perceived lack of TBI related knowledge to hinder optimal clinical practice in this patient population. CONCLUSION: Application of the biopsychosocial model, including interdisciplinary care in the management of patients with TBI, is needed. An improvement in theoretical and practical knowledge encompassing the wide-ranging effects of TBI is critical for the optimal audiological service delivery.

Students' Reflections During Training Workshops on Communication and Information Exchange in Audiology Consultations: An Exploratory Qualitative Study.

PURPOSE: This clinical focus article outlines various communication challenges and scenarios related to information giving encountered by a group of audiology students, as reflected on during a series of communication skills workshops. METHOD: We held two online training workshops during which students reflected on their clinical communication experiences and asked questions related to clinical scenarios. Third-year audiology students from a South African university participated in the workshops (17 in the first, 15 in the second). We analyzed these reflections using thematic analysis. RESULTS: Students' reflections related to four themes: (a) balancing information giving, (b) managing shared decision making, (c) managing linguistic differences, and (d) relating bad news. The first theme was heavily prioritized in students' reflections. Providing students with time to practice skills introduced in the initial communication skills workshop enabled further reflection in the subsequent workshop. We discuss these themes using specific examples raised by students. CONCLUSIONS: Our findings suggest that students first need to master basic information giving skills before they can move on to more advanced skills such as managing shared decision making, linguistic differences, and relating bad news. This study confirms that reflective skills need to be developed with students in an explicit manner, rather than as part of a hidden curriculum. Our approach to providing communication training and encouraging reflection on clinical experiences offers a starting point for clinical educators to support students in developing these skills.

Perceptions of Preceptors and Audiology Students on Practicum During the COVID-19 Pandemic.

PURPOSE: The aim of this study was to assess the perceptions of audiology students and preceptors regarding changes in the practicum as a result of COVID-19. METHOD: This study was conducted during two different periods, with Internet questionnaires posted on social media forums. Preceptors and newly graduated clinicians were recruited in 2019 for a study prior to COVID-19, and students and preceptors were recruited for comparison during COVID-19. Four groups participated in this study: (a) 101 students who were enrolled in the second, third, or fourth year of an Israeli communication disorders Bachelor of Arts (BA) program during the pandemic; (b) 94 newly graduated audiologists with a BA degree from an Israeli communication disorders program granted in the last 3 years (before COVID-19); (c) 18 audiologist preceptors who supervised audiology practicum in an Israeli communication disorders BA programs (before COVID-19); and (d) 20 audiologist preceptors who, during COVID-19, were supervising an audiology practicum in Israel. Perceptions of the various groups were compared. RESULTS: Although perceptions of preceptors and students regarding the practicum were revealed to be similar, perceptions of the practicum before COVID-19 underwent changes in the course of the pandemic. In evaluating the COVID-19 experience, both preceptors and students agreed that more hours of practicum were needed, as well as more variety in types of cases and exposure to varied placements. CONCLUSION: Academic programs and employers should consider implications of changes implemented in the practicum due to COVID-19, which can be addressed either in continuing education and/or by additional supervision in the future workplace. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19855639.