Smartphone-Facilitated In-Situ Hearing Aid Audiometry for Community-Based Hearing Testing.

OBJECTIVES: Hearing loss prevalence is increasing, with an estimated 2.5 billion people affected globally by 2050. Scalable service delivery models using innovative technologies and task-shifting are World Health Organization priorities to improve access to hearing care, particularly in low- and middle-income countries. Smartphone-facilitated audiometry in the community using hearing aids covered by noise-attenuating ear cups ("in-situ") could support more accessible hearing care when provided by less trained individuals such as community health workers (CHWs). This study aimed to determine the validity of this method for potential hearing aid fitting. Study objectives included determining the maximum permissible ambient noise level (MPANL), inter-device reliability, clinical threshold accuracy, reliability, and performance in real-world settings. DESIGN: Experiment 1: 15 normal-hearing adult participants were evaluated to determine MPANLs for circumaural Peltor 3M earcups covering Lexie Lumen hearing aids with smartphone-facilitated in-situ audiometry. MPANLs were calculated by measuring the difference in attenuation between thresholds obtained with standard headphones and in-situ hearing aids. Experiment 2: Pure-tone frequency and intensity output of 14 same-model Lexie Lumen hearing aids were measured to determine inter-device reliability. Pure-tone stimuli were measured and analyzed to determine sound pressure levels in decibels and pure-tone frequency when connected to a test box 2cc coupler. Experiment 3: 85 adult participants were tested in a sound booth to determine the accuracy of automated in-situ pure-tone audiometry (PTA) compared to clinical PTA (500, 1000, 2000, 3000, 4000, 6000 Hz) facilitated by an audiologist. The first 39 participants were tested twice to determine test-retest reliability. Experiment 4: In a community setting, 144 adult participants were tested with automated in-situ audiometry facilitated by CHWs using a smartphone app. These participants were subsequently tested with automated mobile PTA (500, 1000, 2000, 4000 Hz). An additional 44 participants were tested twice to determine test-retest reliability. RESULTS: Experiment 1: MPANLs of the Peltor 3M earcup-covered hearing aids were higher than standard headphones across all frequencies, ranging from 24 to 47.3 dB SPL. Experiment 2: Inter-device performance reliability was high, with all inter-device differences across all intensities and frequencies less than 3 dB. Frequency output was consistent and differed less than 0.7% between devices. Experiments 3 and 4: 85.2% and 83.3% of automated in-situ audiometry thresholds were within 10 dB of thresholds obtained in the sound booth and in a community setting, respectively. Acceptable test-retest intraclass correlation coefficient (ICC) was evident across all thresholds obtained in a sound booth (ICC = 0.85 to 0.93) and in a community setting (ICC = 0.83 to 0.97). CONCLUSIONS: Smartphone-facilitated in-situ audiometry allows for reliable and valid community-based testing. A simple smartphone user interface and automated in-situ audiometry allow CHWs with minimal training to facilitate the testing. With the additional capability to program hearing aids via the smartphone after the initial test, this approach would have the potential to support widespread access to personalized hearing aid fittings facilitated by CHWs in low- and middle-income countries. This approach also supports self-fitting options based on in-situ thresholds, enabling testing and fitting via over the counter hearing aids.

Mobile Health Hearing Aid Acclimatization and Support Program in Low-Income Communities: Feasibility Study.

BACKGROUND: The most common management option for hearing loss is hearing aids. In addition to devices, patients require information and support, including maintenance and troubleshooting. Mobile health (mHealth) technologies can support hearing aid management, acclimatization, and use. This study developed an mHealth acclimatization and support program for first-time hearing aid users and subsequently implemented and pilot-tested the feasibility of the program. The program was facilitated by community health workers (CHWs) in low-income communities in South Africa. OBJECTIVE: This study aimed to evaluate the feasibility of an mHealth acclimatization and support program supported by CHWs in low-income communities. METHODS: An application-based acclimatization and support was adapted and translated for use in low- and middle-income countries. This program was delivered in the form of 20 different voice notes accompanied by graphical illustrations via WhatsApp or 20 different SMS text messages. The program was provided to first-time hearing aid users immediately after a community-based hearing aid fitting in March 2021 in 2 low-income communities in the Western Cape, South Africa. The 20 messages were sent over a period of 45 days. Participants were contacted telephonically on days 8, 20, and 43 of the program and via open-ended paper-based questionnaires translated to isiXhosa 45 days and 6 months after the program started to obtain information on their experiences, perceptions, and accessibility of the program. Their responses were analyzed using inductive thematic analysis. RESULTS: A total of 19 participants fitted with hearing aids received the mHealth acclimatization and support program. Most participants (15/19, 79%) received the program via WhatsApp, with 21% (4/19) of them receiving it via SMS text message. Participants described the program as helpful, supportive, informative, sufficient, and clear at both follow-ups. A total of 14 participants reported that they were still using their hearing aids at the 6-month follow-up. Three participants indicated that not all their questions about hearing aids were answered, and 5 others had minor hearing aid issues. This included feedback (n=1), battery performance (n=1), physical fit (n=2), and issues with hearing aid accessories (n=1). However, CHWs successfully addressed all these issues. There were no notable differences in responses between the participants who received the program via WhatsApp compared with those who received it through SMS text message. Most participants receiving WhatsApp messages reported that the voice notes were easier to understand, but the graphical illustrations supplemented the voice notes well. CONCLUSIONS: An mHealth acclimatization and support program is feasible and potentially assists hearing aid acclimatization and use for first-time users in low-income communities. Scalable mHealth support options can facilitate increased access and improve outcomes of hearing care.

mHealth-Supported Hearing Health Training for Early Childhood Development Practitioners: An Intervention Study.

(1) Hearing health training and promotion is a priority for early childhood development (ECD) practitioners, but training opportunities are limited, especially in low- and middle-income countries (LMIC). mHealth (mobile health) has the potential to deliver scalable ear and hearing training to ECD practitioners. (2) This study investigated the effect of an mHealth training intervention program for ECD practitioners to improve knowledge and perceptions of hearing health in young children. An experimental one-group, pre-post-test study included ECD practitioners working with children between birth and 6 years old across 31 neighbouring communities in the Western Cape Province, South Africa. Hearing health training was provided using WhatsApp messages that encompassed infographics and voice notes. Knowledge and perceptions regarding hearing and hearing-related problems in children were surveyed pre-training, directly post training, and 6 months post training. (3) ECD practitioners (N = 1012) between 17 and 71 years of age received the mHealth training program and completed both the pre-and post-training surveys. Overall, knowledge scores indicated a significant improvement from pre- to post training (Z = -22.49; p < 0.001). Six-month post-training knowledge scores were sustained. Content analysis of ECD practitioners' application of the training information 6 months post training indicated improved awareness, practical application, better assistance for hearing problems, and widespread advocacy. (4) The mHealth training program supports improved knowledge and perceptions of ECD practitioners regarding hearing health for young children. With improved knowledge scores maintained 6 months post training, mHealth hearing health training is an effective intervention. An mHealth training program for ECD practitioners provides a scalable, low-cost intervention for primary and secondary prevention in childhood hearing loss, especially in LMICs.

Community-based adult hearing care provided by community healthcare workers using mHealth technologies.

BACKGROUND: The rising prevalence of hearing loss is a global health concern. Professional hearing services are largely absent within low- and middle-income countries where appropriate skills are lacking. Task-shifting to community healthcare workers (CHWs) supported by mHealth technologies is an important strategy to address the problem. OBJECTIVE: To evaluate the feasibility of a community-based rehabilitation model providing hearing aids to adults in low-income communities using CHWs supported by mHealth technologies. METHOD: Between September 2020 and October 2021, hearing aid assessments and fittings were implemented for adults aged 18 and above in two low-income communities in the Western Cape, South Africa, using trained CHWs. A quantitative approach with illustrative open-ended questions was utilised to measure and analyse hearing aid outcomes. Data were collected through initial face-to-face interviews, telephone interviews, and face-to-face visits post-fitting. Responses to open-ended questions were analysed using inductive thematic analysis. The International Outcome Inventory - Hearing Aids questionnaire determined standardised hearing aid outcomes. RESULTS: Of the 152 adults in the community who self-reported hearing difficulties, 148 were successfully tested by CHWs during home visits. Most had normal hearing (39.9%), 24.3% had bilateral sensorineural hearing loss, 20.9% had suspected conductive hearing loss, and 14.9% had unilateral hearing loss, of which 5.4% had suspected conductive loss. Forty adults met the inclusion criteria to be fitted with hearing aids. Nineteen of these were fitted bilaterally. Positive hearing aid outcomes and minimal device handling challenges were reported 45 days post-fitting and were maintained at six months. The majority (73.7%) of participants fitted were still making use of their hearing aids at the six-month follow-up. CONCLUSIONS: Implementing a hearing healthcare service-delivery model facilitated by CHWs in low-income communities is feasible. mHealth technologies used by CHWs can support scalable service-delivery models with the potential for improved access and affordability in low-income settings.

Newborn hearing screening at a community-based obstetric unit: Screening and diagnostic outcomes.

OBJECTIVE: Postnatal visits at community-based midwife obstetric units (MOUs) have been proposed as an alternative primary healthcare screening platform in South Africa. This study evaluated the outcomes of distortion product otoacoustic emissions (DPOAEs) and automated auditory brainstem response (AABR) screening conducted by a dedicated non-professional screener at a community-based MOU in the Western Cape, South Africa. METHODS: Universal newborn hearing screening (UNHS) at a community-based MOU was evaluated over a 16-month period. A dedicated non-professional screener was trained to follow a two-stage screening protocol targeting bilateral hearing loss. A two group comparative design was used alternating AABR (Maico MB11 BERAphone™()) and DPOAE (Bio-logic AuDX I) technology on a daily basis. Infants referring the initial screen received a follow-up appointment in two days' time and were rescreened with the same technology used at their first screen. Those referring the second stage were booked for diagnostic assessments. RESULTS: 7452 infants were screened including 47.9% (n=3573) with DPOAE and 52.1% (n=3879) with AABR technology. Mean age at first stage screen was 6.1 days. The initial bilateral referral rate was significantly lower for AABR (4.6%) compared to DPOAE (7.0%) and dropped to 0.3% and 0.7% respectively following the second stage screenings. First rescreen and initial diagnostic follow-up rates of 90% and 92.3% were obtained for the DPOAE group and 86.6% and 90% for the AABR group. Follow-up rates showed no significant difference between technology groups. Diagnostic assessment revealed a higher prevalence rate for bilateral SNHL among the AABR group (1/1000) compared to the DPOAE group (0.3/1000). Screening technology had no significant influence on daily screening capacity (23 AABR/day; 24 DPOAE/day). CONCLUSIONS: Postnatal visits at community-based MOUs create a useful platform for hearing screening and follow-up. AABR technology with negligible disposable costs provides opportunity for AABR screening to be utilised in community-based programmes. AABR screening offers lower initial referral rates and a higher true positive rate compared to DPOAE.