Jackie L. Clark

Telehealth in audiology: The need and potential to reach underserved communities

Abstract Permanent hearing loss is a leading global health care burden, with 1 in 10 people affected to a mild or greater degree. A shortage of trained healthcare professionals and associated infrastructure and resource limitations mean that hearing health services are unavailable to the majority of the world population. Utilizing information and communication technology in hearing health care, or tele-audiology, combined with automation offer unique opportunities for improved clinical care, widespread access to services, and more cost-effective and sustainable hearing health care. Tele-audiology demonstrates significant potential in areas such as education and training of hearing health care professionals, paraprofessionals, parents, and adults with hearing disorders; screening for auditory disorders; diagnosis of hearing loss; and intervention services. Global connectivity is rapidly growing with increasingly widespread distribution into underserved communities where audiological services may be facilitated through telehealth models. Although many questions related to aspects such as quality control, licensure, jurisdictional responsibility, certification and reimbursement still need to be addressed; no alternative strategy can currently offer the same potential reach for impacting the global burden of hearing loss in the near and foreseeable future. Sumario La pérdida auditiva permanente es una importante carga para los cuidados de la salud a nivel mundial, con 1 de cada 10 personas afectadas en grado ligero o mayor. La escasez de profesionales entrenados en cuidados de la salud y de infraestructura asociada y la limitación de recursos determina que los servicios de salud auditiva no estén disponibles para la mayoría de la población mundial. La utilización de información y tecnología de la comunicación para los cuidados de la salud auditiva o teleaudiología, combinada con la automatización, ofrece oportunidades únicas para mejorar los cuidados clínicos, ampliar el acceso a los servicios y tener cuidados de salud auditiva costoefectivos y sustentables. La Teleaudiología ha demostrado un potencial significativo en áreas como las de educación y adiestramientio de profesionales de la salud auditiva, profesionales afines, padres y adultos con problemas auditivos; tamiz de problemas auditivos; diagnóstico de pérdidas auditivas y servicios de intervención. La conectividad global está creciendo rápidamente y ha aumentado de manera generalizada su distribución en comunidades con pocos servicios, en donde los servicios audiológicos pueden facilitarse a través de modelos de telesalud. No obstante, existen muchas dudas que deben resolverse y que están relacionadas con aspectos como control de calidad, regulación del ejercicio profesional, responsabilidad jurisdiccional, certificación y reembolso de servicios, pero no existe como alternativa ninguna otra estrategia que pueda ofrecer actualmente el mismo potencial, para impactar el peso global de las pérdidas auditivas en el futuro cercano o previsible.

Intercontinental hearing assessment - a study in tele-audiology

We evaluated the validity of remote pure tone audiometric testing conducted from North America on subjects in South Africa. Desktop-sharing computer software was used to control an audiometer in Pretoria from Dallas, and PC-based videoconferencing was employed for clinician and subject communication. Thirty adult subjects were assessed, and the pure tone audiometric thresholds (125–8000 Hz) obtained through conventional face-to-face and remote testing were compared. Face-to-face and remote audiometry thresholds differed by 10 dB in only 4% of cases overall. The limits of agreement between the two techniques were −8 and 7 dB with a 90% confidence interval of −5 to 5 dB. The average reaction times to stimulus presentations were similar, within −108 and 121 ms. The average test duration was 21% longer for remote testing (10.4 vs. 8.2 min). There were no clinically significant differences between the results obtained by remote intercontinental audiometric testing and conventional face-to-face audiometry. It may therefore be possible to expand the reach of audiological services into remote underserved regions of the world.

Technology for hearing loss – as We Know it, and as We Dream it

Abstract Purpose: Worldwide demand for accessible hearing health technology continues to increase while the numbers of hearing healthcare specialists are grossly inadequate to meet this demand. Proliferation of innovative technology and the advent of greater access to global connectivity are providing an opportunity to identify and harness new resources that may change current audiological service delivery methods to maximize access, efficiency and impact. Methods: By searching through the most current literature and engaging in discussions with industry experts, it is possible to identify avenues that could increase services to those who have hearing loss with innovative healthcare technology. This article aims to review the current state as well as future trends of hearing health technology by addressing: Technology as We Know it; and Technology as We Dream it. Results: Some of the newer technologies we have recently witnessed include: micro processors; personalized computing devices (e.g. smartphones); web-based applications; an expanding clinical repertoire with integrated test equipment; and globalization of telecommunications that opens the door to telehealth; and self-fitting of hearing aids. Yet, innovation continues scaffolding on recent successes with innovations for hearing healthcare expected to increase into the future. Conclusion: As technology and connectivity continue to evolve so should the practice of audiology adapt to the global needs by capitalizing on these advances to optimize service delivery access and sustainability. Implications for Rehabilitation Capital investment in equipment will be dramatically reduced with smaller, lighter, less costly and more portable equipment. Individuals who live in remote regions with little or no hearing healthcare access can undergo valid assessments by a professional via telehealth. Web-based applications allow clinicians to expand their repertoire and reach of services.

Hearing loss in Mozambique: current data from Inhambane Province.

Mozambique is a developing African country recuperating from a lengthy civil war. As a result, documenting the incidence of hearing loss has remained a low priority. This paper provides results from work being carried out by the Mozambique Audiology Program (MAP), which is a philanthropic effort established in 1997 to introduce audiology services and identify auditory disorders in the country. Some decades before the MAP, another program reported extremely high incidence rates of otitis media in 1000 primary school students in the capital city of Maputo. This paper presents the MAP results from mass hearing screenings conducted over a two year period on a cohort group of 2685 students ranging in age from 3–18 years at a preschool and primary school in Chicuque and Maxixe, Mozambique. This current study showed a prevalence of 5% of the total 2685 students across ages with varying degrees of hearing loss resulting from multiple etiologies. External auditory canal obstruction was the greatest otoscopic abnormality (regardless of age), followed by severely limited tympanic membrane mobility (i.e. flat tympanogram) in the absence of EAC obstruction in those students identified with hearing loss. Of the 145 student identified with hearing loss, there were 27 found to have active drainage. Some of the benefits of conducting mass hearing screening in this population are discussed.

Pure-tone audiometry outside a sound booth using earphone attentuation, integrated noise monitoring, and automation

Abstract Objective: Accessibility of audiometry is hindered by the cost of sound booths and shortage of hearing health personnel. This study investigated the validity of an automated mobile diagnostic audiometer with increased attenuation and real-time noise monitoring for clinical testing outside a sound booth. Design: Attenuation characteristics and reference ambient noise levels for the computer-based audiometer (KUDUwave) was evaluated alongside the validity of environmental noise monitoring. Clinical validity was determined by comparing air- and bone-conduction thresholds obtained inside and outside the sound booth (23 subjects). Study sample: Twenty-three normal-hearing subjects (age range, 20–75 years; average age 35.5) and a sub group of 11 subjects to establish test-retest reliability. Results: Improved passive attenuation and valid environmental noise monitoring was demonstrated. Clinically, air-conduction thresholds inside and outside the sound booth, corresponded within 5 dB or less > 90% of instances (mean absolute difference 3.3 ± 3.2 SD). Bone conduction thresholds corresponded within 5 dB or less in 80% of comparisons between test environments, with a mean absolute difference of 4.6 dB (3.7 SD). Threshold differences were not statistically significant. Mean absolute test-retest differences outside the sound booth was similar to those in the booth. Conclusion: Diagnostic pure-tone audiometry outside a sound booth, using automated testing, improved passive attenuation, and real-time environmental noise monitoring demonstrated reliable hearing assessments.

Special issue Technology Transfer of Hearing Aids

Welcome to our special issue of Disability and Rehabilitation: Assistive Technology on Technology Transfer of Hearing Aids to Low and Middle Income Countries (LMICs). This issue carries review articles describing the opportunities and challenges of technology transfer of hearing aids to LMICs. The primary purpose of this issue is to advance the international development literature in assistive technology, while using hearing aids and their service delivery as an example. A second aim is to provide an introduction to the barriers and incentives to establishing sustainable hearing aid projects in LMICs. Many of the articles are written by those with considerable experience with commercialization and service delivery to LMICs. They include perspectives from an international government organization, clinicians, educators, social entrepreneurs and policy experts, at least one of whom has a severe hearing loss. In the article entitled: ‘‘Hearing assistive technologies in developing countries: Background, achievements, challenges’’, Dr. McPherson provides data about the prevalence of hearing loss globally and in LMICs, the need for hearing technology, the dearth of trained professionals and best practice case studies of hearing aid service delivery and training curricula. The article entitled, ‘‘Understanding History, Philanthropy and the role of WHO’’ by the The World Health Organization (WHO) team comprised of Drs. Chadha, Moussy and Friede, describes WHO’s role in promoting accessible and affordable hearing devices, in forming international partnerships and networks of Member states, nongovernmental organizations, philanthropists, manufacturers and users. The Social Business Earth team of Caccamo, Voloshchenko and Dankyi, introduces social entrepreneurship with their article entitled, ‘‘The importance of creating a social business to produce low-cost hearing aids’’, as an antidote to the problem of affordability of hearing aids in LMICs. Social entrepreneurs, unlike business entrepreneurs that measure performance in profit and return, take into account a positive return to society. Two case studies provide examples of strategies for sustainable hearing aid projects in LMICs. Tesni and Santana present CBM’s holistic model, through their article, ‘‘Successful engagement: CBM’s holistic approach to the work in the area of ear care, deafness, hard of hearing and deafblindness’’, which includes intervention at all levels of health care provision, education, Community-based Rehabilitation and Audiology and Speech Therapy and other interdisciplinary services. In ‘‘Service, training and outreach – the EARS Inc. Model for a self-sustainable hearing program in action’’ Carkeet, Pither and Anderson illustrate a process to initiate, support and guide the establishment of a sustainable model for hearing aid provision in the Dominican Republic. Seelman and Werner focus on the international context of assistive technology development and delivery with their article, ‘‘Key Market and Policy Factors in Technology Transfer: Toward Sustainable Hearing Aid Projects’’. They explore the competitive advantage of the hearing aid industry and the balancing force of international governmental organizations, such as WHO. They use the value chain to identify and analyse policy and market factors at each stage in the technology development process which influences technology transfer. Clark and Swanepoel’s article, ‘‘Technology for Hearing Loss – as We Know It, and as We Dream It’’, takes us into the realm of e-health and innovation where the technology we dream about is almost here. They note that demand for hearing health increases but the number of hearing health professionals seems to stagnate. New and less expensive technological resources are becoming available to meet the demand such as those that teleport the professional to the patient. We are confident that readers will find each article not only offering valuable insight into those barriers and incentives that exist when establishing sustainable hearing aid projects in LMICs, but also provide an invaluable resource about international initiatives in assistive technology in LMICs.