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

Teleaudiology Services in Australia: A National Survey of Hearing Health Care Consumers Amid the COVID-19 Pandemic

PURPOSE

The aim of this study was to investigate the perspectives of Australia-based hearing health care consumers regarding the (a) provision and utilization of teleaudiology services, (b) experiences with teleaudiology, and (c) barriers and enablers to future teleaudiology use.

METHOD

A national prospective self-report online survey was completed between April and October 2020, amid COVID-19. Data were analyzed using descriptive statistics (closed-answer items) and content analysis (open-text responses). A total of 381 participants (Mage = 72.07 years ± 10.08, 142 females) were recruited from different states and territories of Australia.

RESULTS

Despite positive outcomes reported by those who undertook teleaudiology appointments during COVID-19, results indicate low-consumer teleaudiology uptake. It can be inferred that consumers were not aware of teleaudiology as an appointment option, clinicians/clinic staff had not informed and/or supported teleaudiology as an option, and biases existed that prevented teleaudiology being more widely adopted. It is unclear whether consumers who were eligible for government subsidies understood that teleaudiology appointments were reimbursed through government funding. Barriers to future teleaudiology uptake were largely related to concerns regarding confidentiality and privacy.

CONCLUSION

Low consumer uptake of teleaudiology appointments appears to be driven by consumer preference for in-person services, which appears to be driven by lack of knowledge regarding the availability and effectiveness of teleaudiology.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25619808.

The use of tele-audiology in ototoxicity monitoring: A scoping review

INTRODUCTION

Due to the growing burden of disease in South Africa, encompassing conditions such as tuberculosis, human immunodeficiency virus, and cancer, the holistic management of affected patients incorporating ototoxicity monitoring is a necessity. However, ototoxicity monitoring in developing countries may be limited due to a lack of resources and inadequate healthcare facilities. Subsequently, the use of tele-audiology may be a revolutionary technique with the potential to provide audiology services to under-served populations with limited access.

METHODS

The study aimed to describe the use of tele-audiology services in ototoxicity monitoring through a scoping review of English peer-reviewed articles from June 2009 to June 2020. Seventeen articles were purposively selected from the following databases: PubMed, Science Direct, Taylor and Francis Online, WorldCat, and Google Scholar. Data was extracted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram and results were analyzed using deductive thematic analysis.

RESULTS AND DISCUSSION

While a minority of the studies indicated that the cost of implementation and network connectivity within a South African context pose as barriers, most researchers reported that tele-audiology provides a reliable, time-efficient, cost-effective, and easily accessible alternative for ototoxicity monitoring. Hardware including the WAHTS, KUDUwave, and OtoID, along with software such as the TabSINT, Otocalc, uHear, and the hearTest, have proven to be useful for ototoxicity monitoring. A need for further investigations regarding the feasibility of tele-audiology implementation in South Africa is evident. Despite this, it provides audiologists with an opportunity to offer contact-less services during COVID-19, thus, confirming its versatility as an augmentative method for ototoxicity monitoring.

Neonatal hearing screening using a smartphone-based otoacoustic emission device: A comparative study

OBJECTIVE

Increasing options are becoming available for clinicians and healthcare professionals who use smartphone-based applications (apps) to identify hearing loss. The use of smartphone-based apps for newborn hearing screening (NHS) has been proposed as an alternative screening method in NHS programs. This study aims to compare the screening outcomes of a smartphone-based otoacoustic emission (OAE) screening device to a commercially available OAE screening device.

METHODS

NHS was conducted in the post-natal maternity ward and neonatal intensive care unit (NICU) of two tertiary public healthcare hospitals over a period of 8 months. Within participant DPOAE and TEOAE screening outcomes of a smartphone-based OAE device (hearOAE) were compared to that of the Otodynamics ILO V6.

RESULTS

A total of 176 infants (n = 352 ears; 48.9 % female) underwent NHS (DPOAE n = 176; TEOAE n = 176). The mean age at was 4.5 days (SD 11.3). Signal-to-noise ratio (SNR) were higher with the hearOAE with TEOAE NHS, and equivalent or higher SNR at four out of six frequencies with DPOAEs. Mean and total noise levels were significantly lower for the hearOAE compared to the Otodynamics with DPOAEs noise levels of five out of six frequencies being equivalent to, or lower than the Otodynamics (p < 0.001). Lower noise levels are likely to be advantageous in less-than-ideal test conditions. Inter-device DPOAE comparison indicated no statistically significant difference in the refer rate between the devices (p = 0.238). DPOAE pass rates between devices differed in 6 ears (p > 0.05), and in 20 ears for TEOAEs, with the hearOAE demonstrating a higher TEOAE pass rate (p = 0.009). The hearOAE did, however, demonstrate lower noise levels at three out five frequencies, which may have impacted the pass rate. No statistically significant correlation was found between the independent variables and the screening outcome (pass/refer) for TEOAEs using either device (p = 0.105 to 0.810). A high concordance of NHS outcomes within-participants of 89.7 % and 85.0 % for DPOAE and TEOAE respectively, was measured.

CONCLUSIONS

The mHealth based OAE device demonstrated good agreement in NHS outcomes compared to a commercially available device. This verifies the performance of the novel smartphone based OAE device, and may facilitate increased accessibility of decentralised NHS service in resource constrained populations.

A hospital-based asynchronous ENT telehealth service for children with otitis media: Cost-minimisation and improved access

AIM

The purpose of this study is to explore the effectiveness of a hospital-based asynchronous ear, nose, and throat (ENT) telehealth service (the Ear Portal) in reducing cost and improving access for children with otitis media.

METHODS

Participants were recruited to the Ear Portal from a tertiary hospital ENT waiting list. Ear and hearing assessments were conducted during appointments by the Ear Portal research assistant, and data was stored for an asynchronous review by the Ear Portal multidisciplinary team. A cost-minimisation analysis was conducted for the Ear Portal and the standard care pathways. Waiting times to provide care for both pathways were calculated for children with semi-urgent (i.e. Category 2) and non-urgent (i.e. Category 3) referrals.

RESULTS

The running cost for the Ear Portal was $67.70 for initial appointments and $37.34 for follow-up appointments. Conversely, the running cost for the standard care pathway was $154.65 for initial appointments and $86.10 for follow-up appointments. A total of 223 appointments were required to offset the initial Ear Portal investment of $19,384.00. The median waiting time for the Ear Portal from initial contact to care plan delivery was <30 days, whereas the median waiting times for children in the standard care pathway were 291 days (interquartile range (IQR) = 117) for Category 2 and 371 days (IQR = 311) for Category 3 referrals.

CONCLUSION

Under the current circumstances, the Ear Portal service can reduce costs for the health care system by reducing marginal costs per patient in addition to providing ENT specialist care within the clinically recommended timeframes.

Remote hearing-aid delivery and support: perspectives of patients and their hearing care providers

OBJECTIVE

To explore the perspectives of patients and hearing care providers (HCPs) about an adult remote hearing-aid delivery service implemented during the COVID-19 pandemic.

DESIGN

Service evaluation via surveys. The patient survey measured satisfaction with the service, perceived hearing-aid handling skills, and preferences for future services. The HCP survey explored the impact of teleaudiology on outcomes compared to in-person care and factors important for successful teleaudiology.

STUDY SAMPLE

378 patients and 14 HCPs.

RESULTS

Patients were highly satisfied with the service and self-reported good hearing-aid handling skills. However, 2 in 3 patients said they would prefer a future hearing-aid fitting to be in-person rather than remote. HCPs thought teleaudiology had positive impacts on convenience, accessibility, and flexibility, but negative impacts on communication, rapport, and the quality of care. HCPs considered computer literacy and individual preferences to be important for successful remote care; the age of the patient was considered less important.

CONCLUSIONS

Patients were generally highly satisfied with the service and for 1 in 3 it was their preferred mode of future hearing-aid fitting. Future services should be aware that a one-size-fits-all approach will not satisfy all patients and that teleaudiology should be offered on the basis of individual preference.

Service delivery approaches related to hearing aids in low- and middle-income countries or resource-limited settings: A systematic scoping review

Hearing loss is an important global public health issue which can be alleviated through treatment with hearing aids. However, most people who would benefit from hearing aids do not receive them, in part due to challenges in accessing hearing aids and related services, which are most salient in low- and middle-income countries (LMIC) and other resource-limited settings. Innovative approaches for hearing aid service delivery can overcome many of the challenges related to access, including that of limited human resources trained to provide ear and hearing care. The purpose of this systematic scoping review is to synthesize evidence on service delivery approaches for hearing aid provision in LMIC and resource-limited settings. We searched 3 databases (PubMed, Scopus, Ovid MEDLINE) for peer-reviewed articles from 2000 to 2022 that focused on service delivery approaches related to hearing aids in LMIC or resource-limited settings. Fifteen peer-reviewed articles were included, which described hospital-based (3 studies), large-scale donation program (1 studies), community-based (7 studies), and remote (telehealth; 4 studies) service delivery approaches. Key findings are that hearing aid services can be successfully delivered in hospital- and community-based settings, and remotely, and that both qualified hearing care providers and trained non-specialists can provide quality hearing aid services. Service delivery approaches focused on community-based and remote care, and task sharing among qualified hearing care providers and trained non-specialists can likely improve access to hearing aids worldwide, thereby reducing the burden of untreated hearing loss.

Evaluation of the Quality and Readability of Online Information about Alzheimer's Disease in China

Background

With the increasing popularity of the internet, a growing number of patients and their companions are actively seeking health-related information online.

Objective

The aim of this study was to assess the quality and readability of online information about Alzheimer's disease (AD) in China.

Methods

A total of 263 qualified AD-related web pages from different businesses, governments, and hospitals were obtained. The quality of the web pages was assessed using the DISCERN tool, and the readability of the web pages was assessed using a readability measurement website suitable for the Chinese language. The differences in readability and quality between different types of web pages were investigated, and the correlation between quality and readability was analyzed.

Results

The mean overall DISCERN score was 40.93±7.5. The government group scored significantly higher than the commercial and hospital groups. The mean readability score was 12.74±1.27, and the commercial group had the lowest readability score. There was a positive correlation between DISCERN scores and readability scores.

Conclusions

This study presents an evaluation of the quality and readability of health information pertaining to AD in China. The findings indicate that there is a need to enhance the quality and readability of web pages about AD in China. Recommendations for improvement are proposed in light of these findings.

Telehealth Awareness, Perception, Practice, and Influence of the COVID-19 Pandemic: A Questionnaire to Speech-Language Pathologists and Audiologists

Introduction: The objective of this work was to investigate Speech-Language Pathologists' (SLPs) and audiologists' telehealth awareness, experience, and perception in terms of applicability, effectiveness, barriers, facilitators, and the influence of the coronavirus disease 2019 (COVID-19) pandemic on telehealth practice. Methods: A questionnaire was developed and validated based on relevant literature, authors' clinical expertise, and a published survey. Sample size was determined through power analysis, and participants were recruited using a snowball-sampling technique. Results: Ninety-five (n = 95) clinicians completed a survey. A majority (87.4%) reported awareness of and 68.4% reported experience with telehealth. The SLPs (86.4%) had more experience than audiologists (38.9%). Overall, 78.5% first used telehealth during the COVID-19 pandemic, with no significant difference in telehealth use during versus after the pandemic lockdown; 63.8% reported telehealth being less effective than in-person. However, there were differences in perceived telehealth effectiveness: Telehealth was significantly more effective for consultations and counseling, with adults aged 18-40 years; and clients with fluency and speech sound disorders. The highest significant barrier to telehealth delivery was network issues, and available workplace resources was the highest facilitator although this was not significant. Conclusions: Most clinicians were aware of telehealth, had a positive attitude toward it, and had experience using telehealth. More SLPs than audiologists used telehealth. The COVID-19 pandemic had a positive influence on telehealth service provision with an increase in use that was maintained after in-person services were re-initiated. Perceived effectiveness of telehealth services varied depending on the type of clinical service, the client's age, and diagnosis. These factors must be considered while planning telehealth services in Speech-Language Pathology and Audiology.

Barriers and facilitators to tele-audiology service delivery in Australia during the COVID-19 pandemic: perspectives of hearing healthcare clinicians

OBJECTIVE

To explore the utilisation, safety, cost, and patient outcomes of delivering tele-audiology services during the COVID-19 pandemic.

DESIGN

A national cross-sectional self-report online survey asking participants to reflect on interactions with hearing services between April and October 2020. Data were analysed using descriptive statistics. The COM-B model of behaviour change guided survey creation and the presentation of a subset of the results.

STUDY SAMPLE

249 Australia-based hearing healthcare clinicians (age range 23-74 years; 162 female).

RESULTS

Clinicians reported an increase in the use of tele-audiology services, with key drivers relating to keeping their patients safe and keeping businesses running. Clinicians generally viewed the provision of tele-audiology services as successful and resulting in improved patient outcomes. Overall, clinicians were highly motivated to provide tele-audiology services, and they expressed being confident in their knowledge and understanding of tele-audiology service delivery. Barriers to providing tele-audiology services included concerns about the reliability of the results obtained from remote assessments, as well as concerns around information security and privacy issues.

CONCLUSIONS

Clinicians' motivations to use tele-audiology services appeared to be driven by their desire to maintain COVID-safe practices during the pandemic and by the COVID-driven increase in availability of funding for tele-audiology services.

Implementation factors influencing the sustained provision of tele-audiology services: insights from a combined methodology of scoping review and qualitative semistructured interviews

OBJECTIVES

The objectives of the current study were to (a) identify long-term tele-audiology services reported to be implemented beyond the research phase and determine whether they are sustained, (b) map the implementation process to Standards for Reporting Implementation Studies guidelines and (c) map the factors that influenced its sustainability to the Implementation Outcomes Framework (IOF) to understand the gaps from an implementation research perspective.

STUDY DESIGN, SETTING AND PARTICIPANTS

This cross-sectional study included a scoping review of articles describing long-term tele-audiology services from around the world to determine the factors influencing the implementation. Six electronic databases (PubMed, Cochrane Library, Web of Science, Scopus, Google Scholar and ProQuest) were searched for literature published between 2010 and 2023. This was followed by semistructured interviews (SSIs), which were guided by the IOF. Six project implementers were interviewed to obtain an in-depth understanding of factors that influenced sustainability of these tele-audiology services. Thematic analysis of the interview transcripts was carried out using a hybrid inductive-deductive approach.

RESULTS

Data were extracted from 32 tele-audiology studies included in the review, which were then mapped to 21 projects. The findings of the scoping review reveal that tele-audiology services were predominantly provided using synchronous telepractice methods. The 'professional-facilitator-patient' model was most commonly used. None of the studies reported the use of implementation research and/or outcome frameworks. Factors that influenced sustainability of tele-audiology services were identified from the combined results of the scoping review and the SSIs. These factors could be mapped to implementation outcomes of acceptability, adoption, feasibility, implementation cost and sustainability.

CONCLUSION

Implementation research and/or outcome framework should be used to guide the implementation processes, its evaluation and measurement of outcomes systematically in tele-audiology service delivery. When such frameworks are used, gaps in information regarding the context influencing implementation, reporting of fidelity and adaptability measures can be addressed.

Hearing Health Care Stakeholders' Perspectives on Teleaudiology Implementation: Lessons Learned During the COVID-19 Pandemic and Pathways Forward

PURPOSE

The purpose of this study was to explore how teleaudiology is perceived by Australian-based hearing health care stakeholders (clients, clinicians, students, academics, and industry partners) to inform future teleaudiology implementation.

METHOD

Five cross-sectional online surveys were adopted, and a total of 366 stakeholders responded (173 clients, 110 clinicians, 58 students, 19 academics, and six industry partners).

RESULTS

Results show that 55% of clients and over 90% of clinicians, students, academics, and industry partners knew what teleaudiology was. Experience in teleaudiology appointments was shared by 85% of clinicians and 7% of clients. Moreover, 98% of clients were not offered any teleaudiology appointments. Teleaudiology apps were used by 66% of clinicians and 26% of clients. Both clients and clinicians acknowledged the benefits of teleaudiology including convenience and accessibility and identified drawbacks, such as loss of personal interaction and communication difficulty. About 80% of students and academics reported inclusion of teleaudiology within their universities' curriculum but only to a limited extent. Low teleaudiology uptake rates in placement clinics, as well as insufficient funding and staffing, were suggested as barriers to learning and teaching teleaudiology. Industry partners were generally confident in training clinicians to use teleaudiology products and teaching students on teleaudiology, but only one industry partner had been invited by universities for teaching purposes.

CONCLUSIONS

Low teleaudiology use and reserved attitudes toward widespread teleaudiology implementation were observed among clients. Clinicians, students, academics, and industry partners generally displayed positive attitudes toward teleaudiology use. Increasing awareness of teleaudiology services and collaboration between stakeholders are crucial in promoting teleaudiology uptake.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23519292.

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.

Test-Retest repeatability of automated threshold audiometry in Nicaraguan schoolchildren

OBJECTIVE

Automated threshold audiometry (ATA) could increase access to paediatric hearing assessment in low- and middle-income countries, but few studies have evaluated test-retest repeatability of ATA in children. This study aims to analyse test-retest repeatability of ATA and to identify factors that affect the reliability of this method.

DESIGN

ATA was performed twice in a cohort of Nicaraguan schoolchildren. During testing, the proportion of responses occurring in the absence of a stimulus was measured by calculating a stimulus response false positive rate (SRFP). Absolute test-retest repeatability was determined between the two trials, as well as the impact of age, gender, ambient noise, head circumference, and SRFP on these results.

STUDY SAMPLE

807 children were randomly selected from 35 schools in northern Nicaragua.

RESULTS

Across all frequencies, the absolute value of the difference between measurements was 5.5 ± 7.8 dB. 89.6% of test-retest differences were within 10 dB. Intra-class correlation coefficients between the two measurements showed that lower SRFP was associated with improved repeatability. No effect of age, gender, or ambient noise was found.

CONCLUSIONS

ATA produced moderate test-retest repeatability in Nicaraguan schoolchildren. Participant testing behaviours, such as delayed or otherwise inappropriate response patterns, significantly impacts the repeatability of these measurements.

Ototoxicity prognostic models in adult and pediatric cancer patients: a rapid review

PURPOSE

A cornerstone of treatment for many cancers is the administration of platinum-based chemotherapies and/or ionizing radiation, which can be ototoxic. An accurate ototoxicity risk assessment would be useful for counseling, treatment planning, and survivorship follow-up in patients with cancer.

METHODS

This systematic review evaluated the literature on predictive models for estimating a patient's risk for chemotherapy-related auditory injury to accelerate development of computational approaches for the clinical management of ototoxicity in cancer patients. Of the 1195 articles identified in a PubMed search from 2010 forward, 15 studies met inclusion for the review.

CONCLUSIONS

All but 1 study used an abstraction of the audiogram as a modeled outcome; however, specific outcome measures varied. Consistently used predictors were age, baseline hearing, cumulative cisplatin dose, and radiation dose to the cochlea. Just 5 studies were judged to have an overall low risk of bias. Future studies should attempt to minimize bias by following statistical best practices including not selecting multivariate predictors based on univariate analysis, validation in independent cohorts, and clearly reporting the management of missing and censored data. Future modeling efforts should adopt a transdisciplinary approach to define a unified set of clinical, treatment, and/or genetic risk factors. Creating a flexible model that uses a common set of predictors to forecast the full post-treatment audiogram may accelerate work in this area. Such a model could be adapted for use in counseling, treatment planning, and follow-up by audiologists and oncologists and could be incorporated into ototoxicity genetic association studies as well as clinical trials investigating otoprotective agents.

IMPLICATIONS FOR CANCER SURVIVORS

Improvements in the ability to model post-treatment hearing loss can help to improve patient quality of life following cancer care. The improvements advocated for in this review should allow for the acceleration of advancements in modeling the auditory impact of these treatments to support treatment planning and patient counseling during and after care.

Impact of COVID-19 Pandemic on Older Adults Using Hearing aid/s: Indian Scenario

The present study explored the impact of COVID-19 on hearing health and problems faced by older adults using hearing aid/s. Fifty older adults in the age range of 55–95 years were selected for the study based on the inclusion and exclusion criteria. Therefore, the developed questionnaire was administered to them. Statistical analysis was performed for all the responses achieved. Closure of hearing aid companies and audiological centers was found to have a negative impact on availing audiological services. Likewise, a huge hike in the price of these services made it impossible for people to afford them. Despite the availability of tele-audiology, older adults were not able to make the best use of it due to numerous reasons. We sought to explore patients’ perceptions to break down these barriers by enhancing the quality of tele-audiology, home visits, and remote services. Therefore, the present report may facilitate in planning and implementation of policies related to audiological services, especially during times of crisis, which may help strengthen our hearing health care system.

An off-the-shelf otoacoustic-emission probe for hearing screening via a smartphone

Otoacoustic emissions (OAEs) provide information about the function of the outer hair cells of the cochlea. In high-income countries, infants undergo OAE tests as part of the screening protocols for hearing. However, the cost of the necessary equipment hinders early screening for hearing in low- and middle-income countries, which disproportionately bear the brunt of disabling hearing loss. Here we report the design and clinical testing of a low-cost probe for OAEs. The device, which has a material cost of approximately US$10, uses an off-the-shelf microphone and off-the-shelf earphones connected to a smartphone through a headphone jack. It sends two pure tones through each of the headphone's earbuds and algorithmically detects the distortion-product OAEs generated by the cochlea and recorded via the microphone. In a clinical study involving 201 paediatric ears across three healthcare sites, the device detected hearing loss with 100% sensitivity and 88.9% specificity, comparable to the performance of a commercial device. Low-cost devices for OAE testing may aid the early detection of hearing loss in resource-constrained settings.

Participatory user requirements elicitation, validation, and prioritization for tele-otology app in deprived populations

BACKGROUND

The timely and accurate diagnosis of ENT (Ear, Nose, and throat) diseases in deprived areas is very important due to the increased burden of the disease in high-risk populations. Therefore, the purpose of this study is to identify, validate and prioritize the information needs of stakeholders of a tele-otology system for diagnosing ear diseases and to provide a solution.

MATERIAL AND METHODS

In this study, to identify the information need of the stakeholders and prioritize them, the spiral-iterative model was used. Data were obtained through direct observation, interviews with 23 stakeholders (6 ENT specialist doctors, 3 health center managers, 2 patients, and 12 health facilitators), and a survey among all ENT specialists and residents (n = 49), working in Kerman province, Iran. Finally, based on the study findings, the important information needs of the stakeholders were considered as the input for developing the tele-otology software.

RESULTS

In the observation phase, the workflow of the tele-otology system was developed. In the interview phase, 4 main themes including patient information; Technology and communication; Policy, guidelines, and requirements; Facilitator skills and knowledge were determined. In total, the four categories of the iterative-spiral model including strategic, patient information, commercial and technical with 8, 9, 3, and 9 sub-categories, respectively, were prioritized by specialists which were considered as input for system development.

CONCLUSION

By applying the spiral-iterative model, the prototype included a mobile app and server system was developed. In the final solution, the possibility of capturing patient history and video images was provided for facilitators to help physicians in effective diagnosis. The results of this study, while identifying the workflow of service providers and determining their information needs can help telemedicine system developers to have an optimal design when designing systems for the diagnosis of ear disease.

Perceptions of Telehealth Services for Hearing Loss in South Africa’s Public Healthcare System

Telehealth promises increased access to hearing healthcare services, primarily in areas where hearing healthcare resources are limited, such as within the South African public healthcare system. Telehealth for hearing healthcare is especially important during the COVID-19 pandemic, where physical distancing has been essential. This study aimed to describe audiologists’ perceptions regarding telehealth services for hearing loss within South Africa’s public healthcare system. This study was divided into two phases. During Phase 1, 97 audiologists completed an electronic survey regarding their perceptions of telehealth for hearing loss within South African public sector hospitals. Synchronous virtual focus-group discussions were conducted during Phase 2. Results indicated that audiologists recognized telehealth services’ potential to improve hearing healthcare efficiency within the public sector, and most (84.1%) were willing to use it. However, telehealth’s actual uptake was low despite almost doubling during the COVID-19 pandemic. Prominent perceived barriers to telehealth were primarily related to hospital resources, including the unavailability of equipment for the remote hearing/specialized assessments, internet-related barriers, and limited IT infrastructure. An increased understanding of telehealth in South Africa’s public healthcare system will assist in identifying and in improving potential barriers to telehealth, including hospital resources and infrastructure.

Understanding the implementation of telepractice in speech and language services using a mixed-methods approach

Background: Telepractice emerged as a solution to overcome the challenges of access issues in the delivery of healthcare. Telepractice in speech language pathology (SLP) has existed for nearly a decade yet there is a significant knowledge gap with respect to the factors influencing the implementation of telepractice as a routine or long-term, sustained effort. This mixed-methods study aimed to identify implementation factors that influence the provision of telepractice in SLP services.

Method: A mixed-methods study consisting of a scoping review and semi-structured interviews (SSI) was carried out. Articles that described telepractice in SLP were included based on an operational definition of implementation and a set of inclusion criteria.

Results: Data was extracted from 11 studies that were mapped to nine projects in telepractice in SLP. The broad focus areas identified included diagnostics and evaluation, therapeutics and comprehensive assessment, management and follow-up care services. Synchronous/ real-time telepractice methods were always used for the provision of diagnostic testing or when providing therapy services using video conferencing. The ‘ professional-facilitator-patient’ model was used most commonly followed by the ‘ professional-patient’ model.  Barriers for long-term sustainability included inadequate initial capital investment, lack of reimbursement and payment options, low internet speed and bandwidth, resistance and hesitancy to use telepractice from the patient’s end, lack of organizational policies and uniform regulations. Sustainable source of funding, having a dedicated team of professionals and technicians with clear roles and responsibilities, and inclusion of systematic planning facilitated implementation. 

Conclusion: In general, telepractice in SLP was not explicitly guided by implementation science or framework. The use of implementation frameworks ensures systematic planning and feasibility assessment to inform the scale-up of implementation. Therefore, it would be worthwhile for program implementers to consider these aspects when exploring telepractice services.

[Telerehabilitation of hearing-impaired children during COVID-19 pandemic]

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.

Effectiveness of an online continuing education course in infant hearing health for primary care professionals

OBJECTIVE

To evaluate the effectiveness of an online continuing education course on infant hearing health for primary care professionals.

DESIGN

A prospective longitudinal study with interrupted time series pre-test/post-test design. The effectiveness of the online course was assessed by comparing pre- vs. post-training performance and analysing responses to evaluations of the quality of the course.

STUDY SAMPLE

The sample comprised individuals enrolled between September 2018 and August 2019 in a Ministry of Health course, "Actions in primary care for the early identification of hearing impairment" offered on the AVASUS platform.

RESULTS

Of the 2908 individuals registered, 1842 (63.3%) completed the course. Their ages ranged from 18 to 77 years, and 67.4% of them were females. Students and doctors were overrepresented among the enrollees. All Brazilian states were included in the sample. Comparisons of pre- and post-training performances showed a significant improvement in knowledge, and 99.3% of the participants provided positive comments regarding the quality of the course.

CONCLUSIONS

The course is an effective distance learning tool on infant hearing health for primary care professionals. The online course circumvents the limitations posed by geographical barriers and also facilitates decentralisation.

Online digital audiometry vs. conventional audiometry: a multi-centre comparative clinical study

OBJECTIVE

The primary objective of the current study was the validation of a cloud-centralized audiometry system for clinical practice.

DESIGN

A cross-sectional study design was used.

STUDY SAMPLE

A convenience sample of patients (>10 years old) booked for follow-up appointments were invited to participate. Participants completed both conventional and online digital audiometry in a standard sound treated clinic space during a single clinic visit; tests were completed in random order. Data for both ears were included. Patients were from one of three audiological practices.

RESULTS

A total of 41 participants completed both audiometric tests. Validation study results showed that the mean difference between the two audiometric test results remained within 5 dB HL for both air and bone conduction thresholds at all tested frequencies.

CONCLUSIONS

Online digital audiometry has been demonstrated as a clinically accurate method for hearing assessment.

Understanding the implementation of telepractice in speech and language services for children and adults using a mixed-methods approach

Background: Telepractice emerged as a solution to overcome the challenges of access issues in the delivery of healthcare. Telepractice in speech language pathology (SLP) has existed for nearly a decade yet there is a significant knowledge gap with respect to the factors influencing the implementation of telepractice as a routine or long-term, sustained effort. This mixed-methods study aimed to identify implementation factors that influence the provision of telepractice in SLP services. Method: A mixed-methods study consisting of a scoping review and semi-structured interviews (SSI) was carried out. Articles that described telepractice in SLP were included based on an operational definition of implementation and a set of inclusion criteria. Results: Data was extracted from 11 studies that were mapped to nine projects in telepractice in SLP. The broad focus areas identified included diagnostics and evaluation, therapeutics and comprehensive assessment, management and follow-up care services. Synchronous/ real-time telepractice methods were always used for the provision of diagnostic testing or when providing therapy services using video conferencing. The ‘professional-facilitator-patient’ model was used most commonly followed by the ‘professional-patient’ model.  Barriers for long-term sustainability included inadequate initial capital investment, lack of reimbursement and payment options, low internet speed and bandwidth, resistance and hesitancy to use telepractice from the patient’s end, lack of organizational policies and uniform regulations. Sustainable source of funding, having a dedicated team of professionals and technicians with clear roles and responsibilities, and inclusion of systematic planning facilitated implementation.  Conclusion: In general, telepractice in SLP was not explicitly guided by implementation science or framework. The use of implementation frameworks ensures systematic planning and feasibility assessment to inform the scale-up of implementation. Therefore, it would be worthwhile for program implementers to consider these aspects when exploring telepractice services.

EHealth and Its Role in Supporting Audiological Rehabilitation: Patient Perspectives on Barriers and Facilitators of Using a Personal Hearing Support System With Mobile Application as Part of the EVOTION Study

Background

Hearing loss is a major public health challenge. Audiology services need to utilise a range of rehabilitative services and maximise innovative practice afforded by technology to actively promote personalized, participatory, preventative and predictive care if they are to cope with the social and economic burden placed on the population by the rapidly rising prevalence of hearing loss. Digital interventions and teleaudiology could be a key part of providing high quality, cost-effective, patient-centred management. There is currently very limited evidence that assesses the hearing impaired patient perspective on the acceptance and usability of this type of technology.

Aim

This study aims to identify patient perceptions of the use of a hearing support system including a mobile smartphone app when used with Bluetooth-connected hearing aids across the everyday life of users, as part of the EVOTION project.

Methods

We applied a questionnaire to 564 participants in three countries across Europe and analysed the following topics: connectivity, hearing aid controls, instructional videos, audiological tests and auditory training.

Key Findings

Older users were just as satisfied as younger users when operating this type of technology. Technical problems such as Bluetooth connectivity need to be minimised as this issue is highly critical for user satisfaction, engagement and uptake. A system that promotes user-controllability of hearing aids that is more accessible and easier to use is highly valued. Participants are happy to utilise monitoring tests and auditory training on a mobile phone out of the clinic but in order to have value the test battery needs to be relevant and tailored to each user, easy to understand and use. Such functions can elicit a negative as well as positive experience for each user.

Conclusion

Older and younger adults can utilise an eHealth mobile app to complement their rehabilitation and health care. If the technology works well, is tailored to the individual and in-depth personalised guidance and support is provided, it could assist maximisation of hearing aid uptake, promotion of self-management and improving outcomes.

Audiologists’ Perceptions of Hearing Healthcare Resources and Services in South Africa’s Public Healthcare System

Background:

Hearing loss poses a significant burden globally. Its prevalence is exceptionally high in countries across the African region, where healthcare resources and services remain inaccessible. This study aimed to describe audiologists’ perceptions regarding hearing healthcare resources and services within South Africa’s public healthcare system.

Methods:

A national self-developed telephonic survey was conducted with audiologists in public healthcare system hospitals across South Africa, with the final sample comprising 100 audiologists.

Results:

Most (82%) audiologists indicated that their hospitals did not have adequate hearing healthcare resources to render efficient audiology services to patients. Binaural amplification devices (invasive and non-invasive) for adults with bilateral hearing loss who adhered to the criteria for these devices were perceived to be unavailable in most hospitals. Audiologists also perceived that universal newborn hearing screening services, adult aural rehabilitation services, and follow-up care for all hearing devices post-warranty expiration were limited.

Conclusion:

Efforts should be made to upsurge hearing healthcare resources, including increasing the financial budgets allocated to audiology resources so that increased diagnostic and screening audiology equipment and hearing devices can be procured where required, and additional audiologists can be employed within the South African public sector hospitals where needed.

Alternative Pathways for Hearing Care May Address Disparities in Access

Background/Objectives: Low-uptake of hearing aids among older adults has long dogged the hearing care system in the U.S. and other countries. The introduction of over-the-counter hearing aids is set to disrupt the predominantly high-cost, specialty clinic-based delivery model of hearing care with the hope of increasing accessibility and affordability of hearing care. However, the current model of hearing care delivery may not be reaching everyone with hearing loss who have yet to use hearing aids. In this study, we examine the group of people who do not use hearing aids and describe their characteristics and health care utilization patterns. We also consider what other healthcare pathways may be utilized to increase access to hearing treatment. Design: Cross-sectional, the 2017 Medicare Current Beneficiary Survey. Setting: Non-institutionalized adults enrolled in Medicare, the U.S. public health insurance program for older adults (65 years and older) and those with qualifying medical conditions and disabilities. Participants: A nationally representative sample of 7,361 Medicare beneficiaries with self-reported trouble hearing and/or hearing aid use. Measurements: Survey-weighted proportions described the population characteristics and health care utilization of those with hearing loss by hearing aid use, and the characteristics of those with untreated hearing loss by health care service type utilized. Results: Women, racial/ethnic minorities, and low-income Medicare beneficiaries with self-reported hearing trouble were less likely to report using hearing aids than their peers. Among those who do not use hearing aids, the most commonly used health care services were obtaining prescription drugs (64%) and seeing a medical provider (50%). Only 20% did not access either service in the past year. These individuals were more likely to be young and to have higher educational attainment and income. Conclusion: Alternative models of care delivered through pharmacies and general medical practices may facilitate access to currently underserved populations as they are particularly high touch-points for Medicare beneficiaries with untreated hearing trouble. As care needs will vary across a spectrum of hearing loss, alternative models of hearing care should look to complement not substitute for existing access pathways to hearing care.

Process Evaluation of an Online SUpport PRogram for Older Hearing Aid Users Delivered in a Cluster Randomized Controlled Trial

Objectives: To evaluate the process of implementing a web-based support program (SUPR) for hearing aid users in the Dutch dispensing setting in order to allow interpretation of the randomized controlled trial's results (positive effects on hearing-aid related outcomes; no effects on psychosocial outcomes).

Design: Measures: context of implementation, recruitment, SUPR's: reach, implementation fidelity, dose delivered, dose received, satisfaction, and benefit. Data collection: quantitative and qualitative.

Study Sample: One hundred thirty-eight clients (mean age 68.1 years; 60% male) and 44 dispensers completed questionnaires. Five clients and 6 dispensers participated in interviews and focus groups.

Results: Clients and dispensers were generally satisfied with SUPR's usefulness. SUPR-videos were watched by 7–37% of the clients. Around half of the dispensers encouraged clients to watch them or informed them about SUPR. Some clients found the SUPR-materials suboptimal, and changes in personnel and limited dispenser-training were barriers acting on a contextual level.

Conclusions: This study identified several factors that contributed to the success of SUPR. Others factors, acting on various levels (e.g., intervention material, dispensers, and implementation context), were suboptimal and may explain the absent psychosocial effects. The identified factors are important to consider in further development of SUPR, and in other web-based support programs.

The reliability of video otoscopy recordings and still images in the asynchronous diagnosis of middle-ear disease

OBJECTIVE

To compare the asynchronous assessment of video otoscopic still images to recordings by an audiologist and ear, nose and throat surgeon (ENT) for diagnostic reliability and agreement in identifying middle-ear disease.

DESIGN

A prospective cross-sectional study, asynchronously assessing video otoscopy, tympanometry and case history (Dx1). A subset was re-diagnosed (Dx2).

STUDY SAMPLE

Video otoscopy and data from 146 children recruited at two public community events; a sub-set of 47 were re-assessed.

RESULTS

The intra-rater diagnostic agreement between Dx1 and Dx2 was moderate (k = 0.445-0.552) for the ENT surgeon, and almost-perfect (k = 0.928) for the audiologist, in both procedures. The agreement between the two procedures was substantial (k = 0.624) and moderate (k = 0.416) for the ENT surgeon in Dx1 and Dx2 respectively, and almost-perfect for the audiologist (k = 0.854-0.978) in both rounds. In Dx1, the inter-rater agreement between the clinicians was substantial using still images (k = 0.672) and moderate using recordings (k = 0.593); in Dx2 it was moderate using both procedures (k = 0.477-0.488).

CONCLUSION

Both video otoscopic procedures, in addition to tympanometry and case history information, can be reliably used for asynchronous diagnosis of childhood middle-ear disease. An audiologist has a potential role in triaging children with middle-ear abnormalities and, therefore, improving access to ear-health services.

Digital Technology for Remote Hearing Assessment—Current Status and Future Directions for Consumers

Globally, more than 1.5 billion people have hearing loss. Unfortunately, most people with hearing loss reside in low- and middle-income countries (LMICs) where traditional face-to-face services rendered by trained health professionals are few and unequally dispersed. The COVID-19 pandemic has further hampered the effectiveness of traditional service delivery models to provide hearing care. Digital health technologies are strong enablers of hearing care and can support health delivery models that are more sustainable. The convergence of advancing technology and mobile connectivity is enabling new ways of providing decentralized hearing services. Recently, an abundance of digital applications that offer hearing tests directly to the public has become available. A growing body of evidence has shown the ability of several approaches to provide accurate, accessible, and remote hearing assessment to consumers. Further effort is needed to promote greater accuracy across a variety of test platforms, improve sensitivity to ear disease, and scale up hearing rehabilitation, especially in LMICs.

Diagnostic Accuracy of Smartphone-Based Audiometry for Hearing Loss Detection: Meta-analysis

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.

Online, Asynchronous Hearing Education and Research Project for Ethnically Diverse Adolescents via Interprofessional Collaboration and Electronic Service-Learning During the COVID-19 Pandemic: A Pilot Study on the Needs and Challenges

Purpose This study discusses the creation of an online, asynchronous presentation to educate adolescents about prevention of noise-induced hearing loss (NIHL) through interprofessional collaborations and electronic service-learning (eSL) during the COVID-19 pandemic. Method The Hearing Education and Research (HEAR) presentation, which included activities and videos to educate a group of ethnically diverse adolescents (n = 100) on NIHL, was created by 11 doctor of audiology (AuD) students through online collaborations toward course-related eSL requirements. Adolescents responded to a baseline survey to assess hearing health-related behaviors prior to reviewing the presentation. A postprogram survey was administered 1 week after the presentation to assess change in knowledge and attitudes toward NIHL prevention. Online collaborations with schoolteachers helped with project implementation. Postreflection papers written by AuD students regarding the eSL activities were analyzed. Lastly, suggestions from a focus group of educators were included that highlight the role of interprofessional collaborations to enhance school-based hearing conservation opportunities. Results The HEAR presentation resulted in changes in knowledge about NIHL among the adolescents. Postreflection papers by the AuD students indicated that the eSL activity served as a high-impact pedagogical assignment, especially during the academic challenges of the pandemic. Feedback from a focus group of schoolteachers helped outline ideas for future implementation of sustainable hearing conservation programs in school settings. Conclusion The pilot data collected in this study serve as a proof of concept for future hearing conservation projects in school-based settings via interprofessional collaborations and by engaging university students via eSL.

Feasibility of community health workers as teleaudiology patient-site facilitators: a multilevel training study

OBJECTIVE

We evaluated the feasibility of a multi-level teleaudiology patient-site facilitator training program for Community Health Workers (CHWs) at a partnering health centre in southern Arizona.

DESIGN

Three levels were offered: Introductory, with basic information on hearing loss and teleaudiology; Intermediate, on technology, team roles, and access issues; and Facilitator, on further knowledge and hands-on skills to serve as patient-site facilitators in synchronous hearing aid service delivery. Six domains of feasibility were addressed using a mixed-methods design. Quantitative data included survey responses and observation of hands-on skills. Qualitative data included field notes from group discussion and open-ended survey questions, and were analysed using CHW core competencies.

STUDY SAMPLE

Twelve CHWs participated in the introductory training, ten moved on to intermediate, and three continued to the facilitator.

RESULTS

Quantitative outcomes indicated that the trainings were feasible according to each of the six domains. CHWs in the facilitator training passed the practical hands-on skill assessment. Qualitative analyses revealed CHWs comments addressed eight of the ten possible CHW core competencies, and focussed on service coordination/navigation, and capacity building.

CONCLUSIONS

Teleaudiology trainings for CHWs were feasible, increasing service capacity for a potential pathway to improve access to hearing health care in low-resource areas.

Remote check test battery for cochlear implant recipients: proof of concept study

OBJECTIVES

(1) To investigate the remote check test battery, designed for self-administration by cochlear implant (CI) recipients, parents/caregivers, to determine if the results give adequate information for clinicians to decide the necessity of an appointment and to capture suggestions for improvement. (2) To gauge acceptance of remote monitoring by CI-recipients and their parents/caregivers.

DESIGN

Prospective, multicentre, un-blinded, non-randomized, single-subject, repeated-measures evaluation. The test battery includes an implant-site photograph, impedance measurements, datalogs, questionnaires, speech perception and aided threshold tests. Clinicians reviewed test battery results, followed by a clinical appointment with each CI-recipient, and reported if the battery identified all the issues. Study sample: n = 93 CI-recipients (73 adults, 20 children) and 28 clinicians.

RESULTS

The test battery identified 94% (615/656) of all issues. The test battery and clinician observations agreed in 99% (92/93) of cases on the need for a clinic visit. For 68% (63/93) of cases, the test battery identified all clinician observed issues. The majority (77%, 72/93) of recipients would be satisfied if clinic visits were based on their test battery results. A significantly high proportion agreed that remote monitoring was more convenient than clinic visits and could result in travel, time and cost reductions.

CONCLUSION

This is the first comprehensive test battery designed for CI-recipient remote monitoring.

Telehealth Audiology and Virtual Hearing Screenings: A Case Report

Clinic closures across the United States in response to the coronavirus disease 2019 (COVID-19) pandemic meant that many audiology services were reduced to phone calls, video visits, and modified services (e.g., curbside, mail-ins, drop offs). Audiologists and other providers needed a way to manage hearing- and ear-related complaints via telehealth. A simple pure tone air conduction threshold test performed at home was used to determine which patients needed to come into the clinic for an in-person appointment. This case will review a 56-year-old male who was being treated for an idiopathic sudden sensorineural hearing loss prior to clinic closure. He had on file a comprehensive audiogram at first onset of symptoms and was treated with oral steroids. Virtual hearing testing was then utilized for a variety of other patients from teenagers to adults to triage hearing- and ear-related complaints while clinics were closed for in-person visits.

International survey of audiologists during the COVID-19 pandemic: use of and attitudes to telehealth

OBJECTIVE

To determine the attitudes of audiologists towards telehealth and use of telehealth for the delivery of ear and hearing services pre-, during- and post- the COVID-19 pandemic, and to identify the perceived effects of telehealth on services and barriers to telehealth.

DESIGN

An online survey distributed through the International Society of Audiology and member societies.

STUDY SAMPLE

A total of 337 audiologists completing the survey between 23 June and 13 August 2020.

RESULTS

There was a significant increase in the perceived importance of telehealth from before (44.3%) to during COVID-19 (87.1%), and the use of telehealth previous (41.3%), current (61.9%) and expected use of telehealth (80.4%). Telehealth was considered adequate for many audiology services, although hearing assessment and device fitting by telehealth received least support. Matters related to timeliness of services and reduction of travel were reported as the main advantages, but relationships between practitioners and clients may suffer with telehealth. Important barriers were technologies related to the client or remote site; clinic-related items were moderate barriers, although more clinician training was a common theme provided through open-ended responses.

CONCLUSION

The COVID-19 pandemic has resulted in audiologists having a more positive attitude towards and greater use of telehealth, but with some reservations.

How Can eHealth Meet the Hearing and Communication Needs of Adults With Hearing Impairment and their Significant Others? A Group Concept Mapping Study

OBJECTIVES

To seek the perspectives of key stakeholders regarding: (1) how eHealth could help meet the hearing and communication needs of adults with hearing impairment and their significant others; and (2) how helpful each aspect of eHealth would be to key stakeholders personally.

DESIGN

Group concept mapping, a mixed-methods participatory research method, was used to seek the perspectives of key stakeholders: adults with hearing impairment (n = 39), significant others (n = 28), and hearing care professionals (n = 56). All participants completed a short online survey before completing one or more of the following activities: brainstorming, sorting, and rating. Brainstorming required participants to generate ideas in response to the focus prompt, "One way I would like to use information and communication technologies to address the hearing and communication needs of adults with hearing loss and their family and friends is to…." The sorting task required participants to sort all statements into groups that made sense to them. Finally, the rating task required participants to rate each of the statements according to "How helpful would this idea be to you?" using a 5-point Likert scale. Hierarchical cluster analysis was applied to the "sorting" data to develop a cluster map using the Concept Systems software. The "rating" data were subsequently analyzed at a cluster level and an individual-item level using descriptive statistics. Differences in cluster ratings between stakeholder groups were examined using Kruskal-Wallis tests.

RESULTS

Overall, 123 statements were generated by participants in response to the focus prompt and were included in subsequent analyses. Based on the "sorting" data and hierarchical cluster analysis, a seven-cluster map was deemed to be the best representation of the data. Three key themes emerged from the data, including using eHealth to (1) Educate and Involve Others; (2) Support Aural Rehabilitation; and (3) Educate About and Demonstrate the Impacts of Hearing Impairment and Benefits of Hearing Rehabilitation. Overall median rating scores for each cluster ranged from 3.97 (educate and involve significant others) to 3.44 (empower adults with hearing impairment to manage their hearing impairment from home).

CONCLUSIONS

These research findings demonstrate the broad range of clinical applications of eHealth that have the capacity to support the implementation of patient- and family-centered hearing care, with self-directed educational tools and resources typically being rated as most helpful. Therefore, eHealth appears to be a viable option for enabling a more biopsychosocial approach to hearing healthcare and educating and involving significant others in the hearing rehabilitation process without adding more pressure on clinical time. More research is needed to inform the subsequent development of eHealth interventions, and it is recommended that health behavior change theory be adhered to for such interventions.

Decentralising paediatric hearing services through district healthcare screening in Western Cape province, South Africa

Background

Childhood hearing loss is a global epidemic most prevalent in low- and middle-income countries where hearing healthcare services are often inaccessible. Referrals for primary care services to central hospitals add to growing lists and delays the time-sensitive treatment of childhood hearing loss.

Aim

To compare a centralised tertiary model of hearing healthcare with a decentralised model through district hearing screening for children in the Western Cape province, South Africa.

Setting

A central paediatric tertiary hospital in Cape Town and a district hospital in the South Peninsula region.

Methods

A pragmatic quasi-experimental study design was used with a 7-month control period at a tertiary hospital (June 2019 to December 2019). Decentralising was measured by attendance rates, travelling distance, number of referrals to the tertiary hospital and hearing outcomes. There were 315 children in the tertiary group and 158 in the district group. Data were collected from patient records and an electronic database at the tertiary hospital.

Results

Attendance rate at the district hospital was significantly higher (p < 0.001). Travel distance to the district hospital was significantly shorter (p < 0.001). Number of referrals to the tertiary hospital decreased significantly during the intervention period (p < 0.001). Most children in both the tertiary and district groups (78.7% and 80.4%, respectively) passed initial hearing screening bilaterally.

Conclusion

Hearing screening should be conducted at the appropriate level of care to increase access, reduce patient travelling distances and associated costs and reduce the burden on tertiary-level hospitals.

Hearing aid acquisition and ownership: what can we learn from online consumer reviews?

OBJECTIVE

To explore the publicised opinions of consumers actively participating in online hearing aid reviews.

DESIGN

A retrospective design examining data generated from an online consumer review website (www.HearingTracker.com). Qualitative data (open text responses) were analysed using the open source automated topic modelling software IRaMuTeQ (http://www.iramuteq.org/) to identify themes. Outputs were compared with quantitative data from the consumer reviews (short response questions exploring hearing aid performance and benefit, and some meta-data such as hearing aid brand and years of hearing aid ownership).

STUDY SAMPLE

1378 online consumer hearing aid reviews.

RESULTS

Six clusters within two domains were identified. The domain Device Acquisition included three clusters: Finding the right provider, device and price-point; Selecting a hearing aid to suit the hearing loss; Attaining physical fit and device management skills. The domain Device Use included three clusters: Smartphone streaming to hearing aids; Hearing aid adjustment using smartphone; and Hearing in noise.

CONCLUSIONS

Although online hearing aid consumers indicate positive performance on multiple-choice questions relating to hearing aid performance and benefit, their online reviews describe a number of barriers limiting their success. Hearing healthcare clinicians must employ a personalised approach to audiological rehabilitation to ensure individual clients' needs are met.

International Practice Recommendations for the Recognition and Management of Hearing and Vision Impairment in People with Dementia

INTRODUCTION

Hearing, vision, and cognitive impairment commonly co-occur in older people. However, the rate of recognition and appropriate management of combined hearing and vision impairment in people with dementia impairment is low. The aim of this work was to codevelop internationally relevant, multidisciplinary practice recommendations for professionals involved in the diagnosis, care, and management of older people with these concurrent conditions.

METHODS

We applied consensus methods with professional and lay expert stakeholders, using an adapted version of the World Health Organization Handbook for Guideline Development. The development involved 4 phases and included: (1) collating existing evidence, (2) filling the gaps in evidence, (3) prioritising evidence, and (4) refining the final list of recommendations. Each phase encompassed various methodologies including a review of existing guidelines within the 3 clinical domains, systematic reviews, qualitative studies, a clinical professional consortium, surveys, and consensus meetings with interdisciplinary domain experts.

RESULTS

The task force evaluated an initial list of 26 recommendations, ranking them in the order of priority. A consensus was reached on 15 recommendations, which are classified into 6 domains of "awareness and knowledge," "recognition and detection," "evaluation," "management," "support," and "services and policies." Pragmatic options for implementation for each domain were then developed.

CONCLUSION

This is the first set of international, interdisciplinary practice recommendations that will guide the development of multidisciplinary services and policy to improve the lives of people with dementia and hearing and vision impairment.

Case Study Comparison: Limitations in Telehealth Relating to Poverty and Family Support

Telehealth appointments have grown in popularity due to the COVID-19 global pandemic. Three cases presented in this article show several different perspectives where telehealth was utilized. For the first patient, appointments were successfully completed via telehealth; however, the patient's family opted to continue with an unsecure internet connection at a local laundromat. For the second patient, a stable internet connection could not be obtained in his home, thus making telehealth appointments unavailable. The caregiver of this patient ended up driving to the clinic to have adjustments made in person. For the third patient, telehealth appointments were unavailable due to unstable internet connections as well as difficulty setting up video interpreting services. These cases highlight the idea that telehealth can be incredibly beneficial, when used correctly. For some, the option to attend appointments virtually gives them access to specialists that otherwise may not be available. For other patients, aspects such as access to smart devices and steady internet access must be considered to ensure a successful connection. The hope is that this article sheds light on some of the potential setbacks that can come from the use of telehealth appointments in a practice and provides discussion regarding for whom telehealth may be appropriate, even in pediatric patients. After reading this article, readers should be able to discuss ways in which there could be solutions for these barriers that may prevent some patients from utilizing these types of virtual appointments.

Tinnitus Management: The Utilization of a Hybrid Telehealth and In-Person Delivery Model

Telehealth, or the delivery of healthcare services from a distance, has historically been used to provide care to underserved populations and to those unable to visit a healthcare center. During the ongoing global COVID-19 pandemic, some providers of tinnitus healthcare services incorporated telehealth into their clinical protocols to allow for continued care for their patients while adhering to social distancing guidelines and safety measures. Bothersome tinnitus can negatively impact one's quality of life. Telehealth has been instrumental in treating this debilitating problem in a time when in-person care has not been easily available. The case of a patient with tinnitus is examined to demonstrate the use of a hybrid delivery model utilizing telehealth and in-person interactions to assess and manage her bothersome tinnitus. In-person services were used for audiological assessments and fitting of treatment devices, while telehealth was utilized for counseling, education, and remote programming of her treatment devices. This combined approach, which has allowed the patient to continue receiving care safely during the pandemic, can be continued for future care. Telehealth offers several advantages to patients and providers alike. While the COVID-19 pandemic will hopefully come to an end, telehealth services for tinnitus management may be here to stay.

Audiology practice during COVID-19 crisis in Jordan and Arab countries

OBJECTIVE

This study investigated audiologists' knowledge of COVID-19 characteristics and infection control measures they followed during the COVID-19 pandemic. Moreover, it examined the impact of COVID-19 on audiology practice, and audiologist's knowledge of telehealth as an alternative.

DESIGN

A web-based cross-sectional study using a questionnaire consisting of four sections.

STUDY SAMPLE

This study engaged 164 audiologists practicing in Jordan and Arab countries.

RESULTS

Fever, cough, difficulty in breathing, and fatigue were identified as COVID-19 characteristics by over 80% of the audiologists. Other symptoms were identified by less than half of the audiologists. The audiologists showed limited knowledge regarding measures against COVID-19 transmission. This study revealed the limited availability of infection control measures in many audiologists' workplace. The majority of audiologists stopped working due to the COVID-19 crisis and only 61.6% of the audiologists were familiar with the concepts of tele-audiology and its related aspects. However, most participants were keen to learn more.

CONCLUSIONS

This study revealed limited knowledge among audiologists regarding some of the COVID-19 characteristics, and limited compliance with the infection control policies. Limited knowledge in the application of telehealth in audiology practice was also shown.

Challenges facing users of hearing aids during the COVID-19 pandemic

OBJECTIVES

To explore the difficulties and obstacles of hearing-technology users during the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN

Descriptive, cross-sectional study.

STUDY SAMPLE

Individuals with permanent hearing loss (n = 278) answered a questionnaire designed to identify potential obstacles caused by using hearing aids during the COVID-19 pandemic, along with the reasons and deleterious effects associated with the devices. Each category reflected challenges in communicating, learning, and working during the pandemic. Different response categories were compared using descriptive and inferential statistics.

RESULTS

The duration of daily device usage before the imposed lockdown was significantly higher than that during (Z = -2.01, p < 0.05), potentially attributable to the pandemic-induced difficulties faced by hearing-technology users. Such challenges include the shortage of batteries for hearing devices, limited access to repair or programming services of said devices and accessories, termination of speech therapy sessions, and obstacles to employment and education.

CONCLUSIONS

Among audiologists, efficiency and professionalism are required to educate the public and private health sectors regarding the prevalent challenges and their harmful impact on hearing-technology users during the COVID-19 pandemic. To overcome these issues, awareness of telepractice and its importance in providing audiological services to hard of hearing individuals should be raised.

Clinician-rated quality of video otoscopy recordings and still images for the asynchronous assessment of middle-ear disease

INTRODUCTION

Video otoscopy plays an important role in improving access to ear health services. This study investigated the clinician-rated quality of video otoscopy recordings and still images, and compared their suitability for asynchronous diagnosis of middle-ear disease.

METHODS

Two hundred and eighty video otoscopy image-recording pairs were collected from 150 children (aged six months to 15 years) by an ear, nose, and throat (ENT) specialist, audiologists, and trained research assistants, and independently rated by an audiologist and ENT surgeon. On a five-point scale, clinicians rated the cerumen amount, field of view, quality, focus, light, and gave an overall rating, and asked whether they could make an accurate diagnosis for both still images and recordings.

RESULTS

More video otoscopy recordings were rated as 'good' or 'excellent' compared to still images across all domains. The mean difference between the two otoscopic procedures ratings was significant across almost all domains (p < 0.05), except 'cerumen amount'. The suitability to make a diagnosis significantly improved when using recordings (p<0.05). Younger participant age was found to have a significant, negative impact on the ratings across all domains (p < 0.03). The role of the tester conducting video otoscopy did not have a significant impact on the ratings.

DISCUSSION

Video otoscopy recordings were found to provide clearer views of the tympanic membrane and increase the ability to make diagnoses, compared to still images, for both audiologists and ENT surgeons. Research assistants with limited practice were able to obtain video otoscopy images and recordings that were comparable to the ones obtained by clinicians.

Challenges and opportunities for telehealth assessment during COVID-19: iT-RES, adapting a remote version of the test for rating emotions in speech

OBJECTIVE

COVID-19 social isolation restrictions have accelerated the need to adapt clinical assessment tools to telemedicine. Remote adaptations are of special importance for populations at risk, e.g. older adults and individuals with chronic medical comorbidities. In response to this urgent clinical and scientific need, we describe a remote adaptation of the T-RES (Oron et al. 2020; IJA), designed to assess the complex processing of spoken emotions, based on identification and integration of the semantics and prosody of spoken sentences.

DESIGN

We present iT-RES, an online version of the speech-perception assessment tool, detailing the challenges considered and solution chosen when designing the telehealth tool. We show a preliminary validation of performance against the original lab-based T-RES.

STUDY SAMPLE

A between-participants design, within two groups of 78 young adults (T-RES, n = 39; iT-RES, n = 39).

RESULTS

i-TRES performance closely followed that of T-RES, with no group differences found in the main trends, identification of emotions, selective attention, and integration.

CONCLUSIONS

The design of iT-RES mapped the main challenges for remote auditory assessments, and solutions taken to address them. We hope that this will encourage further efforts for telehealth adaptations of clinical services, to meet the needs of special populations and avoid halting scientific research.

Mhealth hearing screening for children by non-specialist health workers in communities

OBJECTIVES

To compare outcomes of a community-based hearing screening programme using smartphone screening audiometry operated by specialist (School Health Nurses - SHNs) and non-specialist health workers (Community Health Workers - CHWs) in school children.

DESIGN

This study used a two-group comparison of screening outcomes as conducted by SHNs and CHWs using smartphone screening for children in communities.

STUDY SAMPLE

The study included 71 CHWs and 21 SHNs who conducted community-based hearing screening on 6805 children. One thousand one hundred and fifteen hearing screening tests were conducted by the CHWs and 5690 tests by the SHNs.

RESULTS

No significant difference in screening outcome was evident between CHWs and SHNs using a binomial logistic regression analysis considering age, test duration and noise levels as independent variables. Final screening result was significantly affected by age (p < 0.005), duration of test (p < 0.005) and noise levels exceeding at 1 kHz in at least one ear (p < 0.005). Test failure was associated with longer test duration (p < 0.005; B: 119.98; 95% CI: 112.65-127.30). CHWs had significantly (p < 0.005) longer test durations (68.70 s; 70 SD) in comparison to SHNs (55.85 s; 66.1 SD).

CONCLUSION

Low-cost mobile technologies with automated testing facilitated from user-friendly interfaces allow minimally trained persons to provide community-based screening comparable to specialised personnel.

Effectiveness of a Web-Based SUpport PRogram (SUPR) for Hearing Aid Users Aged 50+: Two-Arm, Cluster Randomized Controlled Trial

BACKGROUND

Hearing aid (HA) use is known to improve health outcomes for people with hearing loss. Despite that, HA use is suboptimal, and communication issues and hearing-related activity limitations and participation restrictions often remain. Web-based self-management communication programs may support people with hearing loss to effectively self-manage the impact of hearing loss in their daily lives.

OBJECTIVE

The goal of the research is to examine the short- and long-term effects of a web-based self-management SUpport PRogram (SUPR) on communication strategy use (primary outcome) and a range of secondary outcomes for HA users aged 50 years and older.

METHODS

Clients of 36 HA dispensing practices were randomized to SUPR (SUPR recipients; n=180 HA users) and 34 to care as usual (controls; n=163 HA users). SUPR recipients received a practical support booklet and online materials delivered via email over the course of their 6-month HA rehabilitation trajectory. They were encouraged to appoint a communication partner and were offered optional email contact with the HA dispensing practice. The online materials included 3 instruction videos on HA handling, 5 videos on communication strategies, and 3 testimonial videos. Care as usual included a HA fitting rehabilitation trajectory only. Measurements were carried out at baseline, immediately postintervention, 6 months postintervention, and 12 months postintervention. The primary outcome measure was self-reported use of communication strategies (3 subscales of the Communication Profile for the Hearing Impaired [CPHI]). Secondary outcome measures included self-reported personal adjustment to hearing loss (CPHI); use, satisfaction and benefit of HAs and SUPR (use questionnaire; International Outcome Inventory for Hearing Aids [IOI-HA], Alternative Interventions [IOI-AI]); recommendation of HA dispensing services; self-efficacy for HA handling (Measure of Audiologic Rehabilitation Self-Efficacy for Hearing Aids [MARS-HA]); readiness to act on hearing loss (University of Rhode Island Change Assessment adapted for hearing loss [URICA-HL]); and hearing disability (Amsterdam Inventory for Auditory Disability and Handicap [AIADH]).

RESULTS

Linear mixed model analyses (intention to treat) showed no significant differences between the SUPR and control group in the course of communication strategy use (CPHI). Immediately postintervention, SUPR recipients showed significantly higher self-efficacy for advanced HA handling than the controls, which was sustained at 12 months (MARS-HA; mean difference immediately postintervention: 5.3, 95% CI 0.3 to 10.4; P=.04). Also, SUPR recipients showed significantly greater HA satisfaction than controls immediately postintervention (IOI-HA; 0.3, 95% CI 0.09 to 0.5; P=.006), which was sustained at 12 months, and significantly greater HA use than the controls immediately postintervention (IOI-HA; 0.3, 95% CI 0.02 to 0.5; P=.03), which was not sustained at 12 months.

CONCLUSIONS

This study provides ground to recommend adding SUPR to standard HA dispensing care, as long-term, modest improvements in HA outcomes were observed. Further research is needed to evaluate what adjustments to SUPR are needed to establish long-term effectiveness on outcomes in the psychosocial domain.

TRIAL REGISTRATION

ISRCTN77340339; http://www.isrctn.com/ISRCTN77340339.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2016-015012.