Hearing and vision screening for preschool children using mobile technology, South Africa

Feasibility of implementing a school entry hearing screening programme in the South-East District, Botswana

OBJECTIVE

To assess the feasibility of implementing a school entry hearing screening programme in the South-East District, Botswana.

DESIGN

A feasibility study design was used. Trained screeners conducted smartphone-based pure tone audiometry screening at 25 dB HL, at 1, 2, and 4 kHz using calibrated headphones. Learners with "refer" results after an immediate rescreen were referred and scheduled for diagnostic hearing assessment at the local hospital. Attendance at diagnostic appointments was encouraged through multiple contacts with the families.

STUDY SAMPLE

The study participants were 403 Grade 1 learners from eight public primary schools.

RESULTS

The overall referral rate for diagnostic hearing assessment was 4.7%, with a referral uptake rate of 90%. The sensitivity and specificity of the hearing screening protocol were 93.3% and 86.4%, respectively. The positive and negative predictive values were 82.4% and 95%, respectively. The average cost per learner screened was US$ 10.75.

CONCLUSIONS

School entry hearing screening programmes can be successfully implemented in the South-East District, Botswana. Lessons learnt from this study can potentially guide phased implementation of school hearing screening programmes in other districts.

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

OBJECTIVES

Hearing loss prevalence is increasing, with an estimated 2.5 billion people affected globally by 2050. Scalable service delivery models using innovative technologies and task-shifting are World Health Organization priorities to improve access to hearing care, particularly in low- and middle-income countries. Smartphone-facilitated audiometry in the community using hearing aids covered by noise-attenuating ear cups ("in-situ") could support more accessible hearing care when provided by less trained individuals such as community health workers (CHWs). This study aimed to determine the validity of this method for potential hearing aid fitting. Study objectives included determining the maximum permissible ambient noise level (MPANL), inter-device reliability, clinical threshold accuracy, reliability, and performance in real-world settings.

DESIGN

Experiment 1: 15 normal-hearing adult participants were evaluated to determine MPANLs for circumaural Peltor 3M earcups covering Lexie Lumen hearing aids with smartphone-facilitated in-situ audiometry. MPANLs were calculated by measuring the difference in attenuation between thresholds obtained with standard headphones and in-situ hearing aids. Experiment 2: Pure-tone frequency and intensity output of 14 same-model Lexie Lumen hearing aids were measured to determine inter-device reliability. Pure-tone stimuli were measured and analyzed to determine sound pressure levels in decibels and pure-tone frequency when connected to a test box 2cc coupler. Experiment 3: 85 adult participants were tested in a sound booth to determine the accuracy of automated in-situ pure-tone audiometry (PTA) compared to clinical PTA (500, 1000, 2000, 3000, 4000, 6000 Hz) facilitated by an audiologist. The first 39 participants were tested twice to determine test-retest reliability. Experiment 4: In a community setting, 144 adult participants were tested with automated in-situ audiometry facilitated by CHWs using a smartphone app. These participants were subsequently tested with automated mobile PTA (500, 1000, 2000, 4000 Hz). An additional 44 participants were tested twice to determine test-retest reliability.

RESULTS

Experiment 1: MPANLs of the Peltor 3M earcup-covered hearing aids were higher than standard headphones across all frequencies, ranging from 24 to 47.3 dB SPL. Experiment 2: Inter-device performance reliability was high, with all inter-device differences across all intensities and frequencies less than 3 dB. Frequency output was consistent and differed less than 0.7% between devices. Experiments 3 and 4: 85.2% and 83.3% of automated in-situ audiometry thresholds were within 10 dB of thresholds obtained in the sound booth and in a community setting, respectively. Acceptable test-retest intraclass correlation coefficient (ICC) was evident across all thresholds obtained in a sound booth (ICC = 0.85 to 0.93) and in a community setting (ICC = 0.83 to 0.97).

CONCLUSIONS

Smartphone-facilitated in-situ audiometry allows for reliable and valid community-based testing. A simple smartphone user interface and automated in-situ audiometry allow CHWs with minimal training to facilitate the testing. With the additional capability to program hearing aids via the smartphone after the initial test, this approach would have the potential to support widespread access to personalized hearing aid fittings facilitated by CHWs in low- and middle-income countries. This approach also supports self-fitting options based on in-situ thresholds, enabling testing and fitting via over the counter hearing aids.

Synchronous remote fine-tuning and follow-up within aural rehabilitation: a randomised controlled trial

OBJECTIVE

The objective of the study was to evaluate the effect of including synchronous remote fine-tuning and follow-up as a part of the aural rehabilitation process.

DESIGN

A randomised controlled trial (RCT).

STUDY SAMPLE

Experienced hearing aid users who were due for renewed aural rehabilitation were randomised to either an intervention group (n = 46) or a control group (n = 49). Both groups underwent all stages of the conventional renewed aural rehabilitation process within our clinics, but the intervention group was also offered remote follow-up visits, including an opportunity for synchronous remote fine-tuning of hearing aids. The Hearing Handicap Inventory for the Elderly/Adults (HHIE/A), the Abbreviated Profile of Hearing Aid Benefit (APHAB), and the International Outcome Intervention for Hearing Aid Users (IOI-HA) were used as outcome measures.

RESULTS

Both groups improved in self-rated hearing difficulties and hearing aid benefits measured with HHIE/A and APHAB. No significant differences were found between the intervention and the control group.

CONCLUSION

Including synchronous remote follow-up and fine-tuning as a part of an aural rehabilitation process may effectively complement clinical visits. Additionally, the synchronous remote follow-up has the potential to further develop person-centred care by enabling hearing aid users to identify individual needs directly in an everyday environment.

Building disability-inclusive health systems

Health systems often fail people with disabilities, which might contribute to their shorter life expectancy and poorer health outcomes than people without disabilities. This Review provides an overview of the existing evidence on health inequities faced by people with disabilities and describes existing approaches to making health systems disability inclusive. Our Review documents a broad range of health-care inequities for people with disabilities (eg, lower levels of cancer screening), which probably contribute towards health differentials. We identified 90 good practice examples that illustrate current strategies to reduce inequalities. Implementing such strategies could help to ensure that health systems can expect, accept, and connect people with disabilities worldwide, deliver on their right to health, and achieve health for all.

Breaking Sound Barriers: Exploring Tele-Audiology's Impact on Hearing Healthcare

Hearing impairment is a global issue, affecting billions of people; however, there is a gap between the population affected by hearing loss and those able to access hearing healthcare. Tele-audiology, the application of telemedicine in audiology, serves as a new form of technology which aims to provide synchronous or asynchronous hearing healthcare. In this article, we reviewed some recent studies of tele-audiology-related topics to have a glimpse of the current development, associated challenges, and future advancement. Through the utilization of tele-audiology, patients can conveniently access hearing healthcare, and thus save travel costs and time. Recent studies indicate that remote hearing screening and intervention are non-inferior to the performance of traditional clinical pathways. However, despite its potential benefits, the implementation of tele-audiology faces numerous challenges, and audiologists have varying attitudes on this technology. Overcoming obstacles such as high infrastructure costs, limited reimbursement, and the lack of quality standards calls for concerted efforts to develop effective strategies. Ethical concerns, reimbursement, and patient privacy are all crucial aspects requiring in-depth discussion. Enhancing the education and training of students and healthcare workers, along with providing relevant resources, will contribute to a more efficient, systematic hearing healthcare. Future research will aim to develop integrated models with evidence-based protocols and incorporating AI to enhance the affordability and accessibility of hearing healthcare.

A mHealth application for the training of caregivers of children with developmental disorders in South Africa: rationale and initial piloting

Background

Evidence-based mobile health (mHealth) interventions have been successful for an array of physical and mental health conditions. Children with developmental disorders (DD) often have secondary speech and language disorders. The lack of high-quality medical and educational services in low- and middle-income countries limits the opportunities for children with DD to succeed in life. South Africa currently offers limited access to education, social, and health services.

Methods

Twelve caregivers of twelve children with DD between the ages of 3 and 6 years who already received monthly early childhood therapy participated in this study. A mHealth app, called Nna'Le'wena, a Setswana phrase meaning "Me and You", was designed, developed, installed, and tested on tablets. The app provided a systematic framework and guidance to the caregivers in order to use evidence-based communication interaction strategies with the children over a twelve-week period. The app could be used offline and provided audio instructions in English and Setswana, two dominant languages in South Africa. The app automatically generated log files and collected answers to weekly surveys. At the end of the study, caregivers were asked to evaluate the app by using relevant portions of the Mobile App Rating Scale (MARS).

Results

Caregivers were able to successfully interact and use the app. The app was well-received and liked by the caregivers. Caregivers listened to the instructional audios in English and Setswana during the 12-week period. They were able to provide communication opportunities to their children during daily living activities, especially during play- and mealtime activities.

Conclusions

The Nna'Le'wena app was successfully deployed and used by caregivers of children with DD. mHealth solutions can be effective and are relatively affordable solutions that can enhance health care and educational delivery in different settings, including in low-and middle-income countries with limited Internet capabilities.

Comparisons of air-conduction hearing thresholds between manual and automated methods in a commercial audiometer

Objective

To investigate the correlation of air-conduction thresholds between automated audiometry in a non-isolated environment and manual audiometry in participants with normal hearing and different degrees of hearing loss.

Methods

Eighty-three participants aged 11-88 years old underwent automated pure-tone audiometry in a non-acoustically isolated environment, and the results were compared with those of manual pure-tone audiometry performed in a standard acoustically isolated booth, with the order of testing randomised. Six frequencies of 250, 500, 1,000, 2000, 4,000 and 8,000 Hz were tested.

Results

All 166 ears were completed and 996 valid hearing threshold data were obtained, with 28 data exceeding the 95% confidence interval in the Bland-Altman plot, accounting for 2.81% of all data. The means and standard deviations of the differences for the six frequencies from 250 to 8,000 Hz were, respectively, 0.63 ± 5.31, 0.69 ± 4.50, 0.45 ± 4.99, 0.3 ± 6.2, -0.15 ± 4.8, and 0.21 ± 4.97 dB. The correlation coefficients of the two test results for normal hearing, mild, moderate, severe and above hearing loss groups were 0.95, 0.92, 0.97, and 0.96, respectively. The correlation coefficient of the automated and manual audiometry thresholds for the age groups under 40 years, 40-60 years, and 60 years above, were 0.98, 0.97 and 0.97, respectively, with all being statistically significant (p < 0.01). The response time of the three age groups were 791 ± 181 ms, 900 ± 190 ms and 1,063 ± 332 ms, respectively, and there was a significant difference between the groups under 40 years and over 60 years.

Conclusion

There was good consistency between automated pure-tone audiometry in a non-acoustically isolated environment and manual pure-tone audiometry in participants with different hearing levels and different age groups.

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.

Remote Technologies to Enhance Service Delivery for Adults: Clinical Research Perspectives

There are many examples of remote technologies that are clinically effective and provide numerous benefits to adults with hearing loss. Despite this, the uptake of remote technologies for hearing healthcare has been both low and slow until the onset of the COVID-19 pandemic, which has been a key driver for change globally. The time is now right to take advantage of the many benefits that remote technologies offer, through clinical, consumer, or hybrid services and channels. These include greater access and choice, better interactivity and engagement, and tailoring of technologies to individual needs, leading to clients who are better informed, enabled, and empowered to self-manage their hearing loss. This article provides an overview of the clinical research evidence-base across a range of remote technologies along the hearing health journey. This includes qualitative, as well as quantitative, methods to ensure the end-users' voice is at the core of the research, thereby promoting person-centered principles. Most of these remote technologies are available and some are already in use, albeit not widespread. Finally, whenever new technologies or processes are implemented into services, be they clinical, hybrid, or consumer, careful consideration needs to be given to the required behavior change of the key people (e.g., clients and service providers) to facilitate and optimize implementation.

Combined hearing and vision screening programs: A scoping review

Background and aim

The World Health Organization (WHO) estimates that 1.5 billion and 2.2 billion people have hearing and vision impairment, respectively. The burden of these non-communicable diseases is highest in low- and middle-income countries due to a lack of services and health professionals. The WHO has recommended universal health coverage and integrated service delivery to improve ear and eye care services. This scoping review describes the evidence for combined hearing and vision screening programs.

Method

A keyword search of three electronic databases, namely Scopus, MEDLINE (PubMed), and Web of Science, was conducted, resulting in 219 results. After removing duplicates and screening based on eligibility criteria, data were extracted from 19 included studies. The Joanna Briggs Institute Reviewer Manual and the Preferred Reporting Items for Systematic Reviews and Meta-analyzes (PRISMA) Extension for Scoping Reviews were followed. A narrative synthesis was conducted.

Results

Most studies (63.2%) were from high-income countries, with 31.6% from middle-income and 5.2% from low-income countries. The majority of studies (78.9%) involved children and the four studies reporting on adults all included adults above 50 years of age. Vision screening was most commonly performed with the "Tumbling E" and "Snellen Chart," while hearing was typically screened using pure tone audiometry. Studies reported referral rates as the most common outcome with sensitivity and specificity rates not reported in any included articles. Reported benefits of combined vision and hearing screenings included earlier detection of vision and hearing difficulties to support functioning and quality of life as well as resource sharing for reduced costs. Challenges to combined screening included ineffective follow-up systems, management of test equipment, and monitoring of screening personnel.

Conclusions

There is limited research evidence for combined hearing and vision screening programs. Although potential benefits are demonstrated, especially for mHealth-supported programs in communities, more feasibility and implementation research are required, particularly in low- and middle-income countries and across all age groups. Developing universal, standardized reporting guidelines for combined sensory screening programs is recommended to enhance the standardization and effectiveness of combined sensory screening programs.

Surveillance for ototoxicity in platinum-based chemotherapy using mobile health audiometry with extended high frequencies

OBJECTIVE

This study investigated mobile health enabled surveillance in ototoxicity.

METHOD

This was a longitudinal study of 32 participants receiving chemotherapy. Baseline and exit audiograms that included conventional and extended high frequency audiometry were recorded within the patient's treatment venue using a validated mobile health audiometer.

RESULTS

Average hearing thresholds at baseline were within the normal range (81.2 per cent left; 93.8 per cent right), reducing at exit testing (71.9 per cent left; 78.1 per cent right). Half of participants presented with a threshold shift according to ototoxicity monitoring criteria. The frequencies affected the most were between 4000 and 16 000 Hz, with left ears significantly more affected than right ears. Noise levels exceeded the maximum permissible ambient noise levels in up to 43.8 per cent of low frequencies (250-1000 Hz).

CONCLUSION

Mobile health supported audiometry proved to be an efficacious tool for ototoxicity monitoring at the treatment venue. Changes in hearing ability over time could be tracked, improving surveillance in patients with full treatment schedules.

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

BACKGROUND

The rising prevalence of hearing loss is a global health concern. Professional hearing services are largely absent within low- and middle-income countries where appropriate skills are lacking. Task-shifting to community healthcare workers (CHWs) supported by mHealth technologies is an important strategy to address the problem.

OBJECTIVE

To evaluate the feasibility of a community-based rehabilitation model providing hearing aids to adults in low-income communities using CHWs supported by mHealth technologies.

METHOD

Between September 2020 and October 2021, hearing aid assessments and fittings were implemented for adults aged 18 and above in two low-income communities in the Western Cape, South Africa, using trained CHWs. A quantitative approach with illustrative open-ended questions was utilised to measure and analyse hearing aid outcomes. Data were collected through initial face-to-face interviews, telephone interviews, and face-to-face visits post-fitting. Responses to open-ended questions were analysed using inductive thematic analysis. The International Outcome Inventory - Hearing Aids questionnaire determined standardised hearing aid outcomes.

RESULTS

Of the 152 adults in the community who self-reported hearing difficulties, 148 were successfully tested by CHWs during home visits. Most had normal hearing (39.9%), 24.3% had bilateral sensorineural hearing loss, 20.9% had suspected conductive hearing loss, and 14.9% had unilateral hearing loss, of which 5.4% had suspected conductive loss. Forty adults met the inclusion criteria to be fitted with hearing aids. Nineteen of these were fitted bilaterally. Positive hearing aid outcomes and minimal device handling challenges were reported 45 days post-fitting and were maintained at six months. The majority (73.7%) of participants fitted were still making use of their hearing aids at the six-month follow-up.

CONCLUSIONS

Implementing a hearing healthcare service-delivery model facilitated by CHWs in low-income communities is feasible. mHealth technologies used by CHWs can support scalable service-delivery models with the potential for improved access and affordability in low-income settings.

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

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

Clinical comparison of two automated audiometry procedures

Objective

Automated pure-tone audiometry has been shown to provide similar hearing threshold estimates to conventional audiometry, but lower correlations were reported at high and low frequencies in audiometric tests than those of manual tests, while the correlations were better in the middle frequencies. In this paper, we used the same equipment and different test procedures for automated testing, and compared the results with manual test results.

Design

One hundred subjects aged 18–36 years were randomly divided into two groups to perform air-conduction pure-tone audiometry (0.25, 0.5, 1, 2, 4, 8 kHz) using the ascending and shortened ascending protocols built-in to the automated audiometer, respectively. Recorded testing time, the total number of responses and the subject’s preference tests were compared with those of manual tests.

Results

Significant difference was found at 250 Hz regarding the distribution of the absolute difference between the two automated and the manual thresholds. The testing time spend in the ascending method (9.8 ± 1.4 min, mean ± SD) was significantly longer than in the shorted ascending method (5.8 ± 0.9 min). The total numbers of responses of the ascending method (90.5 ± 10.8 times) and shorted ascending method (62.0 ± 11.4 times) were significantly different. Finally, no significant difference was found in preferences between automated and manual procedures.

Conclusion

The shorted ascending method can save lots of testing time. The difference between the two automated thresholds at 250 Hz is caused by the different test procedures, and the difference at 8,000 Hz between the automated test and the manual test can be due to the transducer types and allowable differences in calibration.

Telehealth solutions for assessing auditory outcomes related to noise and ototoxic exposures in clinic and research

Nearly 1.5 billion people globally have some decline in hearing ability throughout their lifetime. Many causes for hearing loss are preventable, such as that from exposure to noise and chemicals. According to the World Health Organization, nearly 50% of individuals 12-25 years old are at risk of hearing loss due to recreational noise exposure. In the occupational setting, an estimated 16% of disabling hearing loss is related to occupational noise exposure, highest in developing countries. Ototoxicity is another cause of acquired hearing loss. Audiologic assessment is essential for monitoring hearing health and for the diagnosis and management of hearing loss and related disorders (e.g., tinnitus). However, 44% of the world's population is considered rural and, consequently, lacks access to quality hearing healthcare. Therefore, serving individuals living in rural and under-resourced areas requires creative solutions. Conducting hearing assessments via telehealth is one such solution. Telehealth can be used in a variety of contexts, including noise and ototoxic exposure monitoring, field testing in rural and low-resource settings, and evaluating auditory outcomes in large-scale clinical trials. This overview summarizes current telehealth applications and practices for the audiometric assessment, identification, and monitoring of hearing loss.

Community-based assessment and rehabilitation of hearing loss: A scoping review

Although the World Health Organization (WHO) recommends the use of a Community-Based Rehabilitation (CBR) model, little is known about how CBR has been applied in the hearing healthcare setting. The purpose of this scoping review was to identify and describe studies on Community-Based Hearing Rehabilitation (CBHR) programs within the applied context. The review was conducted in September 2020 with updated searches in November 2021 according to the Joanna Briggs Institute (JBI) methodology and reported using the guidelines and checklist for Preferred Reporting Items for Systematic Reviews and Meta Analyses-Extension for Scoping Reviews (PRISMA-ScR). Fifty-nine peer-reviewed research articles were included in the review. A narrative synthesis was conducted to map out the types of CBHR programs. Studies were classified into audiological themes: awareness, screening and assessment of hearing in newborn/infants, children and adults, training of community health workers, rehabilitation, cost-effectiveness and describing the service delivery models. Further categorisation was made based on CBR aspect matrices for each study. Most of the studies come from high-income countries in North America and Europe. CBHR studies predominantly focused on creating awareness, training and hearing screenings and/or assessments in communities and evaluating effectiveness in providing knowledge and access to hearing health services in rural or underserved communities. Further work is needed to examine the outcomes and effectiveness of CBHR using controlled studies. Moreover, more work is needed in low- and middle-income countries where the application of CBHR is critical for increased access and affordability.

Digital Health Technologies for Maternal and Child Health in African and other LMICs: A Cross-disciplinary Scoping Review with Stakeholder Consultation (Preprint)

BACKGROUND

Maternal and child health (MCH) is a global health concern, especially impacting low- and middle-income countries (LMIC). Digital health technologies are creating opportunities to address the social determinants of MCH by facilitating access to information and providing other forms of support throughout the maternity journey. Previous reviews in different disciplines have synthesized digital health intervention outcomes in LMIC. However, contributions in this space are scattered across publications in different disciplines and lack coherence in what digital MCH means across fields.

OBJECTIVE

This cross-disciplinary scoping review synthesized the existing published literature in 3 major disciplines on the use of digital health interventions for MCH in LMIC, with a particular focus on sub-Saharan Africa.

METHODS

We conducted a scoping review using the 6-stage framework by Arksey and O'Malley across 3 disciplines, including public health, social sciences applied to health, and human-computer interaction research in health care. We searched the following databases: Scopus, PubMed, Google Scholar, ACM Digital Library, IEEE Xplore, Web of Science, and PLOS. A stakeholder consultation was undertaken to inform and validate the review.

RESULTS

During the search, 284 peer-reviewed articles were identified. After removing 41 duplicates, 141 articles met our inclusion criteria: 34 from social sciences applied to health, 58 from public health, and 49 from human-computer interaction research in health care. These articles were then tagged (labeled) by 3 researchers using a custom data extraction framework to obtain the findings. First, the scope of digital MCH was found to target health education (eg, breastfeeding and child nutrition), care and follow-up of health service use (to support community health workers), maternal mental health, and nutritional and health outcomes. These interventions included mobile apps, SMS text messaging, voice messaging, web-based applications, social media, movies and videos, and wearable or sensor-based devices. Second, we highlight key challenges: little attention has been given to understanding the lived experiences of the communities; key role players (eg, fathers, grandparents, and other family members) are often excluded; and many studies are designed considering nuclear families that do not represent the family structures of the local cultures.

CONCLUSIONS

Digital MCH has shown steady growth in Africa and other LMIC settings. Unfortunately, the role of the community was negligible, as these interventions often do not include communities early and inclusively enough in the design process. We highlight key opportunities and sociotechnical challenges for digital MCH in LMIC, such as more affordable mobile data; better access to smartphones and wearable technologies; and the rise of custom-developed, culturally appropriate apps that are more suited to low-literacy users. We also focus on barriers such as an overreliance on text-based communications and the difficulty of MCH research and design to inform and translate into policy.

In pursuit of increasing the application of tele-audiology in South Africa: COVID-19 puts on the alert for patient site facilitator training

BACKGROUND

 The coronavirus disease 2019 (COVID-19) presented and highlighted new and unanticipated challenges to the provision of clinical services, raising an urgency for the application of different models of service delivery, including tele-audiology. In many tele-audiology encounters, a site facilitator is needed at the patient site to help with the hands-on aspects of procedures, and the implications of this requirement are significant for the resource-constrained African context.

OBJECTIVES

 The aim of this scoping review was to investigate published evidence on training provided to patient site facilitators (PSFs) for tele-audiology application to guide the South African audiology community in tele-audiology application initiatives.

METHOD

 Electronic bibliographic databases including Science Direct, PubMed, Scopus MEDLINE and ProQuest were searched to identify peer-reviewed publications, published in English, between 2017 and 2021 related to training of PSFs. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) were followed during the screening process as well as for illustrating the process.

RESULTS

 Findings are discussed under four key themes: (1) type of tele-audiology and the implications thereof, (2) length of training and its implications, (3) diversity in the range of PSFs used and its implications for the training, and (4) heterogeneity in the training.

CONCLUSION

 The findings highlight important considerations for tele-audiology application within the African context, specifically decision-making around who can serve in the role of PSFs, as well as content and nature of training required, with implications for policy and regulations as well as human resource strategy. These findings are important for the COVID-19 pandemic era and beyond.

A longitudinal community-based ototoxicity monitoring programme and treatment effects for drug-resistant tuberculosis treatment, Western Cape

Background

South Africa has a high burden of drug-resistant tuberculosis (DRTB) and until recently, ototoxic aminoglycosides were predominant in treatment regimens. Community-based ototoxicity monitoring programmes (OMPs) have been implemented for early detection of hearing loss and increased patient access.

Objectives

A longitudinal study was conducted to describe the service delivery characteristics of a community-based OMP for DRTB patients facilitated by CHWs as well as observed ototoxic hearing loss in this population.

Method

A descriptive retrospective record review of longitudinal ototoxicity monitoring of 194 DRTB patients undergoing treatment at community-based clinics in the city of Cape Town between 2013 and 2017.

Results

Follow-up rates between consecutive monitoring assessments reached as high as 80.6% for patients assessed by CHWs. Few patients (14.2% – 32.6%) were assessed with the regularity (≥ 6 assessments) and frequency required for effective ototoxicity monitoring, with assessments conducted, on average, every 53.4–64.3 days. Following DRTB treatment, 51.5% of patients presented with a significant ototoxic shift meeting one or more of the American Speech-Language-Hearing Association (ASHA) criteria. Deterioration in hearing thresholds was bilateral and most pronounced at high frequencies (4 kHz – 8 kHz). The presence of pre-existing hearing loss, human immunodeficiency virus co-infection and a history of noise exposure were significant predictors of ototoxicity in patients.

Conclusion

DRTB treatment with kanamycin resulted in significant deterioration of hearing longitudinally, predominantly at high frequencies. With ongoing training and supportive supervision, CHWs can facilitate community-based ototoxicity monitoring of DRTB patients. Current protocols and guidelines may require reassessment for appropriate community-based ototoxicity monitoring.

Digital Approaches to Automated and Machine Learning Assessments of Hearing: Scoping Review

BACKGROUND

Hearing loss affects 1 in 5 people worldwide and is estimated to affect 1 in 4 by 2050. Treatment relies on the accurate diagnosis of hearing loss; however, this first step is out of reach for >80% of those affected. Increasingly automated approaches are being developed for self-administered digital hearing assessments without the direct involvement of professionals.

OBJECTIVE

This study aims to provide an overview of digital approaches in automated and machine learning assessments of hearing using pure-tone audiometry and to focus on the aspects related to accuracy, reliability, and time efficiency. This review is an extension of a 2013 systematic review.

METHODS

A search across the electronic databases of PubMed, IEEE, and Web of Science was conducted to identify relevant reports from the peer-reviewed literature. Key information about each report's scope and details was collected to assess the commonalities among the approaches.

RESULTS

A total of 56 reports from 2012 to June 2021 were included. From this selection, 27 unique automated approaches were identified. Machine learning approaches require fewer trials than conventional threshold-seeking approaches, and personal digital devices make assessments more affordable and accessible. Validity can be enhanced using digital technologies for quality surveillance, including noise monitoring and detecting inconclusive results.

CONCLUSIONS

In the past 10 years, an increasing number of automated approaches have reported similar accuracy, reliability, and time efficiency as manual hearing assessments. New developments, including machine learning approaches, offer features, versatility, and cost-effectiveness beyond manual audiometry. Used within identified limitations, automated assessments using digital devices can support task-shifting, self-care, telehealth, and clinical care pathways.

Telemedicine for Patients With Unilateral Sudden Hearing Loss in the COVID-19 Era

Importance

Developing a telemedicine tool to discriminate between patients who need urgent treatment for sudden sensorineural hearing loss (SSNHL) from those who do not takes on special importance during the COVID-19 pandemic.

Objective

To explore the feasibility of a telemedicine model to assist in the evaluation of new-onset unilateral sudden hearing loss (SHL) among patients who do not have access to medical resources, especially during the COVID-19 pandemic.

Design, Setting, and Participants

This prospective cohort investigation of a telemedicine model was conducted at a tertiary referral medical center between May 2020 and January 2021, with the interpreting physician blinded to the results of formal audiograms. The study included a consecutive sample of adult patients (aged ≥18 years) referred to the otolaryngology emergency department in our medical center with the chief complaint of new-onset unilateral SHL.

Interventions

The telemedicine model comprised 2 sequential steps: a Weber test using the Hum Test and a smartphone-based vibration, and uHear app-based audiometry.

Main Outcomes and Measures

Discrimination between patients with and without SSNHL by using the telemedicine model. All diagnoses subsequently confirmed by a formal audiogram.

Results

Fifty-one patients with new-onset unilateral SHL participated in the study study (median age, 45 [range, 18-76] years; 28 [54.9%] men). The sensitivity and specificity of the telemedicine model for fulfilling the audiometric criteria of SSNHL (loss of ≥30 dB in ≥3 consecutive frequencies) were 100% (95% CI, 84%-100%) and 73% (95% CI, 54%-88%), respectively. The PPV was 72% (95% CI, 53%-87%), the NPV was 100% (95% CI, 85%-100%), and the accuracy was 84.3% (95% CI, 71%-93%). Although 8 participants had false-positive results, all of them had SSNHL that did not meet the full audiometric criteria.

Conclusions and Relevance

The telemedicine model presented in this study for the diagnosis of SSNHL is valid and reliable. It may serve as a primary tool for the discrimination between patients in need of urgent care for SSNHL from those who are not, especially during the COVID-19 pandemic.

Tele-Audiology: Current State and Future Directions

The importance of tele-audiology has been heightened by the current COVID-19 pandemic. The present article reviews the current state of tele-audiology practice while presenting its limitations and opportunities. Specifically, this review addresses: (1) barriers to hearing healthcare, (2) tele-audiology services, and (3) tele-audiology key issues, challenges, and future directions. Accumulating evidence suggests that tele-audiology is a viable service delivery model, as remote hearing screening, diagnostic testing, intervention, and rehabilitation can each be completed reliably and effectively. The benefits of tele-audiology include improved access to care, increased follow-up rates, and reduced travel time and costs. Still, significant logistical and technical challenges remain from ensuring a secure and robust internet connection to controlling ambient noise and meeting all state and federal licensure and reimbursement regulations. Future research and development, especially advancements in artificial intelligence, will continue to increase tele-audiology acceptance, expand remote care, and ultimately improve patient satisfaction.

Prevalence and characteristics of hearing and vision loss in preschool children from low income South African communities: results of a screening program of 10,390 children

BACKGROUND

The majority of children with sensory impairments live in low- and middle-income countries. More studies of hearing and vision impairment prevalence are needed, in order to generate more accurate estimates of trends in sensory impairments. This study aimed to estimate the prevalence and describe the characteristics of hearing and vision loss among preschool children (4-7 years) in an underserved South African community following community-based mobile health (mHealth) supported hearing and vision services.

METHODS

A screening program of sensory impairments was undertaken of children attending preschools in the communities of Khayelitsha and Mitchell's Plain, Cape Town, from September 2017 until June 2019. Hearing and vision screening were done by trained community health workers using mHealth technology. Children who failed hearing and vision screening were seen for follow-up assessments at their preschools. Follow-up assessments were conducted using smartphones that host point-of-care validated and calibrated hearing and vision testing applications (hearTest app, hearX Group, South Africa and PeekAcuity app, Peek Vision, United Kingdom). Descriptive statistical analysis and logistic regression analysis were conducted after extracting data from a secure cloud-based server (mHealth Studio, hearX Group) to Microsoft Excel (2016).

RESULTS

A total of 10,390 children were screened at 298 preschools over 22 months. Of the children screened, 5.6 and 4.4% of children failed hearing and vision screening respectively. Community-based follow-up hearing tests were done at the preschools on 88.5% (514) of children of whom 240 children (54.2% female) presented with hearing loss. A preschool-based follow-up vision test was done on 400 children (88.1%). A total of 232 children (46.1% female) had a vision impairment, and a further 32 children passed the test but had obvious signs of ocular morbidity. Logistic regression analysis found that age was a significant predictor of vision loss (p < 0.05), but not for hearing loss (p = 0.06). Gender was not a significant predictor of hearing (p = 0.22) or vision loss (p = 0.20).

CONCLUSIONS

Hearing loss is prevalent in at least 22 per 1000 and vision loss in at least 23 per 1000 preschool children in an underserved South African community. Timely identification of sensory losses can be facilitated through community-based hearing and vision services supported by mHealth technology.

Hearing Impairment in South Africa and the Lessons Learned for Planetary Health Genomics: A Systematic Review

Hearing impairment (HI) is a silent planetary health crisis that requires attention worldwide. The prevalence of HI in South Africa is estimated as 5.5 in 100 live births, which is about 5 times higher than the prevalence in high-income countries. This also offers opportunity to drive progressive science, technology and innovation policy, and health systems. We present here a systematic analysis and review on the prevalence, etiologies, clinical patterns, and genetics/genomics of HI in South Africa. We searched PubMed, Scopus, African Journals Online, AFROLIB, and African Index Medicus to identify the pertinent studies on HI in South Africa, published from inception to April 30, 2021, and the data were summarized narratively. We screened 944 records, of which 27 studies were included in the review. The age at diagnosis is ∼3 years of age and the most common factor associated with acquired HI was middle ear infections. There were numerous reports on medication toxicity, with kanamycin-induced ototoxicity requiring specific attention when considering the high burden of tuberculosis in South Africa. The Waardenburg Syndrome is the most common reported syndromic HI. The Usher Syndrome is the only syndrome with genetic investigations, whereby a founder mutation was identified among black South Africans (MYO7A-c.6377delC). GJB2 and GJB6 genes are not major contributors to nonsyndromic HI among Black South Africans. Furthermore, emerging data using targeted panel sequencing have shown a low resolution rate in Black South Africans in known HI genes. Importantly, mutations in known nonsyndromic HI genes are infrequent in South Africa. Therefore, whole-exome sequencing appears as the most effective way forward to identify variants associated with HI in South Africa. Taken together, this article contributes to the emerging field of planetary health genomics with a focus on HI and offers new insights and lessons learned for future roadmaps on genomics/multiomics and clinical studies of HI around the world.

mHealth developmental screening for preschool children in low-income communities

Children are often only identified with a developmental delay when they enter primary school due to developmental delays hindering academic progress. Detection of at-risk children in low-income communities is typically unavailable due to several challenges. This study validated an mHealth-based developmental screening tool as a potential time- and cost-effective way of delivering services for preschool children. This cross-sectional within-subject study screened 276 preschool children from low-income communities using the mHealth Parents' Evaluation of Developmental Status (PEDS) tools. The mHealth PEDS tools' performance was then evaluated by comparing caregiver concerns according to the PEDS tools with results obtained using a reference standard assessment tool, the Vineland-3. The mHealth PEDS tools identified 237 (85.9%) of children at risk of developmental delay compared to 80.1% (n = 221) of children identified with a developmental delay using the Vineland-3. Sensitivity of the PEDS tools was high (92.6%) with low specificity (22.5%) using US standardised criteria. Literacy skills were found to be most delayed, according to the PEDS: DM (89.3%; n = 142) and Vineland-3 (87.1%; n = 134). Low specificity of the prescribed criteria may require the implementation of adapted referral criteria within low socio-economic status (SES) settings. The mHealth PEDS tools may still be valuable for preschool developmental surveillance of children within low SES settings. It is recommended, however, that children who are identified with a developmental concern undergo a second screen to reduce false positives.

Community-Based Ototoxicity Monitoring for Drug-Resistant Tuberculosis in South Africa: An Evaluation Study

In response to the drug-resistant tuberculosis (DRTB) ototoxicity burden in South Africa, ototoxicity monitoring has been decentralised, with community health workers (CHWs) acting as facilitators. This study describes a community-based ototoxicity monitoring programme (OMP) for patients with DRTB. Findings are compared to the recommended guidelines for ototoxicity monitoring, the OMP protocol and published studies. This was a retrospective study of longitudinal ototoxicity monitoring of 831 patients with DRTB, using data collected at community-based clinics in the City of Cape Town between 2013 and 2017. Approximately half (46.8%) of the patients had an initial assessment conducted in accordance with the OMP protocol recommendations, and follow-up rates (79.5%) were higher than those of a similar DRTB programme. However, patients in this study were not monitored within the timeframes or with the regularity recommended by the guidelines or the OMP protocol. Extended high-frequency pure-tone audiometry (27.5%) was underutilised by testers and data recording was inconsistent (e.g., 37.7% of patient gender was not recorded by testers). Community-based OMP using CHWs to facilitate monitoring showed improvement over previous hospital-based reports, with more accessible services and higher follow-up rates. However, to improve OMP outcomes, OMP managers should reassess current protocols and data recording practices.

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.

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.

Referral Criteria for Preschool Hearing Screening in Resource-Constrained Settings: A Comparison of Protocols

Purpose This study aimed to describe and compare the performance of two screening protocols used for preschool hearing screening in resource-constrained settings. Method Secondary data analysis was done to determine the performance of two protocols implemented during a preschool hearing screening program using mobile health technology in South Africa. Pure-tone audiometry screening at 25 dB HL for 1000, 2000, and 4000 Hz in each ear was used by both protocols. The fail criterion for the first protocol (2,147 children screened) constituted a no-response on one or more frequencies in either ear. The second protocol required two or more no-responses (5,782 children). Multivariate logistic regression models were used to investigate associations between outcomes and protocol, age, gender, and duration. Results Fail rates for the one-frequency fail protocol was 8.7% (n = 186) and 4.3% (n = 250) for the two-frequency fail protocol. Children screened with the two-frequency fail protocol were 52.9% less likely to fail (p < .001; OR = 0.471; 95% confidence interval [0.385, 0.575]). Gender (p = .251) and age (p = .570) had no significant effect on screening outcome. A percentage of cases screened (44.7%) exceeded permissible noise levels in at least one ear at 1000 Hz across both protocols. True- and false-positive cases did not differ significantly between protocols. Protocol type (p = .204), gender (p = .314), and age (p = .982) did not affect the odds of being a true-positive result. Average screening time was 72.8 s (78.66 SD) and 64.9 s (55.78 SD) for the one-frequency and two-frequency fail protocols, respectively. Conclusions A two-frequency fail criterion and immediate rescreen of failed frequencies significantly reduced referral rate for follow-up services that are often overburdened in resourced-constrained settings. Future protocol adaptations can also consider increasing the screening levels at 1000 Hz to minimize the influence of environmental noise.

Community-Based Hearing and Vision Screening in Schools in Low-Income Communities Using Mobile Health Technologies

Introduction Globally, more than 50 million children have hearing or vision loss. Most of these sensory losses are identified late due to a lack of systematic screening, making treatment and rehabilitation less effective. Mobile health (mHealth), which is the use of smartphones or wireless devices in health care, can improve access to screening services. mHealth technologies allow lay health workers (LHWs) to provide hearing and vision screening in communities. Purpose The aim of the study was to evaluate a hearing and vision school screening program facilitated by LHWs using smartphone applications in a low-income community in South Africa. Method Three LHWs were trained to provide dual sensory screening using smartphone-based applications. The hearScreen app with calibrated headphones was used to conduct screening audiometry, and the Peek Acuity app was used for visual acuity screening. Schools were selected from low-income communities (Gauteng, South Africa), and children aged between 4 and 9 years received hearing and vision screening. Screening outcomes, associated variables, and program costs were evaluated. Results A total of 4,888 and 4,933 participants received hearing and vision screening, respectively. Overall, 1.6% of participants failed the hearing screening, and 3.6% failed visual acuity screening. Logistic regression showed that female participants were more likely to pass hearing screening (OR = 1.61, 95% CI [1.11, 2.54]), while older children were less likely to pass visual acuity screening (OR = 0.87, 95% CI [0.79, 0.96]). A third (32.5%) of referred cases followed up for air-conduction threshold audiometry, and one in four (25.1%) followed up for diagnostic vision testing. A high proportion of these cases were confirmed to have hearing (73.1%, 19/26) or vision loss (57.8%, 26/45). Conclusions mHealth technologies can enable LHWs to identify school-age children with hearing and/or vision loss in low-income communities. This approach allows for low-cost, scalable models for early detection of sensory losses that can affect academic performance.

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.

Applied tele-audiology research in clinical practice during the past decade: a scoping review

OBJECTIVE

The purpose of this scoping review was two-fold, (1) to provide information about the characteristics, type of service delivery, participant information and outcomes related to tele-audiology in clinical popluations, and (2) to describe documented facilitators and barriers to tele-audiology delivery from the perspectives of practitioners and service recipients. Knowledge of these findings can assist audiologists in considering remote service delivery options for their practices.

DESIGN

A scoping review was conducted in November 2019 to identify English-language peer-reviewed journal articles published from 1 January 2010 to 30 October 2019 related to remote clinical service delivery in audiology.

RESULTS

Thirty-six published research articles were included. Research studies were classified into four broad areas with some articles including more than one area within the scope of their article: Screening (n = 5), Diagnostic (n = 5), Intervention (n = 18), and Perspectives (n = 22).

CONCLUSION

Hearing healthcare service delivery is expanding with the changing technological landscape, providing greater opportunities and flexibility for audiologists and patients. There are clear opportunities for interdisciplinary collaboration and for collaboration with on-site local facilitators. Local facilitators, with training, can assist in connecting individuals to follow-up care, provide educational support, and needed hands-on assistance for specialised testing.

eHealth Technologies Enable more Accessible Hearing Care

Hearing loss is a pervasive global health care burden affecting up to one in every seven persons of whom 90% reside in low- and middle-income countries. Traditional service-delivery models are unable to support and promote accessible and affordable hearing care in these setting. Major barriers include a severe shortage of hearing health care professionals, costs associated with equipment, facilities and treatments, and centralized service-delivery models. Convergence of digital and connectivity revolutions are combining to enable new ways of delivering decentralized audiological services along the entire patient journey using integrated eHealth solutions. eHealth technologies are allowing nonprofessionals in communities (e.g., community health workers) to provide hearing services with point-of-care devices at reduced cost with remote surveillance and support by professionals. A growing body of recent evidence showcases community-based hearing care within an integrated eHealth framework that addresses some of the barriers of traditional service-delivery models at reduced cost. Future research, especially in low- and middle-income countries, must explore eHealth-supported hearing care services from detection through to treatment.