Audiologists have taken major strides in boosting hearing care in developing countries, but there's one thing that still leaves them unhappy: progress just isn't happening fast enough.
An estimated 80 percent of the 278 million people suffering from hearing impairment live in developing nations, according to the World Health Organization, and without access to hearing care services, many of them are likely to lead a life of poverty without the opportunity for a good education or a job.
But advances in technology such as teleaudiology, nanocoatings for hearing aid parts, trainable hearing aids, and solar battery chargers are propelling the work of audiologists forward so those living in these areas can gain wider access to hearing care. Programs that address local cultural nuances are also gaining traction, breaking down barriers that prevent people from seeking care. With the costs of basic hearing aids manufactured for developing countries declining, humanitarian groups are finding it more affordable to bring those diagnosed with hearing impairment the devices they need, says Bradley McPherson, PhD, Professor of Audiology and Honorary Director for the Centre for Communication Disorders at the University of Hong Kong and coeditor of the book, Audiology in Developing Countries. (http://bit.ly/McPhersonandBrouillette.)
Demographic shifts in developing countries will also likely affect the way people think about what types of hearing aids will be in demand there. More than half of the world's population lives in cities, but a growing number of poor, rural people are making a transition to the middle class, McPherson says, meaning more families will be able to afford hearing aids.
“They might not be able to afford digital hearing aids, but they can still get something,” he says. “What was high-end five years ago is basic technology now, so the costs keep going down, and hopefully manufacturers will start thinking more seriously about serving these populations.”
THE GREAT ELECTRONIC HOPE
Teleaudiology is being heralded as the solution to dramatically broaden the reach of hearing care services to huge populations in the developing world because so many of those in need live far from urban centers. The programs already being tested vary from place to place, but typically a local health worker or technician in a remote area is trained to conduct basic screenings and sometimes other diagnostic tests. The data are transmitted over the Internet or by satellite cell phones to an audiologist at the large, urban medical center many miles away who can evaluate the information and recommend a course of action.
Teleaudiology is ideal for screenings, but will be more challenging for other hearing care services, such as fittings and rehabilitation, says James W. Hall, PhD, Clinical Professor in the Department of Speech, Language and Hearing Sciences at the University of Florida and an Extraordinary Professor in the Department of Communication Pathology at the University of Pretoria in South Africa. Teleaudiology will make pediatric screenings easier, however, because local health workers know where the children live and because the screening is automated, he says. Fittings for children will be more difficult, however, because audiologists or highly-skilled technicians will be needed to do them properly.
“India is a perfect place to start,” Hall says. “You've got some hope of succeeding there because there are already training programs for audiology in place, you've got smart people, the government is concerned about health care, and telemedicine is already in use in some parts of the country. In China, they have the economic resources to support teleaudiology if they want to pursue it.”
PILOT SHOWS PROMISE
A pilot project testing the validation of teleaudiology in South Africa and Kenya is showing early signs of success, which could eventually provide access to hearing care services for millions of people across Africa. The three-year project was established in South Africa this past year by the Tele-Audiology Network (TAN), and project managers are evaluating its cost-efficiency and validating the technology before it's rolled out to other parts of Africa, according to De Wet Swanepoel, PhD, Associate Professor of Communications Pathology at the University of Pretoria, who is working with Dirk Koekemoer, MD, TAN's Chief Executive Officer and Head of Research at GeoAxon, a healthcare technology company.
Non-health professionals are being trained to facilitate automated audiometry testing using telemedicine-enabled audiometers so they can conduct hearing tests where sound booths are not available. Audiologists receiving the data can monitor the ambient noise levels in the environment to know if the test is reliable, explains Swanepoel. The testing, if done properly, gives audiologists enough information to know whether patients need a medical referral or audiological amplification.
“The trained facilitator just needs to know how to set the patients up with the device, instruct them, and initiate the user-friendly automated software,” he explains. “The testing is done automatically and it doesn't require broadband for transmission either. Cellular networks are more widespread in Africa than wired Internet connections and we're using those to send data.”
Patients in South Africa diagnosed with hearing loss can obtain hearing aids from public health hospitals. At the two remote teleaudiology clinics outside Nairobi, patients have access to hearing aids through a partnership with the Kenya Ear Foundation, which developed a hearing aid lab there to make earmolds and sell devices at reduced cost.
Down the line, the goal is to validate remote fitting of hearing aids using synchronous telehealth systems. The clinics are also currently adding a video otoscope that will allow high-quality digital photographs of the ear canal and tympanic membrane to be sent to a specialist to diagnose inner and outer ear disease. The network is assisted with specialist otology support from Umea University Hospital, under the leadership of Professor Claude Laurent, MD, PhD.
“Our initial overall findings are very promising,” Swanepoel says. “Eventually we will expand to other clinics and we will call on audiologists around the world to help in diagnosis and interpretation of the audiograms. We'll also seek out ENT specialists for the video diagnosis to look for medical abnormalities.”
For now, audiologists within TAN are evaluating the data on patients who have been tested. Swanepoel adds that audiologists anywhere in the world who volunteer will be able to evaluate patients without leaving their home or office. Audiologists from all over the world, especially in the United States, are already expressing interest in participating when the program expands.
They may need that additional expertise soon. Swanepoel says they are planning to open more TAN clinics in Africa and other developing regions within the next year, and may need to tap the outside audiology community for diagnostic evaluations, interpretation of findings, and possibly even for remote hearing aid fittings.
A WORK IN PROGRESS
Slowly but surely, a growing number of infants and small children living in remote parts of China are benefiting from hearing screening programs. Christine Yoshinaga-Itano, PhD, a longtime advocate for universal hearing screenings for newborns, recently returned from her sixth trip to China where she has been working for the past seven years teaching local workers better techniques for hearing screenings, hearing aid fittings, and other services for infants and young children.
Yoshinaga-Itano, who is a Professor at the University of Colorado at Boulder in the Department of Speech, Language and Hearing Sciences, also advocates the globalization of infant hearing screening as Chair of the Joint Committee on Infant Hearing (JCIH). A JCIH policy statement, updated in 2007, sets criteria for these programs, and most countries look to it as the standard but tailor it for their area and culture, she says.
Yoshinaga-Itano has been trotting around the globe for more than 20 years, doing humanitarian work and setting up programs in China, Mexico, and Southeast Asia, including Thailand and the Philippines. Most recently, she and her team worked with audiometric technicians in the rural area of Luoyang, about an hour outside Xian, one of China's ancient capitals. Most technicians in China are trained by manufacturers because no professional audiology program exists there yet, so the technicians typically have big gaps in their knowledge, she admits. During her time there, the team worked with newborns and children between the ages of 2 and 6, and showed technicians how to do secondary levels of testing, checking hearing aids and fitting children for new ones. Most of the children already fitted with hearing aids were underamplified, she says.
“When you're working side-by-side with 10 teachers and technicians at a school, you see right away what they don't understand,” Yoshinaga-Itano says. “But they learned fast and we saw dramatic changes in how they did basic fittings, identification and basic principles of intervention. We also noticed that once we got people trained in an area of China, other people from nearby areas were coming to learn from them. It created a ripple effect in the region.”
With more than a billion people in China, the challenges of reaching the majority of the population are staggering, but Yoshinaga-Itano credits newer automated technology as a big leap forward in bringing newborn screening to needy populations that previously had no access to testing and follow-up care.
Now it's possible to screen newborns just about anywhere in the world, she says. Costs have declined, devices are more portable, and digitization and battery-operated instruments have made screenings more accessible because administrators don't have to rely on local electricity, which isn't available everywhere. And with automated equipment, those with lower skill levels can be trained to use it in remote regions, she adds.
“That's extremely exciting because in the past, services and the ability to identify hearing loss in infants could only be done in large urban areas in the more advanced institutions and private hospitals for people with the financial means to access that care,” she explains. “We couldn't reach places where there's an even greater incidence of hearing loss.”
China is making progress on the audiology front, though. The government is currently working on establishing an audiology profession, with at least five programs already set up, she notes.
BUILDING ON INFRASTRUCTURE
When Vidya Ramkumar was searching for a dissertation topic, she settled on improving early identification and early intervention of hearing loss among children in remote parts of India. After connecting with audiologists who engaged in teleaudiology projects in other countries, obtaining funding from the Indian Council of Medical Research, and convincing Grason-Stadler, Inc., to cover the equipment's shipping costs, this year, Ramkumar, a lecturer in the Department of Speech, Language, and Hearing Sciences at Sri Ramachandra University in Chennai, launched a teleaudiology project as part of her doctorate research.
“The government was already interested in looking for answers to this problem, and they also had a big interest in telemedicine, with some of that infrastructure already in place,” says Ramkumar, who worked on the project with her university colleagues Dr. Kumaravelu Selvakumar, Chairman of Telemedicine, and Dr. Roopa Nagarajan.
In fact, the university where Ramkumar was lecturing already held teleconferences and continuing medical education to reach people living far beyond the city. One program sent a university van to rural areas, where patients could consult with hearing care professionals through video conferencing inside the vehicle.
Ramkumar's project will equip the van for diagnostic hearing testing using an auditory brainstem response system that will transmit data to audiologists back at the university so they can make recommendations. She warns that a hospital or university may not be interested in setting up a telemedicine program just for audiology, but says it can be part of other medical diagnostic testing such as teleradiology.
The project, which started in January, has community workers knocking on doors looking for newborns and young children about 50 kilometers from Chennai. The workers conduct two levels of hearing screening using otoacoustic emissions. If the baby fails the first screening, the worker will return 15 days later to screen him again. If he fails a second time, the worker will schedule a diagnostic evaluation for the child when the van next comes to their village. During that follow-up appointment, the community worker will connect electrodes and transducers on the baby, and Ramkumar will take control of the test remotely back at the university.
Ramkumar is testing two modes of outreach to see which is more effective to get more newborns and young children screened for hearing impairment. She is also looking at whether teleaudiology will result in better compliance for follow-up diagnostic evaluations. In one area, families whose newborns fail both screenings will be asked to come to the university's medical center in Chennai for follow-up. In the other group, the follow-up diagnostic test will take place using the teleaudiology equipment in the van, she says.
“It will be interesting to see what we find. Many of these people are daily wage workers and will lose their wages if they take the trip to the hospital. So many won't come, even if we tell them the care is free,” she says. “They also may not want to leave their other kids behind to take one child all the way to our hospital. We've already seen this. We want to see if using teleaudiology produces real results.”
The pilot project will look only at screening and identification of hearing loss among newborns and young children because no formal program yet offers hearing aids or rehabilitation, says Ramkumar, but they can obtain free body-worn hearing aids from the government. Some families may even be able to afford better ones, she says.
Equally important to the success of this type of program is for caregivers at the rural centers to understand the key role that local workers play in the process, says Ramkumar. “The village people relate better to the community workers, so we have to put in a lot of energy and time to find the best way to recruit community workers who are liked by the villagers.”
Although most community workers are men, Ramkumar's team bucked that trend because mothers are more comfortable handing their babies over to other women for testing in the van. “The cultural barriers can be just as difficult to overcome in setting up these programs,” she says. “The technology only goes so far. If there isn't trust among villagers toward the person who is doing the screenings, it doesn't matter how good the teleaudiology technology is. The success of a community-based program may lie in how well the program is integrated and woven around the local practices and beliefs.”
TWO STEPS BACK
Sometimes bringing hearing care services to the poorest nations can have disappointing setbacks, as Jackie L. Clark, PhD, knows all too well. A Clinical Associate Professor at the School of Behavioral & Brain Sciences at the University of Texas at Dallas’ Callier Center, she has been setting up audiology clinics in the tiny poverty-stricken country of Mozambique since the late 1990s. Her humanitarian trips over the years screened children at clinics and schools, and trained local workers to continue their work.
But challenges remain. Even as the Chair of the Humanitarian Committee of the International Society of Audiology, a coalition of audiologists, otolaryngologists, educators, philanthropists, and others committed to finding hearing care solutions in developing countries, Clark was unable to get clearance for volunteers to enter the country, foiled by the labyrinth of administrative requirements imposed by Mozambique's health ministry.
“Mozambique has a 40 to 50 percent AIDS infection rate and it's very hard to get the ministry of health to say that hearing care is just as important as HIV, cholera, and malaria,” she says. “Right now, they're marginally interested in hearing care programs, so trying to establish the infrastructure has been a challenge.”
But Clark is not easily dissuaded, and knows there is no shortage of other countries where she can do good work. Instead, she organized trips to a rural province of South Africa close to the Mozambique border. It turned out she was still able to care for people from Mozambique because border security was lax enough that they could cross into South Africa. She also traveled to Malawi this summer with a small team to work at an established clinic run by an Australian couple.
THE RIGHT DIRECTION
Teleaudiology holds great promise as a practical way to bring screenings and other hearing care services to those who might otherwise never obtain them, but it will take time before any of these programs are commonplace in poor nations around the world.
Hall estimates that it will take 10 to 15 years before there is any significant use of teleaudiology. “Audiologists in doctoral programs need to be interested because there's a big research component. Technology needs to be changed, and there needs to be a huge infusion of funding on the scale of a Bill & Melinda Gates Foundation getting behind it,” he says.
Perhaps the most important ingredient for success is the buy-in that comes from local governments and residents when they see how their participation can make a difference in creating sustainable programs. That's especially true once foreign audiologists dismantle their clinics and go home, notes Yoshinaga-Itano.
“The obstacles are huge, but in every developing country I've worked in, the passion and investment in learning new things is the highest of everything we see,” she explains. “These people don't have much to work with, but they do great things.”