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First Person: Ensuring Best Practices and Ethical Standards Abroad

McBride, Ingrid AuD

doi: 10.1097/01.HJ.0000462432.18750.c5
Audiology without Borders

Dr. McBride is clinical associate professor at Arizona State University and director of the Audiology Clinic at ASU. To learn more about how volunteering with Hearing for Humanity made an impact on the students who participated, read the program's 2014 blog at Dr. McBride can be reached at



Hearing for Humanity (HFH) is a program at Arizona State University (ASU) with the mission of providing sustainable humanitarian audiologic and rehabilitative services in Malawi, Africa, and clinical training abroad for undergraduate and graduate students in the ASU Department of Speech and Hearing Science.

Malawi, a developing country in southeast sub-Saharan Africa with a population of 16 million people, is ranked as the eighth poorest country in the world. Known as the Warm Heart of Africa, this landlocked country is bordered by Mozambique, Zambia, and Tanzania and has the third-largest lake in Africa, Lake Malawi. A former British protectorate, Malawi gained its independence July 6, 1964, and English is the official language.

Hearing for Humanity is also open to students from other universities and to professionals in the field. The ASU humanitarian audiology study abroad program provides invaluable opportunities for students and a unique clinical experience that exposes them to challenging clinical settings and ear/hearing disorders not commonly seen in the United States.

Students also gain cultural sensitivity, and their experience has the potential to change the course of their future professional endeavors. A 2013 alumna of the ASU Doctor of Audiology program, Courtney Caron, participated in Hearing for Humanity for two years as a student and one year as a professional audiologist. She now lives and works in Malawi as an audiologist for Sound Seekers, a British charity with the mission of improving the lives of children with hearing loss in developing countries of the Commonwealth of Nations.

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I started the Hearing for Humanity program in 2010. Since the inaugural trip, HFH has conducted three additional one-month missions to Malawi, typically in June. In 2014, the HFH team was the largest to date, consisting of four undergraduate students, seven graduate students, two non-ASU audiologists, and two ASU faculty leaders.

The preparation involved in taking a large team abroad is extensive. Student participation in the processes of developing, planning, and implementing a humanitarian audiology mission is an important component of the educational experience.

Students take part in the many predeparture activities, including inventory of fixed and disposable supplies, appeals for manufacturer donations, electroacoustic analysis of hearing instruments, packing, and fundraising events, as well as post-trip activities, including data entry and analysis.

Equally important to a successful trip is the preparation of the team. Setting appropriate expectations regarding physical comforts (accommodations, food, and ground transportation), expanding cultural knowledge (social etiquette, dress and standards of modesty, customs, values and traditions, cultural medical beliefs and practices, attitudes toward disabilities, the status of Malawi's healthcare delivery system, and differences among cultural groups), preparing the students emotionally for what they will experience (culture shock), and teaching them how to be an effective member of a team are essential.

Our approach in working with students has evolved over the years and continues to mature. In addition to mandatory ASU Study Abroad sessions covering health and safety issues, the students are required to participate in a series of nine predeparture meetings.

Three interactive sessions are led by a psychologist and focus on team building, conflict management, and compassion fatigue. Other didactic and hands-on sessions provide training in medical history data collection, testing procedures and use of equipment, pediatric testing techniques, temporary earmold fabrication, and audiologic service delivery in a developing country.

The students are assigned reading material and view documentary films to give them insight into Malawian life and people. The time devoted to these predeparture activities is substantial but, in our experience, absolutely necessary to prepare the team fully before going abroad.

Once in-country, students complete a daily journal and participate in debriefing sessions. Working long hours in what can be emotionally charged settings, enduring long travel days, and being away from home for five weeks exact a physical and emotional toll on everyone. Taking the time to share experiences and to rest and recharge are essential.

Students enrolled in the study abroad experience earn course credit and clinical practicum hours, and are graded on their participation in all predeparture sessions and pre- and post-trip planning, course assignments, clinical and team performance, and the reflection journal. Next year, a new requirement will be an end-of-course reflection paper.

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The Hearing for Humanity model stresses the importance of following best practices in assessment and treatment. The students learn that the same standard of care and quality provided in the university clinic can be offered abroad.

At hospitals, clinics, and schools for the deaf, the HFH team provides screening and diagnostic assessments, collects heath history and audiometric data, and provides hearing aid fitting and rehabilitative services to a large number of children and adults. Testing is conducted in the quietest areas available at each location, and, due to rolling blackouts or lack of electricity at some sites, the use of battery-powered equipment is essential.

We are fortunate also to have access to the Hearing Assessment and Research Center (HARK) mobile audio trailer equipped with two audiometric test booths and a generator during most outreach clinics. Additionally, when we provide services at the ABC Hearing Clinic and Training Center, we have access to a modern full-service clinic that rivals any in the United States.

The Hearing for Humanity model uses a multistage evaluation protocol consisting of an initial screening (otoscopy, tympanometry, distortion product otoacoustic emissions [DPOAE], and pure-tone screening), a secondary screening as needed, and then diagnostic testing consisting of a pure-tone audiogram, including masked air conduction and bone conduction, to establish the degree, nature, and configuration of the hearing loss.

Cerumen management and other procedures such as ear swabbing/mopping are completed as needed, followed by the second screening and diagnostic testing. If the patient is known to have a significant hearing loss or was tested by HFH in prior years, then the initial screening is omitted, and only the diagnostic audiogram is completed. A comprehensive health history is collected to the extent possible from each patient.

Based on the outcome of the multistage evaluation, patients are referred for medical management and/or rehabilitation (Category 1), rehabilitation/intervention (Category 2), or medical management (Category 3). Using this protocol, the Hearing for Humanity team has collected valuable data on all individuals tested, including the degree and type of hearing loss, possible contributing factors, and necessary follow-up.

Due to the high incidence of conductive and mixed hearing losses, the students gain considerable masking experience with air- and bone-conduction testing. The use of diagnostic and portable audiometers with insert earphones is a necessity given the great number of masking dilemmas encountered.

In 2014, the team also completed auditory brainstem response (ABR) and auditory steady-state response (ASSR) assessments, which allowed us to identify a number of auditory neuropathy spectrum disorder (ANSD) cases.

The students also gain considerable experience performing pediatric assessments using visual reinforcement audiometry (VRA) and conditioned play audiometry (CPA) techniques, and are exposed to children with multiple disabilities and a variety of syndromes. In total, the Hearing for Humanity team visits a minimum of 14 locations during the monthlong trip.

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The HFH team provides evidence-based rehabilitative services to both children and adults, with a focus on the quality of the assessment and hearing aid fitting rather than the quantity. Audiologic testing, World Health Organization (WHO) guidelines, and the availability of or access to follow-up services are criteria used to determine hearing aid candidacy.

Over a four-year period, the HFH team tested 2,764 children and adults and fit 748 hearing aids. Gaining access to hearing aids is an ongoing challenge; Hearing for Humanity receives donations of new and used devices from manufacturers, audiologists nationwide, and patients of the ASU Speech and Hearing Clinic.

Used hearing aids are refurbished or repaired, and both analog and digital hearing aids are fitted. With fundraising efforts, HFH is also able to purchase new hearing aids through the International Humanitarian Hearing Aid Purchasing Program (IHHAPP).

For each ear fitted, services include: fabrication of a temporary earmold, real-ear-to-coupler difference (RECD) measurement, potentiometer adjustment or software programming to amplification targets, electroacoustic verification of the fitting using simulated real-ear measures (SREM) and the individualized RECD, informational counseling for care and use, and audiologic rehabilitation counseling. A second set of ear impressions is also taken so that a permanent earmold can be made by a Malawian earmold technician.

The majority of the hearing aids fitted are air-conduction hearing aids; however, many patients have maximum conductive components and chronic drainage issues that require the use of a bone-conduction hearing aid. These patients are referred to in-country audiologists for subsequent fitting and management since traditional bone-conduction hearing aids are a rarity in the United States and, therefore, are difficult for our team to bring to Malawi.

In 2014, a donation from Cochlear allowed the team to fit four softband bone-anchored hearing aids to four patients with bilateral atresia.

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The Hearing for Humanity program also teaches students about the ethics of providing humanitarian audiology.

In order to fit hearing aids responsibly, 1) only fit people who can benefit from a hearing aid, 2) fit hearing aids according to evidence-based practices, 3) ensure that follow-up care is available and provided either locally or, at a minimum, through annual visits by the outside team, and 4) offer education and training for the people fit as well as teachers and parents who help care for the hearing aids.

The HFH team has witnessed firsthand the consequences and poor outcomes of children and adults fit indiscriminately, without diagnostic testing or appropriate hearing aid fitting methods, and encountered many children with no measurable residual hearing who wear hearing aids with dead batteries or no batteries because they cannot tell if the hearing aids are working or not, as well as children who could benefit from hearing aids but were fit with insufficient amplification to provide the needed speech audibility.

Consequences of such unfortunate practices include teachers who do not know which children should legitimately use hearing aids and which ones cannot benefit, and children who are unfairly led to believe they can benefit from hearing aids when they cannot.

For short-term humanitarian programs like Hearing for Humanity to be successful and sustainable, it is essential to work closely with local partners and to train residents of the country to strengthen local capacity and appropriate follow-up.

The HFH program collaborates with in-country partners, including Australian audiologists Peter and Rebecca Bartlett with EARS, Inc., at the ABC Hearing Clinic and Training Center at the African Bible College, as well as ENT physician Wakisa Mulwafu and clinical officers at the Queen Elizabeth Central Hospital (QECH) in southern Malawi. Beginning in 2015, we will also partner with Dr. Caron of Sound Seekers, who is based at QECH.

The combined HFH/EARS team includes Malawian students from the ABC Audiology Technician Training Program, who work alongside ASU students and faculty to provide diagnostic and rehabilitative services as part of their clinical training.

Since Hearing for Humanity is only able to travel to Malawi once a year, the local partners provide the needed interim services and help to coordinate annual follow-up by the HFH/EARS team. As part of our collaboration, ASU HFH faculty members teach course modules in the training curriculum for ABC students.

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The study abroad experience provided by Hearing for Humanity is not all clinical. Students are given many opportunities for cultural exchanges and experiences, including a safari in Zambia.

The most significant cultural opportunity takes place while traveling through Malawi from one clinic location to another. Our close working relationship with local audiologists and Malawian students from ABC allows for open discussion and sharing of U.S. and Malawian culture.

Another special experience involves the group's yearly invitation as honored guests to a village in the southern region of Malawi. James Village is the birthplace of Honorable Victor Musowa, our colleague, friend, member of Parliament, and contact in Blantyre.

The HFH team raises funds every year to supply needed items, and, over the past two trips, we have provided a wood-burning oven and two sewing machines for the village. The oven is the foundation for a bread-making operation that generates funds used to care for the children of people with HIV/AIDS, and the sewing machines are the foundation for a tailoring school that enables women and girls to learn a skill to help support themselves.

During our visits, we are greeted with songs, dances, hugs, and smiles everywhere we go. Our next project is to provide school fees for young girls to complete their education. School costs 15,000 Kwacha per year (about $30), which is beyond the reach of many Malawians, who live on less than $1.25 per day.

Developing and implementing a humanitarian study abroad program has been a wonderful addition to the clinical preparation of students at ASU, and it has been well worth the required time and effort.

The Hearing for Humanity program is committed to improving access to ear and hearing healthcare in Malawi. Our presence in Malawi one month per year helps to bring supplies, including hearing aids, and increased man power to support our in-country partners.

“When I reflect on my experience with the Hearing for Humanity team in Malawi, Africa, I am humbled by how much positive influence a few people can have on so many. I specifically remember arriving at each clinic site every day and seeing a line of people hoping to receive our audiologic services. It is truly difficult to fathom the need for audiologic services in countries such as Malawi. Sure, the days were long and exhausting, but nothing compares to the gratitude and appreciation each patient expressed to our team. I find it impossible to put into words the rewarding, humbling, and life-changing experiences volunteering in the field of audiology has to offer unless you can experience it yourself.”

—Paige Tatge, ASU AuD Student

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Audiology Without Borders

Our Audiology Without Borders column highlights humanitarian hearing healthcare programs.

The column is edited by active humanitarians Jackie Clark, PhD, and King Chung, PhD. Dr. Clark is a member of The Hearing Journal Editorial Advisory Board, clinical associate professor at the University of Texas at Dallas, and research scholar at University of the Witwatersrand in Johannesburg; and Dr. Chung is an associate professor of audiology at Northern Illinois University in DeKalb.

Let us know about your humanitarian program! Send the details to —manuscripts should be about 1,000 words, and photographs are also welcome (300 dpi in jpg, tif, or gif format).

Read past Audiology Without Borders columns in a special collection at

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