Hearing loss, the second most common impairment in the world, often occurs with other distressing auditory conditions such as tinnitus and loss of vestibular function.1,2 The incidence of these conditions increases with age,3-5 which is of concern due to the rising proportion of elderly people.6 As these are chronic, long-term conditions, ongoing management is required, adding to society's health care and economic burden. For hearing loss alone, the resulting annual global costs are $750 billion. Although interventions to address hearing loss, tinnitus, and vestibular disorders are cost-effective, provision of such services is hampered by factors such as lack of resources,7 lack of evidence-based treatments, and limited hearing health care professionals.8 Uptake of interventions is further complicated by multiple factors surrounding accessibility (in terms of location and time), costs, and barriers to engagement and compliance.9
Internet-based interventions (IBIs) have emerged as an approach to address these barriers by offering accessible and affordable audiology services10 that encourage self-management and engagement.11 They provide great flexibility as either a replacement for or supplement to routine care. IBIs can be provided with or without guidance (i.e., professional support). Perhaps the most attractive aspect is that IBIs can be used as a shared global resource, being based online and not in a specific geographic location. Despite these advantages, emphasis needs to be placed on the evidence base of these interventions.
Beukes, et al.,12 undertook a systematic review to summarize the evidence base for hearing-related IBI (for hearing loss, tinnitus, and vestibular difficulties), with a focus on identifying the primary, secondary, and long-term effects of these interventions. The review included 15 studies from Sweden, the United Kingdom, and Germany, with data from 1,811 participants. To improve the quality of the evidence, only randomized controlled trials were included. The majoity (12 studies) were efficacy trials (i.e., tested IBI in controlled conditions) and three were effectiveness studies (i.e., tested IBI in “real” world conditions). All Internet intervention arms provided guidance except for that of vestibular rehabilitation. There was little overlap in the range of interventions (Fig. 1) and comparators used (see Fig. 2 online: bit.ly/31wHHqV), except in the consistent use of cognitive behavioral therapy (CBT) for tinnitus. Comparison of the main findings for each type of IBI is summarized in Table 1.
EVIDENCE FOR HEARING LOSS?
Results indicated that IBI for hearing loss can be of great value, although further high-quality studies are required to improve the evidence base. The optimal IBI model for hearing loss needs consideration. This may be a blended approach, where hearing aids are fitted (face-to-face, remotely, or over the counter) and IBI is provided to address the extensive auditory rehabilitation required. Another consideration is how to address different rehabilitation needs for each stage of the hearing rehabilitation pathway, including pre-intervention counselling, post-fitting rehabilitation, and management of emotional and functional effects. Finding the time or expertise to address the psychological distress associated with hearing problems is usually a challenge. IBIs are very viable options for such help. Further development of these interventions may also help improve the impact they have on improving patients’ quality of life.
EVIDENCE FOR TINNITUS?
The tinnitus IBI stood apart from the other interventions since a more unified approach was followed using the theoretical principles of CBT. Despite the proved effectiveness of CBT for tinnitus,28,29 its provision is often hampered because not many qualified professionals can offer this support.30 The present review found that internet-based CBT for tinnitus indicated a clear potential to improve access to evidence-based interventions. These interventions also contributed to reducing the impact of various comorbidities, such as insomnia, anxiety, and depression, and improving patients’ quality of life. The evidence base is further enhanced as results were maintained long-term (i.e., measured up to one year post-intervention). Future research should identify which aspects of IBIs should be modified to further improve their clinically significant impact.
EVIDENCE FOR VESTIBULAR DISORDERS?
Only one study included in the review examined the efficacy of IBI for vestibular disorders, which suggests an immediate need to develop IBI for various types of vestibular disorders. The study in this review addressed motion-provoked dizziness. Another IBI for Ménière's disease31 was identified but did not meet the inclusion criteria. Considering the high prevalence of vestibular problems, IBI could significantly help address these difficulties. Many vestibular disorders require long-term intervention, which is not always possible due to inadequate clinical and/or financial resources—burdens that IBI could potentially relieve.
IMPLICATIONS FOR HEARING CARE
Perhaps the greatest challenge is getting these interventions implemented in clinical practice. Hearing care providers are uniquely positioned to advocate for the increased provision of quality audiology care across the globe, so they can play a central role in advocating for the inclusion of IBIs.32 To date, IBI development has focused largely in Europe, but these interventions should be developed and adapted for use in different populations, cultures, and areas where audiology services are particularly limited.
IBIs can contribute to the provision of comprehensive rehabilitation, which has been shown to improve treatment outcomes and patients’ quality of life.33 These interventions also provide numerous opportunities that promote self-management among individuals with hearing-related conditions and promote public-patient involvement, which could further unite and strengthen audiology service provision.
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