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

Figures & data

Figure 1. Four phases in the mHealth service-delivery model, using CHWs to implement hearing healthcare in LMICs.

Figure 2. (a): Participant’s ear canal and tympanic membrane being evaluated by a CHW via video-otoscopy. (b): Participant having a hearing assessment via in-situ audiometry and circumaural ear cups. (c): Hearing aids, smartphone, and circumaural ear cups used in service-delivery model.

Table 1. Participant demographics and hearing threshold results for those assessed (n = 146) and those subsequently fitted with hearing aids (n = 19).

	Adults screened n = 146	Adults fitted with hearing aids n = 19
Age (years)
Mean (sd)	59.3 (14.8)	71.7 (13)
Range	18–102	48–96
Age distribution (years)	% (n)	% (n)
18–39	7.5 (11)	n/a
40–59	43.2 (63)	21.1 (4)
60–79	41.1 (60)	52.6 (10)
80+	8.2 (12)	26.3 (5)
Sex	% (n)	% (n)
Male	23.3 (34)	21.1 (4)
Female	76.7 (112)	78.9 (15)
Hearing (0.5, 1, 2 and 4 kHz pure tone average)
Mean four frequency PTA (sd) Left	30 (20)	44.2 (13.4)
Mean four frequency PTA (sd) Right	29.1 (18.5)	46.4 (12.9)
PTA Range Left	10–80	26.3–73.8
PTA Range Right	10–80	25–67.5
Degree of hearing loss (better ear PTA)	% (n)	% (n)
Normal (0–24 dB HL)	62.3 (91)	n/a
Mild (25–40 dB HL)	22.6 (33)	42.1 (8)
Moderate (41–60 dB HL)	10.3 (15)	47.4 (9)
Moderately Severe (61–80 dB HL)	4.8 (7)	10.5 (2)
Severe (81+ dB HL)	n/a	n/a
Period of self-reported hearing loss (years)	% (n)	% (n)
1–5	n/a	57.9 (11)
6–10	n/a	5.3 (1)
11–20	n/a	26.3 (5)
20+	n/a	10.5 (2)

Figure 3. Individual hearing thresholds for participants (n = 19) fit bilaterally with hearing aids according to degree of hearing loss. (a): Left ear. (b): Right ear.

Table 2. Inductive thematic analysis of participant (n = 19) responses to open-ended questions on awareness of hearing aids and perceptions of hearing loss before hearing aid fitting.

Themes	Frequency	Example quotes
How has your hearing problem affected your life?
Difficulty in conversations	11	‘I can’t communicate properly with my family members.’
Difficulty with phone calls	3	‘I can’t hear on calls; I always ask for repetition.’
Difficulty in church	2	‘It is difficult to hear at church’ ‘I am not able to hear at church.’
Causes worry or embarrassment	2	‘I feel worried and embarrassed’ ‘Sometimes people laugh at me.’
Not affected	1	‘It has not affected my daily life.’
How do other people treat you because of your hearing problem?
Normal	8	‘No one has noticed that I cannot hear properly’ ‘They treat me normally.’
Supportive and understanding	6	‘They are very understanding’ ‘My family is very supportive.’
With irritation	5	‘They get irritated as they have to repeat all the time’ ‘They ignore me most of the time.’

Table 3. Inductive thematic analysis of participant (n = 18) responses to an open-ended question 45 days post fitting on perceptions of others’ treatment towards them since hearing aid fitting.

Themes	Frequency	Example quotes
Did people treat you any differently since you have a hearing aid?
Positively	5	‘People respond positively to the fact that I wear HAs. They notice that I respond more and quicker than before. They previously thought that I was unfriendly. They did not realise that I could not hear.’
Same as before hearing aids	9	‘No. No one has even noticed the hearing aids.’
With curiosity/interest	4	‘Yes. People in the street would notice and ask about the hearing aids. Many did not know what it was, so I used it as an opportunity to educate on what it is and why I wear them.’

Table 4. IOI-HA median, IQR, mean, and sd scores at the 45-day (n = 18) and six-month (n = 16) follow-up.

	45-day follow-up		Six-month follow-up
	Median (IQR)	Mean (sd)	Median (IQR)	Mean (sd)
Daily Use	4.5 (4–5)	4.4 (0.7)	4 (3–4)	3.8 (0.8)
Benefit	5 (5–5)	4.6 (1)	5 (5–5)	4.8 (0.4)
Residual Activity Limitation	5 (4.8–5)	4.6 (1)	5 (5–5)	4.8 (0.6)
Satisfaction	5 (4–5)	4.6 (0.5)	5 (5–5)	4.8 (0.4)
Residual Participation Restrictions	5 (5–5)	4.9 (0.5)	5 (4–5)	4.7 (0.5)
Impact on others	5 (4–5)	4.6 (0.6)	5 (5–5)	4.3 (1.5)
Quality of Life	5 (4.8–5)	4.7 (0.6)	5 (4.3–5)	4.7 (0.6)

Table 5. Inductive thematic analysis of participant (n = 16) responses on impact of hearing aids on their lives, difficulties, and recommendations at six-month follow-up.

Themes	Frequency	Example Quotes
If you still use your hearing aids, can you share how the hearing aids have impacted your life?
Improved hearing over phone	3	‘My life has been changed a lot. I am able to hear the phone better now.’ ‘Can hear better now over the phone during phone calls.’ ‘I can speak on the phone freely.’
Improved hearing at church	4	‘I normally wear them to church and can now hear the pastor well.’ ‘Even at church, I can hear the pastor better.’ ‘I can hear the pastor nicely now at church.’
Improved environmental sounds	4	‘I can hear cars on the road when I am going to town.’ ‘When I go to town, I can hear the sounds of the cars and the people at the shops.’ ‘Helps a lot at the malls.’
Improved communication	6	‘I can hear my family nicely now when we are talking.’ ‘Around the home, I can engage with the family and participate in any family discussions.’ ‘Helps when talking to people.’
Improved TV/Radio enjoyment	4	‘Helping a lot, especially when watching TV.’ ‘It has changed my life; I can hear very well from far, and I don’t need the radio to be as loud anymore.’ ‘Everything is fine now; my life has been changed. No need to turn up the TV or radio volume anymore.’
No longer using hearing aids	2	n/a
If still using your hearing aids how often do you wear your hearing aids?
Daily	9	‘I wear them every day without being helped.’
A few days a week	1	‘Couple of days a week.’
Twice a week	1	‘Twice a week’
Three to four times a week	2	‘3 to 4 times a week.’
Only for certain events	1	‘Only for certain events like going to the shops.’
Not applicable	2	n/a
Are you experiencing any difficulties with your hearing aids?
No	14	‘No difficulties at all, everything is good’ ‘I am not experiencing any difficulties. They fit me nicely.’
Pain	1	‘Pain mostly in the right ear.’
Discomfort	1	‘When I put the hearing aids on, it does not feel comfortable, like it shocks or shivers, but the volume is not too loud.’
Are you able to change the batteries?
Able to change batteries Independently	12	‘I am able to change batteries myself whenever they are flat.’
Family member assists	4	‘Grandchildren and daughter help change the batteries whenever it is necessary.’
Are you able to clean your hearing aids?
Able to clean the hearing aids independently	10	‘I am able to clean the hearing aids myself at the end of the day.’
Family member assists	5	‘I clean them twice a week with the help of my son.’
Not cleaned	1	‘They have not been cleaned. My grandchild does not help me as he is supposed to do.’
Do you have any concerns about wearing your hearing aids?
No	14	‘No concerns, the hearing aids made a big difference.’
Pain	1	‘The right ear is sometimes painful.’
Discomfort	1	‘No concerns except the shivering/shock I experience when putting on the hearing aids or shortly after.’
Would you recommend hearing aids to other people with hearing difficulties? Why/Why not?
Yes, they help to hear better	6	‘Yes, because it improves hearing’ ‘Yes, I would recommend it because it helps to hear, and it can help someone else too.’
Yes, they allow for better communication	5	‘Yes, they allow you to talk nicely with your family’ ‘I would recommend the hearing aids as a good tool to hear well, and more people will feel free to communicate with you if you have hearing aids because they won’t have to repeat.’
Yes, they are very helpful	5	‘Yes, I recommend it a lot as hearing aids are very helpful’ ‘Yes, the hearing aids help a lot. They change lives.’
What advice would you give to someone who is struggling to hear?
Go to clinic/doctor for hearing test	9	‘Go to the clinic to have their hearing tested’ ‘I would advise them to visit the clinic or doctor to get them the help they need.’
Get hearing aids	3	‘Advise them to go and get hearing aids’ ‘I would advise them to buy hearing aids.’
Contact CHWs	9	‘I will give him/her the advice to look for the CHWs.’ ‘Contact the CHWs to help.’