Hearing Screening – Where It Goes Wrong

The audiologist can be a solitary species. Choosing to lose ourselves in our work and focus on patient care instead of the heady social life we see zooming around us. Maybe it’s because we are very focused, or perhaps it’s because many of us are in some ways introverted. After all, this is the path we chose, and we are sticking to it.

But, if you are anything like me, when I get a chance for a little “shop talk“ with a fellow hearing health professional, that all changes and a chin will wag as much as a chin can. We love sharing the often hilarious and sometimes shocking experiences we have in our beloved profession.

It was during one such conversation that a particular story struck me in a way that left me feeling uncomfortable.

It was a good story. You know, the one where the big NGO sets out to help an underprivileged rural community with all manner of technology. Team members brimming with enthusiasm and a backpack full of degrees ready to change the world. Culminating in an inevitably triumphant sunset scene born right out of Hollywood. The victorious clan walking off into the distance puff-chested and ready to tell the world of their humanitarian victory.

Don’t get me wrong, I love those stories. They warm our hearts and inspire us to do more, be more, help more. But there was something about this story that, at first, I almost didn’t notice. But, when it hit me it was like a double walled sound-booth had been dropped on my head, cartoon style.

The story I was told was of an NGO backed audiology outreach program in the very beautiful and very rural province of KwaZulu-Natal, South Africa. In this particular instance, 30 adults from the community were tested using an app-based audiometer and supra-aural headphones for pure-tone air testing. Because of the lack of suitable facilities the testing was carried out in the community hall. Unlike some of the beautifully appointed and sometimes sound treated halls one might find in a city, this hall was filled with a team of staff, mumbling patients and the occasional squawk of one of the local free range chickens whose owners are unknown until dinner time. It was safe to say that this hall was not quiet enough for testing.

Nevertheless, testing continued and once completed 12 adult patients were found to have at least, moderate hearing loss and 2 weeks later, hearing aids were programmed at a hearing aid distribution head office, and sent back to the community for fitting.

It’s an inspirational story. It shows the positive impact we as a community can have on the world when we work together. Or is it?

Was the NGO’s intention honest and good?


Was everyone passionately committed to the cause?


This should have been a good thing. So why wasn’t it?

It’s all down to that homeless chicken. More specifically, noise levels in the testing environment.

The app-based audiometer could have easily elevated thresholds because of the ambient noise levels. While technological advancement has managed to get us pretty far, a supra-aural headset and a cell phone does not equate to an audiometer nor soundbooth level attenuation. A requirement of any standard. The lack of which could easily result in incorrect hearing aid fitting and overamplification. These patients could actually have had conductive hearing loss, and would have been better and more appropriately assisted by a referral for medical management.

In my professional opinion, a full diagnostic assessment should have been properly conducted in order to plan and manage the patients accurately and safely. Not to mention the fact that there was no follow-up on fitment and subsequent adjustments.

This is just one scenario, but cases like these are not rare. Good Samaritans with undoubtedly good intentions, use untested equipment with no validity in clinical application, all for a “good” cause.

One may argue, “at least someone did something’’, but what happens when that “something” is the very cause of future injury. Who actually carries the burden of cost when things go wrong and the samaritan has already set sail for their next destination or back to the comfort of their air-conditioned practice swivel chair?

One thing is certain, healthcare should never forfeit quality for the sake of quantity all in the name of global health coverage. There is a serious global need for “quality” healthcare, and not just enough to say we did something.

We are better than that, we can do better than that.

Recent advances in technology have certainly tried to tackle the issue of health coverage, and this article is not intended to undermine that endeavour. The point is, if you are going to do something, do it right. Do it ethically with the patients at the core, and not just to add something to your growing list of good deeds.

So what’s all the fuss about app-based audiometers.

What are they? Where do they fit in the spectrum of audiology.

App-based audiometers are available on smartphones or tablets. They simulate an audiometer and, in general, are paired with supra-aural headphones which do not attenuate ambient noise sufficiently.

As such, they cannot substitute or match up to the accuracy of standard audiometry testing done by a qualified audiologist. Some may argue ‘’…the results from some studies show thresholds comparable to standard audiometry, so why not use them in clinical applications?’’ While the first part of that statement holds true, in some cases app-based audiometry has been found to correlate with conventional audiometry and in other cases not. What that tells us is there is insufficient consensus. Hearing threshold variations of 10 dB have been observed between the app-based and conventional audiometer, which are categorized as sub-clinical within the context of clinical diagnostic audiometry. It should be noted that in paediatrics and ototoxicity monitoring, a difference of 10 dB could be significant. Moreover, in general, app-based audiometers are not able to distinguish between conductive and sensorineural hearing loss. The key feature in the basic diagnosis and management of auditory disorders.

Based on current data, app-based audiometers can be used for very basic screening purposes, especially in settings with no audiological services whatsoever. When a problem is detected, referral for full diagnostics with a standard audiometer is recommended. Unfortunately, the false referral rate is much higher when using these tools to deliver hearing healthcare, and as we already established, without available audiological services, where will these patients actually be referred to? The result is a huge impact on the economy and a massive burden on already overloaded audiology services where they do exist. It begs the question, why not use clinically accurate screening tools, in an optimal testing environment in the first place? Audiology has always been a profession that relies heavily on technology in order to diagnose and manage auditory disorders. With the advancement of technology and proliferation of app-based audiometry services, audiologists ought to be at the forefront of ensuring evidence based practices that ultimately protect and benefit patients.

So the question here is, should the industry forgo accuracy in order to manage patient volumes? And if we let go of the need for accuracy, are we not simply placing the burden back onto the patient’s shoulders?

In a nutshell, app-based audiometers have a place in creating awareness of hearing loss and perhaps, even for screening purposes. But these apps should not be confused with high accuracy screening, and certainly not diagnostic tools. Though its current applications are restricted, they can form part of early detection which could be an effective preventative strategy for underserved areas without access to hearing healthcare.