How Tele-Audiology Is Taking Hearing Care to Patients in Remote Areas

What could possibly be in common between astronauts living on the International Space Station (ISS) and people eking out a living in rural sub-Saharan Africa? It’s not just isolation that joins these two sets of seemingly contrasting faces of humanity. Ironically enough, it is access to high-quality hearing health care.

At one of the humanity’s most celebrated symbols of technological achievement, astronauts are hard-pressed to get quick access to healthcare services, as the nearest hospital is a good 249 miles (400km) and a shuttle ride away. Given that this isn’t an option unless, in the rarest of circumstances, solutions have been found in Telemedicine and Task-Shifting.

‘Telemedicine’ refers to the use of telecommunication technologies to remotely diagnose and dispense medical advice where the doctor-patient geographical divide presents a challenge.

‘Task-shifting’ refers to the “process of delegation whereby tasks are moved, where appropriate, to less specialized health workers.” (WHO)

It has been devised to tackle the challenge of serious shortage of health workers in the remote, rural and underserved areas of our planet and beyond.

And therein lies the lesson, or the seeds, of a health care delivery model that can be successfully emulated and implanted in some of the most rural and remote areas here on Earth — to diagnose and treat some of the most debilitating human health conditions, including disabling hearing loss (DHL).

How Bad is it?

Disabling hearing loss (DHL) affects about 360 million people globally (as per a WHO Global Burden of Disease study). This includes only people with bilateral moderate to profound hearing loss. And if one were to include people with mild hearing loss, the number 360 million might very well double.

Background Image: Anne Cusack/Los Angeles Time (via

Stats: WHO

DHL takes untold tolls on the lives of those who suffer from it. From affecting learning and development of speech and interpersonal skills in children, DHL has a profound impact on the psychological well-being, economic independence, and hence, the quality of life of an individual suffering from it. But the cost of rehabilitative services is so high that early diagnosis and primary prevention seems to be the only effective way in dealing with DHL. In fact, a huge number of DHL cases in children could be prevented through early diagnosis and appropriate medical intervention.

However, the traditional mode of delivering hearing healthcare services is fraught with its own set of challenges (discussed in brief in the section below) which restricts its reach and impact. This is where remote diagnosis and treatment, or Telemedicine, could play a significant part in mitigating the challenges posed by the traditional means of delivering audiological services in the remote and rural areas of the world.

Challenges in dispensing hearing healthcare services

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Nowhere else is the paradox of global inequality and health care disparity more pronounced than in hearing healthcare. As per WHO estimates, more than 80% of people with hearing loss reside in developing countries, and underserved communities where hearing healthcare services are either non-existent or very limited. (source)

Unlike developed nations where the average ratio of audiologists to the general population is about 1:20,000, the ratio of audiologists to the population in the developing world could be lower than 1 for every million people. (source) In South Africa, the ratio of audiologists/speech therapists to the general population is 1:45,000. Despite this, as many as 3.6% of the South African population above the age of 5 years has hearing difficulties (Stats SA Census 2011).

What could possibly explain this is the fact that while 38% of the South African population live in poorer rural communities, most of the hearing healthcare professionals are clustered around the urban centers.

What further aggravates the problem is the requirement of attenuated (sound proof) booths for diagnostic assessments. These costly booths are by no means portable, and it could be a challenge to take them to locations where road connectivity is deplorable. A large proportion of the global population fighting disabling hearing loss (DHL) is required to travel long distances to get to these centers where the audiometric booths can be found.

Traveling to these centers can also be an expensive proposition for the affected individuals and their families, as most of them are poor and hence simply do not have the financial means to access audiological services.

In their 2008 paper titled ‘Audiology education and practice from an international perspective’, Dr Helen Goulios and Dr Robert Patuzzi concluded that “the scarcity of both services and hearing health care professionals can be ascribed to three factors: a reported lack of professional and public awareness, lack of government funding, and most importantly, lack of available training programmes.” (Information Source)

Despite these challenges, there are many humanitarian organizations and hearing healthcare professionals and a whole host of other people trying their best to make a difference in the lives of people with disabling hearing loss in some of the most rural and remote parts of the world.

eMoyo Technologies (the makers of KUDUwave™ audiometers) work with the likes of John Hopkins University, JPS Africa, National Department of Health (SA), and Janssen Pharmaceutica to fight and prevent hearing loss induced in multi-drug-resistant TB (MDR-TB) patients by the ototoxic drugs that are used in the treatment of TB. eMoyo also participated in a number of outreach programs, testing as many as a 1000 people for hearing loss.

Menace of hearing impairment and access to hearing health care services in the developed world

While what we talked about so far has revolved around the challenges of addressing hearing loss in developing nations, the developed nations are not without their own set of challenges when it comes to tackling DHL. If a shortage of trained hearing healthcare professionals and access to hearing healthcare infrastructure are a challenge in the developing world, so are they in the rural and remote areas of the developed world. Because most of the specialist physicians and healthcare resources are concentrated around the urban areas, people from the rural and remote areas of the developed nations are also required to travel long distances, at the cost of time, money and wage loss.

The lengthy time travel and distance to the urban centres, where the majority of the healthcare infrastructure are flocked, in addition to impediments like economic disparities present effective barriers to accessing health care services, including audiological services.

As per an article, ‘A “Medical Mission” at Home: The Needs of Rural America in Terms of Otolaryngology Care’ published in The Journal of Rural Health, authors Ryan Winters et al. note that “for many uninsured, impoverished, rural Americans, access to specialty care is nearly as unattainable as in Africa.”

As per a new study from John Hopkins University, by 2020, 44 million adults above the age of 20 years are expected to suffer from hearing loss. The research also predicts that this number (44 million) will jump to 73 million by 2060.

This growth spurt in the number of people with hearing loss will largely be driven by the ageing American population. According to the census bureau, in 2014, there were 46.2 million Americans in the 65+ age group. This number is set to reach 82.3 million by 2040.

“Current services are neither set up nor prepared to cope with this potential demand. In addition to best practice audiology services, the increased need for affordable interventions and access to trained hearing specialists will require novel and cost-effective approaches to hearing health care,” write the John Hopkins University study authors.

Thus we see that the present methods of addressing hearing loss in remote and underserved areas, whether in developing or developed nations, are clearly inadequate in reaching the vast number of people with hearing loss. There is, therefore, an urgent need to evaluate the current hearing health care delivery methods while strongly considering the use of alternative methods like Tele, or Mobile Audiology that could provide a comprehensive solution to tackling the challenges surrounding the provision of hearing health care delivery.

Telemedecine — A means to overcome geographical barriers in hearing healthcare delivery

Tele-Audiology is simple the delivery of audiological services to underserved populations in rural and remote locations by making use of telecommunication technologies. In layman’s terms, it connects a patient with hearing impairment to a hearing healthcare professional (an audiologist or a speech therapist) via the internet. There is a trained individual who facilitates the connection and acts as the mediator.

For this to work, you need the right equipment. Fortunately, the rapid advancement in technology, improvement in internet penetration and leaps forward in audiometry software has boosted the viability of providing tele-audiological services .

3 methods of tele audiology implementation

  1. Synchronous:
    This happens in real-time via interactive video conferencing.
  2. Asynchronous:
    Particularly useful for areas where an active internet connection is an issue. Here patient data is collected and later forwarded to an audiologist from a facility where internet access is available. The audiologist scrutinizes the data and the reports and then returns recommendations.
  3. Hybrid:
    This is a combination of both the synchronous and the asynchronous models.

This helps to improve the reach and accessibility of audiological services for people with hearing disorders living in underserved areas of both the developing and the developed world.

Limitations of the existing measures in addressing hearing loss

In traditional clinical audiology, to make a decision regarding treatment and intervention, an audiologist depends on precise diagnosis and accurate identification based on a diagnostic test procedure called pure tone audiometry.

Pure tone audiometry is often considered as the gold standard for describing hearing sensitivity. When performed in conjunction with bone conduction testing (another diagnostic method), the type of hearing loss can usually be precisely distinguished.

Pure tone audiometric tests are traditionally conducted by trained staff in specially designed sound booths or rooms where ambient noise levels do not interfere with the hearing assessment and are so low that they permit assessment of hearing threshold as low as 0 dB. But, as mentioned earlier, the sound proof booths that are being used traditionally in the audiometric tests are neither cost-effective nor portable. This severely limits their access to a majority of those who suffer from hearing loss.

KUDUwave™ — A portable answer to inaccessible sound booths

KUDUwave™ is a range of innovative and portable audiometers that literally brings advanced audiological services to the doorsteps of those living with hearing disorders in rural and remote areas. It is a revolutionary portable medical device that has been validated for use in audiometric tests without a sound booth. KUDUwave™ integrates the power and the capabilities of the booth and audiometer together, in the shape of a lightweight headset.

The audiometer features a pair of insert earphones that are covered by circumaural ear cups with sound blocking and active noise monitoring technology built-in. The sound blocking ability of the KUDUwave™ is superior to that of any other audiometry headset on the market.

To ensure environmental noise does not interfere with the hearing assessment process, the circumaural earcups are fitted with internal and external microphones. The microphones ensure that the environmental noise levels remain within acceptable limits during the assessment.

During the entire assessment process, the remote clinician and the patient, remain in audiovisual contact (via a video conferencing software like Skype) through computers connected to the internet. The clinician remotely takes control of the computer at the patient site through an application sharing software. Sufficient measures are taken to protect information privacy, and all the information collected are stored on the test site computer.

The whole process is facilitated and monitored by a specially trained individual at the assessment site.

KUDUwave™: Being part of an innovation that cut across continents

About 7 years ago, in 2010, Dirk Koekemoer, Jackie Clark, and De Wet Swanepoel got together to do an intercontinental hearing assessment — to evaluate the validity of pure tone audiometric testing conducted from North America on subjects in South Africa. Up until then, no remote intercontinental hearing assessment was reported.

Equipped with laptops, the internet, a portable KUDUwave™ audiometer, and other ancillary gadgets and software, the researchers assessed thirty subjects (volunteers) between the age 18 and 65. While the volunteers were in Pretoria, South Africa, the remote clinician was 14,680 km away in Dallas, USA. Through video conferencing, the remote clinician was in audiovisual contact of the subjects.

Both conventional and telemedicine means were used to assess the hearing of the thirty subjects in the same room. After performing the test on all thirty subjects, the results through conventional methods and remote testing were compared. The results obtained by remote intercontinental audiometric testing were equivalent to the results obtained via conventional face-to-face audiometry.

This demonstrated the feasibility of using telemedicine — and KUDUwave™ audiometers by extension — as an effective tool to delivering audiological services in rural, remote and underserved regions of the world.

In this hearing assessment test, the subjects were in Pretoria, South Africa, and the clinician was in Dallas, USA, the test could have been replicated in any two locations and the results would still have been the same. The subjects could have been in (say) rural Burkina Faso and the clinician in urban Melbourne, and yet the results wouldn’t have varied.

This is just one of the reasons that Audiology, as a profession, is not the Dodo some think it is.

KUDUwave™ — Expanding the reach of audiological services

Shortage of hearing healthcare professionals, absence of physical and institutional infrastructure, geographical and political challenges, financial and logistical barriers, ethnic and linguistic diversity, connectivity woes, unavailability of cost-effective and portable assessment tools, cultural attitude towards non-fatal disorders like hearing disability, etc. have for long affected the efficient delivery of audiological services to those who are in most need of these services.

But with the advent of affordable and portable audiological tools like KUDUwave™ audiometers, the hearing healthcare delivery system will witness profound and positive changes. KUDUwave™ audiometers render it unnecessary for hearing impaired persons in rural and remote areas to travel great distances at the cost of time and money to access basic audiological services.