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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 24  |  Issue : 1  |  Page : 28-32

Delivering an audiology outreach clinic in Gujarat: Clinical observations and challenges


Division of Audiology, Faculty of Health and Life Sciences, De Montfort University, Leicester, UK

Date of Web Publication24-May-2018

Correspondence Address:
Dr. Jeff Davies
Faculty of Health and Life Sciences, Room H2.25L, Hawthorn Building, De Montfort University, The Gateway, Leicester LE1 9BH
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_70_17

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  Abstract 


Introduction: Audiology staff and students from De Montfort University delivered an audiology outreach clinic in Wankaner, Gujarat, with the aim of providing free audiological examination, hearing tests, and hearing aids to local residents with hearing loss. In addition, the project also presented a valuable opportunity to evaluate the spectrum of hearing-related symptoms in this rural region of India. Subjects and Methods: This was a prospective, observational clinical study. Participants aged 5+ were invited for a consultation at the Devdaya Diagnostic Centre. The consultation comprised of an audiological history, otoscopy, and a hearing test. Middle ear evaluation through tympanometry was also available. Digital receiver-in-ear hearing aids were fitted to participants deemed clinically suitable. Red flag otological symptoms were referred onward to an ENT consultant. Clinical consultations were translated into Gujarati by the local hospital staff. Results: Over 2 days, 170 participants (aged 6–94 years) were screened; 116 males and 54 females. A wide range of otological symptoms and conditions was observed including tinnitus in 70 participants (41%), perforated eardrums (22%), active ear discharge (15%), occluding wax (12%), otalgia (8%), and a history of noise exposure (5%). Average hearing threshold configuration showed a bilateral moderate-to-severe sensorineural hearing loss which was worse in males. Twelve participants had normal or mild hearing loss. Hearing aids were offered to 97 (57%) participants, 88 of which reported listener benefit and agreed to wear the aids on a daily basis. The remaining 44 participants were not considered suitable for hearing aids. Conclusions: A new partnership between De Montfort University and the Devdaya Diagnostic Centre has provided the local community of Wankaner with access to free audiological healthcare. While there were a number of environmental and technological challenges to overcome, this maiden visit proved to be successful, laying the foundation for future clinics.

Keywords: Audiology, hearing aids, hearing loss, hearing screening, outreach clinic


How to cite this article:
Davies J. Delivering an audiology outreach clinic in Gujarat: Clinical observations and challenges. Indian J Otol 2018;24:28-32

How to cite this URL:
Davies J. Delivering an audiology outreach clinic in Gujarat: Clinical observations and challenges. Indian J Otol [serial online] 2018 [cited 2019 Jan 18];24:28-32. Available from: http://www.indianjotol.org/text.asp?2018/24/1/28/233131




  Introduction Top


Hearing loss is an unseen disability which affects hundreds of millions of people around the world. Alarmingly, half of all hearing loss cases are avoidable through primary care.[1] This has particular resonance when considering less developed countries, where primary care may be limited. In India, around 63 million people have a significant auditory impairment.[1] Attempts to combat this has been made by the Indian government with the launch of the National Programme for Prevention and Control of Deafness in 2006.[2] The aims of the initiative were to reduce the burden of hearing loss-related diseases through the promotion of public awareness and provision of additional ear care clinics. Despite such efforts, a lack of funding, facilities, and workforce continue to restrict the initiative.[3] Varshney reported that the audiologist to participant population ratio is 1:500,000, however, such healthcare practitioners are often located in urban areas whereas over 70% of India's population are rurally located.[4] This creates additional geographical restrictions not only when trying to access healthcare, but also when conducting research into hearing loss epidemiology across India.

Even with these challenges, three early but large-scale surveys of hearing loss have been conducted. From 1977 to 1980, a multi-center study on hearing loss prevalence and etiology was carried out by the Indian Council of Medical Research.[5] Over 22,000 participants from four centers (Delhi, Calcutta, Madras, and Trivandrum) were surveyed. Overall hearing loss prevalence was 10.2%. A later and larger study, the National Sample Survey (2002) surveyed disabilities in 45,571 rural and 24,731 urban households.[6] Hearing loss was found to be the second-most common disability. Congenital hearing loss onset was found in around 7% of responders while the majority reported late-onset hearing loss in line with age. Again, the prevalence of hearing loss was higher in rural locations. Beyond hearing loss prevalence, the 2003 WHO survey reported the major causes of hearing loss in India.[7] Ear wax (15.9%) then presbyacusis (10.3%) were the most common causes of hearing loss followed by middle ear disease (~5.2%) and finally eardrum perforations (0.5%) and congenital deafness (0.2%).

In 2016, De Montfort University (DMU), Leicester, launched an initiative known as DMU Square Mile India which helps support Indian communities through the sharing of student and staff skills in a wide range of areas such as healthcare and technology. Recently, clinical-academic staff and audiology students launched a hearing screening outreach clinic as part of this initiative with the primary aim of providing free audiological care to those in need. In addition, the initiative also provided a timely and valuable opportunity to evaluate the spectrum of hearing loss among the people of Wankaner, Gujarat.


  Subjects and Methods Top


Study design and setting

This prospective, cross-sectional observational study of hearing loss was conducted at Devdaya Diagnostic Centre, located in Wankaner, a small rural town in the state of Gujarat. The hearing screening outreach clinic took place over 2 days in December 2016.

Procedures

Participants aged 5 years and older were invited for a free audiological consultation at Devdaya Diagnostic Centre. The clinic was advertised in local newspapers and through word of mouth by hospital staff. The consultation was triaged into three stages [Figure 1], each stage was conducted in a different room in the hospital. The quietest room, furthest from the waiting area was chosen to conduct the hearing tests. The clinic was led by two experienced audiologists (JD and WS) and six undergraduate audiology students (EH, DJ, SW, SG, JS, and BA). All aspects of the clinical consultations were translated into Gujarati by the local hospital staff.
Figure 1: Stages of the clinical pathways

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Stage 1 comprised of an audiological history and otoscopic examination. “Red flag” otological symptoms such as unilateral pulsatile tinnitus, chronic ear infections, or any other abnormal findings were referred onward for further ENT investigation and medical management.

Stage 2 included a pure tone audiogram hearing screen (0.5 kHz – 8 kHz) using portable Shoebox audiometers calibrated to ANSI standards.[8] Participants under 5 years old were excluded due to their limited behavioural ability to perform pure tone audiometry. Middle ear evaluation through an Interacoustics TITAN handheld tympanometer was also carried out where clinically indicated. Participants with “normal” or only mild hearing loss could exit the triage process after Stage 2, leaving those participants with greater listening difficulties to progress to the final stage of the triage.

In stage 3, digital receiver-in-canal hearing aids were fitted monaurally to suitable participants. Two different models of hearing aid were available for fitting; GN resound DOT and GN resound Alera. In anticipation of high participant numbers and due to restrictions in equipment portability, the hearing aids were preprogrammed in the UK to four anticipated configurations of hearing loss [Figure 2] using the NAL-NL2 fitting formula.[9] This saved significant amounts of time allowing more participants to be seen. A volume control was given to provide flexible listener comfort. Once fitted, basic subjective checks were made by the audiologist through the translator to determine hearing aid benefit. Participants were instructed on insertion and maintenance of the device and were given a 3 months' supply of batteries. Further supplies of batteries were also given to Devdaya Diagnostic Centre for future rationing among participants. Written and pictorial information was provided to improve understanding and encourage hearing aid use among participants. On average, one participant could be assessed and fitted in 30 min.
Figure 2: Audiometric configurations used for hearing aid preprogramming

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Ethical considerations

Written informed consent was obtained from all participants or their legal guardians (for minors) before taking part. In the case of illiterate participants, local hospital staff were able to verbally translate study information before consent was obtained. Permission to conduct the hearing screening outreach clinic was granted by the hospital owner (RM) and ethical permission from the Health and Life Sciences Faculty Research Ethics Committee at DMU was also sought before the trip. All participant data were anonymized through number assignment.


  Results Top


Participant demographics

Over a 2 day period, 170 participants were screened; 116 males (68%) and 54 females (32%). Participants were aged between 6 and 94 years (mean: 58 years, standard deviation: 17.7 years) [Figure 3]. Most participants who attended the hearing outreach clinic were in their 60s; however, the clinic also attracted 12 participants under the age of 30 years.
Figure 3: Histogram of participant age distribution

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Otological symptoms

A wide range of otological symptoms and conditions were observed during the clinic. Tinnitus was the most frequently reported symptom (n = 70). This was unilateral and constant in nature for seventeen participants. Thirty-seven participants were found to have perforated eardrums, of which six cases were bilaterally perforated. Other symptoms included active ear discharge (n = 26), occluding wax (n = 16), otalgia (n = 14), and a history of significant noise exposure (n = 9). [Figure 4] illustrates the flow of participants from initial screening through to hearing aid fitting.
Figure 4: Participant flow from initial screening through to hearing aid fitting

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A total of 32 new ENT referrals were made, reasons for which can be found in [Figure 4]. Six participants were already under the current management of an ENT consultant, and a further 12 had received ENT care in the past.

Audiometric profile

Audiometry was carried out on 153 participants. Average hearing threshold configuration showed a bilateral moderate-to-severe sensorineural hearing loss which was significantly worse in males (post hoc t-test of average hearing thresholds P = 0.01) [Figure 5].
Figure 5: Mean average hearing thresholds for males and females

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Twelve participants had normal or mild hearing loss and did not require a hearing aid. Four participants reported long-standing listening difficulties from birth or early childhood. Monaural hearing aids were offered to 97 participants, 88 of which reported listener benefit and agreed to wear the aids on a daily basis. Participants were not considered suitable for hearing aid provision if they had active ear discharge, damp perforations, occluding wax, or profound levels of deafness outside of the hearing aid's capable amplification range.


  Discussion Top


In partnership with the Devdaya Diagnostic Centre, audiology staff and students at DMU set out to deliver a hearing screening outreach clinic in Wankaner, as part of the DMU Square Mile India initiative. Demand for audiological healthcare in the region was high, with 170 participants being screened in just 2 days. The majority of participants were males in their 60s and presented with at least a moderate degree of hearing loss. These findings reflect those of the National Sample Survey (2002) which reported a higher prevalence of hearing loss amongst males in rural Gujarat.[6] Numerous other otological conditions were also uncovered such as tinnitus, ear wax, ear infections, and perforations, giving hints as to probable hearing etiology among participants. In such instances, advice regarding safe ear care practices was given. As with many developing countries, awareness and knowledge of unsafe ear care practice such as the traditional use of nonsterile sticks for ear “cleaning” were low among participants.[10] Therefore, creating better awareness of aural health could help reduce disease burden among the local community, a notion which will be taken forward in future visits.

Given the “pop up” nature of the clinic, a number of technical and logistical challenges were observed. To obtain accurate hearing threshold measurements and reduce the masking effects of ambient noise it is necessary to conduct audiometry within a quiet test environment, as stipulated in a variety of national standards, for example, ANSI S3.1-1999 (R2003)/BS EN ISO 8253-1:1998.[8],[11] As we were operating a maiden mobile hearing screening outreach clinic in an unfamiliar hospital environment, test conditions were largely unknown. In anticipation of this, we selected the ShoeBOX audiometer which operates through an iPad tablet (Apple Inc.) and Sennheiser HDA 280 headphones. These audiometers were chosen due to their portability and ability to provide accurate threshold measurements outside of the soundproof booth.[12],[13] During audiometry, ShoeBOX utilizes the tablet's microphone to monitor frequency-specific ambient noise levels. By noting the attenuation capabilities of the headphones, a calculation of apparent ear-level background noise levels can be made and compared against ANSI standards for maximum permissible ambient noise levels during audiometry. Where noise levels are found to exceed that of the presented test frequency, the tester is notified that a confounded threshold may have been measured. While it is possible that background noise levels could interfere with threshold accuracy leading to false-positive test results, the overwhelming majority of our participants had at least moderate degrees of hearing loss. As Rourke et al. point out, background noise presence becomes less important as hearing loss severity increases.[12] For future trips, it will be useful to take a sound-level meter for independent monitoring of ambient noise levels.

Just over half of all participants who were screened were fitted with a hearing aid. Despite the known benefits of binaural amplification,[14] the decision to fit monaurally was taken early on in an effort to ration the hearing aid supply. Due to restrictions in both time and equipment portability, real-ear measurements could not be performed. Emphasis was instead placed on participant's subjective experience of the hearing aid. Flexibility in amplification was offered through an active volume control which was available on both hearing aid models. While this method of working might not satisfy the UK recommended clinical protocols, it was realistic given the nature of the clinic and proved to be effective with 91% of participants (88/97) reporting listener benefit from their hearing aid. At the time, this clinic was originally considered as a one-off visit making it difficult to administer long-term follow-up care or implement a “pre-post treatment” outcome measure. Staff at Devdaya Diagnostic Centre received only basic training in hearing aid operation and battery insertion. Future visits will see the further training of staff in an effort to support a more sustainable aftercare system as well as promoting better awareness of aural health care within the community. There may also be an opportunity to train hospital staff to perform basic hearing assessment through a portable audiometer, a model of health care which has been used successfully in previous outpatient clinics in India.[15]


  Conclusions Top


Partnership among the Division of Audiology at DMU and the Devdaya Diagnostic Centre has provided the local community of Wankaner with access to free audiological healthcare as well as training opportunities for local hospital staff and DMU students. While there were a number of environmental and technological challenges to overcome, this first visit proved to be successful. It is hoped that this newly established platform will serve as a foundation for future outreach clinics in this region of India.

Acknowledgment

The author would like to acknowledge the kind and critical support of Amplifon who donated hearing aids and Rayovak who donated batteries for this trip. I also warmly thank all the staff at Devdaya Diagnostic Centre, my fellow colleague and friend Wendy Stevens and our students who helped run the clinics.

Financial support and sponsorship

This trip was funded by De Montfort University.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Deafness and Hearing Loss. World Health Organization; 2016. Available from: http://www.who.int/mediacentre/factsheets/fs300/en/. [Last accessed on 2016 Nov 08].  Back to cited text no. 1
    
2.
Directorate General of Health Services. National Programme for Prevention and Control of Deafness, Project Proposal. New Delhi: Ministry of Health and Family Welfare; 2006.  Back to cited text no. 2
    
3.
Garg S, Chadha S, Malhotra S, Agarwal AK. Deafness: Burden, prevention and control in India. Natl Med J India 2009;22:79-81.  Back to cited text no. 3
[PUBMED]    
4.
Varshney S. Deafness in India. Indian J Otol 2016;22:73-6.  Back to cited text no. 4
  [Full text]  
5.
Indian Council of Medical Research Report. Collaborative Study on Prevention and Etiology of Hearing Impairment. New Delhi: Indian Council of Medical Research; 1983.  Back to cited text no. 5
    
6.
National Sample Survey Organization. Disabled persons in India, NSS 58th round (July-December 2002) Report no. 485 (58/26/1). New Delhi: National Sample Survey Organization, Ministry of Statistics and Programme Implementation, Government of India; 2003.  Back to cited text no. 6
    
7.
World Health Organization. State of Hearing and Ear Care in the South East Asia Region. WHO Regional Office for South East Asia. WHO-SEARO. SEA/Deaf/9. Available from: http://www.searo.who.int/LinkFiles/Publications_HEARING_ and _EAR_CARE.pdf. [Last accessed on 2016 Nov 08].  Back to cited text no. 7
    
8.
ANSI S3.1-1999. American National Standard Maximum Permissible Ambient Noise Levels for Audiometric Test Rooms; R2003.  Back to cited text no. 8
    
9.
Keidser G, Dillon H, Flax M, Ching T, Brewer S. The NAL-NL2 prescription procedure. Audiol Res 2011;1:e24.  Back to cited text no. 9
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10.
Dosemane D, Ganapathi K, Kanthila J. Knowledge, attitude and practice of ear care in coastal Karnataka. J Clin Diagn Res 2015;9:MC01-4.  Back to cited text no. 10
    
11.
BS EN ISO 8253-1: Acoustics. Audiometric Test Methods. Part 1: Basic Pure Tone Air and Bone Conduction Threshold Audiometry. (Identical to ISO 8253-1:1989.); 1998.  Back to cited text no. 11
    
12.
Rourke R, Kong DC, Bromwich M. Tablet audiometry in Canada's North: A Portable and efficient method for hearing screening. Otolaryngol Head Neck Surg 2016;155:473-8.  Back to cited text no. 12
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13.
Thompson GP, Sladen DP, Borst BJ, Still OL. Accuracy of a tablet audiometer for measuring behavioral hearing thresholds in a clinical population. Otolaryngol Head Neck Surg 2015;153:838-42.  Back to cited text no. 13
[PUBMED]    
14.
McArdle RA, Killion M, Mennite MA, Chisolm TH. Are two ears not better than one? J Am Acad Audiol 2012;23:171-81.  Back to cited text no. 14
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15.
Emerson LP, Job A, Abraham V. A model for provision of ENT health care service at primary and secondary hospital level in a developing country. Biomed Res Int 2013;2013:562643.  Back to cited text no. 15
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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