Previous Projects
Research Highlights
In India, though the profession of Speech Language Pathology and Audiology is 50 years old, the geographical distribution and availability of SLPs and Audiologists is skewed. Therefore, needs of the vast population needing services and requirement of specialization to serve specific populations are unmet. There are several countries in Asia (Bhutan, Myanmar, Afghanistan) where Speech Pathology and Audiology does not exist as a profession, there are no training programs or may have only a handful of SLPs or Audiologists. It is in trying to meet this huge void that alternate models have emerged. There have been several attempts to provide, develop or reach services in regions where such services are not available, where needs are many but resources few. Swanepoel and the team in South Africa have explored tele-audiological approaches to reach remote areas (Swanepoel et al., 2010; Swanepoel, Olusanya, & Mars, 2010). The exploration of alternative models of service delivery was prompted by the challenge to deliver speech, language and hearing services in remote rural locations in India. For a decade and a half we have explored use of information and communication technology integrated into community-based approaches to reach services based on the demand of beneficiaries.
Strategy of using Tele-medicine approach: Integration of Tele-Technology for diagnostic confirmation of ear and hearing status in rural communities
We have engaged in several minor and major projects integrating ICT in reaching speech, language and hearing services to remote rural locations. Below is a description of two of our major projects that involves audiological diagnosis using tele-technology.
Application of store and forward tele-medicine in the identification and management of middle ear disorders in a rural cleft care program.
This program was conceptualized to devise a grassroots-level strategy to identify individuals with middle ear diseases (MEDs) in the rural community using a telemedicine approach. MEDs among individuals with CLP was identified using store-and-forward video otoscopy, hearing status was assessed using synchronous pure tone audiometry and tympanometry for those identified with tympanic membrane (TM) and MEDs and provided with tele-diagnostic confirmation of ear and hearing status.
Community workers scheduled home visits in the community to perform store-and-forward (asynchronous) video otoscopy using a video otoscope integrated with an android mobile phone. Community workers documented each patient’s demographic details and ear and hearing history using the customized mobile application “Shruti”, which was available in the local language, Tamil. The community worker then captured the image of the TM and ear canal using the video otoscope. The obtained image, along with patient data and history, was then uploaded to the cloud using mobile data Internet. The Audiologist viewed the images at the back-end (at the tertiary care hospital) using the ClickMedix platform. This platform has unlimited cloud storage and provides an interface for the audiologist to access the demographics details, patient history, and the images captured by the community worker in the rural community to provide appropriate recommendations.
The audiologist periodically viewed the data and, when necessary, could export the data or share patient data using the same platform in an encrypted format to the otolaryngologist for recommendations on appropriate management. Those with impacted cerumen were recommended cerumen management (using Soliwax solution) based on the Otolaryngologist’s advice. The community worker repeated video otoscopy subsequently to ascertain the status of the middle ear. Those identified with MEDs by the Otolaryngologist were recommended an appropriate medication or a surgical intervention. Prescriptions were mailed to the community workers, who hand-delivered them to the patients. The community workers subsequently followed up to repeat video otoscopy.
The audiologist at the tertiary care hospital conducted pure tone audiometry and tympanometry tests synchronously by remotely accessing the equipment at the rural community. In the case of pure tone audiometry testing, noise levels were measured in the test environment before each testing using a mobile application (BOSCH iNVH). Tympanometry preceded pure tone audiometry testing. The community worker selected an appropriate ear tip and placed the probe in the individual’s ear. The audiologist remotely assessed the accuracy of seal and initiated the testing. The audiologist provided counseling via video conferencing regarding hearing status and appropriate management options. Finally, follow-up compliance for intervention was documented to evaluate the usefulness of telemedicine approach.
Impact of research
From 2017 onwards we implemented the telemedicine approach in the identification and management of middle ear disorders in a rural cleft care program. In this program, a 55% improvement in diagnosis and management was obtained post implementation of telemedicine approach
E-MPOWER
Real-time remote diagnostic ABR in a rural community-based hearing screening program
Real-time remote diagnostic ABR in a rural community-based hearing screening program
A community-based hearing screening programme for infants and young children was conducted in 94 rural villages of two administrative unit within the Kancheepuram district in the state of Tamil Nadu, India. Hearing screening with distortion product otoacoustic emissions (DPOAEs) was conducted by trained village health workers (VHWs) at the doorstep of the child’s home in a two-stage screening protocol. Trained VHWs attempted to conduct door-to-door DPOAE screening on all children under 5 years of age in the selected villages. VHWs gathered information regarding new births and details of children under 5 years of age residing in each village through local balwadi (pre-school) teachers. If the child was referred in first screening, the VHW attempted a re-screen within two weeks. Children yielding a refer outcome upon re-screening were directed to an Audiologist for remote diagnostic auditory brainstem response (ABR) assessment. Follow-up ABR assessment of hearing was initially conducted remotely in a mobile tele-van using satellite connectivity due to the lack of internet penetration in rural areas. However, within one year of the programme’s start broadband internet access, available in the rural area through an NGO, was adopted for the remote ABR assessment.
An Audiologist located at the tertiary care hospital performed ABR measurement in real time using remotely accessed equipment. Specially trained VHWs prepared the child for ABR assessment. Preparation included electrode placement, positioning of child and ensuring that the child was asleep through the ABR assessment. A tele-technician set-up the equipment and established the connectivity. This study was conducted over a period from 2011 through 2013. We evaluated hearing screening coverage, referral rate and diagnostic follow-up rate.
Impact of research
In 2011 the community-based hearing screening programme for infants and young children was implemented with real-time remote diagnostic ABR conducted in the rural community. We found an improved follow-up compliance for tele-diagnostics (90% follow-up) which resulted in cost saving per child tested.