Background
Methods
Development of RAHL methodology
Study design
Sample size and sampling
Data collection teams
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One enumerator: to enumerate eligible participants, obtain informed consent, and complete a sociodemographic questionnaire
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Two hearing testers: to complete hearing screening. The pilot in Malawi found that with only one hearing tester per team, less than 20 people can be seen per day. In order to reach an adequate cluster size (i.e. at least 30 people), two testers were required. The diagnostic accuracy study in Malawi found that non-specialist health workers can be trained to accurately assess hearing [27].
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One ear examiner: to complete an ear examination using otoscopy and assign causes (Ear Nose and Throat (ENT) specialist). Pilot work in Malawi suggested at least an ENT clinical officer (mid-cadre health worker with 18 months of clinical training) is required to be in the field [27].
Data collection procedures
Assigning the probable causes of hearing loss
Assigning the type of hearing loss
Service needs
Need | Diagnosis | Hearing test result | Description |
---|---|---|---|
Diagnostic audiology assessment (possible hearing aid) | Sensorineural (acquired or congenital) or mixed hearing loss in both ears | Bilateral hearing loss (> 25 dB HL) | This involves air and bone conduction audiometry in sound proof room to confirm hearing levels and potential hearing aid fitting (depending on degree, and duration of loss). If a hearing aid is not suitable, other interventions such as cochlear implants, or sign language training may be suitable [32]. For mixed hearing loss, the underlying cause of the conductive component also needs to be treated. |
Surgical assessment | Chronic otitis media – wet perforation Chronic otitis media – dry perforation Chronic otitis media – possible cholesteatoma | N/Aa | Chronic otitis media – wet or dry require tympanoplasty to mend tympanic membrane [33] Chronic otitis media – possible cholesteatoma requires surgery to remove |
Medication | Acute otitis media (AOM) Chronic otitis media – wet perforation Chronic otitis media – possible cholesteatoma Otitis externa (OE) | N/Aa | AOM requires analgesics, and antibiotics [34] Chronic otitis media – wet perforation requires aural toilet, and ear drops (medication) to allow otorrhea (discharge) to clear prior to surgery [33]. Chronic otitis media – cholesteatoma may also require medication OE requires antifungal or antibiotic ear drops [35] |
Impacted wax or foreign body removal | Impacted wax (IW) Foreign body (FB) | Hearing loss > 25 dB HL in either ear | IW and FB are removed using suction or hooks depending on skill and equipment availability [51] |
Review (“watchful waiting”) | Otitis media with effusion (OME) | Hearing loss > 25 dB HL in either ear | OME requires re-examination of ears, and repeat audiometry [37] |
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a is the number of participants with any level of hearing loss (bilateral), probable mixed or sensorineural in nature in both ears, who report that they own a hearing aid (met need);
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b is the number of people with any level of hearing loss (bilateral), probable mixed or sensorineural in nature in both ears, who report not owning a hearing aid (unmet need)
Study outcomes
Field-testing the RAHL in Gao’an, China
Setting, sample size and sampling
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One enumerator: medical student
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Two hearing testers: one audiometry nurse; one medical student
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One ear examiner: ENT specialist.
Data analysis and outcome variables
Feasibility outcomes
RAHL outcomes
Results
Feasibility of the survey protocol
Overview of the study population
Population in Jiangxi | Available | Not available | Refused | Total | |
---|---|---|---|---|---|
Overall 50+ | 9,868,486 (100.0) | 1344 (94.6) | 38 (2.7) | 39 (2.7) | 1421 (100.0) |
Male | 4,933,243 (50.0) | 533 (39.7) | 28 (71.8) | 22 (57.9) | 583 (39.7) |
Female | 4,935,243 (50.0) | 811 (60.3) | 11 (28.2) | 16 (42.1) | 838 (71.8) |
Age group | |||||
50–59 | 4,769,228 (48.3) | 408 (30.4) | 25 (64.1) | 11 (29.0) | 444 (31.3) |
60–69 | 2,854,726 (28.9) | 522 (38.8) | 10 (25.6) | 19 (50.0) | 551 (38.8) |
70–79 | 1,659,973 (16.8) | 297 (22.1) | 3 (7.7) | 5 (13.2) | 305 (21.5) |
80–89 | 532,685 (5.4) | 104 (7.7) | 1 (2.6) | 2 (5.3) | 107 (7.5) |
90+ | 51,874 (0.5) | 13 (1.0) | 0 (0.0) | 1 (2.6) | 14 (1.0) |
Prevalence of hearing loss and ear disease
All | Male | Female | ||||
---|---|---|---|---|---|---|
N | % (95% CI) | N | % (95% CI) | N | % (95% CI) | |
Moderate or greater hearing loss (> 40 dB better ear) | ||||||
All | 283 | 16.3 (14.3, 18.5) | 125 | 16.2 (13.4,19.4) | 158 | 16.4 (13.8, 19.5) |
50–59 | 20 | 5.2 (3.0, 8.8) | 7 | 5.5 (2.5, 11.5) | 13 | 4.8 (2.6, 8.8) |
60–69 | 83 | 14.8 (11.7, 18.5) | 41 | 16.4 (11.6, 22.6) | 42 | 13.1 (9.9, 17.1) |
70–79 | 101 | 34.5 (28.6, 41.0) | 51 | 36.3 (29.0, 44.2) | 50 | 32.9 (25.5, 41.3) |
80+ | 79 | 64.9 (54.4, 74.1) | 26 | 59.7 (36.2, 79.5) | 53 | 68.2 (58.1, 76.8) |
Any level (> 25 dB ear better ear) | ||||||
All | 789 | 53.2 (49.2, 57.1) | 339 | 55.6 (49.9, 61.2) | 450 | 50.7 (46.6, 54.8) |
50–59 years | 137 | 36.5 (30.3, 43.1) | 55 | 42.7 (33.0, 52.9) | 82 | 30.1 (24.5, 36.4) |
60–69 years | 300 | 55.9 (50.8, 60.7) | 136 | 58.2 (50.6, 65.5) | 164 | 53.4 (47.6, 59.0) |
70–79 years | 236 | 81.2 (75.4, 85.9) | 109 | 78.9 (70.3, 85.5) | 127 | 83.3 (75.3, 89.1) |
80+ years | 116 | 98.7 (91.4, 99.8) | 77 | 96.7 (79.5, 99.6) | 39 | 100.0 |
Degree (better ear) | ||||||
None (0-25 dB) | 553 | 46.8 (42.9, 50.7) | 192 | 44.3 (38.7,50.0) | 361 | 49.3 (45.2, 53.4) |
Mild (26-40 dB) | 506 | 36.9 (33.3, 40.7) | 214 | 39.5 (33.9, 45.5) | 292 | 34.3 (30.9, 37.9) |
Moderate (41-60 dB) | 201 | 11.7 (10.1, 13.7) | 109 | 11.5 (9.4, 13.9) | 92 | 12.0 (9.5, 15.2) |
Severe (61–80 dB) | 70 | 4.0 (3.0, 5.3) | 43 | 4.4 (3.1, 6.2) | 27 | 3.5 (2.3, 5.3) |
Profound (81 dB +) | 12 | 0.6 (0.3, 1.0) | 6 | 0.5 (0.2, 1.2) | 6 | 0.6 (0.3, 1.4) |
Left ear | Right ear | Total ears | ||||
---|---|---|---|---|---|---|
N | % (95% CI) | N | % | N | % | |
Any ear disease | 86 | 6.0 (4.7, 7.5) | 80 | 6.0 (4.5, 8.0) | 166 | 6.0 (4.7, 7.5) |
Outer | ||||||
Impacted wax | 37 | 2.3 (1.6, 3.2) | 33 | 2.0 (1.3, 3.1) | 70 | 2.2 (1.6, 3.0) |
Otitis externa | 5 | 0.7 (0.3, 1.8) | 3 | 0.6 (0.2, 1.7) | 8 | 0.6 (0.3, 1.6) |
Middle | ||||||
COM – wet perforation | 12 | 1.0 (0.5, 2.0) | 11 | 0.9 (0.4, 1.7) | 23 | 0.9 (0.5, 1.6) |
COM – dry perforation | 26 | 1.6 (1.0, 2.5) | 24 | 1.7 (1.1, 2.8) | 50 | 1.7 (1.1, 2.5) |
OME | 1 | 0.07 (0.01,0.5) | 5 | 0.4 (0.1, 1.1) | 6 | 0.2 (0.07, 0.6) |
Other middle ear | 5 | 0.3 (0.1, 0.7) | 4 | 0.4 (0.1, 1.2) | 9 | 0.3 (0.2, 0.7) |
Normal ear examination | 1255 | 93.8 (92.1, 95.1) | 1261 | 93.7 (91.7, 95.3) | 2516 | 93.8 (92.1, 95.0) |
Total | 1344a | 100.0 | 1344a | 100.0 | 2688 (100.0) |
Probable causes of hearing loss
Left ear (n = 789) | Right ear (n = 789) | |||
---|---|---|---|---|
N | % | N | % | |
Probable conductive | ||||
Impacted wax | 17 | 2.2 | 18 | 2.3 |
Otitis externa | 3 | 0.4 | 2 | 0.3 |
COM – wet perforation | 5 | 0.6 | 5 | 0.6 |
COM – dry perforation | 12 | 1.5 | 10 | 1.3 |
OME | 0 | 0.0 | 3 | 0.4 |
Other middle ear | 2 | 0.3 | 0 | 0.0 |
Total | 39 | 4.9 | 38 | 4.8 |
Probable sensorineural | ||||
Acquired | 723 | 91.6 | 727 | 92.1 |
Congenital | 1 | 0.1 | 0 | 0.0 |
Total | 724 | 91.7 | 727 | 92.1 |
Probable mixed | ||||
Impacted wax | 11 | 1.4 | 8 | 1.0 |
Otitis externa | 0 | 0.0 | 2 | 0.3 |
COM – wet perforation | 3 | 0.4 | 2 | 0.3 |
COM – dry perforation | 11 | 1.4 | 10 | 1.3 |
OME | 1 | 0.1 | 1 | 0.1 |
Other | 0 | 0.0 | 1 | 0.1 |
Total | 26 | 3.3 | 24 | 3.0 |
Population needs and coverage of services
People in need | Ears | ||||||
---|---|---|---|---|---|---|---|
Sample (n = 1344) | Populationa | Sample (n = 1344*2) | Populationa | ||||
Definition of need | N | % | n | N | % | n | |
Diagnostic audiology (possible hearing aid) | Bilateral sensorineural or mixed type of hearing loss (>25dB) | 726 | 54.0 | 108,000 | - | - | - |
Surgery | COM (any) with or without hearing loss | 65 | 4.8 | 9,500 | 75 | 2.8 | 11,000 |
Medication | AOM, OE, COM (wet) with or without hearing loss | 27 | 2.0 | 4,000 | 32 | 1.2 | 5,000 |
Wax or foreign body removal removal | Impacted wax with hearing loss (>25 dB) in either ear | 46 | 3.4 | 7,000 | 59 | 2.2 | 9,000 |
Watchful waiting | OME; Hearing loss >25dB HL in either ear | 4 | 0.5 | 500 | 5 | 0.2 | 500 |
Risk factor analysis
N (%) | Univariate | Multivariate | |||
---|---|---|---|---|---|
aOR^ (95% CI) | P value | aORb (95% CI) | P value | ||
Age (continuous) | – | 1.12 (1.10, 1.14) | < 0.001 | 1.11 (1.09, 1.13) | < 0.001 |
Sex | |||||
Male | 533 (39.6) | 1.0 (base) | – | 1.0 (base) | – |
Female | 811 (60.3) | 0.73 (0.55, 0.97) | 0.029 | 0.68 (0.50, 0.93) | 0.016 |
Highest education | |||||
Less than primary | 347 (25.8) | 1.0 (base) | – | ||
Primary | 701 (52.2) | 0.70 (0.48, 1.02) | 0.061 | – | – |
Secondary | 270 (20.1) | 0.80 (0.50, 1.29) | 0.354 | – | – |
Post-secondary | 26 (1.9) | 0.56 (0.14, 1.51) | 0.194 | – | – |
Literacy | |||||
Unable to read | 358 (26.6) | 1.0 (base) | – | 1.0 (base) | – |
Able to read | 986 (73.4) | 0.71 (0.50, 0.99) | 0.045 | 0.71 (0.50, 0.99) | 0.048 |
SEP quintile | |||||
1 - poorest | 304 (22.7) | 1.0 (base) | – | – | – |
2 | 366 (27.3) | 0.84 (0.54, 1.32) | 0.670 | – | – |
3 | 336 (25.0) | 0.92 (0.55, 1.53) | 0.742 | – | – |
4 - richest | 336 (25.0) | 0.77 (0.45, 1.31) | 0.321 | – | – |
Noise exposure | 18 (1.3) | 1.05 (0.35, 3.13) | 0.924 | – | – |
Hypertension | 387 (28.8) | 0.88 (0.63, 1.23) | 0.451 | – | – |
Diabetes | 115 (8.6) | 0.92 (0.57, 1.46) | 0.707 | – | – |
Cancer medication | 20 (1.5) | 2.68 (0.82, 8.72) | 0.099 | – | – |
Trauma | 53 (3.9) | 1.05 (0.54, 2.06) | 0.880 | – | – |
Smoking | |||||
Not at all | 1097 (81.6) | 1.0 (base) | – | – | – |
Some days | 41 (3.1) | 0.73 (0.25, 2.10) | 0.549 | – | – |
Every day | 206 (15.3) | 1.33 (0.84, 2.10) | 0.217 | – | – |
HIV | 0 (0.0) | – | – | – | – |
Malaria | 76 (5.7) | 1.68 (1.04, 2.70) | 0.034 | 1.67 (1.08, 2.59) | 0.022 |
TB | 11 (0.8) | 1.04 (0.31, 3.46) | 0.954 | – | – |
Other infectious diseasea | 52 (3.8) | 1.13 (0.51, 2.49) | 0.762 | – | – |