Pilot Implementation Outcomes of a Community-Based Tele- Practice Model for Identification and Rehabilitation of Children with Hearing loss within a Public-health system of a Rural District in Southern India

doi:10.21203/rs.3.rs-3974966/v1

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Research Article

Pilot Implementation Outcomes of a Community-Based Tele- Practice Model for Identification and Rehabilitation of Children with Hearing loss within a Public-health system of a Rural District in Southern India

https://doi.org/10.21203/rs.3.rs-3974966/v1

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Background

The current study is an effort to evaluate pilot outcomes of a comprehensive tele-practice model for identification and rehabilitation of hearing loss among children below 6 years of age which can then inform suitable adaptations prior to the implementation. The outcomes of tele-facilitator training, limited-efficacy measures, and caregiver acceptability and satisfaction with tele-practice were analysed.

Method

Two special educators were trained as tele-facilitators for tele-diagnostic testing. Screening was done using the validated SRESHT screener in the Perambalur district by trained nurses in UPHC’s at all 4 blocks until at least 5 children with ‘refer’ results were obtained. 5 children with hearing loss using amplification devices enrolled in the District Early Intervention Centre (DEIC) were enrolled for tele-rehabilitation. To measure the limited- efficacy, the outcomes of pre-pilot and post-pilot were compared. The caregiver acceptability and satisfaction with tele-practice was also assessed

Results

In all 12 children with ‘refer’ results loss underwent tele- diagnostic testing. Tele-rehabilitation outcomes were studied on 5 children with hearing loss already using amplification devices. When comparing the outcomes of limited -efficacy with the existing data it was found that the model identified older children with hearing loss. The time lapse between screening/hearing loss suspicion to diagnosis reduced from a median of 216 days to 8 days. For tele- rehabilitation the number of sessions attended in a span of 3 months increased from a median of zero to 3 sessions. Based on the satisfaction questionnaire, most people had a positive experience, and found the travel time to the testing site convenient and affordable. Few parents reported encountering difficulties as a result of inadequate ventilation and internet connectivity within the mobile van where tele-diagnostic testing was conducted.

Conclusion

The pilot outcomes suggests that a block level service enabled using tele- practice to overcome professional shortages, beneficial in reducing time gap between screening/suspicion to diagnosis and also enhanced attendance for rehabilitation. The pilot outcomes provided insights on adaptations related to screening site, test infrastructure and internet optimization that may be required before implementation.

Children with Hearing impairment

rural community

tele-practice model

mobile van

caregiver acceptance and satisfaction

Hearing loss, in childhood can considerably impact development of spoken language and has concurrent impacts on societal inclusion, accessing information and knowledge, and eventually desirable academic and vocational academic outcomes. To reduce the impact of hearing loss, it is pertinent to detect congenital hearing loss before 3–6 months of age (1) through newborn hearing screening programs. Further introduce school screening programs to mitigate the consequences of unidentified late onset and other preventable hearing losses.

Towards early identification of disabilities, the Government of India initiated a national program in 2013 to screen and identify any defects, disease, deficiencies and disabilities among children from 0 to 18 years of age. These screening efforts were conceptualised at the village level by a health team, and those suspected with concerns are directed to the Early Diagnostic Centre (EDC) at the district general hospital (GH) for diagnosis. Further, post confirmation of disability, the individual is directed to the District Differently Abled Welfare office (DDAWO’s) for welfare benefits, aids and appliances and early intervention.

In 2015 the ‘Mobile Therapy Unit’ was implemented through the State Commissionerate for the Differently Abled to improve consistency of rehabilitation services, increase last mile coverage and overcome the challenge of patient’s access to services. This service is provided with existing professionals available through DDAWO or local non-governmental 4 organizations (NGOs). However, this initiative is also challenged by higher demand on professional’s time, who are engaged in both clinical services and administrative work. A recent situational analysis confirmed this mismatch of demand versus need (2)

Tele-practice/ tele-health has been explored as one of the options to overcome the challenges of demand versus capacity and access barriers. There is a growing body of evidence on the use of telehealth in hearing health care, including screening (3),diagnostic assessment (4) ,hearing aid fitting (5)and rehabilitation (6). Several studies from Africa, USA and India, have shown promising outcomes in reaching the rural community through tele-practice for individuals with hearing, speech-language disorders (7) (8) (9), (10), (11) (12), (13). Despite these, there have been only a few attempts to investigate a comprehensive diagnostic audiology solution (7)(14)(15). Even these, however, have focussed only on diagnostic testing and did not include rehabilitation. Furthermore, only a few studies examined outcomes of implementing teleaudiology in a health care system (7)(7)in high income country context. There are no such reports from the low-middle income country context.

A comprehensive tele-practice model for the identification and rehabilitation of children with hearing loss among children below 6 years of age in rural communities was developed (intervention) for integration within the public-sector health services in a rural district in 5 Southern India. The proposed intervention is complex as it involves multiple steps (as stated above), multiple departments (District Differently Abled Welfare Office, Early Intervention Centre, Non-Government Organisations), many stakeholders at various stages of implementation (ASLP, child with disability, caregivers, nurses, special educators, government officers, non-professional staff). The intervention requires stakeholders to adopt technology to a greater extent than presently used and therefore will alter their work process. Implementation characteristics were identified and mapped to the Consolidated Framework for Implementation Research (CFIR) (16).The model was designed for implementation in four blocks of a rural district (Perambalur Block, Veppanthattai Block, Alathur Block, and Veppur/Kunnam Block). Prior to the model's finalisation, several stakeholders from the state commissionerate for the welfare of differently abled, departments of health, social justice and welfare, and education, as well as parents of children with and without disabilities, were involved to ensure model optimization and convergence of efforts toward early identification and intervention (2).In this model, nurses in Upgraded Primary Health Centers (UPHC) were to be trained to screen for hearing impairment using a validated tablet-based screening device (SRESHT screener) in order to triage disabling hearing losses ( > = 60 dB HL) as defined in the RPWD Act 2019. For individuals who ‘refer’ the hearing screening, tele-diagnostic testing would be delivered remotely from the University lab (see SRESHT Lab) to children in a mobile-van with audiology test facility at each of the four block UPHCs. Staff from NGOs or government EICs served as tele-facilitators. Finally, individuals identified were to receive tele-rehabilitation services at the Block Resource Centers of the ‘Education for All’(Sarva Siskha Abhiyan) scheme of the government of India(SSA-BRC), with the assistance of computer assistants/SSA 6 teachers and under the supervision of a remote audiologist/speech language pathologist/Auditory Verbal Therapists (Fig. 1).

Insert Fig. 1 -Comprehensive Tele-practice model

The aim of the current study was to evaluate the pilot outcomes of this comprehensive tele-practice model. The objectives were: (i) to evaluate the outcomes of training tele- facilitators to assist in remote diagnostic hearing assessment and rehabilitation services (ii) to evaluate the limited -efficacy outcomes of the pilot. Limited-efficacy is defined as “analysis conducted with a convenience sample, intermediate rather than final results, shorter follow-up periods, or with limited statistical power (17)and (iii) to evaluate the patient acceptance and satisfaction of tele-diagnostics and telerehabilitation components of the comprehensive tele-practice model.

Study site

The pilot implementation site (Perambalur district) was chosen based on the selected implementation site with the local government for the project funded by DBT/Wellcome Trust India Alliance. This district has an area of 1,757 Sq.Km. The population per block includes 1,17,534 in Veppur, 5,692 in Perambalur, 1,48,743 in Veppanthattai and 1,57,947 in 7 Alathur blocks respectively. The pilot was implemented for a period of 3 months from 1st April 2023 to 1st July 2023.

Study design

Quasi-experimental within-site design

Study subjects

Sample for tele-diagnostic evaluation

Hearing screening was done using the validated SRESHT screener for children below 6 years in the communities of Perambalur district by trained nurses working in UPHC’s at all 4 blocks of the district until at least 5 children with ‘refer’ results were obtained. These children were then referred for tele-diagnostic evaluation.

Sample for tele-rehabilitation

Using convenience sampling method, 5 children with hearing loss using amplification devices (Hearing aids/Cochlear Implant) and enrolled in the District Early Intervention Centre (DEIC) were included for tele-rehabilitation.

Procedure

Training and assessment of tele-facilitator’s knowledge and skill

A special educator and a trainee special educator for hearing impairment (HI) deputed from the District Differently Abled Welfare Office (DDAWO) were trained as tele-facilitators to assist tele-diagnostics and tele-rehabilitation. Three audiologists conducted the training over 2-days for 5 hours/day. The training primarily covered aspects of internet connection, TeamViewer application (version 15.40.8) to connect remotely to the audiologist, purpose of testing, setting-up equipment in the mobile van, instructions to the parent on the test 8 procedure, patient preparation for testing, equipment connections, and placement of the transducer/probe/electrodes on the patient. A hands-on training session was also held to familiarize them with the software, equipment connections, and transducer/probe/electrode placement. At the end of the training session, a procedure manual (see Additional file 1) along with a video demonstration developed in English and local language (Tamil) (available at https://www.youtube.com/watch?v=xEKYm4sKnWg )

A questionnaire and an Objective Structured Clinical Examination (OSCE) was used to assess the tele-facilitators' knowledge and skill respectively (see Additional file 2 and Additional file 3). Using Bloom's taxonomy (18) a 10-item, 4-choice close-ended knowledge evaluation questionnaire was. Five of the questions were about technical factors such as internet connection, audio-video call, and troubleshooting, while the other five were about audiological test processes.

A questionnaire with images of the equipment was also used to assess the proficiency in labelling the components of the equipment (see Additional file 4). Correct responses received a score of one, while erroneous responses received a score of zero. The knowledge questionnaire, OSCE checklist and labelling forms were validated for relevance, adequacy and appropriateness by two audiologists (one with 3 years of experience and one with 14 years of experience in tele-practice) and one special educator who was also an Auditory Verbal Therapist with 15 years of experience

Step 2: Tele-diagnostic audiological testing

Patient site set-up

The tele-diagnostic testing was conducted in a mobile-van near the UPHC with 4G internet bandwidth enabled using mobile phone hotspot. This van was equipped with a bed, fan, power sockets and seating facilities. The mobile-van was scheduled to visit each UPHC located at all 4 blocks once in a month on a fixed day of the week.

Insert Fig. 2

The test equipment included video- otoscopy (Firefly pro DE550), Pure Tone Audiometry (PTA) (Harp Inventis plus calibrated to ANSI S3.6 standards), Oto-Acoustic Emission (OAE) calibrated as per EN 60645-6:2010 standards, and Auditory Brainstem Response (ABR) calibrated as per EN 60645-7:2010 standards (Neuro-Audio version 1.0.104.1) was used for the diagnostic assessment of hearing.

The software for all testing was pre-installed in the laptop (Lenovo) for remote testing. The Teamviewer application (version 15.40.8) and V-See application (version 4.17.1) was installed in the laptop. A web-camera was connected to the laptop for video-conferencing in the remote site. These features helped the audiologist to view the placement of transducers, otoscope, probe tips, insert tip and electrodes with more clarity.

Set-up at the audiologist site

A laptop (Acer) with 8.00 GB RAM and 11thGen Intel(R) Core (TM) i5-1135G7@ 2.40 GHz was used by the audiologist at the University to provide tele-diagnostic evaluation and rehabilitation services. The laptop was configured with Teamviewer application (version 15.40.8) and V-see application (version 4.17.1) for the audiologist to remotely access the laptop.

Testing method

All children who required diagnostic testing either from the hearing screening using SRESHT screener or suspected with hearing loss by government pre-school teachers (anganwadi teachers), village health nurses or community workers were asked to follow-up at the mobile van during the scheduled visit to the block level UPHC, closest to the child’s home. The tele-facilitator provided instructions about the test prior to the test procedure. If there were any doubts they were clarified by the remote audiologist via video-conferencing.

All children diagnosed with hearing loss were counselled to enroll for hearing aids/cochlear implants at DDAWO/the district GH or other government centers nearby. The parents were also given the option to use temporary hearing aids (Tarang) provided through the project and programmed according to their hearing loss, until they bought their own hearing aids/Cochlear implant. All the reports of the patient were emailed to the parents and also made available to the DDAWO.

Step 3: Tele-rehabilitation

A dedicated noise-free room was chosen in the SSA BRC. The VSee video-conferencing application was installed in the laptop available at the respective BRC’s. A computer assistant available at the center assisted with the process. Therapy materials available at the BRC that could be used during the sessions were identified with the help of the facilitator. Additional materials that were used were procured/asked the parent to bring for the session. Each therapy session lasted for 45 minutes.

Step 4: Parental satisfaction with tele-practice (diagnostic and rehabilitation)

To assess parental satisfaction with tele-diagnostic evaluation, a 10-item questionnaire with open and closed ended questions was used. The tele-rehabilitation satisfaction questionnaire was adapted from one developed by (19). Both the questionnaire's relevance, adequacy, and appropriateness were content validated (see Additional file 5) by two audiologists and one Auditory Verbal Therapist (AVT). Following the tele-diagnostic assessment, the tele-diagnostic satisfaction questionnaire was administered. The tele-rehabilitation satisfaction questionnaire was administered following two tele-rehabilitation sessions (see Additional file 6)

Analysis

1. The tele-facilitator's knowledge and skill adequacy was evaluated using percentage of correct responses and the task completion of pre-defined skills, and the skills respectively.

2. The limited efficacy measure (from the Bowen’s Feasibility Framework, 2009) was used to evaluate outcomes of the pilot by comparing against the existing outcome data available prior to the commencement of pilot. The following outcomes were analyzed as part of the limited efficacy:

i) Rate of follow-up for tele-diagnostic evaluation before and after the commencement of pilot: The number of children with refer results in screening was compared with the number of children who followed-up for tele-diagnostic evaluation. This data was further compared with the number of children screened at the existing district general hospital for a period of 3 months prior to the commencement of the pilot.

ii) Time lapse between screening and diagnosis of hearing impairment before and after the commencement of the pilot: For the purpose of this analysis, the data of all children diagnosed via tele-diagnostic as part of the pilot (Group 1) was compared with equal number of children pre-diagnosed with hearing loss currently in EIC (Group 2). The parents of children enrolled in EIC were contacted and details were collected from their records (screening date, and place and date diagnosis). For Group 1 and Group 2, the time interval between the screening/suspicion of hearing loss stage to diagnostic evaluation was calculated. The median was calculated for both Group 1 and Group 2 for comparison.

iii) Rate of follow-up for tele-rehabilitation before and after the commencement of the pilot: The number of tele-rehabilitation sessions completed per child was documented and compared with the number of rehabilitation sessions before the pilot for a period of 3 months

3. Patient/caregiver satisfaction with tele-practice measured using the questionnaire was analysed using percentage analysis and reported descriptively.

Tele-facilitator knowledge and skill post training

Tele-facilitator’s knowledge and skill adequacy was a prerequisite for them to be involved in the pilot. In all two facilitators underwent training. No assessment was done pre-training, as they were not expected to know any information pertaining to tele-practice. On post training knowledge assessment, both trainee 1 and 2 obtained 90% correct responses, with accurate answers for questions related to remote-testing. The incorrect responses were for questions related to situations where the audio-video call was not clear.

On the skill adequacy assessment, both the trainees performed 18 out of the 20 skills that were expected of them that includes establishing internet connection, placement of transducers, probes and electrodes, and preparation of the patient for each test.

The trainees were asked to label various parts of the equipment/transducers so that they understand the audiologist’s instruction during remote testing. Trainee 1 obtained 47% correct responses and trainee 2 achieved 93%. When asked to describe the utility of the part labelled, both trainees accurately described the usage of each part, even if they did not label it correctly.

Both trainees were involved as tele-facilitators, while trainee 2 was assigned as the primary facilitator based on the trainees score of more than 80% on both knowledge and skill evaluation and trainee 2 was asked to shadow and support trainee 1.

Limited- efficacy outcomes

Rate of follow-up for tele-diagnostic evaluation

In all 41 children (age range of 5 months to 5 years 3 months)were screened using the SRESHT screener at the four UPHC’s of the district by nurses. Of them, 11 had ‘refer’ results in the screening and 10 of them followed up for tele-diagnostic evaluation. Parent of one child was not willing for a confirmatory diagnostic hearing evaluation as she did not 13 suspect/perceive any problem. The month-wise data of screening and follow-up is provided in Table 1. In addition, two children directly came for tele-diagnostic evaluation without undergoing hearing screening based on suspicion of hearing loss. Of these ,11 children were confirmed to have hearing loss

Table 1
Month and Year	Number of hearing screening (birth to 6 years)	Number of children with refer results	Number of children followed up for tele- diagnostic testing
April 2023	8	2	2
May 2023	32	9	8
June 2023	1	0	0

As a comparison, the month-wise data of the number of children screened at the district EDC in GH was collected for a period of 3 months from January 2023 to March 2023 (Table 2). In all 459 children were screened at birth using an OAE screener by an audiologist. There was only one refer from the screening, and this child received diagnostic evaluation by traveling to a nearby city. Therefore, the number of children followed up for tele-diagnostic evaluation before the commencement of the pilot was zero and after was 12.

Table 2
Month and Year	No. of hearing screening at birth	No. of children with refer results	Number of children followed up for diagnostic evaluation at a nearby city
Jan 2023	176	0	0
Feb 2023	107	0	0
March 2023	176	1	1

Age -appropriate tele-diagnostic test battery was conducted to confirm hearing loss among 10 children who were referred from UPHCs and two other children who were referred directly from EDC at GH. Out of the 12 children who were tested, one child had normal hearing sensitivity, seven children had confirmed sensorineural hearing loss, two children were suspected with neuro-maturational delay, two children had conductive hearing loss. The demographic details, case history, test performed and the diagnosis of all the 12 children is tabulated (see additional file 7).

Insert Additional File 7

Time lapse between screening and diagnosis for hearing impairment before and after the commencement of the pilot

The time lapsed since suspicion/screening to diagnose a child with hearing impairment for Group 1 (post- pilot) and Group 2 (pre- pilot) are represented in Fig. 2 and Fig. 3 respectively. The median number of days lapsed pre- pilot and post -pilot was calculated for both the groups. The median time taken to diagnose a child for hearing using tele-practice (Group 1) was 8 days whereas pre- pilot, the time taken was 216 days (Group 2).

Insert Fig. 2- Time lapse between hearing loss suspicion/screening to tele-diagnosis

Insert Fig. 3- Time lapse between hearing loss suspicion/screening to diagnosis

Rate of follow-up for tele-rehabilitation before and after the commencement of the pilot

In all five children attended tele-rehabilitation at the SSA-BRC. Four of these children were cochlear implant users and attended the EIC for special education and one of them was a child identified from the pilot implementation and was directly enrolled for tele rehabilitation using temporary hearing aids given from the project. Each session was carried out for 45 minutes, where the initial 10 minutes was to review with the parent regarding home plan activities. At the end of each session, the goals and activities were reiterated to the parents and discussed any doubts/concerns regarding the child’s progress. The number of sessions attended for a period of 3 months before and after the commencement of the pilot is tabulated (see additional file 8). The median number of sessions pre- pilot was zero and post- pilot was three

Insert Additional File 8

Patient / caregiver satisfaction with tele-practice

Tele-audiology diagnostic service

All 12 parents of children who underwent tele-diagnostic testing completed the satisfaction questionnaire. Parents reported to have had either a ‘good’ (58%) or ‘very good’ (42%) experience and none of them reported to have any hesitation to avail tele-testing. All parents (100%) reported being able to comprehend and express their concerns with the audiologist in a satisfactory manner.

Testing was conducted in the mobile-van for 50% of the children, for 33% testing was shifted from mobile-van to a room within the UPHC. Few parents (17%) reported that during the initial visit in the mobile- van the test was not completed as the child was not cooperative and they had to follow-up to the EIC for testing.

Predominantly (92%) parents did not require assistance from the tele-facilitators in asking their questions to the audiologist. However, few (8%) of them required some assistance from the tele-facilitators.

Majority of the parents (75%) reported to have had no difficulty during the tele-testing. Yet, 33% reported that the ventilation was poor in the mobile-van. Poor internet connectivity and ventilation in the mobile van caused difficulties for 33% of parents due to which remote testing had to be relocated from the van to the UPHC. Parents reported that in the absence of such tele-testing service they would have travelled to nearby cities such as, Trichy (60 kms)

(66%), Chennai (276kms) (25%) and few (8%) planned to check if services were available at the district GH in Perambalur. Majority (75%) of them preferred that such a testing alternative be continued in the district, while some (25%) parents preferred to undergo hearing testing in-person in nearby cities.

Tele- rehabilitation services

All parents were satisfied (80%) with tele-rehabilitation since the clarity of speech with the therapist was adequate via video-conferencing. They were all ‘satisfied’ (60%) in communicating with the therapist and had ‘met their expectation’ (80%). Parents found it easy (80%) to voice out their concerns and all the parents (100%) said they would recommend tele-therapy to others, and were ‘very comfortable’ (80%) as the location was suitable for all the parents. Majority of the parents were ‘very likely’ (60%) to continue with this service as they were able to recognize the instructions given by the therapist (60%) and also trusted the therapist “very well’ (80%).

This study explored the pilot outcomes of the first known effort to integrate tele- practice services for childhood hearing loss in the public health system of a low middle income country. Very limited studies have explored the outcomes of providing comprehensive hearing care using tele-practice (15,14,7)

Tele-facilitators in audiological testing are required at the patient site to support placement of probes, electrodes and transducers as required, and also provide technical support (20). In a scoping review it was identified that predominantly audiologists, audiology students, and unspecified technicians served as tele-facilitators and limited studies reported details of the training they had received (21). In the current study, we trained one special educator who was deputed from the government EIC to support remote-testing whenever required. Such capacity building is necessary to optimize shared resources to support implementation of services where none exists. We also trained another trainee special educator as a back-up, to avoid discontinuity in services due to leave of absence.

The comprehensive model of tele-practice was conceptualized as a community-based model that includes children from birth to 6 years, to overlap with the Government of India’s age criteria of early identification. The SRESHT screener supports the triaging of 40% (60 dB HL) hearing loss from the community to the nearest block level UPHC for tele-diagnosis. However, due to lack of diagnostic services in the district GH, there was considerable demand for diagnostic services among parents /caregivers who had suspicion about their child's hearing.

On the other hand, district GH had catered only to ‘at birth’ population using the OAE screener, which is capable of triaging even milder hearing losses (> 25–30 dB HL). While the coverage was higher at birth, older children with hearing loss were unidentified and missed. In low-middle income country, the age of identification of hearing loss still continues to be higher (22) and there are only a few screening programs to have focused beyond the newborn stage.

In the comprehensive tele-practice model, screening was integrated at a primary health facility (UPHC) to support block level triaging of those who need diagnostic testing. However, during the test-bed, it was noted that, the suspicion and referrals were predominantly from the SSA special educators (educational department) and then were redirected to the UPHC for screening. Therefore, screening at the SSA- BRC can also be explored to assess if triaging is better compared to UPHC based screening.

Even though a test battery approach was used, children were subjected only to tests that were required to obtain a complete understanding of their ear and hearing status. This was done to optimize the use of resources such as mobile-van availability, internet bandwidth, and limited amount of time to obtain an accurate diagnosis. Sometimes, some tests were not conducted if children were less co-operative.

The loss to follow-up rate for tele-diagnostic testing was 8.3% in the current study, which is much lower than that reported in several EHDI programs in India (23)(24),(25), (26), (27).Lower loss to follow-up is also reported in few other studies that implemented tele-diagnostics in EHDI in Canada (14)and the USA (7) study. This suggests that in a tele- practice model the loss to follow-up rate is less when compared to in-person testing.

The rate of follow-up for tele-rehabilitation when compared to in-person rehabilitation was better in terms of number of sessions attended. Similar results were reported in a tele- Auditory Verbal Therapy program in Logan, USA (28). The coordinated follow-up and scheduling by the tele-facilitators and the therapist based on availability of the parent/caregiver is likely to have promoted better follow-up.

We found that the time between the suspicion of hearing loss/screening to diagnosis was less for the children who availed tele-diagnostic testing. This confirms that having local resources within a block facilitates better follow-up as well as timely diagnosis. Similar results were found earlier in a (29) where the time taken between second screening and tele-ABR assessment in a rural community-based program was a median interval of 30 days.

Majority of the parents in the current study did not have any difficulty during the testing but some reported poor ventilation in the mobile-van which caused difficulties for the child to be comfortable and cooperative for the testing. While tele-testing within their block was preferred by the majority of the parents, few wanted to seek diagnostic services in nearby cities as they felt in-person testing would be better. Even though during COVID-19 there was a surge in tele-practice across all health disciplines, there exists a preference for in-person services (30),(31)Therefore, tele- practice can augment services where none exists and until suitable infrastructure and resources are allocated.

The current study also suggests that caregivers found the tele-rehabilitation to be acceptable, trustworthy, and the location (at block level) to be suitable, comfortable, satisfied with the level of communication with the therapist and had met their expectation. As they had trust in the clinician, they were also likely/very likely to continue receiving tele- rehabilitation services. In a study it was found that majority of the patients partially trusted the therapist in audio-video communication (19). These results are found to be similar with another study (32), where majority of the felt that tele-therapy was convenient, cost-effective and improved the attendance of the sessions. But some had reported about the increased use of gadgets and screen time for their children.

There are limitations to our current findings, owing to small sample size (due to test-bed), as well as limitations of a questionnaire-based approach that does not provide an in-depth unbiased perspective. These will however be explored on an on- going basis to study the feasibility outcomes of the overall implementation in the future.

Overall, it can be concluded that this comprehensive tele-practice model can be effectively implemented to overcome professional shortages, and was beneficial in reducing time gap between screening/suspicion to diagnosis and also enhanced attendance for rehabilitation. The pilot helped to identify the aspects of the model that are suitable (e.g. block level implementation of diagnostic and rehabilitation services, community level screening including older children) and the aspects that need adaptations (ventilation in the mobile van, center-based tele-testing within the block, multi-adapter internet dongles for more stable internet or a mobile-phone call for audio communication, with video- conferencing alone through the desktop-based software).

After suitable adaptations made, the feasibility outcomes of implementing this model will be studied using the limited-efficacy measures, economic analysis as well as qualitative methods to assess the various other constructs of the Bowen’s framework (17)

ABR	Auditory Brainstem Response
ASHA	American Speech Language Hearing Association
ANSI	American National Standard Institute
AVT	Auditory Verbal Therapy
CI	Cochlear Implant
CE	Conformité Européenne
CPA	Conditioned Play Audiometry
DPOAE	Distortion Product Oto-Acoustic Emission
DDAWO	District Differently Abled Welfare Office
DDRC	District Disability Rehabilitation Center
EHDI	Early Hearing Detection and Intervention
EIC	Early Intervention Center
EDC	Early Diagnostic Center
EN	European Standards
FCC	Federal Communication Commission
GH	General Hospital
HA	Hearing aid

HI	Hearing Impairment
JCIH	Joint Committee on Infant Hearing
LTL	Learning to Listen
LMIC	Low Middle-Income Countries
NGO	Non-governmental Organization
NHS	Newborn Hearing Screening
OSCE	Objective Structured Clinical Examination
PTA	Pure Tone Audiometry
RBSK	Rashtriya Bal Swasthya Karyakram
RoHS	Restriction of Hazardous Substances in Electrical and Electronic Equipment
SRESHT	Services to Reach children with Speech and Hearing disorders using Tele-
SSA-BRC	practice Sarva Shiksha Abhiyan Block Resource Center
UPHC	Upgraded Primary Health Care Center
VHN	Village Health Nurses
WHO	World Health Organization

Ethics approval and consent to participate

This study received ethical clearance (IEC-NI22/DEC/85/124) from Institutional Ethics Committee (IEC) in Sri Ramachandra Institute of Higher Education and Research (Deemed to be University). Informed consent was obtained from the respective parents of children who participated, prior to the study.

Competing interest

The authors declare that they have no competing interests.

Funding

This study is funded by the DBT Wellcome India Trust Alliance

Consent for publication

Not Applicable

Availability of data and materials

All data supporting the findings of this study are sufficiently anonymized and available within the paper and its Supplementary Information.

Authors' contributions

KS conducted the data collection, data analysis and wrote the main manuscript text

VR conceptualised the study, obtained funding, conducted the data collection (in-part), reviewed the data anaylsis, edited and finalised the manuscript

DJ conducted the data collection (in-part) and reviewed the manuscript

BE provided on field support with resources for data collection

Bornstein S. The Importance of Early Identification and Intervention for Children with Hearing Loss. Part 1: Human Development. Journal of Health Care Communications [Internet]. 2017 [cited 2023 Nov 15];3(1):0–0. Available from: https://www.primescholars.com/articles/the-importance-of-early-identification-and-intervention-for-children-with-hearing-loss-part-1-human-development-96303.html
Jesudass N, Ramkumar V, Kumar S. Needs and readiness to use tele-practice for identification and rehabilitation of children with hearing and speech-language disorders: perceptions of public sector care providers in South India. Early Child Dev Care [Internet]. 2023 Nov 2 [cited 2023 Nov 15]; Available from: https://www.tandfonline.com/doi/abs/10.1080/03004430.2023.2276660
Clark JL, Swanepoel DW. Technology for hearing loss – as We Know it, and as We Dream it. http://dx.doi.org/103109/174831072014905642 [Internet]. 2014 [cited 2023 Jul 6];9(5):408–13. Available from: https://www.tandfonline.com/doi/abs/10.3109/17483107.2014.905642
Ramkumar V, Hall JW, Nagarajan R, Shankarnarayan VC, Kumaravelu S. Tele-ABR using a satellite connection in a mobile van for newborn hearing testing. J Telemed Telecare. 2013 Jul 1;19(5):233–7.
Penteado SP, De Lima Ramos S, Battistella LR, Marone SAM, Bento RF. Adaptação à distância de próteses auditivas acústicas: A teleaudiologia aplicada na melhoria da condução das Políticas Públicas no Brasil. Int Arch Otorhinolaryngol. 2012 Jul;16(3):371–81.
McCarthy M, Muñoz K, White KR. Teleintervention for infants and young children who are deaf or hard-of-hearing. Vol. 126, Pediatrics. 2010
Dharmar M, Simon A, Sadorra C, Friedland G, Sherwood J, Morrow H, et al. Reducing Loss to Follow-Up with Tele-audiology Diagnostic Evaluations. Telemedicine and e-Health. 2016 Feb;22(2):159–64
Govender SM, Mars M. The use of telehealth services to facilitate audiological management for children: A scoping review and content analysis. J Telemed Telecare. 2017 Apr 1;23(3):392–401.
Havenga E, Swanepoel DW, le Roux T, Schmid B. Tele-intervention for children with hearing loss: A comparative pilot study. J Telemed Telecare. 2017 Jan 1;23(1):116–25.
Maleka BK, Van J, Linde D. SMARTPHONE-BASED DEVELOPMENTAL SCREENING BY COMMUNITY HEALTH CARE WORKERS In the department Speech-Language Pathology and Audiology at the UNIVERSITY OF PRETORIA FACULTY OF HUMANITIES SUPERVISORS: Prof. De Wet Swanepoel. 2016.
Swanepoel DW, Clark JL, Koekemoer D, Hall JW, Krumm M, Ferrari D V., et al. Telehealth in audiology: The need and potential to reach underserved communities. Int J Audiol. 2010;49(3):195–202.
Van Der Merwe MN. Early detection of developmental delays in vulnerable children by community care workers using an mHealth tool Dissertation submitted in fulfillment of the requirements for the degree MA (Speech-Language Pathology) in the Department of Speech-Language Pathology and Audiology at the UNIVERSITY OF PRETORIA FACULTY OF HUMANITIES. 1206.
Kasturi VJ, Kasturi Goswami S P VJ. Task Compliance to App-based Rehabilitation in Persons with Aphasia in India [Internet]. Vol. 10, INTERNATIONAL JOURNAL OF MIND, BRAIN & COGNITION. Available from: https://www.researchgate.net/publication/336059410
Hatton JL, Rowlandson J, Beers A, Small S, Small SA. Telehealth-enabled auditory brainstem response testing for infants living in rural communities: the British Columbia Early Hearing Program experience. International Journal of Audiology Submitted. 2018.
Ramkumar V, Krumm M. Tele-audiology diagnostic testing services for children with disabilities in a school setting: A pilot study. Int J Pediatr Otorhinolaryngol. 2023 Feb 1;165.
Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Address: 1 HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System (11H), 2215 Fuller Rd. 2009 [cited 2023 Dec 28]; Available from: http://www.implementationscience.com/content/4/1/50
Bowen DJ, Kreuter M, Spring B, Cofta-Woerpel L, Linnan L, Weiner D, et al. How We Design Feasibility Studies. Vol. 36, American Journal of Preventive Medicine. 2009. p. 452–7.
Krathwohl DR. A revision of bloom’s taxonomy: An overview. Vol. 41, Theory into Practice. Ohio State University Press; 2002. p. 212–8.
Eslami Jahromi M, Ahmadian L. Evaluating satisfaction of patients with stutter regarding the tele-speech therapy method and infrastructure. Int J Med Inform. 2018 Jul 1;115:128–33.
Krumm M. Audiology telemedicine. J Telemed Telecare. 2007 Jul 1;13(5):224–9.
Coco L, Davidson A, Marrone N. The Role of Patient-Site Facilitators in Teleaudiology: A Scoping Review. Am J Audiol [Internet]. 2020;29:661–75. Available from: https://doi.org/10.23641/asha.
Neumann K, Mathmann P, Chadha S, Euler HA, White KR. Newborn Hearing Screening Benefits Children, but Global Disparities Persist. Vol. 11, Journal of Clinical Medicine. MDPI; 2022.
Sharma Y, Bhatt SH, Nimbalkar S, Mishra G. Non-compliance With Neonatal Hearing Screening Follow-up in Rural Western India. Indian Pediatr. 2018 Jun 1;55(6):482–4.
Sija S, Gireeshan VK, Ajith Kumar VT, Rajesh T V. Outcome of a Newborn Hearing Screening Program in a Tertiary Care Center, South India. The Journal of Early Hearing Detection and Intervention. 2022;(1):101–7.
Nishad A, Gangadhara Somayaji KS, Mithun HK, Sequeira N. A study of incidence of hearing loss in newborn, designing a protocol and methodology to detect the same in a tertiary health-care center. Indian Journal of Otology. 2020 Apr 1;26(2):85–8.
Satish HS, Anil Kumar R, Viswanatha B. Screening of Newborn Hearing at a Tertiary Care Hospital in South India. Indian Journal of Otolaryngology and Head and Neck Surgery. 2019 Nov 1;71:1383–90.
Jacob J, Kurien M, Sindhusha, Kumar P, Krishnan L. Challenges of Universal Newborn Hearing Screening in a Developing Country-a Double-Edged Sword. Indian Journal of Otolaryngology and Head & Neck Surgery [Internet]. 2022 Aug 1 [cited 2023 Aug 5];74(Suppl 1):395. Available from: /pmc/articles/PMC9411324/
Blaiser K, Edwards M, Behl D, Muñoz K. Telepractice services at Sound Beginnings at Utah State University. Volta Review [Internet]. 2012 Dec 1 [cited 2023 Jul 19];112(3). Available from: https://digitalcommons.usu.edu/comd_facpub/384
Ramkumar V, John KR, Selvakumar K, Vanaja CS, Nagarajan R, Hall JW. Cost and outcome of a community-based paediatric hearing screening programme in rural India with application of tele-audiology for follow-up diagnostic hearing assessment. Int J Audiol. 2018 Jun 3;57(6):407–14.
Saxena U, Chacko G, Kumar SBR, Nagabathula V, Damarla V, Saxena U, et al. Effect of COVID-19 on cochlear implant users: parental perspectives. Clin Arch Commun Disord [Internet]. 2021 Apr 30 [cited 2023 Jul 28];6(1):12–7. Available from: http://e-cacd.org/journal/view.php?number=113
Kim S, Roman AM, Moore A. Patient and caregiver satisfaction regarding telepractice versus in-person services at a university speech, language, and hearing clinic. Clin Arch Commun Disord. 2022 Dec 1;7(3):83–93.
Sikka K. Parent’s Perspective on Teletherapy of Pediatric Population with Speech and Language Disorder During Covid-19 Lockdown in India. Indian Journal of Otolaryngology and Head and Neck Surgery. 2023 Mar 1;75(1):14–20.

No competing interests reported.

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Pilot Implementation Outcomes of a Community-Based Tele- Practice Model for Identification and Rehabilitation of Children with Hearing loss within a Public-health system of a Rural District in Southern India

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Abstract

Background

Method

Results

Conclusion

Figures

BACKGROUND

Insert Fig. 1 -Comprehensive Tele-practice model

METHOD

Study site

Study subjects

Sample for tele-diagnostic evaluation

Sample for tele-rehabilitation

Procedure

Step 2: Tele-diagnostic audiological testing

Patient site set-up

Insert Fig. 2

Set-up at the audiologist site

Testing method

Step 3: Tele-rehabilitation

Step 4: Parental satisfaction with tele-practice (diagnostic and rehabilitation)

RESULTS

Tele-facilitator knowledge and skill post training

Limited- efficacy outcomes

Rate of follow-up for tele-diagnostic evaluation

Insert Additional File 7

Insert Fig. 2- Time lapse between hearing loss suspicion/screening to tele-diagnosis

Insert Fig. 3- Time lapse between hearing loss suspicion/screening to diagnosis

Rate of follow-up for tele-rehabilitation before and after the commencement of the pilot

Insert Additional File 8

Patient / caregiver satisfaction with tele-practice

Tele-audiology diagnostic service

Tele- rehabilitation services

DISCUSSION

CONCLUSION

List Of Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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