Keywords
humanitarian - Peru - hearing health care - sustainability - best practice
A sustainable health care system including hearing health care is something typically
accessible within the United States and other developed high-income countries. At
times patients may have to wait longer than they would prefer to see physicians or
specialists or pay more than anticipated for services; however, for all intents and
purposes, the option of health care, specifically hearing health care, is readily
available. In contrast, what if general health care was not accessible and specialty
care was not even an option? Patients in less developed countries experience this
on a day-to-day basis. For example, when a child or an adult develops an ear infection
in a remote village in Peru, patients and caregivers have very limited avenues to
seek out medical help. Home remedies may be administered or traditional medicine of
the culture may be searched out and used when modern medical treatment is not available.
However, research[1]
[2] has shown chronic middle ear dysfunction, when left untreated or without proper
monitoring, can lead to permanent hearing loss and other complications. Modern intervention
would dictate a child with hearing loss, acquired or congenital, would be fit with
amplification within weeks, if not days, after diagnosis in the United States when
audiologically appropriate. Early intervention is essential and would begin immediately
to avoid a delay in communication development. In contrast, this is not the typical
intervention pathway for children who experience middle ear dysfunction and other
audiological ailments in villages of countries that are less developed. Congenital
hearing loss is being undiagnosed and conditions that cause acquired hearing loss
are being untreated in both children and adults, greatly affecting hearing outcomes.
Background
International humanitarian programs are one way for individuals within low-income
countries to access hearing health care. As reported by Stringer,[3] the traditional model for international humanitarian programs is for foreign professionals
to travel to a country with minimal resources for a short period of time, volunteer
their expertise in providing direct services, and temporarily alleviate health care
needs in a specific community. However, this model is not sustainable as hearing health
care is an ongoing need especially when amplification and other technologies are utilized
for intervention. Sustainability is possible for humanitarian programs; however, it
may not look the same for each international community. To create a sustainable humanitarian
program, groups must connect with local communities, communicate with all stakeholders,
learn from past experience, and build the program based on the needs of the patients
and the community requiring hearing health care.
Faculty and students from the Idaho State University (ISU) Audiology Program have
traveled to several locations within less developed countries over the past 15 years.
Most recently, the ISU Audiology Program has partnered with Idaho Condor Humanitarian
to provide hearing health care services to the Peruvian indigenous population. Idaho
Condor Humanitarian is a nonprofit organization based in Pocatello, Idaho. ISU Audiology
has traveled with Idaho Condor Humanitarian for the past 4 years with a goal of providing
the best possible audiological care and creating sustainable hearing health care for
the population served. However, creating sustainable hearing health care in an area
that has little to no access to medical care is a difficult task. One thing that can
be used to help establish sustainability is past experience. Faculty at ISU have gained
this experience while participating in medical expeditions which provided audiological
services in Guatemala, Uganda, and Ecuador.
Past Experience
Guatemala. The experience in Guatemala was with a well-established and highly organized international
medical expedition group. Since 2003, this medical group and an audiology team traveled
annually to the urban town of Antigua, Guatemala. Services are provided from a local
hospital. Additionally, other humanitarian groups visit this location annually. Essential
hearing health care is provided by trained audiological providers at least twice a
year at this location. The audiology clinic within the Guatemalan hospital includes
a quiet location with a sound-treated room, permanent audiology equipment, trained
onsite staff, and maintained medical files. Additionally, local hospital staff and
volunteers have been trained to help with amplification troubleshooting, schedule
biannual appointments for established patients, and identifying individuals within
the community in need of hearing health care.
The sustainable program started as most humanitarian programs do, with an initial
evaluation of health service needs within the community. With donations of equipment,
volunteers, space, and time, the permanent audiology clinic was established over several
years. This would be an excellent model for sustainability; however, this model does
not fit the needs of Peru. In Peru, the medical expedition moves to different villages
each day over a period of a week. Each year, new villages are selected for the expedition
and only occasionally the expedition returns to a previous village. Therefore, the
experience gained during the Guatemala medical expedition demonstrates one way of
creating sustainability; however, it is not a model that can be applied currently
in Peru.
Uganda. The experience in Uganda was limited to one medical expedition traveling to an orphanage
outside the capital city of Kampala. The medical expedition had established a good
and presumably feasible goal: screen each child to determine who required further
audiological evaluation. However, once on site, the group quickly learned that the
goals of the expedition were not aligned with the primary needs of the staff and children
at the orphanage. Although hearing health care was a need for many children at the
Uganda orphanage, it was not the highest priority. At the time of the medical expedition,
the children were also completing end of year examinations. Good performance on the
examinations was required for students to continue their education, which naturally
made attending class a priority. Students did not want to leave class for extended
periods to have a hearing evaluation, or return to the clinic for intervention. This
experience highlighted the need for extensive, preexpedition communication with all
stakeholders, especially the intended population to be served. Over the course of
5 days, 138 hearing screenings and 16 full audiological evaluations were completed.
Cerumen management was provided to 35 individuals and one hearing aid was fit. Plans
were made to return to the Ugandan orphanage; however, due to the instability of the
government at that time, the return trip was canceled.
Ecuador. The experience in Ecuador encompassed one successful expedition with a well-established
and organized international expedition group. The medical and audiology team traveled
to Ambato, Ecuador, and provided services in the local municipal hospital. Over a
period of 5 days, 135 hearing evaluations were performed and 48 hearing aids were
fit. In an effort to create sustainability, the audiology team prepared for a second
expedition the following year. As the return trip was in the planning stages, the
Ecuador government determined medical expeditions were not in the best interest of
the country. The government would not allow the group to return. This experience again
highlighted the need for international groups to work with all stakeholders, including
the government of the intended humanitarian expedition country.
Peruvian Health Care System
Peruvian Health Care System
The total population of Peru in 2018 was estimated at just over 31 million with close
to 78% of citizens residing in an urban city. The remaining 22% lived in rural communities
and had limited access to modern health care.[4] In 2002, the Peruvian government created the Coordinated Decentralized National
Health System in an effort to work toward providing comprehensive health care to all
Peruvians. According to the Pan American Health Organization[5] (PAHO) “The health system is structured according to a pluralistic model, with both
public and private service providers, and is organized by specialized functions.”
In 2015, the PAHO[5] estimated the ratio of health care providers to citizens was only 17.6 per 10,000
persons in rural areas. Many of the Peruvian citizens residing in rural environments
receive comprehensive health insurance through Seguro Integral de Salud. According
to PAHO,[5] “Seguro de Salud provides health care to the poor and extremely poor population
through the Ministry of Health's network of services. Members receive the services
covered under the Essential Health Insurance Plan, together with some additional benefits
covered through a special solidarity fund for the treatment of cancer and other high-cost
diseases.” However, the individuals in these rural villages often live hours away
from the nearest health care facility and have limited options for transportation.
As with any aging population, hearing health care remains a significant need. The
PAHO[5] states, “Between 2000 and 2015, the population over 64 years of age grew from 1,235,855
(4.8%) to 2,043,348 (6.6%) of the total population… and life expectancy at birth rose
from 70.5 to 74.1 years. In the latter year, 80.8% of older women and 68.0% of older
men had some type of chronic health condition, and 45.8% had some type of disability….
Difficulties in the use of arms and legs (33.3%) and impairments of vision (13.4%)
and hearing (13.4%) were the leading forms of disability.”
However, aging is not the only cause of hearing loss in Peruvian citizens. The PAHO[5] reported, “In 2015, the Ministry of Labor received 435 reports of occupational diseases,
of which 26% were related to noise-induced hearing loss or deafness. That same year,
the Ministry of Energy and Mines received 6,708 reports of occupational diseases related
to mining, of which noise-induced hearing loss or deafness accounted for 95.2%.” Additionally,
limited access to health care often results in untreated infections of the outer and/or
middle ear.[6] This could result in fluctuating temporary or permanent hearing loss for both children
and adults. In addition, there is no universal newborn hearing screening program in
Peru and children born with hearing loss are often not identified until later in life.
Based on the ISU Audiology team's expeditions to Peru and a search of online medical
clinics, there are limited options for hearing health care. The capital, and largest
city in Peru, Lima, has a hospital that provides audiologic services including cochlear
implants; however, reaching that hospital would require a minimum of 24-hour bus ride
one way from most of the villages that surround Cusco. A handful of otorhinolaryngology
specialists and hearing aid dispensers have clinics in Cusco; however, this would
still require a 2- to 3-hour trip for most individuals residing in surrounding villages
where transportation options are not easily accessible.
Another aspect of Peruvian culture that guides provision of hearing health care on
medical expeditions is the strong family bonds and loyalty to caring for elderly family
members. Family is one of the most important and sacred aspects of the Peruvian culture.[7] As a result, approximately 50% of people in Peru live with extended families. Over
the past 4 years, ISU Audiology has observed this first hand, when young adults bring
their elderly parents or grandparents to audiology clinics. They request their elderly
family members receive services above their own needs. This emphasizes the loyalty
to caring for elderly family members.
Current Experience: Idaho Condor Humanitarian
Current Experience: Idaho Condor Humanitarian
Idaho Condor Humanitarian,[8] a well-established nonprofit organization, travels to Cusco, Peru, and surrounding
villages to provide medical, dental, surgical, and audiological services. According
to their Web site,[8] “Idaho Condor Humanitarian, Inc. is a national non-profit organization dedicated
to providing cost-free medical care to the indigent of Peru. The organization is built
on the idea that a collective of caring people can affect positive changes on individuals,
communities and nations.”
Member of the Idaho Condor Humanitarian group have been traveling to Peru for the
past 10 years. Each year, a team of health care professionals, interpreters, and student
volunteers trek to remote villages to create temporary clinics. Although Idaho Condor
Humanitarian is an American-based nonprofit organization, it works closely with local
Peruvian physicians to determine which villages are in need of additional health care.
The Peruvian physicians also help maintain good public relations between the citizens
of Peru and the humanitarian expedition. For example, the Peruvian physicians will
meet with the Mayor of each village to discuss the services offered by the medical
expedition and obtain permission to come to the village. Idaho Condor Humanitarian
also works closely with other government officials to seek the necessary approvals
for traveling in-country for the purpose of providing medical services. The local
government will then announce the dates of the expedition and each village that will
be visited. As a result, some individuals will travel from surrounding areas hours
away to come to a village where Idaho Condor Humanitarian is providing services. The
Seguro Integral de Salud is also provided information regarding the expedition and
may refer patients to come see the “American doctors.” Over the past 10 years, Idaho
Condor Humanitarian has maintained an outstanding track record of caring for the citizens
of Peru, while respecting the customs and traditions, and involving local officials
when planning each expedition.
In 2016, Idaho Condor Humanitarian invited faculty and students from the ISU Audiology
Program to participate in their annual expedition. Two audiologists and a third-year
audiology graduate student set out to establish the need for audiology services and
to lay the foundation for future trips. Along with medical and dental professionals,
the audiology team traveled to six different villages and provided hearing health
care services to approximately 159 people. Audiology services included otoscopy, tympanometry,
cerumen removal, and minimal hearing screenings due to limited access to quiet-test
environments in each village. Even though hearing aids were unable to be fit on this
inaugural trip, the need for amplification was evident.
ISU Audiology was invited to return for the 2017 expedition. The team consisted of
two audiologists, three graduate students, and one volunteer. The team provided much
needed hearing health care as well as fit 25 hearing aids. Even though hearing aid
orientation was covered and a 1-year supply of batteries was provided, the audiology
team recognized that follow-up care was necessary, but unavailable. Creating a plan
for follow-up care, particularly for individuals receiving a hearing aid, was the
primary focus for future expeditions.
ISU Audiology recently completed their fourth expedition to Peru with Idaho Condor
Humanitarian. The team consisted of four audiologists and three graduate students.
Each year, the team gathers data on the hearing health care needs of the Peruvian
people and fits donated hearing aids. The team has identified and prioritized specific
needs of the people served as well as initiated a plan for continuing to develop follow-up
care and sustainability.
Student involvement. The goal as university faculty and audiologists is to expose students to working
in less-than-ideal environments with limited resources. A goal to foster cultural
awareness, interprofessional collaboration, critical thinking, and an attitude of
service was also put in place. One of the audiology students who volunteered during
an expedition summarized her experience as follows[9]:
This experience was life changing for me—as a student and as a future clinician. I
learned what it was like to work under limited conditions, often with no running water,
limited electricity, and only the supplies we could carry on an airplane. It really
showed me how much good can be accomplished with determination, ingenuity, and a good
base of audiological knowledge. We made do with what we had, and most importantly,
provided care to individuals who needed it.
Student involvement is important in our humanitarian work; however, it also creates
its own challenges. Supervising students of varying levels of experience is difficult
in a fast-paced remote clinic. Students who may feel confident in a university clinic
may be unsure of this new role and responsibility when the clinic suddenly becomes
a room with a simple desk and chair, no sound booth, no clean surface, and no electricity.
Close supervision is necessary, as the primary goal always remains to provide the
best care to the patients, whether in Idaho or in Peru. Typically, students become
more confident throughout each clinic day, and by the end of the week they are “creating”
our clinic space with ease, setting up each workstation, and interacting comfortably
with our patients. By the end of the expedition, our students have gained valuable
experience related to cultural awareness, critical thinking, flexibility, creativity,
and interprofessional collaboration.
Idaho Condor Humanitarian expeditions include a variety of other medical professionals
and our collaboration with these providers is crucial. We are conscientious to follow
the appropriate line of care when a potential medically treatable problem is identified.
One of the advantages of sharing the clinic space with the full medical team is that
a consult with another provider is just a few steps away. Recruiting an otolaryngologist
or other ear, nose, and throat (ENT) specialty provider, possibly a physician assistant,
has become a future goal due to the high number of middle ear diseases and other pathological
conditions encountered during each trip.
Audiology Best Practice in Peru
Audiology Best Practice in Peru
Audiologists are obligated to provide the best possible hearing health care services
using the guidelines set forth by the national organizations.[10]
[11] The professional practice guidelines or best practices help hearing health care
providers use the appropriate procedures for the diagnosis and treatment of hearing
and vestibular disorders in accordance with evidence-based practices. When providing
audiologic care within the United States, the professional practice guidelines are
easy to follow and allow the provider to optimize patient outcomes. Typically, each
audiologist has the resources needed to perform and provide evidenced-based, quality
patient care. However, when traveling to other areas of the world, audiologists may
not have the resources needed to provide the same standard of care. For example, the
audiologic assessment may not be completed in a sound-treated room and the audiologist
must choose the quietest place possible to obtain the necessary audiometric information.
Furthermore, portions of the basic assessment, bone conduction and speech testing,
are eliminated due to the testing environment. This creates challenges since the type
of hearing loss and other factors needed to adequately treat the patient remain unknown.
This is only one example of how best practices are modified when resources are limited.
On each expedition, the ISU Audiology team navigates a variety of barriers associated
with limited resources to provide quality hearing health care for the people of Peru.
Expedition preparation. To overcome the limitations while keeping best practices in mind, the audiology team
prepares and plans extensively for the expedition. Adequate preparation allows the
providers to consider the potential problems and devise solutions prior to arriving
in-country. For example, irrigation is one strategy used during cerumen management;
however, the running water available at each village is cold and would be uncomfortable
for the patient. Instead of utilizing cold water for irrigation, the audiology team
packs an insulated bag to transport hot water from the hotel to the village every
day. When the need for cerumen management arises, the hot water is adjusted to the
appropriate temperature. In addition, packing lists and inventory spreadsheets have
been crucial components of the preparation phase that ensure the team is adequately
prepared for each expedition.
Documentation. Another limitation to providing best practices is the ability to document and track
patient data. Over the last 4 years, the audiology team has modified and streamlined
the documentation process. Prior to 2019, spreadsheets were used to record the procedures
performed, test results, and treatment provided for each patient. This tracking system
was inefficient, difficult to use, and time consuming. For the most recent expedition,
a new documentation and tracking system was implemented. Basic patient information
and audiologic results were documented through a survey program created within Qualtrics
and allowed documentation to be completed through the corresponding Qualtrics application
on any team member's cellular phone or tablet. Each day, the information was gathered
through the offline feature of the application and then uploaded at the end of the
day once Wi-Fi was available. Using this method, the process was streamlined for accuracy
and efficiency.
Otoscopy. Completing otoscopy is within the scope of practice for an audiologist and is a necessary
component of the assessment process. This allows the audiologist or audiology student
to examine the outer ear, ear canal, and tympanic membrane. Professional practice
guidelines serve as a guideline for the outer ear exam during each expedition to Peru.
In this case and with careful preparation, the audiology team has all the resources
needed to follow the best practice guidelines. Each provider packs and uses standard
otoscopes, while at least three video otoscopes are also available for use during
the clinic days. All providers follow strict infection control policies and procedures.
Otoscopy is completed on all patients seen by the team with the exception of a few
children and those with microtia or complete atresia.
For the 2019 expedition, the audiology team completed an otoscopic examination on
459 ears. A total of 94 ears were identified as partially occluded or occluded with
cerumen. Along with the occluded ears, other pathological conditions were noted. Many
individuals had scarring, cloudy eardrums, retraction pockets, and perforations. Others
had more serious conditions such as drainage, fungus, foreign objects, granulated
tissue, infection, and possible cholesteatomas. When a serious condition was identified,
the patient was referred immediately to the medical team for evaluation and treatment.
In addition, an in-country ENT specialty physician referral was provided to those
who needed specialized otologic care. [Fig. 1] depicts pictures captured using a video otoscope. The pictures display a few of
the pathological conditions seen throughout the expedition. Out of all of the pathologies
present, perforations were the most common pathology noted.
Figure 1 Pathologic conditions captured with a video otoscope during the 2019 medical expedition.
Tympanometry
Tympanometry is an objective measure to assess middle ear function and is an important
feature of the evaluation process. Tympanometry helps identify any potential pathological
conditions relating to the outer ear, eardrum, and middle ear. When used in conjunction
with otoscopy, it is possible to accurately identify perforations, cerumen occlusion,
and middle ear disease. Similar to otoscopy, tympanometry is performed on each patient
unless there are extenuating circumstances such as atresia or patient refusal.
Each year, an Interacoustics Titan is used to provide a diagnostic assessment of middle
ear function. Most patients seen in 2019 had normal middle ear function in both ears;
however, several patients had abnormal results. [Fig. 2] shows the specific tympanometric types collected over a 2-year span. When compared
with the previous data, there is a high percentage of patients who have normal middle
ear function or stiff middle ear systems. It is uncertain as to the cause of the tympanograms.
Equipment limitations in relation to the high altitude may be a contributing factor;
however, further exploration is needed on this topic. Patients who have flat tympanograms
are either referred to the medical team or to an ENT in Cusco depending on the information
gained from otoscopy and case history.
Figure 2 Types of tympanograms collected over a 2-year span, 2018–2019.
Cerumen removal. In the United States, it is within the scope of practice in most states to remove
cerumen for the purposes of evaluation, custom earmold impressions, and the treatment
of hearing loss. Three main strategies are utilized to remove cerumen: irrigation,
manipulation, and suction. The audiologist must choose the best strategy or combination
of strategies for safe and successful removal. The strategy used depends on the consistency
of cerumen. In some cases, the wax is impacted with a solid consistency and an over-the-counter
solution, such as carbamide peroxide, may be necessary to soften the wax prior to
removal. Audiologists should have over-the-counter products, such as oxymetazoline,
available to stop bleeding if needed. Finally, strict infection control protocols
are followed to prevent the spread of harmful pathogens. All reusable tools are cleaned,
decontaminated, and disinfected prior to use on another patient and all tools are
cleaned in an ultrasonic system with a disinfectant cleaner at the end of the day.
While in Peru, best practices for cerumen removal are followed and tympanometry is
always conducted prior to removal regardless of the strategy used. On the most recent
expedition, wax removal was needed in 94 ears and was removed successfully in the
majority of cases. In those individuals in whom the wax could not be fully removed,
over-the-counter wax softeners and flushing bulbs were provided with instructions.
If possible ear pathology was noted after cerumen management, the patient was referred
to the medical team for evaluation and treatment. The number of patients in need of
cerumen removal has increased over the last 4 years. This may be due to an increase
in the number of patients seen each year and the villages' awareness of the audiologic
services provided. [Fig. 3] illustrates changes in cerumen management over the last 4 years.
Figure 3 The changes in cerumen management provided during the medical expedition from 2016
to 2019.
Distortion product otoacoustic emissions. Distortion product otoacoustic emissions are a useful tool for evaluating cochlear
function. When in Peru, the Interacoustics Titan is used to assess outer hair cell
function in younger patients or those who cannot perform standard behavioral testing.
A standard diagnostic protocol is used while in Peru.
Behavioral audiometry. Pure tone thresholds, air and bone conduction, are the gold standard for establishing
the degree, type, and configuration of a hearing loss. Within the United States, patients
are typically evaluated in a sound-treated room and are required to provide a behavioral
response when a sound is detected. When performing the hearing test, the audiologist
assesses hearing acuity for a variety of frequencies including those outside the typical
speech frequencies. Patients are encouraged to respond to all sounds no matter how
soft or how loud. The thresholds are used to determine whether or not a hearing loss
is present and helps guide the audiologist toward treatment strategies. However, while
in a less-developed country with limited resources, a hearing health care provider
must adapt to the surroundings to gather the necessary information as it relates to
hearing sensitivity. Even though the basic procedure for determining thresholds is
similar, other confounding factors may influence the results. The test environment,
equipment issues, inability to determine the type of hearing loss, language barriers,
and cultural differences all contribute to challenges experienced throughout the assessment
process. The astute audiologist must find ways to overcome each issue to obtain the
most accurate threshold information. If the room noise is too loud, hearing thresholds
are likely elevated, especially in the low frequencies. If a patient has a hearing
loss and could benefit from hearing aids, the elevated thresholds will influence the
hearing aid fitting, resulting in over amplification and reduced hearing aid benefit.
One of the most significant confounding factors identified in Peru is the test environment,
which affects threshold determination, frequencies tested, and the ability to determine
the type of hearing loss. In Peru, each day is a new experience with a new village.
Upon arrival at each village, the expedition leaders must examine the location or
building provided for the medical and dental teams. The audiology team must try to
find a quiet room or space away from noise sources. On an average day, the team contends
with patient noise from the medical team, equipment noise from the dental team, music
from a loudspeaker, and music generated from the National Police of Peru Band who
entertains the villagers while waiting for medical, dental, or audiologic care. To
compensate, the audiology team seeks a room away from the noise sources and completes
biological checks for each portable audiometer. The thresholds obtained during a biological
check are compared with the known thresholds of that audiology team member. If needed,
correction factors for each frequency are applied. Not only does the test environment
affect accurate determination of hearing thresholds but limits the frequencies that
can be tested as well. According to best practices, the audiologist should find thresholds
for 250 to 8,000 Hz including the interoctave frequencies. Testing all frequencies
is ideal but may not be possible due to the test environment encountered during each
clinic day. The lowest and highest frequencies, although useful, are typically not
evaluated and omitted from the audiogram. To compensate, the audiologist evaluates
the frequencies primarily responsible for speech understanding. Fortunately, the “speech
bananas” for English and Spanish are quite similar; however, the speech frequencies
necessary for the native Peruvian language, Quechua, are not well documented. Quechua
is the native language and also refers to the indigenous ethnic groups in South America,
especially in Peru.
A noisy test environment eliminates a valuable component of audiometric testing, bone
conduction. However, assessing bone conduction in the absence of a sound-treated room
leads to elevated thresholds and the conductive component is likely underestimated.
In Peru, bone conduction thresholds are not evaluated at this time; therefore, this
test does not assist in distinguishing between a conductive or mixed hearing loss
versus a sensorineural hearing loss. The audiology team members consider the tympanometric
results to help determine the type of hearing loss and treatment options.
Another factor that likely influences hearing thresholds is the language barrier and
cultural differences. At times, the audiologist and student question the accuracy
of the pure tone audiogram due to the instructions provided. In small villages surrounding
Cusco, two languages are spoken, Spanish and Quechua. Therefore, instructions must
be translated from English to Spanish and then Spanish to Quechua. Even though the
audiology team has a designated English to Spanish translator, it is difficult to
maintain a consistent translator who can convey the necessary information from Spanish
to Quechua. Hence, the patient may or may not respond when the tone is heard or they
may wait until it is louder prior to responding. If the patient waits to respond,
then the thresholds are elevated and inaccurate. To help solve this issue, the audiologist
uses verbal instructions as well as demonstrates the task while using a tone of sufficient
intensity. In addition, the audiologist may use a hand-over-hand approach to help
train the patient to the task. Finally, pure tone testing is not an everyday task
for the patients seen in the villages. Many villagers live in remote areas and a hearing
test is a new concept, let alone a new experience. Providing instructions in multiple
modalities and patience has proven to be the most effective method of obtaining accurate
hearing thresholds.
Despite all the factors that influence pure tone thresholds and the challenges in
obtaining accurate hearing information, the people of Peru are affected by hearing
loss and there is a need for audiologic services. Within the last 2 years, the majority
of patients reported difficulty hearing in one or both ears and, when tested, had
a measurable hearing loss that could be treated with amplification. Out of the 438
patients seen during the 2018 and 2019 expeditions, 211 participated in a hearing
test. The average pure tone thresholds for the speech frequencies indicated a mild
or greater hearing loss in one or both ears. [Fig. 4] shows the average hearing loss in the right and left ears from the data gathered
in 2019, while [Fig. 5] shows the average hearing loss from 2018. Unfortunately, the audiometric data from
2017 could not be included in the averages, as two of the audiology teams' equipment
bags were lost in Peru at the end of that expedition, both of which contained the
audiograms.
Figure 4 Average hearing loss in the right and left ears (n = 107) from the 2019 medical expedition.
Figure 5 Average hearing loss in the right and left ears (n = 104) from the 2018 medical expedition.
Fitting hearing aids. From data collected and our observations over the last 4 years, hearing loss is prevalent
and the effects of hearing loss are noticeable in each village. The patients and loved
ones report communication difficulties that affect quality of life. Family members
describe scenarios of isolation when a parent or grandparent can no longer hear or
when the hearing loss is caused by trauma or a medical condition. Many of the patients
seen during each clinic day have hearing loss in both ears and the majority could
benefit from hearing aids or other assistive listening devices. Unfortunately, only
a limited number of hearing aids are available and the team must determine who receives
a hearing aid and who does not. For most team members, this is the hardest decision
made on the expedition. Furthermore, adult patients are fit unilaterally even if a
bilateral hearing loss is present to provide amplification to as many individuals
as possible. If a pediatric patient is identified with a hearing loss and the family
is unable to travel to Cusco, he or she will be fit bilaterally.
Prior to the first clinic day, the team establishes a base criterion for fitting hearing
aids. The criterion varies significantly from the standard practices seen within the
United States and is based on the degree of hearing loss in the better ear, age, dexterity,
family support, and cognition. First, the patient must have a mild hearing loss or
greater with a pure tone average of 40 dB HL at 2000, 3000, and 4000 Hz in the better
ear to be considered a hearing aid candidate. Second, the patient's age is considered
and, finally, the patient must display adequate dexterity along with the ability to
understand the care and maintenance of the device if there is no family support. If
family support is available within the household, then a hearing aid may be considered
even in the presence of reduced dexterity and limited capability to independently
maintain the hearing aid. Although the criterion for fitting a hearing aid is less
than ideal, it is a necessary component when resources are limited.
The hearing aid selection and fitting process differs when compared with standard
practices. The patients can only be fit with the instruments available; however, the
audiologist chooses the most appropriate hearing aid to achieve maximum benefit when
considering the hearing loss and communication difficulties reported during the brief
case history. For the fitting, a custom earmold is made, if needed, and the hearing
aid is programmed to the hearing loss using the manufacturer's standalone software
on a laptop. Even though the audiology team subjectively assesses hearing aid benefit,
objective measures to verify the hearing aid fitting are unable to be performed due
to equipment issues. Subjective assessment includes a validation process using an
interview to determine hearing aid benefit perceived by the patient. Adjustments are
made depending on the initial information provided by the patient and responses to
the hearing aid benefit interview. Finally, hearing aid orientation is provided either
in a one-on-one setting or in a group using available translators. If family members
accompany the patient, they are invited and encouraged to take part in the hearing
aid orientation process. The content is typically limited to the use, care, and function
of the hearing aid as well as realistic expectations. Along with the hearing aids,
patients receive cleaning tools and a 1-year supply of batteries. [Fig. 6] shows the number of hearing aids fit within the last 3 years.
Figure 6 The number of hearing aids fit during the medical expedition from 2017 to 2019.
Follow-up and ongoing care for each hearing aid fitting, although necessary, is not
currently available and one of the many pitfalls of providing audiologic treatment
in Peru. The audiology team recognizes that follow-up care is an integral component
for hearing aid use and optimal benefit. Creating sustainability is the primary goal
of future expeditions. Furthermore, hearing aids are not the only solution or option
for providing those with hearing loss access to sound.
Due to the limited opportunities for follow-up care and some of the inherent challenges
related to traditional behind-the-ear hearing aids, other amplification options may
be beneficial for some patients. Considerations for future expeditions include bone
conduction devices and pocket talkers. Due to the high number of patients with suspected
conductive hearing loss, a softband or adhesive sticker bone conduction device could
be a viable option. This would eliminate the need for an earmold and tubing, which
often are components in need of replacement. Pocket talkers or similar hearing-assistive
technologies may be beneficial for individuals who lack the dexterity or support to
effectively use traditional hearing aids. Many of the patients who could benefit from
hearing aids have limited experience with modern technology and may be unable to troubleshoot
common issues related to traditional hearing aids. The simplicity of pocket talkers
or similar devices could still meet the listening needs of these individuals without
the complexity of more advanced technologies. Additionally, the cost for these types
of devices is significantly less than hearing aids, making it feasible to either purchase
more devices or obtain additional devices through donations.
Creating Sustainability
Over the last 4 years, audiology has become a valuable component of the Idaho Condor
Humanitarian expedition. An audiology clinic director was appointed and added as a
board member and meets with the board on a monthly basis. This allows for representation,
influence for future expeditions, and support of the audiology team's goal of sustainability.
The ISU Audiology team and Idaho Condor Humanitarian advisory board have identified
three factors that will help create sustainability and better meet the needs of the
patients. First, the team would like to select a few villages each year where the
team will return the following year. This will provide the opportunity to establish
a comprehensive follow-up clinic during the expedition. Next, the team has identified
the need to connect and communicate with local hearing health care professionals in
Cusco to discuss opportunities for collaboration. This will create pathways for follow-up
for some patients with transportation access to Cusco. Finally, key individuals within
each village will be identified and trained to provide basic follow-up care for those
who were fit with a hearing aid or other amplification device.
Conclusion
Even though there are many challenges to providing services outside the United States,
many of those challenges may be solved by adequate preparation and making good clinical
decisions while keeping the best professional practice guidelines in mind. Even with
the best planning and preparation, it is inevitable that unforeseen challenges which
need to be addressed will arise and possible preventive measures could be put in place
to avoid or reduce those challenges. If asked to define one characteristic necessary
for an audiologist interested in pursuing humanitarian work, the answer would most
likely be “flexibility.” Humanitarian expeditions usually come with limited resources,
less-than-ideal clinic environments, and language/cultural barriers. When limited
resources are available, difficult choices must be made, but keeping best practice
guidelines at the forefront of decision making will allow the audiologist to make
appropriate decisions using solid clinical judgement. By including students in this
experience, we hope to move the profession forward by modeling best practice even
in the presence of challenges. Students also help seasoned audiologists think outside
the box and come up with innovative ideas to address challenges and sustainability.
A truly sustainable humanitarian hearing health care program requires perseverance
and patience; it will not happen overnight. Although the expeditions to Peru may still
not be considered fully sustainable, they have each provided the framework and necessary
pieces to continue building a sustainable program. At times, the path to best practice
and sustainability for a humanitarian program may look different from what is used
in the United States; however, they are achievable with the right mindset and support.
