This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Medical Informatics, is properly cited. The complete bibliographic information, a link to the original publication on http://medinform.jmir.org/, as well as this copyright and license information must be included.
Hearing loss can affect approximately 15% of the pediatric population and up to 40% of the adult population. The gold standard of treatment for hearing loss is amplification of hearing thresholds by means of a hearing aid instrument. A hearing aid is an electronic device equipped with a topology of only three major components of aggregate cost. The gold standard of hearing aid fittings is face-to-face appointments in hearing aid centers, clinics, or hospitals. Telefitting encompasses the programming and adjustments of hearing aid settings remotely. Fitting hearing aids remotely is a relatively simple procedure, using minimal computer hardware and Internet access.
This project aimed to examine the feasibility and outcomes of remote hearing aid adjustments (telefitting) by assessing patient satisfaction via the Portuguese version of the Satisfaction With Amplification in Daily Life (SADL) questionnaire.
The Brazilian Portuguese version of the SADL was used in this experimental research design. Participants were randomly selected through the Rehabilitation Clinical (Espaco Reouvir) of the Otorhinolaryngology Department Medical School University of Sao Paulo. Of the 8 participants in the study, 5 were female and 3 were male, with a mean age of 71.5 years. The design consisted of two face-to-face sessions performed within 15 working days of each other. The remote assistance took place 15 days later.
The average scores from this study are above the mean scores from the original SADL normative data. These indicate a high level of satisfaction in participants who were fitted remotely.
The use of an evaluation questionnaire is a simple yet effective method to objectively assess the success of a remote fitting. Questionnaire outcomes can help hearing stakeholders improve the National Policy on Hearing Health Care in Brazil. The results of this project indicated that patient satisfaction levels of those fitted remotely were comparable to those fitted in the conventional manner, that is, face-to-face.
The prevalence of hearing loss in Brazil has been identified as 50%, specifically, individuals with permanent hearing loss of more than 41 decibels hearing level (dB HL) in the municipality of Minas Gerais [
The treatment of sensorineural hearing loss typically consists of the use of hearing aids (HA), and in cases of profound hearing loss, cochlear implants are used [
Fitting an HA demands specific technical knowledge of the electroacoustic characteristics of the device in relation to the patient’s hearing loss and, in Brazil, must be performed by an audiologist [
Diagram of a basic adjustment with digital HAs.
After receiving an HA, it is essential to monitor the patient in order to understand changes that affect the auditory system [
Cox and Alexander [
Telemedicine has evolved in many health care areas. With a greater coverage area and lower operating costs, it is fast becoming a suitable method for assessment, diagnosis, and rehabilitation of various conditions. In an early work with hearing rehabilitation through telemedicine, Wesendahl [
Some publications in diverse areas of telemedicine.
Authors | Area of science | Region | Results/ remarks | |||
Chorbev & Mihajlov [ |
Several | Macedonia | Increased the population’s access to health services, reducing costs, spread of knowledge to more distant centers | |||
Jaakkola & Loula [ |
Public Policy | Finland | Decreased transport of patients and increased access to database of patients | |||
Khaleel et al [ |
Several | United States | Blood pressure, heart rate, body temperature, blood glucose and ECG signals can be transmitted to remote centers in real time | |||
Lavanya et al [ |
Dermatology | Singapore/United States | Dermatologists believed telemedicine to be beneficial when classroom visits were not possible or were troublesome | |||
Penzel et al [ |
Management | Germany/ France/ Portugal | It was possible to establish a European network of Internet access among different clinics and other partners | |||
Schreier et al [ |
Dermatology | Austria | Telemedicine using mobile phones equipped with camera enabled personalized therapy for psoriasis patients | |||
Siddiqua & Awal [ |
Several | Bangladesh | Telemedicine was considered a way to improve the quality of health services, with improved access and lower costs | |||
Shen et al [ |
Gynecology | United States | Preliminary studies have shown the effectiveness of developed systems, which improves the performance and diagnosis of breast diseases in remote areas | |||
Stoian et al [ |
Disaster management | Romania | Telemedicine provided immediate results with greater chances than traditional methods | |||
Sudhamony et al [ |
Oncology | India | Telemedicine offered great advantages in the practice of oncology as well as a decrease in the number of visits to emergency medical staff | |||
Arriaga et al [ |
Neurology | United States | Telemedicine is a viable delivery model for neurotology care delivery | |||
Audebert et al [ |
Cardiology | Germany/United States | Telemedicine recommended for the treatment of stroke | |||
Bonato [ |
Rehabilitation | United States | The emergence of new sensors attached to the body capture the activity level of patients, helping the effectiveness of pharmacological interventions more efficiently and specifically | |||
Capampangan et al [ |
Vascular | United States | The hit rate for decision conduit thrombosis in patients with acute stroke was broader with the use of telemedicine than with the use of telephone | |||
Cardoso et al [ |
Cardiology | Brazil | Public efforts are key to implementing remote distance interventions for underserved populations in Brazil | |||
Knobloch et al [ |
Reconstructive surgery | Germany | Using phone with HD camera delivers positive results in reconstructive surgery | |||
Levine & Gorman [ |
Neurology | United States | Use of computer-based technology may be integrated with the neuroradiology, among others, to take care to distant areas | |||
Mora et al [ |
Surgery | United States | Solution-based telemedicine can help in intermittent surgical services among patients and medical professionals | |||
Mucic [ |
Psychiatry | Denmark | Patients preferred and recommended the use of telepsychiatry instead of psychiatry face-to-face with interpreters | |||
Sacco et al [ |
Neurology | Italy | Patients with subarachnoid hemorrhage require the implementation of telemedicine in rural areas to minimize the high incidence of mortality |
With regard to telemedicine nationally, a study conducted by the University of Sao Paulo described the effectiveness of video conferencing for transmitting video-laryngoscopic images [
A study of remote HA fittings [
The National Policy on Hearing Health Care in Brazil was established through Ordinance #2.073/04 GM (September 2004). Ordinance #402 (February 2010) of the Ministry of Health established the program nationwide (ie, Brazil Telehealth). Telemedicine in a structured format has aimed to quantify how to expand and strengthen strategies in family health. The Brazilian Federal Board of Audiology issued Resolution #366 (April 2009) that defined the lawful exercise of Telehealth in audiology with the use of information technology in order to “assist, promote education and conduct health research”. According to official data, the government has become the largest purchaser of HAs in Brazil, as shown in
Investments in hearing health in Brazil (Ordinance #587 and #589).
Year | Total importation of HAs, units | Total purchases of HAs by the federal government, units | Percentage of purchases of HAs by the federal government, % |
2005 | 169,575 | 113,983 | 67 |
2006 | 183,707 | 104,059 | 57 |
2007 | 214,310 | 134,194 | 57 |
2008 | 272,690 | 183,703 | 63 |
2009 | 280,578 | 184,646 | 66 |
2010 | 301,315 | 212,477 | 71 |
2011a | 331,645 | 225,331 | 68 |
2012a | 334,613 | 220,250 | 66 |
2013a | 402,497 | 277,723 | 69 |
aProjection due to lack of official data.
Ordinance SAS/MS #58 specifies that HAs must be dispensed through centers accredited by the Unified Health System (SUS), where professionals must “perform diagnosis and rehabilitation of hearing loss in all age groups spanning neonates to geriatrics, and perform consulting ENT, neurological, pediatric audiological evaluation”. Additionally, they must “ensure rehabilitation through clinical treatment in otolaryngology; selection, fitting and provision of an HA and speech therapy”. The Ministry of Health has a list of 139 accredited centers to serve the population, which was 190,732,694 inhabitants divided into 8,514,876,599 km2, according to the 2010 census.
Our research describes a pilot study conducted with 8 patients fitted remotely through telemedicine, using the Brazilian Portuguese version of the SADL as a tool for measuring subjective satisfaction, with the goal of improving hearing health policies in Brazil.
This research protocol was approved by the Ethics Committee for Analysis of Research Projects under #0293/11. The data collection was completed between June and October 2012.
The Brazilian Portuguese version of the SADL was used (see
Additionally, Question 3 required a change as hearing aids were provided free of charge. The original question “Are you convinced that obtaining your hearing aids was in your best interests?” was changed to “Are you convinced that the received devices was the best option?” The documents used in this research are presented in
Study documents.
Document | Model | Version |
Consent form | FMUSP | V 1.2 |
SADL questionnaire | Standard | Brazilian Portuguese |
Terms and agreement of HA donation | TD | V 1.0 |
The Windows operating system was used for the data collection in this study because it has a large set of commercial applications available and is the largest PC platform used in Brazil. A broadband Internet connection was provided by the specialized unit (SU) and the remote unit (RU). The SU had a trained audiologist, who provided support and scientific training for the audiologist at the RU, thus acting as a facilitator.
The digital HAs donated and used this study were developed by researchers at the Medical School University of Sao Paulo, manufactured by Politec Saude (
Study equipment.
Description | Model | Manufacturer | Location |
Notebook | Vostro 3500 | Dell | SU |
Notebook | Vostro 1510 | Dell | RU |
Hearing aid interface | HI-PRO | GN ReSound | RU |
Router | 78-0454ARB | GTS | SU |
Router | ADSLCPE | ZTE | RU |
Headphone | HT-301MV | Wasta | SU/RU |
Web cam | 1270 | NAa | RU |
Speakers | ND | FlexPc | RU |
aVostro 3500 Notebook has a built-in Web camera.
Study applications and operating systems.
Name | Description | Version | Location |
easyFIT | Hearing aids fitting | 5.8.3.0 | SU |
TeamViewer | Remote access, VoIPa | 7.0.14563 | SU/RU |
Medidor de velocidade de Internet | Internet speed meter on line | Full version | SU/RU |
Operational system 32 bits | Windows 7 | Professional | SU |
Operational system 64 bits | Windows 7 | Professional, Pack 3 | RU |
aVoIP: Voice over Internet Protocol. We chose VoIP by TeamViewer GmbH because it (1) had a free non-commercial version, (2) had compatible remote access, (3) allowed for message and file sharing, (3) allowed for recording sessions, (4) had a Portuguese version, (5) allowed adjustment of the microphone sensitivity, and (6) required minimal PC hardware requirements.
Participants were randomly selected through the Rehabilitation Clinical (Espaco Reouvir) of the Otorhinolaryngology Department Medical School University of Sao Paulo based on the following criteria: (1) male and female individuals aged between 18 and 90 years, (2) with either no obstruction of the external auditory canal or middle ear pathology, or an absence of any neurological or psychological impairment, (3) individuals with no prior HA experience, (4) bilateral sensorineural hearing loss of varying degrees (ie, mild, moderate, moderate-severe), (5) postlingual hearing loss, and (6) native Brazilians.
It was important to include participants with no prior experience with HAs as long-term fitted subjects would have had difficulty answering Question 10 of the SADL, which relates to amplification. Furthermore, participants with no prior experience of amplification could make a judgment based solely on the amplification fitted in this study.
Summary of participant data
Name (abbreviation) | Gender | Age (years) | Distance between home and remote unit (miles/km) |
RRS | Female | 83 | 3/4.8 |
APS | Male | 85 | 14/22.5 |
FRO | Male | 73 | 7/11.2 |
MCS | Female | 56 | 9/14.5 |
GPS | Male | 90 | 3/4.8 |
RNS | Female | 48 | 8/12.8 |
NLSN | Female | 59 | 12/19.3 |
MEC | Female | 79 | 9/14.5 |
We used an experimental research design. The following procedures were done face-to-face with the participants: (1) interview and otoscopy by otolaryngologist, (2) impedance and audiological measurements by audiologist, (3) agreement between patient and professional on the HA fitting, (4) earmold impressions, and (5) initial programming procedures with patient.
The following elements were remote (telefitting): (1) presence of an audiologist in RU, (2) presence of an audiologist in the SU (as the facilitator), (3) remote aid adjustments and changes to fitting data based on patient audiogram and subjective feedback, and (4) verification of patient satisfaction using the SADL questionnaire.
The SADL questionnaire was used as an interview schedule, that is, read aloud and completed by a trained interviewer for this purpose. The sessions were described as face-to-face (F) and remote assistance (R). There were two face-to-face sessions (F1 and F2) done within 15 working days of each other. The remote assistance (R) was 15 days after F2. This 15-day delay was justified so that patients would have adequate time and experience with the device and thus be able to respond accordingly to the SADL. At F1, patients agreed and signed the informed Consent Form (Chart 7). In the initial fitting sessions, the HAs were programmed through the easyFIT application, and the SU audiologist provided the necessary guidance to the patient. The face-to-face sessions followed the basic scheme described in
The SU had an audiologist trained to fit the HA Mini Retro C through easyFIT while the audiologist at RU had no specific training for the Mini Retro C, nor for easyFIT. Both units were supervised by an otologist, while 2 information technology professionals offered the technological support, one for each side.
For the remote (telefitting) sessions (
The SU audiologist then remotely accessed the fitting application easyFIT and began procedures to check the HA settings. The patients were questioned subjectively about various aspects of their HA usage, which allowed the audiologist at SU to make adjustments remotely. In all cases, adjustments were required. Remotely, the SU audiologist recorded the new settings in the HAs and updated patient information in easyFIT. Additionally, situational/environmental advice was provided to the patient remotely before the SU audiologist ended their interaction with the patient.
Finally, the RU audiologist administered the SADL. The methodology of the questionnaire was explained, and each question was read aloud. This allowed for participants with poor literacy to fully understand all questions posed. Frequent pauses and repetitions were allowed for so that the patient had time to think about the answers. The session ended with the signing of Terms of Donation (TD - Chart 7) of HAs, again read aloud, so that patients with poor literacy were made aware of issues around the need to service HA quarterly from the date of signing the TD, as well as warranty periods, etc.
Basic scheme in telefitting session.
In the initial telefitting session on September 18, 2012, 30 random measurements of Internet speed between the SU and RU were conducted (
The results of the SADL from this study compared to four other studies are provided in
Internet speed in the specialized unit and the remote unit measured on September 18, 2012.
Parameters | RU | SU | ||||
Lowest | Highest | Average | Lowest | Highest | Average | |
Downloada (kbpsb) | 1521 | 4025 | 2842 | 9269 | 12,779 | 11,935 |
Uploadc (kbps) | 552 | 2554 | 1820 | 7496 | 11,160 | 9910 |
Pingd (mse) | 34.4 | 95.6 | 58.5 | 4.2 | 11.5 | 7.3 |
aDownload: speed (kbps) to download a particular file server.
bkbps: kilobyte per second = 1000 bits/ second; the digital signal transmission rate.
cUpload: speed (kbps) to load a particular file server.
dPing: latency; the time (ms) necessary to test connectivity between information technology devices.
ems: millisecond = 0.001 second.
Summary of responses of patients to the SADLa.
Patients | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 |
RRS | G | A | G | A | B | G | A | G | G | G | A | G | A |
APS | G | A | G | A | G | G | A | G | G | G | G | G | A |
FRO | G | A | F | A | G | G | A | F | G | F | F | G | F |
MCS | G | F | G | B | E | G | A | G | G | G | D | G | A |
GPS | G | A | G | G | G | G | A | G | G | E | E | G | A |
RNS | G | A | G | A | G | G | A | G | G | E | G | G | A |
NLSN | G | A | G | E | G | G | A | G | G | F | G | G | A |
MEC | F | A | G | A | F | F | A | F | F | D | E | G | A |
aA=not at all, B=a little, C=somewhat, D=medium, E=considerably, F=greatly, G=tremendously; see
Results of our SADL compared with four other works (mean score and SD).
Factors | Cox and Alexander [ |
Danieli et al [ |
Mondelli et al [ |
Farias and Russo [ |
Our research (2012) |
Positive effects | 4.9 (1.3) | 5.1 (1.3) | 6.5 (0.5) | 6.2 (0.8) | 6.5 (0.4) |
Negative features | 3.6 (1.4) | 4.5 (1.7) | 6.3 (0.9) | 6.2 (1.0) | 6.2 (1.0) |
Service and cost | 4.7 (1.2) | 5.5 (0.8) | 4.7 (1.5) | 6.7 (0.6) | 7.0 (0.0) |
Personal image | 5.6 (1.1) | 5.9 (0.9) | 5.4 (1.6) | 6.7 (0.4) | 6.4 (0.7) |
Average | 4.7 (1.3) | 5.2 (1.2) | 5.7 (1.1) | 6.4 (0.5) | 6.5 (0.5) |
aThese authors presented a two-decimal precision of measurement, here rounded to only one decimal for purposes of comparison, according to National Center for Education Statistics NCES Standard: 5-3.
bThese authors separated the results according to gender of patients. The results presented here are those of the larger group (males), although the gender difference is minimal.
Telefitting can help improve hearing health policies in Brazil by gradually expanding the current 139 accredited centers to centers closer to patients’ homes as Basic Services Units, or health clinics, so the patient can receive adjustments to their HAs in their homes, with greater comfort and a greater chance of success in hearing rehabilitation. The participants in our study had a mean age of 71.5 years and had to travel an average of 8 miles (12.8 km) from home to RU.
Despite missing official data, it is possible to speculate that all the government-run health centers have at least one PC and probably an Internet account, which highlights the possibility of performing telefitting supported by an SU. There are 537 Basic Services Units (ambulatory level) throughout the city of Sao Paulo alone. Furthermore, it may not be necessary to have the hardware component HI-PRO, since it could be replaced by an application installed over the Internet. A universal programming cable for all HA manufacturers could be used instead of standard cables for a particular manufacturer. In general, most clinics have to operate with a large number of programming cables for various manufacturers.
The 2010 Brazilian Census reports that between 2005 and 2008, Internet access increased by 75.3% or 56 million users, due to various factors such as PCs and notebooks as well as high-speed Internet connections being more accessible and available at a lower cost. These factors, combined with other applications, can promote the use of telemedicine. Swanepoel et al [
In this study, applications and user-level information technology were used, which although limited, allowed for the fitting of HAs in 8 patients. Nevertheless, if more advanced technology were used (eg, application-specific videoconferencing), the possibility of conducting real-time orthoscopic reviews would be increased. In addition, traffic-encrypted data over the Internet, access from other accredited PCs on the network, as well as integration with other applications, would ensure that management costs are kept to a minimum. There would also be a reduced number of patient visits to the clinic and a database of valuable patient information to allow for remote HA adjustments.
In a more comprehensive telemedicine approach, it would be beneficial to include video training for the audiologist, as well as detailed training on the equipment and troubleshooting for complex fittings. An online tutor can assist in immediate cases (eg, when the audiologist at RU has doubts or is not familiar with fitting HAs), while full online courses on anatomy and physiology of hearing, interpreting audiometry, among others may be available.
Other questionnaires that could be used include the IOI-HA questionnaire, adapted to Brazilian Portuguese. It consists of seven questions, with a closed set of five different responses, and is thus easier to apply compared with SADL. The HHIE adapted to Brazilian Portuguese is structured into 25 questions, with a closed set of three possible answers on which Aiello et al [
One can standardize the application of a satisfaction questionnaire, after the initial HA fitting and before the end of the warranty period. Thus, two questionnaires could record satisfaction levels at two significant times in the hearing rehabilitation process.
This study was one of the first of its kind with regard to adjusting HA settings via the Internet in Brazil. Furthermore, it creates a baseline for future research in this area of remote audiology and telefitting. However, our sample size of participants was small and within a limited geographical area. In addition, a limited number of applications were utilized.
In this study, certain applications and features were used to perform remote adjustments and fitting of HAs in 8 patients without injury. In the more comprehensive telemedicine approach, it would be necessary for the RU audiologist to have additional training and support. Further studies with a larger sample population should be conducted to explore the reproducibility of the results recorded here.
For implementation and public policy, we recommend the Windows platform be replaced by an open platform (eg, Linux, Ubuntu, Android) in order to reduce costs and promote the development of local solutions. The Internet services should ideally be linked to attributes such as stability, availability, speed, absence of risk, and confidentiality of patient data must be protected.
Furthermore, investigations conducted with the Brazilian Portuguese version of IOI-HA and APHAB questionnaires may be valuable. Although recording patient satisfaction through questionnaires provides valuable information about the use of HAs, the information derived is not entirely sufficient to assess the quality of overall hearing health. Bevilacqua et al [
A key step is to monitor satisfaction with technical issues by use of key performance indicators described by Kaplan and Norton [
Remote HA adjustments (telefitting) have proved effective for these 8 patients, as indicated by their dynamic responses in SADL. Results were comparable to those of patients fitted in the conventional manner (ie, face-to-face fittings). Thus, the use of telefitting can be seen as an effective method to improve service delivery of hearing health in Brazil.
Brazilian Portuguese version of the SADL.
Mini Retro C Datasheet.
The SADL normative data.
Abbreviated Profile of Hearing Aid Benefit
behind the ear
hearing aid
Hearing Inventory for Elderly
International Outcome Inventory for Hearing Aids
personal computer
remote unit
Satisfaction with Amplification in Daily Life
specialized unit
Unified Health System
universal serial bus
This work was supported by the Otorhinolaryngology Foundation.
None declared.