Feasibility of hearing aid service-delivery in low- and middle-income communities

The majority of individuals affected by hearing loss reside in low- and middle-income (LMI) settings where access to hearing healthcare is limited. The World Health Organization (WHO) recommends task-sharing among community healthcare workers (CHWs) and professionals, including audiologists and ENTs, to improve access in LMI settings. This study evaluates the feasibility of a WHO-recommended hearing aid service-delivery approach for adults in LMI settings using Bowen’s framework. This feasibility study was conducted from October 2023 to July 2024, in three LMI South African communities: Khayelitsha and Paarl Valley in the Western Cape and Atteridgeville in Gauteng. Three CHWs were trained over five days. Training included a theoretical and practical component on facilitating hearing assessments, hearing aid fittings, and follow-up care using mHealth tools. Feasibility was evaluated within Bowen’s feasibility framework across domains of acceptability, demand, implementation, integration, practicality, and adaptation. The research specifically examines (i) CHW training and competency in delivering hearing services, (ii) patient engagement and community acceptability, and (iii) logistical and organizational factors influencing implementation through questionnaires. CHWs demonstrated high competency levels, with improvements in knowledge and self-confidence post-training. 166 adult community members were enrolled, with 36 (21.7%) ultimately receiving hearing aids. Of the 36 participants initially eligible, 28 (77.8%) accepted hearing aids at the time of assessment, while 8 more were fitted following reassessment. Of the 36 fitted participants, 34 were still using their hearing aids six months later. Only two participants returned their hearing aids as they felt unable to cope with the hearing aids due to mental health difficulties ( n = 1) and blindness ( n = 1). Community acceptance of the approach was high, with 97.1% ( n = 33) of the participants fitted with hearing aids reporting that the services were “greatly” helpful at the six-month follow-up. The program manager reported limited support from referral clinics due to long waiting times for appointments and low community awareness as significant challenges. Recommendations for implementation improvement included establishing a panel of audiologists for rapid remote case reviews, scheduling regular wax removal days, and developing support groups for hearing aid users. The WHO-recommended CHW-led hearing aid service-delivery approach in LMI settings demonstrated high CHW competency after training, positive community engagement, and sustained hearing aid use at the six-month follow-up. Task-sharing among CHWs and professionals, supported by mHealth tools, can enhance access to hearing care in LMI settings. However, improved clinic support and ongoing CHW training are essential to optimize service sustainability and scalability.