others and, as such, it can enable provision of more services, to a wider population, and in a personalized manner.
The area of m-health, in particular, is gaining momentum. A general definition of m-health was introduced by the World Bank in 2012, i.e., the use of mobile technology for health care (Qiang et al., 2012). As such, m-health encompasses the use of mobile and wearable devices to deliver health-related information, to access or analyze data, to provide clinical services, or to support health care delivery in clinical as well as in nonclinical settings. Ozdalga, Ozdalga, and Ahuja (2012) described m-health as a novel facilitator to address key health care challenges such as access to care, quality of services, affordability of technology, or matching of resources. The U.S. Food and Drug Administration (FDA) (Food and Drug Administration, 2015) in the Digital Health Innovation Action Plan highlighted the impact of m-health and emphasized that mobile applications (apps) and devices can help people manage their own health, promote healthy living, and provide access to useful information when and where needed. The National Broadband Plan by the U.S. Federal Communications Commission (Federal Communications Commission, 2010) highlighted that m-health uses mobile networks and devices in supporting e-care, leveraging health-focused applications on general-purpose tools such as smartphones or tablets to drive active health participation by consumers and clinicians. Compared to earlier e-health solutions, m-health devices have unique features. Specifically, the core characteristics of m-health have been described in terms of: (a) rapid propagation into populations; (b) widespread availability of apps; (c) wireless broadband access to the internet, communication speed, and connectivity; and (d) direct connection with individuals due to increasing capability of locating, measuring data, monitoring function, and communicating with others (Davis, DiClemente, & Prietula, 2016). Increasing smartphone capabilities, functionality, and sensor integration, along with a widespread use of consumer devices, opened new possibilities for health and well-being. Data recorded by multiple sensors can be combined, for example, with behavioral and clinical data and can be used to address and monitor the health status and well-being of an individual (Cornet & Holden, 2018). Due to ubiquitous use of personal mobile devices (e.g., smartphones and tablets) and the related increase in popularity of m-health apps, the area of m-health has grown rapidly (IMS Institute for Healthcare Informatics, 2013; Statista Portal, 2016). Recently, it has been estimated that about 325,000 health apps are available on the leading app stores overall (Research2 guidance, 2017).
The range of uses of e-health is large in several medical specialties as well as for health management and disease prevention. Evidence in the area of audiology is growing. Recently, the term eAudiology has been proposed as a concept that encompasses technologies and services for remote provision of audiologic care at each stage along the patient journey, including screening, assessment, coaching, adjustments, monitoring, assistance, rehabilitation, and aftercare (Montano et al., 2018). Throughout this chapter, the term e-health is used as broader in scope than remote delivery of health services, according to the above WHO definitions (World Health Organization, 2005, 2016). Several e-health-enabled services have been introduced for audiologic rehabilitation throughout the years, and there is growing evidence that these services can deliver significant value for patients as they can help them overcome challenges of distance and access to care (e.g., Bright & Pallawela, 2016; Gladden, Beck, & Chandler, 2015; Paglialonga et al., 2018a; Montano et al., 2018; Paglialonga, Pinciroli, & Tognola, 2015; Saunders & Chisolm, 2015; Swanepoel & Hall, 2010; Tao et al., 2018). As this is a growing field, however, it is characterized by a number of potential benefits for the users and the health care systems along with several possible challenges and risks, as outlined in the following section.
Benefits and Challenges of E-health: The Complex Nature of Quality
The area of e-health in audiology is dynamic and shows promise. Yet, it is an emerging area and, therefore, the actual benefits and potential challenges of introducing these novel solutions into the clinic are still a matter of debate. In fact, there is ample interest about the benefits and challenges of e-health in general.
As said above, e-health apps have been seen since the beginning as a possible way to support health systems and improve access to care, quality, and cost efficiency to enable provision of high-quality, personalized services to the widest possible population, including those living in underserved communities (Ozdalga et al., 2012; World Health Organization, 2005). In fact, it is known that socioeconomic context, educational level, age, gender, and ethnicity can strongly influence access to high-quality care delivered through conventional clinic-based models. Moreover, low income and education levels are typically associated with reduced capability to acquire and understand health information and to prevent or manage pathologies (Nutbeam, 2008). In this context, digital technology can support health care delivery and help health workers, caregivers, and patients living in resource-limited settings to access higher-level medical knowledge. Services delivered remotely, either on conventional or on mobile platforms, are potentially a valuable approach to limit health inequalities as they can enable access to care and reduce intervention time and cost for vulnerable patients who live in rural regions (Akter & Ray, 2010; Asamoah-Odei et al., 2012).
The potential benefits of e-health for the individual user (including patients, significant others, citizens, and professionals) have been widely studied. For example, digital technologies can open novel ways to address health and well-being that can translate into preventive behaviors and behavior change (Zhao, Freeman, & Li, 2016). Mobile applications, for example, can support management of chronic conditions and risk factors through instant tailored feedback on the smartphone, allowing detailed patterns to emerge in the outcomes of interest (Scherer et al., 2017). Tailored use of m-health can promote patient engagement with treatment, which includes behavioral, affective, and cognitive components that can contribute to maximize treatment outcome. More generally, significant benefits of m-health in patient empowerment, person-centered care, and effective patient-clinician relationships have been identified (Kim & Lee, 2017; Paglialonga et al., 2019a; Paglialonga et al., 2019b).
In the area of audiology, these novel technologies promise to pave the way to more effective adult hearing care and might lead to improved patient outcomes and satisfaction by bringing technology closer to patients. As outlined later in this chapter, an increasing number of functions and services can now be implemented by using modern platforms, e.g., data collection, teleconsultation, remote monitoring, remote fitting, delivery of educational content, and personalized programs for auditory and cognitive training (Paglialonga et al., 2018a; Tao et al., 2018).
Along with the several advantages of introducing digital technology into the clinic, the ongoing digital transformation in health care can also bring along specific challenges and risks that need to be understood and, whenever possible, addressed. A prominent aspect associated with the most recent developments in e-health and m-health is related to clinical evidence. Clinical evidence, in turn, encompasses diverse elements that complement each other. First of all, for digital solutions to be effective in the clinic, adherence to available guidelines and recommendations is essential. This needs to be taken into account throughout the design and development process, and needs to be verified by the clinician interested in adopting digital technologies into the clinic. Similarly, it is necessary to address the degree of scientific verification and clinical validation as available in the professional literature and related databases (e.g., EMBASE, MEDLINE, Global Health, Web of Science, CINAHL, and mHealth Evidence). However, in the area of m-health apps, the evolution of the market is so rapid that apps are typically put on the market well before any published article is available on scientific journals. As a result, the newest health apps, even if scientifically sound and reliable, might be penalized due to insufficient evidence. Therefore, specific criteria are needed for mobile apps evaluation and adoption (Aungst et al., 2014; Paglialonga, Lugo, & Santoro, 2018b). Potential app users cannot rely solely on the information reported on vendor markets due to the huge number of applications and to the inherently fragmented nature of the information provided. Moreover, app information as reported on the app stores’ websites is at the discretion of developers so it is not necessarily a reliable indication of quality and usefulness. In this context, potential app users (patients, clinicians, medical students, and other consumers) may have difficulty in keeping an overview of all the health apps that are available. Some recently developed methods for automated app classification and characterization promise to compensate, at least in part, for the effects of app overload on the market (Albrecht, Hillebrand, & von Jan, 2018; Paglialonga, Schiavo, & Caiani, 2018c; Paglialonga et al., 2017a; Paglialonga et al., 2017b). These novel automated methods are able to extract information from the web and, as such, they may become the basis for user-oriented support tools able to highlight meaningful knowledge about health apps, especially if they are used to extract information from reliable sources.
Considering the difficulties associated with app discovery and quality verification on the vendor markets, specific databases and web resources have been created to index, comment, and review health-related apps, such as the U. K. National Health Service (NHS) Apps Library,1 the Organisation for the Review of Care and Health Applications (ORCHA),2 the RANKED Health Project,3 or MyHealthApps4 by PatientView. Trustworthy resources about m-health apps can be helpful to support potential users in identifying the most promising means to answer specific needs. However, it is of note that these resources, although more reliable and accurate than the vendor markets, are not exempt from limitations. As the review process is inherently subjective, there is potential for bias. Moreover, there is an inherent delay from app release to assessment as reviews can take a significant amount of time, effort, and resources to be effective, so the app reviewed may receive updates and substantial revisions before a review is released.
In addition to information from the scientific literature and web resources, potential users can also assess aspects related to quality. These factors include the credentials of who developed the e-health or m-health tool, the sponsors and their reliability, the scientific methodology, or the documented involvement of the relevant stakeholders in the development process (i.e., scientists and health care professionals as well as the target user groups according to the principles of participatory design) (Clemensen et al., 2017).
Other important challenges of digital health are related to privacy, data protection, and security. These issues are especially important whenever services are delivered remotely over the internet or through smartphone apps. However, despite its importance, data protection is frequently overlooked in the area of digital health. Whereas existing electronic systems and servers in health care operate behind secure firewalls, in novel digital solutions and mobile health apps, data protection regulations are rarely fulfilled. Gaps in compliance with data protection principles in accredited health apps have been reported. For example, a study on 79 health apps certified as clinically safe and trustworthy by the U.K. NHS Health Apps Library showed that personal information stored locally was not encrypted and that identifying information sent over the internet was not encrypted in two-thirds of apps. Some apps (20%) did not have a privacy policy and, among the apps having some form of privacy policy, the majority (78%) transmitted information without describing the nature of personal information included in transmissions, and two apps put the users at risk of data theft (Huckvale et al., 2015). The issue of data protection, so crucial in health, is still largely unresolved in m-health and is challenging, as it is difficult to identify the appropriate basis for data processing and the requirements of explicit, informed consent. In addition, complexity of information systems and system networks make the exercise of data subjects’ rights more difficult (Mantovani & Quinn, 2014). Access to patient data through mobile devices would require careful consideration of the ethical, security, and governance aspects of data handling (Charani et al., 2014). Addressing data protection is part of the broader concept of trustworthiness, which is just one of the main reported concerns when dealing with digital health technology. In general, aspects related to trust can be difficult to address so some frameworks have been introduced to try to assess trustworthiness in a comprehensive way by evaluating, for example, elements of transparency, data management and reuse, data protection and privacy, purpose, reliability of content, and imprint (Albrecht, Noll, & von Jan, 2014; Lewis, 2013).
All of the abovementioned aspects (i.e., clinical evidence, quality of developers, scientific soundness, involvement of professionals, participatory design methodology, data protection, transparency, and reliability of content) contribute to the broad, complex concept of quality in digital health. However, for a comprehensive evaluation of quality, one more component needs to be addressed: the users’ perspective. Examples of user-oriented elements of quality are usability, quality of experience, functional design and aesthetics, ease of use, perceived quality of content and function, and perceived effectiveness (Brown et al., 2013; Lemon et al., 2018; Martínez-Pérez et al., 2013; Moumane, Idri, & Abran, 2016; Paglialonga et al., 2018b).
Overall, it is clear that the assessment of quality in e-health is an open debate, as the concept of quality is complex and subjective in nature. It is difficult to define standards for digital health assessment as it is difficult to identify the core components of quality as well as appropriate measures to assess them. Generally, there is a need for comprehensive recommendations on how to identify, characterize, and evaluate e-health and m-health solutions (Larson, 2018; Paglialonga et al., 2018b). Related to this, in the heterogeneity of hearing data and devices in the area of e-health, there is a need to move toward interoperability and standardization of data types, collection, exchange with communication protocols, handling, storage, and interpretation. Interoperability refers to health information systems that work together within and across organizations. Standardization is the process of developing and implementing technical standards and, as such, it is the necessary basis for securing interoperability, compatibility, quality, safety, and repeatability (Laplante-Lévesque et al., 2016). Research in this direction is needed and important as it can help raise the quality of solutions available to clinicians.
E-health in Audiologic Rehabilitation
In the field of audiology, use of e-health was introduced as early as in 1994 by Cherry and Rubinstein, who suggested remote follow-up by telephone following face-to-face hearing aid (HA) fitting. Nowadays, the range of digital technologies for hearing is wide and several services are available for different target users and age groups, including children with hearing loss (HL) and their parents, adults fitted with HAs or implantable devices, older adults and their significant others, or tinnitus sufferers. This section outlines the latest trends in the area of adult audiologic rehabilitation, the evolution of platforms for service delivery, the various solutions available throughout the patient journey, and the research needs and open questions.
Evolution of E-health Platforms in Audiologic Rehabilitation
Since the earliest attempts to deliver remote audiologic services through the telephone, the area of e-health for hearing has evolved in a way that services can now be delivered over a variety of platforms. These platforms can be categorized into three broad categories: offline, internet-based, and mobile-based.
Offline Platforms
Offline platforms include telephone, DVDs, or PC-based programs that do not use the internet. The telephone was introduced early as a straightforward, accessible means to complement face-to-face clinical encounters. Examples range from clinician-initiated follow-up calls to address questions related to HA fitting (Cherry & Rubinstein, 1994) to telephone-based consultations and weekly discussions between clinicians and HA users as complements to a home-based educational program on hearing and HAs (Lundberg, Andersson, & Lunner, 2011). DVD- and PC-based applications have been used to deliver educational content or auditory and cognitive training programs (e.g., Ferguson et al., 2016; Henshaw, McCormack, & Ferguson, 2015; Olson, Preminger, & Shinn, 2013).
DVD- and PC-based programs have represented an important advancement in audiology as they can be used to implement user-tailored exercises for auditory and cognitive training or to deliver personalized educational content. As such, these programs can enable clients to train or learn skills such as communication strategies and to cope with hearing-related problems in their home environment (Kramer et al., 2005; Sweetow, 2006). Even though DVD- and PC-based programs were introduced well before the advent of the internet, they are still widely used in audiology. The success of offline platforms is due to a combination of factors, such as full maturity of technology, availability of clinical evidence, and the fact that these offline platforms, differently than those relying on the internet, are easier to use and can function under less than ideal conditions (e.g., poor connectivity, underserved settings, or untrained personnel with low technical skills) (Paglialonga et al., 2018a).
Internet-Based Platforms
The broad category of internet-based platforms includes any application and service delivered over the internet (except the native mobile solutions that are described in the next section). Internet-based platforms have increased in popularity due to the growing rate of internet usage. Interestingly, high prevalence of internet use has also been reported in community-living older adults with HL (Gonsalves & Pichora-Fuller, 2008), with elderly people with HL using the internet more than those with normal hearing (Henshaw et al., 2012; Thorén et al., 2013).
Various audiological services have been introduced on internet-based platforms. For example, web portals for hearing-related information or virtual communities (Rothpletz, Moore, & Preminger, 2016; Shoham & Heber 2012), rehabilitation programs and auditory training (Abrams, Bock, & Irey, 2015; Malmberg et al., 2015; Thorén et al., 2014), remote control of clinical equipment for HA fitting (Ferrari & Bernardez-Braga, 2009), and audio- and videoconferencing for teleconsultation (Pross, Bourne, & Cheung, 2016). Overall, compared to earlier offline platforms, the use of internet-based services in audiology has opened novel opportunities for effective dissemination of information on hearing and postfitting care, easier exchange among peers, and delivery of remote services. Complementing audiologic rehabilitation in the clinic with internet-based services has been shown to contribute to increased participation, easier data collection, reduced time and cost, and improved patient outcomes (Malmberg et al., 2015; Thorén et al., 2014; Thorén et al., 2011).
Mobile-Based Platforms
This category includes m-health technologies; that is, solutions that make use of mobile and wearable devices for audiologic rehabilitation. The m-health branch in audiology is relatively new but the interest among researchers and clinicians is growing rapidly, especially in the area of mobile apps (Bright & Pallawela, 2016; Clark & Swanepoel, 2014; Galster, 2012; Paglialonga, Pinciroli, & Tognola, 2019c; Paglialonga et al., 2015).
Thanks to their portable and instant nature, m-health technologies can enable on-demand information and data sharing. A variety of personalized solutions can be implemented to connect different hearing care actors such as patients, audiologists, and manufacturers. An increasing number of apps for hearing are made available on the market, providing a wide range of functions and services for the different target user groups throughout the whole journey: from professional and patient education to hearing screening, from remote counseling to auditory training, and from personal sound amplification to support tools for patients and their significant others (Paglialonga et al., 2019c).
Overview of E-health Services Along the Patient Journey
The area of e-health in audiology has grown not only in digital platforms as described above, but also in type of solutions that can support the prefitting, fitting, and postfitting phases of the HA adult patient journey (Paglialonga et al., 2018a). A wide range of services related to adult audiologic rehabilitation have been developed and tested on digital platforms throughout the years albeit with varying degrees of clinical implementation and uptake. Overall, these services can be categorized into three broad areas: education and counseling; screening and assessment; and hearing rehabilitation (Paglialonga et al., 2019c; Paglialonga, Pinciroli, &Tognola, 2017c).
Education and Counseling
The area of education and counseling includes any function that delivers information to patients, significant others, audiologists, or health care professionals. As such, this area includes services that aim to improve general knowledge and awareness about hearing, HL, and HAs or cochlear implants (CIs); support tools for patients and significant others (e.g., educational material, counseling, motivational interviewing, or psychological interventions); peer-to-peer support groups and online discussions; and professional education resources.
Using e-health for patient education and counseling in the prefitting phase can support patients in their needs; increase awareness, motivation, and attitude to change behavior; and engage patients by having them share information about their choice of interventions and their needs and expectations. Recent literature shows that adult patients show growing interest in the internet as a means to improve knowledge and awareness about HL and hearing rehabilitation options. For example, Peddie and Kelly-Campbell (2017) interviewed a sample of adults and older adults with HL in New Zealand and showed that all but one had used the internet as a source of health-related information, and most of them had searched for hearing health information. Interestingly, all of the participants reported they had not discussed which websites to read with a hearing professional—typically, they read websites in the top 10 listed results in the search engine. It is therefore important that audiologists are aware that not only do patients feel the need for accessible knowledge about hearing, but they also tend to search for information on their own. Audiologists need to take this into account during clinical encounters and, if possible, recommend which resources to look at or discuss with their clients about their current knowledge and beliefs. To address the needs of people with HL, several online resources have been created and launched recently (e.g., information websites, virtual communities, and online forums for patients) (Ng et al., 2015; Shoham & Heber, 2012).
Counseling programs over the internet can be useful to bridge the gap between hearing screening and rehabilitation. For example, motivational interviewing over the internet has been proposed to promote movement in the stages of change and help seeking in people who failed an online hearing screening (Weineland et al., 2015). The study adapted the intervention to the internet format by delivering videos, written exercises, and texts in a fully automated way, and by including automatic feedback to the user. Fully automated counseling programs over the internet are currently under investigation and show promise as a possible means to influence the behavior of people with hearing impairment who may be reluctant to seek help initially, but may accept person-centered online psychological approaches as a way to find motivation. Acceptance of such interventions may be higher than expected, including in the older age groups. For example, a study demonstrated acceptance of internet resources for hearing health care in a sample of older adults who failed a hearing screening (Rothpletz et al., 2016). The study showed that participants in general did not perceive themselves to be knowledgeable about how to manage their hearing problems, and seemed to believe that it was important to become informed about management strategies. Even though participants in the study sample were fairly diverse in age, education attainment, computer skills and experience, and personal access to the internet, overall they were generally accepting of computers and hearing health care websites. The study also pointed out the importance of website design (e.g., simple user interfaces, reminders) and short-term training to increase acceptance and ultimately use of internet delivery of hearing information among older adults. This stage (seeking information after failing hearing screening) can be particularly important for people with hearing problems to become aware of their needs and begin to self-manage their HL until they are ready to seek conventional clinical services.
The approaches to patient education through e-health in the prefitting phase are diverse. For example, Ferguson et al. (2015) introduced an educational program to improve knowledge of HAs and communication in first-time HA users. The program was based on the concept of reusable learning objects; i.e., short, highly visual chunks of interactive multimedia learning to support specific learning goals. A randomized controlled trial published in 2016 demonstrated the benefits of this program, delivered on PC, DVD, or the internet, to first-time HA users. Use of reusable learning objects led to significantly greater HA use for suboptimal users and, in general, to significantly better knowledge of practical and psychosocial issues and significantly better practical HA skills (Ferguson et al., 2016). Another example of online counseling in the prefitting phase comes from the study by Manchaiah et al. (2014), who introduced an online prefitting counseling program for individuals with hearing disability and their communication partners. The program was person centered and focused on the lived experiences of hearing disability with significant emphasis on patients’ self-reflection regarding their journey and their interaction with communication partners. Such programs, tailored to the patient as enabled by digital technology, can be used to support patients in their social and emotional needs, help them modify attitudes, and engage them by discussing their experiences and choices regarding intervention. Online resources for group audiologic rehabilitation have also been developed. For example, the Group Rehabilitation Online Utility Pack (GROUP), an online tool developed by Montano et al. (2013) to support hearing health care professionals to develop and offer group audiologic rehabilitation in their clinical practice. The tool includes the evidence for implementing group audiologic rehabilitation, content for preparation and planning, instructions for facilitating groups, and group activities.
Interestingly, psychological interventions such as cognitive behavior therapy and acceptance and commitment therapy have also been proposed for online delivery. For example, internet-based delivery of acceptance and commitment therapy to people with hearing impairment was also introduced recently as a potentially effective approach to psychological symptoms associated with hearing problems. Acceptance and commitment therapy is a form of cognitive behavior therapy that aims to help individuals accept their symptoms, feelings, and thoughts to live a fulfilling life. A pilot randomized controlled trial showed improvements in perceived psychosocial handicap and quality of life, and reduced depressive symptoms with internet-based acceptance and commitment therapy that combined text readings, mindfulness exercises, and interaction with therapists (Molander et al., 2018). Similarly, the positive effects of internet-based cognitive behavior therapy for tinnitus have been demonstrated. Recent randomized controlled trials showed that online cognitive behavior therapy was more effective on tinnitus-related distress and associated symptoms compared to weekly monitoring or moderated online discussion forums (Beukes et al., 2018; Kalle et al., 2018; Weise, Kleinstäuber, & Andersson, 2016).
As shown by the examples above, several studies have introduced services on offline and internet-based platforms in the area of education and counseling. On the other hand, only a few studies about educational services on mobile-based platforms can be found to date. Wong and Fung (2015) reviewed 75 educational apps relating to otolaryngology–head and neck surgery and classified them into four main categories: (a) education; i.e., educational resources for medical students, residents, physicians, and health care professionals; (b) journal/conference; i.e., apps containing abstracts and articles from journals and apps designed for conferences and meetings; (c) clinical; that is, apps to support clinical activities and patient-doctor interactions; and (d) patients; that is, patient-oriented information. Broader reviews of the market of m-health apps for hearing showed that in the area of education and counseling, the available apps offered services such as lay audience-modified scientific information; service finder tools; educational support tools for clinical encounters; professional resources (interactive anatomy atlases, videos of clinical procedures, reference guides, continuing education programs and question banks); awareness tools (audio simulations of HL and hearing amplification solutions); and tools for HL prevention and noise monitoring (Paglialonga et al., 2015; Paglialonga et al., 2017c).
In addition to the examples in the prefitting phase outlined above, there is also increasing evidence about use of e-health for education and counseling in the fitting and postfitting phases of the patient journey. In fact, the educational component is one of the core elements of hearing rehabilitation whereby HA and CI fitting can be complemented by counseling and tailored educational programs for overall better benefit and improved patient outcomes. Improved knowledge of HL and communication strategies can help increase social interaction and reduce hearing disability (Ferguson & Henshaw, 2015a; Kramer et al., 2005; Lundberg et al., 2011; Sweetow, 2006; Thorén et al., 2011). Audiologic counseling on e-health platforms can be a powerful enabler of successful intervention as even simple strategies such as daily emails between patients and audiologists can improve understanding of day-to-day experiences. This can facilitate more timely responses compared to face-to-face encounters (Laplante-Lévesque, Pichora-Fuller, & Gagné, 2006). Online discussion groups and interaction with peers have also been investigated as possible means to complement HA rehabilitation. For example, randomized controlled trials demonstrated that a comprehensive online intervention program including self-studies, professional coaching, HA fitting, communication strategies, and peer-to-peer discussions can significantly reduce perceived hearing handicap in experienced HA users (Thorén et al., 2011; Thorén et al., 2014). Other investigators suggested similar programs, such as a combination of reading material, home training assignments, online and telephone interaction with an audiologist, and participation in a discussion forum (Malmberg et al., 2015); a support system comprising messaging tools, individual client tasks, agendas for next face-to-face visits, memo possibility, and a library with educational videos (Brännström et al., 2015); and a personalized online rehabilitation system for HA users able to provide content based on each user’s own individual needs and guide the user throughout the entire rehabilitation process (Denev et al., 2008).
In general, internet-based delivery of educational and counseling programs can be advantageous in data collection, participant access to content, personalization of programs, feedback, and clinician participation in terms of personnel, training, time, and cost. It can also translate into improved patient knowledge and awareness, increased motivation, and stronger self-management capabilities compared to conventional delivery in the clinic. However, the clinician willing to use internet-based services for education and counseling needs to be aware that these tools can be effective to the extent that individuals are in a position to use them appropriately.
Factors such as digital skills, internet competency, literacy, and quality of online material play an important role in determining the uptake, adherence, and benefits of e-health interventions. For example, a randomized controlled trial on about 200 first-time HA users showed that internet competency predicted practical knowledge about HAs and handling skills, controlling for factors such as age, hearing sensitivity, educational status, and gender. Better internet competency led the study participants to use reusable learning objects fewer times because of improved self-efficacy (Maidment et al., 2016). Previous knowledge of the e-health tools is also an important factor related to acceptance of remote delivery of education and counseling services (Eikelboom & Atlas, 2005) or, in the absence of previous knowledge, brief training to use online resources can help (Rothpletz et al., 2016). Digital skills and proficiency with the internet can be key to rehabilitation as effective use of online educational tools can, in turn, enable more effective management of HL. Literacy and health literacy also determine the way individuals use and understand health information from the internet (Norman & Skinner, 2006). For example, Laplante-Levesque et al. (2012) and Laplante-Lévesque and Thorén (2015) demonstrated that between 9 and 14 years of education may be required to be able to understand the online information available. Low literacy can be a barrier to adoption of internet-based educational tools, especially for older adults and for people in disadvantaged socioeconomic groups (Carroll et al., 2017; Joseph et al., 2016; Kontos et al., 2014; Moore, Rothpletz, & Preminger, 2015). The structure of the websites and navigation features are also important. For example, Thorén, Pedersen, and Jørnæs (2016) found that users of an online rehabilitation system reported difficulty navigating the system and completing the designed hands-on tasks. Possible solutions to improve usability of educational websites may be simplification of website structure and navigation options; limitation of the hierarchical structure; and establishment of an effective learning flow that will allow users to become aware easily of their progress. In addition to complex language and structure of online resources, other barriers to effective online delivery of information may include outdated or poorly maintained websites or disabilities such as visual or cognitive impairment that may make it difficult for patients to read and understand the information provided.
Hence, for effective user involvement and empowerment, it is important that e-health services developed for the patients meet the expected skills and literacy of the target groups and that the information provided can be understood easily. Collecting users’ feedback is important for improving existing systems, whereas involving users in the initial design process should be considered. Participatory design of e-health-enabled educational resources can be key to successful rehabilitation as patients can contribute to original and effective innovations of health technology (Kanstrup et al., 2017a; Kanstrup et al., 2017b). Recognizing the role of the end users and audiologists through codesign and involving them across all stages of development can help create educational content that is user friendly, easy to understand, and accurate, ensuring the end product is fully aligned to the users’ needs (Ferguson et al., 2018).
Screening and Assessment
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