Objective To determine whether a non‐specialist health worker can accurately undertake audiometry and otoscopy, the essential clinical examinations in a survey of hearing loss, instead of a highly skilled specialist (i.e. ENT or audiologist). Methods A clinic‐based diagnostic accuracy study was conducted in Malawi. Consecutively sampled participants ≥ 18 years had their hearing tested using a validated tablet‐based audiometer (hearTest) by an audiologist (gold standard), an audiology officer, a nurse and a community health worker (CHW). Otoscopy for diagnosis of ear pathologies was conducted by an ENT specialist (gold standard), an ENT clinical officer, a CHW, an ENT nurse and a general nurse. Sensitivity, specificity and kappa (κ) were calculated. 80% sensitivity, 70% specificity and kappa of 0.6 were considered adequate. Results Six hundred and seventeen participants were included. High sensitivity (>90%) and specificity (>85%) in detecting bilateral hearing loss was obtained by all non‐specialists. For otoscopy, sensitivity and specificity were >80% for all non‐specialists in diagnosing any pathology except for the ENT nurse. Agreement in diagnoses for the ENT clinical officer was good (κ = 0.7) in both ears. For other assessors, moderate agreement was found (κ = 0.5). Conclusion A non‐specialist can be trained to accurately assess hearing using mobile‐based audiometry. However, accurate diagnosis of ear conditions requires at least an ENT clinical officer (or equivalent). Conducting surveys of hearing loss with non‐specialists could lower costs and increase data collection, particularly in low‐ and middle‐income countries, where ENT specialists are scarce.

Objective: To describe the profile of patients attending the Queen Elizabeth Central Hospital (QECH) audiology clinic in Malawi, over a two-year period (2016)(2017). Design: A retrospective patient record review.Study sample: There were 2299 patients assessed at the QECH audiology department between January 2016 to December 2017. Adult patients' ages ranged from 18 to 94 years (M = 45.8, SD = 19.22). The mean age of children included in this study was 7.7 years(SD= 5.21). Overall, 45.4% of patients were female.Results: Of the 61.6% of adults and 41.7% of children found to have some degree of hearing loss, 28.3% and 15.4% were fitted with hearing aids, respectively. The number of patients seen in 2017 (n=1385) was 34% higher than that of 2016 (n=914).Conclusion: This study found that demand for hearing services is increasing in this Malawian Audiology department but uptake of hearing aids for those in need is low. Future evaluation of service provision and treatment outcomes is needed. Results from this study can be used to inform the development of future audiology clinics in low resource settings.

(1) Introduction: Poor uptake of referral for ear and hearing services in Malawi has been demonstrated in previous research. A multi-component educational intervention was developed to address poor uptake. The aim of this study was to explore the feasibility and acceptability of the intervention. In addition, we aimed to provide a case study of an intervention development and feasibility testing process in preparation for a potential randomised trial. (2) Methods: The intervention included three components: (i) an information booklet; (ii) personalised counselling by a community health worker and an expert mother; (iii) a text message reminder. To assess feasibility, the counselling and information booklet were provided for caregivers of eligible children (<18 years) at ear and hearing outreach camps in Thyolo. Text message reminders were sent to caregivers after the camps. After 4 weeks, all caregivers were revisited and completed a structured questionnaire and a subset were interviewed in-depth. (3) Results: 30 children were recruited, and 53% took up the referral. Interviews found counselling with a booklet was acceptable. It provided motivation, enabled a two-way conversation, and helped dispel fear. It allowed information to be shared with social networks, initiating conversations about raising funds. The text message reminder was reported to be a valued prompt. Challenges to feasibility included low network coverage, and time needed for counselling. Residual barriers included the costs of transportation. The cost was £3.70/camp. (4) Conclusions: The study found that counselling with an information booklet was feasible and acceptable. The process of testing the feasibility of the intervention identified some adaptations to the intervention components and delivery which could be implemented before it is tested in a trial. This study highlighted the value of the feasibility testing process.

This study has two main objectives: 1) to assess the value of combining the rapid assessment of avoidable blindness (RAAB) and the recently developed rapid assessment of hearing loss (RAHL) based on existing population-based data from Cameroon andIndia; 2) to test the feasibility of a combined RAAB-RAHL protocol. Methods A secondary data analysis of population-based disability surveys in India and Cameroon (in 2013-2014) was conducted, focussing on people aged 50+. Hearing impairment (HI) was defined as pure tone average of �41dB (better ear).Visual impairment (VI) was defined as presenting visual acuity of <6/18 (better eye). The relationship between HI and VI was examined. The feasibility of a combined RAAB-RAHL survey was assessed within a RAHL conducted among adults aged 50+ in Malawi in 2018. Outcomes included: time taken, costs, number of people examined in a day, and qualitative feedback from participants and field teams. Results The prevalence of combined VI and HI among people aged 50+ was 4.4% (95% confidence interval (CI) 3.0, 6.4) in India and 4.8% (95%CI 3.0, 8.0) in Cameroon. Among participants with VI, approximately a third in India (29.3%) and Cameroon (35.1%) also had HI. A quarter of participants in India (25.4%) and Cameroon (26.9%) who had HI also had VI. In Malawi, the total time taken to complete both RAAB and RAHL assessments was approximately 27 minutes per participant. It was feasible to complete 30 participants per day for a team of four people. The estimated cost of a combined RAAB-RAHL approach in comparison to two separate impairment surveys is up to 37% less depending on the method of combination.

This research has been made possible through the hard work of many individuals and organisations.Firstly, we would like to thank the study participants for their generous time in taking part in the study. Secondly, we recognise the efforts of the village leaders from Malawi for their assistance in coordinating the survey. We also thank hearX and colleagues for their support in the use of hearTest and integration of ODK with hearTest. Finally, we thank colleagues from the International Centre for Evidence in Disability for their input in to the survey protocol development. Electronic data solutions were provided by LSHTM Open Research Kits (odk.lshtm.ac.uk). Conflicts of interestThe fifth author (DW) is a scientific advisor to the hearX group. His relationship includes equity and consulting.