 Hello everyone, it's really good to be giving another webinar in our Connecting with Niles Soundbytes webinar series. So today I'm going to be talking about smartphone connected hearing aids and this is one of the number of webinars that we're going to be giving on remote technologies over the next couple of weeks. So smartphone connected hearing aids empower hearing aid users and the message from today's is that the take home message is that it's not the technology for what people do with the technology. So there are a number of benefits to mHealth. So mHealth is one healthcare delivered through mobile technologies such as smartphones and tablets and there are a number of benefits which are shown here. First of all mHealth increases access to healthcare so this overcomes barriers of geography, time and mobility. Easy access and convenience can lead to greater empowerment, a more personalised and tailored approach to healthcare approach and moves away from the more traditional one size fits all and can lead to more personalised healthcare. By being able to interact more with the mobile technologies people are better able to engage not only with their healthcare but also their healthcare condition. By being able to self-evaluate and self-monitor how people are getting on they're better able to self-manage their health condition and by having greater control over how to manage their hearing healthcare this can lead to greater participation in everyday life. One of the big advantages of mobile health and mobile technologies is the ability to be able to collect a lot of data. So by methods such as ecological momentary assessment we're able to gather large amounts of data that can be analysed using new and novel methodologies such as AI and machine learning. Finally there's often limited healthcare so being able to have high volume healthcare at low cost can lead to new service delivery models. So there are a number of different types of mobile technology for connected hearing healthcare and for self-management shown here and we're going to be talking about all these different aspects in our webinar series. Today I'm going to be talking about smartphone connected hearing aids as I said. So this is the patient pathway that we're very familiar with and the the smartphone connected hearing aids really come in at the intervention part of the pathway but also in terms of ongoing support by the way that smartphone connected hearing aids are able to support people beyond the clinic appointment. So a copy review that I published a couple of years ago has shown that hearing aids are effective so the review showed that for hearing related quality of life and listening ability there were large beneficial effects and this was moderate quality evidence which is actually really very high for systematic review. For health related quality of life and for the first time we were able to go and show that there was a small although albeit significant beneficial effect in health related quality of life and again this was this used moderate quality evidence. So the conclusion of the copy review was that the evidence is compatible with the widespread provision of hearing aids, the first line clinical management in those seeking help for hearing difficulties. So hearing aids are effective but we know that hearing aids get bad press so why is this? Well traditionally hearing aids have had really bad press in terms of the way they look in terms of being a bit big bulky plasticy with custom earmiles and really not very attractive and this is caused people get really quite bothered about the sort of cosmetic appearances of hearing aids. Even though hearing aids are effective and can really help improve people's quality of life there are still occasions when people will have difficulties being able to hear. So for example in difficult listening situations such as having conversations of groups you can see this group of people in a restaurant here and particularly when there is background noise. One of the issues around hearing loss if hearing aids aren't helping so much is that people often feel quite isolated and they can be isolated either in a situation where there's lots of people around themselves like in this one here but where they withdraw from themselves because they're unable to communicate or participate well or they may even become isolated where they don't even attend social or other types of functions or meetings or activities. And then finally it's been well known for many many years that there's a stigma attached with hearing aids really sort of encapsulating a lot of what I've been talking about so far. So a couple of years ago we asked the question can new technologies help overcome some of these issues. So over the last few years we've seen a real explosion in the use of smartphone connectivity. I've got three examples of how that might be used here in terms of self-fitting hearing aids being able to adjust the sound quality of the hearing aids and then being able to adjust hearing aids remotely so where the audiologist is in the clinic and the patient is at home. But today I'm going to be focusing on this the user adjustment aspects of smartphone connectivity. So we're coming out to study a couple of years ago in Nottingham in the UK and the research question we asked was does the functionality of a smartphone app provide benefits in everyday life. So the two main aims the first was to assess the benefits of the smartphone app. The second was to explore people's usability, how do they use them and what were their preferences of the app. So this is a screen shot of what the app looked like and the app was used with Phonax Audio B90 direct hearing aids which were programmed using the Phonax Digital adaptive algorithm. So the number of programs that were available there were some sound modifiers so this enabled people to be able to adjust the volume, the gain, to be able to reduce noise, set microphone directionality and adjust compression. So a bunch of different types of sound modifiers to adjust. There were some preset programs that had been set at the outset so factory presets so these were programs that had been shown previously to be helpful either watching television or watching television, listening in a restaurant or listening to music. There's also the option for people to be able to customize and the sound and then be able to save those custom programs, store them, give them a name and then use them whenever they wanted to. So the study involved 44 hearing aid users, the hearing aid users were recruited from a clinic in the UK's National Health Service and there were some eligibility criteria. It was really important that people had an Apple iPhone because the app wasn't available on Android so they had to have an iPhone that was at least iOS 10 and one of the criteria was that people used the phone more than just sending texts. So we did a single centre perspective observational study which I'll say more about in a minute and we used a mixed methodology which we're using more and more in our hearing research studies. So we used a mixture of both quantitative and qualitative methodologies including two focus groups. So this is the study design. It was a seven-week study so a baseline, people came into the clinic, they were fitted with the new hearing aid, the phonac hearing aid, we collected some patient-reported outcome measures and carried out an interview. Patients came back one week later where the hearing aid was fine-tuned and we checked that they were getting on okay with the hearing aids and again we repeated some patient-reported outcome measures and carried out a speech and noise test. The participants were then left for six weeks, told to go home, use the hearing aids as they would normally. The home trial included some hearing tests that we asked them to do and we also got them to make a note of their different experiences. So after the six-week trial they came back a week seven and we repeated the outcome measures and the speech and noise speech and noise test and had a final interview and then some people were randomly selected to take part in the focus group so if you get a bit of a more of a handle on you know what they what their experiences were. So down here are the characteristics of the participants, very typical of NHS clinic patients, two-thirds of the patients were existing hearing aid users, they were all just under the age of 70 so this is very typical of what we would see in the Nottingham Clinic as were the pure technology grams. So in terms of the results, so first of all just looking at the hearing aid users and looking at hearing aid outcomes we saw across the board that hearing aid outcomes improved and most of the outcomes improved with large clinical effect sizes. So for the existing hearing aid users I've shown here the results in the Glasgow Hearing Aid Difference Profile and the device-orientated subjective outcome questionnaire, the dozo. So for the Glasgow Difference Profile this people had to go and say how much more benefit or satisfaction their new hearing aid gave them compared to their previous ones and 100% meant that they were, this was 100% improvement of benefit and satisfaction. So everybody reported that the new hearing aids gave them more benefit and satisfaction. For the dozo there's six different scales so these would include things like listening in noise, listening in quiet, convenience and I'm showing you the results here for listening effort. So this is the listening effort rating that people reported with their previous hearing aids of baseline and we can see that there's a significant improvement six weeks later with the new hearing aids. There's a highly significant difference between the previous and the study hearing aid but we're particularly interested in the size of that effect and the D here is Cohen's D effect size and we can see down here anything that greater than is it greater than 0.8 is a large effect size. For both the new and existing hearing aids use I've got the results here of participation restrictions and fatigue. So for participation restrictions we use the HAIE, the hearing handicap infantry for the elderly and you can see for the new hearing aid users unaided there were significant participation restrictions reported and these reduced enormously, a highly significant reduction in a very large effect size. For the existing hearing aid users with their previous hearing aid there was less of an improvement but this was still highly significant and it was still a large effect size. In terms of fatigue we use the Vanderbilt fatigue scale which is a relatively new outcome measure and we see similar results so unaided our new hearing aid users reporting a lot of fatigue which was much reduced seven weeks later after using the hearing aid and again similar to the participation restrictions we're seeing that of existing hearing aid users there was a reduction in reported fatigue which was still significant and highly significant and still had a large effect size. So we took quite a bit of feedback from patients about what they thought of the app and the hearing aids the app was rated highly was rated four stars out of five and to summarize some of the patient feedback we saw that for about two-thirds of the participants the app met their needs extremely well. The best feature reported was the ability of participants to be able to adjust the hearing aids using the app. This was by far the most important measure and really helped people to improve their listening abilities in lots of different conditions and you can see here that people also reported that the best feature was being able to use their hearing aids in different listening environments. The where the app was reported to be most useful was having a conversation noise with about half of the people reporting that and about a third of the people reporting that the app was most useful and much in television. We asked if people experienced tiredness and about 87% said no and so this supported some of the results that we had from the fatigue questionnaire. So we carried out a couple of focus groups they took about an hour to run and then we transcribed the interviews and we analyzed the results using a deductive thematic analysis based on the combi model of how behaviour change. So for those who are not familiar with the combi there are three different components which impact on behaviour capability and opportunity both impact on motivation and the three impact on the behaviour and behaviour itself the target behaviour can impact on both on capability, motivation and opportunity. So I'm going to go talk through some of the themes from the focus groups first off capability so looking at knowledge and skills and we see by far that the sort of the biggest and the most important thing that came through was around people's ability to be able to adjust and their hearing aids using the app this led to better or increased participation and people felt more confident so this ties in with the feedback that we had previously. One of the things that came through was this idea of experiential learning so the more people use the app the more they were able to learn how to use it best and they're more confident that they became. So typically people use the app a lot more in the beginning and then it's got more used to it so the programmes the use of this tailored app but this idea that people learned what to do came through quite strongly. In terms of complexity of controls some people thought there were too many controls too many things to do other people really liked it this led to the complexity controls led to something called decisional birds when people spend quite a bit of time in the beginning working out what to do and this is something that was supported that could be improved upon. In terms of opportunity the listening context was a theme that came through and this is where people tended to use the app in situations which were much more challenging where they thought it could make a real difference. People reported that there was less stigma the fact that they had smartphones they could show people exactly what they were doing they could see how it could affect their hearing. People felt much more confident about being open and upfront about having their hearing aids. There was an aspect around societal smartphone norms so some people felt a bit awkward about using a smartphone in situations such as a work or if they were out at the pub for example and feeling that you know they were seen to be filling with the phone and they felt a bit uncomfortable about that. In terms of motivation empowerment was came through as a really strong theme from a number of different aspects and there's some quotes here it's great it gives you control it's not of the people running my life it's me and another quote was in a restaurant it meant I didn't have to sit with my back to the wall anymore I could sit where I wanted so there was a strong theme of empowerment and this led to having increased confidence and also reports that it benefited other family members and friends so this idea of self-tuning being able to facilitate feelings of empowerment when people felt more in control which meant that they led to increase confidence and participation and it came through that it was really the ability of people to be able to have the power the ability to self-tune the hearing aids that was really important rather than the technology per se. So one of the things that we'll hear about in future webinars and both Brent and I spoke about in the last couple of webinars is this the slow uptake of mobile technology and health and other teleordiology applications into clinical practice so I've run a number of studies looking at remote technologies and this comes up every time this idea of age and the digital divide so from the patient point of view and it's commonly cited in our hearing studies others people's hearing studies and in studies that are not specific to hearing does this sort of unfound belief that people all the people think their ability to use technology is much much poorer relative to others for example younger people and we see this not only with patients but we also see with the audiologists so you know it's been reported that some audiologists will only recommend smartphone connected hearing aids after they have made a judgment of what they think they would praise some of their patient's technology competencies and quite often audiologists will rule out people as not meeting the criteria of smartphone hearing aids and so people miss out on that opportunity and I know I've seen it myself when I sat in on hearing aid clinics where people who could benefit are not even given the opportunity. In terms of smartphone ownership this comes up all the time the Deloitte study showed that 80 percent of over 55s were smartphone owners a study by Ipsos Morris showed that this figure was 90 percent so we're seeing smartphones being used and being used for lots of different different ways of them just being used as a phone. So this idea of experiential learning this idea of being able to trial in there and learn how best to use the smartphone now really empowers people and I think the message here like this really probably the most important message of the whole presentation is that smartphone hearing aids are not just for the tech savvy we saw that people when they were given the opportunity even if they thought they weren't that technologically able that they could get on with it and they got lots of benefit from their hearing aids by using the app. So there's a real role for audiologists here to support new hearing aids users to help them agree the goals in terms of trialling how they use the smartphone connected hearing aids and to self monitor their use and I think this idea that we really should be giving people an opportunity as default to go and have the hearing aids set up for bluetooth smartphone tech and so so people are able to at least try the hearing aids and not make a judgment about them before they've even got the hearing aids and then of course there are other ways of being able to inform and provide patient education and improve knowledge with programs such as c to here online that I developed a number of years ago and that is freely available on this website. We've also got another version called enter here which is developed for mobile technologies and I'll be talking about these in a later webinar. So to conclude smartphone connected hearing aids get good press they're more cosmetically appealing. We showed that they improved listening and participation and they resulted in less fatigue and less listening effort. Patients felt more empowered by using smartphone connected hearing aids and stigma was reduced. So in terms of benefits of mHealth so these are the these are the benefits that we've seen increasing access empowerment more person-centered approach increased participation the ability to be able to for the use to control their hearing aids and better confidence and self-efficacy, self-management and improvements in knowledge and skills. So what I became quite interested in this idea of empowerment from a study that we published in 2019 and we started reading upon it and we're now doing a study with a WSA audiology with Sarah Gottevich and Kerry Nismetz with Powell and Shirtian taking unit now to look to explore how empowerment in fact manifests itself for adults with hearing aids across the whole of the patient journey. We're using some of the we're using Zimmerman's model of empowerment and actually it's really interesting to see how the five key domains of the empowerment model really reflect a lot of what we've seen in the study I just spoken about in a couple of other remote technology studies. So this is user control, self-efficacy, participation, knowledge and skills so we'll be asking about all of these in a series of interviews that we're carrying out in Denmark, Sweden and Australia over the coming months and one final point about this so this is the ICF framework so we're very much moving away from participation which is where a lot of the research I do sits and moving looking at sort of personal factors, things around empowerment and we're seeing this as some of our other outcomes work. So I'd like to go and thank my colleagues at Nottingham who helped run the study that I spoke about which was funded by Phonak and the audiological science department and the lead working with a number of colleagues on a number of different type of connected health studies that you'll be hearing about over the next coming weeks and finally hearing Australia who were carrying out a number of different type of connected and health studies.