The HFH model stresses the importance of following best practices in assessment and treatment of hearing loss. The expectation is that the same standard of care and quality provided in the university clinic can be provided while abroad. At hospitals, clinics, and schools for the deaf, the HFH team provides screening and diagnostic assessments, collects heath history and audiometric data, and provides hearing aid fitting and rehabilitative services to a large number of children and adults. Testing is conducted in the quietest areas available at each location and due to rolling blackouts or lack of electricity at some locations, the use of battery-powered equipment is essential. However, through our partnership with EARS, Inc., we are fortunate to also have access to the HARK (Hearing Assessment and Research Centre) mobile audio trailer equipped with two audiometric test booths and a generator during most outreach clinics. Additionally, when we provide services at the ABC Hearing Clinic and Training Centre we have access to a modern full service clinic that rivals any clinic in the USA. The HFH model uses a multi-stage evaluation protocol consisting of an initial screening (otoscopy, tympanometry, DPOAE, pure tone screen), a secondary screening as needed, and then diagnostic testing consisting of a pure tone audiogram, including masked air conduction, bone conduction, to establish the degree, nature, and configuration of the hearing loss. Cerumen management and other procedures such as ear swabbing/mopping, are completed, as needed, followed by a second screening and diagnostic testing. A comprehensive health history is collected to the extent possible from each patient. Using this protocol the HFH team has collected valuable data on all individuals tested including the degree and type of hearing loss and possible contributing factors and the needed follow-up. In Malawi, the use of diagnostic and portable audiometers that use insert earphones is a necessity given the high number of masking dilemmas encountered. The team also performs ABR and ASSR assessments, which has allowed us to identify a number of Auditory Neuropathy Spectrum Disorder (ANSD) cases. Pediatric assessments are performed using Visual Reinforcement Audiometry (VRA) and Conditioned Play Audiometry (CPA) techniques and the team encounters a number of children with multiple disabilities and a variety of syndromes. The HFH team provides evidence-based rehabilitative services to both children and adults with a focus on quality of assessment and hearing aid fitting rather than quantity. Audiologic testing, WHO guidelines, as well as the availability or access to follow-up services, are criteria used to determine hearing aid candidacy. Hearing aid fitting services include the following for each ear fitted: fabrication of a temporary earmold, Real Ear to Coupler Difference (RECD) measurement, potentiometer adjustment or software programming to amplification targets, electroacoustic verification of the fitting using simulated real ear measures (SREM) and the individualized RECD, informational counseling for care and use, and audiologic rehabilitation counseling. A second set of ear impressions is also taken so that a permanent earmold can be made by a Malawian earmold technician.
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