Open AccessSIG 18 TelepracticeResearch Article19 Jun 2019

Internet-Based Audiological Interventions: An Update for Clinicians

    Abstract

    Purpose

    Advancements in digital and computing technologies have created opportunities for innovations in the provision of health care remotely. The aim of this article is to provide audiological professionals with a summary of literature regarding existing audiological Internet-based interventions (IBIs). The specific objectives are to (a) provide an overview of the range of audiological IBIs for adults with hearing loss, balance disorders, and tinnitus; (b) identify the features included in these IBIs and possible benefits; and (c) identify difficulties and challenges regarding the implementation and use of audiological IBIs.

    Method

    Relevant articles were identified through literature review conducted in the PubMed database and gray literature. The relevant information from these sources, such as the type of intervention and main outcomes, were summarized.

    Results

    A range of IBIs were identified, with the majority addressing tinnitus distress. Those for hearing loss have been applied at different stages of the patient journey. Unguided IBIs for vestibular difficulties included self-help for Ménière's disease and vestibular rehabilitation. Most tinnitus IBIs provided cognitive behavioral therapy. Overall, IBIs showed benefits in terms of outcome and accessibility. Barriers include uncertainties surrounding cost-effectiveness, optimal level of support, and improving intervention compliance.

    Conclusions

    Telehealth applications are expanding in audiology, and IBIs have been developed to provide auditory rehabilitation, vestibular rehabilitation, and tinnitus interventions. IBIs have the potential to offer accessible and affordable services. More work is required to further develop these interventions and optimize outcomes.

    Hearing loss, vestibular disorders, and tinnitus are some of the most prevalent disabilities worldwide. Around 15% of the world's population have some degree of hearing loss (Olusanya, Neumann, & Saunders, 2014), with hearing loss of greater than 20 dB being the second most common impairment (Vos et al., 2015). The prevalence of dizziness has been reported to be about 20%–30% among adults (Agrawal, Carey, Della Santina, Schubert, & Minor, 2009; Benecke, Agus, Goodall, Kuessner, & Strupp, 2013), and at least 10% of the adult population has tinnitus (Bhatt, Lin, & Bhattacharyya, 2016; Shargorodsky, Curhan, & Farwell, 2010). Often, hearing-related conditions may not occur in isolation as hearing loss is one of the most common causes for developing tinnitus (Nondahl et al., 2011), and tinnitus is often accompanied by hyperacusis (Baguley & Andersson, 2008). In certain pathologies, vertigo attacks, hearing loss, and tinnitus may co-occur as is the case in Ménière's disease (Nakashima et al., 2016). Hearing-related conditions thus add to the health care and societal economic burden. Untreated hearing loss poses an annual global cost of $750 billion dollars (Chadha, Cieza, & Krug, 2018) and greater health care costs over a 10-year period compared with those without hearing loss (Reed et al., 2018). The annual cost of tinnitus interventions in the United Kingdom was calculated to be £750 ($960) million in total, and the annual societal cost relating to tinnitus was calculated at £2.7 ($3.5) billion (Stockdale et al., 2017). In the United States, the annual economic burdens of unilateral and bilateral vestibular disorders were found to be $3,531–$13,019 per patient (Sun, Ward, Semenov, Carey, & Della Santina, 2014).

    In most cases, hearing-related difficulties, such as hearing loss, tinnitus, and vestibular disability, may require longer term support. This largely involves provision of extensive rehabilitation consisting of several interrelated components, including the use of amplification, behavioral modification, and psychological support (Fuller et al., 2017). Although the provision of hearing aids and cochlear implants is instrumental in improving outcomes for those with hearing loss (Barker, Mackenzie, Elliott, Jones, & de Lusignan, 2016), they are unable to restore natural hearing and listening effort may remain (Peelle & Wingfield, 2016). The adoption of amplification is influenced by many factors, such as provision of additional support and rehabilitation (Ng & Loke, 2015). Additional support and rehabilitation are crucial due to the negative impact hearing-related difficulties can have on daily function and quality of life (Miura et al., 2017; Nordvik et al., 2018), often leading to social isolation, reduced cognitive function, anxiety, and depression (Benecke et al., 2013; Ciorba, Bianchini, Pelucchi, & Pastore, 2012; Hall et al., 2018; Langguth, 2011). Although such support would be ideal, provision of this extensive rehabilitation is difficult, in the context of many health care systems facing increasing pressures and limited resources. Despite proven benefits, audiological services are unavailable to provide this rehabilitation to much of the world's population (Swanepoel & Hall, 2010), and there remains a shortage of audiologists worldwide (Mulwafu, Ensink, Kuper, & Fagan, 2017; Windmill & Freeman, 2013). It is estimated that, in more developed countries, there is one audiologist per 20,000 people. This ratio decreases to one audiologist per 0.5–6.25 million people in less developed countries (Goulios & Patuzzi, 2008). Even in countries with extensive health care, such as the United Kingdom, specialist audiological services are not readily available, particularly in remote geographical regions (Hoare, Broomhead, Stockdale, & Kennedy, 2015). Lack of resources and suitably trained professionals with specialist skills to address complex audiological conditions are further barriers in the provision of evidence-based practice (Hall et al., 2011). The challenge is thus overcoming these restrictions in the provision of audiological rehabilitation. A further challenge is planning for growing service demands as the proportion of elderly people is rising (Vos et al., 2015; World Health Organization, 2013) and the prevalence of auditory-related conditions generally increases with age (Bainbridge & Wallhagen, 2014; Jönsson, Sixt, Landahl, & Rosenhall, 2004; McCormack, Edmondson-Jones, Somerset, & Hall, 2016). Future planning to ensure that resources are in place is vital.

    Advancements in digital and computing technologies have allowed for innovations in health care service delivery models. One innovation that has made great progress in the last decade is the use of telehealth, which refers to the provision of health care delivered remotely by means of digital and telecommunication technologies (Capobianco, 2015). Widespread applications of telehealth are developing due to its potential to offer support to remote populations, thereby improving health care accessibility at reduced costs (Andersson & Titov, 2014). Telehealth can provide access to clinical care for those with difficulty accessing face-to-face (FTF) care. Reasons for these difficulties could include the proximity of clinics, transportation difficulties, health-related problems, loss of income when taking time off of work, or stigma associated with seeing health care professionals (Cuijpers, van Straten, & Andersson, 2008). Within the field of audiology, various teleaudiology solutions have been developed for screening, diagnostic, pediatric, remote programming, and rehabilitation purposes (Krupinksi, 2015; McCarthy, Leigh, & Arthur-Kelly, 2018; Paglialonga, Nielsen, Ingo, Barr, & Laplante-Lévesque, 2018; Swanepoel & Hall, 2010; Tao et al., 2018). Ways in which to deliver these solutions range from offline platforms (such as PC-based applications, DVDs; Vreeburg, Diekstra, & Hosman, 2018) to Internet-based interventions (IBIs; Carlbring, Andersson, Cuijpers, Riper, & Hedman-Lagerlöf, 2018) and mobile health devices, such as smartphone applications (Akter & Ray, 2010). As the Internet is such a powerful tool, many telehealth self-help interventions are Internet based (Reavley & Jorm, 2011). An IBI has been defined as “a primarily self-guided intervention program that is executed by means of a prescriptive online program operated through a website and used by consumers seeking health- and mental-health related assistance. The intervention program itself attempts to create positive change and or improve/enhance knowledge, awareness and understanding via the provision of sound health-related material and use of interactive web-based components” (Barak, Klein, & Proudfoot, 2009, p. 5). Internet interventions either are independent of professional support (unguided) or offer some form of support (guided). Guidance is a mechanism whereby individuals can obtain “external” information about themselves and their progress (Barak et al., 2009). Guidance can be synchronous (e.g., real-time chats), asynchronous (e.g., not occurring at the same time, such as when using e-mail), or a blended approach combining various means. A systematic review has indicated that outcomes for guided interventions are more favorable than those for unguided interventions (Baumeister, Reichler, Munzinger, & Lin, 2014). Routine use of teleaudiological screening and diagnostic applications has been implemented more widely than IBIs. A systematic review found that 79% of the identified papers related to hearing-related teleaudiology involved the identification of hearing loss (Molini-Avejonas, Rondon-Melo, Amato, & Samelli, 2015). Due to the importance of rehabilitation in the audiological field, providing access to rehabilitation is important. The Internet is a valuable resource in delivering such interventions and frequently used by those with hearing impairment. Studies undertaken in Sweden, the United Kingdom, and Canada have indicated greater Internet use in people with hearing impairment than in the general population (Gonsalves & Pichora-Fuller, 2008; Henshaw, Clark, Kang, & Ferguson, 2012; Thorén, Öberg, Wänström, Andersson, & Lunner, 2013). Promoting wider implementation of IBIs is one way of improving access to audiological rehabilitation. More familiarity regarding these interventions and the implications for clinical practice may help adaptation of teleaudiological rehabilitation options. The aim of this article is to provide audiological professionals with a summary of the literature regarding existing audiological IBIs. The specific objectives were to (a) provide an overview of the range of audiological IBIs for adults with hearing loss, balance disorders, and tinnitus; (b) identify the features included in these IBIs and possible benefits; and (c) identify difficulties and challenges regarding the implementation and use of audiological IBIs.

    Method

    In line with the objectives of this article to summarize the existing literature regarding IBIs, a preliminary literature review was undertaken. However, it is noteworthy that this is not a formal scoping or systematic review and, hence, may not include all the studies conducted in this area. The focus of this preliminary review was to identify experimental studies that have evaluated the use of self-help–related IBIs focused on adults (aged ≥ 18 years) with hearing loss, vestibular disorders, and tinnitus. The PubMed database, together with searching gray literature, such as Google scholar, was used to identify the types of Internet interventions available. To focus the scope of this review to self-help interventions, those targeting remote programming or cochlear implantation follow-ups and hearing aid fittings were not included. To focus on experimental studies, those focusing solely on the development, experiences, qualitative analysis, or processes involved in such interventions were also excluded. Data that would be relevant for audiological professionals were gathered from the studies describing Internet interventions. This included (a) the country in which the intervention took place; (b) Internet intervention type (auditory training, rehabilitation); (c) additional intervention features; (d) online guidance; (e) effect size for the main outcome measure; and (f) main findings.

    Results

    Range of Audiological IBIs

    IBIs for Hearing Loss

    IBIs for hearing loss have taken a varied approach (see Table 1). They have been applied at different stages of the patient journey (for prefitting, for new and experienced hearing aid users, and for those with significant hearing disability regardless of use of amplification). Of interest was that support was provided in all the studies, either asynchronous online or taking a blended approach by supplementing FTF clinical care by such an intervention. IBIs can thus be used either as a replacement and/or supplementary to routine health care. Some of these interventions have been developed by the involvement of service users (e.g., Ferguson, Brandreth, Brassington, & Wharrad, 2015).

    Table 1. Internet-based interventions for hearing loss.

    Intervention focus Reference Country Guidance Stage Reduction in hearing disability in comparison to the control group
    Audiological rehabilitation (n = 6) Brännström et al. (2016), Malmberg et al. (2017), Thorén et al. (2011), and Thorén et al. (2014) Sweden (n = 4) Asynchronous by a clinical psychologist (n = 1) or an audiologist (n = 2) Blended approach (n = 3) First-time hearing aid users (n = 3) Experienced hearing aid users (n = 3) Small effect (n = 2) Moderate effect (n = 1) No effect (n = 2) Greater knowledge of practical issues (n = 1)
    Ferguson et al. (2015, 2016) United Kingdom (n = 2)
    Acceptance and commitment therapy Molander et al. (2018) Sweden Asynchronous: by clinical psychologists Those with significant hearing disability Large effect (n = 1)
    Prefitting hearing aid counseling Manchaiah et al. (2014) United Kingdom Asynchronous by an audiologist Pre–hearing aid fitting No effect (n = 1)

    One study investigated the efficacy of an Internet-based pre–hearing aid fitting counseling intervention (Manchaiah, Rönnberg, Andersson, & Lunner, 2014). For this particular intervention, treatment compliance was poor and high dropout rates were found. The Internet has been used in a blended manner together with FTF counseling support for first-time hearing aid users in three studies (Brännström et al., 2016; Ferguson, Brandreth, Brassington, Leighton, & Wharrad, 2016; Ferguson et al., 2015). Brännström et al. (2016) found that Internet-based auditory rehabilitation leads to a significant reduction in self-reported hearing disability postintervention. Ferguson et al. (2015, 2016) provided hearing aid familiarization for about 60 min via DVD, PC, or the Internet and found that, although knowledge of practical and psychosocial issues improved, self-reported hearing disability had not decreased after viewing the information. The Internet has also been used for experienced hearing aid users. Thorén et al. (2011, 2014) found that self-reported hearing disability decreased after provision of guided online rehabilitative education for existing hearing aid users. For this study, receiving or not receiving guidance seemed to have no effect on the outcome. The only effectiveness study was by Malmberg, Lunner, Kähäri, and Andersdson (2017), indicating that the implementation of Internet-based aural rehabilitation for Swedish hearing aid users improved communication skills. The Internet has furthermore been used to reduce psychological distress in those with hearing problems (Molander et al., 2018). In this study, acceptance and commitment therapy (ACT) was used. ACT focuses on decreasing experimental avoidance by accepting the existence of negative thoughts and emotions (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). The potential of incorporating the Internet at different stages of the patient pathway to reduce the effects of hearing loss is evident. Prior to implementation, further work is required to improve outcomes of these interventions. More effectiveness studies are required to assess outcomes on clinical populations.

    IBIs for Vestibular Disorders

    There have been two unguided IBIs for vestibular difficulties (see Table 2). A study in Finland by Pyykkö, Manchaiah, Levo, Kentala, and Juhola (2017) investigated an Internet-based self-help intervention for the management of Ménière's disease in a single-group open trial. Improvements in posttraumatic growth and general health-related quality of life were reported. A U.K.-based randomized controlled effectiveness study by Geraghty et al. (2017) found that Internet-based vestibular rehabilitation reduced dizziness and dizziness-related disabilities in 296 older patients. Although this existing body of research is encouraging, IBIs have been largely unexplored in this area. Due to the prevalence of vestibular disabilities, there is an immediate need for the development of further IBIs for vestibular disorders as well as research regarding the efficacy and effectiveness of these interventions.

    Table 2. Internet-based interventions for vestibular disorders.

    Intervention focus Reference Country Guidance Main outcomes
    Vestibular rehabilitation Geraghty et al. (2017) United Kingdom None Lower dizziness-related disability compared with the control group
    Rehabilitation for Ménière's disease Pyykkö et al. (2017) Finland None Improvement in general health-related QOL and past traumatic growth inventory

    Note. QOL = quality of life.

    IBIs for Tinnitus

    There is more published literature regarding Internet interventions for tinnitus than for any other hearing-related difficulties. The first Internet-based tinnitus interventions were initiated in the late 1990s in Sweden (Andersson, Strömgren, Ström, & Lyttkens, 2002). The rationale for this study was to increase the availability of evidence-based tinnitus care. Cognitive behavioral therapy (CBT) is a psychological intervention for tinnitus, directed toward altering maladaptive responses to tinnitus through behavior modifications. As it has the most evidence of effectiveness in reducing tinnitus distress (Hesser, Weise, Westin, & Andersson, 2011), an Internet-based CBT (ICBT) intervention was developed. Since this development, the efficacy of ICBT in reducing tinnitus distress has been evaluated in Sweden, Germany, Australia, and the United Kingdom (see Table 3). Service users were partly involved in the development of the U.K. intervention (Beukes et al., 2016). Due to the shortage of clinical psychologists providing CBT for tinnitus, guidance for the intervention developed in the United Kingdom was provided by an audiologist (Beukes, Andersson, Allen, Manchaiah, & Baguley, 2018; Beukes, Baguley, Allen, Manchaiah, & Andersson, 2018). Despite not having a CBT qualification, outcomes were similar to those trials with clinical psychologists providing guidance. Effect sizes have generally been greater in later studies that have benefited from using updated Internet features and tighter methodological designs (Weise, Kleinstäuber, & Andersson, 2016). Further studies using active control groups have also indicated that outcomes using ICBT for tinnitus are similar to those of group-based care (e.g., Jasper et al., 2014; Kaldo et al., 2008) and Internet-based ACT (Hesser et al., 2012). The effectiveness of ICBT has furthermore been evident when compared with outcomes for individualized FTF tinnitus care (Beukes, Andersson, et al., 2018) and group-based CBT that provides rehabilitation to different groups of patients one at a time (Kaldo et al., 2013; Kaldo-Sandström, Larsen, & Andersson, 2004). Outcomes have been maintained up to 1 year postintervention (Beukes, Allen, Baguley, Manchaiah, & Andersson, 2018; Hesser et al., 2012; Kaldo et al., 2008; Weise et al., 2016). The intervention effects have moreover been shown to reduce tinnitus-related difficulties, such as insomnia, anxiety, depression, and decreased quality of life (Beukes, Andersson, et al., 2018; Beukes, Baguley, et al., 2018; Hesser et al., 2012; Weise et al., 2016). As Internet-based tinnitus interventions have indicated long-term reduction of tinnitus distress and tinnitus-related comorbidities, they have the potential to be more widely implemented in order to improve accessibility to evidence-based tinnitus care.

    Table 3. Internet-based interventions for tinnitus.

    Intervention focus Reference Country Guidance Reduction in tinnitus distress
    CBT (n = 13) Abbott et al. (2009) Australia (n = 1) Asynchronous Not superior to the control information–only program
    Jasper et al. (2014), Nyenhuis et al. (2013), and Weise et al. (2016) Germany (n = 3) Asynchronous by clinical psychologists (n = 2) None (n = 1) Compared with a control group: small effect (n = 2), medium effect (n = 2), and large effect (n = 1) Comparing the effect of guidance:  no difference (n = 1) Within-group effect (no control):  medium effect: (n = 2) Where assessed, effects maintained 1-year postintervention (n = 3)
    Andersson et al. (2002), Kaldo-Sandström et al. (2004), Kaldo et al. (2008, 2013), and Rheker et al. (2015) Sweden (n = 5) Asynchronous by clinical psychologists (n = 5)
    Beukes et al. (2017), Beukes, Allen, et al. (2018), Beukes, Andersson, et al. (2018), Beukes, Baguley, et al. (2018), Beukes, Manchaiah, et al. (2018) United Kingdom (n = 4) Asynchronous by an audiologist (n = 4) Some synchronous guidance involving pre- and postintervention phone calls Large within-group effect size, no control group (n = 1) Moderate effect size compared with a weekly check-in group (n = 1) and maintained 1 year ( n = 1) Similar improvements achieved to that obtained by specialized, individualized clinical care (n = 1)
    One-arm CBT, one-arm ACT Hesser et al. (2012) Sweden Asynchronous by clinical psychologists (n = 1) Moderate effect for CBT and ACT and effects maintained 1 year postintervention

    Note. CBT = cognitive behavioral therapy; ACT = acceptance and commitment therapy.

    Although a large number of management strategies have evolved, many lack empirical support. Psychological interventions, such as CBT, currently have the most evidence of efficacy in reducing tinnitus distress (Hesser et al., 2011; Martinez-Devesa, Perera, Theodoulou, & Waddell, 2010).

    Features, Benefits, and Challenges of IBIs

    The features and benefits of the IBIs identified for both patients and services, together with the challenges related to provision of IBIs, are summarized in Table 4. Overall, these interventions show potential to reduce hearing and dizziness-related disability and tinnitus distress, as well as comorbidities such as anxiety and depression, and maintain these effects (where assessed, 1 year postintervention). They offer an accessible intervention with the ability to monitor engagement and progress. Uncertainties surrounding IBI include a lack of clarity regarding cost-effectiveness as cost–utility analysis has not been done. Further uncertainties include the optimal level of support and improving intervention compliance, which can be low.

    Table 4. Features, benefits, and challenges of Internet-based interventions (IBIs).

    Patient benefit or intervention feature Example references Difficulties in terms of uncertainties/challenges Example references
    Reduction in hearing and dizziness-related disability and tinnitus distress Hearing loss (e.g., Brännström et al., 2016; Malmberg et al., 2017; Molander et al., 2018; Thorén et al., 2011, 2014) Vestibular (e.g., Geraghty et al., 2017) Tinnitus (e.g., Beukes et al., 2017, Beukes, Baguley, et al., 2018; Hesser et al., 2012; Weise et al., 2016) Clinically significant changes not obtained by all (range: 40%–73%) Beukes, Baguley, et al. (2018), Hesser et al. (2012), Jasper et al. (2014), and Weise et al. (2016)
    Similar outcomes to face-to-face support Compared with group-based CBT (Jasper et al., 2014; Nyenhuis et al., 2013) Compared with specialized individualized tinnitus care (Beukes, Andersson, et al., 2018) Cost-effectiveness/cost–benefit analysis not done
    Improved quality of life IBIs hearing loss (Molander et al., 2018), Ménière's disease (Pyykkö et al., 2017), and tinnitus (Beukes, Baguley et al., 2018; Hesser et al., 2012) Cost–utility analysis not done
    Reduction in anxiety and depression IBIs related to hearing loss (Molander et al., 2018) and tinnitus (Beukes, Baguley, et al., 2018; Jasper et al., 2014; Kaldo-Sandström et al., 2004; Thoren et al., 2011; Weise et al., 2016)
    Maintenance of long-term effects (1 year postintervention) For ICBT for tinnitus (Andersson et al., 2002; Beukes, Allen, et al., 2018; Hesser et al., 2012; Kaldo et al., 2008; Weise et al., 2016), not investigated in other IBIs Maintenance of long-term effects only evaluated for tinnitus interventions and not for longer than 1 year post intervention and not in controlled studies
    Self-efficacy promoted, understanding and knowledge of practical and psychosocial issues Evaluated only in hearing loss IBIs (Ferguson et al., 2015; Thorén et al., 2014) Uncertainty regarding the intervention features that aid favorable outcomes
    Support provided Either by means of messages from a health professional (most tinnitus and hearing loss IBIs) Optimum support not identified. No difference in outcomes when guidance is provided and not provided. Rheker et al. (2015)
    Accessibility Responsive on different devices: PC and laptop (iTerapie platform; Vlaescu et al., 2016) Low uptake, partly attributable to poor Internet in more rural areas Beukes, Andersson, et al. (2018)
    Service benefits
    Time effective 2.7 times more time effective than individualized face-to-face care (Beukes, Andersson, et al., 2018); 1.7 times more time effective than group therapy (Jasper et al., 2014; Kaldo et al., 2008)
    Integrated assessments Feature of interventions on the iTherapie system (e.g., iTerapie platform; Vlaescu et al., 2016)
    Able to monitor engagement and weekly log-in Able to send weekly questionnaires to monitor progress (e.g., Beukes, Baguley, et al., 2018) Compliance can be poor and variable Low (e.g., Abbott et al., 2009; Manchaiah et al., 2014)
    Tailoring/individualization possible Able to select certain modules, worksheets, and activities (iTerapie platform; Vlaescu et al., 2016)
    Data protection and anonymity The majority of these interventions were developed on the iTerapie platform utilizing security features such as the use of encryption for data protection (Vlaescu et al., 2016)

    Note. CBT = cognitive behavioral therapy; ICBT = Internet-based CBT.

    Discussion

    Range of IBIs

    A range of IBIs for hearing rehabilitation and vestibular rehabilitation, as well as to address tinnitus distress, have been tested in efficacy and effectiveness trials. The majority of trials have targeted tinnitus in the form of ICBT. A range of different interventions have been applied to those with hearing loss as different stages of their treatment pathway, indicating the extensive rehabilitation required for this population, both before treatment commences, following hearing aid fitting and for experienced hearing aid users. IBIs are a means of providing such extended rehabilitation with limited resources. More uniformity in the intervention created may further promote the use of IBIs for hearing loss. The area with the least development of IBIs was for vestibular disabilities. Those with vestibular disorders often benefit from extensive vestibular rehabilitation. These interventions can also be tailored to the type of vestibular difficulties presenting. Further work in this area of IBIs for vestibular difficulties will be beneficial. Within the included studies, very few effectiveness trials were found. There was only one hearing loss IBI (Malmberg et al., 2017), one vestibular rehabilitation IBI (Geraghty et al., 2017), and three tinnitus IBIs (Beukes, Andersson, et al., 2018; Kaldo et al., 2013; Kaldo-Sandström et al., 2004). More effectiveness trials are required, as well as studies formulating models, to include these studies into routine clinical care.

    Features of Internet Interventions

    Many of the interventions had a strong theoretical framework, being based on CBT or ACT principles. These components addressed everyday difficulties, such as sleep and concentration difficulties (Beukes et al., 2016). They also added an element of tailoring, as some modules were selected only if a problem in that area was evident. Incorporating features known to increase the success of IBIs are patient education, ways of promoting self-efficacy, self-management, and the inclusion of a frequent communication partner to promote social support and self-tailoring (Preminger & Rothpletz, 2016). None of the present interventions explicitly involved communication partners, indicating the need to include this feature during further development work.

    Although IBIs are largely self-help interventions, the option of professional support (guided intervention) can be incorporated, as was the case for the majority of interventions. The communication mode was asynchronous (i.e., offline communication between health care professionals and patients, such as e-mail) or a mixture of these two methods (blended approach). Elements of synchronous guidance (i.e., real-time communication between health care professionals and patients) were incorporated by including initial and final telephone calls. The later interventions are responsive to adapt to different screen sizes and thus accessible from computers or mobile devices (e.g., Beukes, Baguley, et al., 2018). Some had the choice of being viewed online, on DVD, or via PC application (Ferguson et al., 2015).

    From a service development viewpoint, there are features that can streamline processes. One is that assessment measures and/or patient-reported questionnaire measures can be incorporated within the intervention (Vlaescu, Alasjö, Miloff, Carlbring, & Andersson, 2016), creating the opportunity to administer various domains, such as severity of symptoms, quality of life, anxiety, and depression. In this way, patients can be managed in a more holistic manner.

    Challenges

    Although there is a shift toward delivery of health care services enabling self-management (Hood & Friend, 2011), achieving active participation in IBIs is challenging (Pryce, Hall, Laplante-Lévesque, & Clark, 2016; Rolfe & Gardner, 2016). Compliance was particularly low for a pre–hearing aid fitting IBI (Manchaiah et al., 2014) and a tinnitus IBI run in Australia (Abbott et al., 2009). Low compliance may have been partly attributed to the interventions not having been adapted for the population's selected patients (e.g., industrial workers for the tinnitus trial). It is encouraging that many of the IBIs indicated an involvement of service users in the development processes (see Beukes et al., 2016), and more are developing (see Ferguson, Leighton, Brandreth, & Wharrad, 2018; Nielsen, Rotger-Griful, Kanstrup, & Laplante-Lévesque, 2018; Thorén, Pedersen, & Jørnæs, 2016). Such developments may facilitate creating patient-centered IBI solutions tailored for specific populations. Interventions being used in IBIs should carefully consider including design features to improve outcomes and active participation such as those provided by Morrison, Yardley, Powell, and Michie (2012) and Yardley et al. (2016).

    Not all the interventions reviewed had favorable outcomes. Identifying the factors that may have contributed to obtaining these outcomes is important. One method is running a process evaluation in parallel to consider the influence of factors such as the treatment dose delivered (completeness), treatment dose received (exposure), treatment fidelity, treatment adherence and maintenance, satisfaction, and perceived benefit (Beukes, Manchaiah, Baguley, Allen, & Andersson, 2017). The identified factors can then be addressed. Technical barriers may be one barrier preventing active engagement (Beukes et al., 2016). Ensuring that IBIs' offer of personalized rehabilitation strategies is not technically challenging, especially for an elderly population, is an important aspect but poses various challenges (Nielsen et al., 2018). Considering the level of Internet competency for the target population is important, as this may influence engagement and subsequent outcomes. Ensuring the accessibility of the information provided in terms of ease of readability related to levels of comprehensiveness should be also considered (Aldridge, 2004). Accessibility in terms of reading level is also important. Guidelines from the USA Health and Human Services and the American Medical Association recommend that health materials be written in plain language at or below the sixth-grade reading level. Reporting readability has only more recently been reported (e.g., Beukes et al., 2016). Prioritizing access in terms of readability is important as online hearing-related health care information has been reported to be above the recommended grade levels (Laplante-Lévesque & Thorén, 2015; Manchaiah et al., 2018).

    Implications for Audiology Professionals

    Teleaudiological application provided by a qualified provider, primarily developed for patients with limited access to health care, validated for efficacy and cost-effectiveness, with equivalent outcomes to those achieved via FTF measures, is supported by the American Academy of Audiology and the American Speech-Language-Hearing Association. At present, a low clinical adoption of teleaudiology has been identified (Eikelboom & Swanepoel, 2016), despite a positive attitude regarding acceptance of teleaudiology by professionals (Eikelboom & Swanepoel, 2016; Ravi, Gunjawate, Yerraguntla, & Driscoll, 2018; Singh, Pichora-Fuller, Malkowski, Boretzki, & Launer, 2014). The lack of education and training regarding IBI provided in current degree programs could partly contribute to the low clinical adoption of teleaudiology. Provision of guidance online to that in a clinical setting is different, and no standardized training to provide teleaudiology exists. Further education regarding teleaudiology application to students and audiological professionals is crucial to enable further adoption of IBIs. There are additional factors that may hamper the use of IBIs, such as licensing issues related to how IBIs are provided. Some states in the United States require an FTF consultation before offering Internet-based rehabilitation. IBIs are also not always recognized as a reimbursable service by insurance companies. Clear benefits regarding the cost-effectiveness of IBIs will be required prior to acceptance from insurance companies. Moreover, service development models providing both IBI rehabilitation and FTF care need to be designed. Identifying which patients are best suited for IBIs is still challenging. For some, the complexity of their condition may preclude them from undertaking an IBI. To date, outcome predicators from controlled trials with regard to demographic and clinical variables have not been identified (e.g., Andersson, 2016; Beukes, Allen, et al., 2018; Kaldo-Sandström et al., 2004). There may be variables not yet considered that identify which patients are most suited for IBIs. Individuals who find attending clinics difficult due to working full-time, who have transport difficulties, or who find that clinical environments create anxiety have valued the opportunity of receiving health care online (Beukes, Manchaiah, et al., 2018).

    Audiological IBIs can be further developed. In certain areas, there exists a need to extend the application of IBIs to wider populations, such as elderly populations or military veteran populations. Social support for those with hearing-related difficulties is important. The availability of online support groups, together with supportive family and friends, has indicated benefits (e.g., Cummings, Sproull, & Kiesler, 2002). A thematic analysis of tinnitus online discussion forums has indicated the benefits of these forums in terms of sharing knowledge and experiences and having support and finding additional coping strategies (Ainscough, Smith, Greenwell, & Hoare, 2018). Less favorable consequences related to these interventions were also identified, which include negative messages, lack of communication, information overload, and conflicting advice. Further research into the value of these groups in isolation and together with interventional support is required.

    Limitations and Future Directions

    In this article, we present an overview of IBIs in the area of audiology. The main limitation of this study is the limited scope and depth in the literature search as we only used one database for search. Hence, it is worth noting that this article may not include all the studies in this area. Due to the range of studies identified, a systematic review is indicated. Also, in this article, we present the research studies in this area. However, our understanding is limited on where and what kind of teleaudiology services are being offered across different countries. It would be useful to conduct a survey study to understand how teleaudiology is being applied in practice.

    Conclusions

    Numerous audiological IBIs have been developed in recent years focusing on hearing loss, vestibular disorders, and tinnitus. Effective ways of incorporating them into routine hearing health care delivery are required. Such models can only be developed when clinicians, researchers, professional organizations (e.g., American Academy of Audiology, American Speech-Language-Hearing Association), patient organizations (e.g., Hearing Loss Association of America), and other stakeholders work together to promote accessibility of audiological rehabilitation.

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    Author Notes

    Disclosures

    Financial: Eldré W. Beukes has no relevant financial interests to disclose. Vinaya Manchaiah has no relevant financial interests to disclose.

    Nonfinancial: Eldré W. Beukes has no relevant nonfinancial interests to disclose. Vinaya Manchaiah has no relevant nonfinancial interests to disclose.

    Correspondence to Vinaya Manchaiah:

    Editor: Geralyn Schulz

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