Short Communication

A Smartphone‑Based Assessment of Hearing Impairment

among Students of a Medical College, Delhi, India‑ A
Cross‑Sectional Study
Mogan KA, Poornima Tiwari, Blessy Joseph, Aabhas Katia, Ayush Kumar, Ankush Chugh
Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Abstract
Introduction: The burden of hearing impairment in India is substantially high, largely preventable, and avoidable. The present study aimed
to estimate the prevalence of hearing impairment using a smartphone-based tool among medical students and to study the factors associated,
including personal audio device usage in a medical college hospital in Delhi, India. Material and Methods: We conducted a cross-sectional
study among undergraduate medical students. The study participants were enrolled via. Stratified random sampling. We assessed hearing
impairment via—HearWHO application with scores ranging from a minimum of 0 to a maximum of 100 with categorization into i) above 75
ii) 50-75 iii) below 50. A p-value less than 0.05 was considered statistically significant. Results: A total of 96 study participants were included,
with the mean age of study participants as 20.3±1.4 years. On assessment with HearWHO, 36 (37.5%) were in the category of score above
75, 51 (53.1%) in score category 50-75, and 9 (9.4%) in score below 50. The overall mean score of the hearing assessment was 68.9±13.4
(Range: 12 to 94). Among the earphone device users, 27.1% do not comply with volume alerts on user devices. Conclusion: Among the
study population, 9.4% of the study participants were likely to be having hearing loss and 53.1% should be screened regularly for hearing
impairment. Addressing hearing loss remains crucial among the young population, especially the medical professionals, which is feasible and
imperative in the current scenario.

Keywords: Earphones, hearing impairment, medical professionals, smartphone, technology

Introduction advances in tools such as smartphone‑based assessment have

Over 430 million people all over the globe require rehabilitation
to address their disabling hearing loss. Globally, one in every
ten people will have disabling hearing loss by 2050 and
over 1 billion young adults are at risk of avoidable hearing
loss due to unsafe listening practices globally. Failure to act
will impact both the health and well‑being of those affected
and financial implications.[1] The prevalence of hearing loss
in South East Asia ranges from 4.6% to 8.8%. The burden of
hearing impairment in India is also substantially high.[2]
The noise‑induced hearing loss remains highly prevalent in
occupational settings and has recently been caused by social
noise exposure such as personal music players.[3] Listening
habits toward loud music may even promote behaviors that
could cause damage to the cochlea and may cause both
temporary or permanent hearing loss.[4] Recent technological
Access this article online
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Website:
www.ijcm.org.in
DOI:
10.4103/ijcm.ijcm_570_22
proved to identify ear diseases and hearing loss with limited
training and resources.[5,6] Although the smartphone applications
were validated, many were not studied independently in a field
setting, and validation studies were desirable for each available
application for hearing assessments.[7]
The World Health Assembly adopted resolution WHA70.13,
urging governments to integrate ear and hearing care into
their national health system framework.[8] Tools such as
“HearWHO” and other technology‑based solutions enable
Address for correspondence: Dr. Mogan KA,
1475, South Extension‑1, New Delhi ‑ 110 003, India.
E‑mail: moganka1994@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
How to cite this article: Mogan KA, Tiwari P, Joseph B, Katia A, Kumar
A, Chugh A. A smartphone‑based assessment of hearing impairment among
students of a Medical College, Delhi, India‑ A cross‑sectional study. Indian
J Community Med 2023;48:196-200.
Received: 02-07-22, Accepted: 12-12-22, Published: 01-02-23

196 © 2023 Indian Journal of Community Medicine | Published by Wolters Kluwer - Medknow
 Mogan, et al.: Smartphone‑based assessment of hearing impairment
screening for ear diseases and hearing loss to be undertaken
in settings with limited training and resources.[9] The use of
technology in hearing health and safe listening has not been
studied systematically.[10]
The majority of Medical colleges managed to switch to online
classes teaching during the COVID‑19 pandemic, further
increasing the chances of earphone usage.[11,12] There is a lack
of the literature on the burden of hearing impairment among
medical students in the Indian context and the applicability of
smartphone‑based screening assessments. Hence, the present
study was conducted to estimate the prevalence of hearing
impairment using a smartphone‑based audiometric tool among
medical students and study the factors associated, including
personal audio device usage in a Medical college hospital, in
Delhi, India.
Methods
We conducted a descriptive cross‑sectional study among
the undergraduate Medical students of a large teaching
hospital in South Delhi, India, in May 2021. It is one of
the prominent institutions under the Ministry of Health and
family welfare, Government of India, catering to around 150
undergraduates per year. Taking the prevalence of 6.3% of
hearing impairment, 95% confidence interval (CI), 80% power,
5% absolute precision, 5% alpha error, and non‑response
rate of 10%, the minimum sample size required was 90
using the formula (Zά/2) 2pq/l2.[13] We conducted a stratified
random sampling, i.e., undergraduates were stratified based
on the year of study, i.e., year 1, 2, 3, and 4. Further, simple
random sampling using Microsoft Excel was performed to
select study participants from each year following probability
proportionate size from each stratum. The sampling frame was
compiled from the list obtained from the academic section of
the Medical College.
The hearing impairment was assessed via the HearWHO
application developed by World Health Organization (WHO).
The app gives the public access to a hearing screener to check
their hearing status and monitor and keep a personalized track
record of their hearing status over time. The app is compatible
with both iOS and Android Devices. The HearWHO app is
based on digits in noise hearing, presenting three digits in
23 sets over various background noise levels. The screening
determines the signal‑to‑noise ratio (SNR), which is indicative
of hearing ability. The test has demonstrated sensitivity
and specificity exceedingly 85%. The score ranges from a
minimum of 0 to a maximum of 100, categorizing into i)
above 75, ii) 50‑75, and iii) below 50. The study participants
with scores less than 50 are likely to have some hearing loss.
We obtained permission from the WHO to use the HearWHO
application. In addition, a semi‑structured questionnaire was
administered to receive a basic demographic profile and to
study factors associated with hearing impairment. We excluded
the participants who were already diagnosed with hearing
impairment as the tool is intended for screening purposes. We
Indian Journal of Community Medicine ¦ Volume 48 ¦ Issue 1 ¦ January-February 2023
installed the HearWHO app on the participant’s device, and
the hearing score was abstracted. We conducted the hearing
assessment in a separate silent room with study participants
using over‑the‑ear headphones or earbuds, following which the
participant’s self‑volume adjustment to ensure all three digits
was heard before the assessment. The inbuilt programming
of the application gives the instructions for assessing the
hearing score. In addition, the personal information, including
age and gender, was saved on their respective devices for
self‑monitoring. We obtained ethical clearance from the
Institute Ethics Committee of the Vardhman Mahavir Medical
College, informed consent, and maintained the subjects’
privacy and confidentiality of information. We minimized
the information bias by following the application instructions
and using over‑the‑ear headphones or earbuds. In addition,
the initial trial self‑volume adjustment over the headphones
further increases the precision of the score.
The data were cleaned for errors and missing values and analyzed
using the Statistical Package for Social Sciences (SPSS)
version 26.0. Two models were constructed in logistic regression
with outcome variables, i.e., binary outcome variable of model
1 as scores above 75 and ≤75 and model 2 as scores below
50 and >50. We presented odds ratio with 95% confidence
interval (CI). Independent t test and ANOVA (analysis of
variance for more than two groups) tests were run to detect
statistically significant univariate differences between the means
of hearing scores among the explanatory variables. A P value
less than 0.05 was considered statistically significant.
Results
There were a total of 96 responses with a non‑response rate of
4%. Of these, the majority were in the age group of 21 years,
with the mean age of study participants as 20.3 ± 1.4 years. The
sample was skewed to males, with 66.7% of respondents being
male (64 vs. 32 females). Among the study participants, 5.2%
had undergone screening for hearing impairment previously.
All the participants were using either headphones or earphones
with a mean duration of 4.9 hours per day (range 45 minutes
to 18 hours). The majority used the audio device for online
classes and lectures (90.6%), followed by music, games, and
calls. Among the study participants, 27.1% do not comply with
volume alerts on user devices [Table 1].
On assessment with the HearWHO application, 36 (37.5%)
were in the category of the score above 75 (80.8 ± 4.7),
51 (53.1%) in score category 50‑75 (65.2 ± 7.5), and 9 (9.4%)
in scores below 50 (41.8 ± 11.8). The overall mean score of
the hearing assessment was 68.9 ± 13.4 [Table 2].
The differences in means of continuous outcome variable,
i.e., HearWHO application scores, between independent
explanatory variables are reported in Table 3. The students
aged more than 20 years of age had higher scores; however,
the difference was not statistically significant. There was a
statistically significant difference in mean hearing scores
between years of study (p = 0.01). The students who have
197
 Mogan, et al.: Smartphone‑based assessment of hearing impairment

complying with volume alert were reported to have higher

Table 1: Basic profile of study participants (n=96)
mean scores, the differences are not significant.
Characteristics Frequency Percentage (95%CI)
The distribution of participants with the outcome variable of
Year of MBBS
First year 25 26 (17.6‑36)
scores above 75 and ≤75 was reported in model 1 and scores
Second year 25 26 (17.6‑36)
below 50 and >50 in model 2. There are no statistically
Third year 25 26 (17.6‑36) significant univariate associations between categorical
Final year 21 22 (14.1‑31.5) explanatory variables such as age, gender, year of study,
Age in completed years screening of hearing impairment, tobacco consumption,
18 9 9.4 (4.4‑17.1) family history of hearing impairment, duration of audio device
19 18 18.8 (11.5‑28) usage, and complying with volume alert with the outcome
20 23 24 (15.8‑33.8) variable of model 1 logistic regression. Similarly, there was no
21 29 30.2 (21.3‑40.4) significant association found in Model 2; however, complying
22 12 12.5 (6.6‑20.8) with volume alert has a significant association, i.e., the study
23 3 3.1 (0.7‑8.9) participants who do not comply with volume alert, while using
24 1 1.0 (0.03‑5.7) audio devices had 6.7 higher odds of scores below 50.
25 1 1.0 (0.03‑5.7)
Sex
Female 32 33.3 (24‑43.7)
Discussion
Male 64 66.7 (56.3‑76) The present study is one among the few studies to study
History of screening for hearing hearing impairment using a smartphone‑based audiometric
impairment tool. In the present study, 9.4% of the study population had
Yes 5 5.2 (1.7‑11.7) scores below 50 who are likely to have hearing loss, and
No 91 94.8 (88.3‑98.3) 53.1% had scores 50 to 75 who should screen regularly for
Family history of hearing loss hearing impairment. The prevalence of hearing loss was 25.1%
Yes 15 15.6 (9‑24.5) in a community study conducted by Garg et al.[14] among
No 81 84.4 (75.5‑91) the general population in Delhi. The higher prevalence was
Duration of headphone use
probably explainable due to the inclusion of the geriatric and
<5 h 44 45.8 (35.6‑56.3)
older adult population. The prevalence of hearing impairment
≥5 h 52 54.2 (43.7‑64.4)
in National data, India, was 6.3%, which is lower than the
Current history of ear infection
present study’s findings.[13] The difference may be due to the
Yes 3 3.1 (0.7‑8.9)
No 93 96.9 (91.1‑99.4)
fact that the national data showed the estimate of the population
Current history of nose and
diagnosed with hearing impairment, while the present study
throat infection predicted the degree of hearing impairment risk based on the
Yes 8 8.3 (3.7‑15.8) grading. In the study results of Kim et al., 94.3% of them use
No 88 91.7 (84.2‑96.3) personal audio devices ranging from 1‑3 hours per day, while
History of head injury in the past in the present study it was 4.9 hours per day on average. The
Yes 9 9.4 (4.4‑17) use of headphones and earphones in the present study was
No 87 90.6 (83‑95.6) higher probably due to the medical lectures being conducted
History of ear surgery in the past online given the COVID‑19 pandemic.
Yes 3 3.1 (0.7‑8.9)
No 93 96.9 (91.1‑99.4) Low hearing scores in almost one‑tenth of students, coupled with
History of tobacco consumption the finding of better scores among those previously screened
Never 14 14.6 (8.2‑23.3) for hearing impairment, suggest that such screening should
Ever 82 85.4 (76.7‑91.8) be included in the medical examination done at the time of
History of current tobacco enrollment. Moreover, the screening may be repeated periodically
consumption as more than half (53%) had scores between 50 and 75.
Yes 5 5.2 (1.7‑11.7)
No 91 94.8 (88.3‑98.3)
In this study, students who did not comply with volume alert
Comply with alert to volume in
while using audio devices had significantly lower hearing scores
audio devices and had 6.7 higher odds of scores below 50. In comparison, the
Yes 70 72.9 (62.9‑81.5) study conducted by Byeon[15] showed that adolescents who used
No 26 27.1 (18.5‑37.1) earphones above the threshold limit had a 4.5‑fold higher risk
of hearing loss. In other literature reviews, there was alarming
screened for hearing impairment prior were reported to have evidence of noise‑induced hearing loss with audio devices.
higher scores, i.e., 81 ± 9, compared to those who had never Long‑term exposure to loud sounds may put them at risk of
undergone screening (68.24 ± 13.3), and the difference is hearing loss.[16,17] The findings indicate a need to reinforce the
statistically significant (p = 0.03). Though the participants warning regarding the harms of ignoring the earphone volume

198 Indian Journal of Community Medicine ¦ Volume 48 ¦ Issue 1 ¦ January-February 2023

 Mogan, et al.: Smartphone‑based assessment of hearing impairment

alerts. There was a significant association with a family history The primary strength of the study is the applicability of an
of hearing loss in the study conducted by McMahon et al.[18] innovative, validated smartphone‑based device to estimate
hearing impairment. Furthermore, probability random sampling
was undertaken to increase the validity and generalizability.
Table 2: Characteristics of HearWHO scores among the
Besides, factors such as audio device usage were compared
study participants (n=96)
with hearing impairment. Identifying individuals with hearing
Hearing n % (95% CI) Mean±SD Minimum Maximum impairment leads to a connection with screening opportunities
category and modifying their risk of developing consequences prior to
Above 75 36 37.5 (27.8‑47.9) 80.8±4.7 76 94 the development of significant loss. The WHO smartphone
50‑75 51 53.1 (42.6‑63.3) 65.2±7.5 51 75 tool empowers the users to screen systematically and educate
Below 50 9 9.4 (4.3‑17.1) 41.8±11.8 12 49 regarding the risk factors. In addition, the tool is feasible to

Table 3: Association of HearWHO score with demographic profile (n=96)

Parameters n (%) Mean±SD of Model 1 (75 and ≤75) Model 2 (50 and ≤50)
Hearing score
Odds ratio (95% CI) Odds ratio (95% CI)
Age
≤20 years 50 (52.1) 66.84±13.71 Ref (1.00) Ref (1.00)
>20 years 46 (47.9) 71.15±12.9 1.04 (0.45‑2.39) 0.27 (0.05‑1.42)
Gender
Male 64 (66.7) 69.41±14.3 Ref (1.00) Ref (1.00)
Female 32 (33.3) 67.91±11.6 1.22 (0.50‑2.96) 0.54 (0.10‑2.77)
Year of study
I 25 (26) 63.58±14.4* Ref (1.00) 0.36 (0.64‑2.09)
II 25 (26) 69.92±11.6 0.79 (0.25‑2.47) 0.17 (0.01‑1.62)
III 25 (26) 67.64±14.4 1.67 (0.49‑5.69) 0.22 (0.02‑2.06)
IV 21 (22) 76.15±9.5 0.43 (0.12‑1.43)
History of screening for hearing impairment
Yes 5 (5.2) 81.0±9.0* Ref (1.00) 0.00
No 91 (94.8) 68.24±13.3 7.37 (0.79‑68.8)* Ref (1.00)
Current history of ear infection
Yes 3 (3.1) 63.6±10.9 Ref (1.00) 0.00
No 93 (96.9) 69.0±13.5 0.00 Ref (1.00)
Current history of nose/throat infection
Yes 8 (8.3) 73.2±10.1 Ref (1.00) 0.00
No 88 (91.7) 65.9±14.6 1.00 (0.22‑4.45) Ref (1.00)
Past history of head/ear injury
Yes 9 (9.4) 71.36±15.6 Ref (1.00) Ref (1.00)
No 87 (90.6) 68.59±13.1 0.81 (0.19‑3.49) 0.81 (0.09‑7.32)
History of head/ear surgery
Yes 3 (3.1) 72.22±15.1 Ref (1.00) Ref (1.00)
No 93 (96.9) 68.55±13.2 0.82 (0.07‑9.47) 0.18 (0.01‑2.31)
Tobacco consumption
Ever 14 (14.6) 66.33±24.3 Ref (1.00) Ref (1.00)
Never 82 (85.4) 68.99±13.1 0.40 (0.10‑1.56) 1.40 (0.16‑12.19)
Current tobacco consumption
Yes 5 (5.2) 67.93±10.6 Ref (1.00) Ref (1.00)
No 91 (94.8) 69.07±13.8 0.40 (0.04‑3.72) 0.38 (0.03‑3.87)
Family history of hearing impairment
Yes 15 (15.6) 62.60±15.75 Ref (1.00) Ref (1.00)
No 81 (84.4) 69.25±13.3 0.80 (0.25‑2.58) 0.32 (0.07‑1.45)
Audio device usage
<5 h 44 (45.8) 68.77±14.7 Ref (1.00) Ref (1.00)
≥5 h 52 (54.2) 69.02±12.31 1.09 (0.47‑2.50) 0.65 (0.16‑2.58)
Comply with volume alert
Yes 70 (72.9) 70.54±10.9 Ref (1.00) Ref (1.00)
No 26 (27.1) 64.50±18.3 0.94 (0.37‑2.39)* 6.70 (1.53‑29.23)*
Outcome variable of Model 1: i) scores above 75 (reference) ii) ≤75, Model 2: i) >50 (reference) ii) scores below 50. *Statistically significant

Indian Journal of Community Medicine ¦ Volume 48 ¦ Issue 1 ¦ January-February 2023 199

 Mogan, et al.: Smartphone‑based assessment of hearing impairment
apply in a high‑risk population, screen regularly, and maintain
records of accomplishment of the hearing scores. However, the
audio device usage pattern for educational and other purposes
was not captured in this study.
It can be concluded that 9.4% of the study participants were
likely to be having hearing loss and 53.1% should screen
regularly for hearing impairment. With most of the young
population listening to online lectures for studies, audio
devices gradually increase, given the COVID‑19 pandemic. It
seems essential to educate about healthy usage of earphones,
coupled with regular screening for hearing impairment among
medical students.
Acknowledgment
Project batch students, May 2021 batch, Vardhman Mahavir
Medical College.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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