Diagnostic accuracy of non-specialist versus specialist health workers in diagnosing hearing loss and ear disease in Malawi

Tess Bright*, Wakisa Mulwafu, Mwanaisha Phiri, Robbert J.H. Ensink, Andrew Smith, Jennifer Yip, Islay Mactaggart, Sarah Polack

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

9 Citations (Scopus)


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.

Original languageEnglish
Pages (from-to)817-828
Number of pages12
JournalTropical Medicine and International Health
Issue number7
Publication statusPublished - Jul 2019
Externally publishedYes

Bibliographical note

Funding Information:
We thank all study participants for their time. We also thank Emmanuel Singano, Prisca Kalinde, Mabel Jasi, Stella Banda, Catherine Kafula and Towera Kameme for their participation in the study, and we are grateful to hearX for technical support throughout the study. Electronic data solutions were provided by LSHTM Open Research Kits (odk.lshtm.ac.uk).

Publisher Copyright:
© 2019 John Wiley & Sons Ltd


  • community health worker
  • diagnostic accuracy
  • epidemiology
  • hearing loss
  • prevalence


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