Institutional review board approval was granted by the Research Ethics Committee, Faculty of Humanities, University of Pretoria (HUM030/0621). Participants were provided with detailed information about the study in their home language, and written informed consent was obtained from all participants before data collection commenced. Participants could keep their hearing aids free of charge once the study ended. Study data were deidentified to ensure privacy and confidentiality.

This study formed part of a community-based service-delivery model previously reported by Frisby et al [25]. This study, however, focuses specifically on the mHealth acclimatization and support program. The study comprised two phases: (1) development of the mHealth acclimatization and support program designed for LMICs and (2) implementation and pilot testing of this program. This study commenced in March 2021 and took place in 2 low-income communities in the Western Cape, South Africa. It used the Bowen et al [47] feasibility study framework with an implementation science approach for developing and piloting a CBR model for providing an mHealth acclimatization and support program. To determine the feasibility of this program, participant responses to illustrative open-ended questions were collected and analyzed. Positive stakeholder opinions and perspectives and hearing aid use were considered indicators of feasibility.

Raw data were recorded in an Excel 2016 (Microsoft Corp) spreadsheet and imported for statistical analysis into the SPSS software (version 27; IBM Corp). Observational descriptive analysis, including mean, frequency counts, and SDs, were determined for quantitative statistics such as participant age, gender, and degree of hearing loss. Qualitative open-ended questionnaire responses were analyzed using inductive thematic analysis with a semantic approach [56]. To ensure trustworthiness and credibility, the first author (CF) applied a rigorous and systematic process to data analysis. The first author (CF) familiarized herself with the data through transcription and by recording the raw data onto an Excel spreadsheet, generated initial codes, and performed a qualitative analysis to identify and categorize broad themes. To enhance credibility and reduce bias, this analysis was independently reviewed and vetted by the last author (DWS), who served as a critical reader. Through this collaborative review process, any potential biases or misinterpretations were addressed, ensuring that the data were accurately represented and that the analysis was robust and reliable.

In total, 20 messages were adapted and developed from the Lexie Hearing application (Lexie Hearing; Table 1). The mean readability score of all English language messages was 85.3 (SD 9.4, range 55-96.5), with a mean grade-level score of 5.4 (SD 0.9, range 4-7).

A total of 19 participants fitted with hearing aids received an mHealth acclimatization and support program over 45 days. Participants’ ages ranged from 48 to 96 (mean 71.7, SD 13) years. Females accounted for 78.9% of participants. Participant hearing status and competence in operating a mobile phone are reported in Table 2. A third of the participants (6/19, 32%) needed assistance to operate a phone. Most participants (15/19, 79%) received the program via WhatsApp, and 21% (4/19) elected to receive this program via SMS text message.

Overall, 14, 7, and 15 participants could be contacted during phone calls 1, 2, and 3, respectively, and all reported using the program (ie, receiving the messages and then reading the messages, listening to the voice notes, or viewing the images). Most participants who could be contacted for phone calls 1, 2, and 3 (n=12, n=6, and n=14, respectively) were satisfied with the hearing aids and program. Four participants had a complaint regarding the hearing aids during the 3 phone calls. This included feedback (n=1), pain (n=1), hearing aids falling out (n=1), hearing aids not working, and confusion regarding the drying kit (n=1). How these hearing aid issues were addressed is reported in Table 3. No participants contacted the CHWs with questions or concerns outside of the 3 phone calls.

Overall, 17 participants took part in the 45-day follow-up and 16 in the 6-month follow-up. All participants reported making use of the program and felt a general sense of support provided by the program. Most participants (11/17, 65%) relied on others in their homes to receive the information as they did not own phones or could not operate a phone independently. Of these participants, 64% (7/11) relied on their children, 18% (2/11) on their spouses, and 18% (2/11) on grandchildren. Participant responses to open-ended questions asked at the follow-up visits are reported in Table 4.

All participants (n=17) reported feeling well supported and that messages were easy to understand. Most participants (14/17, 82%) reported that the program messages covered all questions about their hearing aid. A total of 7 participants reported difficulties performing specific tasks with the hearing aids, including difficulties putting on the hearing aid on (n=3), cleaning the hearing aid (n=3), and changing the batteries (n=1). These reported difficulties were covered by the program messages, and these participants reported that the information provided in the program made these tasks easier. Only 3 of 17 (18%) participants reported that the acclimatization and support program did not answer all their questions (drying kit color change, where additional capsules could be bought, how and when to change the dome of the hearing aid). Almost half (8/17, 47%) of participants reported that they reviewed the program messages several times. Two participants reported that although they did not experience any difficulties, they reviewed all messages as a general reminder of the concepts covered.

Among the 16 participants who participated in the 6-month follow-up visit (Table 4), 14 reported that they were still using their hearing aids. Three participants reported reviewing the messages since the 45-day follow-up. Some general comments the participants made about the acclimatization and support program include “I liked that I could refer back to the messages - for example, how to clean the hearing aid,” “The text messages gave me advice on what to do. I loved them because they are in isiXhosa,” “I am forgetful as a result of my age and often forget things and will ask for the messages to be shown to me again,” and “Initially I struggled but used pictures to help, and now I’m fine.” Participants were asked an open-ended question on their perceptions regarding any improvements that could be made to the program. Although the overall responses were positive, 2 of 16 (13%) participants indicated that additional information might be required to improve the program’s content (expected lifespan of the hearing aids, if a family member could receive the hearing aid should the participant pass away, permanency of their hearing loss, and how long the use of the hearing aids would be necessary). An additional 3 participants reported that improvements could be made to the program. These included increasing the volume of voice notes and increasing the text size on graphical illustrations (n=1), and additional home visits by the CHWs to provide hands-on training on hearing aid use and maintenance to supplement the messages (n=2).

This study implemented and evaluated an mHealth acclimatization and support program for first-time hearing aid users in low-income communities, facilitated by CHWs. The mHealth program aimed to improve first-time hearing aid users’ usage of their hearing aids by providing basic information covering how a hearing aid works, optimal use and care, troubleshooting, and motivational support. The feasibility of the mHealth acclimatization and support program in this study could be ascribed to several factors, including the accessible information with text developed with lower reading grade levels and accessibility of the platforms used to distribute the program. The readability level of information is critical for ensuring accessible health literacy [57,58]. To ensure patient understanding, it is recommended that the content of health care education materials should not exceed a grade level of more than US grade 5 [57,59]. A recent review examining the readability of patient education materials, including brochures and user guides, found that most of the average reading grade level across the studies ranged from 5.05 to 11.4, which exceeds the recommended reading grade levels [58]. The average reading grade level of the English-language messages used in this program was US grade 5.4. The same level was maintained during translation, which may have contributed to participants’ ease of understanding. Furthermore, most of the participants were bilingual in isiXhosa and English. If not, a significant household member was bilingual to ensure that all participants understood the English textual explanations in the graphical illustrations.

Using an mHealth platform is relevant because nearly 5.7 billion individuals globally are predicted to have access to mobile phones by 2025, of which approximately 84% will be smartphones [60]. Although the penetration rate of mobile phones is relatively high and will continue to increase, most (11/17, 64.7%) of the older participants reported that they were either unable to operate a mobile phone independently or did not own a mobile phone. This challenge was addressed through household members receiving the mHealth program and conveying the information to participants. All participants received the same messages on the respective days of the program, which ensured consistency across study participants. Moreover, as the messages were provided via mobile phones, participants were able to revisit messages. Several participants reviewed the program messages multiple times to revisit concepts they may have felt uncertain about or needed reminding of. The option to revisit messages is a benefit as first-time hearing aid users often report difficulty with the vast amount of information provided during a fitting appointment [27]. This program will likely enhance information retention. Additionally, each message targeted only one specific concept of hearing aid use and management. Therefore, if participants had difficulty with one message, they would not fall behind on other concepts.

The positive reports by participants in this study, indicating an experience of being supported by the program, compare well with other studies [25,37,38]. For instance, 88% of hearing aid users who received an education program via DVD or the internet reported positive experiences [61], and 84% of first-time hearing aid users who received an mHealth educational program accessed via the internet reported feeling more confident with hearing aid use and communication [42]. This study is, however, distinct as it is the first mHealth acclimatization and support program offered via messaging platforms and using the community-based hearing rehabilitation framework [62]. A recent review found that mHealth facilitated by CHWs supported and improved patient outcomes when used for education and supplying information [63]. The results of this feasibility study suggest a similar effect on hearing aid acclimatization and support, but further investigations need to determine the contribution of the mHealth support program to hearing aid use and outcomes using controlled studies.

This study demonstrates that mHealth technologies facilitated by CHWs in low-income communities can support the rehabilitation process of hearing aid users and improve hearing aid use. This study also determined that audiologists are not required in the field during the implementation of such a program and that audiologist-led training and remote support via teleaudiology is sufficient. Although the overall responses were positive, it may be beneficial for future studies to consider incorporating additional information on hearing loss and its permanency, the lifespan of hearing aids, how each hearing aid is personalized for the user, usage of a drying kit, and how to replace domes or tubing.

CHWs were assigned several participants and had to track when to send the messages to each participant. Although no errors were reported in this study, this is a barrier to scaling the intervention. Future studies and implementations should employ automated programs to allow for improved scalability and a reduced chance of human error. The graphical illustrations sent via WhatsApp contained textual explanations that were in English. Future research should consider providing all information in participants’ home language. This study did not perform user testing on the graphical illustrations before implementation, which will be useful in future to ensure the appropriateness and clarity of the images, messages, and font style and size. Future research should consider using a pre-post measurement of practical skills needed to use and maintain hearing aids to investigate postintervention changes. Future studies should investigate how cognitive functioning and literacy levels could influence the benefit of such an intervention. This study had a small sample size, and female participants were overrepresented. Furthermore, objective measures were not included to determine if participants accessed the program or hearing aid use. This study made use of observational descriptive analysis for the quantitative data; future research on larger sample sizes will allow inferential statistics. Most importantly, owing to the feasibility nature of this study, the results should be seen as preliminary. Controlled studies are needed to evaluate the outcome and the effect size of such programs. A cost-effectiveness study is needed to determine the usability of such a program in a real-world context.

An mHealth acclimatization and support program for first-time hearing aid users supported by CHWs was adapted for use in LMICs and implemented successfully. Feedback from the hearing aid users was positive, with all participants feeling well supported, and most were still making use of their hearing aids 6 months later. Making use of a real-world sample of participants illustrated that an mHealth acclimatization and support program provided in the home language of the users is feasible and can assist self-management of first-time hearing aid users in LMICs. These results demonstrate the potential for self-management of hearing aids from first-time hearing aid users’ homes. This is particularly relevant in LMICs where, owing to a lack of resources and professionals, opportunities for in-person interactions with hearing health care professionals may be limited. Scalable mHealth support options can facilitate increased access and quality in hearing care. Future research should consider randomized controlled trials to compare hearing aid self-management outcomes with and without the support program.