Embedding routine hearing health checks within existing Meals on Wheels services – A protocol for the SOUND-BITES Program pilot study

Figures
Abstract
Introduction
There is a high prevalence of undiagnosed and untreated hearing loss among older adults. Due to finite resources, task shifting to trained non-specialists is a strategy to improve equity of access to hearing health care. This pilot study aims to implement and evaluate a novel model of hearing care known as the SOUND-BITES program. This will leverage evidence-based mobile health technologies (Arclight otoscopy and Sound Scouts hearing screening app) and partnerships with Meals on Wheels New South Wales and Master of Clinical Audiology students.
Methods
Citation: Tang D, Turner J, Eze U, Newall J, Sinha K, Mee C, et al. (2026) Embedding routine hearing health checks within existing Meals on Wheels services – A protocol for the SOUND-BITES Program pilot study. PLoS One 21(7): e0354082. https://doi.org/10.1371/journal.pone.0354082
Editor: Rohit Ravi, Manipal Academy of Higher Education, INDIA
Received: April 7, 2026; Accepted: July 2, 2026; Published: July 14, 2026
Copyright: © 2026 Tang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.
Funding: B.G., J.N., K.S., D.T., C.O. NSW Smart Sensing Network https://www.nssn.org.au/grand-challenge-fund The NSSN did not play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. B.G., J.N., K.S., D.T., C.O. Cochlear-Macquarie University Joint Fund https://www.cochlear.com/au/en/home https://www.mq.edu.au/ Cochlear Ltd did not play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. B.G., J.N., K.S., D.T. are staff members at Macquarie University. Individuals responsible for administering the grant at the University did not play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
One in five people have hearing loss globally and this prevalence is expected to rise to one in four by 2050 due to ageing demographics [1]. Despite the availability of effective diagnostic tools and hearing device interventions, adults delay seeking help for their hearing loss by an average of 8.9 years [2]. This delay is caused by numerous barriers including hearing loss-related stigma; hearing screening not being systematically implemented in adults; and lack of public awareness and prioritisation of hearing loss [3]. When left untreated, hearing loss is associated with an increased risk of loneliness, depression, frailty, and falls [4–10]. Hearing loss in midlife (18–64 years) is also suggested to be the single largest modifiable risk factor for a future dementia diagnosis [11]. Early detection of hearing loss and appropriate interventions can prevent these associated adverse effects in older people [3,12]. These interventions can range from hearing devices such as hearing aids and cochlear implants to practical environmental modifications like reducing background noise and using tablecloths and carpet to minimise reverberations [13]. However, the benefits of these interventions cannot be realised if hearing loss goes undetected, and constraints around the availability of and access to hearing healthcare specialists goes unaddressed.
The use of trained nonspecialist providers to close the gap in healthcare access and improve outcomes in vulnerable communities, is a growing approach in both low to middle- and high-income countries [14,15]. This ‘task shifting’ from specialist providers to non-specialist delivered care has been identified by the World Health Organisation as a key strategy to ensuring equitable access to hearing care [16]. The other advantage of this approach is improved quality and cultural competence of hearing service delivery [16]. Evidence supports the benefits of task shifting, with similar outcomes related to disability-adjusted life years averted [17] while being cost-effective and scalable [18].
In hearing health care, there is an opportunity to explore task shifting to audiology students. Beyond closing the hearing healthcare gap, this opportunity presents as an enhanced learning experience for the students to allow for reflection on the link between course content and practice [19], as well as an interprofessional education experience as students work together in the community to provide hearing healthcare to clients [20]. These types of experiential learning are associated with benefits in improved academic outcomes, subject matter understanding, critical thinking and problem solving, collaborative practice patterns as well as interpersonal and personal development [19,20]. They are also a particularly useful opportunity for students to interact with older adult clients, a population group who have an increasing prevalence of hearing loss as they age [21]. This kind of intergenerational connection between younger and older adults has been explored in the research and found to promote intrapersonal development between the two generations and more positive attitudes towards older adults by the younger generation [19,22]. In Australia, there are audiology courses in each state and the development and implementation of intergenerational programs that can enhance student learning experiences and access to hearing healthcare are warranted.
Beyond the involvement of audiology students, mobile health (mHealth) digital technologies can support effective task shifting in hearing health care through easy-to-use equipment that does not require extensive training to operate. Existing mHealth technologies have enabled trained non-specialists to provide hearing screening [23] and diagnostic testing on the go comparable to that of hearing specialists in a clinic [24], using automated testing procedures with quality controls like noise-level monitoring. An example of such technology is the Sound Scouts tablet-based app to screen hearing loss. The initial app gamified speech-in-quiet, speech-in-noise, and tones-in-noise tests and achieved sufficiently high specificity and sensitivity to provide hearing screening in children [25]. The Sound Scouts team have recently adapted this app to include an automatic audiometer which was found to produce valid and reliable hearing thresholds with appropriate calibration of the Sennheiser HD 300 headphones [26]. Training of nonspecialists to administer the app outside of audiology clinics is a strategy worthy of exploration to make hearing screening more accessible and support earlier intervention in this population. Sound Scouts has strong potential as a tool to train audiology students to screen for hearing loss in older people as it has already enabled over 230,000 hearing checks by non-specialist parents and teachers in children.
Further to this, examination of other ear issues like eardrum abnormalities or excess earwax provides more a in-depth understanding of potential hearing loss. However, acquiring training and equipping users with traditional otoscopes can present a practical and financial barrier to the successful task-shifting of hearing care. To overcome this financial barrier, a low-cost, solar-powered pocket otoscope (Arclight) has been developed and tested in both low to middle- and high-income countries [27,28]. In a comparative mixed-methods analysis, Arclight was equally effective in objective diagnostic performance and time to make a diagnosis compared to a traditional otoscope. Where cost presents a significant barrier to training and equipping for hearing healthcare, Arclight offers an affordable alternative that maintains full functionality.
Within communities around the world, Meals on Wheels is a trusted service known for low-cost meal deliveries to older adult clients and a strong reliance on volunteers to support their operations. In Australia, the Meals on Wheels New South Wales (NSW) branch has approximately 14,000 volunteers serving 4,500,000 meals annually to over 22,000 clients. With the organisation’s trademarked slogan “More Than Just a Meal”, Meals on Wheels provides a range of services which includes wellbeing checks performed by trained volunteers at every meal delivery [29]. Currently, the Meals on Wheels wellbeing check does not include a hearing health check (hearing screening and otoscopy). Embedding routine hearing checks using Sound Scouts and Arclight, and education on hearing loss within existing Meals on Wheels services, offers a holistic and low-cost approach to providing support for vulnerable older adults at increased risk of hearing loss.
In the proposed study, we will partner with Meals on Wheels NSW, Sound Scouts, the Arclight project team, as well as Master of Clinical Audiology students, to deliver a co-designed, novel model of hearing care outside of a clinical setting. The aim of this study is to pilot this model of care, known as the SOUND-BITES program, across Meals on Wheels sites in metropolitan Sydney to evaluate its acceptability, feasibility and preliminary efficacy.
Materials and methods
Study design
This pilot study aims to implement and evaluate the SOUND-BITES program using a mixed-methods approach. Ethics approval has been obtained by the Macquarie University Human Research Ethics Committee (ID: 16818) on 11 December 2025. A co-design process involving focus groups, workshops and interviews with staff, volunteers and clients from Meals on Wheels was conducted to inform the design of this pilot study. A separate manuscript is in preparation to present the details of the co-design process.
Research participants
The research participants will be clients from Meals on Wheels NSW and their household members. Clients will be recruited across eight Meals on Wheels NSW sites involved in the pilot study in metropolitan Sydney. These include Parramatta Food Services, The Village Chef, Cumberland Food Services, Holdsworth Street Community Centre, Liverpool Meals on Wheels, Bankstown Food Services, Myrtle Cottage, and Nepean Food Services. Based on discussion with Meals on Wheels NSW, household members such as a spouse, would be included to support the reach and impact of SOUND-BITES. It was also determined that a feasible target sample size for this study would be 60 volunteers and 600 clients and household members across these locations, with every volunteer recruited, supporting the hearing checks of 10 research participants (clients and/or household members).
Master of clinical audiology students
The opportunity to take part in this research study will be presented as a clinical placement option for Master of Clinical Audiology students at Macquarie University. Based on preferences and availabilities of students, they will be allocated to the study by the University Clinical Placement Supervisor.
A summary of the roles and contributions of the Meals on Wheels clients and household members, volunteers and Master of Clinical Audiology students is shown in Table 1.
Volunteer and student training program
In-person training will be provided to both volunteers and students involved in the study. For volunteers, they will participate in a 3-hour training course that will cover:
- General education about hearing health
- Overview of the hearing health check using the Sound Scouts app and Arclight device
- Overview of the hearing check feedback given to clients and/or household members
- Overview of the client and/or household member hearing health education
- Administrative procedures that volunteers need to follow to deliver the SOUND-BITES program. This includes information about participant identification numbers, confidentiality and recording of data/information.
The training serves to raise awareness about hearing health among the volunteers and allows themselves to familiarise with the SOUND-BITES processes. During this pilot study, volunteers are not expected to perform any of the hearing health checks. At the conclusion of the training, the volunteers will complete a brief, anonymous questionnaire to capture demographic information and one question about their experience using a computer, tablet or smartphone to capture familiarity with technology use.
For the Master of Clinical Audiology students, they will participate in a 1.5-hour training course. As the students will be performing the hearing health checks in this pilot study, their training is more practical and builds on their existing clinical training. Therefore, it will cover:
- Overview of Meals on Wheels services and the role they play in the community and the value of community-delivered models of hearing care
- Overview and practice conducting a hearing health check using the Sound Scouts app and Arclight device
- Practice providing hearing check feedback to Meals on Wheels clients and/or household members based on the Sound Scouts app and Arclight outputs
- Practice providing client and/or household member education about hearing health
- Administrative procedures that the students need to follow to deliver the SOUND-BITES program. This includes information about study ID’s, confidentiality, data collection and safety procedures.
SOUND-BITES program delivery
At the end of the visit, clients and/or household members will be given a survey to complete within two weeks in their own time. The survey will take approximately 15–20 minutes to complete and will include questionnaires on demographics, medical history, hearing loss, hearing handicap, falls history and quality of life. Participants will be provided with a reply-paid envelope to return the survey to Meals on Wheels volunteers during subsequent meal delivery runs. The service coordinators at each Meals on Wheels site will then post the envelopes and surveys to the Macquarie University Research Team for data entry into REDCap. Overall, it is proposed that Meals on Wheels volunteers will be involved with baseline hearing health checks across two to four half day shifts of approximately four hours each, two full day shifts of approximately 6.5 hours each or a combination of half and full day shifts, up to a maximum of 16 hours. The audiology students will be involved in four to ten half day shifts, or two to six full day shifts up to a maximum of 40 hours as required for their clinical placement.
SOUND-BITES program outcomes measures
A range of outcome data will be collected through the SOUND-BITES program. This includes clinical data from the Arclight otoscopy examination and Sound Scouts hearing screening test results; quantitative data from the baseline and 6-months post-program surveys and qualitative data from the 4-weeks post-program client and/or household member and volunteer interviews. Each of these outcome measures are described in more detail below.
Clinical data
Clinical data will be captured in a REDCap form. Using Arclight, the otoscopy data will capture observations about the ear canal and ear drum, presence of earwax, ear infection, exostoses and foreign objects. Any other relevant observations can be noted (S1 Appendix). The audiometric data obtained using the Sound Scouts hearing screening app will capture hearing thresholds for each ear at 500, 1000, 2000 and 4000 hertz, down to 20 decibels hearing level. Upon completion of the hearing screening test, the suggested hearing status (normal hearing or potential hearing loss) will be documented. Participants suggested to have a hearing loss will be provided referral details as described earlier.
Quantitative data
A survey will be administered at baseline and 6-months post-program. It will capture demographics, medical history, falls history and responses to the Hearing Handicap Inventory for the Elderly – Short Form (HHIE-S) [37] (primary outcome), The Line tool (hearing intervention readiness) [38], Speech, Spatial and Qualities of Hearing Scale 12 (SSQ-12) [39], and EuroQol (EQ-5D-5L) [40] (Table 2). In addition, the 6-month post-program questionnaire will evaluate post-program help-seeking behaviours. That is, for participants who sought help for their hearing, they can complete questions related to who they consulted with about their hearing loss, their reasons for seeking help, and specify any outcome/s of seeking help such as receiving a hearing aid. For participants who did not seek help for hearing loss identified during the SOUND-BITES program, they will be asked about their reasons for not seeking help and about any intentions for future help-seeking.
Qualitative data
Participating Meals on Wheels clients and/or household members and volunteers will be given the opportunity to participate in an optional audio-recorded one-on-one interview. Participants will be given the option of a telephone interview or online interview using Zoom based on their preference and accessibility needs. For the clients and/or household members, this interview would be scheduled after their hearing health check and involve a mix of multiple-choice questions to evaluate the quality of the overall program, the hearing health check and the education component as well as open-ended questions to reflect on the most useful component of the program and feedback for improvement (S2 Appendix). For the volunteers, their interview would be scheduled at the end of the program when no additional client hearing health checks are needed. These interviews will ask questions around the perceived value of the SOUND-BITES program, comfort and capability to deliver the program with and without the Master of Audiology students, and feedback to improve the program (S3 Appendix). Qualitative insights will inform the acceptability and feasibility of SOUND-BITES (primary endpoints).
Analyses
Descriptive statistics including summarising binary and categorical outcomes (e.g., help-seeking behaviours) using frequency and percentages will be used to describe data collected at baseline and 6-months post-program. Means and standard deviations or median and interquartile ranges will be used to summarise continuous outcomes, e.g., quality of life scores. Chi-squared test or Fisher’s exact test will be applied to compare binary outcomes and independent two sample t-tests for continuous outcomes. The primary endpoints of this pilot study include the acceptability rate of the program and help-seeking among participants (feasibility). These endpoints will be estimated with 95% confidence intervals. Generalised linear models will be fit to investigate differences at baseline and 6-months post-program in, e.g., change in attitudes to loss of hearing and hearing handicap (HHIE-S) scores. Adjustments will be made for potential confounders including age and sex. Economic evaluation using incremental cost of hearing screening will be measured using the EQ-5D-5L scale, which is also a cost-utility analysis instrument.
Audio-recorded interview data from participating clients and/or household members and volunteers will be transcribed using intelligent verbatim in Microsoft Word. Each transcript will be manually checked by a research team member against the audio recording for accuracy. Cleaned transcripts will be returned to the respective participant who will be given two weeks to review the transcript and provide any corrections or additional information. Finalised transcripts will be imported into the latest version of NVivo and through deductive content analysis, coded into the Theoretical Domains Framework (TDF) [41]. The TDF is an ideal framework as it is commonly used to evaluate the implementation of interventions. Prior to coding, the research team will develop a coding guideline to increase the reliability of coding between the two researchers who will be involved in this process (i.e., coders). These coders will then familiarise themselves with the participants’ responses in the transcripts, consider the relevance of the responses to definitions of the TDF domains and then attribute the responses to the most relevant domain/s. The text coded to the TDF domains should reflect an overarching theme. Throughout the coding process, the two coders will meet to discuss their codes to reach an agreement. A third researcher will be engaged if consensus between the two coders is not achieved. Data analysis and data collection via interviews will occur concurrently to determine the point of data saturation. This is the point where the research team does not identify new insights about the SOUND-BITES program from the interviews [42]. According to a systematic review evaluating sample sizes for saturation in qualitative research, saturation is reached after 9–17 interviews [42].
Status and timeline
This study has commenced recruitment of Master of Clinical Audiology students on 01/03/2026. No Meals on Wheels volunteers or clients and/or household members have been recruited into the study yet and no data has been collected. Participant recruitment is expected to be completed by 12/10/2026. Full data collection is anticipated to be completed by 30/04/2027 with subsequent phases dedicated to data cleaning, analysis and generation of meaningful results. Preliminary results are expected by 01/09/2027 and these may be shared at relevant scientific conferences. Full study outcomes will be submitted for peer-reviewed publication upon completion.
Discussion
Hearing loss is a global priority with a financial burden of US$1 trillion per year [43] strategies to increase access to hearing healthcare could significantly alleviate some of this burden. In Australia, task shifting to Meals on Wheels NSW volunteers and Master of Audiology students presents an untapped opportunity to improve access to and management of hearing health for vulnerable older adults. Moreover, the partnership with Sound Scouts and the Arclight team leverages existing evidence-based and user-friendly mHealth technologies to facilitate the upskilling of these trained non-specialists. The valuable knowledge that will be gained from this pilot study will aid in identifying best practices, developing standard operating procedures, and determining the most effective way to deliver and evaluate the SOUND-BITES program on a wider scale.
SOUND-BITES is a promising strategy to not only increase timely identification and education about hearing loss in older adults but will also enable them to live in their own homes with dignity, independence, and in optimal health. However, this pilot study is not without limitations. It has been designed to assess feasibility and acceptability and therefore may not be powered to detect significant changes in quantitative outcomes. As hearing checks are conducted in Meals on Wheels client homes, environmental factors such as background noise, will expectedly vary from home to home and may affect the results of the checks. There may also be challenges with navigating audiology student availability as student involvement is restricted to a 32-week clinical placement period. Moreover, training will need to be provided for every new placement student joining the project and consideration to develop pre-recorded training content may be needed for ongoing sustainability. Similar considerations may also be required if there is a high turnover of Meals on Wheels volunteers or regular intake of new volunteers. Nonetheless, this pilot study will serve to identify the limitations of SOUND-BITES to guide further refinement and will provide the foundation for conversations with the broader Meals on Wheels network and other audiology programs to roll-out the program across other states and territories in Australia. Findings from this pilot study will be disseminated through peer-review journals and conferences as well as community networks.
Supporting information
S1 Appendix. SOUND-BITES hearing assessment data collection.
https://doi.org/10.1371/journal.pone.0354082.s001
(DOCX)
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