Early intervention in South Africa: Moving beyond hearing screening

The Otoacoustic Emissions in the Universal Neonatal Hearing Screening: A Scoping Review Update on the African Data (2004 to 2024)

Background: The reported data on African universal neonatal hearing screening (UNHS) practices tend to be quite scarce, despite the developments in hearing screening the last two decades. The objective of this systematic review was (a) to identify the most recent (in a 20-year span) literature information about NHS/UNHS programs in Africa and (b) to provide data on the procedures used to assess the population, the intervention policies, and on the estimated prevalence of congenital hearing loss with an emphasis on bilateral hearing loss cases. Methods: Queries were conducted via the PubMed, Scopus, and Google Scholar databases for the time window of 2004-2024. The mesh terms used were "OAE", "universal neonatal hearing screening", "congenital hearing loss", "well babies", and "Africa". Only research articles and review papers were considered as good candidates. The standard English language filter was not used, to identify information from non-English-speaking scientific communities and groups. Results: Data from 15 papers were considered, reflecting the neonatal hearing practices of nine African states. No country-wide NHS programs were reported. The various screening realities are implemented within big urban centers, leaving the residents of rural areas unassisted. For the latter, proposals based on tele-medicine protocols have been suggested. The data on HL prevalence are also incomplete, but the available data refer to rates from 3 to 360 subjects per 1000. These data cannot be taken at face value but within the small sample size context in which they were acquired. Regarding the causes of HL, very few data have been reported; consanguinity is the most attributed factor, at least in the Sub-Saharan African states. For the majority of the programs, no data were reported on hearing loss prevalence/incidence or on any strategies to restore hearing. Conclusions: The information on the African neonatal hearing screening are quite scarce, and it is an urgent need to convince audiologists from the African localized programs to publish their hearing screening data.

Coalition for Global Hearing Health Hearing Care Pathways Working Group: Guidelines for Clinical Guidance for Readiness and Development of Evidence-Based Early Hearing Detection and Intervention Programs

Editor's Note: The following article discusses the timely topic Clinical Guidance in the areas of Evidence-Based Early Hearing Detection and Intervention Programs. This article aims to discuss areas of services needed, guidance to countries/organizations attempting to initiate early hearing detection and intervention systems. Expert consensus and systematic/scoping reviews were combined to produce recommendations for evidence-based clinical practice. In Ear and Hearing, our long-term goal for the Point of View article is to stimulate the field's interest in and to enhance the appreciation of the author's area of expertise. Hearing is an important sense for children to develop cognitive, speech, language, and psychosocial skills. The goal of universal newborn hearing screening is to enable the detection of hearing loss in infants so that timely health and educational/therapeutic intervention can be provided as early as possible to improve outcomes. While many countries have implemented universal newborn hearing screening programs, many others are yet to start. As hearing screening is only the first step to identify children with hearing loss, many follow-up services are needed to help them thrive. However, not all of these services are universally available, even in high-income countries. The purposes of this article are (1) to discuss the areas of services needed in an integrated care system to support children with hearing loss and their families; (2) to provide guidance to countries/organizations attempting to initiate early hearing detection and intervention systems with the goal of meeting measurable benchmarks to assure quality; and (3) to help established programs expand and improve their services to support children with hearing loss to develop their full potential. Multiple databases were interrogated including PubMed, Medline (OVIDSP), Cochrane library, Google Scholar, Web of Science and One Search, ERIC, PsychInfo. Expert consensus and systematic/scoping reviews were combined to produce recommendations for evidence-based clinical practice. Eight essential areas were identified to be central to the integrated care: (1) hearing screening, (2) audiologic diagnosis and management, (3) amplification, (4) medical evaluation and management, (5) early intervention services, (6) family-to-family support, (7) D/deaf/hard of hearing leadership, and (8) data management. Checklists are provided to support the assessment of a country/organization's readiness and development in each area as well as to suggest alternative strategies for situations with limited resources. A three-tiered system (i.e., Basic, Intermediate, and Advanced) is proposed to help countries/organizations at all resource levels assess their readiness to provide the needed services and to improve their integrated care system. Future directions and policy implications are also discussed.

Early Childhood Development Is Not Enough: In Defense of Children with Developmental Delays and Disabilities and Their Right to Family-Centered Early Childhood Intervention (In the Global South)

The international recognition of the critical importance of the early childhood phase has been firmly established through decades of rigorous research, evidence-based practices, and undeniable evidence of the returns on investment made during this formative period. Consequently, early childhood development has emerged as a top priority on both national and international agendas. This momentum reached a pinnacle in 2015 with the unanimous adoption of the 17 Sustainable Development Goals (SDGs) by the United Nations, which placed a particular emphasis on children under the age of five within the education-focused SDG 4, notably target 4.2, centered on ensuring that all girls and boys are ready for primary education through the provision of accessible "quality early childhood development, care and pre-primary education". However, the Global South reflects the glaring omission of addressing the needs of children at risk of poor development due to disabilities. This paper underscores the imperative for specialized early childhood intervention tailored to young children with disabilities and their families, commencing as early as possible following birth. It advocates for Early Childhood Intervention (ECI) as a service distinct from general Early Childhood Development (ECD), emphasizing the crucial role of families as active partners from the outset. Furthermore, the paper strengthens the case for Family-Centered Early Childhood Intervention (Fc-ECI) through the integration of evidence-based practices and an in-depth description of one such program in South Africa with specific reference to deaf and hard-of-hearing infants and their families. This model will be guided by core concepts outlined in WHO and UNICEF Early Childhood Intervention frameworks. Through this exploration, the paper aims to shed light on the urgent need for inclusive approaches to early childhood development, particularly for children with disabilities, and to advocate for the adoption of Family-Centered Early Childhood Intervention as a cornerstone of global efforts to ensure the holistic well-being and development of all children.

Audiological profile of deaf and hard-of-hearing children under six years old in the "HI HOPES cohort" in South Africa (2006-2011)

BACKGROUND

This study concerns deaf children under six years in the South African HI HOPES Cohort.

OBJECTIVE

To examine their audiological profile, aetiological risk factors for infant hearing loss as well as the relationship between identification, amplification and socio-economic influences.

DESIGN

Using a cohort design, secondary data analysis of a pre-existing dataset demonstrated adequate representation of South African demographic characteristics.

STUDY SAMPLE

A total of 532 deaf and hard-of-hearing infants enrolled in the HI HOPES early intervention programme in three provinces (2006-2011).

RESULTS

The median age of identification of children with bilateral hearing loss (n = 502) was 24.0 months (IQR = 12-36 months). Infants with aetiological risk factors were identified later than those without risk factors, and the latest age of identification (28.5 months) was for those with three aetiological risk factors (n = 42). The median age of amplification was 32 months with 102 children eligible for amplification at 31.1 months still unamplified. Early identification did not imply early amplification, and the more economically advantaged a Province the smaller the gap between ages of identification and amplification.

CONCLUSIONS

In a field with little population-level evidence, the size, and representativeness of this dataset makes a significant contribution to our understanding of infant hearing loss in South Africa.

A systematic scoping review of early interventions for parents of deaf infants

BACKGROUND

Over 90% of the 50,000 deaf children in the UK have hearing parents, many of whom were not expecting a deaf child and may require specialist support. Deaf children can experience poorer long-term outcomes than hearing children across a range of domains. After early detection by the Universal Newborn Hearing Screening Programme, parents in the UK receive support from Qualified Teachers of the Deaf and audiologists but resources are tight and intervention support can vary by locality. There are challenges faced due to a lack of clarity around what specific parenting support interventions are most helpful.

METHODS

The aim of this research was to complete a systematic scoping review of the evidence to identify early support interventions for parents of deaf infants. From 5577 identified records, 54 met inclusion criteria. Two reviewers screened papers through three rounds before completing data extraction and quality assessment.

RESULTS

Identified parent support interventions included both group and individual sessions in various settings (including online). They were led by a range of professionals and targeted various outcomes. Internationally there were only five randomised controlled trials. Other designs included non-randomised comparison groups, pre / post and other designs e.g. longitudinal, qualitative and case studies. Quality assessment showed few high quality studies with most having some concerns over risk of bias.

CONCLUSION

Interventions commonly focused on infant language and communication followed by parental knowledge and skills; parent wellbeing and empowerment; and parent/child relationship. There were no interventions that focused specifically on parent support to understand or nurture child socio-emotional development despite this being a well-established area of poor outcome for deaf children. There were few UK studies and research generally was not of high quality. Many studies were not recent and so not in the context of recent healthcare advances. Further research in this area is urgently needed to help develop evidence based early interventions.

An Integrative Review of Current Practice Models and/or Process of Family-Centered Early Intervention for Children Who Are Deaf or Hard of Hearing

Over the past few decades, there has been an increasing shift toward emphasizing the importance of the child's family taking an active role in the habilitation process through family-centered early intervention (FCEI) programs. Accordingly, the Health Professions Council of South Africa recommends that early intervention services following confirmation of hearing loss must be family-centered within a community-based model of service delivery that is culturally congruent. The aim of this study was to explore and document current evidence reflecting trends in FCEI for children who are deaf or hard of hearing (DHH) by identifying and describing current practice models and/or processes of FCEI for these children. This study describes our first steps in formulating a framework for FCEI for children who are DHH in South Africa. An integrative literature review was conducted. Sage, Science Direct, PubMed, and Google Scholar databases were searched for studies published in English between January 2009 and January 2019 reporting on FCEI programs for children who are DHH. Studies that focused on the following were excluded from the study: speech and language outcomes of children, youth, and adults who are DHH; education for children who are DHH; universal newborn hearing screening; professionals' roles in early hearing detection and intervention; diagnosis of hearing loss; and sign language. Kappa statistics were performed to determine agreement between reviewers. Twenty-two studies were included in the review. Cohen's kappa revealed a substantial agreement (κ = 0.8) between reviewers for data extraction and synthesis in terms of the articles that met the criteria for inclusion in the review. Findings were discussed under 5 themes: caregiver involvement; caregiver coaching/information sharing; caregiver satisfaction; challenges with FCEI; and telehealth. Generally, there is sufficient evidence for FCEI, with caregivers indicating the need for full involvement in their children's care. Methods of caregiver involvement involving caregiver coaching/information sharing need to be culturally and linguistically appropriate, with sensitivities around time and manner. This increases caregiver satisfaction with intervention programs and improves outcomes for children who are DHH. Challenges identified by the studies raise implications for early hearing detection and intervention programs, as well as Departments of Health and Social Welfare. These included logistical challenges, professional-related challenges, and caregiver-related challenges. Various aspects of FCEI have been reported in the review. Findings of these studies have significant implications for the formulation of quality FCEI programs to ensure contextually relevant and contextually responsive care of children who are DHH.

Knowledge and Cultural Beliefs of Mothers Regarding the Risk Factors of Infant Hearing Loss and Awareness of Audiology Services

The aim of the paper is to describe the knowledge of mothers in Durban, South Africa, regarding risk factors of hearing loss in infants and their awareness of audiology services, and to describe their cultural beliefs about the risk factors for hearing loss in infants. A descriptive survey design with quantitative methods of analysis were used. Conveniently sampled mothers (n=102) receiving postnatal care for their infants from eight provincial clinics within Durban consented to participate, yielding a response rate of 48%. A questionnaire was used to collect the data and the Cronbach α was calculated yielding a score of 0.835, indicating good internal consistency and reliability of the questionnaire. Sixty percent of the mothers were aware of risk factors, such as middle ear infections, ototoxic medication and consumption of alcohol during pregnancy. Seventy percent were unaware that NICU/mechanical ventilation for more than 5 days, prematurity, rubella and jaundice are considered risk factors for hearing loss, implying a need to create awareness amongst mothers regarding such risk factors. Sixty percent (n=62) believed that bewitchment and ancestral curses can cause hearing loss. Cultural beliefs were associated with hearing loss, therefore, health professionals need to demonstrate cultural competence when providing audiology services, especially in a culturally and linguistically diverse countries such as South Africa. Although the mothers had an average knowledge about risk factors, two thirds did not know which professional to seek help from. There is a need to create awareness amongst mothers regarding the risk factors of infant hearing loss as well as audiology services in order to facilitate early detection and intervention. There is a need for health professionals to demonstrate cultural competence when working with their patients.

The HI HOPES data set of deaf children under the age of 6 in South Africa: maternal suspicion, age of identification and newborn hearing screening

Background

Identification of deafness before 3 months of age substantially improves the socio-linguistic and cognitive development of deaf children. Existing studies demonstrating the feasibility of newborn hearing screening in South Africa have used small samples unrepresentative of general population characteristics. This study establishes the characteristics of the largest data set of deaf infants and their families in South Africa on which there is baseline and longitudinal data (n = 532); explores its representativeness in terms of socio-demographic features and reports on access to and quality of newborn hearing screening within the sample. It examines specifically the relationship between age of maternal suspicion of childhood deafness and age of identification of deafness by cohort characteristics.

Methods

Secondary analysis, using descriptive and inferential statistics, of a pre-existing longitudinal data set (n = 532) of deaf infants under 6 years of age, and their families, collected as routine monitoring of the HI HOPES (HH) early intervention programme.

Results

The HH cohort is representative in terms of racial profile and private/public health care use but displays slightly higher level of maternal education and slightly lower socio-economic status than national comparators. 102 out of 532 infants had undergone newborn hearing screening, resulting in 29 true positives, 15 of whom would have met the criteria for targeted screening. Later onset deafness does not account for the 73 false negatives. The median age of maternal suspicion (n = 247) of infant deafness was 18 months; the median age of identification of 28 months. Age of identification was unrelated to private/public health care status. The median delay between age of suspicion and age of identification was significantly longer in the public sector (7 m; IQR 0–15 m) compared to the private sector (2 m; IQR 0–8.5 m) (p = 0.035). Age of suspicion was unrelated to level of maternal education. Earlier age of suspicion did not predict earlier identification.

Conclusion

Targeted screening as timely response to maternal suspicion offers a viable means to reduce substantially the age of identification of deafness in South Africa until implementation of newborn hearing screening on a population-wide basis can be justified.

Narrative review of EHDI in South Africa

Background

With 17 babies born with hearing loss every day in South Africa, there is a pressing need for systematic Early Hearing Detection and Intervention (EHDI) services. Progress is being made in offering newborn hearing screening and studies have been conducted to document these processes within South Africa. However, due to the lack of a national and holistic overview of EHDI services to date, an accurate picture of the current status of EHDI within the South African context is required.

Objective

To document and profile what has been published within the field of EHDI in South Africa over the last two decades (Jan 1995–Sept 2014) in order to gain a comprehensive overview of the current status and practice of screening and diagnosis in the field of paediatric hearing loss.

Method

A narrative review of peer-reviewed articles related to EHDI in South Africa was conducted by searching the EBSCOHOST, SCOPUS and JSTOR databases for the period January 1995 to September 2014.

Results

Results indicate that over the last two decades research and publications in the field of EHDI have increased considerably. These publications have revealed extensive knowledge related to paediatric hearing screening and intervention services in South Africa; however, this knowledge seems to be limited primarily to the provinces of Gauteng and the Western Cape. Furthermore, studies pertaining to diagnosis have revealed that, although much has been written on the scientific aspects on tools for diagnosis of hearing loss, there is a lack of comprehensive information on diagnostic protocols and procedures.

Conclusion

Despite the clear progress being made in South Africa in the field of early hearing detection and intervention, there is a need for comprehensive studies on protocols and procedures in diagnosing paediatric hearing loss. Finally, the narrative review revealed a clear need to ensure that development and growth in the field of EHDI is a national priority and extends beyond the two provinces currently showing growth.

National survey of paediatric audiological services for diagnosis and intervention in the South African private health care sector

OBJECTIVE

A national survey of early hearing detection and intervention services was undertaken to describe the current status of diagnostic and intervention services in the South African private health care sector.

METHODS

All private hospitals with obstetric units (n = 166) were surveyed telephonically. The data was integrated with data collected from self-administered questionnaires subsequently distributed nationally to private audiology practices providing hearing screening at the respective hospitals reporting hearing screening services (n = 87). Data was analysed descriptively to yield national percentages and frequency distributions.

RESULTS

Average reported age at diagnosis was 11 months. Most participants (74%) indicated that less than 20% of infants fitted with hearing aids received amplification before the age of 6 months. Most (64%) participants indicated that the average period between confirmed diagnosis and hearing aid fitting was 1 month, on par with international benchmarks. Only 16%-23% of participants included all diagnostic procedures recommended by the Health Professions Council of South Africa's 2007 position statement for minimum diagnostic test batteries for infants and young children.

CONCLUSIONS

Diagnosis of hearing loss, hearing aid fitting and audiological intervention is delayed significantly in the South African private health care sector. Improved services should include integrated systematic hospital-based screening as part of birthing packages with diagnostic referral to specialist paediatric audiologists for accurate assessment and management of patients in a timely manner.

Congenitally deaf children's care trajectories in the context of universal neonatal hearing screening: a qualitative study of the parental experiences

The objective of this study is to examine the early care trajectories of congenitally deaf children from a parental perspective, starting with universal neonatal hearing screenings. The analysis using a three-dimensional care trajectory concept is aimed at developing a basic typology of postscreening care trajectories. Children with severe/profound hearing loss, registered in the Flanders' (Belgium) universal neonatal hearing screening program, born between 1999 and 2001. Thematic content analysis of qualitative data collected retrospectively from participant's parents. Two basic types of care trajectories emerged; based on differences in care-use in the phase of further diagnosis and related parental experiences. Subtypes resulted from events related to cochlear implantation. Five trajectory phases were identified: screening, further diagnosis, care and technology, cochlear implantation, and reduction of care and were characterized by specific parental experiences such as confusion, disbelief, disappointment, and uncertainty. Those experiences relate to care professionals' acts and communication and the child's functional evolution. Early care interventions could benefit from coordinated transition between phases, parent support throughout the care trajectory, and a broad approach to deafness in professionals' communication.

Early hearing detection and intervention in South Africa

Early hearing detection and intervention programs have become the standard of care to ensure optimal outcomes for infants with hearing loss, their families and society at large. The overwhelming majority of infants with congenital or early-onset permanent bilateral hearing loss are however born in developing countries like South Africa where services are scarce and awareness poor. Despite its comparatively well-developed economic and reasonably developed health care infrastructure in sub-Saharan Africa, limited information on infant hearing loss and the status of early hearing detection and intervention has been available for South Africa. Recently however, an increasing number of initiatives and reports have highlighted the extent of infant hearing loss and the status of identification and intervention services offered in the country. This report provides a review of the available evidence on infant hearing loss and the status of current early hearing detection and intervention services in South Africa.