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

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.

A call for linguistic and culturally congruent family-centred early hearing detection and intervention programmes in South Africa

Early Hearing Detection and Intervention (EHDI) programmes are recognised as the standard of care for newborns and infants presenting with hearing impairment, globally. However, widespread implementation of these programmes is far from being realised and faces numerous challenges within the South African context. The United Nations' sustainable development goal 3.8 and South Africa's national development plan seek to achieve equitable access to healthcare service, including EHDI. However, healthcare access is a complex concept which encompasses the dimensions: availability, affordability, acceptability and accommodation in healthcare. South Africa has made great progress towards universal implementation of EHDI programmes. Despite this progress, availability and affordability of these programmes are limited and their acceptability has received limited research focus in this context. Furthermore, accommodation of caregivers, as co-drivers of EHDI programmes and ensuring that EHDI programmes are linguistically and culturally congruent have also been overlooked within the South African context.Contribution: Increased robust efforts in improving access through availability and affordability of EHDI programmes are warranted in South Africa. However, improving access to these programmes through availability and affordability initiatives alone will not result in a pragmatic improvement in their accessibility. Acceptability of these programmes and accommodations such as involving caregivers and family members of children with hearing impairment as equal partners in EHDI programmes and being cognisant of their linguistic and cultural needs must be considered.

Family-Centered Early Intervention Deaf/Hard of Hearing (FCEI-DHH): Cultural & Global Implications

This article is the third in a series of eight articles that comprise this special issue on family-centered early intervention for children who are deaf or hard of hearing and their families (FCEI-DHH). It highlights the origins of FCEI-DHH in Western contexts and well-resourced locations and emphasizes the role of culture(s) in shaping FCEI-DHH. This article also cautions against the direct application of the 10 FCEI-DHH Principles presented in this issue across the globe without consideration of cultural implications. Cultural perceptions of decision-making processes and persons who can be decision-makers in FCEI-DHH are explored. Deaf culture(s) and the benefits of exposure to DHH adults with diverse backgrounds are introduced. Structural inequities that impact families' access to FCEI-DHH programs/services and systems, within and among nations and regions, are noted. The need to consider the cultural influences on families is emphasized; this applies to all levels of FCEI, including the development of systems through implementation of supports.

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.

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.

Plurality of perspective: Doctor-parents of deaf children in a low-to middle-income country

OBJECTIVES

Pediatric deafness is an important consideration in neurodevelopment. Early identification and intervention are major factors in seeing that deaf children reach their full potential. Often, it is the medical professionals who themselves have limited knowledge about hearing loss or the consequences of delayed language acquisition. These knowledge gaps can negatively influence the timeous and holistic care that children with hearing loss require. With a dual experiential expertise gained through both parenting children with disabling hearing loss and being medical doctors, the purpose of this study was to better understand the field of pediatric hearing loss through doctors' insights gained as parents.

STUDY DESIGN

Interpretative Phenomenological Analysis was the approach used for this qualitative enquiry. Five South African participants with children between the ages of two and ten years, were selected using purposive sampling and an in-depth semi-structured interview used as the data instrument. Thereafter, three levels of thematic analysis were conducted.

RESULTS

Generally, doctors have limited knowledge of pediatric deafness. Perceptions towards deafness are typically through a medical-model lens, while appreciation of Universal Newborn Hearing Screening is lacking. Through exploring the various gains of parenting a deaf child, participants acknowledged the power of the lived experience in changing their own practice as both parents and practitioners.

CONCLUSION

Doctors need to know more about pediatric deafness. The pathway of care from identification to intervention in South Africa needs revision. Exposure to the lived experience is a powerful means of enabling expert insights to influence such change in a practical and meaningful way.

Perspectives of newborn hearing screening in resource constrained settings

Newborn hearing screening is an effective strategy for early identification of hearing loss in the newborn which result in early intervention and best outcome. However implementing universal screening strategy is a challenge in many resource constrained settings. There are various limitations towards successful implementation of hearing screening program in the developing countries. The cost effectiveness of the screening program also needs to be considered in a resource constrained settings. We attempt to provide a viewpoint that can be potentially helpful for the successful implementation of hearing screening in a resource constrained settings of the developing countries.

The Professional's experience with causes of delay in the diagnosis and management of children with a congenital hearing loss in Libya

The aim of this study was to collect and interpret narrative and observational data from Audiologists and ENT doctors' experiences of delays in the identification and management of congenital hearing loss (CHL) in Libya. This qualitative study sought to explore and understand the reasons behind the delay. Participants were three Audiological Physicians and five Otolarngologists (ENT) working in public hospitals in four large cities in Libya. They were interviewed to explore the causes of such delays and themes were generated from their experiences. All participants revealed that the main causes might be associated with limited facilities and availability of audiology services, lack of awareness and knowledge of the magnitude of the issue and the importance of early detection and intervention for CHL in Libya. In contrast to other developing countries, the financial situation and poverty were not considered to be the main cause in Libya. Furthermore, socioeconomic status of the children's families appears relevant.

'The world is full of magic things, patiently waiting for our senses to grow sharper' (WB Yeats): enhancing resilience among deaf young people in South Africa through photography and filmmaking

This article concerns deaf children and young people living in South Africa who are South African Sign Language users and who participated in an interdisciplinary research project using the medium of teaching film and photography with the goal of enhancing resilience. Specifically, this paper explores three questions that emerged from the deaf young people's experience and involvement with the project: (i) What is disclosed about deaf young people's worldmaking through the filmic and photographic modality? (ii) What specific impacts do deaf young people's ontologically visual habitations of the world have on the production of their film/photographic works? (iii) How does deaf young people's visual, embodied praxis through film and photography enable resilience? The presentation of findings and related theoretical discussion is organised around three key themes: (i) 'writing' into reality through photographic practice, (ii) filmmaking as embodied emotional praxis and (iii) enhancing resilience through visual methodologies. The discussion is interspersed with examples of the young people's own work.

Hearing impairment detection and intervention in children from centre-based early intervention programmes

The study aimed to describe ages at identification and initiation of early intervention (EI) services for children enrolled in centre-based EI programmes in Gauteng, as well as to describe the nature of EI services that the children received. The researchers conducted retrospective record reviews of the EI programme files. In addition, caregivers of eight children identified with hearing impairments and enrolled in centre-based EI programmes in Gauteng completed a newly constructed questionnaire. The caregiver questionnaire produced data pertaining to the child's family demographics, background information and schooling history. Descriptive statistics were used to analyse the data, using frequency distribution and measures of central tendency. None of the children received newborn hearing screening services, thus they were identified late following maternal suspicion of hearing impairment. Late identification of the hearing impairment resulted in suboptimal initiation of EI services. All the children received aural habilitation and/or speech-language therapy services. These findings indicate that there is a great need for the establishment of widespread early hearing detection and intervention programmes that will lead to earlier identification of infant and childhood hearing impairment and timely initiation of EI services.

Communication and school readiness abilities of children with hearing impairment in South Africa: A retrospective review of early intervention preschool records

Background

The national prevalence of hearing impairment in South Africa is estimated to be four to six in every 1000 live births in the public health care sector. An undetected hearing impairment in childhood can lead to delayed speech and language development as well as put the child at risk of not achieving the necessary school readiness abilities that will enable them to achieve academic success. However, through early hearing detection and intervention services, children with hearing impairment can develop communication and school readiness abilities on par with children with normal hearing.

Objective

The aim of the study was to describe communication and school readiness abilities of children who were identified with hearing impairment and enrolled in early intervention (EI) preschools in Gauteng.

Methods

Within a descriptive research study design, a retrospective record review was conducted on files of eight children, ranging in age from 9 years and 7 months to 12 years and 7 months, identified with a hearing impairment and enrolled in EI preschools in Gauteng, South Africa. Descriptive statistics were used to analyse the data, using frequency distribution and measures of central tendency.

Results

Current findings revealed that children with hearing impairment who were enrolled in EI preschools in Gauteng were identified late. This consequently led to delayed ages at initiation of EI services when compared to international benchmarks and the Health Professions Council of South Africa’s (HPCSA) guidelines of 2018. Consequently, participants presented with below average communication and school readiness abilities, which are characteristic of hearing impairment that is identified late.

Conclusions

Transference of current contextually relevant research findings into practice by both the Department of Health and the Department of Basic Education forms part of future directions from this study. This conversion of research findings into service delivery must be conducted in a systematic manner at all levels in these two sectors to facilitate achievement of Early Hearing Detection and Intervention (EHDI), resulting in better communication and school readiness outcomes.

State of deaf children in West Bengal, India: What can be done to improve outcome

OBJECTIVE

Prelingual deafness in children demands urgent action as best outcome is dependent on earliest possible diagnosis and intervention. Objective of this study was to determine age of suspicion, diagnosis, intervention, and outcome in a representative group of deaf children in West Bengal, India, and suggest ways of improving these parameters.

METHODS

In this cross-sectional study, ages of suspicion, diagnosis, intervention and outcome of 303 randomly selected deaf children were elicited from a cohort of 1316 children with deafness identified in an earlier study.

RESULTS

Median ages of suspicion, diagnosis and amplification were 18, 72 and 84 months respectively. Age of suspicion was significantly related to parental education (p < 0.05); age of diagnosis to parental education and socio-economic status (p < 0.001) and children's geographic location (p < 0.01). Following diagnosis, 86% of children received hearing aids but only 6% used their aids consistently; 86% were non-verbal, 12% could communicate with a mixture of speech and gesture and only 2% with speech alone.

CONCLUSION

Current situation of deaf children in West Bengal, and evidence indicates, in much of India, is insupportable. However, widely diverse socio-economic conditions and scarcity of public health infrastructure preclude one solution of the problem for the whole country. In absence of the ideal universal newborn hearing screening, rigorously monitored and costed pilot programs of different models of early detection and intervention using newborn hearing screening, targeted screening and trial of calibrated noisemakers by primary care workers should be tried to see which works best where, so that successful programs can be scaled up over time.

The First Step to Early Intervention Following Diagnosis: Communication in Pediatric Hearing Aid Orientation Sessions

PURPOSE

This preliminary study aimed to explore communication processes and information exchange in pediatric hearing aid orientation (HAO) sessions. Effective information exchange in such sessions is crucial to support appropriate hearing aid use.

METHOD

Using a qualitative sociolinguistic framework, we recorded and analyzed 5 HAO sessions between 2 audiologists and 5 caregivers of children who had just been fitted with hearing aids. We also conducted semistructured interviews with the audiologists and caregivers and analyzed these using content analysis.

RESULTS

By necessity, audiologists provide a significant amount of information about hearing aids to caregivers in HAO sessions. Although caregivers in our study recalled and understood certain points such as the importance of not getting the hearing aids wet, crucial information about insertion and cleaning was often not recalled. Some caregivers misunderstood how the hearing aids would assist their child.

CONCLUSIONS

Caregivers need time to practice and absorb the information given, particularly given the emotional aspects associated with the diagnosis and "switch-on." There is a need to revisit approaches to information giving, which align with the ongoing early intervention process. We offer some suggestions for improving HAO sessions and information giving about hearing aids.

Is hearing impairment associated with HIV? A systematic review of data from low- and middle-income countries

OBJECTIVES

To systematically review evidence on the prevalence and characteristics of hearing impairment among children and adults living with HIV in low- and middle-income countries (LMIC).

METHODS

Articles were identified up to January 2016 through searching four electronic databases. Epidemiological studies conducted in LMIC that explored the association between HIV status and hearing loss, with or without an HIV-uninfected comparison group, were eligible for inclusion. Results were screened and assessed for eligibility, and data were extracted by two reviewers, with discussion in the case of disagreement. Findings were narratively synthesised.

RESULTS

The search identified 638 unique references, of which 21 studies were included in the review, including 3491 people with HIV from 13 LMIC. There was lack of consistency in the definition used for hearing loss, making comparability across studies difficult. Among children with HIV, across the three studies that used a cut-off of >15 dB in either ear, the prevalence of hearing loss ranged from 22 to 37%. Among the three studies that used >25 dB in either ear, the prevalence ranged from 32 to 39%. Among adults with HIV, for the five studies that used a threshold of >25 dB for either ear, the prevalence ranged from 10 to 43%. The prevalence of hearing impairment was significantly higher among people with HIV than in controls in eight of the ten studies that assessed this comparison. Conductive hearing loss was the most common type of hearing loss in children with HIV, while sensorineural hearing loss was more common in adults with HIV. There was a lack of evidence for an association between ART use and hearing loss, although there was some suggestion that late stage of HIV disease or low CD4 count was related to hearing loss. There were concerns about the quality of the studies included in the review.

CONCLUSIONS

The current evidence is suggestive of a high prevalence of hearing loss among people living with HIV compared to people without HIV, or to WHO estimates for the general population. More research is needed to better understand the aetiology of hearing loss in relation to HIV, and whether screening for and treatment of hearing loss can be effectively integrated into HIV treatment services needs further research.

Paediatric diagnostic audiology testing in South Africa

INTRODUCTION

With the increased emphasis on the importance of early identification of paediatric hearing loss within developing countries such as South Africa and Nigeria there has been a recognition of the ethical obligation to ensure access to timely diagnostic and intervention services for children identified with hearing loss; regardless of their geographic or socioeconomic status. There are limited studies on diagnosis of paediatric hearing loss in a developing world context.

OBJECTIVES

The objective of this study was to determine processes used for diagnosis of paediatric hearing loss in South Africa, across the private and public healthcare sectors, and to profile the age of testing for each component of the diagnostic test battery.

METHODS

Diagnostic audiology testing data of 230 children enrolled in an early intervention programme was analysed to profile the reporting of diagnostic audiology testing as well as diagnostic audiology procedures employed. Results were analysed according to province as well as healthcare sector to compare diagnostic services across regions as well as healthcare sectors.

RESULTS

The differences in audiology practice and tests employed with paediatric clients across the regions of Gauteng, Kwazulu Natal and Western Cape indicates that services across regions and across the public and private sector are not equitable. Each region is equally unlikely to complete a full, comprehensive diagnostic evaluation on paediatric clients. The age of testing highlights the increased age of diagnosis of hearing loss.

CONCLUSION

Paediatric diagnostic audiology is a section of Early Hearing Detection and Intervention services that requires attention in terms of the appropriateness of procedures as well as equity of services. Further studies on diagnostic practice and resources in South Africa will provide information on factors that are preventing adherence to international best practice guidelines for paediatric diagnostic audiology.