Abstract
Background: Public awareness of auditory pathologies, has been explored in the literature. However, there is limited evidence regarding public awareness of middle ear pathologies and their risk factors in South African communities.
Objectives: The aim of this study was to describe public awareness regarding middle ear pathologies and their associated risk factors in the community of Giyani, Limpopo province, South Africa.
Method: A quantitative cross-sectional survey design was conducted among 94 adults aged 18 years and older living in Giyani, Limpopo province. A questionnaire was used to collect data. Descriptive statistics was used to summarise the data, while a Chi-squared test was used to determine if there is any association between awareness and independent variables with categorised outcomes.
Results: Adults aged between 18 and 65 years participated in this study. Most participants were aware of aural itchiness (71.3%) and pain (35%) as symptoms related to middle ear pathologies. The use of cotton buds (51.1%) and other illnesses (35.5%) were primarily reported as risk factors for middle ear pathologies. There were varied responses with regard to awareness of which professionals manage middle ear pathologies, indicating a general lack of awareness. No statistically significant association was found between the dependent and independent variables (p > 0.005).
Conclusion: The study indicated a general lack of public awareness regarding middle ear pathologies and their associated risk factors among Giyani community.
Contribution: The study raises implications for public awareness campaign that educates communities about middle ear pathologies, risk factors and social determinants of health associated with these pathologies.
Keywords: awareness; middle ear pathologies; risk factors; primordial prevention, South Africa.
Introduction
Public awareness of auditory pathologies is a topic of scholarly importance, especially in the context of preventive audiology. Such awareness helps communities to recognise the condition of interest, including their symptoms and associated risk factors. Resultantly, if communities are aware of health-related conditions, this can significantly improve early identification and interventions (Khoza-Shangase, 2022), especially in the context of low- and middle-income countries (LMICs) where resources to manage these conditions are lacking (Fagan & Jacobs, 2009; Pillay et al., 2020). While several studies have explored public awareness of various auditory pathologies such as hearing loss (Alanazi & Al Fraih 2021; Alshehri et al., 2019; Joubert et al., 2017), there is limited evidence on public awareness of middle ear pathologies. The dearth of evidence regarding public awareness of middle ear pathologies is concerning given that the World Health Organization (WHO) has reported that approximately 700 million people live with middle ear pathologies (WHO, 2021).
In LMICs, the prevalence of middle ear pathologies is also reported to be significantly higher, accounting for 30% of the total global prevalence (WHO, 2021). In South Africa, the prevalence of middle ear pathologies has also been reported to be high (Ramma & Sebothoma, 2016; Sebothoma & Khoza-Shangase, 2022). The persistence of middle ear pathologies can result in a number of other problems such as hearing loss. Mulwafu et al. (2016) reported that 36% of the hearing loss in LMICs results from untreated middle ear pathologies. The WHO has reported that approximately half of individuals with untreated acute middle ear pathologies will develop chronic suppurative otitis media (CSOM) (WHO, 2021), which often requires specialised services such as those offered by ear, nose and throat (ENT) specialists. Choi and Park (2015) also noted that untreated middle ear pathologies can cause facial paralysis and brain problems.
While subtle or less severe form of middle ear pathologies can be treated successfully at the primary level care, services to effectively treat chronic middle ear pathologies and middle ear sequalae are extremely limited (Fagan & Jacobs, 2009). Indeed, the scarcity of these specialised services poses significant challenges for people living in rural and township areas to access them. This can result in a significant delay in receiving hearing healthcare service, affecting the identification and intervention of middle ear pathologies. In addition, limited access to specialised services may affect help-seeking behaviour (Mtimkulu & Khoza-Shangase, 2023), resulting in community members resorting to readily available methods that may be hazardous for hearing health (Joubert et al., 2017).
Public awareness can play a crucial role in preventive audiology, particularly in the early identification and intervention of middle ear pathologies. The WHO (2018) emphasised the importance of raising public awareness in order to facilitate early identification of hearing health conditions, such as middle ear pathologies. Creating public awareness may influence policymakers to implement strategies at primary and primordial level of care (Khoza-Shangase, 2022). At the primary level of care, public awareness may focus on ensuring that communities have the necessary information for simple preventive strategies, promoting health and seeking hearing health for early identification and intervention (Chadha, 2013). Primordial level of care focuses on reducing risks at the population level (Khoza-Shangase, 2022). While the latter may be difficult to achieve, especially in resource-constrained environments with high burden of diseases (Moroe, 2022), public awareness may influence national policy to address the issues that cause middle ear pathologies to persist in the community.
Given the importance of public awareness data about audiological services and auditory pathologies, this study intends to extend the knowledge by investigating public awareness of middle ear pathologies, their associated symptoms and risk factors in a community of Limpopo province, South Africa. The study hypothesises that the community of Giyani in Limpopo province has a higher awareness of middle ear pathologies.
Aim and objectives
The aim of this study was to describe public awareness of middle ear pathologies in the community of Giyani, Limpopo province, South Africa. The objectives were to: (1) describe the awareness of symptoms associated with middle ear pathologies in community of Giyani, Limpopo province; (2) describe the awareness of risk factors associated with middle ear pathologies in community of Giyani, Limpopo province; (3) Describe awareness of healthcare professionals responsible for middle ear assessment and management and (4) determine the association between symptoms and/or risk factors and other demographic factors.
Research methods and design
Study design
A quantitative cross-sectional research survey design was used to investigate public awareness of middle ear pathologies, associated symptoms, risk factors and information needs of the communities. Quantitative research designs are useful in collecting numerical data (Watson, 2015) and using statistical methods to examine the relationship between variables such as demographic characteristics of the participants and awareness of middle ear pathologies (Irwin et al., 2014).
Setting
This study was conducted in Limpopo province, one of the nine provinces in South Africa, which has approximately 6 million people (Statistics South Africa, 2022). In this province, audiological services and audiologists are limited (Pillay et al., 2020), with only 4% of the health sector in Limpopo providing audiological services (Maluleke, 2021; unpublished). There are many socioeconomic challenges in the province, including high levels of unemployment and poverty, low literacy and educational levels (Stats SA, 2022; Tambe et al., 2023). As a result, the community of Giyani was selected as the study setting because it represents a typical South African rural area with myriads of challenges and scarcity of hearing health services.
Study population and sampling strategy
A probability systematic random sampling strategy was employed to recruit participants (Polit & Beck, 2010). In a systematic random sampling strategy, participants are selected based on a system of intervals in a numbered population (Bhardwaj, 2019). For the purpose of this study, simple systematic random sampling strategy was used to select every third home in Giyani community. This type of sampling strategy has previously been used in audiology survey research (Joubert et al., 2017; Kisten et al., 2022). This sampling strategy has several benefits, including moderate costs, high internal and external validity, and ease of verification (Acharya, et al., 2013). Within homes, the researcher asked at least one individual who met the inclusion criteria to participate. Inclusion criteria involved adults aged 18 years and above who were part of the visited homes. Participants were excluded if they were ill on the day of the survey. Of the approximately 26 000 homes in the study population, and using a confidence level of 95%, a power of 80% and a margin of error of 5%, the estimated sample size was approximately 380. However, a total of 94 adults in 94 homes were surveyed.
Data collection
Data collection was conducted using a self-administered questionnaire. This questionnaire consisted of 5 sections and a total of 15 items (questions). The sections included the demographic information of the participants, awareness of the symptoms related to middle ear pathologies, awareness of professionals responsible for assessment and management of middle ear pathologies, and awareness of risk factors for middle ear pathologies. The items (questions) on the questionnaire were primarily closed-ended in nature, with an option of ‘other’ for those who wanted to provide more information. This questionnaire was developed based on previous research (Alanzi & Fraih, 2021; Berardino et al., 2013; Joubert et al., 2017), but were modified to suit this specific research. The questionnaire was piloted with five adults using the same procedure as the main study. This process allowed the research to determine the feasibility of the questionnaire, including the language used. Some community members and leaders were also asked to review the questionnaire and commented on the linguistic and cultural appropriateness of the questions. The questionnaire was then administered to participants who volunteered to participate and signed the consent form. For participants who were literate, the researcher (second author) provided the questionnaire for self-completion. For participants who could not read, the researcher read the statements or questions and options aloud, allowing them to select the most appropriate options. However, for participants who could not write, the researcher administered the questionnaire reading the statements and allowing the participants to choose the most appropriate answer. The researcher administered the questionnaire by asking questions on the questionnaires. Data collection took approximately 4 weeks to complete.
Data analysis
Raw data were imported into an Excel spreadsheet (Microsoft Office 360) and then converted to STATA software version 15.2 for analysis. Data cleaning was performed by dropping any missing values and unnecessary variables. Descriptive analysis was then conducted to summarise all the data (Pagan et al., 2022). Frequencies and percentages for all categorical data were used. Inferential statistics was used to determine if there were any associations between the dependent variables (e.g. awareness of middle ear pathologies) and independent variables such as demographic information. Because the outcomes of the dependent and independent variables were categorised, a Chi-squared test was used to establish if this association exists, under the research hypothesis that there is association between awareness of middle ear pathologies and certain independent variables, with significance level set at P < 0.005.
Ethical considerations
The community targeted comprised approximately 26 000 homes. Before this study was conducted, ethics clearance was obtained from the Human Research Ethics Committee (HREC) (reference number STA_2023_29) of the University of the Witwatersrand, Johannesburg, South Africa. Permission to conduct the study was sought from the Giyani municipality. Potential participants were informed about the study via word of mouth by community leaders and other community members. Flyers were also distributed at strategic points where it was visible to community members. The municipality was provided with a detailed information letter that provided an overview of the study, including the nature and purpose of the study, eligibility criteria of adults aged 18 years and above, and the possible duration of the study. Community leaders were also informed about the details of the study. Because homes were randomised, community members were not asked to indicate their participation before the study began. The researcher entered a home using a randomised process set for this study and asked if they would like to take part in the study. Consent to participate was obtained after participants in the home understood the details of the study and agreed to participate. Obtaining informed consent was not an issue, as the researcher spoke the language of the community (O’Sullivan et al., 2021).
Results
Ninety-four adults (n = 94) participated in the study. A little over half (57%) of the participants were males, while 43% were females, with no statistically significant difference between the two groups (p > 0.005). Majority of the participants (91.5%) spoke Xitsonga, which is the predominant language of the community. Half of the participants (50%) had attained some tertiary education, while the rest had variety of education levels (Figure 1). Figure 2 shows the age group distribution of the participants, with most participants aged ranging between 26 and 35 years.
 |
FIGURE 1: The education level distribution of the participants. |
|
 |
FIGURE 2: The age group distribution of the participants. |
|
Objective 1: Describe the awareness of the symptoms of middle ear pathologies among the community
Table 1 shows the responses of the participants with regard to the awareness of symptoms associated with middle ear pathologies. About 71.3% indicated that itching, pain in the ear (35.1%), discharge (pus) (4.3%) and feeling of fullness (13.8%) were symptoms related to middle ear pathologies. When participants were asked if they were aware of other individuals with symptoms related to middle ear pathologies, 35.1% indicated they knew some with itching ear, painful ears (32.3%), discharge ears (13.8%) and only a few were aware of people experiencing a feeling of fullness (8.5%) in the ear. Some participants (21.2%) indicated that those who had presented with symptoms related to middle ear pathologies were friends, family members (35.1%) or community members (12.8%).
| TABLE 1: Awareness of middle ear pathologies’ symptoms. |
Objective 2: Descriptions of awareness regarding risk factors related to middle ear pathologies
Table 2 shows the risk factors associated with middle ear pathologies. About 3.2% of the participants were aware that second-hand smoking is a risk factor for middle ear pathologies, while 6.4% and 18.1% were aware of overcrowding and trauma as risk factors, respectively. Majority of the participants (51.1%) were aware that the use of cotton buds can contribute to the development of middle ear pathologies. Some participants (35.2%) indicated that some illnesses may be risk factors for middle ear pathologies.
| TABLE 2: Risk factors for middle ear pathologies. |
Objective 3: Description of awareness of professionals responsible for middle ear assessment and management
Figure 3 shows the distribution of the professionals who assess and manage middle ear pathologies. Almost half (45.7%) indicated that general medical practitioners (GPs) assess and manage middle ear pathologies. About 28.6% and 25.7% indicated that they were aware that otorhinolaryngologists (ENTs) and audiologists, respectively, assess and manage middle ear pathologies.
 |
FIGURE 3: Distribution of knowledge of professionals who assess and manage middle ear pathologies. |
|
Objective 4: Association between demographic characteristics and awareness of middle ear pathologies
Table 3 and Table 4 show a distribution of the association measurements between the demographic characteristics of gender and level of education, and awareness of middle ear pathologies (p > 0.005). Chi-squared test indicated that there was no association between any of the variables measured.
| TABLE 3: Association between gender and symptoms of middle ear pathologies. |
| TABLE 4: Association between level of education and symptoms of middle ear pathologies. |
Discussion
The purpose of this study was to investigate and describe public awareness of middle ear pathologies, symptoms associated with middle ear pathologies and risk factors among community members residing in Giyani, Limpopo province. Although previous studies have described public awareness of other auditory pathologies such as hearing loss and demonstrated that there is a general lack of awareness of auditory pathologies (Alnuman & Ghnimat, 2019; Joubert et al., 2017; Mahomed & Panday, 2024), this is one of the first studies that described awareness of middle ear pathologies and related risk factors.
Community members were generally aware of symptoms associated with middle ear pathologies. Participants were mostly aware of itchiness and pain as the main symptoms related to middle ear pathologies. Very few participants reported feeling of fullness and discharge as the symptoms related to middle ear pathologies. These findings were not surprising given that itchiness and pain seem to be some of the common symptoms for middle ear pathologies, indicating an onset of the pathology (Martin & Clarke, 2019). In a study conducted in Nigeria, Musa et al. (2015) found that just over 50% of the participants presented with ear pain and itchiness as a major complaint. Similar studies have also indicated that ear itchiness is a common symptom among adult population (Olajide et al., 2015; Vallur et al., 2021).
Few participants were aware of other people presenting with or complaining of symptoms related to middle ear pathologies. About 32.3% indicated that they were aware of other people who presented with pain, while 13.8% were aware of people presenting with discharging ears. These findings were not surprising given that people who present with pain and/or discharging ears can easily be seen (Gaddey et al., 2019), as they constantly scratch their ears or/and complain about the symptom, especially if they are close friends and family members. Furthermore, people who experience middle ear symptoms such as pain or ear discharge may report these symptoms to family members or friends.
Awareness of risk factors associated with middle ear pathologies was varied, but generally poor among the community members. Participants in this study were mostly aware of the use of cotton buds (51.1%) and ‘other illnesses’ (35.15%) as risk factors. However, participants did not specify which illnesses contribute to the development of middle ear pathologies because this information was also not elicited from the participants, which requires further exploration. Several studies have indicated that medical conditions such as human immunodeficiency virus (HIV), which are epidemic in LMICs (UNAIDS, 2022), are associated with middle ear pathologies and its related symptoms (Khoza-Shangase & Anastasiou, 2020; Sebothoma & Khoza-Shangase, 2020; Van der Westhuizen et al., 2013).
This study also showed that community members in Giyani are not aware of health professionals who assess and manage middle ear pathologies. Less than 30% of the participants indicated that audiologists assess middle ear, while approximately 46% of the participants reported that general practitioners assess and manage middle ear pathologies. These findings are consistent with a study by Joubert et al. (2017) who indicated that majority of the communities are not aware of audiologists. Not knowing or being aware of hearing health professionals can lead to delayed identification and intervention of middle ear pathologies (Sebothoma & Khoza-Shangase, 2022), resulting in permanent auditory damage with the potential to significantly affect the quality of life (Swain, 2022) and incurring high costs for assessment and management (McDaid et al., 2021; Thai et al., 2022).
The findings of this study indicate that community members, particularly in underserved areas, are not aware of the symptoms associated with middle ear pathologies and the risk factors related to middle ear. Information deficit regarding middle ear pathologies was also evident among the participants. Lack of public awareness has implications for early identification and intervention of middle ear pathologies (Sebothoma & Khoza-Shangase, 2022). Literature has indicated that when communities are not aware of and have information deficits about auditory pathologies and treatment options, they may resort to hazardous methods (Joubert et al., 2017). Therefore, providing tailor-made awareness campaigns may help communities to seek hearing health and prevent the sequalae of untreated middle ear pathologies.
The present findings further provide evidence for the need of effective preventive audiology strategies, especially in LMICs where resources are generally scarce. While the WHO suggests that prevention of middle ear pathologies must focus on early identification to prevent the development of chronic otitis media (WHO, 2021), current authors argue that effective management of middle ear pathologies should involve a primordial preventive strategy. These strategies must aim at averting risk factors for middle ear pathologies. Middle ear pathologies have been associated with risk factors related to social determinants of health (Delacy et al., 2020). Therefore, in line with the sustainable development goal, whose intentions are to address social determinants of health (Stats SA, 2023), public awareness campaigns may play a crucial role in educating the society, addressing some of these risk factors (Pazhayapisharath & Maruthy, 2023). In addition, government may also need to implement public health policies to reduce risk factors associated with middle ear pathologies.
Limitations
Despite the important evidence presented in this current study, there are some limitations that require findings to be interpreted with cautions. One important limitation for this study is small sample size, which has the potential to affect generalisation of the findings. This study was also conducted in one community in a single province, which has slightly different demographics and other socioeconomic factors than other provinces within the country and other countries. There were further methodological limitations. Participants were not asked to provide detailed information about their awareness of middle ear pathologies because of the use of a quantitative research. Instead, participants were given mostly closed-ended questions. A qualitative study could be used in future research to allow participants to provide detailed information about their awareness of middle ear pathologies. While the sampling strategy used in this study is relatively strong, those who were not found in their homes may have been excluded from participation. Future studies should focus on addressing the limitations of this study.
Conclusion
Middle ear pathologies remain high and continue to rise especially in LMICs (WHO, 2018). This current study indicated that despite the high prevalence of middle ear pathologies and the multiplicity of risk factors, many community members surveyed were generally not aware of the symptoms and risk factors of middle ear pathologies and had varied responses regarding the professionals responsible for dealing with these pathologies. While studies have indicated the importance of awareness campaigns (Joubert et al., 2017; Mukara et al., 2017), current authors argue for public awareness campaigns that focus on primordial care such as addressing social determinants of health that are associated with middle ear pathologies (DeLacy et al., 2020).
Acknowledgements
The authors would like to thank the participants who took part in this study.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
S.B. and B.N. conceptualised the study and contributed to the methodology. B.N. collected the data. S.B. supervised the project. S.B. and B.N. analysed the data. S.B. wrote the original article. S.B. and B.N. reviewed and edited the article.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
The data that support the findings of this study are available on request from the corresponding author, B.S.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
References
Acharya, A.S., Prakash, A., Saxena, P., & Nigam, A. (2013). Sampling. Why and how of it? Indian Journal of Medical specificities, 4(2), 330–333.
Alanazi, A.A., & Al Fraih, S.S. (2021). Public awareness of audiology and speech language pathology in Saudi Arabia. Majmaah Journal of Health Sciences, 9(2), 36–51. https://doi.org/10.5455/mjhs.2021.02.005
Alnuman, N., & Ghnimat, T. (2019). Awareness of noise-induced hearing loss and use of hearing protection among young adults in Jordan. International Journal of Environmental Research and Public Health, 16(16), 2961. https://doi.org/10.3390/ijerph16162961
Alshehri, K.A., Alqulayti, W.M., Yaghmoor, B.E., & Alem, H. (2019). Public awareness of ear health and hearing loss in Jeddah, Saudi Arabia. South African Journal of Communication Disorders, 66(1), a633. https://doi.org/10.4102/sajcd.v66i1.633
Berardino, F., Forti, F., Iacona, E., Orlandi, G.P., Ambrosetti, U., & Cesarani, A. (2013). Public awareness of ear and hearing management as measured using specific questionniare. European Archives of Oto-Rhino-Laryngology, 270, 449–453.
Bhardwaj, P. (2019). Types of sampling in research. Journal of Practice of Cardiovascular Science, 5, 157–163.
Chadha, S. (2013). Increasing community awareness of ear and hearing health. Community Ear & Hearing health, 10(13), 1–12. https://doi.org/10.56920/cehh.83
Choi, J.W., & Park, Y.H. (2015). Facial nerve paralysis in patients with chronic ear infections: Surgical outcomes and radiologic analysis. Clinical and Experimental Otorhinolaryngology, 8(3), 218–223. https://doi.org/10.3342/ceo.2015.8.3.218
DeLacy, J., Dune, T., & Macdonald, J.J. (2020). The social determinants of otitis media in Aboriginal children in Australia: Are we addressing the primary cause? A systematic content review. BMC Public Health, 20(492), 1–9. https://doi.org/10.1186/s12889-020-08570-3
Fagan, J.J., & Jacobs, M. (2009). Survey of ENT services in Africa: Need for a comprehensive intervention. Global Health Action, 2(1), 1–7. https://doi.org/10.3402/gha.v2i0.1932
Gaddey, H.L., Wright, M.T., & Nelson, T.N. (2019). Otitis Media: Rapid Evidence Review. American Family physician, 100(6), 350–356.
Irwin, D.L., Pannbacker, M., & Lass, N.J. (2014). Clinical research methods in speech-language pathology and audiology (2nd edn.). Plural publishing.
Joubert, K., Sebothoma, B., & Kgare, K.S. (2017). Public awareness of audiology, hearing and hearing health in the Limpopo Province, South Africa. South African Journal of Communication Disorders, 64(1), a557. https://doi.org/10.4102/sajcd.v64i1.557
Khoza-Shangase, K. (2022). Preventive audiology: Ramping up efforts towards an ear-and-hearing healthy nation. In K. Khoza-Shangase (Ed.), Preventive audiology: An African perspective (pp. 1–20). AOSIS Book.
Khoza-Shangase, K., & Anastasiou, J. (2020). An exploration of recorded otological manifestations in South African children with HIV/AIDS: A pilot study. International Journal of Pediatric Otorhinolaryngology, 133, 109960. https://doi.org/10.1016/j.ijporl.2020.109960
Kisten, J.D., Tlou, B., & Dlungwane, T.P. (2022). Utilization of rehabilitation services at a public health facility in KwaZulu-Natal. Global Journal of Health Science, 14(4), 1–19.
Mahomed, H., & Panday, S. (2024). Awareness, attitudes and perceptions of students towards leisure noise in Durban, South Africa. South African Journal of Communication Disorders, 71(1), a1040. https://doi.org/10.4102/sajcd.v71i1.1040
Maluleke, L.L. (2021). Access to public ear and hearing health care services in the Limpopo Province: Geographic location and user experience. Unpublished undergraduate research report, University of the Witwatersrand.
Martin, F.N., & Clarke, J.G. (2019). Introduction to Audiology (13th edn.). Plural Publishing.
McDaid, D., Park, A.l., & Chadha, S. (2021). Estimating the global costs of hearing loss. International Journal of Audiology, 60(3), 162–170. https://doi.org/10.1080/14992027.2021.1883197
Moroe, N.F. (2022). Early detection and management of occupational and environmental noise. In K. Khoza-Shangase (Ed.), Preventive audiology: An African Perspective (pp. 213–233). AOSIS.
Mtimkulu, T.K., & Khoza-Shangase, K. (2023). Barriers and facilitators influencing hearing help-seeking behaviors for adults in a peri-urban community in South Africa: A preventive audiology. Frontiers in Public Health, 11, 1095090. https://doi.org/10.3389/fpubh.2023.1095090
Mukara, K.B., Lilford, R.J., Tucci, D.L., & Waiswa, P. (2017). Prevalence of middle ear infections and associated risk factors in children under 5 years in Gasabo District of Kigali City, Rwanda. International Journal of Pediatrics, 2017, 4280583. https://doi.org/10.1155/2017/4280583
Mulwafu, W., Kuper, H., & Ensink, R.J.H. (2016). Prevalence and causes of hearing impairment in Africa. Tropical Medicine and International Health, 21(2), 158–165.
Musa, T.S., Bemu, A.N., Grema, U.S., & Kirfi, A.M. (2015). Pattern of otitis externa in Kaduna Nigeria. Pan African Medical Journal, 21, 165. https://doi.org/10.11604/pamj.2015.21.165.5577
O’Sullivan, L., Feeney, L., Crowley, R.K., Sukumar, P., McAuliffe, E., & Doran, P. (2021). An evaluation of the process of informed consent: Views from research participants and staff. BMC Trials, 22, 544. https://doi.org/10.1186/s13063-021-05493-1
Olajide, T.G., Usman, A.M., & Eletta, A.P. (2015). Knowledge, attitude and awareness of hazards associated with use of cotton bud in a Nigerian community. International Journal of Otolaryngology and Head & Neck Surgery, 4(3), 248–253. https://doi.org/10.4236/ijohns.2015.43042
Pagan, M., Gauvreau, K., & Mattie, H. (2022). Principles of biostatistics (3rd edn.). CRC Press.
Pazhayapisharath, I.C., & Maruthy, S. (2023). Help-seeking behaviour of parents of children with hearing loss in India. A qualitative study. International Journal of Audiology, 1–9. https://doi.org/10.1080/14992027.2023.2272557
Pillay, M., Tiwari, R., Kathard, H., & Chikte, U. (2020). Sustainable workforce: South African Audiologists and Speech Therapists. Human Research Resources for Health, 18(47). https://doi.org/10.1186/s12960-020-00488-6
Polit, D.F., & Beck, C.T. (2010). Generalization in quantitative and qualitative research: Myths and strategies. International Journal of Nursing Studies, 47(11), 1451–1458. https://doi.org/10.1016/j.ijnurstu.2010.06.004
Ramma, L., & Sebothoma, B. (2016). The prevalence of hearing impairment within the Cape Town Metropolitan area. South African Journal of Communication Disorders, 63(1), a105. https://doi.org/10.4102/sajcd.v63i1.105
Sebothoma, B., & Khoza-Shangase, K. (2020). Middle ear pathologies in adults living with human immunodeficiency virus: A systematic review. Annals of Otology, Rhinology & Laryngology, 129(8), 821–828. https://doi.org/10.1177/0003489420909847
Sebothoma, B., & Khoza-Shangase, K. (2022). Preventing middle ear pathologies in the South African context: A proposed programmatic approach. In K. Khoza-Shangase (ed.), Preventive audiology: An African perspective (pp. 93–109), AOSIS Books.
Statistics South Africa. (2022). Mid-year population estimates 2022. Retrieved from https://www.statssa.gov.za/publications/P0302/P03022022.pdf
Statistics South Africa. (2023). Sustainable development goals: Country report 2023. Retrieved from https://www.statssa.gov.za/MDG/SDG_Country_report.pdf
Swain, S.K. (2022). Psychosocial impact of chronic otitis media on quality of life – A review. Journal of Indira Gandhi Institute of Medial Science, 9(2), 106–110. https://doi.org/10.4103/jigims.jigims_31_23
Tambe, B.A., Mabapa, N.S., Mbhatsani, H.V., Mandiwana, T.C., Mushaphi, L.F., Mohlala, M., & Mbhenyane, X.G. (2023). Household socio-economic determinants of food security in Limpopo Province of South Africa: A cross sectional survey. Agriculture & Food Security, 12, 19. https://doi.org/10.1186/s40066-023-00424-6
Thai, A., Aaron, K.S., Kaufman, A.C., & Maria, P.L.S. (2022). Long-term health utilization and outcomes in chronic suppurative Otitis Media. Otolaryngology-Head and Neck Surgery, 167(2), 341–349. https://doi.org/10.1177/01945998211050626
Vallur, S., Raghavan, A., Jagdeeswaran, V.U., & Kumar, P.G. (2021). Evaluation and management of ear itching: Our experience. International Journal of Otorhinolaryngology and Head and Neck Surgery, 7(10), 1617–1623. https://doi.org/10.18203/issn.2454-5929.ijohns20213895
Van der Westhuizen, Y., Swanepoel, D.W., Heinze, B., & Hofmeyr, L.M. (2013). Auditory and otological manifestations in adults with HIV/AIDS. International Journal of Audiology, 52(1), 37–43. https://doi.org/10.3109/14992027.2012.721935
Watson, R. (2015). Quantitative Research. Nursing Standard, 29, 44–48. https://doi.org/10.7748/ns.29.31.44.e8681
World Health Organization. (2018). Addressing the rising prevalence of hearing loss. Retrieved from https://iris.who.int/bitstream/handle/10665/260336/9789241550260-eng.pdf?sequence=1
|
Hide
Show all
Email this article (Login required)
