Participants were audiologists practising in South Africa, recruited through two professional organisations which distributed an invitation and survey link to their respective membership databases. A total of 133 completed surveys were included in the analysis. The majority of respondents were employed in the public health sector (52%; n = 68), followed by the private sector (40%; n = 53) and non-governmental organisations (NGOs) (6%; n = 8). The remaining participants were employed in academic or corporate settings. Among those working in the public sector (n = 68), 46% (n = 32) were based at tertiary hospitals, 28% (n = 19) at district hospitals, 16% (n = 11) at regional hospitals, 4% (n = 3) at community health clinics and 3% (n = 2) at primary healthcare clinics. Participants had a mean of 8.74 years of clinical experience (standard deviation [s.d.] = 7.94; range: 1–35 years).

A self-developed, descriptive survey consisting of 36 questions across three sections was used to collect data. The survey was developed based on WHO recommendations for early hearing detection and intervention programmes (WHO, 2020, 2021b) and existing literature on barriers to NHS implementation in low- and middle-income countries (El-Jardali et al., 2019; Kanji, 2021a, 2022; Kgare & Joubert, 2024; Naidoo & Khan, 2022). The questionnaire included a mix of closed-ended, open-ended and Likert-type questions. The first section gathered demographic information and details about respondents’ clinical experience. The subsequent sections were tailored based on whether participants conducted hearing screenings. For those who performed hearing screenings, the survey explored aspects such as the equipment used, personnel involved, screening sites, recruitment and training of screeners, and overall programme management. For those not involved in hearing screening, the survey examined referral practices and perceived barriers to conducting screenings. The survey underwent a pilot testing phase with three audiologists to assess face validity, item clarity and completion time. Feedback from pilot participants resulted in the rewording of three questions for clarity and the addition of a question on the use of mHealth technology.

Data were collected between March 2022 and July 2022. The survey was distributed using REDCap (Research Electronic Data Capture), a secure, web-based platform designed to support data capture for research studies. The software is licensed by the University of the Witwatersrand. Potential participants received an email from their professional organisation containing a link to the survey, along with a participant information sheet detailing the purpose and nature of the study. At the beginning of the survey, participants were assured of anonymity and confidentiality and were informed that completion of the survey implied consent.

Survey data were exported from REDCap into Microsoft^® Excel^® (for Microsoft 365 MSO – Version 2602) for analysis. Descriptive statistics were used to summarise and analyse the data.

This project was approved by the University of the Witwatersrand Human Research Ethics Committee (Non-medical) (Protocol number: H211015) prior to data collection.

The availability of NHS services varied considerably across South African provinces and healthcare sectors (Table 1). Of the 108 reported NHS services, 49% (n = 53) were provided in the public sector, 44% (n = 48) in the private sector and 7% (n = 7) by non-governmental organisations (NGOs). Gauteng and the Western Cape accounted for the majority of services, contributing 32% (n = 35) and 24% (n = 26), respectively. These two provinces also demonstrated the greatest distribution across all three sectors. In contrast, provinces such as North West (1%), Limpopo (5%) and Mpumalanga (6%) reported fewer services, with several provinces lacking services in the private and/or NGO sectors. Notably, private sector NHS services were absent in Limpopo, Mpumalanga and North West, while NGO involvement was limited to four provinces.

In the public sector, hearing screening is most commonly offered at tertiary-level hospitals (55%; n = 31), followed by district hospitals (21%; n = 12) and regional hospitals (16%; n = 9). Screening services are limited at community-based facilities, with only 4% (n = 2) available at primary healthcare centres and 4% (n = 2) at community health clinics.

Table 2 presents the availability of NHS equipment across the private, public and NGO sectors. The three most commonly used types of equipment, AABR, OAE and tympanometry were similarly distributed across sectors. The public sector reported the highest absolute availability for each (57%; n = 30), followed by the private sector (49%; n = 23). The NGO sector, while representing a small portion of services, reported the highest relative availability of AABR (86%; n = 6), OAE (71%; n = 5) and tympanometry (57%; n = 4). This suggests that although NGOs operate fewer sites, these are generally well-equipped. Use of mobile health (mHealth) technology for hearing screening was limited to only 4% (n = 2) of public sector sites, with no adoption reported in either the private or NGO sectors.

Across all healthcare sectors, audiologists are the primary personnel responsible for conducting NHS, with 85% (n = 40) of private sector sites, 87% (n = 46) of public sector sites and 43% (n = 3) of NGO sites reporting audiologist-led screening (Table 3). In total, 18 sites across all sectors utilised non-audiologists for screening, most of whom were trained dedicated hearing screeners (n = 14). The number of dedicated screeners per site ranged from one to eight, with a mean of two screeners per site. These personnel received a reported average monthly salary of R5400.00 (~$300.00). Notably, at one public hospital, trained parents of Deaf or hard-of-hearing children were engaged as screeners, while one private practice employed a trained receptionist for this role. In a small number of instances, Speech-Language Therapists conducted the screenings. Importantly, all NHS programmes employing non-audiologist screeners were overseen and managed by audiologists, who were also responsible for the initial training of these individuals.

Participants across all sectors reported multiple challenges related to the implementation of NHS programmes (Table 4). The two most frequently cited challenges, common to all sectors, were the lack of parental awareness about the importance of hearing screening and poor follow-up attendance after a refer result. These challenges were reported by 28% (n = 33) and 22% (n = 26) of respondents in the private sector, 16% (n = 28) and 21% (n = 38) in the public sector, and 19% (n = 3) and 25% (n = 4) in the NGO sector, respectively.

Sector-specific patterns were evident. In the private sector, a key concern was the lack of medical aid coverage for hearing screening, reported by 18% (n = 21) of respondents. Other notable issues included time constraints (14%; n = 16) and non-attendance for initial screening appointments (13%; n = 15). In contrast, public sector respondents highlighted operational barriers, including staff shortages (16%; n = 28), time constraints (16%; n = 29) and malfunctioning or uncalibrated equipment (11% each; n = 20 and n = 19, respectively). Although NGO sector participants represented a smaller sample, similar operational challenges were reported, including staff shortages (19%; n = 3), time constraints (13%; n = 2) and a lack of funding (13%; n = 2). Issues such as the absence of quiet screening areas and poor referral systems from lower-level services were only mentioned in the public sector, albeit infrequently.

Twenty-five participants from the private, public and NGO sectors reported that they do not conduct NHS. The most common reasons cited were the high cost of equipment (41%; n = 9), staff shortages in the public sector (32%; n = 7), and broken equipment, also predominantly in the public sector (14%; n = 3).

All audiologists in the private sector who do not offer newborn hearing screening (n = 7) reported referring infants to colleagues who do provide screening services. In the public and NGO sectors (n = 18), infants are typically referred to the nearest healthcare facility where NHS is available. In most cases, the referral destinations were either district hospitals (22%; n = 4) or tertiary-level hospitals (22%; n = 4).

The availability of NHS services remains unevenly distributed across South African provinces, with a significant concentration in urban and economically advantaged provinces such as Gauteng and the Western Cape. These two provinces alone accounted for more than half (56%) of all reported NHS services. In contrast, provinces such as the North West, Limpopo and Mpumalanga are critically underserved, particularly in the private and NGO sectors. This urban-rural divide in NHS coverage reflects broader systemic inequities in healthcare access and human resource distribution (Pillay et al., 2020) and aligns with previous research documenting regional disparities in EHDI implementation across South Africa (Kgare & Joubert, 2024; Khoza-Shangase et al., 2017). Although the public sector provided the greatest number of NHS services overall (49%), these services were predominantly offered at tertiary-level hospitals, with limited integration at primary and community healthcare settings. This centralisation of services presents a significant barrier to timely detection, particularly in rural and underserved communities where access to tertiary care is limited (Olusanya et al., 2004; WHO, 2021a). Decentralisation and integration of NHS into lower-level health facilities remain critical to improving service coverage, accessibility and equity (Kanji, 2022; Kgare & Joubert, 2024; Petrocchi-Bartal & Khoza-Shangase, 2016). Notably, the findings also highlight the potential and growing contribution of non-governmental organisations (NGOs) and public–private partnerships in addressing service gaps, particularly in provinces where state-provided healthcare infrastructure is lacking. Although NGOs accounted for only a small proportion of services, they reported high relative levels of equipment availability, suggesting that such entities can provide well-resourced, targeted interventions. Similarly, public–private partnerships have demonstrated the capacity to extend NHS services into underserved settings by leveraging shared resources and expanded workforce capacity (Joudyian et al., 2021; Kgare & Joubert, 2024). These collaborative models should be further explored and scaled to enhance reach and sustainability, especially in support of achieving the WHO’s 2030 target of increasing NIHS coverage by 20% (WHO, 2021a).

Availability of screening equipment was generally high across all sectors, particularly for AABR and OAE. This aligns with previous findings that these tools are considered the gold standard for objective screening in newborns and infants (Kanji, 2021a; Olusanya et al., 2014). NGOs, while representing a smaller portion of the sample, demonstrated a notably high relative availability of screening equipment, suggesting targeted investment and external donor funding that enable well-equipped service delivery even in otherwise under-resourced contexts. Despite relatively good access to conventional screening equipment, the use of mHealth technologies was limited. Only 4% (n = 2) of public sector facilities reported use of mHealth tools, with no reported use in the private or NGO sectors. This represents a significant missed opportunity, given the mounting global interest in leveraging mHealth for expanding healthcare access in low- and middle-income countries, particularly where geographic and infrastructural barriers exist (Swanepoel & Clark, 2019; WHO, 2021a). Evidence from South Africa and other resource constrained contexts has shown that smartphone-based hearing screening applications can deliver accurate results while significantly lowering costs and logistical demands (Madzivhandila et al., 2024; Swanepoel & Clark, 2019). Given that mHealth screening devices are relatively new to the South African context, further implementation research may be necessary to inform national scale-up efforts, particularly in rural and primary care settings (Madzivhandila et al., 2024).

Most NHS services in all sectors were conducted by audiologists, affirming their central role in the implementation and oversight of EHDI programmes. However, given the shortage and uneven distribution of audiologists in South Africa, particularly in rural provinces and within the public health system (Pillay et al., 2020), reliance solely on audiologists is not sustainable for achieving universal coverage. The inclusion of trained non-audiologist screeners, particularly in the NGO sector, suggests a gradual shift toward task-sharing models. These models, when appropriately supervised and supported, can enhance service delivery in settings with a limited audiology workforce (Eksteen et al., 2019; Kgare & Joubert, 2024; Suen et al., 2019; WHO, 2020). Encouragingly, all non-audiologist screeners in this study were trained and supervised by audiologists, which aligns with global recommendations for maintaining screening quality within task-shifting frameworks (JCIH, 2019).

Participants across all sectors reported a range of challenges affecting the successful implementation of NHS. The two commonly cited issues, poor parental awareness of NHS and failure to return for follow-up, highlight the persistent gap in caregiver education and underscore the urgent need for improved caregiver education. These challenges have been consistently identified in both local and international research as major impediments to effective early hearing detection and intervention (Das et al., 2020; Ehlert & Coetzer, 2020). Caregiver knowledge, beliefs and perceived urgency around hearing loss are well-established determinants of screening follow-up rates. Without targeted public awareness campaigns, many families may not understand the long-term developmental implications of missed or delayed diagnosis, nor the necessity of follow-up appointments when initial screening results are inconclusive or indicate possible hearing loss (Das et al., 2020). In resource-constrained settings such as South Africa, operational barriers further exacerbate these challenges. In the public and NGO sectors, participants reported chronic staff shortages and significant time constraints. These findings are consistent with earlier studies that have documented insufficient audiology posts in the public sector, compounded by hiring freezes and budgetary austerity (Naidoo & Khan, 2022; Pillay et al., 2020). A lack of equipment was also reported, consistent with findings of a recent study that explored the availability of hearing screening equipment at public hospitals (Bhamjee et al., 2022). In contrast, the private sector, while generally better resourced in terms of staffing and equipment, faces unique economic constraints. One prominent barrier identified was the lack of medical aid coverage for NHS services, which limits uptake, a barrier that has been previously highlighted (Das et al., 2020; Theunissen & Swanepoel, 2008). These challenges collectively illustrate the need for sector-specific strategies, including resource investment, advocacy for funding mechanisms, and integration of screening into existing maternal and child health workflows.

Among participants who did not conduct NHS, the most frequently reported barriers were high equipment costs, a lack of staff and broken equipment, particularly in the public sector. These findings are consistent with research in South Africa, which has highlighted capital investment limitations and the impact of austerity-driven hiring freezes on the provision of essential services (Khoza-Shangase, 2021, 2025; Naidoo & Khan, 2022). Despite these barriers, referral practices in the absence of on-site NHS services were generally appropriate. In the private sector, audiologists who did not offer NHS reported referring infants to colleagues within their professional networks. In the public and NGO sectors, referrals were made to the nearest district or tertiary hospitals where NHS services were available. This practice aligns with standard EHDI protocols that emphasise prompt referral following risk identification or failed screening (JCIH, 2019). However, reliance on external referral systems is problematic when geographic proximity, transport availability or service capacity are lacking, conditions commonly encountered in rural and under-resourced communities (Kgare & Joubert, 2024). Strengthening referral pathways and ensuring continuity of care remain vital components of a comprehensive EHDI system (Khoza-Shangase, 2025).

The study has several limitations that should be acknowledged. Firstly, the cross-sectional survey design and recruitment through professional organisations may have led to selection bias, with potentially lower uptake from audiologists in under-resourced or rural areas who may have limited access to professional networks or online platforms. This may have resulted in under-representation of perspectives from critically underserved provinces. Secondly, the data were collected between March 2022 and July 2022 and therefore do not capture any NHS initiatives or policy developments implemented in the subsequent period. Given the rapidly evolving landscape of hearing healthcare in South Africa, more recent developments such as expanded mHealth implementations or new public–private partnerships are not reflected in these findings. Thirdly, the self-reported nature of the survey data may introduce response bias, particularly regarding equipment availability and service coverage.