Hearing loss (HL) in children is a serious but often overlooked public health issue in low-resource areas, causing major delays in development and education. Globally, an estimated 34 million children live with hearing loss (World Health Organization [WHO], 2025), with projections indicating that more than 2.5 billion people could be affected by 2050 (WHO, 2021). In low- and middle-income countries (LMICs), particularly in sub-Saharan Africa, most children with hearing loss are neither diagnosed nor treated and do not get the help they need (Abdalla & Omar, 2011; Mahomed-Asmail et al., 2016; Waterworth et al., 2022). This is largely because of a severe shortage of ear, nose and throat (ENT) specialists, audiologists and hearing services, as well as low awareness and health literacy about ear and hearing care (Mahomed-Asmail et al., 2016; Mulwafu et al., 2017; WHO, 2021). Hearing loss in children impacts language and cognitive development, academic performance, social inclusion, quality of life and future employability, and they often have lower reading scores, need special education and are more likely to repeat classes (Le Clercq et al., 2020; Lieu, 2020; WHO, 2025). Early identification of hearing loss is key to implementing effective hearing care and requires accessible hearing screening for the detection of those who are at risk (WHO, 2025). School-based hearing screening programmes have been recommended as a practical and cost-effective first step in resource-constrained environments (Bright, 2011; Dawood et al., 2021). Such programmes utilising digital hearing screening can detect both temporary and permanent hearing losses and facilitate timely management of preventable causes such as impacted earwax and middle-ear infections. Studies from South Africa have demonstrated the feasibility and value of school-based hearing screening programmes (Govender et al., 2015; Mahomed-Asmail et al., 2016; Phanguphangu, 2017; Pierce & Stemela-Zali, 2025). A person is said to have hearing loss if they cannot hear as well as someone with normal hearing (WHO, 2025). WHO defines hearing with reference to hearing threshold levels of 20 dB or better in both ears (WHO, 2025). Furthermore, disabling hearing loss refers to hearing loss greater than 30 dB in the better hearing ear in children with an average of 500 Hz, 1000 Hz, 2000 Hz and 4000 Hz (Olusanya et al., 2019). Hearing loss may be permanent or temporary, and it can range from mild to profound, and it can affect one or both ears. Hearing loss can be categorised into three main types: conductive hearing loss (CHL), sensorineural hearing loss (SNHL) and mixed hearing loss, which is a combination of CHL and SNHL, each with unique characteristics and causes, especially among primary schoolchildren (Madell & Flexer, 2014). Conductive hearing loss occurs when sound waves cannot efficiently travel through the outer and middle ear to the inner ear. Ear infections, impacted earwax and a foreign body blocking the ear canal and abnormalities in the outer and/or middle ear may cause CHL in children (Robson, 2023). Sensorineural hearing loss arises from damage or dysfunction of the inner ear or the auditory nerve. In children, the most common causes of SNHL include genetic factors, congenital infections, exposure to ototoxic medications and noise-induced hearing loss (Korver et al., 2017). While CHL might be preventable, SNHL is often permanent, requiring appropriate interventions that may include hearing aids, cochlear implants or other assistive listening devices (Kleinjung & Londero, 2024). Evidence on the prevalence of hearing loss among primary schoolchildren in sub-Saharan Africa remains limited. Reported prevalence of hearing loss varies widely depending on screening protocols and thresholds used (Moepeng et al., 2021; Shinn et al., 2021). Data on school-based hearing screening performance covering the whole of Ethiopia are particularly scarce (Birhanu et al., 2021; Haile et al., 2023; Meshesha et al., 2025). Therefore, this study aimed to conduct school-based hearing screening in primary schools to determine hearing screening outcomes among primary schoolchildren in Jimma Town, Southwest Ethiopia. The specific objectives were: (1) to measure the rate of children who failed pure-tone audiometry at different thresholds and (2) to identify common otoscopic findings among children who failed screening.

This study reports the outcome of hearing screening rather than confirmed hearing loss, as diagnostic audiometry in a clinical setting, tympanometry and bone conduction testing were not performed. All findings should be interpreted as screening results. The study showed a proportion of children who failed hearing screening among primary school students in Jimma Town. The screening failure rate varies by age, gender and school setting. A substantial proportion of children (13.3% – 22.2%) in four schools and 68.9% in School ‘A’ failed the hearing screening at the 25 dB HL threshold. This raises significant public health concerns and underscores the necessity for enhanced awareness and intervention strategies in the population, as it could significantly impact the schoolchildren’s social interaction, communication and overall quality of life (WHO, 2021). The distinction between low-frequency (28.8%) and high-frequency (24%) screening failures indicates that low-frequency failures are more common, with implications for auditory processing and communication skills, especially in educational settings (Škerková et al., 2023). Although 7.6% of participants exhibited low-frequency failure exclusively, compared with 2.8% showing only high-frequency failure, this pattern may partly reflect exposure to persistent low-frequency background noise in the study environment. Nevertheless, because noise-induced hearing impairment typically affects higher frequencies, other factors – such as middle-ear conditions or measurement artefacts – could also contribute to this finding. This finding aligns with the existing literature emphasising the impact of low-frequency sounds in everyday communication, particularly in noisy environments (Buono et al., 2021). Targeted screening and early intervention programmes could help address these issues. The hearing screening failure rate observed in our study is higher than the global estimates, ranging from 1% to 5% for children with mild to moderate hearing loss, from 7% to 17% in Tanzania (Ertzgaard et al., 2020), 11.9% in Ghana (Osei et al., 2018), 9.2% in Egypt (Morgan et al., 2021), and the global average, which is 20% (WHO, 2023). The observed difference between the global figures and the findings from Jimma may reflect contextual or environmental factors that warrant further investigation. However, the current study’s findings are lower than those conducted in another part of Ethiopia, where the prevalence was 34% in Addis Ababa (Haile et al., 2023). This variation could be attributed to differences in design and sample size. Several factors may be associated with higher screening failure rates, including limited access to healthcare, environmental factors and socio-economic challenges (Adadey et al., 2022; Lee et al., 2024; Mo et al., 2024; Mulwafu et al., 2017). Limited access to healthcare services, particularly to ENT specialists and audiologists, can result in untreated or poorly managed ear conditions. Environmental factors, such as increased exposure to noise in overcrowded school environments, could also contribute to screening failure. Moreover, socio-economic barriers, including financial constraints, may prevent children from receiving preventive care or timely treatment for ear conditions, increasing the risk of screening failure. The findings suggest unmet hearing health needs and the need for targeted interventions to address hearing health in primary schoolchildren; however, a confirmatory diagnostic assessment is required to determine the true prevalence of HL. This includes improving access to healthcare, raising awareness and implementing preventive measures to reduce the burden on families and the healthcare systems (Khoza-Shangase, 2021). The high screening failure may also reflect a lack of early childhood hearing screening programmes in the current study. In many high-income countries, universal newborn hearing screening programmes have been implemented, leading to earlier identification and intervention for hearing loss. However, in low-income settings like Ethiopia, such programmes are often lacking, which may partly account for the higher prevalence observed in the current study. The other finding is differences in hearing screening participation rates across the five schools in the study. The highest screening failure was reported in School ‘A’ (68.9%), while Schools ‘B’ and ‘D’ had much lower prevalence, at 14.6% and 13.3%, respectively. These differences may reflect exposure to higher noise levels, limited access to healthcare and the family’s socio-economic status. Exposure to higher levels of noise may also contribute to noise-induced hearing loss. Noise-induced hearing loss is a well-documented phenomenon that can occur even at relatively low noise levels if the exposure is prolonged (Basner et al., 2014). School ‘A’ has a relatively overcrowded class environment, which might result in elevated noise levels and, combined with potentially limited access to hearing care services, could explain the significantly higher rates of screening failure. However, this study did not directly measure noise exposure or confirm noise-induced hearing loss. Differences in healthcare access across schools, including ear and hearing care, could be another factor explaining variation between schools. Schools with a higher screening failure rate may serve communities that face more significant barriers to accessing healthcare, including financial constraints, geographic isolation or a lack of awareness about hearing health. The revealed age-related pattern is consistent with previous findings showing that older children exhibit higher rates of screening failures. This age-related pattern is consistent with the idea that hearing loss can be cumulative, with the risk increasing as children age due to prolonged exposure to environmental risks and untreated ear conditions (Charles Stewart Mott Children’s Hospital [CSMCs], 2024). The observed increase in the screening failure rates with age may be due to the gradual development of chronic conditions, such as recurrent ear infections or noise-induced hearing loss (Teele et al., 1989). Additionally, older children may be more exposed to environmental noise, such as through increased participation in extracurricular activities, attendance at noisy events or use of personal audio devices (e.g. headphones) at higher volumes, all of which can contribute to SNHL over time (Shargorodsky et al., 2010). It may also reflect cumulative exposure to risk factors over time, although causality cannot be inferred from the current cross-sectional design. The study also identified higher screening failure rates among females (40.5%) compared to males. This finding is somewhat paradoxical, as other studies from Lusaka, Zambia (Hapunda et al., 2020) and Cape Town, South Africa (Kuschke et al., 2020) have reported that males are generally at higher risk of screening failure than females in the general population, and requires further investigation. However, the higher rates of screening failure among females in the study may reflect contextual or unmeasured factors that were not directly assessed in this study. Potential biological differences, such as hormonal variations, could also affect susceptibility to hearing loss, though this area requires further research (McFadden, 2014). Possible sociocultural or environmental explanations warrant exploration in future studies. Regarding the otoscopic findings, impacted earwax was the most common reversible condition identified, but if left untreated, it can lead to conductive hearing loss by blocking sound from reaching the eardrum. This highlights the need for improved ear hygiene and access to basic healthcare services in the community. Public health interventions addressing ear hygiene practices, particularly in schools, could significantly reduce the burden of hearing loss caused by impacted earwax (Schwartz et al., 2017). The WHO estimated that 60% of hearing loss is preventable (Mo et al., 2024). This finding supports the importance of preventive ear and hearing care services in school settings. According to the WHO, improving living conditions, promoting good personal hygiene and screening for early detection of hearing loss can all help reduce the likelihood of hearing loss (WHO, 2016). While infections accounted for a relatively small proportion of hearing loss, it is important to note that untreated ear infections can lead to more severe complications, including permanent hearing loss. This finding underscores the need for early diagnosis and treatment of ear infections to prevent long-term hearing damage in children.

This hearing screening study found that a substantial proportion of primary schoolchildren in Jimma Town demonstrated elevated hearing thresholds (≥ 25 dB) during assessment, ranging from 13% to 22% across four schools and 68.9% in the fifth school. Early detection is crucial for addressing hearing difficulties, as untreated hearing loss can profoundly affect language acquisition, educational outcomes and social development. The findings from this study underscore the urgent need for a multi-tiered approach to improve ear and hearing health among schoolchildren in Jimma and similar low-resource settings. Children who fail screening require confirmatory diagnostic evaluations, including speech audiometry, bone conduction testing and tympanometry, as preliminary results cannot distinguish between temporary impairments and permanent hearing difficulties. Given that reversible conditions such as impacted earwax accounted for a substantial proportion of screening failures, preventive and early intervention measures are highly warranted. This measure includes integrating ear hygiene education into school curricula, raising teachers’ awareness of safe wax removal techniques and establishing annual screening with clear referral protocols. Environmental factors also warrant attention by introducing noise reduction strategies, such as sound-absorbing classroom materials, which could mitigate both false positives and genuine noise-induced damage. Critically, these efforts must align with resource realities in low-income settings. Partnerships with NGOs and government agencies should focus on subsidising diagnostic services and deploying mobile clinics to expand rural access. However, resource allocation decisions should not rely solely on screening outcomes without confirmatory diagnostic evaluation, which may be inflated by environmental artefacts or reversible conditions; hence, pilot programmes validating cost-effective diagnostic pathways are essential to ensure equitable and efficient use of limited resources.