With 17 babies born with hearing loss every day in South Africa, there is a pressing need for systematic Early Hearing Detection and Intervention (EHDI) services. Progress is being made in offering newborn hearing screening and studies have been conducted to document these processes within South Africa. However, due to the lack of a national and holistic overview of EHDI services to date, an accurate picture of the current status of EHDI within the South African context is required.
To document and profile what has been published within the field of EHDI in South Africa over the last two decades (Jan 1995–Sept 2014) in order to gain a comprehensive overview of the current status and practice of screening and diagnosis in the field of paediatric hearing loss.
A narrative review of peer-reviewed articles related to EHDI in South Africa was conducted by searching the EBSCOHOST, SCOPUS and JSTOR databases for the period January 1995 to September 2014.
Results indicate that over the last two decades research and publications in the field of EHDI have increased considerably. These publications have revealed extensive knowledge related to paediatric hearing screening and intervention services in South Africa; however, this knowledge seems to be limited primarily to the provinces of Gauteng and the Western Cape. Furthermore, studies pertaining to diagnosis have revealed that, although much has been written on the scientific aspects on tools for diagnosis of hearing loss, there is a lack of comprehensive information on diagnostic protocols and procedures.
Despite the clear progress being made in South Africa in the field of early hearing detection and intervention, there is a need for comprehensive studies on protocols and procedures in diagnosing paediatric hearing loss. Finally, the narrative review revealed a clear need to ensure that development and growth in the field of EHDI is a national priority and extends beyond the two provinces currently showing growth.
South Africa is estimated to have 16–17 babies with hearing loss born daily (Swanepoel,
In response to the international drive for effective and early EHDI programmes, the Health Professions Council of South Africa (HPCSA) published a position statement in 2007. This statement describes internationally benchmarked indicators of screening at birth, amplification by three months and enrolment in early intervention by six months of age (as published in Joint Committee on Infant Hearing [JCIH],
Universal newborn hearing screening and the subsequent early diagnosis of infant hearing loss is a new practice in South Africa when compared to international progress. In the USA as early as 1965, health, education and welfare departments recommended universal evaluation of hearing loss on a national level. Hearing screening has since become universal in the USA (every newborn is offered the option of having a hearing screening), with only 5% of newborns not having their hearing screened (Eiserman et al.,
In the United Kingdom (UK), hearing screening forms part of their general screening regimen and is preceded by screening procedures for medical disorders such as haemoglobin disorders, metabolic disorders and neurogenetic disorders. By 2004, as part of the Universal Newborn Hearing Screening Programme in England, between 90% and 94% of mothers had been offered hearing screening for their newborn (Bamford, Uus & Davis,
The implementation of effective hearing screening programmes as outlined in developed countries requires numerous resources and financial investment A number of conceptual and research articles have recognised the impracticalities inherent in attempting to implement developed world models of hearing screening in a developing country (Swanepoel, Delport & Swart,
Although numerous screening programmes have been implemented in hospitals and local South African communities, research to report on the outcomes are isolated and broader studies describing a collated overview of the general knowledge base and status of EHDI in South Africa are missing. Furthermore, areas in which there are gaps in knowledge have not been systematically presented nor has there been an outlining of strengths and weaknesses of EHDI systems and identification of areas where additional research is necessary.
A review of published studies on EHDI in South Africa was therefore needed to gain a comprehensive understanding of the current practice and status of newborn screening and diagnosis of paediatric hearing loss.
This study, whilst sharing much in common with the systematic review in terms of an academic database search with clear parameters (Liberati et al.,
In telling the story about the publications, the aims of this narrative review are:
To detail the number of peer-reviewed papers on EHDI in South Africa from January 1995 to September 2014 and to classify the articles according to type of publication: a conceptual or research article or a letter to the editor.
To describe the main and secondary focus of each paper in order to get an overview of the work that has been done in the field within this time-frame.
To outline the chronological progress within the field of early hearing detection and intervention over the period of twenty years, January 1995 to September 2014.
An electronic academic-database search of EBSCOHOST, SCOPUS and JSTOR databases was conducted using a combination of search terms related to the general EHDI topics of screening and diagnosis of paediatric hearing loss in South Africa. The two search parameters required that all the articles had to be peer-reviewed – thereby excluding theses and dissertations – and published between January 1995 and September 2014 (
Description of the search results identifying articles for the narrative review.
Procedural steps | Number of reports | Description |
---|---|---|
a) Database search results | 759 | 3 databases (EBSCOHOST, JSTOR and SCOPUS), 9 search strategies |
b) Database search results –duplicates omitted | 676 | 83 duplicates from the 5 searches were omitted |
c) Database results examined for scope of review | 41 | 676 titles and keywords were examined for relevance to the review topic. Where there was uncertainty about relevance abstracts were reviewed. 635 articles were omitted – 634 not relevant to topic and 1 citation |
d) Time frame for review identified as from 1995 to September 2014 | 35 | 6 articles were omitted due to being published before 1995 |
e) Identification of additional reports relevant to review | 8 | Reference lists of articles reviewed to identify additional relevant articles |
f) Reports included in review | 43 | Articles forming part of the final systematic review |
Of the 759 articles identified using the search terms across the three databases as noted above, 83 were identified as duplicates. The remaining 676 articles were examined for relevance and 635 were omitted as being irrelevant. An additional six were omitted as they were published before 1995. The 35 remaining articles were studied and reference lists were reviewed in order to identify any additional relevant articles, from which eight were identified. A final total of 43 peer-reviewed articles were included in the narrative review. Masters and PhD dissertations, as well as the HPCSA Position Statement were excluded from the review, as they are not peer-reviewed academic articles.
Articles were classified according to: (1) type of publication, whether it was conceptual, editorial or a research paper; (2) year of publication in order to determine chronological progression of EHDI in South Africa; and (3) primary and secondary focus of the publication. If the majority of the article related to a specific area, it was classed as the primary focus. If some reference was made to a specific area, but was not the main topic, it was classed as the secondary focus.
43 peer-reviewed articles were identified in the field of EHDI in South Africa for the period January 1995 to September 2014. These included 15 conceptual articles, 26 research articles and two letters to journal editors. In classifying the papers by their primary and secondary areas of focus, the following four categories arose: (1) screening, which includes the process and forum for identification of hearing loss; (2) diagnosis, which involves the comprehensive testing and classification of the hearing loss; (3) intervention, which refers to the fitting of amplification and referral to early intervention services and (4) data management, which includes reference to the follow-up and referral network. A summary of the 43 papers can be found in Appendix A.
The analysis revealed that almost 60% (
Area of focus for articles included in narrative review.
Primary focus | Secondary focus | |||||
---|---|---|---|---|---|---|
Screening | Diagnosis | Intervention | Data management | No secondary focus | Total | |
Screening | - | - | 6 | 2 | 16 | 24 |
Diagnosis | - | - | 1 | - | 10 | 11 |
Intervention | - | - | - | - | 5 | 5 |
Data management | 1 | - | - | - | - | 1 |
Total | 1 | 0 | 7 | 2 | 31 | 41 |
When considering the chronological pattern that emerged over the 20 years of publications, the research increased considerably over time (see
The chronological pattern. Note: Article type (
The period of 1995–2002 showed minimal focus on the area of EHDI, with just two publications: one being a letter to the journal editor discussing the feasibility of introducing universal newborn hearing screening in South Africa (1995) and the other being a conceptual article discussing the Auditory Steady State Response (ASSR) as a tool for diagnosis of paediatric hearing loss.
More conceptual than research articles were published between 2004 and 2007. The focus of these articles was mainly on hearing screening forums and the importance of early identification and intervention for paediatric hearing loss. In 2008 a number of research articles dedicated to the proceedings of the first EHDI in Africa conference (held in 2007) was published in a special edition of the
The 43 articles included in the narrative review will be discussed chronologically, with reference to specific themes within each time period.
It is only in the new millennium (2000 onwards) that research in the field of EHDI has shown considerable growth in South Africa with studies in the specific areas of screening and early intervention. In 1993, the US National Institute of Health (NIH) Conference addressed the issue of late identification of hearing loss and made the recommendation of universal newborn hearing screening (NIH Consensus Statement, 1993). This led to a meeting at the Departments of Otolaryngology, Logopaedics and Neonatal Paediatrics at the University of Cape Town in South Africa. The conclusion of this meeting was that UNHS in South Africa was not feasible due to the lack of proof of effectiveness of hearing screening and the workload impracticality (Prescott,
Further research in this area then showed a decline until 2002, when general scientific research to determine the effectiveness of the ASSR in diagnosis of hearing loss in infants was conducted by South African authors (Swanepoel, Schmulian & Hugo,
The year 2004 also saw the importance of early identification and intervention for paediatric hearing loss being well recognised, with five conceptual articles (Swanepoel,
The areas of research and South African specific knowledge in the field of EHDI were highlighted when the first EHDI Africa conference was held in South Africa in 2007. A special supplement of the International Journal of Audiology (IJA) was dedicated to the publishing of proceedings from conference presentations. The introductory editorial article (Swanepoel & Störbeck,
The period of 2009–2010 produced a number of conceptual/review articles relating to the implementation of newborn hearing screening, early intervention and the importance of a follow-up referral network (Copley & Friderichs,
This highlights the importance of focused studies taking into account all aspects of the situation in Africa, including the professional knowledge of all specialists involved in the EHDI process, as well as the impact of ear infections and illnesses such as meningitis on acquired hearing loss. Data management and cross-disciplinary diagnostic data are clearly lacking in South African studies within the time period of the review.
Studies up until the 2009–2010 period focused mainly on the public healthcare sector, and thus provided little indication of EHDI services available to the 15% of the population that use private healthcare services. In 2011 and 2012 a survey of hearing screening practice in the private healthcare sector was conducted on a national level (Meyer & Swanepoel,
More recent research activities (from 2012) have focused on retrospective and, less commonly, prospective review of audiology records. The prospective studies focused on using audiology records to determine the impact of risk factors for hearing loss in low birth-weight babies (Kanji & Khoza-Shangase,
Studies following from screening to diagnosis, and the outlining of research related to diagnostic procedures and protocols, have only recently been conducted internationally (Larsen, Munoz, DesGeorges, Nelson & Kennedy,
A study on audiology equipment and protocols used for paediatric assessment and hearing aid fitting highlighted the lack of both equipment as well as evidence-based guidelines for assessment in South Africa (Teixeira & Joubert,
The South African journey of research into EHDI services from 1995–2014 highlights the progress made in outlining the implementation of paediatric hearing screening services in a developing world context. The need for education of parents and professionals on the importance of early screening, the practical aspects of implementing screening programmes and the importance of South African specific risk factors being recognised was clearly highlighted. After the period of the review end date (September 2014) a further three articles were published in the field of EHDI in South Africa. One article focused on procedures and protocols for hearing screening at immunisation clinics in two South African provinces (Petrocchi-Bartal & Khoza-Shangase,
Comprehensive research and evaluation of paediatric diagnostic audiology services and the procedures to be followed in the diagnosis of paediatric hearing loss in South Africa has emerged as a gap in the field. The use of tools such as the ASSR for diagnosis of paediatric hearing loss is an area of scientific knowledge for South Africa. However, comprehensive studies on diagnosis of paediatric hearing loss are lacking. The use of diagnostic tools and how they relate to the use of evidence-based guidelines for diagnosis of paediatric hearing loss, as well as the development of South African specific diagnostic guidelines (as was the case for recognition of the need for South African specific risk factors for screening), are areas for development and expansion.
An area of strength in EHDI research in South Africa is inclusive information on implementation of screening at different forums within the public and private healthcare sectors. The progress in development of South African specific risk factors with targeted screening as an option, as well as the need for the education of parents and professionals on the importance of hearing screening is clearly laid out. Whilst there is an acknowledgement of staff and equipment shortage for implementation of screening in the public health sector, there is not as much comprehensive information on the private health sector. An area that is also lacking is one that focuses on screening methods used and the effectiveness thereof. Related to this is what seems to be a lack of prioritisation of data management in the South African context, as few studies related to data management have been conducted
Limitations of this study include the fact that, as a narrative review, the study did not consider qualitative aspects of the research such as study sample or size, nor did it evaluate the research for possible bias or weakness in the individual studies. Additionally, the search, though exhaustive, did not include an independent researcher for verification.
South Africa has taken many strides in growing the knowledge base of the field of EHDI, and has recognised and tried to overcome challenges in the implementation of EHDI services by researching and identifying alternative forums for screening, parent reasons for refusing screening and the availability of early intervention services. However, studies are mainly conducted in, and related to the context within, the Gauteng and Western Cape provinces of South Africa. Additionally, a large portion of the research is mainly focused on the screening process, with some studies into the usefulness of ASSR as a diagnostic tool and record reviews related to diagnostic procedures.
The research has shown that South Africa lacks a nationally agreed battery of tests and protocols for diagnosing hearing loss for infants and babies, and although a draft document on diagnostic guidelines for the paediatric population has been released for comment by the HPCSA, (Swanepoel,
Studies looking at the development of universal screening, diagnosis and intervention across both the public and private healthcare systems will provide much needed information on all aspects of EHDI in a developing world context.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
This article is a write-up of part of S.M.'s (University of the Witwatersrand) PhD., with C.S. (University of the Witwatersrand) being the academic supervisor. The research process (including data collection and analysis) was completed by the first author, while the writing of the article was a collaborative process.
Appendix 1: Database and search strategy details
Search strategy | Identifiers | Database | Number of articles |
---|---|---|---|
Articles related to early hearing detection and intervention in South Africa | Early hearing detection AND “South Africa” | Ebscohost Web-Academic Search Complete | 4 |
JSTOR | 5 | ||
SCOPUS | 21 | ||
Hearing loss AND ”South Africa” | Ebscohost Web-Academic Search Complete | 15 | |
JSTOR | 313 | ||
SCOPUS | 123 | ||
Articles focusing on screening for paediatric hearing loss in South Africa | hearing screening AND ”South Africa” | Ebscohost Web-Academic Search Complete | 8 |
JSTOR | 9 | ||
SCOPUS | 57 | ||
Articles focusing on diagnosis of paediatric hearing loss in South Africa | “ hearing loss” AND “diagnosis” AND ”South Africa” in title | Ebscohost Web-Academic Search Complete | 96 |
“diagnosis of paediatric hearing loss” AND South Africa” | JSTOR | 33 | |
Diagnosis of hearing loss” AND ”South Africa” | SCOPUS | 75 | |
“Diagnosis of hearing loss” | |||
“Diagnosis of deafness |
Appendix 2: Summary of articles included in review
Title | Year of Publication | Article Type | Article focus | |
---|---|---|---|---|
1 | Should routine screening of neonates for deafness be introduced in SA | 1995 | Letter to journal editor | Discussion of international introduction of UNHS and whether this should be introduced in SA |
2 | The effectiveness of the auditory steady state response in diagnosing hearing loss in infants | 2002 | Conceptual | A review of the Auditory Steady State Response as a procedure for the diagnosis of hearing loss in infants |
3 | Universal newborn hearing screening in South Africa: a First-World dream? | 2004 | Editorial | The importance of early hearing detection and intervention in both a first world and developing country context is outlined |
4 | Auditory steady state response for children with severe to profound hearing loss | 2004 | Research | The clinical usefulness of the Auditory Steady State Response in estimating behavioural thresholds for children with severe to profound sensorineural hearing loss |
5 | Implementing infant hearing screening at maternal and child health clinics: Context and interactional processes | Research | A qualitative description of the context and interactional processes observed at two maternal and child health clinics in a single province of South Africa | |
6 | Infant Hearing Screening in the Developing World: rethinking First World Models | 2005 | Conceptual | The lack of feasibility of first world models of screening before hospital discharge is explained, and alternative screening forums and protocols proposed. |
7 | Audiology in South Africa | 2006 | Conceptual | The history and development of audiology as a profession in South Africa is presented |
8 | Infant hearing screening at immunization clinics in South Africa | 2006 | Research | 510 infants enrolled at a clinic hearing g screening programme were analysed in terms of DPOAE coverage, high frequency tympanometry, and follow-up screening appointment attendance |
9 | Early hearing detection at immunization clinics in developing countries | 2006 | Conceptual | Description of the importance of early hearing detection and intervention as standard part of neonatal care in the developed world. Practical and culturally appropriate options for EHDI are being explored in developing countries. |
10 | Newborn hearing screening in a South African private health care hospital | 2007 | Research | A retrospective study of data from a screening programme at private hospital in Gauteng. |
11 | A novel service delivery model for infant hearing screening in developing countries | 2007 | Conceptual | A service delivery model for the implementation of infant hearing screening in developing countries is proposed. |
12 | Equal opportunities for children with hearing loss by means of early identification | 2007 | Editorial | Evidence for the importance of early hearing detection and intervention, nationally and internationally is presented |
13 | EHDI Africa: Advocating for infants with hearing loss in Africa | 2008 | Editorial | An introduction to articles related to conference proceedings from “Building Bridges in Africa”, the first EHDI Africa international conference held in South Africa in 2007. |
14 | Early hearing detection and intervention services in the public health sector in South Africa | 2008 | Research | The status of newborn infant hearing screening in the public sector (44 of 86 speech therapy and audiology departments). Diagnostic procedures used at 13 sites and data management at 12 sites is presented |
15 | Infant hearing loss in South Africa: age of intervention and parental needs for support | 2008 | Research | Questionnaire surveys and focus groups conducted with parents of children diagnosed with hearing loss |
16 | Early intervention in South Africa: moving beyond hearing screening | 2008 | Research | Data of 32 infants registered in a home-based early intervention programme is outlined |
17 | Maternal views on infant hearing loss and early intervention in a South African community | 2008 | Research | A survey of 100 mothers attending an immunization clinic in Gauteng, regarding their views and attitudes on infant hearing loss, was conducted. |
18 | Hearing instrument fitting of preschool children : Do we meet the prescription goals | 2008 | Research | Comparison of hearing instrument output values at 65 and 90dBSPL input signals fitted to preschool children to targets prescribed by DSLm across the frequency range. |
19 | Auditory steady-state responses to bone conduction stimuli in children with hearing loss | 2008 | Research | Investigation of bone conduction ASSR thresholds in children with normal hearing and various degrees of hearing loss |
20 | Auditory steady-state response and auditory brainstem response thresholds in children | 2009 | Research | Comparison of ASSR and ABR thresholds in 48 infants with varying degrees and type of hearing loss. |
21 | Identifying infant hearing loss - never too early, but often too late | 2009 | Editorial | The importance of prompt referral of children for hearing testing and the process of early identification is outlined |
22 | Early hearing detection and intervention in South Africa | 2009 | Conceptual | Review of the evidence and status of infant hearing loss and early hearing detection and intervention services in South Africa |
23 | Early detection of infant hearing loss in South Africa: editorial | 2009 | Editorial | A summary of the current status of EHDI in South Africa, together with evidence of the importance of developing infant hearing screening programmes on a wider scale |
24 | Paediatric meningitis and hearing loss in a developing country : Exploring the current protocols regarding audiological management following meningitis | 2010 | Research | Retrospective review of medical records of 47 children admitted with a diagnosis of meningitis to 2 academic hospitals in the Gauteng province. |
25 | Hearing screening follow up return rate in a very low birth weight project. A retrospective record review | 2010 | Research | Retrospective analysis of records of patients with low birth weight to determine the follow-up return rate in a hearing screening programme |
26 | An approach to hearing loss in children | 2010 | Conceptual/ Review | Difficulty on diagnosis of hearing loss in young children is outlined. The Ivan Toms Infant Hearing Screening Programme in Cape Town is presented as a pilot project for future UNHS programmes in South Africa |
27 | Protocols for early audiology intervention services: Views from early intervention practitioners in a developing country | 2010 | Research | Identification of the protocols and practices for early intervention in Gauteng government hospitals and how they compare to principles for effective early intervention. |
28 | Bridging the gap between early identification and intervention in the paediatric population with hearing impairment | 2010 | Conceptual | Description of the development of the Wits Hearing Aid Bank to bridge the gap between identification of hearing loss and actual intervention. |
29 | Newborn hearing screening in the private health care sector - a national survey | 2011 | Research | Hearing screening procedures implemented at and challenges in implementing screening in the private health care sector of South Africa |
30 | Clinical Status of the Auditory Steady-State Response in Infants | 2011 | Conceptual | The strengths and limitations of the ASSR for use with infants as well as the role of the ASSR in the paediatric test battery is presented. |
31 | Efficacy of a community based infant hearing screening program utilising existing clinic personnel in Western Cape South Africa | 2012 | Research | Evaluation of a UNHS programme with nurses trained as screening personnel at clinics in the Western Cape |
32 | Childhood hearing loss and risk profile in a South African population | 2012 | Research | Retrospective record review of 100 patient files to determine the hearing loss and associated risk profile of children diagnosed at a paediatric referral clinic |
33 | The occurrence of high risk factors for hearing loss in very low birth weight neonates: a retrospective exploratory study of targeted hearing screening | 2012 | Research | Determining the type and frequency of risk factor for hearing loss, as a backdrop for the argument for or against targeted hearing screening |
34 | Early detection of infant hearing loss in the private health care sector of South Africa | 2012 | Research | A national survey of EHDI services in the private healthcare sector of South Africa |
35 | The role of the neonatal nurse in early hearing detection and intervention in South Africa | 2012 | Conceptual | The multiple roles nurses play in the early identification and intervention of children with hearing loss is outlined. |
36 | Age of diagnosis for congenital hearing loss at Universitas Hospital, Bloemfontein | 2013 | Research | A retrospective, descriptive study to determine the age of diagnosis of hearing loss in the Free State province |
37 | Hearing screening record keeping practices at primary healthcare clinics in Gauteng | 2013 | Research | Review of hearing screening and record keeping practices at 20 primary healthcare clinics in Gauteng, south Africa |
38 | Paediatric chronic suppurative otitis media in the Free State province: Clinical and audiological features | 2013 | Research | A prospective study of the audiological, ontological and bacteriological findings of children (113 ears) with chronic serous otitis media at an academic hospital in the Free State province |
39 | Quality and readability of information pamphlets on hearing and paediatric hearing loss in the Gauteng Province, South Africa | 2014 | Research | The quality and readability of information pamphlets relating to hearing loss at hospitals in the Gauteng province were evaluated (n=21) |
40 | Why parents refuse newborn screening and default on follow up screening a South African perspective | 2014 | Research | A retrospective record review of 2 universal newborn hearing screening programmes to determine parent reasons for screen refusal and follow-up default |
41 | Why parents refuse newborn hearing screening in South Africa? | 2014 | Response to letter to editor | A response to a letter to the editor regarding the article “Why parents refuse newborn screening and default on follow up screening a South African perspective” |
42 | Early Intervention in Audiology: Exploring the Current Status from a Developing Country Context | 2014 | Research | Retrospective record review of the files of 70 patients between birth and 3 years from 3 state hospital audiology clinics in Gauteng |
43 | Availability of audiological equipment and protocols for paediatric assessment and hearing aid fitting in Gauteng, South Africa | 2014 | Research | A cross-sectional survey to determine the availability of audiological equipment and protocols for paediatric assessment and hearing aid fitting was conducted in the Gauteng province |