According to Schellack, Wium, Ehlert, Van Aswegen and Gous (2015), pharmacotherapy-induced ototoxicity is a growing issue, especially in developing countries such as South Africa. The prevalence of tuberculosis (TB), human immunodeficiency virus (HIV) and malaria in South Africa predisposes these patients to hearing loss which is induced by agents used to treat these conditions (Schellack et al., 2015). While there are no real statistics regarding the incidence of hearing loss because of HIV and malaria, Petersen and Rogers (2015) estimate that up to 90% of patients with TB, specifically drug-resistant TB, may experience hearing loss. Neonates, particularly those born prematurely, are more prone to infections because of their immunocompromised nature. Furthermore, the antibiotics, for example, amikacin, that are used to treat these infections have been shown to be ototoxic in approximately 59% of these babies (Engler, Schellack, Naude, & Gous, 2013).

Furthermore, Schellack et al. (2015) state that pharmacists along with medical professionals and nurses play an integral role in identifying and monitoring ototoxic agents, while audiologists often get involved only after the patients have completed therapy and start experiencing hearing loss. Early identification of hearing loss and balance problems (ototoxicity monitoring) is of paramount importance to prevent or minimise permanent impairment and therefore improve the quality of life post-treatment (Saindane, 2016). Thus, audiologists need to be involved at the initial stages of patient care and part of the multidisciplinary team.

To assist this multidisciplinary care, interprofessional education (IPE) is needed. According to Treadwell and Havenga (2013), IPE refers to the learning from and between the disciplines of various health science students in order to improve collaboration and the quality of patient care. Interprofessional education is an important approach to develop health science students, as trained students are more likely to become collaborative interprofessional team members who show respect and positive attitudes towards each other and work towards improving patient outcomes (Bridges, Davidson, Odegard, Maki, & Tomkowiak, 2011). However, medicine, pharmacy, nursing and other health professions are supposed to work together in a clinical environment, which requires effective teamwork and communication skills. The majority of university-based health professional education currently delivers a discipline-specific model of teaching (Lapkin, Levett-Jones, & Gilligan, 2013).

Furthermore, a relationship between the physician (as the prescribers) and nurses (as the care takers) needs to be established. This relationship should be supported by education regarding the importance and benefits of drug monitoring and as well as the evaluation of possible adverse effects, which should be discussed with the patients (Konrad-Martin, Wilmington, Gordon, Reavis, & Fausti, 2005). According to Vasquez and Mattucci (2003), many physicians do not understand the importance of otolaryngologists and audiologists in pre-treatment counselling and evaluation and the need for follow-up assessments of the patient’s auditory function.

A multidisciplinary team approach, particularly between physicians, pharmacists, audiologists and nurses, is integral to collaborative patient education programmes regarding ototoxic medication, its effects and management. This is considering that most primary care clinicians and clinical pharmacists, particularly in developing countries such as South Africa, have seen patients who have suffered from ototoxicity at some point in their careers (Schellack et al., 2015). Hearing loss, especially when occurring during childhood, can negatively impact communication development, scholastic performance and quality of life (Phanguphangu & Ramma, 2018). Therefore, identification and understanding of the drugs and their impacts can improve patient care and outcomes. However, literature pertaining to the core curriculum or knowledge and perceptions of these healthcare workers in training is limited, especially in the South African context.

This study evaluated final year pharmacy, medical, nursing and audiology students’ knowledge regarding pharmacotherapy-induced ototoxicity. To the best of our knowledge, this study is the first to assess these aspects amongst pharmacy, medical, nursing and audiology students across South African universities. This study attempted to assess all South African universities; however, not all chose to participate in the study.

The results indicated that the majority of the students across different universities and professional fields of studies may not have adequate basic knowledge regarding pharmacotherapy-induced ototoxicity, as determined by the questionnaire in this study. Across all universities, the students were able only to define ototoxicity, but could not identify the signs of ototoxicity and risk factors involved. The results are also in agreement with those reported by Khoza-Shangase and Jina (2013), a study which revealed that doctors do not have adequate knowledge of ototoxicity symptoms and treatment. Pharmacy students, however, scored much better (97%) than students from other courses in terms of general knowledge regarding pharmacotherapy-induced ototoxicity, which may be attributed to the fact that they have more extensive pharmacology training at undergraduate level than the other courses. However, as they should take an active role in the identification of ototoxic drugs, and the potential management, a greater knowledge is still required.

Furthermore, most of the respondents could not adequately identify drugs that cause ototoxicity. Audiology students scored the lowest for this question (32%), which can be explained by the fact that they do not have pharmacology training at undergraduate level. This supported a study conducted by Naidoo (2006) in which the majority of the audiologists were of the opinion that their undergraduate clinical training had left them unprepared to implement pharmacotherapy-induced ototoxicity monitoring services. This could indicate that perhaps the curriculum needs to be adapted to include pharmacology for audiologists. The respondents’ knowledge regarding the type of damage caused by ototoxic medicine was shown to be poor. Respondents could not adequately identify whether certain medicines caused reversible or irreversible hearing loss. Also, the respondents could not determine the signs that arise because of damage to a specific structure of the ear (cochlear and vestibular system) as well as which drugs cause damage to which structure.

With respect to discipline-specific questions, pharmacy and medical students performed relatively well in terms of identifying the steps to follow if a patient starts experiencing ototoxicity and preventative measures that can be taken, including the pre-treatment that can be used when a patient is receiving ototoxic medicine, as compared to the other disciplines such as nursing and audiology. This is in line with an article by Lapkin et al. (2013), who described a report by the World Health Organization (WHO, 2016) which suggested that a large percentage of hearing impairment was attributed to ototoxic medication as a result of inappropriate use by healthcare providers, most especially from those prescribing. Knowledge was inadequate regarding when audiological monitoring should be initiated, and also regarding prevention and pre-treatment of pharmacotherapy-induced ototoxicity. Nursing students showed poor knowledge in terms of steps to be taken when a patient starts experiencing ototoxic side effects. Audiology students scored acceptably with regard to the steps that need to be followed when patients start experiencing ototoxic side effects and showed slight knowledge regarding when audiological monitoring should be initiated, as the majority of them indicated that audiological monitoring can be done only once a patient has completed treatment.

A strength of the study was that it was conducted amongst final year undergraduate students at a point when they had completed most of their formal academic curriculum to ensure that their knowledge would be assessed close to completion of their degrees. The study also had some limitations; use of an online survey might have reduced the response rate and difficulty permission from some universities. Also, not all universities that train these professionals participated in the study. The reasons for the lack of participation was either because the relevant head of department or dean did not respond to the numerous emails that were sent out or declined to participate in the study.

The study demonstrated that final year pharmacy, medical, nursing and audiology students across South African universities lack sufficient knowledge regarding pharmacotherapy-induced ototoxicity. The gaps in knowledge regarding the topic indicate that there may be insufficient undergraduate training pertaining to ototoxicity. The results suggest that pharmacy, medical, nursing and audiology students should be adequately trained at undergraduate level to handle cases of pharmacotherapy-induced ototoxicity once they get into the professional multidisciplinary healthcare environment to ensure patient safety. This would include the identification of potentially ototoxic medication, counselling of patients, and further ongoing monitoring and management of the drug and hearing loss. Schellack and Naude (2013) highlighted the importance of a coordinated and cooperative healthcare team in the early detection of cochleotoxicity, which holds especially true for a country such as South Africa that has a high disease burden, which often includes treatment by potentially ototoxic medication.