Barriers to timely diagnosis and treatment for children with hearing impairment in a southern Indian city: a qualitative study of parents and clinic staff

Access to ear and hearing care services in Cambodia: a qualitative enquiry into experiences of key informants

OBJECTIVE

In Cambodia, little is known about the state of ear and hearing care, or the roles providers or key stakeholders play in delivering services.

METHOD

This was an exploratory study using semi-structured qualitative interviews and a questionnaire addressed to key stakeholders to explore their perceptions and experiences in providing services to people suffering from ear disease or hearing loss in Cambodia.

RESULTS

Several challenges were described including a lack of hearing services to meet the demand, especially outside Phnom Penh in primary care and aural rehabilitation. Supply-side challenges include a shortage of trained professionals, facilities and resources, poor co-ordination between providers, unclear referral pathways, and long wait times.

CONCLUSION

Now is an opportune time to build on the positive trend in providing integrated care for non-communicable diseases in Cambodia, through the integration of effective ear and hearing care into primary care and strengthening the package of activities delivered at government facilities.

Help-seeking behaviour of parents of children with hearing loss in India: a qualitative analysis

OBJECTIVE

The age of identification of hearing loss in children is highly influenced by the hearing help seeking behaviour of their parents, particularly in countries without universal newborn hearing screening programs. In this study, an attempt was made to identify the factors associated with help seeking behaviour in parents of children with hearing loss, and the relationship of such factors with the age of identification of hearing loss.

DESIGN

Focus group discussions based on the framework of health belief model were carried out. The discussions were transcribed and the transcripts were thematically analysed.

STUDY SAMPLE

Participants were 35 parents of children with hearing loss from the state of Karnataka in India.

RESULTS

The findings revealed 30 factors related to their awareness about hearing loss, geographical location, socio-economic status, family, and society. The factors differed between early and late help seekers.

CONCLUSIONS

Awareness, accessibility, and affordability are the key factors that influenced the hearing help seeking behaviour of the participants. Effective public awareness programs, newborn hearing screening programs, and provisions to make hearing healthcare affordable to all can reduce the age of identification of paediatric hearing loss in India.

Prevalence of Hearing Impairment in High-Risk Neonates at Kalaburagi Region of Northern Karnataka: A Hospital-Based Cross-Sectional Study

The study estimated the prevalence of hearing impairment in high-risk neonates and effect of high-risk factors on the hearing. A hospital-based cross sectional study was conducted on 327 neonates with high-risk factors. All the high-risk babies were screened using TEOAE and AABR followed by diagnostic ABR testing. Six (2%) of high-risk neonates were found to have bilateral severe sensorineural hearing loss. Risk factors associated with hearing impairment include multiple risk factors of Preterm delivery, hyperbilirubinemia, congenital anomalies, neonatal sepsis, viral or bacterial infection, positive family history of hearing loss and prolonged NICU stay. Further, the inclusion of AABR along with TEOAE has been shown to be a useful tool in reducing false-positive rates and identifying hearing loss.

A Study of JCIH (Joint Commission on Infant Hearing) Risk Factors for Hearing Loss in Babies of NICU and Well Baby Nursery at a Tertiary Care Center

Babies in Neonatal Intensive Care Units (NICU) have an additional risk for hearing loss due to various risk factors like, prematurity, low birth weight, mechanical ventilation, hyperbillirubinemia, ototoxic drugs, low APGAR score etc. as compared to the babies from well baby nursery (WBN) who, poses risk factors mostly family history, syndromic deafness. So the present study was aimed know the risk factors responsible for hearing loss in NICU and WBN babies and to assess the incidence of deafness. A total of 800 babies from NICU (n = 402) and WBN (n = 398) underwent hearing screening from a tertiary care center. Hearing screening was done using two staged screening protocol as per JCIH guidelines with Distortion product Evoked Otoacoustic Emissions (DPOAE) and Automated Auditory Brainstem Responses (A-ABR). According to DPOAE test, 311 from NICU and 383 from WBN passed the test and during second screening, 80 out of 91 from NICU and 11 out of 13 from WBN passed the DPOAE test. Further BERA was done at the 3^rd month of corrected age where 6 out of 11 showed positive responses from NICU and 3 babies from WBN had profound hearing loss. Data analysis revealed that family history of deafness, anemia and hypertension in ANC, TORCH in mother, low Apgar score and hyperbillirubinemia in newborns were a major risk factor for hearing impairment. We conclude that the diagnoses of auditory disorders at early stage due to various risk factors are important since appropriate therapeutic intervention and rehabilitation would help in better development of children.

Barriers to access to ear and hearing care services in low- and middle- income countries: A scoping review

People living in low- and middle- income countries (LMICs) meet significant challenges in accessing ear and hearing care (EHC) services. We conducted a scoping review to identify and summarise such barriers, to recognise gaps in the literature, and to identify potential solutions. Reviewers independently screened titles, abstracts and full-text articles and charted data. We undertook thematic analysis of supply and demand side dimensions of access, and summarised findings mapped against the Levesque framework. Of 3048 articles screened, 62 met inclusion criteria for review. Across the five access dimensions, supply-side constraints were more frequently described, the most common being a shortage of EHC workforce or appropriate facilities, despite high demand. We identified a thin geographical spread of literature on barriers to accessing EHC services in LMICs, reflecting low availability of such services. LMICs face a diverse range of demand and supply side challenges including workforce, equipment and resource shortages, and challenges for the majority of the population to pay for such services. There is a need for many LMICs to develop health policy and programmes in EHC, including integration into primary care, scaling up the EHC workforce through increased training and education, and improving EHC literacy through public health measures.

Community health workers and mHealth systems for hearing screening in rural Nicaraguan schoolchildren

Background

We aimed to investigate the effectiveness of using minimally trained community health workers (CHW) to screen schoolchildren in rural Nicaragua for hearing loss using a tablet-based audiometric system integrated with asynchronous telehealth evaluations and mobile health (mHealth) appointment reminders.

Methods

A population-based survey was conducted using community health workers (CHWs) to perform tablet-based audiometry, asynchronous telehealth evaluations, and mHealth reminders to screen 3398 school children (7-9 years of age) in 92 rural Nicaraguan communities. The accuracy of screening, test duration, testing efficiency, telehealth data validity, and compliance with recommended clinic visits were analyzed.

Results

Minimally trained CHWs successfully screened children within remote rural schools with automated audiometry (test duration = 5.8 minutes) followed by manual audiometry if needed (test duration = 4.3 minutes) with an estimated manual audiometry validity of 98.5% based on a review of convergence patterns. For children who were referred based on audiometry, the otoscopy and tympanometry obtained during telehealth evaluations were high quality (as reviewed by 3 experts) in 44.6% and 80.1% of ears, respectively. A combination of automated short message service (SMS) text messages and voice reminders resulted in a follow-up compliance of 75.2%. No families responded to SMS messages alone.

Conclusions

Tablet-based hearing screening administered by minimally trained CHWs is feasible and effective in low- and middle-income countries. Manual audiometry was as efficient as automated audiometry in this setting. The physical exam tasks of otoscopy and tympanometry require additional training. Mobile phone messages improve compliance for confirmatory audiometry, but the utility of SMS messaging alone is unclear in this population.

Socioeconomic Status and Vision Care Services in Ontario, Canada: A Population-Based Cohort Study

OBJECTIVE

To test the association of material deprivation and the utilization of vision care services for young children.

STUDY DESIGN

We conducted a population-based, repeated measures cohort study using linked health and administrative datasets. All children born in Ontario in 2010 eligible for provincial health insurance were followed from birth until their seventh birthday. The main exposure was neighborhood-level material deprivation quintile, a proxy for socioeconomic status. The primary outcome was receipt of a comprehensive eye examination (not to include a vision screening) by age 7 years from an eye care professional, or family physician.

RESULTS

Of 128 091 children included, female children represented 48.7% of the cohort, 74.4% lived in major urban areas, and 16.2% lived in families receiving income assistance. Only 65% (n = 82 833) had at least 1 comprehensive eye examination, with the lowest uptake (56.9%; n = 31 911) in the most deprived and the highest uptake (70.5%; n =19 860) in the least deprived quintiles. After adjusting for clinical and demographic variables, children living in the least materially deprived quintile had a higher odds of receiving a comprehensive eye examination (aOR 1.43; 95% CI 1.36, 1.51) compared with children in the most materially deprived areas.

CONCLUSIONS

Uptake of comprehensive eye examinations is poor, especially for children living in the most materially deprived neighborhoods. Strategies to improve uptake and reduce inequities are warranted.

Analysis of barriers and facilitators to early hearing detection and intervention in KwaZulu-Natal, South Africa

Background

Objectives

Method

Results

Conclusion

Barriers to access and utilization of healthcare by children with neurological impairments and disability in low-and middle-income countries: a systematic review

Background: Neurological impairments (NI) and disability are common among older children in low-and middle-income countries (LMICs). We conducted a systematic review to examine the barriers limiting access and utilization of biomedical and rehabilitative care by children and adolescents with NI in LMICs.

Methods: We searched PubMed, Latin America and Caribbean Health Sciences Literature, Global Index Medicus, and Google Scholar for studies published between 01/01/1990 and 14/11/2019 to identify relevant studies. We included all studies reporting on barriers limiting access and utilization of preventive, curative, and rehabilitative care for children aged 0-19 years with NI in five domains: epilepsy, and cognitive, auditory, visual, and motor function impairment. Data from primary studies were synthesized using both qualitative and quantitative approaches.

Results: Our literature searches identified 3,258 reports of which 20 were included in the final analysis. Fifteen studies (75.0%) originated from diverse settings in sub-Saharan Africa (SSA). Factors limiting access and utilization of healthcare services in >50% of the studies were: financial constraints (N=17, 85.0%), geographical and physical inaccessibility (N=14, 70.0%), inadequate healthcare resources (N=14, 70.0%), prohibitive culture and beliefs (N=12, 60.0%), and inadequate education/awareness (N=11, 55.0%). Factors reported in <50% of the studies included competing domestic roles (N=4, 20%) and a lack of confidentiality for personal information (N=2, 10.0%). Very few reports were identified from outside Africa preventing a statistical analysis by continent and economic level.

Conclusions: Financial constraints, geographic and physical inaccessibility, and inadequate healthcare resources were the most common barriers limiting access and utilization of healthcare services by children with NI in LMICs.

PROSPERO registration: CRD42020165296 (28/04/2020)

Hearing Impairment in South Africa and the Lessons Learned for Planetary Health Genomics: A Systematic Review

Hearing impairment (HI) is a silent planetary health crisis that requires attention worldwide. The prevalence of HI in South Africa is estimated as 5.5 in 100 live births, which is about 5 times higher than the prevalence in high-income countries. This also offers opportunity to drive progressive science, technology and innovation policy, and health systems. We present here a systematic analysis and review on the prevalence, etiologies, clinical patterns, and genetics/genomics of HI in South Africa. We searched PubMed, Scopus, African Journals Online, AFROLIB, and African Index Medicus to identify the pertinent studies on HI in South Africa, published from inception to April 30, 2021, and the data were summarized narratively. We screened 944 records, of which 27 studies were included in the review. The age at diagnosis is ∼3 years of age and the most common factor associated with acquired HI was middle ear infections. There were numerous reports on medication toxicity, with kanamycin-induced ototoxicity requiring specific attention when considering the high burden of tuberculosis in South Africa. The Waardenburg Syndrome is the most common reported syndromic HI. The Usher Syndrome is the only syndrome with genetic investigations, whereby a founder mutation was identified among black South Africans (MYO7A-c.6377delC). GJB2 and GJB6 genes are not major contributors to nonsyndromic HI among Black South Africans. Furthermore, emerging data using targeted panel sequencing have shown a low resolution rate in Black South Africans in known HI genes. Importantly, mutations in known nonsyndromic HI genes are infrequent in South Africa. Therefore, whole-exome sequencing appears as the most effective way forward to identify variants associated with HI in South Africa. Taken together, this article contributes to the emerging field of planetary health genomics with a focus on HI and offers new insights and lessons learned for future roadmaps on genomics/multiomics and clinical studies of HI around the world.

An Integrative Review of Current Practice Models and/or Process of Family-Centered Early Intervention for Children Who Are Deaf or Hard of Hearing

Over the past few decades, there has been an increasing shift toward emphasizing the importance of the child's family taking an active role in the habilitation process through family-centered early intervention (FCEI) programs. Accordingly, the Health Professions Council of South Africa recommends that early intervention services following confirmation of hearing loss must be family-centered within a community-based model of service delivery that is culturally congruent. The aim of this study was to explore and document current evidence reflecting trends in FCEI for children who are deaf or hard of hearing (DHH) by identifying and describing current practice models and/or processes of FCEI for these children. This study describes our first steps in formulating a framework for FCEI for children who are DHH in South Africa. An integrative literature review was conducted. Sage, Science Direct, PubMed, and Google Scholar databases were searched for studies published in English between January 2009 and January 2019 reporting on FCEI programs for children who are DHH. Studies that focused on the following were excluded from the study: speech and language outcomes of children, youth, and adults who are DHH; education for children who are DHH; universal newborn hearing screening; professionals' roles in early hearing detection and intervention; diagnosis of hearing loss; and sign language. Kappa statistics were performed to determine agreement between reviewers. Twenty-two studies were included in the review. Cohen's kappa revealed a substantial agreement (κ = 0.8) between reviewers for data extraction and synthesis in terms of the articles that met the criteria for inclusion in the review. Findings were discussed under 5 themes: caregiver involvement; caregiver coaching/information sharing; caregiver satisfaction; challenges with FCEI; and telehealth. Generally, there is sufficient evidence for FCEI, with caregivers indicating the need for full involvement in their children's care. Methods of caregiver involvement involving caregiver coaching/information sharing need to be culturally and linguistically appropriate, with sensitivities around time and manner. This increases caregiver satisfaction with intervention programs and improves outcomes for children who are DHH. Challenges identified by the studies raise implications for early hearing detection and intervention programs, as well as Departments of Health and Social Welfare. These included logistical challenges, professional-related challenges, and caregiver-related challenges. Various aspects of FCEI have been reported in the review. Findings of these studies have significant implications for the formulation of quality FCEI programs to ensure contextually relevant and contextually responsive care of children who are DHH.

Stakeholders' Perspective for Improved Universal Newborn Hearing Screening Uptake in Odisha, India

Universal Newborn Hearing Screening (UNHS) is a significant public health initiative as early diagnosis and intervention are critical for children's cognitive development. In India, priority for UNHS has been provided since 2013; however, there are various operational challenges associated with it. There is a lack of multi-stakeholders perspective on UNHS, which is crucial for improving the service intake. Therefore, this study attempted to understand the perspective of various stakeholders to explore the practices, processes and technologies used in the existing UNHS landscape in Odisha, India. The qualitative in-depth interviews were conducted among various stakeholders including 15 mothers, 5 service providers (audiologists), 10 districts and state-level programme managers. Data were analysed using content analysis approaches. Two major themes emerged were 'social-shaping of technology for UNHS' and 'mothers' understanding and experience on UNHS'. Employee retention, equipment limitations, facilities maintenance and little knowledge among mothers about hearing screening have been described as major operational challenges. The study revealed that to increase universal coverage 'screening technology should be socially shaped'. There seems to be a need for 'portable technology with ease to use and better diagnostic accuracy' for first-stage screening at various levels of healthcare facilities along with community literacy on UNHS.

Barriers to access and utilization of healthcare by children with neurological impairments and disability in low-and middle-income countries: a systematic review

Background: Neurological impairments (NI) and disability are common among survivors of childhood mortality in low-and middle-income countries (LMICs). We conducted a systematic review to examine the barriers limiting access and utilization of biomedical care by children and adolescents with NI in LMICs. Methods: We searched PubMed, Latin America and Caribbean Health Sciences Literature, Global Index Medicus, and Google Scholar for studies published between 01/01/1990 and 14/11/2019 to identify relevant studies. We included all reports on barriers limiting access and utilization of preventive, curative, and rehabilitative care for children aged 0-19 years with NI in five domains: epilepsy, and cognitive, auditory, visual, and motor function impairment. Data from primary studies were synthesized using both qualitative and quantitative approaches, and we report a synthesized analysis of the barriers identified in the primary studies. Results: Our literature searches identified 3,074 reports of which 16 were included in the final analysis. Fourteen studies (87.5%) originated from rural settings in sub-Saharan Africa (SSA). Factors limiting access and utilization of healthcare services in >50% of the studies were: financial constraints (N=15, 93.8%), geographical inaccessibility (N=11, 68.8%), inadequate healthcare resources (N=11, 68.8%), inadequate education/awareness (N=9, 56.3%), and prohibitive culture/beliefs (N=9, 56.3%). Factors reported in <50% of the studies related to the attitude of the patient, health worker, or society (N=7, 43.8%), poor doctor-patient communication (N=5, 31.3%), physical inaccessibility (N=3, 18.8%), and a lack of confidentiality for personal information (N=2, 12.5%). Very few reports were identified from outside Africa preventing a statistical analysis by continent and economic level. Conclusions: Financial constraints, geographic inaccessibility, and inadequate healthcare resources were the most common barriers limiting access and utilization of healthcare services by children with NI in LMICs. PROSPERO registration: CRD42020165296 (28/04/2020)

Perspectives of newborn hearing screening in resource constrained settings

Newborn hearing screening is an effective strategy for early identification of hearing loss in the newborn which result in early intervention and best outcome. However implementing universal screening strategy is a challenge in many resource constrained settings. There are various limitations towards successful implementation of hearing screening program in the developing countries. The cost effectiveness of the screening program also needs to be considered in a resource constrained settings. We attempt to provide a viewpoint that can be potentially helpful for the successful implementation of hearing screening in a resource constrained settings of the developing countries.

Public awareness of ear health and hearing loss in Jeddah, Saudi Arabia

Background

Knowledge of ear health and hearing loss is essential for early intervention and treatment, but the state of public knowledge of such in Jeddah, Saudi Arabia, remains unknown.

Objectives

To measure public knowledge of ear health and hearing loss.

Method

This cross-sectional study was conducted during August 2018 in Jeddah, Saudi Arabia. An electronic survey questionnaire was distributed to 2372 residents of various districts in Jeddah. The survey was created in 2013 by adopting previously published World Health Organization material, designed to assess knowledge and perception of ear health. All males and females aged 10 years or older living in Jeddah had the chance to participate in this study. A total of 2372 people participated. Percentages mean ± standard deviation, one-way analysis of variance (ANOVAs) and independent t-tests were applied to determine the significant difference. p-values of 0.05 or less were considered significant.

Results

The overall mean number of correct responses on the survey’s true/false questionnaire was 10.66 ± 1.92 out of 14. Female participants gave a higher mean number of correct answers than did male participants (10.73 ± 2.03 vs. 10.54 ± 2.03, respectively). Participants with a family history of hearing loss gave a higher mean number of correct answers compared with participants who reported a negative family history (10.89 ± 1.82 vs. 10.53 ± 1.97, respectively).

Conclusion

Overall awareness of ear health and hearing loss management is fair. However, the results indicate a need for more integrated educational materials to be made available both to the general population as well as to hearing loss individuals and their families.

Parental Decision-Making and Deaf Children: A Systematic Literature Review

Parents or caregivers of children who are deaf or hard of hearing are required to make complex and rational decisions soon after the confirmation of hearing loss. Ways of facilitating decision-making have been a focus within the healthcare sector for two decades and shared decision-making is now widely viewed as the standard for good clinical care. A systematic literature review was undertaken to identify the extent to which the principles of shared decision-making and informed choice have been implemented for parents when they make decisions related to their children with permanent hearing loss. Five databases were searched for peer-reviewed papers describing the results of original research published from 2000 to 2017, yielding 37 relevant papers. Studies were reviewed using the three phases of decision-making-information exchange, deliberation, and implementation. Two decisions dominated these studies-implantable devices and communication modality. Most papers dealt with decision-making in the context of bilateral hearing loss, with only one study focusing on unilateral hearing loss. The review identified gaps where further research is needed to ensure the lessons learnt in the broader decision-making literature are implemented when parents make decisions regarding their child who is deaf or hard of hearing.