Methods: All private hospitals with obstetric units (n = 166) were surveyed telephonically. The data was integrated with data collected from self-administered questionnaires subsequently distributed nationally to private audiology practices providing hearing screening at the respective hospitals reporting hearing screening services (n = 87). Data was analysed descriptively to yield national percentages and frequency distributions.

Results: Average reported age at diagnosis was 11 months. Most participants (74%) indicated that less than 20% of infants fitted with hearing aids received amplification before the age of 6 months. Most (64%) participants indicated that the average period between confirmed diagnosis and hearing aid fitting was 1 month, on par with international benchmarks. Only 16%–23% of participants included all diagnostic procedures recommended by the Health Professions Council of South Africa’s 2007 position statement for minimum diagnostic test batteries for infants and young children.

Conclusions: Diagnosis of hearing loss, hearing aid fitting and audiological intervention is delayed significantly in the South African private health care sector. Improved services should include integrated systematic hospital-based screening as part of birthing packages with diagnostic referral to specialist paediatric audiologists for accurate assessment and management of patients in a timely manner.

Unlike many other congenital or early-onset disabilities, infants with hearing loss could develop speech and language skills on par with normal hearing peers, provided that the loss is identified and intervention initiated early enough (Nelson, Bougatsos & Nygren, 2008; Watkin et al., 2007). If these infants were screened shortly after birth, audiological and medical evaluations were conducted before 3 months of age, confirmation of permanent congenital or early-onset hearing loss was no later than 4 months of age and intervention was initiated before 6 months of age, they would have had the potential to develop age-appropriate speech and language skills (Boudewyns et al., 2011; Health Professions Council of South Africa [HPCSA], 2007; JCIH, 2007; Yoshinaga-Itano & Thomson, 2008).

However, if these children are not identified early, it could cause developmental delays in speech, language, social, emotional and cognitive development (HPCSA, 2007; Korver et al., 2010; Olusanya, 2008; Olusanya & Newton, 2007; Yoshinaga-Itano & Thomson, 2008). The longer the hearing loss goes undetected, the poorer speech, language, literacy and educational outcomes are likely to be for the child, with higher associated long-term costs to the family, society and the country (Joint Committee on Infant Hearing [JCIH], 2007; Korver et al., 2010; Morton & Nance, 2006; Olusanya, 2008; Olusanya & Newton, 2007; Olusanya, Ruben & Parving, 2006; Swanepoel, 2008; Swanepoel, 2010; Yoshinaga-Itano & Thomson, 2008). Ultimately, infants with hearing loss are often consigned to a life of exclusion and stigmatisation (Olusanya et al., 2006; Swanepoel, 2008; Swanepoel, 2010).

In South Africa, infant hearing loss is primarily detected passively when parents become concerned about speech and language delays or unusual behaviour, which usually occur after 2 years of age, when the critical age of language development has passed (Swanepoel, 2008; Swanepoel et al., 2009; Swanepoel, 2010; Swanepoel, Johl & Pienaar, 2013; Theunissen & Swanepoel, 2008). Recent studies performed on urban samples from two provinces reported a mean age at hearing loss diagnosis of 23 and 31 months, respectively, and a mean age at initial hearing aid fitting of 28 and 39 months, respectively (Van der Spuy & Pottas, 2008; Venter & Viljoen, 2008). In these urban samples, it was furthermore reported that the mean age at initial enrolment into an early intervention programme was 31 months and 43 months, respectively (Van der Spuy & Pottas, 2008; Venter & Viljoen, 2008). In a more recent study at a diagnostic referral clinic, nearly half (47%) of participants were only diagnosed after 36 months of age although 40% of them were suspected of having a hearing loss before 12 months of age (Swanepoel et al., 2013).

The delayed age at diagnosis could partly be attributed to the poor status of current early hearing detection services in South Africa (Meyer & Swanepoel, 2011; Meyer, Swanepoel, Le Roux & Van der Linde, 2012; Swanepoel et al., 2013; Theunissen & Swanepoel, 2008). In the public sector, only 7.5% of hospitals provide some form of neonatal and infant hearing screening, whilst less than 1% offer universal screening (Theunissen & Swanepoel, 2008). Although screening coverage might have improved since the Theunissen and Swanepoel (2008) publication, no updated survey on the current status has been published since. In the private sector, universal newborn hearing screening is only offered in 14% of obstetric units (Meyer & Swanepoel, 2011).

Other possible reasons for late diagnosis and enrolment into early intervention programmes in the public health care sector are poor follow-up return rates, a lack of awareness amongst parents of the importance of infant hearing screening and the detrimental effects of permanent childhood hearing impairment, and a possible delay in hearing aid procurement (Swanepoel, Ebrahim, Joseph & Friedland, 2007; Theunissen & Swanepoel, 2008).

Until recently, however, there has been no national survey of early hearing detection and intervention (EHDI) services in the private health care sector (Meyer et al., 2012; Meyer & Swanepoel, 2011; Swanepoel et al., 2009). As the private health care sector serves a minority (15%) of the South African population but comprises the majority of national health care expenditure (Dambisya, Modipa & Health Systems Research Group, 2009), it may appear as though more resources are available for EHDI services in this sector as opposed to the public health care sector. However, screening programmes in these private health care institutions are mostly dependent on individual initiatives from audiologists in private practice who may face similar problems with programme implementation as the public health care sector (Blecher & Harrison, 2006; Dambisya et al., 2009; Swanepoel et al., 2009).

The Health Professions Council of South Africa’s (HPCSA) position statement on EHDI programmes in South Africa (HPCSA, 2007) specifies recommended diagnostic protocols, practices and targets for EHDI programmes. To date it is unknown whether audiologists in private practice are aware of the HPCSA position statement and its recommended guidelines for best practice or to what extent they adhere to these guidelines. In light of this, the objective of the current study was to describe the audiological diagnostic protocols and intervention practices implemented in the South African private health care sector. The study is part of the first national survey on EHDI services in the South African private health care sector (Meyer et al., 2012; Meyer & Swanepoel, 2011). A review of existing audiological diagnostic and intervention practices in EHDI provides baseline information essential for planning and coordination of improved widespread early hearing detection, diagnosis and intervention services into the future.

• to describe diagnostic audiological protocols for EHDI
• to determine the average age at diagnosis
• to determine the average age at hearing aid fitting
• to determine the delay from diagnosis to audiological intervention
• to describe intervention practices.

FIGURE 1: Flowchart of study populations and survey methods.

All private health care (non-government funded) institutions in South Africa were contacted telephonically in order to determine whether they provided obstetric services. A total of 304 such institutions, including hospitals, clinics and private practices listed in the national registry (Medpages, 2009), were considered for potential inclusion in the population. After removing duplicated listings (6 listings), partially government funded institutions (8 listings) and institutions that no longer existed (4 listings), 286 institutions remained to be considered as eligible private health care sector institutions. Of these, 122 institutions did not provide obstetric services, whilst the remaining 166 did (Population 1, Figure 1). Infant hearing screening was conducted at 87 of those institutions. The 87 audiologists that offered infant hearing screening at those institutions (Population 2, Figure 1) were sent questionnaires to complete. Participants who worked at more than one private health care institution were asked to complete one questionnaire per institution to ensure that data was representative for each respective hospital or clinic.

FIGURE 2: Inclusion of tests in minimum diagnostic test battery for infants aged 0–6 months and 7–36 months (n = 53).

For the 7–36 months category (Figure 2), participants generally replaced high-frequency tympanometry with standard tympanometry (89%; 47/53). More participants included behavioural observation, speech detection and speech recognition testing in testing for the older age group.

One in four participants (26%; 14/53) that provided diagnostic testing for babies 0–6 months of age did not use auditory evoked potential testing (i.e. ABR or auditory steady state response (ASSR)). This percentage increased to 36% (19/53) in the older age group (7–36 months). Five participants (9%) included ASSR for the 0–6 months age group only and not for the 7–36 months age group. A single participant included ASSR for the 7–36 months age group only and not for the 0–6 months age group. Eighty percent of participants (61/76) were aware of the HPCSA (2007) position statement. On further analysis of the data it was found that a significant association existed between participants’ years of experience and awareness of the HPCSA position statement (chi-squared and Fisher’s exact tests; p < 0.05). The more years of experience participating audiologists in private practice had, the less likely they were to be aware of the HPCSA position statement.

The average reported age at diagnosis amongst the particular participants that conducted diagnostic audiological assessments ranged from 1–36 months (Figure 3). If participants did not provide diagnostic audiological testing services, their responses were not included. Twenty-seven percent (13/48) of participants indicated that infants were diagnosed on average between 0 and 3 months of age whilst 44% (21/48) indicated an average age at diagnosis of 9 months or older. The total average reported age at diagnosis in the private health care sector was 11 months (minimum age of 1 month; maximum age of 36 months; standard deviation of 9.98).

FIGURE 3: Reported average age at which diagnosis of a permanent congenital or early-onset hearing loss is confirmed (n = 48).

FIGURE 4: Estimated percentage of children in different age groups fitted with hearing aids in the previous 12 months (n = 34).

The most commonly reported factors contributing to delayed audiological intervention services (Figure 5) were the family’s personal funding for amplification (62%; 48/77), approval for funding from medical aids (60%; 46/77) and parents’ delay in returning for follow-up appointments (43%; 33/77). The ‘other’ category (10%; 8/77) included factors such as transport to attend appointments, parental denial, parental resistance to accepting the diagnosis, the process of seeking a second opinion, the waiting period for donated hearing aids for orphans and the lengthy process of cochlear implant candidacy investigations.

FIGURE 5: Contributing factors that prolong the waiting period between diagnosis and first visit for audiological intervention.

Seventy-one percent of participants (55/77) indicated that they referred children to other private practices, 70% (54/77) to schools or intervention centres, 45% (35/77) to non-governmental organisations such as Hi Hopes (Störbeck & Pittman, 2008) and 34% (26/77) to public hospitals when their services or the patient’s funding are insufficient. One participant indicated having to refer children to another province as there are no available services in the vicinity, three participants reported that they refer to a cochlear implant team for intervention in possible candidacy cases, one indicated often referring to the occupational therapist and another two participants refer children and their parents to the local parent support group. None of the participants indicated that it is the parents’ own responsibility to find a suitable facility that offered early intervention services.

Ten participants (13%) in the present study included all the recommended procedures (HPCSA, 2007) in their minimum diagnostic test batteries for young children (older than 6 months) except the screening of communication and language milestones. Although the screening of communication and language milestones is part of both the audiology and speech-language therapy scope of practice, it seems that audiologists in the private health care sector may rather refer to a speech-language therapist for formal assessment of speech and language. Often the speech-language therapists referred to already have experience with children with hearing impairment.

High-frequency tympanometry was omitted from the diagnostic test battery for the 0–6 months age group by 36% (19/53) of participants. The prevalence of otitis media with effusion in the newborn population has been reported to approximate 1 in 250 (Boudewyns et al., 2011). These infants will not be identified or receive appropriate treatment early enough without using high-frequency tympanometry (Boudewyns et al., 2011). Standard tympanometry was omitted from the diagnostic test battery for the 7–36 months age group by 11% (6/53) of participants. The highest prevalence rates for otitis media are between the ages of 6 and 48 months; more than 50% of children are expected to have at least one episode of otitis media with effusion in the first year of life (Boudewyns et al., 2011). This emphasises the importance of including tympanometry in the minimum test battery in order to identify otitis media with effusion promptly (Boudewyns et al., 2011).

Nine percent of participants included ASSR in their minimum test batteries for the 0–6 months age group but not for the 7–36 months age group. However, the relationship in young infants between behavioural thresholds and ASSR is not well defined and remains variable throughout the first year of life, especially during the first 3 weeks of life (John, Brown, Muir & Picton, 2004; Rance, 2008). Participants might have chosen to include ASSR in the younger group as opposed to the older group as infants become increasingly active and mobile as they get older, which could make ASSR testing challenging or require conscious sedation during testing.

The variations in procedures included in diagnostic protocols amongst participants might be attributed partly to the increased equipment and consumable costs associated with certain tests, such as high-frequency tympanometry, ABR or ASSR (Swanepoel, 2009). Diagnostic tests utilised are entirely dependent on the devices acquired by audiologists, resulting in significant variability in diagnostic protocols (Meyer et al., 2012). Comprehensive test batteries in accordance with HPCSA recommended protocols are necessary not only for correct and prompt diagnosis but also for optimal amplification and verification (HPCSA, 2007; Strauss & Van Dijk, 2008).

The variations in protocols may furthermore be ascribed in part to a lack of awareness of national and international recommendations, benchmarks and quality indicators of EHDI programmes. This study established that 80% of participants (61/76) were aware of the HPCSA (2007) position statement, a document that specifies recommended protocols, practices and targets for EHDI programmes. However, awareness of the HPCSA position statement does not mean that recommended HPCSA protocols are implemented, as confirmed by this survey.

Non-compliance of minimum diagnostic audiological test batteries with international benchmarks and quality indicators may result in incorrect or late identification of infants with hearing impairment and subsequent suboptimal amplification (HPCSA, 2007; Korver et al., 2010; Olusanya, 2008; Olusanya & Newton, 2007; Strauss & Van Dijk, 2008; Yoshinaga-Itano & Thomson, 2008). This in turn might cause delayed speech, language, cognitive, social and emotional development (HPCSA, 2007; Korver et al., 2010; Olusanya, 2008; Olusanya & Newton, 2007; Yoshinaga-Itano & Thomson, 2008). Ideally, paediatric diagnostic testing would be conducted at specialised paediatric facilities across the country where all necessary tests are included in the diagnostic test battery and experienced paediatric audiologists are available.

The average age at diagnosis reported in this survey was 11 months. Although this does not meet the target of earliest possible diagnosis (before 3 months and no later than 4 months of age), it is better than reported in studies conducted on small urban samples in Gauteng and the Western Cape, where the average age at diagnosis was 31 and 24 months, respectively (Van der Spuy & Pottas, 2008; Venter & Viljoen, 2008). In a recent referral clinic study, the average age at diagnosis was 42 months (Swanepoel et al., 2013). The delayed age at diagnosis may be attributed to several factors, including poor follow-up return rates (Meyer et al., 2012; Russ, Dougherty & Jagadish, 2010; Shulman et al., 2010; WHO, 2010), late-onset or progressive hearing loss (HPCSA, 2007; Murphy & Radford, 2006; Shulman et al., 2010; Swanepoel et al., 2007) and poor data management systems for ensuring that the diagnostic assessment is efficient and has adequate quality control (HPCSA, 2007; Meyer et al., 2012; Shulman et al., 2010; Swanepoel et al., 2007; Swanepoel et al., 2013).

The most commonly reported factors contributing to delayed first visit for audiological intervention in the private health care sector were the family’s personal funding for amplification or approval for funding from medical aids (financial) and the parents’ delay in returning for follow-up appointments (administrative). The ‘other’ category in participant responses included factors such as transport to attend appointments (administrative) and the lengthy process of cochlear implant candidacy investigations (medical). A further category that might be added is parental acceptance of hearing impairment. Parental denial, parental resistance to accept the diagnosis and the process of seeking a second opinion were listed as significant factors that might contribute to the suboptimal waiting period for initiating intervention services. These factors are not unique to the South African context as similar factors also delay processes of EHDI programmes in the United States of America (Nelson et al., 2008; Shulman et al., 2010; Yoshinaga-Itano & Thomson, 2008).

In one particular province in South Africa, there were no intervention services available and children had to be referred to a neighbouring province for intervention. This emphasises the need for upscaling integrated and comprehensive EHDI service infrastructure to make services accessible to all young children and their families, as well as establishing a national data management system to track young children as they progress through the system (Meyer et al., 2012; Meyer & Swanepoel, 2011; Russ et al., 2010; Shulman et al., 2010; Swanepoel et al., 2009; Watkin & Baldwin, 2011; WHO, 2010).

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