Review articleEarly hearing detection and intervention in South Africa
Introduction
It was recently estimated that 718 000 infants are either born with, or acquire early-onset, permanent bilateral hearing impairment every year [1]. This means that everyday almost 2000 babies are born with or acquire permanent bilateral infant hearing loss around the world and this figure will be significantly higher if milder (<40 dB) and unilateral losses are included. Unlike many other congenital or early-onset disabilities, infants with hearing loss have the prospect of outcomes potentially matching those of their hearing peers provided the loss is identified early and intervention is initiated by 6–9 months of age [2], [3], [4]. Since hearing loss cannot be identified by routine clinical examination, screening with objective electrophysiologic equipment (i.e. otoacoustic emissions and auditory brainstem responses) is recommended for universal screening of all newborns and infants [5], [6], [7]. This is the only way to ensure early identification and early access to services including personal amplification and family-centred early communication intervention.
Despite these recommendations and the proven benefits of early identification and intervention for infant hearing loss the vast majority of infants with hearing loss have no prospect of early identification because they are born in developing countries around the world [8]. More than 90% of the estimated 718 000 infants born annually with congenital or early-onset permanent bilateral hearing loss reside in developing countries where environmental risks are more prevalent and early identification programs are extremely uncommon [1]. Although some progress in initiating pilot early hearing detection and intervention programs have been reported in developing countries these are still only reaching very limited numbers of people [9], [10]. Nowhere is this situation more pronounced than in sub-Saharan Africa where 25% of all infants with permanent bilateral hearing loss, estimated at 180 000, are born annually [9], [10], [11].
Until recent reports from Nigeria and South Africa emerged, almost no information was available on early detection and intervention services in sub-Saharan Africa [12], [13], [14], [15]. The dearth of reports from the region reflects a total lack of EHDI services and can be attributed to several factors including a high burden of infectious diseases, restricted resources and the lack of tertiary education for audiologists or other hearing health care specialists. South Africa is the only country in sub-Saharan Africa which offers a professional tertiary qualification for audiology. Also, being the strongest economic power in the region, South Africa has the responsibility to take the lead in advocacy and development of EHDI services throughout the region.
The country of South Africa is classified as an upper middle income country with pockets of developed contexts in an overall developing context [16]. Although two-thirds of the world's least developed nations are in sub-Saharan Africa, South Africa, which occupies the southern tip of the African continent, has a comparatively well-developed infrastructure. In contrast to most other countries in the region it has a reasonably developed health care infrastructure although it is characterized by inequality according to race and socioeconomic status. The vast majority of the population (approximately 85%) relies on the public health sector whilst the remaining minority (approximately 15%) accesses the private health care sector which comprises the majority of national health care expenditure [17]. Those who can afford private health care can receive state-of-the-art medical services whilst the majority of the population relies on the public sector, which in most cases offer less-resourced services although these are offered free of charge or at minimal administrative fees. This report summarizes the current status of infant hearing loss and EHDI services in South Africa.
Section snippets
Prevalence of infant hearing loss
Apart from a single study reporting an estimated prevalence rate for infant hearing loss in the private health sector there has been no large-scale systematic newborn or infant hearing screening programs conducted to determine the true prevalence of infant hearing loss in South Africa [14]. The extent of infant hearing loss can however be estimated using recently reported prevalence rates. For the public health sector, which primarily serves people from developing contexts, an estimated
Age of diagnosis and intervention
Due to a lack of legislation and awareness regarding infant hearing loss the initial detection in South Africa remains primarily passive as a result of caregiver concern about observed speech and language delays, unusual behavior or the complications of otitis media [20]. A recent report of a representative sample of 54 children with hearing loss from the Western Cape region has provided some indication of the ages for diagnosis and intervention as summarized in Table 2 [21]. The average age of
Early identification services
Limited information is available on the status of early identification services for infant hearing loss in the country [23]. A recent national survey of early hearing detection programs in the public health sector has shed some light in the absence of any other indications [24]. The questionnaire based study, sampled all hospitals (n = 86) in eight of the nine provinces in South Africa with audiology and/or speech-language therapy services (51% return rate). Less than one third (27%) of the
Early intervention services
The recent developments and reports on infant hearing loss in South Africa have mainly focused on the screening and diagnosis with little information on the intervention in terms of amplification or cochlear implantation and the intervention programs available. The well-established history of audiological training in South Africa provides a reasonable infrastructure for pediatric hearing aid fittings. An unpublished 2005 survey however indicated that less than 25% of South African audiologists
Parental attitudes and knowledge
Public awareness and attitudes towards childhood disabilities in developing countries have been reported to be poor in general and often aggravated by superstitious customs and beliefs in developing countries [33], [34], [35], [36]. Decisions made by caregivers for infants with hearing loss in relation to early identification and intervention may have far reaching consequences. A recent survey of 100 mothers, representative of a developing South African context, has provided insight into
Moving forward
The first EHDI in Africa conference was held in South Africa in 2007 and the proceedings recently published [10]. This milestone event for the continent was a first step towards uniting parents of children with hearing loss, professionals, governmental and non-governmental organizations to explore and develop EHDI programs across Africa. An outcome of the meeting was the formation of a working group for EHDI services in South Africa that is now actively working towards advocacy, support and
Conclusion
South Africa is uniquely positioned in terms of its health care infrastructure and the available training for hearing health care professionals such as audiologists and otolaryngologists, to lead the way in sub-Saharan Africa for implementing widespread and systematic EHDI services. Despite this comparative advantage over other countries in the region it is clear that EHDI services are not reaching the overwhelming majority of the numerous newborns and infants with permanent hearing loss.
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