Community-based hearing services for children in early childhood development centers using mobile technologies

Abstract

Unidentified hearing loss has a negative impact on a child’s speech, language and communication abilities. This in turn creates a barrier to social development and educational achievement placing a child at a risk for failure and drop out from school. Within low- and middle-income countries (LMICs) like South Africa, children have limited access to early identification services due to several challenges, including a shortage of human resources for ear and hearing care, a lack of appropriate equipment as well as other health care priorities. This study identified early childhood developmental centers (ECD) as a potential platform for the identification of children affected by hearing loss prior to school entry. It aimed to provide research-based recommendations for delivering hearing screening within ECD centers using a low-cost smartphone-based hearing screening application operated by community members with no formal training on hearing care. It also investigated the current knowledge and attitudes of ECD practitioners to ensure the acceptance and success of such programs. Lastly, this study aimed to determine the nature and profile of hearing loss in a community representative of typical LMICs. A total of 6424 children (3446 females, 2978 males) between the ages of three to six years were recruited from 250 ECD centers to determine the efficacy and feasibility of a smartphone hearing screening application, hearScreenTM. A referral rate of 24.9% was obtained with females 1.26 times more likely to fail compared to males. An increase in age was associated with a decreased likelihood of test failure, with overall referral rates varying from 19.6 to 45.8% for children six and three years of age, respectively. The quality index reflecting test operator test quality increased to 99-100% during the first few months of testing, thus indicating reliable testing by non-specialist personnel with support in early roll-out phases. Mean test duration, including both initial and rescreen test times for both ears, was 68 seconds (SD 2.8) for participants that passed and 258.5 seconds (SD 251.2) for those who failed. Only 39.4% of children who failed ECD screenings attended their follow-up appointment at their local primary health care (PHC) facility, of which 40.5% referred on their second screening. A total of 725 children received a diagnostic assessment. Diagnostic testing revealed that 9.3% of children presented with impacted cerumen and 18.7% presented with a hearing loss (56.5% bilateral). Conductive hearing loss (65.2%) was the most common type of hearing loss found in these children. No gender or age effects were found (p>0.01). The majority of preschool children who failed hearing screenings and received a diagnostic assessment were in need of intervention services for conductive hearing losses, followed by sensorineural and mixed losses. A questionnaire was administered amongst 82 ECD practitioners to determine their current knowledge and attitudes towards hearing health in poor communities. More than 80% of ECD practitioners correctly identified genetics and ear infections as etiological factors of hearing loss. Gaps in knowledge regarding identification techniques for children three to six years of age and the impact of hearing loss in the classroom were evident. ECD practitioner’s duration of experience had a significant effect on overall knowledge and attitude. ECD practitioners displayed a positive attitude towards children receiving a hearing test (88.3%) and almost all participants indicated the need for more information regarding hearing loss (93.5%). Findings from this study provide baseline data for future research, planning and implementation of ECD-based hearing health services within LMIC contexts such as South Africa. Implementation of smartphone-based hearing screening programs within ECD centers is a feasible solution to improve access to ear and hearing care services to children in LMICs. Whist ECD practitioners demonstrated a general readiness for the implementation of ECD hearing screening programs, additional information and guidelines are needed to improve practitioner knowledge and attitudes. Using mobile health technologies offers a number of advantages that can support communitybased hearing services and overcome some of the traditional challenges faced when screening within an informal educational setting.