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Early identification in different levels of health care service delivery
ОглавлениеNo formal, standardised newborn hearing screening (NHS) system currently exists at public hospitals across South Africa. According to Theunissen and Swanepoels' study (2008), only 27 percent of public health care hospitals at the time of their study had any form of NHS in place. Meyer and co-authors (2014) reported a marked delay in hearing impairment diagnosis and early intervention provision in their national survey of private health care. To date, South African EHDI studies have revealed a non-holistic approach to services rendered nationally (Moodley & Störbeck, 2015). This is in stark contrast to high-income countries such as the United States of America and the United Kingdom, where formalised screening and diagnostic and intervention systems are in place. However, some systems are complex, and numerous resources as well as financial support are required (Moodley & Störbeck, 2015).
As emphasised by the JCIH (2007, 2013, 2019) and the HPCSA (2007, 2018), context is key to EHDIs' success. To better understand the South African setting, it is necessary to interrogate the practicability and efficiency of hearing screening at the various levels of care, as guided by published evidence in these contexts (see Table 4.2). The hearing screening contexts include public health care (primary, secondary and tertiary levels) and private health care:
Level of care 1 (PHC):Hearing screening at a community health care (CHC) centre or clinic using OAEs within six hours of birthHearing screening using OAEs three days after birth at the MOUHearing screening using OAEs and AABR at mostly <14 days post birth at the MOUHearing screening at PHC immunisation clinics.
Level of care 2 (secondary):Hearing screening at a secondary level hospital, using OAEs within 30 days of birthHearing screening using OAEs and AABR at newborn follow-up visits after discharge for high-risk infants.
Level of care 3 (tertiary): Hearing screening at tertiary level health care using OAEs and AABR in neonatal intensive care units and/or step-down wards.
Private health care: Hearing screening at private health care facilities.
Table 4.2 Practicability and efficiency of NHS in various South African health care contexts
| Context detail | Hearing screening age | Practicability and efficiency | Factors that may impact practicability and efficiency |
|---|---|---|---|
| Public health care sector, secondary level:CHC centre/clinic | ≤6 hours post birth | Low pass rateLow patient yield (babies missed screening) | Time of birth relative to dischargeResourcesEnvironmental factorsReferral rate increased |
| Public health care sector, secondary level:All neonatal wards | ≤30 days post birth | Pass rates affected by vernix caseosa, noise levels | Staff availabilityEquipment/resourcesEnvironmental factorsEarly discharge |
| Public health care sector, primary level:MOU | 3 days post birthOAE (TEOAE, DPOAE) | High pass rateHigh patient yield/return rate | Return rate for follow-up highReferral rate decreased |
| Mostly <14 days post birth (mean age 6 days) | High pass rateHigh patient yield/return rate | Return rate for follow-up highRefer rates decreased using AABR and two-stage screening protocol | |
| Public health care sector, tertiary level:Neonatal intensive care unit (NICU) and/or step-down wards when baby stable | Dependent upon babys' wellness level | High bilateral refer rates for TEOAE, less for AABRDependent upon babys' wellness levelWell babies missed (approximately 50%) TEOAE | Delays in EHDI timing strongly associated with infants' birth status and complexity of medical needsOther factors – increased ambient noise levels, securing informed consent from parents may be difficult, aspects related to discharge |
| Public health care sector, tertiary level:Newborn follow-up clinic post discharge | 1st newborn follow-up clinic post discharge | Highest refer rates for DPOAE and AABR, lowest for TEOAELow patient yield/return rate | Low patient yield/return rate |
| Public health care sector, primary level:PHC clinic | At 6-, 10- and/or 14-week immunisation clinic | Assets: nurse willingness, high patient yield/return rateBarriers: space, equipment, environmental factors, high staff demands, prioritising other health conditions, lack of nurse awareness regarding hearing impairment, inconsistent record keeping | Fine-tuning required to address barriers formally to improve feasibilityDedicated screening staff can improve competency through experience and thus reduce false positives/over-refers; relieve already overburdened PHC staff who may prioritise other diseasesA screening coordinator can facilitate higher return rates through strategies such as telephonic appointment reminders and in-file visual rescreen reminders, facilitating consistent record keeping |
| Private health care | Within 24 hours post birth | High patient yield if hearing screening part of birthing package, otherwise coverage rates significantly less than 50%Loss of patients to early discharge out of audiologist working hoursDifficulty tracking patients who have the option to choose the screening/audiology service | Parental education prior to birth to impart importance of hearing screening and facilitate consentStructure screening as part of the birthing package to improve patient yieldEducate ward staff regarding the importance of hearing screening to ensure hearing screening before dischargeEnsure programme monitoring to improve programme efficiency and decrease refer ratesTo improve quality control and accountable service provision, ensure appropriate data management and tracking |
Sources: Bezuidenhout, Khoza-Shangase, De Maayer, & Strehlau, 2018; De Kock, Swanepoel, & Hall, 2016; Friderichs, Swanepoel, & Hall, 2012; Joubert & Casoojee, 2013; Kanji, Khoza-Shangase, Petrocchi-Bartal, & Harbinson, 2018; Meyer & Swanepoel, 2011; Swanepoel, Ebrahim, Joseph, & Friedland, 2007
Note: TEOAE = Transient evoked OAEs; DPOAE = Distortion product OAEs
As Table 4.2 indicates, hearing screening at CHC centres/clinics is possible prior to hospital discharge within six hours of birth, but it comes with significant challenges in the South African context (Khoza-Shangase & Harbinson, 2015). These challenges include the possibility of low patient capture, despite the babies being inpatients. This may be a result of staff availability. For example, audiologists are employed during standard daytime working hours, but babies’ arrivals cannot be timed to fit in with these hours – they may be born at night or over the weekend and discharged before their hearing is screened. Some births in South Africa also take place at home (Bezuidenhout, Khoza-Shangase, De Maayer, & Strehlau, 2018; Khoza-Shangase & Harbinson, 2015). Likewise, in many other LAMI countries (Olusanya & Somefun, 2009) a large number of infants are born outside hospital settings. Community-oriented NHS must thus be emphasised, particularly in these contexts (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018). In addition, hearing screening pass rates in these contexts may be low because of vernix caseosa (Albuquerque & Kemp, 2001; Korres et al., 2003), which may result in a hearing screening refer due to obstruction in the external auditory canal. This higher hearing screening refer rate, not as a result of a hearing issue per se, is thus a factor that raises challenges with cost-effectiveness and parental psycho-emotional status management in an already vulnerable system.
At secondary level hospitals where UNHS was attempted on neonates within 30 days of birth in all wards, significant challenges were identified: reduced staffing, resource issues (lack of back-up equipment due to resource constraints) and factors that further impede testing, such as ambient noise levels in wards. Furthermore, as noted, additional findings were the presence of vernix caseosa as well as babies being missed due to discharge during audiologists’ non-working hours (Bezuidenhout et al., 2018). Bezuidenhout and colleagues (2018) suggest that hearing screening should be conducted at the three-day MOU visit in order to overcome the challenges raised by early discharge and vernix caseosa during screening. The fact that there are not enough audiologists available to screen all neonates may be resolved by training non-audiologists to conduct the screening, as recommended by the HPCSA (2018), with audiologists serving as managers of the screening programmes. This strategy would also allow for 24-hour access to screening services which are currently impeded by audiologists’ limited working hours.
At three-day MOU clinics, where scheduled appointments are made, patient capture rates are markedly improved and return rates are reported to be high when hearing screening coincides with the postnatal general medical check-up (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018; Khoza-Shangase & Harbinson, 2015). Capture rates are high because infants tend not to be missed due to off-duty staff factors and home births. High return rates suggest that babies born outside medical facilities are brought to the three-day follow-up clinic. Moreover, hearing screening pass rates are reported to be high because factors such as the negative influence of vernix in the external auditory canal have mostly been minimised by this stage (Bezuidenhout et al., 2018). Hearing screening protocol selection (OAEs versus AABRs) is therefore important to reduce the number of refers, although the importance of obtaining accurate results as early as possible remains paramount (De Kock, Swanepoel, & Hall, 2016).
Thus, while hearing screening may be possible within six hours postpartum, it is more efficient and practical to screen infant hearing at the MOU assessment clinic, particularly the three-day appointment post birth. This setting maximises patient capture rates relative to other contexts, and significantly reduces false positive rates. Time of birth in relation to discharge, environmental aspects, resource availability, referral rates and return for follow-up rates have all been identified as possible factors that impact the practicability and efficiency of screening in specific contexts. Ng, Hui, Lam, Goh, and Yeung (2004) report similar findings where newborns were missed in terms of hearing screening because of time of birth and discharge out of normal working hours. However, contrary to these findings, evidence also indicates highest coverage to take place for screening before discharge in non-South African contexts where discharge occurs after six hours post birth (Adelola, Papanikolaou, Gormley, Lang, & Keogh, 2010; Lim & Daniel, 2008). These factors underscore the importance of EHDI coordinators being mindful of circumstances which may cause infants to be overlooked within the particular NHS system.
In South Africa, the importance of investigating alternative avenues for contextually appropriate hearing screening is also emphasised. Such screening may need to be included in the scheduling of other medical visits. According to Theunissen and Swanepoel (2008), the most frequently reported reasons for shortages of NHS programmes in South Africa are the lack of appropriate hearing screening equipment and the relatively small number of audiologists in the country, within whose remit hearing screening mainly falls. Chan and Leung (2004), as well as Olusanya, Wirz, and Luxon (2008), suggest using nurses and community health workers for NHS. The HPCSA (2018) advocates that with appropriate training, the use of non-audiologist staff may help to optimise time and resources at all levels of service delivery. This would require compliance with the HPCSAs' minimum standards of training to ensure quality.
A clear caution is the prospect of false positive results before discharge, when a hearing impairment is not present but the infant does not pass the hearing screening (Herrero & Moreno-Ternero, 2005). This has been documented as a major NHS concern (Kanji, Khoza-Shangase, & Moroe, 2018; Korres et al., 2005; Lam, 2006).
In NICU and step-down wards such as the kangaroo mother care ward, timing of NHS is dependent upon the newborns’ level of wellness, ranging up to 62 days post birth (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018), as well as other medical conditions in the high-risk neonatal population that may impede timely hearing screening as per JCIH (2013, 2019) and HPCSA (2007, 2018) guidelines (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018). This is confirmed by Chapman et al. (2011), who purport that EHDI process delays are strongly associated with the infants' medical status at and post birth. Delays for babies with concomitant health issues are on average 25 days later for hearing screening and 2.5 months later for hearing impairment diagnosis. Initial NICU screening in the South African context may also demonstrate high referral rates (Kanji, Khoza-Shangase, Petrochhi-Bartal et al., 2018), which is in agreement with reports by Chen et al. (2012) and Colella-Santos, Hein, De Souza, Do Amaral, & Casali (2014). Refer rates tend to decrease with an increase in the infants' age, reflecting that the longer the interim period between the initial and the rescreen, the lower the refer rate (Akinpelu, Peleva, Funnell, & Daniel, 2014; Kanji & Khoza-Shangase, 2018a). Practicability and efficiency in the South African NICU context may be further negatively affected by high ambient noise levels in wards, difficulty obtaining informed consent for hearing screening because of caregiver absence from the NICU, and, where discharge dates are not clearly detailed in patient files, the unanticipated discharge of the patient prior to screening (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018). The latter factor may necessitate booking the neonate for the outpatient rescreen on the same day as the next follow-up visit (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018).
Return rates may decrease at the first newborn follow-up clinic appointment, which usually takes place six weeks post discharge (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018). This does not bode well for NHS test–retest protocols, as neonates and infants may be lost to follow-up, compromising NHS programme quality (Vos, Lagasse, & Levêque, 2014). It is thus important to consider follow-up rates in general and screening contexts.
Tables 4.3 and 4.4 indicate assets and barriers to hearing screening in PHC immunisation clinics in South Africa.
Table 4.3 Assets facilitating the efficiency of hearing screening at PHC immunisation clinics
| DoH policy assets | DoH funding assets | Logistics assets | Other factors/assets |
|---|---|---|---|
| PHC immunisation policies and strategiesInfant record documentationReferrals | Otoscope supply | Patient return rates for immunisationsImmunisation days availableMethods prompting infant returns for follow-up appointmentsInfant record documentation systems | Parental awareness, education and willingness, regarded as mostly surmountable through educationOngoing surveillance by caregiversDisability policy |
Source: Kanji, Khoza-Shangase, Petrocchi-Bartal, & Harbinson, 2018, p. 5
Table 4.4 Barriers influencing the practicability of hearing screening at PHC immunisation clinics
| DoH policy liabilities | DoH funding liabilities | Other factors/liabilities |
|---|---|---|
| The nursing scope of practice delineates rudimentary hearing screening techniques such as:PHC package protocols, including: Road to Health Card assessmentsIntegrated management of childhood illness (IMCI) protocols, including: Hearing assessments framed predominantly within the context of otitis media | Inconsistent otoscope usageLack of formal objective equipmentClinic infrastructure, e.g. lack of space available for hearing screeningStaff complement and work distributionFunding inequity between districtsStaff training, where:IMCI protocols are emphasisedFunding needs assessment in terms of added hearing screening specific training | Burden of diseaseStaff currently working at capacityStaff knowledge base pertaining to hearing loss in general |
Source: Kanji, Khoza-Shangase, Petrocchi-Bartal, & Harbinson, 2018, p. 6
Clear PHC immunisation policies at a government level are key. These policies should facilitate the practicability of NHS in the PHC context. As far as assets in this context are concerned, they should include, firstly, immunisation day guidelines and positive approaches to prompt infant follow-up returns for immunisations (DoH, 2001). High hearing screening coverage is anticipated as a consequence, given that return rates for infant immunisation are reportedly between 90 and 100 percent (Day & Gray, 2008; DoH, 2009). Hearing screening that coincides with clinic schedules for infant immunisation, as recommended by the HPCSA (2018), is thus strategic in achieving high screening coverage. Secondly, assets should include generalised documentation pertaining to infant record keeping. Electronic databases are already in place in certain regions (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018). DoH policies advocate for accountable infant record documentation, especially with respect to otitis media (DoH, 2005). Such databases are promising for the practical and efficient addition of hearing screening data, and this is already being implemented in some levels of service delivery in provinces such as Gauteng.
Thirdly, acceptable continuity of care is facilitated by adequate resources for referrals. The capacity to refer infants for diagnosis and intervention appears to be generally satisfactory in provinces such as Gauteng and North West (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018). As such, hearing impairment diagnosis by four months of age with intervention by eight months, as promulgated by the HPCSA (2007, 2018), appears practicable, dependent upon demand versus capacity at secondary and tertiary facilities (Bezuidenhout et al., 2018; Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018).
Lastly, information about hearing impairment can be incorporated into existing caregiver health education programmes, such as the Vitamin A supplementation programme (DoH, 2001). Khoza-Shangase (2019) highlights the importance of engaging and involving caregivers as key stakeholders in EHDI programmes. She documents various factors compromising early intervention, as reported by caregivers in the South African context. These include long distances between the few EHDI services that are available and the places of residence of service users; significant costs linked to the services; limited skills and knowledge of professionals regarding hearing impairment; inconsistent and conflicting professional opinions about the childs' diagnosis and treatment; as well as limited community awareness about hearing impairment and services available for hearing-impaired children (Khoza-Shangase, 2019).
In terms of barriers at PHC immunisation clinics, a lack of funding may underpin logistical issues regarding the identification of hearing impairment (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018). The practicability of hearing screening in the South African context can be improved by addressing factors such as the lack of specialised hearing screening equipment (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018). Barriers also include rudimentary hearing screening techniques, where non-audiometric or non-evoked potential hearing screening techniques are delineated by the scope of practice for nurses who are the frontline professionals employed in South Africas' immunisation clinics (HPCSA, 2018).
Adherence to screening techniques appears to be inconsistent, which may be the result of protocol ambiguity between central and district levels, with district autonomy prevailing (DoH, 2009). This may also be influenced by differences in district and provincial funding (Day & Gray, 2008; DoH, 2009). Another barrier to hearing screening in South Africa is the increased burden of disease, resulting in priority being given to life-threatening conditions rather than hearing impairment (Olusanya, 2005).
Friderichs, Swanepoel, and Hall (2012) propose training and assigning dedicated screening staff to the immunisation clinics as a possible solution. By so doing, hearing screening competency through experience can be improved and false positives and high refer rates reduced. These authors explain that dedicated hearing screening staff can also relieve already overburdened PHC staff, who may prioritise conditions such as HIV/AIDS and TB (Friderichs et al., 2012). Moreover, a screening coordinator can facilitate higher return rates through applying strategies such as caregiver telephonic appointment reminders and in-file visual rescreen reminders, facilitating consistent record keeping and using tele-audiology. Joubert and Casoojee (2013) identified inconsistency in record keeping as a challenge, specifically with regard to recording hearing screening results. This is despite the presence of electronic databases in some regions (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018).
These findings accentuate the importance of fine-tuning assets and addressing barriers to prepare the HPCSA clinic-based PHC platform for EHDI actualisation (Kanji, Khoza-Shangase, Petrocchi-Bartal et al., 2018). Only in this way can the practicability and efficiency in the PHC context be improved to enable feasible hearing screening for infants.
In the private health care sector, high screening coverage has occurred when hearing screening has been included as part of the birthing package (Swanepoel, Ebrahim, Joseph, & Friedland, 2007). Running screening programmes outside the birthing package is the most frequently recorded challenge to hearing screening implementation in the private sector (Meyer & Swanepoel, 2011). Practicability and efficiency would thus be dramatically improved if hearing screening were included in the birthing package (Meyer & Swanepoel, 2011). To facilitate improved parental involvement, parental education prior to birth regarding the importance of hearing screening is recommended to facilitate consent (Swanepoel et al., 2007). Additionally, because caregivers in the private health care system have the liberty to consult with their preferred service provider, patient tracking becomes difficult. As such, data management and tracking solutions are key to improving quality control (Swanepoel et al., 2007). Lastly, challenges relating to unethical business practice have been raised around screening in the private sector and need to be addressed.
