Читать книгу Early Detection and Intervention in Audiology - Группа авторов - Страница 8

Amisha Kanji and Katijah Khoza-Shangase

Early hearing detection and intervention (EHDI) has been extensively researched internationally, with a significant focus on the efficacy of implementing early identification through universal newborn hearing screening (UNHS) programmes (Kanji, 2016). However, most of this research has been conducted in high-income countries, and is not easily generalisable to low and middle-income (LAMI) contexts such as Africa, which differ in terms of populations, resources (human, equipment), health priorities, the burden of disease, as well as the neonatal protocols adopted. These differences require African countries to carefully consider context in EHDI programme implementation in order to ensure best practice that is contextually relevant and responsive. We thus call for a paradigm shift in EHDI initiatives within the African context. This chapter offers an introduction to such initiatives in South Africa, detailing the rationale for their value and relevance in this context. We outline approaches to EHDI, factors that influence its implementation, the positioning of these factors in the various levels of service delivery in the South African health care context, as well as continuity of care of the hearing impaired within the educational setting. Also addressed are the complexities surrounding EHDI implementation in South Africa, including EHDI in the context of other sensory impairments, in the context of the family, in the context of HIV/AIDS and in the context of tele-audiology. The goal is to recommend a paradigm shift for best/next practice for children at risk of, or with confirmed hearing impairment.

EHDI encompasses the earliest possible identification, diagnosis and provision of intervention for newborns and infants with hearing impairment in order to enable them to develop to their maximum potential and communicate effectively. This approach supports their individual needs as well as their later involvement in society and the countrys' economy (Health Professions Council of South Africa [HPCSA], 2007). The implementation of EHDI has been clearly associated with positive developmental outcomes, including communication (Fulcher, Purcell, Baker, & Munro, 2012; Kennedy et al., 2006; Sininger, Grimes, & Christensen, 2010). These outcomes have been specifically recorded in high-income countries where EHDI programmes, particularly early identification programmes, are well established.

EHDI arguably falls within the broader focus area of early childhood intervention (ECI), particularly as ECI programmes encompass a range of specialised services extending from service planning, rehabilitation and family-centred support to special education. Previous definitions of early intervention (EI) define ECI as the early identification and management of children from birth to three years of age (Rossetti, 2001). However, this definition has evolved, with the Consultative Group on Early Childhood Care and Development (2012) specifying early childhood as the period from prenatal development to eight years of age. The South African National Integrated Early Childhood Development Policy refers to the provision of early childhood development (ECD) services, and defines this period from conception until the year before children enter formal schooling. In the case of children with developmental difficulties and disabilities, this period is defined as the year before the calendar year they turn seven, as this is the age of enrolment in compulsory schooling or special education (Republic of South Africa, 2015). To position this book within the African context, the definition we adopt falls within the ECI programmatic outlook, and stretches to the elementary, basic education age.

EHDI remains a significant need for Africa, given the global prevalence and incidence of childhood hearing impairment. Recent estimates indicate that globally, 34 million (7 percent) of the 466 million individuals with disabling hearing impairment are children, of whom 7.5 million are below five years of age (Neumann, Chadha, Tavartkiladze, Bu, & White, 2019). Within these global estimates, prevalence rates have been reported to be higher in LAMI countries, specifically in South Asia, sub-Saharan Africa and the Asia Pacific regions. LAMI countries comprise 80 percent of the worlds' population, and are home to two-thirds of individuals with hearing impairment (Tucci, Merson, & Wilson, 2010). These prevalence and incidence rates are further exacerbated by the health care realities in LAMI countries, such as the burden of disease and poor social determinants of health, which place individuals at greater risk for hearing impairment.

The health care systems, as well as linguistic, cultural and socio-economic diversity in the sub-Saharan African context, present a unique setting for knowledge generation in terms of research, as well as academic and clinical teaching and practice in this field. Published evidence has acknowledged the impracticalities of attempting to implement developed world models for EHDI in LAMI countries such as South Africa (Moodley & Störbeck, 2015; Swanepoel, Delport, & Swart, 2004; Swanepoel, Hugo, & Louw, 2005). While research findings from high-income countries may be of value, it is vital to acknowledge that outcome-based recommendations from these studies may be costly and more difficult to implement in practice in LAMI countries. This is due to a number of reasons, including contextual differences, disease definition and response, as well as a different focus on disease prevalence. The sole reliance on evidence from international contexts may result in the specific, local needs of LAMI countries being neglected (Chetwood, Ladep, & Taylor-Robinson, 2015), leading to inappropriate and inefficient interventions and impacting negatively on the health outcomes of these populations. This highlights the need for a paradigm shift in EHDI in (South) Africa to a more contextually relevant and responsive approach driven by research that is sensitive to context while being internationally comparable.

Various initiatives are in place to address the gap in transferring theory into practice in the area of EHDI. The South African governments' heightened focus on increasing access to health care through the re-engineered primary health care (PHC) model, and the efforts to achieve universal health coverage through National Health Insurance (NHI) as well as ECD programmes, make this an opportune time for establishing and documenting evidence-based research for clinicians, researchers and students. The existing body of literature in the field is almost entirely from the global North. This book therefore aims to provide evidence-based and contextually responsive information on EHDI from the global South, covering both detection and intervention aspects of hearing impairment. The information provided extends beyond the strictly defined age period of seven years. EHDI implications and possibilities are explored in the educational setting as part of the continuity of care for hearing-impaired children.

The book has deliberately adopted an African rather than a South African perspective, for several reasons. Firstly, the contextual realities under which health care delivery occurs are similar across the African continent. These include:

 resource constraints

 reliance on international aid and guidelines for some health care initiatives

 inadequate human resources across sub-Saharan African health systems, resulting in the use of task shifting in attempts to increase access (Maphumulo & Bhengu, 2019)

 negative impact on health care systems of the high burden of diseases such as HIV/AIDS and tuberculosis (Naidoo, 2012)

 challenges in terms of the social determinants of health.

Secondly, borders across Africa are porous. Migration due to socio-political and economic reasons is common and impacts health care planning, implementation and monitoring. Thirdly, the influences of linguistic and cultural diversity on seeking and delivering health care are arguably similar across the African continent in terms of cultural beliefs and how illness is understood, as well as linguistic differences between patients, nurses and doctors.

This book is divided into three sections. The first two sections focus on the early detection of hearing impairment and EI, respectively. The third section considers factors that are significant to the South African context and how they influence EHDI, including family influences, the burden of disease, co-morbid conditions and ethical considerations.

EHDI is the gold standard for practising audiologists and the families of infants and children with hearing impairment. According to international guidelines, EHDI programmes aim to identify hearing impairment within one month of birth, diagnose by three months, and provide intervention to children with hearing impairment (as well as those at risk of hearing impairment) by six months of age to ensure that they develop and achieve in line with their hearing peers (Joint Committee on Infant Hearing [JCIH], 2007). Context-specific adjustments to these timelines have been made for South Africa: completion of hearing screening by six weeks of age, diagnosis by four months of age and commencement of intervention by eight months of age (HPCSA, 2018). These adjustments have taken the various South African screening platforms into account as well as other contextual factors such as home births, discharge timeframes and scheduled immunisation visits at the PHC level. The health care system in South Africa consists of both public and private health care. The public system is multi-tiered with primary, secondary and tertiary contexts offering different levels of care and service delivery. The feasibility of implementing EHDI programmes requires further deliberation in South Africa due to the countrys' unique health care context, as well as future plans for NHI and the re-engineering of PHC. The practicability and efficiency of newborn hearing screening (NHS) is discussed in chapter 4 of this book to ascertain feasibility within each level of service delivery. The chapter illustrates factors that may positively contribute to or impede early identification services, with clear recommendations for the South African context.

While international guidelines have been successfully achieved in studies from high-income countries (Ching, Dillon, Leigh, & Cupples, 2018; Fulcher et al., 2012; Fulcher, Purcell, Baker, & Munro, 2015), this is not so in sub-Saharan Africa. A retrospective review of the audiological management of children with hearing impairment, conducted at three public sector hospitals in South Africas' Gauteng province, found that the average age of diagnosis of hearing impairment is 23.65 months. Enrolment into an EI programme occurs at an average age of two years and five months (Khoza-Shangase & Michal, 2014). Similar findings were reported in the Western Cape and Free State provinces by Van der Spuy and Pottas (2008) and Butler et al. (2013). Delays in meeting the stipulated EHDI timeframes have been attributed to administrative challenges (such as procurement delays), lack of human resources, the busy schedules of speech-language therapists and audiologists in the public health care sector, and a lack of NHS services (Khoza-Shangase, Barratt, & Jonosky, 2010; Khoza-Shangase & Michal, 2014).