A comprehensive range of audiologists’ perceptions regarding hearing healthcare resources and services in SA’s public healthcare system were obtained in this survey study. On average, the perceived number of permanently employed (1.8) and community service audiologists (1.0) per hospital were relatively low in this study. Evidence suggests that 78% of countries across Africa have a ratio of less than one audiologist per million people, whereas 52% of countries across Europe have more than ten audiologists per million . Within SA particularly, previous studies revealed that the estimated ratio is 8.3 audiologists per million people [1, 15] and a shortage of audiologists within South African public sector hospitals . While SA appears to have more available audiologists per million than many other countries within Africa, there is still a shortage of audiologists compared to other world regions such as Europe. Therefore, the current study’s findings confirm that within SA, a significant barrier towards hearing healthcare service delivery is the lack of human resources, which is also an overall challenge experienced throughout Africa. Furthermore, there is an unequal distribution of audiologists between the private and public health sectors in SA [23, 29]. A recent study conducted on the speech therapy and audiology workforce in SA revealed that a mere 22% of qualified speech therapists and audiologists are employed in the public sector . Within the public healthcare sector, challenges to human resources include the international migration of professionals or national migration to the private sector, freezing of government posts, and attrition [23, 30]. Naturally, human resource shortages negatively impact service delivery and patient accessibility to hearing healthcare services such as early hearing detection and intervention (EHDI) services, provision of assistive hearing devices, and aural rehabilitation [9, 28, 31]. A maintainable workforce within the public healthcare sector is therefore central to delivering these hearing healthcare-related services.
In addition to the shortage of audiology staff, audiologists in this study perceived that there is also a shortage of ENT specialists within the public sector and across the hospitals and provinces. Within SA, an estimated ratio of 4.6 ENTs per million people has previously been reported [1, 15], which confirms the shortage of ENTs within SA when likened to European countries where more than 70% have more than 50 ENTs per million . Furthermore, audiologists in the current study perceived that ENT service provision within the public sector is limited due to a lack of resources. These findings are consistent with a study conducted in 2009 on the availability of ENT, audiology, and speech-language therapy services across 18 countries in Sub-Saharan Africa, which revealed a severe shortage of these trained hearing healthcare professionals, and also a lack of hearing healthcare resources in these countries . Consequently, individuals in Sub-Saharan Africa have minimal or no access to the simplest and most basic hearing evaluation and rehabilitation resources and the simplest hearing restoration surgeries, for instance, ventilation tubes and tympanoplasties .
In addition to trained professionals, basic hearing healthcare services also requires specific equipment and infrastructure, resulting in limitations in hearing healthcare service delivery in low-resource settings, including SA [15, 32, 33]. This challenge was confirmed in the current study, where most (82.0%) of the audiologists perceived that their hospital did not have adequate resources to render efficient audiology services to patients. Furthermore, in their open-ended responses, resource challenges (in terms of the hospital’s audiology department’s equipment, staffing, finances, and infrastructure) were identified as the most central challenge perceived by audiologists.
The Health Professions Council of South Africa (HPCSA) endorses the use of objective physiologic hearing screening measures, namely AABR and otoacoustic emission (OAE) (distortion-product OAE (DPOAE) or transient-evoked OAE (TEOAE)) screening equipment as part of an infant hearing screening protocol which is aligned with international guidelines [34–36]. However, at least 50% of audiologists in this study perceived that their hospital did not have an AABR screener, and 30% and 26% did not have a TEOAE or DPOAE screener, respectively. Additionally, in their open-ended responses, audiologists perceived that the lack of screening equipment in their hospitals was a challenge hindering hearing healthcare service provision. Newborn/infant hearing screening is a service that would typically be impacted by the absence of screening equipment such as an AABR or DPOAE screener. Both of these screening measures are easy to perform in newborns and infants and are successfully used for UNHS programs [37, 38]. Consequently, due to lack of screening equipment, only 30.0% of audiologists in this study perceived that their hospital provided targeted hearing screening services, and 21.0% perceived that their hospital provided UNHS.
UNHS is a viable means of reducing the burden of hearing loss and has become the standard of care for newborns in most developed countries . It has since proven efficient in identifying infants born with hearing loss at the correct time to ensure that they are treated most adequately through early hearing amplification, thereby maximizing the infants' linguistic competence and literacy development [36, 40]. A recent South African study on UNHS in the public healthcare sector confirmed that the insufficient number of audiologists within the public healthcare sector to perform hearing screening and limitations with screening equipment were factors hindering the implementation of UNHS . Comparably, findings from the current study also suggest that a shortage of audiologists and limitations in screening equipment are barriers to the execution of UNHS across South African public sector hospitals. Since a dearth of specialist workforce hinders attempts to make hearing healthcare available and equitable to all individuals, task sharing is a possible solution for ameliorating this situation [14, 42]. Recruiting nursing staff or trained hearing screeners to conduct hearing screening is an example of task sharing and could be beneficial within the public sector since audiologists would have additional personnel to assist them with the screening . The successful use of non-specialist staff to conduct infant hearing screening has been previously demonstrated within SA’s public healthcare system as well as in other African countries such as Nigeria and Zambia [1, 43–45]. Moreover, to the authors’ knowledge, the most recent national newborn hearing screening study conducted in SA’s public sector was in 2008 and reported that approximately 7.5% of the public hospitals across the country provided some form of infant hearing screening, and less than 1% provided UNHS at the time of the study . It can therefore be assumed that very few advancements have been made within the past 12 years in the field of UNHS within the South African public healthcare system.
More than a third of audiologists perceived that their respective hospitals did not have but required diagnostic DPOAEs, TEOAEs, auditory steady state response (ASSR), or auditory brainstem response (ABR) equipment, and 41.46% of audiologists perceived that their hospitals did not have access to VRA equipment. Thus, the implication would be that many public sector hospitals in SA are not optimally equipped to conduct diagnostic pediatric audiological assessments. According to the Joint Committee on Infant Hearing’s (JCIH) 2007 position statement, which are endorsed in SA as well by the HPCSA; ABR/ASSR, DPOAE, and/or high-frequency tympanometry (1000-Hz probe tone) equipment are required to appropriately diagnose infants less than six months [34–36]. Additionally, ABR/ASSR and behavioral audiometry (including VRA) are required as part of the audiological test battery to appropriately diagnose children between 6-36 months [34–36]. The absence of these types of equipment at a hospital would imply that pediatric patients would need to travel to referral hospitals that have access to the required equipment. However, this could delay the hearing loss diagnosis and subsequent hearing intervention due to the possibility of long waiting lists at most referral hospitals, traveling distances between the hospitals, and the cost and time implications for a patient’s family.
Succeeding the detection and diagnosis of a hearing loss, necessary hearing intervention services are required for both the adult and pediatric populations. The insufficient accessibility of hearing devices such as hearing aids and CIs for individuals with hearing loss constitutes one of the barriers to hearing healthcare service delivery worldwide, and this barrier is also experienced in SA’s public healthcare system . In this study, only 31.0% of audiologists perceived that an adult patient with bilateral hearing loss would receive two hearing aids in their hospital setting. Similarly, a study by Pienaar et al. (2010) found that South African adult patients diagnosed with bilateral hearing loss within a public sector hospital were often fitted monaurally due to resource shortages . The benefits of binaural hearing aid fittings for bilateral hearing loss are evident with regard to listening effort, binaural summation, improved localization abilities, spatial hearing, release of masking, source segregation, speech reception in noise, and the avoidance of head-shadow effects [47–49]. As such, patients with bilateral hearing loss tend to be more satisfied with binaural hearing aid fittings than monaural hearing aid fittings for their bilateral hearing loss . Possible barriers to the provision of hearing aids within the public healthcare sector include budgetary constraints as well as structural constraints since each public healthcare setting can only cater to the population of patients residing within its pre-determined geographical/ catchment area [32, 51, 52]. As with the provision of hearing aids, the provision of CIs within SA’s public healthcare sector also faces challenges. Since CIs are considered to be a privileged intervention in SA, there is minimal public funding available for this intervention, and hence a severely restricted number of individuals who adhere to CI criteria are implanted within SA’s public healthcare sector [53, 54]. Therefore, the majority of the individuals requiring CIs have to either have sufficient finances or access to private medical aid to afford this intervention and the costly lifelong maintenance demands thereafter . This, therefore, explains why only 5.0% of audiologists perceived that cochlear implantation would be possible for patients requiring this intervention at their hospitals.
Patients who access hearing devices within the public sector further require lifelong maintenance of their devices (such as earmould repairs, replacement, retubing; supply of hearing aid batteries; hearing aid adjustments, repairs, and replacements) [52, 55–58]. The South African Department of Health is responsible for covering all costs relating to the payment of hearing assistive devices and the subsequent maintenance, repairs, and re-issuing of assistive devices and the necessary assistive device consumables according to the individual’s income and UPFS classification . However, this study indicated that follow-up care following the fitting of hearing devices is perceived to be limited by many audiologists working within the public sector as pediatric and adult patients are perceived to be liable for covering all hearing device repairs or replacement costs once their device’s warranty has expired. These findings are consistent with a previous study conducted within SA’s public sector which revealed hearing devices, in particular, hearing aids fitted within the public sector, are not sufficiently cared for and are underutilized, with financial constraints serving as the greatest barrier towards adequate hearing aid utilization and maintenance . Therefore, it is evident that accessing and maintaining hearing devices within SA’s public healthcare sector is often challenging.
Appropriate and effective amplification followed by aural rehabilitation services has the potential to reduce the negative effects of hearing loss . It has been demonstrated that adult aural rehabilitation within a South African public healthcare setting effectively contributes to positive patient-perceived benefits post-hearing aid fitting . Only 41.0% of audiologists perceived that their hospitals provided adult aural rehabilitation services post-hearing aid fitting within the current study. This confirms the findings from a previous South African study on adult aural rehabilitation services, which found that these services were not optimally provided in SA and that improved aural rehabilitation services were required so that the adult hearing impaired population in SA could benefit from it .
This study’s findings suggest that based on the perceptions of audiologists employed within South African public sector hospitals, hearing healthcare resources are strained within the South African public healthcare system. This, in turn, influences hearing healthcare service delivery and exacerbates the burden of hearing loss. Hearing healthcare should therefore be prioritized by increasing financial allocations to audiology departments. This would enable the procurement of necessary hearing resources and the placement of more audiologists within audiology departments. Ultimately, the burden of hearing loss can be addressed by promoting awareness and advocating for hearing healthcare in SA, advancing towards a reduction in the risk factors that contribute to disabling hearing loss, and promoting early identification and intervention services .
A possible limitation of this study is that 43.0% of participants were audiologists completing their obligatory community service year, and 56.0% had less than two years of experience. Audiologists’ position in the hospital, their years of experience, and whether they are permanently employed or community service audiologists are all factors that could potentially influence their perceptions of the hearing healthcare resources and services within the hospital. A study conducted in China on the perceptions of patient safety culture among healthcare employees also found that socio-demographic characteristics such as healthcare workers' years of experience and their position and education level influenced their overall perceptions . Nevertheless, this is the first national study conducted in SA’s public sector to describe audiologists' perceptions of hearing healthcare resources and services, and since the sample was representative of audiologists employed within South African public sector hospitals, results can be generalized.
Data obtained from this study should be utilized to direct national policy on the improvement of hearing healthcare resources and service provision within SA at a national level, and particularly within the public healthcare sector, to ensure that the country is able to efficiently deliver hearing healthcare services to all patients requiring such services.