Keywords
pediatrics - hearing aids - conductive hearing loss - outcome measures - caregivers
Introduction
It is estimated that 466 million people globally have a disabling hearing loss, with
at least 34 million being children under 15-years-old.[1] Hearing loss is the second most prevalent disability, affecting at least 15.5 million
children globally under the age of 5 years.[2] Sub-Saharan Africa (SSA) has one of the greatest prevalence rates of hearing loss.[3] Estimates suggest that the prevalence of hearing loss in children from 5 to 14 years
of age is 1.9% in SSA, more than double that of high-income countries (0.4%).[4]
More than 60% of hearing loss in children under the age of 15 years old is preventable.[5] However, many cases of childhood hearing loss, while preventable, are common in
low-to-middle-income countries (LMICs), constituting almost half (48.9%) of all cases.[6] Prenatal and perinatal complications are risk factors related to hearing loss in
LMICs, with postnatal infections being more prominent.[7] It is well documented that poor socioeconomic factors can lead to an increase in
middle ear pathology and the associated preventable hearing loss, in addition to the
restricted access to human resources and ear health care.[1]
[7]
[8]
The most prevalent causes of childhood hearing loss are associated with otitis media
(OM, 57.1%) and congenital abnormalities (21.1%).[2] Several pathologies are associated with conductive hearing loss (CHL) and persistent
contributors include outer ear malformations (atresia or microtia), middle ear malformations
(cholesteatoma or ossicle malformation) and genetic syndromes (Treacher Collins, Down
syndrome, Goldenhar syndrome, Cornelia de Lange syndrome, and CHARGE syndrome).[7]
[9] These contributors tend to occur more frequently in LMICs, adding to the high incidence
of CHL in SSA.[10] The most common and treatable cause of CHL is OM.[7] Additionally, OM is the greatest contributor (63.7%) of hearing loss in children
under the age of 5 years.[11]
[12]
[13] Chronic OM is often associated with mild to moderate CHL, and if left untreated
can lead to permanent sensorineural hearing loss (SNHL).[1]
[12]
Globally, more than 98.7 million people have hearing loss secondary to acute OM and
chronic suppurative otitis media (CSOM).[14] At least 80% of all children will have an episode of acute otitis media (AOM) before
3 years of age, with an incidence of at least 43% in SSA.[15]
[16]
[17] The global incidence of CSOM is 4.8%, and it accounts for more than half of the
global burden of hearing loss.[12]
[16]
[18] The second highest prevalence rate of CSOM globally is SSA,[12]
[13] with HIV-positive children being more prone and severely affected than immunocompetent
children.[19]
Previously, it was estimated that South Africa had a childhood OM prevalence rate
between 3.8 and 12%.[20]
[21] However, these studies only focused on school-age children, rather than younger
preschool children who are more likely to acquire OM.[16]
[22] It was recently found that otitis media with effusion (OME) was the most common
pathology in South African children aged 2 to 5 years (23.9%), with AOM only found
in 3% of the children younger than 2-years-old.[16] Additionally, CSOM was found to occur more frequently in children aged 6 to 15 years,
with a notable prevalence of 9.3%.[16]
[18] While the prevalence of OM decreases with age, its impact on hearing has long lasting
effects.[12]
The development of spoken language is proportionate to hearing ability.[23] If not addressed timeously, hearing loss may not only have implications for language
development, but also cognitive development, academic performance, as well as socio-emotional
development.[24]
[25]
[26] Children who develop postlingual hearing loss are also impacted by hearing loss,
often in terms of the quality of speech production, and cognitive and literacy skills.[11]
[13]
[27] Children with CHL were found to have increasing difficulties in speech perception
and reading, delayed reaction to auditory input, vocabulary limitations, and attention
difficulties.[28]
[29]
[30] In addition, CHL is associated with poor task orientation skills and difficulties
with independent class work.[29]
[31] Two separate studies in children with unilateral atresia and CHL (older than 5 and
6 years respectively), indicated no grade failure when they used hearing technology
such as FM systems and amplification devices.[10]
[30] The National Institute for Clinical Excellence (NICE) have recommended the use of
hearing aids for OME that has not resolved within three months, or as an alternative
to ventilation tube insertion.[32] Additionally, the use of hearing aids has been recommended while awaiting surgery
to limit the negative effects of temporary hearing loss on a child's academic performance.[32] The use of hearing aids during this time will assist by optimizing the child's listening
and learning environments.[32]
[33] In children with a genetic predisposition to CHL, such as Down syndrome, behind-the-ear
(BTE) hearing aids have already been recommended as the standard of care.[32]
[33]
While hearing aids are an option to manage CHL, they are only effective if frequently
used by the child.[34] Previous reports confirmed that at least two thirds of children with CHL due to
OM, and who were fitted with BTE hearing aids, made use of them.[35]
[36] A more recent study indicated that at least a third of pediatric Ear, Nose and Throat
(ENT) patients with OME were referred to a hearing health professional for temporary
hearing aid fitting, with up to 50% receiving this intervention while the remainder
had their CHL resolved by the time of assessment.[34] Of those who received intervention, it was reported that 95% used their hearing
aids, but average usage time was varied.[34] There is limited data available on the outcomes of children with CHL fitted with
BTE hearing aids, with available studies using small sample sizes and focusing mostly
on high income countries.[34]
[37] Research into the management and outcomes of children with CHL is necessary to support
evidence-based service delivery and improved, family centered care.
Understanding caregivers' experiences is also important for hearing health professionals
to provide family centered care.[38] While some studies have investigated the experiences of caregivers of children with
hearing loss who were fitted with hearing aids, these have been limited to caregivers
of school-aged children and children with permanent SNHL.[39]
[40] However, the data from these studies suggest that caregivers' experiences, challenges,
and perceived benefits of hearing aids can impact outcomes in terms of hearing aid
use.[38]
[39]
[40] There is a dearth of data on caregivers' experiences of children with CHL fitted
with hearing aids, with current available data focusing only on reasons for poor hearing
aid use.[34]
As a common management option for OM, it is necessary to determine whether hearing
aids are an effective and utilized treatment for childhood CHL, as well as what caregivers'
perceptions and experiences are regarding perceived outcomes. Therefore, this study
describes hearing aid outcomes and caregivers' experiences for children with CHL fitted
with BTE hearing aids.
Methods
This study was approved by the University of Pretoria Human Research Ethics Committee
(HUM064/0519), the University of Cape Town Human Research Ethics Committee (176/2019),
and the Red Cross War Memorial Children's Hospital Ethics Committee (RCC202).
Study Population
Red Cross War Memorial Children's Hospital is the first independent tertiary institution
in SSA dedicated entirely to child health care. The Department of Audiology provides
specialized diagnostic and intervention services for children from birth to 13 years
of age from the public health sector. We conducted a retrospective review of clinical
data from children aged 0 to 13 years, diagnosed with unilateral or bilateral CHL,
who were fitted with BTE hearing aids between January 2017 and March 2020. A cross-sectional
prospective caregiver-focused telephonic survey was conducted between July 2020 and
December 2020.
The definition for CHL used by the Department of Audiology is adapted from Schlauch
and Nelson[41] and constitutes a difference of 15 dBHL between air conduction and bone conduction
thresholds, with bone conduction thresholds being better than 20 dBHL; at all thresholds
between 500 Hz and 4000 Hz. When CHL is diagnosed, an ENT consultation takes place
to determine which method of management will be followed: watchful waiting, medical
management in terms of prescription medication, scheduling of surgical management,
or monitoring of hearing until eligible for surgical management. Each child then receives
a follow-up hearing assessment in 3 months' time to determine whether the selected
management option was successful. In cases where there is no improvement in hearing
thresholds, no active otorrhoea, or the child is awaiting surgical treatment until
they are old enough, the hearing health professional in consultation with the child
and caregiver will discuss the benefits of amplification by means of hearing aid fitting.
Academic performance is also taken into consideration for decision-making, and a report
from the child's teacher is required to determine if the hearing loss had an impact
on school performance. Should the child and caregiver consent, ear mold impressions
are taken, and an appointment for hearing aid fitting is scheduled.
Children (0–13 years old) diagnosed with CHL (unilateral or bilateral) and fitted
with BTE hearing aids (unilaterally or bilaterally) for at least one month, and with
data available for at least one functional outcome measure—be it the Parents' Evaluation
of Aural/Oral performance of Children (PEACH) or the Teachers' Evaluation of Aural/Oral
performance of Children (TEACH)—were considered as eligible participants for this
study. Caregivers were later identified through their relationship with the pediatric
hearing aid users and contacted regarding their willingness and availability to participate
in a telephonic survey.
Data Collection Materials and Procedures
Retrospective Record Review
Patient data are routinely captured by the Department of Audiology in an electronic
database. This database was utilized to retrospectively identify participants with
CHL, who were fitted with BTE hearing aids between January 2017 and March 2020. Some
data, not present in the electronic database, were captured from clinical records
of patients' hospital files. Data collected included demographic information, family
income, age of diagnosis of hearing loss, age at fitting of hearing aids, hearing
aid fitting information—such as real-ear-to-coupler difference (RECD) and aided speech
intelligibility index (SII) scores for average sounds—average daily hearing aid use
(in hours) at the one month follow-up (data-logging), and hearing aid functional outcome
measures (PEACH and TEACH questionnaires).
The PEACH (designed for children > 2 years)[42] and TEACH (designed for school aged children)[43] questionnaires were routinely issued to caregivers and teachers in hard copy at
the initial hearing aid fitting, and they were asked to complete the questionnaires
the day before the first follow-up appointment (scheduled for one month after hearing
aid fitting). Thus, PEACH and TEACH outcomes were obtained one month after the hearing
aid fitting. These questionnaires were used in their original English format. Both
questionnaires were scored, and results were recorded by the hearing health professional
at the follow-up appointment. The PEACH and TEACH questionnaires measure everyday
functional and auditory communication performance at home and school, respectively.[42]
[43]
[44]
[45] Listening performance is rated in a variety of communication situations, in quiet
and noisy environments.[42] Several studies have recommended the PEACH and TEACH questionnaires to evaluate
pediatric hearing aid use, as they obtain real-life examples of the impact of hearing
loss,[34]
[44]
[46] and are quick and easy to complete.[46] These questionnaires are not only used for SNHL, but also for monitoring children
with OM, as they account for fluctuations in hearing loss.[34] Additionally, the questionnaires were validated on both normal hearing children
and children with hearing loss. Good test-retest reliability (0.93) and internal consistency
(0.88) were confirmed.[42]
The PEACH and TEACH questionnaires rate listening behavior according to a five-point
rating scale from 0 (Never) to 4 (Always). The PEACH questionnaire consists of 13
items: 2 regarding the child's hearing aid usage and loudness comfort; the remaining
11 items gather information about the child's auditory behavior, and awareness to
environmental sounds in quiet (5 questions) and noisy (6 questions) situations.[42] The TEACH questionnaire consists of 11 items: two regarding the child's hearing
aid usage and loudness comfort; the remaining 9 items gather information about the
child's auditory behavior, and awareness to environmental sounds in quiet (5 questions)
and noisy (4 questions) situations.[43] In both questionnaires a percentage score is calculated for quiet, noisy, and overall
results. The total percentage score for each subset is plotted, and auditory behavior
with hearing aids is then determined as typical performance, possible review indicated,
or further review indicated[42]
[43].
Prospective Telephonic Caregivers Survey
Data on caregivers' perceptions and experiences were collected using a telephonic
survey (Appendix). The survey's data were used to enhance and supplement the retrospective, descriptive,
and functional outcome data. Specific sections of the Parent Hearing Aid Management
Inventory (PHAMI) were used in the survey, with minor adaptions.[38] The PHAMI questionnaire was specifically developed to better understand caregivers'
access to information and their experiences with their child's hearing aid management
through four domains.[38] We used 2 domains of the PHAMI questionnaire, with minor adaptations, for this study,
namely the “feelings and habits” and “hearing aid use”. Internal consistency has been
confirmed for the PHAMI.[38]
The telephonic survey obtained caregivers' information regarding their child's hearing
aid use; thoughts and feelings regarding management and use of hearing aids; and hearing
aid use challenges encountered. The survey was designed to be answered in English,
but for cases in which isiXhosa speaking caregivers struggled to understand the question,
the interviewer would then translate accordingly into isiXhosa. The survey consisted
of five sections, and a total of 36 items were included: 30 close-ended questions
and 6 open-ended questions. A Likert scale (1 = strongly disagree to 5 = strongly
agree) was used in the 2 sections that contained the 2 domains from the PHAMI questionnaire.
A section with open-ended questions regarding expectations and challenges was included,
to attain a better understanding of the specific challenges encountered by caregivers
of children with CHL fitted with hearing aids. Caregivers were contacted telephonically,
and the verbal consent form was read to them to validate their participation in the
survey. On confirmation of consent, the survey was carried out by the interviewer,
which took between 15 and 20 minutes. All survey information was captured manually
in hard copy by the interviewer, and was later recorded electronically for analysis.
Data Analysis
All data were captured on an Excel spreadsheet, using Microsoft Excel 2018 (Microsoft
Corp. Redmond, WA, USA). The data were analyzed using SPSS 27 (IBM Corp. Armonk, NY,
USA) version 27.0. Quantitative data analyses consisted of descriptive statistics,
in terms of measures of central tendency and measures of variability; with internal
consistency of the two Likert scale survey sections calculated by the Cronbach Alpha
test. In both the PEACH and TEACH questionnaires, percentage scores were calculated
for the quiet, noisy, and overall domains. A thematic analysis was conducted for the
qualitative data obtained from the open-ended questions of the telephonic survey.
This qualitative data was categorized, coded, and subsequently grouped according to
central themes.
Results
A total of 3,333 children were diagnosed with hearing loss at Red Cross War Memorial
Children's Hospital between January 2017 and March 2020, of which 2,135 (64.1%) were
diagnosed with CHL. During this period, 43 children with CHL were fitted with BTE
hearing aids (unilaterally or bilaterally). Of this group, 19 children were included
in this study, since they were fitted with BTE hearing aids for at least one month
and had data available for at least one functional outcome measure. The mean age at
diagnosis of CHL for this sample was of 77.6 months (36.0 SD; range 12.0–144.0), and
the mean age at the one month hearing aid follow-up was of 88.6 months (36.9 SD; range
14.0–149.0).
Hearing Aid Fitting and Use
The mean age at hearing aid fitting was 87.6 months (36.9 SD; range 13.0–148.0) with
a mean delay from time of diagnosis to hearing aid fitting of 10.1 months (12.0 SD;
range 0.0–39.0). A total of 11 pediatric hearing aid users (57.9%) were fitted bilaterally,
and 8 (42.1%) were fitted unilaterally (n = 19). Most children (84.2%, n = 16/19)
presented with some form of OM, and the degree of hearing loss was either mild (47.4%,
n = 9/19) or moderate (52.6%, n = 10/19). [Table 1] provides a description of the sample population.
Table 1
Demographic characteristics of pediatric hearing aid users and their caregivers
|
Pediatric hearing aid users (n = 19)
|
n (%)
|
Caregivers (n = 13)
|
n (%)
|
|
Gender
|
|
Respondent for caregiver survey
|
|
|
Male
|
10 (52.6)
|
Father
|
1 (7.7)
|
|
Female
|
9 (47.4)
|
Mother
|
10 (76.9)
|
|
|
Other
|
2 (15.4)
|
|
Home language
|
|
Caregiver home language
|
|
|
Afrikaans
|
6 (31.6)
|
Afrikaans
|
4 (30.8)
|
|
English
|
6 (31.6)
|
English
|
3 (23.1)
|
|
isiXhosa
|
7 (36.8)
|
isiXhosa
|
6 (46.2)
|
|
Language of instruction
|
|
Interview language
|
|
|
Afrikaans
|
2 (10.5)
|
Afrikaans
|
0 (0)
|
|
English
|
11 (57.9)
|
English
|
9 (69.2)
|
|
isiXhosa
|
6 (31.6)
|
isiXhosa
|
4 (30.8)
|
|
Educational setting
|
|
|
|
|
Mainstream school
|
15 (78.9)
|
|
|
|
Special needs school (mainstream curriculum)
|
1 (5.3)
|
|
|
|
Special needs school (alternative curriculum)
|
2 (5.3)
|
|
|
|
Too young for school
|
1 (5.3)
|
|
|
|
Family income
|
|
H0 (formally unemployed)
|
8 (42.1)
|
|
|
|
H1 (0 USD–400.62 USD per month*)
|
8 (42.1)
|
|
|
|
H2 (400.62 USD–1430.84 USD per month*)
|
3 (15.8)
|
|
|
|
H3 (>1430.84 USD per month*)
|
0 (0.0)
|
|
|
|
Comorbidities
|
|
Microtia
|
1 (5.3)
|
|
|
|
Congenital ptosis
|
1 (5.3)
|
|
|
|
Fetal alcohol syndrome
|
1 (5.3)
|
|
|
|
Down syndrome
|
2 (10.5)
|
|
|
|
Neonatal jaundice
|
1 (5.3)
|
|
|
|
Premature birth
|
1 (5.3)
|
|
|
|
OM
|
16 (84.2)
|
|
|
|
Types of OM (n = 16)
|
|
AOM
|
2 (12.5)
|
|
|
|
Chronic OM
|
7 (43.8)
|
|
|
|
CSOM
|
5 (31.3)
|
|
|
|
OME
|
2 (12.5)
|
|
|
|
Degree of CHL**
|
|
|
|
|
Mild (16–40 dBHL)
|
9 (47.4)
|
|
|
|
Moderate (41–60 dBHL)
|
10 (52.6)
|
|
|
Abbreviations: AOM, acute otitis media; CHL, conductive hearing loss; CSOM, chronic
suppurative otitis media; OM, otitis media; OME, otitis media with effusion. Notes:
* Exchange rate of 1 USD = R14.56 (South African rand/ZAR). **Degree of hearing loss
according to Clark.[48]
Hearing aid fitting details were available for 17 of the 19 (89.5%) participants at
the initial hearing aid fitting. The RECD was measured for 3 children (17.6%), and
specific age predicted RECD values were used for 14 children (82.4%). The aided SII
values for average speech input at initial fitting were reviewed for this study. As
pediatric hearing aid users were fitted either unilaterally or bilaterally, we used
the aided SII percentages for the ear with the higher percentage value for bilateral
hearing aid users. Across the sample (n = 17) the aided SII value was 86.4% on average
(6.1 SD; range 78.0–100.0). The aided SII values for average speech input (65 dB SPL)
were plotted by severity of hearing loss (pure tone average in dB HL) using the Aided
SII Normative Values Worksheet.[47] Hearing aid users in this study sample with available data (n = 17) had SII values
for average speech input representative of typical audibility for the severity of
their hearing loss.[47]
Hearing aid use was tracked through data logging at the one month follow-up appointment
for the 14 pediatric hearing aid users whose hearing aids had data logging functionality.
Data logging for bilateral hearing aid users was determined by selecting the recorded
logging of the better ear. The average hours per day that hearing aids were used was
similar for unilateral (6.2 hours/day, 2.6 SD; range 3.8–10.1; n = 5) and bilateral
hearing aid users (6.5 hours/day, 2.0 SD; range 4.1–10.3; n = 9).
Caregiver and Teacher Reported Outcomes and Experiences
PEACH and TEACH Ratings
The PEACH questionnaires were completed by caregivers and submitted by 12 caregivers
of pediatric hearing aid users at the one month follow-up appointment. Caregivers'
reports indicated that most pediatric hearing aid users (83.3%, n = 10/12) used their
hearing aid(s) often or always, and seldom or never complained of sensitivity to loud
sounds (83.3%, n = 10/12). [Figure 1] indicates the caregivers' reported ratings of hearing aid use and loudness discomfort
for 12 pediatric hearing aid users. The mean PEACH scores were similar in both Quiet
(74.5%) and Noise (72.1%), indicating typical performance in those environments when
aided ([Table 2]). Based on PEACH scores, more than half of the participants (58.3%, n = 7/12) showed
typical performance overall ([Figure 2]).
Fig. 1 Caregiver-reported ratings of children's hearing aid use and loudness discomfort
level (n = 12).
Table 2
Mean PEACH and TEACH percentage (%) scores for quiet, noise, overall
|
PEACH (n = 12)
|
M (SD)
|
Range
|
|
Quiet
|
74.5 (19.7)
|
30.0–100.0
|
|
Noise
|
72.1 (17.4)
|
45.0–100.0
|
|
Overall
|
73.4 (18.3)
|
36.0–100.0
|
|
TEACH (n = 13)
|
|
Quiet
|
78.1 (22.1)
|
30.0–100.0
|
|
Noise
|
72.0 (31.5)
|
6.3–100.0
|
|
Overall
|
75.4 (26.1)
|
19.4–100.0
|
Fig. 2 PEACH percentage score represented as auditory behavior for quiet, noise, and overall
(n = 12).
The TEACH questionnaires were completed by involved teachers and submitted by 13 caregivers
of pediatric hearing aid users at the one month follow-up appointment. Teachers' reports
indicated that almost all pediatric hearing aid users (92.3%, n = 12/13) used their
hearing aid(s) often or always, and seldom or never (84.6%, n = 11/13) showed sensitivity
to loud sounds. [Figure 3] indicates the teachers' reported ratings of hearing aid use and loudness discomfort
for 13 pediatric hearing aid users. The mean TEACH percentage scores were higher in
Quiet (78.1%) than in Noise (72.0%) ([Table 2]).
Fig. 3 Teacher-reported ratings of children's hearing aid use and loudness discomfort level
(n = 13).
Prospective Caregiver Survey
Only 13 (68%) of the 19 caregivers consented to a telephone survey (4 caregivers could
not be reached and 2 declined). At the time of the telephone survey, 6 children (46.2%)
were still active hearing aid users, while 7 children (53.8%) did not use their hearing
aids anymore (n = 13). Caregivers' reasons for their children no longer using their
hearing aid(s) was largely due to improved hearing (57.1%, n = 4/7), with the remaining
42.9% reporting otorrhoea (n = 1/7), bullying (n = 1/7), or patient's discomfort (n = 1/7)
as reasons for interrupted use. The average duration of hearing aid use for the active
hearing aid users at the time of the telephonic survey was of 43.6 months (41.8 SD;
range 2.0–156.0), while the average duration of hearing aid use for those who did
not use hearing aids anymore was of 14.4 months (13.1 SD; range 2.0–37.0).
Caregivers were asked to report on typical daily hearing aid use for their children.
Those whose children were no longer actively using their hearing aid(s) were asked
to report this in retrospect. Most caregivers (69.2%, n = 9/13) reported hearing aid
use from 5 to 10 hours a day, with almost a quarter (23.1%, n = 3/13) reporting hearing
aid use of less than 5 hours a day, and only 1 caregiver reporting hearing aid use
for all waking hours.
The sub-sections that utilized Likert scale questions (feelings, habits, and challenges
related to hearing aid use) were checked for internal consistency and were found to
have a Cronbach α value of 0.11 and 0.88, respectively. This indicates that the section
related to challenges showed good consistency, similar to previous findings of the
PHAMI questionnaire (Cronbach α = 0.82).[38] Questions related to feelings and habits showed poorer consistency, but could not
be compared to previous PHAMI findings as consistency was not reported in the original
study for this section.[38] Possible reasons for poor internal consistency could be related to the subjective
nature of the questions and the fact that they do not follow a specific theme.
When reviewing caregivers' feelings and habits ([Table 3]), all caregivers (100.0%, n = 13/13) felt that the hearing aid(s) help/helped their
child; with more than three quarters of them (76.9%, n = 10/13) reporting that they
could confidently tell when their child's hearing aids were not working correctly.
Almost all caregivers reported that they checked their child's hearing aids every
day (92.3%, n = 12/13).
Table 3
Caregivers' feelings and habits towards hearing aids (n = 13)¥
|
Disagree*
n (%)
|
Unsure
n (%)
|
Agree*
n (%)
|
|
|
I accept/accepted my child's hearing loss
|
2 (15.4)
|
2 (15.4)
|
9 (69.2)
|
|
I am/was concerned with the appearance of my child's hearing aids
|
5 (38.5)
|
0 (0.0)
|
8 (61.5)
|
|
I am/was concerned about what others think**
|
5 (38.5)
|
3 (23.1)
|
5 (38.5)
|
|
I am/was concerned about how I will/would deal with my child's feelings about their
hearing aids
|
3 (23.1)
|
2 (15.4)
|
8 (61.5)
|
|
I think the hearing aids help/helped my child
|
0 (0.0)
|
0 (0.0)
|
13 (100.0)
|
|
My child does not/did not need hearing aids
|
8 (61.5)
|
1 (7.7)
|
4 (30.8)
|
|
I think occasional hearing aid use is/was enough for my child to learn
|
4 (30.8)
|
1 (7.7)
|
8 (61.5)
|
|
I feel/felt quite frustrated with handling the hearing aids every day
|
7 (53.8)
|
0 (0.0)
|
6 (46.2)
|
|
I feel/felt confused about how to keep the hearing aids on my child
|
8 (61.5)
|
0 (0.0)
|
5 (38.5)
|
|
I feel/felt confident I can tell when my child's hearing aids are not working correctly
|
0 (0.0)
|
3 (23.1)
|
10 (76.9)
|
|
I check/checked my child's hearing aids every day
|
1 (7.7)
|
0 (0.0)
|
12 (92.3)
|
|
Talking with other parents helps/helped me manage the hearing aids**
|
4 (30.8)
|
4 (30.8)
|
5 (38.5)
|
|
The fact that the hearing aids are/were supposed to be temporary helps/helped me to
manage them
|
3 (23.1)
|
2 (15.4)
|
8 (61.5)
|
Notes: ¥Adapted from Munoz et al.[38] * Ratings of “strongly disagree” and “disagree” were combined as a “disagree” response
and ratings for “strongly agree” and “agree” were combined as an “agree” response.
** Due to rounding, percentages may not precisely reflect the absolute figures.
When asked about how their child's hearing aid use is/was affected by various challenges
([Table 4]), caregivers reported difficulty with frequent ear infections (61.5%, n = 8/13),
frequent ear pain (53.8%, n = 7/13), maintaining use during activities (53.8%, n = 7/13),
and frequent feedback (46.2%, n = 6/13). However, most caregivers reported that they
did not have difficulty getting into a set routine (76.9%, n = 10/13) and coping with
the demands of managing the hearing aids (76.9%, n = 10/13). When reviewing audiological
management as a possible challenge, most caregivers felt there was not a long wait
time to get an appointment with the hearing health professional (84.6%, n = 11/13)
and almost all caregivers felt that the hearing health professional was able to answer
their questions during their appointments (92.3%, n = 12/13). Additionally, most caregivers
(84.6%, n = 11/13) reported they did not run out of batteries before their next appointment.
Table 4
Caregivers' challenges experienced impacting hearing aid use (n = 13)¥
|
Disagree*
n (%)
|
Not Sure
n (%)
|
Agree*
n (%)
|
|
Distractions and needs of other children in the home
|
8 (61.5)
|
0 (0.0)
|
5 (38.5)
|
|
Activities (playing outside, riding in the car)
|
5 (38.5)
|
1 (7.7)
|
7 (53.8)
|
|
My child's behavior**
|
6 (46.2)
|
2 (15.4)
|
5 (38.5)
|
|
Difficulty getting a set routine
|
10 (76.9)
|
0 (0.0)
|
3 (23.1)
|
|
Long wait time to get an appointment with the hearing health professional
|
11 (84.6)
|
0 (0.0)
|
2 (15.4)
|
|
Other caregiver's ability to manage hearing aids
|
11 (84.6)
|
2 (15.4)
|
0 (0.0)
|
|
The hearing health professional's lack of response to my questions during the appointment
|
12 (92.3)
|
0 (0.0)
|
1 (7.7)
|
|
Difficulty coping with the demands of managing hearing aids
|
10 (76.9)
|
0 (0.0)
|
3 (23.1)
|
|
Frequent ear infection, such as leaking ears
|
4 (30.8)
|
1 (7.7)
|
8 (61.5)
|
|
Frequent ear pain
|
6 (46.2)
|
0 (0.0)
|
7 (53.8)
|
|
Frequent feedback (whistling/squealing) from the hearing aids
|
7 (53.8)
|
0 (0.0)
|
6 (46.2)
|
|
My concern with the appearance of my child's hearing aids
|
9 (69.2)
|
1 (7.7)
|
3 (23.1)
|
|
Running out of batteries before my next appointment
|
11 (84.6)
|
0 (0.0)
|
2 (15.4)
|
|
The hearing aids not working correctly
|
11 (84.6)
|
1 (7.7)
|
1 (7.7)
|
|
My child's reaction to sounds when wearing the hearing aids
|
8 (61.5)
|
0 (0.0)
|
5 (38.5)
|
|
Difficulty keeping the hearing aids on
|
9 (69.2)
|
1 (7.7)
|
3 (23.1)
|
Notes: ¥Adapted from Munoz et al.[38] * Ratings of “strongly disagree” and “disagree” were combined as a “disagree” response
and ratings for “strongly agree” and “agree” were combined as an “agree” response.
** Due to rounding, percentages may not precisely reflect the absolute figures.
The answers to open-ended questions from the telephone survey were gathered from 13
caregivers. The questions inquired about benefits and challenges of hearing aid use,
expectations of hearing aids, as well as the pediatric hearing aid users' feelings
towards using hearing aids. Six themes were extracted following qualitative inductive
thematic analysis. These themes are summarized with examples in [Table 5], in terms of perceived benefits, challenges, expectations, and the child's feelings.
Table 5
Thematic analysis of open-ended questions of the caregiver telephone survey (caregiver
perceptions and experiences) (n = 13)
|
Themes
|
Sub-themes
|
Examples/ illustrative quotes
|
|
Benefits
|
Improved hearing and communication
|
“He has improved speech, communication and learning”
“Hears better at school… she understands us better”
“Don't have to shout anymore. Can talk softer now”
“Struggles to communicate when hearing aids are not on”
“She stopped looking at my mouth when I talk”
|
|
Improved behavior
|
“She is more pleasant person”
“She copes better at school”
“Improved her behavior at school; she used to become frustrated and was very short
tempered”
|
|
Challenges
|
Stigma / bullying
|
“She was bullied a lot at school”
“She is seeing she is different and doesn't like to wear them”
“Other children made fun of him”
|
|
Device compliance
|
“Difficulty keeping them in his ears, especially on the playground”
“He didn't want to wear it… he took them out all the time”
“I forget to put the hearing aids on over the weekend”
“Teacher was always complaining that the hearing aid is making a noise”
|
|
Expectations
|
|
“That he would learn at school”
“Help him hear better and do better at school”
“Help her hear better as she speaks loudly”
|
|
Child's feelings towards hearing aid use
|
Acceptance
|
“He loved them!”
“No problems. She reminds me in the morning”
“He loves them... asks for them”
“Feels normal”
“Most of the time she doesn't mind wearing them and often fetches them for me”
“She did not have a problem because it helped her”
“She loved them so much she even wanted them back when she no longer needed them”
|
|
Dislike
|
“She does not like them at all and does not want to wear them”
“He did not really like them, but he knew they help him”
|
Discussion
Hearing aid use for all children with CHL in this study showed consistent daily use
within the first month post-fitting. Additionally, the caregivers' reported outcomes
indicated typical auditory performance with hearing aids for more than half of the
children (53.8%) at 1 month post-fitting. Survey responses indicated that all caregivers
supported the use of hearing aids and noted an improvement in their child's hearing
from the time of hearing aid fitting. Based on the positive auditory performance and
the fact that most of the sample (84.2%) presented with some form of OM, the benefit
of BTE hearing aids was confirmed for this population of children with CHL.
The average age of diagnosis of CHL in this sample was 6.5 years, which is the age
of entry to formal schooling in South Africa. The average age at hearing aid fitting
was just over 7-years-old. A recent South African study investigating predictors of
hearing technology use in children under the age of 11 years at an early intervention
center in the Western Cape (with various types of hearing loss), noted lower means
for both age of diagnosis (2.5 years) and hearing aid fitting (2.8 years).[49] This delay in diagnosis of CHL and subsequent hearing aid fitting is expected considering
that 84.2% of this sample had a temporary CHL due to OM. Additionally, the delay between
diagnosis and hearing aid fitting of almost one year (10.1 months) in this study sample
could be attributed to long waiting periods for an ENT appointment, as well as recommended
periods of watchful waiting.[32]
[50]
The average daily hearing aid use (6.2 and 6.5 hours for unilateral and bilateral
fittings, respectively) and caregivers' reported use were comparable to the 5 to 8 hours/day
previously reported for children with SNHL.[38] However, hearing aid use in this study was lower than the 9.4 hours per day recently
reported by another South African study[49] for children with various types of hearing loss (including CHL), as well as the
10 hours per day required for adequate language development.[51] To the authors' knowledge, there are no recommended guidelines regarding hearing
aid use specific for children with CHL. The fact that almost half of the children
(47.4%) in this study had a mild degree of hearing loss and 42.1% were fitted unilaterally
may have contributed to the slightly lower reported usage, since severity of hearing
loss is usually proportionate to hearing aid use.[45]
[49] Pediatric hearing aid users in this study likely used their hearing aids predominantly
in certain listening and learning environments, with many probably having decreased
usage over weekends and during holidays.[35]
[36] The fact that more than two thirds (68.8%) of pediatric hearing users with OM had
less severe forms of the disease (AOM, COM, OME) may possibly explain why more than
half (53.8%) only used their hearing aids for over 1 year. Furthermore, the nature
of CSOM, the number of children diagnosed with CSOM (31.3%), as well as the long waiting
period to access appropriate surgical management[1]
[50] are possible reasons why 46.2% of pediatric hearing aid users wore their devices
for approximately four years (43.6 months).
Caregivers' reported outcomes according to the PEACH questionnaire results indicated
that more than half (58.3%) of the pediatric hearing aid users in this study had typical
auditory performance overall at one month post-fitting. The overall PEACH score of
73.8% reported here is slightly lower than that of a study on children with unilateral
SNHL (84%), and slightly higher than that of a study on children with bilateral SNHL
(68.3%).[52]
[53] The remaining hearing aid users (41.7%) required possible (16.7%) or further (25%)
review based on PEACH scores. Since almost one third (31.3%) of this study sample
had CSOM, the benefit of hearing aids during periods of otorrhoea may have been limited.
Additionally, the fact that all children in this study had either a mild (47.4%) or
a moderate (52.6%) degree of hearing loss could have further influenced the auditory
performance in some cases. The PEACH and TEACH scores indicated that auditory behavior
of pediatric hearing aid users in this study was better in quieter than noisier environments,
and supported the positive correlation between these two questionnaires, as previously
found by Ching et al.[43] High noise levels are known to have an impact on listening and learning, both at
home and at school.[29]
[31] To overcome this, an increased signal to noise ratio is required, which can be supported
by hearing aids or assistive listening devices like FM systems.
Results from the telephone survey showed that all caregivers felt that the hearing
aids helped their child, which is in agreement with another study on hearing aid benefit
in children with CHL.[35] Survey results indicated that caregivers observed an improvement in their child's
hearing when using hearing aids, and that hearing aids should therefore be considered
by both ENT specialists and hearing health professionals in the management of CHL.
In contrast, Sjoblad et al.[54] found that almost two thirds of caregivers of children with SNHL questioned the
benefit received from hearing aids initially, but this perception improved with time.
The differences experienced by caregivers of these two groups of children could be
related to the limited development of speech and language skills of children with
SNHL, as well as the impact that severity of SNHL has on these skills.[54] Regardless of the reported benefit, several caregivers in this study were still
concerned about the hearing aids' appearance (61.5%), and more than a quarter (38.5%)
were concerned about opinions of others. These stigma concerns are in line with several
studies on children with CHL and SNHL, which noted that caregivers felt that hearing
aid aesthetics and thoughts of others were a concern.[34]
[35]
[38]
[46]
[54] This suggests that the concerns of caregivers in this study regarding their child's
hearing aids are comparable to those in high-income countries. Furthermore, it highlights
the importance of how hearing health professionals impart information to caregivers
and support them to achieve effective hearing aid management and outcomes.[38]
The results of qualitative analyses of caregivers' reported expectations were in line
with the benefits reported (improved hearing, communication, and behavior). Caregivers'
reported challenges included stigma, device compliance, bullying specifically by school
peers, and lack of buy-in from teachers as being barriers to hearing aid use. Several
studies on children with both CHL and SNHL fitted with hearing aids have noted caregivers'
challenges and concerns regarding stigma and bullying by school peers.[34]
[38]
[46]
[54]
[55]
[56] This may partly explain why the majority (61.5%) of caregivers felt that only occasional
hearing aid use was enough for their child to learn, in addition to the large number
of children with CHL as a result of OM (84.2%). In this study only a few caregivers
reported daily hearing aid tasks as challenges to hearing aid use, with 3 caregivers
reporting difficulty coping with the demands of managing hearing aids and 1 caregiver
having reported running out of batteries. Surprisingly, only 38.5% of caregivers reported
their child's behavior as a challenge to hearing aid use, which is a much lower rate
than the 50% reported by Munoz et al.[38] Based on the answers of the open-ended questions, most caregivers (76.9%) reported
positive feedback from the pediatric hearing aid user regarding wearing their hearing
aids. There were, however, some (23.1%) children who were not as amenable to wearing
their hearing aids, with 1 reporting that it was due to bullying at school. This feedback
highlights the importance of counselling both the caregivers and the child, as well
as liaising with teachers to address and alleviate stigma and bullying at school.[38]
While previous studies on pediatric hearing aid users focused on predictors of hearing
aid use,[45]
[49] this study focused on the outcomes of a unique population—children with CHL that
use BTE hearing aids. Due to the small sample size and variable age range (14.0–149.0
months) of pediatric hearing aid users in this study, possible associations between
independent variables and outcome variables could not be evaluated. The discrepancy
in daily hearing aid use between children with CHL and those with more permanent types
of hearing loss could be because daily hearing aid use was reported at a single point
in time – at the one month post-fitting follow-up – whereas other studies reported
longitudinal data with multiple data points over time. Additionally, in comparison
to children with CHL, the permanence and degree of SNHL can also account for the increase
in daily hearing aid use seen for children with SNHL. Despite a limited sample size,
this study provides contextual information regarding hearing aid use for CHL, allowing
a better understanding of caregivers' experiences during the period of hearing aid
use. Further studies with a larger sample size could investigate hearing aid outcomes
of children with CHL prospectively, considering multiple data points for outcomes
as well as possible predictors of hearing aid use for this unique population.
Conclusion
Children with CHL used their hearing aids for 6 hours a day on average. Caregivers
reported that the auditory performance was typical for more than half of the children
in this sample, confirming hearing aid benefit. Children experienced minimal listening
discomfort at home and school after one month of hearing aid use. All caregivers supported
the use of hearing aids for CHL, with clear reports of expectations meeting benefits.
The challenges experienced by caregivers (stigma and compliance) are reflective of
their counterparts in high-income countries, and of children with SNHL. While this
study population is limited, caregivers of children with CHL see more auditory benefit
at the initial follow-up than their SNHL counterparts. As the majority of pediatric
hearing aid users in this study presented with some form of OM, study results suggest
that the fitting of BTE hearing aids is a viable management option to limit the period
of hearing loss, and should be a common recommendation by ENT specialists and hearing
health professionals for children with CHL.
Appendix: Telephone Survey Questions
Study title: Outcomes of children with conductive hearing loss that are fitted with hearing aids
in the Western Cape, South Africa
Section A: Caregiver's Information
Child's code: __________________________________________________
Home language of parent/primary caregiver: ________________________
Language in which interview was conducted: ________________________
Primary caregiver: □ Mother □ Father □ Other: __________________
Section B: Hearing Aid Use
1. Does your child still wear (use) his/her hearing aid(s)?
□ YES □ NO*
*If you have answered “No”, please kindly answer the remaining questions thinking
back to the time when your child was wearing hearing aid(s).
a. If “Yes”, in your opinion why do you think it is important that your child wear
(uses) his/her hearing aid(s)? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
b. If “No”, what are the reasons for your child not wearing (using) his/ her hearing
aid(s) anymore?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. Each day my child typically uses/used their hearing aids:
□ all waking hours □ most of the day (8-10 hours) □ some of the day (5-7 hours) □ a
portion of the day (less than 5 hours)
Section C: Feelings and Habits
|
My feelings & habits
(Circle the number that best describes how much you agree with the statement)
|
Strongly Disagree
|
Disagree
|
Not Sure
|
Agree
|
Strongly Agree
|
|
1. I accept/accepted my child's hearing loss*
|
1
|
2
|
3
|
4
|
5
|
|
2. I am/was concerned with the appearance of my child's hearing aid(s)*
|
1
|
2
|
3
|
4
|
5
|
|
3. I am/was concerned about what others think*
|
1
|
2
|
3
|
4
|
5
|
|
4. I am/was concerned about how I will/would deal with my child's feelings about their
hearing aid(s)*
|
1
|
2
|
3
|
4
|
5
|
|
5. I think the hearing aid(s) help/helped my child*
|
1
|
2
|
3
|
4
|
5
|
|
6. My child does not/did not need hearing aid(s)*
|
1
|
2
|
3
|
4
|
5
|
|
7. I think occasional hearing aid use is/was enough for my child to learn*
|
1
|
2
|
3
|
4
|
5
|
|
8. I feel/felt quite frustrated with handling the hearing aid(s) every day*
|
1
|
2
|
3
|
4
|
5
|
|
9. I feel/felt confused about how to keep the hearing aid(s) on my child*
|
1
|
2
|
3
|
4
|
5
|
|
10. I feel/felt confident I can tell when my child's hearing aid(s) are/ were not
working correctly*
|
1
|
2
|
3
|
4
|
5
|
|
11. I check/checked my child's hearing aid(s) every day*
|
1
|
2
|
3
|
4
|
5
|
|
12. Talking with other parents helps/helped me manage the hearing aid(s)*
|
1
|
2
|
3
|
4
|
5
|
|
13. The fact that the hearing aids are/were supposed to be temporary helps/helped
me to manage them
|
1
|
2
|
3
|
4
|
5
|
|
*Adapted from Munoz et al., 2015. Pediatric Hearing Aid Use: Parent-Reported Challenges.
Ear & Hearing, 36; 279–287.
|
Section D: Challenges Relating to Hearing Aid Use
|
My child's hearing aid use is/was affected by:
(Circle the number that best describe how much you agree with the statement)
|
Strongly Disagree
|
Disagree
|
Not Sure
|
Agree
|
Strongly Agree
|
|
1. Distractions and needs of other children in the home*
|
1
|
2
|
3
|
4
|
5
|
|
2. Activities (e.g. playing outside, riding in the car)*
|
1
|
2
|
3
|
4
|
5
|
|
3. My child's behavior*
|
1
|
2
|
3
|
4
|
5
|
|
4. Difficulty getting a set routine*
|
1
|
2
|
3
|
4
|
5
|
|
5. Long wait time to get an appointment with the hearing health professional*
|
1
|
2
|
3
|
4
|
5
|
|
6. Other caregiver's ability to manage hearing aids*
|
1
|
2
|
3
|
4
|
5
|
|
7. The hearing health professional's lack of response to my questions during the appointment*
|
1
|
2
|
3
|
4
|
5
|
|
8. Difficulty coping with the demands of managing hearing aids*
|
1
|
2
|
3
|
4
|
5
|
|
9. Frequent ear infection, such as leaking ears*
|
1
|
2
|
3
|
4
|
5
|
|
10. Frequent ear pain
|
1
|
2
|
3
|
4
|
5
|
|
11. Frequent feedback (whistling/squealing) from the hearing aids*
|
1
|
2
|
3
|
4
|
5
|
|
12. My concern with the appearance of my child's hearing aids*
|
1
|
2
|
3
|
4
|
5
|
|
13. Running out of batteries before my next appointment
|
1
|
2
|
3
|
4
|
5
|
|
14. The hearing aids not working correctly*
|
1
|
2
|
3
|
4
|
5
|
|
15. My child's reaction to sounds when wearing the hearing aids*
|
1
|
2
|
3
|
4
|
5
|
|
16. Difficulty keeping the hearing aids on*
|
1
|
2
|
3
|
4
|
5
|
|
*Adapted from Munoz et al., 2015. Pediatric Hearing Aid Use: Parent-Reported Challenges.
Ear & Hearing, 36; 279–287.
|
Section E: Caregiver's Thoughts and Feelings Regarding Hearing Aid(s)
1. In your opinion, how do/did the hearing aid(s) help your child?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. In your opinion, what do/did you find most challenging about your child's hearing
aid use?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. What did you expect from the hearing aids when your child started using them?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. Did you feel that the hearing aid(s) did what you expected them to?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5. How did/does your child feel about wearing his/her hearing aids?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
