Integration of ear and hearing care into primary health care in Malawi with special reference to task-sharing.
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Introduction: The prevalence of hearing impairment has increased rapidly over the last two decades. The burden is higher in Africa and South East Asia than in richer parts of the world. The majority of this hearing impairment is preventable and can be managed at primary care level. However, the primary care level is generally weak in the provision of ear and hearing services. In recognition of this gap, the overall aim of the present thesis is to investigate the need for and feasibility of integrating ear and hearing care into primary health care in Malawi, specifically through task-sharing. Methods: The thesis is composed of five sub-studies. Apart from the first two studies which were trans-national, all the other studies took place in Malawi. The first study aimed to synthesise the available data on the prevalence and causes of hearing impairment in Africa through a systematic review of literature. The second study aimed at assessing availability and progress of ENT, Audiology and Speech Therapy services in Africa. It was a cross sectional study and a questionnaire was distributed by email to an ad hoc group of ENT Surgeons and Audiologists across Africa. The third study aimed at assessing the outcome of children with ear and hearing disorders, three years after diagnosis, in terms of uptake of referral to hospital, treatment given and satisfaction, and their participation in different aspects of life (school enrolment, ability to make friends, and ability to communicate needs). This was a longitudinal analysis of a population-based sample of children with hearing disorders, screened clinically and through questionnaires at baseline (2013) and follow-up (2016). The fourth study aimed to assess the uptake of and barriers to referrals to ear and hearing services for children in Thyolo District, Malawi. This was a mixed methods study, using both quantitative and qualitative methods. The fifth study was a cluster randomised control trial and was aimed at assessing the feasibility and accessibility of training community health workers (CHWs) in ear and hearing care and their ability to identify participants with ear and hearing disorders. . CHWswere given a pre-test and post-test to assess the effect of training on their knowledge of ear and hearing care. Results: The thesis showed that sub-Saharan Africa bears a high burden of ear and hearing disorders and that there are gaps in resources available to address these ear and hearing disorders. In Africa, the estimated prevalence for hearing impairment in children was 7.7% (2.4%–21.3%) using a cut-off of 25 dB HL and 17% for the general population of all ages. Our study II indicated that there are between 0.1 and 4.6 ENT surgeons per million persons across the region. Apart from South Africa, there is less than one audiologist for every million persons in sub-Saharan African countries. The impact of ear and hearing disorders often goes unnoticed and has not been explored adequately in low and middle income countries (LMICs). Study III showed that school enrolment among children with hearing loss was associated with ability to communicate and ability to make friends. Among children with hearing loss, those with speech impairment were more likely to report difficulties in making friends and in communicating needs. Among children with hearing loss, older children, girls and those with an illiterate caregiver were less likely to be enrolled in school. Training of CHWs in ear and hearing disorders proved feasible and acceptable and that CHWs were able to identify patients with ear and hearing disorders, and make referrals to a tertiary hospital as appropriate. A follow-up study on the uptake of referrals showed that there was a low uptake and the thesis has highlighted that while caregivers appeared to be motivated to seek care for their child, several often-interacting factors prevented them from doing so. These included location of/distance to the hospital, indirect costs, lack of transportation, procedural challenges in camps, awareness and understanding of ear and hearing issues, fear and uncertainty about the referral hospital, and lack of availability/visibility of hearing health services. Conclusion: There is high prevalence of ear and hearing disorders in Africa. The majority of the causes are avoidable and these conditions have significant impact on the people affected. There are low levels of services available for people with ear and hearing disorders and low uptake due to difficulties with accessing services. Task-sharing at primary level is feasible and acceptable and could help to fill gaps in service provision.
Has partsPaper I: Mulwafu W, Kuper H, Ensink RJ. Prevalence and causes of hearing impairment in Africa. Trop Med Int Health. 2016 Feb;21(2):158-65. The article is available in the main thesis. The article is also available at: https://doi.org/10.1111/tmi.12640
Paper II: Mulwafu W, Ensink R, Kuper H, Fagan JJ. Survey of ENT services in Sub-Saharan Africa: Little progress between 2009 and 2015. Global Health Action. 2017;10:1289736. The article is available at: http://hdl.handle.net/1956/18397
Paper III: Mulwafu W , Tataryn M, Polack S, Viste A, Goplen FK, Kuper H. Children with hearing impairment in Malawi, a cohort study. Bulletin of the World Health Organization. 2019;97:654-662. The article is available in the main thesis. The article is also available at: http://dx.doi.org/10.2471/BLT.18.226241
Paper IV: Bright T, Mulwafu W, Thindwa R, Zuurmond M, Polack S. Reasons for low uptake of referrals to ear and hearing services for children in Malawi. PloS one. 2017 Dec 19;12(12):e0188703. The article is available in the main thesis. The article is also available at: https://doi.org/10.1371/journal.pone.0188703
Paper V: Mulwafu W, Kuper H, Viste A, Goplen FK. Feasibility and acceptability of training community health workers in ear and hearing care in Malawi: a cluster randomised controlled trial. BMJ open. 2017 Oct 1;7(10): e016457. The article is available in the main thesis. The article is also available at: http://dx.doi.org/10.1136/bmjopen-2017-016457