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Hark Western Cape Progress Report - December 1999

Contents
INTRODUCTION   ESTABLISHMENT OF SITES   CAPE METROPOLE REGION   BOLAND/OVERBERG REGION   QUANTITATIVE INFORMATION   QUALITATIVE INFORMATION   CAPE METROPOLE REGION   BOLAND/OVERBERG REGION	OBJECTIVES AND PRIMARY HEALTH CARE       (PHC) PRINCIPLES   SOME EMERGING ISSUES   ENT (UCT) EAR CAMPS   RESEARCH   DATA COLLECTION/ STORAGE/ ANALYSIS   FUND RAISING

1. INTRODUCTION

The progress report of July 1999 reflected on the planning stages and the formulation of operational plans for the HARK Project - Western Cape. In this progress report the establishment of the project including quantitative and qualitative information will be documented. Furthermore an attempt will be made to evaluate the progress of the project according to its primary objectives and the five core principles of the Primary Health Care Approach.

2. ESTABLISHMENT OF SITES

2.1 Cape Metropole Region

The project has been established in four of the six districts/substructures of the Cape Metropole Region. The project has not been established in the Tygerberg or South Peninsula districts as an audiology service is provided by the Carel Du Toit Centre/Tygerberg Hospital and the Deaf Child Centre in each of these areas, respectively.

The project has been established in the following districts and sites:
City of Cape Town: Brown's Farm Day Hospital
Blaauwberg: Tableview Municipal Clinic and Wesfleur Day Hospital
Helderberg: Somerset West Municipal Clinic
Oostenberg: Kraaifontein Centre (Day Hospital) and Kleinvlei Centre (Day
    Hospital)

2.2 Boland/Overberg Region

Following the working group committee meeting, the establishment of the project at the following sites was recommended:
Worcester: Eben Donges Hospital
Ceres: Ceres Municipal Clinic
Ashton: Zolani Municipal Clinic
Hermanus: Hermanus Municipal clinic
Swellendam: Railton Municipal Clinic
Grabouw: Grabouw Municipal Clinic

As can be seen above, the service is provided at ten sites throughout the Cape Metropole and the Boland/Overberg Regions. The sites are visited once per month, except for Eben Donges, which is visited on a weekly basis. A timetable for 1999 (see Appendix A) was agreed upon by all parties. The frequency of visits to each site is proving to be sufficient in terms of providing effective rehabilitation and the present demands of the number of children referred for assessment or rehabilitation.

3. QUANTITATIVE INFORMATION

In Tables 1 and 2 below quantitative information regarding the service, which has been provided over the past 4 months, is presented

METROPOLE REGION: SUMMARY OF STATISTICS

BOLAND/ OVERBERG: SUMMARY OF STATISTICS

As can be seen in Table 1, the number of children having received hearing aids is lower than the number of children diagnosed with a hearing impairment. This figure reflects the procedure required in which a diagnostic hearing assessment is conducted and an ear mould impression is taken on the first visit, followed by a hearing aid fitting on the second visit. Hence, at the next follow up visit the children diagnosed with hearing impairments will be fitted with hearing aids.

To date, the service has not been provided at Oostenberg. However meetings have been held in which discussions concerning where the site should be based within this region was undertaken. The need to provide services to both the Municipal Local Councils Services and the Community Health Centres Organisations was recognised and will be implemented in 2000.

As is illustrated in Table 1, to date, 79 children have been diagnosed with a hearing loss, 28 children with a sensori-neural hearing loss and 51 children with a conductive hearing loss. These figures clearly reflect the need for the audiology service provided by the HARK Project.

4. QUALITATIVE INFORMATION

In this section qualitative information concerning each site is presented.

4.1 Cape Metropole Region

Blaauwberg: Tableview Municipal Clinic

This site is proving to be an extremely successful site. The nursing staff are
    highly involved in referring patients and undertaking all bookings for the HARK
    Project. Much team- work between the audiologists and the nurses is
    undertaken. The nurses are involved in research and further studies and have
    clearly indicated that they would like to acquire additional information and
    knowledge in the field of deafness.

Blaauwberg: Wesfleur Day Hospital

This is a large day hospital, which is staffed by numerous medical personnel. The
    need for audiology services at Wesfleur Day hospital has been clearly observed
    and expressed.
It is felt that further awareness of the project among the medical personnel is
    required. Meetings with medical personnel and awareness campaigns will be
    established in 2000.
Numerous referrals have been made from the Deaf Child Centre and Red Cross
    Hospital to the HARK Project at this site. The referrals back from a
    secondary/tertiary health care level to a primary health care level appears to be
    most effective in that patients have expressed that the accessibility of the HARK
    Project at this site has allowed them to make repeated visits for rehabilitation.

City of Cape Town: Brown's Farm Day Hospital

At this site the Health Care Workers play an integral role in the project. As a
    result of their regular home and pre-school visits, the Health Care Workers are
    critical in the referral of children with possible hearing impairment. The Health
    Care Workers are very happy to assist the project and the audiologists will
    provide the Health Care Workers with further training in the field of deafness in the
    near future.
 This location of this site is accessible to a large population from the surrounding
    areas of Phillipi, Guguletu, Cross Roads, Nyanga and Langa. A meeting was
    scheduled with the nurses from the Day Hospitals and Municipal Clinics from
    these surrounding areas so as to inform them of the HARK project and the means
    of referring patients. However this meeting had to be cancelled as a result of a
    local strike. The meeting will be re-scheduled early in 2000.
Hearing screening in the local creches and pre-schools has been initiated and will
    be continued in the following year.
Due to a shortage of accommodation at the site, the audiologists utilise the
    HARK vehicle for assessments and rehabilitation. Although this is proving to be
    satisfactory, it limits the number of children that can be seen.

Helderberg: Somerset West Municipal Clinic

The nursing staff have been highly supportive and involved in the HARK Project.
    They have been responsible for all referrals and bookings of patients. Meetings
    providing information about the HARK Project with nursing staff from clinics in the
    surrounding areas have been undertaken.
This clinic was chosen due to its central location in the district and it was
    reported that transport for patients in surrounding areas was available. However
    the audiologists are of concern that the clinic may not be accessible to certain
    populations from surrounding areas. This will be more fully explored early in 2000.

4.2 Boland/Overberg Region

Ceres: Ceres Municipal Clinic

It is felt that increased contact and collaboration is required with other medical
    and paramedical professionals in the area. Furthermore closer liaison with a
    mobile health clinic which services the area will be undertaken in 2000.

Ashton: Zolani Municipal Clinic

Many children referred to the HARK Project are from schools in the surrounding
    area. The nursing staff at the clinic have made contact with the schools regarding
    the HARK Project.
There is concern as to the clinics accessibility to populations in other local areas
    and the possibility of sharing the service between two clinics is currently being
    undertaken.

Hermanus: Hermanus Municipal Clinic

The nursing staff has been highly supportive and involved in the project. This has
    resulted in many referrals being made to the HARK Project and 67 patients have
    already been seen in three visits. The nursing staff are enthusiastic to acquire
    more knowledge in the field of deafness and training will be undertaken in 2000.

Swellendam: Swellendam Municipal Clinic

The nursing staff have been highly supportive and much team work between the
    audiologists and nursing staff has been carried out.
Numerous referrals have been made from the UCT ENT ear camps held in this
    area.
There has been concern regarding the accessibility of patients from surrounding
    towns, therefore Caledon is being examined as an alternate or additional site for
    2000.
Parent training programmes are required and will commence in the new year.

Grabouw

This site is visited every fifth Wednesday of a month. This is proving to be
    satisfactory as patients requiring more regular service are able to access the
    sites in Somerset West or Hermanus. Further dates will be scheduled for 2000
    should the need arise.

Worcester: Eben Donges Hospital

Much collaboration between the HARK Project, based at the hospital, and the
    local schools for the deaf has been established. This collaboration has involved
    referrals, assessment and rehabilitation.
In the initial stages of establishing the HARK service at Eben Donges Hospital,
    numerous meetings with medical and paramedical personnel were held.
    Awareness of the project and the services it offers was well carried out. This has
    resulted in many referrals being made and much multi-disciplinary work being
    undertaken. This in turn has resulted in a highly comprehensive service being
    offered to hearing impaired children.
The audiologists are involved in hearing screening in the neonatal unit at Eben
    Donges and all patients are followed up on a regular basis.

5. OBJECTIVES AND PRIMARY HEALTH CARE (PHC) PRINCIPLES

Evaluation of the project in terms of its objectives and PHC principles:

Vision and Objectives

The project has continued to focus its service on early identification and intervention. Initial attempts to apply the service at sites in which the Developmental Screening Tool is being administered, has not yet proved to be successful as few children under the age of 18 months are being identified as having possible hearing impairments and then being referred to the project. However further support for the Developmental Screening Tool will be undertaken in 2000 and research concerning the hearing component of the tool will be conducted.

The project continues to move towards sustainability by implementing the project within existing infrastructure, using current resources and working in close collaboration with various departments and sectors. Furthermore, the collection of epidemiological data hopefully will highlight the need for the continuation of such services. The development of a sustainable service delivery model for hearing assessment and rehabilitation is being developed on an ongoing basis.

The objectives (see Appendix B) for the HARK Project are being met in terms of the audiology service provided, liaison with DEAFSA and DCCT, and empowerment of families of hearing impaired children.

HC Principles

Interdisciplinary and intersectoral collaboration

Much intersectoral collaboration has been undertaken at the levels of the advisory
committee and working groups. Representatives from various departments from
the University of Cape Town, the Department of Health, the Western Cape
Education Department and DCCT have jointly determined the vision and
objectives of the project as well as monitored its progress (See Appendix C -
Minutes from the Second Advisory Committee Meeting). Collaboration across
sectors and across levels and division of services within the Department of Health
has been achieved at a working group committee level (See Appendices D and E
- Minutes of the Second Working Group Committee Meetings). This
collaboration has resulted in joint decisions being made with regard to the location, nature of the service and implementation of the HARK Project in the Cape Metropole and the Boland/Overberg Regions.

In addition, collaboration with other professionals within the health and educational sectors has been conducted at the primary and secondary health care sites.

Maximum community participation in health and health care

Integral to this project has been the involvement of professionals already
operating within the health and educational services within the various
communities. This has involved health care workers, nursing staff, school health
nurses, school clinics, primary health care practitioners, medical health
officers, and other paramedical personnel. In addition school principals, teachers
and therapists have participated in the project.

Initial attempts have been made to identify deaf adults within the various communities. The parents will be integrally involved in the project with the commencing of the parent training programmes early in 2000.

Consumer accessibility to health and health services

As has been mentioned previously, the working group committees recommended the selected sites. The majority of the sites are at a primary health care level and are accessible to the local population. Concern regarding accessibility for all local population groups at the Somerset West Clinic and the Zolani Clinic in Ashton has arisen and the possibility of establishing an additional site in both of these areas will be addressed early in 2000. The project is conducted at two sites at a secondary health care level, namely Eben Donges Hospital (Boland Overberg Region) and Deaf Child Centre (Cape Metropole).

Appropriate use of technologies such as resources and strategies

The adoption of otoacoustic emissions (OAE) as the preferred screening tool is based on the advantages of OAE's being simple, fast, non-invasive, objective, sensitive, reliable and valid. Screening of hearing is undertaken in conjunction with the primary health care clinics and the school health clinics. The future provision of solar powered hearing aids will alleviate the difficulties experienced concerning the financial cost of the purchasing of batteries.

Protocols concerning referrals for screening, diagnostic audiological evaluations and rehabilitation have been compiled jointly by the various professionals involved in the health and educational services within the regions. Referrals made by the audiologists to other health professionals support existing referral pathways.

Close liaison with schools for hearing impaired children within the regions is carried out and existing resources offered by the schools are utilised. In turn referrals, support and training is offered to educators and other professionals within the schools for hearing impaired children and in the mainstream schools attended by hearing impaired children.

Existing channels for the dissemination of information is utilised at all sites. The dissemination of information regarding the HARK Project and hearing impairment will be undertaken through existing channels at a regional and district level. Public awareness of hearing impairment and the services offered by the HARK Project has been undertaken using community based radio stations.

Health Promotion and prevention of illness and disability

The importance of public awareness of hearing impairment and its effect on the acquisition of speech and language is well recognised by the HARK Project. Posters and pamphlets are currently being designed and will be disseminated through existing channels. An objective of increasing the awareness among other health professionals is undertaken on a regular basis at the various sites.

6. SOME EMERGING ISSUES

Hearing screening

Over the past six months limited screening of hearing has been undertaken in creches and pre-schools in the areas serviced by HARK. However the need for hearing screening of children between the ages of 2-6 years is well recognised. As from January 2000 a screening programme will be implemented in the immediate areas serviced by HARK. This will entail working closely with the creches and pre-schools in the area.

Greater involvement of school clinics and school health nurses

Following the working group committee meetings, held in November 1999, it was acknowledged that to date that although the HARK Project had been working in very close collaboration with the Municipal Local Clinics (MLC's ), additional collaborative work was required with the school clinics and school health nurses. This will be undertaken in 2000.

Marketing and public awareness

It is clear that there is much need within the communities and the health professions for increased awareness of hearing impairment, the psycho-social and educational implications of a hearing impairment and the need for early intervention. A primary objective of the HARK Project is to disseminate this information. Use of existing channels for the dissemination of information within the health system will be undertaken. An attempt to disseminate this information in the education system will be explored in 2000. Workshops and training sessions for other professionals will be undertaken on a regular basis. Much information is imparted to parents of hearing impaired children obtaining a service from HARK during counselling and within the parent training programmes.

  Support from and training of University of Cape Town and University of
     Stellenbosch Speech Pathology/Audiology students

As from January 2000, the HARK Project in the Cape Metropole Region and Eben Donges in Worcester will become clinical practicum sites for students from the Department of Logopaedics, UCT and the students from the University of Stellenbosch, respectively. This hopefully will provide the students with much training in aural assessment and rehabilitation at a community level as well as provide the HARK project with support, allowing for increased numbers of children to be seen.

7. ENT (UCT) EAR CAMPS

The HARK Project and the Department of Otolarngology, UCT, have worked in close collaboration over the past six months concerning the ear camps. The ear camps have been conducted in the sites adopted by the HARK Project. This has allowed for additional medical support at these sites. The ear camps provide ear care to persons of all ages, however as the focus of the HARK Project is on early identification and intervention, discussions regarding HARK's involvement in the ear camps being restricted strictly for children are currently being held.

8. RESEARCH

Research currently being undertaken involves measuring the efficacy of the use of solar powered hearing aids in a developing country (See Appendix F - research proposal). Two groups of hearing impaired children, one in the Cape Metropole and the other in the Boland/ Overberg have been identified for the research project. Ear moulds have been manufactured for the group of children in the Cape Metropole Region. Prior to the fitting of the aids the need to re-assess the children's hearing and the need to work closely with the parents of the children was recognised. This resulted in some time delay however it was felt imperative that the audiologists work closely with the parents regarding the care and use of the hearing aids so as obtain reliable results in the future.

The Department of Logopaedics will act in support of the research project in terms of providing sophisticated technology, which will allow for an objective hearing aid fitting to be undertaken for each child in January 2000. Evaluation of the efficacy of the hearing aids will be undertaken using quantitative and qualitative measures at three and six months post fitting of the hearing aids.

Future research to be undertaken in 2000:
The sensitivity and specificity of the Developmental Screening Tool for the
    screening of hearing impairment in children between the ages 0-18 months
The role of an interpreter in aural rehabilitation and parent training programmes for
    hearing impaired children
Epidemiological studies concerning hearing impairment in the Western Cape

9. DATA COLLECTION/ STORAGE/ANALYSIS

Each patient's case history and audiological information is collected and filed on site. This information is then entered into a data base at the Deaf Child Centre.

Recently, the HARK Project was provided with assistance from a student recruited through the Job Opportunities Bureau (UCT) and funded by the Kellog Foundation. The student's assistance allowed for all the data gathered over the past four months to be stored using the software "Statistica". In order for the student to be able to undertake this task, she attended a course on "Statistica" offered by UCT. The cost of her course was funded by the Deaf Child Centre. This package allows for an in-depth and efficient means of analysis of the data.

10. FUND RAISING

Liaison with the Development Office at UCT has been undertaken. Through the Development office fund raising proposals have been forwarded to two possible sources of funds. Additional funding is required to support the salary of a cultural broker who will assist in the interpretation of linguistic and cultural issues.

For more information about CHU activities contact: Professor Marian Jacobs
Child Health Unit, 46 Sawkins Road, Rondebosch 7700; Tel: +27 (021)  6898312; Fax: +27 (021) 6895403
Last Update: 28/07/00

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