REPORT ON VISIT TO SOUTHERN CAPE/KAROO

Contents

INTRODUCTION QUANTITATIVE AND QUALITATIVE RESULTSS MANAGEMENT PROVIDED AND IMPLICATIONS WAY FORWARD

INTRODUCTION

From 11 - 15 September the Deaf Child Centre Hark Project team visited the Southern Cape/ Karoo Region of the Western Cape with the aim of providing audiological services, including audiological evaluations and rehabilitation, to the paediatric population of this region.

Clinics were conducted on a daily basis at a total of six health sites including Alma and D'Almeida Clinics (Mossel Bay), Knysna Hospital (Knysna), Bongolethu and Bridgeton Clinics (Oudtshoorn) and Conville Clinic (George). As the visit of the Hark Project was co-ordinated through the School Health Directorate in the Southern Cape/ Karoo, the majority of referrals to Hark were made by local schools through the school health nurses. Additional referrals were however also received from other health professionals in the region as well as a small number of self-referrals obtained through marketing in the public.

QUANTITATIVE AND QUALITATIVE RESULTS

A total of 274 patients were managed during the course of the visit. Of the total cases referred for audiological assessments, just under 50% were identified with hearing disorders. Quantitative results from each of the sites visited can be seen in Table 1 below.

As can be seen in the table above, of the group of children identified with hearing loss, 37 % (96 children) presented with hearing loss as a result of middle ear infection, that is, conductive hearing loss, while 12 % (30 children) presented with permanent sensorineural hearing impairment. Although these statistics do not reflect prevalence data of hearing impairment for the region as such, the number of children identified with conductive and sensorineural hearing impairment do indeed represent epidemic proportions.

It is likely that the large number of children seen with auditory pathology during this visit represent a backlog of cases who have either not been previously identified or have not received audiological intervention, owing to the lack of speech-language/ hearing services in the Southern Cape/ Karoo. Similar trends of an "uncovered backlog" were observed in the initial implementation stages of the Hark Project in the Cape Metropole and Boland/ Overberg regions of the Western Cape, however it is felt that this phenomenon is exacerbated in the Southern Cape/ Karoo region. The reason for this is that both the Cape Metropole and Boland/ Overberg did have some public audiological services prior to Hark's involvement (absent in Southern Cape/ Karoo) as well as a closer geographical location to the tertiary hospitals in Cape Town.

These findings therefore highlight the need for further involvement by the Hark Project in the region to assist in the management of previously unidentified or untreated children with hearing impairment. Critical to this process, however, would be the creation of a speech therapy/ audiology post in the Southern Cape/ Karoo Department of Health, in order to ensure that the hearing intervention programme initiated by the Hark team can be continued and supported on a daily basis in the region.

MANAGEMENT PROVIDED AND IMPLICATIONS

In addition to the hearing assessments conducted during the course of the week, the Hark team undertook to provide those children identified with ear and hearing pathology with the necessary follow-up required. As can be seen in Table 2 below, 20 children have been fitted with hearing aids in either George or subsequently in Cape Town or are still awaiting amplification. Hearing aid orientations have been conducted where possible with the children's caregivers and guidelines on managing the hearing impaired child and hearing aids in the classroom setting have been sent to each of the school teachers concerned. A training workshop with the school health nurses from the region has also been planned in order that the school nurses can continue to follow-up on these children in the absence of the Hark team. This is felt to be critical to the success of Hark's involvement in the region. Without this follow-through, the management already carried out will be of no great benefit to the children in the long-term.

Also important to note in the abovementioned data is the number of referrals for intervention at both a primary health care and more specialist level. These statistics serve to highlight the key role that primary health care practitioners now play in the management of outer and middle ear pathology as well as the dire need for E.N.T. and other specialist services in the region. Because hearing loss as a result of middle ear pathology is preventable and bearing in mind the large proportion of children identified with conductive hearing loss by the Hark team, E.N.T. services should ideally be increased in the Southern Cape/ Karoo region.

Although the table above reflects that only 5 children were referred for special schooling, it is felt that this figure is not truly representative of the number of deaf children requiring special schooling. There are in fact a number of other children who have not yet been referred for special school placement for various reasons. More importantly, of the 5 children referred, all were identified with hearing impairment at a young age but owing to the absence of educational facilities for the deaf in the region, these children have not yet been attending school. These children have therefore not received intervention during their critical language period and will be unable to achieve high academic standards owing to a lack of language. This has major implications for the children themselves as well as the economy in general. The LSEN Directorate of Western Cape Education Department has previously requested Hark's input regarding deaf schooling in the Southern Cape and results from this visit will be shared with the Education Department in the near future.

Finally, the abovementioned findings confirm the need for the early identification of the hearing impaired child. It is indisputable that a child develops the bulk of his/ her speech and language in the first five years of life. Thus it is essential that a hearing impaired child be identified early and that he/ she receives intervention without delay. This has vast implications not only on the child's ability to communicate and function in daily life but also his/ her academic performance and ultimately what contribution he/ she is able to make to the economy of the country.

In terms of the implementation of speech-language/ hearing services in the Southern Cape/ Karoo, we therefore need to look at the involvement of other Department of Health Directorates, in particular Maternal, Child and Women's Health (MCWH) and Chronic Care and Rehabilitation. The role of the developmental screening tool developed within the rhelms of the MCWH Directorate and the referral pathways suggested in accordance with this tool, are critical in order to identify and intervene with the younger child with a hearing disability. Hence it is recommended that these directorates as well as the Education Department (discussed above) are brought on board to ensure effective management of the hearing impaired child.

WAY FORWARD

Involvement of Hark
    As mentioned above, the Hark Project team would like to continue their involvement
    in the Southern Cape/ Karoo and at least two visits to the region will be scheduled
    for 2001. Through their involvement the Hark team will aim to continue to manage
    the backlog of cases that have not received audiological intervention. In addition,
    follow-up to those cases identified in this initial visit to the region is proposed.
Programme for future visits and involvement of MCWH and CC&R
    The Hark team would like to liaise again with the School Health Directorate as well
    as the MCWH and CC&R directorates of the Southern Cape/ Karoo Department of
    Health in planning their programme for 2001, bearing in mind the abovementioned
    aims of Hark's involvement.
Feedback to Western Cape Department of Education - motivation for
    special schooling
    As discussed above, special schooling is a key element of the implementation of
    speech-language/ hearing services in the region. The Hark team will inform the
    Department of Education of this need through the submission of a written report
    and verbal communications to the LSEN Directorate of the Department.
Motivation for speech-language/ hearing therapy post within Southern
    Cape/ Karoo Department of Health
    The quantitative and qualitative findings presented in this report undoubtedly   
    indicate the need for a speech-language/ hearing service in the Southern Cape/
    Karoo region. Although the Hark Project will continue to support the region on a
    biannual basis, the creation of a speech therapy/ audiology post in the Southern
    Cape/ Karoo Department of Health, is critical to this process. While realising the  
    existence of financial constraints within the Department of Health, it is strongly felt
    that the absence of these services are having a vast impact on the development of
    the children in this region and ultimately their contribution to the South African
    economy. We therefore urge the Department to respond to this need and seriously
    consider the creation of a paediatric speech therapy/ audiology post for the
    Southern Cape/ Karoo.

Report compiled by Lori Michelson, Shannon Brewis and Natashia van Wyk
(Hark audiologists)
5 October 2000