Enablers and barriers to accessing hearing assessments for children in Australia

Difficulty hearing, whether it is caused by blockage or damage to the outer or middle ear (conductive hearing loss), or damage to the inner ear or cochlear nerve (sensorineural hearing loss), can impact the development of oral language and literacy acquisition (Lund et al., 2015; Scarborough, 2001). Children with hearing loss, even mild to moderate loss, are at risk of poor outcomes in speech, language and literacy (Ching et al., 2018; Tomblin, Oleson, Ambrose, Walker, & Moeller, 2020; Zussino et al., 2022). The reduced quality auditory input causes imprecise and inaccurate representations of sounds (Nittrouer & Burton, 2005) which can lead to distorted perception of sound, speech sound production errors, reduced syntactic complexity and receptive language delays (McGuckian & Henry, 2007; Zussino et al., 2022). Therefore, early identification and intervention for hearing loss is important for allowing young children (aged five and under) to access good quality auditory information, and reduce the probability and severity of speech, language and literacy delays and disorders associated with hearing loss (Ching et al., 2017; Moeller & Tomblin, 2015).

The Universal Newborn Hearing Screening (UNHS) program was implemented in Australia in 2001, to promote early identification and intervention for children in Australia (Australasian Newborn Hearing Screening Committee [ANHSC], 2001). However, the UNHS program only identifies children with moderate to severe hearing loss (ANHSC, 2001). Therefore, children with mild to moderate hearing loss in Australia are not being identified at birth. This cohort of mild to moderate hearing loss makes up 75% of the children with hearing loss in Australia (Parliament of Australia, 2010). Many of these children will experience speech, language and literacy delays as their hearing loss goes unidentified (Zussino et al., 2022).

In addition to not being identified at birth, many children with potential mild to moderate hearing loss also experience health inequalities and barriers to accessing healthcare, specifically hearing assessment beyond the newborn period, due to social determinants of health (DeLacy et al., 2020; World Health Organization [WHO], 2021). Living in a rural or remote location can also further complicate access to healthcare. This is important to note since approximately one-third of Australians live in regional, rural and remote locations (Australian Bureau of Statistics [ABS], 2014). There is also a high proportion of Aboriginal and Torres Strait Islander populations living in regional, rural and remote locations, and these populations already experience many health disparities compared with other Australians (DeLacy et al., 2023). Aboriginal and Torres Strait Islander populations, herein respectfully referred to as First Nations people, are also more likely to experience hearing loss, especially conductive hearing loss (Australian Institute of Health and Welfare [AIHW], 2021). This research seeks to understand the enablers and barriers to accessing hearing assessment for children in Australia and compare these enablers and barriers for metropolitan and regional, rural and remote locations.

The overall research used an explanatory sequential mixed methods approach, utilising a Pragmatism paradigm (Mitchell, 2018). Firstly, as part of the research, a systematic review was conducted that critically reviewed the empirical evidence for speech, language and literacy outcomes in children with mild to moderate hearing loss. Secondly, three empirical studies were conducted that explored the perceptions of enablers and barriers to hearing assessment in Australia by three important stakeholders: parents (Study 2); speech pathologists (Study 3); and clinical service leads (Study 4). A clinical service lead is a leader of a team of professionals who provide audiology services, who has some control over the service delivery decisions of their team. Studies 2 and 3 were mixed methods while Study 4 was a qualitative study.

The findings of the systematic review provided evidence of the importance of early identification and intervention for mild to moderate hearing loss and the detrimental effect of mild to moderate hearing loss on speech, language and literacy outcomes for children. The findings of Study 2 suggested that parents in all geographic locations experienced barriers to accessing hearing assessments, and geographic location itself was not a predictor of increased difficulty in accessing hearing services. Rather, health literacy skills and individual circumstances such as the ability to afford private services, access to flexible appointments and access to childcare, enabled parents to access hearing assessment services. The findings of Study 3 suggested that similar accessibility issues to parents were reported by speech pathologists in all geographic locations, such as long wait times, complex criteria, and inexperienced clinicians. Speech pathologists also reported that the awareness and knowledge of the importance of hearing for speech and language, and where to go for hearing assessments is low in parents, which contributed to the decreased uptake of hearing assessment services. For Study 4, service leads reported similar enablers and barriers to parents and speech pathologists, including long wait times, lack of awareness of the importance of hearing and accessing hearing services, and difficulty with recruitment and retention of audiologists. However, service leads in Study 4 also identified that while the current UNHS program is working well, there are inconsistent hearing assessment services after the newborn screening process. Service leads also identified the importance of embracing technology as a way forward in designing innovative service delivery models which may overcome some barriers to accessing hearing assessment services; however, care must be taken with co-designing services so that they are accessible for the people who require them. The findings of this research provide preliminary insights into enablers and barriers to hearing assessment for children in Australia, and current service delivery methods that are, and are not working.

The findings may be used in the design of more efficacious, inclusive hearing services that ensure that all Australian children with hearing loss are identified early and receive early intervention to reduce the impact upon their speech, language and literacy development.