Patient-Centered Care Within Community-Based Domains Provides Added Value

The first study of hearing and hearing disorders was documented in the Ebers Papyrus, a medical journal, that dates to 1550 BC. Remedies are described in the text, for “ears that hear badly.” ¹ About 3,500 years later, audiology emerged as a profession in the mid-20th century due to the close bond to speech-language pathology. During those emerging and growing times, audiologists self-identified as speech and hearing specialists and primarily worked in hospital and clinic settings by providing diagnostics and later rehabilitation services to patients with hearing disorders secondary to trauma incurred during military service. C.C. Bunch authored the first published textbook (CV Mosby Company, St. Louis), “Clinical Audiology” in 1943, which ensured consistency and accuracy in measuring hearing status. ² At that time (and even now), clinical collaborations typically occurred with a small number of non-audiology professionals. Despite the history of professional partnerships, there continues to be limited awareness of the role of audiologists especially in community-based domains, such as: nutrition, pulmonology, pharmacology, neonatology, educational therapy, endocrinology, and epidemiology (to name a few). Audiologists have an opportunity to improve outcomes for their patients especially in community-based rural settings through fruitful interaction with other health professionals.

www.shutterstock.com. Community-based care, patient-centered care, South Africa

This article highlights potential collaboration with other health professionals in community-based service provision and the potential for audiology to expand its services and collaborate more effectively with other professions in community-based settings. Audiology as a field has historically been closely tied to a variety of health professionals such as: speech--language pathologists, physicians (otolaryngologists, primary care physicians, neurologists), and physiotherapists. As sister professions, speech-language pathology and audiology have been interconnected, especially in relation to aural rehabilitation and rehabilitation services provided to individuals with hearing loss. Collaborative care provided to these individuals and their families, improve outcomes, and help them achieve optimal communication and functional abilities.

COMMUNITY-BASED COLLABORATIONS WITH OTHER HEALTH PROFESSIONALS

South Africa’s current population of 60.2 million continues to grow at a rate of approximately 1.28% annually, with a birth rate of about 19.9 births per 1,000 people and death rate of 9.3 deaths per 1,000 people. ³ Though, the country population density in 2021 was 49.58/sq kilometer, ⁴ 32% of the population reside in rural areas. ⁵ Health care services in these areas are limited to district hospitals, community health centers (CHCs) and primary healthcare clinics (PHCs), which all fall within the public health care domain. Audiology services at district hospitals, if available, are limited to basic diagnostic assessment and management of hearing difficulties (e.g., provision of hearing aids) and no services are available at CHCs or PHCs. Specialized audiological and hearing health services are only available at tertiary hospitals located in major urban centers. The challenges for the provincial health departments are rooted in the paucity of health care professionals (including audiologists) and other resources, putting the health care system under extreme pressure.

In light of the overwhelming needs within each province, there remains a necessity for more creative cross-professional collaboration for audiologists working in the rural community health domain. In the rural community-based audiology service provision, there are a number of creative collaborations that will ensure best patient care. Some of these collaborations would include primary care nurses, general community health care workers, and social workers.

PHCs are the first point of entry into the health care system for the overwhelming majority of South Africans. These services are nurse-led. As the first point of contact, primary care nurses and community health workers (CHWs) are well-placed to identify individuals who present with ear and hearing disorders, regardless of the cause. Primary care nurses employed in PHCs work as independent practitioners who manage and treat minor ailments (e.g., ear disease), chronic illnesses (e.g., diabetes and hypertension) and infectious diseases (e.g., HIV and Tuberculosis). Training primary care nurses on risk factors for hearing loss, identification of ear disease and hearing loss, basic treatment of ear disease, as well the importance of prompt referral to specialist services, is essential. ⁶ The WHO ⁷ recently proposed guidelines for hearing screening that specifically highlights the role of primary care nurses in the early identification of ear disease and hearing loss across the lifespan. In the identification of hearing loss in the elderly for example, their role is twofold: first, to ask pertinent questions about the status of hearing and experience of hearing difficulties such as “Do you have a hearing loss?” or “How would you characterize your hearing?” should the person then indicate hearing difficulties; to secondly conduct screening tests to check for hearing loss (e.g., digit triple-in-noise test, whispered voice test, etc.). The results would guide the appropriate referrals for diagnostic assessment and management.

Primary care nurses do not work in isolation. They are supported by CHWs whose role is to deliver health promotion and prevention services in the community. Although trained in the context of intervention, they do not have formal certificated education. Despite not being certified, CHWs are vital members of the PHC team as they provide health education to the public. Health education is one on the most important primary prevention strategies of health conditions. This also applies to the prevention of ear disease and hearing loss. Across the globe, CHWs have been successfully trained to educate the public on the risk factors for hearing loss, practices related to healthy ear care, safe listening, and the role of the audiologist in the identification and management of hearing loss. ^8,9 There is also evidence that CHWs have been trained to screen for hearing loss in Early Hearing Detection and Intervention (EHDI) programs and using mHealth technology. ¹⁰

In the World Report on Hearing ¹¹, numerous success stories from around the world are shared of the effectiveness of ear and hearing care trained primary care nurses and CHWs in strengthening the capacity of audiologists and ENT specialists. The successes lie in shifting some tasks such as awareness raising (e.g., prevention and promotion activities), as well as the early identification and basic management of e.g., ear disease to these cadres. This, coupled with prompt referral to audiologists and other specialist services, increases the availability and access to basic ear and hearing health services. An important consideration is however that following the initial training, audiologists should provide supervision and ongoing support to primary care nurses and CHWs.

In a community-based setting, social workers are employed to help meet basic and complex needs and enhance the overall well-being of individuals and communities. In rural, poverty-stricken, and resource-constrained communities, audiologists can collaborate with social workers to ensure that individuals with hearing loss and their families access appropriate services. Often, once hearing loss has been identified and a management plan developed, individuals with hearing loss do not return for follow-up appointments. This loss to follow-up is often due to travel distance to services, unaffordable transport costs and limited income. ¹² Social workers can facilitate access to hearing health services by providing information and advice relating to support, assistance with accessing services (e.g., arrange hospital transport to access specialised services e.g., ENT services in other towns or cities), or providing direct social work services (e.g., addressing the impact of hearing loss through counselling, etc.).

In community-based domains the limited availability of audiological services necessitates collaboration with health care workers who work in the community to ensure access to ear and hearing care services and improve patient outcomes for individuals with hearing loss and their families.

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