Journal Logo

Online Exclusives

Access online-exclusive articles and updates published ahead of print.

Tuesday, March 5, 2019

Trends in Early Hearing Intervention in Taiwan

By Pei-Hua Chen, PhD; Tang-zhi Lim, MSc; and Shu-Fen Yeh, MSc

Chen was only 8 months old when he was diagnosed with hearing loss after his universal newborn hearing screening test (UNHS), just a year after the test's first implementation in Taiwan in 2012. In contrast, Zhu was diagnosed with hearing loss 29 months before the UNHS. Before the implementation of the UNHS, the average age of pediatric hearing diagnosis was around 42 to 48 months old, and only very few children were diagnosed before 24 months old (Halpin, Smith, Widen, & Chertoff, 2010; Sininger et al., 2009; Yoshinaga-Itano, 1999). Notably, some studies have demonstrated that diagnosis before a child turns 3 months old and early intervention before 6 months may greatly improve the child's language outcomes (Yoshinaga-Itano, Sedey, Coulter, & Mehl, 1998; Moeller, 2000). Thus, the UNHS has a pivotal role in shortening early identification waiting time and ensuring early intervention and prompt treatment for these children.


Social marketing addresses the needs of target audiences, promoting behaviors that maximize their welfare, whereas the 4Cs marketing structure (consumer needs, cost, convenience, and communication) focuses on promoting target concepts or behaviors among target audiences (Lauterborn, 1990). Social marketing concerns the desire of target audiences for improved quality of life and health, and balances their willingness to pay for it. Communicating with target audiences is crucial to understand their needs and to provide assistance by shaping behaviors and attitudes. The goal of the UNHS is to address and fulfill health-related needs; therefore, the 4Cs theoretical framework, which is based on consumer views, may be used to investigate consumer-oriented behavioral responses after UNHS implementation (Draskovic & Valjak, 2012). We take the Children's Hearing Foundation (CHF) as an analytic example, because the CHF started auditory–verbal (AV) sessions for children with hearing loss over 20 years ago in Taiwan. We analyze the effects of the UNHS on public awareness and share ways in which the CHF had utilized the 4Cs of social marketing after the implementation of the UNHS (see Fig. 1).



Consumers' willingness for improving their health and quality of life is often unclear; thus, defining the meaning of these needs and the actions that must be changed to achieve health benefits is essential to social marketers. Between the conception of the UNHS in 2012 and the end of 2015, 1039 families (a total of 45,406 people) contacted the CHF regarding AV sessions. The first contact period of parents to the CHF has been decreasing significantly each year, from an average of 311 days required in 2012 to 133 days in 2015 (F[3,363] = 9.45 , p < .001), meaning that the first contact period in 2015 was significantly shorter than those in 2012, 2013, and 2014. Furthermore, the age of intervention decreased significantly from 610 days in 2012 to 377 days in 2015 (F[3,363] = 11.65 , p < .001), and the post hoc analysis results were similar to the first contact period. The results have demonstrated the need for early intervention.


People with hearing loss might face more language-related, social, behavioral, and emotional-development difficulties than their peers without hearing loss do (Stevenson et al., 2017; Theunissen et al., 2014; Wong, 2017). Because Taiwan's UNHS program is still young, few studies or reports exist on the effects of the UNHS, meaning that the real costs of the UNHS are difficult to investigate. The World Health Organization (WHO, 2017) estimated that the annual average cost of education support for children with hearing loss worldwide is approximately US$3.9 billion. In addition, the social cost of social isolation or communication difficulties related to hearing loss is estimated to be approximately US$573 billion per year.

Moreover, Lee (2007) calculated the estimated costs of the UNHS using the formula proposed by Gorga and Neely (2003): According to this estimate, if a child receives the UNHS when he or she is born, then immediate intervention, special education classes during preschool, and further education in a mainstream school might save US$117,075 in education costs. Furthermore, people with severe or profound hearing loss can receive approximately 30% less income than their peers without hearing loss. In other words, people with the aforementioned levels of hearing loss might lose US$220,000 to US$440,000 income before their retirement (Shield, 2006). People with superior language outcomes may save approximately US$428,000 of social cost expenses in their entire lifetime compared with those with poor language outcomes. For this reason, using early intervention to improve language outcomes among people who have hearing loss might change productivity loss by an estimated 75% over their entire lives.


UNHS implementation means that many infants with hearing loss can be screened very early. The demand for early intervention is consequently higher. To provide relevant information on early intervention and to frequent AV sessions, the CHF not only established four service centers in various parts of Taiwan for face-to-face intervention but also offered online AV (telepractice) sessions for families unable to attend face-to-face intervention sessions. Moreover, the CHF also provided home-visit service sessions for families in rural or remote areas and completed approximately 25 home-visit service sessions by the end of 2015. Calculations using Google Maps confirm that the CHF has saved families in remote areas approximately 65.34 miles' worth of travel to AV sessions. Moreover, home-visit service sessions have also reduced time spent attending AV sessions by nearly 134.66 minutes for families traveling by car and by 183.16 minutes for families taking public transportation. Most notably, both telepractice and home-visit services also supported families unable to visit the CHF regularly—for reasons related to pregnancy, physical weakness, or large families—such that children with hearing loss in these families could receive AV sessions without interruption.


To emphasize the importance of early intervention and to counter stereotypes about hearing loss, the CHF actively engaged and communicated with public and target audiences through various platforms and planned various courses. From 2012 to 2015, approximately 232 people per year attended the CHF's experience courses and institution visits. Approximately 13,862 people per year used the CHF's Newborn Hearing Screening Consultation Hotline to get hearing-related information. Moreover, the CHF has provided e-newsletters to approximately 6,863 subscribers per year, and about 190,567 people access their website per year. In addition, the CHF established a Facebook fan page, which is regularly updated with hearing-related information and events.

First contact periods shortened every year after the implementation of the UNHS, and the proportion of families that contacted the CHF increased by 75% at the end of 2015. However, the mother or grandmother of a child with hearing loss was the person most likely to call the CHF, according to our statistics. This result indicates public recognition that early intervention is valuable. Obtaining information is no longer a passive process; the public has begun to actively obtain relevant information through various platforms.

In all, the impact of the UNHS shows that public awareness has incrementally increased along with the demand for early intervention.

 Acknowledgment: We want to thank our research assistants, Ms. Huang Wan-Qi and Mr. Liu Ting-Wei from Children's Hearing Foundation for collecting and coding the data.

ABOUT THE AUTHORS: Pei-Hua Chen is a research fellow at the Speech and Hearing Science Research Institute, Children's Hearing Foundation in Taiwan, where Tang-Zhi Lim is a research assistant focusing on popular science writing from the perspective of psychological view. Shu-Fen Yeh is an executive officer of the Children's Hearing Foundation in Taiwan.

Carney, A. E., & Moeller, M. P. (1998). Treatment efficacy: Hearing loss in children. Journal of Speech, Language, and Hearing Research, 41(1), S61-S84.

Draskovic, N. & Valjak, A. 2012. The 4Cs of the Croatian public healthcare system: social marketing challenges at the dawn of EU accession. World Review of Entrepreneurship, Management and Sustainable Development, 8(2): 221-235.

Gorga, M. P. & Neely, S. Y. 2003. Cost-effectiveness and test-performance factors in relation to universal newborn hearing screening. Mental Retardation and Developmental Disabilities Research Reviews, 9: 103-108.

Halpin, K. S., Smith, K. Y., Widen, J. E., & Chertoff, M. E. 2010. Effects of universal newborn hearing screening on an early intervention program for children with hearing loss, birth to 3 yr of age. Journal of the American Academy of Audiology, 21(3): 169-175.

Shield, B. 2006. Evaluation of the social and economic costs of hearing impairment. Hear-it AISBL, 1-202.

Sininger, Y. S., Martinez, A., Eisenberg, L., Christensen, E., Grimes, A., & Hu, J. 2009. Newborn hearing screening speeds diagnosis and access to intervention by 20-25months. Journal of the American Academy of Audiology, 20: 49-57.

Stevenson, J., Pimperton, H., Kreppner, J., Worsfold, S., Terlektsi, E., Mahon, M., & Kennedy, C. 2018. Language and reading comprehension in middle childhood predicts emotional and behaviour difficulties in adolescence for those with permanent childhood hearing loss. Journal of Child Psychology and Psychiatry. 59(2), 180-190.

Theunissen, S. C., Rieffe, C., Kouwenberg, M., De Raeve, L. J., Soede, W., Briaire, J. J., & Frijns, J. H. 2014. Behavioral problems in school-aged hearing-impaired children: the influence of sociodemographic, linguistic, and medical factors. European Child & Adolescent Psychiatry, 23(4): 187-196.

Wong, C. L., Ching, T. Y., Cupples, L., Button, L., Leigh, G., Marnane, V., ... & Martin, L. 2017. Psychosocial development in 5-year-old children with hearing loss using hearing aids or cochlear implants. Trends in Hearing, 21: 1-19.

Yoshinaga-Itano, C. 1999. Benefits of early intervention for children with hearing loss. Otolaryngologic Clinics of North America, 32(6): 1089-1102.