Evaluation of the current situation and quality of neonatal hearing screening from hearing screening practitioners’ perspective: a cross-sectional study

Abstract

Background

In recent years, neonatal hearing screening (NHS) has gained rapid traction in both developed and developing nations. However, the efficacy of these efforts depends on comprehensive standardization across all screening facets. This study aimed to assess the status and quality of NHS by investigating the knowledge, attitudes, beliefs, and practices of hearing screening practitioners regarding NHS.

Methods

A cross-sectional survey was conducted, and an online questionnaire based on the knowledge-attitude/belief (A/B)-practice model was distributed to all NHS practitioners in Luzhou, western China. Valid questionnaires were examined and uniformly graded.

Results

A total of 63 valid questionnaires were collected. The practitioners were mainly female (96.83%), with nursing backgrounds (63.49%), and undergraduate degrees (66.67%). Most had ≤5 years of experience (74.60%) and had junior/intermediate titles (93.65%). The NHS within the Luzhou area started in 2006 with provincial institutions, expanding to 42 institutions by 2022. Statistically significant correlations were observed between the A/B score and the conducting years of each NHS institution (p < .05) as well as between the Knowledge (K) and Practice (P) scores (p < .01). No significant correlation was found between the K score, P score, A/B score, and working years of practitioners (p > .05), or in the total score of NHS institutions at different levels or in different counties by one-way ANOVA (p > .05).

Conclusions

It has been 17 years since the first medical institution in Luzhou launched NHS, and the overall performance of practitioners from different institutions has been consistent in terms of their knowledge, attitudes, or level of practice. However, there is room for further improvement in both the professional development of individuals and aspects related to work, such as health education and long-term follow-up.

Keywords:

• Neonatal hearing screening
• congenital hearing impairment
• tertiary prevention
• the questionnaire survey
• western China

Introduction

Hearing loss stands as the most common congenital defect affecting newborns globally, impacting approximately 34 million children, with a prevalence rate of 0.5–5 per 1000 newborns and infants [1]. The World Health Organization predicts that over 700 million individuals will face disabling hearing loss by 2050 [1]. Timely detection is essential, facilitating prompt interventions and averting setbacks in language acquisition and speech development. Consequently, neonatal hearing screening (NHS) assumes a pivotal role in early detection [2], sparking growing interest, particularly in developing countries, where its cost-effectiveness is evident [3–5]. In China, despite a notable increase in NHS coverage from 29.9% in 2008 to 86.5% in 2016 [6], there remains a disparity compared to developed nations like the USA (98.0%) [7], the UK (97.5%) [8], Poland (96.0%) [9], and some regions of Italy (99.3%) [10]. Regional variations within China also exist, with eastern provinces reaching 93.1%, compared to 84.9% and 79.4% in central and western provinces. These disparities may stem from differences in NHS initiation, economic gaps between regions, limited healthcare resources, and lower prioritization of NHS [11,12].

NHS standards and guidelines vary between countries. Studies have shown that the NHS guidelines in the USA and the UK are high quality because of their well-established hearing screening programs, early initiation of screening, and comprehensive guidelines [13,14]. Similarly, China’s Technical Specification for Newborn Screening (2010 version), tailored to its developmental stage, maintains a high level of coherence and credibility [15]. However, regional variations exist in China, such as Fujian Province requires practitioners have five years of experience [16], whereas Hunan Province mandates three years [17]. It’s worth mentioning that practitioners’ knowledge, attitudes, and practices are critical to the quality of screening. Studies have noted that practitioners in different specialties vary in the knowledge of NHS and show diversity in attitudes and practices [18–22]. The accuracy of screening may be compromised by some practitioners due to a lack of systematic training [18] or inadequate knowledge of NHS [23–25]. Some practitioners demonstrate noncompliance and low regard for published guideline, further reducing the quality of screening [21,24]. Of concern is the failure of practitioners to keep up to date with the latest developments and updates in NHS, which may make screening methods lagging behind [26].

The screening rate and quality varied according to factors such as regional income level, birth rate, and maternity distribution [27]. Eighty percent of people with disabling hearing loss live in low- and middle-income countries [28]. Luzhou, situated in the economically less developed southern Sichuan region, boasts a population exceeding 4.2 million within an area of approximately 12,000 km². While the implementation of NHS in Luzhou has been gradual, there are concerns that it may not align with established normative standards. Hence, this study delves into the knowledge, attitudes, and practices among NHS practitioners in Luzhou. We hope that this study will offer a fundamental understanding of practitioner perspectives and practices in our region, contributing support for the normative implementation of NHS.

Materials and methods

Questionnaire respondents

This study surveyed frontline clinical practitioners and professionals involved in NHS work in the entire Luzhou area. We aimed to involve at least one representative from each eligible NHS institution in the questionnaire survey, excluding administrative, logistical, or internship staff.

Instrument

We conducted an online questionnaire survey using the Knowledge-Attitude-Belief-Practice (KABP) model. The questionnaire consisted of two parts. The first part collected demographic information of respondents. The second part focused on the core content of the questionnaire, designed based on the Technical Specification for Newborn Hearing Screening (2010 version) [29] and Clinical Audiology section on NHS [30]. It aimed to assess practitioners’ knowledge, attitudes, and practices related to NHS. Following the KABP model, the second part was further divided into knowledge-related questions (items 8, 9, 10, 14, 16, and 20), attitude- and belief-related questions (items 24, 25, and 27), and practice-related questions (items 11, 12, 13, 15, 17, 18, 19, 21, 22, and 23). Each segment was scored individually, resulting in K, attitude/belief (A/B), and P to ensure the validity and clarity of the questionnaire, a preliminary version was tested with hearing screening practitioners at The Affiliated Hospital of Southwest Medical University. Their feedback led to iterative improvements in the content and structure of the questionnaires. This preliminary survey confirmed the clarity and surface validity of the questionnaire.

Distribution and collection of questionnaires

We received support from the Luzhou Branch Center for Neonatal Hearing Impairment Diagnosis and Treatment in Sichuan Province as well as the Luzhou Hearing Screening Office. The online questionnaire was distributed as a formal administrative document notification after informed consent and administrative authorization were obtained. It was accessible for 30 days and completed voluntarily and anonymously. We also ensured that at least one individual from each medical institution participated in the study. If we encountered ambiguous responses that could have affected the analysis, we proactively contacted the respective agency’s leader by phone to seek clarification.

Statistical analysis

The study commenced by presenting basic information. Data from the second part were analyzed using SPSS 23.0 (SPSS Inc., Chicago, IL), generating descriptive statistics for respondents’ basic information. Spearman’s correlation analysis explored relationships between various scores and relevant factors. One-way ANOVA compared total scores of NHS institutions across different grades and counties. Subjective questionnaire responses were summarized based on key points, and insights from open-ended questions were independently documented by two authors and not scored, resolving any disparities through collaborative discussion.

Results

The basic characteristics of the respondents

Ultimately, a total of 63 valid questionnaires were obtained. The basic information of the respondents (Table 1) is as follows: the gender distribution was predominantly female (96.83%); the educational background consisted mostly of undergraduate degrees (66.67%); the primary profession reported was nurse (63.49%), followed by obstetrician–gynecologist (12.70%); the majority of practitioners had less than or equal to five years of working experience (74.60%); and the prevalent job titles were junior and intermediate positions (93.65%).

Table 1. The basic characteristics of respondents.

Basic characteristics	N (total = 63)	%
Gender
Female	61	96.83
Male	2	3.17
Education background
Undergraduate	42	66.67
Doctor/master	0	0
Others	21	33.33
Profession
Nurse	40	63.49
Obstetrician–gynecologist	8	12.70
Pediatrician	7	11.11
Audiologist	2	3.17
Others	6	9.52
Working years
≤5 years	47	74.60
5–10 years	11	17.46
>10 years	5	7.94
Job title
Junior	39	61.90
Intermediate	20	31.75
Senior	4	6.35

Overview of newborn hearing screening coverage in the Luzhou area

The Luzhou area comprises four counties and three districts, with a population exceeding 4.2 million. The survey covered all NHS-conducting medical institutions (42 institutions) and majority of NHS practitioners (63 out of 116) in the region (Figure 1). Classified by the level of medical institutions conducting NHS, there were 15 primary institutions, 13 secondary institutions, and 14 tertiary medical, maternal. From the time of implementation, the work first began in 2006, initiated by a provincial tertiary medical institution, to the 2012–2019 large-scale succession, and the rise in the last two years tapered off (Figure 2).

Figure 1. Total number of NHS institutions and NHS practitioners in each district and county of Luzhou area.

Figure 2. Trends in the number of NHS institutions.

Quality profiling of NHS in Luzhou area (KABP model)

Knowledge

More than half of the respondents (65.08%) reported receiving systematic training in NHS at the provincial or municipal level. About 61.90% of the participants mentioned regularly learning about the latest developments related to NHS to stay abreast of the latest advancements. However, 22.22% admitted a lack of comprehensive knowledge regarding the parameters of screening equipment, restricting them to basic operations. A consensus emerged on the purpose and significance of health education in hearing screening (Tables 2a and 2b). Correlations between the K score and working years of practitioners were tested, revealing no statistically significant correlation (r = 0.017, p > .05) (Table 3).

Table 2a. Questions in the questionnaire related to knowledge and attitudes/belief.

Question	N	%
Total number of respondents	63	100
8. Have you been trained in technical skills related to NHS?
Provincial level training and certificate	25	39.68
Municipal level training and certificate	16	25.40
No	22	34.92
9. Systematic study of NHS theory (classroom or self-study)?
Yes	44	69.84
Little	18	28.57
No	1	1.59
10. Regular learning about the latest developments of NHS?
Yes	39	61.90
No	24	38.10
14. Starting point for health education in NHS (multiple choice)
Purpose and significance of hearing screening	63	100
Current situation of hearing loss in infants and children	50	79.37
Process of hearing screening (initial and re-screening)	55	87.30
Methods of initial screening and related matters	53	84.13
Methods of re-screening and related matters	49	77.78
Significance of screening results	56	88.89
Diagnosis of hearing loss	37	58.73
Intervention and prognosis of hearing loss	40	63.49
Methods of observing normal hearing in infants	51	80.95
16. Proficiency in screening equipment parameters?
Well	38	60.32
Partially	11	17.46
Little	14	22.22
20. Hearing screening care knowledge (multiple choice)
Newborns in a quiet state; sedation if necessary	28	44.44
Check cleanliness of newborn’s external ear canal	62	98.41
Well-ventilated NHS rooms; ambient noise controlled (<45 dB)	59	93.65
Check probe for blockage before and after operation	61	96.83
Repeat the test 2–3 times if not passed	58	92.06
24. Attitude toward relationship between standardized NHS and accuracy/pass rates?
Positive	60	95.24
Negative	1	1.59
Neutral	2	3.17
25. Need for further standardization of NHS at your institution?
Yes	37	58.73
No	25	39.68
Not sure	1	1.59

Table 2b. Questions in the questionnaire related to practice.

Question	N	%
Total number of institutions surveyed	42	100
11. Dedicated NHS room at your institution?
Yes	38	90.48
No	4	9.52
12. Parents signed the informed consent form of NHS?
Yes	41	97.62
No	1	2.38
13. Health education for NHS (multiple choice)
Purpose and significance of NHS	41	97.62
Current status of hearing loss in infants	23	54.76
Process of hearing screening	39	92.86
Methods of initial screening and related matters	38	90.48
Conducting rescreening and related matters	31	73.81
Significance of screening results	36	85.71
Diagnosis of hearing loss	15	35.71
Intervention of hearing loss	20	47.62
Prognosis of hearing loss	17	40.48
Methods of observing normal hearing in infants	28	66.67
15. Institution’s primary screening/re-screening method
OAE	42/38	100/90.48
AABR	0/2	0/4.76
OAE + AABR	0/2	0/4.76
17. Primary screening time at your institution
1–2 days	9	21.43
3–5 days	31	73.81
Others	2	4.76
18. Rescreening time at your institution
<30 days	10	23.81
30–42 days	27	64.29
>42 days	5	11.90
19. NHS care at your institution (multiple choice)
Newborns in a quiet state; sedation if necessary	19	45.24
Check cleanliness of newborn’s external ear canal	41	97.62
Well-ventilated NHS rooms; ambient noise controlled (<45 dB)	42	100
Check probe for blockage before and after operation	41	97.62
21. Hearing screening target groups (multiple choice)
Newborns in general wards	41	97.62
Newborns in general outpatient clinics	28	66.67
Newborns in NICU	15	35.71
Newborns with risk factors for hearing loss	21	50.00
Repeat the test 2–3 times if not passed	38	90.48
22. Archiving method for NHS results
Paper	12	28.57
Electronic	2	4.76
Both	28	66.67
23. Follow up infants who fail rescreening but pass hearing diagnosis at least once a year until 3 years of age
Yes	5	11.90
No	37	88.10

In the case of multiple respondents from the same institution filling out the questionnaire, for the same question, we selected the option most frequently chosen by that institution for repeated answers.

Table 3. Spearman’s correlation analysis.

Correlation analysis	r	p
K score and working years^a	0.017	.892
P score and working years	−0.031	.808
K score and P score	0.742	.000
A/B score and conducting years^b	0.217	.044
Working years and conducting years	0.306	.007
A/B score and working years	0.110	.195

^a The working years of practitioners.

^b The conducting years of each NHS institution.

Attitude/belief

Some respondents (39.68%) thought that NHS practice in their institutions generally adhered to relevant norms and did not necessitate further standardization, and the vast majority (95.24%) concurred that standardized work could improve the accuracy and pass rate of screening (Table 2a). The open-ended question regarding recommendations to standardize NHS in Luzhou city (item 27) garnered eight comprehensive responses. Five participants stressed the importance of heightened publicity, two suggested regular training, and one proposed the sharing of big data. Despite the limited responses, all contributors underscored the urgency of promoting awareness about NHS and expressed anticipation for corresponding training initiatives. To explore potential relationships, Spearman’s correlation analyses were conducted. First, a correlation was examined between the A/B score and the conducting years of each institution, revealing a statistically significant correlation (p < .05). Similarly, Spearman’s correlation analysis was conducted between the working years of practitioners and the conducting years of each institution, uncovering a statistically significant correlation (p < .01). However, the correlation between the A/B score and the working years of practitioners was not statistically significant (p > .05) (Table 3).

Practice

Otoacoustic emission (OAE) was extensively used for primary screening in all NHS institutions in Luzhou, with over 90% equipped with dedicated hearing screening rooms. Most strictly adhered to the Technical Specification for Newborn Hearing Screening (2010 version). In terms of health education, respondents widely agreed on the purpose and significance of NHS (97.62%) and demonstrated a strong understanding of the screening process (92.86%) and its associated aspects. However, there were limited educational efforts (<50%) on hearing loss diagnosis, intervention, and prognosis. Some institutions (45.24%) used sedation for excited newborns during screening. Different institutions targeted distinct screening populations, with general wards achieving a high newborn screening rate (97.62%). Only 66.67% of institutions used both paper and electronic data archiving, while 33.33% relied on a single method (Table 2b). Spearman’s correlation analysis showed no significant correlation between practitioners’ working years and the P score (p > .05). However, a significant correlation existed between the P- and K-scores (p < .01) in the same context (Table 3).

Total score

The total score, ranging from 0 to 54, was derived from the sum of the K score, AB score, and P score. Artificial inferences were made based on the respondents’ perspectives, and the mean total scores were classified into three levels (0–32, 33–43, and 44–54) to assess their knowledge, attitudes, or practices relative to the norms. The grading results showed that practitioners in 11 institutions scored low, in 23 institution practitioners were in the middle of the pack, while practitioners in eight institutions received high scores. However, a subsequent one-way ANOVA on the mean total scores of practitioners from agencies at different levels or districts showed that the difference was not statistically significant (p > .05) (Figure 3).

Figure 3. Total score of NHS institutions at different levels.

Discussion

NHS is widely adopted in Luzhou, covering institutions at various levels and reflecting a balanced distribution. The number of NHS institutions has significantly increased over the past decade, possibly linked to the rapid development of medical and healthcare in China [31]. However, this growth has slowed in the past two years, likely due to the unprecedented impact of the COVID-19 pandemic. During the pandemic, centralized training for hearing screening faced challenges, resulting in limited standardized training for new practitioners and the establishment of new screening institutions [32]. The lack of formal education and training may result in practitioners having a poor understanding of screening processes, standards, and techniques, which, in turn, may diminish the accuracy of the screening process.

The fact that shorter work experience and lower titles among hearing screening practitioners indicates the rapid expansion of the screening workforce. Unfortunately, in audiology-related screening tests, many nursing professionals fulfill specialized roles without audiology expertise. This prevalence, coupled with a shortage of audiological professionals across various institutions, may inadvertently lead to a compromise the quality of the screening process [33]. Despite the seemingly straightforward nature of hearing screening, its successful execution requires the collaboration of numerous practitioners [34]. For example, the staffing requirements and specific roles for screening practitioners, testers, and administrative staff are comprehensively outlined in the Hearing Screening Technical Specification (2010 version). A study emphasizes the need for substantial human and material resources, along with strengthened training for hearing screening teams to ensure smooth and successful implementation [35].

In addition, the P and K scores were not significantly correlated with the number of working years for each practitioner, whereas the K score was correlated with the P score. This suggests that the threshold for practitioners working in NHS is not high, but much work experience and theoretical knowledge are needed to improve the quality of hearing screening [36]. The A/B score was positively correlated with the number of years that each NHS institution had been in operation, suggesting that newly established screening institution and their practitioners are not yet motivated to further standardize this work. This may be the result of a combination of factors, including a lack of standardized processes in the early years of an institution’s existence, inexperienced practitioners or a lack of awareness of the importance of processes [11,12]. In order to increase the importance of NHS among practitioners in new institutions, there is a need to inform and educate them about the standardization of NHS in order to increase the importance of the process.

Long-term follow-up poses a significant challenge for all hearing screening institutions [37], especially those in Luzhou with shorter establishment times and lower hospital levels in our study. Previous studies have found that poor healthcare accessibility, incomplete documentation of hearing screening, and lack of knowledge of NHS outcomes among primary care providers increase the risk of lost visit [38]. Socio-demographic factors of infants and parents can also influence adherence to follow-up after NHS referral [39]. In terms of health education, while almost all NHS practitioners agree on its purpose and significance, there is uneven understanding of the content, and awareness of the importance of hearing screening needs enhancement. Studies have also shown that many parents’ lack of awareness of the significance of the NHS may lead them to believe that further screening is not necessary even if their child has a hearing problem [32], which may result in newborns missing out on the golden years of language development. In Luzhou, newborns who did not pass the primary screening were not able to attend hearing screening institutions for rescreening in time, resulting in interruption of the hearing screening process, which can be attributed to both objective factors like remoteness and poor economic conditions, and the lack of attention to rescreening and follow-up mechanisms in these institutions [40]. To enhance the follow-up in Luzhou’s NHS, there is an urgent need to improve internal processes, staff training, and raise public awareness about the significance of hearing screening through social education.

In the present study, practitioners in lower-level NHS institutions score relatively low on knowledge, attitudes, or practices. This may stem from a lack of theoretical knowledge, non-standardized working practices, inadequate management of screening data, and insufficient referral processes between screening and diagnostic institutions [34]. Some practitioners in Luzhou have undergone NHS training but may not meet provincial health administration requirements. Staying informed about the latest NHS developments can enhance expertise and encourage the adoption of advanced techniques [26]. However, some individuals do not actively seek information on the latest developments. Despite these challenges, Spearman’s correlation analysis indicated that the differences in means were not statistically significant. This lack of correlation may be attributed to the maturity of hearing screening practices, well-established systems and industry standards, and comprehensive understanding and mastery of core methods by various healthcare providers.

However, this study had some limitations. First, KABP survey captures opinions, which may not necessarily align with actual practices, and future follow-up through field research and other means may be needed to better reflect the current status of NHS quality. Second, this study was a voluntary sample, not all practitioners participated in the survey, and the portion of practitioners who did not participate in the survey may have contributed to a degree of skewing of the results. In order to improve the robustness of the findings, a stratified sampling method could be used in future studies, taking into account the size of the different levels in the target population.

Conclusions

It has been 17 years since the first medical institution in Luzhou launched NHS, and the overall performance of practitioners from different institutions has been consistent in terms of their knowledge, attitudes, or level of practice. However, there is room for further improvement in both the professional development of individuals and aspects related to work, such as health education and long-term follow-up.

Ethical approval

Ethical approval and consent to participate were obtained from the Luzhou Branch Center for the Diagnosis and Treatment of Neonatal Hearing Impairments in Sichuan Province (No. 5105025092121).

Consent form

The questionnaire was designed to be anonymous and informed consent was obtained from each respondent. The data were kept confidential, and the results did not identify the respondents personally.

Author contributions

Dan Lai and Hongli Lan contributed to the study conception and design. Hongli Lan supervised all aspects of its execution and wrote the manuscript. Maojie Liu assisted with data analysis and interpretation and wrote the manuscript; Dan Lai contributed to manuscript revision. All authors helped to conceptualize ideas, interpret findings, and review the drafts of the manuscript. All authors have read and approved the final manuscript.

Acknowledgements

The authors would like to thank all respondents for participating in the survey.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Additional information

Funding

None.