Assessment of hearing screening programmes across 47 countries or regions I: provision of newborn hearing screening

Figures & data

Figure 1. Flow chart displaying the number of participating countries, the number of reports made and the number of countries with NHS implemented. In some cases, multiple CRs filled out the questionnaire for the same country, in other cases, more reports were made for regions within the same country.

Table 1. Programme reach and protocols described for low and high-risk infants in each country or region.

Country	Region represented	Programme organisation & reach		Test sequence low-risk infants	Age step 1	Single/dual protocol	Test sequence high-risk infants	Cluster
Albania		No NHS programme						1
Kosovo		No NHS programme						1
Malawi		No NHS programme						1
Rwanda		No NHS programme						1
Montenegro		No NHS programme						1
Malta		Not nationwide	Selective				OAE, OAE	2
North Macedonia	Skopje Region	Not nationwide	Selective				OAE, OAE	2
Romania		Not nationwide	Universal	OAE^a, OAE	24–72 h	Dual	OAE	3
Bosnia Herzegovina	Tuzla Canton	Not nationwide	Universal	OAE, OAE	24–72 h/>72 h	Single	OAE, OAE	3
Latvia		Nationwide	Universal	OAE, OAE	>72 h	Single	OAE, OAE	3
Lithuania		Nationwide	Universal	OAE, OAE	24–72 h/>72 h	Single	OAE, OAE	3
Serbia	Belgrade	Not nationwide	Universal	OAE, OAE	24–72 h	Single	OAE, OAE	3
Moldova	Chisinau	Not nationwide	Universal	OAE, OAE	24–72 h	Single	OAE, OAE	3
Faroe Islands		Nationwide	Universal	OAE, OAE, aABR	>72 h	Single	OAE, OAE, aABR	3
Estonia		Nationwide	Universal	OAE^a, OAE, aABR	24–72 h	Single	OAE, OAE, aABR	3
Belgium	Wallonia-Brussels Federation	Nationwide	Universal	OAE, OAE	24–72 h	Dual	Diagnostic assessment	4
Russia		Nationwide	Universal	OAE^a	24–72 h	Dual	OAE, diagnostic assessment	4
Austria	Upper Austria	Nationwide	Universal	OAE, OAE	24–72 h	Dual	aABR, aABR	4
Croatia		Nationwide	Universal	OAE, OAE	24–72 h	Dual	aABR/(OAE), aABR	4
Czechia	East Bohemia	Not nationwide	Universal	OAE^a, OAE	24–72 h	Dual	aABR, aABR	4
Poland		Nationwide	Universal	OAE, OAE	24–72 h	Dual	OAE, OAE, diagnostic assessment	4
Luxembourg		Nationwide	Universal	OAE, OAE	24–72 h	Dual	aABR, aABR	4
Spain	Aut. Comm. Valencia	Nationwide	Universal	OAE^a, OAE	24–72 h	Dual	aABR	4
Bulgaria		Nationwide	Universal	OAE^a, OAE	24–72 h	Dual	OAE + aABR	4
Portugal	Lisbon Region	Nationwide	Universal	OAE, OAE	24–72 h	Dual	aABR	4
Slovakia		Nationwide	Universal	OAE, OAE	24–72 h	Dual	OAE + aABR	4
Slovenia		Nationwide	Universal	OAE, OAE	24–72 h	Dual	aABR	4
Switzerland		Nationwide	Universal	OAE, OAE	24–72 h	Dual	aABR	4
Spain	Princip. Asturias	Nationwide	Universal	OAE, OAE, OAE	24–72 h	Dual	OAE + aABR, (OAE, OAE)	4
Hungary		Nationwide	Universal	aABR^a	24–72 h	Single	aABR	5
China		Not nationwide	Universal	OAE, aABR	24–72 h	Dual	OAE + aABR	5
Cyprus	Southern part	Nationwide	Universal	OAE, OAE, aABR	>72 h	Dual	OAE + aABR	5
Israel		Nationwide	Universal	OAE^a, aABR^a	24–72 h	Dual	OAE + aABR	5
Denmark		Nationwide	Universal	OAE/aABR, OAE + aABR	>72 h	Dual	OAE + aABR	5
Belgium	Flanders	Nationwide	Universal	aABR, aABR	>72 h	Single	aABR, aABR	5
France	Ile de France	Nationwide	Universal	OAE/aABR, OAE/aABR, (OAE/aABR)	24–72 h	Dual	aABR, aABR, aABR	5
Germany	Westphalia-Lippe	Nationwide	Universal	OAE/aABR, aABR	<24 h–>72 h	Dual	aABR, aABR	5
Greece	Attikon Hospital	Not nationwide	Universal	OAE, OAE, aABR	24–72 h	Dual	OAE + aABR, aABR	5
Iceland		Nationwide	Universal	OAE, OAE, aABR	>72 h	Dual	OAE + aABR, aABR	5
Netherlands		Nationwide	Universal	OAE, OAE, aABR	>72 h	Dual	aABR, aABR	5
Italy	Veneto Region	Not nationwide	Universal	OAE, OAE, aABR	24–72 h	Dual	OAE + aABR, OAE + aABR	5
Sweden	Stockholm Region	Nationwide	Universal	OAE, OAE, OAE, aABR	24–72 h	Dual	OAE + aABR	5
Finland		Nationwide	Universal	OAE, OAE, aABR	24–72 h	Dual	Varies (aABR included)	5
Ireland		Nationwide	Universal	OAE, OAE, aABR	<24–72 h	Dual	OAE + aABR	5
England (UK)	S.E. London	Nationwide	Universal	OAE, OAE, aABR	<24 h	Dual	OAE + aABR	5
Turkey		Nationwide	Universal	OAE^a, OAE^a, aABR^a	24–72 h	Dual	aABR	5
India		Not nationwide	Varies	Varies			Varies	–

The cluster analysis grouped countries or regions into five clusters based on five key variables of NHS programme design. The cluster number depicts the result of the cluster analysis, indicating to which cluster each country or region was assigned. The clusters are numbered as follow: 1 = No NHS, 2 = Selective NHS, 3 = Single OAE-only, 4 = Dual OAE-only, 5 = Dual including aABR.

^aMultiple screens allowed within 1 step. Brackets indicate screening steps that are sometimes performed. '/' indicates that either OAE or aABR may be used depending on the region or hospital. The age indicated is the time period in which the majority of infants are screened.

Figure 2. Type of protocol against number of steps. Protocols for low- and high-risk infants were combined with single-protocol design, in which the same protocol is used for both low- and high-risk infants. High-risk programmes that directly refer to diagnostic assessment without screening and programmes with varying protocols across a country or region were omitted. OAE, aABR: only the final step includes aABR, aABR for high-risk infants: aABR may be performed alone or together with OAE (OAE + aABR). A step is defined as that screening is performed and a result of pass or refer is obtained.

Table 2. Results of the cluster analysis.

		No NHS (n = 5)	Selective NHS (n = 2)	Single OAE-only (n = 8)	Dual OAE-only (n = 14)	Dual incl. aABR (n = 17)
NHS programme type (none / selective / single-design / dual-design)		None	Selective	Single (n = 7)	Single (n = 0)	Single (n = 2)
		(n = 5)	(n = 2)	Dual (n = 1)	Dual (n = 14)	Dual (n = 15)
Low-risk infants	Tests used in protocol	N/A	N/A	OAE only (n = 6)	OAE only (n = 14)	aABR incl. (n = 17)
	Number of steps	N/A	N/A	2 steps (n = 6)	2 steps (n = 11)	3 steps (n = 10)
High-risk infants	Tests used in step 1	N/A	OAE only (n = 2)	OAE only (n = 8)	aABR incl. (n = 14)	aABR incl. (n = 17)
	Number of steps	N/A	2 steps (n = 2)	2 steps (n = 5)	1 step (n = 8)	1 step (n = 10)

Clusters of protocols in 46 countries or regions with similar approaches for NHS design were revealed. Five variables were used that most comprehensively represent the NHS protocols. Categories for NHS programme type are: no NHS programme is established, if NHS is selective (high-risk only), if a one protocol is used for all infants (single-design) or if separate protocols are used for high-risk and low-risk infants (dual-design). India was excluded from the cluster analysis because insufficient information was available regarding the different protocols used, categories could not be assigned.

Figure 3. Box plots displaying the Human Development index and health expenditure per capita separately for each cluster expect the Selective NHS cluster and for all five clusters combined. The selective NHS cluster is not displayed because only two countries are included, Malta and North Macedonia. Health expenditure per capita and human development index for each country are available in Table 2, Supplementary Appendix 2. The No NHS cluster contains countries without established NHS. Single OAE only contains mostly protocols that screen infants with low and high risk for HI with the same protocol (OAE only). In Dual OAE-only and Dual including aABR different protocols are used to screen infants with low and high risk for HI. For protocols in Dual OAE-only, only OAE is used to screen low-risk infants; protocols in Dual including aABR include aABR. The box plots represent the median (centre line), the 25th and 75th percentile (length of the box) with whiskers indicating the minimum and maximum values.