hearing screening in filipino schoolchildren: the accuracy of the hearing screener device

Hearing Screening

in Filipino

Schoolchildren

The Accuracy of the Hearing Screener Device

Report on the January 2014 Forum

HEARING SCREENING IN FILIPINO SCHOOLCHILDREN JANUARY 2014 3

About PNEI

Since 2001, the Philippine National Ear Institute (PNEI), under the National Institutes of Health

(NIH), has championed the health and stability of hearing of Filipinos. Aside from providing

epidemiological and integrated research on hearing, balance, and communicative disorders, it

also aims to provide an environment that will facilitate further research and education in such

clusters as surveillance, treatment, prevention, and rehabilitation of hearing and balance

disorders.

Guided by objectives ranging from the initiation of innovative research to the formulation of

policies and programs geared towards the betterment of the health sciences sector in the

country, the PNEI spearheads several research efforts in the often overlooked field of hearing

and balance. In view of these objectives and its vision, it has also conducted research on the

feasibility and accuracy of a new hearing screening device. Filipino schoolchildren were the

subjects of this research, as the growing importance of checking for hearing loss as early as

possible has been identified by the PNEI. This growing importance, and the entirety of the

research, is expounded upon in the NIH forum of January 2014.

Ongoing research projects of the PNEI include TB infection in acute otitis media (chronic

inflammation of the ear, particularly in infants and young children), different forms of acute

otitis media and their clinical implications, dizziness and a practical approach to their

management, anatomy and physiology of the vestibular system and their clinical correlation,

and the role of immune modulators in the treatment of common ENT (Ear, Nose and Throat)

infection.

About NIH

The National Institutes of Health (NIH) was founded by the UP Board of Regents on January 26,

1996 for the development of UP Manilas research facility, and to serve as a hub of local

researchers and research organizations in the fields of health and medicine. It was made into a

national health research center through the implementation of Republic Act (R.A.) 8503, or

more commonly known as the Research and Development Act of 1998" on February 13, 1998

during the term of President Fidel V. Ramos.

The organization envisions itself to be the country's recognized authority in health research

and development and the key source of critical health information for national development in

the Philippines and Southeast Asia (Historical Highlights-NIH, 2005.). It aims to fullfill such

vision through its "Partnership for Better Health" framework which entails specific actions such

as influencing of policy makers in the enactment of health laws, policies and guidelines which

improve delivery of quality health programs, providing health organizations relevant health


research and development and improving their health service delivery, development of

capabilities of health researchers and health research institutions, etc. (The Organization-

NIH, 2005).

At present, NIH has numerous partner organizations and study groups which continue to help it

achieve its vision through presenting significant outputs for the crafting of national health

policies and programs.

Speakers

DR. GENEROSO T. ABES

Generoso T. Abes, MD, MPH established the Philippine National Ear

Institute (PNEI) through the UP Board of Regents resolution and

through R.A.9245. He has been the director of the institute since the

date of its establishment in 2004. Among his accomplishments as the

PNEI director are the establishment of Newborn Hearing Screening

Reference Center (NHSRC) and the legislation of R.A. 9709, also known

as the law on Universal Newborn Hearing Screening and Intervention

Act of 2009.

He was also appointed as the Chairman of the Department of Otolaryngology of the UP College

of Medicine (UPCM) and the Philippine General Hospital (PGH) from January 2001 to December

2006. Rendering 32 years of service as faculty in UPManila, Dr. Abes also chaired the

Curriculum Committee of UPCM from1999 to 2003 and was able to establish the Master of

Clinical Audiology program, in partnership with the Department of Otolaryngology of the UPCM

and the UP College of Allied Medical Professions (UP CAMP). Moreover, he was able to publish

58 articles on otolaryngology (medical specialty concerned with the study of the ears, nose and

throat; also referred to as otorhinolaryngology), four of which were published in international

journals, and gave lectures on various topics under otolaryngology both on the local and

international level.

DR. TERESA LUISA I. GLORIA-CRUZ Teresa Luisa I. Gloria-Cruz, M.D., MHPed obtained her doctorate degree in 1992 and earned her masters degree in Health Professions Education in 2002 both from UP Manila. She has also been a member of the UP faculty as a Clinical Associate Professor in the College of Medicine since 1998 and has been working as a Research Assistant Professor of the NIHsince 2000. Dr. Gloria-Cruz is an attending otorhinolaryngologist in the Department of ENT of the UP-PGH Medical Center since 1998 and in Asian Hospital and Medical Center.


Among her published works are journals on various topics under otolaryngology and a manual on the Treatment of Acute Diseases and Injuries of the Ear, Nose and Throat. Her responsibilities in the university includelecturing, handling small group discussions, and conducting research activities. These research outputs are reported in the monthly forum held by the NIH. DR. ELLA CECILIA G. NALIPONGUIT

Dr. Ella Cecilia G. Naliponguit is the Director of the School Health and Nutrition Center of the Department of Education (DepEd) and is responsible for evaluating, approving, and managing public health programs, policies, and designs and health program management in public schools in the Philippines. Representing the education sector, Dr. Naliponguit works in partnership

with other government and non-government organizations responsible for devising health policies and public health programs for school children.

DR. MARIA RINA T. REYES-QUINTOS

Dr. Maria Rina T. Reyes-Quintos is an otolaryngologistspecializing in audiology, a branch of

medicine which centers on the study of hearing and hearing disorders. As an attending

physician in private and public hospitals such as the PGH and The Medical City, Dr. Reyes-

Quintos treats patients with different hearing disorders, using such procedures as pure tone

audiometry, a process used to test tonal purity and hearing acuity for sound intensity and pitch

variations; play audiometry videonystamography or VNG (a medical test used to determine the

causes of a patients dizziness or balance disorders), and other types of hearing tests.

Dr. Reyes-Quintos is also involved in various researches in her field of study. Some of her well-

known research and article publications include an article in ACTA MEDICA PHILIPPINA entitled

When do Aided Auditory Thresholds reach the Speech Spectrum after Cochlear Implant Switch

on?which was published in 2012, and a journal article entitled Otoscopic and Audiologic

Findings in an Ati Community in Boracay which was published in 2007 and was written with

other research authors.


Introduction

Aiming to draw attention from both health and educational sectors, the National Institutes of

Health (NIH) Research Dissemination and Utilization (RDU) presented the Philippine National

Ear Institutes (PNEI) latest findings on the accuracy of hearing screening device forFilipino

schoolchildren in the monthly forum held last January 16, 2014.

The forum was held at SentroOptalmologico Jose Rizal Auditorium ofthe Philippine General

Hospital (PGH). Attendees include delegates from various health sectors and the education

sector, advocates of different health institutions and centers and Health Sciences students of UP

Manila.

Among the topics discussed in the program were the PNEIs latest research findings on the

hearing screening conditions and programs in Filipino elementary schools, implications of

hearing loss to students school performance, and an assessment of the accuracy of the hand-

held hearing screener in detecting the presence and possibility of hearing loss among

schoolchildren in the country.

This report, in line with the NIHs continuous effort to gain public awareness and interest in the

institution and its activities summarizes the PNEIs efforts to improve the hearing screening

programs in Philippine schools. Furthermore, this report aims to assist the NIH RDU program in

presenting the latest research findings of the NIHs institutionsand centers to different health

sectors in the country.


Presentation of Studies The Need for Early Hearing Screening

The Philippine National Ear

Institute (PNEI) has long

been an advocate of hearing

health of schoolchildren in

the Philippines. This

advocacy has led the

institution to dedicate much

of its research in coming up

with solutions towards the

increasing cases of hearing

loss among schoolchildren.

Dr. Generoso Abes

emphasized the need for

addressing the different concerns regarding hearing loss in schoolchildren. The study is

anchored in two key research areas: 1) New-born hearing screening and 2) Hearing screening

in Grade 1 pupils. There are four reasons identified that show the value of the two key research

areas:

1. High prevalence of hearing loss in the population group

2. Preventability and treatability of usual causes

3. High impact on learning and speech development on patients affected by hearing loss

4. Nonexistence of programs for hearing screening among the population group

To fulfill the PNEIs vision, No Filipino should be deprived of a functional sense of hearing and

balance, researchers like Dr. Teresa Luisa Gloria-Cruz has conducted studies that can help in

the early detection of hearing loss among schoolchildren in the Philippines. Hearing loss has

been a primary concern for the researchers in the PNEI because of the accompanying effects of

such condition towards the academic performance of the mentionedpopulation group.Hence,

research author Dr. Gloria-Cruz saw the importance of detecting early-childhood hearing loss

among schoolchildren. Research has shown that one child in 1000 is born with profound

deafness, that two children in 1000 will acquire deafness in early childhood, and that nearly

100% of all children will undergo a period of hearing loss from birth to 11 years. The conducted

study showed that 15% of the sample failed the hearing test.


Further results in these studies have shown that children with unilateral hearing loss (hearing

loss in one ear) and those with minimal hearing loss is associated with less satisfactory

scholastic performance, as well as emotional and social difficulties.

In view of all these, the PNEI conducted several researches to devise an accurate, relevant, and

safe mass hearing screening program suitable for schools.

A. Collaboration-training-service-research

The PNEI, in line with its objective of creating a suitable mass hearing screening program for

schoolchildren in the country, worked with the Department of Education (DepEd) in 2004 for a

program entitled, Education for All 2015. The program aims to provide early childhood

preventive health and nutrition services by training school nurses regarding preventive health

care in the school setting.

However, there is no established national hearing-screening program for schoolchildren, unlike

in developed countries where pure audiometry and tympanometry (a test used to detect middle

ear disorders) are common standards for hearing-screening programs in schools.

One of the problems identified in the research is the lack of government-initiated provisions

regarding hearing screening. In addition to this, there is also a lack of equipment and skilled

personnel that are needed to meet the required standards for such provisions.

To address these concerns, the PNEI method of hearing screening in schoolchildren was

devised. It is a practical, effective, and feasible approach in ear examination which uses a pen

light and a particular method of hearing screening using a 512 hertz tuning fork. This was

proposed to be used for mass screening of children in the school setting. In 2004, this became

a nationwide advocacy of the PNEI, in partnership with DepEd,reaching various parts of the

country.

Two studies were published in line with the training program. The first research came up in

2007, Gloria Cruz TL, Chiong CM, Chan AL, Llanes EG, Reyes-Quintos MR, Abes GT. Training of

nurses on Ear Examination and Hearing Screening in the School Setting. Southeast Asian J.

Tropical Med. Public Health 38(1): 188-194. It was followed by a second phase of the same

research published in 2010.

Both studies presented the same result regarding the effectiveness of the training program

designed for school nurses. Furthermore, the two researches indicated that the program is a

feasible tool for the detection of common ear conditions or screening of children in the school

setting. However, limitations of the program include its inability to detect mild cases of hearing

loss that would also have a latter effect on a childs academic performance.


B. Collaboration-Service-Research

The PNEI, together with Manila Archdiocesan and Parochial Schools Association (MAPSA),

devised another program that aimed to provide service missions for hearing health, conducted

in one school for each of three areas in Metro Manila- Quiapo, Pasayand Pasig.

The study resulted in the publication of a third research, HEARING SCREENING IN FILIPINO

SCHOOL CHILDREN: The Accuracy of the Hearing Screener Device, which was the topic of this

forum. It aimed to determine the devices feasibility as a hearing screening tool to be used in

schools with reference to its sensitivity, specificity, and positive predictive value, with pure tone

audiometry as the standard.

Subjects of the study included 418

Grade 1pupils, comprising 238 males

and 180 females ages 5-10,on an

ordinary school day. Each student

underwent five phases namely, the

collection of demographic data,

otoscopy (visual examination of the

eardrum and auditory canal),

screening with hearing screener

device, screening audiometry, and

counselling. The hearing screener

device result can be categorized

according to the color of light it

produces. Green light indicates absence of hearing loss, while yellow and red lights indicate

mild and severe case of hearing loss, respectively.

Results showed that the hand held hearing screening device has a high specificity of 97.8%

(yellow results) to 99.6% (red results), which implies that the device is accurate at determining

individualswithout hearing loss. However, low sensitivity of the device in red (9.1%) and yellow

(16.7%)results indicate that it failed to determine individuals who have moderate to severe

hearing loss. Positive predictive values that indicate the ratio of individuals who scored positive

on hearing loss to those who suffered from such condition, are 26.1% and 50% for red and

yellow results, respectively. The accuracy of the hearing screener device for red results is

95.9% and 94.2% for yellow results.

The low sensitivity of the hearing screening device indicates its ineffectiveness to be used for

mass hearing screening in schools. The setting of the experiment, an ordinary school day with

an ambient noise level of 52.8 decibels, posted a limitation to the device in detecting mild

hearing loss. The handheld screening device is recommended for use in a soundproof

environment, having not more than 40 decibels of ambient noise. It is, therefore, not suitable

for mass hearing screening program in a school setting. Another hearing screening device with

high sensitivity must be considered for conducting another study. Among the factors that must

be considered in choosing another of such tool are safety, portability, ease of use, high


specificity, good accuracy rates, and positive predictive values. The PNEI also recommends the

generation of a better hearing screening program as a national health policy.

Conclusions and

Recommendations The two studies presented in the NIH-RDU forum provided an overview of the condition of the

hearing screening program among schoolchildren in the Philippines. The studies also reported

the current efforts of the PNEI and the evaluation of the actions the institution has taken.

The PNEIs collaboration with DepEd and MAPSA helped the institution work on its advocacy for

hearing health of schoolchildren in the Philippines. The first program which focused on the

training of school nurses and other members of the school stafffor hearing screening of

schoolchildren was found to be effective and feasible for mass hearing screening in a school

setting. The suggested hearing screening procedure with the use of a penlight and 512 hertz

tuning fork was feasible considering factors such as public safety, portability and ease of use.

However, results also showed that continuous and greater efforts must be done to compensate

for the programs limitation in determining moderate hearing loss among schoolchildren.

The presented hearing screening device was proven ineffective for mass hearing screening

among schoolchildren. The devices low sensitivity for determining both mild and severe hearing

loss posted a limitation to its capability of providing appropriate results. Furthermore, the

recommended environment for the use of such device made it not suitable for hearing

screening in an ordinary school setting.

Findings from the two studies indicate

the need forthe NIH and the PNEI to

conduct further studies and devise more

programs that would suit the condition of

elementary schools in the Philippines.

Through such, the PNEI in partnership

with public and private organizations

would be able to recommend a national

standardized program for hearing

screening of schoolchildren for

government policy.


Authors Message

Hearing is a requisite to virtually every activity. It is therefore important to ensure that hearing

health and an environment conducive to its maintenance are provided for. What is the ideal age

to check for hearing loss? Is the current technology for checking for hearing loss adequate, or is

new technology feasible and necessary? These are the major questions whose answers were

provided by the Philippine National Ear Institute (PNEI) during the January 2014 forum of the

National Institutes of Health (NIH). The insights and information articulated in this forum

proved useful as reference for research of the same mold to be undertaken in the future, as

well as to those in attendance seeking clarification on the matter of hearing health and much-

needed orientation on trends in the health sciences, particularly in the Philippines.

Paul Martin Anthony C. Cenizal Group Representative BA Organizational Communication University of the Philippines Manila

From left to right: Crichelle Mendiola, Justine Vigonte, Kristel Artates and Paul Cenizal

References Medical Definitions

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medical_staff

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National Institutes of Health (NIH)

University of the Philippines Manila

623 Pedro Gil Street, Ermita, 1000 Manila

nih.upm.edu.ph

hearing screening in filipino schoolchildren: the accuracy of the hearing screener device

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