Alonzo, Aldaba, Almenario, Bato, Batoon, Bautista, Benito, Bondoc, Borela, Buenaventura L., and

Buenaventura N.Research Adviser: Grace H. Encelan-Brizuela M.D.,

M.S.P.H.

A Survey of the Knowledge, Attitudes and Practices of Pediatricians in relation

to Newborn Hearing Screening

IntroductionHearing Loss Conductive or sensorineural; dB lost from slight to

profound Affects approximately 2-4 per 1000 live birth infants One of the most common congenital anomalies leading to

impediment of speech, language, and development Children identified >6 months can have speech and language

delays. Children identified <6 months do not Greater prevalence rate than that of most other diseases

and syndromes screened at birth such as PKU and sickle cell disease

Introduction In the US, Universal newborn hearing screening is the

standard of care in providing early detection and intervention for infants with permanent hearing loss

1993: less than 5% of newborns screened At present: ~93% newborns screened Over-all success depends on timely and effective

diagnostic and intervention services In the Philippines, NBS program of select metabolic

conditions in 1996 Only country in East Asia Pacific Region with no

government support program for hearing screening (Olusanya et.al.)

Introduction Legislative support, technology and expertise to

implement such program on a national level has only been recently realized

Pediatrician’s roles:- to provide early identification and interventions- to educate families- to ensure follow-up care and surveillance- to make appropriate referrals

Requires pediatricians to have awareness on neonatal hearing loss and the hearing screening process

Significance of the StudyThe study will reflect the degree of knowledge of

our pediatricians regarding NBHS, provide leverage on what they still need to know and how they prefer to learn this new information to further improve their practice. Such findings are essential for creating effective partnership with the family of infants diagnosed with hearing loss in meeting their needs.

Objectives

To determine the knowledge, attitude and practices of pediatricians in hospitals in Quezon City on NBHS using a descriptive study design

To establish a baseline data on knowledge, attitude and practices of pediatricians on NBHS locally

17 Randomly selected Hospitals in Q.C.

9 Hospitals expressed willingness to participate

126 prospected pediatric consultants(Computed minimum sample size, N=96)

Survey Distribution*Weekly follow-ups for 2 months

MethodologyDescriptive Study Design

Survey Collection

Total survey collected: 60Response Rate: 47.62%

Data Analysis: responses for each question were tabulated and expressed in proportion and percentages

Methodology

•Questionaire modified survey form by Moeller, et. al. 2006Survey Tool•6 Pediatric residents of UERMMMCIPretesting

Randomly Selected Hospitals in Quezon City AFP Medical Center Capitol Medical Center Dr. Fe del Mundo Medical Center De Los Santos Medical Center FEU – NRMF East Avenue Medical Center Jesus Delgado General Hospital National Children’s Hospital Philippine Children’s Medical Center Philippine Heart Center Quezon City General Hospital Quirino Memorial Medical Center St. Luke’s Medical Center UERMMMCI United Doctor’s Hospital Veteran’s Memorial Medical Center World Citi Medical Center

Data and Results

Characteristics n(%) N=60Physician Gender

Male 14 (23%)Female 39 (65%)

Unknown 7 (12%)

Experience with Pediatric Population

0-5 years 15 (25%)6-10 years 11 (18.33%)11-15 years 8 (13.33%)15 onwards 18 (30%)

Year of Birth1950-1960 18 (30%)1961-1970 12 (20%)1971-1980 18 (30%)1981-1990 3 (5%)

Unknown 9 (15%)

Table 1. Demographics of sample population

With hearing loss Without hearing loss No Response

0-5 years 11 (73.33%) 2 (13.33%) 2 (13.33%)6-10 years 8 (72.72%) 2 (18.18%) 1 (9.1%)11-15 years 5 (62.5%) 2 (25%) 1 (12.5%)15 onwards 8 (44.44%) 6 (33.33%) 4 (22.22%)Unknown 4 (50%) 1 (12.5%) 3 (37.5%)TOTAL 36 (60%) 13 (21.67%) 11 (18.33%)

68.48% of respondents has majority of patients <5 yo, Q1 An average of 6.62 patients with hearing loss encountered for the past 3yrs (applicable only to respondents with encountered cases of hearing loss), Q2

> 50% Screening Results

<50% Screening Results No Response

0-5 years 2 12 16-10 years 4 6 111-15 years 2 6 015 onwards 5 10 3Unknown 2 4 2TOTAL 15 (25%) 38 (63.33%) 7 (11.67%)

Table 3. Estimate of pediatric cases for 2008 for which pediatricians received screening results

Table 2. Respondents’ number of years in practice and their encounter with patients with hearing loss

Figure 1. Importance of NBHS, Q5

Figure 2. NBHS causes excessive anxiety to parents, Q6

Very Confident

Somewhat Confident Not Confident Unsure

a. causes of hearing loss 45% 53% 2% 0

b. use of sign language vs. auditory communication 18% 52% 30% 0

c. consequences of unilateral or mild hearing loss 29% 63% 8% 0

d. consequences of bilateral hearing loss 27% 62% 10% 1%

e. which infants are candidates for cochlear implants 15% 43% 40% 2%

Average in percent 26.8% 54.6% 18% 0.6%

Table 4. Physicians’ confidence in talking to parents of children with permanent hearing loss, Q10

Figure 3. Physician’s confidence in explaining NBHS process, Q9

Meningitis* 93%

>48hr NICU stay* 50%

History of Cytomegalovirus* 87%

Congenital Syphillis* 67%

Family Hx of Childhood hearing loss*83%

Mother >40 at delivery 38%Congenital heart defect 37%Frequent Colds 48%Hypotonia 33%

* Correct response

Table 5. Percentage of pediatricians who selected specific conditions from a given set as risk factors for Late-Onset NHL, Q14

Infant with profound bilateral hearing loss* 67% (40/60)

Infant with bilateral mild-moderate hearing loss 48% (29/60)

Infant with unilateral mild-moderate hearing loss 25% (15/60)

Infant with unilateral profound hearing loss 43% (26/60)

Unsure 6% (4/60)

*the only correct response; percentage values reflect those who gave that answer over the total population

Table 6. Percentage of pediatricians with correct response per condition as indication for cochlear implants, Q15

Figure 6. Awareness of pediatricians regarding the availability of early hearing detection and intervention programs at their respective hospitals, Q18

Figure 7. Routine referrals of pediatricians for cases of confirmed hearing loss, Q4

88%

5% 7%Reasonable

Unreasonable

No answer/ unsure

Figure 8. Awareness of the cost of NBHS, Q7

Figure 9. Perception on the practicality of the cost of NBHS, Q8

37%

52%

11% >550 Php

<550 Php

No answer/ unsure

 < 1 mo 1-3 mos 4-6 mos 7-9 mos 10-11

mos> 12 mos

> 24 mos

Total # of responses

a. NB who did not pass the hearing screening should receive additional testing *39.28% 17.86% 26.19% 2.38% 2.38% 8.33% 3.57% 84

b. A child can receive a definite diagnosis of NBHL *25.58% 25.58% 2.33% 2.33% 23.26% 20.93% 86

c. A child can begin wearing hearing aids *5.76% 6.73% 0 0 36.54% 50.96% 104

d. A child with permanent hearing loss should be referred to early intervention *30.36% 3.57% 3.57% 30.36% 32.14% 56

* Responses that are consistent with the Guidelines for Pediatric Home Providers (www.medicalhomeinfo.org)

Table 7. Percentage of physician’s estimates of ages at which follow-up procedures should be conducted, Q13

Figure 10. Primary sources of information on NBHS, Q14

Number of Responses Percentage

Adequate 17 28.33%

Inadequate 33 55%Unsure 8 13.33%

No answer 2 3.33%

Table 5. Perception of the adequacy of pediatric training towards infant permanent hearing loss, Q11

Topics Great Need

Somewhat of a Need

Not Needed

Methods of screening 50 (83%) 10 (17%) --

Protocol for follow-up screening 46 (77%) 14 (23%) --

Methods of screening children 0-5 during well-child visits 50 (83%) 10 (17%) --

Guidelines for informing families about screening results 49 (82%) 9 (15%) 2 (3%)

Impact of different degrees of hearing loss on infant language 51 (85%) 9 (15%) 1 (2%)

Early intervention options 56 (93%) 4 (7%) --

Guidelines for screening late onset hearing loss 53 (88%) 7 (12%) --

Useful contacts for more information 49 (82%) 11 (18%) --

Patient education resources 49 (82%) 11 (18%) --

Hearing aids and cochlear implants 41 (68%) 19 (32%) --

Genetics and hearing loss 42 (70%) 18 (30%) --

Table 8. Pediatrician’s Perceptions About the Need for Training and/or Resources on Various Topics, Q12

Discussion

Profile of Respondents The study showed that majority of respondents (60%),

has encountered patients with hearing loss in their practice (Table 2)

Among the 60%, an average of 6.62 patients with hearing loss were seen for the past 3 years

63.33% of all respondents have estimated that they received <50% screening results from their patients in 2008. Only 25% received >50%. It emphasized on the fact that NBHS is not yet a standard practice among pediatricians (Table 3)

Attitude As for the respondents’ attitude towards NBHS, 90%

deemed it “very important” and 10% as “somewhat important” (Fig. 1)

57% of respondents did not consider the screening process as source of anxiety/concern for parents, while 40% believed otherwise (Fig.2). But a study by Young&Tattersall in 2005, showed that parents’ response may vary significantly. This demonstrates the importance of a reassuring screening manner

The DOH has set a maximum rate of P550 for NBHS and the approximate price in Philippine hospitals is P400. 88% of the respondents agreed that the cost is reasonable, only 5% said that is unreasonable. This reflects the value that the respondents put into the procedure and its benefits

Knowledge The study also reflected a relative lack of confidence of

the respondents in talking to parents on certain issues pertaining to hearing loss as shown by the 54.6% who answered “somewhat confident” compared to a 26.8% with “very confident” response (Table 4)

On the other hand, a majority expressed confidence in explaining the NHBS process to the families of patients (very confident: 58% and somewhat confident: 35% in Fig 3)

When asked about risk factors in developing HL, respondents where able to select from a given set of choices, most of the correct ones. However, there was still a significant number who selected risk factors unrelated to hearing loss (Table 5)

Profound bilateral hearing loss is the only indication for cochlear implants. Only 67% of the respondents selected the correct response among a given set of conditions. (Table 6)

Newborn hearing screening, yet to be mandated by our government or any local professional medical organization, has not been implemented in all hospitals. The study revealed that only 52% of the respondents were aware of the presence or absence of an early hearing detection and intervention program in their respective hospitals (Fig. 6)

52% responded correctly with <P550, 37% estimated it at >P550, the remaining 11% was unsure (Fig. 8) This may cause parents to assume that the

screening is more expensive than what it really is. This may affect their decision to avail of the procedure and this may sacrifice the possible benefits it may provide the infant

A sound knowledge on hearing loss, its causes, risk factors, consequences, possible outcomes given appropriate interventions such as the use of cochlear implants and NBH screening: its cost, availability, indications as well as its advantages will improve the physicians’ confidence and competence in addressing this problem

Practices The study showed that 92% respondents routinely refer

cases of HL to ENT and the remaining 8% to both ENT and Neurology (Fig. 7)

Alarmingly, a significant percentage of their responses on estimates of ages at which necessary follow-ups should be taken per specific case concerning detection and intervention for HL, did not match the recommended age for follow-ups. This will a negative impact on the overall outcome of patients with HL (Table 8)

Miscellaneous The primary sources of information of the respondents

regarding NBHS were lectures, training hospitals and medical textbooks (Fig. 10)

55% of respondents deemed the pediatric training they had was inadequate in addressing hearing loss while only 17.33% reckon it adequate (Table 5)

Respondents expressed the need for further training and access to more resources on various topics regarding HL, screening and interventions as enumerated in (Fig. 8)

ConclusionThere is evidence that pediatricians know of

Newborn Hearing Screening. However, a more in-depth awareness about NBHS is highly recommended to bridge the knowledge gaps through primary sources of information and provision of action-oriented resources that will aid in the familiarity not only about NBHS but also hearing loss itself. This will catapult the pediatricians in a better position to support families and identification of infants with hearing loss and prevention of its ramifications.

Limitations and Recommendations Study population was limited to pediatric consultants

within Quezon City only. A larger sampling population is recommended to better reflect the current status

Only 60 of the 126 distributed survey forms were returned and some were incompletely filled-out. We attribute this to the varying interests of the respondents in participating in such endeavor. Ensuring a properly filled-out forms, a more efficient distribution and collection methods can further increase the accuracy and significance of the study.

Survey questions could still be polished to better fit the local setting

THANK YOU!!!