Lessons Learned from UNHS/EDHI Across The Globe

Robert Traynor
May 18, 2011

A couple of weeks ago at Hearing International we had a Mother’s Day article honoring Dr. Marion Downs and her work in the development of newborn hearing screening procedures. Part of that discussion suggested that these programs were being initiated in other countries. At that time, I asked Dr. Christie Yoshinaga-Itano from the University of Colorado-Boulder if she could be our guest blogger this week and update us on the world’s progress in Universal Newborn Hearing Screening (UNHS)/Early Hearing Detection & Intervention (EDHI). Audiologists in the know, are aware that Dr. Yoshinaga-Itano conducted the first of many studies that actually proved UNHS/EDHI beneficial to hearing impaired children and their families. Christie is an internationally known professor, international speaker, and researcher in the area of UNHS/EDHI. Christie has our thanks and the dubious honor of being our first guest blogger at Hearing International–RMT

UNHI/EDHI is possible in the developing world. There are many examples but I have chosen the two with which I am most familiar.

South Africa: South Africa has a developed profession of audiology and high quality audiology services in the major cities as well as high quality audiology training programs.  Universal newborn hearing screening is being done at some birthing hospitals.  There is a system of high quality early intervention services in the private sector and there are services offered to children/families from the lowest socio-economic levels in the major cities, Cape Town, Johannesburg, and Pretoria.  A national South African EHDI advisory committee with broad interdisciplinary representation has been constituted and meets regularly.  A relatively recent (last few years) SKI-HI system has been established in several tribal areas through South Africa, identifying paraprofessionals in the most remote and rural areas.  Tele-health is being used for audiologic diagnostic services and tele-education for early-intervention mentoring of the trained providers.  There are challenges regarding acquisition of appropriate amplification.  When I first met with the SA national advisory committee, I wondered how a country with the incredible health challenges, many including life-death situations like AIDS, in addition to socio-economic issues of lack of appropriate housing, clean water and electricity, how universal newborn hearing screening could become a health priority.  The response I got taught me a great deal.  There is a high priority for assuring that South Africa has access to the highest quality of medical care.  There is an incredibly high motivation for offering the highest quality of care to all levels of their society.  UNHS/EHDI is a health issue with an agenda with a likelihood of success in a reasonable amount of time.

Brasil: Brasil also has great variation in its socio-economics including favelas, with some similarities to  the townships of South Africa.  Brazil also has a well-established network of professional audiologists and a large number of audiology training programs.  The audiology professionals are a dedicated group who have worked very hard to obtain funding and establish universal newborn hearing screening through early hearing detection and intervention programs for many years.  Their efforts have resulted in funding to establish UNHS/EHDI in the state of Sao Paulo, the most populated state in Brazil.  Establishing the screening programs has already been accomplished in many birthing hospitals and there are a number of high quality pediatric audiologic diagnostic centers for follow-through.   Their socialized health care system provides amplification for children with confirmed hearing loss. There will be challenges in assuring that families and infants who are deaf or hard of hearing receive high quality early intervention services, an issue that remains a problem in programs throughout the developed world.  There are many challenges including wide ethnic/racial diversity and indigenous populations in the Amazon some of whom have little contact with the outside world.  Geographic challenges are significant, as well as access to technology.  I do not know whether tele-health or tele-education are being used in Brasil but I have no doubt that the industrious and passionate professionals in Brasil will continue to work to find solutions.

These are just two examples of audiology professionals around the world who are truly inspiring.  If they can accomplish so much without the finances and privileges that we enjoy, what can we accomplish with the advantages that we in the United States enjoy.  Other efforts to establish EHDI programs are occurring in Africa and South America.  The two countries mentioned have made significant progress in the last ten years.

We share the same language but there are still significant differences.

United Kingdom: Although the United Kingdom consists of England, Wales, Scotland and Northern Ireland, the EHDI programs differ throughout the United Kingdom.  The English Newborn Hearing Screening system has had the longest duration.  Because of the social medical system, this system has best practice protocols, standards for hearing screening equipment, and a system of accountability for screening programs.  The program can assure that screening occurs, that follow-up to diagnostic audiologic evaluation occurs within a timely manner, that amplification is fit appropriately and in a timely manner, and that the child who is deaf or hard of hearing is referred to early intervention.  To have a screening system with standards and accountability, systemically is only a dream for most EHDI systems.  The private characteristics of the majority of birthing hospitals and diagnostic audiology facilities in the United States mean that we are unable to issue mandates for screening protocols, diagnostic audiologic evaluation protocols or amplification fitting protocols.  Despite these limitations, there is an impressive commitment in the United States towards best practice protocols, but the challenges are great.  In the United States, we need to employ both top-down and bottom-up procedures.  We needed to build support requiring a significant emphasis upon convincing everyone at the grassroots, a bottom-up emphasis.   In the UK, emphasis needed to be placed initially from the top-down, but ultimately in order to accomplish EHDI goals, support needs to be at all levels.

Just as in the US, there are significant challenges for early intervention follow-through.  Decisions about what early intervention services are offered to parents/families are decided at the local levels.    Ironically, Colorado has developed a state-wide early intervention program assuring that in this state, all parents with newly identified children receive the same services, by frequency, training of the early intervention providers, consultation, mentorship, assessment protocol, deaf/hard-of-hearing connections, parent-to-parent support, and deaf/hard-of-hearing sign language instructors.

The greatest lessons learned are what we have learned from each other, about how obstacles are overcome and the creative solutions that have worked.  Universal newborn hearing screening has made the world a much smaller place for the field of audiology and those who provide early intervention services for children who are deaf or hard of hearing, uniting us across all corners of the globe.


Christie Yoshinaga-Itano, Ph.D., Professor of Audiology, Univ. of Colorado – Boulder. Dr. Yoshinaga-Itano is both a teacher of the deaf and hard of hearing and an audiologist. She has conducted research in the areas of language, speech, and social-emotional development of deaf and hard-of-hearing infants and children for over thirty years. Over the last 20 years, she has focused on the impact of early-identification and early intervention on the developmental outcomes of children with significant hearing loss. Professor Yoshinaga-Itano was the first to demonstrate that when infants with hearing loss are identified in the first few months of life and provided with appropriate intervention services, that 80% these infants/children with significant hearing loss and no additional disabilities are able to maintain age-appropriate language development and intelligible speech in the first five years of life. As a direct result of her research studies, universal newborn hearing screening programs have now been implemented in all 50 states and also in many countries throughout the world, including the United Kingdom, Canada, Australia, Japan, Poland, and Brazil.




Utah State University, Logan Utah, Retrieved from the World Wide Web May 14, 2011:   www. infanthearing.org




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