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Impact of childhood hearing impairment on early development, health and educational outcomes

Supervisors: Dr Rachel Knowles, Professor Jugnoo Rahi, Dr Valerija Tadic

Background:
Around 112 per 100,000 UK children are living with a permanent hearing impairment (HI) and many more have intermittent or unilateral HI.1 HI has implications for a child’s development and presents considerable educational, occupational and social challenges throughout life. The causes of HI have changed markedly over the decades, as the survival of low birth weight and preterm infants improves, and childhood immunisation programmes reduce the congenital infections, such as rubella, that cause deafness. Children with bilateral HI may be offered hearing aids, speech and language therapy, and/or electronic cochlear implants. Despite this, they remain at risk of delayed speech and language development, with potential impact on their school-readiness, maths and literacy skills, and mental health.[1,2] Over 40% of hearing impaired children leave primary school without achieving the expected levels in reading, writing and maths.[3]

In 2006, the NHS introduced the universal Newborn Hearing Screening Programme (NHSP)[4]; around 3% of babies are referred for diagnostic investigations each year after a positive screen result. Investigation of the contemporary epidemiology of HI following the introduction of newborn screening in the UK is lacking and there is limited research exploring the impact of screening detection of HI on school achievement, such as literacy and numeracy.[5]

Only 7% of babies referred for investigation after a screen positive result are subsequently diagnosed with HI; the remainder are false positive screen results. False positive screen results are a key issue with any screening programme and have been shown to increase the likelihood of subsequent hospital attendance in newborns screened for a metabolic disorder, even after the diagnosis is excluded. Data linkage analyses will explore whether children with false positive screen results have higher rates of health service usage even though they do not have HI. This will be extended in the qualitative study involving semi-structured interviews with parents to explore their experience of receiving a false positive result, and the impact this has on their subsequent concerns about their child’s health and development. This can inform future development of the diagnostic and care pathways associated with a positive screen result.

This mixed methods study aims to improve understanding of the disease burden, care pathways and outcomes of HI, inform future health and education policy, and effect improvements in clinical practice that will optimise the health, development, and school-readiness of children with HI.

The studentship will be based within the Lifecourse Epidemiology and Biostatistics Section of the Population, Policy and Practice Programme at UCL Great Ormond St Institute of Child Health. It offers an opportunity to gain generic and specific research skills and training during the conduct of a mixed methods study with quantitative and qualitative components. The studentship will provide high quality training in health services research, and experience of clinical public health through collaboration with Public Health England screening division.

Aims/Objectives:
This project will: (1) explore the frequency of childhood HI identified in a population with universal newborn hearing screening, as well as the health and educational outcomes at primary school age, (2) identify specific early life or child factors that predict worse outcomes, and (3) explore the impact of false positive screen results on parents and children. This new knowledge should inform future care pathways and the development of interventions that will improve health, neurodevelopment and school achievement.

Methods:
This mixed methods project will involve, (1) critical literature review, (2) data linkage of routine screening, health and education datasets and the application of statistical and epidemiological approaches to quantitative data analysis, and (3) qualitative primary data collection (semi-structured interviews) and thematic analysis.

Timeline:
Phase 1 (months 0-12): analysis of the UK-wide population frequency of HI in children between 2006 and 2018 by sex, ethnicity, socio-economic status and severity of hearing loss, using NHSP data; literature review of child educational outcomes following newborn screening detection of HI; qualitative analysis training; initiation of recruitment for interviews.
Phase 2 (months 13-24): investigating outcomes for children with HI through linkage of NHSP screening data with mortality, hospital attendance or admission data and pupil-level education data. Conducting semi-structured interviews with parents of children with false positive screen results; coding and thematic analysis of qualitative data.
Phase 3 (months 25-36): Analysis of linked routinely collected datasets to investigate the individual child characteristics or early life exposures that predict worse educational outcomes. Completion of qualitative data collection and analysis. Final writing up and submission of thesis.

References:
1.  Davis A, et al. A critical review of the role of neonatal hearing screening in the detection of congenital hearing impairment. Health Technol Assess 1997;1(10):i-iv,1-176.
2.  Pimperton H, et al. The impact of universal newborn hearing screening on long-term literacy outcomes: a prospective cohort study. Arch Dis Child 2016;101(1):9-15.
3.  NDCS note on Department for Education figures for attainment for deaf children in 2014. London: National Deaf Children's Society, 2015.
4.  Wood SA, et al. Performance and characteristics of the Newborn Hearing Screening Programme in England: The first seven years. Int J Audiol 2015;54(6):353-8.
5.  Moeller MP, et al. Current state of knowledge: language and literacy of children with hearing impairment. Ear & Hearing 2007;28(6):740-53.