Impact of COVID-19 on the access to hearing health care services for children with cochlear implants: a survey of parents

Introduction

Hearing is one of the most important senses in humans. Auditory development during a young age is critical for the acquisition of normal speech and language development¹. Pediatric hearing loss constitutes one of the most important public health challenges². Children with hearing loss are identified early and habilitated via hearing aids or with cochlear implants (CIs). Continuous auditory stimulation without any interruptions is essential for the successful attainment of language acquisition. Appropriate care and maintenance as well as continuous auditory verbal therapy (AVT) are also essential in attaining these goals³. These are managed by providing seamless access to hearing health services without interruption and restrictions.

However, during the past six months, from the beginning of the year 2020, the world has witnessed an unprecedented attack on humans by a novel virus. The virus was proven to cause acute respiratory disease; the virus was later named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)⁴ and the disease coronavirus disease 2019 (COVID-2019). Towards the end of January 2020, the World Health Organization announced COVID-19 to be a public health emergency of great concern. This was followed by the announcement of stay at home orders and various precautionary measures enforced by various health authorities in order to contain the spread of the virus.

Though the pandemic has had a profound psychological impact on all⁵, pediatric patients with CIs require additional attention to keep up with their communication needs⁶. Children with hearing loss pose significant challenges to their parents, particularly when there is limited access to their hearing care providers. The break in the routine of their hearing and therapy follow-up services has had considerable effects on the children as well as their parents⁷. Hence, the current study aims to explore the impact of the COVID-19 pandemic on hearing healthcare services for children with CIs.

Methods

Results

A total of 31 parents of CI children were initially approached for the study. Out of these, 24 parents responded to the questionnaire sent to them (Table 1). All the CI users had pre-lingual deafness and the CI had been implanted for longer than one year at the time of the participation in the study.

Of the questions relating to the parents, all of the parents (100%) reported that the COVID-19 pandemic has had an impact on availing timely hearing healthcare services for their children⁸. 96% of the parents reported that they could not follow up with their CI mapping dates with their centers. It was interesting to note that 88% of the parents felt that the COVID-19 pandemic has been psychologically distressing for them. However, 8% of them neither agreed nor disagreed with that statement, with 4% reporting that they totally disagree that psychological distress was caused by the pandemic. With respect to the home training programs and remote learning aspects, 96% of the parents agreed that the home training methods were challenging and 71% of the parents expressed that remote learning lessons were difficult for their children (Table 2, Figure 1).

Figure 1. Percentage of responses to the questions related to the challenges faced by the parents.

Challenges pertaining to the CI users were also reported and seemed to be drastically affecting the parents. With respect to the speech processor breakdown, 79% of the parents agreed that it affected the auditory communication with the child, whilst 17% disagreed. Interestingly, daily usage of the speech processor during the daytime was reported to be neutral by 50%, and 29% agreed that they used the speech processor adequately. However, regarding the access to auditory training sessions, 96% of the parents reported that they had difficulty in accessing the services. 67% agreed that behavioral changes were common during the stay at home restriction period, with 8% disagreeing with this. The home training programs provided by their clinicians or AVTs were reported to have been followed accurately by 50% of the parents. However, significant number of parents reported that they did not follow the methods at home (Table 3, Figure 2).

Figure 2. Percentage of responses to the questions related to the cochlear implant user related challenges.

Discussion

The current study aims to understand the impact of COVID-19 on access to hearing healthcare services for children with CI. The results of the study underline the fact that the current pandemic situation has significantly affected children with CI.

It is an undisputable fact that hearing healthcare access is a complex issue which involves an interplay of multiple factors from both parents as well as care providers^2,7. Pediatric hearing loss has already proven to be a challenge for the parents during the pre – pandemic times. Parents of CI children enrolled in the current study reported that they faced issues with not receiving timely hearing health services for their children. These are mainly related to the break in CI mapping follow-up schedules and speech processor break down. It was reported extensively in the literature that for a successful outcome with CI, continuous usage of the speech processor is critical^9–11. In addition, optimal current levels are necessary for the development of auditory sensation^12,13. It is also evident from the current study that the present situation is psychologically pressing for both parents as well as for their children.

Parents have also reported that home training activities were difficult. This could be attributed to the boredom faced by both children and parents due to being confined at home for a long duration. In such scenarios, the child may not be able to cooperate with the task to achieve the target goal assigned by their clinician. Moreover, they faced greater trouble adapting to the remote learning environment.

It also worth noting that CI user related issues caused an additional burden on the parents. For example, in the current study, 79% of the parents reported that speech processor breakdown affected their auditory mode of communication with the child. It is also important to consider that not all CI users will have spare CI processors readily available at home for replacement¹⁴. This will add to the psychological anxiety of both parents and their children. It is documented in literature that a breakdown of the CI processor or temporary discontinuation of speech processor usage is strongly correlated with expected outcomes in CI children⁷. Interestingly, our results suggest that in the current situation, significant behavioral changes in CI children are shown. This can also be attributed to the lack of access to an auditory mode of communication^15,16. Such global changes in behavior and emotional aspects of parents as well as children will have severe impacts on following the home training programs planned by their clinicians.

The findings from our study focused on the enhanced need for the timely access to hearing health services for CI children. The study also shed light on the various needs and hurdles faced by parents. One of the critical aspects of improving service accessibility is reaching out to users through innovative methods. This includes tele-audiology services^17–19, in which the healthcare professionals can provide remote mapping and necessary trouble shooting for the speech processors. Also, a tele-AVT program is another option for parents to engage the child with therapists. This will ensure better compliance and continuity of the care plan. In addition, this will facilitate containment of behavioral changes in children to a certain extent.

During these unprecedented times, hearing health services can also be availed via homecare visits or mobile hearing health services. However, such services are not widely available. In addition, precautionary measures are critical for both children and healthcare professionals before organizing the home visits.

Conclusions

The COVID-19 pandemic has been reported to have a considerable impact on access to the hearing health services availed by CI children. Parents and CI children are distressed due to the lack of access to services and consequent breakdown in communication. Results from the current study suggest the need for more innovative methods to be employed to meet the needs of CI children. However, the current study has a limitation due to the restricted sample size of participants. Future studies can be carried out by focusing on a wider CI population and their specific needs.

Data availability