Assessment of hearing screening outcomes and risk factors among first grade students in the Umraniye district of Istanbul, Türkiye: a cross-sectional study

Abstract

Background

Given the critical impact of hearing impairments on both individual development and societal outcomes, particularly in the context of children’s education and health, this study conducted a retrospective analysis of hearing screening test results among first-grade students.

Methods

The study employed a retrospective cross-sectional design, analyzing the hearing screening test results of first-grade students (aged 6–7 years) from the Umraniye district during the 2022–2023 academic year. Data from 10,638 children with complete and comprehensive records were included in the analysis. Hearing impairment was measured non-invasively via pure tone audiometry at four frequencies (500, 1000, 2000, and 4000 Hz) at 20 dB over approximately five minutes—with failure defined as no response at any frequency in one or both ears, prompting a repeat screening within 48 h and, if still failed, referral for comprehensive evaluation. Chi-Square test (or Fisher Exact test where appropriate) was used for comparison of categorized data. A binary logistic regression model was applied to assess the effect of the independent variables on hearing screening outcomes (passed in both ears vs. failed in one or both ears), with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) reported. p < 0.05 was considered statistically significant.

Results

The percentage of children who passed the hearing screening test in both ears was 72.8% (n = 7,747). Potential risk factors associated with failed hearing screening in one or both ears were examined. Children who failed the screening test exhibited significantly higher rates of learning difficulties, difficulty hearing when called from another room, a history of ototoxic drug use, and a history of postnatal infections resulting in sensorineural hearing loss (p < 0.001, p < 0.001, p = 0.003, and p < 0.001, respectively).

Conclusion

Our findings underscore the importance of early identification and intervention for hearing loss. Future research should focus on refining surveillance and screening protocols to better detect and manage hearing impairments in at-risk pediatric populations, ensuring timely diagnosis and appropriate intervention strategies.

Background

Hearing loss represents a considerable public health challenge on a global scale [1]. Hearing, crucial in every stage of life, is particularly important in school-age children, impacting their health, quality of life, and academic success. According to World Health Organization (WHO) data, approximately 60% of hearing loss in children is preventable, and children with hearing loss benefit from early detection and intervention [2]. The economic burden on society can be reduced through effective early intervention options for hearing loss, such as hearing aids and cochlear implants [3]. Therefore, conducting studies and screenings on hearing loss is of utmost importance [4]. Hearing loss can be congenital or acquired later in life due to factors such as infections, traumas, and genetic diseases [5]. Permanent hearing loss is reported to affect around 0.9% of the school-age population, with both permanent and temporary hearing loss affecting over 14% of school-age children [6]. Even in cases of unilateral hearing loss, the rate of grade repetition is over 30% [6]. Hearing loss can lead to difficulties in learning and social functions, as well as a decrease in academic and social success in children [6, 7].

In numerous countries globally, national hearing screenings are implemented as an integral component of school screening programs [8]. In this context, Türkiye has instituted the School-Age Hearing Screening Program across all 81 provinces since 2015 [6]. The School-Age Hearing Screening Program is designed to identify, diagnose, and facilitate the rehabilitation of acquired hearing loss in school-aged children at an early stage. Audiometric screenings are conducted for first-grade students (ages 6–7 years) by health personnel trained in hearing assessments at Community Health Centers, District Health Directorates, or Healthy Life Centers, adhering to established protocols. Children who do not pass the screening or present with risk factors are referred to secondary or tertiary healthcare facilities for comprehensive evaluation [6].

Given the profound individual and societal impact of hearing loss on children’s education and health, this study retrospectively evaluates the hearing screening test results of first-grade students in Umraniye District, Istanbul, over a two-year period (2022–2023 academic years), which corresponds to the period in which the study was conducted. While school-age hearing screening is routinely performed, our study aims to go beyond merely reporting screening results by identifying specific risk factors associated with failed hearing screenings. In this context, the study seeks to identify specific risk factors associated with hearing impairment in children and provide recommendations to enhance screening programs and guide targeted interventions.

Methods

Study design

The study employed a retrospective cross-sectional design, aiming to evaluate the hearing screening test results of first-grade children who attended school during the 2022–2023 academic year in the Umraniye district of Istanbul, Türkiye.

Study population and sample

The study population comprised all first-grade students in the Umraniye district without any exclusion criteria. Every public and private school were visited in the district and included all first-grade students—employing a census approach rather than selecting a sample—with data collected only from those children whose families provided consent. Children considered at risk for hearing loss, such as those with a family history of hearing loss, Down syndrome, history of head trauma with loss of consciousness, syndromic conditions associated with hearing loss, use of ototoxic drugs, neurological disorders, or facial structural abnormalities, were also included in the study. Regardless of their test results, these children were referred for further evaluation.

Data collection procedures

Hearing screenings were conducted by a rotating team of approximately ten healthcare professionals from the District Health Directorate, with each screening session carried out by a medical doctor and a nurse. The composition of the teams varied daily, ensuring coverage across all designated schools. The medical doctors participating in the screenings had 1 to 5 years of professional experience in the medical field, while the nurses had approximately 10 to 20 years of professional experience in nursing. The hearing screening tests were conducted in accordance with standardized protocols. Screenings took place in a designated quiet room within the schools, specifically designed to minimize background noise. This controlled environment aimed to ensure the reliability of hearing threshold measurements under the prevailing conditions.

All hearing screenings were performed using calibrated audiometers that were regularly maintained as per the national screening program guidelines. Additionally, daily equipment checks were conducted by the screening team before each session to ensure proper functionality. This information has been added to the data collection section of the methods part. According to the Ministry of Health’s screening protocol, hearing assessments are performed non-invasively using an audiometer across four distinct frequencies (500, 1000, 2000, and 4000 Hz) at a sound level of 20 dB. The duration of the assessment typically spans approximately five minutes, contingent upon the child’s level of cooperation, the testing environment, and the practitioner’s efficiency. A child is deemed to have failed the screening if there is no response to any of the tested frequencies at 20 dB in one or both ears. In such cases, the screening is repeated within 48 h. Children who do not pass the retest are subsequently referred for a comprehensive audiological evaluation and an examination by an otolaryngologist (ENT specialist).

Data on risk factors for hearing difficulties were obtained through a questionnaire distributed to parents prior to the screening. The questionnaire was a part of the routine screening program established by the Ministry of Health and was distributed to teachers by the District Health Directorate [9]. Teachers then provided the questionnaire to families, collecting information on potential risk factors for hearing difficulties. Family consent for participation in the hearing screening was also obtained via questionnaire. Pre- and post-testing of the questionnaire was not performed because the screening program is implemented as a nationwide protocol by the Ministry of Health, which employs standardized questions and procedures across the country.

Variables

In the study, the data on passing/failing the hearing screening was the dependent variable. The presence of risk factors associated with failed hearing screening such as febrile illness, recurrent ear disease, and pre-existing hearing loss, were evaluated in questionnaire as independent variables. The family history of hearing impairment or signs of hearing difficulties, history of head trauma with loss of consciousness, presence of syndromic diseases resulting in hearing loss (Waardenburg, Usher, Pendred, Alport etc.), use of ototoxic drugs (aminoglycosides, furosemide etc.), presence of neurological disorders (Cerebral palsy, Neurofibromatosis Type 2 etc.), facial structural abnormalities (abnormalities of the ear canal, earlobe, and temporal bone etc.) were other independent variables asked in questionnaire.

Statistical evaluation

Statistical evaluation was performed using IBM SPSS (Statistical Package for Social Sciences) version 25. Numbers (n) and percentages (%) were used for descriptive data. Chi-Square test (or Fisher Exact test where appropriate) was used for comparison of categorized data. In the univariate analysis, independent factors that were found to be statistically significant were included in the multivariable analysis. A binary logistic regression model was applied to assess the effect of these selected independent variables on hearing screening outcomes (passed in both ears vs. failed in one or both ears), with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) reported. p < 0.05 was considered statistically significant.

Ethics committee

The ethics committee permission required for the conduct of the study was obtained from the Health Sciences University Umraniye Training and Research Hospital Clinical Research Ethics Committee on 05/10/2023 with decision number 358. Participation in the screening program was voluntary, and written informed consent was obtained from parents before the hearing screening tests. All personal data were anonymized and stored securely, ensuring compliance with data protection regulations.

Results

In the context of the study, a total of 10,638 first-grade children in the Umraniye district underwent hearing screening. Of these, 72.8% (n = 7,747) successfully passed the hearing screening in both ears (Table 1).

Table 1.

Hearing screening test results of the first grade students

		n	%
Hearing screening test results	Passed in both ears	7747	72.8
	Failed in both ears	2276	21.4
	One ear passed, one ear failed	615	5.8

Potential risk factors associated with failed hearing screening were investigated in first-grade children who underwent screening. Among these children, 9.1% (n = 862) had a history of frequent ear infections (occurring at least 2–3 times per year) during the preschool period. Additionally, 1% (n = 93) had a family history of hearing loss, and 1.5% (n = 139) had been diagnosed with learning difficulties. These risk factors for hearing loss are summarized in Table 2.

Table 2.

The risk factors among the screened children

Risk factors		n	%
Family history of hearing loss	No	9417	98.0
	Yes	93	1.0
History of head trauma with loss of consciousness	No	9466	99.5
	Yes	44	0.5
Diagnosis of learning difficulties	No	9372	98.5
	Yes	139	1.5
History of exposure to high noise levels	No	9408	98.9
	Yes	103	1.1
Diagnosis of Down syndrome	No	9495	99.9
	Yes	11	0.1
Cleft palate-lip	No	9454	99.5
	Yes	50	0.5
Use of ototoxic drugs	No	9488	99.8
	Yes	19	0.2
History of postnatal infection causing sensorineural hearing loss	No	9466	99.6
	Yes	34	0.4
Presence of syndromic diseases resulting in hearing loss	No	9486	99.9
	Yes	9	0.1
Neurological disorders	No	9446	99.6
	Yes	38	0.4
Facial structural abnormalities including abnormalities of the ear canal, earlobe, and temporal bone	No	9443	99.5
	Yes	49	0.5
Diagnosis of auditory processing disorder	No	9460	99.6
	Yes	36	0.4
History of frequent ear infections (at least 2–3 times a year) during the preschool period	No	8655	90.9
	Yes	862	9.1

The warning signs and symptoms of hearing impairment was also evaluated. Of the children, 4.2% (n = 398) frequently repeated what was said to them or often misunderstood spoken words, while 3.8% (n = 357) had difficulty watching television at a distance and volume level that other family members found comfortable. Difficulty hearing when called from another room was reported in 3.7% (n = 349) of the children, while 2.3% (n = 222) reported an inability to determine the direction of sound (Table 3).

Table 3.

The warning signs and symptoms of hearing impairment among the screened children

The warning signs and symptoms		n	%
Difficulty hearing when called from another room	No	9140	96.3
	Yes	349	3.7
Ability to determine the direction of sound when sound is heard	No	222	2.3
	Yes	9534	97.7
Frequent repetition of what is said or frequent misunderstanding	No	9110	95.8
	Yes	398	4.2
Difficulty watching television at a distance and volume level that other family members find comfortable	No	9139	96.2
	Yes	357	3.8

The study evaluated potential risk factors associated with failed hearing screening in children who underwent screening. The results indicated that children diagnosed with learning difficulties, those with a history of ototoxic drug use, and those with a history of postnatal infection leading to sensorineural hearing loss had significantly higher rates of failure in the hearing screening test (p < 0.001, p = 0.003, and p < 0.001, respectively). Additionally, children with hearing impairment in one or both ears were significantly more likely to have syndromic conditions associated with hearing loss, neurological disorders, difficulty hearing when called from another room, an inability to determine the direction of sound, and facial structural abnormalities (p = 0.005, p = 0.001, p < 0.001, p < 0.001, and p < 0.001, respectively). Moreover, children who frequently repeated what was said to them or often misunderstood, those who had difficulty watching television at a distance and volume level comfortable for other family members, and those with a history of frequent ear infections during the preschool period also showed significantly higher rates of failure in the hearing screening test (p < 0.001) (Table 4).

Table 4.

The risk factors associated with the results of the hearing screening test

		Auditory Screening Result				P value
		Passed in both ears		Failed in one or both ears
		n	%	n	%
Family history of hearing loss	No	6863	99.1	2382	98.8	0.103
	Yes	60	0.9	30	1.2
History of head trauma with loss of consciousness	No	6896	99.6	2398	99.4	0.116
	Yes	26	0.4	15	0.6
Diagnosis of learning difficulties	No	6852	99.0	2357	97.7	< 0.001
	Yes	71	1.0	56	2.3
History of exposure to high noise levels	No	6859	99.1	2379	98.6	0.075
	Yes	65	0.9	33	1.4
Diagnosis of Down syndrome	No	6914	99.9	2406	99.8	0.166
	Yes	6	0.1	5	0.2
Cleft palate-lip	No	6886	99.5	2396	99.4	0.341
	Yes	32	0.5	15	0.6
Use of ototoxic drugs	No	6913	99.9	2400	99.5	0.003
	Yes	8	0.1	11	0.5
History of postnatal infection causing sensorineural hearing loss	No	6909	99.8	2389	99.0	< 0.001
	Yes	11	0.2	23	1.0
Presence of syndromic diseases resulting in hearing loss	No	6916	100.0	2403	99.8	0.005
	Yes	2	0	6	0.2
Neurological disorders	No	6889	99.7	2392	99.3	0.001
	Yes	18	0.3	18	0.7
Difficulty hearing when called from another room	No	6724	97.3	2261	93.9	< 0.001
	Yes	190	2.7	146	6.1
Ability to determine the direction of sound when sound is heard	No	128	1.8	81	3.2	< 0.001
	Yes	6954	98.2	2413	96.8
Facial structural abnormalities including abnormalities of the ear canal, earlobe, and temporal bone	No	6891	99.7	2386	99.0	< 0.001
	Yes	24	0.3	23	1.0
Frequent repetition of what is said or frequent misunderstanding	No	6679	96.4	2271	94.0	< 0.001
	Yes	246	3.6	144	6.0
Difficulty watching television at a distance and volume level that other family members find comfortable	No	6722	97.2	2260	93.7	< 0.001
	Yes	195	2.8	152	6.3
Diagnosis of auditory processing disorder	No	6902	99.7	2394	99.5	0.055
	Yes	19	0.3	13	0.5
History of frequent ear infections (at least 2–3 times a year) during the preschool period	No	6374	92.0	2129	88.0	< 0.001
	Yes	556	8.0	290	12.0

Based on the multivariate analysis, several factors were found to be significantly associated with failed hearing screening results. Diagnosis of learning difficulties (OR: 1.682, 95% CI: 1.141–2.478, p = 0.009) and history of postnatal infection causing sensorineural hearing loss (OR: 2.847, 95% CI: 1.290–6.285, p = 0.010) were identified as predictors of hearing screening failure. Additionally, facial structural abnormalities, including those of the ear canal, earlobe, and temporal bone (OR: 1.864, 95% CI: 1.003–3.465, p = 0.049), and difficulty determining the direction of sound when heard (OR: 1.369, 95% CI: 1.015–1.847, p = 0.039) were significantly associated with failed screenings. Furthermore, difficulty hearing when called from another room (OR: 1.578, 95% CI: 1.191–2.092, p = 0.001), difficulty watching television at a distance and at a volume level considered comfortable by family members (OR: 1.561, 95% CI: 1.204–2.024, p = 0.001), and a history of frequent ear infections during the preschool period (OR: 1.270, 95% CI: 1.079–1.496, p = 0.004) were also independent risk factors for hearing screening failure. Several variables that demonstrated statistical significance in the univariate analysis did not maintain their significance in the multivariable logistic regression model (Table 5).

Table 5.

Multivariate analysis for the risk factors associated with the results of the hearing screening test

	P value	OR	95% C.I.for OR
			Lower	Upper
Diagnosis of learning difficulties	0.009	1.682	1.141	2.478
Use of ototoxic drugs	0.134	2.350	0.768	7.192
History of postnatal infection causing sensorineural hearing loss	0.010	2.847	1.290	6.285
Presence of syndromic diseases resulting in hearing loss	0.957	0.946	0.131	6.858
Neurological disorders	0.978	0.989	0.459	2.134
Difficulty hearing when called from another room	0.001	1.578	1.191	2.092
Difficulty to determine the direction of sound when sound is heard	0.039	1.369	1.015	1.847
Facial structural abnormalities including abnormalities of the ear canal, earlobe, and temporal bone	0.049	1.864	1.003	3.465
Frequent repetition of what is said or frequent misunderstanding	0.845	0.974	0.747	1.270
Difficulty watching television at a distance and volume level that other family members find comfortable	0.001	1.561	1.204	2.024
History of frequent ear infections (at least 2–3 times a year) during the preschool period	0.004	1.270	1.079	1.496

OR: Odds ratio, CI: Confidence interval

Discussion

Hearing screening in school-age children is a critical tool for identifying cases of hearing loss that were either undetected or not appropriately monitored at birth, as well as those that develop later in childhood. In the absence of routine school-based hearing screenings, students with unilateral, mild, or late-onset hearing loss may remain unrecognized or be misdiagnosed [10]. In the present study, we analyzed data from first-grade children who underwent screening as a part of the school-age hearing screening program implemented by the Ministry of Health in our country. The research was conducted in the Umraniye district, which has a population of 723,760, potentially reflecting broader socioeconomic and sociodemographic characteristics representative of the country. Our findings indicate that 27.2% of children failed the hearing screening test in one or both ears. In comparison, a study of hearing screening tests conducted in first-grade students in Brazil reported a failure rate of 14.6% [11]. Results from hearing screening tests conducted among 5th-grade students in Malatya province, Türkiye, revealed a failure rate of 3% among the screened children [12]. Another study reported a higher failure rate in hearing screening tests among younger Polish children aged 6 to 13 years [13]. It is possible that compliance with the screening test may have increased with advancing age and hearing loss due to acquired causes such as otitis media and trauma may be observed less in older children [14]. In other studies in the literature, the prevalence of hearing loss has been reported to vary between 0.9% and 34.0% [8, 15, 16]. The differences between study results may be due to differences in hearing screening protocols, tests used in screening and threshold values used in different countries [8, 17]. In this context, the development of standardized guidelines for school hearing screening protocols at a global level is necessary.

The literature indicates that hearing loss in school-age children can be associated with certain behavioral risk factors. These behaviors include the desire to repeat sentences frequently, turning the head towards the speaker, making an effort to listen, looking and focusing on the teacher’s lips, preferring social isolation and learning difficulties [11, 18]. In our study, we assessed several risk factors potentially associated with failed hearing screening and examined the relationship between these factors and failure in one or both ears during hearing screening. Our findings revealed that the rates of screening test failure were statistically significantly higher in children with a diagnosis of learning disabilities, those who had difficulty hearing when called from another room, those unable to identify the direction of sounds, children who frequently needed repetition or often misunderstood speech, and those who had difficulty watching television at the same distance and volume level as other family members. Given the association between these behavioral risk factors and failure in hearing screening tests, it is essential to raise public awareness of these observable behaviors, which can be recognized by parents, teachers, and those in the child’s immediate environment. To facilitate early diagnosis and intervention of hearing impairments identified through screening, more frequent screenings may be warranted for children exhibiting these behavioral risks. Additionally, further evaluations guided by ENT specialists may be recommended for such children.

In our study, non-behavioral factors associated with failure in one or both ears during hearing screening included a history of ototoxic drug use, postnatal infections leading to sensorineural hearing loss, the presence of syndromic diseases associated with hearing loss, nervous system disorders, facial deformities, and a history of frequent ear infections during the preschool period. Recurrent middle ear diseases and Eustachian tube dysfunction were also common in this age group [19]. In the literature, it is known that viral infections may be associated with sensorineural (conductive or mixed type is more rare) hearing loss in children with inflammation or direct damage to the inner ear canal [20]. Similarly, it is known that ototoxic drug use may result in hearing loss in school-age children [21]. In the management of viral diseases, it is crucial for physicians and individuals in close contact with the child to maintain a high level of awareness regarding the potential for hearing loss. Given the associations identified between hearing loss and factors such as the presence of syndromic diseases and nervous system disorders in children, those in this cohort require careful monitoring and comprehensive approaches to address their hearing needs alongside their existing medical conditions.

Limitations and strengths

Our study assessed hearing screening outcomes and potential associated risk factors among a substantial sample of first-grade children, which constitutes a significant strength. Furthermore, the study’s focus on identifying behavioral characteristics associated with childhood hearing impairment represents an additional strength, as it promotes awareness of this critical issue. However, the reliance on data from a single district limits the generalizability of the findings. Nevertheless, it is important to note that the Umraniye district, where the research was conducted, has a population of 723,760, which may reflect broader socioeconomic and sociodemographic characteristics of the country [22]. Additionally, the absence of follow-up data on children referred for further examination after failing the screening test constitutes another limitation of our study.

Conclusion

In conclusion, our study highlights the critical importance of school-age hearing screening as a vital tool for identifying hearing loss that may have gone undetected at birth or developed later in childhood. The significant failure rates observed in our cohort underscore the necessity for routine screenings, particularly for children with behavioral risk factors or known medical histories that may predispose them to hearing impairment.

The findings carry important implications: heightened awareness among parents, educators, and healthcare professionals is essential to recognize early signs of hearing difficulties; the identification of both behavioral and non-behavioral risk factors provides a robust framework for targeted follow-up and timely referrals to ENT specialists. Moreover, the variation in failure rates and the potential for undiagnosed hearing loss in children, the development of standardized global guidelines for school hearing screening protocols is imperative. Such guidelines could facilitate more consistent and effective screening practices, ultimately promoting better hearing health in school-age children worldwide. By addressing the multifaceted nature of hearing loss in children and fostering a collaborative approach among caregivers, educators, and healthcare providers, we can ensure that all children receive the necessary support to thrive academically and socially.

Author contributions

ZMA: Conceptualization; data curation; formal analysis; investigation; methodology; validation; writing—original draft; writing—review and editing. AEG: Conceptualization; data curation; formal analysis; investigation; methodology; resources; validation; writing—original draft; writing—review and editing. ATK: Conceptualization; investigation; methodology; validation; writing—original draft; writing—review and editing. UA: Conceptualization; investigation; methodology; validation; writing—original draft; writing—review and editing.

Funding

No funding was received for the study.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Code availability

Not applicable.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki. The ethics committee permission required for the conduct of the study was obtained from the Health Sciences University Umraniye Training and Research Hospital Clinical Research Ethics Committee on 05/10/2023 with decision number 358. Since the study was conducted retrospectively, written informed consent was not obtained from the participants. Informed consent was obtained from the parents for the routine hearing screening program.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.