Paediatric Audiology: An analysis of stakeholder perspectives on advancement in Early Hearing Detection and Intervention for deaf infants in Nigeria

Abstract

Background: Early Hearing Detection and Intervention (EHDI) plays a critical role in improving language, cognitive, and socio-emotional outcomes for infants with hearing loss. In Nigeria, however, EHDI implementation remains limited by fragmented service delivery, uneven technological capacity, and sociocultural factors that delay timely diagnosis. This study explored the perspectives of paediatric audiologists and parents to provide a comprehensive understanding of the opportunities and challenges influencing early hearing care across diverse Nigerian settings.

Methods: A mixed-methods design was employed across audiology facilities selected systematically from four Nigerian geopolitical zones. Twenty-five paediatric audiologists and twenty-three parents of children with congenital hearing loss participated. Quantitative data were collected using a structured questionnaire assessing awareness, diagnostic access, and intervention experiences. Qualitative data were obtained through semi-structured interviews and two focus group discussions. Thematic analysis followed Braun and Clarke’s six-step framework, with dual coding, external auditing, and member validation to enhance credibility.

Results: Quantitative findings demonstrated broad agreement on the diagnostic value of otoacoustic emissions (OAEs) and automated auditory brainstem responses (AABRs), the developmental benefits of early intervention, and the importance of active parental involvement. However, respondents identified persistent barriers including high costs of screening and therapy, poor public awareness of early hearing loss symptoms, and a critical shortage of trained personnel, and unequal distribution of diagnostic tools, particularly in rural and northern regions. Thematic analysis further underscored disparities in diagnostic capacity, sociocultural interpretations of deafness that delay clinical consultation, and economic constraints that hinder continuity of care. While families who accessed early intervention reported improved communication, social engagement, and learning readiness in their children, systemic gaps continue to limit widespread success.

Conclusions: Despite growing technological capacity and awareness of EHDI benefits, significant structural, financial, and sociocultural challenges continue to impede timely diagnosis and intervention in Nigeria. Strengthening national policies, ensuring equitable distribution of diagnostic tools, expanding professional training, subsidising services, implementing culturally sensitive awareness campaigns and integration of Universal Newborn Hearing Screening into routine postnatal care are essential to improving outcomes for deaf infants.

1. Introduction

Early Hearing Detection and Intervention (EHDI) has become a central pillar of paediatric audiology due to its proven effects on language, cognitive, and socio-emotional development (Lieu et al., 2020; White, 2022). Globally, technological advances such as otoacoustic emissions (OAE), auditory brainstem response (ABR), and tele-audiology have transformed early diagnosis, enabling timely identification and intervention for infants with hearing loss. However, despite global progress, significant disparities persist between high-income and low-resource settings, with children in low- and middle-income countries (LMICs) often diagnosed late and receiving inconsistent follow-up care (Amri and Sihotang, 2023; Frazier et al., 2023).

1.1. Importance of EHDI and Critical Periods of Development

The evidence supporting early detection is substantial and has consistently shown that delayed identification beyond the first year leads to persistent developmental delays despite later intervention (Merugumala et al., 2017; Bower et al., 2023). The Joint Committee on Infant Hearing JCIH’s “1-3-6” benchmarks underscore that screening by 1 month, diagnosis by 3 months, and intervention by 6 months dramatically improve auditory–verbal and cognitive outcomes (Cole and Flexer, 2020; Yoshinaga-Itano et al., 2024). Consequently, universal newborn hearing screening (UNHS) and integrated EHDI systems have become global standards.

1.2. EHDI in Nigeria: Current Context and Challenges

In Nigeria, paediatric hearing loss remains largely undetected during infancy, with most children identified only at two to three years of age—well beyond the optimal window for language development. This delay stems from several health-system and sociocultural factors, including limited screening equipment, scarcity of audiology professionals, fragmented referral mechanisms, and insufficient provider awareness (Olusanya et al., 2008; Joshi et al., 2023). Cultural beliefs also shape health-seeking behaviour, with families often attributing hearing loss to spiritual or supernatural causes, delaying biomedical care (Swanepoel and Clark, 2019; Nwankwo et al., 2023).

Although Nigeria lacks a national, standardised EHDI system (Abdul-Majid et al., 2018), isolated pilot newborn screening programs exist, and are mostly in a few tertiary hospitals (Olusanya et al., 2008; Akinola et al., 2014; Labaeka et al., 2018; Abdullahi et al., 2021). Many of the existing initiatives are donor-funded, geographically restricted, and not integrated into maternal or child-health service delivery (Rajanbabu et al., 2024; Yikawe et al., 2025). As a result, loss-to-follow-up rates remain high, and infants identified with hearing loss frequently do not receive timely intervention.

1.3. Stakeholder Roles in Strengthening EHDI

Effective EHDI requires integrated action across multiple stakeholder groups—parents, audiologists, paediatricians, nurses, educators, policymakers, and community leaders. Evidence from LMICs shows that successful EHDI systems incorporate community engagement, clearly defined referral pathways, and collaborative multidisciplinary networks (Joshi et al., 2023; Rajanbabu et al., 2024). Conversely, when stakeholders operate in silos, screening uptake, follow-through, and intervention rates remain poor even in developed countries (Findlen et al., 2023).

Engaging parents, physicians, community leaders, and policymakers facilitates the identification of local issues (such as cost, stigma, and transportation), fosters effective communication strategies, and promotes collaborative development of operational solutions (including task-shifting, integration with immunisation clinics, and family navigators) that consider local norms and available resources (Swanepoel & Clark, 2019; Davenport, 2025). Unaddressed stigma, lack of knowledge, and cultural interpretations can delay or prevent families from seeking timely care (Kim, 2024; Aldè et al., 2025). Similarly, health-system factors—insufficient training for frontline health workers, inconsistent interfacility communication, and lack of policy direction—undermine early detection (Ilesanmi and Aanuoluwapo, 2022; Olusanya et al., 2022). Educational institutions, NGOs, and professional associations also play crucial roles in advocacy and capacity building (Yuskow, 2025).

1.4. Evidence from Studies on Stakeholder Perspectives

International studies demonstrate that stakeholder perspectives improve the cultural appropriateness and acceptability of EHDI programs (Pritchard et al., 2025; Reddy, 2025). However, research focusing on stakeholder involvement in Nigeria remains limited. Existing studies primarily examine technological feasibility or pilot screening outcomes, with minimal consideration of:

• parental beliefs and barriers;

• healthcare providers’ knowledge, workflow constraints, or referral behaviour;

• community-level influences such as stigma and traditional healing systems;

• policy-level facilitators and gaps.

This lack of stakeholder-driven evidence limits the design of contextually responsive EHDI models that align with Nigerian social, cultural, and health-system realities.

1.5. EHDI in Low-Resource Settings: Systemic Barriers

LMICs face distinctive constraints that hinder large-scale EHDI implementation. These include disparities in access to screening technology, high costs of diagnostics and amplification devices, shortages of audiologists and early-intervention specialists, weak referral networks, and insufficient government funding (Ilesanmi and Aanuoluwapo, 2022; Hatzopoulos et al., 2025). Data management systems and national policy frameworks are often inadequate, contributing to inefficiencies and high attrition (Olusanya et al., 2022). These challenges underscore the need for an approach that integrates health systems strengthening with community engagement.

1.6. Applying Bronfenbrenner’s Ecological Systems Theory

Bronfenbrenner’s Ecological Systems Theory provides a holistic lens for understanding how children’s hearing health outcomes are shaped by interconnected systems. At the microsystem level, caregiver awareness and provider competencies directly influence early identification. The mesosystem reflects coordination between home, healthcare, and education—often weak in Nigeria. Exosystem influences include institutional capacity, workforce shortages, and availability of diagnostic equipment (Oyedotun et al., 2025). The macrosystem encompasses cultural norms and policy structures, while the chronosystem illustrates how historical underinvestment in audiology services perpetuates disparities over time (Werfel et al., 2024; Freitag, 2025). This theoretical model supports the argument that improving EHDI in Nigeria requires multi-level stakeholder cooperation.

1.7. Research Gaps and Rationale for the Study

Despite global evidence on the benefits of EHDI, significant gaps persist in the Nigerian context:

• Limited research on culturally grounded, stakeholder-driven approaches to EHDI.

• Absence of national data on screening coverage, diagnostic timelines, and follow-up outcomes.

• Scarcity of studies examining parental perceptions, provider experiences, and policy-level barriers.

• Minimal exploration of how socioeconomic and cultural factors interact with service delivery.

• Insufficient evidence on the adaptation of emerging technologies (tele-audiology, AI-based diagnostics) to Nigerian settings (Khoza-Shangase, 2022; Essaid et al., 2024).

Given these gaps, this study aims to explore the perspectives of key stakeholders involved in paediatric hearing detection and intervention in Nigeria, to provide contextually relevant insights that can inform policy, practice, and the design of sustainable EHDI models. not merely as a technological initiative, but as a strategy to align clinical practice and policy with community needs and expectations, ultimately improving outcomes for affected children

2. Methodology

2.1. Study Site

The research was conducted across multiple medical institutions offering pediatric audiology services in Nigeria. These facilities were intentionally selected to represent the four major geopolitical zones East, West, North, and South thereby ensuring geographical balance and socioeconomic diversity. The selected sites included government teaching hospitals, private audiology centers, and state-run maternity and child health clinics, all offering diagnostic and rehabilitative services. This multi-site approach strengthened the representativeness and generalisability of findings across urban, peri-urban, and rural settings.

2.2. Study Population

The population consisted of two key groups: (1) paediatric audiologists with professional experience in Early Hearing Detection and Intervention (EHDI), and (2) parents or guardians of children diagnosed with congenital hearing loss who had utilised EHDI services. Audiologists contributed technical insights on diagnostic processes and intervention barriers, while parents provided experiential perspectives on early diagnosis, emotional adjustment, and access to rehabilitative care. The combination of these perspectives yielded a holistic understanding of Nigeria’s EHDI landscape.

2.3. Study Design

A mixed-methods design incorporating qualitative and quantitative components was employed. The qualitative component utilised a phenomenological orientation to explore the lived experiences of audiologists and parents. Conversely, the quantitative aspect used structured questionnaires to capture measurable indicators such as awareness levels, service accessibility, and diagnostic timelines. Triangulation enabled convergence and complementarity of findings, thereby improving overall validity.

2.4. Eligibility Criteria

Inclusion:

Paediatric audiologists with at least five years of experience in neonatal or pediatric audiology.

Parents of children with congenital hearing loss who had accessed EHDI services within the past five years.

Exclusion:

Audiologists with less than five years of experience.

Parents who had not used any EHDI service.

Individuals unable to provide informed consent.

2.5. Sample Size and Sampling Technique

Sampling Strategy

The study adopted a multi-stage sampling procedure comprising systematic, purposive, and saturation-guided sampling:

1. Sampling of Facilities (Systematic Sampling):

An official national registry of pediatric audiology facilities was obtained, from which every fifth facility was selected. This ensured a geographically balanced distribution and reduced the risk of site clustering.

2. Sampling of Audiologists (Purposive Sampling):

Within each selected facility, audiologists were included only if they met the ≥5-year experience criterion. This ensured professional comparability and relevance to EHDI practice.

3. Sampling of Parents (Saturation-Driven and Snowball-Assisted):

Parent inclusion followed a saturation principle, concluding at 23 participants when no new concepts emerged. Snowball sampling was used strictly for identifying eligible parents, not selecting them, and each referred individual was screened based on the inclusion criteria.

2.6. Sample Size

A total of 25 paediatric audiologists and 23 parents were included.

Recruitment Procedures

Recruitment was carried out distinctly from sampling to avoid bias and ensure transparency.

1. Recruitment of the First Participant:

The first participant was the Head Audiologist at the first systematically selected facility. The researcher contacted the department directly, presented the study information, and obtained informed consent.

2. Recruitment of Audiologists (Bias Avoidance Measures):

All eligible audiologists within selected facilities were approached individually using a standard recruitment script.

No audiologist was permitted to nominate colleagues, preventing selective or convenience recruitment.

Recruitment continued until all eligible practitioners had been invited, irrespective of acceptance or refusal.

3. Recruitment of Parents (Controlled Use of Snowball Sampling):

Audiologists provided only initial contact information for parents who had accessed EHDI services.

Parents were not allowed to refer other parents directly.

The research team screened all potential participants to avoid homogeneity and overrepresentation.

Recruitment was geographically spread to maintain regional diversity.

These procedures ensured that sampling remained systematic and purposive, rather than convenience-driven.

2.7. Outcome Measures

- Professional assessments of EHDI effectiveness and accessibility.

- Parental insights on diagnostic timeliness, emotional experiences, and intervention impact.

- Quantitative measures such as timeliness of intervention, personnel availability, and awareness levels across regions.

Study Procedures

Participants were engaged through direct outreach, hospital referrals, and professional networks. Three primary instruments were employed: semi-structured interviews, focus group discussions, and questionnaires.

Semi-Structured Interviews:

All 25 audiologists and 12 parents participated. The interview guide was developed after thorough literature review and refined through expert input. Pilot testing ensured clarity and cultural appropriateness. Interviews lasted 45–60 minutes and were conducted in English or the preferred local language.

Focus Group Discussions:

Two FGDs were held with 11 and 10 parents respectively. Each session lasted approximately 90 minutes and explored barriers to access, cultural meanings of hearing loss, and perceptions of intervention efficacy.

2.8. Questionnaires:

A 24-item questionnaire addressing diagnostic awareness, intervention access, and policy perspectives was administered. Items were rated on a five-point Likert scale. Pilot validation yielded strong internal consistency (Cronbach’s α = 0.87).

All data were anonymised and securely stored.

Thematic Analysis and Statistical Plan

Qualitative data were analysed using NVivo following Braun and Clarke’s six-phase framework:

1. Familiarisation: All transcripts were read multiple times by two independent coders.

2. Initial Coding: Inductive, data-driven coding was performed separately by both coders.

3. Verification of Codes: Coders met for code reconciliation and developed a unified codebook. An external qualitative expert audited 15% of the coded transcripts for consistency.

4. Theme Development: Codes were organised into candidate themes through categorisation and conceptual clustering.

5. Theme Review: Themes were evaluated for internal coherence and representational adequacy across the dataset. Redundant themes were merged, revised, or discarded.

6. Theme Definition: Final themes were refined, named, and described, with clear thematic boundaries.

Credibility Measures:

Inter-coder reliability through dual coding.

Detailed audit trail documenting all analytic decisions.

Member validation with selected participants to ensure accuracy.

Peer debriefing with a qualitative research expert to minimise bias.

Quantitative Analysis

SPSS (version 26) was used for descriptive statistics (frequency, mean, standard deviation) and inferential analyses (chi-square tests, correlations).

2.9. Ethical Considerations

Ethical approval was obtained from the Anambra State Research Ethics Committee (Approval Number: ASMOHEREC/2025/14042025/37). Informed consent, confidentiality, cultural sensitivity, and the right to withdraw were emphasized. Data were securely stored, and findings were shared with participants and relevant institutions for transparency and policy improvement

3. Results

The results of this study provide significant insight into the operational realities of Nigeria’s Early Hearing Detection and Intervention (EHDI) system. Table 1 summarises the questionnaire responses.

Table 1. Summary of Questionnaire Responses.

Research Question	Question Item	SA	A	D	SD
Advancements in Detection	OAE has improved early diagnosis.	20	8	2	0
	ABR is effective in detecting hearing loss early.	22	6	2	0
	Portable devices are accessible in rural areas.	10	12	6	2
Effectiveness of Interventions	Intervention programs improve developmental outcomes.	18	10	2	0
	Timely intervention is crucial for success.	25	5	0	0
	Parental involvement enhances effectiveness.	20	8	2	0
Barriers to Access	Cost is a significant barrier to access.	26	4	0	0
	Awareness campaigns are insufficient.	24	6	0	0
	Trained personnel are lacking in rural areas.	27	3	0	0

3.1. Interpretation of Findings

Strongly Agree (SA) dominated responses on financial barriers (26), personnel shortages (27), and the critical importance of timely intervention (25), identifying these as the most severe national service gaps.

Agree (A) responses were moderate on rural access to portable devices (12), indicating partial progress but confirming ongoing disparities.

The disagree responses (D, SD)demonstrate broad consensus on both the strengths and challenges in Nigeria’s current EHDI framework.

3.2. Qualitative Themes and Analysis

Thematic analysis of interview and focus group data from paediatric audiologists and parents produced four major themes with corresponding sub-themes. These themes capture diagnostic realities, intervention pathways, sociocultural influences, and systemic barriers shaping Nigeria’s EHDI system.

3.2.1. Theme 1: Uneven Diagnostic Capacity Across Regions

Sub-themes:

1. Urban–rural technological disparity

2. Equipment sustainability challenges

3. Dependence on outreach and mobile screening

Both audiologists and parents attributed delayed diagnosis to the inconsistent availability of OAE and AABR across regions. Urban hospitals were described as “far better equipped,” while many rural clinics operated with “old machines,” “frequent breakdowns,” or “no screening devices at all.” Some audiologists said they relied on mobile outreach devices but emphasised their limitations due to erratic electricity supply and poor maintenance systems. This theme directly supports quantitative findings showing only moderate agreement (12 respondents) that portable devices are available in rural areas. The qualitative evidence enriches this by showing why availability is poor - systemic underfunding, unreliable power supply, and lack of trained personnel.

3.2.2. Theme 2: Early Intervention as a Determinant of Child Development

Sub-themes:

1. Developmental gains in early-identified children

2. Impact of delayed intervention

3. Centrality of parental involvement

Parents consistently reported that children who started therapy before age two made “faster progress,” had “better speech attempts,” and were “more responsive to sound.” Audiologists confirmed this, noting that delayed intervention often resulted in “limited speech outcomes” or “slower cognitive development.” Parental involvement emerged as a major driver of progress, with therapists reporting that children whose parents participated actively advanced more rapidly. This theme reinforces quantitative responses showing strong agreement on early intervention (90%) and parental involvement (20 strongly agree). The theme explains the mechanisms behind the benefits: early auditory stimulation, structured therapy routines, and family support.

3.2.3. Theme 3: Sociocultural Beliefs and Low Awareness as Drivers of Late Presentation

Sub-themes:

1. Cultural and spiritual interpretations of deafness

2. Low parental awareness of early symptoms

3. Misinformation from community networks

Several parents initially believed hearing loss was “spiritual,” “ancestral,” or “a sign from God.” These beliefs delayed testing as families first sought religious or traditional remedies. Many parents said they “did not know babies could be tested early,” reflecting a gap in health education. Audiologists also highlighted the influence of social stigma, where families “hide the child” or avoid clinics to prevent embarrassment. This theme provides the qualitative foundation for the quantitative finding that awareness campaigns are insufficient (24 SA). It also illuminates how cultural beliefs serve as barriers—by normalising delays and discouraging clinical interpretation of infant behaviour.

3.2.4. Theme 4: Financial and Workforce Constraints Limiting Access to EHDI

Sub-themes:

1. Unaffordable cost of therapy and devices

2. Shortage of trained audiologists in rural regions

3. Impact of economic hardship on continuity of care

Parents described therapy and assistive technologies as “too expensive,” “beyond our salary,” or “a burden we cannot sustain.” Some admitted discontinuing therapy because “transport alone is a challenge,” especially when referral centres are far from rural homes. Audiologists linked the staffing shortage to “lack of training opportunities,” “poor remuneration,” and “brain drain.” This theme aligns with questionnaire data showing financial barriers (26 SA) and lack of trained personnel (27 SA) as the most severe challenges. Qualitative narratives deepen understanding by showing how these barriers affect real-world continuity of care and long-term outcomes.

4. Discussion

This study provides an integrated understanding of the operational realities (strengths and limitations) of Nigeria’s Early Hearing Detection and Intervention (EHDI) system by examining the perspectives of paediatric audiologists and parents. The findings reinforce long-standing challenges in low-resource settings while highlighting areas of progress

A major finding was the persistent disparity in diagnostic capacity between urban and rural regions. Participants reported inconsistent availability and maintenance of OAE and AABR devices, unreliable power supply, limited access to portable tools and, inequities in professional expertise across geopolitical regions. These constraints mirror earlier reports that newborn hearing screening in Nigeria remains concentrated in tertiary facilities (Olusanya et al., 2008) and align with recent African data showing uneven technological distribution and sustainability challenges (Asaju and Ashepo, 2025; Hatzopoulos et al., 2025). Such disparities contribute directly to delayed diagnosis and limited early intervention coverage and, highlight the need for interprofessional collaboration, targeted investment, decentralised screening systems, and consistent policy enforcement to enhance effective service delivery. (Hatzopoulos et al., 2025; Oso et al., 2025a).

Sociocultural beliefs and low awareness remained important contributors to delayed presentation, timely diagnosis and intervention. Parents frequently attributed hearing loss to spiritual or ancestral causes and sought traditional or religious remedies before medical care. This aligns with findings from Uganda and other African contexts (Mwaka et al., 2018; Aldè et al., 2025) as well as global reviews emphasising the role of sociocultural interpretation and stigma in shaping health-seeking behaviour (Swanepoel and Clark, 2019; Pritchard et al., 2025). This contributes to inconsistent therapy uptake, and limited family engagement. The strong agreement among respondents regarding inadequate awareness campaigns indicates a need for culturally tailored health promotion strategies embedded in maternal care pathways, schools, and community health systems, this is in agreement with the findings of Anyanwu et al. (2024).

Consistent with global literature, audiologists and parents emphasised the developmental benefits of early identification and intervention, particularly improvements in communication and social engagement among children diagnosed before two years of age. These findings support the established JCIH 1-3-6 benchmarks (Cole and Flexer, 2020; Yoshinaga-Itano et al., 2024) and echo earlier Nigerian studies demonstrating better outcomes with timely amplification and therapy (Olusanya et al., 2008). However, many children in this study still entered intervention well beyond the recommended timeframe, reflecting systemic barriers similar to those reported by Merugumala et al. (2017) and other LMIC-based studies (Ansari, 2022).

Financial constraints emerged as the most severe barrier to access, with many families unable to afford screening, diagnostic assessments, therapy, or assistive devices. This finding is consistent with literature documenting high out-of-pocket costs as a major obstacle to audiology services in LMICs (Frazier et al., 2023; Pervez and Anjum, 2023). Additionally, a critical shortage of trained audiologists—particularly in northern and rural regions—continues to impede timely diagnosis and follow-up, aligning with previous research pointing to workforce limitations and poor remuneration across Africa (Khoza-Shangase, 2022). These labour and cost barriers suggest that without significant government intervention, early intervention outcomes will continue to favour families with higher socioeconomic status and urban residency (Baranyai, 2023). Sustainable EHDI must therefore consider not only technology but also long-term economic and workforce planning.

Overall, the current findings confirm earlier observations while adding deeper insight into how equipment shortages, sociocultural beliefs, financial barriers, and workforce gaps interact to delay diagnosis and limit continuity of care. Although technological advancements, increased parental recognition of early intervention benefits, and emerging pilot screening programmes represent positive steps, Nigeria’s EHDI framework remains fragmented and inequitable.

5. Conclusion

Nigeria’s EHDI framework shows clear strengths: availability of modern diagnostic tools, growing clinical expertise, and parental recognition of the value of early intervention. However, these strengths remain undermined by: financial barriers, uneven personnel distribution, limited equipment in rural regions, persistent cultural misconceptions, and lack of sustained national awareness strategies. A cohesive national EHDI pathway requires enhanced family-centred support systems as well as, integrated policies that address these structural, financial, and sociocultural constraints while harnessing existing clinical strengths.

6. Recommendations

The study’s findings highlight the need for coordinated, evidence-driven action to strengthen paediatric hearing care in Nigeria. Governments should prioritise equitable distribution of diagnostic tools—particularly portable OAE and AABR devices—to under-resourced facilities and subsidise screening, diagnostic, and early intervention services to ease cost-related delays. Expanding national training programmes for paediatric audiologists and primary healthcare workers is essential to address workforce gaps, while targeted, culturally appropriate community awareness campaigns can improve parental knowledge and reduce late diagnoses. Making Universal Newborn Hearing Screening (UNHS) a mandatory part of postnatal care would help standardise early identification nationwide, and increased investment in locally relevant research, including community-based screening and mobile audiology models, would strengthen long-term sustainability of hearing care services.

7. Strengths and Limitations

This study’s key strength lies in its mixed-methods design, which combined quantitative data with in-depth perspectives from audiologists and parents across multiple regions, providing a comprehensive view of Nigeria’s EHDI system. Rigorous thematic analysis and diverse facility representation enhanced credibility. However, the sample may not fully capture experiences from the most remote communities, and parent recruitment through clinics may have excluded families who never accessed services. Self-reported data also introduce potential recall and social desirability bias. Despite these limitations, the findings offer valuable evidence to guide improvements in early hearing care in Nigeria.

Funding Statement

This research did not receive any specific grant from funding agencies.