# Global Audiology/Africa/Malawi

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# General Information

Malawi is a landlocked country located in southeastern Africa, sharing borders with Tanzania, Mozambique, and Zambia. Lake Malawi, the third-largest lake in Africa, lies along the northeastern border. Lilongwe is the country’s capital.
In the 10th century, Bantu-speaking peoples settled in modern-day Malawi. These tribes ruled until the 18th century, with the introduction of European colonists. In 1891, Malawi became a British colony. Known as the "Warm Heart of Africa," the country peacefully gained independence on July 6, 1964, which is now known as Independence Day, and has remained war-free ever since. In 1994, Malawi adopted a new constitution and is now a multi-party democracy (BBC, 2019).
As of 2020, Malawi has a growing population of 19 million people. The birth rate is among the highest in the world, with 4.3 births per woman (Malawi Demographics, 2020). Malawi has a low urban population of only 18.5% (Malawi Demographics, 2020). Malawi is among the poorest countries in the world, with 51.5% of the population living below the poverty line and 20.1% living in extreme poverty (World Bank, 2016).
Several African languages are spoken, all of which are Bantu languages. Chichewa is spoken by the majority, and other languages include Nyanja, Yao, and Tumbuka. English is the country’s official language.

# History of Audiology

Up until recently, audiology and hearing-related services in Malawi were extremely limited. Hearing aids were fitted by an ear, nose, and throat (ENT) specialist and SOS Children’s Villages hearing rehabilitationist or by visiting projects in the country. However, hearing aids were expensive or of low quality. Other options relied on an intermittent supply of donated hearing devices and materials for making earmolds. Most Malawians are unable to afford these services. Schools for the Deaf have been available; however, teachers of the Deaf, employed by the government school system, have limited access to otoscopy and audiometry equipment to assess the ear health and hearing of students, and some are not adequately trained to use this equipment where it is available. Malawi has six schools for the deaf: Karaonga School for the Deaf, Bandawe School for the Hearing Impairment, Embangweni School for the Hard of Hearing, Mua Deaf School, Maryview School for the Deaf, and Mountain View School of the Deaf.
Over the past decade, EARS Incorporated, an Australian non-for-profit charity has been instrumental in establishing audiology services and hearing health care in Malawi. In early 2010, their mission was accepted at the African Bible College (ABC) in Lilongwe, Malawi. In August 2010, Rebecca and Peter Bartlett, two Australian audiologists, were the first audiologists registered with the Medical Council of Malawi (MCM). Since September 2010, audiology services, including hearing assessment and hearing aid fitting, for children and adults, have been offered through the ABC Community Clinic in Area 47, Lilongwe.
The ABC Hearing Clinic and Training Centre (ABC HCTC), the first specialist audiology facility in Malawi, was opened on October 4, 2013, with a provision of an Australian government AusAID grant and a partnership with Sonova’s Hear the World Foundation. Along with providing quality, low-cost audiological services to nearby communities, the ABC HCTC also operated as a professional training center for Teachers of the Deaf, local staff at the ABC Clinic, and ABC students. Other significant projects for the ABC HCTC included the provision of sustainable earmold services and outreach services to address the hearing health needs of those in remote communities or offsite locations. Today, an important goal of the ABC HCTC is to further develop, facilitate, and implement the delivery of the first Bachelor of Science degree in Audiology in sub-Saharan Africa (outside of South Africa). This program enables audiologists to be cost-effectively trained in Malawi and for these audiologists to provide best-practice and patient-centered audiological services to their communities.
In 2015, the audiology charity Sound Seekers (now Deaf Kidz International) UK sponsored the education of Malawians to earn their Master of Science in Audiology at the University of Manchester in England (Sound Seekers, 2018). In January 2016, funded by UK Aid from the British People, Jersey Overseas Aid, and Sound Seekers UK, another hearing clinic officially opened in the Queen Elizabeth Central Hospital (QECH) in Blantyre (Sound Seekers, 2018). This clinic has since been significant for ear health and hearing services in the southern region of Malawi. On September 13, 2016, Chikondi Chabaluka, Mwanaisha Phiri, and Fletcher Chisalipo graduated from the University of Manchester to become the first ever Malawian audiologists.
On June 1, 2021, the ABC Audiology Department graduated its first class of audiologists, introducing the first ten Malawian audiologists in the entire country. While ear health and hearing services are still lacking, these young audiologists will combine with the three Audiology masters graduates to shape and develop the profession of audiology in Malawi as they work to improve the hearing and quality of life of their fellow Malawians.

# Incidence and Prevalence of Hearing Loss

Currently, there is very little incidence or prevalence data available regarding hearing loss in Malawi. One cross-sectional study estimates the prevalence of unilateral and bilateral hearing impairment in children ages 4-6 years old to be 24.5% and 12.5%, respectively (Hunt et al., 2017). No type or severity data was reported in the study, leaving a significant gap in our understanding of the etiology and ability to treat the hearing losses reported. Researchers found a “high burden of middle ear disease and preventable hearing impairment,” (i.e., conductive hearing loss) within their sample population (Hunt et al., 2017). Additionally, Tataryn, et al. (2019) found that hearing loss was the most common type of disability in children in Malawi. Another study found that, of all children who were referred for ear and hearing services, only 5 out of 150 (3%) followed up with their referral (Bright et al., 2017). With a low uptake of referrals to hearing services in Malawi, the possibility of a high incidence of conductive hearing loss is troubling.
Malawi continues to battle a high rate of HIV; however, with improved access to antiretroviral therapy (ART), HIV is now less of a threat to life and more of a chronic illness. A greater prevalence of hearing loss has been suggested to be linked to HIV-infected children. A study by Hrapcak et al. (2016) found that 24% of 380 pediatric HIV-infected patients had hearing loss. Within this small population, 82% were conductive, 14% were sensorineural, and 4% were mixed (Hrapcak et al., 2016). The study found that there is an urgent need for improved screening tools and treatment for hearing loss in HIV-infected children.
The lack of type and severity of hearing loss data in the general population of children, combined with the nonexistence of hearing loss prevalence data in adults, is indicative of an urgent need for further study in Malawi.

# Information About Audiology
### Educational Institutions

Currently, the only institution in Malawi providing an audiology training course is the African Bible Colleges (ABC), which offers a Bachelor of Science in Audiology degree (B.Sc. Aud). This is a four-year undergraduate program, following the completion of a prerequisite year of foundational ABC Core units. This degree program enables audiologists to be cost-effectively trained in Malawi, consistent with the philosophy that Malawians should be trained in Malawi in a way that best responds to the unique strengths, abilities, and challenges of the country.
The program is designed to develop and produce audiologists of genuine integrity for Malawi and neighboring countries. Through ethical and resourceful leadership, these audiologists will provide best-practice audiology services, training, and outreach in a variety of settings to address the needs of people with ear, hearing, and balance issues. The training of audiologists through this degree program will: 1. ensure that health services are better equipped to deal with ear and hearing health and rehabilitation issues; and 2. ensure that students with hearing impairments and deafness are resourced for inclusion in supportive educational environments.
The goal of this program is to achieve self-sustainable audiology services in Malawi by fostering and educating Malawian audiologists. Once graduated, audiologists will be registered with the Medical Council to continue their exciting career in audiology. To ensure self-sustainability for the ABC HCTC, students may attain higher graduate degrees from other nations so that they are able to become educators themselves to continue the process of training national audiology students.

### Audiology Practice: Public and Private

Malawi’s healthcare system is based on primary healthcare (PHC). Health services are provided by the public, private for-profit (PFP), and private not-for-profit (PNFP) sectors (Makwero, 2018).
In each of its three main cities, Malawi has a public central hospital: the Queen Elizabeth Central Hospital (QECH) in Blantyre, Kamuzu Central Hospital in Lilongwe, and Mzuzu Central Hospital in Mzuzu. The central hospitals, particularly the QECH, have access to otolaryngologists (ear, nose, and throat specialists, or ENTs) and more specialized equipment. Additionally, there are smaller hospitals spread across Malawi’s 28 districts with more limited resources.
Currently, the ABC HCTC and the QECH audiology department are the only two hearing clinics in the country. Although there is an ENT clinic in the Kamuzu Central Hospital, there are limited audiology services available, and those services are offered by audiology technicians. There are currently no available audiology positions within the Ministry of Health's government hospital system, or the Department of Special Needs Education. As more Malawian audiologists are trained and the profession of audiology is further established, it is ideal that audiologists serve a more distinct role in the public sector so that services expand into central and district hospitals across the country

### Audiological Services

The following services are provided by the ABC HCTC:
* Diagnostic hearing assessments, pediatric and adults
* Hearing aid evaluations, fittings, programming, and real-ear verification
* Hearing screening programs
* Earmold impressions and manufacture
* Cochlear implant candidacy evaluation, mapping, and programming
* Electrophysiology (ABR/ASSR)
* Vestibular/balance assessments
* Cerumen (ear wax) management
* Auditory rehabilitation
* Outreach to rural areas
The audiology clinic within QECH provides all the services listed above with the exception of electrophysiology and vestibular evaluations.

### Services offered by Otolaryngologists/Otologists

Within Malawi’s Ministry of Health government hospital system, there are two ENT specialist doctors; 29 ENT Clinical Officers; three nurses trained in audiology at the University of Nairobi, Kenya; and one audiologist, who completed her Masters of Audiology at the University of Manchester in England (Mulwafu, et al., 2017). Services are limited to the larger hospitals in the country. Equipment, resources, and medications are very limited. Although there is a growing number of ENT clinical officers and audiology technicians, a lack of equipment severely limits the services they are able to provide.

### Scope of Practice and Licensing

To practice audiology in Malawi, a clinician must be registered with the Medical Council of Malawi (MCM). All practicing audiologists in Malawi have higher-level degrees specific to audiology. If the clinician is from a nation where the profession of audiology is established, it is a matter of presenting registration from that nation.

### Professional and Regulatory Bodies

There is neither professional licensure nor professional audiology organizations in Malawi, as audiology is still developing as a profession in the country.

# Research in Audiology

We are aware of one published article about audiology services in Malawi (Parmar et al., 2021). Parmar et al. (2021) investigated the profiles of patients attending the QECH audiology clinic using a retrospective patient record review and found that the demand for hearing services is increasing in this public sector, but the uptake of hearing aids for those in need is low. This group is also conducting two new studies: one to trial low-cost hearing aids and one retrospective review to understand the clinical profiles of patients attending the new audiology clinic at Kamuzu Central Hospital.
The following research projects are currently ongoing in collaboration with the ABC HCTC and the University of South Florida, Tampa, Florida, in the United States:

### Survey of Teachers in Malawi: Hearing Health Awareness

There are plenty of unknowns about the nature of ear and hearing health issues in Malawi, and generally, there is a lack of public awareness about hearing health. Prevention, increased awareness, and health education are the most cost-effective tools for reducing hearing loss, which is especially important for low- and middle-income countries (Olusanya et al., 2014). In 2019, it was found that hearing loss occurs in an estimated 11.5% of school-aged children in Malawi (Mulwafu et al., 2019). Since teachers have a lot of contact with school-age children, targeting these professionals with a hearing health education program is expected to improve hearing healthcare by increasing the detection and identification of children with hearing loss.
The aim of this study is to assess primary school teachers’ knowledge of hearing health, audiology services, and management of hearing issues before and after an educational program. A pre-survey will be completed before the intervention, then the teachers will attend an educational training, and finally a post-survey will be completed after the intervention. These pre- and post-surveys will assess the teachers’ knowledge as well as draw conclusions about their opinions regarding hearing health training in their profession. It is hypothesized that the teachers will benefit from the educational training, and that providing them with the knowledge and skills to detect children with hearing loss will improve hearing healthcare in Malawi overall.

### A retrospective study of estimated conductive hearing loss prevalence in Malawi

There is little data on the prevalence of hearing loss in Malawi. One study found 24.5% and 12.5% of children aged 4-6 had a unilateral or bilateral hearing loss, respectively (Hunt et al., 2017). However, the study lacked type and severity data, creating an incomplete picture. With the poor referral uptake seen in ear and hearing healthcare in Malawi, obtaining a more complete picture of the prevalence of hearing loss is vital to the hearing health of the individual as well as the country. Specifically, conductive hearing losses are typically preventable or treatable and have been shown to have a high rate of incidence in other developing countries. Determining the prevalence of this type of hearing loss in Malawi is of great importance for possible legislative and funding purposes.
The goal of this study is to estimate the prevalence of conductive hearing loss in Malawi and compare it to the prevalence in other countries. Audiological records from the ABC HCTC will be reviewed, and the prevalence of conductive hearing loss will be estimated as a percentage of total identified hearing losses. Due to limited resources, a cross-sectional prevalence study was unattainable at this time, but it is our hope that the results of this study will help support further and more thorough studies into hearing loss prevalence in Malawi.

# Audiology Charities
### EARS Incorporated

Mission: EARS Inc. is dedicated to reducing the incidence and impact of hearing impairment through training and equipping local individuals and agencies in low- and middle-income countries (LMIC). We serve and empower people, irrespective of nationality, race, gender, or religion, while showing the love of Jesus through our words and actions. Our vision is for deaf and hearing-impaired people in LMIC to have access to the hearing services they need to become self-sufficient and achieve their potential. (EARS Incorporated, 2021)

### Sonova’s Hear the World Foundation

Mission: The Hear the World Foundation advocates for equal opportunities and an improved quality of life for people with hearing loss all around the world. The foundation actively supports aid projects benefiting people, and particularly children in need with hearing loss, with funding, hearing technology, and expertise provided by Sonova employees as volunteers. (Hear the World Foundation, n.d.)

### Deaf Kidz International

Mission: The Hear the World Foundation advocates for equal opportunities and an improved quality of life for people with hearing loss all around the world. The foundation actively supports aid projects benefiting people, and particularly children in need with hearing loss, with funding, hearing technology, and expertise provided by Sonova employees as volunteers. (Hear the World Foundation, n.d.)

### Arizona State University Hearing for Humanity

Description: Hearing for Humanity is a program of Arizona State University’s Speech and Hearing Clinic that includes a team of audiologists, speech language pathologists, and ASU students to provide humanitarian audiological and speech services in Malawi, Africa. We have been traveling since 2010 with 15-20 students and professionals to conduct our month-long humanitarian missions. (Arizona State University Hearing for Humanity, 2021).

### The Starkey Hearing Foundation

Mission: The Starkey Hearing Foundation’s mission is to give the gift of hearing to those in need, empowering them to achieve their potential. By focusing on education and training and collaborating with governments, nongovernment organizations, and health leaders, our goal is to make hearing healthcare services more accessible for people around the world. To date, we have given the gift of hearing to more than 100 countries. We have trained and educated volunteers around the globe who continue today to help those in need in their communities. (Starkey Hearing Foundation, 2021).

# Challenges, Opportunities and Notes

=== Challenges === The following are the challenges established by the needs assessment, conducted in 2016 by the African Bible College (ABC), as outlined in the degree program curriculum (2018):
* The knowledge and practice of effective ear health are lacking in the general public.
* Ear and hearing services are desperately lacking across the country. Respondents reported a lack of diagnostic resources for proper assessment as well as a lack of preventative care for ear health, including a lack of access to antibiotic medicines and the inappropriate use of ototoxic drugs.
* There are many areas in this health and rehabilitation field requiring coordination, planning, implementation, and evaluation.
* The true nature and extent of the problems regarding ear health and hearing rehabilitation in Malawi are not well known.
* There are few studies pertaining to the prevalence and impact of ear and hearing morbidity in this country.
* The literature indicates that the incidence of hearing loss is a significant public health issue.
* It is likely that there are hundreds of thousands of Malawians who could benefit from wearing assistive hearing devices, such as hearing aids.
* With such a significant need for assistive hearing devices and only a few services to provide them, the gap in infrastructure, personnel, public awareness, specialist education, and rehabilitative resources is obvious.
* With regard to surveying children with hearing impairment and their guardians, the types and levels of hearing loss were often unknown.
* Both adults and children with hearing loss experience stress and difficulties in communication with peers, strangers, and some family members.
* Although a sign language is being developed and is used in schools for the deaf and deaf communities, there is not currently a standardized Malawian sign language, nor is there an official publication supporting the instruction of sign language in Malawi.
* Guardians reported their children with hearing impairments were socially excluded and had reduced access to learning in class. This was associated with poor classroom performance and behavior, plus frustration, withdrawal, misunderstandings, and a lower level of community participation.

# References

African Bible Colleges (2018). Rationale for the Development of the Audiology Program in Malawi, Bachelor of Science in Audiology Curriculum, Malawi.
Arizona State University Hearing for Humanity. (2021). Hearing for Humanity: Who are we?
BBC (2019, March 19). Malawi Profile: A chronology of key events.
Bright, T., Mulwafu, W., Thindwa, R., Zuurmond, M., & Polack, S. (2017). Reasons for low uptake of referrals to ear and hearing services for children in Malawi. PLoS One, 12(12), e0188703.
Caron, C. (2016, March 10). So you want to be a Humanitarian audiologist? [Interview] Student Academy of Audiology.
Deaf Kidz International. (2021). We are Deaf Kidz International
EARS Incorporated. (2021). About us.
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Hear the World Foundation. (n.d.). Equal Opportunities and Improved Quality of Life.
Hrapcak, S., Kuper, H., Bartlett, P., Devendra, A., Makawa, A., Kim, M., Kazembe, E., & Ahmed, S. (2016). Hearing Loss in HIV-Infected Children in Lilongwe, Malawi. PLoS ONE 11(8): e0161421.
Hunt, L., Mulwafu, W., Knott, V., Ndamala, C. B., Naunje, A. W., Dewhurst, S., … & Mortimer, K. (2017). Prevalence of paediatric chronic suppurative otitis media and hearing impairment in rural Malawi: A cross-sectional survey. PLoS One, 12(12), e0188950.
Makwero M. T. (2018). Delivery of primary health care in Malawi. African Journal of Primary Health Care & Family Medicine, 10(1), e1–e3.
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Mulwafu, W., Thindwa, R., Prescott, C., Nyirenda, T. E. (2017). Strategies to combat ear and hearing disorders in a poor African country, the Malawi National Plan. Glob J Otolaryngol 10(1): 555776. DOI: 10.19080/GJO.2017.10.555776.
Mulwafu, W., Tataryn, M., Polack, S., Viste, A., Goplen, F. K., & Kuper, H. (2019). Children with hearing impairment in Malawi, a cohort study. Bulletin of the World Health Organization, 97(10), 654.
Olusanya, B. O., Neumann, K. J., & Saunders, J. E. (2014). The global burden of disabling hearing impairment: a call to action. Bulletin of the World Health Organization, 92, 367-373.
Parmar, B., Phiri, M., Caron, C., Bright, T., & Mulwafu, W. (2021). Development of a public audiology service in Southern Malawi: profile of patients across two years. International Journal of Audiology, 1-8. DOI: 10.1080/14992027.2020.1864486.
Sound Seekers. (2018). Malawi: Developing the first comprehensive audiology service in Southern Malawi.
Starkey Hearing Foundation. (2021). About us.
Tataryn, M., Chokotho, L., Mulwafu, W., Kayange, P., Polack, S., Lavy, C., Kuper, H. (2019). The Malawi Key Informant Child Disability Project. International Centre for Evidence in Disability.
Worldometer.info (2021).
World Bank. (2016). Poverty headcount ratio at national poverty lines (% of population) – Malawi.
| | | | | | | | | Contributors to the original text |
| Kelly Gordie | Nathaniel Davis | Jennifer Jones | Peter Bartlett | Jenna Vallario | Memory Khomera | Grant Kapalamula | Julia Toman | Contributors to the original text |