# Global Audiology/Africa/South Africa

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# General Information

South Africa (SA), the southernmost country in Africa, is among the four nations with the continent’s largest gross domestic product (GDP) (Cooper et al. 2020). Known for its remarkable diversity, SA is divided into nine provinces, each with its own legislature, premier, and executive council. This diversity is also reflected in its 12 official languages: Afrikaans, English, Ndebele, Pedi, Sotho, South African Sign Language, Swati, Tsonga, Tswana, Venda, Xhosa, and Zulu. The late Archbishop Desmond Tutu famously called SA “The Rainbow Nation” in recognition of its rich cultural, linguistic, and ethnic variety (Dixon, 2023).
One of the most significant issues in South African history is apartheid, a system of racial segregation, meaning "apartness." This ideology or law was introduced and supported by the National Party and implemented in 1948 (South African History Online, 2022). During this regime, the apartheid law forced the different racial groups to live separately and develop. Apartheid ended in the early 1990s, culminating in the first democratic elections in 1994, when Nobel Peace Prize laureate Dr. Nelson Rolihlahla Mandela became South Africa’s first black president.
SA shares borders with Botswana, Zimbabwe, Namibia, Lesotho, Eswatini, and Mozambique. Its population is estimated at 63.02 million (StatsSA, 2024). The country is also renowned for its mineral wealth, with mining dating back to the 1800s. Diamonds were discovered in the Northern Cape in 1867, and gold was found in Gauteng in 1884. As such, mining was reported to be the second most influential industry, with manufacturing being the largest in the country (StatsSA, 2017). Due to the nature of this work, both in the mining and manufacturing industries, earliest reports on noise-induced hearing loss (NIHL) were documented among gold miners in the 1980s (Hessel & Sluis-Cremer, 1987).

# Incidence and Prevalence of Hearing Loss

Hearing loss is a widespread public health concern, with Sub-Saharan Africa contributing significantly to global estimates (WHO, 2021). The World Health Organization (WHO) reports that approximately 15.7% of adults aged 15 and older in this region experience hearing loss (WHO, 2021). In South Africa, an estimated 12 million people are affected by some degree of hearing loss, including about 4 million individuals with hearing disabilities, of whom fewer than 600,000 use South African Sign Language (SASL) (World Hearing Report, 2022).
There are notable regional disparities in hearing loss prevalence across South Africa. Less developed provinces generally report higher rates compared to more developed areas. In Cape Town, located in the developed Western Cape province, the overall prevalence of hearing loss in the population was reported to be 12.35% (95% CI: 11.06%- 13.64%), and the prevalence of disabling hearing loss was 4.57% (95% CI: 3.75%- 5.39%) amongst individuals ≥ 4 years old (Ramma & Sebothoma, 2016). Hearing loss prevalence in primary health care settings in urban and peri-urban facilities has been reported as being 17.5%, with most hearing losses being bilateral (70.0%) and sensorineural in nature (84.2%) (Louw et al. 2018). Conversely, the overall prevalence of hearing loss in the Elias Motsoaledi Local Municipal (EMLM) area in rural Limpopo province, was reported to be 19.88% (95% confidence interval [CI]: 0.15–0.2) and 8.94 (95% CI: 0.08–0.12) for disabling hearing loss. The prevalence of ear disease was 13.19% (95% CI: 0.10–0.15), with impacted cerumen and otitis media reported as the most prevalent cause (Joubert & Botha, 2019).
Similar patterns of disparities are observed across age groups, as illustrated in Table 1 below.
Table 1. Prevalence rates across age groups for Limpopo and Gauteng Province
These findings underscore the critical need for comprehensive hearing care services, including prevention, early detection, and intervention, to address the rising prevalence of hearing loss across South Africa.

# Information About Audiology

Hearing healthcare services in South Africa began with limited availability, primarily emerging in the mid-20th century. The development of audiology was closely linked to the establishment of university training programs, which began at the University of the Witwatersrand (Wits) in the late 1930s and early 1940s. In those early years, hearing healthcare services were often provided through hearing aid fitting and assessment programs, and much of the clinical work was associated with hospitals, schools for the deaf, and other special education facilities. Throughout the 1970s and 1980s, more formalized audiology clinics began to emerge in hospitals across South Africa, often as part of larger healthcare systems. During the 1990's, the government started to recognize the need for comprehensive hearing care services, and more initiatives to improve accessibility in both urban and rural settings were developed.
Today, audiology services in South Africa are more widespread; however, they remain concentrated in urban areas. In 2024, 947 audiologists were registered with the Health Professions Council of South Africa (HPCSA), with the majority practicing in private settings rather than public healthcare facilities. This distribution underscores the ongoing gap in access to services.
Audiological Services Audiology services in South Africa encompass both core and advanced diagnostic and rehabilitative options to address a range of hearing and balance disorders. These services play a crucial role in improving the quality of life for individuals affected by hearing loss and balance disorders.
Core Audiology Services
* Pure-tone audiometry (PTA): A standard test to determine hearing thresholds.
* Tympanometry: Evaluation of middle-ear function, including eardrum movement and pressure within the middle ear.
* Impedance audiometry: Assessment of middle-ear reflexes and compliance.
* Otoacoustic emissions (OAE): Screening for cochlear (inner ear) function, particularly for newborn hearing programs, and used for differential diagnostic purposes in older populations.
* Screening auditory brainstem response (ABR): Early detection of auditory pathway integrity, especially for infants and individuals unable to perform standard audiometric tests.
* Hearing aid assessment and dispensing: Comprehensive evaluation and fitting of hearing aids tailored to individual hearing needs.
● Aural rehabilitation: Therapy and counselling to maximize the use of residual hearing and optimize communication skills.
Advanced Audiology Services Advanced audiology services are available at selected practices and hospitals; these services expand diagnostic and rehabilitative options:
* Diagnostic auditory brainstem response (ABR): A detailed evaluation of the auditory
pathway, aiding in the diagnosis of neurological and cochlear disorders.
* Auditory steady-state response (ASSR): Assessment of hearing thresholds, particularly in difficult-to-test populations, including infants.
* Implantable devices: Evaluation, programming, and management of cochlear implants, bone-anchored hearing aids (BAHA), and other implantable hearing solutions.
* Vestibular audiology: Comprehensive assessment and management of balance disorders, including:
- Computerized Dynamic Visual Acuity (cDVA): Evaluation of visual stability during head movements. - Video head impulse testing (vHIT): Assessment of semicircular canal function. - Vestibular evoked myogenic potentials (VEMPs): Measurement of vestibular function through muscle responses. - Electrocochleography (EcoG): Diagnosis of endolymphatic hydrops and other inner ear conditions. - Videonystagmography (VNG): Analysis of eye movements to assess vestibular function. - Posturography: Evaluation of balance and postural control. - Fall Risk Assessment: Identification of individuals at risk of falling using standardized tools, including gait and balance evaluations, timed up-and-go (TUG) test, Berg Balance Scale (BBS), and functional reach tests. Audiologists assess the impact of vestibular dysfunction on postural stability and recommend appropriate interventions to mitigate fall risk. - Vestibular rehabilitation: Customized therapy programs to address balance dysfunction and dizziness, incorporating exercises for gaze stabilization, balance improvement, and compensation strategies. - Central auditory processing disorder (CAPD) testing and management: Identification and treatment of difficulties in the brain’s ability to process auditory information. - Tinnitus management: Multi-faceted approach to alleviate tinnitus symptoms, including sound therapy, counseling, and habituation strategies.
This comprehensive list reflects the range of audiology services available in South Africa, showcasing the country's capacity to provide both foundational and advanced care across diverse populations. These services are critical for addressing the needs of individuals with hearing and balance disorders, contributing to improved quality of life.
The public sector provides audiology services primarily in hospitals and community clinics, but access can be inconsistent, especially in rural areas. While government hospitals offer these services, they are often limited due to resource constraints, including equipment shortages and understaffing. This disparity is accentuated in rural and underserved areas, where audiology services may be entirely unavailable.
In contrast, private audiology practices are more equipped and accessible in urban and suburban areas, offering a broader range of diagnostic and rehabilitative services. Private practitioners often include tinnitus management, vestibular assessments, auditory processing evaluations, and hearing aid fittings as part of their comprehensive care. However, these services are typically funded out-of-pocket or through medical aid schemes, limiting access for economically disadvantaged individuals.

# Scope of Practice and Licensing

To meet the diverse needs of individuals with hearing and balance issues, South Africa relies on a network of hearing healthcare professionals who work collaboratively to provide comprehensive care. These include:
* Audiologists who are central to hearing healthcare, offering services such as hearing assessments, cerumen management, hearing intervention (invasive and non-invasive hearing devices), aural rehabilitation, vestibular evaluations, and interventions. These professionals are trained through accredited university programs and work in a variety of settings, including public and private hospitals, private practices, and community health centers.
* Hearing aid acousticians specialize in the assessment, fitting and maintenance of hearing aids and other assistive listening devices for adults. They typically work in private practices or audiology clinics.
* Ear-, Nose-, Throat, Specialists (otolaryngologists/otologists/otoneurologists) focus on complex ear and balance disorders, managing advanced cases of hearing loss or
vestibular conditions in urban hospitals and private clinics. ENT specialists often collaborate with audiologists, particularly for patients requiring surgical interventions such as cochlear implants or treatments for chronic otitis media. These specialists provide services in both public and private healthcare settings, with their training conducted through accredited medical schools and specialized ENT programs within the country.
* Community healthcare workers (CHWs) and early childhood development (ECD) practitioners, where available, support audiologists and hearing healthcare professionals in underserved areas. They may serve as the first point of contact, conducting basic hearing screenings and referring individuals for further evaluation when necessary. Their community-based position also enables them to monitor at-risk populations, provide early intervention, and raise awareness through health education campaigns on hearing loss prevention, hearing protection, and the importance of early
screening.
In South Africa, the scope of practice for audiologists is clearly defined and regulated by the Health Professions Council of South Africa (HPCSA). Audiologists are authorized to provide or be involved in the following: 1. Hearing Assessment and Diagnosis 2. Hearing Rehabilitation and Management 3. Vestibular Assessment and Rehabilitation 4. Neonatal and Paediatric Audiology 5. Public Health and Education 6. Interdisciplinary collaboration

# References

| | | Contributors to the original text |
| Faheema Mahomed-Asmail | {{{2}}} | Contributors to the original text |