# Integration of ear and hearing care services in low- and middle-income health systems: a systematic review and qualitative synthesis

## TL;DR

This paper reviews how ear and hearing care services can be integrated into healthcare systems in low- and middle-income countries to improve access and outcomes.

## Contribution

The study provides a qualitative synthesis of integration approaches and factors influencing EHC service integration in low-resource settings.

## Key findings

- Most integration approaches are at the micro or individual level.
- Training and mentorship are key enabling factors for integration.
- Inaccessibility of services and healthcare-seeking behavior impact service usage.

## Abstract

Hearing loss is a global public health burden and mostly affects those living in low- and middle-income countries (LMICs). One approach to address ongoing challenges is the World Health Organization’s recommendation for the integration of ear and hearing care (EHC) services into healthcare packages. However, little is known about EHC integration approaches, particularly in LMICs additionally, these approaches have not been investigated through a health systems lens. This qualitative review aimed to describe the various approaches to the EHC service integration in LMICs and to identify enabling and constraining factors. We reviewed 17 studies, with a focus on LMICs, using adaptations of the Valentijn integration and World Health Organization EHC frameworks, following the PRISMA guidelines. Our investigation showed that most integration approaches were at micro or individual level. Enabling factors for integration of EHC services were training, mentorship, collaboration, technology, inclusion of EHC in healthcare packages and investment in EHC services. Barriers were challenges with training, facilities and equipment, policy implementation and resourcing of EHC services. We further described factors influencing healthcare seeking behaviour and the use of integrated EHC services, such as access and ability to pay, referral systems and communication and awareness. This study describes the complex nature of EHC integration and ways to support integration. Key considerations are the level of integration, training to address workforce issues and factors influencing service utilisation as we work towards health system strengthening.

Main findings: This review explored experiences with ear and hearing care service integration into the wider health system in low-resource settings and highlighted the importance of addressing integration at all levels of healthcare including micro, meso and macro levels. Comprehensive and appropriate training programmes for community health workers can address staff shortages and support integration at micro-level.Added knowledge: The inaccessibility of ear and hearing care services impacts the usage of services. Furthermore, issues that can potentially impact healthcare seeking behaviour should be identified and addressed within the integration process.Global health impact for policy and action: The global recommendation for early detection and treatment of hearing loss, such as newborn hearing screening programmes, can only be effective if adapted as national policy and incorporated into primary healthcare packages. The lessons learnt, such as exploring appropriate mentorship programmes to support integration can aid policymakers in developing and implementing policies, which strengthen ear and hearing care services through appropriate integration approaches.

Main findings: This review explored experiences with ear and hearing care service integration into the wider health system in low-resource settings and highlighted the importance of addressing integration at all levels of healthcare including micro, meso and macro levels. Comprehensive and appropriate training programmes for community health workers can address staff shortages and support integration at micro-level.

Added knowledge: The inaccessibility of ear and hearing care services impacts the usage of services. Furthermore, issues that can potentially impact healthcare seeking behaviour should be identified and addressed within the integration process.

Global health impact for policy and action: The global recommendation for early detection and treatment of hearing loss, such as newborn hearing screening programmes, can only be effective if adapted as national policy and incorporated into primary healthcare packages. The lessons learnt, such as exploring appropriate mentorship programmes to support integration can aid policymakers in developing and implementing policies, which strengthen ear and hearing care services through appropriate integration approaches.