Effectiveness and cost-effectiveness of home-based intervention to support early deaf child development in South Africa.

Around 6000 children per year are born deaf or become so in the first weeks of life in South Africa (SA). For the vast majority, the absence of newborn hearing screening and access to hearing technologies in the first few years of life, results in severe impairment to deaf children's linguistic, cognitive and social development. In economically rich countries this is not the case where universal newborn hearing screening plus high quality early intervention has radically reduced the deleterious effects of deafness and positively impacted the life chances of deaf people. WHO recognises hearing impairment as the most prevalent disabling condition globally, affecting an estimated 7.5 million under the age of 5, two thirds of whom reside in the developing world. Although early childhood development is a key priority, impacting this situation for deaf children is hampered by a scarcity of population level data and very few quality early intervention programmes that reach all population demographics. SA is potentially different because there is one large-scale donor funded home based early intervention programme for deaf children and their families that has been evidenced to reach representative diverse populations (HI HOPES). Demographic, hearing and developmental data are available on over 1800 deaf children under 6 years of age making it the largest such data set in sub-Saharan Africa. However, only a small part of this data set has ever been analysed and published. In SA there has been a large government investment in boosting early childhood development with the creation national early learning standards and a country-specific standardised tool- the ELOM (Early Learning Outcome measure). Deaf children so far have been excluded from these steps forward because of the absence of evidence for effective early intervention and the need to adapt the ELOM to be valid for deaf children which in turn will provide evidence for future intervention priorities and programmes. In this context, the goals of our project are: [A] To evaluate the effectiveness and cost-effectiveness of the HI HOPES programme in order to consider its potential for upscaling throughout SA and into other countries of Sub-Saharan Africa. [B] To provide large scale data on the development of deaf children in SA aligned with the SA Government/UNICEF National Early Learning and Development Standards birth to 4 years (NELDS) as a basis for clearer identification of developmental support requirements for this population. [C] To adapt for use with deaf children, in both spoken and signed languages, the SA Government- adopted tool for the evaluation of early childhood development - the ELOM (Early Learning Outcome Measure) - so it becomes possible for the first time in South Africa accurately to evaluate deaf children's developmental progress and needs in all domains (not just language) at point of school entry. Research questions are: A1: What is the impact on communication and language development of exposure to a structured home-based early intervention programme for deaf children birth to 6 years and what variables influence its effectiveness? A2: Is a population level early intervention service to promote deaf child development and parent responsive care cost effective? B: To what extent are deaf children meeting National Early Learning Development Standards in SA? C: What are the reliability and validity characteristics of an adaptation suitable for deaf children of the ELOM? Two deaf-specific research units (one in South Africa, one in the UK) are partnering with HI HOPES and the ELOM Foundation/Innovation Edge to achieve these goals to build both a substantial set of evidence on deaf child development in South Africa and new tools for its monitoring as the basis for further policy and practice development in this field where evidence based practice is lacking and the economic case for early investment for deaf children is yet to be made.

The study concerns deaf children under 6 years in South Africa (SA) who have been enrolled the HI HOPES early intervention programme (n=1800). The research objectives are: [A] To evaluate the effectiveness and cost-effectiveness of the HI HOPES programme in order to consider its potential for upscaling throughout SA and into other countries of Sub-Saharan Africa. [B] To provide large scale data on the development of deaf children in SA aligned with the SA Government/UNICEF National Early Learning and Development Standards birth to 4 years (NELDS) as a basis for clearer identification of developmental support requirements for this population. [C] To adapt for use with deaf children, in both spoken and signed languages, the SA Government- adopted tool for the evaluation of early childhood development - the ELOM (Early Learning Outcome Measure) - so it becomes possible for the first time in South Africa accurately to evaluate deaf children's developmental progress and needs in all domains (not just language) at point of school entry. A process evaluation methodology guides the secondary data analysis of the HI HOPES data set and primary data collection on 200 infants. The outcome measures are a criterion-referenced deaf child language development scales (LDS) and early childhood development assessment (NELDS - SA). In addition, the study will adapt the ELOM (SA) to be suitable for deaf children following an online Delphi consensus approach and a test-retest reliability study (n=80). The cost effectiveness study uses a bottom-up, ingredients-based costing analysis and a cost of illness study from a societal perspective. The project will also supply data on the model, impact and costs of intervention at a level of detail to enable feasibility testing of its scalability at national level and its replicability in other countries of Sub-Saharan Africa.