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Khoza-Shangase K, Moroe NF, editors. Occupational Noise-Induced Hearing Loss: An African perspective [Internet]. Cape Town: AOSIS; 2022. doi: 10.4102/aosis.2022.BK249.011
A significant number of employees with ONIHL within the African context will continue to have their ear-and-hearing health care neglected until efficient and effective HCPs are implemented. These programmes should take careful cognisance of cohesive, systematic and comprehensive nationalised occupational health strategies that are contextually responsive and relevant (Moroe 2020; Moroe & Khoza-Shangase 2018; Seixas et al. 2012). The authors of this chapter fervently believe that ear-and-hearing as well as occupational health care practitioners (OHPs) in Africa bear the ethical responsibility to ensure that the rights of employees at risk and or exposed to hazardous noise levels are upheld through the best practice in HCPs.
The HCPs are CIs that recognise and acknowledge the complexity of ONIHL and are implemented within systems interacting in multiple layers involving various factors (Moroe 2020; Seixas et al. 2012). These CIs call for the audiology community to be alive to realistic and contextually relevant challenges, which, within the African context, require Afrocentric best-practice solutions (Khoza-Shangase 2022). Guided by the systems theory (Mele, Pels & Polese 2010), to be realistic about the implementation, monitoring and evaluation of outcomes of HCPs within the African mining context, this book has raised a call for a paradigm shift in ONIHL and HCPs in Africa. The book has advanced sufficient arguments and evidence that provide the OHPs, audiologists, in particular, who are involved in ONIHL and HCPs with questions and possible solutions for future practice in the African context. The book further provides practitioners with contextually relevant best practice, best practice that is multidisciplinary in nature and engages all stakeholders in all relevant sectors, with the goal of adoption of a preventive audiology approach to ONIHL, rather than the current compensation-oriented approach. This chapter deliberates on the future of HCPs within the African context, focusing on the next best practice that is guided by local evidence, local context and local policies, thus ensuring an Afrocentric contribution to the world of evidence.
Globally, it is reported that over 2 million occupational accidents are recorded annually with approximately 6 000 employee deaths because of poorly implemented OHS regulations (International Labour Organization 2014; Liu et al. 2020). Besides the cost to human lives, these accidents also carry a significant cost to the employer and the economy of the company and country involved. The prevalence of work-related accidents has been reported to be highest in LMICs, while it is reportedly declining in HICs (Abdallah et al. 2020). However, globally, for example, the costs associated with nonfatal occupational accidents approximated 4% of the global GDP in 2014 alone (Liu et al. 2020). This substantial financial cost highlights the importance of OHS programmes that are aimed at curbing or eliminating these accidents. As one of the common and most neglected occupational health hazards in the workplace, ONIHL and its management via HCPs is not routinely or successfully controlled, and HCPs are not universally implemented, especially in the African context (Moroe et al. 2018).
Occupational noise-induced hearing loss is a major occupational hazard caused by excessive noise exposure, which is one of the most common occupational risk factors, among numerous other risk factors for OHL. Evidence indicates that occupational noise exposure threatens the hearing of many employees and has numerous documented negative effects on health, including irritability, insomnia and fatigue (Chen, Su & Chen 2020). The negative impact of noise exposure on hearing function in the form of ONIHL has documented effects on the affected individual’s communication ability, can impair cognition and personal attention (Basner et al. 2014; Masterson et al. 2016) and can also cause elevated levels of sadness, social stress, negative interpersonal relationships, poor confidence and diminished self-identity (Basner et al. 2014; Chen et al. 2020; Masterson et al. 2016). Lin (2012) also maintained that older individuals with mild hearing impairment have twice the risk of developing dementia, with this risk more than doubling (fivefold) where severe hearing loss occurs.
Occupational noise-induced hearing loss has been documented to have devastating effects, not only on the quality of life of the individual affected as presented but also on the country’s economy and the State’s socio-economic resources (Khoza-Shangase 2020b; Moroe 2018). Chapter 2 lists the following challenges as exacerbating the impact of ONIHL in South Africa: (1) the QBoD (Khoza-Shangase 2020a; Yerramilli 2015), (2) low education and literacy levels, (3) low salaries and (4) poor social determinants of health, in the face of poor OHS awareness. For the employee, the profound effects extend to their family, while they are also significant for the employer who incurs costs through various ways, including (1) compensation for OHS claims, (2) loss of productivity from health-related absenteeism and (3) loss of employees if an employee can no longer continue to work because of the ONIHL disability. As far as the socio-economic impact to the State is concerned, the provision of socio-economic grants for employees with ONIHL is an additional strain to the system, the pressure that can be avoided if effective HCPs are implemented. Moroe (2018) advanced some of these reasons why ONIHL is deemed one of the topmost threats to the country’s public health care and economy, hence the importance of efficient HCPs.
Hearing conservation programmes, as an example of a CI in health care, carry increasing costs that have a significant impact on the quality and outcomes of ear-and-hearing health care for employees exposed to excessive hazardous noise, typical of complex health care interventions (De Jonge, Huyse & Stiefel 2006; Moroe & Khoza-Shangase 2022). Numerous studies from the African context signify gaps in HCPs’ conceptualisation, planning, implementation and monitoring, thus leading to fragmented, incoherent and minimally successful management of ONIHL within this context (Amedofu 2007; Amedofu & Fuente 2008; Dekker et al. 2011; Edwards et al. 2011, 2015; Edwards & Kritzinger 2012; Kahan & Ross 1994; Khoza-Shangase 2020a, 2020b; Liu et al. 2020; Moroe 2018, 2020; Moroe et al. 2018, 2019; Moroe & Khoza-Shangase 2018; Mutara & Mutanana 2015; Ntlhakana, Kanji & Khoza-Shangase 2015; Ntlhakana, Khoza-Shangase & Nelson 2020a; Pillay 2020; Pillay & Manning 2020; Strauss et al. 2014).
In a special issue journal hosted by the South African Journal of Communication Disorders, titled ‘Occupational Hearing Loss in Africa: An Interdisciplinary View of the Current Status’ (Khoza-Shangase, Moroe & Edwards 2020), sufficient evidence was presented to support the call for a paradigm shift in HCPs for assessment and management of ONIHL in Africa. Such a paradigm shift requires acknowledgement of the complex nature of ONIHL as well as the complex nature of its intervention, if positive outcomes are to be achieved (Moroe 2018). Complex interventions, within the systems theory approach, demand a realistic approach towards conceptualisation, planning, implementation, evaluating and monitoring of the hierarchy of control pillars of HCPs (Moroe & Khoza-Shangase 2022). This approach is in line with Kuipers et al.’s (2011) definition of complexity in health care provision, where cognisance must be taken of the inevitable interaction between multiple factors, including task-related factors, patient or employee factors, health care practitioner factors, team factors, environmental factors and organisational factors. Chapter 1 presents these factors, offering examples of what constitutes each factor.
Hearing conservation programmes are interventions aimed at reducing or potentially eliminating hazardous occupational noise that exceeds legislated limits in the workplace, thus preventing ONIHL. With the history of HCPs spanning over two decades in South Africa, various strategies have been adopted to address the iniquitousness of excessive noise exposure in the workplace and its impact on the hearing function of workers. Occupational audiometry advances that indicate a clear paradigm shift from compensation as a goal via PLH (Edwards & Kritzinger 2012; Musiba 2020; Ntlhakana et al. 2020a) to prevention as a goal via STS (Attarchi et al. 2010; Musiba 2020; Ntlhakana et al. 2021) have been widely adopted, with South Africa having recently joined this approach (Booi 2020; Moroe & Khoza-Shangase 2020; Ntlhakana et al. 2021; Ntlhakana, Nelson & Khoza-Shangase 2020b).
Such advances in audiometry protocols adopted as part of HCPs signify the value of audiometry in the prevention, identification and diagnosis of ONIHL, over and above compensation. The developments also have significant implications for practice in HCPs and should consider potential changes associated with advances in clinical audiology service delivery models such as tele-audiology. Moreover, they should consider the impact of automation and digitalisation (as presented in ch. 7), to name a few important considerations. This audiometry aspect of HCPs has important propositions for all stakeholders, including both the employer and the employee; therefore, the critical role of audiologists in HCPs needs highlighting. A centrally located role of the audiologist in HCPs ensures that risk factors such as genetic, lifestyle and health factors are consistently and comprehensively considered in the HCP as this forms part of the audiologists’ training and scope of practice. Furthermore, nuanced application and interpretation of audiometry to ensure that early detection of hearing changes is possible; for example, using OAEs as well as STS instead of PLH requires the audiologists’ skills and knowledge. The use of PLH cut-offs as a trigger for intervention has been shown to miss ONIHL until the loss is at a moderate to severe degree range (Kew 2018; Ntlhakana et al. 2020a; 2020b). It is therefore important that the best available measures that can identify hearing loss early, such as ultrahigh frequency audiometry, over and above those already listed, are applied and or supervised by appropriately and adequately trained professionals – audiologists. Consideration of these factors during the implementation of HCPs in an African context is important for successful and sustainable preventive audiology action that is responsive to context.
Successful implementation of HCPs within the African context continues to be a significant challenge because of the various contextual realities that these programmes must contend with. These context-specific realities, such as those of the South African context covered in Chapter 2, call for collaborative engagement, planning, implementation and monitoring of HCPs by all relevant occupational health stakeholders, with audiologists being more centrally placed than they currently are. These contextual challenges have been grouped into six, and they include (1) the global economic collapse and its effect on global demand, (2) uncertainty surrounding regulations and legislation, (3) infrastructure challenges: ports, energy, transportation and water, (4) workforce uncertainty, (5) burden of disease and (6) licence to operate, environmental compliance obligations, illicit and unlicensed mining and local grassroots activism. Arguably, similar contextual challenges exist in the whole continent. The HCP team needs to be cognisant of these challenges as well as the mining industry’s plans to address them. This is particularly important if these plans embed OHS as one of the core priorities in the African context. Thus, the conceptualisation, implementation and monitoring of HCPs should bear these in mind.
The central placement of audiologists within HCPs will be advantageous in resolving the following challenges confronting HCPs:
As reported by Nupen (2020) for the South African context, the prevailing challenges most pressing to the employer relating to legislation and regulations that govern the industry include (1) the recommended revisions to the regulations published in terms of the Mineral and Petroleum Resources Development Act, 2002 (MPRDA) concerning retrenchments, (2) the publication of recommended guidelines for the relocation of communities nearby mines and (3) the already effective ‘once empowered, always empowered’ clause which is engrained in the newest published 2018 Mining Charter. Such employer challenges need to be identified for the rest of the countries in the continent so that solutions are responsive to each context.
Understanding these challenges is important for context-relevant and responsive HCP planning. The current authors believe that proper and comprehensive understanding of these challenges and infusing discussions around ONIHL and HCPs within deliberations around the aforementioned challenges is strategically wise and forward-thinking. Embedding ONIHL and HCPs as part of OHS in all discussions, planning and strategising around regulations and legislation in mining is key to efficacious and sustainable preventive programmes. Conscious updating of both preventive and treatment measures where recent advances exist as far as occupational health conditions are concerned – including ONIHL is also important. Such a strategy will not only ensure best practice in terms of OHS but also contribute towards (1) economic growth, (2) job creation that includes employee empowerment goals, diversifying skills and enhanced employee job performance and (3) poverty alleviation within an investment-competitive sector that is striving for growth (Mbazima 2020).
Given that HCPs are one of the key aspects of OHS within the African mining industry, it is important to consider the realities of the African mining industry so that implementation is contextually relevant and responsive. Specific initiatives that audiologists can be involved in directly linked to current mining industry goals include the following:
As part of confronting realities of HCPs in African mines, contextually relevant risk factors need to be established and embedded in all OHS programme planning. Seixas et al. (2011) and Amjad-Sardrudi et al. (2012) supported the importance of establishing and understanding the pathogenesis or risk factors for ONIHL, as they believe that although ONIHL is a complex condition, it is preventable. Understanding the risk factors is crucial to the development of appropriate preventive measures. The contextualisation of the risk factors, which have been covered in detail in Chapter 3, allows for the African mining industry, audiology community and policymakers to channel their resources efficiently for preventive outcomes, particularly because of the known resource constraints under which the mining industry is operating. This channelling of resources should be for both future planning and reflection on the effectiveness of past interventions.
For future preventive programmes planning within African mines, careful cognisance of the multitude of risk factors for ONIHL is important if primary prevention is to occur. Primary prevention minimises the need for HCPs and or enhances their success. For example, in South Africa, over and above the QBoD that occurs concurrently with noise exposure, employees are simultaneously exposed to several stressors (Chen et al. 2020; Golmohammadi & Darvishi 2019) that include a variety of personal factors (e.g. age, gender, genetic background, smoking, medication and drugs and contextual diseases), physical factors (e.g. lighting, heat, vibration and cold), chemical agents (e.g. carbon monoxide [CO]), solvents, heavy metals and ototoxic chemicals) and occupational factors (e.g. workload and shift work). All these factors require controlling for successful outcomes of HCPs. Employees’ exposure to one or a combination of these risk factors leads to poorer outcomes as far as occurrence of ONIHL and success or failure of HCPs within the African mining industry. Evidence indicating that the combined effect of these risk factors may have synergistic, additive, potentiation or antagonistic effects (Chen et al. 2020; De Jong et al. 2012; Golmohammadi & Darvishi 2019) requires careful consideration in planning, implementation and monitoring of HCPs within the African context, bearing in mind the prevalence and or incidence of these risk factors within the mining industry. In establishing the prevalence and or incidence of risk factors for ONIHL within African mines, the mining industry must also invest in investigations on identified gaps, including (1) establishing solid evidence within the African context on genetic factors as well as contextual diseases and their treatments and their influences on ONIHL, (2) the impact of chemical agents that are most prevalent within the African mining context and (3) the physical factors such as heat, vibration and cold and their influence on ONIHL.
Sufficient global as well as emerging continental evidence is available that shows that ONIHL is influenced by the factors presented earlier (Amiri et al. 2015; Amjad-Sardrudi et al. 2012; Bowens 2018a, 2018b; Brits et al. 2012; Chen et al. 2020; Concha-Barrientos, Campbell-Lendrum & Steenland 2004; Khoza-Shangase 2020b). Some of these factors fall under the burden of disease umbrella, the quadruple burden that South Africa suffers from (WHO 2018). The impact of the burdens of disease on ONIHL and HCPs within the African mining industry needs careful investigating and characterisation. Specifically, the relationship of communicable diseases (HIV and AIDS and TB) to ONIHL, the relationship of noncommunicable diseases (e.g. mental illnesses, diabetes, hypertension and cardiovascular diseases and chronic lung diseases such as asthma and cancer) to ONIHL, as well as the relationship of injury and trauma to ONIHL need exploration. This exploration will allow for contextualised HCPs implementation. Collation of such evidence will facilitate appropriate and accurate risk–benefit evaluations of HCPs. Furthermore, it will enhance the ability to effectively utilise comprehensive and effective PDMS to achieve the preventive outcomes aimed for in this sector.
For appropriate risk–benefit evaluations, the comprehensive investigations that are recommended require that large sets of data be collected, captured and analysed appropriately. This should be done by utilising appropriate data record-keeping systems that are of value not only for efficient HCPs but also for research purposes whose evidence allows for evidence-based best practice within the African mines. Currently, the PDMS that is utilised in South African mines, for example, has been found wanting (Ntlhakana et al. 2020a, 2021), limiting its value to HCPs. Ntlhakana et al. (2020a) argued that an inclusive integrative data management programme that allows access to data from all pillars of an HCP for each employee, including all risk factors, is required.
A clear and contextualised understanding of the complex nature of ONIHL and its complex causes and risk factors allows for assessment and intervention approaches that are contextually responsive and therefore more likely to be successful. This is where technological advances including the 4IR, automation and AI are considered. The civilisations and advances in technology, knowledge and science that have been brought by the IRs have important influences on HCPs. As comprehensively covered in Chapter 6, these developments have facilitated ground-breaking innovations and transitions from manual labour to powered machines, steam engines, mechanisation and, ultimately, easy access to the Internet, information technology and AI. Evidence suggests that with the commercial gains through opening doors to industries and employment prospects and capital investments globally, IRs have also introduced and exposed workers to OHS hazards, including ONIHL. As much as IRs have contributed towards ONIHL, efforts to protect workers from hazardous noise exposure have also been influenced by these revolutions. As such, the current 4IR has been argued to have brought about cost-effective and easily accessible hearing conservation strategies. These strategies need careful consideration within the African context, where significant advances that have been documented globally have not reached yet, with the IR still lagging even in general health care delivery. These strategies include the use of hearing protector device fit-testing, also referred to as field attenuation estimation systems, used to determine the effectiveness of a HPD for individuals when worn correctly (Biabani et al. 2017; Hager 2011). This strategy promotes the proper use of HPDs through Internet-based hearing acuity tests and hearing loss simulation. It includes an optical scanning device for silicone ear impressions using advanced digital imaging, 3D modelling with the advantage of a low-cost, high-speed processing ability (Brauch 2017). Another advancement is seen in the use of smartphones. These smartphones promote low-cost noise measurements through apps that can conduct direct measurements of A-weighted sound pressure level through the use of Bluetooth remote communication which can be linked to a dosimeter and sound level meters (Brauch 2017). The significant shift in methods and systems used in mining over the past 100 years, from manual to full automated systems, including advances in the use of AI, has had an impact on ONIHL and the preventive strategies in place in HCPs. The dynamics of change of machinery and transportation methods in the mines from manually operated systems to mechanisation, and finally to the development of fully automated machinery and transportation vehicles with AI, have been presented in Chapter 7. The authors of Chapter 7 argue that fully automated mines will result in mineworkers, both in surface and underground mining, having minimal interaction with the mining environment, leading to less exposure to hazardous noise levels, with a consequent reduction in the prevalence and or severity of ONIHL within this context. The chapter illustrates this with two case examples, SUGM in Mali, which is a fully automated mine, and the SSW mining company’s initiatives in South Africa. In these mines, automation and preparation to automate the mining environment are being carried out in Africa, with the potential for enhancing the OHS of employees at the same time as maximising outputs for the mining industry. Chapter 7 uses a novel FBA that can be utilised in the transition period to automation to show that as the mining industry transitions to fully automated mining, fewer employees are exposed to hazardous occupational noise. Such advances require collaborative work between all HCPs stakeholders, including engineers.
South Africa is not too far behind in these new developments as automation has been introduced in the extraction of diamonds, coal and copper in some mining companies, as discussed in Chapter 7. Furthermore, the MHSC has collaborated with researchers and mining equipment manufacturers in identifying innovative ways of making automation and digitalisation to improve safety and efficiency as well as more accessibility in all mining sectors. These developments are anticipated to facilitate a transition to real-time information management systems, robotic technologies and IoT as standard operation in the mines. As such, the novel FBA discussed in Chapter 7 can facilitate the transition from manual to full automation in the African mining industry, which, if implemented successfully, will potentially eliminate ONIHL in this sector.
For the next best practice in ONIHL and HCPs within the African context, it is important that the three contextually relevant complexities that have been identified in this book are carefully considered. These are HCPs in the context of OHS, HCPs in the context of burden of disease and HCPs in the context of tele-audiology in African mines. Although the use of tele-audiology has not been widely explored in the mining sector, the advent of COVID-19 has placed occupational audiologists in a unique and opportune position to provide tele-audiology and increase access to occupational audiology in the mining industry. Coronavirus disease 2019 has accelerated telepractice as a model of health care service delivery, and as such, Audiology Australia (2020) confirmed that potentially, tele-audiology can transform and sustain the provision of audiology services beyond COVID-19. This position requires innovative initiatives such as the use of mobile clinics (teleconferencing) and mobile apps, for instance (Wolfgang 2019). To implement these innovations there will be a need to invest in minimal equipment purchases and additional training in most existing practices. A benefit for audiologists is that they will be on the forefront of e-health and will be ahead as the world moves towards non-traditional, alternative and complementary methods of health care provision.
Chapter 10 presents tele-audiology potential in LMICs, with a discussion of the various types of tele-audiology than can be used either singly or in combination in African HCPs. A tele-HCP model is then proposed for audiologists working in occupational health, with considerations that need to be kept in mind while implementing tele-audiology within the African mining industry presented. This tele-HCP model covers all pillars of HCPs allowing for comprehensive implementation of the CI and adherence to international and national noise regulations. Khoza-Shangase et al. (2021) highlighted how the limited use of tele-audiology is a missed opportunity for expanding access to audiological services, both in training platforms and in clinical service provision. The authors of this chapter believe this to be true for the management of ONIHL, particularly in Africa, where capacity versus demand challenges have been well documented. The limited application of tele-audiology in HCPs also missed the opportunities presented by technological advancements such as automation and AI with some of the IR advances presented in Chapter 6 that have significant value for HCPs. The application of booth-less and wireless technology for industrial hearing assessments; the performance of pure-tone audiometry outside a sound booth utilising automation, earphone attenuation and integrated noise monitoring; the conduction of diagnostic pure-tone audiometry without a sound-treated environment; the utilisation of mobile technology for booth-less audiometry; and hearing screening using mobile apps are developments that have changed the future of audiology, with their application up to the audiology community to take advantage of. For the next best practice in ONIHL and HCPs, research in context needs to be conducted to ensure reliability and validity within the African context. The aforementioned examples of advances are located within the audiometric evaluations and monitoring pillar of HCPs; however, expansion of the application of these advances as well as additional new developments in innovations towards HCPs must occur in all the other pillars under the hierarchy of control. This expansion and developments require focused and deliberate investments into research by African mines and university research units into occupational audiology.
The elimination of ONIHL within the mining industry, despite the HCPs in place, may not be possible and achievable within the African context in the near future; however, numerous recommendations and interim solutions are available from conceptualisation, implementation to evaluation and monitoring of CIs aimed at achieving zero harm for mineworkers. These recommendations require a concerted collaborative effort from all stakeholders, with capitalisation on recent advances in both assessment and management of ONIHL. For success, the implementation of recommendations requires sensitivity and responsiveness to the context, while maintaining best practice within the less-than-ideal resource-constrained context. Positive outcomes will benefit not only the employees but also the employers, the State and the country as a whole. Context-responsiveness calls for continuous research to build the evidence that will allow for relevant evidence-based interventions, with complexities around HCPs within the African context forming part of the deliberations and planning that incorporates technological advances and developments in industrialisation, automation and AI. Countries such as South Africa, Ghana, Tanzania and Zimbabwe are making strides towards establishing evidence, while significant gaps still exist in the rest of the continent.
How to cite: Khoza-Shangase, K & Moroe, NF 2022, ‘Best practice for hearing conservation programmes in Africa’, eds. K Khoza-Shangase & NF Moroe, Occupational noise-induced hearing loss: An African perspective, AOSIS Books, Cape Town, pp. 187–198. https://doi
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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