Table 1: Country information (Worldometer.info, 2021)
|Country Name||Republic of Malawi|
|Population||19,129,952 (2020 Estimate)|
|Area||36,401 square miles|
|Gross Domestic Product-GDP (PPP)||$21.843 billion (2016 Estimate)|
|Currency||Malawian Kwacha (1 USD = 720.34 Malawian Kwacha)|
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 northeast 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 under 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.
Up until recently, audiology and hearing related services in Malawi were extremely limited. Hearing aids were fitted by one Ear Nose and Throat (ENT) specialist and SOS Children’s Villages hearing rehabilitationists, or by visiting projects to 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 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.
Currently there is very little incidence/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 anitretroviral therapy (ART), HIV is less of a threat to life but now 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.
Currently, the only institution in Malawi providing an audiology training course is the African Bible College (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 a 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 impairment 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.
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: 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 allocated within the Ministry of Health government hospital system, nor 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
The following services are provided by the ABC HCTC:
The audiology clinic within QECH provides all the services listed above with the exception of electrophysiology and vestibular evaluations.
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 are a growing number of ENT clinical officers and audiology technicians, lack of equipment severely limits the services they are able to provide.
We are aware of one published article about audiology services in Malawi (Parmar et al., 2021). Parmar et al. (2021) investigated 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 gain 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 to the prevalence in other countries. Audiological records from the ABC HCTC will be reviewed and 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.
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?Retrieved September 12, 2021, from: https://pitchfunder.asufoundation.org/project/7261.
BBC (2019, March 19). Malawi Profile: A chronology of key events. Retrieved September 12, 2021, from: https://www.bbc.com/news/world-africa-13881367.
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. https://saa.audiology.org/news/so-you-want-be-humanitarian-audiologist-0.
Deaf Kidz International. (2021). We are Deaf Kidz International. Retrieved September 12, 2021, from: https://deafkidzinternational.org/.
EARS Incorporated. (2021). About us. Retrieved September 12, 2021, from: https://www.earsinc.org/about.
Geography of Malawi. (2021, March 23). In Wikipedia. Retrieved September 12, 2021, from: https://en.wikipedia.org/wiki/Geography_of_Malawi#/media/File:MalawiOMC.png.
Hear the World Foundation. (n.d.). Equal Opportunities and Improved Quality of Life. Retrieved September 12, 2021, from: https://www.hear-the-world.com/en/foundation/mission.
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. https://doi.org/10.1371/journal.pone.0161421.
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. https://doi.org/10.4102/phcfm.v10i1.1799.
Malawi Demographics. (2020). Worldometer.info. Retrieved March 6, 2021, from: https://www.worldometers.info/demographics/malawi-demographics/.
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. Retrieved May 30, 2021, from: https://www.sound-seekers.org.uk/malawi/.
Starkey Hearing Foundation. (2021). About us. Retrieved September 12, 2021, from: https://www.starkeyhearingfoundation.org/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. Retrieved September 12, 2021, from: https://www.lshtm.ac.uk/sites/default/files/2019-06/KIM-Malawi-MAIN-REPORT-v2.pdf.
Worldometer.info (2021). https://www.worldometers.info/world-population/malawi-population/.
World Bank. (2016). Poverty headcount ratio at national poverty lines (% of population) – Malawi. Retrieved March 6, 2021, from: https://data.worldbank.org/indicator/SI.POV.NAHC?locations=MW&most_recent_value_desc=false.
YouTube Videos on ABC HCTC:
You Tube Videos by Hear The World Foundation:
You Tube Videos by Sound Seekers (now Deaf Kidz International):
Kelly Gordie is a Doctor of Audiology student at the University of South Florida in Tampa, Florida, USA. She received her Bachelor of Arts in Communication Sciences and Disorders from the University of South Florida in 2019. Throughout her studies, she has acquired interests in pediatrics, global and humanitarian audiology, vestibular evaluation, and hearing conservation outreach.
Nathaniel Davis is a Doctor of Audiology student at the University of South Florida in Tampa, Florida, USA. He received his Bachelor of Science in Biology and Bachelor of Arts in Geography from the University of Missouri in 2019. During his studies, he has found interest in electrophysiology, global audiology, and vestibular evaluation.
Jennifer Jones Lister, Ph.D., is Associate Dean in
the College of Behavioral and Community Sciences and is a Professor of
Communication Sciences and Disorders at the University of South Florida in
Tampa, Florida, USA. She is a licensed and certified Audiologist and has
conducted research for over 20 years in the areas of aging, hearing impairment,
auditory processing, cortical auditory evoked potentials, and cognition. Most
recently, she has begun research on global audiology. She is collaborating on
multiple research projects with the faculty and students of African Bible
College in Lilongwe, Malawi.
Peter Bartlett and his wife Rebecca are both Australian audiologists who Co-Founded the African Bible College Hearing Clinic and Training Centre (ABC HCTC). The ABC HCTC is located in Malawi’s capital city of Lilongwe, where the Bartletts lived between 2010 and 2016, and it is a ministry of the Australian Christian aid agency EARS Incorporated. Peter has a Bachelor of Science (1992) and Graduate Diploma of Audiology (1993) from the University of Melbourne and a Master of Business Administration (2010) from Federation University. For the last five years, Peter has been an Area Operations Manager and clinical audiologist working for Audika in Victoria, Australia. Peter has been a co-author in published research in to hearing loss in children with HIV AIDS, and presents regularly on humanitarian audiology on behalf of EARS Incorporated.
Jenna Vallario is a clinical audiologist and
professor at African Bible College Hearing Clinic and Training Center in
Malawi, Africa. Jenna graduated with her Bachelor of Science in Communication
Sciences and Disorders from the University of Florida in 2014 and her Doctorate
in Audiology from the University of South Florida in 2019. She has been
involved with Ears, Incorporated since 2017 and is currently a long-term
volunteer with ABC Hearing Clinic and Training Center. Jenna is passionate
about global hearing healthcare and is working to provide sustainable audiology
services to those in Malawi.
ABC HCTC Facebook: https://www.facebook.com/ABChearingclinic
ABC HCTC Fundraising Website by Dr. Jenna Vallario:
Memory Khomera is an audiologist working at ABC Hearing Clinic. She is a hardworking young lady who studied audiology at African Bible College, Malawi campus and she graduated in June 2021. She has passion for children and is currently volunteering at a charity organization called Live Love organization which is an organization whose main focus is children.
Grant Kapalamula is a clinical audiologist at ABC Hearing Clinic and Training Center in Malawi, Africa. He is a holder of a Bachelor of Science in Audiology from African Bible College in 2021. He has a passion and interest in encouraging prevention measures and early diagnosis in pediatrics through hearing screenings and ABR testing. He is particularly interested in Evidence-Based-Practice to improve hearing healthcare in Malawi.
Julia Toman is currently an Assistant Professor at the University of South Florida in Tampa, Florida, USA in the Department of Otolaryngology, Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery. She has a long history of pursuing global health bilateral collaboration. Her research focuses on health disparities and hearing health promotion in underserved communities both within the US and globally. She is an invited participant on the Lancet Commission on Hearing Loss with a planned companion piece on otitis media specifically. She has ongoing collaborations in South Africa, Malawi and Kenya and is passionate about developing research infrastructure and global surgery initiatives.
Fletcher Chisalipo, M.Sc. Aud
The African Bible College Hearing Clinic and Training Centre
Hear the World Foundation
Deaf Kidz International