Community-Level Hearing Screening Tool for CBR workers_English.pdf

This hearing disability screening tool is designed for community-level CBR workers where no specialists or services are available. It is simple and effective, enabling early identification and referral of children with hearing difficulties. Compiled by Nusrat Zerin for CBR workers who are less educated and where no specialized services are available. This will help in ways to provide immediate support to children with hearing disabilities at the community level.

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Community-Level Hearing Screening Tool for Community Based
Rehabilitation (CBR) Workers

Community-Level Hearing Screening Tool for CBR workers (simple , age-wise milestones,
screening form, scoring & referral). It’s aligned with the World Health Organization's (WHO)
Community Based Rehabilitation (CBR) approach and evidence on community hearing screening
and adapted for low-resource / rural Bangladesh contexts. This practical tool can be used by
low-educated field workers confidently where no specialized services or screening facilities and
specialized resource persons are not available.
Objective
To enable CBR field workers to quickly identify children in the community who may have hearing
problems, so they can be counselled and referred for assessment and early intervention when
specialized services are not locally available. This screening is for early detection and referral
only, not diagnosis.
Key reasons why CBR workers can use the Hearing Disability Screening Tool at the community
level:
1. Early Detection:
Enables CBR workers to identify children with possible hearing difficulties at an early
stage, ensuring timely referral and intervention (where there is no specialists or less
specialized services).
2. Simple and Practical:
The tool uses easy language and observation-based questions that low literate or less-
trained CBR workers can confidently apply in rural areas.
3. Community-Based Approach:
Specifically designed for areas where no specialized audiology or ENT services exist,
allowing local workers to take the first step in disability identification.
4. Guides Action:
Provides clear scoring and referral guidance so that workers can make informed
decisions on whether to monitor, counsel parents, or refer the child for further
assessment.
5. Promotes Inclusion:
Early identification helps families access hearing aids, communication training, and
inclusive education, promoting participation of children with hearing disabilities in
community life.

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Age-wise normal auditory development (milestones to expect)
(Use these as a quick checklist to compare a child’s responses to expected behaviours.)
• Birth (3 months)
− Startles or cries at loud sounds; calms when caregiver speaks.
− Looks towards sound or voice.
• 4 - 6 months
− Turns head toward a sound, babbles (repeated syllables like “ba-ba”, “ma-ma”).
− Notices and reacts to name sometimes.
• 7 - 12 months
− Localizes sounds (turns head reliably to voice or sound).
− Responds to simple words and says first meaningful words (like “mama”, “dada”).
• 1 - 2 years
− Follows simple commands without gestures (“bring the ball”).
− Vocabulary increasing (several words); responds to name consistently.
• 2 - 4 years
− Understands and follows multi-step instructions; talks in simple sentences; joins
in songs/games.
− Speech understandable to familiar people.
• 5+ years
− Hears well enough to follow classroom instructions, responds in group, speech is
mostly clear for age.

Red flags at any age:
child does not startle to loud sounds, does not respond to name, little or no babbling / words by
expected ages, or sudden loss of previously acquired hearing or communication. These require
urgent attention.

How CBR workers should use this tool (simple steps)
1. Meet the caregiver, then explain this is a quick hearing check-up process. Keep language
simple and calm.
2. Observe the child and ask the caregiver the short Yes / No questions for the child’s age
group below. Mark all the answers.
3. Score and follow the referral guidance immediately if the concern is moderate / high.
(Form is given below)

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Screening Form
Yes / No questions (age-wise) for Hearing disabilities detection by CBR workers
Child name: ___________
Age: ______
Location: __________
Date: _______
Age Birth – 6 months
1. At loud noise (clap), does the baby startle or blink? Yes / No
2. When caregiver speaks, does the baby calm or look towards the voice? Yes / No
3. Does the baby make different kinds of sounds or babble? Yes / No

Age 7 – 12 months
1. Does the child turn head toward a voice or sound? Yes / No
2. Does the child respond to their name most times? Yes / No
3. Does the child say any meaningful words (e.g., “mama”, “dada”)? Yes / No

Age 1 – 2 years
1. Does the child follow simple commands without showing (e.g., “Give me the toy”)? Yes /
No
2. Does the child use several words and try to name things? Yes / No
3. Does the child respond when called by name? Yes / No

Age 2 – 4 years
1. Does the child follow two-step instructions (e.g., “Take the ball and give to mother”)?
Yes / No
2. Can the child be understood by family most of the time? Yes / No
3. Does the child join simple songs or games that need listening? Yes / No

Age 5 – 10 years
1. Does the child follow teacher or adult instructions in group settings? Yes / No
2. Does the child answer when talked to from across the room? Yes / No
3. Is the child’s speech clear enough for classmates to understand? Yes / No

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Scoring (CBR-friendly)
For the child’s age group, count the number of “No” answers:
• 0–1 No: Low concern
Continue regular monitoring and encourage language activities.
• 2 No: Moderate concern
Give parent advice and repeat screening in 4–6 weeks; consider referral if concerns
persist.
• 3 No: High concern
Refer immediately for a hearing assessment (see referral channel). Community studies
show non-specialist screening can detect children needing referral.
(Reasoning: multiple “No”s suggest the child is not showing expected auditory/communication
milestones.)
Simple parent counselling ways:
• Encourage talking, singing, and playing face-to-face with the child
• Use loud, clear speech and point to objects when naming them.
• Avoid blaming
• Explain that hearing problems are medical and can be helped if identified early.

Referral channel (where to send the child)
1. Local community clinic/health worker (first contact): for ear check (wax, infection) and
basic advice.
2. District hospital ENT / Audiology unit: for tympanometry/otoacoustic emissions or
audiometry (if available).
3. Pediatrician or specialist: for medical assessment and onward referral to hearing
rehabilitation / hearing aids / speech therapy / special education.
4. CBR group / local school: link family to local supports and education services while
awaiting assessment.
(If specialized services are not available locally, note contact details of nearest district hospital
or NGO partner and arrange transport support where possible).

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Practical notes for low-resource rural use:
• Ear infections & wax are common, treatable causes of hearing problems need to be
checked and treated or referred to a health clinic first.
• Where possible, low-cost screening (whisper test, play audiometry, or validated apps) or
smartphone based apps can be used by trained community workers and have shown
feasibility in similar settings.
• Always document findings, actions taken, and follow-up dates in the child’s record.

When to urgently refer (for severe problems identified)
• No startle to loud sounds (birth - 3 months).
• No babbling or meaningful sounds by 9 - 12 months.
• No response to name by 12 months.
• Sudden loss of previously acquired speech / hearing.
• Recurrent ear pain or discharge (could indicate persistent otitis media needing urgent
care).
Reference list (for reports/trainers)
• WHO. Community-based rehabilitation: CBR guidelines (2010).
https://www.who.int/publications/i/item/9789241548052
• Olusanya BO et al., Community-based infant hearing screening: feasibility studies.
(2008). https://pmc.ncbi.nlm.nih.gov/articles/PMC2649576/
• Hussein SY et al., Community-based hearing screening for young children (smartphone
programs / CHWs). (2018).
• Bangladesh National Strategy on Prevention of Deafness and Hearing Impairment
(Bangladesh context). https://cdn.who.int/media/docs/default-
source/searo/bangladesh/pdf-reports/year-2007-2012/national-strategy-on-prevention-
of-deafness-and-hearing-impairment-in-bangladesh-2011-2016.pdf
• CDC / ASHA developmental & hearing milestones guidance. https://www.cdc.gov/act-
early/milestones/index.html