Participants: The mothers were recruited from maternity hospital, Mandya, Karnataka, India, for the study. Questionnaire survey was conducted for duration of a month (June 2016), where a total of 130 deliveries were reported. All mothers were selected from post-natal wards irrespective of the education level, age, order of the child and region. Mothers who were not cooperative (n=8) and who did not give consent (n=4) were not part of the study. Also, few mothers (n=5) who were non-native speakers and who partially filled questionnaire (n=13) were excluded. Hence, a total of hundred (n=100) mothers participated in the study. Age range of mothers selected for the study was from 19 to 36 years (mean age: 21.65 years). It was ensured that the answers were not influenced by any other family members/participants.

An adapted version of the questionnaire used by Olusanya BO et al., was utilized for the study [Appendix-1] [11]. The original questionnaire comprised of 16 questions which had questions on knowledge of risk factors, identification and intervention, superstitious cultural beliefs and attitudes. However, the questionnaire used in the current study consisted of three sections. First section comprised of twelve questions based on prenatal, natal and post natal risks of infant hearing. Second part of the questionnaire was designed to determine participants’ knowledge/attitude on early detection of hearing loss using six questions. The final section included twelve questions to measure participants’ attitude on early intervention of hearing loss.

Procedure: The study was initiated after obtaining approval from the Institutional Ethics Committee, Mandya Institute of Medical Sciences, Mandya. Before starting the study, written consent was taken from the mothers, who participated in the study. Demographic details such as age, place, family history, consanguinity and education were also collected. Data was collected through individual semi structured interview with mothers. The questionnaire was administered by two interviewers who communicated effectively with all participants; in case of difficulty, the questions were rephrased. Personal interview was conducted which had the scope to cross check their knowledge. The responses expected were either yes, no or unsure, where ‘yes’ represented presence of awareness, ‘no’ represented absence of awareness and ‘unsure’ represented lack of information regarding the target questions. Few questions from section two and three were accompanied with probe-in questions to eliminate bias of leading questions. The average time taken for single interview was around 15 minutes, which included collecting the demographic details and administering the questionnaire.

The results obtained in the study were analysed statistically using the Statistical Package for Social Sciences (SPSS) software version 20.0. Chi-Square test was used to test statistically significant relationship between consanguineous and non-consanguineous mother’s responses to its effect on hearing loss. A p-value of less than 0.05 was considered as significant.

The responses for each question from the mothers are shown in [Table/Fig-1].

Out of the 12 risk factors, the mothers knowledge was appreciably high for head injury/slap to the ear (95 mothers) followed by ear pain/discharge (91 mothers). Importantly, 72 mothers believe that family history is a major risk factor for hearing loss, whereas eight of them were not sure. The mothers’ insight was relatively poor for natal causes such as delayed birth cry, neonatal jaundice and post natal cause like high fever, frequent hospitalization which can be linked to cytomegalo virus infection and/or meningitis [Table/Fig-1].

The maternal awareness on presence of congenital hearing loss (n=60) and attitude towards importance of screening programs (n=66) and follow up testing (n=68) were relatively better than the other factors which assist in early identification. However, the mothers were least aware of signs such as sudden withdrawal, misarticulations, inconsistent responses to name call and poor academic performance which may indicate presence of late-onset hearing loss (n=21) or auditory dys synchrony (n=23).

It is unfortunate that, 57 mothers did not know the treatment options for congenital hearing loss. Habilitating the infant with hearing loss by fitting the appropriate hearing aid within six months of age will improve child’s speech and language acquisition [4]. Only 18 mothers were in agreement with the statement. Also, rehabilitation of infant with hearing loss is successful not only with appropriate hearing aid fitting but also by receiving adequate speech-language therapy [5,6]. Only 39 mothers of 100 were aware of therapy necessity. Most of the mothers agree that if the child is identified and habilitated early (<1 year), then the socialization skills (n=71), followed by speech and language development (n=62) and academic success (n=52) will be better compared to late identification. The important speech milestone of typically developing children is utterance of first word by one year of age; only 27 mothers had the knowledge. The government facilities given to individuals with hearing loss were not known to 70 mothers. Around 39 mothers still believe the house medicines will have positive results for ear pain and ear discharge.

Responses of consanguineous and non-consanguineous mothers regarding the effect of consanguinity on hearing loss: Amongst 100 mothers, the demographic data revealed 21 mothers were married in relation; only 10 of them recognized that consanguinity can be one of the risks for hearing loss. Among those who were not into consanguineous marriage (79 mothers), 46 of the mothers were aware of ill effects of consanguinity. To compare and evaluate the differences in distribution of responses among consanguineous and non-consanguineous mothers, chi-square test was applied; it was found that the difference was highly significant with p-value <0.002. Remaining 44 mothers either had wrong or no knowledge regarding the effect of consanguinity on hearing loss.

It is evident from the literature that, unidentified congenital hearing loss can adversely affect speech-language development, academic and socio-emotional development [4]. Mothers play a key role in monitoring child’s speech, language and motor development. Consequently, maternal knowledge regarding hearing loss is critical for the success of early identification and intervention program. The current study makes an important contribution about the mothers’ insight and attitude towards infant hearing loss.

The results showed high awareness on ear infections and slap to ear/ head injury as causes of hearing loss [Table/Fig-1]. This is in agreement with the study conducted by Swanepoel D and Almec N [8], which reported high rate of identifying ear discharge as a risk factor from mothers from Nigeria (73%) and South Africa (79%) respectively due to visible nature of this condition [13]. Additionally, they had poor knowledge on neonatal jaundice and delayed birth cry as the risk factors for hearing loss in present study. It is evident from the literature that infants with neonatal jaundice and/or admitted in Neonatal Intensive Care Unit (NICU) for >five to seven days are at greater risk of developing neural hearing loss [18,19]. Thus, lack of knowledge of mothers in this area may delay the detection of hearing loss and further intervention [4]. Furthermore, mothers ignored the signs and symptoms of late-onset and neural hearing loss [Table/Fig-1]. This lack of knowledge is reported as families may observe the toddler responding to loud sounds in the environment [20]. The results are in consonance with study which reported, factors that contribute to failure to identify children with hearing loss include lack of parental support/awareness of signs of hearing loss in very young children and “wait-and-see” attitude exhibited by physicians [21].

The maternal knowledge regarding the consequences of consanguinity was determined, which showed better awareness (n=56) amongst mothers. However, it can be observed that consanguineous mothers have superior awareness than non-consanguineous mothers [Table/Fig-2]. On contrary, young couples in North of Iran had poor knowledge and attitude towards hazardous effect of consanguinity [17]. Another study showed 7.6% of women in Shindoli village (Belagum district of India) were aware that still births, neonatal mortality, obstetrical complications and congenital malformations could result in consanguineous marriage [22]. In summary, literature reports poor to moderate level of awareness on consanguinity and suggests the importance of sensitizing the public against ill effects of consanguineous marriages.

On the other hand, attitude of mothers towards importance of screening, follow up testing and benefits of early intervention of infant hearing loss is positive [Table/Fig-1]. This is in accordance with the fact that children enrolled in early intervention within the first year of life have been shown to have language development within the normal range of development at five years of age [21]. On contrast, lack of understanding about the management of hearing loss, age appropriate hearing aid fitting, therapy necessity and house medicines will cause delay in intervention of hearing loss. The literature suggests that higher maternal awareness were significantly associated with earlier confirmation of hearing loss and fitting of amplification device, in a group of children with hearing loss [20]. In countries like India, the major hindrances for establishing an effective screening program are the costs involved, the non-availability of equipment and human resources. Thus, educating mothers will support early detection and management of hearing loss.

The present study was conducted for a short period; the sample size was not sufficiently large. The appropriate responses on knowledge of the mothers would be obtained if they were from different geographical area (rural/urban), educational background.

The current study reveals moderate to high levels of awareness on visible causes (ear pain and ear discharge), established causes like family history, consanguinity and benefits of early identification. However, mothers are least aware of other risk factors and management of hearing loss. To reduce the consequences of hearing loss, implementation of sensitization programs for mothers regarding the risk factors of hearing loss, benefits of early identification and intervention is required.