Speech assessment in pediatric audiology: An investigation and innovative solution for audiologists

INTRODUCTION

Speech testing is an integral component of pediatric audiology, providing insights into a child’s speech perception abilities and aiding diagnosis, treatment planning, and monitoring.^[1,2] The American Academy of Audiology^[3] highlights behavioral testing, including speech audiometry, as the gold standard for assessing pediatric hearing, emphasizing the importance of measuring speech perception for effective intervention. Accurate speech testing in children allows audiologists to assess the impact of hearing impairment on language development and communication skills, offering a foundation for intervention planning that can improve long-term speech and language outcomes.^[1]

Audiologists assessing English-speaking children have access to a wide range of resources and speech materials for hearing assessment compared with non-English-speaking populations. A study conducted to examine pediatric audiology and amplification practice in North America showed that 70% of audiologists reported using best-practice protocols for pediatric hearing aid fitting, including the use of speech audiometry.^[4] As 30% of them still do not abide by best practice, the study concluded that it is essential to continuously develop, disseminate, and translate these guidelines as they positively influence the quality of services provided. It also emphasizes the need for researchers to explore and identify the barriers and facilitators involved in the process.

When assessing Arabic-speaking children, access to a wide range of resources and speech materials varies across different regions. For example, Egypt is rich in resources and tools and there exist standardized and validated test batteries for speech assessment that are designed to evaluate individuals across all age groups (above 2 years old).^[5-7] These tests accommodate diverse linguistic abilities and cognitive levels, making them suitable for both normal-hearing and hearing-impaired children, including those using hearing aids or cochlear implants. On the other hand, there is a significant lack of access to materials when assessing speech auditory in children in Saudi Arabia due to the limited available resources. Although an attempt is made by researchers to develop speech assessment tools for Arabic-speaking children in Saudi Arabia [Table 1], accessibility remains an issue as these tests seem to be for research purposes rather than clinical use. Research has shown a significant shortage of validated, culturally appropriate, and accessible speech testing materials, which presents challenges in the effective assessment of pediatric patients and abiding by the best practice guidelines.^[8] This leaves audiologists with limited options to effectively assess and rehabilitate hearing in this demographic. Audiologists may rely on speech materials that are not adapted to the linguistic or cultural context of the patient, such as the Egyptian materials, which may lead to inaccurate assessments and hinder the development of tailored intervention strategies. Culturally and linguistically appropriate speech testing materials are essential for delivering effective care and enhancing diagnostic accuracy in pediatric audiology. A study by Gaeta and John in 2015^[9] discussed the challenges in evaluating speech recognition abilities in young Spanish-speaking children, highlighting the importance of using language-appropriate stimuli for accurate assessment.

In Saudi Arabia, there is a significant gap in research regarding the current practices of audiologists providing services to children and the accessibility of diagnostic tools that support adherence to best-practice recommendations. Thus, the primary objectives of this study were threefold: (1) To examine current speech testing practices among audiologists in Saudi Arabia, (2) to identify barriers they face in conducting speech assessments for pediatric patients, and (3) to assess the clinical value and user experience of a newly developed application that offers access to validated Arabic speech materials.

By investigating these aspects, this study contributes to a broader understanding of the need for culturally appropriate tools in pediatric audiology and offers a practical, technology-based solution that can enhance the quality of speech assessments. This research aligns with global efforts to improve diagnostic resources for non-English-speaking populations and increase the availability of pediatric speech assessment tools that can support a family-centered approach to audiological care.

MATERIALS AND METHODS

RESULTS

Data collection: Part I

Demographics of participants in the first questionnaire

The study received responses from 33 audiologists who met the inclusion criteria and were practicing in Saudi Arabia, covering a range of work settings, qualifications, and years of experience. Table 2 presents the qualifications, years of experience, and geographic distribution of the audiologists who participated in the study. The majority held a bachelor’s degree, with 18 audiologists, most of whom had 4–5 years of experience. Among those with advanced qualifications, there are 7 with a Master’s degree, predominantly with more than 6 years of experience, and 6 had an Au.D. degree, all with over 6 years of experience, and one Ph.D. level audiologist with more than 6 years of experience. In addition, there was one professional with a background in Biomedical Engineering and 1 year or less of experience.

Table 2: Demographic data of study participants.

Category	Qualification/Province	Audiologists count	Years of experience
Qualification	Bachelor’s	3	1 year or less
		15	4–5 years
	Master’s	1	4–5 years
		6	More than 6 years
	Au.D	6	More than 6 years
	Ph.D.	1	More than 6 years
	Biomedical Engineering	1	1 year or less
Province	Aseer	2	More than 6 years
	Eastern	1	More than 6 years
	Makkah	4	More than 6 years
		4	4–5 years
		1	2–3 years
		1	1 year or less
	Madinah	1	4–5 years
	Riyadh	9	More than 6 years
		5	4–5 years
		3	2–3 years
		4	1 year or less

Au.D: Doctor of Audiology; Ph.D: Doctor of Philosophy

Geographically, Riyadh and Makkah providences host the largest number of audiologists with a wide range of experience levels, particularly in Riyadh, where nine audiologists have over 6 years of experience. The Eastern Province, Aseer, and Madinah have smaller representations, mostly with audiologists with significant experience. This distribution underscores the concentration of experienced audiologists in Riyadh and Makkah while also reflecting varying levels of experience across other regions.

Current practices

A substantial majority (91%) agreed that speech testing is beneficial for pediatric audiological assessments; however, they are limited. Despite the recognized importance, 88% reported that they would be more likely to conduct speech testing if accessible and validated Arabic speech materials were available, highlighting a significant gap in resources [Figure 1].

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Figure 1:

Audiologists’ perspectives on speech testing availability and accessibility.

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Reported challenges in speech testing delivery

Participants identified several obstacles that hindered effective speech testing in pediatric audiology [Figure 2]. Table 3 summarizes the primary barriers faced by audiologists in conducting regular speech testing for pediatric patients. The most reported challenges include lack of time (29%), limited access to resources (24%), and insufficiently sensitive materials (24%). Other notable barriers include equipment shortages, non-standardized materials, and language-related issues, each contributing to limitations in delivering consistent and effective speech assessments.

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Figure 2:

Challenges faced by audiologists when conducting pediatric speech testing. HA: Hearing aid.

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Table 3: Reported barriers to performing speech testing regularly.

Barrier	Percentage
Time constraints	29
None	24
Access issues	24
Insensitive materials	24
Irrelevant to HA features	21
Lack of equipment	12
Language issues	6
Uncooperative child	3
No standardized material	3
Lack of training	3

HA: Hearing aid

Development and initial clinical application of the HER application

Based on the survey findings, the HER application was developed to provide audiologists practicing in Saudi Arabia with accessible Arabic speech assessment material, available on the iOS platform, enabling speech perception assessment and aural rehabilitation tasks. To receive access to the HER app, audiologists need to email the author for a username and temporary password, and then audiologists can create accounts for their patients. This application interface showcases an Arabic pediatric speech assessment tool designed to engage children in auditory tasks [Figure 3]. The screens feature a playful design and provide access to the Arabic-CAPT,^[7] which assesses speech perception through closed-set phoneme discrimination tasks and an auditory training game to enhance auditory skills, supporting both clinical use by audiologists and at-home engagement with family involvement. In addition, the application allows the incorporation of other validated speech assessment tools in Arabic and can be easily adapted to other languages.

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Figure 3:

Interface of the hearing evaluation reference application.

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Data collection: Part II

Application evaluation and audiologist feedback

Eleven audiologists evaluated the application and provided positive feedback on its features, with high ratings across several key attributes. Figure 4 illustrates the audiologists’ responses to the features of the HER application. Most users expressed high levels of agreement (3 and 4) across all features, especially for “Application results are clinically useful for diagnosis and treatment” and “The interface is intuitive,” where all respondents either agreed or strongly agreed with the statement. Lower levels of agreement were noted in “accessibility of test results,” where moderate agreement was more prominent, indicating areas for potential improvement in future updates.

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Figure 4:

Audiologists’ rating (from 1 to 4) on the hearing evaluation reference (HER) application. The Y-axis corresponds to the number of respondents while the x access corresponds to the rating domine (1. The HER application provides tools for assessing speech perception; 2. Application results are clinically useful for diagnosis and treatment; 3. The application integrates easily into clinical workflows.; 4. The interface is intuitive; 5. Navigation is user-friendly; 6. Test results are easily accessible; 7. Data can be exported for further analysis).

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Correlation analysis

A Spearman’s rank-order correlation was conducted to assess the relationships between different usability and clinical integration ratings of the HER application. The Spearman’s rank-order correlation analysis revealed several significant relationships among key usability and clinical integration factors of the HER application. A strong positive correlation was found between the perception that the application provides clinical assessment tools and the belief that its results are useful for diagnosis and treatment planning (ρ = 0.91), suggesting that users who value its assessment features also find it beneficial for clinical decision-making. In addition, the belief that the application can be integrated into existing workflows was moderately to strongly correlated with perceptions of navigation clarity and user-friendliness (ρ = 0.77), indicating that ease of use may influence its adoption in clinical practice. The app’s interface intuitiveness was also strongly associated with its perceived clinical usefulness (ρ = 0.76) and navigation clarity (ρ = 0.50), emphasizing the role of user experience in shaping clinical perceptions. Finally, the ability to export test results showed a strong correlation with perceived clinical integration (ρ = 0.79), suggesting that data accessibility is an important factor in the app’s practicality for audiologists.

DISCUSSION

This study investigated the practices, challenges, and resources associated with assessing speech perception in pediatric audiology among audiologists in Saudi Arabia. Key findings revealed that although audiologists recognize the value of speech testing in pediatric assessments, many face substantial barriers, primarily time constraints and a lack of accessible and validated Arabic language materials.

Time constraints in audiological services can be attributed to the significant shortage of clinicians. A previous study^[11] highlighted the difficulty of accurately identifying the number of licensed audiologists in Saudi Arabia, though their numbers remain critically low. The Ministry of Health’s Sector Transformation Strategy 2017-2030^[14] emphasizes the need for a highly educated and skilled workforce to meet the Vision 2030 goals. Such shortages significantly impact the delivery of effective audiological care, leading to long waiting times in hospital clinics and specialized hearing centers. In addition, high-income patients often seek services in Western nations, limiting their ability to receive care in their native country or language.^[15]

To address the current time and staff shortages, integrating newer equipment and technology can help optimize clinical efficiency. Reliable automated audiological testing tools could enable patients to perform self-directed diagnostic or screening audiometry using patented test methods and accuracy algorithms.^[16,17] This technology streamlines the assessment process and allows audiologists to allocate more time to complex cases, patient counseling, and treatment planning. By incorporating automation into routine audiological evaluations, clinics can improve workflow efficiency and enhance service accessibility, ultimately reducing wait times and improving patient care outcomes.

The scarcity of speech materials varies across different regions in the Middle East. Egypt, for example, has no such problem, while the situation could be pretty much worse in other countries in the Gulf Area where the audiologists and workforce are not native Arabic speakers. In Saudi Arabia, where the study at hand has focused, limited access to validated speech materials when assessing speech audiometry in children was a major challenge for participating audiologists. In agreement with the participating audiologists’ responses, researchers attempted to highlight the absence of standardized tools for speech recognition testing when testing Saudi Arabic-speaking children, which led to the development and validation of different word lists tailored for this population [Table 1].^[18-22] These studies also highlighted the critical need for accessible and validated Arabic speech materials in pediatric audiology to improve diagnostic accuracy and clinical outcomes. However, accessibility remains an obstacle, likely since these tests were created for the purposes of research and did not progress to clinical settings, in some cases due to copyright issues. The limited development of Arabic speech perception tests has also been partly attributed to the challenges posed by variations in dialect and diglossia.^[23]

Other barriers identified in this study included inadequate equipment and insufficient training opportunities. These challenges could be mitigated by implementing workshops and continuous training for audiologists and healthcare managers to bridge the gap between clinical needs and available tools.^[24] Thus, training should be conducted in various regions, not only in Riyadh and Makkah, to ensure equitable access to professional development opportunities.

Despite participants’ extensive experience, a lack of standardized protocols in pediatric speech audiometry persists. Our findings showed that experience alone does not determine whether audiologists perform speech testing. The lack of accessibility leads to variability in assessment methods, regardless of the level of experience, impacting diagnostic accuracy and prompting the need for policy amendments and funding opportunities. The logistic regression findings also suggest that multiple factors influence the use of speech testing, rather than a single determinant such as experience or education. This highlights the need for a more comprehensive approach, including improved access to standardized tools, policy support, and clinician training. Nevertheless, the approaches employed by audiologists, as reported in this study, reflect adaptability and an effort to utilize linguistically and culturally relevant materials. These include spondee and monosyllabic words, age-appropriate closed-set tests, and tools such as Ling Six sounds and body part identification. While these approaches demonstrate flexibility, the absence of standardized and validated Arabic-language materials raises concerns regarding the consistency and reliability of clinical outcomes. The variability in tools and procedures underscores the need for validated speech audiometry protocols tailored to Saudi Arabic-speaking pediatric populations, highlighting the importance of research initiatives aimed at developing and standardizing such resources for evidence-based clinical practice.

Limited access to validated Arabic tools often forces clinicians to adapt resources that may lack cultural relevance, particularly for Saudi children. Addressing linguistic diversity in audiological services is essential, and developing accessible, culturally sensitive assessment tools is a pressing need.^[25] These findings emphasize the need for region-specific protocols and accessible tools to ensure consistent, culturally relevant assessments in Arabic-speaking pediatric populations. In addition, the development of centralized platforms, such as HER, could significantly improve access to appropriate resources for audiologists.

The findings of this study provide valuable insights into the field of audiology, particularly in regions where non-English speech assessment resources are scarce. The strong interest in validated, accessible Arabic-language materials for pediatric assessments suggests that making these resources widely available could significantly enhance diagnostic accuracy and treatment planning for Arabic-speaking children. The HER application is a step toward making standardized and validated resources accessible to audiologists. The participating audiologists perceived that the application could provide clinical assessment tools and results that are useful for diagnosis and treatment planning. In addition, they believed that it could be integrated into existing workflows as the navigation of the application is intuitive and user-friendly, and data exportability is easy to attain.

Furthermore, the development and distribution of tools such as the HER application demonstrate the potential for technology to bridge resource gaps in clinical practice. By enabling audiologists and families to conduct assessments in both clinical and home environments, the application facilitates more flexible and inclusive care models, especially for uncooperative children who may respond better in familiar settings. Recently, several mobile applications have been developed to facilitate hearing assessments, providing accessible and efficient alternatives to traditional methods. The hearWHO application, developed by the World Health Organization^[26] utilizes digits-in-noise technology to assess hearing abilities in real-world listening conditions. In addition, uHear has been validated as a cost-effective and automated alternative for preliminary hearing screening.^[27] Like the HER app, these applications illustrate the role of technology in improving the accessibility and efficiency of hearing assessments, particularly for early detection and intervention.

Although this study provides important insights, several limitations should be acknowledged. First, the sample size was small, which may affect the generalizability of findings. In addition, the cross-sectional design of this study does not allow for longitudinal insights into how access to resources, such as the HER application, may influence clinical outcomes over time. Another limitation is the reliance on self-reported data, as audiologists’ responses may be subject to recall bias or social desirability bias, particularly regarding the perceived value and usage of speech testing. Future studies could integrate observational methods or clinical audits to validate self-reported practices against actual clinical behaviors. In addition, collaborative research involving policymakers and healthcare providers could support the establishment of guidelines and funding models to ensure that culturally and linguistically relevant resources become a standard component of pediatric audiology care in Saudi Arabia.

CONCLUSION

Audiologists, in Saudi Arabia, generally agree that speech testing is beneficial for accurate diagnosis and treatment planning in children, yet they have reported that insufficient materials or equipment pose significant challenges. In addition, audiologists expressed a strong willingness to use speech tests if these materials were more readily available, highlighting the pressing need for accessible Arabic language resources.