Status of Audiology in India

This week at Hearing International we have guest authors from India discussing the Status of Audiology in India.  If there are colleagues in other parts of the world, interested telling us how the profession is practiced in their area, please send us submission.  Many thanks to our guest authors this week – RMT

The Status Audiology In India

India is the seventh largest country of the world in area and known for its cultural, religious and language diversity. India is the fastest developing country in the world.  According to WHO (2006), 80% of the hearing-impaired population lives in low and middle income countries. National Sample Survey Organization (NSSO) considered disability as one of the major issues within each of the various countries.

While audiology in India has grown exponentially in terms of manpower development, audiological service delivery and public awareness, there is a dearth of audiologists that serve a population of 1.28 billion. As per the most recent Indian census presented by Indian National Sample Survey Organization in the year 2011 , approximately 2.21% of the Indian population fall under the category of disability where about 5.03 lakh (18.9%)  of the population is with hearing impairment, and 1.98 lakh (7.5%) of the population have various types of speech problems uniformly distributed around the country.  Therefore, with respect to the population demonstrating hearing and speech impairment, there is a severe shortage of audiologists and speech language pathologists in the country, causing a significant delay in fulfilling the dream of eradicating hearing and speech impairment within the next 20 years. In India, according to ISHA (India Speech and Hearing Association), there are 2,500 registered audiologists and speech therapists.  As a result, many people with hearing impairment are untreated or are unable to utilize their implants and hearing aids to their maximum benefit. NSSO (2003) estimated that about 60 percent of individuals with hearing impairment are still not using any type of amplification.  

Education of Professionals

To cope with the increasing need of professionals, various programs in the field of speech and hearing have been designed to generate manpower to cater to the needs of individuals with communication disorders at the metropolitan cities, small towns and villages (grass-root level).  This involves audiologists and speech language pathologists who are well trained with a qualifying degree from a recognized university. They are involved in a spectrum of various kinds activities related to persons with impairment – hearing and/or communication, employed in diverse settings – hospitals, rehabilitation centers, special schools, regular schools, speech and hearing centers, and training and research institutions.  From an educational qualification point of view, for an individual to work independently in India as an audiologist, the minimum qualification required is a Bachelor of Audiology and Speech Language Pathology (BASLP) from a recognized college acclaimed by the Rehabilitation Council of India (RCI). As per RCI norms, there are nearly 45-50 institutions that offer a Bachelor’s degree and about 10 institutions that offer a Master’s degree in Speech and Hearing across the country. According to RCI, approximately 750 candidates graduate at different levels each year, but this is inadequate as compared to the needs of an increasingly disabled population. These numbers are also inadequate with respect to further growth of the profession in terms of both quality and quantity of the services being provided.  In India, most of the professionals are located in the southern part of the country.  This skewed distribution of professionals is due to the geographical locations of institutes offering bachelor and master degree programs in speech and hearing.  In the northern part of India (the states of Jammu and Kashmir, Delhi, Punjab, Rajasthan, Chandigarh, Uttarakhand, Himachal Pradesh, Uttar Pradesh and Bihar), there are only 7 institutions that offer the BASLP (Bachelor of Audiology and Speech-Language Pathology degrees), and only one institute (PGI Chandigarh that has a yearly student intake capacity of 2) that offers a MASLP program.

Emigration of Hearing and Speech Professionals

The effect of emigration of hearing and speech professionals to other countries contributes to the acuteness of this shortage. The magnitude of brain drain among speech and hearing post-graduates is reported to be 48%. The reasons cited relate to better financial income (62%), better career prospects (62%), and better academics. Of the 50% going abroad, about 30% left for higher education, and another 20% for personal reasons.  To meet the current need for professionals, an increasing number of training programs are being developed in smaller towns of the country, sometimes in the same State where two or more training programs already exist. One such course is Diploma Course in Hearing, Language and Speech (DHLS). The main aim behind the commencement of this course by Rehabilitation Council of India is to generate Speech and Hearing Technicians to take up routine clinical work of assessment and therapeutic management for various speech, language and hearing disorders at village, block/taluka and town levels. Wherever possible, they will work under the guidance of a fully-trained graduate or a postgraduate Speech & Hearing clinician and are given the designation as “Speech and Hearing Technicians”. However, such diploma holders are being hired instead of audiologists in many private and government sectors, as they are willing to work for less money than fully qualified audiologists.  This, in turn, motivates private hearing care clinics and hearing aid and cochlear implant companies to offer low salaries and recruit to hire less qualified audiological staff. This is frustrating for audiologists with graduate and post graduate degrees, and the higher pay offered by hearing care clinics in countries such as the USA, Australia, and the UK motivates many qualified audiologist to leave India and work there.

 The courses must also be designed to meet the needs in the country rather than duplicating without review the curricula followed in other countries. These issues need to be addressed by the professional associations and the relevant policy making forums. A close evaluation of training programs must be undertaken periodically in the light of current potential employment opportunities.   However, diploma holders also work on the place of audiologists in many private and government sectors, and many in the Indian audiology community believe that this leads to a poorer quality audiological service – the availability of diploma holders willing to work for less money than fully qualified audiologists motivates private hearing care clinics, hearing aid and cochlear implant companies to offer low salaries and recruiters to hire less qualified audiology staff. This is frustrating for audiologists with graduate and post graduate degrees, and the higher pay offered by hearing care clinics in countries such as the USA, the Australia and the UK motivates many qualified audiologist to leave India and work there.

Audiology Practice in Institutional Set Up

Currently, we are working in India as an Assistant Professor (Audiology), Department of Audiology and Speech-Language Pathology, Amity Medical School, Amity University, Gurgaon. A  degree course in maintained in Audiology and Speech-Language Pathology and soon we are going to start post graduate courses in audiology and speech language pathology. Here, we train and supervise students enrolled for graduate program of Audiology and Speech-Language Pathology.  We take a detailed case history for all patients and according to their requirements which includes personal, medical, amplification and otological history. We refer them for audiological evaluation, ENT evaluation and / or vestibular or tinnitus assessment. Periodic calibration of the audiometric instruments is carried out on a yearly basis and also through daily listening checks. It is important that audiometric instruments should be well calibrated and functioning properly and should be used in acceptable test environment for accurate diagnosis. We take care that pure tone audiometry (AC and BC) should be done with audiometer and transducers that meet ANSI S3.6-2004. Electroacoustic calibration should be done on annual basis, whereas, bio-acoustic measurements should be done on daily basis. Here we also assure that test environment should meet maximum permissible noise levels for audiometric test rooms. Biologic calibration should be done daily after switch on of instrument. Sometimes when the case load is more than 20 in first half of the day, we do biologic calibration again in second half of the day. We also do objective calibration yearly with the help of biomedical engineers and audiologists.

The Assessment

  Otoscopic evaluation is carried out for all patients for the safety of the patient as well as maintenance of equipment involving probes, such as a tympanometer. In case of wax which can affect the tests results and the process of ear impressions, we consider an ENT consultation. We do pure tone audiometry in closed field situation from 250Hz to 8000Hz for air conduction and 250Hz to 4000Hz for bone conduction testing. We use headphones (supra aural or circumaural) for pure tone audiometry as insert earphones require maintenance and they are not always economical.  Middle ear assessments are performed on all patients which include tympanometry and reflexometry (ipsilateral and contralateral). Sometimes, it is necessary to conduct immittance special tests, such as acoustic reflex decay.

In speech audiometry, we do speech recognition threshold (SRT), speech identification score (SIS), most comfortable level (MCL), dynamic range (DR) and uncomfortable level (UCL) on all patients and for selected patients speech perception in noise (SPIN), speech detection threshold (SDT) are also conducted. We also administer otoacoustic emissions (OAEs) and special tests (SISI, tone decay test, quick speech in noise, etc.) if we feel that these will assist in obtaining the proper diagnosis. In cases retrocochlear pathology is suspected (unilateral hearing loss, auditory synchrony etc.), we also will administer auditory brainstem response (ABR) for site of lesion, OAEs and long latency response (LLR) to enable correct diagnosis. 

Special Pediatric Services

For testing children younger than two years of age, we do a combination of behavioral and electrophysiological tests. The behavioral tests we do include behavioral observation audiometry (BOA), visual reinforcement audiometry (VRA) and conditioned play audiometry (CPA). In terms of electrophysiological tests we perform ABR with clicks as well tone-bursts for frequency specific response, OAEs and immittance evaluation. For some infant ASSR are also used if required. Speech audiometry should be done for verbal children. For non-verbal children response to Ling’s six sound, warble tones, NBN, learning to listen sounds should be assessed. Pre-fitting counseling to parents and caregiver is also done which includes detail of diagnosis, management options, hearing aid trial and fitting procedures, different types of hearing aids, benefit with different types of hearing aid, cost of hearing aids and it’s maintenance cost and importance of intensive auditory verbal therapy/listening therapy.   For a few younger children, if we suspect auditory dysynchrony (AD), we also administer LLR. For testing children in the age range of two to five years, we use a combination of tests, i.e. behavioral (CPA + VRA) and electrophysiological (OAE+ABR + ASSR).  Recently, Government of India has started free Cochlear Implant as per ADIP  scheme to 500 children in the age of the child with congenital deafness (since birth) upto 5 years or upto 12 years for child with post lingual deafness i.e. after development of speech & language. The 100% subsidy for family income less than 15,000/- per month and 50% subsidy for income Rs.15,000 to Rs.20,000 per month. 

Adult Amplification / Aural Rehabilitation

Depending upon the results of the audiological evaluation patients are either referred for a hearing aid trial (HAT) or ENT evaluation. For HAT, we take a case history and conduct pure tone audiometry, SRT, SIS, UCL for speech and narrow band noise (at least 500Hz, 1000Hz, 2000Hz, 4000Hz) in sound field.  Following the assessment, pre-fitting counseling discussing the assessments, implication of these findings and the types of amplification considering their audiological requirements, age, personal and professional needs, lifestyle, budget etc. Later, the programming of the selected hearing aid using software. For adults, the NAL-NL1 or NAL-NL2 prescriptions are incorporated, while for children DSL v4 or v5 is usually deemed more appropriate. To verify the fittings in both adults and children the clinic uses real ear, functional gain and patient feedback.  To assess the benefit with hearing aid, aided SRT, aided SIS at 50dBHL and aided UCL are used. Various questionnaires for documentation are also given to patients for the assessment of the perceived benefit from hearing aids. Post fitting counseling is conducted and includes discussion of the uses of the hearing aid, care and maintenance and the need for follow up care. In India, the majority of audiologists still prescribe body level hearing aids because they are affordable, and also because free body level hearing aids are distributed by the Government of India. Behind the ear, custom and RIC devices are also prescribed, but are significantly higher cost than those provided by the government. Patients for vestibular rehabilitation and tinnitus/hyperacusis are treated on a case by case basis. 

We keep ourselves up-to-date with the help of online audiology and ENT journals and magazines and we also attend two to three national meetings / seminars per year in India. The one thing which we want to share with my colleagues in the global audiology community is this: “Annual audiological evaluation should be mandatory for patients with diabetes mellitus”. We believe that audiologists should learn a diabetic patient’s complete case history, including their complications and the specifics of their medications.   The Department of Audiology and Speech-Language Pathology, Amity University, presently is well-equipped with all the hearing evaluation facilities and advanced technology and equipment. However, these facilities are limited for audiologists that provide services private hearing care clinics or other similar institutions. Recently, the All India Institutes of Speech and Hearing, Mysore (premiere institute of India) has opened a new Audiology unit, which has special wings for the pediatric, adult and geriatric populations with more testing booths, advanced audiological instruments and modern facilities for patients. However, the government of India is planning to open more institutes of speech and hearing in different parts of the country, which will facilitate easier access to audiological services.

References

World Health Organization (WHO) (2006). Working together for health. The world health report, 2006.  Retrieved April 16, 2017.

National Sample Survey Organization (NSSO)(2011).  India-National Sample Survey 2011-2012 (68th Round) – Schedule 1.0 (Type 1) – Consumer  

Expenditure.  Retrieved April 16, 2017.

National Sample Survey Organization (NSSO)(2003). India – National Sample Survey 2003 (59th Round) – Schedule 1.0 – Consumer Expenditure.  Retrieved April 16, 2017.

Nambiar S, Shah U. Brain Drain – Is it Affecting the Speech and Hearing Services in India? Unpublished Project Report. Mumbai: AYJNIHH; 2006.

About Our Guest Authors :

Himanshu Kumar Sanju has a post graduate degree in Audiology from All India Institute of Speech and Hearing, Mysore-6, Karnataka, India and is currently working as an Assistant Professor-1 at Department of Audiology and Speech-Language Pathology at Amity Medical School, Amity University, Gurgaon, Haryana, India.  His areas of special interest are vestibular assessment and management, electrophysiology, hearing aids, psychoacoustics, implantable devices and CAPD.

Manisha Choudhury has a post graduate degree in audiology and speech-language pathology from Dr. S. R. Chandrasekhar Institute of Speech and Hearing, Bangalore and currently working as Audiologist and Speech Language Pathologist-1, Department of Audiology and Speech-Language Pathology, Amity Medical School, Amity University, Haryana. Her area of interest is fluency and adult-language disorders.

Arun Kumar Yadav has a post graduate degree in audiology and speech-language pathology from Amity University, Haryana and currently working as Faculty of Audiology, Amity Medical School, Amity University, Haryana. His area of interest is electrophysiology and implantable devices.