# Global Audiology/Americas/Bahamas

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# General Information

The Commonwealth of the Bahamas is an island country consisting of over 700 islands, cays, and islets in the Atlantic Ocean. The population of The Bahamas is approximately 395,904 based on World Bank data for 2018 (World Bank, 2018). The capital and most populous island, New Providence, holds about 255,000 of those inhabitants.
The Bahamas is within the Lucayan Archipelago of the West Indies and is located north of Cuba and southeast of Florida in the United States. The Bahamas became independent from Great Britain in 1973; however, the legal system still follows the English Common Law tradition. The native language of The Bahamas is English, although many Bahamians utilize a native English-based dialect, also known as Bahamian creole. Haitians are the largest minority group in The Bahamas and make up as much as one fifth of the population, according to some estimates. Due to this, Haitian French Creole is a popular second language spoken by many throughout the country.

# History of Audiology

Audiology began in the Bahamas in 1991 with the first Bahamian audiologist, Dr. Deborah NuBirth, who worked at The Centre for the Deaf. The center was established by the Bahamas Red Cross and the Ministry of Education in 1964. It was launched to cater to the growing number of hearing-impaired children in the Bahamas. It is a non-profit institution that provides a deaf education curriculum for preschool through twelfth grade students. At the time, the Center for the Deaf selected one teacher of the deaf to pursue studies in audiology based on a scholarship given by the Ministry of Education.
Prior to this, all audiological services had to be done abroad, with the exception of an otolaryngologist or general practitioner completing a whisper, clap, or tuning fork test. The first audiologist obtained her master’s degree in audiology, which was the highest qualification for the field at the time. She continued working at The Centre for the Deaf, which was also home to the first audiology clinic in The Bahamas. She later obtained her Doctorate in Audiology after the degree requirement was advanced in the United States in 2007. Later, four additional Bahamian audiologists earned Doctor of Audiology degrees, offering mostly private practice services on the island of New Providence.
There are currently no government-mandated early identification and intervention programs for hearing loss within the Bahamas. Newborn hearing screenings are conducted at the private hospital and private practice clinics located in the capital city, Nassau. School hearing screenings are conducted on request by private educational institutions throughout the country. Industrial hearing screenings are also offered upon request. To date, there are also no vestibular assessment services offered by audiologists in the country.

# Incidence and Prevalence of Hearing Loss

There are varying statistics regarding the data on hearing loss prevalence in the Bahamas.
According to the 2005 study from the National Commission on Special Education in the Bahamas (NCSE), 5% of the population has a hearing impairment, using the 2000 census figures. There was no mention of the etiology or severity of the hearing impairment.
Differing from this statistic, the 2010 Census Disability Report revealed 699 people who acknowledged having hearing loss and/or used hearing aids. It also demonstrated a gradual increase in those with hearing loss, as the age range increased. The nation’s population was estimated to be 351,461 at this point.
In The Chief Medical Officer’s Report 2004-2008 by Dr. Merceline Dahl-Regis, annual data was collected for postnatal and infant/toddler health services. Many new mothers received home visits within 10 days following delivery. There were an average of 3,739 deliveries annually, demonstrating a prevalence of approximately 0.62% for abnormal hearing during this period. The criteria for abnormal hearing were not specified in this report.
Government school health services for grades 1, 6, and 10 were also conducted during this period, including hearing screenings. The incidence rates for hearing defects averaged 0.26, 0.7, and 1.48%, respectively. For each grade level, approximately 3,121, 3,592, and 2,644 students were screened annually. Again, no specific criteria for hearing defects were mentioned.
These figures indicate a wide range of variability regarding data on hearing loss prevalence. This inconsistency could be due to differences in screening protocols, criteria for hearing loss, socioeconomic health, and other intrinsic and extrinsic factors based on each participant at the time of data collection.

# Educational Institutions

Education in the Bahamas is provided by both the government and independent entities. However, the Ministries of Youth and Education implement the policies for both public and private educational institutions in The Bahamas. Currently, there is one public college or university, the University of The Bahamas. It was established in 1974 and provides programs leading to bachelor's and associate degrees. There are a few other universities and colleges that offer programs in business, law, and vocational training throughout the country (Caribbean Symposium on Inclusive Education, 2007).
Currently, there are no institutions offering audiology programs or qualifications within the Bahamas or the West Indies/Caribbean. Due to The Bahamas’ proximity to the United States, many Bahamians migrate to the United States for higher education, and particularly to obtain a Doctor of Audiology degree.

# Audiology Practice: Public and Private

At this time, most audiology services are offered privately in the Bahamas.
In the early 2000s, there was a government facility that offered public audiology services called the South Beach Clinic. It was established by the second Doctor of Audiology in the country, Dr. Kim Scriven, under the Department of Public Health. The facility offered pure-tone audiometry, speech testing, annual hearing screenings for all ages, and a hearing conservation program for industrial workers. Currently, there are no audiologists working in the public sector. Now, services offered by public clinics include basic otoscopy and a hearing screening that is performed by one of the clinic's trained hearing screening nurse practitioners.
All private services offered include:
* Comprehensive diagnostic hearing assessments
* Hearing aid evaluations, fittings, and follow-ups
* A hearing conservation program including custom hearing protection and ototoxic monitoring
* Hearing screenings for newborns, school-aged and industrial workers
The private hospital, Doctors Hospital, hosts an audiology clinic that offers cochlear implant evaluations and mapping. They also provide a host of ENT surgeons to facilitate implantable devices and middle ear surgeries.
These services are most often reimbursed by health insurance. However, for those who do not have health insurance or cannot afford an out-of-pocket expense, social security services are available to those who meet certain requirements. This service will cover up to mid-level technology for those needing hearing aids.
A national health insurance program was established in 2016 and is being implemented in phases. The program was implemented to address the deficit of Bahamian citizens' lack of access to healthcare, as some 70% of citizens do not have health insurance. To date, some residents of the country have registered; however, registration has been put on hold since 2019. Once fully implemented, these services will cover primary health care services and later expand to include a wide range of benefits that include specialized care. The system allows for universal coverage of a basic benefit package and for voluntary insurance to be purchased as a top-up policy to cover services or amenities that are not included in the government plan.

# Professionals

According to the registrants of the Bahamas Health Professions Council, the number of professionals involved in hearing healthcare is as follows:
| Professional | Approximate Number | Ratio to the Population |
| Audiologists | 4 | 1:99,000 |
| Otolaryngologists (ENT) | 3 | 1:132,000 |
| Physicians | 194 - General Physicians 390 - Specialists | 1:2,041 |
| Neurologists | 3 | 1:132,000 |
| Nurse Practitioners | 283 - clinically trained (PHA, 2017) | 1:1,399 |
| Speech-Language Pathologists | 8 | 1:49,500 |
| Teachers of the Deaf | 7 currently teaching at The Centre for the Deaf 4 -active retirees 2 assistants | 1:56,571 |

# Audiological services

There are currently three audiologists practicing in the Bahamas. These audiologists are practicing with a license provided by the Ministry of Health. Services include:
* Pure-tone audiometry
* Tympanometry
* Impedance Telemetry
* Hearing aid dispensing, programming, and repairing
* Tinnitus management and counseling
* Cerumen management
* Hearing conservation
* Cochlear implant evaluations and mapping
* Auditory Brainstem Response

# Services Offered by Medical Professionals
#### Otolaryngologists

With only three physicians, services are primarily provided in the capital city. They offer basic ENT (ear, nose, and throat) care, head, and neck surgery, and at least one assesses and treats balance disorders. These physicians mainly practice privately and offer services within the public sector on a part-time basis.
There was previously a consulting ENT surgeon from the United States conducting tympanoplasty, implant, and middle ear surgeries privately in Nassau. This was offered via a private clinic associated with Med-El, a company specializing in implantable hearing devices. However, this service is now defunct.
The first cochlear implant surgery performed in the Bahamas took place at Doctors Hospital in July 2015. The surgery was performed as a collaborative pro bono effort with an American surgeon, Dr. Brian McKinnon, and local ENT surgeons, Drs. Robert Ramsingh and Walter Gibson (ENT), Dr. Sy Pierre (anesthesiologist), and Ranjeeta Ambett (ENT specialist).
Since the inaugural surgery, several more cochlear implant surgeries have taken place at Doctors Hospital with the collaboration of an international and local ENT team.

#### ENT Specialty Nurse

As publicly noted, there is one certified ENT nurse working in the public hospital system (Princess Margaret Hospital). She completed her training in 1977. She manages nursing services within this specialty clinic and is well-versed in areas such as tracheostomy care, ear wax removal, managing nose bleeds, etc.

### Scope of Practice and Licensing

To date, Section 11 of "The Health Professions Regulations, 2000," Part III for Audiology and Speech Language Pathology, provides general guidelines for registration. It specifies having a master’s degree in audiology through an accredited program by the American Speech, Hearing, and Language Association or another qualification approved by the Health Professions Council. The alternative is successful completion of an exam for certification in the jurisdiction of clinical practice experience.
Section 10 concisely specifies authorized health services. Audiologists may practice within the limitations of their certificate of registration and may prescribe hearing aids under the referral of a medical practitioner.
There is no official standardized scope of practice for audiologists in the Bahamas; however, most audiologists follow the American Speech Language Hearing Association or American Academy of Audiology guidelines.
Additionally, only audiologists are allowed to dispense hearing aids in the Bahamas. There are no hearing aid dispensers.

### Professional and Regulatory Bodies

Currently, there is no defining body that represents audiologists in the Bahamas. As mentioned previously, all audiologists practicing in the Bahamas must be registered with the Bahamas Health Professions Council. Although not exclusive to audiology, the Bahamas Health Professions Council has designated investigating and disciplinary committees that assess, ensure due process, and make recommendations regarding complaints. The council makes referrals to these committees and receives their recommendations. Once deemed necessary, disciplinary action may include suspension of registration not exceeding a year, removal from the register, or a fine not exceeding $1,000 paid forward to the government.
Additionally, private practice facilities must be registered for a facilities license with the Bahamas Ministry of Health and meet all the qualifications for a certificate of good standing with the Bahamas National Insurance Board.

# Research in Audiology

A cursory search in various databases and journals reveals virtually nonexistent research regarding hearing and vestibular topics in the Bahamas. Research will further contribute to the nation’s identity and provide invaluable information for clinical application, thus benefiting the population at large.
One Bahamian audiologist wrote her Master’s in Audiology dissertation on the “Feasibility of Implementing a School Hearing Screening Program in The Bahamas: A systematic review.” This review outlines the four main barriers to implementing a school-based hearing screening program and opportunities to address the challenges of implementation. This research has now stemmed into an outreach project/non-profit organization called “The AuD Project: Advocating for little ears one country at a time.” The organization, founded by a group of audiologists, is an initiative dedicated to funding and developing hearing screening programs in underserved areas. The first launch of the project began in Nassau, The Bahamas in 2019. The team of audiologists traveled from the U.S. to Nassau to train a team of healthcare workers on school-hearing screening protocols and equipment. They screened over 300 students in the public-school system for hearing loss. All data, equipment and training materials were given to The Bahamas Ministry of Health to continue this program.

# Audiology Charities, Advocacies and Support Groups
### Rotary Club of East Nassau

This organization is dedicated to humanitarian issues and community service. Audiologist, Dr. Kim Scriven collaborated with the Rotary Club of East Nassau in 2006 to initiate the Gift of Hearing program. Its aim is the provision of free hearing aids and associated services for children in need due to a lack of governmental resources. This is reportedly a yearly initiative.

### The Red Cross Centre for Deaf Children

This school was established in 1964 with the goal of providing educational services to an increasing number of hearing-impaired and deaf children in The Bahamas. It is the culmination of efforts by the Bahamas Red Cross and the government’s Ministry of Education. Children from preschool up to twelfth grade are accommodated. There are approximately twenty-two students present at the center.

### Dairy Queen’s Miracle Treat Day

This is a yearly initiative that raises funds for specific community causes affecting children in The Bahamas. In 2018, funds were raised for hearing-impaired children from the Red Cross Center for Deaf Children. $10,500 was raised from blizzard purchases, which went towards acquiring hearing aids. Perhaps this fundraiser may occur again in the future with Dairy Queen.
Disability Affairs Division of the Department of Social Services
This government sector provides coverage for hearing aids and associated services for those who qualify. It also offers sign-language assistance.

### New Providence Association for the Deaf and Hard of Hearing

This nonprofit advocacy group was launched in 2012, recognizing the lack of resources, and providing appropriate services and representation for deaf and hearing-impaired individuals across Bahamian society. Its vision is to ensure equal rights for this community so that they can become productive citizens. The use and preservation of Bahamian sign language are also highly valued. A strong aim of this group is to eradicate all forms of discrimination against this community. Other goals include gainful employment and educational reform. The late Marvin Finlayson, a former technical educator in the public sector, was the visionary for this organization.

### The National Commission for Persons with Disabilities

This is a statutory board with the responsibility of enforcing The Bahamas’ Persons with Disabilities (Equal Opportunities) Act, 2014. The act focuses on ending discrimination against disabled individuals and advocating for their rights and access to equal opportunities. Deafness and hearing impairment are symbolized in its logo, among other disabilities.

# Challenges, Opportunities and Notes

Currently, there is no established newborn hearing screening program within the public sector (Princess Margaret and Rand Memorial Hospitals). However, as of 2020, there has been a collaborative effort between a few audiologists and physicians to initiate this program. This includes working with the government to procure screening equipment, establish test protocols, and train nurses and other staff to run the program.
A standardized set of protocols should be made available to the public to establish consistency of care for all audiology services, particularly for early identification programs, audiology education requirements, and industrial hearing conservation programs.
The Bahamas is an archipelagic nation, making it difficult to have accessible audiology services on every island. Of the seventeen main islands, there are only three where audiology services are offered. This includes New Providence, where the capital is found, Grand Bahama, and the Abaco Islands. Over the past few years, two audiologists from New Providence have traveled to Grand Bahama and the Abaco Islands to provide services. The regularity of services is based on the demand for and availability of these professionals.
There is a large window of opportunity for telehealth services, as the Bahamas is spread over approximately 100,000 square miles of ocean. This serves as a convenient and cost-effective option for prospective patients on the remote family islands.
Being a small, developing country poses various challenges for professionals educated abroad who wish to return. There are entities such as the Lyford Cay Foundations and the Bahamas government that provide grants and scholarships for study in areas like audiology to help diversify the economy and advance the nation. However, brain drain remains a significant concern. Issues that arise for Bahamian audiologists and other professionals include compensation, limited career opportunities, networking, and generational differences in work ethic, among other concerns. For this reason, many choose to live and work abroad, often on a permanent basis.
All audiologists residing in The Bahamas practice privately and offer limited services within the public sector, affording them a higher standard of living. There is an onus on the Bahamian government to create valuable positions within the public sector, thereby enticing more audiologists to return home.
Audiologists will have to be the designated professionals who demonstrate the necessity and value of vestibular services for dizzy patients. From here, a team-based approach within the wider medical community may be cultivated to thoroughly address the needs of this population. This is particularly important considering that there are little to no vestibular services currently offered.

# References

* Bahamas, D. C. (2015). The National Commission for persons with disabilities.
* Bahamas Medical Council (2020). General medical register – 2020.
* Bahamas Medical Council (2020). Specialist Register – 2020.
* Dahl-Regis, M. (2010). Annual report of the chief medical officer, 2004-2008.
* Education, N. C. O. S. (2005). Report of The National Commission on Special Education
* Education, U.-I. B. O. (2007). Caribbean Symposium on Inclusive Education.
* GNI per capita (current LCU) – Bahamas, The from The World Bank: Data. 2018. 11,625. Kyrgyz Republic. 2019. 84,704. Lao PDR. 2019. 22,250,172. Latvia.
* The Bahamas Health Professions Council (1998). Health Professions Act, 1998.
* The Nurse’s Association of the Commonwealth of The Bahamas (2017). 70th anniversary gala and 2nd biennial zenith awards presentation.
* 2010 Census: Disability report (2010).
| | | Contributors to the original text |
| Ariel Garraway | Treasure Kenny | Contributors to the original text |