# Global Audiology/Americas/Canada

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# General Information

Canada is the second-largest country in total area; however, most of Canada’s roughly 36 million people reside along the southern border. Modern-day Canada is comprised of ten provinces and three territories, all of which stretch across the northern part of North America. Canada’s eastern and western borders are the Atlantic and Pacific Oceans, respectively. To the north lies the Arctic Ocean, and to the south lies the continental United States of America. The state of Alaska lies to the northwest. The nation’s economy is heavily reliant on the vast natural resources found in the sparsely populated areas as much of the country is covered in dense forests and Arctic tundra (“Canada,” 2016)
Canada has been populated for several centuries, first by Aboriginal people, then by French and British settlers. The French established the first colony in Canada in 1537. The British began to colonize parts of Canada before establishing the Thirteen Colonies in what is now the United States. Over the course of the 17th and 18th centuries, the British acquired most of the land that is modern Canada. However, the influence of French culture still permeates much of the eastern half of the country. Due to expansive immigration, many cultures, languages, and religions have flourished. Though English and French are the officially recognized languages, many others are spoken throughout the nation. Nearly 98% of citizens speak English and/or French as a native language (“Canada,” 2016).
There is not an official religion practiced in Canada. Religious freedom is a strictly held principle by the nation, which is protected by the constitution. Christianity is the most commonly reported religion to be practiced in Canada. The 2011 census data indicated that approximately 67% of Canadians categorize themselves as holding Christian beliefs. Catholicism accounts for the largest faction of Christian Canadians. Outside of Christianity, Islam and Hinduism are the most commonly practiced organized religions (“Canada,” 2016).
Canada’s long history and belief in a strong federal government have encouraged the development of a truly unique national identity.
In Canada, the professions of audiology and speech pathology are relatively young; however, they are not well documented. Services were first recorded in the early portion of the 1930s. This is relatively late compared to the clinical services that were being provided in other countries after World War I. It was not until the 1950s and 1960s that audiology services flourished in Canada. The earliest audiologists were individuals educated in other countries and recruited to provide services in Canada. These audiologists worked for government clinics and the Interprovincial School for the Deaf. Early on, it was common for providers to offer audiology and speech pathology services due to the lack of professionals in both disciplines (Martin, 2007). Canadian universities began to offer audiology programs in the early 1960s. The first two were the University of Toronto and the University of Montreal. Today, there are five master’s degree programs for audiologists.
A major issue with tracking the development of services occurred due to a large number of providers that would move between provinces and even their nation of origin (Martin, 2007). The internationally recruited professionals offered a great amount of influence on audiology; especially those from the United Kingdom and the United States. This influence is still evident today.
The regulation of audiology in Canada has a complicated history. Some provinces and territories still do not institute regulations. The federal government did not develop guidelines for the practice of audiology until 1982. The regulation by professional organizations was complicated by the fact that international audiologists typically belonged to an organization in their home country and considered membership in an established institution to be sufficient. Eventually, the Canadian Speech and Hearing Association was founded as a unifying basis for audiology and speech pathology. Since this time, the professions have become somewhat separate while acknowledging the common history that they share (Martin, 2007).

# Hearing loss incidence and prevalence

In 2012 and 2013, the Ministry of Health conducted the Canadian Health Measures Survey (CHMS), which included audiometric assessments of adults and children. The survey results “indicate that 20% of adults aged 19 to 79 years had at least a mild hearing loss in at least one ear" (“Hearing Loss of Canadians,” 2015). Of the adults surveyed, hearing loss was most common in the 60-79 age group at 47%, 16% of adults aged 40-59 years, and 7% of adults aged 19-39 years. The older adults (60–79 years) were also more likely to have bilateral hearing loss. Children between 6 and 18 years old were also included in the survey. The audiometric results indicate that approximately 5% of children had a hearing loss, and most (90%) had a unilateral hearing loss. Male and female children were equally affected. Otoacoustic emissions were completed on children 3-5 years of age, but not audiometry. 7% of children tested with OAEs showed results consistent with conductive hearing loss. The majority of survey participants were unaware of their hearing loss; nor had they been diagnosed with hearing loss by a health care professional (“Hearing Loss of Canadians,” 2015).

# Information About Audiology
### Education

Audiologists in Canada are required to complete a master’s or doctorate degree in audiology in addition to an undergraduate degree. Master’s degree programs are two to three years in duration. For those interested in academia, some universities offer Doctor of Philosophy degrees in audiology (“About Audiology: How to Become an Audiologist”). The Doctorate of Audiology is considered commensurate with the educational requirements.

### Audiology Practice: Public and Private

Audiology services can be accessed in a variety of facilities, which can lead to some confusion about how services are paid for. Publicly funded facilities such as hospitals, community health centers, and schools do not charge patients directly for services that are medically necessary (“Paying for Audiologist Services,” 2016). Cochlear implants can be covered under these terms. To obtain audiological services in public institutions, a physician referral may be required. Many citizens purchase a supplemental health insurance plan to assist with prescriptions, services, and devices that may not be covered by the public program. Many of the supplemental plans assist with the purchase of hearing aids. Audiologic services are covered by public insurance; hearing aids are not covered for adults. Children under the age of sixteen can receive hearing aids at no or reduced cost (Mencher, 2008).
Private clinics are also available for Canadian citizens. In order to access private clinics, patients may utilize private health insurance from an employer or pay out of pocket. By law, private clinics are not supposed to provide services covered under the Canada Health Act; however, many clinics do so at reduced wait times. In these clinics, audiologists can charge for their services in addition to hearing aids (Canadian Health Care, 2004-2007).

### Services offered by Otolaryngologists, Otologists and Otoneurologists

Otolaryngologists offer a diverse selection of ear-related services. Services may include: diagnosis and management of acute and chronic pathologies, balance disorders, and traumatic injuries; surgical management of congenital malformations, pathologies, tumors, and implantable devices. The most common surgical implants available are cochlear implants and bone-anchored hearing aids. Otolaryngologists are highly trained, and many perform complex microsurgeries to improve hearing. Many are also skilled in plastic surgery, which can be helpful when correcting congenital malformations of the ear (“What is an Otolaryngologist-Head and Neck Surgeon?,” 2013).

### Audiological Services

Audiologists practice in several different clinical settings. These include: hospitals, public health clinics, schools, early intervention programs, private practices, hearing instrument manufacturers, research facilities, industrial facilities, and universities. While each setting may require the provision of different services, overall, audiologists are responsible for the identification, diagnosis, and management of individuals with hearing loss, tinnitus, balance disorders, and other ear-related disorders.
Clinical services offered by audiologists include the following:
* Assessment of hearing and balance
* Management of hearing and balance disorders
* Assessment, selection, dispensing, validation and verification of management options including hearing aid and other rehabilitation strategies
* Intraoperative monitoring
* Aural rehabilitation
* Cerumen management
* Screening for communication disorders
Additionally, audiologists are responsible for the education of families regarding identified hearing loss and the community on general hearing health, including hearing protection. Audiologists who work in schools are responsible for optimizing students’ educational experiences related to their hearing. Audiologists are also responsible for educating the next generation of hearing health professionals and advancing the field via research efforts. The efforts of others allow for the continuing practice of the profession through administrative and legal procedures (“Scope of Practice in Audiology,” 2016).

### Professionals

The table below shows the professionals who regularly interact with individuals with hearing loss. The ratios are estimates calculated based on the population of 36,155,487 (“Canada,” 2016).
Ear and Hearing Care Professionals in Canada :
| Professionals | Approximate number | Ratio to the population |
| Audiologists | 1,759 ("Canada's Health Care Providers: Provincal Profiles, 2013," 2013) | 1: 20,555 |
| Otolaryngologists | 733 ("Otolaryngology Profile," 2015) | 1: 49,325 |
| Physician Assistants | 308 ("Canada's Health Care Providers: Provincal Profiles, 2013," 2013) | 1: 117,388 |
| Physicians | 82,198 ("Physicians in Canada, 2015," 2016) | 1: 440 |
| Speech-Language Pathologists | 8,973 ("Canada's Health Care Providers: Provincal Profiles, 2013," 2013) | 1: 4029 |

### Professional and Regulatory Bodies

The Canadian Academy of Audiology (CAA) aims to exemplify the field of audiology in Canada by supporting audiologists in their endeavor to become the primary providers for hearing health. The organization was established in 1996 and incorporated in 1998. CAA provides a scope of practice, ethical standards, educational materials, and advocacy for the profession of audiology. The Academy also publishes The Canadian Audiologist, a bimonthly electronic journal (“Vision/Mission”).
Another professional body for Canadian audiologists is Speech-Language & Audiology Canada (SAC). SAC began in 1964 as the Canadian Speech and Hearing Association. Since the mid-1960s, SAC has been active in developing clinical standards and collecting demographic data relating to communication disorders. In 1998, SAC and the American Speech-Language and Hearing Association collaborated to establish a program for reciprocal certification (“SAC History,” 2016).

### Scope of Practice and Licensing

The Canadian Academy of Audiology published a position paper in 2002 regarding the scope of practice for audiologists as defined below:
“The scope of practice of audiologists is defined by the training and knowledge base of those who are licensed or otherwise regulated to practice audiology. The central focus of the profession of audiology is on human hearing, both normal and impaired, and its relationship to disorders of communication.
(“Scope of Practice,” 2002)
The position paper continues to outline the specific areas in which audiologists are qualified to provide services. These services include, but are not limited to (“Scope of Practice,” 2002):
* Establishing and managing screening programs for patients of all ages
* Assessment and diagnosis
* Habilitation and Rehabilitation
* Hearing Conservation
* Intraoperative Monitoring
* Research
In terms of licensing, each province and territory has its own requirements for licensing audiologists. However, there is a plan to establish a national examination to ensure the commensurate education of audiologists.

# Research in Audiology

Audiology research is fairly active around the nation. Much of the current work focuses on the pediatric population, aural rehabilitation, and signal processing. The university research laboratories continue to explore outcome measurements for amplification users of all ages. Researchers’ interests in aural rehabilitation extend beyond individuals and often center on the family as a whole.
The University of Western Ontario has also contributed a significant amount of research regarding hearing science in the clinical setting. Researchers for the University of Western Ontario are responsible for developing the Real-Ear to Coupler Difference (RECD) procedure, used for improving the accuracy of hearing aid fittings, and the Desired Sensation Level algorithm (“Research,” 2016). These are merely two examples of the major contributions that Canadian researchers have provided to the field of audiology, but these advancements have had international implications on clinical procedures.

# Audiology Charities

There are several philanthropic organizations to assist families and individuals with hearing loss. A few are listed below:
* Canadian Hearing Society
* BC Family Hearing Resource Society
* Voice for Hearing-Impaired Children

# Challenges, Opportunities and Notes

=== Challenges === A major challenge faced by the profession is the lack of consistency within and between the provinces and territories regarding the practice of audiology. Each province or territory has different regulations for the practice of audiology. Additionally, the funding for audiology programs (e.g., newborn hearing screenings) can fluctuate and is not guaranteed for hospitals.
Another challenge that Canada faces is sifting through the complex healthcare system to determine insurance eligibility and coverage. The public health insurance system can cause patients to experience lengthy waiting periods to obtain hearing healthcare.

# References

* About Audiology: How To Become An Audiologist
* Canada’s Health Care Providers: Provincal Profiles, 2013. (2013) (pp. Table 1): Canadian Institute for Health Information.
* Canadian Health Care. (2004-2007).
* Hearing Loss of Canadians. (2015, November 27,2015).
* Martin, V. (2007). History of Speech-Language Pathology and Audiology in Canada: Our First Fifty Years
* Mencher, G. (2008). Universal Hearing Health Care: Canada.
| | Contributor to the original text |
| Ross Roeser | Contributor to the original text |