# Global Audiology/Africa/Ethiopia

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# General Information

Ethiopia is considered a middle-income country and the second-largest sub-Saharan country in Africa. The number of births annually is 35.9 per 1000 inhabitants (World Bank data 2016), and its current population consists of 102 million people. There are two major languages, Amharic and Oromo, which are spoken by 95% of its population. There are several ethnic groups in the country. Ethiopia shares borders with Eritrea to the north; Djibouti and Somalia to the east; Somalia and Kenya to the south; and Sudan in the northwest.
Ethiopia was shortly colonized by Italy and was a kingdom ruled by King Haile Selassie until 1974. After this period, it was ruled by the communist Derg regime, and since 1991, it has been a Federal Democratic Republic. According to the IMF, Ethiopia is one of the fastest-growing economies in the African subcontinent. Agriculture constitutes around 85% of the labor force. Coffee is the major export product.

# History of Audiology and Aural Care

Most audiology services in Ethiopia were initiated by non-governmental organizations. Services probably started in deaf schools around the 1980s. Currently, there are an unknown number of clinics offering hearing assessments. These centers may be privately owned or located in public hospitals. Audiology clinics are mainly concentrated in the capital city of Addis Ababa. We are not aware of audiologic facilities outside the capital city. There are five deaf schools in Addis Ababa. There is one deaf school in the rural parts of Ethiopia, in Hosannah. These estimates may be low. Presently, there are no certified audiologists working in Ethiopia. Ethiopia, like many other African countries, has no early identification and intervention program.

# Incidence and Prevalence Hearing Loss

At this time, no studies on the prevalence of hearing loss in rural and urban populations have been performed. So, it is difficult to assess the prevalence of hearing loss in the general population. Smith et al. performed a study that assessed the presence of hearing loss in children with HIV who are enrolled in one primary school. In this study, defining hearing loss as thresholds greater than 25 dB, the prevalence was 13%; with a pure tone average (PTA) of more than 40 dB, the prevalence was 6%. These numbers seem to be in agreement with estimates from the World Health Organization (WHO). However, there is a definite need for more data that also investigates the prevalence of hearing loss in the general population, especially in rural settings.

# Information About Audiology Education

Currently, there is a “special needs” curriculum within Addis Ababa University that contains a module for speech-pathology, along with some audiology and educational skills. There is no certified training for audiologists except for online courses elsewhere. There is no degree to be achieved. The aim of two different non-profit organizations is to set up an audiology training program in cooperation with St. Paul Millennium Hospital in Addis Ababa.

# Audiology Practice: Public and Private

The following services are available in both private and public settings:
* Pure-tone audiometry (PTA)
* Tympanometry
* Impedance audiometry
* Otoacoustic emissions
* Screening auditory brainstem response
The government supports medical care only for the very poor. In general, it is our impression that the quality of audiometry is very poor in public hospitals. In the public hospitals we have visited, the above-mentioned services are mostly absent. In rural communities, there is no audiological care available.

# Services Offered by Physicians

Otolaryngologists offer ear care services in hospitals in Ethiopia. All of these professionals have received their training in Addis Ababa (Black Lion, Yekatit 12, and St. Paul’s Millennium Hospital). Medical doctors who had their medical training outside Addis Ababa signed a contract to go back to their primary university and practice otolaryngology outside the capital city. However, 80% of ENT care is facilitated in the capital city.

# Audiological Services

Due to the lack of a certified audiologist in Ethiopia, we are not aware of any special service in deaf schools, private or public, provided by an audiologist. There is no special clinics that focus on tinnitus management, vestibular assessment, or auditory processing disorders.
There is a hearing aid specialist in Addis Ababa that works with the Starkey Foundation. Hearing aid supplies in private practice come from Sudan.
Ethiopia had no neonatal screening. There are also no services provided for children from birth to age 3. Due to a lack of training, the hearing aid specialists do not feel comfortable working with this population.
Limited mobile services are only being provided by organizations (from the Netherlands, the United Kingdom, and the United States) on a volunteer basis.

# The Ear and Hearing Care Profession
### Professionals

Ethiopia has a health workforce of 0.7 per 1000 population, which is low compared with the WHO recommendation of 2.3 health workers per 1000 population. The physician to population ratio in Amhara, Oromia, and regional states was computed to be 1: 280,000, 1: 220,000, and 1: 230,000, respectively.
At present, we assume there are no registered audiologists working in Ethiopia. A 2015 survey indicated that one audiologist is working in Ethiopia; however, this is a clinical nurse trained in performing audiometry. We are not aware of any practicing otologists or ENT physician assistants. In rural settings, most hospitals will have an eye nurse, and sometimes nurses with a specialization in ENT are present. This bottom -p procedure is a point of interest and is facilitated by the 4-5 groups working in rural centers in Attat, Wolisio, Butajira, Bahir Dar, Aksum, Tigray, and Aawassa.

### Professional and Regulatory Bodies

There are no professional or regulatory bodies in Ethiopia for audiology.

### Scope of Practice and Licensing

With a limited number of hearing healthcare professionals, information about licensing and scope of practice is not available.

# Audiology Charities

There are several philanthropic organizations to assist families and individuals with hearing loss. A few are listed below:
* Dutch Eardrop Foundation
* Healing the Children
* Aksum Initiative
* Visions Global Empowerment
* Global ENT Outreach
* Hearing Loss Prevention in Ethiopia-Partners for Global Hearing

# Challenges, Opportunities, and Notes

The biggest challenge for audiological and ENT care in Ethiopia will be establishing ear care from a “bottom-up” perspective, starting with raising awareness for the growing disability problem of hearing loss. All LMIC countries will face an enormous increase in hearing problems in young individuals (noise-induced, chronic suppurative otitis media (CSOM), hearing disorders related to HIV and TB treatment); as well as an increase in age-related hearing loss (presbycusis).
Non-government organizations may be able to assist in making aural care accessible by initiating relationships with the public health field and the (local) responsible ministries. More focus should be given to the scope of these problems in a bottom-up procedure that strengthens the work of the clinical officers and basic audiological care like screening programs.
Additionally, there is a lack of state-of-the-art equipment, training facilities, and remote teaching facilities, as well as audiological rehabilitation services.

# References

* Stevens G, Flaxman S, Brunskill E, Mascarentas M, Mathers CD, Finucane M. Global and regional hearing impairment prevalence: an analysis of 42 studies in 29 countries. European Journal of Public Health. (2011); 23:146-152.
* Mulwafu WK, Ensink RJH, Kuper H, Fagan JJ. Survey of ENT services in sub-Saharan Africa Little progress between 2009-2015.GlobHealthAction. 2017;10(1):1289736.
* Prevalence of Hearing-Loss Among HAART-Treated Children in the Horn of Africa. Smith AF, Ianacone D, Ensink R, Melaku A, Casselbrant ML, Isaacson G. International Journal of Pediatric Oto-rhinolaryngology. 2017 Jul;98:166-170.
| | | Contributors to the original text |
| Dr. Amber Morgan | Dr. Robert Ensink | Contributors to the original text |