# Global Audiology/Asia/India

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# General Information

The Republic of India is a country in South Asia. It is the seventh-largest country by area, with 1.4 billion people, the most populous country of the world, and the largest democracy in the world. India is well known for its culture, language, and religion. It is the 7th largest country in the world (Census of India, 2011). The population density of India in 2011 was 382 per sq km-decadal growth of 17.72 percent (Census of India, 2011). India has a total of 28 states and 8 union territories, which spans across 3.3 Million sq. km (Profile| National Portal of India, n.d.). India is in the Lower-middle income category as per the World Income Classifications FY24 and belongs to the Southeast Asia Region.
India has arguably greater linguistic diversity than any other large country. The precise number of languages spoken in India is probably over 1,000. More than 10,000 people speak a total of 122 languages. The big six languages—Hindi, Bengali, Telugu, Marathi, Tamil, and Urdu—are each spoken by more than 50 million people. Hindi and English are the official languages.
India has various religions. The predominant faith of the people is Hinduism, while Islam, Christianity, Sikhism, Buddhism, and Jainism are also followed. Indian culture, often labeled as an amalgamation of several cultures, spans across the Indian subcontinent and has been influenced by a history that is several millennia old. In addition to languages and religions, Indian cultural diversity has also been heavily influenced by the socio-economic status of people.

# Hearing Loss Incidence and Prevalence

In India, according to a recent study, 63 million people suffer from hearing loss (6.3) (Varshney, 2016). Of the total population of persons with disability of 2,68,14,994 in India, 50,72,914 persons are reported to have hearing loss (18.91%) across age groups. Among less than 6-year-old children, 4,76,075 children are reported to have some degree of hearing loss (23.20%) (Census Government of India, 2011). This number might be an understatement due to many unidentified hearing loss and unavailability of data (Paul, 2016; Sija et al., 2022). The prevalence figures could be considered as a broad approximation, as these may include conductive, mild, and unilateral types of hearing loss in addition to permanent hearing losses.
The most commonly used definition of hearing loss is as per the (Rights of Persons with Disability, 2016), which states that; -“deaf” means persons having 70 DB hearing loss in speech frequencies in both ears & -“hard of hearing” means person having 60 DB to 70 DB hearing loss in speech frequencies in both ears

# Information About Audiology
### History

The profession of otolaryngology in ancient India can be dated back to between 1000 BC and 100 AD (Pothula et al., 2001); however, otology as an independent profession gained more recognition after 1950 (Bhargava & Bhargava, 1996). The profession of audiology is relatively new and took root nearly half a century ago. Since then, both of these professions have undergone some major developments and offer a wide range of ear and hearing healthcare services.
Indian traditional medicine, such as Ayurveda, Unani, and Siddha, has some treatment solutions for ear and hearing problems commonly referred to as Badhiriya (hearing loss) in ayurvedic terms. The traditional Ayurvedic medicine focuses on diet and natural herbs as a treatment solution to hearing loss, with the view that these herbs will have beneficial healing effects over the complete human body in a natural way, including the ear (Kotwal et al., 2018; Prajapati et al., 2023).
Influence of Western Medicine (American models) led to hearing healthcare services that include equipment-based hearing assessment and rehabilitation with the use of devices such as hearing aids.
Typically, children born with significant hearing loss have been educated in special schools for hearing impairment, where education via Indian Sign Language is promoted (Jepson, 1991; Vasishta et al., 1978; Zeshan et al., 2005). There are two diploma courses: Diploma in Indian Sign Language Interpretation and Diploma in Teaching Indian Sign Language (Department of Empowerment of Persons with Disabilities & Ministry of Social Justice and Empowerment, 2023). Audiological rehabilitation with amplification is becoming popular, and oral communication has become more prevalent. Many special schools have upgraded their mode of instruction to oral. Fully-fledged hearing services were established in some parts of the country as the field of audiology developed.
Education of Audiology professionals in India first started at University level as a Masters program, similar to that in other countries. There are now a number of higher education institutions providing speech and hearing education and services across India. Also, hearing healthcare services are available throughout the country at different levels, although mainly in urban areas.

### Education

India has robust training and education for audiologists compared to many low- and middle-income countries. In 1964, the first Audiology and Speech Language Therapy program was started at the twin institutes, BYL Nair Charitable Hospital and T. N. Medical College in Mumbai. In the same year, the All India Institute of Speech and Hearing (AIISH) was established by the Government of India, which is now a premier speech and hearing institute in Southeast Asia. Both programs were heavily influenced by American colleges and offered a dual degree in audiology and speech and language pathology. This dual degree practice is still present in most schools for bachelor's, however, the master's was bifurcated into masters in audiology and masters in speech language pathology
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 50 institutions that offer Bachelor’s degree and about 10 institutions that offer a Master’s degree in Speech and Hearing across the country. According to the Rehabilitation Council of India (2023), approximately 750 candidates graduate at different levels each year. These programs are four years in duration and focus on speech and hearing sciences with approximately 1,500 hours of clinical practice. The typical program includes both audiology and speech language pathology, although various specialized master's programs in audiology and speech language pathology also exist (Kumar Sanju et al., 2017).
To meet the demand, RCI initiated the Diploma Course in Hearing, Language and Speech (DHLS) to train Speech and Hearing Technicians for clinical assessment and therapeutic management of various speech, language, and hearing disorders. They work under guidance of fully-trained graduate or a postgraduate Speech & Hearing clinician and are given the designation as “Speech and Hearing Technicians" (Rehabilitation Council of India, 2023).
The Rehabilitation council of India (RCI) provides accreditation for these programs. The curriculum is regularly updated through RCI-mandated workshops and all the schools follow a minimum common curriculum. Many of these programs are internationally recognized, offering students the opportunity to study with people of different linguistic and cultural backgrounds. To assist in this, the course has an expectation that students be able to communicate in English.
Following are some of the audiology programs in India:
* Topiwala National Medical College c/o BYL Nair Charitable Hospital
* All India Institute of Speech & Hearing (AIISH), Mysore University
* Ali Yavar Jung Institute for the Hearing Handicapped (AYJNIHH) in four different cities across India
* Manipal College of Allied Health Sciences, Manipal University
* Sri Ramachandra Faculty of Audiology and Speech Language Pathology, *Sri Ramachandra Institute of Higher Education and Research (SRIHER)
* Kasturba Medical College, Mangalore
* Bharati Vidyapeeth Deemed University, Pune
* MERF Institute of Speech and Hearing, Chennai
* Post Graduate Institute of Medical Education & Research (PGIMER)
The list of RCI-approved institutions are available at Indian Speech and Hearing Association
Following are some of the courses:
* Bachelors in Audiology and Speech Language Pathology (BASLP)
* Bachelor of Education – Hearing Impaired (BEd-HI)
* Masters of Science – Audiology and Speech Language Pathology (MSc ASLP)
* Masters of Science – Audiology
* Masters of Science – Speech Language Pathology (MSc SLP)
* Master of Education – Hearing Impaired (MEd – HI)
* Doctor of Philosophy (PhD) – Audiology
* Doctor of Philosophy (PhD) – Speech Language Pathology
* Doctor of Philosophy (PhD) – Speech and Hearing Sciences

### Audiological Services

Audiological services in India include hearing assessment, selection and fitting of hearing aids, and aural rehabilitation. Some of the centers have successful cochlear implantation programs; however, the services in some of the specialized audiology areas like vestibular assessment and rehabilitation, assessment and management of auditory processing disorders, and tinnitus rehabilitation are limited.
It is important to note that most audiological facilities are based in urban areas, making it difficult for people in rural areas to access such services. A few public sector organizations and non-governmental organizations (NGOs) work to extend audiological services to rural and remote areas by conducting residential camps and appointing public health workers to facilitate identification of hearing disorders and appropriate referral. Hence, although there is a great need, demand for audiological services in rural areas is limited, and patients generally tend to travel to urban areas to use the available services.
Services offered in the public sector are either paid for or subsidized by the government. However, the patients generally pay for services offered by the private facilities, although in some instances various NGOs and charities may pay for them, especially for children.
Audiologists in the private sector are greater in number than those in the public sector. These are generally equipped with all the necessary diagnostic instruments and their work is mainly focused in hearing aid dispensing. The patient has to pay for private sector service. There are also some well-known private cochlear implant centers across South Asia that attract patients from other countries. Generally, these clinics or institutes are not easily accessible to people living in rural settings, as most of them are based in urban locations. In addition, a concern in relation to private sector provision is that the practice of hearing aid dispensing is not well regulated, although some regulations from the Rehabilitation Council of India (RCI) exist.
Public sector facilities with audiology services are mostly district-level hospitals, educational institutes, and district differently abled welfare offices. The services provided are free or at concessionary rates.

### Professionals

As discussed earlier, generally, audiologists and otolaryngologists mainly offer specialist audiological services in India. A few otologists and otoneurologists practice exclusively in their specialty. However, various professionals, including general medical practitioners, teachers of the deaf, health workers, and community volunteers at various levels, offer some of the services.
As per Nayaka & Subramaniam (2021), more than 6,000 registered Audiology and Speech-Language Pathology professionals are there in India. Verma et al. (2021) reported that in India, there is one audiologist for every 500 000 individuals, while the number of otorhinolaryngologists is one per 140 0006,55 (the WHO recommendation is one per 25,00054).
As per Rehabilitation Council of India, 2023): 11031 audiologist/speech language pathologist. Therefore estimated Audiologist/Speech Language Pathologist Population: 4.41:1,00,000.
In India, most of the audiologists 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. There is considerable brain drain with westward migration of audiologists due to low salaries (Singh et al., 2022).
The majority are employed in India; however, many of them have found employment in the USA, Australia, the UK, New Zealand, and the Gulf countries. In recent years, there has been an increase in the global demand for audiologists due to the modernization of audiology, especially in western countries. This has resulted in a major drain of skilled audiologists to western countries and a shortage of qualified audiology professionals in India.

### Professional and Regulatory Bodies

The Indian Speech and Hearing Association (ISHA) is the professional and scientific association with over 2,500 members, while the Rehabilitation Council of India (RCI) is the regulatory body that regulates training and professional practice.
The Indian Speech and Hearing Association (ISHA) was formed in 1967. It is a professional and scientific association for audiologists and speech and language pathologists in India with over 2,500 registered members. Its role is the promotion of excellence in the speech, language, and hearing profession and rehabilitation services through advocacy, leadership, and continued education. It is also working to develop an ethical framework, monitor professionals, encourage networking, and support research.
The Indian Speech and Hearing Association has provided a Scope of Practice document to guide the professionals and is available here (ISHA, 2016).
The Rehabilitation Council of India (RCI) was set up as a registered society in 1986. In 1992, the Government of India implemented action to regulate the curriculum, training, and practice of rehabilitation courses under the Rehabilitation Council of India Act (Manchaiah et al., 2009). Apart from monitoring the curriculum, RCI has also laid down strict norms for practicing rehabilitation sciences. RCI also maintains a Central Rehabilitation Register (CRR) of all qualified professionals and personnel working in the field of rehabilitation and special education, which requires registration and periodic renewal. The RCI act mandates membership of CRR for practicing allied health professionals. The RCI also prescribes disciplinary action against unqualified persons delivering services to persons with disability, although such efforts have been limited.

### Workforce Problem

1) India's speech and hearing professionals predominantly reside in the southern region due to the geographical distribution of institutes offering these degrees. In the northern region, only seven institutions offer BASLP degrees, and one institute offers MSc programs. 2) However, these certificate holders (DIPLOMA/ audiometricians) are being hired to work without supervision instead of audiologists in various private and public sectors as salaries can be further reduced. This situation exists in both public and private health systems, and there is migration of these diploma holders to major cities. As a result, the rural areas, tier two, and three cities that were supposed to receive supervised services from diploma holders do not have any services. Further, private hearing care clinics, as well as hearing aid and cochlear implant corporations, are motivated to provide low salaries. This is challenging for audiologists with graduate and postgraduate degrees, and the greater compensation offered by hearing care clinics in countries such as the United States, Australia, and the United Kingdom encourages many competent audiologists to leave India and work elsewhere. 3) There are more audiologists in the private sector than the public sector.

### State of Ear and Hearing Care - Policy

I. National strategy implemented through Ministry of Health as part of National Health Mission;
* National Programme for Prevention and Control of Deafness (Ministry of Health and Family Welfare, 2016) for preventable hearing loss- across age groups and focused on preventable/acquired hearing losses.
* Rashtriya Bal Swasthya Karyakram is implemented through the District General Hospital (Rashtriya Bal Swasthya Karyakram, 2013) and early diagnostic and intervention centres for childhood disability, including hearing loss.
II. National strategy implemented through Ministry of Social Justice and Empowerment
* Screening camps through Ministry of education (SSA) and through District Differently Abled welfare office
* Provision of hearing aids through ADIP scheme
* Provision of disability ID cards
* Allowances for persons with disabilities
III. State-level strategies:
* Provision of cochlear implants through Chief minister schemes
* Allowances for persons with disabilities. State of reimbursement of audiology services and aural rehabilitation services (Archana et al., 2016)
* National health plan: Only hearing aids are covered under the CGHS scheme (for central government employees and their family members). (Ministry of Health and Family Welfare, 2020)
* National level-speech therapy: CGHS issued guidelines for reimbursement of Speech Therapy, Occupational Therapy, Behavioral Therapy for Children with ASD, ADHD and SLI. Reimbursement Ceiling Rate Per Session: Rs.400 (Controller General of Defense Accounts, 2023)
* State level: Cochlear implant surgeries, AVT (for 1 year), accessories are covered in insurance (Sharma et al., 2024)
* State level: Tamil Nadu state is considering a rights-based social model with inclusion of speech therapy services among many other therapy services under insurance.

# Research in Audiology

Research in Audiology is predominantly from educational institutions. In the formative years of the profession, audiology research was to develop suitable locally relevant materials for testing speech identification, or speech perception. Adapting western tools and validating these tools were some of the lines of work. Parallelly, some institutions pursued basic science research in hearing, while other institutions gravitated to clinical and translational research. Some institutions have received extramural funding to pursue research in specific areas such as speech perception in relation to hearing aid technology and vestibular research at AIISH, Mysuru, community-based participatory models for hearing care using e and mhealth at SRIHER (DU), Chennai; research on perception of spatial cues, spatial release from masking, and vestibular research at KMC Mangalore, Tinnitus research at the School of Allied Health Sciences, MAHE, Manipal; and vestibular research at Bharathi Vidya Peeth, Pune.
The scientific community over the years has diversified its publication from national to international peer-reviewed journals in the past decade. The Indian Speech and Hearing Association has its own journal called the Journal of Indian Speech and Hearing Association, where predominantly postgraduate student dissertations or student research papers are published. There is also the Journal of All India Institute of Speech and Hearing, which represents work from AIISH, Mysuru and some other Indian studies.
Despite this, research gaps exist in understanding some pertinent epidemiological evidence of hearing loss across age groups and multi-centric cohort studies to build robust evidence on outcomes of early identification and cochlear implantation or hearing aids. Also, more cohort case-control studies to establish more valid outcomes of clinical relevance may have to be considered to advance hearing care.

# Audiology Charities

In recent years, many non-governmental organizations (NGOs) and charities have become very active and are working towards improving ear and hearing healthcare services or facilities in India. The following are some of the major non-governmental organizations or charities:
* Audiology India
* Aural Education for the Hearing Impaired (AURED)
* Development Education Empowerment for the Disadvantaged in Society (DEEDS)
* I Hear Foundation
* Nambikkai Foundation
* Research Education & Audiological Development Society (READS)
* Rotary Foundation (India)
* Society to Aid the Hearing Impaired (SAHI)

# Challenges, Opportunities and Notes
### Challenges

* Awareness and access to hearing health are still major concerns in the rural population, where the majority of the Indian population lives. Hence, there is a need to adopt a public health approach and community-based hearing rehabilitation. The complexity in terms of educational, religious, and socioeconomic backgrounds of such a diverse population needs to be considered in this.
* Health literacy, superstitions, finances, and local access to services are the major barriers to hearing healthcare.
* A developing middle-class (middle-income) population has created a new demand for hearing healthcare services.
* Ensuring an even geographical distribution of audiology professionals and infrastructure and improving accessibility to audiological services for people living in remote and rural settings.
* There is a great need for developing training and clinical services in areas including auditory processing disorders, vestibular disorders, and tinnitus.
* There is a need to better define the scope of practice for audiologists with different training levels and to develop standardized procedures for practice, which may result in more uniform service provision.
* The Defense Research and Development Organization (DDRO) is working towards the development of an indigenous cochlear implant. This could significantly bring the cost down, making it more affordable for low and middle-income families and helping over a million children who suffer from profound hearing impairment.
* Although private sector practices have state-of-the-art facilities, the practice is not well regulated, resulting in many unqualified (or poorly trained) individuals practicing. Hence, much effort is needed from RCI and ISHA to enforce the necessary practice regulations.
* Audiology practice in India is based on models from western countries. Considering that social and cultural aspects vary vastly in India compared to western countries, there is a great need to develop research in India that should inform practice. Hence, there is a need for improving clinical and applied research, initially starting with epidemiological studies to better understand the extent and nature of hearing disorders.
* Many charities and NGOs have been working actively to improve hearing healthcare services, especially in rural areas.
* There is a need for the establishment of patient organizations, which may provide a platform for people with hearing impairment and their family members to share ideas and concerns to better promote hearing healthcare.
* Reducing the brain drain and increasing the manpower of hearing healthcare professionals
* Raise funding for both clinical and research work through the government and, various national and international charities and organizations

### SWOT or SCORE analysis of the country situation

No SWOT analysis conducted for rehabilitation professionals -audiologist / ear and hearing care providers. Only one SWOT addressed Allied Health Professionals but that is restricted to the context training from national institutions such as AIIMS and PGI (Chaudhary, 2018). WHO tools were not used for this analysis. This analysis which is un-specific to audiology but yet is somewhat common is as follows:
STRENGTHS
* Institutions of good quality and reputation (nationally & internationally)
* High quality Laboratories
* Tradition and knowledge transfer
* Research & Development on priority basis
* Exposure to high profile professionals and peers
* Exposure to special expertise and high-end technology
* Low cost but strong infrastructure
* High quality results
* Competent workforce
* Certain rehabilitation professions are Governed by a council
WEAKNESSES
* Some rehabilitation professions are not governed by council
* Inability to meet demand
* Uneven geographical distribution
* Low paid job opportunities
* Limited utilization of AHPs
* Lack of associations and union activities
* Low priority areas for the GOI
* Limited career options
* Very weak promotion avenues after employment
* Social stigma due to low esteem resulting into high rate of brain drain
* No dedicated infrastructure for training of AHPs
* No dedicated faculty (doctors are acting as teachers who are already overburdened)
* No attention is paid to faculty development program
* Lack of motivation and recognition
OPPORTUNITIES
* Arrival of new medical technologies.
* Emergence of new marketing opportunities.
* Advancement in technology demand trained individuals who can handle sophisticated machinery to produce reliable results in conjunction with patient safety.
* Health sector reform at national level.
* Today, there is an urgent need for competent people for accreditation and licensing of healthcare organizations.
* Better job prospects both globally and nationally (Job Outlook, 2018)
THREATS
* Ever changing technology; (Evolving technologies you’re unprepared for)
* Changing market trends
* New and increased competition
* Economic slowdowns/ difficulties
* Lack of standard protocols for their education and practical training in different parts of India
* Mushroom growth of unauthorized teaching institutes; giving diplomas/ degrees without providing quality teaching or practical training

### Summary of Gaps

* Educational Quality: Ensuring that RCI-approved institutions and professionals provide high-quality education and training is an enormous challenge. Advocacy is not strongly promoted in the curriculum or training
* Lack of mainstreaming of rehabilitation: Many people in India remain unaware of the purpose and significance of rehabilitation services. This is because rehabilitation is not mainstream in the health system.
* Skilled Professional Shortage: Skilled professionals are in short supply in India's rehabilitation sector. The RCI must address this issue by encouraging and regulating the training and education of experts in this field.
* Decentralized health-care facilities and facility centers using the Public-Private Partnership Model and competent institutions offering knowledge and services can address the challenges.(Nayaka & Subramaniam, 2021)
* Increasing Demand for Rehabilitation Services: With an aging population and increasing prevalence of disabilities due to chronic diseases and accidents, there is a growing demand for rehabilitation services.
* Technological Advancements: The use of technology in rehabilitation services is on the rise. The RCI can leverage this trend to enhance training and education for professionals and ensure that they are equipped with the latest knowledge and skills.
* Government Support: Increasing salaries for audiologists, increasing number of positions within the public health system can increase the reach of services.(D.ED SPECIAL EDUCATION, 2023)
* Information that could have been used to help identify problems and resources: Publications on alternative models of care / implementation published from India could have served to guide programs like RBSK , NPPCS and other govt programs.

# References

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* Jepson, J. (1991, March). Urban and Rural Sign Language in India. https://www.jstor.org/stable/4168208
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# Useful Links

* Indian Speech and Hearing Association
| | | | | Contributors to the original text |
| Vidya Ramkumar | Deeptaa Prabhakar | R. Vishnu Saravana | Vinaya Manchaiah | Contributors to the original text |