# Global Audiology/Europe/Malta

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# General Information

Malta, officially known as the Republic of Malta (Maltese: Repubblika ta’ Malta), is a southern European island country consisting of an archipelago in the Mediterranean Sea. It is one of the world’s smallest and most densely populated countries. The capital of Malta is Valletta, which, at 0.8 km2, is the smallest national capital in the European Union. Malta has two official languages: Maltese and English.

# Incidence and Prevalence of Hearing Loss

There is currently a lack of data on the demographics of Maltese individuals with hearing loss.
Grech’s study (1999) reported that only 6.1% of congenital hearing loss is diagnosed by six months of age. Moreover, more than 75% of hearing impaired children are identified after one and a half years of age, with more than 50% identified beyond three years of age (Grech, 1999). This is mainly due to the absence of a newborn hearing screening program, which has been in the pipeline for many years but has still not materialized.
Around 1% of the Maltese population is reported to have deafness or partial hearing loss and is not able to hear clearly with a hearing aid (Census 2011).
At the time of data collection, 92% of the children in Grech’s study (1999) had a bilateral loss, while 8% suffered from a unilateral loss. Furthermore, 66% had a congenital loss while 20% had an acquired loss. Parents of 14% of the children were uncertain whether the loss was congenital or acquired.
According to the only acute general hospital’s database, 71 patients have been implanted with a cochlear implant, 29 of whom are children. Only seven of these children have been implanted unilaterally. In addition, approximately 150 children wear a hearing aid, with 15% being unilateral users. Ten individuals were implanted with a bone-anchored hearing aid in 2017.

# Information About Audiology
### History

Audiological services were initiated approximately 40 years ago and took place mainly in government hospitals. The increase in awareness regarding hearing loss and ear care triggered the need to evolve in audiology and increase the number of professionals trained in the field. Major landmarks include the new audiology department, which opened with the new hospital, Mater Dei, in 2007, and the beginning of the Maltese Cochlear Implant Program in 2006. In addition, the launch of the Malta Association of Audiology in 2017 was also a major step forward. The Universal Newborn Hearing Screening, which should start in 2018, should also be a milestone in audiology, in terms of identification and age of implantation.

### Education

The previous route to becoming an audiologist was through foreign UK-based universities such as the School of Audiology at UCL London, the Mary Hare School in Newbury, and the University of Manchester. The first postgraduate audiology course was opened in 2012 within the Faculty of Health Sciences at the University of Malta as a Master of Science directed by Professor Helen Grech. It is a 3-year, part-time course leading to a M.Sc. in Audiology. The program of studies aims at providing candidates with the opportunity to acquire advanced knowledge in the diagnostic audiology field that addresses current literature and evidence-based practice. The course includes a substantial element of clinical practicum. This program of studies leads to a qualification analogous to that in other European teaching establishments. Graduates would need to register with the Council for Professions Complementary to Medicine, which is the governmental registration body, to be eligible to practice as an audiologist.

### Audiology Practice: Public and Private

Malta has a long history of providing publicly funded health care. Today, Malta has both a public healthcare system, where healthcare is free at the point of delivery, and a private healthcare system. Malta has a strong general practitioner-delivered primary care base, and the public hospitals provide secondary and tertiary care.

#### Public services offered at the local general hospital
##### Procedure

A person who fulfills the eligibility criteria to benefit from this service can be referred by a consultant within the Department of Health or by his or her family doctor to audio-vestibular consultants, who will then refer for the necessary audiological services.

##### Eligibility

All Maltese citizens or foreigners holding a residency permit can benefit from audiology services. Bilateral digital hearing aids are offered to pediatric clients, while a unilateral analogue hearing aid is offered to adults if a referred person has the Schedule ll (Pink) form. If a person has a profound hearing loss, he or she will be eligible to receive a cochlear implant, unilateral for adults and bilateral for children. ​

##### Required Documents

ID card, and The Pink Form (Schedule ll) if the referral is for a hearing aid.

##### Back Office Process

A referral for a hearing aid usually occurs after the ENT or audio-vestibular consultant has ruled out any other medical or surgical treatment options for the cause of the hearing loss. A person referred for a hearing aid will be given an appointment by the Audiology Unit so that the necessary impression of the ear can be taken and the hearing aid can be ordered. In adults, a request form along with a copy of the Pink Form will be sent to the entitlement unit within the health ministry. When the approval is given and the mold is received, the client is called to be fitted with the hearing aid. A follow-up appointment will be given to monitor progress with the hearing aid and take care of any difficulties the user may have. A hearing aid repair service is also available; patients may call the audiology unit and make an appointment so that the hearing aid can be seen by the Audiology Lab Technician. If this will take some time, a replacement will be given until the hearing aid is repaired.

##### Private services offered at private hospitals/clinics/hearing aid outlets

The private sector mainly specializes in adult hearing aid fittings as well as sales of FM systems, earplugs, and other hearing-related accessories that are not provided by the public sector.

#### Services offered by Otolaryngologists, Otologist’s and Otoneurologists

Otolaryngologists, or ENT doctors and surgeons, as they are more commonly known in the Maltese Islands, offer a range of services in the diagnosis and treatment of ear disorders. ENT professionals offer medical and surgical treatment of conductive and sensorineural hearing loss, traumatic injuries, ear infections, balance disorders, and tinnitus. The most common surgical intervention performed on children is grommet insertion, which is done as a day surgery. Cochlear implants and bone-implantable hearing aids are also carried out locally.

### Audiological Services

Audiologists can work mainly in four settings, which are described below:
* ENT Outpatients at local general hospital: The audiology department is part of the ENT clinic at the acute general hospital. Audiologists work in collaboration with ENT doctors and offer a variety of services in relation to the diagnosis and management of hearing disorders. These include screening and basic hearing tests​, advanced audiology tests, hearing aid provision (including bone conduction hearing aids), and cochlear implant mapping. Intraoperative monitoring can be conducted by audiologists during surgical procedures. Balance is mainly assessed and treated by ENT doctors and audio-vestibular physicians. Audiologists provide monitoring services throughout the course of medical management.
* Private Practice: Private practice audiologists mainly provide hearing and vestibular assessments and dispense hearing aids, especially targeting the adult population.
* University Clinic: The Teaching and Resource Clinic (TRC) forms part of the university, is closely linked to the hospital, and is used mainly as a teaching and research facility by the Department of Communication Therapy. TRC provides students with hands-on clinical experience in a multitude of services including hearing diagnostics, including free field audiometry, adult audiometry, tympanometry, and impression taking, as part of the M.Sc. A course in Audiology. Audiology-related credits are also included in the undergraduate program for the education and training of speech-language pathologists as part of the B.S. Communication Therapy course.
* Educational Institution: Educational audiologists provide audiological services to schoolchildren with hearing aids and cochlear implants. These services include hearing tests, hearing aid checks, FM set-up and maintenance and advocacy and support for students with hearing loss.

### Professionals

| Professionals | Approximate Number | Ratio to the Population |
| Audiologists | 11 | 1:45,000 |
| Otolaryngologists/ ENT | 8 | 1:56,250 |
| Audiological Assistants | 5 | 1:90,000 |
| Physicians | 2 | 1:225,000 |
| Speech-Language Pathologists | 183 | 1:2,459 |
| Teachers of the Deaf | 10 | 1:45,000 |
| Hearing Aid Specialists | 1 | 1:450,000 |

### Professional and Regulatory Bodies

In accordance with Legal Notice 422 of 2011 and the Health Care Professions Act, 2003 (Cap. 464), Article 28 (1), the Council for the Professions Complementary to Medicine regulates the profession of audiology.

### Scope of Practice and Licensing

Audiologist can practice according to the scope of practice as stipulated by the local regulatory body, the CPCM (Council for Professions Complimentary to Medicine). It is mainly in line with the scope of practice in countries where audiology has developed into an independent profession, such as England, the US, Australia, etc. Since 2010, a license is required to practice audiology and is needed to fit hearing aids, although it is not enforced. These licenses are obtained via the CPCM.

# Audiology Charities
### Deaf People Association (Malta)

Founded in the 1970s, the DPA has always striven to improve Deaf people’s lives. Apart from social activities and international participation, the association was always at the forefront of promoting Maltese Sign Language as a key element in enabling fuller participation in society for deaf persons. In 2016, MSL became a recognized language, and Agenzija Sapport employed sign-language interpreters for the first time. Previously, and at immeasurable sacrifice, the association, which is small, had provided the service itself for over 15 years. The aims of the association are as follows:
* to ensure that Deaf persons have equal opportunities to live an independent life of the highest possible quality
* to exert reasonable pressure on Maltese authorities to ensure that Deaf people have equal opportunities to enable them live an independent life of the highest possible quality
* to investigate ways Deaf people can have equal opportunities;
* raise public awareness on how Maltese Society can change to offer equal opportunities to deaf people to enable them to live an independent life of the highest possible quality
* disseminate information on existing facilities available to Deaf people;
* enter into partnership with government authorities and organizations that are consonant with the association’s aims
* encourage international contacts with similar organizations abroad and take part in international meetings

### Cochlear Implant Association

The association was founded in 2006 by a number of parents whose children were in the process of being implanted, and the aims of the association are:
* To give support to those parents who had just had their child diagnosed as deaf.
* To organize educational activities, especially when it comes to the education of the children, during which experts talk about the problems these children might face during the academic years.
* To organize fundraising activities during which we invite implant recipients, family, and friends to attend and meet and share problems with other implant recipients, besides having fun.
* To have meetings with authorities (both from the health and education departments) to air concerns and problems that implant recipients and their families may encounter.

### Malta Association of Audiologists (MAA)

Founded in 2017 with 5 members, the MAA has the following objectives:
* Promote audiology as an autonomous profession;
* Support the Council for Professionals Complementary to medicine;
* Work to improve and promote quality services for patients;
* To seek and promote, on a national level, the participation of the organization;
* To raise public and political awareness on hearing conservation, noise exposure and balance disorders;
* To provide standards, education and training for professionals and others interested in audiology;
* To promote and present the interests of the Organization’s members to local administration and authorities, international organizations and other authorities;
* To form part of any national or international organization(s) whose aims are similar to that of the organization;
* To encourage and promote research;
* To do all that is ancillary, incidental, or conducive to the attainment of the above objectives.

# Challenges, Opportunities and Notes

=== Challenges === There is a general lack of awareness of the profession by the general population and about the importance of hearing loss prevention. There is also a lack of understanding by the government of the importance of audiology and a limited number of qualified audiologists. Local ongoing research is focused on the development of an APD assessment battery and speech audiometry tests tailor-made for the local population.