HEARING IMPAIRMENT - Rehabilitation Council of India

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HEARING
IMPAIRMENT
Chapter 1

                                           Introduction

The Ear and Its Work                                           damage to the inner ear, makes it difficult to tolerate

T     he sense of hearing provides a background,               loud sounds.
      which gives a feeling of security and                           For children with hearing impairment,
participation in life. It plays a critical role in the         congenital or acquired before development of
development of speech and language and in                      speech and language, normal speech development
monitoring one’s speech.                                       is interfered with.
       The ear is a complex, but delicate structure                   With unilateral hearing impairment also,
designed to perform a variety of functions: to able            there is difficulty in localizing sound, reduced
to hear very soft sounds over a wide frequency                 speech discrimination. Lower speech and language
range as well as withstand the very loud sounds, to            development in children has significant effect on
discriminate between sounds that vary in pitch and             their educational, linguistic and auditory perceptual
loudness; to be able to locate the direction of arrival        development.
of a sound and in the presence of noise, to be able
to switch on and off a sound of interest.                            The hearing-impaired persons have in
                                                               common, their difficulty in hearing spoken and
      The human ear perceives simple tones in the              other sounds. They also depend on what they see
range of 20 to 20,000 Hz and also complex signals              which they supplement to what they hear.
such as speech and music. Both types of signals
are used in the assessment of hearing loss.                    Assessment
                                                                     Hearing sensitivity of each ear is
Impact of Hearing Impairment
                                                               measured separately and the severity/degree of
      Consequences of hearing impairment will                  hearing impairment/ hearing loss is generally
depend on the ear/s involved, the degree and the               classified in seven categories as per Goodman’s
type of hearing loss and the age of onset.                     (1965) classification and an additional category
     Hearing impairment leads to loss of normal                - slight hearing loss is added between the
verbal communication. Due to distortion of                     normal hearing and mild hearing loss
sounds, differentiation of environmental sounds,               especially when assessing the hearing
including speech, is difficult; making sounds                  sensitivity of young children. Table 1 shows
louder does not improve the clarity or quality of              the classification of severity of hearing
sound. Similarly, recruitment, which is an                     impairment.
abnormal growth in loudness, a characteristic of

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Table 1: Classification of Severity of                Percentage of Hearing Disability
               Hearing Impairment                            (Threshold + Speech Discrimination
                                                             Score Based)
Classification                        PTA range in
                                        dBHL                       The Ministry of Social Justice and
Normal Hearing                          -10 to 15            Empowerment, Government of India notified
Slight Hearing Loss                     16 to 25             guidelines for evaluation of various disabilities and
Mild Hearing Loss                       26 to 45
                                                             procedure for certification vide Notification No.
Moderate Hearing Loss                   46 to 55
                                                             16-18/97-NI dated 1st June 2001. Procedure for
                                                             calculating hearing disability is based on pure tone
Moderately-severe Hearing Loss          56 to 70
                                                             thresholds as well as speech discrimination score
Severe Hearing Loss                     71 to 90
                                                             in order to arrive at the percentage of the disability.
Profound Hearing Loss                 91 and more
                                                             The minimum degree of disability should be 40%
                                                             in order to be eligible for any concessions/ benefits.
      The level of normal conversational speech
is approximately 65dBSPL. Thus, for a person with
                                                             Issue of Disability Certificate
hearing impairment of 60dBHL or more, verbal
                                                                   The certificate of disability is to be issued by
communication would be difficult. This level of
                                                             a medical board consisting of at least three
hearing impairment has been equated as 40%
                                                             members, of which one shall be an
hearing impairment as in Persons with Disability
                                                             otolaryngologist. Percentage of disability can be
(Full Participation, Equal Opportunity and
                                                             determined considering Pure Tone Average and
Protection of Rights) Act, 1995. The definition of
                                                             Speech Discrimination Score as shown in Table 2.
hearing disabled as stipulated in the PWD Act, 1995
is a person who has a minimum of 60dBHL of
hearing impairment in the better ear in speech
conversation frequencies.

                                      Table 2: Percentage of Disability

   Category               Type of           PTA of Better              Speech Discrimination          Percentage
                        Impairment          Ear in dBHL                  Score of Better Ear         of Disability
   I                  Mild                     26-40                        80-100%                    < 40%
   II(a)              Moderate                 41-60                         50-80%                   40-50%
   II(b)              Severe                   61-70                         40-50%                   51-70%
   III(a)             Profound                 71-90                          91                         Very Poor                   100%

       To obtain Speech Discrimination scores,               nor standardized tests for speech discrimination in
specialized skills, instruments and standardized             various languages are presently available in all
tests are required. Neither the range of instruments         centers in the country.

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Chapter 2

                                Historical Perspective

H      istorical developments have been dealt with
       comprehensively in the Disability Status
Reports published by the RCI, in 2001 and 2003.
                                                              mean that any effort to initiate early intervention
                                                              services should be accompanied by short term
                                                              training programs for qualified professionals.
Since then, significant events such as establishment          These programs should be aimed at equipping
and support of early identification and early                 rehabilitation professionals to handle aspects
intervention centers by the AYJNIHH, Mumbai                   especially pertinent to very young children.
and the Disability Helpline initiated during 2004-            Keeping these issues in view, the project was
05 are worthy of mention.                                     evolved. The project was conceptualized in two
                                                              phases:
Establishment of Early Intervention
                                                                    Phase I: Training of manpower to enable
Centers and Training of Personnel
                                                                             them to handle very young
      A collaborative project by AYJNIHH,                                    children.
Mumbai and Balavidyalaya, Chennai on ‘Early
Identification and Early Intervention towards                       Phase II: Running the early intervention
Inclusive Education of Children with Hearing                                  programs.
Impairment (0 to 5 years)’ was initiated in 2002.                   Under the project, it was decided that a one-
An urgent need was felt to lower the age of                   month orientation program would be given to
identification of hearing impairment and                      already qualified professionals to work with
strengthen intervention service delivery. If a larger
                                                              children in the age range of 0 to 5 years. Seven
number of children with hearing impairment
                                                              centers were chosen to run the project, namely
acquire abilities ensuring their success in
                                                              AYJNIHH, Mumbai; its four regional centers at
mainstream education, they pave the way for more
                                                              Secunderabad, Delhi, Bhubaneshwar and Kolkata;
severely affected children to avail the services of
                                                              Balavidyalaya, Chennai and NISH, Trivandrum.
special schools. The gains shown by children who
                                                              A training package with curriculum specified, video
have gone through the process of early intervention
                                                              films and manual was evolved. The uniformity of
in India were convincing enough to start a greater
                                                              execution across centers was ensured through a
number of early intervention programs on a pilot
project basis. However, the diploma and degree                program for Training of Trainers (TOT). Two
courses in special education do not focus enough              representatives from each of the seven centers
on aspects of habilitation with very young children           attended the TOT program. Each center was
with the exception of the Diploma in Training                 directed to periodically conduct one month
Young Hearing Impaired Children which is                      orientation programs with an aim to have at least 5
available only in three centers in India. This would          per year with ten trainees per batch. Special schools

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already running programs for pre-school children                Disability Helpline
and institutions conducting diploma and degree                        Frequently due to lack of awareness among
courses in special education were approached and                the persons with disabilities and the community,
encouraged to depute professionals/suggest                      the early identification and rehabilitation processes
candidates from among past students of degree and               are delayed. Also the benefits of services offered
diploma courses. Interested fresh and or                        by Government and Non-Government
unemployed special educators were also enrolled.                organizations for the rehabilitation of persons may
      The seven centers under the project were                  not be availed of by the target group on account
already providing diagnostic and or intervention                of lack of information. The Disability Line
services for children in the 0 to 5 year age group.             launched by AYJNIHH, Mumbai in 2005 was
Thus it was decided that for the second phase, it               envisaged to bridge this gap to some extent by
would be ideal to run the intervention programs                 enabling the public to have easy access to
under close supervision of these centers. Each of               information regarding disabilities, the services
the centers could appoint a teacher/speech-                     available in their neighborhood as well as the
language pathologist and audiologist who had                    schemes and concessions offered by the
undergone the one month orientation program. If                 Government.
a center had more than 25 children, two teachers                     Specifically, the Disability Line provides
could be employed. The center could also appoint                information about:
two ayahs/helpers. Until now, the focus was on the
                                                                     •    Different types of disabilities.
0 to 2.5 year age group. This was reflected in the
orientation programs as well which focused only                      •    Diagnosis and intervention strategies.
on this age group. The next stage of orientation
                                                                     •    Diagnostic and therapy centres.
programs to handle the 2.5 to 4.5 year age group
will be launched in the near future. The project is                  •    Educational opportunities and Special
being monitored by an advisory group consisting                           schools.
of senior professionals.
                                                                     •    Vocational     training        and     job
      Since its commencement in the year 2002,                            opportunities.
nearly 100 rehabilitation professionals have been
                                                                     •    Special Employment Exchanges.
trained through orientation programs to equip
them to handle the 0 to 2.5 year age group. Nearly                   •    Government Schemes and facilities.
150 children with hearing impairment under the                       •    Organizations working for PWDs.
age of 2.5 years have received intervention at the
seven centers under the project. AYJNIHH plans                       •    Prevention and management of
to increase the number of intervention centers by                         disabilities.
training more professionals and also by providing
technical as well as financial assistance to the extent
possible.

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•    DRS/NHFDC forms by fax.                          Thus the Disability Helpline would help overcome
      Disability Help Line has presently been              the barrier of lack of information which has
implemented in Maharashtra, Goa and Delhi                  blighted many lives in the past.
Telecom Circles and can be accessed by dialing the               The most promising development in recent
following telephone numbers:-                              years is the coming together of a diverse group of
     Maharashtra/Goa :       022-26404019/24/43            professionals, parents/caregivers, policy makers, lay
                             or 155206                     persons and the hearing-impaired themselves in
     Delhi              :    011-29825094/95               the prevention, diagnosis/identification and
                                                           management of hearing-impairment. Such a
      The implementation of Disability Line for            scenario portends well for persons with disabilities
UP, MP, Bihar, Tamil Nadu, Assam & West Bengal             as well as for the professionals in the various
are in the pipeline. It would be possible to cover         spheres of rehabilitation.
the whole country in a span of five years or so.

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Chapter 3

                             Manpower Development

Introduction                                                 Variations

M      anpower in the field of Speech and Hearing
        consists of professionally qualified persons
who are involved in a spectrum of activities related
                                                                   Variation in the eligibility for admission at
                                                             the under-graduate level among universities exists;
                                                             Physics, Chemistry and Biology combination is
to persons with impairment–hearing and/or                    compulsory at the 12th standard level, but other
communication employed in diverse settings–                  combinations are also acceptable.
hospitals, rehabilitation centers, special schools,
                                                                     Variations in post-graduate program earlier
regular schools, speech and hearing centers,
                                                             affiliated to the Mumbai University, shifted in 2006
training and research institutions.
                                                             to Maharashtra University of Health Sciences,
                                                             Nashik provides for specialization either in
Training Programmes
                                                             Audiology or Speech-language Pathology, in part
      Training programs available at various levels          II (Final year).
are discussed below:
                                                                    Since 2003, M.Sc. (Speech and Hearing)
     Under-graduate: B.Sc. (Speech and                       affiliated to Mysore University has been replaced
Hearing), AST, BASLP.                                        by Master’s degree in Audiology or Speech-
     Post-graduate: M.Sc.(Speech and Hearing),               language Pathology, a pattern also followed both
MASLP, M.Sc. Speech-Language Pathology, M.Sc.                at Mangalore and Bangalore Universities.
Audiology.                                                         Training institutions being required to follow
                                                             the norms of the affiliating universities, variations
Admission Requirements
                                                             among different programs are seen in depth of
     Those who have successfully completed pre-              information, method of teaching, differences in the
university (10+2) in the science stream are                  pattern of examination and in following the
admitted to the B.Sc. course.                                semester system as against the annual system.
       To the two-year program, MASLP, candidates            These are also true of the Master’s level programs.
with B.Sc. (Speech and Hearing) or equivalent                       The Bachelor’s program currently runs for
from a recognized institution are admitted.                  four years; during the first three years the focus is
Admission requirements have moved from                       on preparing theoretical knowledge base and
performance at the Bachelor’s level to the entrance          providing insights into developing requisite clinical
test conducted by the respective universities.               skills followed by the internship year.

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Despite the uniformity maintained due to                         The demand for professionals with
RCI regulations regarding minimal infrastructure                 doctorates is on the increase with the advent of
facilities, there still exists inter-program variability         many new training programs and the recruitment
due to the differences in budgetary allocation and               rules for teaching institutions. The next doctoral
availability of funds in the various institutions. The           program in speech and hearing has commenced
national institutes have larger budgets thereby                  at AYJNIHH, Mumbai from the year 2007 with
enabling state-of-the-art facilities for their trainees.         affiliation to Maharashtra University of Health
The programs that have to depend on their own                    Sciences, Nashik.
resources are not able to provide similar facilities.
                                                                 Diploma in Hearing, Language and
Internship                                                       Speech (DHLS)
       Introduction of internship as per the RCI                        Earlier known as Diploma in Management
guidelines, prior to the award of degree, is a                   of Communication Disorders (DMCD) and also
progressive step, which has the merits of creating               Diploma in Communication Disorders (DCD), it
parity among the various degree courses and                      is a one-year course post higher secondary school
providing services in the rural areas. Institutional             certificate qualifying them to assist the speech and
variations in the settings, in the placement duration,           hearing professionals and to take up routine clinical
payment of stipend, are in need of further                       activities. This program is being conducted in about
regulations.                                                     15 institutions in different parts of the country.
      Recent years have witnessed a global shift in                    Contrary to the course objectives, most of
the perception and treatment of Persons with                     the products are found to be self-employed or
Disabilities towards a human rights perspective.                 working in private ENT setups as speech and
This has influenced the various training programs                hearing professionals. This may possibly be because
bringing about modifications, time and again, in                 the government does not include the post of speech
the type and content of courses in Speech and                    and hearing assistant in their grant-in-aid schemes
Hearing, both at the B.Sc. and M.Sc. levels.                     for schools for the deaf or the mental relardation
                                                                 or the spastics.
Doctoral Program
                                                                       Wherever possible and feasible, the DHLS
       The Ph.D. program in speech and hearing                   personnel may work as substitute teachers or
was available so far only at AIISH, Mysore affiliated            teacher aides in schools. The syllabus and the
to the University of Mysore. Some candidates have                examinations currently conform to RCI
also got their doctorates in allied streams such as              regulations.
Linguistics and Psychology from other
Universities/institutions. In spite of interest in                    The AIISH, Mysore plans to launch the
pursuing doctoral degrees, the fact that full-time               DHLS program through the distance mode,
candidates only were being accepted by University                simultaneously in five different locations in the
of Mysore, and availability of guides were                       country.
limitations.

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Diploma in Hearing Aid and Ear Mould                          rather than duplicating without review the
Technology                                                    curricula followed in other countries. These
      The RCI has standardized a training program             issues need to be addressed by the professional
in ear mould making and hearing aid technology                associations and the relevant policy making
for those successful at higher secondary level. A             forums.
one-year course, started at AIISH, Mysore since                    A close evaluation of training programs must
2002-03, generates skilled personnel. AYJNIHH,                be undertaken periodically in the light of current
Mumbai also conducts a similar, short duration                potential employment opportunities.
program for educators and personnel working in
special schools.                                              Resources for Training
                                                                    Shortage of human resources to man the
Disparity Between Available and
                                                              training programs is a major challenge. Fresh
Requisite Manpower
                                                              graduates with little or no experience are recruited
       About 25 institutions offer Bachelor’s degree          to provide training to the new entrants.
and about 10 institutions offer Master’s degree in
Speech and Hearing across the country.                               Published resource material used for the
Approximately 750 candidates graduate at different            training programs are mainly from the West, which
levels each year which is woefully short compared             cost substantially. Availability of Indian editions and
to the needs of manning training programs,                    an increasing number of Indian journals coming
furthering the growth of the profession, providing            up in the field of speech and hearing and allied
services. The skewed distribution, geographically,            disciplines has reduced the budgetary burden.
of available professionals in the country and on                     Programs attached to medical institutions
account of emigration of the professionals overseas,          such as TNMC, Mumbai; SRMC, Chennai; and
the shortage felt is more acute. There is economic            MAHE, Manipal have access to extensive medical
factor also, the cost per trainee being approximately         literature.
Rs. 3 lakh/student (Savithri, 2003).
                                                                    Access to the main university libraries by the
      The magnitude of brain drain among speech               speech and hearing trainees being limited, the
and hearing post-graduates is reported to be 48%              respective programs have to have their own
(Nambiar and Shah, 2006). The reasons cited being             libraries. Many institutions have also provided
better financial gains (62%), better career prospects         computer and internet facilities to the trainees
(62%), and better academics. Whereas 50% went                 thereby increasing the resource base.
abroad seeking employment, about 30% left for
higher education, and other 20% for personal                  Continuing Education
reasons.                                                            Continuing Education (CE) is the key for
      An increasing number of training programs               ensuring that professionals adapt to new
are coming up in smaller towns of the country,                developments, which will lead to the growth of
sometimes in the same State where two or more                 the profession with consequential benefits to the
training programs already exist. The courses must             individual and to the society.
also be designed to meet the needs in the country

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CE may be obtained through workshops,                   range of duties such as teaching, clinical supervision
seminars, symposiums and conferences conducted                 and/or clinical services do not get comparable
by institutions, by the professional associations at           remuneration. Also employment settings dictate
the State and the National levels. These may be                the salary structure and not the duties or the
RCI approved CE programs of three or five day-                 academic qualifications.
duration since it is mandatory for the professionals
                                                                     Possessing higher than the requisite academic
to attend such programs for the renewal of their
                                                               qualifications does not guarantee better
RCI registration.
                                                               remuneration for the individual professional,
                                                               irrespective of how earned while on the job or on
Career Prospects
                                                               study leave. This leads to dissatisfaction/ frustration
       Currently, a professional in the area of speech         leaving little motivation among the professionals
and hearing is able to find employment in a variety            who have aptitude and abilities to improve their
of settings, unlike in the past. However, there is a           qualifications and skills.
distinct difference in the number of opportunities
and the type of work available to those with interest                Our training programs are well received both
in Audiology and those affiliated to Speech-                   in the country and outside; programs in other
language pathology. The latter can practice at lower           developing countries have looked for support from
investment since infrastructure requisite is less, but         our programs. Many professionals, products of our
is more man-hour intensive, while the practice of              programs, have been admitted into doctoral
Audiology requires considerably more financial                 programs in specialized streams earning accolades.
investment, but less manpower dependent.                       The American Speech-Language-Hearing
                                                               Association takes cognizance of the course work
      In spite of the absorption of our graduates in           completed in India for purposes of Clinical
jobs in diverse settings, the jobs are isolated and            Certification, both in Speech-Language Pathology
the one or two persons employed there have to                  and Audiology.
attend to all aspects of the discipline. In some
instances, the rigorous training imparted to the               Manpower in Special Education of the
trainees is not being fully utilized for want of the           Hearing Impaired
requisite infrastructure including audiometric
                                                                     Special education can be thought of as a
rooms and test instruments. A lack of awareness
                                                               means of secondary and tertiary prevention of
about the diverse role the speech and hearing
                                                               impairments that eluded primary prevention. The
professional plays in diagnosis and management,
                                                               aim of the special educators is to enable the children
may lead to their being treated as technicians, often
                                                               with hearing impairment to realize their full
in    a     subordinate       position      without
                                                               potential, so that they can achieve a respectable
acknowledgement of their role as competent
                                                               place in society and enjoy a better quality of life.
members of an interdisciplinary diagnostic
management team.                                                     Special educators have traditionally been
                                                               primarily placed in special schools for children with
Remuneration                                                   hearing impairment. In the prevailing conditions,
      Professionals whose work includes a wide                 there are various types of educational programs

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available in India for children with hearing                  in Mumbai and regional centers in the north
impairment as given below:                                    (NRC), south (SRC) and east (ERC), AYJNIHH
                                                              also has collaborative centers, involving the State
     (1) Early Childhood Education or Early
                                                              Governments and the NGOs.
         Intervention programs (Pre-school
         Education) for infants and younger                         Recognition of the dearth of master trainers
         children (0 to 5 years) with varying                 to be appointed as faculty at these centers and the
         degrees of hearing impairment.                       poor quality of the model teaching schools,
     (2) Special school programs for children                 prompted negotiations with the Universities of
         with substantial degree of hearing                   Osmania (Hyderabad) and Calcutta, for
         impairment.                                          commencement of the B.Ed. (H.I.) training
     (3) Integrated education programs for                    program at the SRC and the ERC of AYJNIHH,
         children with milder degrees of                      in addition to the programs conducted at Mumbai
         impairment in a regular school set up.               since 1997. This enabled several schools to upgrade
                                                              their D.Ed. training levels. The M.Ed. (H.I.)
     (4) Inclusive Education under the Sarva
                                                              program was started at AYJNIHH from 1995–96,
         Shiksha Abhiyan Scheme where
                                                              and is affiliated to the University of Mumbai.
         children with impairment of different
         types and degrees are educated in regular                  The training programs in Special Education
         schools with normal peers.                           for the Hearing Impaired are regulated by the RCI.
     (5) Apart from this, persons with disability             Presently there are two centers offering
         within age group of 14-35 are given the              M.Ed.(H.I.), 15 offering B.Ed. (H.I.) while 38 offer
         opportunity for education through                    D.S.E. (H.I.) and three centers offer D.T.Y. (H.I.).
                                                              In spite of the many special educators trained at
         National Open School (NOS).
                                                              various levels, a wide gap exists between supply
      Thus, it can be seen that there is change in            and demand.
the focus of education from segregation to
inclusion, and late intervention to early                           Keeping this in view, NCERT through its
intervention. A numerical increase is seen in the             Regional Institutes started Multi-category Teacher
special educators working as early interventionists,          Training Programs, which includes orienting the
resource persons in regular schools and itinerant             regular school teachers to categories of
teachers in inclusive education.                              impairments and the modifications required for
                                                              teaching such children. Such teachers were then
      Teacher Training Programs and other                     enrolled in Integrated Schools under I.E.D.C.
technical services for the deaf in the country                (Integrated Education of Disabled Children
received a boost with the establishment of Ali Yavar          Scheme) and P.I.E.D. (Project Integrated Education
Jung National Institute for the Hearing                       for the Disabled).
Handicapped (AYJNIHH) in Mumbai in 1983. At
that time, only eight centers were conducting                 Distance Education
teacher training programs as reported by Dr. Rita                   RCI has also recognized technical expertise
Mary (1993). Besides conducting D.Ed. [now                    of the Madhya Pradesh Bhoj (Open) University
D. S. E. (H.I.)] and B.Ed. (H.I.) at its headquarters         (MPBOU) for conducting the B.Ed. Special

                                                        108
Education program through the distance mode.                conducting applied research in the field of
Other Universities have also begun to show                  education of the hearing impaired. However, many
interest in running similar programs.                       graduate level teacher training programs do not
                                                            include sufficient input to the teacher trainees
Resources for Training                                      about research and documentations. Systematic
      As most trainees in these courses, especially         orientation towards research would bring about
the diploma courses, are from vernacular medium             fruitful outcome.
with poor knowledge of English, their limited
experience in using reference material, utilization         Conclusion
of the resource material from Western countries                   There is a need to gear the training programs
poses a major limitation. Short duration of the             to meet the specific needs of the multi-lingual and
programs is an added constraint.                            multi-cultural population of the country. In spite
                                                            of the big strides in the past several decades, much
      RCI has invited experts in the respective
                                                            needs to be done especially to retain the
subject to prepare requisite material in language
                                                            professionals to provide quality services in the cause
easy to understand. Some experts have also taken
                                                            of which there has been a heavy investment. If
an initiative in developing resource material in
                                                            emigration is a problem, so is professional mortality
regional languages such as Marathi, Tamil, Telugu,
                                                            and seeking other vocations within the country.
etc.

Research
      Since the M.Ed. program has been
introduced, there has been an increased focus on

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Chapter 4

                         Incidence and Magnitude of
                         Hearing Impairment in India

T     he National Sample Survey Organization
      (NSSO) and Census of India, defined
hearing disability in a manner not requiring services
                                                                    Hearing disability was defined as a person’s
                                                              inability to hear properly. As non-medical
                                                              investigators/non-professionals conducted the
of professionals, standard test procedures and a test         survey, hearing disability was assessed based on the
environment meeting stringent criteria.                       quantum of impairment in the better ear. If a
                                                              person reported normal hearing in one ear and total
Hearing Disability (NSSO Perspective)                         loss of hearing in the opposite ear, normal hearing
      In the International Year for the Disabled              was the verdict for the purpose of the survey.
Persons, the NSSO undertook during the second
                                                                    Usage of hearing aids was not taken into
half of 1981, the most comprehensive survey in its
                                                              account in assessing hearing disability. A person was
36th round for collecting information related to
                                                              stated to have profound hearing impairment if he/
persons with disability.
                                                              she could not hear at all or could only hear loud
      In 1991, the NSSO with an extended                      sounds (such as thunder) or used only gestures to
definition of disability, conducted its 47th round            communicate.
of survey in July-December 2002, on the specific
                                                                    If a person could only hear when the speaker
request of the Ministry of Social Justice and
Empowerment, Government of India. Its 58th                    shouted or could hear only if the speaker was sitting
round of survey was conducted adopting a stratified           in front, hearing loss was considered severe.
multi-stage sample design methodology. It                            Moderate hearing disability was the verdict,
included information on physical and mental                   if a person having hearing loss did not fit either in
disability, socio-economic characteristics of the             profound or severe category. Such a person would
disabled persons, such as age, literacy, vocational           ask for repetitions when spoken to or would like
training, and the cause, age of onset of disability,          to see the face of the speaker. In other words, if the
marital status, educational level, living                     person reports difficulty in conducting
arrangements and activity status.                             conversation due to hearing problems, he was
      As this was one of the more comprehensive               considered to be in the moderate category of
surveys, defining disability was done in a very               hearing disability.
careful and guarded way to minimize the bias on
the part of the investigators and the respondents.            Hearing Disability (Census of India,
The definition of disability and each type of                 2001 Perspective)
disability was carefully agreed upon by a group with               Interest in enumerating the number of
experts in their respective areas.                            persons with hearing impairment began in 1876

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in India. In the past counting of such people did            the Union Territory of Chandigarh, Delhi, and
not indicate adopting a clear definition.                    Daman and Diu.
      The recent head count conducted by Census
                                                                   NSS 58th Round of Survey estimated
of India, 2001 defined persons with hearing
                                                             persons with disability to be 18.49 million (1.8 per
disability as those who cannot hear at all (deaf) or
                                                             cent of the total population). Ten per cent of the
can hear only loud sounds which clearly excluded
                                                             persons with disability are likely to have hearing
people who had hearing impairment but who could
                                                             disability of moderate to profound degree. This
hear through use of amplification devices.
                                                             number is likely to go up if we add lower degree
However, the Census did include as disabled,
                                                             of hearing disability.
people who could not hear with one ear but his/
her other ear was functioning normally.                      Prevalence and Incidence of Disability
The Magnitude of the Problem                                       A broad idea about the magnitude of
                                                             disability can be known if we compare the
      As on 1st March 2001, India’s population
                                                             prevalence of disability as found in National
stood at 1,027,015,247 and projected population
                                                             Sample Surveys conducted at different points of
in 2016 would be 1,263,543,000 (Census of India,
                                                             time. Tables 1 and 2 show that there is a significant
2001). With the present set of concept of hearing
                                                             decline in the prevalence and incidence of disability
disability, the Census of India, 2001 counted
                                                             including hearing disability. This can be attributed
1,261,722 people in whom hearing disability existed
                                                             to the general growth in health, education and
(Males 53.4% and Females 46.59%).
                                                             infrastructure sector.
     A majority of persons with hearing disability
were identified in rural India (81.06%) except in

           Table 1: Prevalence Rate of Disabled Persons Per 100,000 Persons (Hearing Disability)

   NSS                   36th Round 1981                     47th Round 1991               58th Round 2002

   Rural                    1844 (573)                          1995 (467)                   1846 (310)

   Urban                    1420 (390)                          1579 (339)                   1499 (236)

                     Table 2: Incidence Rate of Hearing Disabled Persons Per 100,000 Persons

   NSS                   36th Round 1981                     47th Round 1991               58th Round 2002

   Rural                       19                                  15                            8

   Urban                       15                                  12                            7

                                                       111
The incidence is almost the same in both the         Conclusion
rural and urban India. The incidence is also                      Persons with hearing impairment constitute
observed to be higher among males than females              a significant portion of our population who can be
as is the prevalence rate.                                  contributing citizens. Efforts made to provide
     The rates among males are 9 and 8, as against          diagnostic and therapeutic services and the efforts
7 and 6 among females, respectively, in rural and           put forth to mainstream them will create an
urban areas.                                                inclusive, barrier-free and rights-based society for
                                                            persons with disabilities.

                                                      112
Chapter 5

                    National Program of Prevention of
                    Hearing Impairment in Operation

A     national program on prevention of hearing
     impairment carried out will discharge our
responsibilities as well as comply with the
                                                                Methods to Prevent Disabilities
                                                                      The most effective way to carry out
                                                                prevention is through pubic education. Educating
stipulations in the Persons with Disability Act,                different target groups on the causes of hearing
1995.                                                           impairment creates greater awareness among them.
       Measures stipulated in the Act to be taken               The increased awareness should help in preventing
for prevention and early detection of hearing                   hearing impairment.
impairment include conducting surveys to                              As the manpower directly dealing with the
determine the underlying cause of disabilities;                 needs of the hearing impaired is comparatively less,
utilizing various methods to prevent disabilities;              availing services of allied professionals becomes
screening of children at least once a year; providing           necessary in creating the country-wide awareness.
training to staff at the primary health centres; taking         Existing grass root level personnel working in the
steps for prenatal, perinatal and postnatal care of             Departments of Health, Education, and Woman
children; educating the public and creating                     and Child, is being used effectively in educating
awareness through mass media.                                   the general public on prevention of hearing
     Some or all of the above activities are                    impairment.
being carried out in different centres across                         While the nomenclature varies depending on
the country.                                                    the State involved, the function or job description
                                                                of these personnel is by and large the same. This
Surveys to Determine the Cause of                               group of enthusiastic individuals could be
Disabilities                                                    empowered to function more effectively with the
      Data has accrued on the hearing status of                 right kind of encouragement.
adults. But there is dearth of information on the
                                                                      It is imperative that a prevention program
incidence and prevalence of hearing impairment,
                                                                should provide immunization for expectant mothers,
among infants and children. Through
                                                                infants and adolescent girls to such conditions as
questionnaires alone, valid and reliable information
                                                                maternal rubella, measles and meningitis.
on hearing loss cannot be garnered. Only surveys
where competent persons have evaluated the                            It is important to reduce the incidence of
infants or toddlers would provide the numbers                   hearing problems in children since its effects are
with hearing-impairment in this age group.                      more devastating especially on their

                                                          113
communication abilities which in turn would affect             grass root level workers, such as, Anganwadi
their school performance. Being the future citizens            workers, Accredited Social Health Activists
of the country, they should be given the necessary             (ASHAs), traditional birth dais and Auxiliary Nurse
help at the earliest.                                          Midwives (ANMs) or Multipurpose Health
                                                               Workers (MPHWs). In the absence of these in the
       While the above measures may reduce the
                                                               locality, the responsibility would be taken by
occurrence of hearing problems, this would not
                                                               Education Guarantee Scheme (EGS) teachers or
totally eliminate the problem. Hence, it is essential
                                                               Lower Primary School (LPS) teachers who would
to carry out tests to identify the presence of a
                                                               be supervised by a medical officer at the Primary
hearing problem. These tests should be carried out
                                                               Health Centre (PHC) (Figure 1).
at the earliest to enable early rehabilitation both in
terms of fitting appropriate amplification devices                                PHC Medical Officer
and providing speech and language therapy. Early
rehabilitation is required since there is a critical
age for speech and language development. The later
the hearing impairment is identified, the gap to be
bridged between normal and hearing impaired
individuals would be more. Further, the                             ANMs and                        EGS and LPS teachers
psychological stress in such individuals would be                Anganwadi Workers
less since they would have better speech and
language skills, which in turn would enable them               Figure 1: Allied personnel involved in the prevention of hearing
to succeed in inclusive set ups. Children with good                      impairment
speech and language would also find it easier to               Training of the Professionals
find appropriate job placements later in life. Not
only it is important to identify hearing loss early in               Figure 2 shows the personnel involved in the
individuals with a congenital hearing loss but also            cascading of information to the grass root level
in those with an acquired hearing loss since hearing           workers.
is required for monitoring of speech.                                                  Apex Institute
      At the program on “National Consensus on                                         Professionals
Prevention, Identification and Management of
Hearing Impairment” held at the All India Institute
of Speech and Hearing, Mysore, in 2005, various
experts involved with hearing conservation,                           Master Trainers (Taluk Health Officer,
representing government and the non-government                         Medical Officer, School Teachers)
sectors, gave their viewpoints.

Personnel Involved in Prevention
                                                                                 Anganwadi Workers/
      The consensus among experts was that
                                                                                ASHAs/ANMs/MPHWs
prevention of hearing impairment should be
carried out at the doorstep of each household by               Figure 2: Personnel involved in cascading of information to the grass
                                                                        root level workers

                                                         114
Number of Professionals to be Trained                                        (d) Determine whether in a given case is at
at a time                                                                        risk for a hearing loss using the high risk
      Figure 3 depicts the number of professionals                               register for medical professionals.
to be trained at a time.                                                     (e) Practice early medical remedy in cases
                                                                                 of external and middle ear infections.
         Professional from Apex Institute
                 (1 professional)                                            (f)   Suggest appropriate referrals as and
                                                                                   when required.
                                                                        ASHAs / ANMs / Anganwadi workers / EGS and LPS
           Master Trainers (20 trainers)                                teachers must
                                                                             (a) Get trained on early identification of
                                                                                 hearing impairment.
             Grass root level workers                                        (b) Orient the general public on how to
          (2 batches of 30 workers each,                                         prevent a hearing loss:
         in a PHC covering a population                                            (i) Inform them about possible causes
                 of appox. 30,000)                                                     of hearing loss.
      Figure 3: Professionals and the number to be trained in a                    (ii) Educate them about immunization
                session                                                                 and also administer vaccinations on
                                                                                        infants, adolescent girls and
Duties of the Professionals
                                                                                        expectant mothers.
      The qualified speech and hearing
                                                                             (c) Determine whether a given case is at risk
professionals, from the apex centres, would orient
                                                                                 for hearing loss using the high risk
the master trainers on prevention of hearing
                                                                                 register for medical professionals.
problems as well as on basic evaluation to be carried
out by the grass root level workers. The evaluations                         (d) Screen for hearing loss through
would include: administration of the high risk                                   behavioural observation audiometry.
questionnaires, carrying out behavioral                                      (e) Suggest appropriate referrals as and
observations and orientation to audiological tests                               when required.
requiring instrumental usage. The duties of the
                                                                               The “High Risk” babies should be identified
speech and hearing professionals and the others
                                                                        at birth and screened immediately. They should
involved would be as follows:
                                                                        be asked to follow-up regularly subsequently for 2
Duties of the Medical Officer                                           to 3 years.
     (a) Get himself trained on the hows of early                             It is essential that there is co-ordination
         identification of hearing impairment.                          among all the professionals associated in the
     (b) Train and orient the grass root level                          prevention and identification of hearing loss since
         workers.                                                       best results are an outcome of team efforts. Figure
     (c) Monitor the activities of the ANMs/                            4 provides an illustration of the linkage between
         anganwadi workers.                                             the professionals that are involved.

                                                                  115
Figure 4: Illustrating the linkages among the professionals

Protocol to be Used for Infant Screening                    Yathiraj, Vanaja and Manjula based on the
       Due to cost factor, the protocol that is             literature. All children who might have a hearing
currently suggested for prevention and                      loss should be identified by the age of 3 months
identification is restricted to using simple                irrespective of whether or not they are at high
behavioural techniques. However, in due course,             risk (Figure 5).
it is proposed to use the protocol developed by

                                                      116
Figure 5: Flow chart of the test protocol suggested to be used for infant hearing screening

                                      117
Protocol Used for Screening School                           Frequency and Media to Train the
Children                                                     Professionals
       It is also necessary to identify school-going               Once in two years, refresher programs
children with hearing impairment. Hearing loss               should be conducted in the local language using
in school-going children can be identified by the            minimum technical terms for the master trainers
teacher by using a checklist regarding the signs and         and their support staff using audio-visual aids and
symptoms of hearing loss. In addition, it is                 demonstration of the test procedures. Using the
recommended that Ling’s 6 sound test may be used.            materials available at the national institutes, the
Teachers can carry out this test with minimal                training sessions should follow a test module,
training. For children who can read, the test can            which incorporates pre- and post-evaluation of the
be carried out in small groups. They could be asked          trainees’ understanding of the disorder, its
to select the correct sound (phoneme) from a group           assessment and management.
given in a print form. For younger children, the
                                                                    Currently, the All India Institute of Speech
script could be associated with pictures such
                                                             and Hearing, Mysore, has put in place the infant
“aaaah” with sweets or “iiiiii” with brushing the
                                                             screening program at a few districts in the southern
teeth. Depending on the region where the test is
                                                             states. Team effort is a necessary ingredient for the
being administered, the choice of phonemes would
                                                             success of a program purporting to identify hearing
vary.
                                                             loss where every member and all concerned work
                                                             in co-ordination.

                                                       118
Chapter 6

                 Early Identification and Intervention

                                        Section I
                        Hearing Screening for Early Identification

T     he issues in early identification to be
      addressed are (i) population/location of
screening, (ii) technique/tools for screening, (iii)
                                                             given by Joint Committee on Infant Hearing
                                                             (2000) was used to develop and evaluate an infant
                                                             hearing screening module to identify bilateral
human resources for screening, (iv) cost, (v)                severe to profound hearing loss. Behavioral,
challenges in screening, and (vi) intervention for           TEOAE and ABR techniques were compared with
the identified.                                              the involvement of the mother/caregiver for
                                                             behavioral screening and the nurse for both
Population/Location of Screening                             behavioral and TEOAE screening.
      The larger projects/services have dealt with                 They reported that 25% of the babies were
both universal hearing screening as well as                  not available for screening due to various reasons.
screening only those at high risk.                           For screening no-risk babies, the parents as well as
       Under the Project of Prevention of Deafness           hospital staff were non-cooperative. Suitable
undertaken at All India Institute of Speech and              location for screening (with ambient noise with
Hearing, Mysore, funded by the Ministry of Health
risk infants was 10.75 per 1000 whereas that for               Behavioral Observation Technique
no-risk infants was 4.70. Their results show that                    Behavioral Observation Technique continues
screening only the ‘at risk infants’ may result in             to be used even though they do not provide ear
missing out 70% of the newborns with hearing                   specific results for screening as reported by
impairment.                                                    Anupriya (2001), Yathiraj et al. (2002)), Basavaraj
      Mathur and Dhawan (2007) report about                    and Nandurkar (2007), Nagapoornima et al.
TEOAE screening of 1000 randomly selected                      (2007).
neonates in the first 48 hours of life in a tertiary
hospital. Those failing the first screening were re-           Checklists
screened using TEOAE at three weeks, three                           Hearing screening checklists have been used
months and six months of age. Infants who did                  to obtain the report of the caregivers regarding the
not ‘pass’ at these stages were subjected to ABR               auditory behavior of their children. One such
and oto-endoscopy. They recommend the TEOAE                    checklist is incorporated in the Interactive Voice
screening at three months of age as the pass rate of           Reception System (IVRS) of the Disability
TEOAE at 48 hours was only 79%, which increased                Helpline launched by Ali Yavar Jung National
to 97% at 3 months.                                            Institute for the Hearing Handicapped, Mumbai.

       Apart from these, neonatal infant hearing                     In the website www.checkhearing.nic.in,
screening programs are under way in several other              Basavaraj et al. (2006) have incorporated four such
tertiary hospitals such as Sri Ramachandra Medical             check lists for four different age groups. The
College, Chennai, Post-graduate Institute of                   checklists have been validated and they report the
Medical Education and Research, Chandigarh, All                overall sensitivity and specificity of the checklists
India Institute of Medical Sciences, New Delhi,                as 82% and 75%, respectively.
etc. and as part of training programs in some
training institutions.                                         HRR
                                                                     High Risk Register (HRR) continue to be
Technique/Tools for Screening                                  used as a screening technique. Several versions of
       The technique/tools used for hearing                    HRR specific to Indian population have been
screening have a lot to do with the population and             reported in RCI Disability Status reports (2000 and
funds available for screening. The objective of the            2003). Several projects use the HRR of American
screening also determines the technique and tools              Joint Committee on Infant Screening (2000) as a
used. From the abundant literature available on                benchmark HRR.
hearing screening programs undertaken in USA,
UK, Australia and other developed countries, it is             OAE
evident that the objective of screening is to identify               A variety of makes and models of OAE such
all degrees and types of hearing loss in each ear. In          as, fully automated, hand held screening
India, one may have to work out the requirement                instruments, diagnostic instruments are available
bearing in mind the infrastructure facilities                  (see Table 5 for details). Thus, OAE screening has
available for follow up.                                       been used widely in the developed countries

                                                         120
reporting very high sensitivity and specificity for                 Hearing checklists are being used under the
both TEOAE and DPOAE measures. However,                      project ‘Prevention of Deafness’ at AIISH, Mysore
the same has not been documented in the Indian               since 1995-96 to identify school children with
studies.                                                     hearing loss. Checklists are available on the website
                                                             www.checkhearing.nic.in which can be used by
ABR                                                          caregivers, pre-school/school teachers and also for
     Automated ABR has been used for screening               self-assessment by the older group.
in the last decade. Portable instruments with                       Behavioral screening is carried out by trained
automated ABR and OAE are available. The                     technicians or audiologists especially if the tool is
sensitivity and specificity of ABR has been                  a kit of noise makers. Training is also required to
documented to be very good. However, ABR has                 develop the skills to observe the auditory
been used more as a second step for the                      behavioural response.
confirmation of hearing loss in the screening
process.                                                           A checklist to screen school children under
                                                             the scheme of Sarva Shiksha Abhiyan of Ministry
Human resource for screening                                 of Human Resource Development, Government
       Human resource is directly related to the             of India is also available.
tools used, but the validity of screening results in               Attempts have been made to sensitize the
relation to different categories of human resources          caregivers about the normal developmental stages
is lacking apart from sporadic published/                    of auditory behaviour by means of handouts. The
unpublished reports.                                         Disability Helpline of AYJNIHH, Mumbai
      Basavaraj and Nandurkar (2007) studied the             provides this information through its IVRS.
feasibility of utilizing mothers/care-givers and                   OAE screening is mainly done by
nurses in hearing screening and report no                    audiologists. Nurses have been trained to use the
significant differences between the mother/                  automated OAE in projects (Basavaraj and
caregivers, nurses and audiologists in carrying out          Nandurkar, 2007). The scenario is same as for ABR
behavioral screening in case of bilateral severe to          screening.
profound hearing loss; also there was no significant
                                                                    Besides the techniques/instruments
difference between the nurse and the audiologist
                                                             mentioned in Table 1, high risk registers and check
when automated TEOAE was the equipment in
                                                             lists to be used for various age groups have been
use.
                                                             developed and are in use.
      HRRs especially those developed for medical
and non-medical persons (Anitha, 2001) can be
administered by a whole range of personnel
including trained volunteers.

                                                       121
Table 1: Hearing Screening Tools/Methods

      Sl.         Source of                             Frequencies                        Type of                     Tester                Approximate
      No.         stimuli                               (in Hz) covered                    Response                                          cost (in Rs.)

      1.    A set of noise makers with a                                             Behavioral (eye blink,       Trained Personnel        1000-1500
            combination of the items                                                 startle, facial grimace,
            mentioned below:                                                         localization, etc.)
            i) Drum                          i)     800-1700 Hz (peak at 800 Hz)
            ii) Metal Khanjeera              ii)    1140-7360 (peak at 2500 Hz)
            iii) Jingles                     iii)   800-1700 (peak at 6080 HL)
            iv) Squealer (high frequency)    iv)    Maximum between 4 and 8 kHL
            v) Wooden rattle                 v)     900 to 1600 Hz
            vi) Steel bell                   vi)    >4000 Hz
      2.    Hand held audio screeners                                                Behavioral (involuntary      i)  Professionals—       i) 1250 to 2500
            i) Pure tones (discrete and/or   i)     500 Hz, 1 kHz, 2 kHz, 4 kHz      response, viz., eye blink,       audiologists             for indigenous
                 sweep frequency)                                                    startle, facial grimace,     ii) Trained                  one (available
            ii) NBN (discrete and/or         ii) Center frequency of 500 Hz,         localization). Behavioral        Personnel                at AYJNIHH,
                 sweep noise)                     1 kHz, 2 kHz, 4 kHz                response as in play/                                      Mumbai)
            iii) Environmental sounds        iii) Variable frequency                 standard audiometry if                                ii) 20,000-40,000

122
                                                                                     the subject is old/                                       for the
                                                                                     intelligent enough and                                    imported ones.
                                                                                     without associated
                                                                                     problems
      3.    Portable screening audiometers   500 Hz, 1 kHz, 2 kHz & 4 kHz            Behavioral (conditioned           -do-                25,000 onwards
                                                                                     responses)
      4.    Handheld Tympano-meters          NA                                      Physiological measure,       i)   Audiolgists and
                                                                                     viz., tympanogram                 Otolaryngologists
                                                                                                                  ii) Auomated ones        1.2 lakhs onwards
                                                                                                                      may be used by
                                                                                                                      technicians
      5.    Handheld Immittance meters       NA                                      Physiological response            -do-                2.0 lakhs onwards
                                                                                     Tympanogram & presence/
                                                                                     absence of Acoustic reflex
6.    Immittance Audiometer              NA                                    Physiological response,      Audiologists            2.3 lakhs onwards
                                                                                     Tympanogram Acoustic         & Otolaryngologists
                                                                                     threshold
      7.    OAE screener
            i) TEOAE                           Clicks to elicit OAE in frequency     Physiological response       i)   Audiologists &     1.3 lakh onwards
                                               bands of 1 kHz, 1.5 kHz, 2 kHz, 2.8 kHz TEOAE                          Otolaryngologists
                                               & 4 kHz, (may vary from make/model                                 ii) Nurses
                                               to make/model)
            ii) DPOAE                          1 kHz, 2 kHz, 2.5 kHz, 3 kHz, 4 kHz   DPOAE Automated                     -do-             3.0 lakh onwards
                                               & 6 kHz                               equipment gives result as
                                                                                     pass /refer
      8.    Diagnostic OAE with TEOAE/         -do-                                  Physiological response       Audiologists &          4.5 lakhs onwards
            DPOAE options                                                            TEOAE/DPOAE                  Otolaryngologists
      9.    Automated ABR                      •    Clicks                           Result as pass/refer         Audiologists &          2.0 lakhs onwards
                                               •    Tone bursts of 500 Hz, 1 kHz,                                 Otolaryngologists
                                                    2 kHz & 4 kHz
      10.   Diagnostic ABR                     •    Clicks                           Physiological response       -do-                    4.5 lakhs onwards
                                               •    Tone bursts of 500 Hz,           indicating ABR wave

123
                                                    1, 2 & 4 kHz                     form to assess threshold
                                                                                     of hearing
      11.   ASSR                               AM/FM frequencies of 500 Hz,          Physiological responses      Audiologists            7.0 lakhs onwards
                                               1, 2 & 4 kHz                          indication
                                                                                     Threshold of hearing at
                                                                                     the respective frequencies
            Instruments with a combination of the above are also available.
High Risk Register/Checklists for Screening                     fillip. Government of India Gazette notification
Developed in India between 2000 and 2007                        of June 2001 with respect to disability screening
                                                                and certification has recommended including 500
     (1) HRR for Medical persons (Anitha, T.,
                                                                Hz, 1, 2 and 4 k Hz for hearing screening at 25
         2001)
                                                                dBHL. The Non-Government Organizations
     (2) HRR for Non-medical persons (Anitha,                   (NGOs) such as Rotary, Lion, Jaycee Clubs
         T., 2001)                                              continue to participate in arranging school
     (3) Hearing Screening Checklist (Basavaraj                 screening programs. However, documentation/
         et al. 2006)                                           publication of reports on school screening
           (i) 0-2 years                                        program continues to be minimal.
           (ii) 2-6 years                                             The introduction of Sarva Shiksha Abhiyan
           (iii) 6-18 years                                     (Education For All) of Ministry of Human
           (iv) 18+ years                                       Resource Development in the year 2001 has
                                                                sensitized the primary and secondary school
     (4) The Screening Checklist for Auditory
                                                                authorities under the State Governments to arrange
         Processing (SCAP) (Yathiraj &
                                                                hearing screening, the school teachers being trained
         Mascarenhas, 2002)
                                                                to identify hearing impairment in children besides
     (5) Self Assessment Hearing Handicap :                     other disabilities. Budgetary provision has been
         Short-form scale (Vanaja, 2000)                        made for such activities as well as for the
     (6) Checklist for identification of hearing                intervention of the children identified with
         impairment in school going children,                   disabilities.
         Department of Audiology, AIISH,
                                                                      Identification of Auditory Processing
         Mysore
                                                                Disorders in school-going children needs urgent
Challenges in Screening                                         attention. The screening checklist developed by
                                                                Yathiraj and Mascrenous, 2002 is not used as widely
       Challenges in undertaking newborn/infant
                                                                as desirable due to lack of awareness of the
hearing screening are: the lack of awareness in both
                                                                condition by parents and teachers.
the public and the professionals regarding the
importance of early identification of hearing
                                                                Identification of Noise-induced and
impairment; high levels of ambient noise in the
                                                                Age-related Hearing Loss
test areas in hospitals; deliveries at homes especially
                                                                      No significant progress has been made in
in rural areas with the assistance of dais/other
                                                                screening industrial workers and others for
attendants; poor follow-up bringing the initial
                                                                suspected noise induced hearing loss. The same is
efforts to nought; and scarcity of technical
                                                                the status with regard to age-related hearing loss.
manpower.
                                                                       People seeking training or employment in the
Hearing Screening in Schools                                    aviation sector are referred to institutes/hospitals
     As part requirement of the clinical work of                for audiometry. Self-assessment questionnaires
under-graduate programs (in Speech and                          (Vanaja, 2000) developed can be put to use to cover
Hearing), the school screening has received a                   larger population.

                                                          124
National Programme for Prevention                               In the first phase, a pilot project is being
and Control of Deafness (NPPCD)                          conducted in 25 districts in 10 States and 1 union
      The Ministry of Health and Family Welfare,         territory for two years, from 2006 to 2008. It is
Government of India in 2006, launched the pilot          proposed to expand this programme, in a phased
phase of the National Programme in Prevention            manner, to include a total of 203 districts covering
and Control of Deafness. One of the objectives is        all the States and Union Territories by 2012.
early identification, diagnosis and treatment of         Table 2 shows distribution of the same.
hearing loss.

 Table 2: States/Union Territories, Medical Colleges and Districts Covered under the Pilot Phase of NPPCD

 Sl. No.   State/UT                  Medical College                              Districts

 1.        Andhra Pradesh            Osmania Medical College/                     •    Mehboob Nagar
                                     Govt. ENT Hospital, Hyderabad                •    Nalgonda
                                                                                  •    Hyderabad
 2.        Assam                     Guwahati Medical College, Guwahati           •    Kamrup
                                                                                  •    Sonitpur
                                                                                  •    Nalberi
 3.        Gujarat                   Govt. Medical College, Jamnagar              •    Jamnagar
                                                                                  •    Rajkot
                                                                                  •    Bhavnagar
 4.        Karnataka                 All India Institute of Speech and            •    Mandya
                                     Hearing, Mysore                              •    Hubli
                                                                                  •    Hassan
 5.        Manipur                   RIMS, Imphal                                 •    Imphal
 6.        Sikkim                    Sikkim Manipal Institute of Medical          •    Gangtok
                                     Sciences, Gangtok
 7.        Tamil Nadu                Christian Medical College, Vellore           •    Vellupuram
                                                                                  •    Vellore
                                                                                  •    Thanjavur
 8.        Uttarkhand                Himalayan Institute of Medical               •    Haridwar
                                     Sciences, Dehradun                           •    Dehradun
                                                                                  •    Narendernagar
 9.        Uttar Pradesh             King George Medical University,              •    Barabanki
                                     Lucknow                                      •    Gorakhpur
 10.       Delhi                     Lady Harding Medical College, Delhi          •    North west
                                                                                  •    West
 11.       Chandigarh                Govt. Medical College, Chandigarh            •    Chandigarh

                                                       125
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