Global Audiology/Africa/Tunisia

Tunisia is considered a middle-income country and is located in North Africa. Its current population is approximately 12 million people, based on the latest statistics from the World Bank in 2018. Although Arabic is the official language of the country, French is spoken fluently by the majority of the population. Tunisia shares borders with Algeria in the west and Libya in the east and is situated on the southern border of the Mediterranean Sea below the Italian Peninsula. Tunisia was colonized by France in 1881 but declared its independence in 1956 to officially become the Republic of Tunisia. Economically, Tunisia has been struggling since 2011, following the Arab Spring revolution, with a current real GDP growth of -1% according to the IMF. According to the World Bank, the main sectors of the Tunisian economy are agriculture, accounting for 10.4% of the GDP and employing 15% of the workforce; industry, representing 22.7% of the GDP; and services (tourism and communication technologies), representing 63.6% of the country’s GDP (The economic context of Tunisia, 2020).

In terms of healthcare, the public health care system in Tunisia is funded by taxation and covers medical services for residents and citizens within the public system. Coverage for medical care within the private sector—audiology services, for example—follows certain criteria and requires a pre-approval.

Information regarding the incidence of hearing loss and the equipment available at the national level is very scarce. To the best of our knowledge, only two hospitals have acquired otoacoustic emission devices: Charles Nicolle and Nabeul. For auditory brainstem response (ABR), three hospitals perform it: Tunis, Nabeul, and Monastir. Similarly, there is no national data regarding the incidence of hearing loss in Tunisia. We were able to find two research studies on two state levels, Tunis and Nabeul.

The first project was made by the neonatology department of the Charles Nicolle Hospital in Tunis. The data included 3,260 newborns that underwent a newborn hearing screening in the period between one day after birth and one month of age. The results showed three cases of mild bilateral hearing loss (0.9%), five cases of unilateral profound hearing loss (1.5%) in the right ear, and one case of anacusis (Nouaili, E.B.H. et al., 2010).

The second research study was an OAE hearing screening performed at Mohamed Tlatli Hospital in Nabeul State, conducted by Asma Bouaziz Abed, et al.

The goal was to determine the frequency of hearing loss among newborns and infants under six months of age. The research included 397 infants aged between four days and five months who were at risk. They received a hearing screening with an ABR and OAE. The results showed no hearing loss in 360 infants and 37 (9,32%) with some type of hearing loss whether unilateral or bilateral. Twenty-seven infants out of the 37 diagnosed positively were referred to an ABR, which was negative in 20% of the cases. In 1.76% the ABR displayed the word refer (Abed, A.B. et al., 2013).

History
In the aftermath of independence in 1956, the medical system in Tunisia followed the example of France. France adopted a 3-year education program for certification to practice audiometry, with the possibility of an additional two years for a master’s to become an audiologist (Onisep, 2020).

Tunisia’s first school of audiometry was founded recently, in 2015. The program is a three-year program following the French system, without the option of pursuing a master’s degree currently.

Generally, the position of an audiometrist in Tunisia has similar licensure requirements for practice as a hearing aid dispenser in the US. The duties of audiometrists are mostly limited to basic audiometry and hearing aid programming, which does not include in-depth diagnostics, results, counseling, cochlear implants, vestibular disorders, or pediatrics. Currently, there are only 4 audiologists and about 60 audiometrists active in the private sector.

An organization in support of the Deaf community called “Association Voix du Sourd de Tunisie (A.V.S.T.)” was created in 1983. Despite the progressive position of audiological care, Tunisia has no early identification and intervention program.

Educational Institutions
To this day, there are no audiology schools in Tunisia; however, an audiometrist school was founded in 2015. The school is accredited by the Ministry of Higher Education in Tunisia, and its curriculum consists of a 3-year education with a thesis at the end of the final year.

Audiology Practice: Public & Private
In public hospitals, only clinical audiology would be performed for diagnostic purposes. These services are reimbursed 100% through Tunisian universal healthcare's "Caisse National d’Assurance Maladie” (CNAM). However, if the patient needs hearing aids, he is referred to the private sector, to an audiometrist's office. The following services are provided, usually supervised by an ENT:


 * Pure-tone audiometry
 * Tympanometry
 * Impedance audiometry
 * Auditory Brainstem Response (ABR)
 * Balance evaluation

In the private setting, audiometrists can only perform pure-tone audiometry for dispensing purposes. The following services are provided by audiometrists:


 * Pure-tone audiometry
 * Hearing aid dispensing

Government hearing aid compensation through the public insurance “Caisse National d’Assurance Maladie” (CNAM). If a patient qualifies for hearing aids, the public insurance system will compensate depending on the following criteria:


 * If patient is under the age of 60 years old, and has a severe hearing loss or better, Then the CNAM will compensate 340TND (≈ $123) for one hearing aid, and 565TND (≈ $205) for two.
 * If patient is under the age of 60 years old, and has a profound hearing loss, Then the CNAM will compensate 440TND (≈ $160) for one hearing aid, and 665TND (≈ $241) for two.
 * If patient is over the age of 60 years old, and has a severe hearing loss or better, Then the CNAM will compensate 340TND (≈ $123) independently of how many hearing aids needed
 * If patient is over the age of 60 years old, and has a profound hearing loss, Then the CNAM will compensate 440TND (≈ $160) independently of how many hearing aids needed.
 * If patient is a school-aged child and is attending school, Then the CNAM will compensate 1000TND (≈ $363) independently of how many hearing aids needed.
 * If patient is under the age of 4 years old, and has a severe hearing loss or better, Then the CNAM will compensate 340TND (≈ $123) for one hearing aid, and 565TND (≈ $205) for two.
 * If patient is under the age of 4 years old, and has a profound hearing loss, Then the CNAM will compensate 440TND (≈ $160) for one hearing aid, and 665TND (≈ $241) for two.

Professionals
According to the Tunisian Ministry of Health, as of 2017, the number of professionals in different sectors related to audiology is presented in the table below (Mokdad, M. et al., 2019). However, a few of these numbers, such as the audiometrists, were procured through unions and other sources, which makes them approximate due to the lack of online reports in human resources on allied health professions.

Audiological Services
There are currently four audiologists in Tunisia, so there is no defining body that represents them or an official scope of practice. The current audiologists are practicing with a license provided by the Ministry of Health and have a more expanded scope of practice than audiometrists, which includes:


 * Pure-tone audiometry (for diagnostic and hearing aid programming purposes)
 * Tympanometry
 * Impedance audiometry
 * Hearing aid dispensing
 * Tinnitus evaluation
 * Auditory Brainstem Response
 * Balance evaluation (VNG, VHIT, VEMP, etc.)
 * Hearing aid dispensing

Professional and Regulatory Bodies
The audiometrists in Tunisia are represented by a union called “Chambre Syndicale des Audioprothésistes Tunisien” Mona Zouari Melliti is the appointed president, and Maroua Charfi is her vice president. The goal of the union is to protect the rights of audiologists and audiometrists, update the laws, and organize the profession to prevent an infringement on its rules.

Scope of Practice and Licensing
As mentioned before, there is no defining body that represents audiologists or an official scope of practice for the profession due to a lack of numbers. However, licensing is still granted only by the Ministry of Health in cooperation with the Ministry of Higher Education. The scope of practice is determined based on the curriculum and level of education accumulated in other countries since there are no schools of audiology in Tunisia and, therefore, no official recognition of the profession.

Currently, only audiometrists have a clear scope of practice.

Services offered by otolaryngologists/otologists
Aside from medical and surgical services, ENTs can provide the following audiological services:


 * Pure-tone audiometry (for diagnostic purposes)
 * Cerumen Management
 * Tympanometry
 * Impedance audiometry
 * Hearing aid dispensing
 * Tinnitus evaluation
 * Auditory Brainstem Response
 * Balance evaluation (VNG, VHIT, VEMP, etc.)

As mentioned previously, there were only two studies related to audiology that we were aware of and could have access to.

The first project was made by the neonatology department of the Charles Nicolles Hospital in Tunis. It consisted of a hearing screening on newborns to determine the incidence of hearing loss within a sample of newborns.

The second research study was an OAE hearing screening performed at Mohamed Tlatli Hospital in Nabeul State, conducted by Asma Bouaziz Abed, et al.

The goal was to determine the frequency of hearing loss among newborns and infants under six months of age.

Association Voix du Sourd de Tunisie (A.V.S.T.)
The association was created in 1983 and has more than 25,000 members. The main objectives of this group are to support deaf young people in order to facilitate their social integration, defend the rights of the deaf, and promote cultural and sports activities.

Rotary Club Tunis Les Berges du Lac
The club was created in 2009 and currently has 24 members. Their main goal is to improve the quality of life of others through action in the areas of water, mother and child, literacy, and health. They recently procured hearing aids for two children in need to help them return to school. The club took care of the cost of the hearing aids and the fees for four years of follow-up appointments with an audiometrist.

Tunisia’s public health system suffers from a lack of funding. Public hospitals are lacking personnel and equipment in order to compete with the private sector. The absence of digitized systems makes it difficult for professionals to access patient information, health histories, or previous testing. This is why it is hard to find data on a national scale.

In addition, hearing aid compensation is insufficient compared to other countries, and the criteria for eligibility are not up to date with the international guidelines, especially for children and the elderly.

Audiologists are also not officially recognized by the Ministry of Health, as the profession is fairly new and the course of study is not taught in the country. At this moment only audiometrist are recognized with a three-year diploma.

However, Tunisia is in a transitional period, and the current government is showing more of a concrete interest to restructuring the health system in the country. Digitization of the country, investments, and funding of the public health system are currently hot topics that hopefully will see concretization soon.

Contributors to the original text (before transfer to Wikiversity) were Drs. Ali Melliti and Saifallah Melliti.

Abed, A. B., Saad, H., Mustpha, R., Chiha, M., & Ben Gamra, S. (2013). Early hearing  screening by otoacoustic emissions and auditory brain stem response in Nabeul. La Tunisie Medicale, 91(11), 643–647.

Diplôme d’Etat d’audioprothésiste. (n.d.). Onisep.

Melliti, A., Melliti, S., & Sherwood, L. (2019). The history of audiology in Tunisia: Student audiogram. Student Academy of Doctors of Audiology

Mokdad, M., Brayek, A., Abidi, B., & Gam, W. (2019, March). Santé Tunisie en chiffre 2017. (pp. 93–94). Tunisian Ministry of Health.

Nouaili, E.B.H., Chaouachi, S., Bezzine, A., Hamadi, M., Mbarek, C., Benlallehom, L., & Marrakchi, Z. (2010). Dépistage systématique de la surdité en maternité par oto- emissions acoustiques provoquées (O.T.E.A.P): Etude pilote. La tunisie Medicale: 88(7), 482-485.

The World Bank. Country Profile – Tunisia | Data. (n.d.).

The economic context of Tunisia. (2020, July). Nordea

Tunisia [Map]. (2019). In One World- Nations Online.