Global Audiology/Asia/Iran

Iran, an Islamic republic, is the second-largest country in the Middle East. Persia is the ancient name of this country. It is located between the Gulf of Oman, the Persian Gulf, and the Caspian Sea. It is bordered by Iraq to the west; Turkey, Armenia, and Azerbaijan to the northwest; Turkmenistan to the northeast; and, to the southeast, by Afghanistan and Pakistan. Iran is a historic country and home to one of the world’s oldest civilizations. The country’s central location in Eurasia and Western Asia and proximity to the Strait of Hormuz enhance its geostrategic importance. Tehran is the country’s capital and largest city. One of the most beautiful cities in the country, Tehran is also the political, economic, and cultural center of Iran. The majority of Iran’s population speaks Persian, which is also the official language of the country. The majority of Iranians practice Islam; however, other religions, including Christianity, Judaism, and [https://en.wikipedia.org/wiki/Zoroastrianism#:~:text=Zoroastrianism%20is%20an%20Iranian%20religion,conquest%20of%20evil%20by%20good. Zoroastrianism] are accepted and held by a small percentage of the population (Iran, 2019).

According to the National Guidelines on Newborn and Children Hearing Screening Program (2017), the prevalence of moderate to profound hearing loss in Iran is between 3% and 5%. In 2017, the scientific secretary of the Iranian Audiology Association announced that the prevalence of newborns with congenital hearing loss is between 4 and 5 per 1,000 newborns (Prevalence of hearing loss in Iran, 2017). Asghari et al. (2017) assessed the prevalence of hearing loss among 6,521 individuals in Iran. The results revealed that the prevalence of hearing loss was 42.6% among adults aged 61–70 years and 70.4% among adults aged 71 years and older. The overall prevalence of some level of hearing impairment in this study was 14.72%.

Fortunately, Iran has tremendous early hearing loss identification and intervention programs for newborns. These programs also help parents and families of children with hearing impairments and ensure that they are offered adequate treatment and intervention plans.

History
Aural care in Iran has a very long history, beginning with Avicenna’s important contributions to medical science. Avicenna was a Persian polymath and one of the most influential philosophers of the pre-modern era. He also had a significant historical impact on the health care systems in the region. In one of his books, he discusses ear anatomy and different ear diseases (Azizi, 2007); this suggests that the basics of audiology in Iran were developed a long time ago. However, as in many other countries, audiology has only recently been recognized as an official profession in Iran.

In 1924, Jabbar Baghtcheban established the first school in Iran for hearing-impaired children. He was also the inventor of Persian-language cued speech. Zabih Behrouz was a scientist who played an important role in the education of children with hearing loss through his research on this population (Hearing Impaired People Encyclopedia, 2016). The first newborn hearing screening program in Iran was initiated in 1999 and is currently performed across the country in accordance with the Joint Committee on Infant Hearing (JCIH) guidelines (Rahimi et al., 2014). Furthermore, preschool hearing screening, part of the National Integrated School Health Screening Program, has been conducted since 1992 to identify children with hearing problems (Health and educational screening of school-age children, 2020). Some of the audiological testing equipment being used is imported, as Pejvak Ava, owned by Saeed Salek, is the only Iranian company that makes diagnostic and screening audiometers and tympanometers.

The key point to recognize about this profession is that it is growing rapidly. About 40 years ago, there were only three universities in the country offering an audiology program. Currently, there are more universities throughout the country that have such programs, and students can be accepted by taking an annual national exam called the Iranian Universities Entrance Exam. It takes four years of full-time study and clinical experience to earn a bachelor’s degree in audiology. Graduates can then apply for a master’s degree and, afterward, a PhD.

Educational Institutions
Iran’s first national university to offer an associate degree in audiology was Shahid Beheshti University in 1973. In 1976, the Iran University of Medical Sciences started offering a bachelor’s degree in the field, making it the first in the country. A master’s degree was later offered in 1992. Finally, in 2008, a PhD program in audiology was pioneered at Tehran University of Medical Sciences (Persian Wikimedia Contributors, 2009). Currently, there are 11 universities in various cities where one can study audiology under distinguished professors to earn a bachelor’s degree. Also, a master’s degree is offered by four universities, and three universities offer PhD programs.

Audiology Practice: Public and Private
In most of Iran, people now have access to audiology services through both the public and private sectors. As in many other countries, there are significant differences between the costs of services offered in private and in public; audiology clinics and public services cost considerably less. People can choose which service they want to use. Currently, some private clinics accept limited forms of health insurance. However, most insurance plans require a referral from a medical specialist for the patient to receive audiology services.

The quality of services provided by government-owned institutions is generally high. Most of them are well equipped—especially in university clinics—and they have experienced experts. However, long wait times and crowding due to the higher numbers of patients dissuade some from using public options.

The State Welfare Organization of Iran, which is a government-owned institution, also has many branches all over the country. They offer some diagnostic and rehabilitation services at little to no cost. This organization also distributes hearing aids for free to almost all children and some adults who are qualified.

Professionals
In Iran, audiologists, otolaryngologists, and speech-language pathologists are the main members of the hearing care team. However, other professionals such as primary care physicians, psychologists, and educators might help with hearing care depending on the age of the patients and the services needed.

Services Offered by Otolaryngologists
Otolaryngologists in Iran provide services that cover the different congenital and acquired pathologies of the ear. These services include diagnosis, medical and surgical treatment of chronic otitis media, common malignant and benign tumors of the temporal bone, and implanting hearing devices. Otolaryngologists use a range of advanced methods for hearing restoration. Novel otology surgeries, such as cochlear implants (CI) and implant hearing aids, have been performed in Iran for decades. The most commonly used devices are the CI, the Bone Anchored Hearing Aid (BAHA), and the Vibrant Soundbridge (VSB).

Not only do Iranian otolaryngologists offer hearing restoration, but they also diagnose and treat balance disorders. Otolaryngologists’ other duties include microsurgical surgeries in the cerebellopontine angle, facial nerve surgeries, reconstruction of ear anomalies, and lateral skull base trauma treatment. The most common surgeries in this field are tympanoplasty, tympanomastoidectomy, glomus tumor surgery, acoustic neuroma surgery, CI, and ventilation tube (VT) insertion. Due to the region’s location, treatments and educational services such as, regional and temporal bone dissection courses, are occasionally offered to neighboring countries.

Audiological Services
While residents all over Iran currently have access to audiology services, some places—such as clinics and hospitals in bigger cities—offer more comprehensive services. Audiologists in Iran work in many different settings, including ENT offices, private clinics, universities, hospitals, special education organizations, the Department of Veterans, and industries.

Main audiology services include:


 * Assessment of hearing
 * Selection, dispensing, and fitting of hearing aids
 * Aural rehabilitation
 * Assessment of balance
 * Vestibular rehabilitation
 * Diagnosis and management of hearing and balance disorders
 * Tinnitus assessment and rehabilitation
 * Monitoring, mapping, and programming cochlear implants, and other related surgical implants
 * Newborn hearing screenings and infant diagnostic tests
 * Noise measurements in work environments and hearing screening for industrial employees; hearing protection is also provided

Although some of these services are limited, most of them are widely available. For instance, balance assessment, vestibular rehabilitation, and the monitoring, mapping, and programming of cochlear implants are limited. These services are currently available only in some university clinics, hospitals, public institutions, and a few private clinics in larger cities.

Scope of Practice and Licensing
With the exception of nurses, all health care professionals in Iran are registered with the Islamic Republic of Iran Medical Council (IRIMC). This institution is a non-governmental organization (NGO) responsible for all licensing, authorizations, and registrations relevant to practicing in the country (IRI Medical Council, n.d.). All audiologists active in a private hearing center need to have a license from the IRIMC. This license also allows them to dispense hearing aids.

Some of the requirements to obtain a license include a university degree in audiology, at least two years of related experience, and CEU credits of conference attendance. While practicing, audiologists must also earn continuing education credits to be able to renew their license. The Curative Affairs of Medical Science Universities departments in each city act as supervisors for audiologists. They also check hearing clinics to ensure they meet standard requirements.

Professional and Regulatory Bodies
The Iranian Association of Audiology (IAA) is one of the main professional organizations for audiologists in Iran. IAA officially began working in 2005. Some of the IAA’s primary goals include supporting audiologists, holding conferences and workshops, developing educational programs, determining audiology standards, and cooperating with other related professionals. The association has more than 2,000 members (Persian Wikimedia Contributors, 2009).

Audiology Charities
As previously mentioned, the welfare infrastructure in Iran offers important benefits for people who have any kind of disability, including hearing impairments. For people with hearing loss, especially children, some organizations offer free or very low-cost audiology services, including hearing aids. For instance, the BAKHSHESH organization and Komak Charity Foundation assist children with hearing loss with cochlear implant surgery costs and provide support and information for their families (Beneficence, n.d.; Help Charity, n.d.).

One important organization that increases accessibility to medical services is Heyat Omana Arzi (HOA), or the Board of Trustees for Patients' Treatments with Currency Saving. This is a non-governmental organization that plays a key role in providing medical services. One of the goals of this organization is to offer cochlear implantation and ENT surgery equipment. They provide financial assistance to patients requiring cochlear implants. Relatively speaking, these surgeries are not exorbitantly expensive for patients due to this financial assistance (Heyat Omana Arzi – HOA, n.d.). Currently, cochlear implant surgery in Iran can be performed by 14 different medical institutions. Approximately 1,500 implants are performed annually in Iran with the support of this organization. Also, welfare infrastructure and some other smaller charities in different states help patients receive cochlear implants and hearing care services.

Various audiologic studies have been performed in Iran. Most of them are conducted under the supervision of audiology professors from medical universities. These studies are usually shared with audiologists at annual national conferences, and some of them are published in international related journals.

Furthermore, Auditory and Vestibular Research (AVR) is a quarterly, double-blind, peer-reviewed publication provided by Tehran University of Medical Sciences, Iran. In 1992, this journal was a Persian publication called “Audiology.” Currently, AVR is a unique journal in the region, only available online. It is published in English to provide individuals interested in audiology with the latest findings. Recently, the journal has been accepted for inclusion in Scopus (Auditory and vestibular research, n.d.).

=== Challenges === Some of the challenges audiologists face in Iran are as follows: the average costs for various audiology services are relatively low, few insurance policies cover all audiologic tests and services; no Iranian companies currently produce hearing aids that are more affordable; and no Iranian universities offer an Au.D. program.

Challenges aside, audiology in Iran is a respected and relatively well-recognized profession that is growing toward a more valued position in the health care system. Trained and certified audiologists in Iran can work in a variety of settings and provide important services. With an increasing number of audiologists, more people around the country will have access to hearing and balance assessment services. National newborn and preschool hearing screening programs have significantly lowered the age of hearing impairment diagnosis.

Currently, there are 12 universities that offer accredited bachelor’s, master’s, and PhD audiology programs. There are also a few international students studying in master’s and PhD programs. The findings of audiologic research conducted in Iran are presented at the annual National Congress of Audiology and the biannual CAPD Congress. Additionally, there are many continuing education opportunities, such as seminars, workshops, and webinars held by universities and the Iranian Association of Audiology, that help audiologists to stay current on the latest in research and provide the best hearing-related services. The Auditory and Vestibular Research Journal, the only English audiology journal published in the region, has increased interest in more research in this field.


 * 1) Asghari, A., Farhadi, M., Daneshi, A., Khabazkhoob, M., Mohazzab-Torabi, S., Jalessi, M., & Emamjomeh, H. (2017). The prevalence of hearing impairment by age and gender in a population-based study. Iranian Journal of Public Health, 46(9), 1237–1246.
 * 2) Auditory and vestibular research. (n.d.)
 * 3) Azizi, M.-H. (2007). The otorhinolaryngologic concepts as viewed by Rhazes and Avicenna. Archives of Iranian Medicine, 10(4), 552.
 * 4) Bakshesh | بخشش. [Beneficence]. (n.d.).
 * 5) Heyat Omana Arzi – HOA|HOA is a nongovernmental public organization. (n.d.).
 * 6) IRI Medical Council > home. (n.d.).
 * 7) Rahimi, F., Firoozbakht, M., Esmaeelzadeh, M., Mahmoudin, M., Alaeddini, F., & Rafiee, M. (2014). برنامه ملی کشوری، برنامه جامع غربال فراگیر شنوایی نوزادان  [National program- The comprehensive program of neonatal hearing screening]. Birjand: Chaharderakht Publisher; Persian.
 * 8) Iran. (2019, April 23). In Wikipedia.