Global Audiology/Asia/Nepal

The Federal Democratic Republic of Nepal is a sovereign country situated in southern Asia, lying along the southern slopes of the Himalayan Mountain ranges. Nepal is well known for many things, such as being the home to many of the highest peaks in the world, including Mt. Everest, the fearless [https://en.wikipedia.org/wiki/Gurkha#:~:text=The%20Gurkha%20units%20are%20composed,war%20zones%20around%20the%20world. Gurkha] soldiers, and the birthplace of Lord Buddha.

The current population of Nepal is 29,500,464 as of Sunday, March 14, 2021, based on Worldometer's elaboration of the latest United Nations data. It is the 49th largest country by population. Nepal is a land of cultural diversity and ethnicity. There are 123 different languages spoken as the mother tongue in Nepal, although the official languages are Nepali and English.

Nepal is a landlocked country located between India to the east, south, and west and Tibet to the north. It has a territory of around 500 miles (800 kilometers) from east to west and 90 to 150 miles from north to south. Nepal has an area of 147,516 square kilometers. Kathmandu is the capital of Nepal. Administratively, Nepal is divided into 77 districts, which combine to form seven provinces. The landscape of Nepal is primarily comprised of hilly and mountainous regions, which occupy a total of 85% of the land.

Nepal is a developing nation, ranking 142nd in the Human Development Index (HDI) in 2019. The GDP of Nepal was estimated to be around 32.16 billion dollars. The citizens of Nepal are known as Nepalis or Nepalese. Though Nepal is an agricultural country, tourism is one of the largest and fastest-growing industries in Nepal.

Like most developing countries, Nepal is also developing in terms of its infrastructure and facilities. Healthcare in Nepal is also making progress along with other services; however, the rehabilitation aspect is still in its infancy. The state has not been able to provide substantial guidance for most people with disabilities. Advocacy and support for reducing hearing loss have had their fair share of difficulties. Hearing loss and hearing aids are still stigmatized in many parts of Nepal, and awareness is concentrated in the major cities.

Pascolini and Smith (2009) stated that a 1990 Nepal national survey reported 7.5% of the total population has some amount of hearing loss. Little information is available regarding the extent of disabilities, including hearing loss. There are also a few existing programs and organizations that assist in developing rehabilitation programs for hearing loss. Another study conducted by Mahajan et al. (2006) reported the prevalence of otitis media effusion in Nepalese children was 13.2%, and those with hearing loss comprised 12.47%. This prevalence was much higher in school-going children compared to adults, and it was even higher amongst children belonging to the lower socio-economic strata. Conditions complicating otitis media are more common and severe in children as compared to adults. A study in a school for the deaf in Kathmandu estimated that 7% of the children were affected by congenital Rubella syndrome. Recent data about incidence and prevalence are still lacking.

Education of Hard of Hearing
The initial school for the hard of hearing was established in Kathmandu in 1965. This school was previously known as Bahira Balak ko School. It was renamed as the Speech Instruction Centre for Deaf Children and was located in Bir Hospital before moving to Bal Mandir in Naxal, a neighborhood in central Kathmandu (Acharya, 1997). Presently, it is known as the Central Secondary School for the Deaf. This institution, along with the Kathmandu Association of the Deaf (KAD), is said to be the origin of the Nepali Sign Language (NSL). The blossoming of NSL took place even though the Central Secondary School followed an oral philosophy when it was founded. In 1988, it adopted a total communication philosophy involving the production of spoken Nepali along with signs in Nepali word order (Acharya, 1997; Hoffmann, 2008; Hoffmann-Dilloway, 2011). Four other deaf schools were established in the same time frame in Surkhet, Bhairahawa, Saptari, and Dharan (NDFN, 2019).

History
The field of audiology in Nepal is still in its infancy and taking its first steps. The first audiology-related services were noted in the late 1980s, when the audiology service was started within the Tribhuvan University Teaching Hospital (TUTH), a tertiary care center located in Kathmandu.

TUTH is the only institute that produces manpower in the field of audiology. Audiology services at TUTH began in 2009. Since then, this profession has undergone major growth and offers a vast range of ear and hearing healthcare. Most audiological services are centered in major cities such as Kathmandu, Pokhara, and Biratnagar.

Educational Institutions
Hearing health care education system is not well developed in Nepal. There is only one course offered in Speech and Hearing Science. A Bachelors in Audiology and Speech Language Pathology (BASLP) is a 4-year academic program under the leadership of S.L. Karna and Kabiraj Khanal that are offered at the Institute of Medicine (IOM), which is affiliated with Tribhuvan University. The course enables the speech and hearing specialist, commonly referred to as an audiologist and speech pathologist, to provide services to sufferers of hearing disorders and speech defects, such as aphasia, stuttering, voice disorders, delayed speech, motor speech disorders, and language development disorders.

Gandaki University is planning to start an undergraduate program in speech and hearing science, but it has not yet started.

Audiology Practice: Public and Private
In Nepal, professional audiology services are provided in the private and public sectors. The public institutions include government- and community administered hospitals and university medical colleges.

Public institutions charge a minimum amount for different audiological services, whereas private clinics are more expensive due to high administrative and instrument costs. For the cochlear implant program, the government provides funds; however, this fund is small when compared to the number of patients who require implantation. Few non-governmental organizations (NGOs) provide free or low-cost hearing aids. Public hospitals provide only diagnostic services. A patient with hearing aids will have to visit a private clinic for services. Audiological services are not covered by insurance.

Private clinics are available for all Nepali citizens. To access private clinics, patients must pay out of pocket. Kathmandu is the only place where there are more than 15 clinics. Public clinics and hospitals should open more vacancies for audiologists to provide services for the marginalized population. Also, a low-cost, high-quality hearing aid should be developed for developing nations like Nepal.

Professionals
There are currently a total of 91 registered professionals working in Nepal in the field of speech and hearing. Out of which 12 have a postgraduate degree and 79 have undergraduate degrees as their qualification. This is based on data of registered professionals as August 24, 2020 with the Nepal Health Professional Council (NHPC), which is the common governing body for licensing and regulation of all health professionals, including audiologists and speech-language pathologists

There is only one ear, nose, and throat (ENT) surgeon for every 600,000 people in Nepal, and just one audiologist for every 6,000,000 people. As a result, untreated ear disease can cause serious problems, including severe pain and life-threatening infections (Felltham et al., 2014).

Audiological Services

 * 1) Hearing assessment both behavioral and electrophysiological (PTA, VRA, BOA, Play audiometry, BERA, OAE, Tympanometry)
 * 2) Selection, fitting, and verification of fitting
 * 3) Cochlear implant mapping, auditory training, and assessing audiological candidacy
 * 4) Vestibular rehabilitation and assessment
 * 5) Tinnitus and hyperacusis assessment and management
 * 6) Newborn hearing screening, etc.

It is important to note that most audiological facilities are based in urban areas, making it difficult for people in rural areas to access such services. There are many organizations that work to extend audiological services to rural and remote areas by conducting hearing screening camps and appointing public health workers to facilitate the identification of hearing disorders and appropriate referrals. However, general awareness of hearing healthcare in rural areas is still poor. The lower socio-economic status of people living in rural Nepal makes it difficult for them to travel to urban areas to receive services.

Services Offered by Otolaryngologists
Otolaryngologists in Nepal provide services for different congenital and acquired diseases of the ear. The facility includes diagnostic services and medical and surgical treatment of different diseases of the outer, middle, and inner ear. Otolaryngologists use a range of surgical methods for hearing restoration, such as cochlear implants (CI) and other implantable hearing aids.

Scope of Practice and Licensing
The regulatory body has not produced any documentation regarding the scope of practice.

To be an audiologist in Nepal, an individual must have a minimum of an undergraduate degree in Speech and Hearing Science. Undergraduate professionals are trained and educated for the identification of hearing loss at all ages and the assessment and diagnosis of hearing and vestibular disorders by performing behavioral and electrophysiologic measures. These undergraduate professionals are also trained to provide treatments such as amplification devices, assistive listening devices, auditory training, and rehabilitation of vestibular function.

An audiologist with a postgraduate degree is trained to do basic audiological services along with special audiological services like cochlear implant mapping, intraoperative monitoring, vestibular evaluation and management, and tinnitus assessment and management

Professional ad Regulatory Bodies
The Speech and Hearing Association of Nepal (SHAN) is the professional and scientific association with over 70 members, while the Nepal Professional Health Council (NHPC) is the regulatory body that regulates training and practice.

The Speech and Hearing Association of Nepal (SHAN) was formed in 1999. It is a professional and scientific association for speech-language pathologists and audiologists in Nepal. Its role is to promote hearing, speech, and language professions and rehabilitation services through advocacy and continuing rehabilitation education (CRE). It is also involved in monitoring professionals, encouraging and supporting research in the field of speech and hearing. SHAN has organized many conferences, CRE opportunities, awareness rallies, and camps.

Currently, there are 63 life members, 29 associate members, and 2 foreign members within the association. Other associations include:


 * 1) Cochlear Implant Nepal Group (CING) is a group of otologists, audiologists, speech language pathologists, nurses, pediatricians, and others who are focused on cochlear implant patients in Nepal. This organization strives to raise awareness regarding cochlear implants and obtain government support. CING was able to obtain funding for cochlear implants, where the government bears 50% of the cost of the implant. Even with funding, CIs are a costly option in Nepal and post cochlear implantation rehabilitation services are mainly limited to Kathmandu.
 * 2) Society of Otolaryngologists Nepal (SOL) is mainly an association for ENT surgeons in which audiologists and SLPs are associate members.

Every year, SHAN, in collaboration with CING and SOL, organizes events and an awareness program to mark World Hearing Day on the 3rd of March. SHAN has also organized two national conferences, the last one being in 2017.

The Nepal Health Professional Council (NHPC) is an autonomous body established under the Nepal Health Professional Council Act 2053 (1996). The aim of this council is to register all “health professionals” omitting medical doctors and nurses according to their qualification and bring them into a legal system to make their services effective, timely, and evidence based. The Nepal Professional Health Council (NHPC) has classified professionals in 4 levels: Specialization level (Post Graduated), First level (Undergraduate), and second level (diploma in speech and Hearing) (Nepal Health Professional Council, 2021). NHPC also enforces disciplinary action against unqualified persons delivering health services.

Currently, research in the field of audiology is increasing. Most of the research is conducted at the Tribhuvan University Teaching Hospital and the Green Pasture Hospital, and the Nepal Speech and Hearing Association (SHAN), along with the Society of Otorhinolaryngology Nepal (SOL), organizes regular scientific conferences to promote scientific activity in the field of ears and hearing in Nepal. The Nepal Health Research Council (NHRC) also supports and governs research activity in Nepal.

Research focused on developing high- and low-frequency speech audiometry test materials and tinnitus and vestibular research. Picture identification tests for children are some of the research topics that are published in national and international peer-reviewed journals. There are very old studies on the prevalence of hearing loss. Recently, interest has been directed toward developing test metrics for central auditory processing disorders (CAPD), both screening and diagnostic. A few hospitals have started newborn hearing screenings, and mass school screenings and treatments for ear disease are being conducted.

[https://impactnepal.org.np/#:~:text=IMPACT%20Nepal%20(IN)%20is%20committed,of%20race%2C%20gender%20or%20religion. Impact Nepal (IN)] was established in 1993 with the aim of preventing disability. IN serves throughout Nepal, and specific projects are implemented in the districts of Kathmandu, Rautahat, Parsa, Bara, Saptari, Udayapur, Kailali, Kanchapur, Dhoti, and Dadeldhura.

IMPACT Nepal operates community-based primary ear care programs in several rural districts of Nepal to provide primary and secondary ear care services to the local communities. These community-based activities are targeted towards the prevention of the causes of unwanted ear disease and subsequent hearing loss. Plans are also in place to extend such a program to the far-western region of Nepal. While this program is focused on primary and secondary level ear care, tertiary level ear care is also available to these marginalized communities through mobile ear surgery camps held in or near these districts as well as through the Ear Care Center in Lahan, Siraha district. This hospital is well equipped with facilities for tertiary-level ear care.

Ear Aid Nepal is a non-profit charity organization that was established to promote hearing health care services in Nepal, which include identification, diagnostics, and rehabilitation.

This charity is associated with the International Nepal Fellowship (INF) and is focused on the development of the INF Ear Hospital and Training Center (IEHTC) in Nepal. This is an establishment that provides hearing health care services for the population of western Nepal.

This organization is continuously educating the people of Nepal regarding the hearing health care system. It is also promoting and funding the research projects. Ear Aid Nepal also organizes free hearing camps in rural areas of Nepal, where the volunteers come and provide the hearing services to the public.

Objectives of this organization:


 * 1) To provide specialist advice to the hospital management team to improve the quality of life of persons with hearing disabilities.
 * 2) To educate the public about hearing loss and its impact in order to provide good ear care to individuals in Nepal and the Himalayan region.
 * 3) To develop research-based projects related to hearing health care in Nepal.
 * 4) To plan an organization model that provides fundraising and then utilizes the money in improving the hearing health care in Nepal.
 * 5) To provide help in the organization and construction of the hospital that is proposed by INF.
 * 6) To support the INF ear camps providing care to the remote rural population of western Nepal.
 * 7) To improve the quality of services to persons with hearing loss in terms of diagnostics and rehabilitation in rural areas.

This organization also performs all kinds of ear surgeries for free in the ear hospital. The aim is to provide all forms of surgery to the ear (Example: the external ear or pinna, the ear canal, ear drum and middle ear, etc.)

Microsurgical operations such as myringoplasty, tympanoplasty, ossiculoplasty, stapedotomy, atticotomy, mastoidectomy, and reconstruction are intended to be routinely available.

INF has been organizing many medical camps in Nepal for over six decades now. These ear camps are usually organized in rural areas. Ear Aid Nepal has been providing extensive professional support with the help of volunteers and opened the Ear Center in November 2015. Ear Aid Nepal’s principal aims are to support the ear hospital and the ear camp work, people with ear disease and deafness, and particularly those with limited means and poor access to care. This includes training locals, extending the range of services available in the country, and conducting basic and primary care research.

Shruthi National Association of Hard of Hearing and Deafened Nepal was established in Nepal in 2012. This organization is a member of the Asia-Pacific Federation of the Hard of Hearing and Deafened (APFHD).

This organization was established to address issues that concern those with hearing disabilities in Nepal. The motto of this organization is to develop an inclusive society with no communication barrier and where those with hearing disabilities live a dignified life (Bhattarai & Bacala, 2017).

The Nepal Association of the Hard of Hearing is an organization that is working to improve the quality of life for people with disabilities. It has been affiliated with the International Federation of the Hard of Hearing since 2015 and became a member of the Human Rights Treaty Monitoring Coordination Center in 2016.

=== Challenges === There is a huge lack of awareness about audiology services among different health professionals and the public.

There is also a lack of research in the field of hearing in Nepal, with a limited number of professionals involved in current research.

There is a lack of skilled providers, and these are limited to a few big cities. Services should be extended to remote areas.

Hearing instruments are expensive, and a cost-effective solution in developing countries should be invented.

The government should give equal priority to rehabilitation services, including auditory rehabilitation.

There is a lack of evidence-based practice and monitoring for unethical practices.

Although many private sector practices have state-of-the-art facilities, the practices are not well regulated (especially for hearing aid dispensing), resulting in many unqualified (or poorly trained) individuals practicing. Hence, much effort is needed from NHPC and SHAN to enforce the necessary practice regulations.

Many qualified professionals are leaving the country for better opportunities. This process should be reduced by increasing the number of students, developing new speech and hearing colleges, and expanding to a Master's or Doctor of Audiology (Au.D.) program.

There is a need to increase and promote professionals for clinical and research work.

There is a need to increase the number of job openings in both the government and private sectors and to monitor the quality of services.

There is a need to advocate for inclusive education and special education for children with hearing impairments.


 * 1) Acharya, K. (1997). History of the Deaf in Nepal (E. Hoffmann-Dilloway & D. Chemjong, Trans). Unpublished manuscript. Kathmandu: National Association of the Deaf and Hard of Hearing.
 * 2) Bhattarai, N. K., & Bacala, T. M. (2017). Promoting Hearing Health Care in Nepal. The Hearing Journal, 70(3), 22-24.
 * 3) Hoffmann, E.G. (2008). Standardization beyond form: Ideologies, institutions, and the semiotics of Nepali Sign Language. Unpublished doctoral dissertation, University of Michigan.
 * 4) Hoffmann-Dilloway, E. (2011). Lending a hand: Competence through cooperation in Nepal’s Deaf associations. Language in Society, 40, 285-306. doi:10.1017/S0047404511000194
 * 5) National Federation of Deaf Nepal. (2019). About us: History of NDFN.
 * 6) Nepal Health Professional Council. (2021).
 * 7) Pascolini, D., & Smith, A. (2009). Hearing Impairment in 2008: a compilation of available epidemiological studies. International journal of audiology, 48(7), 473-485.