Global Audiology/Asia/Saudi Arabia

Saudi Arabia comprises about four-fifths of the Arabian Peninsula in Southwest Asia and is known to be the third-largest country in Asia, after China and India. The climate is generally cold in winter and dry and hot in summer, with temperatures slightly lower along the coasts. Mostly, Saudi people (or Saudis) have a common Arabian ancestry, making the population generally homogeneous in terms of ethnicity, religion, and language. Arabic is the native language, and English is spoken and understood among most business people, commercial centers, and healthcare workers. Islam is the state religion. The holy city of Mecca is the center of Islam, where all Muslims around the world face during prayer. A pilgrimage to Makkah is one of the five basic pillars of Islam for every Muslim who is physically and financially able to perform it. The economy is heavily dependent on oil production, and the country has the largest reserves of petroleum in the world. The government budgets billions of SAR for health and social services. The public health care system is supported by the government, which provides integrated health services free of charge or at a nominal fee to all citizens. The private healthcare system also provides excellent healthcare services for people who have healthcare insurance. Again, the government spends billions of SAR on education, which is free at all levels, including college and postgraduate study. There are more than 30 governmental and private universities in the kingdom.

According to the World Health Organization (2012), the prevalence of disabling hearing loss is estimated to be around 0.9% in Middle Eastern countries, including Saudi Arabia. The estimated incidence of permanent congenital or early onset hearing impairment in developing countries in 2012 was six cases per 1000 live births (Olusanya, 2012). Zakzouk (1997) reported in an epidemiological study of hearing impairment in children in Riyadh, Saudi Arabia, that the prevalence of hearing impairment was found to be 7.5% of the children surveyed, with 2.6% of them having sensorineural hearing loss. In another study, Zakzouk et al. (1999) found that the prevalence of hearing impairment among children, who were screened in random areas of Saudi Arabia, was 13% of 10,000 children aged up to 15 years. He reported that 1.5% of the children in Saudi Arabia suffered from either a unilateral or bilateral permanent sensorineural hearing loss. Habib and Abdelgaffar (2005) conducted a study to find the incidence of congenital hearing impairment in the Saudi population. A total of 11986 non-high-risk neonates were screened by transient evoked otoacoustic emission over a period of 8 years. They estimated the incidence of sensorineural hearing loss to be 0.18%, with no significant difference between males and females. In a cross-sectional study of 2,574 children aged 4-8 years, Al-Rowaily et al. (2012) diagnosed 45 children with hearing impairment, with an overall prevalence of 1.75%.

History
The field of audiology is relatively new in Saudi Arabia. It is thought that the audiological history of Saudi Arabia goes back to the 1980s, when the first audiology and speech-language pathology program was established at King Saud University.

Education
The first audiology and speech-language pathology program were established at King Saud University about 30 years ago, whereas the Saudi Society of Speech-Language Pathology and Audiology (SSSPA) was officially established in 2003 (SSSPA, 2014). The idea of establishing new audiology and speech-language pathology programs in some educational facilities has become popular across Saudi Arabia; yet, only four undergraduate and graduate programs are currently available. At present, Saudi universities offer three undergraduate programs and only one graduate program in audiology and/or speech-language pathology, of which two are governmental and one is private. King Saud University offers a combined undergraduate program (i.e., a dual degree program) in speech and hearing rehabilitation for male and female students. Princess Nourah Bint Abdulrahman University provides two separate undergraduate programs in audiology and speech-language pathology for female students. Dar Al-Hekma University offers undergraduate and graduate programs in speech-language pathology for female students (SSSPA, 2014).

Audiology Practice: Public and Private
Most audiologists practicing in Saudi Arabia are Saudi citizens with different levels of experience. Audiologists, who are mainly working in government hospitals as full-time workers, serve different numbers of geriatric and pediatric patients on a daily basis. However, the main government hospitals, rehabilitation centers, and schools in Saudi Arabia only hire a few graduated audiologists. There are several reasons, but the lack of understanding of the professional services provided by audiologists and the complexity of recruitment policies and procedures are the main ones.

Services Offered by Otolaryngologists, Otologists and Otoneurologists
Ear-related services provided by ENT doctors in Saudi Arabia include diagnosis and medical and surgical treatment of ear pathologies and balance disorders of all ages, from common conditions to some of the most complex medical cases. Cochlear implants and bone-anchored hearing aids have become among the most common surgical procedures in Saudi Arabia. Other common procedures, such as the placement of ventilation tubes, tympanoplasty, mastoidectomy, and hearing reconstruction with prosthetic ossicles, are also conducted in the main hospitals. The other hearing-related service provided by nurses is the hearing screening of newborns. Nurses are mainly responsible for performing newborn hearing screenings in hospitals that have the newborn hearing screening program.

Audiological Services
Audiologists practicing in Saudi Arabia provide several audiological services. A summary of audiology services is shown in the following figure:

Figure. Summary of audiology services and the percentage of audiologists. OAEs: otoacoustic emissions; PTA: pure-tone audiometry; H. phones: Headphones, I.E. phones: Insert earphones, SRT: Speech recognition threshold, SDT: Speech detection threshold, WRS: Word recognition threshold, ABR: Auditory brain stem response, ASSR: Auditory steady-state response, CIs: Cochlear implants; Re/hab: Re/habilitation, APD: Auditory processing disorder, M.E.Is: Middle ear implants, NHS: Newborn hearing screening, and H.P.P.: Hearing protection program (Alanazi, 2017)

Professionals
There is no available data about the number of licensed audiologists or other hearing health-related practicing specialists (e.g., speech-language pathologists) in Saudi Arabia. The Saudi Commission for Health Specialties (SCHS), which conducts licensure examinations for native and foreign diplomats and foreign nationals before they may practice in Saudi Arabia and ensures quality of care, should announce these numbers.

Professional and Regulatory Bodies
The Ministry of Education supervises and regulates all academic programs, including audiology programs, at all universities. Moreover, it accredits all foreign qualifications in audiology and other academic fields. SCHS conducts licensure examinations for native and foreign diplomats and nationals before they may practice in Saudi Arabia. The Saudi Society of Speech-Language Pathology and Audiology (SSSPA) works to develop the audiology profession by connecting audiologists with each other and with other professionals, providing scientific advice in the field of audiology, encouraging theoretical and clinical scientific research, and facilitating the exchange of scientific production and scientific ideas in the interests of association between relevant bodies and organizations within and outside Saudi Arabia.

Scope of Practice and Licensing
An undergraduate degree in audiology is mandatory to practice audiology in Saudi Arabia. Before graduation, audiology students must complete a 12-month (or a 6-month internship if the program is combined) supervised internship in audiology clinics. After graduation, audiologists must be licensed by SCHS to practice in Saudi Arabia.

=== Challenges === The current undergraduate programs are not enough to cover the high demand for audiology services in Saudi Arabia. Trained audiologists will be increasingly needed to meet the demands of the community. More undergraduate and graduate programs must be established. The efforts aiming to establish academic programs in Saudi Arabia may encounter a number of obstacles, such as the complexity of regulations and a shortage of faculty with research and academic degrees. Further, there are other challenges, one of which is the national accreditation of the clinical doctorate programs (i.e., Doctor of Audiology [Au.D.] programs). The Ministry of Education in Saudi Arabia accredits Au.D. degree as a bachelor's degree. The Au.D. degree should be equivalent to at least a master’s degree for a person who already has an undergraduate degree. The profession of audiology is still in its infancy in Saudi Arabia. Cooperation among a diverse group of stakeholders, including SSSPA, SCHS, current audiology academic program directors and faculty members, the Ministry of Health, the Ministry of Education, and the King Salman Center for Disability Research, should be started and supported to achieve better education and practice and encourage research.


 * 1) Alanazi, A. A. (2017). Audiology and speech-pathology practice in Saudi Arabia. International Journal of Health Sciences, 11(5), 43-55.
 * 2) Al-Rowaily, M, A, AlFayez, AI., AlJomiey, M. S., AlBadr, A. M., & Abolfotouh, M. A. (2012). Hearing impairments among Saudi preschool children. International Journal of Pediatric Otorhinolaryngology, 76(11), 1674-1677.
 * 3) Habib, H. S., & Abdelgaffar, H. (2005). Neonatal hearing screening with transient evoked otoacoustic emissions in Western Saudi Arabia. International Journal of pediatric Otorhinolaryngology, 69(6), 839-842.
 * 4) Olusanya, B. O. (2012). Neonatal hearing screening and intervention in resource-limited settings: An overview. Archives of Disease in Childhood, 97, 654-659.