Global Audiology/Asia/Turkey

Turkey, officially the Republic of Turkey, is a transcontinental Eurasian country that is located mainly in Asia with a smaller proportion located in Southeastern Europe. Turkey has an area of 783,562 square kilometers. With a coastal length of 7,200 km, it borders the Mediterranean Sea, the Aegean Sea, and the Black Sea. Greece and Bulgaria neighbor Turkey in the northwest, while Georgia, Armenia, and Azerbaijan are its neighbors in the northeast. Turkey also borders Iran in the east and Iraq and Syria in the south. The population of Turkey is 83,154,997 (TUIK, 2019a). The capital city is Ankara, and the official language is Turkish. Of the total population, 50.2% are males and 49.8% are females. Turkey’s annual population growth rate was reported to be 14.7 per 1,000 in 2018. In 2018, the working-age population (15–64 years old) was 67.8% and the child population (0–14 years old) was 23.4% of the total population. Hence, the proportion of the population aged 65 years and older was 8.8%.

According to the projections made based on the assumption that the current demographic trends will continue, the ratio of the elderly population will be 9.8% for 2021 and 10.2% for 2023. It is estimated that the elderly population will increase by 1.2% in the next 6 years. The ratio of the elderly population to the total population will be 18.84% in 2040 and 22.64% in 2060. Accordingly, it is estimated that Turkey will have an elderly population of one-fourth of its total population (25.60%) in 2080 (TUIK, 2018).

The latest information on the disabled population in Turkey, released by the Turkish Statistical Institute (TURKSTAT), belongs to the year 2011 (TUIK, 2019b). The number of disabled people registered in the National Disabled People Database was 4,882,841 (6,6%), of whom 57,2% were females and the remaining 42,8% were males. The number of people with self-reported hearing difficulties in Turkey was 836,000, and the number of people with speech difficulties was 507,000. The percentage of individuals with hearing problems in the total population of Turkey is 4.5% for all ages, 3.9% for men, and 5.0% for women. 1.1% for individuals between 15 and 44 years old, 4.1% for 45-54 years old, 5.4% for 55-64 years old, 15.0% for 65-74 years old, and 34.7% for over 75 years old (Ministry of Family, Labor and Social Services, 2011).

Approximately 1,300,000 babies are born every year in our country, and 1,300–2,600 of these babies have congenital hearing loss (Gökçay et al., 2014). This rate increases to 4% among infants in the intensive care unit. In 2018, 1,195,930 babies went through the newborn hearing screening program, and 29,310 of them did not pass the test. The infants that failed the newborn hearing screening were referred for comprehensive audiological assessments. Hearing loss was detected in 3,604 of those who failed the screening.

Bolat and Genç (2012) stated that, in the newborn screening study conducted at Hacettepe University Faculty of Medicine between 1998-2003, 5,485 babies were screened, and 11 babies (2/1000) were diagnosed with bilateral advanced hearing loss. Övet et al. (2010) conducted a similar study and found that 19,464 babies were screened, and bilateral advanced hearing loss was detected in 18 (0.1%) babies (Övet et al., 2010). In a study conducted by Türkmen et al. (2013), this rate was given as 1.2 per 1,000 babies (Türkmen et al., 2013). These studies showed that the rate of severe hearing loss in Turkey complies with world literature.

History
Audiology in Turkey started at Hacettepe Hospital in 1967 under the leadership of Prof. Dr. Nazmi Hosal. In the same year, Soner Özkan from the Faculty of Medicine's ENT Department went to the USA to continue his education in audiology. When he returned to Turkey, he took part in the establishment of the science of audiology in that country. Between 1969 and 1971, David Resnick and Dr. Richard Israel contributed to the development of audiology in Turkey. Dr. Richard Israel implemented and regulated audiology training programs in Turkey (Gök, M., 2017).

In 1974, a doctoral program was established with the help of Dr. Jack Katz at Hacettepe University. In 1984, the first audiometry associate degree program was started at Hacettepe University Health Services Vocational School, and the first Audiology Department was established at Marmara University under the Faculty of Medicine in 1990. Later, a master’s degree program in audiology was also initiated at Hacettepe University (Belgin, 2015).

The first bachelor’s degree program in audiology was started on April 26, 2011 at Istanbul University under the leadership of Prof. Dr. Ahmet Ataş. Audiology was officially recognized by the Council of Higher Education, which is responsible for all higher education institutions in Turkey

Educational Institutions
Currently, nine state universities and eleven private universities offer education in audiology in Turkey. The degrees currently offered in the field of audiology in Turkey are a four-year undergraduate degree (Bachelor of Science; B.Sc.), a master’s degree (Master of Science; M.Sc.), and a doctorate (Doctor of Philosophy; Ph.D.). Estimates suggest that there were about 3,000 graduates of the audiology undergraduate programs at the end of 2019. The programs in Turkey focus on hearing sciences and speech with approximately 400 to 450 hours of clinical practice. The bachelor’s degree is sufficient for earning the title of “audiologist” as an entry-level to practice; however, there are a few universities with master's and doctoral programs to train clinical scientists at a higher level.

Following are some of the well-recognized audiology programs in Turkey:
 * University of Health Sciences (Istanbul): Sc. degree in Audiology
 * Istanbul University Cerrahpaşa: Sc. degree in Audiology, M.Sc. degree in Audiology and a Ph.D. degree in Audiology
 * Marmara University: Sc. degree in Audiology, a Ph.D. degree in Audiology
 * Hacettepe University: Sc. degree in Audiology, M.Sc. degree in Audiology and a Ph.D. degree in Audiology
 * Ankara University: Sc. degree in Audiology and Speech Pathology, a Ph.D. degree in Audiology and Speech Pathology

Audiology Practice: Private and Public
In Turkey, professional audiological services are available in both the public and private sectors. The number of audiologists in the private sector is higher than that of the 198 audiologists working in the public sector (Ministry of Health, 2020). Healthcare services, including audiological services, are offered at primary, secondary, and tertiary levels. The national neonatal hearing screening program is applied in hospitals at all levels. Services in primary level hospitals are provided by audiometrists and nurses. An audiometrist is a 2-year associate degree-holding graduate health technician. They are responsible for performing basic audiological tests, which are an auxiliary laboratory service in the diagnosis and treatment of ear diseases after the examination of the ENT doctor. They work in public and private hospitals, private centers that apply hearing tests, and hearing aid centers.

There is no audiology clinic in all primary level hospitals, but simple ear examinations, treatment, and orientation are performed there. Audiology clinics exist in secondary level hospitals and offer all audiological services by audiometrists and audiologists, except cochlear implant surgeries because related devices are not available. In tertiary hospitals, services are provided by a multidisciplinary team consisting of audiologists, ENT surgeons, psychologists, speech and language pathologists, and audiometrists. Depending on the problem, a wide range of services is performed, such as medical examinations and treatments, surgery, detailed audiological investigations, and interventions. Ear and hearing examinations, electrophysiological evaluations, hearing aid application and fitting, cochlear implantation, post-op implant fitting and follow-up services, and vestibular evaluations and rehabilitation are performed in audiology clinics located in tertiary-level hospitals.

Infants who fail the hearing screening at any level are referred to the tertiary level hospitals. Advanced audiological evaluations are applied to all children who are referred to tertiary level audiology clinics. Across Turkey, all children are diagnosed in the first three months and receive proper amplification in the first six months. All children who meet the appropriate conditions are given bilateral hearing aid support by the state until the age of 18. Newborns who fail the first hearing screening and meet the inclusion criteria for cochlear implants are eligible for cochlear implants at 132 cochlear implant centers across the country. All costs of bilateral cochlear implantation before the age of four are covered by the state. Additionally, these patients are eligible to receive free individual (8 hours/week) or group (4 hours/week) rehabilitation services These services are mainly operated by public facilities at no cost.

Additionally, all the above-mentioned services are provided in the private sector. All fees for the services offered in private hospitals are covered by the state if there are agreements between the social security institution and the hospital. Mentioned fees for the services offered in private hospitals are covered by the patients when there is no agreement.

Recent estimations suggest that there are over 1,000 audiology clinics and about 132 cochlear implant centers located all over Turkey (Ministry of Health, 2020). Currently, a total number of 198 audiologists work in these cochlear implant centers. Although there are audiology clinics all over Turkey, patients are restricted in their access to many of these services due to the majority of these audiology clinics, especially outside city centers, not employing audiologists.

Services Offered by Otolaryngologists, Otologists, and Otoneurologists
There is no distinction between otolaryngologists, otologists, and otoneurologists. A general otolaryngologist is a doctor trained in the medical and surgical treatment of the structures related to the ears, nose, throat, and head and neck. Otolaryngologists deal with hearing-related disorders, such as ear infections, balance disorders, and facial nerve or head nerve disorders, along with the medical and surgical treatment of congenital diseases and cancers of the outer ear and inner ear. They also provide treatment for diseases of the larynx, upper respiratory system, digestive tract, nasal cavity, and care of the sinuses. Otorhinolaryngologists are also trained in the treatment of infectious diseases, tumors (malignant and benign), facial trauma, and facial deformities in the head and neck region.

Audiologists Working at Hearing Aid Companies
Audiologists practicing in all hearing aid centers primarily work in branch management. Audiologists follow the general functioning of the hearing center and ensure the necessary actions are performed for effective service delivery. Understanding and informing the patient, performing the necessary otoscopic examination and audiological tests, determining the hearing loss of the patient, analyzing the patient’s problem, recommending and applying the device that is most suitable for the hearing test, providing device adjustment and technical support, controlling the device stocks, and following the social security system are among the responsibilities of audiologists. In summary, audiologists contribute to the achievement of company goals by managing the treatment and rehabilitation process to best suit the needs of patients, ensuring patient satisfaction.

Audiologists Working at Rehabilitation Centers
The main duty of audiologists working in special education and rehabilitation centers is auditory rehabilitation. Audiologists have duties such as evaluating the auditory perception of the identified and assisted pediatric group, evaluating language development, creating individual training programs, developing auditory rehabilitation programs, and providing audiological counseling. Also, audiologists can take part in the language education of children with developmental language disorders. Audiologists are engaged in the development of the receptive-expressive language, expanding the vocabulary, providing concept acquisition, and improving social and communication skills. Audiologists are also responsible for the auditory rehabilitation of the adolescent, adult, and geriatric population. Audiologists organize auditory training plans, provide auditory perception training, and offer auditory attention and memory studies for individuals with central auditory processing disorders.

Audiologists Working at Hospitals
The main task of clinical audiologists is to diagnose hearing loss in hospitals and private centers. Performing hearing screening programs, making objective and subjective evaluations of auditory disorders, diagnosing hearing loss, informing the family about hearing aids, directing patients to cochlear implantation if they do not benefit from hearing aids, managing the auditory rehabilitation process after conducting amplification, performing auditory perception evaluations, performing patient check-ups, and providing audiological consultancy are among the responsibilities of audiologists who work at hospitals. Also, they diagnose peripheral and central vestibular system disorders and perform vestibular rehabilitation on patients. Audiologists are also responsible for mapping and managing tinnitus and evaluating and managing central auditory processing disorders.

Audiologists Working at Cochlear Implant Companies
One of the main tasks of an audiologist who works at a cochlear implant company is supporting ENT surgeons and operating theatre staff to implement correct use of the cochlear implant tooling, sterilization procedures, and objective measures during surgery in various cities. They provide audiological and technical training and support for cochlear implant (CI) centers, hospitals, and rehabilitation centers throughout Turkey. They also conduct follow-ups with the patients after surgery and track their routine fittings. In addition, they are responsible for the monitoring of patients in their assigned area, planning regular hospital and rehabilitation center visits, and providing remote support when necessary.

Professionals
The table below shows the professionals who regularly interact with individuals with hearing loss (Ministry of Health, 2017). The ratios are estimates calculated based on the population of 83,154,997.

Professional and Regulatory Bodies
There are several professional organizations available to audiologists in Turkey. The primary organizations are:


 * Turkey Audiologists & Speech Pathologists Association (Türkiye Odyologlar & Konuşma Bozuklukları Uzmanları Derneği)
 * Association of Istanbul Audiology, Speech and Language Disorders (İstanbul Odyoloji, Konuşma Ve Dil Bozuklukları Derneği)
 * Hearing Aids Acoustic & Audiology Association (İşitme Cihazları Akustik & Odyoloji Derneği)
 * Language, Speech and Deglutation Research Association (Dil, Konuşma ve Yutma Araştırmaları Dergisi)
 * Audiology Association (Odyoloji Derneği)
 * Audiologists Association (Odyologlar Derneği)

Scope of Practice and Licensing
Graduates with a bachelor’s degree in hearing sciences are legally allowed to practice audiology. However, graduates with a master’s degree in speech and hearing sciences are permitted to practice as an audiologist, a speech-language pathologist, or both.

Unlike the regulations in the United States, no special license is needed to practice audiology in Turkey. University graduates can work in public hospitals, private institutions, and universities. However, to work in public hospitals, it is necessary to pass the examination made by the state, which includes basic sciences and general cultural knowledge.

The way of applying the audiology profession in Turkey has been determined by state law (Presidency of T.R., 2011). According to this law, audiologists who have graduated from universities that provide undergraduate education in audiology or who have completed a master’s degree or Ph.D. degree in audiology after graduating from other undergraduate education areas, can be healthcare professionals who conduct studies for hearing and balance controls, prevention of hearing disorders in healthy individuals, identify hearing and balance disorders, rehabilitation, and then determine the devices used for these purposes.

The number of studies conducted in the field of audiology in Turkey is increasing every year. Most of the research is done by audiologists in audiology clinics at universities. Most of the research done in university clinics are student projects (undergraduate projects, master’s theses, and doctoral theses). These studies can be accessed from university libraries and through the website of the Council of Higher Education (YOK). Current studies in these clinics cover all areas of audiology.

Currently, research conducted in Turkey focuses on the areas of results of short-term and long-term cochlear implantation, tinnitus, noise-induced hearing loss, cochlear implantation, and music perception; hearing loss and associated cognitive changes; hearing algorithms in hearing aids; localization skills of hearing aid and cochlear implant users; and satisfaction surveys.

In Turkey, there are several peer-reviewed and indexed journals that publish research in audiology and related fields, such as the Journal of International Advanced Otology, the Balkan Medical Journal, the Turkish Archives of Otorhinolaryngology, and the Journal of Academic Research in Medicine.

The Journal of International Advanced Otology (JIAO) is an international, peer-reviewed, open-access publication that is fully sponsored and owned by the European Academy of Otology & Neuro-otology, and the Politzer Society. It has been in publication since 2009. The journal’s archive is available online, free of charge, at www.advancedotology.org. The journal’s 5-year impact factor is 0.899.

The Balkan Medical Journal (BMJ), which was established in 2011, is a peer-reviewed open-access international journal that publishes clinical and experimental research conducted in all fields of medicine. The journal is the official scientific publication of the Trakya University Faculty of Medicine in Edirne, Turkey. The journal’s archive is available online, free of charge, at www.balkanmedicaljournal.org. The journal’s impact factor was 1.203 in 2019.

Hearing screening tests are applied in the neonatal period for the early diagnosis of babies born with hearing loss. Screening tests are the only valid method for the early diagnosis of congenital hearing loss. In Turkey, there are two national hearing screening programs: (a) Newborn Hearing Screening (2004) and (b) School-Age Hearing Screening (2015). Newborn hearing screenings were initiated under the leadership of the Audiology departments at Hacettepe University and Marmara University. Screening studies gained momentum with the initiation of a hearing screening program for babies born in Ankara Zübeyde Hanım Maternity Hospital in 2000. In 2004, the National Newborn Hearing Screening Campaign, covering maternity hospitals, was launched all over the country.

The Newborn Hearing Screening Program and School-Age Hearing Screening Program in Turkey are major, successful ongoing projects in Turkey. It is aimed at continuing the success of these programs and to a start geriatric hearing screening program throughout the country.

Newborn Screening Program
The Newborn Hearing Screening Program was initiated in 2000 and has become a national practice since 2004. Currently, approximately 95% of all newborns go through the Newborn Hearing Screening.

As of 2018, there were 1,153 hearing screening centers across Turkey. The number of newborns who went through the newborn hearing screening was 1,195,930 in 2018. The screening rate for newborns is approximately 95.8% as of 2018. The screening rate of newborns by year is given in Figure 1.

School-Age Hearing Screening Program
School-age hearing screenings are an integral tool in identifying children with hearing loss who were not identified at birth, lost to follow-up, or who developed hearing loss later.

The School-Age Hearing Screening Program in Turkey began at the end of 2015. Some pre-schools and elementary schools started to perform school hearing screenings as part of a pilot study. These screenings have become a widespread practice.

More than 1.5 million children are registered in schools across the country every year. The target population for school-age hearing screening is all school-entry learners (grade 1). Hearing screenings are still ongoing in all 81 provinces.

Screening personnel include nurses, midwives, community health workers, or audiometrists. They receive adequate training in screening methods and referral pathways.

Children are screened across four frequencies: 500–1000–2000–4000 Hz. If the child’s hearing threshold is worse than 20 dB at any frequency, he or she is re-tested within 48 hours to one week at a maximum. Children who do not pass the screening repeat are referred to the ENT specialist for a complete ENT examination and audiological evaluation.

The ratio of the number of students covered by the screening program to the total number of students is shown in the figure.

The following are a few of the many highly active audiology-related charities:


 * Türkiye İşitme Engelliler Derneği
 * İşitme Engelliler ve Aileleri Derneği
 * İşitme Engelliler Federasyonu: https
 * İşitme Engelliler Eğitim Faaliyetleri Derneği
 * Dilkonder-Dil ve Konuşma bozuklukları derneği
 * Şişli İşitme ve Konuşma Engelliler Derneği
 * Marmara İşitme Engelliler Derneği
 * Üsküdar Sağır ve Dilsizler Derneği
 * İstanbul İşitme Engelliler Turizm Kültürel Ve Dayanışma Derneği
 * Türkiye Beyazay Derneği

=== Challenges ===
 * Due to undergraduate level audiology being very new in Turkey, audiology departments do not have a sufficient number of qualified teaching staff.
 * Especially the undergraduate and graduate departments of audiology, which are opened by private schools without the necessary qualifications, have many insufficient graduates.
 * Most of the audiology departments opened do not have laboratories, applications, or research areas. Since there are no exams specific to audiology after graduation to practice the profession, audiologists who have received adequate training in the field are not recognized and are forced to work for low salaries.
 * In our country, the audiology profession is not sufficiently recognized, and the necessary attention is not given. Audiologists are yet to fully explore the areas of work outside clinical settings. For example, audiologists do not work in schools or industrial audiology areas.
 * Despite the studies, awareness of hearing loss is still very low in the country. For example, adults with hearing loss begin to use hearing aids only when they experience severe hearing loss.
 * Fittings of hearing aids are not performed by audiologists in many places. By law, it has been decided that hearing aid fittings should be made by audiologists and audiometrists in private hearing aid centers. Hearing aid sales centers can be opened with limited and inadequate training for their workers, who do not have to hold any higher education. For this reason, this is thought to cause incorrect hearing aid selection and improper hearing aid fittings most of the time, and these centers (and some private clinics) cannot provide adequate and quality service even though they have the latest technology equipment. To correct this situation, it would be beneficial to establish a supervisory professional organization (e.g., ASHA), which organizes education and studies with the participation of universities and other interested parties, in accordance with developed countries.
 * Education and clinical services in areas such as auditory processing disorders, vestibular disorders, and tinnitus are very limited and need to be improved.


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