HEARING IMPAIRMENT - Rehabilitation Council of India
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HEARING IMPAIRMENT
Chapter 1
Introduction
The Ear and Its Work damage to the inner ear, makes it difficult to tolerate
T he sense of hearing provides a background, loud sounds.
which gives a feeling of security and For children with hearing impairment,
participation in life. It plays a critical role in the congenital or acquired before development of
development of speech and language and in speech and language, normal speech development
monitoring one’s speech. is interfered with.
The ear is a complex, but delicate structure With unilateral hearing impairment also,
designed to perform a variety of functions: to able there is difficulty in localizing sound, reduced
to hear very soft sounds over a wide frequency speech discrimination. Lower speech and language
range as well as withstand the very loud sounds, to development in children has significant effect on
discriminate between sounds that vary in pitch and their educational, linguistic and auditory perceptual
loudness; to be able to locate the direction of arrival development.
of a sound and in the presence of noise, to be able
to switch on and off a sound of interest. The hearing-impaired persons have in
common, their difficulty in hearing spoken and
The human ear perceives simple tones in the other sounds. They also depend on what they see
range of 20 to 20,000 Hz and also complex signals which they supplement to what they hear.
such as speech and music. Both types of signals
are used in the assessment of hearing loss. Assessment
Hearing sensitivity of each ear is
Impact of Hearing Impairment
measured separately and the severity/degree of
Consequences of hearing impairment will hearing impairment/ hearing loss is generally
depend on the ear/s involved, the degree and the classified in seven categories as per Goodman’s
type of hearing loss and the age of onset. (1965) classification and an additional category
Hearing impairment leads to loss of normal - slight hearing loss is added between the
verbal communication. Due to distortion of normal hearing and mild hearing loss
sounds, differentiation of environmental sounds, especially when assessing the hearing
including speech, is difficult; making sounds sensitivity of young children. Table 1 shows
louder does not improve the clarity or quality of the classification of severity of hearing
sound. Similarly, recruitment, which is an impairment.
abnormal growth in loudness, a characteristic of
99Table 1: Classification of Severity of Percentage of Hearing Disability
Hearing Impairment (Threshold + Speech Discrimination
Score Based)
Classification PTA range in
dBHL The Ministry of Social Justice and
Normal Hearing -10 to 15 Empowerment, Government of India notified
Slight Hearing Loss 16 to 25 guidelines for evaluation of various disabilities and
Mild Hearing Loss 26 to 45
procedure for certification vide Notification No.
Moderate Hearing Loss 46 to 55
16-18/97-NI dated 1st June 2001. Procedure for
calculating hearing disability is based on pure tone
Moderately-severe Hearing Loss 56 to 70
thresholds as well as speech discrimination score
Severe Hearing Loss 71 to 90
in order to arrive at the percentage of the disability.
Profound Hearing Loss 91 and more
The minimum degree of disability should be 40%
in order to be eligible for any concessions/ benefits.
The level of normal conversational speech
is approximately 65dBSPL. Thus, for a person with
Issue of Disability Certificate
hearing impairment of 60dBHL or more, verbal
The certificate of disability is to be issued by
communication would be difficult. This level of
a medical board consisting of at least three
hearing impairment has been equated as 40%
members, of which one shall be an
hearing impairment as in Persons with Disability
otolaryngologist. Percentage of disability can be
(Full Participation, Equal Opportunity and
determined considering Pure Tone Average and
Protection of Rights) Act, 1995. The definition of
Speech Discrimination Score as shown in Table 2.
hearing disabled as stipulated in the PWD Act, 1995
is a person who has a minimum of 60dBHL of
hearing impairment in the better ear in speech
conversation frequencies.
Table 2: Percentage of Disability
Category Type of PTA of Better Speech Discrimination Percentage
Impairment Ear in dBHL Score of Better Ear of Disability
I Mild 26-40 80-100% < 40%
II(a) Moderate 41-60 50-80% 40-50%
II(b) Severe 61-70 40-50% 51-70%
III(a) Profound 71-90 91 Very Poor 100%
To obtain Speech Discrimination scores, nor standardized tests for speech discrimination in
specialized skills, instruments and standardized various languages are presently available in all
tests are required. Neither the range of instruments centers in the country.
100Chapter 2
Historical Perspective
H istorical developments have been dealt with
comprehensively in the Disability Status
Reports published by the RCI, in 2001 and 2003.
mean that any effort to initiate early intervention
services should be accompanied by short term
training programs for qualified professionals.
Since then, significant events such as establishment These programs should be aimed at equipping
and support of early identification and early rehabilitation professionals to handle aspects
intervention centers by the AYJNIHH, Mumbai especially pertinent to very young children.
and the Disability Helpline initiated during 2004- Keeping these issues in view, the project was
05 are worthy of mention. evolved. The project was conceptualized in two
phases:
Establishment of Early Intervention
Phase I: Training of manpower to enable
Centers and Training of Personnel
them to handle very young
A collaborative project by AYJNIHH, children.
Mumbai and Balavidyalaya, Chennai on ‘Early
Identification and Early Intervention towards Phase II: Running the early intervention
Inclusive Education of Children with Hearing programs.
Impairment (0 to 5 years)’ was initiated in 2002. Under the project, it was decided that a one-
An urgent need was felt to lower the age of month orientation program would be given to
identification of hearing impairment and already qualified professionals to work with
strengthen intervention service delivery. If a larger
children in the age range of 0 to 5 years. Seven
number of children with hearing impairment
centers were chosen to run the project, namely
acquire abilities ensuring their success in
AYJNIHH, Mumbai; its four regional centers at
mainstream education, they pave the way for more
Secunderabad, Delhi, Bhubaneshwar and Kolkata;
severely affected children to avail the services of
Balavidyalaya, Chennai and NISH, Trivandrum.
special schools. The gains shown by children who
A training package with curriculum specified, video
have gone through the process of early intervention
films and manual was evolved. The uniformity of
in India were convincing enough to start a greater
execution across centers was ensured through a
number of early intervention programs on a pilot
project basis. However, the diploma and degree program for Training of Trainers (TOT). Two
courses in special education do not focus enough representatives from each of the seven centers
on aspects of habilitation with very young children attended the TOT program. Each center was
with the exception of the Diploma in Training directed to periodically conduct one month
Young Hearing Impaired Children which is orientation programs with an aim to have at least 5
available only in three centers in India. This would per year with ten trainees per batch. Special schools
101already running programs for pre-school children Disability Helpline
and institutions conducting diploma and degree Frequently due to lack of awareness among
courses in special education were approached and the persons with disabilities and the community,
encouraged to depute professionals/suggest the early identification and rehabilitation processes
candidates from among past students of degree and are delayed. Also the benefits of services offered
diploma courses. Interested fresh and or by Government and Non-Government
unemployed special educators were also enrolled. organizations for the rehabilitation of persons may
The seven centers under the project were not be availed of by the target group on account
already providing diagnostic and or intervention of lack of information. The Disability Line
services for children in the 0 to 5 year age group. launched by AYJNIHH, Mumbai in 2005 was
Thus it was decided that for the second phase, it envisaged to bridge this gap to some extent by
would be ideal to run the intervention programs enabling the public to have easy access to
under close supervision of these centers. Each of information regarding disabilities, the services
the centers could appoint a teacher/speech- available in their neighborhood as well as the
language pathologist and audiologist who had schemes and concessions offered by the
undergone the one month orientation program. If Government.
a center had more than 25 children, two teachers Specifically, the Disability Line provides
could be employed. The center could also appoint information about:
two ayahs/helpers. Until now, the focus was on the
• Different types of disabilities.
0 to 2.5 year age group. This was reflected in the
orientation programs as well which focused only • Diagnosis and intervention strategies.
on this age group. The next stage of orientation
• Diagnostic and therapy centres.
programs to handle the 2.5 to 4.5 year age group
will be launched in the near future. The project is • Educational opportunities and Special
being monitored by an advisory group consisting schools.
of senior professionals.
• Vocational training and job
Since its commencement in the year 2002, opportunities.
nearly 100 rehabilitation professionals have been
• Special Employment Exchanges.
trained through orientation programs to equip
them to handle the 0 to 2.5 year age group. Nearly • Government Schemes and facilities.
150 children with hearing impairment under the • Organizations working for PWDs.
age of 2.5 years have received intervention at the
seven centers under the project. AYJNIHH plans • Prevention and management of
to increase the number of intervention centers by disabilities.
training more professionals and also by providing
technical as well as financial assistance to the extent
possible.
102• DRS/NHFDC forms by fax. Thus the Disability Helpline would help overcome
Disability Help Line has presently been the barrier of lack of information which has
implemented in Maharashtra, Goa and Delhi blighted many lives in the past.
Telecom Circles and can be accessed by dialing the The most promising development in recent
following telephone numbers:- years is the coming together of a diverse group of
Maharashtra/Goa : 022-26404019/24/43 professionals, parents/caregivers, policy makers, lay
or 155206 persons and the hearing-impaired themselves in
Delhi : 011-29825094/95 the prevention, diagnosis/identification and
management of hearing-impairment. Such a
The implementation of Disability Line for scenario portends well for persons with disabilities
UP, MP, Bihar, Tamil Nadu, Assam & West Bengal as well as for the professionals in the various
are in the pipeline. It would be possible to cover spheres of rehabilitation.
the whole country in a span of five years or so.
103Chapter 3
Manpower Development
Introduction Variations
M anpower in the field of Speech and Hearing
consists of professionally qualified persons
who are involved in a spectrum of activities related
Variation in the eligibility for admission at
the under-graduate level among universities exists;
Physics, Chemistry and Biology combination is
to persons with impairment–hearing and/or compulsory at the 12th standard level, but other
communication employed in diverse settings– combinations are also acceptable.
hospitals, rehabilitation centers, special schools,
Variations in post-graduate program earlier
regular schools, speech and hearing centers,
affiliated to the Mumbai University, shifted in 2006
training and research institutions.
to Maharashtra University of Health Sciences,
Nashik provides for specialization either in
Training Programmes
Audiology or Speech-language Pathology, in part
Training programs available at various levels II (Final year).
are discussed below:
Since 2003, M.Sc. (Speech and Hearing)
Under-graduate: B.Sc. (Speech and affiliated to Mysore University has been replaced
Hearing), AST, BASLP. by Master’s degree in Audiology or Speech-
Post-graduate: M.Sc.(Speech and Hearing), language Pathology, a pattern also followed both
MASLP, M.Sc. Speech-Language Pathology, M.Sc. at Mangalore and Bangalore Universities.
Audiology. Training institutions being required to follow
the norms of the affiliating universities, variations
Admission Requirements
among different programs are seen in depth of
Those who have successfully completed pre- information, method of teaching, differences in the
university (10+2) in the science stream are pattern of examination and in following the
admitted to the B.Sc. course. semester system as against the annual system.
To the two-year program, MASLP, candidates These are also true of the Master’s level programs.
with B.Sc. (Speech and Hearing) or equivalent The Bachelor’s program currently runs for
from a recognized institution are admitted. four years; during the first three years the focus is
Admission requirements have moved from on preparing theoretical knowledge base and
performance at the Bachelor’s level to the entrance providing insights into developing requisite clinical
test conducted by the respective universities. skills followed by the internship year.
104Despite the uniformity maintained due to The demand for professionals with
RCI regulations regarding minimal infrastructure doctorates is on the increase with the advent of
facilities, there still exists inter-program variability many new training programs and the recruitment
due to the differences in budgetary allocation and rules for teaching institutions. The next doctoral
availability of funds in the various institutions. The program in speech and hearing has commenced
national institutes have larger budgets thereby at AYJNIHH, Mumbai from the year 2007 with
enabling state-of-the-art facilities for their trainees. affiliation to Maharashtra University of Health
The programs that have to depend on their own Sciences, Nashik.
resources are not able to provide similar facilities.
Diploma in Hearing, Language and
Internship Speech (DHLS)
Introduction of internship as per the RCI Earlier known as Diploma in Management
guidelines, prior to the award of degree, is a of Communication Disorders (DMCD) and also
progressive step, which has the merits of creating Diploma in Communication Disorders (DCD), it
parity among the various degree courses and is a one-year course post higher secondary school
providing services in the rural areas. Institutional certificate qualifying them to assist the speech and
variations in the settings, in the placement duration, hearing professionals and to take up routine clinical
payment of stipend, are in need of further activities. This program is being conducted in about
regulations. 15 institutions in different parts of the country.
Recent years have witnessed a global shift in Contrary to the course objectives, most of
the perception and treatment of Persons with the products are found to be self-employed or
Disabilities towards a human rights perspective. working in private ENT setups as speech and
This has influenced the various training programs hearing professionals. This may possibly be because
bringing about modifications, time and again, in the government does not include the post of speech
the type and content of courses in Speech and and hearing assistant in their grant-in-aid schemes
Hearing, both at the B.Sc. and M.Sc. levels. for schools for the deaf or the mental relardation
or the spastics.
Doctoral Program
Wherever possible and feasible, the DHLS
The Ph.D. program in speech and hearing personnel may work as substitute teachers or
was available so far only at AIISH, Mysore affiliated teacher aides in schools. The syllabus and the
to the University of Mysore. Some candidates have examinations currently conform to RCI
also got their doctorates in allied streams such as regulations.
Linguistics and Psychology from other
Universities/institutions. In spite of interest in The AIISH, Mysore plans to launch the
pursuing doctoral degrees, the fact that full-time DHLS program through the distance mode,
candidates only were being accepted by University simultaneously in five different locations in the
of Mysore, and availability of guides were country.
limitations.
105Diploma in Hearing Aid and Ear Mould rather than duplicating without review the
Technology curricula followed in other countries. These
The RCI has standardized a training program issues need to be addressed by the professional
in ear mould making and hearing aid technology associations and the relevant policy making
for those successful at higher secondary level. A forums.
one-year course, started at AIISH, Mysore since A close evaluation of training programs must
2002-03, generates skilled personnel. AYJNIHH, be undertaken periodically in the light of current
Mumbai also conducts a similar, short duration potential employment opportunities.
program for educators and personnel working in
special schools. Resources for Training
Shortage of human resources to man the
Disparity Between Available and
training programs is a major challenge. Fresh
Requisite Manpower
graduates with little or no experience are recruited
About 25 institutions offer Bachelor’s degree to provide training to the new entrants.
and about 10 institutions offer Master’s degree in
Speech and Hearing across the country. Published resource material used for the
Approximately 750 candidates graduate at different training programs are mainly from the West, which
levels each year which is woefully short compared cost substantially. Availability of Indian editions and
to the needs of manning training programs, an increasing number of Indian journals coming
furthering the growth of the profession, providing up in the field of speech and hearing and allied
services. The skewed distribution, geographically, disciplines has reduced the budgetary burden.
of available professionals in the country and on Programs attached to medical institutions
account of emigration of the professionals overseas, such as TNMC, Mumbai; SRMC, Chennai; and
the shortage felt is more acute. There is economic MAHE, Manipal have access to extensive medical
factor also, the cost per trainee being approximately literature.
Rs. 3 lakh/student (Savithri, 2003).
Access to the main university libraries by the
The magnitude of brain drain among speech speech and hearing trainees being limited, the
and hearing post-graduates is reported to be 48% respective programs have to have their own
(Nambiar and Shah, 2006). The reasons cited being libraries. Many institutions have also provided
better financial gains (62%), better career prospects computer and internet facilities to the trainees
(62%), and better academics. Whereas 50% went thereby increasing the resource base.
abroad seeking employment, about 30% left for
higher education, and other 20% for personal Continuing Education
reasons. Continuing Education (CE) is the key for
An increasing number of training programs ensuring that professionals adapt to new
are coming up in smaller towns of the country, developments, which will lead to the growth of
sometimes in the same State where two or more the profession with consequential benefits to the
training programs already exist. The courses must individual and to the society.
also be designed to meet the needs in the country
106CE may be obtained through workshops, range of duties such as teaching, clinical supervision
seminars, symposiums and conferences conducted and/or clinical services do not get comparable
by institutions, by the professional associations at remuneration. Also employment settings dictate
the State and the National levels. These may be the salary structure and not the duties or the
RCI approved CE programs of three or five day- academic qualifications.
duration since it is mandatory for the professionals
Possessing higher than the requisite academic
to attend such programs for the renewal of their
qualifications does not guarantee better
RCI registration.
remuneration for the individual professional,
irrespective of how earned while on the job or on
Career Prospects
study leave. This leads to dissatisfaction/ frustration
Currently, a professional in the area of speech leaving little motivation among the professionals
and hearing is able to find employment in a variety who have aptitude and abilities to improve their
of settings, unlike in the past. However, there is a qualifications and skills.
distinct difference in the number of opportunities
and the type of work available to those with interest Our training programs are well received both
in Audiology and those affiliated to Speech- in the country and outside; programs in other
language pathology. The latter can practice at lower developing countries have looked for support from
investment since infrastructure requisite is less, but our programs. Many professionals, products of our
is more man-hour intensive, while the practice of programs, have been admitted into doctoral
Audiology requires considerably more financial programs in specialized streams earning accolades.
investment, but less manpower dependent. The American Speech-Language-Hearing
Association takes cognizance of the course work
In spite of the absorption of our graduates in completed in India for purposes of Clinical
jobs in diverse settings, the jobs are isolated and Certification, both in Speech-Language Pathology
the one or two persons employed there have to and Audiology.
attend to all aspects of the discipline. In some
instances, the rigorous training imparted to the Manpower in Special Education of the
trainees is not being fully utilized for want of the Hearing Impaired
requisite infrastructure including audiometric
Special education can be thought of as a
rooms and test instruments. A lack of awareness
means of secondary and tertiary prevention of
about the diverse role the speech and hearing
impairments that eluded primary prevention. The
professional plays in diagnosis and management,
aim of the special educators is to enable the children
may lead to their being treated as technicians, often
with hearing impairment to realize their full
in a subordinate position without
potential, so that they can achieve a respectable
acknowledgement of their role as competent
place in society and enjoy a better quality of life.
members of an interdisciplinary diagnostic
management team. Special educators have traditionally been
primarily placed in special schools for children with
Remuneration hearing impairment. In the prevailing conditions,
Professionals whose work includes a wide there are various types of educational programs
107available in India for children with hearing in Mumbai and regional centers in the north
impairment as given below: (NRC), south (SRC) and east (ERC), AYJNIHH
also has collaborative centers, involving the State
(1) Early Childhood Education or Early
Governments and the NGOs.
Intervention programs (Pre-school
Education) for infants and younger Recognition of the dearth of master trainers
children (0 to 5 years) with varying to be appointed as faculty at these centers and the
degrees of hearing impairment. poor quality of the model teaching schools,
(2) Special school programs for children prompted negotiations with the Universities of
with substantial degree of hearing Osmania (Hyderabad) and Calcutta, for
impairment. commencement of the B.Ed. (H.I.) training
(3) Integrated education programs for program at the SRC and the ERC of AYJNIHH,
children with milder degrees of in addition to the programs conducted at Mumbai
impairment in a regular school set up. since 1997. This enabled several schools to upgrade
their D.Ed. training levels. The M.Ed. (H.I.)
(4) Inclusive Education under the Sarva
program was started at AYJNIHH from 1995–96,
Shiksha Abhiyan Scheme where
and is affiliated to the University of Mumbai.
children with impairment of different
types and degrees are educated in regular The training programs in Special Education
schools with normal peers. for the Hearing Impaired are regulated by the RCI.
(5) Apart from this, persons with disability Presently there are two centers offering
within age group of 14-35 are given the M.Ed.(H.I.), 15 offering B.Ed. (H.I.) while 38 offer
opportunity for education through D.S.E. (H.I.) and three centers offer D.T.Y. (H.I.).
In spite of the many special educators trained at
National Open School (NOS).
various levels, a wide gap exists between supply
Thus, it can be seen that there is change in and demand.
the focus of education from segregation to
inclusion, and late intervention to early Keeping this in view, NCERT through its
intervention. A numerical increase is seen in the Regional Institutes started Multi-category Teacher
special educators working as early interventionists, Training Programs, which includes orienting the
resource persons in regular schools and itinerant regular school teachers to categories of
teachers in inclusive education. impairments and the modifications required for
teaching such children. Such teachers were then
Teacher Training Programs and other enrolled in Integrated Schools under I.E.D.C.
technical services for the deaf in the country (Integrated Education of Disabled Children
received a boost with the establishment of Ali Yavar Scheme) and P.I.E.D. (Project Integrated Education
Jung National Institute for the Hearing for the Disabled).
Handicapped (AYJNIHH) in Mumbai in 1983. At
that time, only eight centers were conducting Distance Education
teacher training programs as reported by Dr. Rita RCI has also recognized technical expertise
Mary (1993). Besides conducting D.Ed. [now of the Madhya Pradesh Bhoj (Open) University
D. S. E. (H.I.)] and B.Ed. (H.I.) at its headquarters (MPBOU) for conducting the B.Ed. Special
108Education program through the distance mode. conducting applied research in the field of
Other Universities have also begun to show education of the hearing impaired. However, many
interest in running similar programs. graduate level teacher training programs do not
include sufficient input to the teacher trainees
Resources for Training about research and documentations. Systematic
As most trainees in these courses, especially orientation towards research would bring about
the diploma courses, are from vernacular medium fruitful outcome.
with poor knowledge of English, their limited
experience in using reference material, utilization Conclusion
of the resource material from Western countries There is a need to gear the training programs
poses a major limitation. Short duration of the to meet the specific needs of the multi-lingual and
programs is an added constraint. multi-cultural population of the country. In spite
of the big strides in the past several decades, much
RCI has invited experts in the respective
needs to be done especially to retain the
subject to prepare requisite material in language
professionals to provide quality services in the cause
easy to understand. Some experts have also taken
of which there has been a heavy investment. If
an initiative in developing resource material in
emigration is a problem, so is professional mortality
regional languages such as Marathi, Tamil, Telugu,
and seeking other vocations within the country.
etc.
Research
Since the M.Ed. program has been
introduced, there has been an increased focus on
109Chapter 4
Incidence and Magnitude of
Hearing Impairment in India
T he National Sample Survey Organization
(NSSO) and Census of India, defined
hearing disability in a manner not requiring services
Hearing disability was defined as a person’s
inability to hear properly. As non-medical
investigators/non-professionals conducted the
of professionals, standard test procedures and a test survey, hearing disability was assessed based on the
environment meeting stringent criteria. quantum of impairment in the better ear. If a
person reported normal hearing in one ear and total
Hearing Disability (NSSO Perspective) loss of hearing in the opposite ear, normal hearing
In the International Year for the Disabled was the verdict for the purpose of the survey.
Persons, the NSSO undertook during the second
Usage of hearing aids was not taken into
half of 1981, the most comprehensive survey in its
account in assessing hearing disability. A person was
36th round for collecting information related to
stated to have profound hearing impairment if he/
persons with disability.
she could not hear at all or could only hear loud
In 1991, the NSSO with an extended sounds (such as thunder) or used only gestures to
definition of disability, conducted its 47th round communicate.
of survey in July-December 2002, on the specific
If a person could only hear when the speaker
request of the Ministry of Social Justice and
Empowerment, Government of India. Its 58th shouted or could hear only if the speaker was sitting
round of survey was conducted adopting a stratified in front, hearing loss was considered severe.
multi-stage sample design methodology. It Moderate hearing disability was the verdict,
included information on physical and mental if a person having hearing loss did not fit either in
disability, socio-economic characteristics of the profound or severe category. Such a person would
disabled persons, such as age, literacy, vocational ask for repetitions when spoken to or would like
training, and the cause, age of onset of disability, to see the face of the speaker. In other words, if the
marital status, educational level, living person reports difficulty in conducting
arrangements and activity status. conversation due to hearing problems, he was
As this was one of the more comprehensive considered to be in the moderate category of
surveys, defining disability was done in a very hearing disability.
careful and guarded way to minimize the bias on
the part of the investigators and the respondents. Hearing Disability (Census of India,
The definition of disability and each type of 2001 Perspective)
disability was carefully agreed upon by a group with Interest in enumerating the number of
experts in their respective areas. persons with hearing impairment began in 1876
110in India. In the past counting of such people did the Union Territory of Chandigarh, Delhi, and
not indicate adopting a clear definition. Daman and Diu.
The recent head count conducted by Census
NSS 58th Round of Survey estimated
of India, 2001 defined persons with hearing
persons with disability to be 18.49 million (1.8 per
disability as those who cannot hear at all (deaf) or
cent of the total population). Ten per cent of the
can hear only loud sounds which clearly excluded
persons with disability are likely to have hearing
people who had hearing impairment but who could
disability of moderate to profound degree. This
hear through use of amplification devices.
number is likely to go up if we add lower degree
However, the Census did include as disabled,
of hearing disability.
people who could not hear with one ear but his/
her other ear was functioning normally. Prevalence and Incidence of Disability
The Magnitude of the Problem A broad idea about the magnitude of
disability can be known if we compare the
As on 1st March 2001, India’s population
prevalence of disability as found in National
stood at 1,027,015,247 and projected population
Sample Surveys conducted at different points of
in 2016 would be 1,263,543,000 (Census of India,
time. Tables 1 and 2 show that there is a significant
2001). With the present set of concept of hearing
decline in the prevalence and incidence of disability
disability, the Census of India, 2001 counted
including hearing disability. This can be attributed
1,261,722 people in whom hearing disability existed
to the general growth in health, education and
(Males 53.4% and Females 46.59%).
infrastructure sector.
A majority of persons with hearing disability
were identified in rural India (81.06%) except in
Table 1: Prevalence Rate of Disabled Persons Per 100,000 Persons (Hearing Disability)
NSS 36th Round 1981 47th Round 1991 58th Round 2002
Rural 1844 (573) 1995 (467) 1846 (310)
Urban 1420 (390) 1579 (339) 1499 (236)
Table 2: Incidence Rate of Hearing Disabled Persons Per 100,000 Persons
NSS 36th Round 1981 47th Round 1991 58th Round 2002
Rural 19 15 8
Urban 15 12 7
111The incidence is almost the same in both the Conclusion
rural and urban India. The incidence is also Persons with hearing impairment constitute
observed to be higher among males than females a significant portion of our population who can be
as is the prevalence rate. contributing citizens. Efforts made to provide
The rates among males are 9 and 8, as against diagnostic and therapeutic services and the efforts
7 and 6 among females, respectively, in rural and put forth to mainstream them will create an
urban areas. inclusive, barrier-free and rights-based society for
persons with disabilities.
112Chapter 5
National Program of Prevention of
Hearing Impairment in Operation
A national program on prevention of hearing
impairment carried out will discharge our
responsibilities as well as comply with the
Methods to Prevent Disabilities
The most effective way to carry out
prevention is through pubic education. Educating
stipulations in the Persons with Disability Act, different target groups on the causes of hearing
1995. impairment creates greater awareness among them.
Measures stipulated in the Act to be taken The increased awareness should help in preventing
for prevention and early detection of hearing hearing impairment.
impairment include conducting surveys to As the manpower directly dealing with the
determine the underlying cause of disabilities; needs of the hearing impaired is comparatively less,
utilizing various methods to prevent disabilities; availing services of allied professionals becomes
screening of children at least once a year; providing necessary in creating the country-wide awareness.
training to staff at the primary health centres; taking Existing grass root level personnel working in the
steps for prenatal, perinatal and postnatal care of Departments of Health, Education, and Woman
children; educating the public and creating and Child, is being used effectively in educating
awareness through mass media. the general public on prevention of hearing
Some or all of the above activities are impairment.
being carried out in different centres across While the nomenclature varies depending on
the country. the State involved, the function or job description
of these personnel is by and large the same. This
Surveys to Determine the Cause of group of enthusiastic individuals could be
Disabilities empowered to function more effectively with the
Data has accrued on the hearing status of right kind of encouragement.
adults. But there is dearth of information on the
It is imperative that a prevention program
incidence and prevalence of hearing impairment,
should provide immunization for expectant mothers,
among infants and children. Through
infants and adolescent girls to such conditions as
questionnaires alone, valid and reliable information
maternal rubella, measles and meningitis.
on hearing loss cannot be garnered. Only surveys
where competent persons have evaluated the It is important to reduce the incidence of
infants or toddlers would provide the numbers hearing problems in children since its effects are
with hearing-impairment in this age group. more devastating especially on their
113communication abilities which in turn would affect grass root level workers, such as, Anganwadi
their school performance. Being the future citizens workers, Accredited Social Health Activists
of the country, they should be given the necessary (ASHAs), traditional birth dais and Auxiliary Nurse
help at the earliest. Midwives (ANMs) or Multipurpose Health
Workers (MPHWs). In the absence of these in the
While the above measures may reduce the
locality, the responsibility would be taken by
occurrence of hearing problems, this would not
Education Guarantee Scheme (EGS) teachers or
totally eliminate the problem. Hence, it is essential
Lower Primary School (LPS) teachers who would
to carry out tests to identify the presence of a
be supervised by a medical officer at the Primary
hearing problem. These tests should be carried out
Health Centre (PHC) (Figure 1).
at the earliest to enable early rehabilitation both in
terms of fitting appropriate amplification devices PHC Medical Officer
and providing speech and language therapy. Early
rehabilitation is required since there is a critical
age for speech and language development. The later
the hearing impairment is identified, the gap to be
bridged between normal and hearing impaired
individuals would be more. Further, the ANMs and EGS and LPS teachers
psychological stress in such individuals would be Anganwadi Workers
less since they would have better speech and
language skills, which in turn would enable them Figure 1: Allied personnel involved in the prevention of hearing
to succeed in inclusive set ups. Children with good impairment
speech and language would also find it easier to Training of the Professionals
find appropriate job placements later in life. Not
only it is important to identify hearing loss early in Figure 2 shows the personnel involved in the
individuals with a congenital hearing loss but also cascading of information to the grass root level
in those with an acquired hearing loss since hearing workers.
is required for monitoring of speech. Apex Institute
At the program on “National Consensus on Professionals
Prevention, Identification and Management of
Hearing Impairment” held at the All India Institute
of Speech and Hearing, Mysore, in 2005, various
experts involved with hearing conservation, Master Trainers (Taluk Health Officer,
representing government and the non-government Medical Officer, School Teachers)
sectors, gave their viewpoints.
Personnel Involved in Prevention
Anganwadi Workers/
The consensus among experts was that
ASHAs/ANMs/MPHWs
prevention of hearing impairment should be
carried out at the doorstep of each household by Figure 2: Personnel involved in cascading of information to the grass
root level workers
114Number of Professionals to be Trained (d) Determine whether in a given case is at
at a time risk for a hearing loss using the high risk
Figure 3 depicts the number of professionals register for medical professionals.
to be trained at a time. (e) Practice early medical remedy in cases
of external and middle ear infections.
Professional from Apex Institute
(1 professional) (f) Suggest appropriate referrals as and
when required.
ASHAs / ANMs / Anganwadi workers / EGS and LPS
Master Trainers (20 trainers) teachers must
(a) Get trained on early identification of
hearing impairment.
Grass root level workers (b) Orient the general public on how to
(2 batches of 30 workers each, prevent a hearing loss:
in a PHC covering a population (i) Inform them about possible causes
of appox. 30,000) of hearing loss.
Figure 3: Professionals and the number to be trained in a (ii) Educate them about immunization
session and also administer vaccinations on
infants, adolescent girls and
Duties of the Professionals
expectant mothers.
The qualified speech and hearing
(c) Determine whether a given case is at risk
professionals, from the apex centres, would orient
for hearing loss using the high risk
the master trainers on prevention of hearing
register for medical professionals.
problems as well as on basic evaluation to be carried
out by the grass root level workers. The evaluations (d) Screen for hearing loss through
would include: administration of the high risk behavioural observation audiometry.
questionnaires, carrying out behavioral (e) Suggest appropriate referrals as and
observations and orientation to audiological tests when required.
requiring instrumental usage. The duties of the
The “High Risk” babies should be identified
speech and hearing professionals and the others
at birth and screened immediately. They should
involved would be as follows:
be asked to follow-up regularly subsequently for 2
Duties of the Medical Officer to 3 years.
(a) Get himself trained on the hows of early It is essential that there is co-ordination
identification of hearing impairment. among all the professionals associated in the
(b) Train and orient the grass root level prevention and identification of hearing loss since
workers. best results are an outcome of team efforts. Figure
(c) Monitor the activities of the ANMs/ 4 provides an illustration of the linkage between
anganwadi workers. the professionals that are involved.
115Figure 4: Illustrating the linkages among the professionals
Protocol to be Used for Infant Screening Yathiraj, Vanaja and Manjula based on the
Due to cost factor, the protocol that is literature. All children who might have a hearing
currently suggested for prevention and loss should be identified by the age of 3 months
identification is restricted to using simple irrespective of whether or not they are at high
behavioural techniques. However, in due course, risk (Figure 5).
it is proposed to use the protocol developed by
116Figure 5: Flow chart of the test protocol suggested to be used for infant hearing screening
117Protocol Used for Screening School Frequency and Media to Train the
Children Professionals
It is also necessary to identify school-going Once in two years, refresher programs
children with hearing impairment. Hearing loss should be conducted in the local language using
in school-going children can be identified by the minimum technical terms for the master trainers
teacher by using a checklist regarding the signs and and their support staff using audio-visual aids and
symptoms of hearing loss. In addition, it is demonstration of the test procedures. Using the
recommended that Ling’s 6 sound test may be used. materials available at the national institutes, the
Teachers can carry out this test with minimal training sessions should follow a test module,
training. For children who can read, the test can which incorporates pre- and post-evaluation of the
be carried out in small groups. They could be asked trainees’ understanding of the disorder, its
to select the correct sound (phoneme) from a group assessment and management.
given in a print form. For younger children, the
Currently, the All India Institute of Speech
script could be associated with pictures such
and Hearing, Mysore, has put in place the infant
“aaaah” with sweets or “iiiiii” with brushing the
screening program at a few districts in the southern
teeth. Depending on the region where the test is
states. Team effort is a necessary ingredient for the
being administered, the choice of phonemes would
success of a program purporting to identify hearing
vary.
loss where every member and all concerned work
in co-ordination.
118Chapter 6
Early Identification and Intervention
Section I
Hearing Screening for Early Identification
T he issues in early identification to be
addressed are (i) population/location of
screening, (ii) technique/tools for screening, (iii)
given by Joint Committee on Infant Hearing
(2000) was used to develop and evaluate an infant
hearing screening module to identify bilateral
human resources for screening, (iv) cost, (v) severe to profound hearing loss. Behavioral,
challenges in screening, and (vi) intervention for TEOAE and ABR techniques were compared with
the identified. the involvement of the mother/caregiver for
behavioral screening and the nurse for both
Population/Location of Screening behavioral and TEOAE screening.
The larger projects/services have dealt with They reported that 25% of the babies were
both universal hearing screening as well as not available for screening due to various reasons.
screening only those at high risk. For screening no-risk babies, the parents as well as
Under the Project of Prevention of Deafness hospital staff were non-cooperative. Suitable
undertaken at All India Institute of Speech and location for screening (with ambient noise with
Hearing, Mysore, funded by the Ministry of Healthrisk infants was 10.75 per 1000 whereas that for Behavioral Observation Technique
no-risk infants was 4.70. Their results show that Behavioral Observation Technique continues
screening only the ‘at risk infants’ may result in to be used even though they do not provide ear
missing out 70% of the newborns with hearing specific results for screening as reported by
impairment. Anupriya (2001), Yathiraj et al. (2002)), Basavaraj
Mathur and Dhawan (2007) report about and Nandurkar (2007), Nagapoornima et al.
TEOAE screening of 1000 randomly selected (2007).
neonates in the first 48 hours of life in a tertiary
hospital. Those failing the first screening were re- Checklists
screened using TEOAE at three weeks, three Hearing screening checklists have been used
months and six months of age. Infants who did to obtain the report of the caregivers regarding the
not ‘pass’ at these stages were subjected to ABR auditory behavior of their children. One such
and oto-endoscopy. They recommend the TEOAE checklist is incorporated in the Interactive Voice
screening at three months of age as the pass rate of Reception System (IVRS) of the Disability
TEOAE at 48 hours was only 79%, which increased Helpline launched by Ali Yavar Jung National
to 97% at 3 months. Institute for the Hearing Handicapped, Mumbai.
Apart from these, neonatal infant hearing In the website www.checkhearing.nic.in,
screening programs are under way in several other Basavaraj et al. (2006) have incorporated four such
tertiary hospitals such as Sri Ramachandra Medical check lists for four different age groups. The
College, Chennai, Post-graduate Institute of checklists have been validated and they report the
Medical Education and Research, Chandigarh, All overall sensitivity and specificity of the checklists
India Institute of Medical Sciences, New Delhi, as 82% and 75%, respectively.
etc. and as part of training programs in some
training institutions. HRR
High Risk Register (HRR) continue to be
Technique/Tools for Screening used as a screening technique. Several versions of
The technique/tools used for hearing HRR specific to Indian population have been
screening have a lot to do with the population and reported in RCI Disability Status reports (2000 and
funds available for screening. The objective of the 2003). Several projects use the HRR of American
screening also determines the technique and tools Joint Committee on Infant Screening (2000) as a
used. From the abundant literature available on benchmark HRR.
hearing screening programs undertaken in USA,
UK, Australia and other developed countries, it is OAE
evident that the objective of screening is to identify A variety of makes and models of OAE such
all degrees and types of hearing loss in each ear. In as, fully automated, hand held screening
India, one may have to work out the requirement instruments, diagnostic instruments are available
bearing in mind the infrastructure facilities (see Table 5 for details). Thus, OAE screening has
available for follow up. been used widely in the developed countries
120reporting very high sensitivity and specificity for Hearing checklists are being used under the
both TEOAE and DPOAE measures. However, project ‘Prevention of Deafness’ at AIISH, Mysore
the same has not been documented in the Indian since 1995-96 to identify school children with
studies. hearing loss. Checklists are available on the website
www.checkhearing.nic.in which can be used by
ABR caregivers, pre-school/school teachers and also for
Automated ABR has been used for screening self-assessment by the older group.
in the last decade. Portable instruments with Behavioral screening is carried out by trained
automated ABR and OAE are available. The technicians or audiologists especially if the tool is
sensitivity and specificity of ABR has been a kit of noise makers. Training is also required to
documented to be very good. However, ABR has develop the skills to observe the auditory
been used more as a second step for the behavioural response.
confirmation of hearing loss in the screening
process. A checklist to screen school children under
the scheme of Sarva Shiksha Abhiyan of Ministry
Human resource for screening of Human Resource Development, Government
Human resource is directly related to the of India is also available.
tools used, but the validity of screening results in Attempts have been made to sensitize the
relation to different categories of human resources caregivers about the normal developmental stages
is lacking apart from sporadic published/ of auditory behaviour by means of handouts. The
unpublished reports. Disability Helpline of AYJNIHH, Mumbai
Basavaraj and Nandurkar (2007) studied the provides this information through its IVRS.
feasibility of utilizing mothers/care-givers and OAE screening is mainly done by
nurses in hearing screening and report no audiologists. Nurses have been trained to use the
significant differences between the mother/ automated OAE in projects (Basavaraj and
caregivers, nurses and audiologists in carrying out Nandurkar, 2007). The scenario is same as for ABR
behavioral screening in case of bilateral severe to screening.
profound hearing loss; also there was no significant
Besides the techniques/instruments
difference between the nurse and the audiologist
mentioned in Table 1, high risk registers and check
when automated TEOAE was the equipment in
lists to be used for various age groups have been
use.
developed and are in use.
HRRs especially those developed for medical
and non-medical persons (Anitha, 2001) can be
administered by a whole range of personnel
including trained volunteers.
121Table 1: Hearing Screening Tools/Methods
Sl. Source of Frequencies Type of Tester Approximate
No. stimuli (in Hz) covered Response cost (in Rs.)
1. A set of noise makers with a Behavioral (eye blink, Trained Personnel 1000-1500
combination of the items startle, facial grimace,
mentioned below: localization, etc.)
i) Drum i) 800-1700 Hz (peak at 800 Hz)
ii) Metal Khanjeera ii) 1140-7360 (peak at 2500 Hz)
iii) Jingles iii) 800-1700 (peak at 6080 HL)
iv) Squealer (high frequency) iv) Maximum between 4 and 8 kHL
v) Wooden rattle v) 900 to 1600 Hz
vi) Steel bell vi) >4000 Hz
2. Hand held audio screeners Behavioral (involuntary i) Professionals— i) 1250 to 2500
i) Pure tones (discrete and/or i) 500 Hz, 1 kHz, 2 kHz, 4 kHz response, viz., eye blink, audiologists for indigenous
sweep frequency) startle, facial grimace, ii) Trained one (available
ii) NBN (discrete and/or ii) Center frequency of 500 Hz, localization). Behavioral Personnel at AYJNIHH,
sweep noise) 1 kHz, 2 kHz, 4 kHz response as in play/ Mumbai)
iii) Environmental sounds iii) Variable frequency standard audiometry if ii) 20,000-40,000
122
the subject is old/ for the
intelligent enough and imported ones.
without associated
problems
3. Portable screening audiometers 500 Hz, 1 kHz, 2 kHz & 4 kHz Behavioral (conditioned -do- 25,000 onwards
responses)
4. Handheld Tympano-meters NA Physiological measure, i) Audiolgists and
viz., tympanogram Otolaryngologists
ii) Auomated ones 1.2 lakhs onwards
may be used by
technicians
5. Handheld Immittance meters NA Physiological response -do- 2.0 lakhs onwards
Tympanogram & presence/
absence of Acoustic reflex6. Immittance Audiometer NA Physiological response, Audiologists 2.3 lakhs onwards
Tympanogram Acoustic & Otolaryngologists
threshold
7. OAE screener
i) TEOAE Clicks to elicit OAE in frequency Physiological response i) Audiologists & 1.3 lakh onwards
bands of 1 kHz, 1.5 kHz, 2 kHz, 2.8 kHz TEOAE Otolaryngologists
& 4 kHz, (may vary from make/model ii) Nurses
to make/model)
ii) DPOAE 1 kHz, 2 kHz, 2.5 kHz, 3 kHz, 4 kHz DPOAE Automated -do- 3.0 lakh onwards
& 6 kHz equipment gives result as
pass /refer
8. Diagnostic OAE with TEOAE/ -do- Physiological response Audiologists & 4.5 lakhs onwards
DPOAE options TEOAE/DPOAE Otolaryngologists
9. Automated ABR • Clicks Result as pass/refer Audiologists & 2.0 lakhs onwards
• Tone bursts of 500 Hz, 1 kHz, Otolaryngologists
2 kHz & 4 kHz
10. Diagnostic ABR • Clicks Physiological response -do- 4.5 lakhs onwards
• Tone bursts of 500 Hz, indicating ABR wave
123
1, 2 & 4 kHz form to assess threshold
of hearing
11. ASSR AM/FM frequencies of 500 Hz, Physiological responses Audiologists 7.0 lakhs onwards
1, 2 & 4 kHz indication
Threshold of hearing at
the respective frequencies
Instruments with a combination of the above are also available.High Risk Register/Checklists for Screening fillip. Government of India Gazette notification
Developed in India between 2000 and 2007 of June 2001 with respect to disability screening
and certification has recommended including 500
(1) HRR for Medical persons (Anitha, T.,
Hz, 1, 2 and 4 k Hz for hearing screening at 25
2001)
dBHL. The Non-Government Organizations
(2) HRR for Non-medical persons (Anitha, (NGOs) such as Rotary, Lion, Jaycee Clubs
T., 2001) continue to participate in arranging school
(3) Hearing Screening Checklist (Basavaraj screening programs. However, documentation/
et al. 2006) publication of reports on school screening
(i) 0-2 years program continues to be minimal.
(ii) 2-6 years The introduction of Sarva Shiksha Abhiyan
(iii) 6-18 years (Education For All) of Ministry of Human
(iv) 18+ years Resource Development in the year 2001 has
sensitized the primary and secondary school
(4) The Screening Checklist for Auditory
authorities under the State Governments to arrange
Processing (SCAP) (Yathiraj &
hearing screening, the school teachers being trained
Mascarenhas, 2002)
to identify hearing impairment in children besides
(5) Self Assessment Hearing Handicap : other disabilities. Budgetary provision has been
Short-form scale (Vanaja, 2000) made for such activities as well as for the
(6) Checklist for identification of hearing intervention of the children identified with
impairment in school going children, disabilities.
Department of Audiology, AIISH,
Identification of Auditory Processing
Mysore
Disorders in school-going children needs urgent
Challenges in Screening attention. The screening checklist developed by
Yathiraj and Mascrenous, 2002 is not used as widely
Challenges in undertaking newborn/infant
as desirable due to lack of awareness of the
hearing screening are: the lack of awareness in both
condition by parents and teachers.
the public and the professionals regarding the
importance of early identification of hearing
Identification of Noise-induced and
impairment; high levels of ambient noise in the
Age-related Hearing Loss
test areas in hospitals; deliveries at homes especially
No significant progress has been made in
in rural areas with the assistance of dais/other
screening industrial workers and others for
attendants; poor follow-up bringing the initial
suspected noise induced hearing loss. The same is
efforts to nought; and scarcity of technical
the status with regard to age-related hearing loss.
manpower.
People seeking training or employment in the
Hearing Screening in Schools aviation sector are referred to institutes/hospitals
As part requirement of the clinical work of for audiometry. Self-assessment questionnaires
under-graduate programs (in Speech and (Vanaja, 2000) developed can be put to use to cover
Hearing), the school screening has received a larger population.
124National Programme for Prevention In the first phase, a pilot project is being
and Control of Deafness (NPPCD) conducted in 25 districts in 10 States and 1 union
The Ministry of Health and Family Welfare, territory for two years, from 2006 to 2008. It is
Government of India in 2006, launched the pilot proposed to expand this programme, in a phased
phase of the National Programme in Prevention manner, to include a total of 203 districts covering
and Control of Deafness. One of the objectives is all the States and Union Territories by 2012.
early identification, diagnosis and treatment of Table 2 shows distribution of the same.
hearing loss.
Table 2: States/Union Territories, Medical Colleges and Districts Covered under the Pilot Phase of NPPCD
Sl. No. State/UT Medical College Districts
1. Andhra Pradesh Osmania Medical College/ • Mehboob Nagar
Govt. ENT Hospital, Hyderabad • Nalgonda
• Hyderabad
2. Assam Guwahati Medical College, Guwahati • Kamrup
• Sonitpur
• Nalberi
3. Gujarat Govt. Medical College, Jamnagar • Jamnagar
• Rajkot
• Bhavnagar
4. Karnataka All India Institute of Speech and • Mandya
Hearing, Mysore • Hubli
• Hassan
5. Manipur RIMS, Imphal • Imphal
6. Sikkim Sikkim Manipal Institute of Medical • Gangtok
Sciences, Gangtok
7. Tamil Nadu Christian Medical College, Vellore • Vellupuram
• Vellore
• Thanjavur
8. Uttarkhand Himalayan Institute of Medical • Haridwar
Sciences, Dehradun • Dehradun
• Narendernagar
9. Uttar Pradesh King George Medical University, • Barabanki
Lucknow • Gorakhpur
10. Delhi Lady Harding Medical College, Delhi • North west
• West
11. Chandigarh Govt. Medical College, Chandigarh • Chandigarh
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