2014 Chung Et Al HearingReportChina AudiologyToday2014

AUDIOLOGY TODAY May/Jun 201442

A Hearing Report from ChinaThe living standard and accessibility to hearing servic-es for people living in cities have improved greatly. Yet time is frozen for people living in poor areas, and it is almost impossible for them to access hearing services.

BY KING CHUNG, BECKY YING MA, MICHAEL WEN-PENG CUI, SHU-FENG WANG, AND FANG XU

May/Jun 2014 AUDIOLOGY TODAY 43

is the largest country in the world by population. It is one of the four ancient countries of the world and has treaded through many social and economic challenges. Today, China has the second largest economy in the world and is well-known for its cultural heri-tage, delicious food, beautiful scenery, technology advancement, and rapid economic growth.

Audiological Education and Practices Audiology is a relatively new and rapidly developing field in China with most infrastructures for hear-ing care developed in the past 30 years. The first audiological service center was established in 1983 by the Department of Otolaryngology-Head and Neck Surgery of Beijing Tongren Hospital, which is affiliated with Capital University of Medical Sciences in Beijing. Two years later, two more hearing and rehabilitation centers were established in two hos-pitals at Tianjin City and Xuzhou.

The first formal audiology was initiated in 1996 through the Joint Sino-Australia Audiology Program, which was jointly developed by Australia Hearing, Capital University in Medical Sciences in China, and Macquarie University in Australia. Most of the initial 14 participants are ear, nose, and throat (ENT) physicians. Eight of them were sent to Australia for clinical practicum training and received a joint masters degree from the two universities (Liu

et al, 2009). The program continues to train hearing care professionals, and it has produced approximately 1,000 graduates to date (Liang and Mason, 2013).

Currently, there are three uni-versities offering bachelors degrees in audiology in China. The Capital University of Medical Sciences in Beijing established a biomedical engineering degree with audiol-ogy emphasis in 1999. It produces approximately six to eight gradu-ates each year (Feng and Su, 2009). Zhejiang Chinese Medical University in Hangzhou established the first audiology bachelors degree pro-gram in 2002. The program enrolls approximately 30 new students each year (Feng and Su, 2009). East China Normal University in Shanghai estab-lished the second bachelors degree program in audiology in 2004. It is currently the only higher education institution that also offers masters and doctor of philosophy degrees in audiology (Feng and Su, 2009). Although several other medical uni-versities also offer masters degrees, those mainly train ENT doctors with an audiology emphasis.

Several higher education insti-tutes also offer diploma programs with an audiology emphasis. For example, Beijing Union University offers a three-year diploma program, and Nanjing Technical College of Speech Education offers several audi-ology courses in the Department of Rehabilitation Sciences.

China, a country with more than 5,000 years of civilization,


Limb1.8% (24.7 million)

Hearing1.5% (20.5 million)

Multiple1.0% (13.8 million)

Vision0.9% (12.6 million)

Mental0.5% (6.3 million)

Intellectual0.4% (5.7 million)

Speech and Language0.1% (1.3 million)

A Hearing Report from China

China is experiencing a great shortage of professionals who can provide quality hearing care. There are only 10,000 hearing care professionals with various levels of training serving a population of 1.37 billion in China (i.e., one per 137,000 people). The professional-to-population ratio is extremely low compared to that in the United States (i.e., one personnel per 9,000 people), approximately 13,000 full-time audiologists, 9,000 hearing aid dispensers, and 10,000 ENTs for a population of 314,000,000 (Freeman, 2009; ASHA, 2012; Neuwahl et al, 2012).

Despite the shortage, there is a general lack of finan-cial support from the central government because the Department of Education does not recognize audiology or hearing sciences as majors in universities (Feng and Su, 2009). Thus, no designated student quota or govern-ment funding is allocated to audiology programs. The universities would need to squeeze the quota from other programs in order to establish an audiology program. Many audiology programs, therefore, rely on foreign donations, advocacy groups, and/or foundations for dis-abled persons for financial support. Some programs have closed because of lack of fundingthe most well-known one was a joint masters program for ENT doctors by Sichuan University West China Hospital and Dalhousie University in Canada.

Another factor contributing to the shortage is that many graduates from audiology programs are ENTs, for whom audiology is only a small part of their medical practices. The attrition rate from the profession is also high as some people with university degrees or diplomas do not remain in the field after graduation. This short-age is often partially met by short-term training courses provided by universities (e.g., Sichuan University West China Hospital), professional organizations (e.g., Beijing Hearing Society), nonprofit organizations (e.g., Ying Wah Fishermen Association), or hearing aid/cochlear implant manufacturers through short-term courses, which ranged from two to five days to a few months.

Audiology Education in ChinaThere is no defined scope of practice because audiology is not recognized as a medical profession in China. The range of services that a hearing professional provides greatly depends on the training of the individual. ENTs work-ing in the hospitals often provide electrophysiologic and vestibular function tests. Hearing aid dispensers working in private practices may only perform air and bone conduc-tion pure tone tests, comfort and discomfort level testing. Cerumen management is a task for ENT physicians.

FIGURE 1. Number of people with and without disabilities in China.

Wit

hout

Disa

bilities

93.8% (1.28 billion)



In 2010, China established a three-tier certification system for hearing aid dispensers. Their rankings are clas-sified as the fourth, third, and second grade in the five-tier Chinese National Vocational Qualifications system, which defines the knowledge, skills, and competency of different professions. Applicants seeking the hearing aid dispenser certifications need to take written and practicum exams as well as satisfy a set of requirements (APPENDIX A).

As this qualification system is relatively new, the participation is voluntary. In Beijing, for example, only 4 billion from 2025 to 2040.

Data reported in professional journals indicate the hearing aid adoption rate is between 1.1 and 8.0 percent (Jiang and Zou, 2006; Miao, 2012). Many people do not wear hearing aids because of

1. The lack of awareness for hearing loss and its negative consequences,

2. Financial concerns,

3. The belief that remediation is not needed, as hearing loss is a natural process of aging,

4. Cosmetic concerns, and

5. The lack of accessibility to hearing health care (Wong and McPherson, 2008).

Hearing aids are generally more accessible in large cit-ies. The range and quality of services, however, can vary greatly. Large national-level government hospitals are gen-erally better equipped and have better qualified hearing

TABLE 1. Classification for the Degree of Hearing Disability

(Better Ear) Speech Discrimination Score in Quiet (%)

Permanent Hearing Loss at 500, 1000, 2000, and 4000 Hz (dB HL)

Level 1



care professionals. Small hearing aid dispensing offices can often be found in the shopping strips along the streets of large cities. Sound rooms and equipment beyond audi-ometers are rare finds. It is, however, common for larger offices or some chain stores to have their own earmold labs because there is no earmold company in China.

The Disabled Persons Federation directly manages the welfare of adults with hearing loss. If local chapters receive allocations from the central federation or dona-tions from nonprofit organizations, they would provide adults with low income (i.e., 800,000 children with hearing loss who are under seven years, and approxi-mately 40,000 are born with hearing loss every year.

Chinas first Universal Newborn Hearing Screening program was implemented in 1999. Since then, the program has been expanded to 30 of the 32 provinces, autonomous regions, and direct municipalities. In large cities, approximately 95 percent of the babies are screened between 48 and 72 hours after birth using otoacoustic emissions. If they fail, re-screening is car-ried out using otoacoustic emissions at approximately 42 days. Those who fail the re-screening are usually tested using automatic auditory brainstem responses (ABR) at three months old. Some hospitals also conduct genetic

NIU team members (Left: Dr. King Chung, Felix Zheng, Thomas Bishop, Emily Hehn, Maggie Clements, Danielle Morrow, and Alexandria Rosenbalm). A student at the school for special education got his ears checked. Emily, Ms. Ma, and Sandy are testing the principal of the school for special education.



screening at the same time to examine the genes that are known to cause hearing loss or deafness.

In rural and remote areas, however, high-risk children are referred to screening centers within one month of birth, and the parents of others are only distributed pam-phlets to inform them of the risk and consequences of hearing loss (Liang and Mason, 2013). High-risk children who failed the initial screening are recommended for rescreening and follow-up services. Due to the lack of awareness of the negative effects of hearing loss on childrens speech, language, hearing, and cognitive development, the attrition rate for follow-up services is generally high in both cities and rural areas.

The China Rehabilitation and Research Center for Deaf Children is responsible for providing comprehensive ser-vices and managing the welfare of children with hearing loss, although they also started to distribute hearing aids for adults in recent years. Its mission is to provide com-prehensive clinical services, to conduct basic and applied research, to advocate for social and educational integra-tion, and to serve as an education and technical training center for children with hearing loss and deafness. It also collaborates with universities to establish speech and hearing sciences programs, and publish text books and professional reference books to increase the standards of audiological services and to disseminate audiology and rehabilitation information.

Rehabilitation centers are established throughout China. Large centers are well equipped, and they adopt a multidisciplinary approach and provide otolaryngology and audiology services, dental care, radiology, psycho-logical evaluations, genetics testing and counseling, aural rehabilitation, and speech language therapy services. Smaller local centers are responsible for rendering habilitation and rehabilitation services to children with hearing aids and cochlear implants. Children are fitted with binaural hearing aids, and the level of technol-ogy depends on the financial resources of the family. Children from low- income families receive binaural digital hearing aids with midlevel technologies for free every five to eight years. The recommended aural reha-bilitation options are either full-time school with 0.5 hour of individual instruction or three times per week for one hour each time. Parent instructions are also required for children enrolled in the latter option.

Cochlear Implant ServicesAccessibility to cochlear implants has been a challenge. The costs of cochlear implants and associated surgery are almost prohibitively high for the majority of people in China. The combined cost can range from 100,000

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RMB (~16,400 USD) for a low-cost cochlear implant made in China (Nurotron) and 300,000 RMB (~46,000 USD) for the newest model made from the big three international cochlear implant companies.

There are only approximately 60 well-trained cochlear implant surgeons in mainland China (Liang and Mason, 2013). The support from the government for cochlear implants to adults is limited because most resources are allocated to servicing children. Adults represent only 14 percent of the total units implanted in China in 2011 (Liang and Mason, 2013). Those with severe sensory hear-ing loss can seek cochlear implantation in their hospitals of choice using private funds. Individuals with financial resources often go to Hong Kong, Taiwan, or foreign coun-tries for the cochlear implant surgery believing that better and more reliable services are offered outside of China.

Most governmental resources are invested on implanting children one to six years old (63 percent of units implanted). Cochlear implant systems are usu-ally paid for by charity organizations or government agencies (Jiang, 2013). The newest government program is Project Rainbow Dream, which is supported by a government tender system and from a Taiwanese com-pany. Approximately 33,500 cochlear implantations are

budgeted between 2011 and 2015. The program provides one cochlear implant unit per child, and subsidizes the majority of fees associated with the surgery and one year of aural rehabilitation after the implantation at the 199 selected rehabilitation centers (criteria in APPENDIX B).

Children between 7 and 17 years of age can also apply, but they need to be postlingually deafened or have received rehabilitative services and enrolled in main-stream school. The number of cochlear implants granted to the older age group would not exceed 15 percent of the total cochlear implants available for the fiscal year.

Prior to being granted free cochlear implants, children need to go through a comprehensive test protocol that includes pure tone audiometry, aided sound field thresh-olds, speech recognition tests, otoacoustic emissions, ABR, learning ability evaluations, psychological and behav-ioral assessments, auditory steady-state response tests, tympanometry, CTs and MRIs, and genetic tests. Children waiting for cochlear implantation can also apply for free loaner hearing aids to reduce the cost associated with amplification.

Due to Chinas massive population, much work is still needed to increase the quality of hearing health care and

FIGURE 2. Hearing status of students in mainstream primary schools and adults in nursing homes in Shandong, China.

100

90

80

70

60

50

40

30

20

10

0

Pe

rce

nt

(%)

Pass

Students in Mainstream Primary School

N = 184

Adults in Nursing Homes

N = 106

PassRefer ReferCNT CNT/DNTMonitor MonitorHL

Wax plus Wax only Clear canal Clear canal



to make hearing health services accessible. Immediate actions are needed to

1. Recognize audiology as a medical profession;

2. Create more quality audiology programs to train future audiologists;

3. Educate the public about the importance of hearing and the negative consequence of hearing loss;

4. Establish hearing centers, especially in rural areas for adult and geriatric populations;

5. Encourage research and dissemination of information to both professional communities and the general public;

6. Institute systems to allow the sharing of informa-tion among the local hospitals that provide newborn hearing screening, the rehabilitation centers, and the Disabled Persons Federation so that followed-up services can be coordinated among different agencies throughout the life span; and

7. Increase funding to subsidize hearing aids and cochlear implants and to provide follow-up re/habilita-tion services throughout the life span.

With approximately one-fifth of the worlds popula-tion, China should be the largest hearing aid market in the world. Yet consumer data showed that only approxi-mately three percent of the worlds hearing aids were bought by China in 2004. As the population ages and the size of middle class grows, the number of hearing aids sold has been increasing steadily. China and India are expected to be the most rapidly growing hearing aid markets in the world.

Results of Hearing Tests in Shandong, ChinaA faculty member (first author) from Northern Illinois University took a group of students and an alumnus to China. They provided hearing tests for elderly in four nursing homes, students in four primary schools, and a special education school in the Yimeng Shan region a mountainous area marked by natural beauty but poor living conditions. Some schools and nursing homes could only be accessed via winding unpaved country roads.

The screening protocol included otoscopy, distortion product otoacoustic emissions at 1.5, 2, 3, 4, 5, and 6 kHz,

and tympanometry (EroScan Pro). Those who failed the screening were followed up by pure-tone audiometry.

Students in the mainstream primary schools had an 87.0 percent passing rate (FIGURE 2), which is among the highest passing rates in the underserved populations the NIU team tested in the past several years. Only 9.8 percent failed, and most of these students (7.6 percent) needed wax removal. One student was newly identi-fied with mild hearing loss and his teacher and parents were informed. The generally high passing rate is likely a reflection of the Chinese culture to take care of and invest in their children even though parents have limited financial resources.

We met one female student in a primary school who had a known severe to profound hearing loss. She was wearing two different brands of hearing aids with insuf-ficient power that she received from two separate charity events. Her teacher told us that she was from a farmers family with several children (the younger children were born illegally because of Chinas One Child policy). Her parents had very limited resources, and they were basi-cally waiting for her to grow up and get married. We were touched by her story, and we found a local hearing

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aid dispenser who was willing to provide free hearing aid fitting and follow up services for her. We then contacted a hearing aid company in Singapore and China that donated and fitted a pair of high-power high-performance digital hearing aids and secured unlimited free follow-up services for her.

Data from the special education school are not plot-ted because of the small number of students (N = 8). Five passed, one could not be tested, and two had wax accumulation and unknown hearing status in at least one ear. Their teachers and parents were informed of the conditions.

Adults in the nursing homes had an alarmingly high referral rate even though the 40 dB HL fence level was used (91.5 percent, FIGURE 2). Many residents had dis-abilities, such as blindness, hearing loss, or intellectual disabilities. Close to 60 percent had sensorineural hear-ing loss (i.e., failed with clear ear canal). Another 29.6 percent had significant wax accumulation with hearing thresholds exceeding 40 dB HL (i.e., Wax Plus). Most of them likely had sensorineural hearing loss because they had Type A tympanograms. Requests have been made to their local chapter of the Disabled Persons Federation to provide follow-up hearing services.

China is an awakening giant that enjoys 8.9 percent of economic growth in the past 30 years. The living standard and accessibility to hearing services for people living in cities have improved greatly. Yet time is frozen for people living in poor areas, and it is almost impossible for them to access hearing services. A great deal of work and pro-fessional development are still needed so that individuals with hearing loss and deafness can reach their full poten-tial and be fully integrated into the society.

More information about the Heart of Hearing Humanitarian Research and Service Program to China can be found on www.blurb.com/my/book/detail/4579999.

King Chung, PhD, is an associate professor of audiology at Northern Illinois University. Becky Ying Ma, BA, is the director of education at the Beijing Society of Audiology. Michael Wen-Peng Cui, BS, is the general secretary of Linqu in Shandong Province. Shu-Feng Wang, MS, MD, is the vice president of the Beijing Society of Audiology and the director of technology and education of the Audiology Development Foundation of China. Fang Xu, BS, is a businesswoman in China.

Acknowledgment: Sincere thanks to students at Northern Illinois University who worked very diligently during the program and to the government officials, school principals, and

nursing home personnel in Linqu, Shandong, for making all the testing and lunch arrangements. Many thanks to Etymotic Research for lending two EroScan Pro units, to Oticon, USA, for their generous monetary support, and to Siemens China and Siemens Singapore for donating a pair of high-power digital hearing aids.

References

All cited Web sites were accessed in February 2014.

American SpeechLanguageHearing Association (ASHA) (2012). www.asha.org/uploadedfiles/personnel-to-population-ratios-state-2012.pdf.

Feng DX, Su, J. (2009) www.doc88.com/p-499549860080.html.

Freeman B. (2009). www.acaeaccred.org/ComingCrisis21.6.pdf.

Liang Q, Mason B. (2013) Enter the dragonChinas journey to the hearing world. Cochlear Implant Intl 14 (S1):S27-S31.

Liu B, Liu ZC, Xu SG, Newall P, Han DM. (2009). http://www.entnews.net.cn/uploads/soft/magz3/2009/200901/ztlt/005.pdf.

Newhal S, Fraher E, Pillsbury H, Weissler MC, Ricketts T, Gaul K. (2012) www.facs.org/fellows_info/bulletin/2012/hpri0312.pdf

Miao Y. (2012) Progress in the research of presbycusis. Chinese Journal of Rehabilitation Theory and Practice 18(6):554-557.

Wong LLN, McPherson B. (2008) www.asha.org/publications/leader/2008/081216/f081216c.htm.



Appendix A

Hearing Aid Dispenser Requirements for Chinese National Vocational Qualification

Grade 4 (Entry Level) Hearing Aid Dispensers:

(Satisfy one of these requirements)A. Worked continuously in the field for >1 yearB. Holds an intermediate-level vocational school or equivalent diplomaC. Obtained proper training for at least 480 hours and received completion certificate

(Satisfy all of the following requirements)

Work Function Competency

Case history a. Taking case historyb. File management

Pure-tone audiometry a. Otoscopyb. Pure tone audiometry including air and bone conduction testing,

masking if needed, most comfortable level, and discomfort testingc. Play audiometry

Hearing aid selection a. Audiogram interpretation, refer if neededb. Hearing aid selectionc. Hearing aid feature selection

Earmold making a. Proper insertion and removal of earmold materials

Hearing aid fitting a. Maximum power output adjustmentb. Gain adjustment

Verification a. Aided threshold testingb. Administer and interpret questionnaires

Rehabilitation counseling a. Hearing aid orientationb. Follow-up services

Grade 3 (Medium Level) Hearing Aid Dispensers:

(Satisfy one of these requirements)A. Worked continuously in the field for >6 yearsB. Holds a high-level vocational or technical school or equivalent diplomaC. Worked continuously in the field for >4 years after obtaining Grade 4 Hearing Aid Dispenser competency certificateD. Worked continuously in the field for >3 years after obtaining Grade 4 Hearing Aid Dispenser competency certificate

AND obtained proper training for at least 240 hours and received completion certificateE. Graduated from an audiology bachelors program or related-professional program or aboveF. Graduated from other professional programs in a university and worked continuously in the field >1 yearG. Graduated from other professional programs in a university AND obtained proper training for at least 240 hours and

received completion certificate





Hearing evaluation a. Speech audiometryb. Tympanometryc. Visual reinforcement audiometry

Earmold making a. Making impressions of ears with pinna deformity b. Making impressions of ears with ear canal deformity

Hearing aid fitting a. Directional microphone adjustmentb. Hearing aid programmingc. Hearing aid feedback management

Verification a. Real ear measurementb. Speech evaluation

Habilitation/rehabilitation counseling a. Hearing aid use counselingb. Aural rehabilitation training

Grade 2 (Senior Level) Hearing Aid Dispensers:

(Satisfy one of these requirements)A. Worked in the field continuously for >13 yearsB. Worked continuously in the field for >5 years after obtaining Grade 3 Hearing Aid Dispenser competency certificateC. Worked continuously in the field for >4 years after obtaining Grade 4 Hearing Aid Dispenser competency certificate

AND obtained proper training for at least 120 hours and received completion certificateD. Graduated from an audiology bachelors program or related professional program or above AND worked continuously

for >5 yearsE. Graduated with a bachelor of science degree from a related field AND worked continuously in the field >4 years after

obtaining Grade 3 Hearing Aid Dispenser competency certificateF. Graduated with a bachelor of science degree from an audiology program or a related-professional program, worked

in the field continuously for >3 years after obtaining Grade 3 Hearing Aid Dispenser competency certificate, AND obtained proper training for at least 120 hours and received completion certificate

G. Graduated from a masters degree program or above AND worked in the field continuously for >2 years



Hearing evaluation a. Acoustic reflexesb. Otoacoustic emissions

Hearing aid fine-tuning a. Electroacoustic analysis b. Noise reduction adjustment

Verification a. Listening in background noise testb. Speech discrimination testing

Training a. Training Grade 3 Hearing Aid Dispenserb. Training Grade 4 Hearing Aid Dispenser



Appendix B

Priority Selection Criteria for Cochlear Implantation

Children who have: 1. Severe to profound sensory hearing loss in both ears2. No severe cochlea deformity3. Worn hearing aids for >3 months and receive minimal benefit4. No seizure or other conditions that are contraindications for surgery 5. Normal mental, intellectual, and behavioral development 6. A family with appropriate expectations7. A family with limited resources (does not need to meet the low-income requirement)8. A family that is supportive of long-term rehabilitation training, willing to carry out daily maintenance for the

cochlear implant, can afford cochlear implant accessories, and can provide an environment for aural communication

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