Brazil, officially known as the Federative Republic of Brazil, is the largest country in Latin America. At 8.5 million square kilometers (3.2 million square miles) and with over 211 million people, Brazil is the world’s fifth-largest country by area and population. The Brazilian government has grouped the country’s states into five large geographic and statistical units called the Major Regions which include: North, Northeast, Central-West, Southeast, and South. The federation is composed of 26 states, the Federal District, and over 5,500 municipalities. The nation’s burgeoning cities, huge hydroelectric and industrial complexes, mines, and fertile farmlands make it one of the world’s major economies.
Table 1: Country information [Source: Wikipedia, date: October 1st, 2020; https://www.statista.com/statistics/263763/total-population-of-brazil/]
|Country Name||Federative Republic of Brazil|
|Area||8,515,767 km2(3,287,956 sq mi)|
|GDP (PPP)||$3.524 trillion|
Brazil is considered an upper-middle-income economy by the World Bank. It is the largest country with Portuguese as the official language and the only one in the Americas; it is also one of the most multicultural and ethnically diverse nations, due to over a century of mass immigration from around the world. The Brazilian culture is one of the world’s most varied and diverse with influences from various nationalities which resulted in a modern-day Brazilian culture that is unique and very complex. Brazil is a presidential federal republic, whereby the president is both head of state and head of government, and a multi-party system.
Sanctioned on December 9, 1981, by President João Figueiredo, Law number 6965, regulated the profession of speech pathology and audiology (in Portuguese Fonoaudiólogo). In addition to identifying the competencies of this profession, Federal and Regional Councils were created with the purpose of supervising the professional practice. Since 1981, the 4-year bachelor’s degree became the entry-level degree for clinical practice.
The first minimum coursework load (3,700 hours), which identified required disciplines, was regulated by Resolution No. 54/76 of the Federal Council of Education. Coursework includes disciplines related to the biological sciences and the health area, such as anatomy, physiology, genetics, and pathologies. As it pertains to social and human sciences, the student takes classes in psychology, pedagogic methods, and ethics. However, most of the training is devoted to specific content of the profession, such as the auditory system, oral and written language, or speech. Supervised clinical experience and the completion of a monograph are required.
The activities of the Federal Speech and Hearing Therapy Council (CFFa) began in 1983 (https://www.fonoaudiologia.org.br/cffa/). On September 15, 1984, by Resolution CFFA No. 010/84, the first Code of Ethics of the profession was approved which included the rights, duties, and responsibilities inherent to the various relationships established for professional activity. The CFFA exercises a normative function by publishing resolutions that aim to establish interpretations that facilitate the execution of the provisions of the law, according to the professional reality and the technical-scientific advancements. All resolutions come into force after publication in the Official Gazette of the Union. The Regional Councils have the priority role of enforcing the provisions of the Law, the Professional Code of Ethics, and norms of the Federal Council directing and supervising the professional practice in the area jurisdiction. For this purpose, the Regional Council is responsible for the issuance of professional records, the establishment of ethical-disciplinary and/or administrative processes, the adjudication of infractions, and applying the penalties provided for in the law.
According to the last census (Demographic Census, 2010) there are 9.8 million individuals with hearing impairment in the country; however, the accuracy of this information must be considered in terms of time and the methodology used which is a self-report i questionnaire.
Although there is a shortage of specific statistical data on hearing impairment in Brazil, according to the World Health Organization (WHO), 1.5% of the Brazilian population would have some degree of hearing impairment (WHO, 1999). An analysis of different epidemiological studies in audiology in Brazil, published in 2011, concluded that there is greater concern regarding hearing disorders related to their occupation (Arakawa et al., 2011). Considering that Brazil is a country the size of a continent, there are regional particularities which may influence the population’s general health profile including hearing health, prevalence of tropical diseases in Northern areas, cultural characteristics which determine different habits of overall health care, and the logistical difficulties imposed by the geographic and economic characteristics of each region. This reality is reflected in the only two population-based studies using the World Health Organization Ear and Hearing Disorders Survey Protocol in opposite regions of the country. In 2003, the urban area of Canoas, Southern Brazil had the prevalence of disabling hearing impairment of 6.8%, prevalence of moderate hearing impairment of 5.4%, severe hearing impairment of 1.2%, profound hearing impairment of 0.2%, and slight hearing impairment of 19.3% (Béria et al., 2007). On the other hand, in the urban area of Montenegro city, RO, of 2005 to 2007, the results showed that 3.8% of population were classified in the disabling hearing impairment category. The prevalence of moderate hearing impairment was 3.4%, severe hearing impairment was 0.4%, and profound hearing impairment was not found (Bevilacqua et al., 2013). Different prevalence of congenital sensorineural hearing loss ranging from 2.3:1000 live births (Chapchap & Segre, 2001) to 0.96:1000 have also been reported (Bevilacqua et al., 2010).
The Comitê Multiprofissional em Saude Auditiva (COMUSA) advocates that the diagnosis of hearing impairment should be made up to three months of age and intervention initiated up to six months, an internationally similar recommendation (Lewis et al., 2010). Therefore, it is important for early detection of this condition through newborn hearing screening, a procedure capable of detecting and intervening early in hearing deficits that may interfere with the individual’s life. Such programs have been developed since the 80’s with populations of high and low risk factors, using behavioral and electrophysiological procedures. Nowadays, all newborns are expected to go through neonatal hearing screening instead of only those with a risk indicator for hearing loss.
The Ordinance GM / MS no. 1,328 of December 3, 2012 pertaining to the care network for people with disabilities addresses the Guidelines for Attention to Newborn Hearing Screening under the Brazilian Unified Health System (SUS – Sistema Único de Saúde). Universal Neonatal Hearing Screening is considered the main strategy to identify neonates and infants, in order to achieve early diagnosis and intervention which are crucial for the acquisition of oral language in these children. There is no official data on the total number of maternity hospitals that have the neonatal hearing screening program in Brazil. The Ministry of Health Management Report (2018), establish the goal to equip 308 non-profit maternity hospitals and 259 public administration maternity hospitals by 2019. However, despite government efforts, the goal of universal neonatal hearing screening has not yet been achieved. In 2015 only 37.2% of newborns were tested, with no significant increase from previous years (Paschoal et al., 2017).
Ineffective referral and counter-referral systems, along with a limited adherence of families to the different stages of the child hearing health program, hinder the prevention, identification, and treatment of hearing loss at the ideal age (Turati et al., 2016). The early identification of hearing loss should not be exclusively linked to neonatal hearing screening programs. Thus, the World Health Organization and the Ministry of Health (2012) have recommended the collaboration with primary health care, which will enable the identification of acquired or progressive hearing losses, as early as possible, minimizing their impact on child development. In this proposal, the Community Health Agent has an extremely important role due to the scope of the Family Health Strategy and the close relationship between the professional and the families (Oliveira, 2020).
According to the primary health care indicator panels, using April 2020 as a reference, Brazil had 44,716 Family Health Strategy teams which reflects an estimate of 65.4% coverage or 137,360,577 people. This reflects an increase of 76.5% (160,780,129 people) when considering primary care as a whole (Aps Indicator Panels, n.d.). The continuous growth of coverage by the Family Health Strategy and primary care throughout the Brazilian territory is notorious; however, there are differences in coverage when considering the regions, states, and municipalities of the country. There is a large number of people without access to the proposed monitoring.
In Brazil, studies present a variety of prevalence of hearing loss between 24% to 45% in the elderly population showing a higher prevalence in men (Costi et al., 2014; Mattos & Veras, 2007). Brazil is undergoing a demographic shift with an increase in the proportion of older adults in the population composition which is likely to impact the overall rates of hearing conditions and demand for audiological services (Population Projections | IBGE, n.d.). In 2043, a quarter of the population is expected to be over 60 years old while the proportion of young people up to 14 years old will be only 16.3%. The aging rate is expected to increase from 43.19% in 2018 to 173.47% in 2060. Because of the growing aging of the population, the journal specialized in careers reports that there will be a growth of 34% in the labor market for hearing care professionals. For professionals working in this sector, job opportunities continue to grow due to factors such as advances in public health policies, coverage of medical covenants, aging of the population, and modern technological resources used in the various areas of health care.
Since the recognition from the Federal Government (Law n°6965), the undergraduate course in speech pathology and audiology “aims to train professionals qualified to work in the two areas”. The availability of graduate training not only raised the standard of professional care, but also expanded professional opportunities and the scope of practice for audiologists in the country. In 2020 there were 87 undergraduate courses in speech pathology and audiology recognized by the Ministry of Education. Of those, 24 (27.6%) are offered by public universities, while 63 (72.4%) are offered by private ones.In addition, at the graduate level different courses are offered in the four areas of specialization defined by the Speech-Language Pathology and Audiology Council (audiology, language, oral motor disorders, and voice).
Therefore, speech pathologists and audiologists are health professionals who specialize in the identification, diagnosis, treatment, prevention, and monitoring of communication disorders and orofacial functions. The following weblink has the current universities that offer speech-language pathology and audiology courses: https://www.fonoaudiologia.org.br/cffa/index.php/ensino-superior/
The speech pathologists and audiologists who work in the audiology area (audiologists) perform diagnostic evaluations of auditory and vestibular disorders, select and fit hearing aids, map cochlear implants, and provide auditory rehabilitation. Currently, audiologists in Brazil work at public and private establishments. The public institutions include community clinics, elementary schools, colleges, hospitals, industries, and universities.
Unified Health System
Universal and equal access to healthcare is one of the guiding principles of Brazil’s Unified Health System (Sistema Único de Saúde: SUS). The SUS is organized into three levels of care and audiological services are available at each level. Each successive level involves services of increasing complexity. All levels work together in an organized network of assistance, referral, and counter-referral. Priorities are defined in health conferences and supervising councils make decisions.
In 1993, the Unified Health system began to reimburse the following procedures related to the diagnosis of hearing loss: adaptation of individual hearing aids, speech therapy, and necessary follow-up after adaptation. In 2000, these procedures were regulated by an ordinance, then later in 2004, the procedures were organized by National Policy of Attention to Hearing Health by the Ministry of Health by basic, medium and high complexity care to better organize the patient flow and its distribution in the network. This ordinance ensures the citizens access to the Hearing Health Program which aims to develop actions to promote, prevent, intervene, and develop hearing health care.
Basic attention (primary health care)
This level includes health services of low cost and technology. It involves an interdisciplinary team working in conjunction with the patient and the family. In the area of hearing loss, the Unified Health System services at the basic level include provision of information and community guidance to assist in the early identification of hearing problems, public health programs to prevent the main causes of avoidable hearing impairment, and identification of community resources for the person with hearing impairment. Currently, the basic attention system is examining a proposal to have providers ask the basic question, ‘Does your child hear well?’ in every interaction with parents. Orienting families to the hearing health of their children emphasizes the importance of early detection of hearing loss and encourages parents to monitor speech, language, and hearing milestones and report any concerns (Bevilacqua et al., 2008).
This level involves the operation of public clinics where professionals offer diagnostic and rehabilitative services, technical support to basic attention level teams, and identify and refer cases that require higher level services. In regards to hearing health, secondary level programs include ENT and audiological evaluations, such as hearing screening in newborns, preschoolers, and school-aged children, audiometric monitoring of noise-exposed individuals, aural rehabilitation, speech-language pathology evaluations and therapy and hearing-aid selection and fitting. Related services include psychological assessment and therapy, social work assistance, family and school orientations, and home and/or institutional visits. Secondary level service providers inform basic attention teams the main causes of hearing loss, methods for prevention, and methods for early identification of hearing problems (Bevilacqua et al., 2008).
High complexity (tertiary level)
This service level provides advanced diagnostics and treatment, as well as basic care to difficult to treat populations. Additionally, this level is responsible for the qualification of basic attention level personnel and oversight of services provided at the secondary level. In the realm of hearing health, tertiary level teams provide sophisticated testing services including otoacoustic emissions evaluation (distortion-product and transient-evoked) and auditory evoked potential testing (including auditory brainstem responses and middle and long latency potentials). They also provide testing and hearing-aid services to children under age three and patients with multiple disorders (Bevilacqua et al., 2008).
In 2011, this systematic action was changed by another government policy called Plano Viver sem Limite in an attempt to improve access to care and promote citizenship. In this plan, new specialized rehabilitation centers were created which must serve a minimum of 2 of the following areas: auditory, motor, visual, or cognitive.
Otorhinolaryngology (ENT) is a clinical-surgical medical specialty that treats problems related to the ear, nose, sinuses, and throat through medications, surgical procedures, or rehabilitation. An ENT or otolaryngologist is a physician who has specialized in caring for the ears, nose, and throat. The main difference between ENTs and audiologists is that an ENT is a medical ear doctor, while an audiologist is a professional hearing doctor without a medical degree.
ENTs are trained in performing surgery on the ears, nose, and throat. They can also prescribe medication. They usually handle conductive hearing loss issues in adults and children with devices such as cochlear implants. Audiologists work on sensorineural hearing loss, which affects the inner ear. Other conditions ENTs treat are hearing loss due to ear trauma, infection, and benign tumors. Once ENTs perform surgery and prescribe necessary medications, they often refer patients to an audiologist for continued care, especially if rehabilitation is part of the aftercare.
After any determination of hearing loss or vestibular abnormality is present, the professional will provide recommendations to the patient (for example, hearing aids, cochlear implants, or an appropriate medical referral). They are trained to diagnose, manage and/or treat hearing, tinnitus, or balance problems.
They promote, manage, and adapt hearing aids, evaluate the potential application, and map cochlear implants. They advise families when there is a new diagnosis of hearing loss in infants and provide coping and compensation skills for adults who become deaf.
Audiologists also help develop and implement personal and industrial hearing safety programs, newborn hearing screening programs, hearing screening programs for school-aged children, and provide special fittings for ear plugs and other hearing protection devices to help prevent hearing loss. Audiologists are trained to evaluate peripheral vestibular disorders arising from internal ear pathologies. They also offer treatment for certain vestibular and balance disorders. In addition, many work as scientists developing and innovating new techniques and approaches to treat individuals with vestibular and audiologic conditions.
Figure 1 presents the number of speech pathologists and audiologists by region and state in Brazil (Federal Speech and Hearing Therapy Council). From a total of 7,071; 35% are audiologists, as presented in Table 2.
Figure 1: Number of speech pathologists and audiologists by region and state in Brazil.
Font: Federal Speech and Hearing Therapy Council, 2019 (https://www.fonoaudiologia.org.br/fonoaudiologos/quantitativo-de-fonoaudiologos-no-brasil-por-conselho-regional/)
Table 2: Distribution of speech pathologists and audiologists due to specialties in Brazil, according to Federal Speech and Hearing Therapy Council, 2019.
|Specialties||CFRa 1st Region||CFRa 2nd Region||CFRa 3rd Region||CFRa 4th Region||CFRa 5th Region||CFRa 6th Region||CFRa 7th Region||CFRa 8th Region||CFRa 9th Region||Total|
The number of professionals with master’s and doctorate degrees have also been steadily increasing. In the 2010-2020 decade the number of field-specific master’s and doctorate programs increased, but they remain concentrated in the south and southeast regions.
Table 3: Hearing Care Professionals in Brazil
|Professionals||Approximate Number||Ratio to the Population|
Font: Physician Demography in Brazil (2015); Federal Nursing Council (2019); Federal ENT Council (2018).
The areas involving research are diverse in the field of audiology starting from prevention and diagnosis to treatment (clinical and surgical intervention) of individuals with hearing loss in different age groups. In addition, several interdisciplinary research projects are linked with the public guidelines in hearing health. In Brazil, a governmental website entitled Directory of Research Groups of the National Council for Scientific and Technological Development (CNPq) is currently responsible for more than 40 registered research groups in audiology associated with public and private institutions in all regions over the country (Feitosa et al., 2020).
The first research group in the area was created in 1990 and named Center for Audiological Research (CPA). It worked in partnership among the Department of Speech Therapy at the Faculty of Dentistry of Bauru City (FOB) and the Rehabilitation Hospital of Craniofacial Anomalies (HRAC) (http://dgp.cnpq.br/dgp/espelhogrupo/8082). This collaboration promoted a significant increase of researchers from other centers and universities and allowed national and international collaborations, providing and developing multicenter research, as well as inter-institutional academic agreements.
Most of the research in audiology is supported by postgraduate programs (master and doctorate levels). At this time, the country has 12 postgraduate programs in the field of audiology disseminated in eight states from the country.
The activities and movements for the professional and course recognition started in the 70’s. Subsequently, bachelor’s courses were established. The first at the University of São Paulo, authorized in 1977.
In 1981, the federal government formally recognized the profession through Legislative Acts 6965/81 and 87218/82 (Brazil, 1981). In addition to determining the competence of the profession, the Federal and Regional Councils of Speech-Language Pathology and Audiology were created with the main purpose of supervising professional practice.
The activities of the Federal Council started in 1983 and the following year the first Code of Ethics of the profession was published. This document presents the rights, duties and responsibilities of the profession (Resolution CFFa No. 010/84). The progress and the expansion allowed awareness of the class.
The Federal Council has a normative purpose, issuing resolutions designed to regulate the profession according to the Federal Law (Constitution) and technical-scientific progress.
The Regional Councils are responsible for applying and inspecting the Ethical Code and the Federal Council rules. They also guide and supervise professional practice in their jurisdiction. Examples would be the issuance of professional records, the establishment of ethical-disciplinary and/or administrative processes, and the judgment of infractions. As mentioned before, there are nine councils in Brazil that cover the different states of the country.
According to Law 6965/81, an annual payment to the Regional Council of the respective jurisdiction constitutes a condition of legitimacy for the exercise of the profession.
It is important to mention that in addition to the Councils in Brazil, the Classes Societies also exist. These classes are regulated by a statute which regulates the fundamental purposes of the institution and specifies its operation. In Brazil, the Brazilian Society of Speech Therapy (SBFa), was created and lead by the Department of Hearing and Balance with support from the Brazilian Academy of Audiology (ABA).
In Brazil, speech pathology and audiology are interconnected; therefore, the profession developed as a unified field. A double license is granted after the four-year course and the professional is allowed to practice in any area after complying with the federal regulatory standards. Audiology was established as one of the specialties of speech therapy, among the other eleven different ones recognized by the Brazilian Federal Speech Language Pathology and Audiology Council.
There are several options for degrees and coursework. Some courses offer a 500-hour course of study which provides advanced clinical training. In addition, some universities have master’s and doctoral degree courses designed to provide the necessary training for those aiming at a career in research and education.
Audiology is perceived as the field related to promotion, prevention, diagnosis, and rehabilitation of the auditory and vestibular function, including research. The goal is guaranteeing the quality of life of the individual (Conselho Federal de Fonoaudiologia, 2006).
According to the Federal Council of Speech Therapy (Resolution CFFa nº 320, of February 17, 2006), the domain of the specialist in audiology includes knowledge in:
There are several philanthropic organizations to assist families and individuals with hearing loss in Brazil, some of them are listed below:
As the field is constantly evolving, it is important to be prepared to continue studying. The advance of public health policies, the federal law that requires medical covenants to cover at least six sessions per year, the aging of the population, and the modern technological resources of medicine are some of the main factors that increase the demand for this profession. Opportunities for the profession can be found mainly in large urban centers. The best opportunities are in public settings and public health where the professional manages and creates policies.
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Speech and Hearing Brazilian Society
Brazilian Academy of Audiology
Federal Council for Speech Pathology and Audiologist
Brazilian ENT Society
Brazilian Geriatric – Gerontology Society
Brazilian Ministry of Health
Brazilian Institute of Geography and Statistics
Lilian Felipe – Graduated in Audiology and Speech Pathology at Universidade de Minas Gerais (2004); Master’s degree (2004) and PhD (2010) in Health Sciences (Infectology and Tropical Medicine), School of Medicine, from the Universidade Federal de Minas Gerais. Post-doctorate in audiology and vestibular assessment at Maastricht University Medical Center (MUMC+), The Netherlands (2015). Professor at the Speech and Hearing Sciences Department at Lamar University, in Texas-USA.
Katia de Freitas Alvarenga – Graduated in Audiology and Speech Pathology from the Universidade do Sagrado Coração (1987); Master’s degree (1993) and PhD (1997) in Human Communication Disorders from the Universidade Federal de São Paulo. Post-doctorate in audiological assessment in children from the University of Manchester, England (1999) and in Electrophysiology from the University of Michigan, United States (2000). Full-time Professor at the University of São Paulo, campus Bauru (2013). Member of the cochlear implant team of the Craniofacial Rehabilitation Hospital/USP, campus Bauru (1992). Researcher of the Audiological Research Center, CNPq. Inclusion in Who´s Who in Medicine and Healthcare (2009-2010). President of the Brazilian Academy of Audiology (2015-2017). Currently, Coordinator of the Hearing and Balance Department of the Brazilian Society of Audiology and Speech Pathology (2020-2022).
Lilian C. B. Jacob Corteletti – Graduated in Audiology and Speech Pathology from the Universidade do Sagrado Coração (1990); Master’s degree (1994) from Universidade Federal de São Carlos – SP, and PhD (2000) in Human Communication Disorders from the Universidade de São Paulo. Professor in undergraduate and graduate courses at Universidade Tuiuti do Paraná (1999-2009). Professor in undergraduate and graduate courses at Universidade de São Paulo, campus Bauru (2010). Researcher of the Audiological Research Center, National Council for Scientific and Technological Development – CNPq.
Eliene Silva Araújo – Graduated in Audiology and Speech Pathology from the University of São Paulo (USP), campus Bauru (2009); Master’s degree (2012) and PhD (2015) in Sciences from the USP. Professor in undergraduate and graduate courses at Federal University of Rio Grande do Norte (UFRN – Natal-RN) and Researcher of the Audiological Research Center, CNPq. Currently, Coordinator of the Hearing Health Promotion, Prevention and Diagnosis Committee of the Brazilian Society of Audiology and Speech Pathology (2020-2022).
Thais C. Morata is a Founding Editorial Board Member for International Journal of Audiology and a Senior Researcher at the National Institute for Occupational Safety and Health, of the Centers for Disease Control and Prevention in the USA.
Received: October 5,2020
Revised: December 22, 2020
Accepted: February 22, 2020
Published: March 4, 2021
Reviewed and Edited by:
Senior Editor: Vinaya Manchaiah
Regional Resource Editor (South America): Lilian Felipe
Proofreading and Copyediting: Taylor Eubank & Jessica Sickels