The current population of Nepal is 29,500,464 as of Sunday, March 14, 2021, based on Worldometer elaboration of the latest United Nations data. It is the 49^th largest country by population. Nepal is a land of cultural diversity and ethnicity. There are 123 different languages spoken as the mother tongue in Nepal, although the official languages are Nepalese and English.

Nepal is a landlocked country located between India to the east, south, and west and Tibet to the north. It has a territory of around 500 miles (800 kilometers) from east to west and 90 to 150 miles from north to south. Nepal has an area of 147,516 sqaure kilometers. Kathmandu is the capital of Nepal. Administratively, Nepal is divided into 77 districts which combines to form seven provinces. The landscape of Nepal is primarily comprised of hilly and mountainous regions, which occupy a total of 85% of land.

Nepal is a developing nation, ranking 142th in the Human Development Index (HDI) in 2019. The GDP of Nepal was estimated to be around 32.16 billion dollars. The citizens of Nepal are known as Nepali or Nepalese. Though Nepal is an agricultural country, tourism is one of the largest and fastest growing industries in Nepal.

Like most of the developing countries, Nepal is also developing in terms of its infrastructure and facilities. Healthcare in Nepal is also making progress along with other services; however, the rehabilitation aspect is still in early stages its infancy. The state has not been able to provide substantial guidance to most disabilities. Advocacy and support for reducing hearing loss has had its fair share of difficulties. Hearing loss and hearing aids are still stigmatized in many parts of Nepal and awareness is concentrated in the major cities.

HISTORY OF AUDIOLOGY

TUTH is only institute which produces manpower in the field of audiology. Audiology services at TUTH began in 2009. Since then, this profession has undergone major growths and offers a vast range of ear and hearing healthcare. Most of audiological services are centered in major cities such as Kathmandu, Pokhara, and Biratnagar.

The initial school for hard of hearing was established in Kathmandu in 1965. This school was previously known as Bahira Balak ko School. It was renamed as the Speech Instruction Centre for Deaf Children and was located in Bir Hospital before moving to Bal Mandir in Naxal, a neighbourhood in central Kathmandu (Acharya, 1997). Presently, it is known as the Central Secondary School for the Deaf. This institution along with the Kathmandu Association of the Deaf (KAD) is said to be the origin of Nepali Sign Language (NSL). The blossoming of NSL took place even though the Central Secondary School followed an oralist philosophy when it was founded. In 1988, it adopted a Total Communication philosophy involving production of spoken Nepali along with signs in Nepali word order (Acharya, 1997; Hoffmann, 2008; Hoffmann-Dilloway, 2011). Four other deaf schools were established in the same time frame in Surkhet, Bhairahawa, Saptari, and Dharan (NDFN, 2019).

INCIDENCE AND PREVALENCE

Pascolini and Smith (2009) stated that a 1990 Nepal national survey reported 7.5% of the total population has some amount of hearing loss. Little information is available regarding the extent of disability including hearing loss. There are also few existing programs and organizations that assist in developing rehabilitation programs for hearing loss. Another study conducted by Mahajan et al. (2006) reported the prevalence of otitis media effusion in Nepalese children was 13.2% and those with hearing loss comprised 12.47%. This prevalence was much higher in school going children compared to adults and was even higher amongst children belonging to the lower socio-economic strata. Conditions complicating otitis media are more common and severe in children as compared to adults. A study in a school for the deaf in Kathmandu estimated that 7% of the children were affected by congenital Rubella syndrome. Recent data about incidence and prevalence is still lacking.

INFORMATION ABOUT AUDIOLOGY

Hearing health care education system is not well developed in Nepal. There is only one course that is offered in Speech and Hearing Science. A Bachelors in Audiology and Speech Language Pathology (BASLP) is a 4-year academic program under the leadership of S L Karna and Kabiraj Khanal that is offered at the Institute of Medicine (IOM), affiliated with Tribhuvan University. The course enables the speech and hearing specialist, commonly referred to as an audiologist and speech pathologist, to provide services to the sufferers of hearing disorders and speech defects, such as aphasia, stuttering, voice disorders, delayed speech, motor speech disorders, and language development disorders.

Gandaki University is planning to start undergraduate program in speech and hearing science, but it is not yet started.

In Nepal, professional audiology services are provided in the private sector and the public sector. The public institutions include government and community administered hospitals and university medical colleges.  

Public institutions charge a minimum amount for different audiological services. Whereas private clinics are more expensive due to high administrative and instrument cost. For the cochlear implant program, the government provides funds; however, this fund is small when compared to the number of patients who require implantation. Few non-governmental organizations (NGO) provide free or low-cost hearing aids. Public hospitals provide diagnostic services only. A patient with hearing aids will have to visit a private clinic for services. Audiological services are not covered by insurance.

Private clinics are available for all Nepali citizens. To access private clinics, patients must pay out of pocket. Kathmandu is the only place where there is more than 15 clinics. Public clinics and hospitals should open more vacancies for audiologists to provide services for the marginalized population. Also, a low-cost quality hearing aid should be developed for developing nations like Nepal.

There are currently a total of 91 registered professionals working in Nepal in the field of speech and hearing. Out of which 12 of them have a post graduate degree and 79 have undergraduate degrees as their qualification. This is based on data of registered professional as on 24^th August 2020 with Nepal Health Professional Council (NHPC), which is common governing body for licensing and regulation of all health professionals including Audiologist and Speech Language Pathologist.

There is only one ear, nose, and throat (ENT) surgeon for every 600,000 people in Nepal, and just one audiologist for every 6,000,000 people. As a result, untreated ear disease can cause serious problems, including severe pain and life-threatening infections (Felltham et al, 2014).

Audiological services in Nepal include:

1. Hearing assessment both behavioral and electrophysiological (PTA, VRA, BOA, Play audiometry, BERA, OAE, Tympanometry)
2. Selection, fitting, and verification of fitting
3. Cochlear implant mapping, auditory training, and assessing audiological candidacy
4. Vestibular rehabilitation and assessment
5. Tinnitus and hyperacusis assessment and management
6. Newborn hearing screening, etc.

 It is important to note that most audiological facilities are based in urban areas making it difficult for people in rural areas to access such services. There are many organizations that work to extend audiological services to rural and remote areas by conducting hearing screening camps and appointing public health workers to facilitate identification of hearing disorders and appropriate referrals. However, general awareness of hearing healthcare in rural areas is still poor. The lower socio-economic status of people living in rural Nepal makes it difficult for them to travel to urban areas to receive services.

Otolaryngologists in Nepal provide services for different congenital and acquired diseases of the ear. The facility includes diagnostic services and medical and surgical treatment of different diseases of the outer, middle, and inner ear. Otolaryngologists use a range of surgical methods for hearing restoration such as cochlear implants (CI) and other implantable hearing aids.

Currently, research in the field of audiology is increasing. Most of research is conducted at Tribhuvan University Teaching Hospital, Green Pasture Hospital. Speech and Hearing Association (SHAN) along with the Society of Otorhinolaryngology Nepal (SOL) organize regular scientific conferences for promoting scientific activity in the field of ear and hearing in Nepal. Nepal Health Research Council (NHRC) also supports and governs research activity in Nepal.

Research focused on developing high frequency and low frequency speech audiometry test material, and tinnitus and vestibular research. picture identification tests for children are some of the research topics that are published in national and international peer reviewed journals. There are very old studies on the prevalence of hearing loss. Recently, interest is directed to developing test metrical for central auditory processing disorders (CAPD) both screening and diagnostic. A few hospitals have started newborn hearing screenings and mass school screenings and treatments for ear disease are being conducted.

SCOPE OF PRACTICE AND LICENSING

The regulatory body has not made any documentation regarding scope of practice.

To be an audiologist in Nepal an individual must have the minimum of an undergraduate degree in Speech and Hearing science. Undergraduate professionals are trained and educated for identification of hearing loss at all ages, and assessment and diagnosis of hearing and vestibular disorders by performing behavioral and electrophysiologic measures. These undergraduate professionals also are training to provide treatment such as amplification devices, assistive listening devices, auditory training, and rehabilitation of vestibular function.

An audiologist with a postgraduate degree is trained to do basic audiological services along with special audiological services like cochlear implant mapping, intraoperative monitoring, vestibular evaluation and management, and tinnitus assessment and management

PROFESSIONAL AND REGULATORY BODIES

The Speech and Hearing Association Nepal (SHAN) is the professional and scientific association of over 70 members, while Nepal Professional Health council (NHPC) is the regulatory body that regulates training and practice.

The Speech and Hearing Association of Nepal (SHAN) was formed in 1999. It is a professional and scientific association for speech language pathologists and audiologists in Nepal. Its role is to promote hearing, speech and language professions and rehabilitation services through advocacy and continuing rehabilitation education (CRE). It is also involved in monitoring professionals, encouraging, and supporting research in the field of speech and hearing. SHAN has organized many conferences, CRE opportunities, awareness rallies and camps.

Currently, there are 63 life members, 29 associate members, and 2 foreign members within the association. Other associations include:

1. Cochlear Implant Nepal Group (CING) is a group of otologists, audiologists, speech language pathologists, nurses, pediatricians, and others who are focused on cochlear implant patients in Nepal. This organization strives to raise awareness regarding cochlear implants and obtain government support. CING was able to obtain funding for cochlear implants, where the government bears 50% of the cost of the implant. Even with funding CIs are a costly option in Nepal and post cochlear implantation rehabilitation services are mainly limited to Kathmandu.
2. Society of Otolaryngologists Nepal (SOL) is mainly an association for ENT surgeons in which audiologists and SLPs are associate members.

Every year, SHAN in collaboration with CING and SOL organize the events and awareness program to mark the world hearing day on the 3^rd of March each year. SHAN has also organized two national conferences, with the last one being in 2017.

Nepal Health Professional Council (NHPC) is an autonomous body established under the Nepal Health Professional Council Act 2053 (1996). The aim of this council is to register all “health professionals” omitting medical doctors and nurses according to their qualification and bring them into a legal system to make their services effective, timely, and evidence based. The Nepal Professional Health Council (NHPC) has classified professionals in 4 levels: Specialization level (Post Graduated), First level (Undergraduate), and second level (diploma in speech and Hearing) (Nepal Health Professional Council, 2021). NHPC also enforces disciplinary action against unqualified persons delivering health services.

Impact Nepal (IN) was established in 1993 with the aim of preventing disability. IN serves throughout Nepal and specific projects are implemented in the districts of Kathmandu, Rautahat, Parsa, Bara, Saptari, Udayapur, Kailali, Kanchapur, Dhoti, and Dadeldhura.

IMPACT Nepal operates community based primary ear care programmes in several rural districts of Nepal to provide primary and secondary level ear care services to the local communities. These community-based activities are targeted towards prevention of causes of unwanted ear disease and subsequent hearing loss. Plans are also in place to extend such a programme to the far-western region of Nepal. While this programme is focused on primary & secondary level ear care, tertiary level ear care is also available to these marginalized communities through mobile ear surgery camps held in or near these districts as well as through the Ear Care Centre Lahan, Siraha district. This hospital is well equipped with facilities for tertiary level ear care.

Ear Aid Nepal is a non-profitable charity organization that was established to promote the hearing health care services in Nepal, that includes, identification, diagnostics, and rehabilitation.

This charity is associated with the International Nepal Fellowship (INF) and is focused on the development of the INF Ear Hospital and Training Centre (IEHTC) in Nepal. This is an establishment that provides the hearing health care services for the population of western Nepal.

This organization is continuously educating the people of Nepal regarding the hearing health care system. It is also promoting and funding the research projects. Ear Aid Nepal also organizes free hearing camps in rural areas of Nepal where the volunteers come and provide the hearing services to the public.

Objectives of this organization:

1. To provide specialist advice to the hospital management team to improve the quality of life of persons with hearing disability.
2. To educate the public about hearing loss and its impact in order to provide good ear care to individuals in Nepal and the Himalayan region.
3. To develop research-based projects related to hearing health care in Nepal.
4. To plan an organization model that provides fundraising and then utilizes the money in improving the hearing health care in Nepal.
5. To provide help in the organization and construction of the hospital that is proposed by INF.
6. To support the INF ear camps providing care to the remote rural population of western Nepal.
7. To improve the quality of services to the persons with hearing loss in terms of diagnostics and rehabilitation in rural areas.

This organization also performs all kinds on ear surgeries for free in the ear hospital. The aim is to provide all forms of surgery to the ear (Example: the external ear or pinna, the ear canal, ear drum and middle ear, etc.)
Microsurgical operations such as myringoplasty, tympanoplasty, ossiculoplasty, stapedotomy, atticotomy, mastoidectomy and reconstruction are intended to be routinely available.

INF has been organizing many medical camps in Nepal for over 6 decades now. These ear camps are usually organized in rural areas. Ear Aid Nepal has been providing extensive professional support with the help of volunteers and opened the Ear Center in November 2015. Ear Aid Nepal’s principal aims are to support the ear hospital and the ear camp work, people with ear disease and deafness, and particularly those with limited means and poor access to care. This includes training locals and extending the range of services available in the country and conducting basic and primary care research.

Shruthi National Association of Hard of Hearing and Deafened Nepal was established in Nepal in 2012. This organization is a member of Asia-Pacific Federation of the Hard of Hearing and Deafened (APFHD).

This organization was established to address issues that concern those with hearing disabilities in Nepal. The motto of this organization is to develop an inclusive society with no communication barrier and where those with hearing disabilities live a dignified life (Bhattarai & Bacala, 2017).

Nepal Association of the Hard of Hearing is an organization that is working to improve the quality of life for persons with disability. It is affiliated with the International Federation of Hard of Hearing since 2015 and is also a member of the Human Rights Treaty Monitoring Coordination Center in 2016.

CHALLENGES, OPPORTUNITY AND NOTES

There is a huge lack of awareness about audiology services among different health professionals and the public.

There is also a lack of research in the field of hearing in Nepal with limited number of professionals involved in current research.

There is a lack of skilled providers and these are limited to a few big cities. Services should be extended to remote areas.

Hearing instruments are expensive and a cost-effective solution in developing countries should be invented.

The government should give equal priority of rehabilitation services including auditory rehabilitation.

There is a lack of evidence-based practice and monitoring for unethical practices.

Although many private sector practices have state of the art facilities, the practices are not well regulated (especially for hearing aid dispensing), resulting in many unqualified (or poorly trained) individuals practicing. Hence, much effort is needed from NHPC and SHAN to enforce necessary practice regulations.

Many qualified professionals are leaving the country for better opportunities. This process should be reduced by increasing the number of students, developing new speech and hearing colleges, and expanding to a Master or Doctor of Audiology (Au.D.) program.

There is a need to increase and promote professionals for clinical and research work.

There is a need to increase the number of job openings in both government and private sectors and a need to monitor the quality of services.

There is a need to advocate inclusive education and special education for children with hearing impairment.

ACKNOWLEDGEMENTS

I would like to thank Mr. Bebek Bhattarai for proofreading and editing. Also, I would like to thank Mr. Rajat Gautam, Mrs Susmita Shrestha, Ms. Kranti Acharya, Mrs. Sharah Reggsbee for providing information and editing. At last, I cannot pen down without thanking the pillars of Nepal’s speech and hearing filed Mr. S L Karna sir and Mr. Kabiraj Khanal sir.

REFERENCES

Acharya, K. (1997). History of the Deaf in Nepal (E. Hoffmann-Dilloway & D. Chemjong, Trans). Unpublished manuscript. Kathmandu: National Association of the Deaf and Hard of Hearing.

Bhattarai, N. K., & Bacala, T. M. (2017). Promoting Hearing Health Care in Nepal. The Hearing Journal, 70(3), 22-24.

Hoffmann, E.G. (2008). Standardization beyond form: Ideologies, institutions, and the semiotics of Nepali Sign Language. Unpublished doctoral dissertation, University of Michigan.

Hoffmann-Dilloway, E. (2011). Lending a hand: Competence through cooperation in Nepal’s Deaf associations. Language in Society, 40, 285-306. doi:10.1017/S0047404511000194

National Federation of Deaf Nepal. (2019). About us: History of NDFN. Retrieved from http://www.deafnepal.org.np/page/history-of-ndfn.

Nepal Health Professional Council. (2021). Retrieved April 18, 2021, from https://www.nhpc.org.np/browse/subject-wise-registration

Pascolini, D., & Smith, A. (2009). Hearing Impairment in 2008: a compilation of available epidemiological studies. International journal of audiology, 48(7), 473-485.

USEFUL LINKS

Nepal Health Professional Council: https://www.nhpc.org.np/

EarAidNepal: https://www.earaidnepal.org/

Nepal Association of the Hard of Hearing: http://nahoh.org.np

Key Dates
Received: March 15, 2021
Revised: April 5, 2021
Accepted: April 19, 2021
Published: April 30, 2021

Reviewed and Edited by:
Senior Editor: Vinaya Manchaiah
Regional Resource Editor (Asia): Vinaya Manchaiah
Proofreading and Copyediting: Taylor Eubank