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The profession of audiology took root in Brazil nearly a half a century ago and has since blossomed into a flourishing, well-developed field. Currently, audiologists in Brazil work at private institutions, including private medical practices and dedicated speech and hearing clinics. They are also employed in a wide array of public institutions, including community clinics, elementary schools, colleges, and universities. In both the private sector and health clinics, audiologists perform diagnostic evaluations of auditory and vestibular disorders, select and fit hearing aids, and provide aural rehabilitation. At the public level, they assist with workers' health programs, dispense hearing aids, and aural rehabilitation. There is always room to grow, however, and the future of audiology in Brazil holds both challenges and opportunity. The following article will sketch the development of audiology training and practice in Brazil, provide a picture of how the field stands today, and summarize the unique challenges which the profession faces in this large and diverse nation.
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Maria Cecilia Bevilacqua
*
Beatriz Caiuby Novaes
§
Thais C. Morata
%
*
Universidade de Sa
˜
o Paulo, Centro
de Pesquisas Audiolo´gicas, Brazil
§
Pontifı´cia Universidade Cato´ lica de
Sa
˜
o Paulo (PUC-SP), Brazil
%
Universidade Tuiuiti do Parana´,
Brazil, and National Institute for
Occupational Safety and Health,
Cincinnati, USA
Key Words
Developing country
Hearing loss
Public health
Communication disorders
Original Article
International Journal of Audiology 2008; 47:4550
Audiology in Brazil
Abstract
The profession of audiology took root in Brazil nearly a
half a century ago and has since blossomed into a
flourishing, well-developed field. Currently, audiologists
in Brazil work at private institutions, including private
medical practices and dedicated speech and hearing
clinics. They are also employed in a wide array of public
institutions, including community clinics, elementary
schools, colleges, and universities. In both the private
sector and health clinics, audiologists perform diagnostic
evaluations of auditory and vestibular disorders, select
and fit hearing aids, and provide aural rehabilitation. At
the public level, they assist with workers’ health pro-
grams, dispense hearing aids, and aural rehabilitation.
There is always room to grow, however, and the future of
audiology in Brazil holds both challenges and opportu-
nity. The following article will sketch the development of
audiology training and practice in Brazil, provide a
picture of how the field stands today, and summarize
the unique challenges which the profession faces in this
large and diverse nation.
Sumario
La profesio´n de La Audiolo´a echo´raı´ces en Brasil hace
casi medio siglo y desde entonces se transformo´enun
campo floreciente y bien desarrollado. Actualmente, los
audio´logos en Brasil trabajan en instituciones privadas
que incluyen pra´ctica me´dica privada y clı´nicas de
audicio´n y lenguaje de gran dedicacio´n. Tambie´n esta´n
empleados en un amplio rango de instituciones pu
´
blicas,
incluyendo clı´nicas comunitarias, escuelas primarias,
colegios y universidades. Tanto en el sector privado
como en las clı´nicas de salud, los audio´logos llevan a
cabo evaluaciones diagno´sticas de problemas auditivos y
vestibulares, seleccionan y adaptan auxiliares auditivos y
proveen rehabilitacio´ n auditiva. En el nivel pu
´
blico,
apoyan programas de salud de trabajadores, distribuyen
auxiliares auditivos y proporcionan rehabilitacio´n audi-
tiva. Sin embargo, siempre hay espacio para crecer y el
futuro de la Audiologı´a en Brasil tiene tanto desafı´os
como oportunidades. El siguiente artı´culo esboza el
desarrollo de la capacitacio´n y la pra´ctica de la Audio-
logı´a en Brasil, provee un panorama de co´ mo esta´
actualmente el campo y resume los excepcionales desafı´os
que enfrenta la profesio´n en esta grande y diversa nacio´n.
Some background information about Brazil is necessary in order
to better understand the state of audiology in that country.
Brazil is the largest and most populous country in South
America, occupying nearly 50% of the continent and boasting
a population of nearly 190 million people. It has numerous
natural resources including agricultural products (coffee, soy-
beans, sugar, oranges, tobacco, and cocoa), livestock products
(meat, poultry, and leather footwear), wood products (pulp,
paper, veneer, and plywood), and mineral and metal products
(iron, steel, and aluminum). It is the economic leader among
South American countries. Table 1 summarizes some of Brazil’s
economic and demographic indicators for the year 2007.
Following the Second World War, Brazil’s economic develop-
ment was spurred on by a period of import-substituting
industrialization, facilitated by a huge domestic market. For
the next 35 years, the country’s economy expanded rapidly and a
large and diversified industrial sector developed. Strong external
demand and an active export policy has contributed to increased
trade and booming export earnings since 2003.
With a population approaching 190 million, Brazil is the
seventh most populous country in the world (Central Intelligence
Agency, 2007). Its inhabitants are concentrated primarily along
the coastline and in the larger cities, while some areas of the
interior are sparsely inhabited. One significant problem is the
highly unequal distribution of income among the citizens of
Brazil, with approximately 10% of the population earning 50% of
the overall income. According to comparative figures published
by the World Bank (The World Bank Group, 2005), Brazil has a
Gini coefficient of 0.59, indicating that, as a country, it has one of
the most unequal distributions of wealth in the world. The Gini
coefficient is a measure of income or wealth inequality ranging
from 0 (perfect equality) to 1 (perfect inequality); as the Gini
coefficient increases, inequality increases. Unfortunately, the
tendency toward income inequality in Brazil is typical of many
South and Central American countries and is clearly noticeable
in many ways. All stages of development exist simultaneously in
Brazil in many facets of life, including economic, social,
educational, and medical aspects. This impacts the availability
of, and access to, audiological services, as will be illustrated.
Brazil is composed of 26 states and one federal district. The
State of Sa
˜
o Paulo is the cradle of audiology in Brazil, and the
state where many of the training programs and audiology
practitioners are still located. Therefore, a brief summary of
Sa
˜
o Paulo’s socioeconomic and demographic data is also useful.
Although Sa
˜
o Paulo ranks only twelfth among the Brazilian
states in terms of area, it ranks highest in terms of population,
having 40 million inhabitants and accounting for over 20% of the
Brazilian population. Sa
˜
o Paulo is also the richest state in Brazil,
contributing over one-third of the nations GDP. However, the
state reflects the same unequal income distribution problem that
plagues Brazil as a whole. Although many enjoy a high standard
of living, there are areas of intense poverty as well. Table 2
summarizes some economic and demographic indicators for the
state of Sa
˜
o Paulo for the year 2000.
ISSN 1499-2027 print/ISSN 1708-8186 online
DOI: 10.1080/14992020701770843
# 2008 British Society of Audiology, International
Society of Audiology, and Nordic Audiological Society
Maria Cecilia Bevilacqua
Universidade de Sa
˜
o Paulo, Centro de Pesquisas Audiolo´gicas,
Rua Silvio Marchione, 3-20 Bauru, SP, 17043-900, Brazil.
E-mail: cecilia@implantecoclear.com.br
Received:
July 23, 2007
Accepted:
October 26, 2007
Downloaded By: [Centers for Disease Control and Prevention] At: 16:22 30 January 2008
Development of the profession of audiology in Brazil
In Brazil, as in many other countries, audiology began as an
outgrowth of the ear, nose, and throat (ENT) medical specialty.
Initially, technicians called audiometrists performed pure-tone
audiometry in ENT clinics. Because of the limited testing
procedures, hearing evaluations were far from thorough, and
accurate diagnoses could not be made. ENT physicians, there-
fore, went abroad to study audiology, and on their return, they
fostered the development of the field in Brazil.
One early pioneer, Dr. Orozimbo Alves Costa Filho, spent five
years at Washington University in St. Louis, Missouri, USA,
studying under such internationally-recognized experts as Drs.
Hallowell Davis, S. Richard Silverman and Ira Hirsh. Dr. Costa
returned to Brazil in 1968, bringing with him extensive knowl-
edge of new audiological procedures, including electrophysiol-
ogy. Dr. Costa thus greatly expanded options for testing and
treating persons with hearing impairment in Brazil. He also
opened up many horizons for audiological research in the
country.
Another early influence on the field of audiology in Brazil was
the practice of phoniatrics in the neighboring country of
Argentina. Professionals trained primarily in language pathology
and known as phoniatricians came to Brazil in the late 1960s and
proposed the creation of a course of study in phoniatrics, but it
did not attract more than half a dozen students. However, some
ENTs and other professionals in Brazil obtained training in
speech-language pathology and introduced speech therapy into
the emerging field of audiology. Thus, in Brazil, speech pathology
and audiology were intertwined from the very beginning, and the
professions continued to develop as a unified field.
In 1981, the profession of speech-language pathology and
audiology*or fonoaudiologia, as it is called in Brazil*was
formally recognized by the federal government through Legis-
lative Acts 6965/81 and 87218/82 (Brasil, 1981). Also in 1981, the
Brazilian Speech-Language Pathology and Audiology Council
was created, first at the national level and later at a regional level
with seven regional offices, each representing three or four states.
This association represents professionals working in the field and
is the only agency that can provide a common licensure to
speech-language pathologists, audiologists, and speech, lan-
guage, and hearing scientists. It also maintains a code of ethics
which sets forth the fundamental principles and rules guiding
ethical conduct and professionalism for speech pathologists and
audiologists in Brazil.
Prior to 1980, audiology practice was largely limited to private
practice in hospitals, physicians’ offices, and private clinics. Few
had access to very sophisticated care. The majority of the
population was underserved. Some limited speech therapy
services were available through public institutions. However,
during the 1980s, several occurrences helped facilitate the
expansion of audiology into other venues.
The end of more than 30 years of military rule in 1985 was an
event that contributed, in many ways, to the expansion of the
field of audiology in Brazil. A new constitution was ratified in
1988, which devoted specific attention to the protection of
workers’ health and created mandates for worker health promo-
tion.
The Interunion Department of Studies and Research on Work
Health and Environment (Departamento Intersindical de Estu-
dos e Pesquisas de Sau
´
de e dos Ambientes de Trabalho,
DIESAT) was created to support workers and strengthen unions
in issues related to occupational safety and health. DIESAT
created Workers’ Health Programs in the Public Health System
(today called Reference Centers in Workers’ Health), first in
several cities in the state of Sa
˜
o Paulo and eventually through
most of Brazil. These centers encouraged the participation of
union representatives in health and safety programs, improved
the quality of workplace inspections, and highlighted the
magnitude and seriousness of hearing loss among workers due
to exposure to noise and other causes (Santos & Morata, 1994).
The changes brought about by the new Brazilian political system
not only strengthened the occupational health arena but also
Table 1. 2007. Chief demographic and economic indicators for
Brazil.
Brazilian demographic and economic indicators
Area 8 511 965 square kilometres
Population
190 010 647
(014 years: 25.3%; 1564
years: 68.4%;65 years: 6.3%)
Population growth rate 1.008% /year
Birth rate 16.3 births/1000 people
Infant mortality rate 27.6 deaths/1000 live births
Life expectancy at birth 72.2 years (male: 68.3 years;
female: 76.4 years)
Literacy (age 15 who
can read and write)
88.6% (2004)
GDP- Brazilian real (R$)
growth rate
3.7% /year
GDP-(R$) per capita:
purchasing power parity
$8800
Unemployment rate 9.6%
Population below poverty
line
31% (2005)
Source: Central Intelligence Agency (2007).
Table 2. Demographic and economic indicators for the state of
Sa
˜
o Paulo, Brazil. Data are for the year 2000 (latest information
available), unless noted.
Current demographic and economic indicators for the State of Sa
˜
o
Paulo
Population 9 million (22% of the Brazilian
population)
Infant mortality
rate
21.2 deaths/1000 live births
Literacy 83.8% (age 15 who can read and write)
GDP contribution 36.9%.
Sa
˜
o Paulo State
budget (2004)
Total R$ 69.7 billion ( USD 32 billion);
Health R$ 7.2 billion ( USD 3.3 billion);
Source: Ministe´rio do Desenvolvimento, Indu
´
stria e Come´rcio Exterior,
2004; Instituto Brasileiro de Geografia e Estatı´stica, 2000.
46 International Journal of Audiology, Volume 47 Number 2
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accelerated the placement of audiologists into other public
health areas.
In 1986, the Sa
˜
o Paulo State Health Department and the
undergraduate speech pathology and audiology course at the
Pontifı´cia Universidade Cato´lica de Sa
˜
o Paulo developed a joint
program in which audiologists worked with industry to collect
data on noise exposure and hearing levels across different
occupational sectors. Prior to this effort, the audiologist’s role
in the area of occupational health had been quite limited,
characterized exclusively by the audiometric monitoring of
workers (Morata & Carnicelli, 1988). The collaboration between
the health department and the university was a great success.
The data obtained in the first year of the partnership identified
high rates of noise-induced high-frequency hearing loss, provid-
ing the impetus for the university to request that the State Health
Department purchase audiological equipment and hire
audiologists that would be exclusively dedicated to workers’
health programs. In the following years, various workers’ health
programs were funded by other state and municipal health
departments and made similar progress in identifying cases of
hazardous noise exposure, and protecting workers’ hearing.
An example of the further expansion of audiology into public
sector programs was the addition of audiology services to public
health clinics. This was initiated in 1990 by the University of Sa
˜
o
Paulo at Bauru. The University had past experience in working
with the Federal Health Ministry on craniofacial pathologies. In
1990, it started to offer a speech pathology course, and the
existing experience of the professionals in the craniofacial
pathologies group was transferred to audiology. This partnership
resulted in a 1993 resolution of the Health Ministry, by which
cochlear implants were guaranteed in the public health system,
free of charge. In 2000, the resolution was expanded to include
the concession of hearing aids by public health clinics. In 2004,
this resolution was incorporated into Brazilian law (Ministe´rio
da Sau
´
de, 2004).
Another effort to expand audiological services encompasses
neonatal hearing screening. In the past 15 years, a few maternity
hospitals in several regions of Brazil have started screening
newborns for hearing loss. Most use otoacoustic emissions,
though some use a high risk registry to refer for an evaluation.
Several research groups and professional organizations are
investigating alternatives to provide hearing screenings for
newborn babies across the whole of Brazil (Lewis, 1996).
It is likely that the adoption of neonatal screening will be
gradual and varied in different areas of the country. Feasibility
surveys conducted in recent years (unpublished) suggest that it
might not be possible in the short term to use a uniform protocol
across states or regions. Some regions might adopt a universal
screening policy while others may need to begin by screening
only those babies identified as high risk through a registry
approach. Some facilities may use otoacoustic emissions to
screen hearing while others might use auditory brainstem evoked
responses. Much depends on the availability of equipment and
competent personnel, as well as the capacity to provide services
to infants identified as hearing-impaired. Increased public
interest in this service might, of course, facilitate the expansion
of newborn hearing screening programs throughout the country.
The role played by universities was pivotal to the introduction
and diversification of audiologic services in the Brazilian public
health system. Through collaborations such as these involving
universities and the public health sector, the presence of
audiologists in public services and the labor market dramatically
increased. As a consequence, other opportunities for hearing
professionals became available in unions, industry, and other
health services.
During the 1990s, several individuals obtained doctoral
degrees in audiology, achieving greater autonomy from other
professions and boosting research development. These very
dedicated individuals played an important role in consolidating
the scope of practice and shaping the scientific and scholarly
basis for the profession of audiology in Brazil. Since the early
1990s, audiology has become clearly recognized as an indepen-
dent area of knowledge in Brazil, as evidenced by the increasing
number of presentations at national and international confer-
ences, the proliferation of scientific publications, and the
growing presence of audiologists in both private and public
practice.
Development of audiology training in Brazil
The first training program in communication disorders was
established in 1960 at the University of Sa
˜
o Paulo with the
primary objective of training speech therapists. The program
soon expanded into a two-year, and shortly after that into a
three-year course that offered a diploma in logopedics, or speech
therapy. By 1970, the University of Sa
˜
o Paulo realized that the
breadth of the field required more extensive training, and
changed the curriculum to a four-year undergraduate profes-
sional degree course in fonoaudiologia (speech pathology and
audiology), which is still the entry level degree of the profession.
In 1981, when the legislative acts establishing fonoaudiologia as a
legal profession were passed, there were 10 undergraduate
programs in speech-language pathology and audiology in Brazil.
Prior to the 1970s, the coursework consisted primarily of
speech and language pathology classes, due to the influence of
the phoniatricians from Argentina. However, the ENT physi-
cians who went abroad to study audiology returned to Brazil and
facilitated the development of courses in various areas of
diagnostic hearing testing and rehabilitation of hearing loss. In
1970, a group of professionals who desired to see audiology
established as an independent field of study launched the first
graduate course in audiology. The course was housed at the
Pontifı´cia Universidade Cato´lica de Sa
˜
o Paulo (PUC.SP), in
collaboration with the Department of Otorhinolaryngology in
the medical school of the Santa Casa de Miserico´rdia de Sa
˜
o
Paulo. Two years later, a masters degree course in communica-
tion disorders was also created at PUC.SP, specializing in
speech-language pathology. In 1996, the Speech-Language
Pathology and Audiology Council passed Resolution 15796,
defining four areas of graduate study in the field: audiology,
language, oral motor disorders, and voice (Conselho Federal de
Fonoaudiologia, 1996). The availability of graduate training not
only raised the standard of professional care, but also expanded
professional opportunities and the scope of practice for audiol-
ogists.
At this time, the entry level for the profession remains
the baccalaureate degree. The undergraduate course in fonoau-
diologia involves a double major with coursework in both
speech-language pathology and audiology. Classes include the
basic sciences, anatomy and physiology, human development,
Audiology in Brazil Bevilacqua/Novaes/Morata 47
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linguistics, phonetics, psychology, the nature and process of
audition and balance, normal and abnormal communication
development, and supervised clinical practicum. A double
license is granted to graduates of this four-year course, and
they are free to work in any area of the field. Graduates must
also comply with federal regulatory (licensure) standards in
order to practice. According to the Brazilian Federal Speech-
Language Pathology and Audiology Council (Conselho Federal
de Fonoaudiologia, 1996), there are currently 117 undergraduate
courses in speech-language pathology and audiology in Brazil,
and an average of 2000 students graduate each year. Table 3
displays the number of undergraduate courses of study by region
within Brazil.
It is at graduate level that 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). There are several options for
degrees and coursework. Some courses offer a 500-hour course
of study which provides advanced clinical training focused in one
of the four areas of specialization, and graduates receive the title
‘Specialist’. In addition, a few universities offer masters and
doctoral degree courses designed to provide the necessary
training for those aiming at a career in research and education.
Currently, there are 32 specialization courses and eight graduate
courses in communication disorders throughout Brazil;
the geographic dispersion of these programs is also given in
Table 3.
Audiology in Brazil today
At the time of writing, 30 911 individuals have completed an
undergraduate course of study in speech-language pathology
and audiology, and obtained licensure to practice in Brazil.
Audiologists work in a wide array of private and public settings.
The majority of these professionals are in the southeast region of
the country, which encompasses Sa
˜
o Paulo and Rio de Janeiro.
See Table 3 for a complete distribution of professionals by region
(Conselho Federal de Fonoaudiologia, 2007).
In addition, approximately 1000 people have completed a 500-
hour specialization course in audiology; an estimated 500 people
have obtained a masters degree in either speech-language
pathology or audiology; and about 300 individuals have
obtained a doctoral degree in one of these areas (Conselho
Federal de Fonoaudiologia, 2007).
In view of the country’s population and size, there is an
obvious shortage of qualified audiologists. The World Health
Organization estimates the prevalence of incapacitating hearing
loss to be 6% in developing countries. A study conducted in the
south region of Brazil resulted in a very similar estimate,
projecting the prevalence of hearing loss to be 6.2% (WHO,
2003). Extrapolating from this estimate, there are approximately
17 million individuals with hearing loss in Brazil who need
hearing aids, and 200 000 people who need cochlear implants.
Comparing the number of licensed professionals with the
estimated number of individuals with some degree of hearing
loss, it is evident that a large percentage of the population is
underserved regarding audiological care.
As stated above, audiology is practiced in a number of public
and private practices in Brazil. A recent study conducted in the
southern states of Brazil asked speech-language pathologists and
audiologists to categorize their worksite as private, non-profit,
or governmental. Of the 986 speech-language pathologists and
audiologists who provided specific information about their work
setting, 590 (60%) reported working in private practice clinics
(Silva et al., 2000). This trend toward private employment is
evident in other regions of Brazil as well, and raises concerns
regarding the availability of services to lower-income persons.
Speech-language pathology and audiology services are less
available in community clinics; hospitals; rehabilitation centers;
centers for persons with developmental disabilities; public
schools; and federal, state, and local health departments or
other government agencies. This implies that mostly those who
can afford private health care*a small fraction of the Brazilian
population, as the Gini coefficient indicated*will have access to
audiological care. Indeed, poorer Brazilians are still unaware of
the existence of the profession and the scope of services provided
by speech-language pathologists and audiologists.
Despite the fact that fewer audiologists work in the public
sector than in the private sector, the availability of hearing
services available through governmental organizations is increas-
ing. Brazil has a national health care system that is universal, but
only in the last decades have comprehensive audiological services
become available. These services are coordinated through the
Unified Health System (Sistema U
´
nico de Sau
´
de, or SUS). The
SUS pledges to offer health assistance to all Brazilians through
the diagnosis and treatment of disease and injury, integral
ambulatory and hospital care, and domiciliary assistance. The
SUS has five principles:
. Universality, that is, the whole Brazilian population has
unrestricted access to all health services;
. Equity, that is, health services are distributed in an equitable
manner, avoiding inequalities in the offer of assistance;
. Democratization, that is, supervisors, providers, and benefi-
ciaries of services all participate in the establishment of
guidelines for the SUS;
Table 3. Number of audiology training courses by level and region in Brazil, and number of graduates by region.
Number of audiology training courses by level and geographic region
Course level North Northeast Southeast South Central west Total
Undergraduate 5 22 61 20 9 117
Specialization 621 4 1 32
Number of graduates by geographic region
Course Level North Northeast Southeast South Central west Total
Undergraduate 860 4592 19 096 4204 2159 30911
Source: Conselho Federal de Fonoaudiologia (2007).
48 International Journal of Audiology, Volume 47 Number 2
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. Decentralization, that is, management in the three spheres of
government, with clearly-defined roles for the union, states,
and municipalities; and
. Integrality, that is, holistic assistance to each individual, with
access to all available technologies.
The SUS is organized into three levels of care, and audio-
logical 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 makes decisions.
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, SUS
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.
Secondary level
This level involves the operation of public clinics where
professionals offer diagnostic and rehabilitative services, provide
technical support to basic attention level teams, and identify and
refer cases that require higher level services. With regard to
hearing health, secondary level programs include ENT and
audiological evaluations; hearing screening in newborns, pre-
schoolers, 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 orienta-
tions, and home and/or institutional visits. Secondary level
service providers advise basic attention teams as to the main
causes of hearing loss, methods for prevention, and methods of
early identification of hearing problems.
High complexity (tertiary level)
This service level provides advanced diagnostics and treatment,
as well as basic care to difficult-to-treat populations. Addition-
ally, 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 includ-
ing otoacoustic emissions evaluation (distortion-product and
transient-evoked) and auditory evoked potential testing (includ-
ing auditory brainstem responses, middle, and long latency
potentials). They also provide testing and hearing-aid services to
children under age three, and patients with multiple disorders
who are difficult to test. Advanced neurological, psychological,
speech pathology, and social services are available as well.
Hearing aids and cochlear implants are guaranteed to the
Brazilian population through the SUS, which coordinates their
distribution. Although hearing aids are also available through
the private sector to those who can afford to obtain them, more
than 60% of the hearing aids fitted in Brazil are dispensed by the
SUS, and this percentage is increasing (Ministe´rio da Cieˆncia e
Tecnologia, 2006). Table 4 shows the distribution of hearing aids
by the government in recent years.
Although the quantity of hearing aids dispensed has increased
annually, the numbers indicate that only a small fraction of the
estimated 17 million Brazilian people who would benefit from
amplification are being served.
Future challenges and opportunities
Audiology in Brazil has a promising future. Government services
are expanding, providing professionals with new markets and a
broadening scope of practice. Neonatal screening programs are
being adopted across Brazil, resulting in earlier identification of
debilitating hearing loss and expanding hearing aid services to
the pediatric population. Professional organizations are increas-
ing, creating opportunities for collaboration and fostering the
talents of practitioners through interaction. In 2002, the
Brazilian Academy of Audiology was founded; this very active
organization is likely to boost audiology at national level and
create a new dynamic among professionals both nationally and
internationally.
The profession also faces some challenges in the years ahead.
Additional support is needed for research and surveillance
programs. Quality indicators should be established for monitor-
ing the audiological services provided at each level, including
prevention efforts, screening and identification of hearing loss,
diagnostic testing, hearing-aid fitting, and provision of cochlear
implants.
Audiological services need to be better integrated throughout
the public health system network. Audiological practice is still
characterized by the diagnosis and treatment of communication
disorders, rather than their prevention. More activity is neces-
sary in the area of primary prevention. In addition, decision-
making processes regarding the use of secondary and tertiary
level services need to be streamlined and improved. It
is important that audiologists network through professional
Table 4. Number and value (in US dollars) of hearing aids
distributed through the Unified Health System (Sistema U
´
nico
de Sau
´
de, or SUS) for the past five years.
Year
Number of hearing
aids given
Value in US
Dollars
2002 34 025 19 645 351.00
2003 64 884 42 986 101.00
2004 81 361 51 463 493.00
2005 113 983 105 374 078.00
2006 (through August) 68 849 45 511 314.55
Source: Brazilian Ministe´rio da Sau
´
de (2006), presented at the 4th Joint
WHO/CBM Workshop on hearing aids and services for developing
countries (Nascimento, 2006).
Audiology in Brazil Bevilacqua/Novaes/Morata 49
Downloaded By: [Centers for Disease Control and Prevention] At: 16:22 30 January 2008
organizations and outreach activities to form partnerships
throughout the country. Teamwork will facilitate the ability to
monitor hearing health status, identify and investigate health
problems, conduct research to enhance prevention, develop and
advocate solid public health policies, implement prevention
strategies, promote healthy behaviors, foster safe and healthful
environments, and provide leadership and training.
Decentralization of audiology services and a greater geo-
graphic distribution of professionals are necessary in order to
meet the needs of all Brazilians. At present, most professionals
are concentrated in the south and southeastern regions of the
country, and there is an extreme need for more audiologists in
the midwest, north, and northeastern regions. Recently, mea-
sures have been adopted by the Ministry of Health to establish a
national network of hearing health services to give support to
centers in Brazil’s poorest regions (Ministe´rio da Sau
´
de, 2004).
Professional education and training also needs to be evaluated
and modified to meet the changing needs of the profession in
Brazil. Public health programs in Brazil rely on professionals
who are general practitioners. Professionals in speech language
pathology and audiology have been required to work on a wide
array of communication disorders. The need for professionals
with more specific training in the area of audiology has recently
been addressed by the Hearing Health Resolution in 2004 of the
Ministry of Health (Ministe´rio da Sau
´
de, 2004), which estab-
lished more stringent requirements for the training of profes-
sionals. Undergraduate educational policies are being reviewed
throughout Brazil; however, the focus is still mainly on improv-
ing professional training at the undergraduate level. Recent
trends in the public educational system are directed at increasing
professional training after completing a basic cycle common for
all students. Coursework more compatible with recent develop-
ments in technology and public health is also essential, both at
graduate and undergraduate levels. This would consolidate the
production of knowledge at the international level.
The challenges that lie ahead, however, only increase the
exciting opportunities that the future holds for audiologists in
Brazil. The progress achieved in recent decades places Brazil in a
leadership position in Latin America and other Portuguese-
speaking countries with regard to the prevention, diagnosis,
treatment, and rehabilitation of hearing loss. No doubt audiol-
ogists in Brazil will forge ahead into their future, determined to
fulfill their own professional mission.
Acknowledgements
Christi Themann and Rick Davis (National Institute for
Occupational Safety and Health) and, Robert W. Keith (Uni-
versity of Cincinnati) provided helpful critiques of the manu-
script.
Disclaimer
The findings and conclusions in this report are those of the
author(s) and do not necessarily represent the views of the
National Institute for Occupational Safety and Health.
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50 International Journal of Audiology, Volume 47 Number 2
... At least 4 years are required for the completion of coursework, which involves, among other studies, speech-language pathology, audiology, voice, and oral myology. Dual-certification (SLP-Audiology) is granted to those who successfully complete the program and they are free to work in any area of the field [32,33]. ...
... Although public health programs in Brazil rely on generalists, there is a need for professionals with more specific training in the area of audiology, particularly since 2004, when PNASA was established [33]. However, the concentration of training programs in the Southeast and South of the country hinders continuing professional education. ...
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... Estes três níveis funcionam conjuntamente em uma rede de assistência, referência e contrarreferência. Nos últimos anos, o SUS foi responsável por 60% das adaptações de aparelhos de amplificação sonora individuais (AASIs) (4) , sendo esta indicação a alternativa mais comum na maioria dos casos de perdas auditivas neurossensoriais, com comprovado benefício e melhora na qualidade de vida dos indivíduos afetados (5) . ...
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... A triagem auditiva neonatal pode ser realizada de maneira universal, para todas as crianças nascidas ou para as que apresentam fatores de risco para a perda auditiva. Estima-se que a prevalência de deficiência auditiva neonatal é de aproximadamente 1 a 3 em cada 1.000 recém-nascidos, e aumenta para de 1 a 6 em cada 1000 em bebês provenientes de unidades de terapia intensiva neonatal [10][11][12][13]6 . Quanto menor a idade gestacional (menos que 30 semanas) e o peso ao nascimento ( inferior à 1500g), maior a chance de falha na triagem auditiva. ...
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This study employs statistical modeling and mapping techniques to analyze the availability and accessibility of audiologists (practitioners who diagnose and treat hearing loss) in the United States at the county scale. The goal is to assess the relationships between socio-demographic and structural factors (such as health policy and clinical programs which train audiologists) and audiologist availability. These associations are analyzed at the county level, via a mixed effects hurdle model. At the county level, the proportion of older adults reporting difficulty hearing is negatively associated with audiologist supply. The findings show that audiologists tend to locate in metropolitan counties with higher median household incomes, younger populations, and lower proportions of older adults reporting hearing difficulty, suggesting an inverse care-type relationship between audiologist availability and need for hearing health services. Notably, neither state legislation requiring insurance plan coverage of hearing services for adults or Medicaid coverage of audiology services were significant predictors of audiologist supply at the county level.
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Few of the low and middle income countries have national plans or programmes forprevention of hearing loss. WHO believes that strong national plans need to be alignedwith its own programmes and policies in order to achieve people-centred care deliveredthrough strong integrated health systems. It has followed up this ideal with the setting ofindicators and targets to measure the number of Member States that are implementingcomprehensive national plans on this subject together with relevant strategiesrecommended by the World Health Organisation (WHO).The following three mega-countries have already taken the lead and developed plansto prevent hearing loss and commenced to implement them. All of them are differentaccording to differing national needs, but all of them are attempting to reduce the burdenof hearing loss in the most effective way possible. How they are doing this is set out inthe following pages.
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The objective of the study is to investigate the results of the newborn hearing screening program carried out in a Public Hospital in Brazil, in the first 3 years regarding: (1) the prevalence of hearing impairment; (2) the influence of the universal hearing screening program on the age at which the diagnosis of hearing loss is defined; (3) the cost effectiveness of the program; (4) the outcomes, in terms of the age in which the hearing rehabilitation started. A descriptive study of the first 3 years after starting the universal newborn hearing screening in a Public Hospital of Bauru, São Paulo state, Brazil. The screening method consists of a two-stage screening approach with transient otoacoustic emissions (TOAE), conducted by an audiologist. If the outcome in the second-stage screening is REFER, the infant is submitted to diagnostic follow-up testing and intervention at the Audiology and Speech Pathology Clinic at the University of São Paulo, campus of Bauru. The evaluation of the costs of the universal newborn hearing screening program per each screened newborn (around 4000/year) was done based on a proposal by the National Center for Hearing Assessment and Management, of the Utah State University, United States of America. 11,466 newborns were submitted to hearing screening, corresponding to 90.52% of the living newborns. The prevalence of sensorineural hearing loss was 0.96:1000. Of the 11 children with sensorineural hearing loss, eight children received hearing aids and five started the therapeutic process before the age of 1. Currently, four children between the ages of 11 months and 2 years old were submitted to cochlear implant surgery. The cost of hearing screening was US$7.00 and the annual cost of the universal newborn hearing screening program was US$26,940.47. The hospital-based universal newborn hearing screening carried out through the Brazilian National Health System is viable, with promising results. However, in a country such as Brazil, which presents large socio-economic differences, the same type of analyses should be performed in several regions, so as to take into account specific aspects, to implement the newborn hearing screening along with the Public System.
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