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Country Name	Chile
Population	19,828,563 (Estimated for June-30-2022) (National Institute Statistics of Chile (INE), 2022a)
Area	292,260,029 Square miles 774,558 square miles (Excluding Continental Sea) (INE, 2022b)
GDP (PPP)	252.9 billion USD
Currency	Chilean Peso (CLP)
Official Language(s)	Spanish
Language of original towns	Aymara, quechua, ckunza, rapa nui, kawésqar, yagán y mapudungun (Ministry of Culture, Arts and Heritage of Chile, 2012).

Demographic Information

The independence process of Chile took place from 1810 to 1823. After the decisive patriot victory in the Battle of Maipú, this phase culminated in 1823 with the abdication of O'Higgins as Supreme Director and declaration of national independence and the consequent search for a political project through which Chile was to be organized.

Chile is a country in South America, located between the highest segment of the Andes Mountains and the Pacific Ocean. Is one of the longest countries in the world, at 4,300 km in length, but also one of the narrowest, with an average width of only 180 km (Gobierno de Chile, 2022).

One of the most characteristic things about Chile is its geographical diversity. Chile has three continental zones, so it is defined as a three-continental country.

One of these is continental Chile, including between the southeastern shore of the Pacific Ocean to the highest peaks of the Andes mountain range.

The second geographic zone is insular (island) Chile, which corresponds to a group of islands of volcanic origin in the South Pacific Ocean.

The third area is the Chilean Antarctic Territory, which is an area of Antarctica of 1,250,257 km² between meridians extending its southern limit to the South Pole (Gobierno de Chile, 2022).

These different demographic zones along the country allow a wide cultural diversity and also, different languages in the same country.

History of Audiology

Audiology is the science that studies hearing in both health and pathology. The otorhinolaryngologist and audiologist have classically included this subject in their training, assuming in daily clinical practice the performance of the diagnostic tests, as well as introducing new technologies in our country.

At its inception, in the 1940s the discipline of otorhinolaryngology and audiology in Chile was influenced by the teachings emanating from the French and German schools. As a consequence of the European isolation due to the second world war, a group of young medicals specialists in otorhinolaryngology look for a path that would lead the Chilean ENT to catch up with the progress of medicine in general, following the new influences of renewal in this area coming from the United States (Cordaro, F., 2000). In those times in Chile, medicine with a specialty in otolaryngology was the unique profession related to this area. With the passing of years increased needs of the country in this topic, so other professionals with training and knowledge of audiology were required to work together with the physicians with specialty in otolaryngology. Thus, the disciplines of phonoaudiology and medical technology with otolaryngology specialty were born in our country.

The beginnings of the Phonoaudiology (Speech and Language Therapist) Career take place in the decade of the 50s from the effort and vision of some academics from the Faculty of Medicine of the University of Chile. From this initiative, in 1958 twenty-one female students graduated with the title of speech therapists. Subsequently, from 1971 to 1972 with the support of ENT medicals and speech therapists, was officially created the Phonoaudiology Career of the University of Chile to contribute to carried out rehabilitation tasks in people with disorders in the areas of voice, speech, language and/or hearing (Colegio de Fonoaudiología, 2020).

On other hand, The School of Medical Technology began as a technical school and hospital administration in 1948 in Chile for professionals training, to develop research and to support the functioning of the hospitals and other health care services. On March 1960 the first The School of Medical Technology in Chile with a university character in the Austral University of Chile in Valdivia was created, and on December 5, 1960, the Superior Council of the University of Chile founded the School of Medical Technology, annexed to the School of Medicine and the School of the National Health Service (Colegio de Tecnólogos Médicos de Chile, 2013).

From 1974 to 1975 the specialty of otolaryngology was created in The School of Medical Technology of the University of Chile to contribute to the diagnosis and rehabilitation of people who have alterations in their hearing and balance functions, in addition to evaluating alterations in nasal function and sleep disorders, also to participate prevention programs for hearing loss in newborns, childs, teenagers, adults, elderly people, workers, and so on (University of Chile, 2013).

Currently the ministry of health of Chile recognizes medical technologists with specialty in otorhinolaryngology and phonoaudiologists with a postgraduate degree in audiology as audiologists.

Incidence and Prevalence of Hearing Loss

According to the epidemiology data (Ministry Health of Chile (MINSAL), 2022) there are about 1,160,126 individuals suffering from hearing loss and require hearing aids to improve their functionality in Chile. According to the National Health Survey the prevalence of hearing loss at 2009-2010 was 32.7% and at 2016-2017 was decreased to 22,5% (Health Ministry of Chile, n.d.).

According to the II National Study on Disability conducted by SENADIS (National Disability Service) in 2015, ear diseases (hearing loss or deafness) represented 31.4% of people with hearing loss over 18 years old with disabilities (SENADIS, 2015). The incidence is between 1-3 per 1,000 live births susceptible to cochlear implant treatment (Health Ministry of Chile (MINSAL), 2022).

In Chile, the burden of hearing loss, measured by years lost due to disability, is 1.88% (1.44%-2.45%). However, this percentage rises to 3.03% (2.26%-3.94%) in the population over 70 years of age (Health Ministry of Chile (MINSAL), 2022).

According laboral health data of Chile from Social Security Superintendence (SUSESO), the hearing loss due to noise and ototoxic exposure is now one of the top five of illnesses that have an occupational origin (Superintendencia de Seguridad Social, 2022).

Information About Audiology

Educational Institutions

In Chile, the audiology discipline is a mainly university specialty that is taught in the undergraduate careers of phonoaudiology, medical technology and medical.

The medical technology in otorhinolaryngology career and Phonoaudiology career has a duration of 5 years, and it is conducted in Accredited state and private Universities of Chile.

On the other hand, ENT Physician is a specialty which has a duration of 3 years, and to this end, firstly, requires a general medicine undergraduate degree of 7 years and it is also conducted in Accredited state and private Universities of Chile.

At the present time, we can find in universities master degrees and graduate programs offering postgraduate degrees in audiology. There are also training courses in the audiological area, focused on careers such as nurses, medicine, and other healthcare professionals.

Audiology Practice:Public vs Private

The health system in Chile is considered a mixed system, which includes entities of the Public and Private Health Network, composed of primary, secondary and tertiary care facilities. Also, they have connection with health services from others institutions like National Board of School Aid and Scholarships (JUNAEB), which is a public organization that depends on the Ministry of Education of Chile, and laboral system health that include health laboral units where provide laboral health services covered by law 16.744.

The levels of health care have different public and private facilities that are interconnected to provide health care in Chile related to audiology services (figure 4).

Figure 1 shows an outline of the interaction of health system and levels of care in Chile, where the primary health attention related to audiology takes place in Otorhinolaryngology Primary Care Units (UAPORRINO), where attention is provided by ENT, audiology laboratory test, otoneurology or vestibular laboratory test and rehabilitation. Primary health care is also coordinated with JUNAEB's medical services. When the complicated audiology health cases are referred to secondary health attentions like Diagnostic and Treatment Center (CDT), Specialties Care Center (CAE) or Health Reference Center (CRS). Also in this health attention level exist private establishment health, where anyone can be attended following the same steps for evaluation and treatment. The tertiary health attention of audiology in Chile is conducted in 37 public hospitals and 204 private establishment health. On the other hand, the net of health includes laboral health system that refers audiology patients to secondary health attention facilities when the ear problem doesn't have work-related causes.

Figure 1. Level of Primary, Secondary and Tertiary attention related to hearing health and their connections

The health system of Chile operates through two insurance systems of care which include public insurance, called national health fund (FONASA) and a private health care system called Social Security Health Institutions (ISAPRE). Also the Private Health Providers like hospitals, clinics and independent professionals attend both ISAPRE policyholders and FONASA contributors.

In Chile, anyone can choose if their healthcare system will be from the state or private, and in both systems, a worker has the obligation to contribute monthly a percentage from their salary. The percentage is 7% in FONASA and in ISAPRE is 7% or more, due to it may increase according to the health care plan, besides the worker comorbidities and fertile age in the case of women. The audiology health care is covered by both systems (Becerril-Montekio, et al., 2011).

Furthermore, to help cover the cost of diagnosis and treatment of hearing loss in Chile the state has state policies to cover it, like the explicit health guarantee (GES), law Ricarte Soto and JUNAEB health program (Cáceres, M., 2021).

The explicit health guarantee (GES) is a specific subset of medical care guaranteed by law for everyone in the system FONASA or ISAPRE to facilitate access to benefits of 85 health care problems that today is included in the GES list (Here). In the audiology matter, there exist GES 56, GES 59 and GES 77.

GES 56. Bilateral hearing loss in people aged 65 years and over who require the use of a hearing aid: It benefits hearing aids to patients with bilateral hearing loss aged 65 and over within 45 days after diagnosis confirmation. It covers the pay of hearing aid fitting cost (fitting and controls), covering from 80% to 100% of total cost service through copayment, according to the patient's insurance system of care (level of FONASA or ISAPRE). For more details, you can see the translated document here
GES 59. Bilateral sensorineural hearing loss in premature infants: It guarantees the access to health care and treatment required which can be through hearing aids or cochlear implants, to premature and/or risk factors newborn. It covers from 80% to 100% of total cost service through copayment, according to the patient's insurance system of care (level of FONASA or ISAPRE). For more details, you can see the translated document here
GES 77. Treatment of moderate, severe and profound hearing loss in children under 4 years: It guarantees the access, treatment, supplies and implements as a hearing aid or cochlear implants to children below 4 years old with bilateral hearing loss, also it includes controls. It covers from 80% to 100% of total cost service through copayment, according to the patient's insurance system of care (level of FONASA or ISAPRE). For more details, you can see the English version document here.

For those patients outside the GES coverage, the Law 20.850, also named Ricarte Soto’s law, provides financial support for high cost diagnose and treatment pathologies. In matter of audiology this law provides a pays one cochlear implants unilateral, replace accessories, and the speech processor every 5 years to patients with bilateral severe or profound post-lingual sensorineural hearing loss, from the age of 4, who meet the criteria for inclusion establishes by the committee of clinical experts of the approved provider. For more details, you can see the English version document Here.

The students from second years of primary school to Secondary school receive hearing care from the National Board of School Aid and Scholarships (JUNAEB), which provides attention by ENT, audiology laboratory test, hearing aid fit and cochlear implants and hearing rehabilitation to students of Chile.

In addition, as mentioned above, in Chile we have a laboral system health covered by Law 16.744, that guarantees laboral audiology health care in aspects of prevention, monitoring for hearing conservation, hearing health surveillance, identification of hearing loss in workers exposed to laboral agents that cause damage to the hearing organ, hearing aid fit and cochlear implants, hearing rehabilitation and labor reinsertion to ear occupational diseases. Mutuals and delegated bodies are responsible for giving the health benefits to workers in Chile.

A graphic illustration of all these cover systems across the lifespan in Chile is presented in figure 2.

Figure 2. Hearing health coverage across the lifespan in Chile

For its part, members of the armed forces (Army, Navy, Aviation and Police) and their families are beneficiaries of a non-FONASA and non-ISAPRE health insurance that provides care at their own health facilities and providers where they receive audiology health attentions like ENT attentions, audiology laboratory test, otoneurology laboratory test, hearing aid fit and cochlear implant and rehabilitation (Becerril-Montekio et al., 2021, 132-143)

Patients can also take any audiology services like out-of-pocket payment (without FONASA or ISAPRE) and also they can go directly to hearing aid branch office to receive evaluation and fit hearing aid.

Figure 3 shows an outline of the main financing components of the private, public and armed forces health care systems in Chile. The public and private agencies in which these services are provided are also shown.

Figure 3. Public, Private and Armed Forces Health care system.

Services Offered by Otolaryngologists and Audiologists.

The otolaryngologists in Chile offered service ear related diagnosis and management of acute and chronic pathologies. Also, this professional performs surgical procedures like Vestibular schwannoma surgery, intratympanic gentamicin treatment, cochlear implant surgery, head and neck surgery.

The audiologist in Chile (Medical technologist with specialty in otolaryngology or Phonoaudiologist with postgraduate degrees in audiology) offer service ear related testing hearing and balance functions made in audiology and otoneurology lab to contribute with diagnosis of patients. Also contribute to the hearing and vestibular rehabilitation.

Audiological Service

In Chile, the services offered by Otolaryngologists related to audiology are medical procedures and they are given by doctor's visit to ambulatory and hospitalized patients. The surgical procedures are given in the surgical room

The audiological services offered by Audiologist are procedures of laboratory to test status hearing system and vestibular system, also to make hearing rehabilitation and vestibular rehabilitation. These services are made in Laboratories of audiology, otoneurology and rehabilitation. Also, some hearing testing services are marked in patients' rooms (like OAE to newborn) or workplace (audiometry test to hearing conservation program). However, all audiology testing depends on the administration of the respective laboratory. Furthermore, the audiologist offers the service of monitoring and mapping cochlear implants.

To more details about audiological services in Chile see table 1

Table 1. Details of audiological service in Chile

1. Audiological Service by Otolaryngologists
Doctor's visit in medical consultation or Hospital Room ● ENTs through medical assessment of ear and hearing health in doctor's visits can find the root of the problem and determine the best method of treatment (prescription for use of medication or medical devices, like hearing aid, cochlear implant, and so forth). In case of the ENT requiring more information to diagnose could refer the patients to a hearing test with an audiologist to audiology/otoneurology lab. Surgical procedures ● Tympanostomy ● Tympanostomy tube insertion ● Tympanoplasty ● Mastoidectomy ● Stapedectomy ● Cochlear implant ● Bone conduction implants ● Middle ear implants ● Intratympanic steroid injection
2. Audiological Service by Audiologist
Audiology/Otoneurology Laboratory: ● Hearing audiologic evaluation: Dedicate to assess the hearing function in patients along the lifespan in social, laboral and common aspects through a battery test that include Otoscopy and ear wax management, audiometry, tympanometry, otoacoustics emission, auditory brainstem evoked potential, free field audiometry testing, conditioned play audiometry, Auditory processing disorder test. These testing can be made to diagnosis, screening programs and hearing conservation programs. ● Evaluation of Balance: The audiologist can assess the vestibular performance using test like caloric test, vestibular evoked myogenic potentials (VEMP), vertical visual subjective, Videonystagmography and electronystagmography, head impulse test, Video Head Impulse Test (vHIT), McClure and dix hallpike test, rotatory chair, static and dynamic posturography. ● Measurement of hearing protector attenuation: This process involves using audiometric techniques to measure hearing thresholds both with and without the hearing protectors in place. Rehabilitation Laboratory: ● Audiologic rehabilitation: The audiologist participates in audiologic rehabilitation making the assessing hearing according to the candidate's characteristics and prepares a report on each one to select, dispenser and sett hearing aids and implant calibrations for the specific hearing loss and lifestyle of the patient aimed at optimizing a person's ability to hearing and participate in activities that have been limited as a result of hearing loss. The audiologist also executes the audiometric control in the time. The hearing rehabilitators perform evaluation of communication skills and language of the candidate and execute the re/habilitation auditory-verbal of implant patients or hearing aid users. ● Vestibular rehabilitation: Participate actively in the rehabilitation process for vestibular patients through exercise for rehabilitation, using exercises and balance rehabilitation unit (BRU) and reposition maneuvers for treatment of benign paroxysmal positional vertigo (BPPV). ● Tinnitus Treatment/management: To treat tinnitus it is important to identify the source of it. Due to the diversity of origins of tinnitus, to manage it the general audiologist participated in a multidisciplinary team, making the hearing evaluation and symptom analysis of tinnitus and its impact. This plays a fundamental role guiding the treatment in the different ways that could be done like, hearing Aid, counseling for sound therapy, cervical and temporomandibular treatment, neurosurgical procedure (made by physician), Treatment with medication, cognitive behavioral therapy (CBT). Surgical Room: ● Monitoring and mapping cochlear implant: The audiology measures the electrophysiological aspects of cochlear implants during the operation through to intra-surgical telemetry, and makes activation of the implant (turned on of electrodes) post-operative, and audiologic assessment and calibration.

Professionals

The table below (table 2) shows the number of professionals related to hearing care in Chile. This information was taken from the National Plan for hearing health and care of Chile, elaborated by the Health Ministry of Chile (Health Ministry of Chile (MINSAL), 2022).

Table 2. Amount of professionals per specialty

Professionals	Count	Source
ENT	585	Superintendence of Health
Audiologist (Medical technologist with specialty in otolaryngology or Phonoaudiologist with postgraduate degrees in audiology)	552	SOCHIAUDIO y SOCHIAR
Hearing Rehabilitators	5633	Superintendence of Health

Research in Audiology

Research in audiology in Chile is conducted in fundamental and applied research in topics of the prevention, diagnosis and treatment of individuals with hearing loss from different groups (newborn, child, young, students, workers, older, and so forth). The main institutions where researchers work are universities, hospitals and state institutes of investigations.

There are studies on animal models such as those carried out at the Institute of Biomedical science of the University of Chile, clinical test such as made in universities in the pre degree-and post-degree process, Alfonso Asenjo Neurosurgeon institute and The Public Health Institute of Chile (ISP by its Spanish initials).

In addition, there are scientific societies with the purpose to support the science and disclose the advances in the matter of audiology. Some examples are:

● Audiology society of Chile (SOCHIAUDIO by its Spanish initials)

● Otolaryngology society of Chile (SOCHIORL by its Spanish initials)

Some repository and science journal with audiology research of Chile:

● Repository of University of Chile

● Repository of The Pontifical Catholic University of Chile

● Science journal of Otolaryngology Society of Chile

● Repository of Public Health Institute of Chile

● Repository of University Andres Bello (UNAB)

Notable projects from Chile:

● Early Hearing Damage Prevention in Young People Project - HWG02 2019A

https://www.apec.org/publications/2021/09/early-hearing-damage-prevention-due-to-recreational-noise-exposure-in-young-people

https://aimp2.apec.org/sites/PDB/Lists/Proposals/DispForm.aspx?ID=2536

Professional and Regulatory Bodies

The practice of all health profession in Chile is regulated by the Health Code. It establishes that only those graduates of the University of Chile or another university recognized by the State may practice medicine. In this section consider the medicine practice of Otolaryngologists or ENT.

Furthermore, the Health Code indicated the specific functions for the other health professions. However, the audiologist is not included in it. However, audiology as a profession being part of the healthcare system, is regulated by entities of the health authority, which is divided into two: The Ministry of Health and the Regional Ministerial Secretariats (SEREMI).

Due to grow up of health system and emergence of others professional health in the last decades in Chile, the Health Code is reviewing by Ministry of Health to evaluated the include specific description and functions of others health professions related to audiology, like Medical technologist with specialty in otolaryngology and Phonoaudiologist.

Scope of Practice and Licensing

Chile has no specific regulatory bodies about practice and licensing in audiology, however to practice medicine and healthcare the university grade from University of Chile or another university recognized by the State is required like the Health Code established.

In laboral health to practice making a hearing test to set the disability level of a worker with a hearing professional disease has a certificate of competence granted by the Superior Education Establishment authorized is required.

Audiology Charities

The following are listed some organization related to audiology charity in Chile:

● Deaf Institute https://institutodelasordera.cl/

● Hearing loss corporation https://corporacionhipoacusia.org/donaciones

● National Service of Disability (SENADIS by its Spanish initials) https://www.senadis.gob.cl/pag/641/1950/programa_de_ayudas_tecnicas_2022

● Benefit baskets of municipalities

● Deaf’s Parents and Friends Corporation of Chile, Effeta.

Challenges, Opportunities and Notes

It is important to strengthen more public health policies related to ear and hearing care. Also the advance with modification of health code to include the Medical technologist with specialty in otolaryngology and Phonoaudiologist is necessary.

The Research required more Research Projects conducted by research associated groups from multicenter and not only isolated research. Also more funds to support the research in this topic are required.

In clinical topics the advance in implementation of universal screening to newborn is needed. Also encourage the use of standards about quality management and general requirements for the competence of testing in audiology laboratories of Chile to assure and demonstrate the quality and reliability of their results based on ISO standard, Ministry health regulations and national reference laboratory (Public Health Institute of Chile) recommendations.

Furthermore, strengthen refer from primary health system (UAPORRINO) to laboral health system is required to patients with ear disease with laboral cause is identified.

Finally, the biggest challenge is the implementation of action indicated into the National Plan of hearing health and ear care of Chile to 2021 - 2030 elaborated by the ministry of health.

Acknowledgements

T.M. ORL. Jose Luis Bahamondes Lira - Hospital San José

FLGa. Valentina Contreras Díaz

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