Global Audiology/Europe/Belgium

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General Information

Table 1. Country information [2020]

Population	+/-11.500.000
Area	30.689 km²
GDP (PPP)	550 billion USD
Languages	Dutch (ca. 60% of population); French (ca. 40% of population); German (ca. 0,7% of population)
Currency	Euro (€)

The Kingdom of Belgium is a sovereign state in Western Europe bordered by France, the Netherlands, Germany, Luxembourg, and the North Sea. It is a small, densely populated country. Belgium is home to two main linguistic groups: the Dutch-speaking, mostly Flemish community, which constitutes about 60% of the population, and the French-speaking, mostly Walloon population, which comprises 40% of all Belgians. Additionally, there is a small group of German-speakers who live in the East Cantons, located around the High Fens area and bordering Germany.

Historically, Belgium, the Netherlands, and Luxembourg (along with parts of Northern France and Western Germany) were known as the Low Countries; it once covered a somewhat larger area than the current Benelux group of states. From the 16th century until the Belgian Revolution in 1830, when Belgium seceded from the Netherlands, the area of Belgium served as the battleground between many European powers, causing it to be dubbed the “Battlefield of Europe,” a reputation strengthened by both world wars.

Today, Belgium is a federal constitutional monarchy with a parliamentary system of governance. It is divided into three regions and three communities that exist next to each other. The King (Philippe I) is the head of state, though with limited prerogatives.

Belgium’s strongly globalized economy and its transport infrastructure are integrated with the rest of Europe. Its location is at the heart of a highly industrialized region.

Since the country’s independence, Roman Catholicism, counterbalanced by strong freethought movements, has played an important role in Belgium’s politics.

Basic education is situated between 3 and 18 years of age for Belgians and is compulsory from 6 to 18 years. Among the Organization for Economic Co-operation and Development (OECD) countries in 2002, Belgium had the third highest proportion of 18- to 21-year-olds enrolled in postsecondary education, at 42%.

Today's Belgium has seen the flourishing of major artistic movements that have had tremendous influence on European art and culture.

Some famous painters: Jan van Eyck, Peter Breughel, Peter Paul Rubens, James Ensor, René Magritte, Luc Tuymans

Some famous architects: Victor Horta, Henry van de Velde Some famous musicians: Jacques Brel, Adolphe Sax, Toots Thielemans, Stromae, dEUS Some famous authors: Hendrik Conscience, Georges Simenon, Amélie Nothomb

Some famous comic books: The Adventures of Tintin by Hergé, The Smurfs by Peyo, Lucky Luke

Belgium is famous for beer, chocolate, waffles, and fries with mayonnaise. Popular sports in Belgium are soccer, cycling, tennis, swimming, judo, and basketball.

Some famous athletes: Eddy Merckx, Philippe Gilbert, and Tom Boonen (cyclists); Jean Marie Pfaff (goalkeeper); Kim Clijsters and Justine Henin (tennis); Jacky Ickx (rally); Stefan Everts (motorcross).

History of Audiology

Summarized and translated from Verstraete, 2016.

History of Education and Rehabilitation of Deaf Children

The so-called "Institute for Deaf Girls" in Ghent, the first Belgian school for deaf girls aged 10 to 18, was founded in 1820 by Canon Triest (1760-1836). He sent a novice to Paris to study and learn the method of Abbé de l'Epee (sign language). In 1867, David Hirsch (of Rotterdam, the Netherlands) taught the novices the German Method, based on articulation and lip-reading. In 1868, the Mixed Method was introduced, which combined sign language and speech. Later, the institute became convinced that the oral method had the most benefits in educating deaf children (1881).

In the early years of the 20th century, oral education was greatly improved by the introduction of the Belgian method (Alexandre Herlin). This method was inspired by the educational principles of Ovide Decroly and laid the groundwork for the elaboration of the "Reflective Native Language Method" by priest-psychologist Antoon van Uden. The Belgian method is a global method in which words, sentences, and conversations are the baseline. The long and tedious analytical and alphabetical exercises were abolished.

With the installation of the "radio" (an amplifier and a connection microphone combined with various helmets) in 1936, a new era had begun; it meant the introduction of an aural component in oral education.

As quoted above, from 1947 to 1966, the "Reflective Native Language Method" of Antoon van Uden was used. The method is based on everyday language and tries to combine it with learning language rules.

In the mid-1950s, a kindergarten for deaf boys and girls and an institute for higher economic education for the deaf were founded. In 1965, the "Laboratory for Voice, Speech, and Language Research" was founded, but in 1968, it transformed into a rehabilitation center. Meanwhile, the verbotonal method developed by linguist Petar Guberina (Zagreb, Yugoslavia) made its introduction in Flanders. This method starts with the optimal hearing spectrum and the reinforcement of the child's residual hearing. Perception encourages speech, and hearing is the basic condition for speech. The verbotonal method includes four disciplines: individual therapy with hearing training and speech and language development; corporal rhythm; musical rhythm; and group therapy with audiovisual and structural components.

In the late 1960s, kindergartens and elementary schools for deaf children were established, sometimes combined with (semi) boarding schools; in the early 1970s, day nurseries with a mix of deaf and hearing babies were opened.

Different rapid successive evolutions can be determined in the following years:

• Good audiometry led to better diagnostics, which resulted in the differentiation between "hearing impaired" and "deaf."
• Class amplification systems were introduced in 1966 and FM systems in 1974.
• In 1979, the Ministry of Education introduced the first integration project for deaf children in the regular educational system.
• A universal early hearing screening of babies or toddlers between 9 and 13 months was installed in 1980. Initially, the distraction test (based on the orientation reflex on familiar sounds), also known as Ewing's test, was used. Since 1998, ‘Child and Family has used the highly reliable AABR-test in the first 4 to 5 weeks after birth. A successful structured follow-up system is in place.

These developments—the early screening and rehabilitation, the use of wireless FM equipment, and the integration project—stimulated the school integration of deaf and hearing-impaired children. In different rehabilitation centers (geographically spread), aural rehabilitation was offered, completed with parental, and environmental guidance and counseling.

History of Sound Amplification and Hearing Aids

In the 19th century, mechanical hearing aids such as the horn were "sold" on the Belgian market. At the beginning of the 20th century, carbon microphones were introduced. In the post-war year of 1947, the transistor was invented, a revolutionary step in hearing aid technology. In the mid-1960s, body-worn hearing aids made an appearance. A milestone in the evolution of the use of hearing aids was the use of FM.

From that moment on, remarkable and steady improvements in sound reinforcement and hearing aid technology were visible: developments in the miniaturization of devices, digital techniques (from 1988), evolution in fitting possibilities in signal processing (the CROS-fittings, open fits), developments in the aesthetics of hearing aids and other aids, cochlear implants (1988) and other implants, Bluetooth, the evolution of hearing aids to hearing solutions, etc. The adaptation of hearing aids and other assistive listening devices is much more than just a technical adjustment. This is seen as part of a comprehensive approach in relation to the individual and environment-oriented aspects of the person with a hearing loss.

History of Medical Audiology

Medical audiology (hearing and balance) had the same rapid and continuous evolution as hearing aid technology, in subjective and semi-objective techniques as well as in objective audiometry.

History of the Education / Profession of the Audiologist

Throughout the years, the role of the audiologist has changed and expanded. Nowadays, the audiologist is the health care professional who works in the prevention of and screening for noise-induced hearing loss (NIHL), clinical and diagnostic audiology, hearing aid and cochlear implant fitting, rehabilitation, and tinnitus management.

Incidence and Prevalence of Hearing Loss

Unfortunately, there are no clear general figures on the incidence and prevalence of hearing loss in Belgium. There are only general estimates of hearing loss in Belgium.

Hearing Loss

Based on the most recent numbers within the EuroTrak studies, the prevalence of self-reported hearing loss in Belgium is 9.6%, or 1.10 million citizens. Table 2 shows an increase in the prevalence numbers from 2.3% in the youngest age group (<15 years) up to 33.7% in the oldest age group (>74 years).

Congenital Hearing Loss

Kind en Gezin (Child and Family) is a governmental agency that works actively in the "Public Health, Welfare, and Family" policy area. This Flemish agency focuses on preventive treatment and guidance of young children until school age, geared toward good outcomes in the future. This agency is, among other things, responsible for newborn hearing screening. Table 3 shows that in 2017, unilateral or bilateral congenital hearing loss was determined in 1.88 of 1,000 newborns.

Hearing aids

The Joint Report of the European Associations AEA, EFHOH and EHIMA shows that the uptake of hearing aids by Belgian people with self-reported hearing problems in 2017 was 30.7%, which was a little less than the European average of 33%. In 2019, the uptake in Belgium increased to 32.6%. These numbers are based on the refund of hearing aids in Belgium by the National Institute of Sickness and Disability Insurance.

The growth potential in selling hearing aids remains relatively high, considering that the Belgian population is growing older and the demand for a hearing aid increases with age.

Information About Audiology

Educational Institutions

In Belgium, there is a professional bachelor's and master's program in audiology. Both lead to the same protected title of "audiologist" or "audicien" (hearing aid specialist).

Professional Bachelor in Audiology

There are five institutions of higher education that offer a professional bachelor's program in audiology.

For the Flemish-speaking part:

• Artevelde University of Applied Sciences, Ghent
• HOGENT, Ghent
• Thomas More University of Applied Sciences, Antwerp
• Vives University of Applied Sciences, Bruges

For the French speaking part

• Marie Haps Institute (Haute École Léonard de Vinci), Brussels

These programs cover 180 European Credit Transfer and Accumulation System (ECTS) credits, spread over 3 years. In the Flemish-speaking part, all the audiology programs are linked with the professional bachelor program in speech and language therapy, with at least 60 and up to 120 ECTS-credits in common.

Master in Speech-Language Pathology and Audiology Sciences: Specialization Audiology

Two universities offer a master's program in speech-language pathology and audiology sciences with a specialization in audiology, both in the Flemish-speaking part of Belgium:

• Ghent University
• Catholic University of Leuven

These programs cover 300 ECTS-credits, spread over a 3-year academic bachelor's course followed by a 2-year master's study. These master's programs are more or less in line with the master's program with a specialization in speech-language pathology.

Both bachelor and master programs contain essentials such as psychology, communication, health care, physics-acoustics, (electro)technology, anatomy, neurology, pathology, geriatrics, speech and language development, (neuro- and psycho-)linguistics, ethics, law, organization, management, marketing, mathematics, statistics, and IT. It also covers the necessary knowledge and skills needed to practice clinical audiology and vestibulometry, hearing aid fitting and cochlear implantation, aural and vestibular rehabilitation and counseling, sound measurements, and the prevention of hearing loss. Students work on a scientific research project and complete a compulsory 600 hours of practical training. All of this is prescribed in the law protecting the profession of audiologist/audicien (Koninklijk besluit betreffende de beroepstitel en de kwalificatievereisten voor de uitoefening van het beroep van audioloog en van audicien, 2004).

The aim of the professional bachelor's programs is to offer the theoretical knowledge, practical skills, and essential attitudes needed to function as an audiologist in the four main domains of audiology. The master's program offers a strong theoretical and scientific basis in the academic bachelor's year and in-depth knowledge and skills across different clinical domains in the master's year, in addition to focusing on management skills and research.

Websites of the universities and university colleges of applied sciences:

• www.arteveldehogeschool.be
• www.hogent.be www.thomasmore.be
• www.vives.be www.ugent.be
• www.kuleuven.be
• www.vinci.be
• www.ilmh.be

Audiology Practice: Public & Private

Clinical audiology, (aural and vestibular) rehabilitation, and cochlear implantation are considered public services. The main costs are covered by the National Institute for Health Insurance. The assessment, fitting ,and therapy requires a prescription from ENT specialist and care conducted in a recognized clinic, rehabilitation center, or implant center

The hearing aid fitting is also a public service. A prescription from the ENT specialist is required to cover a portion of the patient's costs; however, the reimbursement rates are fixed. There are guidelines and obligations concerning the assessment, trial period, and condition of hearing aids. However, in this domain, the audiologist can either work in a recognized audiological center or in a private practice.

Unfortunately, at this moment, tinnitus assessment and therapy are not covered by the general social health care system.

Professionals

Table: Ear and Hearing Care Professionals in Belgium (Jaarstatistieken mbt beoefenaars gezondheidsberoepen België, 2018/12/31)

Professionals	Approximate Number	Ratio to the Population
Audiologists	1,238	1/9,289
Audiciens (Hearing Aid Specialists)	1,794	1/6,410
Otolaryngologists	755	1/15,232
General Practitioners	16,263	1/707
Speech-Language Pathologists	14,955	1/769

Audiological & Audicien (Hearing Aid Specialist) Services

Clinical / Diagnostic Audiology

• screening for hearing loss
• objective and subjective audiometric evaluation of auditory, vestibular and otoneurological functions, including auditory processing disorders
• assessment of tinnitus/hyperacusis

Hearing Aid Fitting

• amplification of mechanical, electroacoustic and electronical devices (hearing aids, technical / aided devices, and implants) in people with all different types of hearing loss (and multiple / complex needs) and includes advising and guiding family and environment

Rehabilitation

• aural rehabilitation including hearing, communication and social skills training, counseling, guidance
• vestibular rehabilitation
• rehabilitation/management of tinnitus/hyperacusis
• management of auditory processing disorder

Prevention / Noise Management

• prevention of and sensibilization for (noise induced) hearing loss
• noise measurements (sonometry, dosimetry)
• amplification of noise protection systems

Educational Audiology

• services for school children
• screening for minimal/unilateral hearing loss
• class amplification
• maintenance of hearing aids
• set-up and maintenance of assistive listening devices (e.g. FM-systems)
• education and guidance of teachers/school environment

Audiologists in Belgium work in different settings (see table):

1. University, clinics, hospitals and otolaryngology offices
2. Private audiology practices
3. Rehabilitation centers
4. Educational institutes
5. Industry

Services Offered by Otolaryngologists

Otolaryngologists oversee the medical and surgical management and treatment of patients with diseases and disorders of the ear, nose, throat (ENT), and related structures of the head and neck.

In the domain of ear disorders, otolaryngologists are trained in both the medical and surgical treatment of external and middle ear disorders, perceptive hearing loss, balance disorders, and tinnitus with all possible causes.

Scope of Practice and Licensing

The paramedical profession of audiologist is protected by a Royal Decree (Koninklijk besluit betreffende de beroepstitel en de kwalificatievereisten voor de uitoefening van het beroep van audioloog en van audicien, 2004, 4th of July).

This law prescribes:

• The necessary education: at least 3 years of bachelor's or master's training, covering different aspects (theory/skills/practical training/thesis) described in Educational Institutions
• The acts or services audiologists are allowed to provide are described in Services offered by audiologists.
• All the acts that can be conducted without a prescription of a physician; that need a prescription of an ENT specialist; and/or that need to be on a prescription of a rehabilitative physician.

Only persons who meet the necessary education mentioned above can work as an audiologist. Certain services provided by the audiologist can only be covered by the audiologist, such as the hearing aid fitting. On the other hand, some of the services provided by the audiologist can also be covered by other professions (e.g., clinical diagnosis by the ENT specialist, rehabilitation by the speech and language therapist, sound measurements by an engineer or prevention manager, universal early hearing screening, and school-age screening by trained nurses).

Professional and Regulatory Bodies

Regulatory Bodies in Audiology

All persons holding an audiology degree (bachelor's or master's) that meets the qualification requirements of the Royal Decree of 2004, need ratification and a visa in order to work as an audiologist.

Technically, there are two separate ratifications, which over time have been combined: "audiologist" and "hearing aid fitter" (known in Belgium as ‘audicien’). In the past, a person could be a hearing aid fitter but not an audiologist (medical audiology, rehabilitation, etc.). For all new applicants who covered the same compulsory educational bachelor or master training since 2004, these two will always be granted at the same time.

First, ratification as a paramedic is required. In Flanders, the ratification is provided by the regional Agency of Care and Family. Ratification committees will give negative or positive advice on the application. In Wallonia, the Ministry of Education is responsible. After the ratification, the agency or ministry will communicate with the Federal Public Service Health, Food Chain Safety, and Environment, who administer the actual visa. In addition, audiologists working in hearing aid fitting need a ratification number from the National Institute for Health Insurance and Invalidity.

Professional Organizations in Audiology

The UCBA/CEUPA is the Executing Committee of Audiology Unions in Belgium, established in 1989. Six audiology unions are associated in this UCBA/CEUPA.

• UBDA (Union Belge des Audiologues)
• BGV-ABA (Belgische Vereniging Gehoorprothesisten)
• UNAS-NUAS (Nationale Unie Audio Specialisten)
• BVA –UPA (Beroepsvereniging van Audiciens)
• VBA (Vlaamse Beroepsvereniging Audiologen)
• VOAA (Vereniging Onafhankelijke Audiologen en Audiciens)

The UCBA/CEUPA is a member of the Association Européenne d’Audioprothésistes (AEA).

All of the unions mentioned above try to unify audiologists in Belgium, in order to defend professional concerns.

• Suggest the government's regularizations, laws, decrees, etc.
• Advise educational institutes concerning professional and educational profile of the audiologist
• Guide over an ethical/deontological code
• Guide over a scientific approach of the profession

The VBA (Vlaamse Beroepsvereniging Audiologen) developed the ethical code mentioned above (2016), which is recognized by the UCBA/CEUPA and the AEA.

http://www.vbaudiologen.be/UCBA-CEUPA-Deontologische-code-voor-Audiologen-en-Audiciens.pdf

Scientific Organizations in Audiology

In addition to abovementioned societies, B-audio is the Belgian audiological society with focus on scientific research. It is affiliated with the Royal Belgian Scientific Society for ENT-ORL. The most important objective of B-Audio is the promotion of information exchange in audiology, with the following activities:

• gather the critical mass, and stimulate discussion and collaboration in the field of audiology in Belgium, across the different related disciplines (ENT, hearing aid professionals, audiologists, researchers, teachers, etc.)
• regular organization of sessions at a scientific congress
• organization of training and education
• maintain relations with international audiology-organizations.

Audiology Charities

ONICI – independent information center on cochlear implants

AHOSA

Association of Menière patients

VLOK-CI – Flemish parents of children with cochlear implants

Fevlado – Federation of Flemish Associations for the Deaf

Onder Ons - Association for adult hearing-impaired persons

De tuut van tegenwoordig – platform for youth with tinnitus

Challenges, Opportunities and Notes

Challenges

The rapid technological evolution encourages audiologists, especially in hearing aid fitting and cochlear implantation, to pursue lifelong learning. More audiologists should be more comprehensively trained in tinnitus management, since there are long waiting lists for patients. There should be more sensibility in the developed guidelines on hygiene in audiological practice. The guidelines should be applied in all settings. The role of the school audiologist must find a stronger base, possibly through supportive educational agencies.

References

		Contributors to the original text
Griet De Smet	Melina Williams