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Thursday, June 6, 2019

By Raymond H. Hull, PhD, CCC-A/SP, FASHA

In The Art of Listening Well,1 Eugene Raudsepp tells a story that clarifies what listening involves. A zoologist was walking down a busy street with a friend. In the midst of the honking horns and screeching tires, he told his friend, "Listen to that cricket!" The friend looked at the zoologist in astonishment and said, "You hear a cricket in all of this noise and confusion?" Without a word, the zoologist reached into his pocket, took out a coin, and flipped it into the air. As it lands and clinks several times on the sidewalk, a dozen heads turned to check it out. The zoologist said quietly to his friend, "We hear what's important to us."

Listening is an art developed at a conscious level because it is a critical part of communication. Many of us become good because it is something that we need and even want to do well. We actually participate in the process of communication when we become good and active listeners.

The art of constructive listening can be illustrated in the following situations2,3:

  1. If the person you are listening to asks your opinion about an important matter, answer directly and honestly. Don't hedge or try to circumvent your response to her or him. The person explicitly requested your opinion, so don't be afraid to give it.
  2. Don't deny the person's concerns by saying, "Oh…you're making too much out of it," or "You worry too much!" It is best to simply listen carefully and constructively, and allow the person to express herself or himself freely.
  3. When asked for your opinion, try diligently to see things from the other person's point of view. Share your viewpoint but don't stress it at the cost of suggesting that your opinion is correct but the other person is not.  
  4. When a patient shares his or her thoughts or concerns, do not interject your opinions before the person has finished talking. Even though you feel that you have the solution, interrupting is both inappropriate and disrespectful. It shows that you really didn't care to hear the patient's concerns, and you wanted to solve it quickly so you could go on with whatever you were previously doing. I feel that men are guilty of this more frequently than women.
  5. Give the person who is speaking cues that we are listening. Those involve both verbal and nonverbal cues that means being empathetic if the person with whom you are communicating is relaying a sad occurrence in her or his life. But do not demean by implying, "You poor thing!"
  6. No side glances! And, never look at your watch! That's a dead giveaway that you are not really interested in what the other person is saying.
  7. We determine the meaning of what is being said based on our own experiences, so it is important that we ask questions to confirm our understanding. Pay attention to the nonverbal aspects of what is being said, not just the words that are being spoken. Those include tone of voice and any gestures that are being used. Does the conversation partner appear excited, sad, or confused?
  8. Avoid miscommunication at all costs. By confirming your understanding by paraphrasing or rewording what we heard, you can avoid misunderstanding what was said. By asking, "Did you mean…?" or "Did I understand you to say…?" you can clarify the meaning and intent of what was said and avoid misunderstanding.
  9. Our own biases and prejudices can become a roadblock to listening. If we have already decided that we do not like or respect the one who is speaking, then listening constructively and with an open mind becomes difficult. Recognizing our biases is important. It gives us a basis for working to get over them.
  10. According to Marshall,4 tuning in is the very first step in achieving any level of effective listening. We must be both physically and mentally prepared to "tune in" It also means turning off any mind chatter—erasing anything else we are thinking about. The author advises suspending judgment regarding what someone is saying until he or she is done talking.            

Minor slip-ups in listening can have major repercussions.2 A manager who dreaded to see his secretary go away for a week vacation was angry when she left. The secretary later said, "I told my boss three times I was planning on taking my vacation in October. Apparently, he wasn't listening or it didn't register." The manager was either not listening to his secretary, or was somehow distracted when she was telling him about her vacation. One way or the other, however, there was a miscommunication as a result of this important part of communication called "listening."

Becoming a skilled listener requires work, self-discipline, and skill. Ask any good salesperson or negotiator about the value of listening in silence, and he or she will tell you that good listeners generally make more sales and better deals. As my mother said to me as I was growing into maturity, "Remember—people like good listeners better than good talkers!" And, to develop good listening skills, we need patience and practice.



Dr. Raymond Hull is a professor of communication sciences and disorders at Wichita State University in Wichita, KS. He has published books on rehabilitative audiology and interpersonal communication.


  1. Raudsepp, Eugene. "The Art Of Listening Well.", Inc., 1 Oct. 1981.
  2. Stovall, J & Hull, R (2016). The Art of Communication. Sound Wisdom Publishing, PA: Shippensburg.
  3. Stovall, J. & Hull, R (2018). The Art of Influence. Sound Wisdom Publishing. PA: Shippensburg.
  4. Marshall (2013)

Monday, April 22, 2019

By Pei-Hua Chen, PhD; Su-Fen Liu, PhD; and Tang-Zhi, Lim

Self-exploration is a dynamic process that helps people evaluate who they are as individuals and allows them to establish a concept of self. When a person recognizes who they are and what they are capable of, they may then need to gauge what rights they possess. However, this process does not come easily; it requires time, effort, questioning, and resilience.

Many teenagers with hearing loss face the problem of exploring their own identities while having to deal with hearing loss. They might face more problems and greater prejudice than teenagers without hearing loss do. In a report by Taiwan's ministry of health and welfare (2018), approximately 3,028 persons aged less than 18 years have been diagnosed with hearing impairment in Taiwan; half are teenagers, and they might suffer a potential identity crisis. our previous study interviewed 12 teenagers with hearing loss (9 girls, 3 boys) from mainstream schools, and their degree of hearing loss ranged from moderate to profound. Their ages ranged from 12–16 years old (m = 14.8 years old). All of them were able to communicate with others orally. every interview lasted between 1 and 1.5 hours. From the results of the study, we integrated several points of view to describe how these teenagers with hearing loss felt and what they experienced during their daily lives (Liu & Chen, 2017).

First, these teenagers with hearing loss may have switched roles or identities in different situations. they were only conscious of having hearing loss when they were in noisy environments, but most of the time, they noticed no difference between themselves and people without hearing loss.

"I don't think so, wearing hearing devices is just like wearing glasses, they are same," said participant 02-276. We found that half of the participants who had friends with hearing loss demonstrated a more positive attitude toward hearing loss than did participants who had no friends with the condition. Moreover, half of the participants described having experienced bullying, in that they had been physically hurt, teased, or excluded by others. these participants' concept of self had suffered, and they demonstrated a low intention toward communication or an awareness of their personal rights. As explained by participants 12-535 and 11-294, being a person with hearing loss made them felt sinful and guilty.

During our interview, we noted characteristics that may have made individuals susceptible to bullying, and some of these characteristics were related to self-advocacy (Test, Fowler, Wood, Brewer, & Eddy, 2005). Poor ability to advocate for oneself may be associated with bullying in classes (See Table 1). Surprisingly, we found that speech intelligibility is not correlated with bullying, indicating that teenagers with hearing loss who have low speech intelligibility do not necessarily become victims of bullying. 

"Sometimes I felt like I'm alone, I wish to join others, but I cannot because of my hearing problems," said participant 12-535. "Hmmm, just like when they saw me sit down, then they will move their seat away from me," said participant 11-294.

Table 1. Characteristics of teenagers who had been bullied and teenagers who had never been bullied.

Self-conceptNegative, withdrawn, silent, passivePositive, enthusiastic, curious, active
Awareness of RightsAware of rights but unable to express themAware of rights and able to express them
LeadershipOutsider, bystanderLeader, generator/starter

From the perspective of Chinese parents, the most crucial task that these teenagers must undertake is studying. Most of the time, emotional or peer-relationship issues are ignored by these parents; only excellent academic results define a successful son or daughter. Poor support and negative self-concept cause teenagers with hearing loss to have more difficulty in their role-identifying ability, as they have no listening or support system to guide them in their self-exploration journey. Furthermore, we have observed that some parents overprotect their children by not telling them why they need to wear hearing devices or explaining how severe their hearing loss is. This may cause problems; for example, children may not understand the nature of their hearing loss and might lack knowledge about audiograms or hearing-related technology. These teenagers may have complex beliefs about their hearing loss status that hinder their self-exploration process.

The findings of our study indicated that self-advocacy might be fundamental for teenagers with hearing loss. Especially when they were being bullied or experiencing emotional issues, advocating for themselves and saying "no" or sharing emotions with people they trusted helped them to avoid negative status (Warner-Czyz, 2018). However, clinicians might need to facilitate the self-exploration of teenagers with hearing loss, as self-concept and awareness of rights are fundamental to self-advocacy. After understanding who they are and what rights they have, these teenagers might shed irrational beliefs about hearing loss. This is invaluable for reassuring them that hearing loss need not run their lives. Becoming active and involved in the community were also essential for self-advocacy among teenagers with hearing loss from the study. Also, giving them the means to rectify others' misperceptions of hearing loss. Moreover, instilling confidence and encouraging self-expression reduces negative stereotypes and prejudices among peers, who are thereby less likely to see teenagers with hearing loss as different to themselves. Finally, strong self-advocacy and confidence can help teenagers with hearing loss orient themselves in ther self-identification journey.

Tuesday, March 5, 2019

By Pei-Hua Chen, PhD; Tang-zhi Lim, MSc; and Shu-Fen Yeh, MSc

Chen was only 8 months old when he was diagnosed with hearing loss after his universal newborn hearing screening test (UNHS), just a year after the test's first implementation in Taiwan in 2012. In contrast, Zhu was diagnosed with hearing loss 29 months before the UNHS. Before the implementation of the UNHS, the average age of pediatric hearing diagnosis was around 42 to 48 months old, and only very few children were diagnosed before 24 months old (Halpin, Smith, Widen, & Chertoff, 2010; Sininger et al., 2009; Yoshinaga-Itano, 1999). Notably, some studies have demonstrated that diagnosis before a child turns 3 months old and early intervention before 6 months may greatly improve the child's language outcomes (Yoshinaga-Itano, Sedey, Coulter, & Mehl, 1998; Moeller, 2000). Thus, the UNHS has a pivotal role in shortening early identification waiting time and ensuring early intervention and prompt treatment for these children.


Social marketing addresses the needs of target audiences, promoting behaviors that maximize their welfare, whereas the 4Cs marketing structure (consumer needs, cost, convenience, and communication) focuses on promoting target concepts or behaviors among target audiences (Lauterborn, 1990). Social marketing concerns the desire of target audiences for improved quality of life and health, and balances their willingness to pay for it. Communicating with target audiences is crucial to understand their needs and to provide assistance by shaping behaviors and attitudes. The goal of the UNHS is to address and fulfill health-related needs; therefore, the 4Cs theoretical framework, which is based on consumer views, may be used to investigate consumer-oriented behavioral responses after UNHS implementation (Draskovic & Valjak, 2012). We take the Children's Hearing Foundation (CHF) as an analytic example, because the CHF started auditory–verbal (AV) sessions for children with hearing loss over 20 years ago in Taiwan. We analyze the effects of the UNHS on public awareness and share ways in which the CHF had utilized the 4Cs of social marketing after the implementation of the UNHS (see Fig. 1).



Consumers' willingness for improving their health and quality of life is often unclear; thus, defining the meaning of these needs and the actions that must be changed to achieve health benefits is essential to social marketers. Between the conception of the UNHS in 2012 and the end of 2015, 1039 families (a total of 45,406 people) contacted the CHF regarding AV sessions. The first contact period of parents to the CHF has been decreasing significantly each year, from an average of 311 days required in 2012 to 133 days in 2015 (F[3,363] = 9.45 , p < .001), meaning that the first contact period in 2015 was significantly shorter than those in 2012, 2013, and 2014. Furthermore, the age of intervention decreased significantly from 610 days in 2012 to 377 days in 2015 (F[3,363] = 11.65 , p < .001), and the post hoc analysis results were similar to the first contact period. The results have demonstrated the need for early intervention.


People with hearing loss might face more language-related, social, behavioral, and emotional-development difficulties than their peers without hearing loss do (Stevenson et al., 2017; Theunissen et al., 2014; Wong, 2017). Because Taiwan's UNHS program is still young, few studies or reports exist on the effects of the UNHS, meaning that the real costs of the UNHS are difficult to investigate. The World Health Organization (WHO, 2017) estimated that the annual average cost of education support for children with hearing loss worldwide is approximately US$3.9 billion. In addition, the social cost of social isolation or communication difficulties related to hearing loss is estimated to be approximately US$573 billion per year.

Moreover, Lee (2007) calculated the estimated costs of the UNHS using the formula proposed by Gorga and Neely (2003): According to this estimate, if a child receives the UNHS when he or she is born, then immediate intervention, special education classes during preschool, and further education in a mainstream school might save US$117,075 in education costs. Furthermore, people with severe or profound hearing loss can receive approximately 30% less income than their peers without hearing loss. In other words, people with the aforementioned levels of hearing loss might lose US$220,000 to US$440,000 income before their retirement (Shield, 2006). People with superior language outcomes may save approximately US$428,000 of social cost expenses in their entire lifetime compared with those with poor language outcomes. For this reason, using early intervention to improve language outcomes among people who have hearing loss might change productivity loss by an estimated 75% over their entire lives.


UNHS implementation means that many infants with hearing loss can be screened very early. The demand for early intervention is consequently higher. To provide relevant information on early intervention and to frequent AV sessions, the CHF not only established four service centers in various parts of Taiwan for face-to-face intervention but also offered online AV (telepractice) sessions for families unable to attend face-to-face intervention sessions. Moreover, the CHF also provided home-visit service sessions for families in rural or remote areas and completed approximately 25 home-visit service sessions by the end of 2015. Calculations using Google Maps confirm that the CHF has saved families in remote areas approximately 65.34 miles' worth of travel to AV sessions. Moreover, home-visit service sessions have also reduced time spent attending AV sessions by nearly 134.66 minutes for families traveling by car and by 183.16 minutes for families taking public transportation. Most notably, both telepractice and home-visit services also supported families unable to visit the CHF regularly—for reasons related to pregnancy, physical weakness, or large families—such that children with hearing loss in these families could receive AV sessions without interruption.


To emphasize the importance of early intervention and to counter stereotypes about hearing loss, the CHF actively engaged and communicated with public and target audiences through various platforms and planned various courses. From 2012 to 2015, approximately 232 people per year attended the CHF's experience courses and institution visits. Approximately 13,862 people per year used the CHF's Newborn Hearing Screening Consultation Hotline to get hearing-related information. Moreover, the CHF has provided e-newsletters to approximately 6,863 subscribers per year, and about 190,567 people access their website per year. In addition, the CHF established a Facebook fan page, which is regularly updated with hearing-related information and events.

First contact periods shortened every year after the implementation of the UNHS, and the proportion of families that contacted the CHF increased by 75% at the end of 2015. However, the mother or grandmother of a child with hearing loss was the person most likely to call the CHF, according to our statistics. This result indicates public recognition that early intervention is valuable. Obtaining information is no longer a passive process; the public has begun to actively obtain relevant information through various platforms.

In all, the impact of the UNHS shows that public awareness has incrementally increased along with the demand for early intervention.

 Acknowledgment: We want to thank our research assistants, Ms. Huang Wan-Qi and Mr. Liu Ting-Wei from Children's Hearing Foundation for collecting and coding the data.

ABOUT THE AUTHORS: Pei-Hua Chen is a research fellow at the Speech and Hearing Science Research Institute, Children's Hearing Foundation in Taiwan, where Tang-Zhi Lim is a research assistant focusing on popular science writing from the perspective of psychological view. Shu-Fen Yeh is an executive officer of the Children's Hearing Foundation in Taiwan.

Carney, A. E., & Moeller, M. P. (1998). Treatment efficacy: Hearing loss in children. Journal of Speech, Language, and Hearing Research, 41(1), S61-S84.

Draskovic, N. & Valjak, A. 2012. The 4Cs of the Croatian public healthcare system: social marketing challenges at the dawn of EU accession. World Review of Entrepreneurship, Management and Sustainable Development, 8(2): 221-235.

Gorga, M. P. & Neely, S. Y. 2003. Cost-effectiveness and test-performance factors in relation to universal newborn hearing screening. Mental Retardation and Developmental Disabilities Research Reviews, 9: 103-108.

Halpin, K. S., Smith, K. Y., Widen, J. E., & Chertoff, M. E. 2010. Effects of universal newborn hearing screening on an early intervention program for children with hearing loss, birth to 3 yr of age. Journal of the American Academy of Audiology, 21(3): 169-175.

Shield, B. 2006. Evaluation of the social and economic costs of hearing impairment. Hear-it AISBL, 1-202.

Sininger, Y. S., Martinez, A., Eisenberg, L., Christensen, E., Grimes, A., & Hu, J. 2009. Newborn hearing screening speeds diagnosis and access to intervention by 20-25months. Journal of the American Academy of Audiology, 20: 49-57.

Stevenson, J., Pimperton, H., Kreppner, J., Worsfold, S., Terlektsi, E., Mahon, M., & Kennedy, C. 2018. Language and reading comprehension in middle childhood predicts emotional and behaviour difficulties in adolescence for those with permanent childhood hearing loss. Journal of Child Psychology and Psychiatry. 59(2), 180-190.

Theunissen, S. C., Rieffe, C., Kouwenberg, M., De Raeve, L. J., Soede, W., Briaire, J. J., & Frijns, J. H. 2014. Behavioral problems in school-aged hearing-impaired children: the influence of sociodemographic, linguistic, and medical factors. European Child & Adolescent Psychiatry, 23(4): 187-196.

Wong, C. L., Ching, T. Y., Cupples, L., Button, L., Leigh, G., Marnane, V., ... & Martin, L. 2017. Psychosocial development in 5-year-old children with hearing loss using hearing aids or cochlear implants. Trends in Hearing, 21: 1-19.

Yoshinaga-Itano, C. 1999. Benefits of early intervention for children with hearing loss. Otolaryngologic Clinics of North America, 32(6): 1089-1102.

Thursday, January 3, 2019

By Sandro Burdo,  MD

The first year of life is the most important time for linguistic and cognitive development as human beings exploit their higher neuro-plasticity capacity for learning. In this period, the inter-neural connections will form on the basis of sensory experience mainly of the hearing apparatus, which is a real cognitive hub for the configuration of the individual connectome (Lancet Neurol. 2016; May;15(6):610). This is why congenital hearing loss not only involves hearing difficulties but also affects the linguistic and cognitive spheres.


Today, it is well-established that hearing is crucial for the brain maturation, which makes newborn hearing screening vital. In the same way, it is clear that a cochlear implant (CI) surgery is the preferred treatment for disabling deafness. However, due to evident and practical reasons, CI surgery cannot be carried out at birth and has to be postponed by some months, during which other rehabilitative activities must be organized. The aim of these activities is not to complete hearing recovery but to kick-start adequate linguistic and cognitive development.

For this purpose, clinicians should not forget that the residual hearing ability of a profoundly deaf child can be used as a support to activate the communicative pre-requisites of verbal communication. This way the deaf child is able to develop the skills to detect and meaningfully process speech that can be phonetically discriminated through lip reading*[1] but not through the hearing. As such, before CI surgery, it is essential to use visual inputs to guarantee linguistic-cognitive development, as residual hearing is insufficient.

But residual hearing must not be abandoned; it must be stimulated for functions it can fulfill without pushing for other unreachable functions like phonetic discrimination.

Before the age of CIs, it was well-established that severely deaf people were capable of perceiving low-frequency sounds, activating spatial awareness, attention, auditory detection, and processing prosodic speech features (acoustic contour of speech) that transmit communicative meaning during the first months of life (semantic prosody; RERC, 2000).

The rationale was about the role of residual hearing in activating communication pre-requisites so that lip reading could advance to phonetic discrimination, and consequently, the central nervous system could elaborate words (identify then recognize) to reach verbal comprehension (see Fig. 1). To get effective results, hearing aids had to be fit not only to deliver high amplification but also to extend this feature to low-frequency sounds, amplifying acoustic energy especially in the bandwidth where the child has more efficient residual hearing (Ross 2000).

Burdo Figure 1.jpg

Unfortunately, high amplification of the low-frequency sounds is taken for granted in modern digital hearing aids that can sufficiently compensate all degrees of hearing loss (except the more profound ones). Furthermore, the bandwidth limit is associated with a high cost due to the sophisticated electronics that are hardly ever used in this kind of hearing loss. We can call these powerful, low-frequency hearing aids "prosodic" as they leave out sophisticated acoustic features that are useless for people with profound hearing loss. Thanks to these characteristics, prosodic hearing aids can be sold at significantly lower prices.

Going back to clinical practice, it seems obvious that the clinicians must fully understand two things to ensure an optimal pre-operative rehabilitation: They must activate the pre-requisites for verbal communication and facilitate the development of lip reading skills enable rehabilitation. Once again, the importance of communication pre-requisites must be underlined because, before the surgery of people with severe-to-profound deafness, it is not possible to enable any further processing after prosodic discrimination. However, it should be noted that any communicative process cannot start without activating the communication prerequisites of awareness and attention.


Another form of hearing transmitted in the low frequencies is unconscious primitive hearing, which was described by Ramsdell at the end of World War II as one of the skills lost after a sudden hearing loss (Ramsdell 1978). Ramsdell described four hearing levels as follows:

1. The primitive level gives us the subconscious perception of background sounds completing the 180 degrees of the visual space for the environment's control. Ramsdell asserts that the perception of these sounds maintains our feeling of being a part of a living world. He comes to the conclusion that the loss of sound's perception on the primitive level is the major cause of depressive feelings reported by deaf adult patients. Furthermore, the lack of this hearing level could explain the motor hyperactivity that, as we have seen in our clinical experience, is highly common in deaf children. It may be related to the patient's needs of checking the environment around them and it is indicative that this kind of hyperactivity disappears with a correct sensory stimulation. The lack of these primitive functions could also be the cause of neck muscles hypotonia in babies. This inhibits proper contraction in response to a stimulus. It is useful to understand that the primitive level is sustained by the noise floor where low-frequency sounds are prevalent. It is also important to outline the concept that the noise floor keeps continuously active the unconscious primitive hearing level, but the same acoustic stimulus can stir the individual "awareness" when the brain decides to be conscious of the same sounds.

2. The warning level alerts and prepares us for action during a variation of the noise floor. At this level, we activate our attention, for example, to listen. 

3. The aesthetic level involves sounds that have an impact on our feelings.

4.  Finally, the symbolic level is when we understand speech to be informed, educated, entertained, and so on.


During the first months of life, it is important to provide the child with the necessary stimuli to activate the pre-requisites for communication and enable primitive hearing to give the child a feeling of safety. These stimuli can be provided using two devices: hearing aids for low-frequency amplification (prosodic hearing aids for primitive hearing, awareness, sounds detection, and semantic prosody) and a single-channel pre-sternal vibrator that has the unique function of activating communicative attention through signals (both environmental and verbal), giving "eyes in the back of one's head." While the skin doesn't allow for speech discrimination, it can be used to transmit the basic sounds. Recent research on the skin and speech discrimination have been confined to laboratories without any large practical diffusion. Moreover, our choice to place the vibrator on the skin over sternum was confirmed experimentally to be correct by Suarez, et. al (1997).

The vibrator and hearing aids must be used simultaneously all day and not only during the rehabilitation sessions. Only the combined use of these two devices can stimulate primitive hearing and activate the pre-requisites of communication in addition to prosodic discrimination. Clinical reports by Parravicini, et al., showed that using each device by itself is not as efficient as their combined use (2016). Primitive hearing and communication pre-requisites enable the easy construction of an individual connectome, which does not remain unaltered in the absence of stimulation but is destroyed without. As such, technology has to be used continuously.

Previous incorrect comparisons were made between the results obtained using CIs and a sternal vibrator. The results underlined the superiority of CIs (Carney 1993), and so sternal vibrators were eventually abandoned. However, this traditional method could still be useful in the first months of life of a severely deaf child until he or she undergoes surgery.

Some researchers also suggested the prolonged use of hearing aids and a sternal vibrator. Nittrouer and Chapman (2009) have demonstrated that children could benefit from a period of bimodal stimulation by delaying the bilateral surgery since prosody could aid in learning how to perceptually organize the signal received through a CI. Huang et al., (2017) combined electrical stimulation with tactile stimulation of the index finger, obtaining better results in noise when compared with electric stimulation alone.

If these last experiences confirm that tactile stimulation and prosodic amplification are beneficial in language acquisition and speech recognition, then it follows that they are absolutely indispensable in the period before the CI surgery because they represent the only tools to free the deaf child from silence.

Any treatment undertaken before cochlear implantation cannot be limited to checking whether a non-invasive technology is insufficient for a deaf child's complete rehabilitation, thereby justifying the CI surgery. Instead, clinicians must help a deaf child gain control his or her environment and form linguistic-cognitive connectome during this developmental period, keeping in mind the rule "Use it or lose it" in neurocognitive maturation (Burdo 2018).

[1] We use the terms "lip reading" in place of "speech reading" only for a historical reason because  the second expression is more correct (Ross 2000)

Burdo headshot.pngABOUT THE AUTHOR: 

Dr. Burdo is the Scientific Responsible of the Italian Association Free to Hear ( and a consultant otologist at the Bassini Hospital in Milan, Italy. 

He was the director of the audiovestibology unit at Varese Circolo Hospital where he led one of the main European centers for deaf rehabilitation.

Sunday, December 16, 2018

By Vinaya Manchaiah, PhD; Spoorthi Thammaiah; and Rajalakshmi Krishna, PhD

Sustainability has become the talk of today's stakeholders in the modern era in all areas from climate change to health care. In general context, sustainability refers to finding a way to use resources in a manner that prevents their deprivation. However, for charitable non-profit groups, the term "sustainability" refers to the organization's long-term ability to sustain itself and continue to fulfill its mission. Hence, the sustainability in the non-profit context extends beyond financial capacity and includes succession planning, adaptability, and strategic planning. Notably, the main aspect that most non-profits organizations struggle with is financial sustainability.

For a non-profit to be sustainable, the organization's key players need to know how much it costs to deliver the programs and services, so that they can raise enough resources to cover these costs. Otherwise, the organization will end up in a "starvation cycle" in which the main focus will become finding resources instead of accomplishing its mission. Hence, non-profits need to embrace a sustainable mindset from the beginning and review every stage and level of the organizational process—as is the strategy learned by Audiology India.


Audiology India is a non-government and not-for-profit organization that aims to promote hearing health care in India by breaking down known barriers to hearing service delivery. Founded by Vinaya Manchaiah, PhD, and Srikanth Chundu, AuD, in 2009, Audiology India was first established as a website that offered information about ear and hearing health care specifically for audiologists and audiology students. Expanding from the goals of a successful website, it has grown into a multidisciplinary team serving individuals with hearing difficulties, especially in suburban and rural communities. The group's main objectives are to:

(1) provide hearing health care services for underserved population using a community-based rehabilitation model;

(2) raise public and professional awareness of the importance of hearing health; and

(3) conduct high-quality research to understand the social and environmental factors that influence hearing health care outcomes and implement best practices in care delivery.

Audiology India mainly conducts free hearing screening camps and community-based hearing rehabilitation (CBHR). Hearing rehabilitation with hearing aids is conducted systematically in three phases that focus on the underserved and financially communities in the Southern India. So far, Audiology India has conducted 43 hearing screening camps and tested more than 2,100 individuals. At the screening camps, about 950 behind-the-ear (BTE) hearing aids have given for free to individuals who need them.

Audiology India also conducts public awareness programs on hearing and related disorders. Audiology India has organized more than 20 such programs so far including rallies, orientation programs, and newspaper articles.

In addition, Audiology India team has been conducting need-based research in the hearing-health sector in India. A survey-based project examined the practice across the country, places of work, and professional issues related to audiologists practicing in India (Indian J Otolaryngol Head Neck Surg. 2013 Dec; 65(Suppl 3): 636–644; Audiology Today. 2009;21(6): 38-44;; ENT & Audiology News. 2016; 25(1):73-74). Such surveys repeatedly provide evidence for the need to develop nation-wide guidelines for service delivery, diversification, and definition of clear roles for audiology professionals from varied degrees/background in training. More recently, the team members are involved in studying the efficacy and effectiveness of CBHR in comparison with the institution-based hearing rehabilitation (IBHR). First stage of this project was focused on translation and adaptation of structured outcome measures to Kannada language (Audiol Res. 2016 Apr 20; 6(1): 153; Int J Audiol. 2017 Mar;56(3):194-201; Disabil Rehabil. 2018 Nov;40(22):2650; Int J Audiol. 2018 Mar;57(3):161-175). In the current stage, we are gathering outcome data using these outcome measures to compare the hearing rehabilitation outcomes as a result of CBHR and IBHR service delivery models.


Funding requirements have grown since our humble beginning, where much of Audiology India activities were managed through collaborations. For instance, (CBHR) camps are usually sponsored by other government or non-government organizations (e.g., Rotary Clubs). However, our expanded objectives demand more directed funding to support an office, a full-time employee and travel expenses for volunteers.

Currently, we rely heavily on donations and fundraising activities conducted locally in Mysore, Karnataka. In the last seven years, the Audiology India team has conducted only two fundraising events. The team has agreed that the any fundraising initiative should have various other outcomes in addition to merely raising money, i.e., (1) promoting Audiology India's mission and activities; and (2) building good public relations.

The first fundraising activity was conducted in Mysore, India during July 2015. This included a musical event in which the local upcoming singers were recruited through auditions for a singing competition. The funds were raised through ticket sales paid by public for attending the music event and the event expense was generated through sponsorships. The second event was conducted in 2017 and it was a standup comedy show. These events generated ongoing news in the local media and by the end of the event most people in Mysore were aware about the organization and its mission.


After seven years of running a non-profit organization, we have identified various factors related to sustainability. Consider the ideas below that help ensure an organization's sustainability.

  • Have clarity of thought: People who are interested in humanitarian activities are enthusiastic. Often, they like to solve the problems in the world and they have plenty of ideas and projects in mind. The first step in making anything workable and sustainable is to develop clear objectives and working plan. Non-profit initiatives and organizations should give the highest importance to clarity of thought in their mission.
  • Keep costs low: There is no better way to be sustainable than keeping costs low. This could be related to products (e.g., finding affordable hearing aids of good quality, making earmolds in local place at cheaper price), services (e.g., finding volunteers, finding consultants who will work for limited allowances) and finding space (e.g., using schools during weekend as a place to offer services). Consider the best possible ways to reduce cost without compromising quality.
  • Recruit and retain committed volunteers: Volunteers play a key role in the success of charity and non-profit organizations. Attracting those who are interested in serving the organization, providing them with appropriate training, and keeping them engaged is important for sustainability. In our view, developing a good working relationship—in which volunteers become friends and not just co-workers—has proven to be an effective strategy. This way volunteers always find a way to meet, exchange ideas and to work on a common goal.
  • Collaborate with other organizations: Often the hearing health care organizations are small with limited resources. However, there are many other non-profit organizations with broader mission and sufficient resources. Hence, collaborating with such organizations by providing them required services in exchange to resources required to the organization could be one of the important considerations for ensuring ongoing endeavor.
  • Pilot test your service program to test feasibility and then scale it up: Many organizations often develop new ideas in launching a service program. To avoid the risk of failure, pilot test the program to see its feasibility and eventually scale it up to improve the chances of success and reduce risk.
  • Provide consultancy services to generate income: Often the volunteers of non-profit organizations may have various specialist skills. Such organizations can conduct various consultancy services (e.g., industrial hearing screening) in which volunteers will work for free and generate income that can be used to pay for key programs and services to meet the mission.
  • Conduct ongoing reviews and adaptation of goals and activities to ensure continuous work: Finally, one of the important elements of sustainability is to develop projects in such a way that there is continuity in work. Also, the goals and activities should be reviewed regularly  and necessary adaptations should be made to ensure the growth in the project meet service requirements.

ABOUT THE AUTHORS: Dr. Manchaiah is affiliated with Lamar University in Texas, as well as with Audiology India and the Manipal University in Karnataka, India. Ms. Thammaiah is affiliated with Lamar University in Texas, as well as with Audiology India. Dr. Krishna is affiliated with Audiology India and All India Institute of Speech and Hearing at the University of Mysore in India.