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Vinaya K. C. Manchaiah1,2 , Vijayalakshmi Easwar3, Sriram Boothalingam3, Srikanth Chundu4 & K. Rajalakshmi5

Department of Vision and Hearing Sciences, Anglia Ruskin University, Cambridge CB1 1PT, United Kingdom
Linnaeus Centre HEAD, The Swedish Institute for Disability Research, Department of Behavioral Sciences and Learning, Link�ping University, SE-58183, Link�ping, Sweden
National Centre for Audiology, Faculty of Health Sciences, Western University, London ON, Canada N6G 1H1
University of Southampton Auditory Implant Service, Southampton SO17 1BJ, United Kingdom
All India Institute of Speech and Hearing, University of Mysore, Mysore-570001, India 

Corresponding Author
Contact person: Vijayalakshmi Easwar 
Address: National Centre for Audiology, Faculty of Health Sciences, Western University, London ON, Canada N6G 1H1
Email:  HYPERLINK "mailto:vijayalakshmi.easwar@gmail.com" vijayalakshmi.easwar@gmail.com 


Abstract
Objective: The study examined the self-reported work environment and professional satisfaction among Indian audiologists. Method: A cross-sectional online survey was conducted using the demand-control-support questionnaire (DCSQ), a short version of the effort-reward-imbalance (ERI) questionnaire and open-ended questions to explore professional issues. Seventy-one Indian audiologists participated in the survey. Results: The results indicate significant differences in several variables between Indian audiologists, from the current study and Swedish audiologists from a previous study. No association was found between demographic factors (i.e., gender, education, work type, and work settings) and the DCSQ and ERI subscales. Using the demand control model, 14% of audiologists reported working in a high-stress psychological work environment. Using the ERI ratio to estimate the imbalance between efforts and reward, it was observed that 72% of the participants experienced unfavourable working situations where the reward did not correspond to the effort made. Audiologists identified various professional issues including �lack of awareness of the profession among public� and �unethical practice by other professionals and unqualified people is a concern�, and also made some suggestions on how to overcome them. Conclusions: The results suggest that a high percentage of audiologists perceive to be working in unfavourable working conditions in comparison with audiolgoists in other countries such as Sweden. Further work is required to understand, and possibly overcome various professional concerns raised by audiologists. 

Key Words
Audiologist, hearing healthcare, healthcare professional, occupational stress, organisational form, India
Introduction 
Audiology as a healthcare profession has existed in India since mid-1960�s. In 2007, the estimates suggested that there are nearly 1200 audiologists in India [1]. However, the field of audiology in India has expanded exponentially in recent years. There is a rapid expansion in the number of institutes offering audiology courses. Currently there are nearly 50 institutes, which are accredited by the Rehabilitation Council of India (RCI) and over 30 of them actively offering courses. With this information in mind, we anticipate that there are currently over 4000 audiologists practicing in India. 

Traditionally audiology services in India were limited to tertiary level publically funded hospitals and national institutes. However, there has been a significant increase in the number of private clinics in India, likely due to efforts from national chains. Currently, audiologists in India work in a variety of work places including publically funded hospitals, private clinics, educational institutes, hearing instrument manufacturers and so on [2,3]. However, little is known about the practice trends across these work places. 

Studies from the fields of human resources and business management have suggested that the psychological work environment has an impact on both psychological well-being and physical health [4]. Little is known about the work environment and professional satisfaction of audiologists, with the exception of two studies in western countries including the USA and Sweden [5, 6].  In our previous survey we explored aspects related to audiological practice in India [3]. The aim of the current study as a natural progression was to examine the psychological work environment among Indian audiologists. We also compared our results with Swedish audiologists� data from a recent study [5]. In addition, we also examined the professional issues faced by audiologists using a qualitative approach. 

Method
Study Design
The current study used a cross-sectional survey design. The survey was directed towards audiologists currently practicing in India. The survey was advertised in Audiology India Facebook page with brief information and a link to the online survey administered via Google Form. Seventy-four audiologists completed the survey. However, three of them had to be excluded, as they were either students or audiologists practicing outside India. The final sample included in the analysis consisted of 71 audiologists. Research ethics board of the All India Institute of Speech and Hearing, Mysore approved the study methods.

Outcome Measures
The survey included four sections: (1) Demographic information; (2) Demand-Control-Support Questionnaire (DCSQ); (3) Effort Reward Imbalance (ERI) questionnaire; and (4) Two open ended questions. 

Demographic information section included: age, gender, education, number of years of experience, population served (e.g., adults, children), work environment (e.g., public clinic, private clinic), number of audiologists in the practice and average number of patients seen per day. 

The DCSQ consists of 17 items that are divided into three sections: psychological demand (five items); control or decision latitude (six items); and social support (six items). The demand subscale examines the effect on workload and task related requirements on mental alertness or arousal. The control subscale examines intellectual decisions and authority over decisions. The social support subscale probes into the experience of support at work. All the three subscales are rated on a 4-point Likert scale (e.g., �Yes, often� to �No, almost never� in the demand and control subscales; �I totally agree� to �I totally disagree� in the support subscale). The scores on the demand subscale range from five to 20 and scores on the control and support scales range from six to 24. Lower score on demand scales indicate higher demand, lower scores on control subscale indicate more control, and lower scores on support subscale indicates more social support. Two constructions can also be produced using the subscales. Variable �strain� is calculated by dividing the demands by control subscale scores and the variable �iso-strain� is calculated by dividing the strain by support subscale scores. Sum of each subscales, strain and iso-strain scores are reported in this paper. 

ERI is a 16-item questionnaire, which is divided into two sections: effort subscale (five items); and reward subscale (eleven items). The effort subscale examines perceived demand and the reward subscale examines rewards at work and coping strategies. The responses in both subscales are obtained in two steps: firstly, agree (yes) or disagree (no) on a statement; and secondly, rating on 4 point Likert scale (i.e., Agree, I don�t feel distressed to Agree, I am very distressed). For this reason, the scores on each items range from 1 to 5. The scores on effort subscales range from 5 to 25 and the scores on reward subscales range from 11 to 55. For each individual participant, the effort-reward-ratio (i.e., ERI ratio) can be calculated using the formula e/(rc) where e is sum of effort subscale, r is the sum of reward subscale and c is a correction factor (0.454545) to account for imbalance in the number of items in subscales. A effort-reward-ratio below 1.0 is considered to be a favourable working condition. This would refer to a situation at work where the participant puts in relatively low effort but receives high reward. A ratio greater than 1.0 is considered unfavourable. This would refer to a situation where the participant puts in lot of effort but does not receive adequate, or the expected reward. The sum of scores in each subscale and the effort-reward-ratio are reported in this study. 

There were two open-ended questions aimed at understanding audiologists� opinion on current professional issues. The first question asked about the main professional issues related to audiologists practice in India in the order of importance. The second question asked about the audiologists� recommendation of actions that could be taken to overcome the main professional issues they listed in the previous question. 

Data Analysis
Descriptive statistics were used to examine the data in the first instance. T-tests were performed to compare the results of the current study with that of a previous study in Sweden [5]. Chi-square test was used to study the association between demographic variables and demand control and effort reward scale results. Pearson�s correlation was performed to study the association between DCSQ and ERI factors. The open-ended questions were analysed using qualitative content analysis [7]. 

Results and Discussion
Table 1 shows the demographic details of the current study in relation to study on Swedish audiologists published recently [5]. The table also presents the results of t -tests that compares a few variables between two study samples. The two study samples showed differences in terms of many variables: age [t(70)=-16.4, p < 0.001]; duration of work experience [t(70)=-6.79, p < 0.001]; number of appointments per day [t(70)=3.93, p < 0.001]; control [t(70)=-7.57, p < 0.001]; social support [t(70)=6.62, p < 0.001]; ERI effort [t(70)=-8.86, p < 0.001]; ERI reward [t(70)=-3.65, p < 0.001]; and ERI effort reward ratio [t(70)=-3.86, p < 0.001].

In the current study, audiologists population responded to survey in India differed in number of ways (e.g., age, duration of work experience) when compared with Swedish audiologists population in the recent study, hence the difference in DCSQ and ERI results may have been influenced by differences in such factors.

[Table 1 about here]

Dichotomized responses on the control and demand subscales and ERI ratio
Participants� responses on the DSCQ subscales were dichotomized as a score: below the median value (low score) and above the median value (high score). A low score on the demand subscale was considered as a situation with high demand, a low score on control subscale was considered a situation with high control and a low score on support subscale was considered a situation with high social support [8]. Chi-square test results showed no association between DSCQ subscales (i.e., demand, control and support) and factors such as gender, education, work type and work settings. Table 2 shows the distribution of participants based on demand-control model. These results indicate that 37% of the participants have a psychological work environment that is low in demands and low in control (i.e., passive), about 28% work in an environment that is low in demands and high in control (i.e., low stress), about 14% work in an environment that is high in demands and low in control (i.e., high stress), and about 21% work in an environment that is high in demands and high in control (i.e., active). 

These numbers are encouraging, as only 14% of the participants appear to be perceive that their work environment as stressful. Professionals in the high-stress work environment category tend to have higher risk of job dissatisfaction, and increased risk of psychosomatic health complaints [9]. On the contrary, an active work environment is considered to be most nurturing where increased learning and motivation, and skill improvement are thought to occur [10]. This situation leads to increased job challenge and satisfaction. Sannes et al. [9] showed that anxiety and depression levels increased linearly with increased demand, but increased control appears to have a synergistic effect on increasing demand. However, a large majority of the professionals (37%) perceive their job environment to be passive, i.e., less professionally and intellectually nurturing. This is not a desirable trend as passive job environment can lead to loss of previously learnt skill. Finally, professionals in a low-stress work environment are likely to have higher than average levels of health and happiness. These results suggest that most audiological work places are less stressful, compared to, for example a hospital nurse [11]. However, the large passive work environment warrants improvement in both demand and control in audiological work environments. The non-relationship between the work environment trends and any of the personal variables is surprising. One possible reason for this result could be due to lower spread of participants among the different categories.
[Table 2 about here]

The participants ERI ratios were also dichotomized as a score below 1.0 (low score) that was regarded as favourable working conditions (i.e., relatively low effort for high reward) and score equal to or above 1.0 (high score) was regarded as an unfavourable work situation (i.e., high effort for not receiving adequate or expected reward). Chi-square test results showed no association between ERI ratio and factors such as gender, education, work type and work settings. Overall, the dichotomized results of ERI ratio suggest only 28% of participants reported favourable work condition (low effort and high reward), while 72% reported unfavourable work condition (high effort and low reward). 

An unfavourable work environment will cause negative emotions such as low self-esteem and increased stress [12]. On the other hand, a favourable work environment will promote self-esteem, self-worth, hence, satisfaction and success [13]. The estimates obtained among Indian audiologists appear better than Swedish audiologists, where only 14% report to work in a favourable work environment. However, the sample size of the current study is lower than the Swedish study, with a possibility that only the more enthusiastic and modern audiologists responded to the current survey.  

Correlation between DCSQ and ERI factors
Table 2 shows Pearson�s correlation among DCSQ and ERI subscales. The results suggest a weak but positive correlation among the following factors: DCSQ demand and control subscales, DCSQ control and support subscales, DCSQ control and ERI reward subscales, DCSQ support and ERI reward subscales. A weak but negative correlation was found between DCSQ demand and ERI effort subscales. Also, a moderate and positive correlation was found between ERI effort and reward subscales. 

[Table 3 about here]

An acceptable correlation among sub-scales of the main scale suggests that although they are measuring different aspects they are connected. As expected, correlation between DCSQ and ERI suggests that higher the perceived reward higher the control and support at work. Also, correlation between DCSQ and ERI suggests that higher the perceived demand lower the effort, although we don�t have valid reason for explaining these findings. In addition, as the correlations were weak, these results must be viewed with caution. 
 
Analysis of responses to open-ended questions
Of the 71 respondents, 53 and 49 replied to the first and second open-ended questions respectively. The most common responses to each of the question were examined using the content analysis. Detailed themes and sub-themes identified are reported in the appendix section. The most common professional issues, as reported by audiologists regarding professional issues and suggestions to overcome those issues are reported tables 4 and 5.

[Table 4 about here]

The majority of the respondents reported that there was lack of awareness about audiology profession among public and other professionals (n=25) and about quarter (n=15) reported that unethical practice in Audiology by other professionals is a concern.  They also reported that there is interference by non-audiology managers and other medical professionals in decision making related to patient care. The other major professional issues reported were related to pay scale not currently in accordance with other professionals. The final concern expressed was that other professionals and Government medical hospitals refer to audiologists as technicians. 
[Table 5 about here]
The common suggestions to overcome some of the professional issues in the field of audiology were to increase the awareness of the profession of audiology among public and other professionals (n=18).  The other reported suggestions included development and implementation of strict guidelines to prevent unqualified or inadequately qualified professionals to practice (n=9), increase in the number of Audiologist jobs in the government sector (n=7), proposing pay structure and increasing the pay (n=7). 

These findings from qualitative methods provide valuable insights into professionals� perspective of the issues in audiology profession in India. However, this was mote of an exploratory attempt and an in-depth interview design in future studies might help better understand some of the aspects highlighted in this study. Moreover, efforts are needed by the professional and regulatory bodies to address the professional issues and also to track if such changes would bring measurable effect in terms of work environment and professional satisfaction. 

Study Implications and Limitations
Current study provides useful information about audiologists� current working condition. These findings may provide some insights into what measures are needed to improve working conditions both in terms of policy making and also in education and training. 

Although this study is first of its kind in India as known by the authors, it has some limitations. Due to small sample size the results must be viewed with caution and further studies with large sample size are needed. Due to recruitment strategy used (i.e., advertisement in Facebook page) there could be some response bias and this did not allow us to calculate response rate. The same reason may have contributed to relatively young audiologists (i.e., average age is 30 years) completing the survey. 

Acknowledgements
The authors would like to thank all the participants for taking part in the study. 

Conflict of Interest
None to declare

References
Manchaiah, V. K. C., Sivaprasad, M. R., Chundu, S. & Dutt, S. N. (2010). Ear and Hearing Healthcare Services in India. ENT & Audiology News, 19(5), 93-95. 

Manchaiah, V. K. C., Sivaprasad, M. R. & Chundu, S. (2009). Audiology in India. Audiology Today, 21(6), 38-44.

Easwar, V., Boothalingam, S., Chundu, S., Manchaiah, V.K.C. & Ismail, S.M. (2013). Audiological practices in India: An internet based survey of audiologists. Indian Journal of Otolaryngology and Head & Neck Surgery, 65(3), 636-644.

Theorell, T. & Karasek, R.A. (1996). Current issues relating to psychological job strain and cardiovascular disease research. J Occup Health Psychol, 1, 9-26.

Saccone, P. & Steiger, J. (2012). Audiologists� professional satisfaction. American Journal of Audiology, 21, 140-148.  

Br�nnstr�m, K.J., B�sjo, S., Larsson, J., Lood, S., Lund�, S., Notsten, M. & Taheri, S.T. (2013). Psychological work environment among Swedish audiologists. International Journal of Audiology, 52(3), 151-161.

Graneheim, U. H. & Lundman B. (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurs Educ Today 24, 105-112.

Sanne, B., Mykletun, A., Dahl, A.A., Moen, B.E. & Tell, G.S. (2005). Testing the Job Demand-Control-Support model with anxiety and depression as outcomes: The Hordaland Health Study. Occupational Medicine, 55, 463-473.

De Jonge, J., Bosma, H., Peter, R., & Siegrist, J. (2000). Job strain, effort-reward imbalance and employee well-being: a large-scale cross-sectional study. Social Science & Medicine, 50(9), 1317-1327.

Van der Doef, M., & Maes, S. (1999). The job demand-control (-support) model and psychological well-being: a review of 20 years of empirical research.�Work & Stress,�13(2), 87-114.

Foxall, M. J., Zimmerman, L., Standley, R., & Bene Captain, B. (1990). A comparison of frequency and sources of nursing job stress perceived by intensive care, hospice and medical-surgical nurses.�Journal of Advanced Nursing,�15(5), 577-584.

Siegrist, J. (2002). Effort-reward imbalance at work and health. Research in occupational stress and well-being, 2, 261-291.

Antoniou, A. S. G., & Cooper, C. L. (Eds.). (2005). Research companion to organizational health psychology. Edward Elgar Publishing.



 
















Tables
Table 1: Descriptive statistics 

India
(n=71)Sweden (n=500)Significant difference
* = p< 0.001Age in years (Mean�SD)29.27�7.9344.7�11.2*Gender (%)
Male
Female
49.3
50.7
6.2
93.8Education (%)
Bachelors
Masters
Doctorate
Other
36.6
56.3
2.8
4.2
NAWork type (%)
Full-time
Part-time
91.5
8.5
65.6
34.4Population served (%)
Both adults and children
Adults only
Children only
94.4
4.2
1.4
NAWork setting (%)
Public clinic
Private clinic
Education
Other
9.9
66.2
8.5
15.5
NANumber of audiologists in the workplace (Mean�SD)6.15�13.17NAAudiologists work experience (Mean�SD)5.63�7.4116.9�11.6*Number of patients seen per day (Mean�SD)10.94�10.376.1�2.4*DCSQ (Scores�SD)
Psychological demand 
Control / decision latitude
Support 
Strain 
Iso-strain 
10.41�2.03
11.46�2.29
11.87�2.38
0.93�0.21
0.08�0.03
10.5�1.9
9.4�1.9
10�3.1
NA
NA

*
*

ERI (Scores�SD)
Effort 
Reward 
Effort-reward-ratio 
12.49�4.19
24.20�9.21
1.21�0.37
16.9�3.6
28.2�7.6
1.39�0.4
*
*
*





Table 2: Distribution of sample (n=71) to the demand-control model

Control 
TotalHigh controlLow controlDemandHigh demand15 (21%)10 (14%)25 (35%)Low demand20 (28%)26 (37%)46 (65%)Total35 (49%)36 (51%)71 (100%)
















Table 3: Correlation between DCSQ and ERI factors (* = p < 0.01; ** = p < 0.001)

DCSQ DemandDCSQ 
ControlDCSQ 
SupportERI 
EffortERI 
RewardDCSQ 
Demand1.00DCSQ 
Control0.39**1.00DCSQ 
Support0.160.46**1.00ERI 
Effort-0.32**0.180.151.00ERI 
Reward-0.100.34**0.30*0.60**1.00









Table 4: Most common professional issues listed by respondents 

Main themes on professional issuesNo  of respondentsLack of awareness among public and other professionals 25Unethical practice by other professionals15Interference by non-audiology managers and other medical professionals in decision making11Pay not in accordance with other professions8Inappropriate labelling of Audiologists as �technicians�6














Table 5: The most common suggestions listed by respondents

Main themes on suggestions for addressing professional issuesNo of respondentsIncrease awareness among public and professionals18To issue strict guidelines and develop legal framework so that other professionals and unqualified people cannot practice audiology9More government jobs need to be created7Government should propose pay structure and increase pay scale7













Appendix

Main professional issues related to audiologists practice in IndiaAwareness & TrainingLack of awareness among public and other professionals
No proper training from the institutes
Outdated syllabus 
Relevant topics not taught
New graduates are not confident working independently
Not enough clinical exposure from educational institutesEmployment and professional interferenceNo clear professional boundaries
Hearing aid manufacturers encouraging other professionals
No government jobs
Pay is not in accordance with other professions
Poor employment prospects & poor job security
Diploma holders given priority over Audiologists
Audiology practice/decisions intervened by non-audiology managers running the clinics
Stressful working situations
Lack of further training/continuous professional developmentIssues regarding profession and regulatory bodies Malpractice and unethical practice by other professionals
Qualified Audiologists  and medical professionals encouraging non-qualified people to practice Audiology
Inappropriate labelling of Audiologists as �Technicians�  
No unity among the Audiology fraternity 
No proper respect from other professionals
No proper administration by ISHA and RCI in terms of safeguarding profession 
No proper guidelines about the role of Audiologist i.e. scope of practice
Bribery and commissions by audiologists and hearing aid companies to ENTsOtherMost Audiology professionals do routine Audiology test and hearing aid fitting
Need to offer other services like Balance, Electrophysiology and APD.
What need to be done to overcome the main professional issuesAwareness & trainingIncrease awareness of the professions among public and professionals 
Educational institutes should update their syllabus
Uniformity among the syllabus taught
Uniformity of the course titles (BASLP or BSc Speech and Hearing)
Audiology course curriculum should emphasise more on practical training
More Speech and Hearing colleges need to be set up
Uniformity among the cut off mark for entrance in to the Speech and hearing institutesEmployment & individualityDefine clear professional boundaries
Work with other professionals than work under other professionals
More government jobs need to created
Government should propose pay structure and increase pay scale
Appropriate use of  title �Audiologist� than technician by government/other professionals
Employers offering periodic training or supporting Continuous professional development
Audiology departments to be head by audiologists than other professionals
Audiologist should handle the schemes related to hearing impairedIssues related to Profession and regulatory bodiesNeed to curb malpractice/unethical practice by other professionals
Audiologists should stop encouraging non-qualified people to practice
Develop integrity and unity among the qualified audiologists
To issue strict guidelines and develop legal framework so that other professionals cannot practice audiology
Clear distinction of the job titles and duties of Diploma holders and Graduates
Use of DR as title
Need to have a separate Speech and Hearing council and not under RCI
Associations should bring strict rules on hearing aid companies, and audit the clinic setup for service delivery
Association should do more than just organising conferences
The ISHA panel members need to be changed with more active members
Develop a new association which works against the malpractice
 









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