have long been reported in the majority of developed countries and a few in developing countries. examples of programs in developing countries include columbia, costa rica, cuba, nicaragua, panama, kenya, ghana, and jamaica (madriz, 2001; macharia, 2003; amedofu et al., 2003; lyn et al., 1998). according to mcpherson and olusanya (2008), "school screening audiometry has concentrated on the detection of possible disorders in primary (elementary) school children. this has been due to: an underlying rationale for screening being that there is an advantage in the earliest possible treatment of the condition detected (paradise & smith, 1979); the common finding that there are a number of children with previously undetected hearing losses entering the primary school system (roeser & clark, 2004). this may be particularly so in developing countries in the absence of neonatal or infant screening programs (mcpherson & holborow, 1988); the generally higher prevalence of otitis media with effusion related hearing loss in the earlier school grades. however, programs for secondary (high) school children have also been implemented in many areas (hodges, 1983)." ethical considerations when determining the best protocol for school-based screenings, it is important to note the limitations of both equipment and potential screening staff. for example, the screening staff may not have the skills in otoscopy, or ear examination, to identify ear pathology as such, other than through gross visual examination for disorders such as pinna abnormalities, discharge, or impacted wax (mcpherson & olusanya, 2008). gell et al., (1992) advises against the use of tympanometry in screening for developing countries where the prevalence of otitis media is high since "(a) ear discharge can be better noted through visual inspection of the ear, and (b) identification of moderate to severe hearing loss is a priority" (mcpherson & olusanya, 2008). school screening audiometry techniques and protocols considerations when determining an effective school-based screening protocol in developing countries includes hearing loss criteria, screening tools, and an appropriate referral pathway. in regards to the pass/fail criteria for hearing screenings, the american speech-language-hearing association (asha) guidelines use a >20 db hl cut-off intensity (roush, 1990) though there is a growing tendency for audiologists in developed countries to use a >15 db hl criteria. the world health organization (who) criterion for "priority for hearing aids" in children is an average hearing loss in the 31 to 80 db hl range in the better ear (who, 2004). however, if there is a local capacity to provide appropriate hearing health care, according to mcpherson and olusanya (2008), then this does not preclude screening that also targets milder degrees of hearing loss. research has shown that even minimal intervention such as preferential seating in the classroom may improve educational outcomes for children with slight and mild hearing loss and unilateral hearing loss (mcpherson & holborow, 1985; olusanya et al., 2004). the three recommended tests in school-based-screenings for developing countries are otoscopy, pure-tone audiometry screening, and otoacoustic emissions (oaes). otoscopy is useful in the examination of the external ear, ear canal, and tympanic membrane. otoscopic examination is useful in ruling out impacted cerumen. according to rao et al. (2002), lyn et al. (1998), and swart et al. (1995), impacted cerumen is one of the most common ear diseases and causes of hearing loss, with prevalence rate between 7.4% and 63%. additionally, otoscopy does not require a great deal of expertise beyond basic training and is useful to refer a child when the tympanic membrane cannot be visualized due to occlusion of the external auditory meatus by cerumen. pure-tone audiometry screening, in which there is typically no attempt to find threshold, has been found to accurately assess hearing status in children six years and older, when trained health workers in the community of rural bangladeshi village used a simple condition play response procedure (berg et al., 2006). recommended test frequencies are 1000, 2000, and 4000 hz, at 20 db hl according to the asha (1997) guidelines for screening audiometry. however, 500 hz has been found to identify the auditory impact of otitis media with effusion in children and should be included at 25 db hl when permitted by ambient noise levels (who, 1997). in regards to equipment, noise-excluding earphones are advisable in order to limit external noise factors. if possible, though costly, an effective way to reduce background noise is through the use of a mobile hearing screening facility. examples of such a facility include the use of a 4x4 vehicles in the hark project of south africa (ogilvy & michelson, 2003). these facilities incorporate a sound-treated environment for hearing screening. lastly, in order to reduce operator errors, roeser and clark (2004) recommend a minimum training program of no less than five days while who recommends an initial three-week training program (who, 2004) for ‘primary ear health workers.’ otoacoustic emissions (oaes) can be in both newborns and child based hearing screenings. oaes are an objective tool that can be used to measure the integrity of the outer hair cells in the cochlear; however, test results below 2000 hz can be adversely affected by high levels of ambient noise in the school environment (nozza, 2001). oaes can be used in populations where responses to pure-tone audiometry are either unable to be obtained or results are unreliable. oaes may be particularly useful in the screening of preschool age children. availability and management of amplification due to the lack of available research and data on amplification availability and management in developing countries, the information below is from case studies and low-income communities in developed countries. according to the world health organization (who, 2013), approximately 360 million people worldwide have a hearing loss greater than 40 db hl. of these 360 million, less than 10% either own or have access to proper hearing aids. the vast majority of this population lives in low- and middle- income countries, with the majority residing in south asia, the asian pacific, and sub-saharan africa. more developed cities, such as hong kong, offer over-the-counter hearing aids sold at electrical and department stores around the city. the styles of hearing aids currently available over-the-counter include: in the canal (itc), behind the ear (bte), and body worn (bw) hearing aids. an average over-the-counter hearing aid typically costs approximately $25us for bte and bw and $250us for itc in comparison to $250us to $1,500us for the same hearing aids prescribed by an audiologist. therefore, over-the-counter hearing aids offer a relatively more affordable option to developing countries where the majority of citizens do not have the money to seek hearing aids from within the professional setting. unfortunately, cheng and mcpherson (2000) write, many over-the-counter hearing aids are set for very specific hearing losses, especially for those that require more low frequency gain than high frequency gain. alternatively, hearing aids donated in developed countries can be brought and fit by humanitarian organizations in developing countries. currently, finding appropriate amplification that is fit to the individual user's hearing loss is an area in great need of attention. smith (2003) writes that 50% of hearing loss is avoidable (e.g., noise exposure, medical intervention, etc.), thus leaving 50% unavoidable (e.g., genetic or hereditary hearing loss) and requiring amplification. developing countries list of developing countries as of january 1, 2013: afghanistanguineapanama albaniaguinea-bissaupapua new guinea algeriaguyanaparaguay american samoahaitiperu angolahondurasphilippines argentinaindiaromania armeniaindonesiarussian federation azerbaijaniran, islamic rep. ofrwanda bangladeshiraqsamoa belarusjamaicasão tomé and príncipe belizejordansenegal beninkazakhstanserbia bhutankenyaseychelles bolivia (plurinational state of)kiribatisierra leone bosnia and herzegovinakorea, democ. p. rep. ofsolomon islands botswanakosovosomalia brazilkyrgyz republicsouth africa bulgarialao people's democ. rep.south sudan burkina fasolatviasri lanka burundilebanonst. kitts and nevis cambodialesothost. lucia cameroonliberiast. vincent and the grenadines cape verdelibyasudan central african republiclithuaniasuriname chadmacedonia, the f.y.r. ofswaziland chilemadagascarsyrian arab republic chinamalawitajikistan colombiamalaysiatanzania, united republic of comorosmaldivesthailand congo, democ. republic of themalitimor-leste congo, rep.marshall islandstogo costa ricamauritaniatonga côte d'ivoiremauritiustunisia cubamexicoturkey djiboutimicronesia, fed. states ofturkmenistan dominicamoldovatuvalu dominican republicmongoliauganda ecuadormontenegroukraine egypt, arab rep.moroccouruguay el salvadormozambiqueuzbekistan eritreamyanmarvanuatu ethiopianamibiavenezuela, (bolivarian republic of) fijinepalvietnam gabonnicaraguawest bank and gaza* gambia, thenigeryemen georgianigeriazambia ghanapakistanzimbabwe grenadapalau guatemala *"occupied palestinian territory"