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Tier 1 - Health status and outcomes

1.15 Ear health

Key facts

Why is it important?

Hearing loss among Aboriginal and Torres Strait Islander people is widespread and much more common than for non-Indigenous Australians (Burns & Thomson 2013; Darwin Otitis Guidelines Group 2010). Hearing loss may result from several factors, including genetic causes, complications at birth, infectious diseases, chronic ear infections, use of certain medicines, injuries and accidents, exposure to loud noise and ageing. Worldwide, 60% of childhood hearing loss is due to preventable causes (WHO 2016). Otitis media (inflammation and infection of the middle ear) is a significant cause of hearing loss in Indigenous Australian children. The main forms of the disease include:

Otitis media in Indigenous children is characterised by earlier onset, higher frequency, greater severity and greater persistence than in non-Indigenous children (Jervis-Bardy et al. 2014; Kong et al. 2017). Several studies have found that Indigenous children living in remote communities experience high rates of severe and persistent ear infections (Edwards & Moffat 2014; Gunasekera H. et al. 2009; Kong & Coates 2009; Morris et al. 2007). Population surveillance across remote Northern Territory and Western Australian communities found that almost 90% of young children had otitis media (generally bilateral) and 14% to 20% had chronic suppurative otitis media (Leach & Morris 2017; Leach et al. 2014; Leach et al. 2016). Across the communities participating in the study since 2001, the proportion of young children with bilateral normal ears has been below 10% (Leach & Morris 2017; Leach et al. 2016; Morris et al. 2005). Overcrowded housing has been identified as a significant risk factor for otitis media, and exposure to campfire and tobacco smoke are also risk factors for early otitis media in infants (Leach & Morris 2017). Breastfeeding during the first six months of life can prevent many episodes of otitis media.

Hearing loss, especially in childhood, can lead to linguistic, social and learning difficulties and behavioural problems in school. Such difficulties may reduce educational achievements and have lifelong consequences for wellbeing, employment, income, social success, contact with the criminal justice system and attaining future potential (Burrow et al. 2009; Hogan et al. 2011; Williams & Jacobs 2009; Yiengprugsawan et al. 2013). Children with hearing problems may be at risk of developing mental health disorders, without appropriate intervention (Hogan et al. 2011).

Burden of disease

In 2011, hearing and vision disorders contributed 1.2% of the total burden of disease for Indigenous Australians. Hearing loss accounted for 62% of the total burden of disease for hearing and vision disorders, and other hearing and vestibular disorders contributed 17%. Hearing loss and other hearing and vestibular disorders are slightly more common for Indigenous females (51% and 54%, respectively) compared with Indigenous males (49% and 47%, respectively) (AIHW 2016).

Findings

What does the data tell us?

Measured hearing loss

In 2018–19, the National Aboriginal and Torres Strait Islander Health Survey (Health Survey) offered a voluntary hearing test for participants aged 7 and over. An estimated 290,400 (43%) Indigenous Australians aged 7 and over were found to have hearing loss in one or both ears, and proportions were similar for both Indigenous males (43%) and females (42%).

The proportion of measured hearing loss increased steadily with age, from 29% for Indigenous Australians aged 7–24, to 82% for those aged 55 and over (ABS 2019) (Figure 1.15.1).

Figure 1.15.1: Measured hearing loss, Indigenous Australians aged 7 and over, by age and whether self-reported hearing loss, 2018–19

This stacked bar chart shows that measured hearing loss increased with age for Indigenous Australians aged 7 and over. The proportion for those aged 7 to 24 was 29% and this increased to 82% for those aged 55 and over. In all age categories, majority of people with measured hearing loss had not self-reported having hearing loss.

Source: National Aboriginal and Torres Strait Islander Health Survey 2018–19 (ABS Table 32.3).

Measured hearing loss for Indigenous Australians aged 7 and over was higher in Remote areas (59%) than Non-remote areas (39%). Of Indigenous Australians aged 7 and over who were found to have measured hearing loss, 79% did not report having long-term hearing loss.

Measured hearing loss was found to be clearly correlated with several key socioeconomic outcomes. For instance, among all Indigenous Australians who did not have any hearing loss, 41% had completed Year 12 or equivalent educational qualifications, while 56% were employed. The equivalent proportions among Indigenous Australians who had measured hearing loss in one or both ears were 26% and 40%, respectively. Among those with hearing loss in both ears, only 21% had completed Year 12 or equivalent, and 32% were employed.

The severity of the hearing loss (among Indigenous Australians with loss in both ears) also affected these outcomes. For instance, among those with severe or profound hearing loss, 18% had completed Year 12, and 17% were employed, compared with 23% with Year 12 and 36% employed among those with mild hearing loss (in both ears) (ABS 2019).

Self-reported ear health in children

Self-reported survey data may underestimate health conditions because it only includes conditions diagnosed by a doctor or nurse. Data from the 2018–19 Health Survey showed that 19,060 Indigenous children aged 0–14 had self-reported ear or hearing problems. Indigenous children aged 0–14 had an ear or hearing problem at 2.3 times the rate of non-Indigenous children (6.9% compared with 3%). For Indigenous children, there was a decline in self-reported ear or hearing problems, from 11.2% in 2001 to 6.9% in 2018–19. The greatest decline was in Remote areas, from 18% to 10% over the period (Table D1.15.3, Table 1.15-1).

Table 1.15-1: Long-term hearing problems children aged 0–14 years, by Indigenous status and remoteness, 2001, 2004–05, 2008, 2012–13, 2014–15 and 2018–19

Indigenous status

2001

2004–05

2008

2012–13

2014–15

2018–19

Total Indigenous

11.2%

9.5%

8.5%

7.1%

8.4%

6.9%

      Non-remote

8.5%

8.5%

8.0%

6.6%

7.5%

6.4%

      Remote

17.7%

12.6%

10.3%

9.1%

11.4%

9.7%

Total non-Indigenous

4.7%

3.0%

3.0%

3.6%

2.9%

3.0%


Source:
Table D1.15.3. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19; and ABS (unpublished) National Health Survey 2017–18.

Total or partial deafness was reported for 3.8% of Indigenous children, otitis media (middle ear infection) for 2.6%, and other diseases of the ear for 0.5%. Rates of hearing problems among Indigenous children were higher in Remote areas (9.7%) than Non-remote areas (6.4%) (Table D1.15.3, Figure 1.15.2).

Figure 1.15.2: Indigenous children aged 0–14 with a long-term hearing problem, by remoteness, 2018–19

This bar chart shows that Indigenous children in remote areas had higher rates of long-term hearing problems than those in non-remote areas (9.7% compared with 6.4%). In remote areas, 5.8% were with deafness, 3.2% had otitis media, and 0.4% had other ear or hearing problems. In non-remote areas the proportions were 3.3%, 2.5% and 0.6% respectively.

Source: Table D1.15.3. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19; and ABS (unpublished) National Health Survey 2017–18.

Self-reported ear and hearing problems were less common among Indigenous children aged 0–3 (4%) than those aged 4–14 (8%). A higher proportion of Indigenous boys aged 0–14 reported ear or hearing problems (7.4%) than Indigenous girls of the same age (6.4%).

By jurisdiction, the rate of ear and hearing problems for Indigenous children in 2018–19 was highest in Western Australia (9%) and lowest in New South Wales (6%) (Table D1.15.9, Figure 1.15.3).

Figure 1.15.3: Reported hearing or ear problems for Indigenous children aged 0–14, by jurisdiction, 2018–19

This bar chart shows the proportion of Indigenous children with a long-term hearing problem was highest in WA at 9% and lowest in NSW, Victoria, and Tasmania/ACT, which were all 6%. Nationally, 7% Indigenous children had a long–term hearing problem.

Source: Table D1.15.9. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19.

In 2014–15, of Indigenous children aged 0–14 with ear or hearing problems, 83% received some form of treatment, including:

  • medication (including eardrops or antibiotics) (48%)
  • checked by an ear or hearing specialist (46%)
  • surgery (31%).

The remaining 16% of Indigenous children did not have any treatment for their ear and hearing problems. Not receiving treatment for ear or hearing problems was more common for Indigenous children in Remote areas (26%) than Non-remote areas (14%) (Table D1.15.20).

Self-reported ear health among all ages

Data from the 2018–19 Health Survey showed that 14% (111,700) of Indigenous Australians of all ages reported having an ear or hearing problem (Table D1.15.4). The survey collected comprehensive long-term health condition data for all age groups. Ear or hearing problems were reported for 7% of Indigenous children aged 0–14 and rose steadily to 34% for those aged 55 and over.

After adjusting for differences in age structure between the two populations, ear or hearing problems for Indigenous Australians were 1.4 times the rate for non-Indigenous Australians (17% and 13%, respectively). Indigenous Australians aged under 54 had higher rates of ear or hearing problems than non-Indigenous Australians, and rates for those aged 55 and over were similar between the two populations (34% and 32%, respectively) (Table D1.15.5, Figure 1.15.4).

Figure 1.15.4: Rate of Australians reporting ear or hearing problems, by Indigenous status and age, 2018–19

This bar chart shows that proportions of self-reported ear/hearing problems for Indigenous Australians increased with age and were higher than for non-Indigenous Australians in all age groups. The proportion for Indigenous Australians increased from 7% for ages 0 to 14, to 34% for ages 55 and over. For non-Indigenous Australians these proportions were 3% and 32%, respectively.

Source: Table D1.15.5. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19 and National Health Survey 2017–18.

In 2018–19, after adjusting for differences in the age structure between the two populations, otitis media among Indigenous Australians was 3.3 times the rate for non-Indigenous Australians (1% compared with 0.3%), and deafness was 1.5 times the rate for non-Indigenous Australians (14% and 9%) (ABS 2019).

Indigenous Australians of all ages living in Non-remote areas reported an ear or hearing problem at similar rates to those in Remote areas (14% and 13%, respectively). By jurisdiction, the rate of Indigenous Australians reporting an ear or hearing problem was highest in the Australian Capital Territory (21%) and lowest in the Northern Territory (10%) (Table D1.15.4).

Indigenous Australians aged 15 and over who lived in the most disadvantaged socioeconomic areas (1st quintile) were 1.4 times as likely to report ear or hearing problems than those living in the most advantaged areas (5th quintile) (18% compared with 13%).

Of Indigenous Australians aged 15 and over who had completed Year 12, 15% had an ear or hearing problem compared with 23% of those who had completed Year 9 or below as their highest year of school.

Indigenous Australians aged 15 and over who reported their health as fair/poor (28%) were twice as likely to report having an ear or hearing problem as those reporting their health as excellent/very good/good (14%) (Table D1.15.6).

Ear and hearing health outreach services for Indigenous children and young people aged under 21 in the Northern Territory

Data were collected for Indigenous children and young people prioritised to receive Australian Government-funded hearing outreach services in the Northern Territory. In 2018:

  • 1,922 audiology services were provided to 1,751 Indigenous children and young people.
  • 717 ear, nose and throat services were provided to 668 children and young people—approximately 150 fewer services than in 2017.
  • 1,817 children and young people received at least one type of ear service.

As of December 2018, over 3,000 Indigenous children and young people had outstanding referrals for hearing health services and were on waiting lists, a high number primarily explained by a shortage of available specialists.

Of those receiving hearing health outreach services, the percentage of Indigenous children and young people with at least one ear disease decreased by 5 percentage points, from 66% to 61% between 2012 and 2018. The proportion of children with hearing loss decreased by 8 percentage points, from 55% to 47% between 2012 and 2018.

At their last service provision, 61% (1,111) of Indigenous children and young people receiving hearing health outreach services were diagnosed with at least 1 type of ear condition:

  • 23% had otitis media with effusion
  • 18% had Eustachian tube dysfunction
  • 15% had chronic suppurative otitis media without discharge
  • 13% had chronic suppurative otitis media with discharge (AIHW 2019a).

Ear health and hospitalisations

From July 2015 to June 2017, there were 6,449 hospitalisations for Indigenous Australians due to ear disease. After adjusting for differences in the age structure between the two populations, Indigenous Australians were 1.2 times as likely as non-Indigenous Australians to be hospitalised for ear disease (3.3 and 2.8 per 1,000, respectively) (Table D1.15.12).

For Indigenous and non-Indigenous Australians, the most common reason for hospitalisation relating to the ear were for middle ear and mastoid diseases (78% compared with 57%) (Table D1.15.13, Figure 1.15.5).

Figure 1.15.5: Hospitalisations for principal diagnosis of diseases of the ear and mastoid process, Indigenous Australians, by age, July 2015 to June 2017

This bar chart shows that the majority of hospitalisations for diseases of the ear and mastoid process for Indigenous Australians were for disease of the middle ear and mastoid (78%), followed by diseases of the external ear (9%), other disorders of the ear (7%) and diseases of the inner ear (6%). This differed by age, with children aged 0-14 having higher rates of hospitalisation for diseases of the middle ear and mastoid, and those aged 15 and over having higher rates of diseases of the external ear and diseases of the inner ear.

Source: Table D1.15.13. AIHW analysis of National Hospital Morbidity Database.

For Indigenous children aged 0–14, the rate of hospitalisation for ear disease was highest for those living in Remote and Very remote areas (both 15 per 1,000, respectively), compared with Outer regional areas (6.9 per 1,000) and Major cities and Inner regional areas (both 6.5 per 1,000) (Table D1.15.14).

Between 2004–05 and 2016–17, in the six jurisdictions with Indigenous identification data of adequate quality (New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory), there was a 50% increase (5.7 to 8.7 per 1,000) in ear-related hospitalisations for Indigenous children aged 0–14. In the same period, there was a 67% increase (1.3 to 2.5 per 1,000) in hospitalisations for Indigenous Australians aged 15 and over (Table D1.15.15, Figure 1.15.6).

Figure 1.15.6: Age-standardised hospitalisation rates for principal diagnosis of diseases of the ear and mastoid process, by Indigenous status and age group, NSW, Vic, Qld, WA, SA, NT, 2004–05 to 2016–17

This line chart shows that the hospitalisation rate for diseases of the ear and mastoid process were higher for children (0-14) compared with adults (15 or over), for both Indigenous and non-Indigenous populations. From 2004-05 to 2016-17 for Indigenous children aged 0 to 14, the hospitalisation rate for diseases of the ear and mastoid process increased from 5.7 per 1,000 to 8.5 per 1,000. For Indigenous adults, the rate increased from 1.3 to 2.5 per 1,000. The rates for non-Indigenous children decreased while for non-Indigenous adults the pattern increased slighty, however, rates for both non-Indigenous children and adults remained lower than for Indigenous.

Source: Table D1.15.15. AIHW analysis of National Hospital Morbidity Database.

In 2017–18, the rate of myringotomy procedures (incision in the eardrum to relieve pressure caused by excessive fluid build-up) in hospital was 1.7 per 1,000 for Indigenous Australians and 1.6 per 1,000 for Other Australians (AIHW 2019b) (Other Australians includes non-Indigenous Australians and those whose Indigenous status is unknown).

Public hospital waiting list data showed that the median elective surgery waiting time for myringotomy procedures was 64 days for Indigenous patients, compared with 66 days for Other Australian patients (AIHW 2018a).

Between July 2014 and June 2016, there were nearly 3,700 hospitalisations for Indigenous children (aged 0–14) for diseases of the middle ear and mastoid process. Three-quarters (76%) had myringotomy and/or tympanoplasty. Between July 2014 and June 2016, the overall rate of myringotomy (repair of middle ear perforation) and tympanoplasty (a reconstructive surgical treatment for a perforated eardrum) procedures for children aged 0–14 was similar for Indigenous children (5.6 per 1,000) and non-Indigenous children (5.7 per 1,000). However, non-Indigenous children had their procedures at relatively younger ages than Indigenous children (AIHW 2018b).

General practitioner reported ear health

For Indigenous children aged 0–14, otitis media was managed by general practitioners (GPs) at a similar rate (67 per 1,000 encounters) to the rate for Other Australian children (64 per 1,000 encounters). Rates were also similar for total ear problems in 2010–15 (105 compared with 98 per 1,000 encounters, respectively) (Table D1.15.19).

Primary health care services and ear health

Australian Government-funded Indigenous primary health care organisations provided access to ear, nose and throat specialists. These were provided onsite or though facilitating access to offsite facilities. In 2017–18, 22% of services were provided onsite only, 56% offsite only and 13% were a combination of onsite and offsite (AIHW 2019c).

Queensland Deadly Ears program

In 2008–2019, data collected through the Queensland Deadly Ears program showed that of the children aged 0–4 who received an audiology assessment, 3,352 (24%) had hearing loss in both ears and 13% in one ear. For the 7,819 Indigenous children aged 5–14 who received an audiology assessment, 29% had hearing loss in both ears and 22% in one ear (Table D1.15.17, Figure 1.15.7).

Figure 1.15.7: Proportion of Deadly Ears Program clients who received an audiology assessment, by hearing loss and age group, Queensland, 2008–2019

This line chart shows that rates of bilateral conductive hearing loss and unilateral conductive hearing loss for Indigenous children aged 0-4 and 5-14 were quite volatile over the period. Bilateral conductive hearing loss fluctuated over the period, peaking in 2010 for both age groups (45% for 0-4 and 47% for 5-14) before ending at 30% for both groups in 2019. The proportion of unilateral conductive hearing loss fluctuated for both age groups.

Source: Table D1.15.17. Deadly Ears program data.

Of the 5,306 Indigenous children aged 0–4 who received an ear, nose and throat (ENT) assessment through the Deadly Ears Program during 2007–2019, 11% had chronic suppurative otitis media, 6% had dry perforation, and 32% had otitis media with effusion. Of the 10,782 Indigenous children aged 5–14 who received an ENT assessment, 9% had chronic suppurative otitis media, 10% had dry perforation, and 20% had otitis media with effusion (Table D1.15.18).

What do research and evaluations tell us?

Research conducted by the Menzies School of Health Research suggests that the prevalence of chronic suppurative otitis media in remote Northern Territory fell from 24% in 2001 to around 13% in 2013, mainly due to the introduction of pneumococcal conjugate vaccines (Leach & Morris 2017; Leach et al. 2016; Morris et al. 2005). Randomised controlled trials have shown that pneumococcal vaccines can prevent infections caused by several (up to 13) strains of pneumococcus (Leach & Morris 2017). However, there are no vaccines licensed for two of the predominant pneumococcal strains, and there are over 90 strains that can cause otitis media. Developing an effective vaccine is not yet fully achieved. Ten-valent pneumococcal Haemophilus influenzae protein D conjugate vaccine (PHiD-CV10) and 13-valent pneumococcal conjugate vaccine (PCV13) were licensed in Australia for use in large-scale immunisation programs in 2009 and 2011, respectively (Oguoma et al. 2020). The Northern Territory was the only jurisdiction to include PHiD-CV10 in the childhood immunisation schedule as a 3+1 (2, 4, 6, +18 months) vaccination schedule for Indigenous Australian children from October 2009 to October 2011, when it was replaced by PCV13. A randomised controlled trial will give Indigenous children a booster dose of either PHiD-CV10 or PCV13 at 12 months of age and compare outcomes at 18 months of age.

A study monitoring the prevalence of suppurative otitis media in Indigenous children in remote Northern Territory from 2010 to 2013 found that otitis media was rarely associated with pain (as reported by their parents) (Leach et al. 2016). Early-onset of otitis media may be a factor in asymptomatic acute otitis media among Indigenous children—as documented over many years (Leach et al. 2016; Senate Community Affairs References Committee 2010). This means that parents and health-care providers can be unaware of infections, which go untreated and become chronic (Leach & Morris 2017). Evidence suggests that diagnostic inaccuracy for otitis media is common (Blomgren & Pitkäranta 2003; Blomgren et al. 2004; Garbutt et al. 2003) and leads to delayed treatment, under- or over-treatment and an increased risk of complications, including hearing loss and antibiotic resistance (Gunasekera Hasantha et al. 2007; Lieberthal et al. 2013; WHO 2013). In some remote communities, otitis media has become normalised, and parents are unlikely to seek treatment (Leach & Morris 2017; Senate Community Affairs References Committee 2010).

A study of 419 myringoplasty operation outcomes in the West Kimberley from 2004 to 2014 found that follow-up and outcomes remain poor for Indigenous Australians. Only 21.5% of operations had complete follow-up. Of those with complete follow-up, 29% had closure of the tympanic membrane with normal hearing. Success rates were higher among patients with dry ears before the operation.

The Department of Health engaged a consultant to undertake an examination of the six Indigenous Ear and Hearing Health Initiatives funded under the Indigenous Australians’ Health Programme (Siggins Miller Consultants 2017). This evaluation found that, while these programs facilitated and improved access to multidisciplinary ear health care for Indigenous children and young people, the evidence suggests the burden of disease has not significantly declined. One of the key recommendations at the program level was for more communication about the programs to Indigenous communities, service providers, peak bodies, State and Territory governments and other stakeholders. Another recommendation was to require adherence to the National Otitis Media Clinical Care Guidelines as a condition of Commonwealth funding. While the evaluation found that the Guidelines were influential and there was evidence of their increasing use by service providers, it also noted there were systemic barriers to service providers following the recommended care pathway and delivering timely care to children with or at risk of developing ear disease.

Otitis media is associated with crowded housing conditions, nutritional deficiencies, poverty and overall social and economic disadvantage (Burns & Thomson 2013; DeLacy et al. 2020; Jacoby et al. 2011). Tobacco smoking rates among Indigenous Australians remain high (see measures 2.03 Environmental tobacco smoke and 2.15 Tobacco use). Exposure to tobacco smoke can cause of middle ear infection (Jacoby Peter A et al. 2008; Jervis-Bardy et al. 2014; Office on Smoking and Health (US) 2006) and exposure to tobacco and campfire smoke are risk factors for early otitis media in infants (Leach & Morris 2017). Other social determinants such as lower levels of education and lack of employment among parents and carers can also contribute to high rates of untreated acute and chronic infections (Leach & Morris 2017).

Using data linkage, an observational cohort study of 3,744 Indigenous children in the Northern Territory found that Indigenous children with any level of hearing impairment were likely to have lower school attendance rates in Year 1 than their peers with normal hearing (Su et al. 2019). The effect of unilateral hearing loss (normal in one ear and any degree of hearing loss in the other ear) on school attendance was similar to the effect of mild and moderate hearing loss.

A retrospective cohort study of 1,533 Indigenous children from remote Northern Territory communities used linked individual-level information to investigate the association between hearing impairment in early childhood and youth offending (He et al. 2019). This study demonstrated a high prevalence of hearing impairment among Indigenous children with a record of an offence (boys: 55.6%, girls: 36.7%) and those without an offence record (boys: 46.1%, girls: 49.0%). In univariate analysis, a higher risk of offending was found among Indigenous boys with moderate or worse hearing impairment, but no evidence of an association was found among Indigenous girls. However, after controlling for other factors, such as community factors, child maltreatment and Year 7 school attendance, an association between hearing impairment and youth offending was not evident. The reasons for the lack of an association for Indigenous boys after adjusting for other factors is unclear, and it is possible that the effects of hearing impairment were masked by the much stronger effect of child maltreatment and community factors.

Tools have been developed to assist health professionals, teachers and early childhood professionals to work with parents to identify Indigenous children who may be at risk of hearing and communication issues. The Parents’ Evaluation of Aural/oral performance of Children (PEACH) ear health screening questionnaire was developed and validated for use with young children in the general population who have unimpaired or impaired hearing (National Acoustic Laboratories 2018). The Parent-evaluated Listening and Understanding Measure (PLUM) is an adaptation of the PEACH to be suitable for the Indigenous Australian context. The Hear and Talk Scale (HATS) was also developed to identify children who may have speech communication difficulties. The PLUM and HATS were co-designed with Indigenous and non-Indigenous primary health and early childhood professionals (National Acoustic Laboratories 2020) and have been validated for use with Indigenous Australian children aged 0–5 (National Acoustic Laboratories 2018). These tools make use of parents’ and carers’ observations of children in everyday situations and can reveal early signs of hearing difficulty and hindered language development to assist with early intervention (DoH 2020).

The Deadly Ears Deadly Kids Deadly Communities Framework 20092013 was developed in Queensland to address otitis media in Indigenous children spanning areas of prevention, detection and surveillance, treatment, partnerships and workforce. An evaluation showed a reduction in presentations of chronic suppurative otitis media in children from 2009–10 to 2013–14 (using Deadly Ears Clinic data), following health promotion and education activities in 2010. There was also improved access to appropriate specialist and mainstream services to treat and manage otitis media and other ear and hearing problems, and improved learning and development support within schools for children affected by otitis media (Durham et al. 2015). A separate but related evaluation concluded that sustained progress in improving the ear health of Indigenous children requires a holistic, system-wide approach with the appropriate government structures geared towards multi-sector involvement, shared system-level goals and system-wide feedback processes (Durham et al. 2018).The Deadly Kids Deadly Futures: Queensland’s Aboriginal and Torres Strait Islander Child Ear and Hearing Health Framework 2016–2026 aims to strengthen the primary health-care sector to diagnose and manage the effects of middle ear disease and associated hearing loss as part of routine child health checks and provide opportunistic care on every occasion of service. In addition, the framework will track progress in health, early childhood and schooling sectors with targets and actions aimed at health promotion and prevention, improvements to services, workforce development and data collection and research (State of Queensland 2016).

Implications

Rates of GP management of ear problems and otitis media for Indigenous children 0–14 years are similar to non-Indigenous rates, yet the prevalence of self-reported ear or hearing problems is over twice as high. Self-reported ear and hearing problems have been shown to be under-reported in the Indigenous Australian population, particularly children, with 92% of Indigenous children aged 7–14 years with measured hearing loss not reporting they had a long-term hearing impairment in 2018-19 (ABS 2020).

For some forms of ear disease, the recommendation for children in populations not at high risk of chronic suppurative otitis media is to ‘watch and wait’ (Darwin Otitis Guidelines Group 2010). Hospitalisation rates for myringotomy are similar for Indigenous Australians and other Australians, as are wait times for myringotomy procedures in public hospitals. This suggests that health services and hospitals are not yet meeting the need for treating ear or hearing problems for Indigenous Australians.

The regular collection of data on the prevalence of measured hearing loss among Indigenous Australians, in addition to the self-reported estimates traditionally collected in the Health Survey, remains a priority given the high rates of measured hearing loss found nationally in the 2018–19 Health Survey. There remains a gap in the national measured hearing loss data for Indigenous children aged under 7.

A comprehensive approach combining prevention, early treatment and coordinated management is required to reduce the incidence of hearing loss among Indigenous Australians. Primary prevention includes working with families on encouraging breastfeeding (Bowatte et al. 2015) eating a healthy diet, reducing exposure to second-hand smoke, nasal passage clearing, seeking early medical assessment and encouraging vaccination.

Otitis media and hearing loss have become normalised in some remote communities and can go unrecognised with parents rarely seeking help for these conditions (Leach & Morris 2017). Therefore, routine and regular surveillance for hearing loss and regular ear checks in the neonatal and pre-school period is recommended for Indigenous children given the high prevalence of otitis media. Routine child health checks, including an assessment of Indigenous children’s ear health on each occasion of contact with a health service, are needed to monitor hearing health in the case of recurrent infections, and to support the identification of issues associated with hearing loss such as delays in speech and language development and impaired listening skills.

Once otitis media develops, medical management should be consistent with the Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations. When hearing loss is detected, access and referral to a range of health services is needed, including speech therapists and audiology support services (Darwin Otitis Guidelines Group 2010). If permanent hearing loss is detected, access and referral to support for hearing augmentation and other remedial therapies should be sought.

In addition to a focus on 0–4 year olds for early identification and intervention, detection and management of hearing loss on entry into primary school should be included in measures to help improve school attendance (Su et al. 2019). As with younger children, this approach should be considered as part of a “whole-of-child” check to support the identification of other developmental impacts associated with hearing loss. Strategies in schools such as classroom management strategies, language therapy, and sound amplification have been successful tools for those with hearing impairment (Burns & Thomson 2013; Massie et al. 2004).

The discrepancy between self-reported and measured hearing loss underscores the importance of routine surveillance to objectively detect ear and hearing problems as part of whole-of-child health checks.

Practical, evidence-based indicators to support the continuous quality improvement of health services in the management of otitis media in Indigenous children were developed by a group of experts, including working in Aboriginal Community Controlled Health Organisations (Sibthorpe et al. 2017). The indicators cover routine surveillance, incidence of ear disease, appropriate prescribing, audiological testing, care planning and timely follow-up.

Current interventions are primarily focused on medical approaches, such as antibiotics and surgical procedures. While these are essential, a broader public health lens is required to address the underlying social determinants that are driving the high rates of otitis media among Indigenous children, including overcrowding (DeLacy et al. 2020). A significantly increased focus on both primordial prevention to address these social determinants and primary prevention, including family and community health literacy about otitis media, is needed (Australian Medical Association 2017).

The policy context is at Policies and strategies.

References

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