The challenges of improving ear health in South Australia
The Anangu Lands Paper Tracker has previously provided information about ear health and hearing loss amongst Anangu children. You can read these posts here and listen to a radio interview with Linnett Sanchez, Associate Professor of Audiology through Flinders University here. You can also read Professor Sanchez’s presentation to the Aboriginal Lands Parliamentary Standing Committee in which she highlights the very serious ear health and hearing problems that remote Aboriginal children in Australia experience and the connection between those problems and educational failure and disadvantage.
A recent article in the Sunday Mail of 9 July 2017 by Nadja Fleet – ‘Fighting the disease of disadvantage’ – highlights the findings of Dr Trish MacFarlane, an ear nose and throat surgeon at Flinders Private Hospital who has worked with children from remote communities. She believes that ‘the rates of ear disease in Aboriginal communities in South Australia are some of the worst in the world … You’ve got children from infancy that can’t hear, can’t learn, can’t get an education, can’t get a job because they can’t get an education and it really just sets them up for failure. These children have hearing loss and ear diseases that are not being recognised and treated and essentially it’s endemic’.
South Australia’s Ear Health Framework
Having healthy ears and being able to hear properly is a very important part of child health and development. Children learn to speak by hearing other people talking, and learn to interact and engage with their world through hearing and talking. It’s therefore very important that ear health is looked after during every child’s early years of life, while their speech and neural pathways are developing.
For Aboriginal children, the most significant ear health and hearing problems are caused by middle ear infections (called otitis media) that can result in hearing loss. Research has shown that between the ages of two and 20 years, Aboriginal people could be expected to have 32 months of otitis media – this adds up to more than two and a half years of living with an ear infection by the time the person is 20 years old – and is compared to only three months in the non-Aboriginal population for this same timeframe.
In addition to the short-term consequences of illness, distress and school absence, middle ear disease can lead to long periods of fluctuating hearing loss.
To look at this issue, the South Australian Aboriginal Ear Health Reference Group developed An Aboriginal Ear Health framework for South Australia, which was published in March 2017. This Framework places a particular emphasis on tackling the causes and consequences of middle ear disease and states that the management of ear disease and hearing loss can make a significant positive difference, not only to children’s health outcomes, but in education, employment and social relationships.
Determinants of Middle Ear Disease/Otitis Media
The Framework outlines the factors that can contribute to middle ear disease, such as each child’s individual characteristics, as well as factors in a child’s family, environment and broader community.
Some individual factors associated with increased risk of ear disease include age, overall health and being born prematurely. A child’s health status is also affected by aspects of family life and their immediate environment. For example, breastfeeding is known to protect against infection and is associated with better ear health. Access to healthy food promotes good nutritional status and a healthy immune system to fight infection. Exposure to tobacco smoke increases the risk of airway irritation and infections. Children are also more likely to develop upper respiratory tract infections when in close contact with other children who are sick or if they live in crowded housing.
Government policies and access to healthcare can influence ear health and the risks of hearing loss. For example, policy can support access to culturally-appropriate health care where families and children can receive adequate care for acute ear infections, as well as access to protective interventions such as others not smoking near children and mothers being encouraged to breastfeed their babies. Housing policy can address factors such as access to appropriate housing with well-functioning services and equipment.
When childhood ear disease is seen in this context, it becomes clear that improving the socio-economic determinants of health will assist in tackling ear disease. The effects of persistent ear and hearing problems can cause a cycle of disadvantage for families. Therefore, a health promoting environment is needed to break this cycle. This also includes access to early childhood education and literacy support. This approach highlights the importance of acting at multiple levels, in order to make sustained improvements in ear health.
Consequences of ear disease
The Framework outlines that, for many Aboriginal children, middle ear disease becomes a recurrent or chronic condition. There may be otitis media with effusion or chronic suppurative otitis media, the latter being a particular issue for children living in remote areas. Episodes of otitis media are associated with fluctuating conductive hearing loss. This can result in difficulty following classroom instructions and conversation. Consequences may include speech and language delays, and later auditory processing problems due to periods of hearing loss in the crucial developmental time of early childhood. Children may also develop long-term hearing loss as a result of chronic middle ear disease.
For some Aboriginal children, these difficulties are compounded by a classroom environment that is not tailored to their first language. Speech and language difficulties can lead to misunderstandings in communication, and to the psychological consequences of difficult interactions with peers and teachers. If strategies are not applied early to prevent these consequences, then educational outcomes and employment will suffer.
Burden of ear disease in Australia
A review focusing on otitis media in Australian Aboriginal children, largely with reference to remote areas, found a prevalence of the following conditions amongst these children:
- 1-12.8 per cent for acute otitis media
- 5-30.3 per cent for active chronic otitis media
- 31-50 per cent for tympanic membrane perforation.
Another research study by Rothstein and others found a prevalence of Chronic Suppurative Otitis Media (CSOM) of 24.6 per cent in Aboriginal children, and under five percent in non-Aboriginal children. This percentage for Aboriginal children is 20.6 per cent higher than the World Health Organisation’s indicator of anything over 4 per cent as being ‘a massive public health problem’ (WHO, 2004). The high level of otitis media and hearing loss amongst Aboriginal children has significantly exceeded what is understood internationally as a serious public health problem.
Ear disease in South Australia
Children in remote areas such as the APY Lands were much less likely to pass hearing tests (audiometric screening). Although pass rates improved with age, for the 11-12 year olds the pass rate in remote SA was less than half the pass rate for the metropolitan area. This table indicates that for five to six year old children, more than half these children (66.3 per cent) failed the hearing test. These early years are probably the most important for brain, language and speech development.
|Age in years||Metropolitan (Adelaide)||Remote (APY lands)|
|Pass bilaterally: no freq. >25 dBHL (%)||Pass bilaterally: no freq. >25 dBHL (%)|
Table: Proportion of Indigenous children passing audiometric screening by geographical location in SA Adapted from Sanchez et al. (2010).
The graphic below (from the Aboriginal Ear Health Framework for SA, p. 13) highlights the differences in ear and hearing health between those children living in remote communities and those in metropolitan areas.
The key principles included in the Framework
Here is an overview of the key principles in the Framework (p. 14):
- Aboriginal governance and community involvement
- Support for strong Aboriginal governance, leadership and participation; regardless of where care is provided.
- Community involvement, which will necessarily include the primary health care sector, Aboriginal Community Controlled Health Organisations and the wider primary health care sector.
- Family engagement and enabling family responsibility for ear health through education and assistance in navigating services.
- Community-based programs, tailored to local needs and strengths, and utilising existing relationships.
- Prevention focus
- Recognition of the importance of preventive health and health promotion activities.
- A need to address the socio-economic determinants of ear health, to prevent the consequences of ear disease and hearing loss.
- Ear health is prioritised and promoted, including through linkage to broader health and community outcomes.
- Early and effective intervention
- Screening/surveillance and diagnosis must be accompanied by follow-up care (this principle may require consideration of specific enabling mechanisms).
- Emphasis is placed on early detection (by screening and surveillance) and intervention, with a particular focus on early childhood (0-5 years of age) and primary health care involvement.
- State-wide care
- A systematic approach that recognises available local services and referral pathways.
- Good communication and appropriate information-sharing.
- An equity-based approach, with programs guided by need.
- Adoption of a standardised, consistent, guideline-based approach.
- Aim for sustainability of programs and services.
- Programs must be designed in such a way that they can be audited/evaluated, with information owned by the community.
Having set out the key principles, the Framework highlights the current gaps in care, the areas that should be prioritised, the importance of investing in children’s ear health and the need for appropriate funding and resources.
 Couzos and Murray, 2003, cited in Australian Institute of Health and Welfare (2011).
 The SAAEHRG worked with Australian Hearing, Department for Education and Child Development, Flinders University South Australia – Audiology Department, Rural Doctors Workforce Agency, SA Health – Country Health SA LHN, SA Health – Public Health Partnerships Branch (PHPB), SA Health – WCHN Children’s Audiology Service, SA Health – Watto Purrunna (includes Under Fives program) (NALHN), SA Health – Aboriginal Health Services (SALHN), The Cora Barclay Centre (CBC), The Aboriginal Health Council of South Australia (AHCSA) and member South Australian Aboriginal Community Controlled Health Services (ACCHSs)
 SAAEHRG, 2017, An Aboriginal Ear Health framework for South Australia, p. 7.
 Jervis-Bardy, J., Sanchez, L. & Carney, A. S. 2014. Otitis media in Indigenous Australian children: review of epidemiology and risk factors. The Journal of Laryngology and Otology, 128, s16-s27.
 Cited in Jervis-Bardy et al. (2014).