1.15 Ear health
Why is it important?
Hearing loss among Aboriginal and Torres Strait Islander peoples is widespread and much more common than for non-Indigenous Australians. 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 employment, income, social success and contact with the criminal justice system (Williams et al. 2009).
Otitis media is an inflammation of the middle ear. Otitis media with effusion involves a collection of fluid within the middle ear space, and chronic suppurative otitis media occurs with persistent discharge through a persistent perforation in the eardrum and active bacterial infection within the middle ear space, which lasts several weeks or more. The WHO regards a prevalence of chronic suppurative otitis media of greater than 4% as a massive public health problem requiring urgent action (WHO 2004a). Several studies have found that Indigenous children living in remote communities experience high rates of severe and persistent ear infections (Edwards et al. 2014; Morris et al. 2007; Gunasekera et al. 2009; Coates 2009). Indigenous children have earlier onset of otitis media and it persists longer (Jervis-Bardy et al. 2014). Otitis media is associated with poverty, crowded housing conditions, passive smoking and nutritional deficiencies (Burns J et al. 2013).
National survey data which rely on self-reporting may under-estimate conditions that are undiagnosed. For example, while the 2008 Social Survey showed 12% of Indigenous children in the NT had ear/hearing problems, ear disease was found in 30% of the 10,605 Indigenous children tested in prescribed areas (remote areas and town camps) between July 2007 and 30 June 2009 as part of the Northern Territory Emergency Response (NTER) (AIHW & DoHA 2009). Of the 6,894 children who received audiology/ENT services as part of the NTER and the Stronger Futures in the NT programme (SFNT) between August 2007 and June 2014, two-thirds (66%) had at least one middle ear condition, 26% had otitis media with effusion and 12% had chronic suppurative otitis media. In 2012–13, 51% of the children receiving audiology services under the SFNT had some form of hearing loss and 10% moderate/severe/profound hearing impairment (AIHW 2014ac). For those children who had received care under the NTER and then SFNT, the proportion with at least one type of middle ear condition had decreased from 86% to 73%. Most (64%) experienced an improvement in hearing.
There has been a significant decline in the national proportion of Indigenous children aged 0–14 years with self-reported hearing conditions, from 11% in 2001 to 7% in 2012–13. In remote areas the decline was steeper, from 18% to 9%. However, in 2012–13 the proportion of Indigenous children with ear health problems was still twice the rate for non-Indigenous children. WA had the highest rate for Indigenous children (11%) and Qld the lowest (5%). Deafness was reported for 3.4% of Indigenous children, otitis media for 2.8% and other ear diseases 1.2%. In 2012–13, ear/ hearing problems were more common for Indigenous children aged 4–14 years living in the most socio-economically disadvantaged areas (10%) compared with the most advantaged areas (2%). Indigenous children with ear/hearing problems were more likely to visit a doctor in the last 2 weeks (28%) than those without ear/hearing problems (11%).
In 2012–13, 12% of the total Indigenous population had a reported ear health problem. The pattern of ear health problems varies with age. Otitis media is more prevalent in children while reported deafness increases steadily with age. In 2012–13, deafness was reported for 3% of Indigenous children, with rates rising steadily to 26% of those aged 55 years and over. In 2012–13, hearing loss was higher for Indigenous Australians than for non-Indigenous Australians in all age groups from 0–54 years of age. After adjusting for differences in the age structure of the two populations, otitis media among Indigenous Australians was 2.4 times as high as the non-Indigenous rate, with rate ratios of 1.4 for deafness and 1.3 for ear health problems overall.
During the two years to June 2013, there were around 5,300 hospitalisations for Indigenous Australians for ear disease. The Indigenous rate (3.0 per 1,000) was similar to the non-Indigenous rate (2.6 per 1,000). Rates for Indigenous children aged 0–4 years were less than those for non-Indigenous children, while for those aged 5–14 years the Indigenous rate was 1.7 times as high. For Indigenous children aged 0–14 years the rate was 3 times as high in remote and very remote areas (18 and 17 per 1,000) as in major cities 6 per 1,000. Since 2004–05, there has been a 56% increase in ear- related hospitalisations for Indigenous children aged 0–14 years (no change for non-Indigenous children) and a 33% increase for those 15 years and over (6% increase for non-Indigenous Australians) in NSW, Vic, Qld, WA, SA and the NT combined.
In 2012–13, the rate of myringotomy procedures (incision in the eardrum to relieve pressure caused by excessive fluid build-up) in hospital was 1.8 per 1,000 in the population for both Indigenous Australians and other Australians (AIHW 2014f). However, in 2013–14 the elective surgery median wait time for myringotomy procedures was 58 days for Indigenous patients compared with 54 days for other Australian patients (public hospital waiting lists) (AHIW 2014g). In the period from July 2011 to June 2013, Indigenous children aged 0–14 years were hospitalised for tympanoplasty procedures (a reconstructive surgical treatment for a perforated eardrum) at 5.5 times the rate of non-Indigenous children. One in ten children fitted with a hearing aid or cochlear implant in 2010 were Indigenous (AIHW and AIFS 2014).
For Indigenous children aged 0–14 years otitis media was managed by GPs at a similar rate (70 per 1,000 encounters) to that for other Australian children (67 per 1,000). Rates were also similar for total diseases of the ear in 2008–2013 (107 compared with 101). In 2012–13, 22% of Australian Government-funded Indigenous primary health services provided access to ENT specialists on site and 73% off site. In 2011–13, data collected through the Qld Deadly Ears programme showed that of 0–4 year old clients who received an audiology assessment, 23% had hearing loss in both ears and 5% in one; for clients aged 5–14 years, 30% had hearing loss in both ears and 14% in one ear.
Chronic ear disease causing serious hearing damage is common among Indigenous Australians. Indigenous children have been found to wait longer than recommended for ear/hearing services (Gunasekera et al. 2009). The current rate of GP management of ear disease is similar for Indigenous and non-Indigenous children yet the prevalence of ear disease is twice as high for Indigenous children. Evidence suggests that a comprehensive approach combining prevention, early treatment, management and referral will be most successful in addressing the high rates of chronic otitis media. Primary prevention includes working with families on modification of risk factors such as encouraging breastfeeding, eating a healthy diet, reducing passive smoking, nasal passage clearing, seeking early medical assessment and encouraging vaccination. Once otitis media develops antibiotic treatment and surgical interventions (in persistent cases) are recommended. Screening for hearing loss in the neonatal period and pre-school period is recommended for Indigenous children given the high prevalence of otitis media. Regular medical examination of children's ears for otitis media is also recommended for this population. Once permanent hearing loss is detected, access and referral to a range of hearing services is needed such as hearing aids, speech therapists and school based audiology support services (Couzos et al. 2001). Strategies in schools such as classroom management strategies, language therapy, and sound amplification have been successful tools for those with hearing impairment (Massie et al. 2004; Burrow et al. 2009).
Around $31 million over 4 years from 2013–14 has been provided for ear health initiatives to assist in reducing the number of Aboriginal and Torres Strait Islander peoples suffering avoidable hearing loss, improve the coordination of hearing health care, and give Indigenous children a better start to education. Key initiatives include more than $24 million over four years from 2013–14 for the Healthy Ears—Better Hearing, Better Listening Programme, which aims to increase access to ear health services including outreach ENT specialists, audiologists and speech therapists services in rural and remote areas; ensuring the currency of the Otitis Media guidelines; provision of equipment to primary health services and a communication programme to raise awareness of ear disease, promote ear health and 'de-normalise' ear disease. In 2013–14, $3.331 million was provided for the delivery of the Australian Hearing Specialist Programme for Indigenous Australians through outreach sites including remote communities. A further $3.718 million was provided to Australian Hearing to deliver hearing services to eligible Indigenous Australians over 50 years of age. Australian Hearing also undertakes research and development in the areas of hearing loss prevention and mitigation including spatial processing disorder among Indigenous children. The disorder is thought to affect the listening and therefore learning ability of school aged children, and may be more prevalent in children with an existing hearing loss. State and territory governments have implemented a variety of programmes for Indigenous hearing health. In Qld, the Deadly Ears Program has been established to address middle ear disease, including screening services, health promotion, training, and the delivery of allied health, clinical and surgical services.
Figure 1.15.1 shows age-standardised hospitalisation rates from diseases of the ear and mastoid process among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians in NSW, Victoria, Queensland, WA, SA & NT, for each year from 2004–05 to 2012–13. The Indigenous rate (13 per 1,000) was less than the non-Indigenous rate (15 per 1,000). Rates for Indigenous children aged 0–4 years were less than those for non-Indigenous children, while for those aged 5–14 years the Indigenous rate was 1.5 times as high. Since 2004-05, there has been a 56% increase in ear related hospitalisations for Indigenous Australians aged 0-14 years (no change non-Indigenous) and a 33% increase for those 15 years and over (6% increase for non-Indigenous) in NSW, Vic, Qld, WA, SA and the NT combined.
Source: AIHW analysis of National Hospital Morbidity Database
Figure 1.15.2 shows the rate of ear and hearing problems managed by GPs (per 1,000 encounters) among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians aged 0-14 years. Data is presented for the period April 2006–March 2007 to April 2010–March 2011. For Indigenous children aged 0–14 years the rate per 1,000 encounters managed by GPs was similar to the other Australian rate for otitis media (70.1 compared to 67.0) and rates were also similar for total diseases of the ear (107.1 compared to 100.9).
Source: Family Medicine Research Centre, University of Sydney analysis of BEACH data
Note: data for the 1995 NATSIHS available for non-remote areas only.
Source: ABS & AIHW analysis of 1995 and 2001 NHS (Indigenous supplements), 2004–05 NATSIHS, 2008 NATSISS and 2012–13 AATSIHS