The objective of this audit was to assess whether state government entities (entities) are effectively reducing the burden of ear disease for Aboriginal children. In this report we use the term ‘Aboriginal’ to include all Aboriginal and Torres Strait Islander people.
Our audit mainly focused on health services provided by the Department of Health, the Child and Adolescent Health Service and the WA Country Health Service. We refer to these entities as ‘WA Health’ throughout the report. We also included the Department of Communities and the Department of Education in the audit to provide broader context.
Otitis media (OM) is a treatable inflammation or infection in the middle ear that is very common in children. Most children will develop OM at least once in their first 3 years. Early detection and treatment can prevent the condition becoming chronic and severe. Frequent or severe episodes can lead to permanent ear damage and hearing loss, affecting learning as well as education and life outcomes. Some children with OM feel discomfort or pain, but others show no obvious symptoms.
Chronic suppurative OM (CSOM) is the most severe form of the disease, and is defined by continual ear discharge through a persistent hole in the eardrum. In 2004, the World Health Organization found that Aboriginal children have rates of CSOM so high they indicate a significant public health problem in need of urgent attention. In contrast, it noted that the overall Australian rate was amongst the lowest worldwide.
Even temporary hearing loss can seriously impact many parts of life (Figure 1). It can slow down speech development, especially in the vital early years. If not diagnosed or treated, hearing loss makes it harder to learn effectively and do well at school, which has many serious effects on later life. Children that cannot hear well do not always respond to verbal instructions. This can lead to a misplaced reputation for misbehaving at home and school. Children with hearing loss can also have a hard time learning social skills and forming good relationships with their peers.
As well as the development and social issues illustrated in Figure 1, hearing loss can make it harder for Aboriginal children to learn cultural lessons and stories from elders and others in the community. For many Aboriginal people, having a strong culture is a vital aspect of wellbeing.
WA Health has recognised that co-designing services with Aboriginal people is the best way to support them. Co-design involves government developing policies, programs and services with the community to make them more effective and culturally appropriate. It can also help empower socially disadvantaged communities and build programs that reflect their values and needs. The WA Aboriginal Health and Wellbeing Framework and the Sustainable Health Review both cite co-design as a useful approach to improve Aboriginal health in Western Australian (WA).
Key entities involved in monitoring, treating and improving ear health of Aboriginal children are listed below.
- WA Health, including the Child and Adolescent Health Service (CAHS) and the WA Country Health Service (WACHS): Have a role in preventing and detecting potential ear problems in young children. They also provide specialist and hospital treatment when ear problems are severe. The Department of Health (DoH) funds Aboriginal environmental health services in regional and remote areas.
- Department of Communities: Provides housing to many Aboriginal families and plays an important role in reducing environmental risk factors associated with OM. Having access to clean running water and uncrowded houses can help prevent OM.
- Department of Education: Focuses on minimising the impact of OM in classrooms by building staff capacity to support children with hearing loss, including the use of amplification systems in classrooms and additional educational support staff.
Many other stakeholders and service providers are involved in this area. The Commonwealth government funds primary care, including general practitioners (GPs) and Aboriginal Community Controlled Health Services (ACCHS) to provide front-line diagnosis and treatment. The Commonwealth has also funded specific ear health projects and programs over time. Various non-government organisations do research and provide medical services to help Aboriginal families with their children’s ear health.
WA Health and other entities have recognised that the high rate of OM in Aboriginal children in WA is a complex problem with serious health, social and economic consequences. There are some local examples of good practice in preventing, detecting and treating OM in Aboriginal children, but there are still a number of barriers to reducing rates of the disease and its impact.
WA Health does not have adequate information on prevalence, assessment or treatment. Nor is there an effective system of co-designed and collaborative care. The current general approach to preventing, detecting and treating OM has not worked for many Aboriginal children. This means that the audited entities cannot demonstrate that they are effectively reducing the burden of ear disease for Aboriginal children.
Identifying the problem has largely relied on standardised child health screening that does not include physical ear checks. Programs developed specifically for Aboriginal children that include ear checks do not reach most Aboriginal children. Other checks take place when children start school, but by this time many children will already have hearing loss and developmental delays.
Service delivery remains ad hoc. The release of a WA Child Ear Health Strategy in 2017 was a step forward in the effort to tackle OM in Aboriginal children. However, entities still do not know who is ultimately responsible for implementing the strategy, and there are no specific plans or targets for them to measure progress and success.
There is evidence that co-designing services is important to ensuring their success in Aboriginal communities. However, the ear health services offered to Aboriginal children and families generally are not the result of effective co-design. Meaningful co-design will need to be a key part of implementing the strategy for it to effectively improve Aboriginal children’s ear health.
WA Health’s data does not give a clear picture of Aboriginal children’s ear health
WA Health do not track or analyse the rate of OM in Aboriginal children, nor do they know if efforts to reduce the burden or severity of ear disease are working. There are a number of gaps in WA Health’s data linkage and information. For instance, they collect data on instances of care such as Universal child health checks (Universal checks). But these checks don’t reach many Aboriginal children, and there is no linkage to subsequent diagnosis, treatment and outcomes.
Entities do not use existing data to build a clear picture of the prevalence of OM. Researchers, government entities and non-Government organisations (NGOs) all collect some data, but this is rarely shared. Without a coordinated and collaborative approach to data sharing it is difficult to evaluate what programs work best and where, and to provide an accurate picture of OM in the State.
Based on our review of the available research, Aboriginal children experience OM more regularly and suffer longer than non-Aboriginal children. It tends to present at a younger age and is more likely to result in hearing loss. The Telethon Kids Institute performed research in the Goldfields that found Aboriginal children had OM at more than double the rate of non-Aboriginal children (55% compared to 26%). This indicates a continued disparity between Aboriginal and non-Aboriginal children.
Programs to identify OM don’t reach most Aboriginal children early enough
Early detection and treatment is the most effective way to avoid hearing loss and developmental problems, but WA Health are missing key opportunities early in children’s lives to find out if they have OM. The main health screening program for children are the Universal checks from birth to 2 years. But these checks do not focus on ear disease and there is no physical examination inside of a child’s ears unless parents have raised concerns. Further, the Universal checks do not reach most Aboriginal children. Our analysis of CAHS child health data in 2017-18 found that 43.9% of Aboriginal children in Perth received a health check.
Screening also occurs when children start school, an approach that is effective in reaching a lot of children. CAHS data for school screening in 2017 showed that 94% of Aboriginal children entering pre-primary in the metropolitan area had a health check. In addition to school entry, they also screened 1,260 Aboriginal children at 151 primary schools in 2018. However, because this testing comes when children are 4 to 5 years old and above, many will already have hearing loss and development delays from repeated or persistent OM.
The school testing also comes after the most important period when children develop neural pathways for language and hearing. While screening helps identify children who need support in learning, earlier intervention would be more effective in ensuring Aboriginal children are not already disadvantaged before they start school.
The main program specifically targeted at Aboriginal children has a limited reach. The Enhanced Aboriginal Child Health Schedule (EACHS) program is an extension of the Universal checks designed for Aboriginal children, and includes regular physical ear checks. While it appears to work, EACHS has not reached all at-risk Aboriginal children. In 2017-18 there were 1607 EACHS tests in the metropolitan area. CAHS believes this represents meeting 29% of Aboriginal families. There is no reliable data for non-metropolitan EACHS tests.
The EACHS checks program is being revised by WACHS and by CAHS, but in different ways. WACHS plans to keep the schedule but remove the focus on Aboriginal children, so it is for all at risk children and rename it the Enhanced Child Health Schedule. This could impact how much service Aboriginal families can access if resourcing does not change. CAHS has replaced EACHS with a system of tiered Universal checks based on assessed individual and family need. Families using the Aboriginal Health Team services will be offered an extended service that includes physical ear checks. However, it is unclear how both approaches will improve the reach of ear screening to Aboriginal children.
Services have not been co-designed, making them hard for Aboriginal families to use and limiting their effectiveness
To date while WACHS and CAHS have partnered with consumers in the design of some services, these approaches have not been consistently applied to ear health. Broader stakeholder collaboration and coordination is also limited. The State has recognised the benefits of co-designing Aboriginal services in the DoH’s Aboriginal Health and Wellbeing Framework. The medical model of care identifies coordinated healthcare as key to reducing rates of OM. However, co-design has not been mandated by WA Health. When services are not designed for communities, they are less likely to be effective.
Services offered to Aboriginal families once children are diagnosed with OM are generally standardised and are not designed to encourage Aboriginal people to use them. Aboriginal families told us that the system is often difficult to navigate, particularly when they are referred from one service to another. Each referral increases the risk of missing an appointment or disengaging, and leaving OM untreated. Some families are uncomfortable or unable to deal with mainstream services, and some told us they believe that seeking care for persistent ear problems could result in them being ‘reported to child protection’.
There are good examples of how changing service delivery can make them easier for Aboriginal families to use. The Pina Karnbi pilot project in Kalgoorlie has used immunisation as an opportunity to check children’s ears and a nurse works with families to navigate services where a problem has been identified. The development of the Kimberley Regional Ear Health Strategic Plan involved collaboration between WACHS and the Kimberley Aboriginal Medical Service (KAMS). Learning from what is already working would enable continuous improvement in outcomes.
There is now an ear health strategy, but many of the conditions for its successful implementation are not yet in place
In 2017, the WA Minister for Health released the WA Child Ear Health Strategy (the Strategy) but the priorities set out in the Strategy have not been translated into specific actions with timelines, measures and resource requirements. The Strategy is silent on how it will be funded and who is accountable for its implementation. Working groups created under the Strategy have enabled relationship building across the sector, and may assist future partnerships, but they are yet to deliver any tangible actions.
There are broad socio-economic and environmental factors in Aboriginal ear health that involve stakeholders beyond those partnered in the strategy. Environmental health issues, such as overcrowding in housing, access to clean running water, poor nutrition and poverty are key factors and will require collaboration across entities not currently involved in the working groups.
 World Health Organization (2004). Chronic suppuratives otitis media;Burden of illness and management options.Geneva, Switzerland: World Health Organization.
 Lehmann, D., Weeks, S., Jacoby, P., et al. (2008). Absent otoacoustic emissions predict otitis media in young Aboriginal children: a birth cohort study in Aboriginal and non-Aboriginal children in the arid zone of Western Australia. BMC Pediatrics 2008; 8: 32.