Otitis media (middle ear) infections are more prevalent in Aboriginal and Torres Strait Islander children than any other population in the world. Many Aboriginal and Torres Strait Islander children experience chronic or reoccurring otitis media infections that can result in permanent hearing loss. These infections can disrupt a child’s language development and ability to benefit from education. This chapter describes: the prevalence, causes, and effects of otitis media; its links to disadvantage later in life; and possible public health measures to reduce the prevalence of otitis media in Aboriginal and Torres Strait Islander communities.
Specific groups within the Australian community are at greater risk of losing their hearing, or face additional challenges accessing treatment for hearing loss. This chapter also discusses the hearing health of these groups, focussing particularly on people from culturally and linguistically diverse backgrounds, people living in rural and regional areas, the aged population, and veterans and defence personnel.
Aboriginal and Torres Strait Islander People
Prevalence of Otitis Media and Hearing Loss
The Indigenous Affairs Group in the Department of the Prime Minister and Cabinet stated there is ‘a higher proportion of Indigenous Australians experiencing hearing problems than non-Indigenous Australians across most age groups and across remote, rural and metropolitan areas.’
Australian Hearing confirmed that while Aboriginal and Torres Strait Islanders were known to have higher rates of ear disease and hearing loss, a lack of quality data in this area meant that it is difficult to accurately estimate prevalence at a population level.
The ‘predominant cause of hearing loss’ in Aboriginal and Torres Strait Islander children is the contraction of otitis media, or middle ear, infections. Box 3.1 provides information on the types and pathology of otitis media.
Professor Amanda Leach and Professor Peter Morris stated that the prevalence of otitis media among Aboriginal and Torres Strait Islander children is thought to be the highest of any group in the world. In 2013, 90 per cent of Aboriginal and Torres Strait Islander children in remote Northern Territory communities were found to have some form of otitis media.
While not as prevalent as in remote communities, the rate of otitis media among Aboriginal and Torres Strait Islander children living in urban and rural settings is still estimated to be around 40 per cent with two per cent having perforated eardrums.
Dr Damien Howard and Jody Barney stated that ‘it has been estimated that Aboriginal children in Australia experience otitis media throughout their childhood for an average of 2.5 years, while the average for children in the mainstream Australian community is three months.’
The Deadly Ears Program highlighted that in Aboriginal and Torres Strait Islander children otitis media ‘is characterised by:
Earlier onset – Aboriginal and Torres Strait Islander babies and infants acquire the disease at a younger age than children of other Australians
Higher frequency – the disease occurs often and repeatedly
Greater severity – more Aboriginal and Torres Strait Islander children experience the severest forms of the disease
Persistence – the disease lasts for longer periods of time.
Box 3.1: Otitis Media
The term otitis media includes ‘all forms of inflammation and infection of the middle ear.’ Otitis media is ‘nearly always associated with middle ear effusion (fluid in the middle ear space)’.
The common types of otitis media include:
Acute otitis media (AOM): fluid behind the eardrum resulting in symptoms such as: a bulging or red eardrum, pain and fever, that last less than six weeks.
Chronic suppurative otitis media (CSOM) with discharge: a persistent discharge through a hole in the eardrum lasting for more than six weeks. CSOM with discharge is also referred to as ‘runny ear’.
CSOM without discharge: a hole in the eardrum without evidence of discharge or fluid behind the ear.
Otitis media with effusion (OME): middle ear fluid without signs of acute infection or a perforation of the eardrum. OME is also referred to as ‘glue ear’ and may be episodic or persistent.
Otitis media is caused by bacteria and viruses that colonise the back of the nasal passages and ‘access the middle ear space via the Eustachian tube.’ The build-up of fluid in the middle ear prevents the eardrum vibrating and conducting sound to the brain.
Otitis media is a very common condition in young children, with estimates suggesting it affects ‘over 90 per cent of children at least once before their second birthday.’ Non-Indigenous children often experience viral otitis media during winter and the condition tends to resolve naturally. In Aboriginal and Torres Strait Islander children, however, otitis media is commonly bacterial and ‘children under five years of age are the major carriers of these bacteria’. Transmission of the bacteria occurs ‘via human to human contact, spread of nasal secretions via cough, sneezing, kissing and hand contamination’.
Aboriginal and Torres Strait Islander children in remote communities often contract the bacteria that cause otitis media in the first weeks of life. Professor Amanda Leach stated that half the children she sees at 28 days of age already have these bacteria, and that the bacterial strains accumulate as the child gets older. Professor Leach explained:
they have one infection at one month, then they have another strain by two months and then another one the next time. Each strain is accumulating, so they are not eliminating those before they acquire the next. So you have a multipathogen problem, and that is not happening for other children, who have one infection at a time.
The Deadly Ears Program stated that in Queensland and in ‘many other jurisdictions’ the rate of CSOM among Aboriginal and Torres Strait Islander children is reducing. Prevalence rates are still high, however, with recent studies in remote communities finding rates of CSOM with discharge at between 11 per cent and 15 per cent. The World Health Organisation defined a ‘prevalence of CSOM of above one per cent as an avoidable burden of disease, and anything above four per cent as indicative of a massive public health problem requiring urgent attention.’
Chronic otitis media can have a lifelong impact on hearing. Dr Damien Howard and Jody Barney advised that ‘the damage caused by persistent ear disease leaves between 40 per cent (urban) and up to 70 per cent (remote) of Aboriginal adults with, mostly conductive, hearing loss.’
The Northern Territory Government outlined the potential impact of otitis media on hearing ability:
The degree and impact of hearing loss associated with otitis media varies according to the severity and frequency of episodes, but research suggests that three or more episodes before the age of three years may seriously affect auditory and language development.
In 2015-16, hearing loss was present in 49 per cent of the 1976 Indigenous children and young people in the Northern Territory who received audiology services. Bilateral hearing loss accounted for 32 per cent of cases, while 17 per cent had unilateral loss. Between 2012-13 and 2015-16, of the Aboriginal and Torres Strait Islander children and young people in the Northern Territory who received audiology services, the proportion with hearing loss has ’fluctuated but decreased from 52 per cent to 49 per cent.’
The Northern Territory Government further advised that there was ‘substantial variance in prevalence [of hearing loss] across age ranges’ in Aboriginal and Torres Strait Islander children. In 2015-16, hearing loss was most prevalent among the three to five age group. Among Aboriginal and Torres Strait Islander children in this age group who received audiology services, 59 per cent had hearing loss.
Dr Damien Howard and Jody Barney advised that the proportion of the Aboriginal and Torres Strait Islander community who are deaf is thought to be higher than in the rest of the Australian community (although the disparity is not as large as among the hard of hearing population). The increased rate of deafness may be caused by cases of otitis media where infected fluid from the middle ear has entered the inner ear and caused sensorineural hearing loss. Recent research with Aboriginal and Torres Strait Islander women in custody has suggested a further cause could be women whose hearing loss has been exacerbated due to head injuries sustained through family violence.
Causes of Otitis Media
The Deadly Ears Program highlighted both the ‘early colonisation of the nasopharynx with bad bacteria’, which leads to infection and inflammation, and the health impacts linked to entrenched poverty as contributing factors to the prevalence of otitis media in Aboriginal and Torres Strait Islander communities. Deadly Ears added, however, that there is ‘no clear answer’ as to why the rates of otitis media in Aboriginal and Torres Strait Islander communities are the highest in the world.
Professor Leach described otitis media as a ‘condition of disadvantage’. Factors outlined in submissions as potentially contributing to the high levels of otitis media among Aboriginal and Torres Strait Islander children included:
crowded housing, particularly where young children ‘have a lot of contact with other young children’;
low socioeconomic status;
a lack of access to medical practitioners in remote areas;
‘high carriage rates of bacterial pathogens and the prevalence of multiple bacterial strains’.
Impact of Otitis Media and Hearing Loss
The Deadly Ears Program described otitis media and associated hearing loss as the ‘most profound health and development issue for Aboriginal and Torres Strait Islander children’.
Dr Damien Howard and Jody Barney observed that ‘when hearing loss commences early in life, it has a greater impact than the late onset of hearing loss’. Unlike non-Indigenous Australians, who most commonly will experience hearing loss late in life, hard of hearing Aboriginal and Torres Strait Islanders will be impacted by hearing loss for most of their lives (an average of 72 years for women and 67 years for men).
The Northern Territory Government summarised how otitis media infections early in life can have ongoing and wide-ranging effects well into adulthood, stating otitis media in the first few months of life:
… contributes to multiple negative impacts ranging from delayed auditory, cognitive and psychosocial development, to permanent hearing loss. This can contribute to poor school performance, absenteeism, dropout rates and subsequent difficulties gaining employment. Psychosocial development is also hindered as poor hearing and educational performance can engender self‑doubt, behaviour problems, social isolation, family dysfunction and increased interaction with correctional facilities.
Dr Damien Howard suggested there was insufficient focus on the impacts of hearing loss in Aboriginal and Torres Strait Islander communities, stating ‘the consequences of hearing loss on communication is not something that has been adequately or even initially addressed’. To illustrate, Dr Howard relayed a case where he had been approached to do some work on the impact of hearing loss on Aboriginal and Torres Strait Islander employment and was told the experts had ‘never heard of hearing loss impacting on Indigenous employment, so they [did] not believe it [was] actually a real issue’.
Impact on Education
Professor Amanda Leach and Professor Peter Morris described hearing loss as ‘the most prevalent barrier to educational attainment for Aboriginal and Torres Strait Islander children in the Northern Territory.’
The Northern Territory Government observed that early onset otitis media impacts on a child’s ability to ‘learn and interact with others during the most critical years of development: infancy and young childhood.’ Specifically, children who experience multiple episodes of otitis media prior to the start of school are likely to have difficulties with ‘auditory discrimination, auditory processing, phonological awareness, short-term auditory memory, and auditory sequential memory’. As a result it will be more difficult for these children to attain oral communication, literacy, and numeracy skills.
The Northern Territory Council of Government School Organisations (NT COGSO) identified the following actions as being necessary to enable hearing impaired children to participate fully in the classroom environment:
Classrooms with acoustics fitted to an approved national standard;
Soundfield amplification systems in classrooms with Aboriginal and Torres Strait Islander children, and individual amplification devices for one-to-one and group learning;
Community members employed in the classroom who are fluent in the local language and cognisant of local sign languages;
Education and awareness for parents, teachers, and staff regarding conductive hearing loss;
Audiology assessments for students with referral, and access, to audiology services where needed.
The NT COGSO described the role of soundfield amplification systems in classrooms, explaining that the systems consisted of a small microphone worn by the teacher connected to speakers around the room. The speakers amplify the teacher’s voice by a few decibels enabling it to be heard at a uniform volume throughout the room without it being too loud for hearing students.
The NT COGSO stated that an eight week trial of soundfield amplification systems had been carried out in rural Queensland and that it had resulted in an increased level of communication between children and teachers, and among children, including an increased number of interactions initiated by the children.
Interactions with the Criminal Justice System
Dr Damien Howard and Jody Barney advised that research had identified hearing loss as a key issue in the ‘overrepresentation of Aboriginal people in the criminal justice sector.’ In the Darwin and Alice Springs correctional systems, 90 per cent of Aboriginal and Torres Strait Islander inmates have hearing loss. Australian Hearing advised that a similar pattern could be found across Australia, as ‘hearing loss is over-represented in Aboriginal prisoners in all jurisdictions’.
The Council of Presidents of Medical Colleges drew attention to the youth justice system, stating that ‘up to 60 per cent of children in youth detention centres are Aboriginal, of which approximately 80 per cent have ongoing significant hearing issues when tested.’
The Australian Medical Association (AMA) commented that high rates of hearing loss among Aboriginal and Torres Strait Islander people contributes to communication difficulties and that ‘this, in turn, exacerbates problems in regard to interactions with law enforcement and criminal justice’. The AMA recommended that all criminal justice detainees should undergo a health assessment including a screening for hearing loss.
Experiences of Deaf Aboriginal and Torres Strait Islander People
Dr Damien Howard and Jody Barney advised that the majority of deaf Aboriginal and Torres Strait Islander people do not use Auslan. Dr Howard and Ms Barney further advised that ‘in the Northern Territory there are approximately 55 Aboriginal signing systems, with about eight most commonly used systems.’
The diversity of signing systems result in deaf Aboriginal and Torres Strait Islanders being reliant on particular people, often family members, with whom they are able to communicate. Separation from the person with whom ‘an idiosyncratic signing system’ has been developed, for example because of death or imprisonment, can lead to a situation of extreme isolation. In other cases, the limited group of people the deaf person can communicate with leaves them vulnerable to ‘exploitation and abuse by some family members, especially financial and sexual abuse’.
In addition, ‘using community signing systems away from “country” is often not culturally permitted, thus preventing deaf Indigenous people from teaching community signs to outsiders’. This ‘linguistic isolation’ results in deaf Aboriginal and Torres Strait Islanders having limited ‘access to the support services provided to mainstream deaf Australians.’
Dr Damien Howard and Jody Barney advised that deaf Aboriginal and Torres Strait Islanders identify with their local communities, rather than mainstream deaf advocacy groups, and so ‘support has to be through and with local Aboriginal communities’.
DeafNT stated that some deaf children in the Northern Territory ‘grow up without any exposure at all to sign language’. DeafNT advocated that it was an ‘imperative’ that deaf children had the opportunity to learn sign language, as without it ‘they have a very limited linguistic foundation’ and would find it difficult to ‘express themselves and to understand their own needs as well as expressing their needs to others’.
DeafNT advocated for increased resources to support deaf children learn sign languages, including local Aboriginal and Torres Strait Islander sign languages. DeafNT also highlighted the need for greater access to interpreters for medical services. DeafNT relayed the case of a deaf child who, unable to ‘express to the nurses and medical staff through sign language what they were feeling’ passed away due to an ear infection.
Prevention and Treatment of Otitis Media
Professor Amanda Leach commented on the use of vaccines to prevent otitis media, suggesting that although vaccine uptake is very high among Aboriginal and Torres Strait Islanders that:
… this is a complex disease, and the vaccines do not cover all of the pathogens. There are shifting sands, if you like: new strains are coming in, and we have come to a plateau with the vaccines … [which means] we have ended up with an improvement in the worst category of ear disease but not an improvement in the proportion of children who have normal ears, and that is partly to do with this changing pathology.
Professor Amanda Leach and Professor Peter Morris also observed that prevention and treatment strategies in Aboriginal and Torres Strait Islander communities have not been as effective as similar strategies delivered in ‘affluent settings’. This reduced efficacy is ‘partially due to the early age of onset, diversity and multiplicity of [otitis media] pathogens, and the density of bacterial infections.’ Professors Leach and Morris suggested that ‘longer courses and higher doses of antibiotics’ and the provision of vaccines as early as one month of age may be required.
Australian Hearing stated that ‘loss to follow up is a significant issue impacting the management of childhood hearing loss in Aboriginal and Torres Strait Islander communities’. Australian Hearing suggested that the key reasons for this included ‘difficulties in service access, normalisation of ear disease and hearing loss, lack of knowledge of the wide-ranging impacts of hearing loss, and lack of faith that following the pathway will result in improvement’.
Services in Remote Aboriginal and Torres Strait Islander Communities
The Department of Health explained that Aboriginal Medical Service (AMS) clinics, which are ‘comprehensive primary health-care providers’, are structured in a ‘hub-and-spoke’ model with a larger clinic based in a town supporting a number of smaller clinics in Aboriginal and Torres Strait Islander communities. The Department commented that some remote communities did not have local health services and instead relied on health coordinators and outreach services.
The Queensland Aboriginal and Islander Health Council (QAIHC) supported the greater provision of hearing health coordinators, each with the responsibility for a region containing multiple AMS clinics. These coordinators could work with local AMS clinics to develop community engagement and health promotion campaigns. The QAIHC suggested that these campaigns should ‘start in the community from the beginning and discuss the problems and come up with solutions’.
The Northern Territory Government described the challenge of delivering hearing health services in remote communities, stating:
… chronic otitis media needs to be tightly case managed as treatment or surgical interventions are required at critical times. This is confounded by remoteness and significant unmet need in primary health care, allied health (audiology and speech therapy) and specialist services (Ear, Nose and Throat surgeons, Clinical Nurse Specialists – ENT).
Mr Jeff Cook, who manages an Aboriginal Community Controlled Health Organisation, explained that Australian Hearing visits the Laynhapuy Homelands (near Gove in the Northern Territory) four times per year and that the funding for these visits is provided by his organisation. Mr Cook advised that for a forthcoming visit Australian Hearing had a list of 50 people to see, but realistically it may only manage to see up to ten people. Mr Cook stated that the people who miss out ‘do not have access to services, it is that simple, they do not have a level of access to services that they require, and we get used to that.’
In Queensland, the Deadly Ears Program provides services to 11 outreach locations. Deadly Ears sends a team consisting of audiologists, ear, nose and throat (ENT) staff, anaesthetists, and a broad mix of nursing staff, to each location for a week to conduct clinics and surgery. Postsurgical care plans for treated children are developed and passed to primary health providers to implement. Any children with conditions outside the scope of the Deadly Ears team are referred to specialist ENT services.
The Deadly Ears Program was described as ‘an excellent program’ by Speech Pathology Australia and one that does a ‘fantastic job’ by the QAIHC. The Royal Australasian College of Surgeons (RACS) added that while Deadly Ears is ‘a really good program in the sense that it is a holistic care model … there is a real, pertinent need for a national strategy, and [key performance indicators] that we can benchmark off each other.’
Access to Specialist Audiology and Ear, Nose and Throat Services
In the Northern Territory the prevalence of otitis media conditions has resulted in unmet demand for hearing health services. In June 2016, ‘3090 children and young people were waiting for audiology services and 1841 for ENT teletology services.’ Professor Peter Morris commented that although the Australian Government has ‘greatly increased funding for both primary health care and audiology services in the Northern Territory’ that ‘further investment is required’.
The Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) advised that ‘surgical treatment for otitis media in young children is not prioritised on hospital waiting lists’ despite this being a ‘crucial time in their educational and social development’. The ASOHNS proposed that incentives be provided to hospitals to ‘prioritise the medical and surgical treatment of Indigenous children with ear and hearing problems’.
The Department of Health stated that it was not aware of any specific complaints related to the ability to access ENT services and that it had an outreach program to ensure once diagnoses are made, people in remote areas can access necessary treatment.
Primary Health Care Services
Watto Purrunna Aboriginal Health Service observed that because otitis media in Aboriginal and Torres Strait Islander children is often pain free, parents are often unaware their child has an ear infection. Watto Purrunna emphasised the importance of hearing screening programs in diagnosing children with hearing problems at a young age.
The Deadly Ears Program recommended that routine health checks must include ear and hearing checks using otoscopy and tympanometry to pick up asymptomatic forms of otitis media. The QAIHC recommended that a focus was needed on treating very young children, up to the age of four or five, as currently children are being picked up ‘only after the damage is done’.
Professor Amanda Leach and Professor Peter Morris contended that primary health care services needed to be able to provide hearing health services to cover gaps in the provision of specialist hearing services. They stated that it was ‘critical that ear health services are available in Primary Health Care settings, for families to access regularly for diagnosis and follow-up – without being placed on impossibly long waiting lists for six-monthly audiology services.’
Dr Damien Howard suggested that ‘the training of all professionals who are likely to engage Indigenous people in their work needs to incorporate information on communication strategies around hearing loss.’
The Deadly Ears Program drew attention to guidelines developed by the Commonwealth Department of Health and the Menzies School of Health Research to assist health practitioners apply best practice in treating otitis media – the Recommendations for Clinical Care Guidelines on the Management of Otitis Media (Middle Ear Infection) in Aboriginal and Torres Strait Islander Populations 2010 (Clinical Guidelines). The Deadly Ears Program commented that despite the development of Clinical Guidelines ‘alignment of practice with the recommendations remains ad hoc and inconsistent.’
The Deadly Ears Program illustrated the potential value of primary health care workers by referring to the town of Eidsvold in Queensland. In Eidsvold the proportion of the children attending clinics who had otitis media dropped from 83 per cent to 12 per cent over a six year period. The Deadly Ears Program stated that the impact of a health worker and general practitioners (GPs) who were dedicated to improving hearing health made it possible to get ‘on top of ear disease at an early stage and eliminated our need to provide a specialist ENT service to the community.’
The Department of Health advised that it was in the process of training Aboriginal and Torres Strait Islander health practitioners to ‘make sure that they are aware of their clinical guidelines’ and stated in the first year this training involved around 1500 people across 80 locations.
The Department of Health also explained that child health checks were currently the primary means of assessing hearing health in young Aboriginal and Torres Strait Islander children.
Coordination of Programs Addressing Hearing Health
The ASOHNS suggested that the ‘short-term nature’ of programs focussed on Aboriginal and Torres Strait Islander hearing health results in ‘a lack of coordination between the states and the Commonwealth’. The ASOHNS added that it strongly believes ‘that there should be a nationally coordinated approach to the treatment of Indigenous children’. The RACS and ASOHNS added that the national approach should ‘build upon existing community approaches and programs, drawing upon programs that are working well and establishing national benchmarks for service delivery’.
Australian Hearing agreed that a national approach is required to ‘bring about the closure of the gap in ear health and hearing outcomes at the broad population level.’
The Telethon Kids Institute suggested addressing the effects of otitis media on Aboriginal and Torres Strait Islander communities would require a ‘multisectoral approach’ with input from organisations involved in ‘housing, health, education, child development, and corrective services’.
The QAIHC stated that in November 2016 RACS convened a roundtable of stakeholders to discuss hearing health in Aboriginal and Torres Strait Islander communities. The representatives at the roundtable recommended the development of a National Aboriginal and Torres Strait Islander Hearing Health Taskforce and embedding hearing health in the Closing the Gap targets.
The RACS and ASOHNS suggested that the taskforce should evaluate:
the efficacy of existing services;
community engagement in ear disease management and the views of Aboriginal and Torres Strait Islanders on how to address hearing health in their communities;
approaches to culturally appropriate service delivery;
funding of primary and specialist care;
data and reporting practices; and
the use and effectiveness of treatment guidelines.
The RACS and ASOHNS also stated that the ‘absence of ear health from the Closing the Gap targets is a great concern.’ The RACS and ASOHNS added that:
… the prioritisation of ear health in the Closing the Gap strategy and the establishment of a taskforce to develop a best practice plan for a national approach to ear health … can make a significant contribution to the health and wellbeing of Aboriginal and Torres Strait Islander Australians.
The Indigenous Affairs Group (IAG) in the Department of the Prime Minister and Cabinet advised that there was not a specific Closing the Gap target focussed on hearing health, as the targets are not ‘disease-specific’. The IAG added that ‘it is not that we do not think that ear disease is important; it is just the way we would construct the Closing the Gap agenda is around those more holistic sorts of issues’.
The QAIHC stated that there is an ‘absence of accurate and reliable data’ which ‘impedes health service planning and delivery’. The QAIHC recommended the development of a nationally consistent process for collecting data. The QAIHC added that work already undertaken by groups including the Northern Territory Hearing Health program, the Australian Primary Health Care Research Institute, and the Aboriginal Health Council of Western Australia could form a foundation for a consistent dataset.
The Deadly Ears Program agreed that data on the prevalence of otitis media and hearing loss is ‘inconsistent, patchy and unreliable and does not allow robust comparisons across jurisdictions.’ Australian Hearing expressed similar sentiments, describing the type, quality and consistency of data collected on Aboriginal and Torres Strait Islander hearing health as ‘inadequate’. The Deadly Ears Program suggested that consistent data would help with targeting resources and that the data needed to be detailed enough to show whether the otitis media cases in a locality could be handled by GPs or whether an ENT surgeon would be needed.
The Northern Territory Government is developing a digital hearing health record for the use of specialist hearing health practitioners such as ENT surgeons, audiologists, and specialist nurses. A related project being undertaken by the Northern Territory Government will provide hearing health data on individual students to teachers and will also be used to recommend amplification and other sound upgrades for classrooms.
People from Culturally and Linguistically Diverse Backgrounds
The Royal Institute for Deaf and Blind Children (RIDBC) advised that children from culturally and linguistically diverse backgrounds accounted for 30 per cent of the children in its programs. The Shepherd Centre also identified that some of its centres had high numbers of children from culturally and linguistically diverse backgrounds and that it needed improved support from interpreting services in order to assist these clients. The Shepherd Centre stated:
Often at times we cannot get a face-to-face interpreter or we cannot get the same interpreter again and again, which is an ongoing issue for a family— particularly when we are trying to talk through medical terminology and go through implant procedures et cetera.’
The Can:Do Group described the need for ‘culturally appropriate information’ for culturally and linguistically diverse families of hearing impaired children, and the need to work with these communities to increase awareness of available services. Can:Do stated that families from culturally and linguistically diverse backgrounds can have ‘their own cultural beliefs around hearing loss and what this means’, which may include ‘shame within their community’ around hearing loss or a reluctance to wear hearing aids.
The Audiometry Nurses Association of Australia commented on an increase of vulnerable clients and refugees entering its clinics for hearing tests. The Goulburn Valley Hearing Clinic also described the experience of refugees with hearing loss in their region and stated:
We see a lot of people in the refugee group who suffer traumatic hearing loss because of their experience in the country they left. We also see in the newborn population a higher incidence of hearing loss and birth defects … It can be a disincentive to accessing services if people are not comfortable dealing with the professional people, and language is a key part of that. If they do not really understand what the process is and what is happening then it can be really confronting.
Aussie Deaf Kids and Parents of Deaf Children recommended that ‘when non-English speaking parents and culturally Deaf adults need to make decisions that will impact on the future of their child, they must have access to appropriately qualified interpreters.’
Goulburn Valley Hearing Clinic described that, as a small business, it faces difficulties in finding funds for interpreters. Goulburn Valley added that Office of Hearing Services contracts include an expectation that hearing clinics will provide interpreters, but that no funding is provided for this purpose and ‘it is really expensive.’ As a consequence, Goulburn Valley undertakes a lot of its ‘work with those vulnerable groups through the hospital’ in order to access interpreter support.
The Deafness Forum of Australia (Deafness Forum) stated that as a result of the ‘significant cost’ of interpreters, ‘some providers are reluctant to accept clients … who do not bring their own interpreter to appointments.’ The Goulburn Valley Hearing Clinic stated that ‘the provision of some sort of access for translation interpreting services through the Office of Hearing Services is something to consider.’
The RIDBC also advised that culturally and linguistically diverse families who receive National Disability Insurance Scheme (NDIS) packages have not always had interpreting included as part of their package. The RIDBC stated:
We are not really sure how we are supposed to work with families who do not speak English without an interpreter. So it is really important that, through those reference packages, that is considered as well’.
The National Disability Insurance Agency (NDIA) advised that it ‘will fund interpreting (translation) for interaction with the NDIA but not with other providers or in the community.’
Vicdeaf drew attention to its ‘Auslan for Deaf Migrants’ program, which teaches Auslan to deaf migrants. Vicdeaf stated that funding for this program is shifting to the NDIS, and ‘many of the course participants will be unable to participate in such programs in future, as many are presently ineligible for the NDIS.’ Vicdeaf recommended this program, along with other services for migrants, be funded to continue across Australia, and that access be given to people who are yet to meet the residency or visa requirements of the NDIS.
The Deafness Forum advised that the Department of Social Services, under the Translating and Interpreting Service, ‘provides free interpreting services to non-English speaking Australian citizens and permanent residents communicating with approved groups and individuals’. Audiologists and audiometrists, however, are not included as an ‘approved group’ and cannot access this free service for their clients. As such, the Deafness Forum recommended that ‘hearing services providers be included in the Translation and Interpreting Service system of funded support.’
People Living in Rural and Regional Areas
Sounds Scouts Australia put the view that people living outside major cities are more likely to have hearing disorders than those who live in cities. This was attributed to factors including the ageing of Australia’s population outside of cities, and a greater potential for exposure to noise induced hearing loss, particularly in farming and mining.
People with hearing impairment in rural and regional areas can face barriers to accessing hearing services. Country Hearing Care advised that there is an 18 month waiting list for the ENT surgeon in Mildura. Country Hearing Care also commented that since 1990, despite a growing population, the audiologist position at Mildura Base Hospital has been reduced from a full‑time equivalent to a one and a half day a week position.
Goulburn Valley Hearing Clinic similarly stated that there is no ENT specialist in Shepparton, and ‘there is a long waiting list to be seen as a public patient at the Goulburn Valley Health ENT clinic.’ The Royal Flying Doctor Service added that ‘some remote and rural Australians with hearing loss will need to travel hundreds of kilometres to receive specialist hearing services.’
The National Rural Health Alliance (NRHA) stated that for the delivery of hearing health services to children in rural and regional areas there was a need to ‘ensure access to an appropriately resourced, culturally competent multi-disciplinary team to identify, refer and treat ear health locally, supported by telemedicine and surgical intervention when necessary’.
The NRHA identified GPs as a key component of the delivery of hearing health services to adults in rural and remote areas. The NRHA suggested that individuals often ‘prioritise other health issues above their hearing’ and that GPs should be encouraged to ‘raise hearing issues as part of regular primary health care checks’ to ensure hearing ‘is not lost in [the] competing priorities’.
The Telethon Kids Institute identified telehealth, the provision of health services via the internet, as a valuable method for increasing access to hearing health services in rural areas. Telehealth services are discussed in more detail in Chapter 4.
Rates of hearing impairment increase with age, with most people over 65 years of age experiencing hearing loss. Hearing impairment in older Australians is associated with communication difficulties, a decline in cognitive functioning and other health conditions. Deafblind Australia stated that ‘the incidence of people with combined vision and hearing loss (deafblindness) will rise significantly as the population ages.’
Dr Timothy Makeham stated that older people are more likely to miss out on receiving treatment for hearing issues, as they have less ‘propensity to travel to seek out care’ and that this ‘depends on [the] support structure around them.’
Issues regarding older Australians’ interaction with hearing aid providers and the cost of hearing aids are discussed in Chapter 5.
Older Australians in the Aged Care System
The Deafness Forum advised that aged care residents are more likely to have hearing loss than older Australians living in the general community. Australian Hearing stated that people living in aged care facilities are also ‘more likely to have other disabilities, including dementia, vision loss and physical impairments.’ These factors mean that ‘aged care residents require additional support to successfully use and manage devices and often rely on care home staff to access hearing services and maintain device usage.’
Australian Hearing stated that it follows a ‘different client service pathway for many clients in residential care.’ This includes education of facility staff, the use of assistive devices, and involvement of carers in hearing improvement programs.
The Deafness Forum advised that ‘the current model of delivering hearing services needs to be adjusted to better meet the needs of frail elderly clients living in an aged care facility.’ Adjustments recommended by the Deafness Forum include:
using individual hearing and communication plans for clients with hearing impairments;
consulting and educating staff and carers on a client’s abilities and needs;
having a staff member coordinate services and support for clients with hearing care plans;
the provision of advice to aged care facilities regarding any changes needed to enhance communication (such as amplification or captioning); and
instituting evaluation mechanisms to gauge the success of treatment and support.
Audiology Australia stated that the Australian Government should ‘facilitate audiologists to work together with the aged care workforce to meet the needs of care recipients.’ Audiology Australia considered that aged care recipients need access to audiologists who have training in providing services to clients with complex needs; and should only receive hearing aids if they are experiencing hearing difficulties that cannot be addressed through other means and can cope with using the device. Audiology Australia also stated that clarification was needed as to what personal and communication assistance should be provided by residential and home care services.
Australian Hearing made the observation that ‘hearing aids are often used inappropriately by staff and residents in nursing homes and are frequently lost or damaged.’ Better Hearing Australia stated that it sends volunteers to nursing homes to help residents clean and maintain their hearing aids, and to train staff on how to carry out these tasks. Better Hearing Australia recommended the Government provide funding to agencies that provide volunteers to perform these services.
Deafblind Australia stated that services for people with deafblindness are currently inadequate. Deafblind Australia recommended that adults with deafblindness in aged care facilities receive a referral from their aged care service provider to deafblind specific services.
Access to Interpreter Funding and Other Support
Audiology Australia stated that there is ‘currently an option for a greater level of support under the NDIS than is available under the Hearing Services Program.’ Audiology Australia recommended the Australian Government ensure that hearing impaired older Australians are given the same level of access to the supports available under the NDIS, such as funding for hearing aid maintenance and specialist smoke alarms and television devices.
The Coalition of Concerned Deaf Elders and Friends was similarly concerned that, unlike people eligible for the NDIS, deaf Auslan users over 65 years of age do not have access to Auslan funding packages to pay for interpreters. The Can:Do Group stated that the lack of funded Auslan interpreting available for people aged over 65 years leaves them with ‘inequality of access, which is, essentially, a basic human right.’
The Deafness Forum also questioned whether people aged over 65 years will have access to the National Auslan Interpreter Booking and Payment Service (NABS) over the long term, as funding for this service has moved to the NDIS. While the Government has confirmed people over 65 years of age can currently continue to access the NABS, the Deafness Forum stated that ‘this may change as the Government makes plans for the future of services like NABS’ and that ‘a lack of certainty in this area is a concern.’
Access to Government Programs
The Deafness Forum advised that the qualifying age for the pension is scheduled to increase to 67 years by 2023. Further to this, the Deafness Forum stated that ‘access to the NDIS is limited to people under 65 years’.
The Deafness Forum stated the change to the pension age may mean some people aged 65 to 67 years will not be able to access the NDIS or the Voucher Scheme (the majority of Voucher Scheme recipients are pensioners). To address this, the Deafness Forum recommended ‘that the age for accessing the NDIS be increased to 67 years at the same rate as access to the aged pension.’
Eligibility for the Voucher Scheme
National Seniors Australia suggested that the Voucher Scheme should be extended to Commonwealth Seniors Health Card holders. National Seniors stated that ‘many older people do not qualify for free or subsidised hearing services, yet they also do not have the capacity to divert their income or savings to cover the out-of-pocket expenses associated with hearing services.’
The Department of Veterans’ Affairs (DVA) advised that ‘hearing loss is very common in the veteran community and is a reflection of the exposures that veterans face as part of their service’. In particular, the DVA identified ‘prolonged exposure to machinery noise or high intensity impulse munitions in a theatre of conflict’ as causes of hearing damage in veterans.
The DVA stated that sensorineural hearing loss and tinnitus are the first and third most common accepted health conditions, respectively, among veterans of the Vietnam War. For veterans of more recent conflicts, tinnitus and sensorineural hearing loss are the second and third most common accepted health conditions respectively.
In 2015-16, 194 434 DVA clients were registered under the Hearing Services Program. In the same year, 42 629 of these clients received hearing device fittings and approximately another 30 248 received other services such as maintenance or battery replacements.
Arafura Audiology questioned whether it was appropriate for younger, recently returned veterans to be supported through the Voucher Scheme, which is predominantly aimed at pensioners. Arafura explained:
These are young ladies and men coming back from the Middle East or other war-torn areas with significant acoustic trauma incidents. They are broadly now lumped under the care of the Office of Hearing Services. They are provided with a device and/or a service that is the same as that provided to a retiree or a person with very different listening needs. They are potentially significantly limited in their capacity to reintegrate into the hearing world given they have had a significant workplace injury, but the decision was taken two years ago to limit the ongoing care in terms of the funding to applicable technology and services for these people.
The Deafness Forum expanded on this issue by explaining that there has been a recent review of military compensation arrangements for veterans with hearing impairment. Previously, veterans eligible for support under the Safety, Rehabilitation and Compensation Act 1988 (Cwlth) (SRC Act) could receive high level hearing aids at no cost. Since the review, however, hearing support for these veterans has moved to the Hearing Services Program Voucher Scheme which provides a free base level hearing aid but requires a co-payment for higher level hearing aids.
The Deafness Forum observed that these changes have resulted in veterans receiving less support than other people eligible for treatment under the SRC Act. The Deafness Forum stated:
It is unreasonable that veterans who sustained a hearing loss as a result of their military service should be disadvantaged in being able to access high level technology due to a change in administrative arrangements in the management of military compensation, whereas other claimants under the same Act, e.g. public servants, continue to receive high level devices at no cost.
The DVA observed that the transfer to new arrangements of clients eligible for services under the SRC Act ‘has caused some concerns’. The DVA further added the hearing aids previously provided to these clients had often been ‘in excess of what was required to manage their hearing loss, with the cost being borne by Government’. The DVA accepted that the changed arrangements had resulted in a ‘perception that there has been a reduction in entitlements as there is a view that fully subsidised hearing aids are basic and insufficient for veterans with active lifestyles.’
The DVA also stated that as ‘a result of the concerns expressed in relation to hearing aids’ it had recently undertaken a review of its hearing services in consultation with the Department of Health, the Ex Service Organisations Round Table, and leading hearing industry experts. As part of the outcomes of this review, the DVA was ‘liaising with Comcare in clarifying the provision of devices for public servants with hearing impairment under the SRC Act’.
Aboriginal and Torres Strait Islander People
The Committee is concerned by the crisis in Aboriginal and Torres Strait Islander hearing health. At any one time 90 per cent of the children in remote Aboriginal and Torres Strait Islander communities will be experiencing an otitis media infection. Sadly for many of these children frequent otitis media infections will result in permanent hearing damage.
The Committee received evidence that, in comparison to other children, Aboriginal and Torres Strait Islander children experience otitis media infections that start at an earlier age and are more frequent, severe, and persistent. On average two and a half years of their childhood is spent with an otitis media infection. Even for those children who do not experience permanent hearing damage, the time spent struggling to hear can negatively impact their development and educational attainment.
Hearing impairment in early childhood can set off a chain of negative impacts that entrench disadvantage in Aboriginal and Torres Strait Islander communities. The unfortunate link between hearing loss and interactions with the criminal justice system can be seen in the Darwin and Alice Springs correctional facilities where 90 per cent of Aboriginal and Torres Strait Islander inmates have hearing loss.
The Committee is concerned by the limited access to hearing health services in regional and remote areas and the lengthy waiting lists for audiological services and ear, nose, and throat consultations in the Northern Territory. Given the negative impact of treatment delays on children’s development, greater resources are needed to reduce these waiting lists.
The Committee was, however, pleased to see the example of the Deadly Ears Program which operates a mobile hearing health service travelling to outreach locations. The Committee believes it is important that successful programs, such as Deadly Ears, are continued and replicated.
Soundfield amplification in schools offers a practical means of assisting children with otitis media infections or mild hearing loss to remain engaged in the classroom. The 2010 Senate Inquiry into Hearing Health in Australia recommended the installation of soundfield amplification in classrooms but this has not been implemented. The Committee concurs with the findings of the Senate Inquiry regarding soundfield amplification in classrooms and reiterates this recommendation.
Many organisations referred to a lack of coordination between Commonwealth, state and territory programs focussed on Aboriginal and Torres Strait Islander hearing health. A strategic national approach is needed to address the crisis in Aboriginal and Torres Strait Islander hearing health. An important first step will be addressing the deficiencies in data collection regarding hearing loss and the provision of services in Aboriginal and Torres Strait Islander communities. Close cooperation between Commonwealth, state and territory agencies, health organisations, and local communities will be required.
People from Culturally and Linguistically Diverse Backgrounds
Some hearing impaired children and adults from culturally and linguistically diverse backgrounds require access to interpreters when receiving treatment for their hearing loss. The Government already provides a free interpreting service to assist people from culturally and linguistically diverse backgrounds communicate with approved organisations and service providers, however audiologists and audiometrists are not eligible to use this service.
The Committee is of the view that hearing service providers should be added to the list of groups eligible to use this interpreting service. This will help to ensure people from culturally and linguistically diverse backgrounds are fully aware of their options for the effective treatment of hearing loss.
Older Australians living in aged care facilities are more likely to have a hearing impairment, as well as a range of other health conditions. Effectively managing their hearing impairment may improve their quality of life and potentially slow cognitive decline. Using assistive listening devices in nursing homes, such as amplification devices and captioning, could make a difference to the everyday lives of residents. Educating staff, carers, and family members on how to best assist someone with a hearing impairment, including how to look after a hearing device, is also important.
The Committee received evidence that the introduction of the National Disability Insurance Scheme may result in a lack of services, particularly Auslan services, for people aged over 65 years. The Committee considers, given the high prevalence of hearing issues in people aged over 65 years, this cohort should be eligible for a similar level of care and support as those aged under 65 years. In particular, the Committee believes that the National Auslan Interpreter Booking and Payment Service should continue to be accessible to Auslan users over the age of 65 years.
Sensorineural hearing loss and tinnitus are among the three most common conditions experienced by veterans of recent international conflicts. The Committee is pleased that the Department of Veterans’ Affairs provides additional hearing health support to Australia’s veteran community.
The Committee is concerned by reports suggesting that a recent review of hearing health supports for veterans has resulted in a reduction in the quality of hearing aids available to veterans. The Department of Veterans’ Affairs should ensure that, at a minimum, the quality of hearing devices provided to veterans is equal to that provided to other eligible government employees.
The Committee recommends that the Department of Health, in collaboration with Australian Hearing, the Department of the Prime Minister and Cabinet, states and territories, Aboriginal and Torres Strait Islander health organisations, and local communities, develop a national strategy to improve hearing health in Aboriginal and Torres Strait Islander communities aimed at:
coordinating Commonwealth, state and territory services to ensure they are complementary and delivered in a coordinated manner;
developing a nationally consistent data reporting framework to record data on the prevalence of ear health conditions and the provision of services, including a treatment outcomes tracking method;
regular monitoring and evaluating of programs to ensure they are meeting their objectives; and
funding further research into Aboriginal and Torres Strait Islander hearing health issues.
The Committee recommends that the Department of Health and Australian Hearing significantly increase the resources devoted to providing hearing health services in regional and remote Aboriginal and Torres Strait Islander communities. The mobile outreach services of the Deadly Ears Program should serve as a best practice example for national implementation. This program should focus on expanding access to hearing health services in regional and remote locations and reducing the waiting lists for Aboriginal and Torres Strait Islander children requiring hearing health treatment.
The Committee recommends that the Department of Health together with the Department of Education and Training create a hearing health support fund for Aboriginal and Torres Strait Islander students. This fund should:
be responsible for the progressive installation of soundfield amplification systems in the classrooms of all regional, rural, and remote schools with a significant Aboriginal and Torres Strait Islander student population; and
provide support to deaf Aboriginal and Torres Strait Islander children to learn sign language and access interpreters where necessary.
The Committee recommends that the Department of Social Services include audiology and audiometry as eligible services for access to the Free Interpreting Service, delivered by the Translation and Interpreting Service.
The Committee recommends that the Office of Hearing Services review the provision of hearing services to residents in aged care facilities. This review should consider issues including:
the use of assistive listening devices for aged care residents;
service provision for deafblind Australians in aged care facilities; and
the education of aged care facility staff.