Protective and risk factors for ear disease and hearing loss

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Introduction Cultural and social determinants of health Public awareness Causes of ear and hearing health problems over the life span Access to health care services

The factors contributing to ear disease and hearing loss among First Nations people are broad and complex and reflect a combination of historical, social, cultural and economic factors, including interpersonal and institutional racism (Burns and Thomson 2013; DeLacy et al. 2020; Jervis-Bardy et al. 2014; Leach et al. 2020; Leach et al. 2021; NACCHO and RACGP 2018). 

Enhanced health services, and continued improvement in, and access to, comprehensive, culturally appropriate and safe health services are needed to support improvements in health outcomes among First Nations people (AIHW & NIAA 2024).

Cultural and social determinants of health

Health is influenced by cultural determinants and social determinants – the circumstances in which people grow, live, work and age (WHO 2008). A range of information about cultural and social determinants and First Nations people’s health is available from the Aboriginal and Torres Strait Islander Health Performance Framework.

For First Nations people, self-determination and empowerment, cultural identity, family and kinship, Country and caring for Country, knowledge and beliefs, language and participation in cultural activities and access to traditional lands are key determinants of health and wellbeing.

The higher prevalence of otitis media among First Nations children compared with non-Indigenous children has been associated with social determinants, in particular overcrowded housing, as well as low socioeconomic status, low income and poverty, access to services, hygiene and levels of education. That review argued that interventions need to shift from biomedical treatment-focused options to a more preventative model (DeLacy et al. 2020).

Public awareness

Raising awareness about ear and hearing health and associated risk factors helps to prevent ear disease and hearing loss and improve access to treatment.

Public awareness campaigns can help people recognise early signs and symptoms, modify risks, access health care and services, and understand the importance of following treatment procedures. Such campaigns can also support the inclusion of people with hearing loss in the community and reduce the stigma of hearing aids and other hearing devices. They can also support health care providers, teachers and other professionals to build skills to identify ear and hearing problems, navigate complex referral pathways to specialist services, and provide support to families (Box INTRODUCTION 1).

Box INTRODUCTION 1: Raising awareness among new parents

Apunipima Cape York Health Council (Apunipima) is an Aboriginal Community Controlled Health Organisation, providing primary health care to 11 Cape York Communities. Apunipima developed the Baby One Program to support families, women and their children during and after pregnancy up to 1,000 days of life. The program: 

‘provides health education to pregnant women and young families, including the signs and symptoms of otitis media and hearing loss, and the importance of speech and language development for young children. Some of Apunipima’s communities have had access to self-developed health education programs for young school aged children, including the importance of good hearing, good hygiene, how to care for ears, and how to seek help when ears are painful or blocked’. 

(AIHW 2022)

Causes of ear and hearing health problems over the life span

There are many different causes of ear and hearing problems. Some of these causes occur more often at certain stages of life, while others can occur at any age.

Hearing loss may result from ageing and genetic causes, complications at birth, low birthweight, certain infectious diseases, chronic ear infections, use of certain medicines, injuries and accidents, smoke exposure and noise.

Causes of hearing loss over the life span

* These are causes that are not considered preventable.

Sources: Smith 2019; WHO 2016, 2021

Pregnancy, birth and childhood 

Genetic factors are the main cause of hearing loss that is present at birth. A family history of hearing loss, particular genes and some syndromes can also increase the risk of progressive genetic hearing loss at any age. These are not preventable (Shearer 2017, Smith 2019, WHO 2016, WHO 2021). However, regular and timely screening of those at-risk can help improve outcomes if hearing loss occurs.

High-quality care during pregnancy decreases the risk of birth complications, low birthweight, premature birth and infections during pregnancy that can cause hearing loss that is present from birth.

Vaccination during pregnancy and childhood protects against conditions including rubella, measles, Haemophilus influenzae type b (Hib), pneumococcus, meningococcus and influenza that can cause hearing loss.

Middle ear infection (otitis media) is a common childhood disease and is the main cause of ear and hearing problems in First Nations children.

Evidence based preventive strategies for otitis media include:

  • breastfeeding babies for at least the first 6 months
  • avoiding smoke exposure
  • frequent handwashing for children attending day care centres
  • keeping children away from sick children and those with a runny nose, especially at day care centres. 
  • Following childbirth, breastfeeding, a smoke-free environment, good hygiene and adequate housing are protective factors for ear and hearing health (Leach et.al. 2020).

Overcrowded or inadequate housing increases the risk of the spread of otitis media and respiratory infections such as pneumococcal disease that can lead to hearing loss (Jacoby et al. 2011). A study conducted in Northern Territory remote communities found that having a greater number of children aged under 5 in a household increased the risk of the youngest child contracting otitis media (Leach et al. 2014).

Adults and all ages 

Hearing loss is the most common ear and hearing problem among First Nations adults. As well as experiencing the ongoing effects of any ear or hearing problems from childhood, adults may be exposed to other risk factors during their lives.

The ageing process itself is a common cause of hearing loss that emerges later in life. Age-related sensorineural hearing loss is one of the main causes of hearing loss and is not preventable (Senate Community Affairs References Committee Hear Us report 2010). Timely diagnosis can help reduce the impact of age-related hearing loss.

Other common causes of hearing loss that emerges later in life include noise exposure, infectious and chronic diseases, use of certain medicines, and injuries and accidents.

Repeated exposure to loud noise is one of the most common preventable causes of hearing loss. Workplace noise and recreational noise are the most common sources of damaging noise exposure.

Early identification and management of malnutrition and chronic health conditions such as heart disease and diabetes can reduce the risk of developing ear and hearing problems (Bainbridge et al. 2008; Helzner & Contrera 2015; Lin et al. 2012).

Reducing smoking rates and exposure to tobacco smoke can reduce the risk of adults developing sensorineural hearing loss (Leach et al. 2021; NACCHO & RACGP 2018; Jones et al. 2012; Dawes et al. 2014; Lalwani et al. 2011).

Certain medications and chemicals, called ototoxic, can cause damage to the inner ear, which can lead to temporary or permanent hearing loss. The use of ototoxic medications in pregnant women can affect their hearing health and that of their newborns (Duthey 2013).

Traumas and injuries to the ear or head may result in temporary or permanent hearing loss.

Access to health care services

Access to culturally safe ear and hearing health services is crucial for achieving better ear and hearing health outcomes for First Nations people.

Systemic barriers to First Nations people accessing ear and hearing health services can add to the difficulty of navigating a pathway through an already complex health system. An indirect measure of the responsiveness of health services to patients needs is the rate of self- discharge from hospitals (Box INTRODUCTION 2). 

Box INTRODUCTION 2: Self-discharge from hospital

An indirect measure of the responsiveness of health services to patient needs is the rates of self-discharge from hospitals. 

The reasons that patients self-discharge may include dissatisfaction with care, poor communication, long waiting times, and feeling better, as well as family and employment responsibilities. 

These factors, together with a lack of cultural safety, and interpersonal and institutional racism, contribute to the disproportionately higher (around five times higher) rates of First Nations people self-discharging from hospital.

Access may be affected by the availability and accessibility of culturally safe health care services (Box INTRODUCTION 3), a lack of continuity of care, or racism and unconscious bias from health-care providers (AIHW 2021a; Burns and Thomson 2013; Gotis-Graham et al. 2020, Lau et al 2024).

A study that explored the impacts of implicit bias on the experience and care provided to First Nations patients within emergency departments found that:

… implicit racial bias which can result in stereotyping of racial minorities and premature diagnostic closure. Furthermore, it may contribute to distrust of medical professionals resulting in higher rates of leave events and hinder [First Nations people] from seeking care or following treatment recommendations. (Quigley et al. 2021). 

Other barriers include:

  • a complex referral pathway for specialist services and long waiting times for specialist consults, relevant procedures, follow-up and rehabilitation services
  • availability of health professionals with the training and equipment required to conduct tests for hearing and eardrum mobility
  • considerable variability in access to services across Australia, given the wide geographic spread and isolation of some First Nations communities, while audiologists and ENT specialists are mostly located in metropolitan areas
  • some remote areas having strong outreach programs providing communities with timely access to services, with other areas having very limited and infrequent access to services
  • high mobility of First Nations families living in rural and remote areas, which may mean they are not present during outreach service visits
  • access to transport services
  • affordability of health-care services plus the indirect costs of transportation, time taken for travel and having to take time off work.

Box INTRODUCTION 3: Cultural safety

Improving cultural safety for Indigenous Australians can improve access to, and the quality of health care. Cultural safety is an essential component of access to and the quality of health care. This means a health system that respects Indigenous cultural values, strengths and differences, and also addresses racism and inequity (AIHW 2021a). 

The Aboriginal Community Controlled Health Organisations (ACCHO) sector noted the importance of culturally respectful and safe health-care services. 

  • ‘Having a trained Aboriginal or Torres Strait Islander Ear Health worker is absolutely essential for a successful program. The young kids we visit at school (or those that attend the clinic) feel culturally safe and related and we become a familiar face as we see them throughout their starting years at school.’ 
  • ‘Visits are significantly more successful when community can assist with a nurse or driver to help locate community members and help with language barriers and clients feel more culturally safe if a community member can attend with them.’ 
  • ‘Referring clients to another service is not always an appropriate method of service delivery with reports of clients not showing up to the appointment due to feeling culturally unsafe.’ (see Appendix B, AIHW 2022)

 

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