A community-based service enhancement model of training and employing Ear Health Facilitators to address the crisis in ear and hearing health of Aboriginal children in the Northern Territory, the Hearing for Learning Initiative (the HfLI): study protocol for a stepped-wedge cluster randomised trial

Abstract

Background Almost all Aboriginal children in remote communities have persistent bilateral otitis media affecting hearing and learning throughout early childhood and school years, with consequences for social and educational outcomes, and later employment opportunities. Current primary health care and specialist services do not have the resources to meet the complex needs of these children. Method/design This stepped-wedge cluster randomised trial will allocate 18 communities to one of five 6-monthly intervention start dates. Stratification will be by region and population size. The intervention (Hearing for Learning Initiative, HfLI) consists of six 20-h weeks of training (delivered over 3 months) that includes Certificate II in Aboriginal Primary Health Care (3 modules) and competencies in ear and hearing data collection (otoscopy, tympanometry and hearScreen), plus 3 weeks of assisted integration into the health service, then part-time employment as Ear Health Facilitators to the end of the trial. Unblinding will occur 6 months prior to each allocated start date, to allow Community Reference Groups to be involved in co-design of the HfLI implementation in their community. Relevant health service data will be extracted 6-monthly from all 18 communities. The primary outcome is the difference in proportion of children (0 to 16 years of age) who have at least one ear assessment (diagnosis) documented in their medical record within each 6-month period, compared to control periods (no HfLI). Secondary outcomes include data on sustainability, adherence to evidence-based clinical guidelines for otitis media, including follow-up and specialist referrals, and school attendance. Structured interviews with staff working in health and education services, Ear Health Trainees, Ear Health Facilitators and families will assess process outcomes and the HfLI broader impact. Discussion The impact of training and employment of Ear Health Facilitators on service enhancement will inform the health, education and employment sectors about effectiveness of skills and job creation that empowers community members to contribute to addressing issues of local importance, in this instance ear and hearing health of children. Trial registration ClinicalTrials.gov NCT03916029. Registered on 16 April 2019.

Hearing loss at 6-monthly assessments from age 12 to 36 months: secondary outcomes from randomised controlled trials of novel pneumococcal conjugate vaccine schedules

“…[30] Our research program is currently evaluating a primary health care workforce enhancement strategy (the Hearing for Learning Initiative) of remote on-country training and employment of ear health facilitators which could provide a sustainable, culturally appropriate and safe model to detect and prevent disabling hearing loss, and support children who have hearing problems. [31,32] advised on microbiology protocols, and reviewed the final version of the manuscript. SS advised on study design, assisted with funding application, participated in investigator meetings, advised on laboratory protocols, particularly microbiology, and reviewed the final version of the manuscript.…”

The role of Indigenous Health Workers in ear health screening programs for Indigenous children: a scoping review

“…3,5,7,22,24,25,28,29,32,33,35,46,47,49,50,52 IHWs also acted as a liaison between community members and audiology programs, 30,35,36 coordinated referrals and follow-ups, 32,46 delivered ear health education 24,31 and assisted families in the coordination of appointments and accommodation. 22,36 Four studies provided service delivery training to IHWs, including OM diagnosis, videootoscopy, tympanometry and telehealth software 34,52,54,55 ; two studies provided research training including research skills, evidence-based management of OM and data collection. 6,54 IHWs contributed to the development and design of two research projects 23,37 and assisted with research coordination in six studies.…”

“…To further explore the role of Indigenous communities in the included projects, the reviewers examined the acknowledgement sections of the included publications. Twenty-three authorship teams expressed gratitude for the support of Indigenous communities, organisations, health services, or IHWs 3,6,7,23,[25][26][27][28][29][31][32][33]35,39,41,42,45,46,49,51,[53][54][55] ; eight authorship teams did not mention Indigenous organisations 5,9,30,34,43,44,47,48 and nine publications did not have an acknowledgements section. 15,22,24,33,36,38,40,50,52…”

What does microbiology have to do with the Hearing for Learning Initiative (HfLI)?

“…1,2 The Hearing for Learning Initiative is evaluating a community-based workforce enhancement model designed to address ongoing high prevalence of persistent OM, disabling hearing loss and associated educational and social disadvantage. 3 Almost every infant and child in remote communities has early and persistent OM, which is largely asymptomatic despite apparently painful appearance of the tympanic membrane (marked bulging or perforation). 4 Failure to detect early acute OM (AOM) or middle ear effusions (OME) leads to chronic OM (all forms) which is the strongest predictor of developmental delay, high vulnerability on entering school, poor school attendance and performance.…”

“…35 This brings us back to the Hearing for Learning Initiative. 3 An additional and parallel crisis has been highlighted in remote primary health care where average length of stay of health care practitioners is 4 months, and many are infrequent brief but costly fly-in fly-out stays. 36,37 Lack of comprehensive primary ear health programs with scheduled surveillance and appropriate follow up is failing children and over-burdening specialist services (hearing and ENT surgical consultations), which have staggeringly long waitlists of several thousands of children.…”