Australia is the sixth largest country in the world by land mass, but is the 53rd largest by population. The majority of Australians reside in the coastal borders of the country, leaving the midland or “outback” with far fewer. Australia’s population contains a large number of settlers from various countries as well as the first-nations peoples, i.e., Aboriginal Australians and Torres Strait Islanders, who arrived at the mainland and islands more than 50,000 years ago. The first-nations population take great pride in their unique and vibrant culture. Unlike the general Australian population, their resources are limited, including access to audiological services.
Audiology Educational System
Audiology and audiological education have a relatively long history in Australia, beginning in 1948 with the establishment of the Commonwealth Acoustic Laboratories (now the National Acoustic Laboratories and Australian Hearing). This organization was involved in training audiologists in the early years (Upfold, 2008) and continues to be internationally recognized as a premiere research organization. Programs to train master’s level audiologists were established in the late 1970s and since 1999 have been a requirement for professional body membership. Australia has one the highest ratios of audiologists-per-capita in the world, with a smaller number of audiological technicians (audiometrists) also providing hearing aid related and diagnostic services to the community (Goulios and Patuzzi, 2008).
Currently, there are six masters’ programs across Australia. They include Macquarie University, University of Queensland, Flinders University, Melbourne University, La Trobe University, and the University of Western Australia, which offers a joint master/PhD in clinical audiology. Masters’ programs in Australia require graduates to meet a set of clinical competencies and to have completed 250 hours of clinical experience by graduation. There is also a requirement to complete a one-year clinical internship if the graduate wishes to provide services to clients in the large government-funded sector. During this year, interns are prepared for independent clinical practice under the supervision of an experienced audiologist. Once the internship is completed, new graduates are certified either by Audiology Australia or Australian College of Audiology, both are professional organizations representing audiologists in Australia.
At present, there is no national registration process for audiologists in Australia, meaning the profession is largely self-regulated. Although not mandatory, most audiologists belong to one or more professional bodies. These professional bodies provide the certification needed to access a key government-funded reimbursement program: the Australian Government Hearing Services Program. Audiologists must also complete a continuing professional development program to continue to hold this certification. In addition, all members of Audiology Australia are subject to the Code of Conduct set forth by Audiology Australia (AudA), the Australian College of Audiology (ACAud), and the Hearing Aid Audiometrist Society of Australia (HAASA).
Hearing Health-Care System
The Australian hearing health-care system has elements of parallel (public and private system are available for the same service), co-payment (publicly-funded subsidies for services with private co-payments), and group-based (certain groups in the population are eligible for publicly funded services) approaches. The Office of Hearing Services provides public funding for diagnostic and rehabilitative services to those holding pension, disability, or veterans cards. These services are delivered by a range of government-approved providers. In the public system, when an audiologist identifies an individual with medically treatable condition(s), the audiologist would refer the individual to a general practitioner, who, in turn, refers the individual to an otolaryngologist. Otolaryngologists in Australia provide medical hearing care in a model similar to the United States.
Australian Hearing, a government founded statutory authority, is the largest provider of government-funded hearing services, and manages the hearing health-care needs of highly populated Australian cities as well as the sparsely populated areas of the country. The services are provided by government employees, and include audiologists as well as administrative professionals. Over 500 “hearing branches” are in place throughout the country, and each branch provides audiological diagnostic and treatment support as well as education and training to health-care professionals.
Australian Hearing is unique in that the program not only provides equipment and technology for those with hearing loss, but also has a strong focus on patient self-education, quality of life, and assuring skills are sufficient for independent living and maintenance of occupation. All children in Australia are eligible for hearing aid services through the age of 26, and adults are eligible if they can apply for a hearing-services voucher. Adult first-nations peoples over the age of 50 are eligible for hearing services and amplification devices, covering a vast majority of individuals in need of amplification. Funding for diagnostic audiological services can also be accessed by all Australian residents, with a co-payment needed in some cases, through the public health scheme—Medicare. For those individuals who are not eligible for assistance, a reduced cost hearing aid may be available through a hearing aid bank.
Australian Hearing provides outreach services to more than 200 communities in urban, rural, and remote areas, and monitors individuals with chronic otitis media and other hearing disorders. Outreach services include hearing tests, advice, and education on hearing loss, hearing awareness, and staff training, resulting in a program focused on patient care and preventative services, a concept so important in communities where environmental conditions can negatively affect hearing health.
Most states and territories have newborn hearing screening programs. These services are usually provided by public hospitals at no cost to the individual. The loss-to-follow-up rate is usually very low (Barker et al, 2013). Australian Hearing is the single national organization providing the majority of hearing rehabilitation services for children. Once identified with hearing loss, the Australian children receive some of the best, earliest, and most equitable services in the world once they are identified.
In contrast to the widespread adoption of newborn hearing screening, universal school hearing screening programs are not common in Australia. Late-onset, progressive, fluctuating, or mild hearing loss missed by newborn hearing screening are thus often only identified incidentally by caregivers or teachers. Staff who received training in hearing screening refer children in need of further assessment and/or amplification to Australian Hearing, which relies on referrals but does not provide regular school hearing screenings to identify children with hearing loss or with needs for medical intervention.
Although multiple government initiatives have been launched to provide financial assistance and health-care services, people in first-nation communities often depend on outreach services provided by non-profit organizations to receive hearing screenings, and primary ear and hearing care, especially those living in small, remote villages. Although the number of outreach visits by Australian Hearing and non-profit organizations continues to increase every year, access to otolaryngologists for medical check-ups or follow-ups is still challenging for many communities.
General health of first-nations people is poor when compared to the non-first-nations people. Life expectancy, a key health indicator, shows an approximately 10-year gap between the first-nations and non-first-nations Australians. Further, measures of infant mortality, another key indicator of health, suggest an incidence of 6/1000 in the first-nations community, compared to 4/1000 in the non-first-nations community (AIHW, 2014). The disparity exists across a wide range of health conditions, and first-nations people living in remote communities suffer a disproportionate burden of disease (Vos et al, 2009).
The incidence of otitis media is very high among the first-nations people, especially among children. As of 2014, the prevalence of otitis media within the total population of first-nations peoples is up to 15 percent (Khoo, 2014). They are the only population in developed countries having chronic suppurative otitis media prevalence rate exceeding four percent, the rate the World Health Organization defines as a massive public hearing-health problem requiring urgent attention. The origin of the high prevalence is not completely understood. Impedance data from the neonate population suggest genetics might be at play. Neonates who failed a test battery consisting of high-frequency tympanometry and distortion product otoacoustic emissions (DPOAEs) had lower wideband absorbance than those who passed, and first-nations neonates had lower wideband absorbance compared to Caucasian neonates (Aithal et al, 2014). High prevalence of otitis media among first-nations children combined with the lack of accessible medical services create a long-term hearing health-care problem that cannot be ignored.
Clinical Findings in a Queensland First-Nation Community
Two faculty members, eight doctor of audiology (AuD) students, and one undergraduate student from Northern Illinois University, three AuD students from University of Illinois Urbana—Champaign, and two high-school students, traveled to Australia for a humanitarian service program. During the two-week endeavor, we tested the hearing of students in a first-nations community in Far North Queensland, toured the Australian Hearing Hub, and visited local landmarks.
Our mission was to provide hearing services to students in a first-nations community. The hearing screening protocol included otoscopy, tympanometry, and DPOAEs at 1.5, 2, 3, 4, 5, and 6 kHz. As first-nations communities are known to have very high incidence of otitis media and hearing loss (Burns and Thompson, 2013), our screening protocol also included pure-tone testing so that we would not miss those with a low-frequency hearing loss. If the student had wax accumulation, the pure-tone tests were conducted after cerumen management.
We tested a total of 170 students aged between four and 16 years (FIGURE 1). Despite the prior knowledge that children in first nations have earlier onset, more frequent, more severe, and more persistent otitis media than the greater Australian population (Queensland Government, 2016), we were surprised to find that approximately 44.7 percent of the students failed the screening (FIGURE 2). Twenty-two (12.9 percent) students had normal hearing but had wax accumulation that would warrant professional cerumen management. Another nine students (5.3 percent) had wax accumulation and co-existing middle-ear disorders as documented by Type B Tympanograms. We removed the wax from 27 students and could not complete the work on four other students because they were absent from school, did not cooperate, or have deep-seated wax that needed further treatment to remove completely.
Middle-ear disorder is also a prominent problem among students in the first-nations community. In addition to the nine students with middle-ear disorders and wax accumulation, another 17 students had Type B tympanograms (10 percent, ME only in FIGURE 2), 15 students had Type B tympanograms with hearing loss (8.8 percent, ME+HL), and five students had Type B tympanograms, hearing loss, and wax accumulation (2.9 percent, Wax+ME+HL). As wax was removed before further testing, all of the Type B tympanograms are accompanied by either large ear canal volumes, i.e., perforated ear drums, or normal ear canal volumes, i.e., limited ear drum mobility likely due to middle-ear effusion or other middle-ear disorders. Fifteen students (8.8 percent) had Type C tympanograms, indicating they had negative middle-ear pressure, which could be a precursor to or a remnant of middle-ear problems.
Two students are classified as “other” because their hearing thresholds were within the normal limits and Type A tympanograms, but we removed a white paper clump near one child’s ear drum and saw a white mass behind the ear drum of the other child.
We visited the first-nations community in August, which is the winter season in the southern hemisphere. The average temperature was between 20 and 30°C (i.e., 68-86°F). Discounting other co-existing disorders, approximately 27.1 percent of students had active middle-ear disorders or perforated ear drums, i.e., sum of ME = “ME only” + “ME+HL” + “Wax +ME” + “Wax+ME+HL” in FIGURE 2, and approximately 15.3 percent had some degree of hearing loss, i.e., sum of HL = “ME+HL” + “HL.” The overall referral rate of 44.7 percent is so far the highest referral rate among children with normal development we tested during our annual humanitarian research and service trips in the last several years (FIGURE 3):
- Aboriginal Orphans in Taiwan (Chung et al, 2010)
- Students in an impoverished area in Brazil (Chung et al, 2013)
- Students in a poor mountainous area in China (Chung et al, 2014)
- Children in rural areas in Cambodia (Chung, 2016)
Integrating our knowledge of the children’s living conditions and the clinical findings from multiple countries/governing regions, we wondered if the extremely high referral rate in the first-nations community in Australia cannot be entirely due to the students’ social economic status or general living conditions. The Cambodian children we tested lived in rural areas that were accessible only through dirt roads. Most of them lived in orphanages or in huts without doors. Yet the Cambodian referral rate was only 22.9 percent, which is significantly lower than that of the first-nations children with a comparable age range. These findings are consistent with the notion that first-nations children may be genetically pre-disposed to be more prone to have otitis media (Bhutta, 2015) and the lack of community hearing-care services exacerbated the problem.
Additionally, one of the staff in the school told us that some students have normal development and are otherwise competent, yet have a lot of difficulties understanding speech when there is background noise. The staff was wondering if we could test the students. The symptoms he described reminded us of the link between chronic otitis media and central auditory processing disorder (CAPD). Concerned about the validity of CAPD tests developed in North America for testing the first-nations students because of the American accents, we inquired the standard procedures for identifying and treating CAPD in Australia. Currently, such service is provided by private clinics for a fee of $400 AUD/person. The good news is that the research division of Australia Hearing, National Acoustics Laboratories recently have developed LiSN-S and LiSN-U for CAPD screening. Studies are underway to determine their applications to first-nations children.
Our ground contact, Mark Mitchell, hearing health project officer of the Queensland Aboriginal and Islander Health Council, used our clinical findings to advocate for the provision of ENT services for the first-nations community we visited. We hope the availability of hearing health-care service will not only help treat children with ear and hearing disorders, but also prevent the development of hearing loss or central auditory processing disorders that are associated with chronic otitis media.
For more information: Northern Illinois University Heart of Hearing Humanitarian Service Program to Australia.
Sincere thanks to students at Northern Illinois University, University of Illinois Urbana-Champaign, Naperville North High School, and Stuart Country Day School, who worked very diligently during the two-week program. We also want to thank Mark Mitchell at QAIHC for providing ground support, Savana Bulmer at Gurriny Yealamucka Health Services and the school for coordinating the hearing screening, and Belinda Lesina and Clara Manhood at Australian Hearing at Cairns for following up with the students we identified during the trip. Many thanks to Gurriny Yealamucka Health Services and Australian Hearing Hub and Cochlear Corporation for giving us a tour of their facilities, to Etymotic Research for lending equipment, and to Oticon, USA for their generous monetary support.