Selection of sources of evidence
The formal search identified 1,700 studies. Grey literature searches identified a further 97 studies. There were 1,106 studies remaining after duplication removal and these records were all screened by abstract/title. There were 120 studies assessed by full text according to eligibility criteria and 93 of these studies were removed with stated reasons. Twenty-seven studies were included in the synthesis. Study selection follows the PRISMA reporting guidelines and is illustrated in Fig. 1 [56].
(INSERT FIGURE 1 HERE)
Figure 1 PRISMA Flow Chart
Characteristics Of Sources Of Evidence
Identified articles (N = 27) were published between November 2010 and March 2021. Eight articles were classified as descriptive reports [18, 57–63], while the remaining 19 have been classified as studies [19, 20, 42, 64–79]. Of the 20 studies, two were cross sectional [77, 78], six were observational/descriptive [19, 20, 42, 64, 69, 72], five were retrospective [65, 73–76], three were qualitative [64, 68, 79], three were cost-effective [66, 67, 70] and one was a randomized controlled trial [71]. It should be noted that the randomized controlled trial was eligible for inclusion due to the intervention/program approach taken, while prevalence studies were excluded from this review due to only providing prevalence data.
Program Location
Twenty-one programs were reported across 27 studies. Programs were active between 1985–2021. Most programs were conducted in Australia (N = 18), one program was active in Canada (N = 1), and two programs were active in Alaska (N = 2). No programs were identified as being active in New Zealand. Table 2 captures an overview of the ear and hearing care program activities, including the years the programs were active, program location (e.g. state, country), setting (e.g. school), program participants (including age ranges if reported), and an overview of what services the program provided or continues to provide (if program is currently operational).
Focal Areas Of Activity
Programs have been mapped using a public health model of prevention, namely primary, secondary and tertiary prevention. Three programs solely targeted the primary prevention stage of the care pathway. These programs included those which aimed to promote awareness of how to prevent speech and language delay [68], awareness of how to prevent middle ear disease [69] and awareness of hearing loss and tinnitus prevention [64]. Other programs included a primary prevention component [18, 57, 58, 61, 72]. Thirteen screening, surveillance and detection programs were identified at the primary prevention stage of the care pathway. The overall aims of these programs were to bring patients into the first access point of the care pathway [18–20, 42, 57–63, 65, 70, 72–77]. Secondary prevention programs included specialist services such as ENT (Ear, Nose, and Throat) services [18, 61, 63, 66, 67, 78, 79], medical intervention and treatment services [61] as well as regular hearing checks for children known to have ear disease [71]. Four programs were identified at a tertiary prevention stage. Tertiary programs targeted rehabilitation regarding speech therapy [61, 78, 79] hearing aids [19, 20, 42, 61], cochlear implants [42], learning support in schools [61] and counselling [19, 20, 42]. Table 2 captures focal areas of ear and hearing care programs.
(INSERT Table 2 HERE)
Table 2 Ear and hearing care program activities
Table key: P = Prevention, Det = Detection, D = Diagnosis, T = Treatment, R = Rehabilitation
Mapping Programs Onto The Care Pathway
Programs were mapped onto the care pathway to determine whether they focused on prevention, detection, diagnosis, treatment, rehabilitation, or a combination of these pathway areas. Existing literature indicates that understanding the care pathway is essential to ensuring continuity of care through identifying treatment processes and timeframes [80]. As such, mapping programs to the care pathway may help identify which areas of the care pathway efforts have or are currently being concentrated on and subsequently what areas of the care pathway may require further attention. For the purposes of understanding care pathways within the ear and hearing care context, prevention was conceptualised as including education/awareness campaigns on prevention of speech and language delay, middle ear disease, and hearing loss. Detection was conceptualised as awareness of ear disease and hearing loss symptoms, surveillance, and screening. Diagnosis was the determination of condition or severity of the condition. Management included ENT surgery and medical treatment such as antibiotics. Rehabilitation was conceptualised as involving learning support in schools, speech therapy and counselling as well as hearing aids and cochlear implants.
A small number of programs (N = 3) focused exclusively on prevention, while others (N = 4) contained, although not exclusively, a prevention component. Thirteen programs were identified at detection, most of which related to screening of middle ear disease and hearing loss (N = 11). Ten programs were identified at management, which involved medical management and ENT specialist services. Four programs contained a rehabilitation component. Of the 21 programs, eight focused on more than one care pathway stage. Figure 2 captures program mapping to care pathways.
(INSERT FIGURE 2 HERE)
Figure 2 Mapping programs onto the care pathways
Key Barriers Which Programs Aimed To Address
The two most commonly identified barriers to accessing existing (mainstream) services were geographical [18–20, 42, 59, 61, 63, 65–67, 72–76] and lack of cultural safety of services or education/awareness campaigns [18–20, 59, 61, 66, 68, 69, 71, 73–76, 78, 79]. These barriers were identified in the relevant studies or inferred through specific program characteristics. Additional barriers identified included extensive ENT waitlist times [18, 61, 67, 68, 73, 78, 79], lack of service coordination [18, 61], system fragmentation due to separation of screening services from treatment [70], workforce shortages in remote areas [61], cost associated with travel and elective surgery [18, 67] and cost associated with outreach services [19, 20]. Furthermore, implementation difficulties were noted because there was no agreed upon hearing screening protocol for children in some countries (e.g. Australia) after the neonatal period, so that states and territories operated different ear and hearing care programs in an ad-hoc manner [77]. Coordinating access to tertiary care was identified as challenging due to systemic barriers [18]. For example, most First Nations people in Australia live in metropolitan areas, but services are often targeted at rural and remote areas [78, 79]. In fact, 38% of Aboriginal and Torres Strait Islander people live in major cities, 44% live in regional areas, and 18% live in remote areas [81]. Studies identified lack of community awareness of program availability [64], lack of awareness of ear and hearing health issues [18, 58, 69, 72] and lack of access to services [58]. One study noted low access and utilisation rate of ear services by Aboriginal and Torres Strait Islander peoples [70], while another study identified low clinic attendance rates and low adherence to treatment plans [71]. This is most likely the result of other access barriers such as lack of knowledge of program availability, geographical access challenges and lack of cultural safety.
Approaches Taken To Address Barriers
Program approaches (as described within the included articles) included outreach approach [18, 42, 61, 63, 67], public health approach [57, 60, 66, 68], community-level approach [18–20, 58, 65, 69, 70, 72, 74–79], and other approaches such as strengths-based approach and multi-disciplinary approach [18, 58, 62, 64, 71, 73]. Ear and hearing care programs aimed to improve healthcare accessibility by extending geographical reach of existing professional services through telehealth and ensuring cultural safety through means such as involvement of First Nations people in the program. Other solutions implemented to improve healthcare access included removal of cost disincentives [67, 78, 79].
Extend Geographical Reach Of Services (Connecting People To Care)
Telehealth
Eight programs were identified as employing the use of telehealth to extend geographical reach and connect patients to timely care. The mobile screening and surveillance service in Queensland (QLD) Australia [65, 70, 74–76], the Hearing Health Outreach Program in the Northern Territory (NT) Australia [61] and an ear health screening program in New South Wales (NSW) Australia [73] all employed asynchronous telehealth. The Deadly Ears program in QLD Australia [63] utilised asynchronous telehealth to support delivery of ENT services, nursing and allied health services. The Alaska Federal Health Care Access Network (AFHCAN) program utilised synchronous and asynchronous telehealth as facilitated through community health aids liaising with specialists who can manage care remotely. Only, if necessary, a patient would be expedited to receive in-person treatment or surgery thus bypassing delays in receiving necessary health care [42].
An ENT program in Australia (no name) utilised telehealth for post-operative review to address geographical challenges and utilise a cost-effective model of care [67]. This service model for ENT surgery in the NT required the patient to travel to a regional centre for ENT surgery. The report describing this system of care describes two alternative models which would utilise telehealth to improve geographical accessibility [66]. The Hearing Health Outreach Program in the NT also utilised telehealth to reduce patient travel times for ENT services [61].
Outreach
Five programs were identified as employing an outreach approach to extend geographical reach. The Hearing Health Outreach Program utilised an outreach approach to offer rehabilitative services [61]. Healthy Ears - Better Hearing, Better Listening program prioritized services to locations of highest need such as the NT through utilizing an outreach approach [18, 59]. The Australian program Enhanced Child Health Schedule (ECHS) offered additional home visiting contacts for families considered to have high priority needs [62]. The screening programs Hear our Heart Ear Bus Project (HoHEBP) [72] and Mobile screening and surveillance service in Australia [65, 70, 74–76] utilised mobile clinics to extend geographical reach.
Other
The Hearing and Otitis Program (HOP) in Nunavik Canada was established in a specific location in the North in response to geographical access barriers. This program also offered to send individual’s hearing aids to specialists via mail if necessary [19, 20]. The Australian Nursing Student-led School Vision and Hearing Screening Program employed a community-level approach to reduce the need for travel to access primary care services [77]. The Audiological Care and Telehealth in Remote Alaska program is a state-wide telehealth/telepractice network which integrated into clinical practice at 248 sites across the state thereby increasing specialty care access [42]. The Care for Kids Ears program was available online and therefore geographical reach was nationally available Australia-wide [18, 58].
Ensuring Cultural Safety
Indigenous Health Worker (IHW) Involvement
Eleven programs were identified as employing IHWs to ensure cultural safety. The HOP in Nunavik Canada delivered hearing aid services such as fitting, follow-up and minor repairs facilitated through the program’s culturally identified role of the ‘aaniasiurtiapiit’ – a role similar to that of an IHW. If necessary, the aaniasiurtiapiit would send the hearing aid via mail to another specialist for further assistance. Counselling was provided by the siutilirijiit, a cultural counsellor who ensured safety of linguistic and cultural needs regarding proposed solutions to hearing loss [19, 20].
Aboriginal Health Workers (AHWs) provided clinical services, support, follow up services or use of resource kits in seven programs including the Hearing Health Outreach Program [61], Healthy Ears - Better Hearing, Better Listening [18, 59] Care for Kids Ears [18, 58] mobile screening and surveillance service in QLD Australia [65, 70, 74–76], ECHS program [62], HoHEBP [72] and in the current service model for ENT surgery in the NT [66].
The Hearing Health Outreach Program in the NT delivered diagnostic services through outreach teams, which consisted an of audiologist and at least one other additional staff member, which was either a registered nurse, nurse audiometrist, AHW or community health worker [61]. This program also included training of Aboriginal community hearing workers in hearing health education, promotion and prevention [61].
Skilled workforce trained in cultural safety
Three programs were identified as employing a workforce who had been trained in culturally safe work practices. The AFHCAN program aimed to ensure cultural safety through providing an audiologist who understands cultural subtleties of non-verbal communication such as facial movements and eye contact. This program also aimed to provide hearing technology choices that considered the patient’s cultural needs, which varied substantially due to diverse choices of lifestyle and environments including lakes, rivers and tundra [42]. The HOP involved capacity strengthening including training of local community members (95% of the residents of Nunavik are of Inuit ancestry) to take on roles in the hearing program [19, 20]. The Audiological Care and Telehealth in Remote Alaska program utilised culturally competent audiologists [42].
Other
A multi-media messages clinic attendance trial in the NT was classified as medical/wait and watch. This program aimed to ensure cultural safety in clinic multimedia messages sent to patients to increase clinic attendance. The style, design and interpretation of messages were determined in consultation with local Aboriginal teachers and interpreters [71]. The Hearing, Ear health, and Language Services (HEALS) project in NSW Australia, utilised existing Aboriginal Community Controlled Health Organization partnerships to ensure cultural safety of services [78, 79]. The ECHS program was developed in consultation with Aboriginal Health staff, refugee health staff, internal and external health experts [62]. Table 3 captures ear and hearing care core program elements, including the program approach (e.g. outreach), identified access challenges (e.g. geographical remoteness), solutions implemented to address challenges (e.g. telehealth to overcome geographical remoteness), First Nations involvement (in program design, program implementation and/or program evaluation), and identified program sustainability factors (e.g. funding).
(INSERT Table 3 HERE)
Table 3 Ear and hearing care program core elements
*Aboriginal refers to Aboriginal and Torres Strait Islander peoples.
First Nations People Involvement In Program Design, Implementation, And Evaluation
Of the 27 articles, seven did not state if First Nations people were involved in design, implementation, or evaluation of the program. Most of the remaining studies noted that First Nations people were involved in program implementation [18–20, 42, 58, 61, 62, 65, 67–70, 74–76], while a few stated that First Nations people had been involved in design [62, 64, 71] and evaluation [64]. The Multimedia Messaging Service (MMS) clinic attendance trial included consultation with local Aboriginal teachers and interpreters regarding the style, design and interpretation of text messages [71]. The Blow Breathe Cough (BBC) program involved a qualitative questionnaire which was piloted with teachers, one AHW and child health nurses [64]. The ECHS was developed in consultation with Aboriginal health staff, refugee health staff, internal and external health experts [62]. Involvement in implementation most commonly included IHW involvement [18, 58, 61, 65, 66, 70, 73–76] and community member involvement [19, 20, 42]. Only one study stated evaluation and this was achieved through a survey with teachers and community health workers [64].
Indicators Used To Identify Program Success
Of the 27 identified articles, 24 stated indicators used to identify program success. Half of these articles stated outputs which included number of patients receiving various ear and hearing care services. Number of patients receiving services included those who received screening services [57, 65, 73, 75, 77], ENT services [18, 63, 78], Child Nurse Specialist services [61], speech and language services [78] and unspecified audiology and follow-up services [18, 61, 72]. Other commonly utilised indicators included cost effectiveness [66, 67, 70], number of children identified as having an ear or hearing issue [61, 63, 65, 73, 77], and referral rates [57, 65, 75–77]. One study utilised outputs regarding clinic attendance differences between groups in a randomised-control trial [71]. Seven studies included qualitative evaluation outcome measures such as healthcare provider and parent/caregiver perspectives of perceived impact of programs [18, 58, 64, 68, 69, 78, 79]. One article described an ENT program, utilising outcome measures regarding surgical and hearing outcomes at post-surgical review [67]. Table 4 captures study outputs and outcomes.
(INSERT Table 4 HERE)
Table 4 Study outputs and outcomes
*Aboriginal refers to Aboriginal and Torres Strait Islander peoples.
Program Funding And Other Sustainability Factors
Most of the studies identified that programs were sustainable through government funding mechanisms [18, 57, 58, 60–63, 66]. For example, the Healthy Ears, Better Hearing, Better Listening (HEBHBL) program was one of these programs which was dependent on Australian Government funding, however it was noted that annual funding timing created logistical problems [18, 58]. The HoHEBP was funded through philanthropic organisations, community donations, and community fund-raising events which raised seed funding [72]. The AFHCAN program was funded with a $30 million grant in 1998 through the Alaska Federal Health Care Partnership [42]. The HOP received sustainable funding from the Ministry of Health and Social Services to guarantee continuity of the services [19, 20]. Five of the studies did not state what funding mechanisms were utilised for the programs [64, 68, 71, 77]. An ENT program found that use of telehealth for post-operative review was cost and time efficient, however ongoing funding would be required to expand the program [67]. The HEALS program was discounted due to tight funding deadlines and lack of recurrent funding [78, 79].
Sustainability factors noted for the mobile screening and surveillance service were cost-effectiveness, close alignment and integration with existing community services, and ongoing community consultation participation [65, 70, 74–76]. The Dangerous Decibels Program also found that community participation contributed to program self-sustainability [69]. The ear health screening program in NSW Australia was found to be more sustainable when Aboriginal project officers were trained to take on nurse duties [73].