Aboriginal perspective on middle ear disease in the arid zone of Western Australia

Identifying barriers and facilitators for the effective diagnosis and provision of primary health care for otitis media from the perspective of carers of Aboriginal children

AIM

To identify the barriers and facilitators for timely detection and optimal management of otitis media (OM) in Aboriginal children in a primary care setting from the perspective of carers of Aboriginal children.

METHODS

A qualitative, Aboriginal co-designed, participatory action research study with interviews and focus groups in a large town in the Kimberley, Western Australia. The Consolidated Framework for Implementation Research informed stakeholder group identification and interview framework development. Data underwent thematic analysis using NVivo software.

RESULTS

Thirty-two carers of Aboriginal children participated. Key barriers identified for the detection of OM were limited information about OM provided to carers and carers feeling disempowered to express their concerns. Key facilitators identified were the provision of health information through health promotion and the use of culturally secure resources. Having a culturally secure clinical environment was identified as essential, with Aboriginal Health Workers playing a vital role in clinical care. No barriers to management of OM in primary care were reported. Facilitators included health care practitioners (HCPs) emphasising the importance of completing antibiotic course and the clinic providing necessary medications.

CONCLUSIONS

A culturally secure health promotion strategy with health promotion teams, campaigns and resources is needed to increase community awareness of OM signs and symptoms and facilitate appropriate health seeking. It is essential that the local Aboriginal community co-lead and co-develop these initiatives to ensure the unique wisdom and knowledge of Aboriginal people are captured. HCPs and the clinic effectively facilitate management of OM by providing medications and emphasising completion of antibiotics.

Early onset of otitis media is a strong predictor of subsequent disease in urban Aboriginal infants: Djaalinj Waakinj cohort study

AIM

Australian Aboriginal and/or Torres Strait Islander children in rural/remote areas suffer high rates of persistent otitis media (OM) from early infancy. We aimed to determine the proportion of Aboriginal infants living in an urban area who have OM and investigate associated risk factors.

METHODS

Between 2017 and 2020, the Djaalinj Waakinj cohort study enrolled 125 Aboriginal infants at 0-12 weeks of age in the Perth South Metropolitan region, Western Australia. Proportion of children with OM based on tympanometry at ages 2, 6 and 12 months was evaluated, type B tympanogram indicating middle ear effusion. Potential risk factors were investigated by logistic regression with generalised estimating equations.

RESULTS

The proportion of children with OM was 35% (29/83) at 2 months, 49% (34/70) at 6 months and 49% (33/68) at 12 months of age. About 70% (16/23) of those with OM at ages 2 and/or 6 months had OM at 12 months compared with 20% (3/15) if no prior OM (relative risk = 3.48, 95% confidence interval (CI): 1.22-40.1). On multivariate analysis, infants living in houses with ≥1 person/room were at increased risk of OM (odds ratio = 1.78, 95% CI: 0.96-3.32).

CONCLUSION

Approximately half of Aboriginal infants enrolled into the South Metropolitan Perth project have OM by the age of 6 months and early onset of disease strongly predicts subsequent OM. Early surveillance for OM in urban areas is needed for early detection and management to reduce the risk of long-term hearing loss which can have serious developmental, social, behavioural, educational and economic consequences.

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

OBJECTIVE

To identify and describe the involvement of Indigenous Health Workers within ear health screening programs for Indigenous Peoples in Australia, Canada, the US and New Zealand.

METHODS

Peer-reviewed and grey literature sources were systematically searched to identify evidence. This scoping review was conducted in accordance with the scoping review extension of the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

RESULTS

Forty pieces of evidence were included in this review. While almost all included studies identified the critical role of Indigenous Health Workers in ear and hearing health, Indigenous leadership and involvement in research projects and service delivery varied significantly and none of the included studies reported Indigenous health worker perspectives. Approximately half of the authorship teams had at least one Indigenous author.

CONCLUSIONS

There is a clear need for Indigenous leadership in ear and hearing health research and programming. Specialist teams involved in health service delivery and research need to enable this transition by understanding and privileging Indigenous leadership and investing in appropriate training for non-Indigenous specialists providing care in Indigenous health contexts.

IMPLICATIONS FOR PUBLIC HEALTH

These findings are discussed in terms of opportunities to improve Indigenous ear and hearing health research and programming.

The socioemotional challenges and consequences for caregivers of Aboriginal and Torres Strait Islander children with otitis media: A qualitative study

INTRODUCTION

Living with ear disease can have extensive impacts on physical, emotional and social well-being. This study explored otitis media (OM) and its management from the perspective of caregivers of Aboriginal and Torres Strait Islander children.

METHODS

Semi-structured interviews were conducted from 2015 to 2020 with caregivers of Aboriginal and Torres Strait Islander children with OM. Thematic analysis of transcripts was undertaken using a constructivist grounded theory approach through the leadership and the cultural lens of an Aboriginal community-based researcher.

RESULTS

Caregivers described OM as having profound impacts on their child's physical, developmental, and emotional well-being, with long waits for specialist treatment contributing to extra strain on families. Children's well-being suffered when OM was mistaken for poor behaviour and children were punished, with caregivers subsequently experiencing strong feelings of guilt. Concerns were conveyed about the social implications of having a sick child. The variable nature of OM symptoms meant that caregivers had to monitor closely for sequelae and advocate for appropriate treatment. Success in navigating the diagnosis and treatment of OM can be strongly impacted by the relationship between caregivers and health professionals and the perceived access to respectful, collaborative and informative healthcare.

CONCLUSION

OM may have substantial social and emotional consequences for children and their caregivers. A holistic understanding of the way in which OM impacts multiple facets of health and well-being, as well as recognition of challenges in accessing proper care and treatment, will aid families managing OM and its sequelae.

PATIENT OR PUBLIC CONTRIBUTION

Governing boards, managers, staff and community members from five Australian Aboriginal Medical Services were involved in the approval, management and conduct of this study and the wider clinical trials. The caregivers of Aboriginal and Torres Strait Islander patients at these services informed the interview study and guided its purpose.

The Impact of Hearing Impairment on the Life Trajectories of Aboriginal Children in Remote Australia: Protocol for the Hearing Loss in Kids Project

BACKGROUND

Previous studies have reported a high prevalence of chronic otitis media (OM) and hearing impairment (HI) in Aboriginal children in the Northern Territory (NT) of Australia. Children affected by these disorders are believed to be at increased risk for adverse outcomes in early childhood development, school attendance, academic performance, and child maltreatment and youth offending. However, to date, there have been no studies quantifying the association between HI and these outcomes in this population.

OBJECTIVE

This study will investigate the association between HI and the 5 outcomes in Aboriginal children living in remote NT communities.

METHODS

Individual-level information linked across multiple administrative datasets will be used to conduct a series of retrospective observational studies on selected developmental and school outcomes. The predictor variables for all studies are the results from audiometric hearing assessments. The outcome measures are as follows: Australian Early Development Census results, representing developmental readiness for school, assessed around 5 years of age; Year 1 school attendance rates; Year 3 school-based academic performance, assessed in the National Assessment Program-Literacy and Numeracy; incidence of child maltreatment events (including both notifications and substantiated cases); and incidence of a first guilty verdict for youth offenders. Confounding and moderating factors available for the analysis include both community-level factors (including school fixed effects, socioeconomic status, level of remoteness, and housing crowdedness) and individual-level factors (including maternal and perinatal health and hospital admissions in early childhood).

RESULTS

The study commenced in 2018, with ethics and data custodian approvals for data access and linkage. This has enabled the completion of data linkage and the commencement of data analysis for individual component studies, with findings expected to be published in 2019 and 2020.

CONCLUSIONS

This study will provide first evidence of the impact of OM-related HI on the developmental, educational, and social outcomes of Australian Aboriginal children. The findings are expected to have significant implications for policy development, service design, and resource allocation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/15464.

Occurrence of and referral to specialists for pain-related diagnoses in First Nations and non-First Nations children and youth

BACKGROUND

Indigenous youth have higher rates of chronic health conditions interfering with healthy development, including high rates of ear, dental, chest and musculoskeletal pain, as well as headache, arthritis and mental health issues. This study explores differences in pain-related diagnoses in First Nations and non-First Nations children.

METHODS

Data from a study population of age- and sex-matched First Nations and non-First Nations children and youth were accessed from a specific region of Atlantic Canada. The primary objective of the study was to compare diagnosis rates of painful conditions and specialist visits between cohorts. The secondary objective was to determine whether there were correlations between early physical pain exposure and pain in adolescence (physical and mental health).

RESULTS

Although ear- and throat-related diagnoses were more likely in the First Nations group than in the non-First Nations group (ear 67.3% v. 56.8%, p < 0.001; throat 89.3% v. 78.8%, p < 0.001, respectively), children in the First Nations group were less likely to see a relevant specialist (ear 11.8% v. 15.5%, p < 0.001; throat 12.7% v. 16.1%, p < 0.001, respectively). First Nations newborns were more likely to experience an admission to the neonatal intensive care unit (NICU) than non-First Nations newborns (24.4% v. 18.4%, p < 0.001, respectively). Non-First Nations newborns experiencing an NICU admission were more likely to receive a mental health diagnosis in adolescence, but the same was not found with the First Nations group (3.4% v. 5.7%, p < 0.03, respectively). First Nations children with a diagnosis of an ear or urinary tract infection in early childhood were almost twice as likely to have a diagnosis of headache or abdominal pain as adolescents (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.0, and OR 1.7, 95% CI 1.2-2.3, respectively).

INTERPRETATION

First Nations children were diagnosed with more pain than non-First Nations children, but did not access specific specialists or mental health services, and were not diagnosed with mental health conditions, at the same rate as their non-First Nations counterparts. Discrepancies in pain-related diagnoses and treatment are evident in these specific comparative cohorts. Community-based health care access and treatment inquiries are required to determine ways to improve care delivery for common childhood conditions that affect health and development.

Parental perceptions and management strategies for otitis media in Greenland

INTRODUCTION

Otitis media (OM) in Greenland is a substantial problem and the country prevalence is among the highest in the world. However, little is known about how Greenlandic Inuit parents perceive and manage everyday life with children suffering from OM. We hypothesize that having a child with OM has consequences for the families that go beyond the advice and treatment offered in primary health care.

METHODS

We conducted a qualitative study based on semi-structured interviews and focus groups with parents to children suffering from OM. The interviews took place in three different Greenlandic regions; the capital Nuuk and two smaller towns in West and East Greenland. Access to specialized health care differs among the regions, creating an underlying difference on the limitations of referral and thereby level of care. We conducted the data analysis using Systematic Text Condensation.

RESULTS

In total, 27 parents participated in the study. Although most parents perceived OM as a result of genetic or environmental dispositions, individual perceptions and cultural beliefs of causal associations between behavior and OM co-existed with the general understanding of medical explanation models. This created a sense of guilt among the parents. Some parents felt in control of managing the disease of the child and used medically well-established strategies. Others felt frustrated and considered contact to the health clinics as futile, thereby managing the disease by 'waiting it out'. Emerging themes were shame and stigma related to the symptoms of OM, which led to social isolation as a consequence for several of the families.

CONCLUSION

Our results indicate that Greenlandic Inuit families are impacted by OM in a complex and severe manner. Guilt, shame and social isolation were predominant themes influencing the everyday life of the affected families. Perceptions and management strategies go beyond the scope of the medical explanation models which poses a potential challenge for the parents' experiences with the present treatment offer. The results underline the need to develop a broader approach to prevention and treatment for OM - both at the clinical level as well as part of public health promotion at the community level.

Chronic wet cough in Aboriginal children: It's not just a cough

AIM

Chronic respiratory disease is common among Aboriginal Australians. Chronic wet cough is an early marker of chronic disease in children but often goes undetected due, in part, to delayed health seeking by families. Currently, no studies have examined the reasons for delayed health seeking for children's chronic cough. To identify the barriers to, and enablers for, seeking medical help for chronic wet cough in Aboriginal children.

METHODS

This was a qualitative study, gathering data through individual semi-structured, in-depth interviews and focus groups to ascertain Aboriginal family knowledge, attitudes and beliefs about seeking health care for chronic wet cough in children in a regional Kimberley town, Western Australia between October 2017 and March 2018.

RESULTS

Forty Aboriginal community members participated. The three key barriers identified were: 'Cough normalisation', that is, 70% of participants considered chronic cough normal (with 53% of participants' previous interactions with doctors informing their understanding of chronic cough); the lack of health literacy information; and a sense of disempowerment (belief that no medical action would be taken and inability to challenge doctors). The key expressed enablers were provision of health literacy information and health practitioner training to assess and treat chronic wet cough in children. All participants reported that they would seek help for chronic wet cough once they were informed that it could signify underlying disease.

CONCLUSION

Results highlight the need for a culturally appropriate information and education to inform Aboriginal families and their health practitioners of the importance of chronic wet cough in children.

Ascertaining infectious disease burden through primary care clinic attendance among young Aboriginal children living in four remote communities in Western Australia

Infectious diseases contribute a substantial burden of ill-health in Australia’s Aboriginal children. Skin infections have been shown to be common in remote Aboriginal communities, particularly in the Northern Territory, Australia. However, primary care data on skin and other infectious diseases among Aboriginal children living in remote areas of Western Australia are limited. We conducted a retrospective review of clinic presentations of all children aged 0 to 5 years presenting to four clinics located in the Western Desert region of Western Australia between 2007 and 2012 to determine this burden at a local level. Infectious diseases accounted for almost 50% of all clinic presentations. Skin infections (sores, scabies and fungal infections) were the largest proportion (16%), with ear infections (15%) and upper respiratory infections (13%) also high. Skin infections remained high in all age groups; 72% of children presented at least once with skin infections. Scabies accounted for only 2% of all presentations, although one-quarter of children presented during the study for management of scabies. Skin sores accounted for 75% of the overall burden of skin infections. Improved public health measures targeting bacterial skin infections are needed to reduce this high burden of skin infections in Western Australia.

Parental views on otitis media: systematic review of qualitative studies

This study aims to describe parental experiences and perspectives of caring for a child with otitis media. We conducted a systematic review of qualitative studies on parental perspectives on caring for a child with otitis media. We searched electronic databases to July 2015. Seventeen studies involving 284 participants from six countries were included. We identified seven themes: diminishing competency (guilt over failure to identify symptoms, helpless and despairing, fear of complications, disempowered and dismissed); disrupting life schedules (disturbing sleep, interfering with work, burden on family); social isolation (stigma and judgement, sick consciousness); threatening normal development (delaying growth milestones, impairing interpersonal skills, impeding education); taking ownership (recognising symptoms, diagnostic closure, working the system, protecting against physical trauma, contingency planning); valuing support (needing respite, depending on community, clinician validation); and cherishing health (relief with treatment success, inspiring resilience).

CONCLUSION

The additional medical responsibilities and anxieties of parents caring for a child with otitis media, often discounted by clinicians, can be disempowering and disruptive. Chronicity can raise doubt about treatment efficacy and parental competency, and fears regarding their child's development. Care that fosters parental confidence and addresses their concerns about the child's development may improve treatment outcomes for children with otitis media.

WHAT IS KNOWN

• Otitis media is a leading cause of conductive hearing loss in children. • Parental perception of the treatment burden of otitis media can potentially affect their confidence and ability to care for their child. What is New: • We identified five themes to reflect parental perspectives: diminishing competency, disrupting life schedules, social isolation, threatening normal development, taking ownership, valuing support, and cherishing health. • Parents may perceive caring for a child with otitis media as disempowering and disruptive and with reoccurrence doubt treatment efficacy and their parental competency and develop fears regarding their child's development.

Knowledge, attitudes, beliefs and practices related to chronic suppurative otitis media and hearing impairment in Pokhara, Nepal

Background:

Nepal has a high prevalence of chronic suppurative otitis media and hearing impairment. An improved understanding of patients' knowledge, attitudes, beliefs and practices is therefore important for effective healthcare planning and intervention.

Method:

Questionnaires designed to explore their current knowledge, attitudes, beliefs and practices were completed by 153 participants: 71 were affected by a known ear disease and 82 were unaffected.

Results:

In the unaffected group, 31.7 per cent considered breast milk to be a risk factor for ear infection. Home remedies (e.g. leaf paste, oils, and urine and/or bodily fluids) had been used by 42.3 per cent of the affected group. Most participants (71.9 per cent) believed that society discriminates against those with hearing impairment.

Conclusion:

Knowledge deficits and false beliefs were found in both groups, along with a significant use of home remedies and a perception of discrimination against people with hearing impairment. These findings are relevant for healthcare providers and may aid the development of policy, interventions and public education initiatives.

Less germs, less mucus, less snot: teachers' and health workers' perceptions of the benefits and barriers of ear health programs in lower primary school classes

This study explored health and education professionals' perceptions of the health benefits and barriers of different ear health programs used in lower primary school classes in two district education areas in the Goldfields South East Health Region, Western Australia. Health and education staff providing services to children in kindergarten to year three primary school classes were sent a questionnaire about ear health programs provided in their school. Sixty-one questionnaires were returned from 43 teachers, 14 community health nurses, three Aboriginal health workers and one teacher's assistant. Some schools implemented all the ear health programs examined at all year levels while others implemented only one of the programs. Teachers, community health nurses and Aboriginal health workers identified that all ear health programs were beneficial to students. Reported physical health benefits included reduced ear infections, early detection of ear infections and improved hearing. Behavioural benefits included improved concentration, alertness and attention in the classroom. Barriers to implementing the programs were obtaining consent from parents/carers, student transience and attendance, time to implement and conduct the programs and human and physical resources. Evaluation methods used varied from no evaluation for the Breathe Blow Cough and tissue spearing programs to limited data collection for audiometry, otoscopy and ear toilet programs. Respondents perceived that ear health programs were effective in improving health and behavioural outcomes for children. A formal pre-post evaluation to provide objective data to confirm this is needed to inform policy around this important health issue.

Otitis media: viruses, bacteria, biofilms and vaccines

Otitis media typically presents as either acute otitis media (AOM), with symptoms including fever, otalgia, otorrhoea or irritability and short duration; or as otitis media with effusion (OME), which is often asymptomatic and characterised by accumulation of fluid in the middle ear.

Diagnostic certainty of otitis media is challenging, given the young age of patients and variability of symptoms.

Otitis media predominantly occurs as coincident to viral upper respiratory tract infections and/or bacterial infections.

Common viruses that cause upper respiratory tract infection are frequently associated with AOM and new‐onset OME. These include respiratory syncytial virus, rhinovirus, adenovirus, parainfluenza and coronavirus.

Predominant bacteria that cause otitis media are Streptococcus pneumoniae, Moraxella catarrhalis, and non‐typeable Haemophilus influenzae.

Antibiotic therapy does not significantly benefit most patients with AOM, but long‐term prophylactic antibiotic therapy can reduce the risk of otitis media recurrence among children at high risk.

In Australia, 84% of AOM is treated with antibiotic therapy, which contributes to development of antibiotic resistance.

Vaccine development is a key future direction for reducing the world burden of otitis media, but requires polymicrobial formulation and ongoing monitoring and modification to ensure sustained reduction in disease burden.

The impact of otitis media on cognitive and educational outcomes

Otitis media is a common disease in childhood that can adversely affect cognitive and educational outcomes. The literature in this area is equivocal, and findings may be influenced by research design. The impact of otitis media on individual children's development appears to depend on the inter-relationship between several factors. Children who have early-onset otitis media (under 12 months) are at high risk of developing long-term speech and language problems. Otitis media has been found to interact negatively with pre-existing cognitive or language problems. For biological or environmental reasons, some populations have a pattern of early onset, higher prevalence and episodes of longer duration; this pattern leads to a higher risk of long-term speech and language problems. These factors suggest that Indigenous children may be at higher risk of cognitive and educational sequelae than non-Indigenous children.

Absent otoacoustic emissions predict otitis media in young Aboriginal children: a birth cohort study in Aboriginal and non-Aboriginal children in an arid zone of Western Australia

BACKGROUND

Otitis media (OM) is the most common paediatric illness for which antibiotics are prescribed. In Australian Aboriginal children OM is frequently asymptomatic and starts at a younger age, is more common and more likely to result in hearing loss than in non-Aboriginal children. Absent transient evoked otoacoustic emissions (TEOAEs) may predict subsequent risk of OM.

METHODS

100 Aboriginal and 180 non-Aboriginal children in a semi-arid zone of Western Australia were followed regularly from birth to age 2 years. Tympanometry was conducted at routine field follow-up from age 3 months. Routine clinical examination by an ENT specialist was to be done 3 times and hearing assessment by an audiologist twice. TEOAEs were measured at ages <1 and 1-2 months. Cox proportional hazards model was used to investigate the association between absent TEOAEs and subsequent risk of OM.

RESULTS

At routine ENT specialist clinics, OM was detected in 55% of 184 examinations in Aboriginal children and 26% of 392 examinations in non-Aboriginal children; peak prevalence was 72% at age 5-9 months in Aboriginal children and 40% at 10-14 months in non-Aboriginal children. Moderate-severe hearing loss was present in 32% of 47 Aboriginal children and 7% of 120 non-Aboriginal children aged 12 months or more. TEOAE responses were present in 90% (46/51) of Aboriginal children and 99% (120/121) of non-Aboriginal children aged <1 month and in 62% (21/34) and 93% (108/116), respectively, in Aboriginal and non-Aboriginal children at age 1-2 months. Aboriginal children who failed TEOAE at age 1-2 months were 2.6 times more likely to develop OM subsequently than those who passed. Overall prevalence of type B tympanograms at field follow-up was 50% (n = 78) in Aboriginal children and 20% (n = 95) in non-Aboriginal children.

CONCLUSION

The burden of middle ear disease is high in all children, but particularly in Aboriginal children, one-third of whom suffer from moderate-severe hearing loss. In view of the frequently silent nature of OM, every opportunity must be taken to screen for OM. Measurement of TEOAEs at age 1-2 months to identify children at risk of developing OM should be evaluated in a routine health service setting.

The Kalgoorlie Otitis Media Research Project: rationale, methods, population characteristics and ethical considerations

Otitis media (OM) is one of the most common paediatric illnesses for which medical advice is sought in developed countries. Australian Aboriginal children suffer high rates of OM from early infancy. The resultant hearing loss can affect education and quality of life. As numerous factors contribute to the burden of OM, interventions aimed at reducing the impact of single risk factors are likely to fail. To identify key risk factors and understand how they interact in complex causal pathways, we followed 100 Aboriginal and 180 non-Aboriginal children from birth to age 2 years in a semi-arid zone of Western Australia. We collected demographic, obstetric, socio-economic and environmental data, breast milk once, and nasopharyngeal samples and saliva on seven occasions. Ear health was assessed by clinical examination, tympanometry, transient evoked otoacoustic emissions and audiometry. We considered the conduct of our study in relation to national ethical guidelines for research in Aboriginal and Torres Strait Islander health. After 1 year of community consultation, the study was endorsed by local committees and ethical approval granted. Fieldwork was tailored to minimise disruption to people's lives and we provided regular feedback to the community. We saw 81% of non-Aboriginal and 65% of Aboriginal children at age 12 months. OM was diagnosed on 55% and 26% of routine clinical examinations in Aboriginal and non-Aboriginal children respectively. Aboriginal mothers were younger and less educated, fewer were employed and they lived in more crowded conditions than non-Aboriginal mothers. Sixty-four per cent of Aboriginal and 40% of non-Aboriginal babies were exposed to environmental tobacco smoke. Early consultation, provision of a service while undertaking research, inclusion of Aboriginal people as active members of a research team and appropriate acknowledgement will assist in ensuring successful completion of the research.

Hearing screening and middle ear measures in American Indian infants and toddlers

American Indian children have three times the rate of otitis media compared to the general population, yet prospective cohort studies of OME and hearing loss have not been previously reported in American Indian infants. Between 1997 and 2003, a cohort of 421 infants was enrolled at birth from Minnesota American Indian reservations and an urban clinic and followed to age 2 years. This study reports OAE hearing screening results related to OME diagnoses, as well as risk for recurrent hearing screening failure and OME in American Indian infants and children.

METHODS

Infants were prospectively assessed at regular intervals with pneumatic otoscopy, distortion product otoacoustic emissions, and tympanometry by nurses who were trained in all procedures and validated on pneumatic otoscopy.

RESULTS

In the newborn period, 23.5% of infants failed hearing screening in at least one ear. Hearing screening failures increased to 29.9% from 2 to 5 months of age. Technical fail results due to excessive noise occurred frequently in infants 6-24 months of age, making interpretation of true pass and fail rates questionable in older infants. OAE test result was associated with OM diagnosis, and this relationship strengthened with age, with the strongest association above 6 months of age.

CONCLUSIONS

A high rate of hearing screening failures occurred among American Indian infants in the first 5 months of age, and was significantly associated with a correspondingly high rate of otitis media. Only one infant out of 366 was identified with sensorineural hearing loss, thus essentially all of the hearing screening failures reflected either a middle ear origin or other temporary problems. OAE screening provided a valuable hearing screening measure in this population at high risk for recurrent otitis media, but due to excessive noise in infants 6 months and older, practical use of OAE screening is limited. Use of behavioral assessment is needed after 6 months of age, when high rates of OME persist in this population. Increased efforts to develop public and medical education, as well as screening, diagnosis and treatment programs are needed to detect and decrease recurrent OME in American Indian infants and children.