INDIGENOUS HEALTH

The role of Indigenous Health Workers in ear

health screening programs for Indigenous children:
a scoping review
Brianna Poirier,1 Leanne Quirino,2 Michelle Allen,1 Roland Wilson,1 Jacqueline Stephens1,3

D
espite the differences in time and
Abstract
place, Australia, Canada, the US
and New Zealand share a similar Objective: To identify and describe the involvement of Indigenous Health Workers within
colonial history, with the lived experience ear health screening programs for Indigenous Peoples in Australia, Canada, the US and New
of colonisation and its continuing impact Zealand.
on health and social inequities similar for Methods: Peer-reviewed and grey literature sources were systematically searched to identify
Indigenous Peoples in these countries evidence. This scoping review was conducted in accordance with the scoping review extension
(Supplementary File 1).1 In these four high- of the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.
income countries, the prevalence of ear
Results: Forty pieces of evidence were included in this review. While almost all included studies
disease and hearing loss is greater among
identified the critical role of Indigenous Health Workers in ear and hearing health, Indigenous
Indigenous children than among their non-
leadership and involvement in research projects and service delivery varied significantly and
Indigenous counterparts.2,3 For example, in
none of the included studies reported Indigenous health worker perspectives. Approximately
Australia, ear and hearing problems among
half of the authorship teams had at least one Indigenous author.
Indigenous children have been estimated
as occurring at nearly three times the Conclusions: There is a clear need for Indigenous leadership in ear and hearing health research
rate of those in non-Indigenous children and programming. Specialist teams involved in health service delivery and research need to
(8.4% compared with 2.9%, respectively).4 enable this transition by understanding and privileging Indigenous leadership and investing
Indigenous children experience otitis media in appropriate training for non-Indigenous specialists providing care in Indigenous health
(OM) more frequently, for longer periods of contexts.
time, and with more complications.4 Key risk Implications for public health: These findings are discussed in terms of opportunities to
factors associated with a higher incidence improve Indigenous ear and hearing health research and programming.
of OM for Indigenous populations include Key words: otitis media, Indigenous Canadians, Aboriginal and Torres Strait Islander,
rural and remote locations, crowded housing, Community Health Workers, ear health screening
poverty and social disadvantage, passive
smoking and limited access to health and
based and trans-disciplinary health services including Indigenous Health Workers (IHWs),
hearing services.5 Hearing loss due to OM
encompassing prevention, early intervention, have a central role in the effective and
can impact speech, literacy, communication,
community awareness and education and sustainable prevention and treatment of
social skills and cognitive development,
support for families from a child’s birth into ear disease.7-9 IHWs are responsible for the
which directly affects future educational
adolescence.5,7 delivery of a range of health services from
outcomes, employment opportunities,
Outreach visits by ear specialists community-based prevention programs to
interactions with the criminal justice system
to Indigenous communities are primary, secondary and tertiary services.10,11
and social and emotional wellbeing.6 Given
often infrequent, irregular and too short IHWs are becoming an increasingly
the ongoing high burden of OM among
to allow for the necessary follow-up; as indispensable workforce due to their ability
Indigenous Peoples, the model of care must
such, frontline primary health care services, to build on relationships of trust with
adapt to provide more equitable community-
communities and deliver healthcare that

1. College of Medicine and Public Health, Flinders University, South Australia

2. Aboriginal Health Council of South Australia
3. Flinders Health and Medical Research Institute, South Australia
Correspondence to: Jacqueline Stephens, College of Medicine and Public Health, Flinders University, GPO Box 2100, Adelaide SA 5001;
e-mail: [email protected]
Submitted: November 2021; Revision requested: May 2022; Accepted: July 2022
The authors have stated they have no conflicts of interest.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Aust NZ J Public Health. 2022; 46:604-13; doi: 10.1111/1753-6405.13291

604 Australian and New Zealand Journal of Public Health 2022 vol. 46 no. 5
© 2022 The Authors
Indigenous Health Indigenous Health Workers’ role in ear health screening

meets patient needs. There is a growing body extension for Scoping Reviews (PRISMA- Selection of sources
of evidence linking the involvement of IHWs ScR) guidelines (Supplementary File 2) were Search results were imported into Covidence
in service delivery to improved outcomes followed for the reporting of this scoping (https://www.covidence.org/, Veritas Health
for Indigenous Peoples both clinically and review.20 Innovation Ltd, Melbourne, Australia) and
socially, including health promotion and duplicates were removed. A multi-step
prevention and management of chronic Eligibility criteria process was followed to screen the papers
disease.12,13 However, IHWs are limited Papers were deemed eligible for inclusion with each step of the screening process
in their ability to meet the needs of their if they were published in English from 1 conducted by two independent reviewers (JS,
communities when working within Western January 2000 until September 2021 and MA). The reviewers were not masked to the
systems and medicalised ideologies of health reported the involvement of IHWs in ear author or journal names at any stage of the
that inadequately recognise Indigenous health screening programs or strategies process. After title and abstract screening, all
understandings of wellbeing and ways of implemented in Indigenous communities potentially relevant papers were sourced for
working.14 As such, IHW provision of feedback within Australia (Aboriginal, Torres Strait full-text review. All articles were available to
and leadership in program evaluation is Islander), the US (Native American, Amerind), the authors through our institution’s library.
critical to the ear health of Indigenous Canada (First Nations, Inuit, Métis), or New Full-text papers were assessed in detail
Peoples. Zealand (Māori). For the purposes of this using the inclusion criteria with reasons for
While the IHW workforce is increasingly review, ear health screening programs were exclusion documented. Discrepancies during
recognised as being essential to the provision understood as any provision of services that the screening process were resolved through
of culturally safe healthcare to Indigenous included ear health and hearing screening reviewer consensus discussions.
communities,10 there is currently inadequate via both objective and subjective clinical
understanding of the role of IHWs within ear measures. Data charting and variables
health screening programs. This is partly due
Data extraction was conducted by two
to a lack of recognition of IHW education and Information sources reviewers (MA, BP), reviewed by two
qualifications, IHW status within mainstream Literature was identified by systematically Indigenous researchers (LQ, RW) and the
health service and academic settings, ear searching the following indexed databases: senior author (JS), and facilitated using a
health and hearing screening skills developed OVID Medline, OVID Emcare, CINAHL, Microsoft Excel spreadsheet. Extracted data
through education and training, and the Scopus, Sociological Abstracts, PsychInfo, were mapped to pre-defined variables:
level of support and supervision received and Informit (Indigenous Collection, New authors, publication year, publication
regarding ear and hearing health.8,15 As such, Zealand Collection, Rural and Remote title, country, study aim, recruitment
the aim of this scoping review was to identify Health Database, Aboriginal and Torres Strait method, methodology IHW involvement,
and describe the involvement of IHWs within Islander health bibliography). The Australian IHW terminology, study population,
ear health screening programs for Indigenous Indigenous HealthInfoNet was also searched, outcome measures, conclusions, and
Peoples in four high-income countries. as this is a known repository of community recommendations. Where data were missing
These countries share similar histories of publications and reports. The following or not clear, the researchers contacted the
colonisation and current health outcomes community and governmental websites first author of the source papers for additional
for Indigenous Peoples, yet differing treaty were further searched for grey literature: information and clarification.
processes, health systems and recognition Deadly Ears Program, National Aboriginal
of the importance of Indigenous wellbeing. Community Controlled Health Organisation, Quality appraisal
We anticipated the scoping review would NSW Department of Health, and the
identify opportunities to better support While scoping review guidelines do not
Ramahyuck District Aboriginal Corporation. endorse conducting a quality appraisal of
IHWs’ engagement within ear and hearing Reference lists of articles included in this
screening, including the requirement for full-text papers,16 this review has utilised
review were manually searched to identify the Aboriginal and Torres Strait Islander
specialised training and upskilling, and could any additional papers.
be used to advocate for greater investment in Quality Appraisal Tool.21 The decision to
this workforce. utilise this quality appraisal tool was made
Search strategy in part because of the high representation
We developed a search strategy using of included studies from Australia, but
Methods both subject headings and keywords. more so the opportunity this tool provided
Initial searches assisted in refining the in assessing the inclusion of Indigenous
We conducted a scoping review following
search strategy, with the final search terms communities and IHWs across the included
the standard four-step Joanna Briggs
incorporating concepts of ear health, hearing studies. The Aboriginal and Torres Strait
Institute (JBI) scoping review procedure.16
loss, health practitioner, Indigenous health Islander Quality Appraisal Tool is a set of
In accordance with scoping review
worker, Indigenous health service, Australia, 14 appraisal questions created to address
methodologies,17,18 a review protocol
Canada, United States of America, and New the lack of attention to Indigenous
detailing the search strategy, planned data
Zealand. The search strategy was modified epistemologies and values in standardised
extraction and synthesis was made publicly
according to the design of each database critical appraisal tools by offering guidance
available.19 The Preferred Reporting Items
(Supplementary File 3). on how to assess the validity and contextual
for Systematic Reviews and Meta-Analyses
relevance for Indigenous health research.21

2022 vol. 46 no. 5 Australian and New Zealand Journal of Public Health 605
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Poirier et al. Article

Both an Indigenous (LQ) and non-Indigenous synthesised to identify common attributes File 4). The majority of articles included in
reviewer (BP) completed the quality appraisal and findings across the included studies. the appraisal performed poorly across all
independently and then came together to measures of the tool, with only seven22-28 of
discuss any discrepancies between scores. the 33 articles satisfying seven (50%) or more
Questions in the tool include community
Results of the appraisal measures (Table 1).
consultation, involvement, leadership, Sources of evidence
and governance in research projects, data On 9 July 2021, the systematic search Characteristics of sources of evidence
sovereignty of both existing and created identified 1018 publications (Figure 1). After Of the 40 publications included in this review,
data, the use of Indigenous research the removal of duplicates, 720 publications 33 were from Australia, five were from the
paradigms and strengths-based approaches were reviewed. Title and abstract screening US and two were from Canada (Table 2).
(where Indigenous research paradigms are identified 89 publications for full-text review. Program evaluation was the most common
understood as those that reflect Aboriginal During the full-text review process, where study design (N=11),3,7,9,23,24,28-33 followed
and/or Torres Strait Islander ways of knowing, the Indigenous status of health workers was by descriptive reports (N=8),5,15,22,25,34-37
being, and doing, based off knowledges and unclear or there was limited information on exploratory studies (N=4),38-41 cohort studies
lived experiences of Aboriginal and Torres the level of IHW involvement, we attempted (N=4),6,26,27,42 cross-sectional studies (N=3)27,43-
Strait Islander Peoples21), as well as policy to contact the authors for further information. 45
and feasibility studies (N=3)46-48; the
translation, community benefit and capacity An additional six papers and reports were remaining studies used a variety of analytical
strengthening for Aboriginal and Torres Strait identified from grey literature searches. As techniques and study designs. The language
Islander Peoples. The 14 questions are scored a result, screening identified 40 papers for used to define IHWs varied across the studies,
as: yes (Y), partially (P), no (N), and unclear inclusion in this scoping review. with Aboriginal health worker or AHW being
(U).21 employed most frequently (N=14)6,15,22,25-
Quality appraisal 27,29,32,33,38,39,43,46,49
and Indigenous health
Synthesis of data worker or IHW the second most commonly
Two reviewers (LQ, BP) independently
Descriptive analyses, such as frequencies and appraised the 33 (82.5%) peer-reviewed used term (N=6)3,7,30,48,50,51 (Supplementary
proportions, were performed in Microsoft publications from Australia.21 The reviewers File 5). Three of the included studies only
Excel using the built-in data analysis had an inter-rater reliability score of 12.2 mentioned IHWs in their discussion or
functions. There was minimal qualitative data out of 14, calculated as the mean number recommendations for future work.6,32,48
extractable, so findings were combined with of identical scores per article, indicating a These papers proposed IHWs as a potential
study recommendations and categorically high level of agreement (Supplementary solution to existing ear health screening

Figure 1: PRISMA flow diagram.20

Identification of studies via databases and registers Identification of studies via other methods
Identification

Duplicate records removed Records identified from:

Records identified from
before screening Websites (n = 2441)
Databases (n = 1018)
(n = 298) Organisations (n = 876)

Records screened Records excluded

(n = 720) (n = 630)

Reports sought for retrieval Reports not retrieved Reports sought for retrieval Reports not retrieved
(n = 90) (n = 0) (n = 6) (n = 0)
Screening

Reports assessed for eligibility Reports assessed for eligibility

(n = 90) (n = 6)
Reports excluded Reports excluded
(n = 56) (n = 0)
Included

Reports of included studies

(n = 40)

606 Australian and New Zealand Journal of Public Health 2022 vol. 46 no. 5
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Indigenous Health Indigenous Health Workers’ role in ear health screening

challenges; however, these studies did not in improved child behaviour,22,31,38,43 school environmental and educational departments,
actively engage IHWs in any capacity within performance,22,38 family life22,38 and physical especially in remote areas.5,28,37,41,44 Authors
their research project or ear health screening health.43 Three studies primarily focused highlighted the importance of community
program.6,32,48 on strengthening ear health screening control and support for successful programs
skills and confidence for IHWs9,15,51 and and research25,41,45 and the importance of
Results of individual sources of one study stressed the importance of engaging in local contexts.37
evidence providing specialised training for non-
Largely, the publications included in
Indigenous Health Workers to generate a Synthesis of evidence
better understanding of Indigenous health Despite recognition of the importance
this review were measuring outcomes
contexts.35 Challenges research teams faced of IHWs in ensuring culturally safe and
related to ear health screening programs
in maintaining the success of their screening appropriate ear screening programs almost
involving IHWs in some capacity. Projects
programs included the resource-intensive ubiquitously across the studies in this review,
successfully increased the number of
nature of programs,30 high healthcare and IHW involvement in the research programs
children screened3,5,7,29,32 and identified
teaching staff turnover,35,40 limited OM significantly varied. Five of the included
telehealth as feasible and relatively accurate
knowledge in communities and schools,39,40 studies did not utilise IHWs in any capacity
for clinical diagnosis and management of
service accessibility35,39 and limited for their projects but mentioned them in
OM.30,35,36,46-48,51-53 As documented in the
evaluation methods.35,43 Potential solutions either their results or recommendations
literature, studies consistently reported high
to these challenges included supportive as potential solutions to current program
levels (ranging from 42% to 64%) of OM
infrastructure,24 funded staff and staff training limitations.26,30,32,48 IHW involvement
among Indigenous children.26,27,33,42,49 Some
opportunities,24,37,51 as well as strategic was synthesised into three overarching
included studies reported increased OM
multi-level collaborations across health, domains: service delivery, contribution to
knowledge and correct diagnosis resulted

Table 1: Results of the critical appraisal using the Aboriginal and Torres Strait Islander Quality Appraisal Tool.21
Author/Year Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
Abbott et al. 201654 N N Y Y N N N N N N P N P N
Aboriginal and Islander Health Worker Journal 200322 Y Y Y Y Y Y Y Y Y Y Y Y Y Y
Adams et al. 200429 N N N N N N N Y N P Y U Y U
Ching et al. 202023 Y Y Y Y P N N N Y Y Y Y N Y
Clements 200524 Y Y Y Y Y U U Y Y Y Y Y Y Y
Couzos et al. 200349 Y Y Y Y U N N Y Y N N P N U
Couzos et al. 200525 Y Y Y Y P N U Y N Y N Y N P
Doyle et al. 201043 N N N N N N N N N N N N N N
Durham et al. 201844 N N N N N N N N N N N N N N
Eikelboom et al. 20039 N N N N N N N N N N N Y Y Y
Elliott et al. 201046 Y Y N N Y N N N N N N N Y N
Howard et al. 200638 N N Y N N N N N N N N N N N
Jacups et al. 201730 N N N N N N N N N N N P N N
Jacups et al. 202051 N N N N N N N N N N N N N N
Jeffries-Stokes et al. 200439 N N N N N N N N N N N N Y N
Kong et al. 202155 N N Y N N N N N N N N N N N
Lehmann et al. 2008A6 Y N N N N N N N N N N P N N
Lehmann et al. 2008B26 Y P Y Y Y Y Y N Y Y N Y Y N
McCarthy M. 201036 N N N N N N N N N N N P N N
McSwan et al. 200140 N N N N N N U N N N N N N N
Nguyen et al. 201550 N N N N N N N N N N N Y Y N
Pearce et al. 200947 N N N N N N N N N N N N N N
Rees et al. 20205 Y N N N Y N N N N P P Y N N
Reeve et al. 201432 N N N N N N N N N N N N N N
Smith et al. 200648 N N N N N N N N N N N N N N
Smith et al. 20127 Y N Y N Y N N N U P Y Y Y N
Smith et al. 20153 N N N N N N N N N N N Y N N
Stroud et al. 202037 N N N P N N N N N N P P N N
Swift et al. 202027 Y Y Y Y Y Y Y N Y Y U Y Y Y
Walker et al. 201364 N N N N N N N N N N N N N N
Williams et al. 200933 N Y N N N N N N N N N Y Y Y
Young et al. 201628 Y Y Y Y Y N U N Y Y Y Y P Y
Young et al. 201741 N N Y N N N N N N N N N N N
Notes:
Where Y = yes, P = partially, N = no, U = unclear

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Table 2: Characteristics of included studies.

Study Country Study Aim Methods for data collection and Participant characteristics and sample
analysis size
Abbott et al. 201654 Australia* Determine whether watchful waiting is non-inferior to A non-inferiority multi-centre Children aged 2 − 16 years with AOM who
immediate antibiotics for urban Aboriginal and Torres Strait randomised controlled trial protocol are considered at low risk for complications
Islander children with AOM without perforation
Aboriginal and Islander New South Wales, Program was developed in response to concerns raised by the Descriptive report Indigenous children on the south coast of
Health Worker Journal Australia Aboriginal Students and Parents Association NSW (Katungal Aboriginal Medical Service)
200322 (N=72)
Adams et al. 200429 Victoria, Australia Describe the Gippsland Regional Indigenous Hearing Health Audit and evaluation of ear health Aboriginal children under 11 (N=126)
Program (GRIHPH) screen outcomes and management
Ayukawa et al. 201434 Quebec, Canada Describe the extent of hearing problems, some solutions Descriptive report N/A
adapted to the north, and the training and role of Inuit
hearing specialists.
Billard 201435 Quebec, Canada Describe the Hearing and Otitis Program (HOP), its model of Community-based model, descriptive N/A
service delivery, the roles of the different contributors to the report
program, the challenges and avenues to ensure community-
based aspects of the program are maintained.
Ching et al. 202023 Australia* Develop a parent-report measure to assess listening Co-design approach with AHW and Aboriginal and Torres Strait Islander families
behaviours of young Aboriginal and Torres Strait Islander early childhood teachers to develop with at least one child under six years of
children below six years of age to increase detection of the Parents’ Evaluation of Listening age (N=438)
hearing/listening problems. and Understanding Measure (PLUM)
listening skills questionnaire.
Clements 200524 Western Australia, Evaluate the Hearing Health Program which aims to improve Program evaluation Indigenous children in the Ipswich and West
Australia both the service delivery to clients and hearing health Moreton District
outcomes for the Aboriginal and Torres Strait islander
children in the Ipswich and West Moreton District.
Couzos et al. 200349 Australia* Compare the effectiveness of ototopical ciprofloxacin (0.3%; Community-controlled, community- Children aged less than 15 years with
CIP) with framycetin (0.5%), gramicidin, dexamethasone based, multicentre, double-blind, at least 2 weeks of otorrhoea and TM
(FGD) eardrops (5 drops twice daily for 9 days) together randomised controlled trial perforation were eligible for inclusion.
with povidone-iodine (0.5%) ear cleaning as treatments (N=111)
for chronic suppurative otitis media (CSOM) in Aboriginal
children.
Couzos et al. 200525 Australia* Describe methodological issues and principles that underpin Descriptive report of community- N/A
community-controlled health research and its practical controlled health research methods
application.
Doyle & Ristevski 201043 Western Australia, Understand health and education professionals’ perceptions Exploratory study with 25-item Health and education staff providing
Australia of the benefits and barriers of different ear health programs questionnaire with 9 closed and 16 services to children in kindergarten to year
used in lower primary school classes. open ended questions. three primary school classes. (N=61)
Durham et al. 201844 Queensland, Australia Identify which combination of activities, and at which level, Mixed Methods: Review of available Community leaders, educators, healthcare
hold the potential to facilitate systems changes to better documents/policies/frameworks, as workers and service providers involved
support ear health among Aboriginal and Torres Strait well as surveys and interviews in work with Aboriginal and Torres Strait
Islander children Islander children and families. (N=27)
Eikelboom et al. 20039 Western Australia, Gather feedback and evaluation from Aboriginal healthcare Pilot study and evaluation of tele- Students who were either completing the
Australia students undertaking a tele-ology course developed for otology course first year of their course or second year/
primary care providers. already practicing as health care workers.
(N=30)
Elliot et al. 201046 Queensland, Australia Determine the feasibility of integrating a mobile telehealth- Collaborative community Aboriginal and Torres Strait Islander children
enabled ear, hearing, and vision-screening service with intervention between 0 and 16 years, attending schools
existing community-based health services for Aboriginal and and day care centres in the South Burnett
Torres Strait Islander children in Australia. region of Queensland. (N=442)
Howard et al. 200638 Northern Territory, Identify the impacts of conductive hearing loss on family life Interviews Aboriginal Health Workers, Aboriginal
Australia mothers, nurses working in Aboriginal
communities. (N=10)
Hunter et al. 200742 Minnesota, United Determine hearing screening results of an American Indian Prospective cohort study Maternal eligibility criteria were: >16 years
States of America birth cohort old, American Indian (or infant’s father was
American Indian). (N=421)
Jacups et al. 201730 Western Australia, Review an innovative service provision model, developed by Surgical cohort audit Long term category 2 ENT surgical
Australia the regional Health and Hospital Service (HHS) which aimed waitlisted Indigenous children 0-15 were
to mitigate patient risk associated with long wait times for reviewed from referral data submitted to
ENT surgery, and present findings alongside the clinical and the regional referral hospital; each record
hearing outcomes of patients, as a quality assurance process was clinically assessed for inclusion in the
to inform the development of improved ENT services within surgical cohort. (N=16)
the region. Findings may be applicable to other Health
services faced with a backload of elective surgical waitlists
that routinely place patients at increased risk.
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608 Australian and New Zealand Journal of Public Health 2022 vol. 46 no. 5
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Indigenous Health Indigenous Health Workers’ role in ear health screening

Table 2 cont.: Characteristics of included studies.

Study Country Study Aim Methods for data collection and Participant characteristics and sample
analysis size
Jacups et al. 202051 Queensland, Australia (1) Outline primary health care clinicians’ current ENT Participatory action research; mixed- Clinicians and stakeholders with vested
concerns; (2) Gain ENT stakeholders’ perspectives in the methods study: primary health care interest in ear and hearing health service
current gaps and barriers to ENT services in the region; (3) (PHC) clinician’s survey, stakeholder delivery in Cape York. (N=37)
Make recommendations for a new ENT service model. discussion forum and follow-up
stakeholder survey
Jeffries-Stokes et al. 200439 Western Australia, Explore perceptions, knowledge and experience of otitis Qualitative applied research with a Community members of the Wongutha
Australia media (OM) and barriers to compliance with treatment holistic design of naturalistic enquiry, Aboriginal community in Kalgoorlie-
among Aboriginal people of the Kalgoorlie-Boulder area, analysed with grounded theory Boulder. (N=78)
Western Australia.
Kleindienst 201453 Alaska, United States Investigate (1) the value of combining tympanometry with Observational study Audiologists and otolaryngologists from
of America video otoscopy for otolaryngologists’ remote diagnoses of OM Alaskan health services. (N=11)
and (2) the reliability of on-site audiologists’ interpretation of
tympanometry compared to the off-site interpretation.
Kokesh et al. 200852 Alaska, United States Determine if video otoscope still images of the tympanic Comparative concordance, diagnostic Alaskan Native patients who had TT
of America membrane taken in remote clinics are comparable to an in- reliability placement in the prior two years. (N=35)
person microscopic examination for follow-up care.
Kong et al. 202155 Northern Territory, Improve the ear and hearing health of Aboriginal children Open cohort stepped-wedge cluster Communities in the Northern Territory.
Australia living in the Northern Territory. randomised superiority trial protocol.
Lehmann et al. 20086 Western Australia, (1) Identify important, avoidable risk factors for OM in Prospective cohort study Aboriginal and non-Aboriginal children born
Australia Aboriginal and non-Aboriginal children in the Kalgoorlie- in Kalgoorlie Regional Hospital. (N=280)
Boulder area of Western Australia; (2) to understand
how these risk factors arise and interact in the complex
causal pathways in order to develop effective intervention
strategies.
Lehmann et al. 200826 Western Australia, Report the burden of OM in Aboriginal as well as non- Cohort study Aboriginal and non-Aboriginal children born
Australia Aboriginal children aged <2 and assess the use of TEOAEs in in Kalgoorlie Regional Hospital. (N=280)
the first three months of life in predicting subsequent risk of
OM before age 2 years
Martin et al. 201731 Oregon, United States Determine the sustainability of a community-based noise- Analysis of records of ear testing Participants were 4th and 5th grade
of America induced hearing loss and tinnitus prevention program in carried out over a 6-year period in children and interested community
three different types of American Indian settings. three primary schools in Perth. members from three communities in
Oregon (N=200)
McCarthy 201036 New South Wales, Describe how the Royal Institute for Deaf and Blind Children Descriptive report N/A
Australia (RIDBC) Teleschool was adapted to increase uptake among
remote Indigenous communities.
McSwan et al. 200140 Queensland, Australia Reduce the incidence and effects of OM in two target Interviews People involved in program implementation
community; raise community awareness of OM over a year were recruited to participate in phone
(1997); raise teacher and child awareness of OM on children’s interviews or personal interviews (i.e.
learning; improve learning outcomes of children suffering principals, teaching aides, ACCHS workers).
from OM; have teachers develop strategies and materials to
reduce effects of children’s hearing loss; empower students
to exercise control over their learning; embed appropriate
practices in local communities; produce a kit of learning
materials and teacher resources for each school
Milera J & Elarde T. 201215 Australia* Provide an overview of the NACCHO Ear and Hearing Training Descriptive report (presentation – N/A
for the AHW Workforce Project grey literature)
Nguyen et al. 201550 Queensland, Australia Assess the cost-effectiveness of a supplemental mobile Cost-utility analysis Community members from Cherbourg,
telemedicine-enabled ear health screening and surveillance Queensland.
service for Indigenous children living in regional communities
compared with the existing outreach screening and surgical
service alone.
Pearce et al. 200947 Australia* Explore the feasibility of an alternative means of delivering Pilot program Individuals needing hearing aid fitting and
services tuning (N=5)
Rees et al. 20205 New South Wales, Present the development and implementation of the Hear Qualitative narrative of the Children accessing HoHEBP services
Australia our Heart Ear Bus Project (HoHEBP) within a regional city in development, implementation, and (N=1290) and directors of HoHEBP (N=3)
western NSW, Australia. Explore how the program supports refinement of the HoHEBP.
families of both Indigenous and non-Indigenous children
with OM.
Reeve et al. 201432 Western Australia, Reduce waiting lists for ENT specialist and improve primary Retrospective audit of medical School children in Aboriginal communities
Australia ear health care. records before and after in the Fitzroy Valley of Western Australia.
implementation of an ear health (N=858)
program
Robler et al. 202045 Alaska, United States Clearly describe how stakeholder/community involvement Community-engaged research, focus Community members and stakeholders
of America and participation influenced the design of this community groups within the healthcare and education sectors
randomized trial. (N=116)
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Table 2 cont.: Characteristics of included studies.

Study Country Study Aim Methods for data collection and Participant characteristics and sample
analysis size
Smith et al. 200648 Queensland, Australia Compare the accuracy of assessments made in the Pilot study of the accuracy of pre- Patients who attended outreach clinics at
conventional face-to-face (FTF) manner with assessments recorded video in ENT assessments a regional hospital in a central Queensland
made using pre-recorded information, i.e., history and video Indigenous community were invited to
recording of the ears, nose, face, and throat. participate (N=58)
Smith et al. 20127 Queensland, Australia Examine the outcomes of the first three years of operation of Retrospective review of service Children accessing school screening services.
the screening service. activity between January 2009 and (N=1053)
December 2011.
Smith et al. 20153 Queensland, Australia Examine whether there were changes in screening activity, Retrospective review of service Children accessing mobile ear screening
fail and referral rates over time. activity over a six-year period, from service in South Burnett. (N=3105)
Jan 2009–Dec 2014.
Stroud et al. 202037 Western Australia, This paper provides a historical perspective of the current Descriptive report N/A
Australia situation and discusses each of the recommendations
from Aboriginal Health Practitioners working within their
community.
Swift et al. 202027 Western Australia, Determine the prevalence and risk factors associated with Prospective cohort study Aboriginal children living in the South
Australia OM in Aboriginal infants residing in an urban area. Metropolitan Perth area, enrolled prior to 12
weeks of age. (N=125)
Walker et al. 201364 Western Australia, Explore health professionals’ views about Australian Interviews, thematic analysis Health professionals located across diverse
Australia Indigenous people’s health and the delivery of healthcare to regions in the Pilbara. (N=28)
them in the Pilbara region of Western Australia.
Williams et al. 200933 Western Australia, Describe diagnoses and correlates of middle ear disease in Retrospective review of service Aboriginal children accessing screening
Australia Aboriginal primary school children in a targeted school- activity between November 1998 - services in three urban primary schools.
testing program in Perth, Western Australia November 2004 (N=119)
Young et al. 201628 New South Wales, Describe and evaluate Hearing EAr health and Language Case-study with mixed-methods All patients accessing services during
Australia Services (HEALS), a New South Wales (NSW) health initiative evaluation (service delivery the study period were included in the
implemented in 2013 and 2014 as a model for enhanced data audit and semi-structured audit. (N=653). Caregivers of children
clinical services arising from Aboriginal health research. interviews) who received services and health service
professionals were invited to partake in
interviews. (N=38)
Young et al. 201741 New South Wales, Describe stakeholder perspectives on the structure and Interviews, thematic analysis Workers from partnering ACCHS as well
Australia processes of the HEALS programme that led to the improved as parents/caregivers of children who
access to specialist health services for Aboriginal families participated in HEALS. (N=37)
Note:
Where * indicates multiple sites

the research project and participation in rather they were asked about the impact of and confidence among participants.15
research (Supplementary File 6). In terms of hearing loss on family life, perceptions of Due to the limited data available from
service delivery, IHWs were most commonly OM among communities, and to evaluate IHWs’ perspectives, the reviewers sought
responsible for the delivery of ear screening training or screening programs. Further, in to understand the role of Indigenous
programs.3,5,7,22,24,25,28,29,32,33,35,46,47,49,50,52 IHWs seven out of nine studies that included IHWs researchers in the field of ear and hearing
also acted as a liaison between community as participants, IHWs did not constitute the health by determining, where possible,
members and audiology programs,30,35,36 majority of respondents and the respondents’ the Indigenous status of authors across
coordinated referrals and follow-ups,32,46 Indigenous status was not clarified, making the included studies. Of the 174 authors of
delivered ear health education24,31 and it impossible to determine which data sources included in this review, 43 authors
assisted families in the coordination of reflected IHW perspectives.28,38-41,43,51 Four were confirmed as identifying as Indigenous,
appointments and accommodation.22,36 Four studies funded positions for IHWs in order 124 were confirmed as non-Indigenous, and
studies provided service delivery training to minimise the burden of research on seven were not able to be verified either
to IHWs, including OM diagnosis, video- community health services and provide an way. Of the 43 Indigenous authors, 18 were
otoscopy, tympanometry and telehealth opportunity for the professional development confirmed as either current or former IHWs.
software34,52,54,55; two studies provided of the health workers.25,28,46,54 Further, 23 out of 40 (57.5%) authorship
research training including research skills, None of the included studies reported teams had at least one Indigenous author.
evidence-based management of OM and asking IHWs about their perspectives on the To further explore the role of Indigenous
data collection.6,54 IHWs contributed to the implementation of ear screening in their communities in the included projects, the
development and design of two research communities, therefore, a meta-synthesis of reviewers examined the acknowledgement
projects23,37 and assisted with research IHW perspectives was not possible. One grey sections of the included publications.
coordination in six studies.6,25,27,39,46,54 literature report on the outcome of a national Twenty-three authorship teams expressed
While nine studies included IHWs as training program for IHWs in Australia was gratitude for the support of Indigenous
participants,9,28,38-41,43,44,51 these studies the only source to include quotations from communities, organisations, health services,
did not ask the IHWs about their specific IHWs reflecting on the success of the program or IHWs3,6,7,23,25-29,31-33,35,39,41,42,45,46,49,51,53-55;
involvement in ear health programming, in strengthening ear health screening skills eight authorship teams did not mention

610 Australian and New Zealand Journal of Public Health 2022 vol. 46 no. 5
© 2022 The Authors
Indigenous Health Indigenous Health Workers’ role in ear health screening

Indigenous organisations5,9,30,34,43,44,47,48 the papers included herein all referenced and contribution to studies and screening
and nine publications did not have an IHWs, there was limited involvement across programs would benefit other programs.56
acknowledgements section.15,22,24,33,36,38,40,50,52 the entirety of research programs and in
leadership roles. Limitations
Discussion IHWs provide a variety of health services, from The majority of the publications included
community prevention to primary, secondary in this review were from Australia (N=33),
This review identified 40 studies where the and tertiary care for Indigenous communities which may be partially due to the focus on
involvement of IHWs workers was discussed and are becoming an increasingly qualified Australian contexts in the grey literature
in relation to ear health screening programs workforce.11,58 Dickinson59 has described search; this explains the frequent use of
for Indigenous children in Australia, Canada, the seamless connection between the the terminology Aboriginal Health Worker,
New Zealand and the US. However, none of professional and personal roles of IHWs in or AHW, as this is the commonly used
these studies reported IHW perspectives on their communities. While often challenging, terminology in Australia.63 The systematic
their role in the delivery of ear and hearing IHWs explain navigating their visibility search did not identify any articles from
health programming for Indigenous children. and availability as a health worker in their New Zealand eligible for inclusion in this
Nevertheless, these studies highlight the community as necessary to providing review, highlighting a limited evidence base
importance of IHWs in the delivery of quality care; a responsibility described regarding IHW involvement in ear screening
culturally safe ear health programming and by IHWs as poorly understood by their in New Zealand. Further, the systematic
emphasise the critical role of community non-Indigenous colleagues.60 This is search identified few non-research programs;
collaboration in ensuring the success of one example of the many idiosyncrasies it is likely that IHW involvement in ear
preventive ear health and screening services. between Indigenous health paradigms and screening is therefore understated. Seven of
a dominant culture’s understandings of the 40 studies included in this review did not
Summary of evidence health, which stress the fundamental role of undergo quality appraisal from an Indigenous
IHWs in matters of Indigenous health. The perspective because the tool used to perform
This review highlights the need to prioritise
Australian Government has acknowledged
IHW involvement and leadership in the appraisal is specific to publications related to
the significance of IHWs for Indigenous
delivery of ear and hearing health programs Aboriginal and Torres Strait Islander Peoples,
health and as such, has allocated funds for
and provides the necessary evidence base for that is, the Australian context. In addition, the
the expansion of services offered by IHWs,
future research in this area. Multiple benefits quality appraisal tool21 used for evaluation
including programs to address avoidable
would come from a culturally responsive and herein was published after the majority of
deafness.61 To ensure targeted and strategic
reflexive approach to ear and hearing health the studies included in this review. As such,
use of Indigenous healthcare budgets,
for Indigenous communities that emphasises items included in the appraisal tool may have
the work, treatment, utilisation, workforce
the need for changed service delivery been considered during the establishment,
integration and leadership of IHWs must be
models to include Indigenous leadership development and conduct of the various
centred in discussions of Indigenous health
opportunities, flattened hierarchies, cultural studies but may not have been reported in
priorities and related budgetary allocation.
training for non-Indigenous specialists and the published studies. As such, in this review,
The Centre of Research Excellence in Ear
adequate support for IHWs involved in ear we can only recognise that studies did not
and Hearing Health of Aboriginal and Torres
and hearing health programming. First report on aspects related to Indigenous
Strait Islander Children (CRE ICHEAR) has
and foremost, ensuring IHWs have direct community involvement. Furthermore,
similarly called for the need to prioritise
input into the development, delivery and despite best efforts to include all relevant
Indigenous leadership in ear health programs
evaluation of ear health screening programs terms for IHWs, there is no uniform definition
and research projects to ensure Indigenous
through the establishment of leadership leadership in the future.37 Ongoing of IHW across the countries included in our
roles in this area will ensure cultural safety programming should publicly report search, and as such, some works may have
of ear and hearing health programs and will information about Indigenous involvement been missed. Finally, despite contacting the
improve the quality of care for patients.13 in service provision to enable a more primary authors of included papers, we were
Additionally, IHWs are well placed to comprehensive understanding of current unable to confirm the Indigenous status of
identify the strengths and limitations of ear efforts in Indigenous ear health; reporting seven authors and therefore, Indigenous
screening programs and have the capacity and measuring progress on targets is part representation on authorship teams may be
to raise awareness of ear disease among of the national Closing the Gap agreement underreported.
Indigenous communities.56 IHWs must be in Australia.62 Despite the established
central in the development, implementation, importance of IHWs as core members of the Conclusions
delivery, evaluation and enhancement of healthcare team,10 papers included in this
ear and hearing health services; this level of review provided limited opportunities for Ear and hearing health research and
involvement is necessary to achieve increased IHWs to express their opinions regarding programming must prioritise Indigenous
screening and, therefore, improved ear ear health services. Most of the included leadership. Specialist healthcare and
health for Indigenous children.57 Similar to studies adequately described the role and research teams supporting ear and hearing
findings from O’Donovan and colleagues’ capacity of IHWs in ear and hearing health health service delivery for Indigenous
review of community health workers’ roles screening; however, providing a more in- children must shift professionally, culturally
in ear disease, few of the included studies depth discussion of the process of Indigenous and institutionally to enable this needed
demonstrated long-term results.56 While community and health worker engagement transformation. This includes investing in

2022 vol. 46 no. 5 Australian and New Zealand Journal of Public Health 611
© 2022 The Authors
Poirier et al. Article

cultural safety training for non-Indigenous 14. Stajic J. … but what about the Aboriginal and/or Torres 33. Williams CJ, Coates HL, Pascoe EM, Axford Y, Nannup
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Supporting Information
Additional supporting information may be
found in the online version of this article:
Supplementary File 1: Note on Terminology.
Supplementary File 2: Preferred Reporting
Items for Systematic reviews and Meta-
Analyses extension for Scoping Reviews
(PRISMA-ScR) Checklist.
Supplementary File 3: Search strategy.
Supplementary File 4: Inter-rater reliability
score.
Supplementary File 5: IHW Terminology.

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