Otitis media is one of the leading causes of preventable disease amongst Aboriginal and Torres Strait Islander children, and has been determined by The World Health Organisation to be a serious public health issue requiring urgent attention.1-3,11 OM occurs primarily during developmental years and can drastically impact upon speech and language development, which is likely to influence educational outcomes and prospective employability- precursors to potentially life-long socioeconomic disadvantage and poverty.5
This study identifies how social determinants are addressed within grey and peer-reviewed literature, and summarises the primary determinants of OM and management recommendations within the literature. This study highlights gaps between drivers of OM and recommended interventions within the literature. Given the significance of the gap in the literature, further research aimed at identifying more effective management of the social determinants of OM within Aboriginal children is warranted. Furthermore, the inter-related nature of the social determinants of health is emphasised throughout this paper and helps to underline the challenge that an exclusively biomedical model poses in addressing specific aetiology.19(p73-74)
Notably, a shift in ways to manage OM in Aboriginal populations is desperately needed. This review demonstrates that there is an unbalanced research focus towards medical interventions in contrast to developing an understanding of how to address key social determinants driving high rates of OM in Aboriginal children in Australia. Using the social determinants of health framework, this review has identified significant shortcomings in the literature and the current public health management of OM in Aboriginal children in Australia. The social determinants of health framework used within this study identifies three key areas of Aboriginal health that are largely neglected by the available grey and peer-reviewed literature in relation to OM management. Although the literature mentions various social determinants that are consistent with the framework (e.g. housing, education, employment, community engagement, culture and history), none of the included articles evaluated these key areas of Aboriginal health with the objective to establish effective sociodemographic or environmental-focussed interventions for OM. Further, the key social determinants of OM can be argued to stem from the persistent social, economic and cultural discrimination experienced by Aboriginal populations in Australia. Using the social determinants of health framework, this review highlights the need to preserve Aboriginal culture, strengthen Aboriginal self-determination, respect and support Aboriginal connection to land, empower Aboriginal communities, improve education and employment opportunities for Aboriginal people, and address poor housing conditions and overcrowding within Aboriginal communities. Such an approach is needed to help eliminate the cycle of disadvantage that contributes to the social determinants driving ill-health and OM in Aboriginal children in Australia.
Housing-related determinants were reported almost three times more than the next most frequently reported risk factor. Despite acknowledgement of the association between housing and the prevalence of OM in Aboriginal children, there were no intervention studies within the literature that investigated how to effectively address the issue of housing in Aboriginal populations. Despite the fact exposure to cigarette smoke and poor hygiene were not acknowledged as being directly related to housing within this review, these risk factors are likely to be influenced to some degree by the home environment, given the high rates of smoking within the home.15,16 It is evident that addressing the home environment is fundamental to adequately manage OM in Aboriginal populations. Moreover, further research into housing as a determinant of OM and as a means for intervention is desperately needed, given the lack of information available to adequately deal with this facet of Aboriginal health.
Addressing housing issues in Aboriginal communities is a complex issue, particularly when considering the importance of connection to land in contrast with the importance of the physical structure itself. It can be said that the efforts of government housing programmes have been heavily focussed on the logistics. For example, funding and physical infrastructure, with little acknowledgement of the need to develop culturally appropriate housing policies and pathways.20(p207) Carson et al20(p219) stress the lack of intervention studies that link housing to Aboriginal health outcomes and the ability to develop policy is limited as a result. The lack of intervention studies is also highlighted by this review, as no intervention studies looking at social determinants and Aboriginal health outcomes were identified within the literature. Intervention studies are crucial for policy development and although remoteness, and political and social barriers exist for improving housing and infrastructure in Aboriginal communities,20 a shift in focus towards more culturally appropriate housing policy and provision is urgently needed.
Exposure to tobacco smoke is a major contributing factor for Aboriginal children developing OM. Aboriginal children who are exposed to tobacco smoke in the home and who do not attend day-care are at the greatest risk of developing otitis media.18 This is not to say that home-care by parents and family is problematic, however given the high rates of smoking within the home environment,18 it is a particularly important issue for consideration for Aboriginal populations. Jacoby et al18 indicate that children who are exposed to tobacco smoke in the home who also attend day-care are at a lower risk of developing OM, presumably because the time spent at day-care means less time exposed to tobacco smoke in the home. Therefore, day-care attendance may be a protective factor for Aboriginal children developing OM, specifically for those children who are exposed to tobacco smoke in the home. It is important to note, that day-care attendance has previously been associated with a greater risk of OM, and further research may help to explain this relationship. Given the influence exposure to tobacco smoke has on the risk of developing OM, creating greater awareness and developing policy aimed at cigarette prevention initiatives may help to reduce the prevalence of OM within Aboriginal populations.
Education and employment of the primary caregiver is an important determinant for Aboriginal children developing OM. However, no paper within the reviewed literature discussed this any further than listing it as a significant contributing factor. It is important to highlight that low-level education and lack of employment opportunities consign many Aboriginal and Torres Strait Islander people to levels of poverty.21(p108) Furthermore, education that excludes culture and native language has been demonstrated to adversely impact individuals by disempowering Aboriginal communities and harming the cultural identity of these communities.20 Therefore, greater effort to provide culturally relevant schooling is more likely to lead to both improved educational and health outcomes in comparison to efforts aimed at improving attendance rates for Aboriginal students in a westernised schooling system.20 This highlights the need for a shift in research and policy development that focusses on engaging Aboriginal communities in the delivery of culturally appropriate schooling.
Aboriginal community involvement is an area that requires greater emphasis and encouragement from public health promoters, policy makers and service providers. Programmes such as the ‘Healthy Ears, Happy Kids’,9 'Aboriginal Otitis Media Project',22 and ‘Hearing and Ear Health and Language Services’ (HEALS)23 help to draw attention from government and non-government organisations towards the seriousness of the burden OM in Aboriginal communities in Australia. Furthermore, these programmes have been shown to help educate and empower Aboriginal communities and health workers to manage OM more effective and culturally safe way.9,22-23 Given the historical marginalisation, neglect and subjugation of Aboriginal populations in Australia, empowering Aboriginal communities to manage health services, develop and implement research, and provide recommendations is essential to overcome issues of mistrust, and consequently, improve cultural access to essential services.
Evaluation of recommendations and advice for OM management within the literature shows that there is a significant focus on analysing OM associated bacterial carriage in Aboriginal children, and this focus is being driven by the desire to develop more effective antibiotics and vaccines. It is important to note that this type of approach has been the focus of the majority of research for a number of years with no significant improvement seen in the rates of OM in Aboriginal children, as identified by this review. Therefore, a lack of adequate recommendation regarding the management of OM in Aboriginal children within the literature is evident. This is highlighted by the failure to identify how to effectively manage the principal drivers of OM, which include poverty, overcrowded housing, poor housing conditions and exposure to tobacco smoke.
While this review presented a comprehensive analysis of both peer-reviewed and grey literature, this study excluded unpublished masters and doctoral theses. Despite this, findings by Vickers and Smith24 following review of the Cochrane Library, found only one of 878 systematic reviews included data from theses that could have significantly altered the conclusions of the 878 reviews. Moreover, there is limited benefit of including theses in systematic reviews, as they rarely influence the conclusions, and retrieving and analysing unpublished dissertations involves considerable time and effort.24 The timeframe of this project also limited the number of selected databases and consequently the number of papers that were included within the study. However, 50 articles still provides comprehensive scope of the literature to enable thorough analysis, detailed explanation and well supported recommendations. Using Google Scholar presented limitations in search function, as search box options within the database meant that a modified search was needed to fulfil the specified search strategy and to remain consistent with searches performed on the other selected databases.