Professor Kelvin Kong

Objectives: To explore the views of parents and carers regarding the management of acute otitis media in urban Aboriginal and Torres Strait Islander children who are at low risk of complications living in urban communities. Study design: Qualitative study; semi-structured interviews and short telephone survey. Setting, participants: Interviews: purposive sample of parents and carers of urban Aboriginal and Torres Strait Islander children (18 months ¿ 16 years old) screened in Aboriginal medical services in Queensland, New South Wales, and Canberra for the WATCH study, a randomised controlled trial that compared immediate antibiotic therapy with watchful waiting for Aboriginal and Torres Strait Islander children with acute otitis media. Survey: parents and carers recruited for the WATCH trial who had completed week two WATCH surveys. Results: We interviewed twenty-two parents and carers, including ten who had declined participation in or whose children were ineligible for the WATCH trial. Some interviewees preferred antibiotics for managing acute otitis media, others preferred watchful waiting, expressing concerns about side effects and reduced efficacy with overuse of antibiotics. Factors that influenced this preference included the severity, duration, and recurrence of infection, and knowledge about management gained during the trial and from personal and often multigenerational experience of ear disease. Participants highlighted the importance of shared decision making by parents and carers and their doctors. Parents and carers of 165 of 262 WATCH participants completed telephone surveys (63%); 81 were undecided about whether antibiotics should always be used for treating acute otitis media. Open-ended responses indicated that antibiotic use should be determined by clinical need, support for general practitioners' decisions, and the view that some general practitioners prescribed antibiotics too often. Conclusions: Parents and carers are key partners in managing acute otitis media in urban Aboriginal and Torres Strait Islander children. Our findings support shared decision making informed by the experience of parents and carers, which could also lead to reduced antibiotic use for managing acute otitis media.

Objective: This review aims to quantify the pooled functional gain (FG) in different types of hearing loss with the transcutaneous hearing device, Osia (Cochlear, Sydney, Australia) in comparison with the unaided state. Secondary outcomes are patient-reported outcomes measures (PROMs) and complication rates. Data Sources: Medline, Embase, SCOPUS, Cochrane CENTRAL, PROSPERO and Cochrane Library. Review Methods: Systematic review and meta-analysis of indexed search terms relating to "Osia," "Osseointegration," "Cochlear Implant," and "Bone-Anchored Prosthesis" was performed from database inception to September 20, 2022. Results: Of the 168 studies identified, 14 studies with 15 patient cohorts (n = 314) met inclusion criteria for meta-analysis. Pooled overall mean FG for all types of hearing loss was 35.0 dB sound pressure level (SPL) (95% confidence interval [CI] 29.12¿40.97) compared against unaided hearing. Pooled FG for conductive/mixed hearing loss was 37.7 dB SPL (95% CI 26.1¿49.3). Pooled single-sided deafness (SSD) FG could not be calculated due to the small patient cohort for whom SSD data was reported. There is a trend toward improvements in speech receptiveness threshold, signal to noise ratio, and some PROMs compared with baseline hearing. Early complication rates demonstrate risks similar to other transcutaneous implants, with a low predicted explantation (0.11%, 95% CI 0.00%¿1.90%) and wound infection rate (1.92% [95% CI 0.00%¿6.17%]). No articles directly comparing transcutaneous devices were identified. Conclusion: The Osia devices demonstrate clear audiologic benefits and a good safety profile for the included patient population. Our study results indicate that frequency-specific gain, PROMs, and the audiological benefit in single-sided deafness may be areas for future prospective research. Laryngoscope, 134:1531¿1539, 2024.

Objective: To summarise the published research evidence on the epidemiology of otitis media, including the risk factors and sequelae associated with this condition. Data sources: Medline (PubMed), Embase, and the Cochrane Library covering the period from 2019 to June 1st, 2023. Review methods: We conducted a broad search strategy using otitis [Medical Subject Heading] combined with text words to identify relevant articles on the prevalence, incidence, risk factors, complications, and sequelae for acute otitis media, otitis media with effusion, and chronic suppurative otitis media. At least one review author independently screened titles and abstracts of the retrieved records for each condition to determine whether the research study was eligible for inclusion. Any discrepancies were resolved by reviewing the full text followed by discussion with a second review author. Studies with more than 100 participants were prioritised. Results: Over 2,000 papers on otitis media (OM) have been published since 2019. Our review has highlighted around 100 of these publications. While the amount of otitis media research on the Medline database published each year has not increased, there has been an increase in epidemiological studies using routinely collected data and systematic review methodology. Most of the large incidence studies have addressed acute otitis media (AOM) in children. Several studies have described a decrease in incidence of AOM after the introduction of conjugate PCV vaccines. Similarly, a decrease was noted when rates of coronavirus disease of 2019 (COVID-19) were high and there were major public health efforts to reduce the spread of infection. There have been new studies on OM in adults and OM prevalence in a broader range of countries and population subgroups. Conclusion: Overall, the rates of severe and/or suppurative OM appeared to be decreasing. However, there is substantial heterogeneity between populations. While better use of available data is informative, it can be difficult to predict rates of severe disease without accurate examination findings. Most memorably, the COVID-19 pandemic had an enormous impact on the research and clinical services for otitis media for most of the period under review. Implications for practice: The use of routinely collected data for epidemiological studies will lead to greater variability in the definitions and diagnostic criteria used. The impact of new vaccines will continue to be important. Some of the lessons learned during the COVID-19 pandemic concerning behaviours that reduce spread of respiratory viruses can hopefully be used to decrease the burden of otitis media in the future. There are still many countries in the world where the burden of otitis media is not well described. In countries where otitis media has been studied over many years, new potential risk factors continue to be identified. In addition, a better understanding of the disease in specific subgroups has been achieved.

Objective: To investigate the incidence and timing of postoperative haemorrhage between intracapsular (ICT) and extracapsular tonsillectomy (ECT) techniques and evaluate factors influencing haemorrhage risk and severity. Methods: A retrospective review of patients undergoing tonsillectomy over 5 years across otolaryngology services in Australia and New Zealand. Primary outcomes were rate and timing of post-tonsillectomy haemorrhage. Results: A total of 12,275 patients were included in this study. The overall post-tonsillectomy bleed rate was 3.3 %, with 0.65 % requiring return to theatre. ICT had a significantly lower bleed rate of 1.7 % compared to 4.1 % for ECT (p < 0.001). The rate of return to theatre was markedly lower for ICT (0.08 %) compared to ECT (0.93 %, p < 0.001). Median day of bleeding was not different between the techniques. Patients undergoing surgery for recurrent tonsillitis had the highest rate of postoperative haemorrhage (15 %), while those with sleep-disordered breathing alone had the lowest (3 %, p < 0.001). Conclusion: ICT results in significantly lower rates of postoperative haemorrhage and need for surgical intervention compared to ECT. This was most pronounced in paediatric patients with sleep-disordered breathing. ICT may be considered a preferable option for certain patient groups, especially younger children with sleep-disordered breathing, though more evidence is needed to confirm its efficacy and safety in patients with recurrent tonsillitis.

Background: Early detection of long-term, often asymptomatic, middle ear infection in young Aboriginal and Torres Strait Islander children is more likely to be achieved when ear health and hearing checks are routinely undertaken in primary healthcare. Evidence consistently demonstrates the adverse impacts of this condition on the development and wellbeing of children and their families. We aimed to develop feasible, evidence- and consensus-based primary healthcare recommendations addressing the components and timing of ear health and hearing checks for Aboriginal and Torres Strait Islander children aged under 6 years, not already known to have, nor being actively managed for, ear and hearing problems. Methods: A 22-person working group comprising Aboriginal and Torres Strait Islander and non-Indigenous members from the primary healthcare, ear, hearing, and research sectors provided guidance of the project. A systematic scoping review addressed research questions relating to primary health ear health and hearing checks for Aboriginal and Torres Strait Islander and other populations at increased risk of persistent ear health problems. Twelve primary studies and eleven guidelines published between 1998 and 2020 were identified and reviewed. Quality and certainty of evidence and risk of bias ratings were completed for studies and guidelines. In the absence of certain and direct evidence, findings and draft recommendations were presented for consensus input to a 79-member expert panel using a modified e-Delphi process. Recommendations were finalised in consultation with working group members and presented to expert panel members for input on considerations relating to implementation. Results: Overall, the quality, certainty, and directness of evidence in the studies and guidelines reviewed was low. However, the findings provided a basis and structure for the draft recommendations presented during the consensus-building process. After two e-Delphi rounds, seven goals and eight recommendations on the components and timing of Ear Health and Hearing Checks in primary healthcare for young Aboriginal and Torres Strait Islander children were developed. Conclusions: The systematic scoping review and consensus-building process provided a pragmatic approach for producing strong recommendations within a reasonably short timeframe, despite the low quality and certainty of evidence, and paucity of studies pertaining to primary healthcare settings.

Background: Paediatric tracheostomies are complex undertakings for both clinicians and the patient's families, requiring a high level of support from staff, parents and carers for ongoing management. Our study aimed to establish the current trends in the management of paediatric tracheostomies in Australia and New Zealand and identify potential areas of improvement that need to be addressed in order to improve the delivery of care to children with tracheostomies and their families. Methods: A cross-sectional survey was sent to all members of the Australia and New Zealand Society of Paediatric Otorhinolaryngology (ANZSPO). The survey encompassed various aspect of paediatric tracheostomy care including pre-operative preparation, postoperative care, emergency protocols, outpatient practices and long term care. Results: Of the 26 respondents, the majority (57.7%) worked at institutions where >10 paediatric tracheostomies were performed each year. Less than half (46.2%) routinely held a multi-disciplinary team (MDT) meeting prior to tracheostomy placement and less than half (42.3%) offered to connect patients and their families with a tracheostomised patient prior to surgery. All respondents (100%) used a standardised postoperative care protocol and the majority (84.6%) utilised a bedside safety card. Less than a quarter of surgeons (23.1%) conducted weekly multidisciplinary reviews of paediatric patients following insertion of the tracheostomy. The majority (76.9%) required a minimum of two carers to be trained prior to discharge. Most surgeons (80.8%) reported that their institution provided a tracheostomy "Go-Bag" with emergency supplies, while over half (57.7%) also provided a carer emergency card. The majority (76.9%) recommended routine weekly changes of tracheotomy tubes. Most surgeons (53.8%) performed laryngotracheobronchoscopies only when indicated by clinical concerns, rather than for routine surveillance reasons. Conclusions: Our study highlights the ongoing variability in the management of paediatric tracheostomies across Australia and New Zealand, especially in relation to the utilisation of the multidisciplinary model of care and the preparation of patients and families for ongoing management of the tracheostomy. These inconsistencies represent areas that warrant further review in order to develop improved models-of-care to better serve the needs of paediatric patients with tracheostomies and their families.

Introduction: Cochlear implantation (CI) is generally accepted as having a low rate of postoperative complications, but between 9.3% and 13% of cases experience vertigo postoperatively. This study aimed to examine patient, surgical, and device factors contributing toward the risk of postoperative vertigo. Methodology: A retrospective review was conducted of adult patients who underwent cochlear implant in a regional area of New South Wales from 2007 to 2018. A total of 395 cochlear implant cases were included in the final study. Results: The overall incidence of vertigo at 3 months of follow-up was 7.1% (n = 28/395). No difference was identified in this study between rates of postoperative vertigo between device factors, including implant make (Cochlear vs. Med-El), electrode shape (perimodiolar vs. straight), and electrode model. No significant difference was found also for surgical factors such as the number of electrode rings inserted, side of implantation, or surgical approach of tympanic ramp (round window insertion vs. cochleostomy). A higher percentage of patients with preoperative vertigo experienced vertigo postoperatively (18.4%, n = 7/38), compared with the population without preoperative vertigo (6.0%, n = 21/352) (p = 0.005). Patients with previous mastoid surgery also reported a higher rate of postoperative vertigo (20%, n = 9/45) compared with those who had not had mastoid surgery (5.43%, n = 19/ 350) (p = 0.006). The mean age of patients experiencing postoperative vertigo was higher than the population without postoperative symptoms (67 vs. 63). Conclusion: This study of a large multicenter population outlines that patient factors are more critical than surgical or device factors when considering risk factors for vertigo post-cochlear implant.

Background Aboriginal and Torres Strait Islander children experience a high burden of otitis media. We collected data on symptoms associated with acute otitis media (AOM) in a clinical trial involving children receiving primary care at urban Aboriginal Medical Services. Two scales were employed to monitor symptoms over time: the AOM-Severity of Symptoms scale (AOM-SOS) and the AOM-Faces Scale (AOM-FS). This study took place at a mid-point of the un-blinded trial. Methods We examined symptoms at enrolment and day 7, and compared the scales for trends, and bivariate correlation (Spearman's rho) over 14 days. Responsiveness of the scales to clinical change was determined by Friedman's test of trend in two subgroups stratified by day 7 AOM status. We interviewed parents/carers and research officers regarding their experience of the scales and analysed data thematically. Results Data derived from 224 children (18 months to 16 years; median 3.6 years). Common symptoms associated with AOM at baseline were runny nose (40%), cough (38%) and irritability (36%). More than one third had no or minimal symptoms at baseline according to AOM-SOS (1-2/10) and AOM-FS scores (1-2/7). The scales performed similarly, and were moderately correlated, at all study points. Although scores decreased from day 0 to 14, trends and mean scores were the same whether AOM was persistent or resolved at day 7. Users preferred the simplicity of the AOM-FS but encountered challenges when interpreting it. Conclusion We found minimally symptomatic AOM was common among Aboriginal and Torres Strait Islander children in urban settings. The AOM-SOS and AOM-FS functioned similarly. However, it is likely the scales measured concurrent symptoms related to upper respiratory tract infections, given they did not differentiate children with persistent or resolved AOM based on stringent diagnostic criteria. This appears to limit the research and clinical value of the scales in monitoring AOM treatment among Aboriginal and Torres Strait Islander children.

Introduction: Cochlear implantation (CI) is generally accepted as having a low rate of postoperative complications, but between 9.3% and 13% of cases experience vertigo postoperatively. This study aimed to examine patient, surgical, and device factors contributing toward the risk of postoperative vertigo. Methodology: A retrospective review was conducted of adult patients who underwent cochlear implant in a regional area of New South Wales from 2007 to 2018. A total of 395 cochlear implant cases were included in the final study. Results: The overall incidence of vertigo at 3 months of follow-up was 7.1% (n = 28/395). No difference was identified in this study between rates of postoperative vertigo between device factors, including implant make (Cochlear vs. Med-El), electrode shape (perimodiolar vs. straight), and electrode model. No significant difference was found also for surgical factors such as the number of electrode rings inserted, side of implantation, or surgical approach of tympanic ramp (round window insertion vs. cochleostomy). A higher percentage of patients with preoperative vertigo experienced vertigo postoperatively (18.4%, n = 7/38), compared with the population without preoperative vertigo (6.0%, n = 21/352) (p = 0.005). Patients with previous mastoid surgery also reported a higher rate of postoperative vertigo (20%, n = 9/45) compared with those who had not had mastoid surgery (5.43%, n = 19/ 350) (p = 0.006). The mean age of patients experiencing postoperative vertigo was higher than the population without postoperative symptoms (67 vs. 63). Conclusion: This study of a large multicenter population outlines that patient factors are more critical than surgical or device factors when considering risk factors for vertigo post-cochlear implant.

Introduction: Telehealth programs are important to deliver otolaryngology services for Aboriginal and Torres Strait Islander children living in rural and remote areas, where distance and access to specialists is a critical factor. Objective: To evaluate the inter-rater agreement and value of increasing levels of clinical data (otoscopy with or without audiometry and in-field nurse impressions) to diagnose otitis media using a telehealth approach. Design: Blinded, inter-rater reliability study. Setting: Ear health and hearing assessments collected from a statewide telehealth program for Indigenous children living in rural and remote areas of Queensland, Australia. Participants: Thirteen board-certified otolaryngologists independently reviewed 80 telehealth assessments from 65 Indigenous children (mean age 5.7 ± 3.1 years, 33.8% female). Interventions: Raters were provided increasing tiers of clinical data to assess concordance to the reference standard diagnosis: Tier A) otoscopic images alone, Tier B) otoscopic images plus tympanometry and category of hearing loss, and Tier C) as B plus static compliance, canal volume, pure-tone audiometry, and nurse impressions (otoscopic findings and presumed diagnosis). For each tier, raters were asked to determine which of the four diagnostic categories applied: normal aerated ear, acute otitis media (AOM), otitis media with effusion (OME), and chronic otitis media (COM). Main outcome measures: Proportion of agreement to the reference standard, prevalence-and-bias adjusted ¿ coefficients, mean difference in accuracy estimates between each tier of clinical data. Results: Accuracy between raters and the reference standard increased with increased provision of clinical data (Tier A: 65% (95%CI: 63¿68%), ¿ = 0.53 (95%CI: 0.48¿0.57); Tier B: 77% (95%CI: 74¿79%), 0.68 (95%CI: 0.65¿0.72); C: 85% (95%CI: 82¿87%), 0.79 (95%CI: 0.76¿0.82)). Classification accuracy significantly improved between Tier A to B (mean difference:12%, p < 0.001) and between Tier B to C (mean difference: 8%, p < 0.001). The largest improvement in classification accuracy was observed between Tier A and C (mean difference: 20%, p < 0.001). Inter-rater agreement similarly improved with increasing provision of clinical data. Conclusions: There is substantial agreement between otolaryngologists to diagnose ear disease using electronically stored clinical data collected from telehealth assessments. The addition of audiometry, tympanometry and nurse impressions significantly improved expert accuracy and inter-rater agreement, compared to reviewing otoscopic images alone.

Objective: Evaluate ear health and hearing among urban Aboriginal children and quantify relationships with child, family and social factors. Methods: Baseline questionnaire and ear health examinations from 1430 children with diagnoses (0.5-18 years) attending Aboriginal Health Services enrolled in SEARCH. Ear health outcomes were Otitis Media (OM), and hearing loss (three-frequency average hearing loss >20dB) diagnosed using pneumatic otoscopy, tympanometry, and audiometry. Results: Half the children 0.5-3 years had OM (51.5%, 136/264). One third 0.5-18 years (30.4%; 435/1430) had OM, including 1.8% (26/1430) with perforation (0.8% chronic suppurative OM, 0.6% dry perforation and 0.4% acute OM with perforation). One quarter 0.5-18 years (25.7%; 279/1087) had hearing loss; 12.4% unilateral, 13.2% bilateral (70.6% with bilateral loss had concurrent OM). OM was associated with: younger age (0.5-<3 years versus 6-18 years) age-sex-site; adjusted prevalence ratio (aPR)=2.64, 95%, 2.18-3.19); attending childcare/preschool (aPR=1.24, 95%CI, 1.04-1.49); foster care (aPR=1.40, 95%CI, 1.10-1.79); previous ear infection/s (aPR=1.68, 95%CI, 1.42-1.98); and =2 people/bedroom (aPR=1.66, 95%CI, 1.24-2.21). Hearing impairment was associated with younger age (0.5-<6 years vs. =6 years aPR=1.89, 95%CI, 1.40-2.55) and previous ear infection (aPR=1.87, 95%CI, 1.31-2.68). Conclusions: Half the urban Aboriginal children in this cohort had OM and two-thirds with hearing impairment had OM. Implications for Public Health: Findings highlight importance of early detection and support for ear health, particularly in pre-school-aged children with risk factors.

Background: In the Northern Territory (NT) the prevalence of otitis media (OM) in young Aboriginal children living in remote communities has persisted at around 90% over the last few decades. OM-associated hearing loss can cause developmental delay and adversely impact life course trajectories. This study examined the 5-year trends in OM prevalence and quality of ear health services in remote NT communities. Methods: A retrospective analysis was performed on de-identified clinical data for 50 remote clinics managed by the NT Government. We report a 6-monthly cascade analysis of the proportions of children 0¿16¿years of age receiving local guideline recommendations for surveillance, OM treatment and follow-up at selected milestones between 2014 and 2018. Results: Between 6,326 and 6,557 individual children were included in the 6-monthly analyses. On average, 57% (95%CI: 56¿59%) of eligible children had received one or more ear examination in each 6-monthly period. Of those examined, 36% (95%CI: 33¿40%) were diagnosed with some type of OM, of whom 90% had OM requiring either immediate treatment or scheduled follow-up according to local guidelines. Outcomes of treatment and follow-up were recorded in 24% and 23% of cases, respectively. Significant decreasing temporal trends were found in the proportion diagnosed with any OM across each age group. Overall, this proportion decreased by 40% over the five years (from 43 to 26%). Conclusions: This cascade of care analysis found that ear health surveillance and compliance with otitis media guidelines for treatment and follow-up were both low. Further research is required to identify effective strategies that improve ear health services in remote settings.

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.

Background: Little is known about the impact of otitis media (OM) on the quality of life (QoL) of children living in NSW. This study aimed to investigate the use of the OM-6 (Otitis Media-6) survey to assess the QoL of Aboriginal and non-Aboriginal children receiving ventilation tubes (VTs) for OM. Methods: Parents/caregivers of children receiving VT tubes for OM were invited to self-administer the six question OM survey pre-surgery, together with a brief demographic questionnaire. Parents/caregivers were approached on the morning of their child's surgery in the wards of two public hospitals located in the Hunter New England region of NSW. The OM-6 was administered post-surgery at a 6-week follow-up phone call between the research co-ordinator and the study participants. Results: Parents/caregivers of Aboriginal and non-Aboriginal children were equally likely to complete the questionnaire on the day of surgery and at follow-up. The initial uptake was 100%; and followup completion, 69%. Fifty-three percent (53%) of the 101 children were Aboriginal. Significant QoL improvements were evident for each OM domain after VT tube insertion; there was no significant difference between Aboriginal and non-Aboriginal children. Conclusions: The survey provided the first data on QoL for Aboriginal and non-Aboriginal children with OM in the HNELHD regions of NSW. The similarity in responses for Aboriginal and non-Aboriginal children indicates more research is needed to understand the higher prevalence of OM in Aboriginal children.

Introduction: The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main recommendations: We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions. Changes in management as a result of the guidelines: A GRADE approach is used. Targeted recommendations for both high and low risk children. New tympanostomy tube otorrhoea section. New Priority 5 for health services: annual and catch-up ear health checks for at-risk children. Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children. Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration. Concurrent audiology and surgical referrals are recommended where delays are likely. Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis. The use of autoinflation devices is recommended for some children with persistent otitis media with effusion. Definitions for mild (21¿30¿dB) and moderate (>¿30¿dB) hearing impairment have been updated. New "OMapp" enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

Objectives: Data presented in this paper were gathered during the Urban Hearing Pathways study. The objective of the study was to investigate how access to, and availability of, ear health and hearing services contributes to the burden of avoidable hearing loss experienced by young, urban Aboriginal and Torres Strait Islander children and their families. The objective of this paper is to present the perspectives of parents and carers about awareness and concern in their community, detection and diagnosis of children's ear health and hearing problems in primary care, and impacts of delays in diagnosis on children and families. These perspectives are complemented by those of health professionals. Importance of study: The study findings address an evidence gap relating to factors that prompt an ear health and hearing check for young, urban Aboriginal and Torres Strait Islander children. They reveal the difficulties families experience in establishing a diagnosis of chronic ear disease and receiving the care they perceive will effectively addresses their child's needs. Study type: Qualitative study with surveys. Methods: The project team consisted of six Aboriginal researchers and 10 non-Indigenous researchers. Data collection tools and methods were designed by the project team. A total of 33 parents and carers completed surveys, and most also took part in interviews (n = 16) or focus groups (n = 16); 23 described their child's ear health journey. Fifty-eight service providers from the health, early childhood and community service sectors completed anonymous surveys and 26 were interviewed. Descriptive statistics were generated from survey data and thematic analysis was conducted for interview and focus group data. Results: Five main themes emerged from the analysis of parent and carer interviews: community knowledge and parent/carer recognition of signs of ear health and hearing problems; parent and carer action-taking; getting ear health and hearing checks; recognition of persistent problems; and impacts of delays on children and families. Conclusions: Reiterating previous findings, there is no evidence of a systematic approach to ear checks for this at-risk population. A significant proportion of parents and carers are noticing problems by watching their child's listening behaviours: early and reliable indicators of hearing status that can be harnessed. Some persistent ear health problems are being managed in primary care as acute episodes, thus delaying specialist referral and increasing developmental impacts on the child. Parents' and carers' practical recommendations for improving hearing health services are presented.

Objective: To describe and evaluate Hearing EAr health and Language Services (HEALS), a New South Wales (NSW) health initiative implemented in 2013 and 2014 as a model for enhanced clinical services arising from Aboriginal health research. Methods: A case-study involving a mixed-methods evaluation of the origins and outcomes of HEALS, a collaboration among five NSW Aboriginal Community Controlled Health Services (ACCHS), the Sydney Children's Hospitals Network, NSW Health, the Aboriginal Health and Medical Research Council, and local service providers. Service delivery data was collected fortnightly; semi-structured interviews were conducted with healthcare providers and caregivers of children who participated in HEALS. Results: To circumvent health service barriers, HEALS used relationships established through the Study of Environment on Aboriginal Resilience and Child Health (SEARCH) to form a specialist healthcare network. HEALS employed dedicated staff and provided a Memorandum of Understanding (detailing mutual goals and responsibilities) for each ACCHS. Despite very tight timeframes, HEALS provided services for 653 Aboriginal children, including 5,822 speech-language pathology sessions and 219 Ear, Nose and Throat procedures. Four themes reflecting the perceived impact of HEALS were identified: valued clinical outcomes, raising community awareness, developing relationships/networks and augmented service delivery. Conclusions: HEALS delivered rapid and effective specialist healthcare services through an existing research collaboration with five ACCHS, cooperation from local health service providers, and effective community engagement. Implications for Public Health: HEALS serves as a framework for targeted, enhanced healthcare that benefits Aboriginal communities by encapsulating the 'no research without service' philosophy.