SEARCH Study of Environment on Aboriginal Resilience and Child Health
Darwin April 10th 2006
SEARCH
CRIAH (Coalition Research Improve Aboriginal Health)
- Sax Institute - AHMRC (Aboriginal Health and Medical Research Council)
Aboriginal Medical Services (6)
- Sydney - Wollongong - Newcastle - Wagga Wagga Redfern, Daruk, Tharrawal Illawarra Awabakal Riverina
University of Sydney and other institutions
Professor Sandra Eades
Chief Investigators
Jonathan Craig Richard Taylor Sandra Bailey Emily Banks Alan Cass Kathleen Clapham John Daniels Sandra Eades Sue Kippax Peter McIntyre Ann Parker Beverly Raphael Sally Redman Frank Vincent
Other stakeholders
Ken Wyatt (NSW Health) NSW Aboriginal Housing Unit Rio Tinto Aboriginal Foundation Aboriginal Education Consultative Group Others
Brief Summary
SEARCH will investigate the relationship between environmental determinants of health
1. Cross-sectional study
800 urban Aboriginal families in NSW Approx. 2000 children (0-17y)
2. RCT of health broker
3. Cohort study with 5 y follow-up ? 20 y follow-up
Outcomes
Healthy Environments - quality housing - adequate sanitation - safe - access to health services - resilience - adequate income
Outcomes
Health Issues - otitis media - injury - vaccinations - infections - asthma - risk factors - mental health
Where I thought I would be…
Trinidad & Tobago
Vanuatu
Objective 1
To investigate the causes of health and illness in Aboriginal children with a focus on healthy environments and selected child health problems
a) a cross sectional study of 800 families b) a prospective cohort study 5y c) a prospective cohort study 20y
Objective 2
To determine whether a community appointed health broker in:
i) an RCT focused on otitis media ii) a feasibility trial of housing improvement
is an effective sustainable agent for improving the environment and health of Aboriginal children and their families
Cohort: Inclusion criteria
At least one carer is Aboriginal according to the accepted national definition
At least one child less than 18 years Attendance at one of the participating AMSs (Redfern, Daruk, Tharrawal, Awabakal, Illawarra, Riverina)
Flow Diagram of Cross Sectional Study
Family presents to a SEARCH AMS Invited to participate in SEARCH Agree (?60%) Later… HOUSING (subset) Refuse (?40%)
CROSS SECTIONAL STUDY
1. Direct measurement
HISTORY (all)
1. Questionnaire interview
EAR HEALTH (0-17y)
1. Video-pneumatic otoscopy 2. Tympanometry 3. Audiometry 4. Ear and nose swabs
CLINICAL (all)
1. Anthropometry & B P 2. Waist circumference 3. Blood tests 4. Urine tests 5. Dental assessment
MENTAL HEALTH (all)
1. Mental health assessment
Later…
2. AMS Medical Record review 3. Record Linkage (?)
Later…
6. Developmental/Cognitive Prevalence growth delay Prevalence obesity, HT Prevalence IDA Prevalence proteinuria Prevalence dental disease Prevalence Dev Delay / ID
Prevalence of ear diseases Prevalence of other diseases Illness burden Food security/Nutrition Prevalence of risk factors
Prevalence otitis media (and individual forms of OM) Prevalence hearing impairment Description URT colonisation/ resistance patterns
Prevalence mental health problems
Flow Diagram of Cross Sectional Study
Family presents to a SEARCH AMS Invited to participate in SEARCH Agree (?60%) Later… HOUSING (subset) Refuse (?40%)
CROSS SECTIONAL STUDY
1. Direct measurement
HISTORY (all)
1. Questionnaire interview
EAR HEALTH (0-17y)
1. Video-pneumatic otoscopy 2. Tympanometry 3. Audiometry 4. Ear and nose swabs
CLINICAL (all)
1. Anthropometry & B P 2. Waist circumference 3. Blood tests 4. Urine tests 5. Dental assessment
MENTAL HEALTH (all)
1. Mental health assessment
Later…
2. AMS Medical Record review 3. Record Linkage (?)
Later…
6. Developmental/Cognitive Prevalence growth delay Prevalence obesity, HT Prevalence IDA Prevalence proteinuria Prevalence dental disease Prevalence Dev Delay / ID
Prevalence of ear diseases Prevalence of other diseases Illness burden Food security/Nutrition Prevalence of risk factors
Prevalence otitis media (and individual forms of OM) Prevalence hearing impairment Description URT colonisation/ resistance patterns
Prevalence mental health problems
SEARCH Ear Health Measures
Definitions of otitis media
As per OATSIH Guidelines document:
“Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations (March 2001)” OM, OME,AOM,RAOM, CSOM etc
Ear Health Measures: Aims
1. To determine the prevalence of otitis media and its complications among NSW urban Aboriginal children who attend participating Aboriginal Medical Services (AMS)
Ear Health Measures: Aims
2. To determine the prevalence of hearing impairment among NSW urban Aboriginal children who attend participating AMSs
3. To describe the risk factors for development of otitis media among NSW urban aboriginal children
Ear Health Measures: Aims
4. To describe the knowledge and attitudes of each child‟s primary carer to otitis media.
5. To test the efficacy of a health broker in improving access to best treatment as defined in the OATSIH Clinical Care guidelines.
Ear Health Measures
Cross Sectional Study (for all 0-17 year olds)
At initial visit:
History Video-pneumatic otoscopy Tympanometry Ear and nose swabs At a later date: Audiometry (? who will do)
Measures: History
Questions addressing history of ear disease
Questions addressing hearing difficulties Questions addressing treatment
Measures: History
Questions addressing history of ear disease
1. “Has anybody in your family or
‟s father‟s family every had any ear problems?” (source: Otitis media study) 2. “Has every had runny ears (tropical ear/glue ear)” (source: WACCHS) other option… “How old was when they had their first episode of otitis media?”
Measures: History
Questions addressing hearing difficulties
(Source: WAACHS) 1. “Does have normal hearing in both ears?”
2. “Is deaf or partially unable to hear in one or both ears?”
3. “How long has had trouble hearing?” 4. “Does use a hearing aid?”
Measures: History
Questions addressing treatment
(Source: WAACHS) 1. “Has ever been checked by an ear specialist or ever needed ear surgery?”
Measures: Video-otoscopy
Level 1 evidence to support Pneumatic Otoscopy to diagnose middle ear fluid
Takata et al Pediatrics 2003; 112: 1379-1387
Limitation is who performs the pneumatic otoscopy (studies either don‟t report or use ENT experts)
Video-otoscopy enables digital images/videos to be checked by off-site ENT specialist at a later date
Measures: Tympanometry
Also Level 1 evidence to support Tympanometry (can be used to confirm middle ear fluid after pneumatic otoscopy)
Advantage is tympanometry provides an objective quantitative measure which is highly correlated with OME (Type B curve or „flat tympanogram‟)
Hearing Impairment
Pure Tone Audiometry (? In AMS or referral)
Hearing loss defined as average hearing level at frequencies of 500, 1000, 2000 and 4000 Hz in the better ear
Hearing impairment
Average Threshold (decibels) -10 to 15 16 to 25 26 to 30 31 to 40 41 to 55 56 to 70 71 to 90 91+ Terminology Implications
Normal hearing Slight hearing loss MILD MILD “disabling” for child MODERATE “disabling” for adult MODERATELY SEVERE SEVERE PROFOUND
None ? educationally important Australian hearing recommends hearing assistance for individuals with permanent hearing loss > 25 dB
SEACH STUDY FLOWCHART
Family present to a SEARCH AMS Ineligible
Control (n=200 c)
ie late health broker
Eligible (n=1300 f)
Consent (n=800 f)
Refuse
Health Broker RCT
both groups have monthly surveillance & OM awareness Q
Agree to RCT (n=480 c)
R
LTFU (n=80 c)
Cross Sectional Baseline Survey
Measures on all (n=800 f ?2000 c) f=families c=children 0-17
Children with OM (n=1000 c)
Health Broker (n=200 c)
ie early health broker Refuse RCT (n=520 c)
Cohort 5 year Re-Survey
Measures on all (n=800 f ?2000 c)
No children with OM (n=1000c)
Ear Health Measures: summary
Cross Sectional Study (for all 0-17 year olds)
At initial visit:
History Video-pneumatic otoscopy Tympanometry Ear and nose swabs At a later date: Audiometry (? who does)
Ear Health Measures: summary
Cohort Study (for all 0-17 year olds)
At each visit to AMS for ear problems:
Video-pneumatic otoscopy +- Ear and nose swabs +- Tympanometry as required +- Audiometry as required At the 5 year resurvey: Repeat of all Cross sectional measures on all children
Ear Health Measures: summary
RCT Study
1. 2.
3.
(the general principles only at this stage!)
Baseline
- assessment of ear health (= cross-sectional baseline) - assessment of carer‟s understanding of otitis media
Routine surveillance of ear health at regular intervals (?monthly) - involving pneumatic otoscopy and tympanometry
Assessment of how closely otitis media episodes over the 12m were managed in accordance with OATSIH guidelines in the 2 groups (i.e. Health Broker+ and Health Broker -)
4.
End of year - assessment of ear health (as for baseline measures) - assessment of carer‟s understanding of otitis media