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Sepiuta Lopati Prevalence of ear disease and its associated hearing loss among primary school children in Tonga: urban versus rural. Sepiuta Lopati ORCHID ID: https://orcid.org/0000-0001-9720-8235 Submitted in complete fulfilment of the requirements for the degree of Master of Surgery by research. July 2020 Department of Otolaryngology The University of Melbourne Abstract Background. Ear disease and hearing loss among children are significant world- wide health problems that potentially cause speech and language development delay, social isolation, and academic failure. The prevalence is highest in low- and middle- income countries including the Pacific island countries where epidemiological data and resources are limited. National programs to raise awareness and detection rarely existed in most Pacific island countries. The purpose of this case study was to determine the prevalence of ear disease and associated hearing loss in primary school children. The data will be used as informed evidence to develop a propose strategies to address ear and hearing problems among primary school children in Tonga. Methods. This was a cross sectional population- based study which used otoscopy, tympanometry and pure tone audiometry to determine the prevalence of ear disease and hearing loss in 10 urban and 12 rural primary schools in Tongatapu. Results were collected on a digitised form from 489 students (88% of total selected population) class 1 to 6 (5 to 14 years of age) and data were analysed using quantitative statistical and mixed model method. Results. Wax was the most common ear problem found in 54.6% (267 students) of the primary school children both partial and occluded wax and more common in urban children (31%) as compare to rural (24%). This was statistically significant for age and school location but not gender. Followed with middle ear diseases in 12% (60 students, rural 8%, urban 4%) including children with suppurative otitis media (1.4%, perforation with ear discharge), suspected cholesteatoma (0.6%) and possible otitis media with effusion (10%, immobile, dull, retracted, atelectatic ear drum and type B tympanogram). Seven percent (37 students) of the students failed hearing test (defined as > 25 dB of best hearing ear) with middle ear disease (15 students, 41%) the most common cause followed by occluded wax (9 students, 24%), wax plus OME (7 students, 19%) and 6 students (16%) under unknown cause. The mean threshold difference between occluded and non-occluded ears among primary school children were 3 dB. The improvement in mean threshold among children with occluded wax after removal was 7 dB. Of the 15% of children with bilateral hearing loss due to occluded wax, there was 5% reduction in number of students post wax removal. Wax removal benefitted 30% and 35% of students with unilateral and bilateral hearing respectively. Dental caries affected 28% of the primary school children. Conclusion. Ear disease causing hearing loss was commonly found among primary school children in Tonga. A national plan for ear and hearing care for primary school children including i early detection and management through school screening are very important to assist children to achieve better education. ii Dedication To the primary school children in Tongatapu. iii Declaration This is to certify that a. The thesis compromises of my original work towards my Master of Surgery b. The thesis is fewer than 50,000 words in length Sepiuta Lopati iv Acknowledgement This research study had many challenges but with the help and support of many individuals and groups enable the study to achieve what this thesis present. Therefore, I would like to extend my deepest gratitude and specifically acknowledge the following. Firstly, I would like to acknowledge all the primary school children in Tongatapu and their parents and care givers who consented for these children to participate in this study. It was a great pleasure and an exciting time working with you all. You were all very courageous especially children with interventions. Special thanks to the Tonga Government Ministry of Education and Training staff, Manu ‘Akau’ola, Soane Selui and all the officers at the Primary School Department, Directors, Principals and teachers of all mission schools participated in this research for all your support in organising and allowing the students to participate. Secondly, I want to thank my supervisors and advisory group. You have provided me with enormous support with your diverse skills and knowledge. Stephen, your persistent guidance, statistical knowledge and words of encouragement kept me striving. Likewise, your humble decision to help with your wife, Catherine in the research screening. Peter Annear, I thank you for making time and guidance in designing this survey by your informed experience and knowledge. Karina, thank you for being the first chairperson making sure it progresses accordingly. Sudanthi, a great thanks to you for taking the wheel over Karina. Chris and Andrea, your continuous advice in defining details for this research study, likewise your assistance in editing the thesis. Thirdly, I must acknowledge the following groups of people. The screening team members from Melbourne and the nursing staff from the Tonga Ministry of Health. Stephen and Jean-Marc, thank you for allowing a week of your busy schedule to help screening the children. Working outside the normal environment and providing simple intervention like removing occluded wax in children’s ears improved hearing. Jocelyn, Elisabeth (Liz) and Michael, it was with great appreciation to work along with you and thank you for sharing your audiology assessment skills and knowledge to yield this sound data. Catherine, your well organise character provided efficiency to each member’s role. Loleta and all the nurses from the Ministry of Health in Tonga, thank you for all your helping hands from cleaning the tools, organising the children, translator to audiology assessment. Fourthly, I want to acknowledge several colleagues and friends for their support. Lisiate, Lei, and Tonga MOH, thank you for all the support in providing transport and staff to help with the screening. Cameron Patrick, your statistical knowledge had shine lights to gain insights with data analysis. Ben Kreunen, special thanks for your help in designing the digitised forms on v Ipads to make data collection more efficient. An expertise beyond my capability. Suren, Peter Thorne, Liz and Fiona, thank you for sharing your wisdom at all times when I called upon you for advice. Lastly, I must thank my family. To my husband, Steen, our two boys, Kitiseni and Taui and my niece Katalina. Thank you very much for all your sacrifices and support. There were challenges we endured together that gave me courage. I must also thank my 84 years old mother, Mele ‘Eleni for your continuous prayers for our family and believing in me. It was two difficult years being away from home. Lastly to all my relatives and friends near and far who reached out in many forms. A big thank you to you all. vi Table of Contents Abstract ......................................................................................................................................... i Dedication ................................................................................................................................... iii Declaration .................................................................................................................................. iv Acknowledgement ........................................................................................................................ v Table of Figures ........................................................................................................................... x List of tables ............................................................................................................................... xi List of Abbreviations ................................................................................................................. xii List of Appendix ....................................................................................................................... xiii 1. Introduction .......................................................................................................................... 1 1.1. Background. ............................................................................................................................. 1 1.2. Tonga Context. ......................................................................................................................... 3 1.2.1. Geography, Population and Economy ............................................................................. 3 1.2.2. Education ......................................................................................................................... 7 1.2.3. Health ............................................................................................................................... 8 1.2.4. Population Health .......................................................................................................... 13 1.3. Study Context ......................................................................................................................... 14 2. Literature Review. ............................................................................................................... 16 2.1. Introduction ..........................................................................................................................
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