Community

Ear Hearing Volume 10 & Health Issue 13 • 2013

Community outreach in a school setting. PHILIPPINES

ROSARIO R RICALDE Increasing community awareness of ear and hearing health espite 360 million persons1 in the world living amongst primary health care professionals to further Shelly Chadha * Medical Offi cer for with disabling hearing loss, there remains a raise awareness about common ear and hearing Hearing Impairment Dsurprising lack of awareness in society about problems: their causes, prevention, identifi cation and World Health Organization, ear diseases and hearing loss. management. Most importantly, communities must Geneva, Switzerland One of every three individuals above 65 years of be empowered with the knowledge of simple age has a hearing loss,1 yet fewer than 3% of people preventive strategies that would ensure their receive the hearing devices they require.2 Up to continued or improved hearing health. 330 million people across the world are affected by Pertinent issues for raising awareness include the chronic otitis media manifesting as a discharging ear.3 growing magnitude of the problem and its common Ignorance is a key contributor to the current situation, causes, simple and effective prevention strategies, where a high prevalence is compounded by poor consequences of inaction and benefi ts of timely availability of services and of human as well as intervention. All means of communication available fi nancial resources for ear and hearing health. and relevant need to be used – person-to-person communication, print media, posters and electronic Raising awareness: a neglected media – to convey the need for, methods and priority benefi ts of good ear and hearing health. The World Health Organization can play a lead role In order to improve the situation, what we need is a in gathering evidence and developing evidence-based coordinated and sustained effort to raise awareness strategies as well as tools for creating awareness. at all levels. Governments, policy makers and With the support and collaboration of all those *Disabling hearing international agencies need to be targeted through involved in the care of persons with ear conditions loss is defi ned as effective advocacy, as do health care professionals hearing loss greater and the community at large. Advocacy at the highest and hearing loss, as well as the persons themselves, than 40 dB in the we must approach ear and hearing health as a social level can drive change at the grass-root level, and 4 better hearing ear in raising awareness within communities can create an challenge and not merely as a fi ght against disease. persons more than enlightened society – a social movement for 1 WHO, MBD. Global estimates of hearing loss. Geneva: WHO, 2012. 15 years of age and championing ear and hearing health. 2 WHO. World Report on Disability. Geneva: WHO, 2011: 102. greater than 30 dB We need to motivate health professionals working 3 Chronic suppurative otitis media: burden of illness and management in persons up to in the fi eld of ear and hearing to bring services to the options. Geneva: WHO, 2004. 15 years of age. community level. Systematic training is required 4 Olusanya BO. Int J Pediatr Otorhinolaryngol 2000;55: 167–171.

Community Ear & Hearing Health Volume 10 • Issue 13 (2013) 1 Shelly Chadha

Causes of ear disease and hearing loss What health workers need to know to raise awareness about ear and hearing health

IN THIS ISSUE Robin Youngs Consultant Otologist Increasing community Director BRINOS

awareness of ear and (Britain-Nepal Otology RICALDE R ROSARIO hearing health Service), United Kingdom Shelly Chadha 1 www.brinos.org.uk

What health workers ar disease is extremely need to know to raise common and its principal awareness about ear effect is hearing loss. The and hearing health E potential impact that ear disease Robin Youngs 2 can have on an individual, family or community, is profound. Raising awareness to Children with disabling hearing empower communities loss often fail to develop normal to take action 4 speech and language. Adults Key messages to raise with disabling hearing loss awareness of ear and may have problems securing Listening to a talk about ear hearing health in the employment, and the positions and hearing health. PHILIPPINES community they do secure are less well paid. Diego J Santana- Elderly people with hearing loss cytomegalovirus. Genetic predisposition to deafness Hernández 6 can become socially isolated and withdrawn. can also occur. Genetic deafness can be part of a Because hearing impairment is an invisible CASE STUDIES ‘syndrome’ with other congenital abnormalities. disability and ear disease, except in rare cases, is not Consanguinity, particularly in the case of marriages West Nepal 8 fatal, both are frequently neglected by health between fi rst cousins, is an important risk factor in Canada 9 personnel who are already very busy dealing with genetic deafness. Extreme low birth weight and other seemingly more important health problems. Namibia 10 birth hypoxia can be associated with hearing loss, as Communities do not consider ear and hearing can neonatal jaundice. health a priority and, in addition, families often Obituary: Infections in childhood regard hearing impairment as a social stigma. Dr Piet van Hasselt 10 Some are important causes of hearing loss, Improved awareness, both on the part of the community particularly meningitis, measles, and mumps. The effect of noise and of the health worker, plays a key role in preventing Meningitis can cause bilateral profound hearing loss, on hearing 11 problems and in reducing their impact: because of its effect on the inner ear and its Many ear and hearing problems can be prevented How to take care • connections with the brain. by simple measures. of your ears 12 Disorders of the external ear1 • When provided early, treatment may lead to Probably the most common causes of hearing loss complete or partial recovery and/or stabilise are wax accumulation and otitis externa (infection residual hearing levels. of the external ear). In addition, foreign bodies in • Lack of treatment can have severe consequences. the ear canal can cause hearing loss as well as discomfort. These conditions are mostly treatable, Major causes of ear disease and with the hearing loss being completely reversible. hearing loss Middle ear conditions1 Ear disease can affect any age group. The major ‘Glue ear’ (the presence of sterile fl uid in the middle causes of hearing loss are listed in Table 1 opposite. ear, also called middle ear effusion) is an important Congenital deafness cause of hearing loss. It can also lead to a middle ear Children can be born deaf. This can be due to infection (known as ‘otitis media’). This journal is funded by CBM maternal infections such as rubella, syphilis and Chronic otitis media (COM) is a major cause of

Community Editor Printing Community Ear and Hearing Correspondence

Ear Hearing Volume 10 Dr Paddy Ricard Newman Thomson Health, International Centre Please send all enquiries to: & Health Issue 13 • 2013 Editorial committee Online edition for Eye Health, London Joanna Anderson (for Professor Andrew Smith (Chair) See ‘Publications’ on http:// School of Hygiene and contact details, see left). Dr Ian Mackenzie disabilitycentre.lshtm.ac.uk Tropical Medicine, Keppel Copyright Community outreach Professor Valerie E Newton Street, London WC1E 7HT, in a school setting. PHILIPPINES How to subscribe ROSARIO R RICALDE United Kingdom. Email: Articles may be photocopied, Increasing community awareness Dr Padman Ratnesar The journal is sent free of of ear and hearing health [email protected] 1 Dr Diego J Santana-Hernández reproduced or translated, espite 360 million persons in the world living amongst primary health care professionals to further Shelly Chadha * Medical Offi cer for with disabling hearing loss, there remains a raise awareness about common ear and hearing charge to readers working in Hearing Impairment Dsurprising lack of awareness in society about problems: their causes, prevention, identifi cation and World Health Organization, ear diseases and hearing loss. management. Most importantly, communities must Geneva, Switzerland One of every three individuals above 65 years of be empowered with the knowledge of simple age has a hearing loss,1 yet fewer than 3% of people preventive strategies that would ensure their provided they are not used 2 Regional consultant receive the hearing devices they require. Up to continued or improved hearing health. We recommend that readers 330 million people across the world are affected by Pertinent issues for raising awareness include the low- and middle-income chronic otitis media manifesting as a discharging ear.3 growing magnitude of the problem and its common Ignorance is a key contributor to the current situation, causes, simple and effective prevention strategies, where a high prevalence is compounded by poor consequences of inaction and benefi ts of timely Dr Jose M Acuin (Philippines) for commercial or personal availability of services and of human as well as intervention. All means of communication available in high-income countries fi nancial resources for ear and hearing health. and relevant need to be used – person-to-person countries. To subscribe, communication, print media, posters and electronic Raising awareness: a neglected media – to convey the need for, methods and priority benefi ts of good ear and hearing health. The World Health Organization can play a lead role profi t. Acknowledgements In order to improve the situation, what we need is a Editorial assistant make an annual donation in gathering evidence and developing evidence-based please send your name, coordinated and sustained effort to raise awareness strategies as well as tools for creating awareness. at all levels. Governments, policy makers and With the support and collaboration of all those *Disabling hearing international agencies need to be targeted through involved in the care of persons with ear conditions loss is defi ned as effective advocacy, as do health care professionals hearing loss greater and the community at large. Advocacy at the highest and hearing loss, as well as the persons themselves, Joanna Anderson should be made to the we must approach ear and hearing health as a social of UK £10. To subscribe, than 40 dB in the occupation, postal address, level can drive change at the grass-root level, and 4 better hearing ear in raising awareness within communities can create an challenge and not merely as a fi ght against disease. persons more than enlightened society – a social movement for 1 WHO, MBD. Global estimates of hearing loss. Geneva: WHO, 2012. 15 years of age and championing ear and hearing health. 2 WHO. World Report on Disability. Geneva: WHO, 2011: 102. greater than 30 dB We need to motivate health professionals working 3 Chronic suppurative otitis media: burden of illness and management Design please contact Joanna author(s) and to Community in persons up to in the fi eld of ear and hearing to bring services to the options. Geneva: WHO, 2004. phone number and email 15 years of age. community level. Systematic training is required 4 Olusanya BO. Int J Pediatr Otorhinolaryngol 2000;55: 167–171. Community Ear & Hearing Health Volume 10 • Issue 13 (2013) 1 Lance Bellers address to: Joanna Anderson, Anderson (as above). Ear and Hearing Health. CEHH#13_FINAL.indd 1 12/12/2013 16:30

2 Community Ear & Hearing Health Volume 10 • Issue 13 (2013) What health workers need to know to raise awareness about ear and hearing health

long-term hearing loss, and is much more common in These simple measures should help TABLE 1. MAJOR CAUSES OF EAR low- and middle-income countries (LMIC). In this maintain ear health and prevent the DISEASE AND HEARING LOSS condition, there is a perforation of the eardrum, occurrence of ear disease: Note: Preventable or treatable causes which allows microorganisms to enter the middle ear, Personal hygiene is always • are shown in purple resulting in a persistent purulent discharge and hearing important, including hand washing loss. It can sometimes be caused by tuberculosis in before eating or preparing food Maternal infections LMIC where the infection is common. It may also be a and after going to the toilet. • Rubella marker for HIV/AIDS. • Do not swim or wash in dirty • Syphilis Neglecting COM can lead to catastrophic, even fatal, water. This may allow the entry of • Cytomegalovirus complications – such as meningitis, brain abscess and microorganisms into the ear and Genetic conditions facial paralysis – particularly when sufferers do not cause ear infections. have access to specialised medical care. • If there is discharge from the ear, Hereditary conditions and chromosomal abnormalities Use of ototoxic drugs it is important to keep the ears The use of certain drugs has potentially harmful effects completely dry (but do not block Perinatal conditions for the ear. This is known as ototoxicity and is an important the ear with cotton wool). There • Low birth weight cause of hearing loss and balance problems. The most may be a perforated tympanic • Neonatal hypoxia commonly used ototoxic drugs are aminoglycoside membrane with chronic otitis • Neonatal jaundice media. If the discharge continues antibiotics (e.g. gentamicin), which are frequently given Childhood infections to young children to treat fever in LMIC, where their for more than a few days, you should seek treatment from a • Meningitis use is often unregulated. Other ototoxic drugs include • Mumps some of the medications used for the treatment of health centre. • Measles malaria, tuberculosis, leprosy, cancer and HIV/AIDS. • Do not introduce objects into the Some industrial chemicals (e.g. solvents) are also ototoxic. ear, particularly cotton buds. This Nutritional causes can cause wax impaction and e.g. iodine defi ciency Exposure to excessive noise produce hearing loss, as well as This can damage the inner ear and is a major cause of ear infections. Trauma to the head hearing loss (see page 11) in adults of working age. The • Only ear medicines obtained from e.g. from traffi c accidents degree of hearing loss depends on the length and a nurse, doctor or other legitimate Obstruction of the ear canal intensity of noise exposure and on individual susceptibility. healthcare worker should be taken, Wax Most noise damage occurs in people working in heavy • at the correct dosage. Otitis externa industry, construction and the military. The damage • • Herbal remedies and ‘ear candles’ • Foreign body caused by noise can be prevented by good hearing are potentially harmful and should protection strategies, including the use of ear defenders. not be used. Middle ear conditions There is also concern over recreational noise exposure • Avoid exposure to potentially • Serous otitis media (glue ear) in young people, especially the use of personal stereos harmful levels of noise at home • Otitis media with headphones at high volume, and over environmental and at work. When exposure is • Chronic otitis media noise exposure in residential areas, such as that unavoidable it is vital to wear ear Damage to the inner ear caused by heavy traffi c, airports, industry, music protection, such as ear plugs. Ototoxicity establishments, etc. • • Excessive noise exposure Presbyacusis Why it is important to • Age-related inner ear The degeneration of the inner ear with advancing age consult early degeneration (presbyacusis) (presbyacusis) is also a major cause of hearing loss. When ear problems are suspected it • Ménière’s disease The World Health Organization estimates that nearly is important to seek help and advice one-third of people aged over 65 live with disabling at an early stage.2 The box on page 6 hearing loss. These people are frequently socially of this issue lists the situations when you should isolated and adequate rehabilitation with hearing consult a doctor. Early treatment will ensure a much aids, if available, can be extremely effective. better outcome. The role of poverty and malnutrition Many causes of hearing loss in the early stages of Poverty and malnutrition increase the likelihood of life are reversible if correct advice, diagnosis and ear disease and hearing loss. Malnutrition impairs treatment are given. If hearing loss in children is not people’s immunity, which makes them prone to detected and treated, they may not develop normal infections, especially of the ear, nose and throat. speech and language, especially when the hearing loss The availability of clean water supplies and good occurs in the fi rst or second year of life, resulting in sanitation is also important in reducing the an unnecessary disability that will hamper them for occurrence of discharging ears. the rest of their lives.

How to take care of your ears 1 ‘External ear’ designates the ‘visible part’ of the ear, as well as the ear canal. ‘Middle ear’ refers to the eardrum and ossicles situated right Health workers can play a key role in teaching behind it. patients how to care for their ears and discouraging 2 For advice on addressing ear and hearing complaints at primary level, practices that may be harmful. see: Community Ear Hearing Health vol 9 issue 12 (2012).

Community Ear & Hearing Health Volume 10 • Issue 13 (2013) 3 Empowering communities Raising awareness to empower communities to take action

This article was compiled e should not assume that once people have • They hear repeated, simple and consistent by Paddy Ricard, with the been informed about what can be done to messages from different sources. help of practical tips on maintain or improve ear health, they will • They are given time to change, especially if the change W 1 raising community then change their behaviour accordingly. In practice, carries a cost, such as the installation of latrines. awareness by Hannah this is rarely the case. Ayukawa, Heide Firstly, simply delivering a health message does not Engaging with the community Beinhauer, Valerie Newton, Padman Ratnesar ensure that it has been understood. Secondly, even Most of the factors essential to behavioural change and Andrew Smith. when your messages are understood by the require a two-way communication process between community, an awareness of the factors affecting ear the health worker or health educator and community and hearing health is only the fi rst stage towards members. An ongoing dialogue will allow you to: adopting healthier behaviours. Individuals must then • Ensure your health message has been understood. be willing to try a new behaviour and have the means • Build trust and mutual respect. – or be given the means – to do so. Finally, they must • Understand the community’s current behaviours, adopt the behaviour until it becomes a routine habit. preoccupations, and living conditions. • Become aware of obstacles to behavioural change The challenge of changing behaviour and fi nd acceptable solutions with the community. Obstacles to behavioural change • Empower the community to take charge of their We all fi nd it diffi cult to change our behaviour, even own health. when we know it will improve our health or quality of life. For example, in a high-income country with Involving the community in practice straightforward access to services, a hearing-impaired Recruiting local collaborators person might put off being fi tted for a hearing aid • If you do not belong to the community or do not because they are embarrassed to admit to themselves know it well, enlist the help of a person who does or show to others that they have a hearing loss. and who fully understands the aim and methods of Changing behaviour is diffi cult for many reasons: what you are trying to do (and possibly some of • Many of our daily health habits are automatic. To the technical aspects). change behaviour, people must act consciously: • If you do not speak the local language, it will also this requires focus, time and commitment, which be essential from the outset to enlist the help of a might be in short supply, particularly when our reliable and well-educated translator. living conditions are diffi cult. • Involve, or at least get the approval of, the local health • In smaller communities, particularly, people tend system if you are not part of it, and get the help – or to be ‘stuck’ in traditional or social hierarchies and at least the acquiescence – of local health personnel. are often reluctant to really take initiative or challenge the system. Respecting the structure of the community • Behavioural change usually requires new resources Make an effort to understand how the community is or a re-allocation of existing resources (e.g. building organised. It is important to establish and use the latrines, travelling to a health centre, buying ear correct channels of communication, e.g. through the protection). This is more diffi cult when resources local headman, the regional councillors, etc. are scarce or people have little control over them. Identify community leaders on various levels (political, traditional, church). Engage with them, e.g. Factors enabling behavioural change by asking them what they do, listening to their concerns Facts for Life, a resource on maternal and child health and suggesting what they can do for the community. produced by a coalition of international bodies such They are very likely to ask others to join them. as UNICEF and the World Health Organization, Once you have engaged with leaders, contact other summarises the success factors for changing behaviour: members of the community. This can be done in many People are more likely to change their behaviour when:

SH ways: home visits; meetings with parents, mothers and

CL a • They are encouraged to discuss a health message workers. If you get the children to trust you, the elders among themselves and to ask questions to clarify will be more likely to work with you. It is also important their understanding. to speak to hearing-impaired people in the community • They have been shown, and fully understand, how and to ask them to be advocates for your campaign. they, their family and community will benefi t from changing their behaviour. Asking questions and understanding behaviour • The language used to communicate with them is Whilst you may think that your health message is too familiar and compatible with the local culture and important not to be acted upon, community members social norms, avoiding judgmental or prescriptive- may have more pressing concerns requiring their sounding ‘orders’. attention. They may also think of practical or cultural Posters can help highlight • The person presenting the message or the source reasons why they cannot follow your advice. your message. NAMIBIA of information is well known and trusted. It is therefore important to ask people what they

4 Community Ear & Hearing Health Volume 10 • Issue 13 (2013) Interpersonal communication Group meetings or one-to-one communication allow for

XINGKUAN BU XINGKUAN more interaction with community members and encourage ownership. The following may be helpful: • Visual aids (such as drawings, posters or writing on a board) help your audience to understand what you are talking about and remember the content of your message. • Videos are particularly useful and, in the present age, people tend to expect audiovisual presentations. You might also consider fi lming some demonstrations and discussions to encourage participation and show at a later date. • Demonstrations, perhaps with the help of a colleague, can be helpful when speaking to a group. For example, you could show what it is like to have a hearing loss, or show what happens when people have their hearing tested at the clinic. When demonstrating an action you want people to replicate, audience participation is essential. • You can give your audience a leafl et or information Raising want rather than telling them what you want. Find out sheet to take home and read, which will help them awareness about the community’s needs, preoccupations, living remember your message. in schools. conditions, and the diffi culties they would face if they CHINA • SMS reminders can be used to inform people of were to change their behaviour. meeting dates and locations. Mobile phone use is You should also enquire about the community’s current widespread and people tend to keep their numbers. behaviours in relation to health (do they go to traditional • Consider organising some of your meetings in healers fi rst? what are their main heath concerns?). locations that are relevant to your message. E.g., in Knowing this ‘baseline’ behaviour will help you the Inuit community where noise-induced hearing loss determine whether there has been any change later. is a major problem, the audiology team (see page 9) You may also fi nd it useful to conduct a Knowledge, attends loud music concerts to give information about Attitude and Practice (KAP) survey, or organise focus group noise damage and distribute earplugs. 2 discussions and structured interviews. • Think of more playful ways to engage people. For Encourage ownership example, you could organise the performance of a short You may know what community members should be play. You could also organise a raffl e in which people doing differently, but they hold the key to how this can must fi ll out a form about noise effects to participate. be achieved in their context. Mass media Try putting community members ‘in Raising awareness • Explore what media works best for your community. charge’ as they know best what might Ask them how they usually communicate, where they and empowering work in their particular circumstances. “ get their news from and which media have their Empower them to fi nd solutions, people to take preference. It might not be the print media if illiteracy identify individuals with leadership is an issue or if people can only speak but not read a action is a long-term skills and form coalitions of the willing. local language. Perhaps they would respond to Often, once members of the endeavour, requiring community radio or an SMS campaign. community have developed a greater a variety of means of Make your message clear, simple and easy to awareness for a specifi c topic, they tend • remember. For example, CLaSH (see page 10) used the communication to identify other areas of concern. They following catchphrases for radio adverts and banners: also start trusting each other, and ‘No hearing does not mean no sense’, ‘My eyes can helping ”each other more than before they took action hear, my hands can talk’. You could also refer to Helen together to improve their health. Keller’s observation that, if blindness cuts us off from things, deafness cuts us off from people. Communicating your message • Make sure your message is broadcast at an appropriate Key principles time, when your target audience is usually listening or • Simplify messages. Use simple and practical language, watching. be brief and avoid technical details. • Break down information into ‘digestible’ bits that Conclusion can easily be put into practice by your audience in Raising awareness and empowering people to take action their context. Giving out too many recommendations is a long-term endeavour, requiring a variety of means of at once can be confusing, overwhelming or discouraging. communication. Involving community members will • If needed, adapt your health message to your enhance your chances of success and help you overcome context. For example, state how a change of behaviour some of the obstacles to changing behaviour. will benefi t this particular community. • Pre-test your message on a few community members or on a small community and make necessary 1 Facts for Life contains a useful and practical chapter on changing behaviour, which can be found online: http://www.factsforlifeglobal.org/00/guide.html adjustments before circulating it more widely. 2 For an example of how to conduct a KAP survey, see: • If needed, use reliable translators to translate your http://www.stoptb.org/assets/documents/resources/publications/acsm/ message into local languages. ACSM_KAP%20GUIDE.pdf

Community Ear & Hearing Health Volume 10 • Issue 13 (2013) 5 Key messages Key messages to raise awareness of ear and hearing health in the community

ealth professionals and community workers, Provide dietary supplements during pregnancy Diego J Santana • -Hernández particularly in primary health care, have the (iodised salt, folic acid, iron when indicated, etc.). ENT Surgeon Hresponsibility to make sure communities are • Avoid ototoxic medications during pregnancy. CBM’s Senior Advisor for aware of ear and hearing health. They can raise • Identify the presence of herpes in the mother Ear and Hearing Care and awareness by explaining and demonstrating how to before delivery. Coordinator of the EHC prevent ear disease and hearing loss and how to Advisory Working Group; Perinatal care identify problems and seek advice early. Santa Cruz de Tenerife, Promote delivery by midwives or health professionals. It is helpful to tailor health and prevention messages • Spain Promote delivery at healthcare centres or hospitals. to the people you are addressing, by considering what • Promote hygiene during delivery (e.g. suspect risk factors they are exposed to and what actions • cytomegalovirus). they can take to protect their own ears and hearing. • Identify congenital ear malformations and refer early. • Identify very low birth weight (under 1.5 kg) and Raising awareness amongst refer. maternal and child health workers • Identify extreme prematurity (less than 7 months of pregnancy) and refer. Health workers involved in infant and maternal care • Identify and treat neonatal jaundice. should be made aware of the preventive measures • Avoid the use of ototoxic medications. that can be taken at the following stages to avoid ear and hearing problems: Infant care Before or during pregnancy • Promote breastfeeding. • Immunise children, young women and women of • Promote basic hygiene (e.g. hand washing). child-bearing age against rubella (WHO recommends • Promote ear care: e.g. mothers should avoid introducing anything in the ears (see next to only start a rubella immunisation campaign paragraph and pages 3 and 12). when a coverage of at least 80% can be attained Promote the prevention of ear disease at home and to avoid immunisation during pregnancy). • (see next paragraph). Enquire about any history of hereditary hearing • Immunise against tuberculosis. loss in the family. • Immunise infants against measles, mumps and Encourage women to attend all their prenatal • • rubella (MMR). appointments and check-ups. Immunise against Haemophilus and Pneumococcus. Instruct mothers on the prevention of toxoplasmosis • • Avoid using ototoxic medications. during pregnancy. • • Prevent and/or treat syphilis before or during pregnancy. • Highlight the importance of good nutrition during Protecting your ears and hearing pregnancy. at home People are often unaware that it is not health WHEN TO CONSULT A DOCTOR ABOUT YOUR EARS AND HEARING professionals who are in the best position to prevent A good outcome is much more likely if you see a health professional as disease, but the persons themselves. soon as possible. You should consult a doctor in the following situations: Below is a list of messages to introduce the concept of ‘Prevention at home’: • Discharging ear* • It is important to allow your child to be immunised • Bad smell emanating from the ear with all vaccinations included in your local health • Continuous itchiness or scratching of the ears programme, as many times as advised. • Breastfeeding your child helps prevent infections • Redness or swelling of the ear or surrounding area and provides them with good nutrition. • Earache (with or without fever) • When you cook, make sure there is adequate ventilation for the smoke to dissipate quickly. You think you may have a foreign body stuck in your ear • • Avoid smoking inside the home (ideally do not • You feel that your hearing is poor, e.g. you have problems taking part in smoke at all). everyday conversation • Clean the house regularly. Protect yourself from mosquitoes by using bed • You think your child cannot hear everyday sounds • nets, especially for children. • Your child is not developing speech and language at the same rate as • Avoid exposure to loud noise and to industrial children of a similar age solvents, as both can damage the ear. Do not use Q tips (cotton buds) or put any hard *Note: A discharging ear with any of the associated symptoms listed below • could be a life-threatening complications and needs urgent attention: object in the ear. earache, fever, headache, facial weakness, dizziness or drowsiness. • Do not allow dirty water inside the ear (dirty rivers or swamps).

6 Community Ear & Hearing Health Volume 10 • Issue 13 (2013) SH The practice of designating ‘ear monitors’ has been CL a very successful in some settings. The ear monitor is a schoolchild, nominated by the teacher, who speaks to the other children, asks them if they can hear or have any problems, and records the answers in a notebook which they hand over to the teacher once a week. The teacher can then relate this information to each child’s performance, talk to the parents and suggest the child sees a doctor if necessary.

Raising awareness in the workplace Because our jobs enable us to provide for our families, we can be in a vulnerable position when our duties in the workplace go against the preservation of our good health. Labour laws exist to avoid this confl ict, but not all countries have laws protecting the ears, hearing and head. In addition, in some developing countries, the Awareness workshop for • Do not use ear medication that has not been laws may exist but are not enforced in the workplace. parents of deaf children. prescribed by a doctor or healthcare worker. Although it is an employer’s responsibility to adhere NAMIIBIA • Consult a health professional as soon as possible if to labour laws, in this less than ideal world workers one of your children has runny ears, if anyone in need to contribute as much as possible to preserving your family has an ear problem, or if a teacher or their ear and hearing health. relative has noticed a problem (see also Box on It is important to raise awareness amongst workers page 6). of the following preventive measures: • Mothers can also be encouraged to check that • Always wear ear protection in a noisy environment . their husbands, children and extended relatives can • Make sure your ear protection is in good hear well and do not have ear problems. condition and is adequate for the level of noise you are exposed to. Change it if it is damaged. Raising awareness amongst • Keep your ear protectors for your own use only and keep them clean to avoid irritation or teachers infections of your ear canals. If health workers and the child’s relatives have not • Make sure the duration of your exposure to the been able to prevent an ear or hearing condition from noise is reduced if exposure is unavoidable (even occurring, teachers and educators may be the fi rst to with appropriate ear protectors). There are identify a problem. international standards for maximum duration of It is very important that health and community exposure depending on the intensity of the noise workers support the teachers in this ‘extracurricular’ (see page 11). role, so that they may become a strong ally in the • Do not listen to music or use the earpieces as fi ght against ear disease and hearing loss. ear protection or ‘distraction’ from the external Teachers can be taught to identify the signs of a noise (not even under cup ear protectors). The potential hearing problem. A child who does not hear earpieces of personal music players are not designed well may display some or all of the following: for noise protection and their loud volume in a noisy • Does not speak clearly or confuses his words. environment will only add up to the noise damage. • Gives wrong answers to clear questions. • Avoid exposure to solvents or protect yourself • Does not like participating in daily activities in the with appropriate facemasks. Solvents (varnish, classroom. paint, gasoline, other fuels, etc.) also damage your • Is slow to progress compared to other classmates. hearing. • Displays poor academic performance for no other • If your work involves exposure to noise and to obvious reason. solvents at the same time the risk of hearing • Seems always distracted and poorly attentive. damage is much greater than the sum of being • Does not cooperate during role play or group activities. exposed to both of them separately (e.g. car body • Does not get involved with other children in the work, noisy petrol plants, etc.). Maximise your ear KRITI GULATI KRITI playground. protection and minimise the duration of your • Becomes aggressive or confused when challenged exposure to these factors. about performance. • Avoid ototoxic medications. Their effects will add • Tends to personal isolation. up together with those derived from noise exposure. • Has a tendency to low self-esteem. • Always wear a helmet when there is a risk of head The teacher should speak to the child’s relatives and injury (riding a motorbike, a bicycle, working with suggest they consult a health professional if any of the heavy equipment overhead, working in a building above signs are recurrent and confi rmed by relatives. site, etc.). Even in hot and humid environments, it is Creating awareness better to sweat than to end up deaf or even dead in the community on The teacher should also suggest the child sees a doctor International Ear Care if he or she presents any of the other symptoms from a head injury. Day. INDIA described in the Box on page 6. Continues overleaf ➤

Community Ear & Hearing Health Volume 10 • Issue 13 (2013) 7 Key messages

• Have your hearing checked at least once a year persons with congenital deafness whether their (ideally every 6 months). deafness is hereditary or not, so that they can base • Seek medical advice if you already have a their family planning on trusted information. hearing loss or ear condition, or if you notice any Deaf people may need medical treatment for ear change in your hearing, tinnitus (noises or ringing infections, or ear surgery for cholesteatoma or other in your ears), earache, ear discharge, itchiness, or serious middle ear conditions. It is important that any other ear symptoms. health and community workers respect persons living • Raise awareness about what your government with deafness or hearing impairment: when a deaf recommends (or should recommend) for protection person comes to a health centre, they are not looking at the workplace. for sympathy, but exercising their right to health, like everyone else. Persons living with hearing loss It is not just access to health services which will lead to the empowerment of persons with disability, and disability but their full participation in all spheres of health Quite often, persons who are deaf have never been work. They should be included in activities aiming to told the cause of their deafness. Some assume their raise awareness in the community, in schools and in children will be born deaf, while others assume that the health system. Hearing-impaired persons can be their children will hear because their deafness was an important advocates for ear and hearing health and isolated incident, when in reality it was due to for the right of persons with disability to live a full hereditary factors. It is therefore important to inform and productive life.

CASE STUDY WEST NEPAL Training community volunteers to teach the prevention of ear disease

RINOS has developed with its partner agencies Robin Youngs BRINOS Consultant a community ear care programme in remote Otologist Brural areas of West Nepal. Raising community Director BRINOS awareness of the prevention of ear disease is one of (Britain-Nepal its most important aims. Otology Service), This programme, established in 2000, was based United Kingdom www.brinos.org. on a successful Community Eye Care and Health uk Improvement Programme (CEHP) Project of the Nepal Red Cross Society and rests on the training Puran Tharu and appointment of ‘community ear assistants’ (CEAs). Chief Community Ear Assistant CEAs are primarily Community Medical Auxiliaries Nepalgunj, (1 year training after high-school), who receive an Nepal intensive additional 3 months’ course in ear care, over one year. Although the CEAs were initially Community Ear Assistant testing a person’s hearing. NEPAL trained by doctors from the Bheri Zonal Hospital in Nepalgunj, current training is now undertaken ‘in The CEAs, with the support of the community house’ by the senior CEAs. volunteers, undertake a number of important Community volunteer The CEAs in turn are responsible for the training of a functions including: teaching the prevention large number of village community health volunteers. A • Primary ear health care education of deafness and ear large pool of community volunteers is available in • Deafness screening in schools and villages disease. NEPAL Nepal, thanks to two government initiatives. The fi rst is • Treatment of ear infections a network of 800 Village Development • Referral of cases for middle ear surgery Committees (VDCs) that provide an • Hearing aid issue and maintenance administrative framework for the organisation of local public health Since 2000, six CEAs have been appointed, covering awareness. The second initiative is a the districts of Banke, Bardia, Surkhet and Dailekh programme of Female Community (which cover a population of around 2 million people). Health Volunteers (FCHV) which has Partnership with the established network of Community existed since the late 1980s. The Health Volunteers has been a key element for success. success of this programme, which The programme is partly sustainable in that loses fewer than 5% of its volunteers patients pay a small amount for consultations, annually, has been attributed to a medication, hearing aids and operations. The parallel good understanding by policy-makers eye care programme is now fully sustainable and it of the volunteers’ expectations and is the ambition of the ear care project to achieve the offer of incentives appropriate to this position in the future. the local context.1 There are 50,000 1 Glenton C et al. The female community health volunteer programme FCHVs in the country and our CEAs have in Nepal: decision makers’ perceptions of volunteerism, payment and

BRINOS been able to liaise with 880 of them. other incentives. Soc Sci Med 2010 Jun;70(12): 1920–7.

8 Community Ear & Hearing Health Volume 10 • Issue 13 (2013) Case study

CASE STUDY CANADA Raising awareness of noise damage amongst Inuit hunters and fi shermen in Nunavik, Canada

here are approximately 50 000 Inuit in Canada, these tools and their history of noise exposure. We Hannah Ayukawa and 20% of them live in the northern part of found that employers provided earmuffs or earplugs Audiologist Tthe province of Quebec, known as Nunavik. for use in jobs that were noisy, but that noise Tulattavik They were living a nomadic lifestyle until the 1950s protection was seldom used in traditional activities. Health Centre, when they were gathered into villages. This signifi cant With the help of community members, some of Kuujjuaq, change has had an impact on their health. the obstacles to wearing ear protection were Quebec, Canada In 2004, in the course of a survey organised by the identifi ed. For example, one of the Inuit health care Regional Board of Health, the prevalence of hearing workers was a frequent hunter. He came to the loss in Nunavik’s Inuit population was measured meeting convinced that Inuit men would not use using a modifi ed WHO population survey and hearing protection, because hunters had to be able

NBHSS found to be high: one in four adults have bilateral to hear well in order to hunt. Another obstacle was hearing loss. The prevalence is associated with inadequate access: the only forms of ear protection gender: in men aged 18–74 years, 36.6% had available to purchase in the community were foam signifi cant bilateral hearing loss, three times higher earplugs and regular earmuffs, which were disliked. than in women of the same age group. More than Trying on different 75% of men aged 45 years and older had bilateral Finding solutions with the community types of ear protection hearing loss, compared to 25% of women.1 During the week, participating health personnel and during a community Men are more exposed to damaging levels of noise community members tried out different types of ear meeting because of their involvement in traditional activities protection. These included, besides foam earplugs: of hunting (fi rearms), ice fi shing (motorised ice drills), plastic military earplugs (which cut impact noise), and carving (grinders). Indeed, men who hunted regular earmuffs, hunters’ earmuffs and helmets. We more than once a week had more hearing loss than learned that people preferred what is known as the those who hunted less frequently. ‘hunter’s earmuff’. This battery-powered device has a HANNAH AYUKAWA In view of the survey results, we realised that we microphone and amplifi es soft sounds, allowing the needed to raise awareness about noise-induced hunter to hear better.The microphone automatically shuts off when the input level is greater than 80dB, so hearing loss and offer solutions. Snowmobiles the earmuffs attenuate any dangerously loud sound. contribute to noise- In order to solve the problem of access, managers induced hearing loss Bringing together health workers and of the local stores, as well as the mayor, were invited community members to see these earmuffs and asked about their interest We convened a week-long meeting of Inuit primary

NBHSS in making them available for purchase locally. Because ear health care workers from eight communities of their high cost (approximately US $100), it was together with the local audiologist, occupational suggested that we work through the Hunter Support health nurse and technician. We also invited store, a regional government programme, which community members to participate in some of the could subsidise their cost by approximately 50%. week’s activities. Finally, at the end of the week, the Inuit participants Inuit hunter wearing During the week, besides learning theory, we ear protection presented all our fi ndings on the local FM radio: measured the noise levels of various rifl es and they highlighted the prevalence of hearing loss and shotguns, vehicles, electric power tools and gas explained that, in men, the damage may be caused powered ice drills used by the community. We also by noise exposure. They identifi ed the traditional interviewed community members about their use of activities and jobs likely to cause noise damage and talked about the importance of using appropriate ear protection. In the years that followed, the hunter’s earmuffs

HANNAH AYUKAWA have been used by more and more individuals. They have been sold in local villages at the Hunter Support store. They were a success, since every community that put them for sale sold all their stock. There have been some diffi culties subsequently because of store managers not re-stocking their inventory (possibly because staff changes frequently). We therefore continue to educate new managers of Hunter Support stores each time we visit a community. We also demonstrate the equipment to individuals, concentrating on hunters, young boys, and women who accompany men on hunting trips.

Inuit men suffer more hearing loss because of their involvement in traditional 1 Nunavik Inuit Health Survey 2004. Institut national de santé publique activities such as ice fi shing, which now uses motorised ice drills. CANADA du Québec. www.inspq.qc.ca/pdf/publications/659_esi_hearing_loss.pdf

Community Ear & Hearing Health Volume 10 • Issue 13 (2013) 9 Case study

CASE STUDY NAMIBIA Increasing awareness amongst parents of deaf children through sign language classes ince 1994, our association has run the only poverty on a daily basis. Families who could not Sue Bright Pre-School Unit for profoundly deaf children in afford the taxi costs to attend the sign classes have VSO Volunteer Namibia. It has a principal teacher (hearing) been supported fi nancially. Association for S Children with and three ECD (early childhood development) The families appreciate and positively respond to Language, caregivers (deaf) who teach up to 10 children aged consultation, notably about timing. For example, Speech and three to six years in their ‘mother tongue’, i.e. during the summer months, classes were held on Hearing Namibian Sign Language (NSL). Teaching is very evenings that did not involve church activities for Impairments of Namibia (CLaSH), practical and offers lots of outings into the community. parents. During the dark winter nights, when the Windhoek, The children relay what they have learnt to their families expressed concern for their safety, we Namibia families. This makes parents aware that their child can responded by changing the lessons to daylight communicate, although they do not understand what hours. Recognition of the families’ needs resulted in Heide Beinhauer they are signing. We decided to further increase this the increased and consistent attendance of 12 to 14 Director awareness by organising regular NSL classes for family family members, including fathers, each week. CLaSH, members and caregivers, to enable them to understand Windhoek, and respect their child’s communication needs. Making the classes relevant Namibia The classes are prepared and conducted by an Ensuring attendance by considering families’ needs experienced deaf education specialist from the The weekly classes are promoted during home visits United Kingdom, together with a deaf caregiver or parents meetings and reminders are sent every from the Unit. Lessons are fl exible and adapted to Sign language class for week via SMS. current events or specifi c areas of child development. parents of profoundly Most of the families are from vulnerable and The content of the course is examined continuously deaf children. NAMIBIA marginalised communities who struggle with to be relevant for the needs of three- to six-year-old children and their parents. The families can SH

CL a immediately see the purpose of the signs and use them on a daily basis. They love to show the signs their children use at home and ask about the ones they do not understand.

Creating a sense of community The NSL classes have proved to be a good opportunity for parents to talk about their concerns for their children, e.g. sleep problems, toileting and behavioural challenges. It is obvious that the parents love to talk to each other about their children. As one father said: “I have hope for my daughter now that she attends the Pre-School Unit. I can see she is learning and achieving. We can attend sign language classes as a family and can communicate together. We are not alone.”

OBITUARY DR PIET VAN HASSELT (1944 – 2012) By Andrew Smith r Petrus (Piet) van Hasselt, who died on 31 Piet, with Mieke’s help, performed ear operations August 2012, was a superb ENT surgeon, a and trained local ENT surgeons, and practised meticulous and innovative researcher, and, and taught primary ear and hearing care. D Andrew Smith with his wife Mieke, a visionary who brought ear and Piet’s knowledge, expertise and practical ideas hearing care and teaching to the most disadvantaged were vital in developing the World Health people in Africa. He was also a co-founder of Organization Training Resource on Primary Ear Community Ear & Hearing Health. and Hearing Care and he joined its Advisory Piet was born near Nijmegen, Netherlands, the Group. He brought a similar approach to this youngest of 14 children. He graduated in Psychology journal, and served on its Editorial Committee. in 1968, PhD cum laude in 1972, and Medicine in Piet was a staunch friend, always helpful, 1977, specialising in ENT. always hospitable and always willing to share Piet and Mieke’s dream had always been to work his love of Africa, especially its poorest parts. in Africa. In 1994, CBM employed them to build up For their work in Africa, Piet and Mieke were an ear and hearing clinic in Ramotswa, Botswana, honoured with the Netherlands Order of Oranje- where I fi rst met them. Over nine years, similar Nassau in 2008, and, in 2011, Piet was made clinics followed in Madagascar, Malawi and Zambia. Chevalier de l’Ordre National in Madagascar. Piet at work in Madagascar

10 Community Ear & Hearing Health Volume 10 • Issue 13 (2013) Noise damage

Important note: the noise levels and The effect of noise on hearing durations indicated on this graphic are approximate The times shown on the graphic indicate how long you need to be exposed and should only be used to the noise for your hearing to be damaged permanently. Permanent noise as a guide. damage is often not immediately perceptible by the affected person. However, over time and with repeated exposure to noise, the effect will be cumulative and manifest itself as permanent hearing loss. Noise level in The damaging effect of noise also depends on a person’s decibels distance from the source of the noise and on their (dB) individual susceptibility.

Jet taking off (25m away) Gunshot 120 dB

Pneumatic hammer 110 dB 1 minute Noisy nightclub

Chainsaw

100 dB 15 minutes Angle grinder 97 30 minutes

Personal stereo (max. volume) 94 1 hour

Ride-on lawn mower 91 2 hours 90 dB 88 4 hours

85 8 hours Busy road

Power lawn mower LANCE BELLERS 80 dB ALL PHOTOS WIKI COMMONS (EXCEPT WHERE STATED) ALL PHOTOS WIKI COMMONS (EXCEPT 75 – Below this level 70 dB hearing damage Conversation 60 dB is negligible

This graphic has Washing machine 50 dB been adapted 40 dB with the author’s permission from: Library 30 dB Padman Ratnesar, A General Practice Leaves rustling 20 dB Guide to ENT Sound studio Problems, Figure 32 10 dB page 73. Threshold of normal hearing 0 dB

Community Ear & Hearing Health Volume 10 • Issue 13 (2013) 11 Community Ear Hearing & Health Do not swim in dirty water or let dirty into water the ears Do not insert objects into the ear, especially not cotton buds a Consult health as worker soon as possible if in anyone family your has an ear or hearing problem

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LANCE BELLERS LANCE RICARD P SMITH ANDREW

Breastfeeding Breastfeeding child your helps protect them from infections and provides them with good nutrition In case of ear discharge, mop with a clean cloth and see a doctor as soon as possible Avoid exposing to yourself loud noise or a for music long time. Protect with yourself orearplugs earmuffs

PIET VAN HASSELT VAN PIET HASSELT VAN PIET SMITH ANDREW It is important your to allow child to be vaccinated healthcare by workers Avoid cigarette smoking and clear your home from causedsmoke cooking by Do not put put herbal or remedies ‘ear candles’ as in the ear, could they be harmful How to take care of your ears your of care take to How

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ROMAIN GUY ROMAIN RICARD P PIPPA RANGER/DFID PIPPA

12 Community Ear & Hearing Health Volume 10 • Issue 13 (2013)