INdigenous Systems and Policies Improved and Reimagined for Ear and hearing care (INSPIRE): a multi-method study protocol


Despite the healthcare system in Australia ranking among the top performers of high-income countries,1 the World Health Organization (WHO) places prevalence rates of chronic suppurative otitis media among Aboriginal and Torres Strait Islander people as some of the highest in the world.2 3 Otitis media, a viral or bacterial infection of the middle ear which can lead to hearing loss,4 has impacts on communication and cognitive development,5 social-emotional well-being,6 school performance7, employment, and income status.8 Between 2013 and 2019, the Australian Federal Government spent an estimated AUD 35.65 million on Aboriginal and Torres Strait Islander ear and hearing health initiatives.9 To date, there has been limited change in outcomes or prevalence rates of otitis media and hearing loss.4 10 The Australian Public Service Commission states that ‘chronic policy failure’ often surrounds complex issues of disadvantage experienced by Aboriginal and Torres Strait Islander people.11

Mitigating impacts of otitis media is complicated due to the condition being a ‘wicked problem’ among Aboriginal and Torres Strait Islander people who experience comparatively high severity and chronicity of otitis media.4 12 Prevalence rates vary, however, recent literature indicates that up to 35% of Aboriginal and Torres Strait Islander children in urban areas present with otitis media at 2 months, increasing to 49% at 6 and 12 months.13 Wicked problems are often multi-causal, socially complex issues, requiring coordinated efforts from multiple agencies across multiple sectors and levels of government.11 Further, health determinants, the underlying cause of the disease, remain poorly addressed.4 Otitis media is a poorly managed condition due to its fluctuating nature, multiple definitions, difficult access and other health priorities. Otitis media is almost exclusively managed in primary care as a brief episodic health condition, however, the broader long-term impacts5–8 of chronic infection on health, education and disability (social services)14 are not fully considered. Managing otitis media and its impacts takes a multi-disciplinary cross-sectorial approach and families must navigate between sectors, systems, and services in order to access timely care.14

The structure of systems and services is shaped by policy, the development of which is a complex process informed and influenced by actors, institutions and political and contextual factors relevant to the intervention.15 16 The interpretations of the term ‘policy’ differ,17 necessitating a clear differentiation between government-crafted policies (public policy) and those formulated by other entities such as private corporations or non-governmental organisations (NGOs). Policies assume an important role in service delivery, and as such, this complexity could lead to service discoordination, hindering the establishment of effective treatment approaches and care.

For the purposes of this study, public policy is defined as a frame for intended action or outcome, including strategies, frameworks, and guidelines,15 18 directing investment and actions (i.e. programs, services, initiatives) with the aim to improve outcomes for individuals and society.18 Public policy development is a shared responsibility of the federal, state/territory, and local governments, which are tasked with the development of federal policy, state/territory policy and local policy, respectively.15 19 Increasingly, governments are engaging relevant organisations and community groups in the conceptualisation, development, and review of public policy.20 21 Governments and other organisations implement policies and deliver intended policy outcomes, supported by funding allocation and key performance metrics and reporting.21

The ear and hearing care (EHC) system itself encompasses multiple sectors and is shaped by multiple public policies, including sector-specific policies, and policy instruments which support implementation. The interrelated nature of these means that these may have influence beyond the intended scope. For example, post-surgical review outcomes (e.g. hearing loss magnitude) for patients are directed by health policies, the outcomes of which may impact patient interaction with social services (e.g. National Disability Insurance Scheme eligibility) and the education sector (e.g. classroom amplification needs).22 Moreover, a large portion of the intervention demand is shouldered by the private healthcare system. While public policy can influence these behaviours, a disconnection may emerge, intensifying the intricacies of care.

The WHO’s six system building blocks provide a health systems framework (hereafter referred to as the framework) to understand the components which define a system, whereby leadership and governance include policies and policy makers.23 The framework describes health system components, which, if performing, will achieve social and financial risk protection, responsiveness, and improved health and efficiency.23 An extended scope of the framework has been presented here to describe multiple components of the system which influences outcomes for EHC (table 1).

Table 1

WHO Health Systems Framework

Continued reporting of high severity and chronicity of otitis media4 as well as poorer life outcomes24 point to a breakdown along the current EHC system for Aboriginal and Torres Strait Islander people. Such breakdowns can take place at a micro (service delivery), meso (health professionals) and/or macro (policy) levels. Coordinated cross-sectorial policy actions are critical to whole-system performance, however, it is unclear to what extent policy gaps are responsible for this system breakdown. Effective public policy and robust implementation are crucial to the improvement of the EHC system performance, which, in turn, may contribute to closing the gap in education and life outcomes for Aboriginal and Torres Strait Islander people.

The key objective of INdigenous Systems and Policies Improved and Reimagined for Ear and hearing care (INSPIRE) is to improve the EHC system for Aboriginal and Torres Strait Islander people through establishing nationally applicable policy solutions with strong leadership and representation (at least 50%) of Aboriginal and Torres Strait Islander ear and hearing stakeholders. The study will use a Brains Trust which will inform a culturally appropriate methodology and maintain high-quality research to deliver consensus-based policy solutions for EHC.

The key objective of the study will be achieved through a scoping review, yarning circles, and an expert Delphi process with specific aims: (1) to scope public policies in hearing health, social services and education to identify policy gaps, using the WHO framework, (2) to identify challenges and/or limitations in the policies (identified in the scoping review) in enabling accessible EHC programs/services for Aboriginal and Torres Strait Islander people and (3) to establish consensus-based EHC policy solutions for Aboriginal and Torres Strait Islander people.

This post was originally published on