I’ve always been interested in the ‘bigger picture.’
As much as I loved working clinically, I often found myself thinking about gaps in hearing healthcare. For example, why are so many people in vulnerable communities living with untreated hearing loss?
This is why I decided to head back to university this year to study a Diploma in Public Health. A significant area in Public Health in New Zealand is understanding and working to resolve health inequities in our indigenous Māori population.
Why is the Māori population considered ‘vulnerable’ in hearing healthcare?
To provide some background, in New Zealand, the prevalence of hearing loss is in all persons from 60-69 years is 14.87%, and in Māori populations, 32 % over the age of 65 years report experiencing hearing loss.1 Prevalence and self-reported disabling hearing loss is higher yet they have a greater unmet need for special equipment (30.4%) compared to non-Māori (17.4%).1
Using a Māori model of health
To address challenges in Māori populations, it’s important we use frameworks that are appropriate to Māori culture. Te Whare Tapa Wha literally translates to a ‘four-sided house’ and describes the four dimensions that are essential in maintaining well-being.2 It includes:
|1. Taha wairua (spiritual health); 2. Taha hiengaro (mental health); 3. Taha tinana (physical health); and 4. Taha whānau (family health).|
Should there be any damage or loss of one of these components, the house is ‘unbalanced’, and the person becomes unwell.
So let’s use Te Whare Tapa Wha to look at how hearing loss and social isolation can impact overall being. Once we do that, we can look at ways to improve hearing healthcare to reduce inequities associated with untreated hearing loss.
Hearing loss, social isolation and ‘Te Whare Tapa Wha’
- Taha wairua (spiritual health)
In any community, it is essential to feel a ‘part’ of something, whether it be a local community group, cultural activities, church or friends and family. Hearing loss can result in disconnection to the community in which we live and a reduction in spiritual health.
For example, in the Māori world, connection to the indigenous language, Te Reo Māori, is considered essential for their cultural identity.2 Kaumātua (elders), who are at the most significant risk of age-related hearing loss, are often responsible for leading and facilitating huis. Untreated hearing loss can result in their disengagement from such meetings.
- Taha hinegaro (mental health)
Untreated hearing loss can significantly impact mental well-being. The 2021 World Report on Hearing stated that those with hearing loss are more likely to experience depression and report a lower quality of life when compared to their normal hearing counterparts.4
Those with hearing loss will often withdraw socially, feel ‘left out,’ and have stilted and altered social interactions. It is also common to feel embarrassed, rejected and anxious.
- Taha tinana (physical health)
Physical health (taha tinana) can be compromised, where those with a hearing loss are at an increased risk of sedentary behaviour due to reduced engagement in activities.
Often this reduction in engagement is a result of feelings of embarrassment when not following conversations easily or having to ask for repeats. Further, we also know the increased listening effort associated with hearing loss increases overall fatigue.5
- Taha whānau (family health)
Hearing loss has a ripple effect on not only the individual but their spouse and whānau (family) too, which the WHO defines as a third party disability.4,6 This means that the social restrictions placed on the hearing impaired person may also be placed on the family, impacting taha whānau.7
It is evident that untreated hearing loss has a significant impact on the overall well-being of the individual and their family. It is no surprise that unaddressed hearing loss is the third largest cause of years lived with disability globally.4 More concerningly, approximately only 1/3 of those with a hearing loss wear hearing aids.8
Why is it that very few people who need hearing healthcare access it?
The barriers to access in hearing healthcare are likely multifaceted and include persistent social stigma, inequitable access to hearing health care and lack of awareness around hearing health and the risk of untreated hearing loss.
We also know that hearing loss itself can limit access to education and healthcare (the social determinants of health) creating a vicious cycle.9
This Maori model of health is a reminder that well-being is multifaceted. It is also a reminder that health systems need to be structured to cater to different population needs in order to overcome barriers and reduce inequalities.
Even though this is a New Zealand example, it is a reminder to all HCPs that a fundamental part of our being is rooted in connection. Hearing healthcare and technology needs to be equitable for all in order to reduce the risk and consequences of untreated hearing loss.
Four ways we can reduce the risk in vulnerable communities
1. Make technology affordable – One recommendation for the 2021 World Report on Hearing was to ‘strengthen health systems to deliver quality hearing health care at all levels.’4 One way to achieve this is making hearing aids more affordable for those in low socioeconomic brackets.
2. Understand lived realities and values – Services and education need to be tailored in a way that address and take into account the day-to-day challenges that these populations face (e.g., the ability to attend appointments which might be difficult due to geographical location or cost of transport). It can also be the ability of the clinician to frame healthcare in the context of day-to-day lives, so that the client understands what the risks are of not treating their hearing loss.
This is where it can be significantly useful having a family member attend the appointment and is a fundamental aspect of Family-Centered Care.10 Read more about this here.
3. Display cultural competency and safety – It is an absolute necessity that clinicians can display practices of both cultural competency and cultural safety to ensure they know their own biases and attitudes.1
4. Deliver health information appropriately – Health literacy regarding hearing protection and rehabilitation should be delivered in a culturally sensitive way (e.g., In New Zealand this can be via local iwis, local marae, and whānau ora navigators).
Bridging the gap in hearing health
No matter where we practice in the world, it is a necessity we promote hearing protection to reduce risk of hearing loss. This is why it’s fantastic we now have Serenity Choice™ protection range to promote hearing protection.
It is also paramount we improve access to hearing healthcare when rehabilitation is needed, particularly in our most vulnerable communities where health literacy can be low.
To do this we need to ensure that services align with the cultures we serve so that the appropriate support is evident throughout the healthcare journey.
So let’s make a noise about the impact of untreated hearing loss and make sure our services reach out most vulnerable communities. In that way, we ensure we have a solid Te Whare Tapa Wha.2
We invite you to read a related article by Dr. Patricia McCarthy on the importance of cultural competence in family-centered hearing healthcare.
1. Manuel, A.R., Searchfield, G.D. & Curtis, E. (2021). Hearing loss and hearing service experiences among older Māori and whānau: a scoping review. New Zealand Medical Journal; 134(1535).
2. Durie, M.H. (1985). A Maori perspective of health. Social Science & Medicine; 20(5): 483-6.
3. Williams, L. (2019). Untreated severe-to-profound hearing loss and the cochlear implant situation: how policy and practice are disabling New Zealand society. New Zealand Med J; 132(1505): 73-8.
4. World Health Organization (2021). World Report on Hearing. Geneva: World Health Organization; Contract No.: CC BY-NC-SA 3.0 IGO.
5. Hornsby, B.W.Y. (2013). The effects of hearing aid use on listening effort and mental fatigue associated with sustained speech processing demands. Ear and Hearing; 34(5): 523-34.
6. Manchaiah, V.K.C. & Stephens, D. (2013). Perspectives on defining ‘hearing loss’ and its consequences. Hearing, Balance and Communication; 11(1): 6-16.
7. Scarinci, N., Worrall, L. & Hickson, L. (2012). Factors associated with third-party disability in spouses of older people with hearing impairment. Ear and Hearing; 33(6): 698-708.
8. Carr, K. (2020). 20Q: Consumer insights on hearing aids, PSAPS, OTC devices, and more from MarkeTrak 10. AudiologyOnline; 26646.
9. Department of Māori Affairs (1989). The Review Team: Whakarongo mai. Report to the Minister of Māori Affairs. In: Affairs TRTWM, editor. Wellington (NZ).
10. Karmali, K., Grobovsky, L., Levy, J. & Keatings, M. (2011). Enhancing cultural competence for improved access to quality care. Healthcare Quarterly; 14 Spec No 3:52-7.