Table 1.

Observational studies

First Author (year)	Disability/ impairment	Design	Level of Evidence	STROBE score	Population	Setting	Methods	Aims	Key Contributions	Conclusions/recommendations	Strengths	Weaknesses	Category
Aithal, S. (2008)	Hearing	Observational	IV	17.5	Indigenous children (n = 15): 1) English- speaking w/no hearing loss; 2) learning ESL w/no hearing loss; 3) ESL with hearing loss; mean age 13	Island 80km north of Darwin	Hearing test	To examine the effect of hearing loss and native-language phonology on learning English by Australian Indigenous children	ESL children has slower recognition time of English words; hearing impairment related to OM made it even more difficult for ESL children	Phonological awareness programs need to be part of a reading program from preschool for ESL Indigenous children	Inclusion of control group	Sampling not described; use of interpreter not discussed	R
Gunasekera,H. (2007)	Hearing	Cluster survey of consecutive primary health consultations	IV	21	Primary care consults on OM in Indigenous (n = 280) and non- Indigenous (n = 8,510) aged 0–18 years	Australia	secondary analysis of national survey	To assess clinical management of OM in Aboriginal children	Indigenous kids more likely to have severe OM, but not more likely to receive oral antibiotics, ear syringing, referral to specialist.	Indigenous children are 5 times more likely to be diagnosed with severe OM than non-indigenous children, but management is not substantially different; inconsistent with established national guidelines.	Representative national survey of health care consultations; randomized sampling of health consultations	Prevalence and incidence infeasible; no data on progress, treatment of cases; age range only 0-18	A
Gunasekera,H. (2009)	Hearing	Cross-sectional survey	VI	18	AMS medical practitioners managing children's OM in December 2006	Australia	Postal survey	To compare the burden of OM managed by AMS practitioners and the availability of specialist ear health services in rural/remote versus urban Australian settings	More cases managed/week in rural remote and more reported relevant services were not available locally; audiology waiting times longer than the recommended 3 months; equal proportions of urban/rural reported ENT waiting time longer than the recommended 6 months	Need for adequate funding of visiting services in rural/remote settings and outreach programs delivered by Aboriginal HPs, increasing frequency of audiologist visits to rural and remote locations, proportionate hearing service expenditure should reflect the population’s need as well as rurality indices.	Nearly 3/4 of AMS’s represented; audiology assessments had face validity with clinicians an in line with international	55% response rate; no independently verification of waiting times; no comparison	A
Howard, D. (1991)	Hearing	mixed-method; ethnography	VI	8.5	23 Aboriginal students in multi- grade Aboriginal class	Darwin	observation, physiological assessment, teacher interviews & survey	To investigate relationship between Aboriginal children's hearing loss and their learning.	30% of children had hearing loss; teacher- oriented learning behavior associated with attendance and achievement	Hearing loss appears to magnify difficulties in cross-cultural education; need to consider how schools currently meet needs of Aboriginal students with hearing loss and how Western schooling can be altered to better meet these needs.	integration of interview and survey data; Aboriginal teaching staff included; observation longitudinal	limited information on recruitment, interviews; single observer	R
Howard, D. (2006)	Hearing	Case study	VI	14.5	Urban Aboriginal children	Darwin	classroom observation and hearing assessment	To identify cultural differences in attentiveness between Aboriginal and non- Aboriginal children; to examine differences between urban hearing and hearing-impaired Aboriginal children.	Cultural differences in attentiveness style in Aboriginal students with and without hearing loss may lead to inaccurate assessments by assessors.	Without formal screening, cross-cultural misunderstanding is likely to inhibit appropriate teacher referrals of Aboriginal children for hearing tests; regular school hearing screening for Aboriginal children is needed; Teachers to be aware of possible behavioral indicators of Aboriginal children’s hearing loss.	mixed method; integrated data	small sample; single observer	R
D'Aprano, A. (2011)	Development	tool assessment via cross-sectional screening	VI	18	124 Australian Aboriginal children, aged 3–7 years	3 remote communities in NT	pediatrician screening using standardized tool	To trial the Brigance developmental screening tool to identify Australian Aboriginal children at risk of developmental disability and requiring assessment.	All children scored below the cut-off for likely having developmental disabilities or academic delays; all well behind their age peers	Language and cultural relevance, and the method of administration limit the use of tool; need to adapt appropriate instrument to guide developmental surveillance and monitoring in remote Australian Aboriginal communities that incorporates families	Aboriginal research staff involvement; tool sensitive to psychosocial disadvantage	remote-only; recruitment not described; language barriers for some participants; cultural relevance not established for some	R
Howard, D. (2004)	Hearing	Cross-sectional survey	VI	14	167 Aboriginal children	Remote NT	teacher survey and child hearing assessment	To asses extent of social and educational difficulties across cross cultural classrooms.	Aboriginal children with bilateral hearing loss participate less in class, are more disruptive, and require more one to one assistance	Ensure access to Aboriginal teachers and tutors; train Aboriginal teachers and tutors in issues around hearing loss; provide professional development to non-Aboriginal teachers.	teacher report integrated with objective tests; Aboriginal teaching staff included	remote-only; definitive conclusions implausible; no sample size or sampling frame information	R-Q
Bennett, B. (2010)	Development	tool validation within prospective longitudinal cohort study	IV	20	55 urban Aboriginal children at 12 months of age	Southwest Sydney	structured and semi-structured questionnaire; interview; physical exam; social, motor, hearing and speech, eye hand coordination, and reasoning	To determine appropriateness of Griffiths’ Mental Developmental Scales to assess development in cohort of urban Aboriginal children	No significant differences except Gudaga performance scores were significantly less than the reasoning scores in the Griffiths’ standardization sample	Griffiths’ Mental Developmental Scales may be appropriate for urban Aboriginal infants.	Questionnaire administration in person; physician report; 100% response rate; prospective	small sample frame; reasons for poor reasoning performance unclear; definitive conclusions cannot be drawn	R, S
Aithal, V. (2006)	Hearing	Observational; Cross- sectional hearing test; comparison group	VI	14.5	36 Aboriginal children from Tiwi Islands with OM and some hearing loss; (mean age 10); Control group - 62 children from Darwin (normal hearing; mean age 13)	Island 80km north of Darwin and Darwin	Hearing test	To assess utility of masking level difference (MLD) as a measure to detect hearing loss in Aboriginal students with OM history	Aboriginal children showed lower MLD than control group. Auditory processing disorders (APDs) related to early auditory deprivation may have significant adverse effects on school performance.	MLD a less culturally biased measure and more easily administered than many speech and language test procedures.	Comparison group, use of MLD	Sampling not described; uneven groups	S
Nelson, A (2007, 2004)	General disability	Mixed-method (qualitative/quantitative)	VI	12.5	Urban Indigenous families & OTs	Brisbane	Interviews, focus groups, questionnaires	To investigate what constitutes a socially and culturally appropriate OT service for urban Indigenous Australian families in Brisbane	Service provision in context of school favorably; need to develop effective relationships and qualities; understand different backgrounds of client and therapist; address logistical issues of service delivery	OTs may need to make changes to the way in which they organize and deliver services to Indigenous clients.	parents included in sample; majority of participants Indigenous; service coordinated by Aboriginal health service; multiple informants and methods; facilitated reflection of service and practice	limited to 1 service type; children's perspectives not included; potential for response bias	S
Partington, G. (2006)	Hearing	Observational	VI	4	>500 Indigenous students preschool - year 3 (ages 5–8) from 16 schools, >80 teachers and assistants	Western Australia	multi-modal observation, evaluation spanning 2 years; teacher training and interviews, ear health assessment, achievement records, data mapping of classroom observations	To outline effective teaching strategies to improve literacy and education outcomes of Indigenous students	A variety of teaching strategies and environment likely to assist in improving educational outcomes	Teachers and their schools were important factors in improving educational outcomes	theoretical sampling of successful teachers enabled focus on key characteristics, practices	potential for social desirability; no description of sampling, recruitment, response rate; theoretical sampling potentially narrow	S, I

English as a second language (ESL); Otitis Media (OM); Aboriginal Medical Service (AMS); Ears, nose, and throat (ENT); masking level difference (MLD); Auditory processing disorders (APDs); Occupational therapists (OTs); kilometer (km); Category: (R-recognition/awareness; A-Access; S-Solutions; I-Intervention; Q-Sequelae/outcomes); Level of Evidence: I Evidence from a systematic review, meta-analysis of all relevant randomized control trials (RCT) (Strongest); II Evidence from at least one well-designed RCT; III Evidence from well-designed controlled trials without randomization; IV Evidence from well-designed case–control and cohort studies; V Evidence from systematic reviews of descriptive and qualitative studies; VI Evidence from single descriptive or qualitative study; VII Evidence from the opinion of authorities or expert committee reports (Weakest).