Children with otitis media in Greenland - A qualitative study of parental experiences.

INTRODUCTION: The Greenlandic population has one of the world's highest prevalence of otitis media (OM). Approximately 9-14% of all children suffer from OM during childhood. Due to the climate, lack of infrastructure, and minimal access to specialist services, the Greenlandic healthcare system operates under significant challenges. To support treatment implementation, we explored parental experiences of having a child with recurrent acute otitis media (rAOM) and chronic suppurative otitis media in Greenland (CSOM). METHODS: We applied a qualitative methodology with semi-structured interviews, to investigate parents' individual experiences. We included parents from six selected towns and settlements in Greenland, who were primary caregivers to minimum one child who had suffered from rAOM or CSOM. The interviews followed a semi-structured interview guide. RESULTS: Eight interviews were conducted with ten parents (nine mothers, one father) to 13 children (nine girls, four boys) aged two to 20 years (median age five years). We carried out a hermeneutic-phenomenological, Ricoeur-inspired text analysis of data. The first episode of OM was associated with uncertainty about the condition, including pain relief and treatment. However, recurrence led to symptom recognition and a changed disease perception among the parents: from being a simple case of childhood OM to a recognition of a chronic condition that might lead to delayed linguistic development and hearing impairment. CONCLUSION: Under difficult healthcare situations, parents represented a unique resource in care and treatment implementation. Parents often feel alone with the responsibility of care and had concerns for their child's hearing and language development, and they wished for their experiences and observations to be actively included in consultations.

Acute otitis media and pneumococcal vaccination - an observational cross-sectional study of otitis media among vaccinated and unvaccinated children in Greenland.

Streptococcus pneumoniae is one of the main pathogens leading to otitis media. In 2010, the 13-valent pneumococcal conjugate vaccine (PCV13) was implemented in the Greenlandic childhood vaccination programme, but the effect of this change is not yet well documented. The objective of this study is to evaluate the effect of the implementation based on the number of episodes of acute otitis media (AOM). Data are obtained from medical records. We included all children born from 1 January 2015 to 30 September 2016, and thus eligible for the three doses of PCV13 including one year of follow-up time. Exclusion criteria were uncertain vaccination status and predefined comorbidities. The children were divided into two groups based on vaccination status: "Vaccinated" or "Incomplete/delayed". We included 1077 children in total, 742 children were allocated to the "Vaccinated" group and 335 children were allocated to the "Incomplete/delayed" group. There were significantly fewer episodes of AOM in the "Incomplete/delayed" group (p = 0.01). In conclusion Greenlandic children completely and timely vaccinated with PCV13 and born between January 2015 and September 2016 did not have fewer episodes of AOM compared to children who had incomplete or delayed vaccination status. Abbreviations: PCV13: 13-valent pneumococcal conjugate vaccine; OM: otitis media; AOM: acute otitis media; CSOM: chronic suppurative otitis media; WHO: World Health Organisation; NTHi: nontypeable Haemophilus influenzae.

Smartphone otoscopy by non-specialist health workers in rural Greenland: A cross-sectional study.

INTRODUCTION: Greenland has one of the highest prevalences of otitis media in the world. However, access to ear specialists throughout Greenland is limited and currently there are no national guidelines for treatment or prevention. Tele-otoscopy may be beneficial in optimizing diagnosis and treatment. The smartphone otoscopy device, Cupris®, has previously been validated when used by medical doctors on a population primarily consisting of adults. In this study we evaluated the usability of the Cupris® otoscope when used by local health care workers with different levels of training and education, examining children aged 1-6 years. METHODS: We conducted a cross-sectional study in three Greenlandic towns. Health care personnel were asked to perform video-otoscopy on children contacting the health clinic for any reason. The videos were sent for remote evaluation by three ear specialists who rated the videos on a five-point Likert scale and provided information on challenges with the videos. The dichotomous outcome "not useful/useful" was defined as 1-3 and 4-5 on the Likert scale, respectively. RESULTS: In total, 142 videos were recorded on 84 patients. Mean proportion of useful videos was 18.1%, with a modified Fleiss' Kappa interrater agreement coefficient of 0.67 95% CI [0.57-0.76] corresponding to substantial agreement among the three raters. CONCLUSIONS: In this study the usefulness of the Cupris® TYM otoscope did not prove to be sufficient with the presented instruction in the hands of local health care workers when examining Greenlandic children. Focus on training and education of local health personnel is crucial and warranted before advantageous implementation for non-specialist health care workers can be expected.

Parental perceptions and management strategies for otitis media in Greenland.

INTRODUCTION: Otitis media (OM) in Greenland is a substantial problem and the country prevalence is among the highest in the world. However, little is known about how Greenlandic Inuit parents perceive and manage everyday life with children suffering from OM. We hypothesize that having a child with OM has consequences for the families that go beyond the advice and treatment offered in primary health care. METHODS: We conducted a qualitative study based on semi-structured interviews and focus groups with parents to children suffering from OM. The interviews took place in three different Greenlandic regions; the capital Nuuk and two smaller towns in West and East Greenland. Access to specialized health care differs among the regions, creating an underlying difference on the limitations of referral and thereby level of care. We conducted the data analysis using Systematic Text Condensation. RESULTS: In total, 27 parents participated in the study. Although most parents perceived OM as a result of genetic or environmental dispositions, individual perceptions and cultural beliefs of causal associations between behavior and OM co-existed with the general understanding of medical explanation models. This created a sense of guilt among the parents. Some parents felt in control of managing the disease of the child and used medically well-established strategies. Others felt frustrated and considered contact to the health clinics as futile, thereby managing the disease by 'waiting it out'. Emerging themes were shame and stigma related to the symptoms of OM, which led to social isolation as a consequence for several of the families. CONCLUSION: Our results indicate that Greenlandic Inuit families are impacted by OM in a complex and severe manner. Guilt, shame and social isolation were predominant themes influencing the everyday life of the affected families. Perceptions and management strategies go beyond the scope of the medical explanation models which poses a potential challenge for the parents' experiences with the present treatment offer. The results underline the need to develop a broader approach to prevention and treatment for OM - both at the clinical level as well as part of public health promotion at the community level.

The effects of ventilation tubes versus no ventilation tubes for recurrent acute otitis media or chronic otitis media with effusion in 9 to 36 month old Greenlandic children, the SIUTIT trial: study protocol for a randomized controlled trial.

BACKGROUND: The prevalence of otitis media in Greenlandic children is one of the highest in the world. International studies have shown that otitis-prone children may benefit from tubulation of the tympanic membrane. However, it is unknown whether these results can be applied to Greenlandic children and trials on the effects of ventilation tubes in high-risk populations have, to our knowledge, never been conducted. METHODS: The trial is an investigator-initiated, multicentre, randomized, blinded superiority trial of bilateral ventilation tube insertion versus treatment as usual (no tube) in Greenlandic children aged 9-36 months with chronic otitis media with effusion or recurrent acute otitis media. With randomization stratified by otitis media subtype and trial site, a type 1 error of 5% and a power of 80%, a total of 230 participants are needed to detect a decrease of two visits to a health clinic during 2 years, which is considered the minimal clinical relevant difference. The primary outcome measure will be assessed blindly by investigating medical records. Secondary outcome measures are number of episodes of acute otitis media, quality of life, number of episodes of antibiotics administration and proportion of children with tympanic membrane perforations. DISCUSSION: This trial will provide evidence-based knowledge of the effects of ventilation tubes in children with middle ear infections from the high-risk Greenlandic population. Furthermore, this trial will improve the understanding of conducting randomized clinical trials in remote areas, where management of logistical aspects is particularly challenging. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02490332 . Registered on 14 February 2016.

Temporal trends in stroke admissions in Denmark 1997-2009.

BACKGROUND: The Stroke burden is increasing in many populations where health institutions may experience more patients. We wanted to examine whether incidence rates and absolute number of hospitalized stroke patients remained stable in Denmark during a 13 years period where exposure to major stroke risk factors decreased, changes in stroke treatment was implemented, and the age of the population increased. METHODS: The Danish National Patient Register was used to identify all subjects 25 years of age or above admitted with a first time stroke in Denmark from 1997-2009. Incidence rates (IRs) and age-adjusted Poisson regression analyses were used to examine trends in age-, gender- and stroke subtype (ischaemic or unspecified). RESULTS: During the 13-year observation period there were 53.5 million person-years at risk (PY) and a total of 84,626 male and 84,705 female stroke patients were admitted to Danish hospitals. The IRs of hospitalized strokes per 1000 PY was 3.21 (95% confidence interval [CI] 3.16-3.27) in 1997, 3.85 (95% CI 3.79-3.91) in 2003 and 3.22 (95% CI 3.16-3.28) in 2009, respectively.Incidence rate ratios of hospitalized stroke events adjusted for age in the period 2007-2009 compared to 1997-2000 were 0.89 (95% CI 0.87- 0.91) for men and 0.92 (95% CI 0.90-0.94) for women.The incidence of hospitalized unspecified strokes decreased from 1997 to 2009 whereas there was a steep rise in incidence for hospitalization with specified ischemic stroke during this period. CONCLUSION: This study found a constant rate of stroke hospitalization in Denmark from 1997-2009. The overall rate of hospitalized strokes adjusted for age decreased during this period.