Exploration of family/whānau and general practitioner perspectives of paediatric grommet services: a mixed methods study

The interview questions were developed by the first author (MP), an audiologist of European ethnicity, in conjunction with the Ko Awatea co-design team at the study facility to embed Māori and Pacific perspectives and ensure cultural appropriateness within the questionnaire. The questions covered the range of experiences families/whānau may have from pre-referral through to surgery and follow-up care after surgery (Supplementary Appendix S1) and included prompts to stimulate further discussion.

The GP survey was developed by MP, with input from three local GPs (not included in the study) to refine wording and length of the survey (Supplementary Appendix S2). Additional input was sought from a lead GP of a large primary practice to strategise survey distribution and encourage participation. The survey was designed to take less than 5 min to complete and included demographics, five Likert questions (scale 1–5), five short answer questions and space for comments. Survey set-up, distribution and collection of responses was completed using the web application programme, REDCap (Research Electronic Data Capture).¹⁰

Family/whānau participants were contacted by SMS and by telephone. Interviews were undertaken over the telephone (n = 27) or by Zoom (n = 1). To enhance cultural safety, Māori and Pacific families/whānau were contacted, recruited and interviewed by Māori and Pacific research assistants, respectively, from the study facility. European and Asian families/whānau were contacted, recruited and interviewed by a student audiologist of European ethnicity (HF). Interviews were recorded using digital recording devices and transcribed verbatim by the research assistants and HF. Participants were provided transcripts within 2 weeks of the interview and offered 4 weeks to provide amendments to the transcripts and check accuracy of the transcription. A koha (gift voucher) was provided upon completion to each participant.

GP clinics were approached initially by phone or email through the contact information available in Healthpoint. All large GP clinics (defined as more than five GPs) were contacted by phone and a randomised selection of 10 clinics were visited in person ensuring representation across the district. Paper forms of the survey with a QR code survey link were distributed to the clinics visited in-person with a closed survey collection box. Completed forms were collected approximately 2 weeks later. All smaller GP clinics were offered participation through an emailed survey link. Four GP clinics declined to participate.

Participants reported noticing their child’s difficulties communicating and hearing prior to grommet surgery. They had a keen sense of what they considered ‘normal’ development and were aware if their child was not meeting this level or if they were falling behind at school.

She couldn’t even speak at that time. Like you know, she can’t even, like, even talk. (P6)

In the meantime, you know, the family is going crazy because he’s shouting at us, you know? Or he’s turning the TV really loud. (A1)

Despite this awareness, there was a sub-theme of disconnection between understanding that hearing loss can be a symptom of ear disease, and that hearing loss can produce undesirable behaviours. These perceptions involve attributing hearing problems to a child’s supposed lack of attentiveness, selective listening and ignoring behaviour.

For a long time I did feel really, really bad. I felt really bad just, I don’t know, thinking back like, oh my gosh, I really thought she was making this up. You know, being an egg about it. (P6)

Participants faced logistical challenges accessing both primary and secondary health care services for their child’s ear needs. Distance to access services and managing appointments around childcare and work schedules were cited as barriers to receiving care.

Work is quite hard to get off these days and I’ve recently just stopped working to take care of them full-time. (M4)

[I would like] someone just to ring, and or maybe even have a specialist appointment and get them to check and do the hearing test rather than me have to go to the GP and do it. (E3)

Participants also expressed frustration about the lengthy wait times to be seen by the ORL specialists, but also, once seen, to have the surgery. However, only Māori and Pacific participants (compared to European and Asian participants), reported frustrations over what was perceived as delayed referrals from the GP to specialist care when they had concerns.

I was frustrated that it took that long for someone to go because I pushed quite hard, and he ended up getting referred after the third visit and it’s a little bit frustrating. (M4)

The doctor at the time told us it was nothing, sent us away with Pamol and you know, to relieve the pain. And then it got worse a couple of weeks after that, and I took her back in and I said to the doctor I’m not leaving here until I get her referred to like a specialist or something. I didn’t want to be sent away again with like some Panadol. (P6)

After grommet surgery, participants who had follow-up care through specialist services found the process easy, with appointments made automatically for them, although administrative issues meant that families/whānau were not always fully informed of appointment times. In contrast, participants who were discharged to the care of the GP after grommet insertion described the extra effort/planning required to book appointments weeks in advance, due to GPs being heavily booked.

I made a note on my calendar and enter it before. You know, sort of like a couple of weeks, 3 weeks beforehand. (E3)

There was a range of emotions expressed by participants when informed that their child would need surgery. Although some participants were afraid and anxious of the potential pain and complications the procedure could bring, others were just relieved that there was something that could stop their child’s undesirable ear symptoms.

It was suggested when he was little that he get surgery, and I was a bit freaked out by the idea of anyone cutting, or hurting my baby, so I declined the offer. (M1)

I felt relieved because I was told it was going to help. (M9)

Participants expressed acceptance and confidence with the information they received from the professionals, but they also drew on their own or whānau past health experiences with grommet surgery to inform their decision-making. Māori and Pacific participants specifically, expressed a desire for more in-depth health procedure explanations and that this should be delivered in written and verbal formats. They also acknowledged the risk of leaving appointments feeling not sufficiently informed, particularly if they were unable to articulate the questions they wanted answers to.

I feel like the ENT or whoever, you know, decides that should show them, ok, so this is a grommet, you know, this is what is going into your kid’s ear, um, and just educate the parent instead of throwing a piece of paper at them. (P7)

If you don’t understand and you ask questions, they happily go about explaining it. But then again, it comes down to you. You have to make sure that you understand and ask questions. It’s on us the parent or the caregiver to ask questions on behalf of the child. (P1)

But I just felt it was too rushed for the amount of time we had travelled up there because for me, I like to have everything explained to me and what could happen, but there was none of that it was just a quick check, and we were off. (M9)

All participants valued the provision of follow-up appointments after grommet surgery. By and large, they expressed a desire for more frequent follow-ups than what is currently provided or what is logistically possible. Participant reasons for desiring regular follow-up were to confirm that the ear health issues had been resolved by the surgery, that their child’s hearing had improved, and reassurance that they had made the right decision to proceed with the surgery.

We made this decision of getting the grommet so his hearing would be improved, but then there is no factual information that you know, as parents, we put our child through surgery. But did he, did it actually help the cause? (A2)

Additionally, participants viewed follow-up appointments as an opportunity to engage with the specialists and seek further advice and reassurance.

If they go to school and then I am not there to ask questions. I, I’m not present. Yeah. That’s why I like to go in with appointment, so I’m there, present. (P1)

Many participants expressed a desire to see an ORL specialist or audiologist for their follow-up appointments. This was due to the perception that these clinicians had the most ear-specific knowledge, and their competency was valued highly. The rapport that participants had with clinicians was also seen as important and participants expressed a strong desire to feel listened to.

That’s just more what they are trained in, I guess. That’s what they do every day, and whereas the GP covers so many different things….I just feel more reassured going to someone that specialises in that area. (E2)

Yes, [specialist] was amazing. She listened to everything I had to say, and she explained everything. She was amazing. (M7)

Although many participants appreciated follow-up care in familiar settings they had been to before (as this was seen as best for their child), the availability of clinicians and short wait times to receive care were deemed to be particularly important for Māori and Pacific whānau.