Proper hygiene is an issue that is usually attributed to prevention of many health problems. The ear is an important organ that is responsible both for hearing and maintenance of the equilibrium1. However, aural health is an issue that is not well-known to all individuals in various populations. Problems associated with this organ may be caused by lack of awareness and improper practices. Socio-demographic profile and educational background may be a factor in the maintenance of proper aural health. In the four-year census of Department of ORL-HNS in a tertiary Government hospital in Manila1, ear concerns or Otology-related complaints rank first in the out-patient department and second in the emergency room department. Ear-related concerns include but are not limited to ear pain, ear itchiness, ear discharge, and/or hearing loss. Hence this study is implemented to explore the common misconceptions, awareness, and usual practices of a community in Manila. Ensuring that the aural health may be maintained and correct practices is an important factor to limit ear-related concerns. This research aims to explore the common knowledgeability, attitude to ear concerns and what individuals or head of household does when faced with ear problems, either with self or the members of their household. This study aims to determine, or confirm, the relationship of socio-demographic profile affecting the household’s knowledge, attitude, and practices towards aural health. It will expose the common misconception of the improper or unhygienic practices that the general population is following and determine what the population will need to be educated to. This may also help to formulate proper health education materials to teach aural hygiene.

This is a cross-sectional study using self-administered validated questionnaire, which will be filled out by the head of each household in a community in Manila. This study was accomplished according to the recommendation of Tsang, et. al, 2017[3]. The questionnaire was formulated based on the usual ear concerns found at the out-patient and emergency room department of one of the tertiary government hospitals in Manila. The questionnaire will also incorporate the sociodemographic data of the respondents including age, sex, educational attainment, and monthly household income. Questionnaire was developed in English, and was translated into the Filipino language. This is then validated by subject matter experts, content validity ratio and content validity index was computed using Lawshe’s test. Pilot testing was then done for face validity, and Cronbach’s alpha for internal consistency. Sample size computation was done using EPI Info Version 7.2.2.6, with 5% margin of error, adding 20% to the sample size for attrition. The data was encoded and grouped according to presence or absence of exposure. The data obtained from sociodemographic profile, data on the current practices, the attitudes of the household towards ear concerns, and their knowledge with regards to ear problems were analyzed using EPI Info Version 7.2.2.6. KAP were assigned as outcome and were correlated to the exposure to ear symptoms. Variables of the sociodemographic profile and the knowledge, attitude, and practices were correlated using multiple regression using SPSS.

The study included 59 head of the household as respondents to the formulated questionnaire. 33 (56%) of which are composed of female, and 26 (44%) were male. Majority (17, 28.8%) of the respondent are on the age range of 34-41 years old, followed by the 50-57 years old range (10, 16.9%). Most of them, 31 (51.5%), are married, 20 (34%) are single, and 8 (13.5%) are widow/er. The population is composed mainly of those who reached and finished college level (33, 55.9%), then those who reached and finished high school education (22, 37.3%). Those who reached and finished only elementary education (3, 5.1%) and those who took vocational courses (1, 1.7%) are a minority in the sample population. Most of the participants belong to those who have low socioeconomic background (35, 59.3%), followed by the middle income (20, 33.9%) and only few (4, 6.8%) belong to the upper income groups.

Table 1. Sociodemographic Profile of Respondents.

Exposure

Out of 59 respondents, 40 has had exposure to any or all ear symptoms. Accordingly, 36 of the respondents or any member of their household members experienced ear pain, 22 had ear itchiness, and 9 had experienced foreign body stuck in the ear.

Table 2: Knowledge on Aural Health.

Table 3: Attitudes on Aural Health.

Table 4: Practices on Aural Health.

Table 5: Multiple Regression Analysis for the Relationship between Socio-Demographic Variables and Knowledge, Attitudes, and Practices on Aural Health.

The correlation between the sociodemographic profile, and exposure with the knowledge, attitude and practice of the respondents were also investigated. Accordingly, the only significant to note was of presumption that the presence of ear wax was unhealthy. In this study, the respondents who were previously exposed to ear symptoms and had consults were the ones more likely to think that cerumen is dirty. Other factors such as gender and educational attainment did not affect their knowledge. However, with regards to income, those who have low income were the ones more likely to perceive that the cerumen is unhealthy, while those who have middle to high income have no significant effect on the knowledge. The attitudes of the respondents towards aural health were also unaffected by the sociodemographic profile as well as by exposure. The aural health practices are mostly unaffected by exposure and sociodemographic profile. Males are twice more likely than females, as well as those who have low income, to use cotton buds when they experience ear itchiness.

Ear wax, or cerumen, is a substance naturally formed from combination of secretions from the ceruminous and sebaceous glands and the sloughed off squamous epithelium from the tympanic membrane and in the external auditory canal.[4] It serves as protection and lubrication of the external ear canal.[5] The ear has its own mechanism to remove the cerumen and dirt by the process of migration aided by the jaw movement,[5,6] and usually does not need to be cleaned. Cotton tip applicators / cotton buds, or Q-tips have been used as a habit of ear cleaning but accordingly should not be used to dry ears as well as remove cerumen. Use of these cotton buds/tips poses a risk to health such as causes packing the cerumen or dirt deep into the ear canal, as well as may cause ear irritation. [4] One of the usual out-patient otology concern is the impaction of this cerumen.[2] This may be due to chronic use of cotton buds, narrowed ear canal, use of hearing aids and earplugs,[4] as this interrupts the normal self-cleaning mechanism of the ear. Usual concern related to impacted cerumen is conductive hearing loss, as well as pain and itchiness. Several mechanism to remove impacted cerumen includes manual removal, irrigation, and the use of cerumenolytics.[4] However, this should be advised or facilitated by specialists since improper use of the said methods poses health risks.[4] There are three type of cerumenolytics: water-based, oil-based, and non-water/non-oil-based solution.⁴ This includes but is not limited to Sodium docusate, 3% hydrogen peroxide, 2.5% acetic acid, 10% sodium bicarbonate, water or saline, propylene glycol, mineral oil, and almond oil.⁴ However, there are no specific solution that is superior than the other.[4] In this study, age, sex, educational attainment and monthly income does not affect the overall knowledgeability as well as modify the attitudes and practices of the community. Prior exposure to ear problem or symptoms, with or without ear consult, also does not affect the three domains. This may be due to improper health teaching as well as failure of the caregiver or the patient to seek additional information or may have poor health-seeking behavior. Therefore, health education is necessary for proper health promotion. This should also include information dissemination (e.g. visual aids, health teaching, media, etc), identifying risk factors and risk groups, proper treatment of affected individuals, as well as rehabilitation of patients with ear problems. Proper referral system must also be implemented so as to prevent progression of problems. Notably, there is a system developed by the Department of Health in Australia, which has suggested guidelines in health promoting activities for ear health starting from birth.⁷ Their research has provided recommendations for indigenous population as well.[7] Health care professionals, as well as, teachers, and caregivers were included in the promotion of ear health.[7].

This study revealed that the community’s exposure to ear problems is not associated with the overall improvement in their knowledge, attitude and practices towards ear health. As well as, there is poor knowledge, attitude and practice towards the practice of ear care. Sex, Income and educational background does not necessarily affect knowledge, attitude and practice towards ear health. Aural health education and/or information dissemination is therefore needed to avoid preventable damages to the ears.

1. Dhingra PL, Dhingra S eds. Peripheral receptors and physiology of auditory and vestibular systems. In: Diseases of ear, nose and throat & head and neck surgery. 6^th. New Delhi: Elsevier; 2014:13-18.
2. Department of ENT-HNS OMMC. Our patient census. Manual of Accreditation. Unpublished. 2018.
3. Tsang S, Royse CF, Terkawi AS. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi journal of anaesthesia, 11(Suppl 1). 2017; 80-89.
4. Lee D, Roberts D. Flint P, Haughey B, Lund V, Niparko J, Robbins T, Thoma J, Lesperance, M. Topical therapies for external ear disorders. In: Cummings Otolaryngology, Head and Neck Surgery, 6^th Philadelphia: Saunders, 2015;2123-2138
5. Aldawsari SA, Aldawsari AA, Aljthalin AA, Al-Dossari FM, Alhammad MA, Al-Shatri MS, Knowledge, Attitudes and Practices of Self-Ear Cleaning Among Medical Students, Majmaah University, Saudi Arabia. Int J Med Res Prof. 2018; 4:155-561.
6. Alberti PW. Epithelial migration on the tympanic membrane. The Journal of Laryngology and Otology. 1964; 78: 808-830.
7. Australian Government Department of Health [Interne]. Autralia. Updated Feb 2012. Available from: http://www.health.gov.au/internet/publications/publishing.nsf/Content/oatish-indigenous-ear-health-toc~executive-summary