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|Year : 2012
: 14 | Issue : 56 | Page
|The effect of a hearing conservation program on adolescents' attitudes towards noise
Shawna M Dell, Alice E Holmes
Department of Speech, Language, and Hearing Sciences at the University of Florida, Gainesville, USA
Click here for correspondence address
|Date of Web Publication||29-Feb-2012|
Crandell et al., reported that education programs such as hearing conservation programs (HCPs) represent the most common and well-recognized procedure in reducing the incidence of noise-induced hearing loss (NIHL). The purpose of this study was to assess the effectiveness of an HCP in changing knowledge and attitudes toward exposures to high intensity sounds or noise among adolescents aged 12-14 years. Local middle school students in physical education classes were recruited for participation. Sixty-four middle school students between the ages of 12 and 14 received pre- and post-test measures and participated in the HCP. The pre-test measure had 24 questions that included 5 demographic questions and 19 Likert-type questions [modified from the Youth Attitude to Noise Scale] that assess adolescents' attitudes towards noise; and a post-test measure included the identical 24 questions of the pre-test measure in addition to three subjective questions. A Wilcoxon signed rank test and a Two-Factor Analysis of Variance were completed to assess changes in knowledge and attitudes toward noise among the study population after receiving the HCP. A statistically significant reduction (P< 0.003) in pro-noise attitudes among the adolescents was present after the intervention. It was established that an HCP facilitated a change in pro-noise attitudes among adolescents. Further, the students thought this program facilitated learning of the auditory system and healthy hearing behaviors.
Keywords: Adolescents, attitudes, hearing conservation programs, noise
|How to cite this article:|
Dell SM, Holmes AE. The effect of a hearing conservation program on adolescents' attitudes towards noise. Noise Health 2012;14:39-44
| Introduction|| |
Individuals of all ages are at risk to the dangers of high intensity sounds (>85 dB A) that cause anatomical and physiological changes within the cochlea, which houses the auditory sensory cells or hair cells. ,, Specifically, the outer hair cells (OHCs) are sensitive to hazardous high intensity sounds. Noise exposure from high intensity sounds can cause the OHCs to die; and when these cells die they do not regenerate. Thus, repeated noise exposure results in the death of numerous OHCs that produce an irreversible and measurable permanent hearing loss. ,, This permanent sensorineural hearing loss is better known as noise-induced hearing loss (NIHL). ,,, Commonly, NIHL is associated with high intensity sounds caused by occupational and military sound sources; approximately 30 million American workers are exposed to hazardous noise at work.  However, these adults are afforded protection from mandatory regulation enforced by the Occupational Safety and Health Administration (OSHA). , Workers exposed to loud sounds above the action level or 85 dB A are enrolled in mandatory hearing conservation programs (HCPs). These HCPs provide audiologic monitoring, hearing protection devices, noise control, noise surveys, education and motivation. ,,
Although high intensity sounds or noise are often defined as sounds that are undesired or annoying, , sounds that are considered comfortable and enjoyable can also become a risk to hearing. Noise comes from other sources besides occupational exposures or by firing weapons. For instance, sounds from loud music, concerts, hunting, motor sports, and public sporting events , can also contribute to hearing loss. Therefore, within this paper the term noise will be used interchangeably for high intensity sound(s). Hence, the dangers of noise exposure can affect all populations including children that are being exposed to loud sound environments. Consequently, approximately 12.5% or 5.2 million children have NIHL in one or both ears;  and unlike working adults, children that are exposed to noise do not have regulations to protect them from the effects of NIHL. In a recent study, the reported prevalence of hearing loss, especially high frequency hearing loss among adolescents, aged 12-19 years old increased by 31%.  Thus, children and adolescents are being exposed to noise every day in the form of MP3 players, toys, video games, and other recreational activities.
This exposure to noise can cause NIHL; and like any other type of hearing loss, NIHL is also known to cause detrimental effects, such as auditory problems (i.e. inability to discern speech), depression, anxiety, reduced cognition, and poor psycho-social function. ,,, In addition, noise that produces NIHL can generate various physiological ailments that poorly affect the quality of life of individuals of all ages, especially children. These non-auditory effects on health and well-being that are caused by noise include increased stress, inability to concentrate, lack of sleep, elevated blood pressure, and increased heart rate. ,,,, Noise can also cause impaired cognitive function among children. It has been shown that excessive exposure to noise has affects on central processing, language comprehension, and attention (i.e. being able or unable to multitask in the presence of background noise caused by multiple talkers). ,, Hearing loss at high frequencies can also affect children's speech comprehension of the fricative sounds (e.g. f or s), which can lead to decreased speech discrimination for differentiation of words and overall performance in school. Hence, with deficits in speech comprehension and other cognitive function, children with minimal hearing loss caused by noise have an obstacle to overcome when it comes to learning and attaining an education. Therefore, educationally significant hearing losses in the form of NIHL can affect children's potential to succeed and excel in school and ultimately in life. Many children with hearing loss experience reduced academic performance. ,,,
The literature has also shown gender differences among those individuals with NIHL. In the Third National Health and Nutrition Examination Survey (NHANES III), Niskar et al., found a higher prevalence of NIHL in males than females. Also, young males are more likely to engage in more hearing-related risk behaviors than young females. , On the other hand, there is very little literature regarding racial/ethnic differences among African Americans and other groups regarding NIHL. However, from the limited research it can be gleaned that African Americans, adults and children, have a lower prevalence of NIHL. The NHANES III revealed that African American children had the lowest prevalence (11.7%) of high frequency hearing loss or NIHL compared to Caucasian children (12.3%) and Latino children (15.1%),  yet there are no statistical differences between these groups.
NIHL is slow and insidious, yet it is preventable. Within the occupational sector, various US laws from the Walsh Healey Act to the Hearing Conservation Amendment are enforced to protect the workforce from the hazards of NIHL. ,, These laws require the implementation of HCPs. However, unlike other countries, no regulations exist against NIHL caused by recreational noise within the US.  Thus, many Americans, especially children and adolescents, are being exposed to noise that has the potential to cause NIHL among various diverse groups without any protective regulation. There have been numerous calls of action to provide HCPs within the schools. A proponent of the importance of inclusion of HCPs within schools, Robert L. Folmer reported within his review that the need for hearing conservation addition within the education system has been stressed by numerous health policy agencies and experts in hearing science for more than 30 years.  Thus, with the numerous opportunities for children to be exposed to noise, many are unaware of the dangers of noise. Many children of all races believe that hearing loss is only a concern for old people.  Thus, the ultimate goal of preventing NIHL among children would be avoiding the initiation of several risky hearing behaviors, such as attending a loud sporting event without the use of hearing protection. ,, Following the Health Belief Model, an intrapersonal theory that predicts how knowledge, attitudes, and beliefs within the individual will affect health behaviors. , Based on this theoretical framework, knowledge, attitudes, and beliefs regarding the dangers of noise will effect an individual's hearing health behaviors. Positive hearing health behaviors (i.e. using hearing protection) are dependent upon knowledge and attitudes toward noise. Therefore, one way to combat NIHL is through awareness and knowledge, which will hopefully change beliefs and attitudes and ultimately behaviors. Thus, the purpose of this pilot study was (1) to evaluate the effectiveness of an HCP in increasing knowledge and modifying positive attitudes towards noise among adolescents in a school setting and (2) to evaluate if gender and race have an effect on changes seen in children's attitudes.
| Methods|| |
The University of Florida Institutional Review Board (IRB) gave approval (approval # 2009-U-0275) for this study. All participants were instructed that they could withdraw from the study at anytime. The student participants were middle school students (grades six to eight) enrolled in physical education (P.E.) classes from the University of Florida's Developmental Research School. The P.E. teacher was randomly selected and his classes were selected for the study. The students were selected from three P.E. classes that varied by grade and class size due to block scheduling. The first class was made up of 27 sixth graders, the second class had 36 students in the sixth and seventh grades, and the final class included 13 eighth graders for a total study population of n = 76. However, due to absences or failure to give assent, the final study population size was n = 64. Student participants were between the ages of 12 and 14 years (mean age was 13 years). There was an equal distribution of male and female student participants. The racial/ethnic composition of participates were as follows: White non-Hispanic (n = 28, 47.5%), Black non-Hispanic/Latino (n = 21, 35.6%), Hispanic/Latino (n = 7, 11.9%), Asian (n = 1, 1.7%), and Other (n = 2, 3.4%).
All student participants received a pre-test and post-test measure and participated in the HCP. All student participants received a pre-test measure before the HCP and a post-test measure one week after the HCP. The pre-test measure included a total of 24 questions, 5 demographic and 19 Likert-type questions modified from the Youth Attitude to Noise Scale or YANS.  Word choice modifications were made to make the YANS compatible for an American population (i.e. substituting the word discos with dances). The YANS contains 19 questions that measure adolescents' attitudes toward noise. These questions can be broken into four factors or categories which include: (1) Youth Culture or sounds related to leisure time, sound levels at concerts etc. (includes 8 items), (2) Daily Noise or daily sounds, such as sounds from traffic, computers, etc. (includes 3 items), (3) Concentration in Noise or the relationship between noise and concentration (includes 4 items), and (4) Intent to Influence or the wish to influence the environmental sound level (includes 4 items). During the development of the YANS, the four categories had a four factors solution performed and the alpha values are alpha 0.78 for attitudes towards noise associated with youth culture, alpha 0.72 for attitude towards daily noises, alpha 0.53 for intention to influence sound environment, and alpha. 66 for attitudes towards the ability to concentrate in noisy environments.  Sample items are shown in [Table 1]. The post-test measure that was given one week after the HCP included a total of 27 questions, 24 question were identical questions from the pre-test measure in addition to three subjective questions, such as "What were the things you liked from the program?" or "What have you learned?"
The first author, a licensed audiologist with an Au.D. degree, implemented the Dangerous Decibels® educational HCP. Dangerous Decibels® is a highly interactive and evidence-based program targeted to children in grades K-12. , The HCP included information about the anatomy and physiology of the auditory system, the causes of NIHL using NIOSH exposure levels, proper use and care of hearing protection, and ear hygiene. This program stresses three simple ways of protecting one's hearing that include: 1. Turn it Down, 2. Walk Away, and 3. Protect Your Ears. Materials from the Dangerous Decibels Educator Kit was used for the hour long presentation of HCP, which included the Dangerous Decibels DVD, stereocilia model, "physics of sound" demonstration, "sound is vibration" demonstration, "how loud is too loud!" game, and the use of a sound level meter facilitated learning of the functions of the auditory system and the dangers of noise. For instance, the sound level meter activity stressed the effectiveness of walking away when loud music from a radio was played. At the completion of the study, student participants received hearing education materials and free ear protection. Student participants were further instructed on proper insertion and fit of ear plugs within the external ear canal and how to calculate how much hearing protection one could achieve by reviewing the noise reduction rating (NRR) listed on the hearing protection packaging.
| Results|| |
A Wilcoxon signed rank test was used to compare the pre- and post-test measures means of the entire YANS and the 4 sub-factors (youth culture, concentration in noise, daily noise, and intent to influence). The pre-test YANS mean and the post-test YANS mean were 3.64 and 3.49, respectively, and the higher the YANS score (1-5) the more pro-noise views an individual holds. Therefore, when comparing pre- and post-test means of the entire YANS, there was a statistically significant reduction (P<</i>0.003) in pro-noise attitudes among the student participants. Factor One: Youth culture responses also showed a statistically significant (P<</i>0.001) change in adolescents' positive noise attitudes. However, Factor Two Concentration in Noise, Factor Three Daily Noise, and Factor Four Intent to Influence showed no statistically significant differences in the pre- and post-test responses [Table 2]. However, the negative Z-scores show that there was at least a reduction in the positive attitudes in post-test measure responses.
|Table 2: Pre- and post-test means and standard deviations, Z-test scores between pre- and post-scores and the level of significance for each factor|
Click here to view
To evaluate the effects of gender, race and/or ethnicity, and gender and race interaction on the differences between pre- and post-measures, a two-Factor Analysis of Variance (ANOVA) was completed. To increase statistical power when analyzing race/ethnicity, student participants that self identified as Hispanic, Asian, and Other were grouped into one group due to the few number of participants classified in the previously mentioned groups. Therefore, the three racial group categories were Caucasian, African American and Other. When examining the entire YANS, gender had no effect on the changes seen in the post-test measures with a significance level of P=0.639. Further, when looking at race alone and the interaction of race and gender on the changes seen in the post-test measures, there was no effect (P=0.15 and P=0.16). Factor One: Youth culture measure was not affected by gender (P=0.14), race (P=0.059), or gender and race interaction (P=0.16). However, the effect of race influenced the change from positive attitudes to more negative ones (i.e. noise is being viewed as a problem) seen in Factor One: Youth culture responses almost reached a statistically significant level (P=0.059), in that the HCP had a more positive effect in changing their views on noise [Figure 1]. Factor Two: Concentration in Noise measure was not affected by gender (P=0.57), race (P=0.97), or gender and race interaction (P=0.08), yet the interaction between gender and race also showed a trend of influence that was close to a significant level on the responses or attitudes towards concentration in noise. Factor Three: Daily Noise measure was not affected by gender (P=0.86), race (P=0.81), or gender and race interaction (P=0.87). Factor Four: Intent to Influence measure was not affected by gender (P=0.23), race (P=0.68), or gender and race interaction (P=0.75).
The post-test measure also included three subjective questions: "What were the things you liked from the program?" "What have you learned?" and "Would you recommend this program to be taught in other schools?" The majority of the students (approximately 89%) reported that they enjoyed the program and felt that they learned from the program. Review of the responses revealed student participants' consensus that HCPs should be implemented in the school setting, so that other students can become aware of the dangers of noise exposure. For instance, one participant stated "I think that you should do this at other schools all grades. I think that it will have a big impact on teen's lives."
| Discussion|| |
Noise is a great danger that can hide in innoxious forms like music and other pleasurable activities. With the increased popularity of MP3 players, such as IPods, children and adolescents have introduced a new potential form of harm towards their auditory systems. Keppler et al.  reported that young adults exposed to music from MP3 players had greater odds of developing a decrease in hearing acuity compared to those that do not expose themselves to MP3 players. Thus, children and adolescents are exposing themselves to the dangers of noise, yet they may not know it. As a society we must intercede to reduce the poor hearing health outcomes that may affect this population. Recently, Shargorodsky et al.  reported an increase in the prevalence of hearing loss, especially high frequency hearing loss, among adolescents aged 12-19 years old in which there was a reported 31% increase in hearing loss among this population. One way to combat this may be through the use of HCPs, which can increase the knowledge and awareness of NIHL among children. ,,,, Based on the results in this study, the use of the Dangerous Decibels program facilitated a change in pro-noise attitudes, which is supported by the literature. The majority of student participants realized that noise can cause harm to their hearing health. Thus, information from a simple hour-long HCP was retained and made a significant influence in changing positive attitudes towards noise. However, a limitation of this pilot study is that the post testing was done relatively quickly (one week) after the presentation of the HCP. Thus, a future aim would be to look at long-term effects of HCPs by having assessments at longer intervals such as three months to access the amount of retained message and information. Another future aim would be to obtain a larger study population to further examine the differences among males and females and racially diverse populations. The standard deviations for all the factors (i.e. concentration in noise among the sexes) were quite large, so a larger population may help lower the standard deviations. The literature reports a clear gender difference with regards to NIHL, yet none was found within this project.
When comparing prevalence of NIHL and hearing-related risk behaviors among racially/ethnically diverse populations the literature is quite limited. One study by Crandell et al.  examined differences in knowledge, behaviors, and attitudes of African American students compared to Caucasian students. The data revealed that African American students were consistently less likely to correctly identify symptoms of excessive noise and the risk of hearing damage compared to their Caucasian counterparts. This is not surprising and would be expected because different racial and ethnic groups hold different beliefs and attitudes, so these differences in beliefs would also be seen in attitudes towards noise. Our results suggest that these attitudes can be changes with HCPs. In the current study, no significant differences were found among the three racially distinctive groups. However, there was a trend towards significance within the African-American group being more positively influenced by the HCP in the area of Youth Culture.
Through awareness and knowledge, attitudes can be influenced and modified from pro-noise to awareness of the dangers that noise may bring. According to the Health Belief Model,  this change in knowledge and attitude will eventually positively influence hearing-related health behaviors. Thus, the issue of hearing conservation should receive the same resources that other education programs like anti-smoking, anti-drug use, and sexually transmitted infection education programs receive from the school systems and other venues.  There are several effective comprehensive HCPs available that can be implemented in numerous venues. Nevertheless, not many audiologists, teachers, and other health educators are utilizing them. There are several HCPs that can be combined with supplemental educational resources to create programs that accomplish the goals of the presenters or are specifically targeted to a particular adolescent group (i.e. minority students that live in urban environments). As a result, a specific program created for a particular group may be more effective in changing attitudes, beliefs, and behaviors.
In addition, all HCPs should be coupled with audiometric testing to assess the hearing acuity of the participants and to identify and monitor hearing losses, especially educationally significant hearing losses among children and adolescents. The American Speech Language and Hearing Association (ASHA) recommends that children have their hearing screened annually, starting in kindergarten through 3 rd grade and again in 7 th and 11 th grades; however, each state has their own guidelines.  In conclusion, audiologists and other healthcare professionals should advocate for those populations vulnerable to NIHL, so they may live happier, healthier lives. Thus, to combat positive noise attitudes we must provide honest information and empower adolescents so that they have control of their hearing health. One way this can be accomplished is by implementing the use of HCPs among adolescents, parents, teachers, and the community. This investigation provides statistically significant results showing the efficacy of an HCP given in a limited time span in changing adolescents' attitudes toward noise; therefore, making them more aware of the hazards of noise within their cultural environments which is the first step to prevention of NIHL.
| Acknowledgments|| |
The authors would like to thank P.K. Yonge Developmental Research School and the students that participated in the study. In addition, the authors thank Dr. Russ Froman and Coach Willie Powers for all their help and support.
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Shawna M Dell
PO Box 117420, University of Florida, Gainesville, Fl 32611
Source of Support: None, Conflict of Interest: None
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