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ARTICLE  
Year : 2013  |  Volume : 15  |  Issue : 62  |  Page : 42-54
Environmental noise and annoyance in adults: Research in central, eastern and south-eastern Europe and newly independent states

1 European Commission, Joint Research Centre, Institute for Health and Consumer Protection, Chemical Assessment and Testing Unit, Ispra (VA), Italy
2 Institute of Hygiene, Faculty of Medicine, Comenius University, Bratislava, Slovakia

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Date of Web Publication14-Feb-2013
 
  Abstract 

Research work on the adverse effects of noise on annoyance in adults is well documented in Western Europe, but there is a knowledge gap concerning this type of research in Central and Eastern Europe (CEE), South-East Europe (SEE), and Newly Independent States (NIS). The objective of this review was to present findings and to propose future research directions for the studies on the effects of environmental noise on annoyance in adults conducted in these countries. After systematic search in accessible databases, scientific journals, conference proceedings, international and national reports in English and other languages, the authors identified 29 papers to be included to this review: 24 papers related to annoyance due to road traffic noise and 5 papers related to annoyance from other noise sources. In most of the identified studies, a cross-sectional design prevailed and the evaluations were mainly performed subjectively. The lack of recent annoyance studies related to railway and aircraft traffic noise was identified. Only two studies from NIS countries used noise exposure data for the evaluation of population annoyance according to the European Environmental Noise Directive (END). Capacity building in CEE, SEE, and NIS countries is necessary to acquire the "know-how" on how to implement and use the different scenarios for evaluating population annoyance by environmental noise, depending on the availability and suitability of noise exposure data. Particular attention should be given to the possible use of END noise exposure data, where applicable.

Keywords: Annoyance, environmental noise, environmental noise directive, review, road traffic noise

How to cite this article:
Lekaviciute J, Argalasova-Sobotova L. Environmental noise and annoyance in adults: Research in central, eastern and south-eastern Europe and newly independent states. Noise Health 2013;15:42-54

How to cite this URL:
Lekaviciute J, Argalasova-Sobotova L. Environmental noise and annoyance in adults: Research in central, eastern and south-eastern Europe and newly independent states. Noise Health [serial online] 2013 [cited 2014 Nov 22];15:42-54. Available from: http://www.noiseandhealth.org/text.asp?2013/15/62/42/107153

  Introduction Top


Modern society moves toward the cities and develops into a "loud" society, implying that people are surrounded by noise for nearly 24 h a day, and are affected not only by traffic or aircraft noise, but also by neighborhood or leisure noise. A pilot project on the environmental burden of disease in Europe showed that 3-7% of the World Health Organization (WHO) discounted age-weighted burden of disease was associated with nine selected environmental stressors in six participating countries. Among these nine stressors, air pollution had the highest public health impact, followed by second-hand smoke and traffic noise. [1]

Annoyance is the most prominent adverse effect of noise associated with exposure to intermediate and high noise levels. [2] People annoyed by noise may experience a variety of negative responses, such as anger, disappointment, dissatisfaction, withdrawal, helplessness, depression, anxiety, distraction, agitation, or exhaustion. [3],[4] In more, stress-related psychosocial symptoms such as tiredness, stomach discomfort, and stress have been found to be associated with noise exposure as well as with noise annoyance. [5],[6] Annoyance is typically measured by self-reports to a wide range of questions using response scales with a varying number of response categories. The content of the reaction measure ranges from quality of life impairment, general annoyance, and specific activity interferences, to overall indicators of being affected by noise. Two to eleven scale points are usually employed. [2] However, the efforts have been made by the International Commission on Biological Effects of Noise (ICBEN) and the International Organization for Standardization to standardize the questions asking for the degree of annoyance, and to introduce an 11-point numerical scale and a 5-point semantic scale. [7] Annoyance by noise may be modified by the attitudes toward the sources of sound and by personal characteristics such as noise sensitivity. [8] Human perception of noise has changed over time and noise sensitivity is often found to have the largest modifying impact on noise annoyance. The size of this effect is equivalent to that caused by a 10 dB (A) increase in noise exposure. [2] Other modifying factors such as noisy neighborhood or having access to a silent side of the dwelling also play an important role in annoyance evaluation. [2],[9] But as noise annoyance is a subjective indicator of exposure, the results must be evaluated with caution, regarding recall bias. [10] This implies a need for more objective measurements.

European Environmental Noise Directive (END) 2002/49/EC recommends evaluating environmental noise exposure on the basis of estimated noise annoyance and proposes the use of day-evening-night equivalent sound level (L den) as an acoustic indicator. [11] The results of the first round of noise mapping suggested that around 40 million people across the European Union (EU) are exposed to noise above 50 decibels (dB) from roads within agglomerations during the night. More than 25 million people are exposed to noise at the same level from major roads outside agglomerations. These numbers are expected to be revised upward as more noise maps are received and/or assessed. [12] EU Member States have already adopted END and are under the second round of strategic noise mapping. They have already started to use the gathered noise exposure data for health studies, whereas the other Central and Eastern European countries, non-EU members, are under the process of harmonization of environmental noise-related legislation. Despite this, they continue performing research work for evaluating environmental noise effects on health. Only a part of these research results are published in English and are accessible to the international scientific society, but most of studies remain unknown, as they are published in other languages.

The aim of this review was to present the findings of the studies on the effects of environmental noise on annoyance in adults conducted in South-East Europe (SEE), Central and Eastern Europe (CEE), and Newly Independent States (NIS), and to propose the directions for future research in this area.


  Methods Top


This review includes scientific papers on environmental noise and related annoyance in adults. The research period is from 1969 to 2010. This review comprises not only papers published in peer-reviewed journals, but also articles from local journals to fill the "white gaps" on the map of noise reviews. Therefore, authors reviewed the scientific journals, conference proceedings, and local reports published in national languages as well. The originality of this review lies not only in the fact that we searched for and included the studies published in other European languages than English, but also we included studies of the countries which no longer exist in the same political and governmental systems (former Easter Germany, former Union of Soviet Socialist Republics [USSR], former Czechoslovakia, former Yugoslavia). We performed the literature search of all accessible medical and other databases (PubMed, Embase, Scopus, BioMed Central, Web of Science, Toxline, Scientia, Science Direct, etc.) using the terms "environmental noise; community noise; road traffic noise; transportation noise; noise sources; adults; noise annoyance" as key words and country denomination (in alphabetical order: Armenia, Azerbaijan, Belarus, Bulgaria, Bosnia and Herzegovina, Croatia, Czech Republic, former Czechoslovakia, Georgia, German Democratic Republic 1965-1990, Hungary, Kazakhstan, Lithuania, the Former Yugoslav Republic of Macedonia, Moldova, Montenegro, Poland, Romania, Russian federation, Serbia, Slovakia, Slovenia, former Yugoslavia, Ukraine, former USSR). In total, 29 papers were identified by literature search. The identified studies with their characteristics are listed in two tables - in the chronological order by year of issue and by alphabetical listing of author's last name. In the first table, we outlined all the studies related to road traffic noise annoyance, whereas in the second table, we summarized the studies related to noise annoyance from other sources. The tables present the following characteristics of the studies: Location, country, town, and reference (town and country where the study was carried out, the first author and year of publication), aim, and type of the study, sample size, type of exposure assessment (objective or subjective), control variables (covariates), outcome (objective or subjective) and findings. The tables are presented in the special format, which was compiled with the help of the tables from the previous reviews related to noise and health. [13]


  Results and Discussion Top


The review comprises 24 papers related to road traffic noise annoyance [Table 1]. Most of the identified papers are from Serbia (four studies), Poland (four studies), and Slovakia (four studies). Two papers from each of the countries such as former Eastern Germany, Czech Republic and Slovenia, and one paper-from Lithuania, the Former Yugoslav Republic of Macedonia, Romania, and former USSR (Russia) are also included. Finally, two more studies are included where one of co-authors has originated from or part of the research work was carried out in one or several of CEE, SEE, or NIS countries.

Our review also contains five studies exploring other noise sources (aircraft, railway or low frequency noise) and annoyance [Table 2]; two of them come from the former USSR and three from Poland.
Table 1: Studies on road traffic noise annoyance in adults in Central and Eastern Europe, South-East Europe, and Newly Independent States

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Table 2: Studies on other noise sources (aircraft, railway and low frequency noise) and health in adults in Central and Eastern Europe, South-East Europe and newly Independent States

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Noise annoyance from road traffic in urban population

The earliest identified experimental study, which was looking at acoustic analyzer functions, subjective and integral reactions in human subjects, was published in former USSR by Suvorov et al., in 1986. [14] We identified two studies on road traffic noise annoyance in Eastern Germany conducted during 1988-1994 by Schulze and Wölke in the city of Erfurt. [15],[16],[17],[18] Around 20% of the respondents (1000 adult citizens of the city Erfurt) was annoyed by noise, and 90% of these were annoyed particularly by road traffic noise. [17],[18]

In the Czech Republic, environmental noise and its effects on health are observed since 1994 through the environmental health-monitoring system. [19] According to the results published by Sisma in 2000, 64% of the population annoyed by noise suffered from one or more "civilization-related" diseases (such like hypertension, myocardial infarction, gastric and duodenal ulcers, cholelithiasis and urolithiasis, diabetes mellitus, tumors, and frequent catarrhs of the upper respiratory tract). This phenomenon was statistically significant in populations affected by noise levels higher that 55 dB at night. [20] As a result of "Health and Noise" questionnaire survey in 2007 (also part of Czech environmental health monitoring), 4987 responses were collected. The participants expressed the degree of annoyance on a six-point scale ranging from 'not at all' to `very high`. Noise annoyance was registered at the upper end of this scale (the three higher points). In the whole sample, 48% of respondents were affected by noise, but in the noisiest localities, this number increased to 80%. The most frequent cause of disturbance was automobile traffic which disturbed 59% of all the respondents on a daily basis. [19],[21]

Belojevic et al., in 1992 explored the importance of subjective noise sensitivity in mediating the effects of noise on mental performance. The results showed that annoyance while performing tasks under noisy conditions was higher among subjects judged to be noise-sensitive on Weinstein`s scale, compared to those who were judged to have low or moderate subjective noise sensitivity. [22] In later studies, the Belgrade team for biological effects of noise (BETBEN) has studied the principal factors for noise annoyance in the urban Belgrade population. [9],[23],[24] In the most recent population studies, this research team found that the strongest predictors of high noise annoyance were: Subjective noise sensitivity, orientation of windows toward the street in bedrooms or/and living rooms, duration of stay in the apartment, number of heavy vehicles, night-time noise levels, and noise annoyance at the workplace. [9],[23],[25] In the study by Jakovljevic et al., (2009), the residents considered traffic noise much more disturbing/annoying than the neighborhood noise, although noise itself was not regarded the most important environmental hazard in the investigated municipality of Belgrade. [23] Cultural differences may explain the observed inconsistencies. It might be also a reason why many field studies find that noise levels could only partially explain the extent of annoyance in the exposed populations. [8],[26] Paunovic et al ., (2009) showed that noise-related characteristics were less significant predictors of noise annoyance than personal, social, and housing characteristics. The authors stated that noise levels were important indicators of annoyance only in noisy streets and that night-time noise levels and composite day-evening-night noise levels (Lden ) shared similar predictive values. Therefore, they suggested that night-time Leq might be as good as Lden in predicting noise annoyance in noisy urban areas. [9] BETBEN team proposed a four-step pyramidal model for the explanation of noise annoyance. In the base of the model, they placed subjective noise sensitivity, which was independent from noise exposure. The second step included personal perception, expectations, and attitudes toward noise, influenced by personality traits, social status, housing, and working conditions. The third step was formed from some characteristics of noise exposure (sources of noise, type of traffic, number of events, frequency, and time of exposure). Finally, noise exposure level was placed on the top of the pyramid as annoyance indicator in noisy urban areas. [9]

In the Former Yugoslav Republic of Macedonia, the cross-sectional study was performed to identify annoyance level in relation to noise exposure in Skopje. [27] This cross-sectional study was the first national study assessing noise-induced annoyance in adult population. It was designed as the questionnaire-based survey on noise annoyance and health status. Noise exposure indicators-day equivalent sound level (Lday ), night equivalent sound level (Lnight ), and Lden were determined and subjective noise annoyance was evaluated on a 5-point verbal scale and an 11-point numerical scale. Results showed that 13% of the subjects were highly annoyed by noise, 33.5% were moderately annoyed, and 53% were not annoyed at all. According to noise sources and the five-item verbal scale, the most annoying noise came from construction activities, followed by road traffic noise and leisure activities, such as entertainment activities in public places and noise from restaurants and cafeterias. [27]

In Bratislava, Slovak Republic, two noise annoyance surveys were performed in a 10-year interval (1989-1999). This was a period of political and socioeconomic transformations as well as of changes in traffic management. Comparing recent and former risks of different noise exposures, the study has found that the load of community noise, especially road traffic noise, as well as the subjective response to noise had increased in Bratislava. The strength of this study was the comparison in a 10-year interval. [28],[29],[30] Later, the same group of scientists performed another noise annoyance survey and compared its results with the results from earlier studies. [10] Therefore, they compared two noise annoyance surveys (from 1989 to 2004) and two noise annoyance scales (the new and previously suggested five-grade scale and three-grade scale as standard approach) in the period of 15 years in Bratislava. The authors concluded that the use of five-grade noise annoyance questionnaire provides better possibilities for the assessment of environmental noise annoyance in selected population. The authors of the last Bratislava study used a new indicator- percentage of highly annoyed (% HA) persons. This indicator enables the comparison of results from other European and world studies. [10] In other cross-sectional study from Bratislava, Slovakia, (1992) noise annoyance assessment revealed that almost half (49.6%) of the studied adult inhabitants, exposed to noise levels higher than 50 dB (A), were annoyed by noise. [31] One more Slovak study focused on evaluation of the acoustic comfort in a dwelling area with apartment houses built in Slovakia by the prefabrication technology, and investigation of the possible negative impact of non-specific effects on the health of the population was identified. The noise annoyance was assessed in the flats and the use of sleeping pills was discussed. In this study, 36.5% out of 578 respondents found the foot-step noise to be annoying in the panel houses and 59 respondents out of 450 stated using of sedatives and hypnotics in relation to annoying environmental noise in the surroundings. [32]

A search performed through different information sources has shown that in Slovenia, there are no epidemiological studies on environmental noise and related health effects. We were able to identify a general public opinion survey, [33] which showed that the proportion of residents disturbed by noise has increased from 19.6% to 33% and the proportion of those more disturbed has increased from 16.5% to 19.3% in the period of thirty years (1973-2003). Correspondingly, the proportion of residents thinking that noise is not a problem in their environment has dropped from 36.5% to 21.4% in the same period. [33] The results of other survey by Špes et al., (2002) indicated that 36% of participants were over-burdened by noise in the city and that 64.1% of all participants indicated that road traffic noise was the most disturbing source of noise in Ljubljana. [34]

In the recent psychoacoustic experiments in Poland, Kaczmarek and Preis (2010) found that the structure of traffic flow (and the resulting shape of a time pattern) can influence annoyance judgments of traffic noise inside the building. [35] The same group of researchers in two other psychoacoustic experiments tested a hypothesis stating that if annoyance is influenced by sound-source recognition, differences between annoyance ratings of the original and modified noises could be expected; and in contrary, if there are no differences in annoyance ratings of both sounds, the sound-source recognition influences annoyance perception insignificantly. The results showed that the annoyance judgments of two original signals in two experiments were not identical; the annoyance by hybrid-like noises was the same as the original recordings. [36] In the other Polish study, Koszarny (2001) found that the relative risk of appearance of unfavorable health symptoms (e.g., feeling of discomfort, annoyance, mental pressure caused by noise etc.) was 1.5 times higher among people from noisy areas (noise levels above 70 dB[A]) compared to persons from moderately noisy areas (noise levels below 57 dB[A]). [37] An internationally comparable noise reaction measure for social surveys was published by Fields et al., as a result of work performed by the Community Response to Noise Team of the ICBEN. [4] Preis et al., 2003 developed a Polish version of a noise annoyance scale with the most proper words of the 5-point ICBEN verbal noise scale. [38] This adaptation was a result of the participation of Poland in the world network of countries, using the same method for the estimation of noise annoyance. Usage of such a scale permits Polish data to expand the world database on human reactions to noise and become more comparable with the data from other countries. [38]

In the Pan-European study done in several Eastern European cities (former Eastern Germany, Lithuania and Slovakia), noise annoyance was recognized as one of the most prevalent problems affecting residential health and well-being. [39] This field study was performed by the WHO and aimed to highlight housing and health problems of Eastern European countries in transition that could be related to living conditions in panel block buildings. Due to their building style, several housing-related health threats are typical for these types of buildings, with the neighborhood noise being one of the most frequent problems. [39] Study results showed that in all the three analyzed countries, noise exposure was between the most stable factors affecting the perception of health. It was found that the insulation measures and renovation only partially diminished the noise exposure and there were no great differences found between building types. [39] Noise, therefore, emerged as the most pervasive factor influencing health and residential quality in this study, although it cannot be described as the most serious threat to health and well-being. The sample size was small, but a more powerful sample might give a clearer and more conclusive answer to this crucial question in the future studies. [39]

The selected studies on environmental noise and road traffic noise annoyance were mostly cross-sectional studies; some were experimental or social surveys. In the cross-sectional studies, noise annoyance was measured mainly using self-reported questionnaires. Very often, group comparison was used to evaluate the difference between noise-exposed and unexposed urban residents. For the countries where several studies were identified, it was generally the same team of scientists working on a specific subject related to noise annoyance. For example, in Belgrade in Serbia, the same group of researchers was working on the principal factors for noise annoyance, whereas in Slovakia a group of scientists concentrated their work on the comparison of noise annoyance surveys for urban residents from Bratislava in ten-year periods. In Poland, scientists mostly performed psychoacoustic experiments in laboratory conditions on factors influencing noise annoyance judgments. Therefore, studies design and methodologies are often similar inside each country, but are different between the countries.

Noise annoyance from other noise sources

The earliest studies identified in our review were from the former USSR and different noise sources were studied for assessing environmental noise annoyance [Table 2]. [40],[41] Karagodina et al., (1969) investigated aircraft noise and its effects on population residing within a radius of 40 km from airports, [40] whereas Volkov et al., (1972) evaluated the response of public on railway transport noise. [41] Polish scientists published several studies investigating effects of low-frequency noise (LFN) on human health. [42],[43],[44],[45] For example, Mirowska and Mroz evaluated a long-lasting effect of LFN on health of dwellers in the residential buildings. The tests referred to adults living in dwellings where LFN occurred from appliances installed in the building and where at least one person from that flat complained about noise nuisance. The results showed that people considered LFN as annoying or very annoying even at very low levels, not exceeding the acceptable values of A-weighted sound levels. The exposure to such LFN may create depression states or even intensify a degree of pre-existing depression, of which the person is unaware. [43] Other two identified Polish studies related to LFN were performed under laboratory conditions. The results of Pawlaczyk-Luszczynska et al., (2005) showed that highly sensitive subjects reported being highly annoyed by noise. [44] The findings also suggested that LFN at moderate levels might adversely affect visual functions, concentration, continuous and selective attention, especially in subjects highly sensitive to LFN. [44] In a later study, the same group of authors investigated the annoyance by LFN at levels normally prevailing at workplaces, such as control rooms and office-like areas. The results of two experiments showed a significant influence of individual sensitivity to noise on annoyance rating for some LFNs. The authors of the study also predicted that more than half of the subjects were highly annoyed by LFN at the low frequency A-weighted sound pressure level (SPL) or C-weighted SPL above 62 and 83 dB respectively. [46]

Very few studies on environmental noise and noise annoyance from other noise sources were identified. In the recent studies, Polish researchers were investigating the annoyance of LFN under laboratory conditions or in residential buildings, whereas only two previous studies were identified on aircraft noise and railroad noise. Comparing with the research performed in Western Europe, there is a big gap and lack of well-designed studies on environmental noise annoyance from aircraft noise, and particularly, from railway noise.

European Union policy implications related to annoyance in Central and Eastern Europe, South-East Europe and Newly Independent States

European Environmental Agency (EEA) and EU Member States are currently assessing noise data collected in the context of the EU END first round of noise mapping in Europe including major agglomerations and major roads, and will repeat the exercise in the following round for smaller agglomerations and roads. These data seem attractive for researchers working on noise and health issues, but the data must be analyzed and critically reviewed case by case. [47] Therefore, in this review, we also looked for the studies performed in CEE, SEE, and NIS countries, which already tried to use this first European level noise exposure database for health studies. As a result, we identified and included in our review, two recently published studies - one from Lithuania [48] and another from Romania. [49]

The Lithuanian study aimed at evaluating annoyance and sleep disturbance caused by road traffic noise in Vilnius and Kaunas and their possible effect on public health. [48] According to the results of the strategic noise mapping, 7.10% of Vilnius population and 6.68% of Kaunas population were exposed to road traffic noise exceeding noise limits of Lden . The adverse effects on public health caused by road traffic noise were evaluated using the dose-effect relationships between annoyance and Lden for road traffic noise. Therefore, the strategic noise mapping results showed that the percentage of total urban population of the city annoyed by road traffic noise at day, evening, and night in Kaunas was higher than that in Vilnius. 3.97% of Vilnius population was highly annoyed, 9.75% was moderately annoyed, and 18.48% was lightly annoyed. In Kaunas: 4.87% of population was highly annoyed, 12.04% was moderately annoyed, and 22.93% was lightly annoyed. [48] The results of the second round of strategic noise mapping in the five biggest Lithuanian cities will enable to create more comprehensive knowledge about noise exposure and its effect on the population.

In Cluj-Napoca city, Romanian researchers conducted a social survey, which helped to evaluate the population response to urban noise and to provide information for developing action plans and better solutions for urban planning. The need of such a survey appeared in the context of strategic noise mapping. [49] The results of the Romanian study suggest that as the reported equivalent sound pressure level (LAeq ) values frequently exceeded 64 dB (A), it can be considered that the respondents were habituated to the noise in their residential area. Most respondents (46%) reported to be slightly annoyed, 37% annoyed, and 6% not at all annoyed by the environmental noise. [49] Road traffic noise was reported as being one of the most frequent and annoying noise sources near home (75% of all responses), whereas 51% of respondents were most affected and disturbed by noise during the afternoon and evening (15:00-22:00). This study also concluded that the inhabitants were interested in reducing the annoying noise and improving acoustical environment, but they did not receive sufficient information on this topic. [49]

Our results show that the use of END noise exposure data for annoyance evaluation in population is only at the starting point, concerning CEE, SEE, and NIS countries. Some of these countries are not members of the EU and they are not obliged to adopt the END Directive, but they show a considerable interest to adopt the harmonized methods for noise exposure assessment (CNOSSOS-EU) and use the data from a strategic noise mapping for health studies. A lot of harmonization work still has to be done, but the European Commission Directorate General Environment, Directorate General Joint Research Centre, WHO, and EEA already established some collaboration for joining efforts to protect the public health from environmental noise. As proposed by experts on noise and health during the meeting at WHO, [50] continuous efforts from the leading institutions are needed for the development of a common method for assessing the burden of disease from environmental noise in European countries. Different methods have to be proposed to the countries that have already produced strategic noise maps, and alternative method for other countries planning to prepare strategic maps.


  Conclusions Top


The results of our review show that research work on environmental noise and annoyance was conducted in CEE, SEE, and NIS countries from 1969 to 2010 mostly using cross-sectional studies, less often - experimental studies. In the cross-sectional studies, noise annoyance was measured using self-reported questionnaires. Very often, group comparison was used to evaluate the difference between noise-exposed and unexposed urban residents. For the countries for which we identified three or more published studies, we also found out that it was mostly one team of scientists working on specific subject related to noise annoyance. The studies included to this review present very interesting findings related to noise and annoyance assessment, which, in spite of differences and some inconsistencies in methodology, help to fill in the gap in the knowledge in CEE, SEE, and NIS countries. However, there is a lack of recent studies on railway and aircraft traffic noise and annoyance, as a dominant noise source in the identified papers was road traffic noise. There is an increasing interest between researchers in EU Member States to use noise exposure data, collected as required by END. Some of SEE and NIS countries, not being EU Member States, also show a considerable interest to adopt the forthcoming harmonized methods (CNOSSOS-EU) and to develop a common methodology for assessment of burden of diseases from environmental noise. Therefore, capacity building in CEE, SEE, and NIS countries is necessary for "know-how", to implement, and use the different scenarios for evaluating population annoyance by environmental noise, depending on the availability and suitability of noise exposure data.


  Acknowledgement Top


The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement No 226442.

 
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Correspondence Address:
Jurgita Lekaviciute
European Commission Joint Research Centre, Institute for Health and Consumer Protection, Chemical Assessment and Testing Unit, TP 281, Via E. Fermi, 2749, I 21027 Ispra (VA)
Italy
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DOI: 10.4103/1463-1741.107153

PMID: 23412579

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