Exposure to loud sound during leisure activities for long periods of time is an important area to implement preventive health education, especially among young people. The aim was to identify the relations among awareness about the damaging effects of loud levels of sounds, previous exposures do loud sounds, preferences-related to sound levels and knowledge about hearing protection with age, gender, and their parent's educational level among children. Prospective cross-sectional. Seven hundred and forty students (5-16 years old) and 610 parents participated in the study. Chi-square test, Fisher exact test and linear regression. About 86.5% of the children consider that loud sounds damage the ears and 53.7% dislike noisy places. Children were previously exposed to parties and concerts with loud music, Mardi Gras, firecrackers and loud music at home or in the car and loud music with earphones. About 18.4% of the younger children could select the volume of the music, versus 65.3% of the older ones. Children have poor information about hearing protection and do not have hearing protection device. Knowledge about the risks related to exposures to loud sounds and about strategies to protect their hearing increases with age, but preference for loud sounds and exposures to it increases too. Gender and parents' instructional level have little influence on the studied variables. Many of the children's recreational activities are noisy. It is possible that the tendency of increasing preference for loud sounds with age might be a result of a learned behavior.
Keywords: Hearing loss prevention, noise, primary school children, risk behavior, secondary school children
|How to cite this article:|
Knobel KA, Lima MM. Influences of age, gender, and parents' educational level in knowledge, behavior and preferences regarding noise, from childhood to adolescence. Noise Health 2014;16:350-60
|How to cite this URL:|
Knobel KA, Lima MM. Influences of age, gender, and parents' educational level in knowledge, behavior and preferences regarding noise, from childhood to adolescence. Noise Health [serial online] 2014 [cited 2020 Nov 24];16:350-60. Available from: https://www.noiseandhealth.org/text.asp?2014/16/73/350/144400
| Introduction|| |
Until date, it is difficult to establish exactly if the lifestyles of the average adolescent or young adult are likely to be really harmful to hearing and how large the auditory risks really are. , On the other hand, several studies have reported that children and adolescents can be exposed to hazardous levels of recreational and environmental sounds that could be associate with typical noise-induced hearing loss (NIHL) audiograms and tinnitus. ,,,,,,,
Many leisure activities aimed to families or to children can be potentially harmful to the hearing (with mean sound pressure level above 110 dBA), while others are meant for adults but children are allowed to go along. Some examples are concerts with amplified music, , Brazilian carnival festivals and parties (Mardi Gras).  Furthermore, the use of personal listening devices (PLDs) has become very popular among teenagers and young adults and even among young children. Although only a fraction of users of PLDs are at risk for NIHL, , the absolute number of affected consumers may be quite large.  Austrian data from high-frequency hearing screening in adolescent showed that the rate of failing the hearing screening was similar in adolescents with no, little, or moderate exposure to loud music (10-15%), but significantly increased (22-25%) in adolescents with high exposure. 
Thus, exposure to hazardous levels of sound during leisure activities for long periods of time is an important area for audiological health-care professionals to implement preventive work and health education, especially among young people.  For this reason teenagers' and young adults' knowledge experiences, attitudes, hearing health behaviors and their use of PLDs, have been examined. Such study helps mainly to determine the need, content, and preferred format for health promotion initiatives. ,,,,
In a previous study with students from Primary Schools (2 nd to 5 th grades) and their parents Knobel and Lima  showed that 87.4% of the children and 93.9% of their parents considered loud sounds damaging to the ears. Furthermore, most children feel annoyed by noise to the point that would interfere with their tasks, and attempted to avoid it. From such data, one could expect that children from our sample had less exposure to potentially hazardous levels of sound. However, that was not the case. The authors revealed that children were exposed to parties and concerts with loud music (51.9%), carnival festivals and parties (Mardi Gras) (38.2%), firecrackers (36.8%), loud music at home or in the car (33.1%) and loud music from personal listening devices (17.3%). Since they interviewed young children (mean age 8.3 years old), the children's attendance in parties and concerts, as their proximity with firecrackers are supposed to depend on their parents' allowance. Interestingly, >80% of the children reported that the listening volume of music was set by older family members. Altogether it seemed that, despite the parents' awareness of the risks associated with exposure to loud sounds and their children preference for softer sounds, their leisure activities were such that allowed those exposures. Hence, the study deflagrated the relation between cultural and social aspects and the risk-taking behavior-related to the exposure to potentially hazardous sounds among children. In other words, simply considering models of energy or signal transfer with their auditory and nonauditory resultant effects is not enough.  Researchers should try to fulfill the gap in understanding how sound acquires meaning and functions to create social and psychological order. 
According to Rebolloso and Elizondo-Garza  most of the nonoccupational exposures to loud sounds can be considered an element of some ritual, defined as a series of actions that are performed mainly for their symbolic value. Usually, life cycle (birth, adolescence, marriage, death…) inspire societies to build its rites, and as a consequence, part of their identity. Fireworks during New Year's Eve constitute part of many cultures' multi-sensory image of this celebration, for example. The same happens around the world with numerous other ritual activities performed in the public sphere, such as calendar festivals, marriages, processions, sport and musical events.
The use of loud sounds and loud music for rituals, rites and celebrations probably comes from old times. Intuitively, ancient tribal heads and leaders had already noticed that the combination of the physical-chemical-biological stimuli of loud sounds produced states of euphoria that would reinforce a sense of unity.  Actually, the exposure to loud sounds stimulates the hypothalamus-pituitary-adrenal gland system and induces an increase in dopamine, noradrenaline, adrenaline and their metabolites. , Although rites changed in form from ancient times to today, loud sounds are still one of the main elements of military, ecclesiastic, sports or educational celebrations. Loud sounds excite the nervous system, promoting a full immersion of the participants into the rites.  On the top of that, the massive scale and scope of rituals today and the increased human capacity to generate noise makes it potentially hazardous to the hearing.  Furthermore, it seems that the contemporary society is addicted to sensorial stimulation, and many times the noise became a rite itself, which could explain why so many people go out looking for noise in night clubs, sports, political and social events, churches and temples at any free time.  Apparently, for most of the people, and especially for adolescents and young adults, loud sounds evoke vibrancy, happiness and the rush of modern existence.
In addition to it, there is a growing rejection to silence, which is often experienced with discomfort and quickly filled with words. Maybe the fear of emptiness turned silence into something undesirable and anguish. When analyzing several aspects of the moment of silence (usually used to remember wars, tragedies or someone's death), Brown  considered that the experience of participating in a moment of silence is intense, but he says that this intensity does not comes from the remembrance, but from the affective experience of the here and now brought by the perception of the sounds made by the functioning of our bodies, from which one never escape. As usually said, silence brings us back to ourselves.
The purposes of the present study were to identify the relations among:
- Awareness about the damaging effects of loud levels of sounds,
- Reported engagement by children in activities that are potentially hazardous to hearing,
- Preferences related to sound levels and
- Knowledge about hearing protection with age, gender and their parent's educational level among Brazilian primary and secondary school students.
| Methods|| |
This was a prospective cross-sectional study about exposure to potentially injurious noise levels and knowledge about hearing health among children and adolescents in public and private elementary schools in Campinas, a south eastern Brazilian town with 1.1 million inhabitants. The study was carried out between April 2010 and September 2011.
In Campinas there are 143,214 students from 2 nd to 9 th grades (SEADE, 2003). Sixty per cent of them are distributed in 161 State Public Schools, 25% in 44 Municipal Schools and 15% in approximately 180 Private Schools. The city is divided into five macro zones. Because the socioeconomic areas differ, we had schools from all regions. The selection of the schools was made in alphabetical order for each region. After a telephone contact, if the school directors refused to receive us, the next school in alphabetical order in the same area was contacted. Using these criteria we selected 13 schools: Seven State public, three Municipal public schools and three private. In large schools, with more than one class per year, the class was also chosen by letter (8 th years A, for example). In small schools, we interviewed students either from the morning or from the afternoon periods. Usually public schools have few educational resources and for this reason, families with higher incomes usually send their children to private schools. Children go to school either during the morning or afternoon periods.
To have a representative sample of elementary school from of 2 nd to 9 th grades of this Brazilian town, a sample of 1242 children was selected, respecting the proportion of students from municipal public, state public and private schools. Children with mental or psychiatric disabilities were excluded.
Considering the number of the selected sample and the number of interviewed children, the drop-out range was 40.4%. Withdrawals were due to no returns of the informed consent form (32.2%), parental refusals (6.8%), and children with mental or psychiatric disabilities (1.4%). Because some parents' surveys were returned in blank, there were 393 matches between child's interview and his/her own parent's survey. Due to children interview response rate the final sample included 740 children and 610 parents.
The school distributed an explanatory letter and the informed consent letter to be ﬁlled out at home by the parents. One week later, the teachers collected the signed letters, authorizing the researchers to interview the children.
All children gave verbal consent and were individually and privately interviewed by the ﬁrst author in the most silent room available in the school. The children's interview consisted of an open-ended questionnaire, with guideline questions presented orally by the interviewer. The questions consisted of demographic information, self-reported hearing complaints, habits and preferences, assessment of children's knowledge about hearing health and protective behavior regarding loud sound exposures. Care was taken to ensure that children understood the questions and had plenty time to respond. The interviewer did not express either approval or disapproval to the child's answer at any time. Interview was not recorded, but all the answers were written down during the conversation.
The parents' survey sought information on parental impressions of their child's auditory behavior and complaints, history of exposures to loud sounds, the number of episodes of otitis media and background information (9 items, Appendix A). Children took home the printed survey and the informed consent letter and from 1 to 7 days later they gave it back to the teacher (and then to the researcher).
To minimize the differences among individual perceptions about what is a loud sound, "loud" was described as "so loud that you would have to yell to be heard." At no point, we suggested that loud would mean potentially hazardous to hearing. The same definition of loud was provided to the parents in their survey.
Part of the collected data were reported in previous papers. ,
For the children interview a content analysis for the questions that included, descriptions had to be made. Those responses were coded prior to statistical analysis. Codes were defined before and during data analysis, and they derived both from theory and from relevant research findings. Statistical analysis was performed using SAS (version 9.1), and the significance level was 5%.
Homogeneity and other exposure factors were analyzed using Chi-square test for percentage differences and Fischer's exact test for absolute frequencies (n < 5). Analysis of agreement in measurement comparing children's and parents' questionnaires was accomplished by using the Symmetric Test. It analyses how different the answers were.
The present study was approved by the Ethics Committee of research of the State University of Campinas (number 940/2009). Approval was also obtained from the district school board. Formal consent for participation by each student and parent in this study was not required by the Ethics Committee of research. Instead, an informal consent form with a description of the study was sent home. Parents and guardians were required to send the form back to the classroom teacher only if they did not want their child to participate. If parents did not want to participate, they did not complete the survey.
| Results|| |
Seven hundred and forty children (50.8% female) who attended either public or private school participated in this study. Their age ranged from 5 to 16 years old (mean age 9.8, standard deviation 2.3). Six hundred and ten parents participated in the study. There was a great variation among parents educational level: 25% completed primary school, 14% completed the secondary school, 38% attended high school (completed it or not), 13% attended under graduation course (completed it or not) and 10% of them had a bachelor degree.
Previous exposure to loud sounds
The analysis of the exposures to loud sounds reported by the children showed that parties or concerts with loud music were the most common exposures (57.0%), followed by Mardi Gras (Brazilian carnival) (38.9%), loud music (39.9%), fireworks from a distance of 7 feet or less (41.2%), listening to loud music at home or in the car (35.5%), churches or temples with loud music (25.7%), listening to loud music with earphones (23.0%), using recreational motor-vehicles such as 4-wheelers, jet ski, kart and tractors (4.2%) and occupational noise when accompanying adults in a workplace (7.6%). Exposure to firearms was not considered because hunting is not a common activity in the Brazilian region studied.
Children who listen to loud music at home or in the car were asked "who sets the volume of the music?" Less than half of them (43.6%) said that they could choose the volume of the music. All the others said that the volume is usually set by an adult family member or older brothers and sisters. [Table 1] shows that children from families with lower educational levels are more exposed to loud music at home or in the car, while children from families with higher education levels are more exposed to loud music during Mardi Gras (Brazilian carnival) parties. Gender does not influence the occurrence of exposures to potentially hazardous sounds, but older children are definitely more exposed to them [Table 2].
|Table 1: Occurrence of exposures to potentially hazardous sounds according to parents' educational level|
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|Table 2: Occurrence of exposures to potentially hazardous sounds according to gender and children's age group|
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Risk perception and hearing preferences
When asked an open question about what might be harmful to the ears, 67.1% of the children gave answers related to loud sounds, like too much noise, loud music, listening to mp3 devices at loud volumes and screaming into the ears, for example, and 12.3% didn't know.
After a specific question about loud noise exposure risk to hearing, 87.4% considered noise to be harmful to the ears and 7.4% didn't know. Loud music was also considered harmful by 83.4% and 9.5% didn't know. Most of the children (88.9%) said that they would like to protect their hearing if they were told that loud sounds could harm their hearing, while 6.1% said that they wouldn't care and 5.0% answered that they wouldn't believe it. Parents' educational level did not influence any of the above variables (Chi-square test).
[Table 3] shows that older children are much more aware of the risks regarding exposures to loud sounds than the young ones, while gender has no significant impact on it.
|Table 3: Children's risk perception regarding exposures to loud sounds according to their gender and age group|
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Most children said they do not like loud noises (67.0%) or loud music (48.3%) at all, although some like it sometimes (30.5% and 33%, respectively). Neither gender nor parent's educational level influenced children's preferences in relation to exposure to loud noises and loud music [Table 4] and [Table 5]. However, older children showed a significant higher preference for loud sounds and loud music [Table 4].
|Table 4: Influence of gender and children's age on preferences related to exposure to loud sounds|
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|Table 5: Influence of parent's educational level on their children's preferences related to exposure to loud sounds|
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We used linear regression to explore how age influences sound level preferences and behaviors among children. As shown in [Figure 1] it is possible to observe the degree of correlation between age and the studied variables. The plots represent children's positive answers. R2 is the coefficient of determination. The closer the R2 is to 1, the stronger the correlation will be, but for studies with human, values above 0.5 are already considered significant. As shown in [Figure 1]a, for example, the R2 value of 0.61 means that 61% of the variation in the percentage of students who like loud music can be explained by its linear relationship to age.
|Figure 1: Linear regressions according to age. (a) Children that said they liked loud sounds; (b) children exposed to loud music at home or in the car; (c) children that can choose the volume of the music; (d) use of earphones to listen to loud music|
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To the open question about hearing protection strategies that children could use if they were in a very noisy place (defined to them as "so loud that you would have to scream to be heard"), only 1.0% would not do anything and 12.5% did not know. Although 3.1% would adopt inefficient protection (cotton balls or ear warmers), most of them intuitively knew some strategy: Covering the ears with hands (47.4%), going away (20.4%), use of hearing protection (5.7%), turning the volume down (1.7%) or association of two effective strategies (8.1%). A significant difference about the use of protective strategies was found in the children's age group [Figure 2], but not related to parents educational level (P = 0.093, Chi-square test) or gender (P = 0.373, Chi-square test).
|Figure 2: Use of hearing protective strategies according to children's age group|
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Only 28.8% of the children knew what a hearing protection device (HPD) is and were able to describe its usage, with no differences according to gender (P = 0.776, Chi-square test). However, parent's educational level had significant influences on their children's knowledge about it [Figure 3]. The same happened with children's age: 22.1% of the younger ones knew what an HPD is, contrasting with 41.2% in the older group (P < 0.0001, Chi-square test). In [Figure 4], we represent the linear regression used to explore how age influenced the children's knowledge about HPD.
|Figure 3: Children's knowledge about what a hearing protection device is according to their parents' educational level|
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|Figure 4: Children who know what a hearing protection devices is according to age|
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| Discussion|| |
In this study, we showed the results of 740 individual interviews with children from 5 to 16 years old about their habits and preferences related to loud sound exposures, children's knowledge about hearing health and protective behavior regarding loud sound exposures. Most of the children consider that the exposure to loud sounds can be harmful to the hearing, but they do not have a full understanding of the risks associated with it. Knowledge about the risks related to exposures to loud sounds and about strategies to protect their hearing increases with age, but preference for loud sounds and exposures to it increases too. This field of research is of special interest, as the understanding of the relation of awareness of the damaging effects of loud levels of sounds and the knowledge about hearing protection with age, gender, and their parent's educational level will assist the development of effective prevention messages for children and teenagers.
It is worth saying that none of the data collected suggest that children are over-exposed to noise (as a function of sound pressure level and duration of exposure to the hazardous sound). We only intended to reported engagement by children in activities that are potentially hazardous to hearing.
To minimize the intrinsic differences among individual perceptions regarding what is a loud sound, all the questions that included the judgment of "loud," described it as "so loud that you would have yell to be heard."
Though children knew they would participate in a study about hearing, at the beginning they did not know it was also about noise NIHL because we did not want to influence their answers. Hence, we first asked an open question about what might be harmful to the ears. Considering that those children had never taken part in a hearing conservation programs, we consider that they had substantial knowledge about the effects of noise on the auditory system. Our results were similar to the ones found among Mexican adolescents.  As in the present study, they were aware of the effects of noise exposure, but they did not avoid loud sound exposures.
The most frequent occurrences of noise exposure were parties or concerts with loud music and carnival parties (Mardi Gras), fireworks (from a distance of 7 feet or less), churches with loud music and listening to loud music at home or in the car, well-known dangers to the ears. ,,, It really looks like that most of the exposures to loud sounds in the leisure are elements of some contemporary ritual:  Parties and concerts with loud music, Mardi Gras, fireworks and religious' services.
Regarding the open question about hearing protection strategies, most of the children intuitively knew some efficient strategy, such as covering the ears with hands, going away, turning the volume down, or an association of two strategies. The use of hearing protection was mentioned only by 4.9%, much less than reported in a similar study made in Taiwan (55%). 
Even before beginning this study we had the notion that it would not be appropriate to investigate the use of ear protection before exploring the familiarity of children with it. Only 28.8% of the children knew what a HPD is and were able to describe its usage. Even more alarming is the fact that only seven children (0.9% from the whole sample) owed hearing protection. Information on the use of hearing protection is considered to be an important step towards the prevention of hearing impairments, second only to the general reduction of sound levels in society. ,
Parents' educational level
One of the most consistent observations in public health research is the finding of an inverse relation between socioeconomic level and health. Social class, including educational level, is a strong predictor for health-related perceptions and behavior and for health outcomes in general. ,
In considering some of the differences among parents' educational levels and their children' exposures to loud sounds, our findings showed a significant difference regarding exposures to loud music at home or in the car [Table 1]. Children whose parents had fewer educational opportunities were 2.2 times more exposed to loud music at home or in the car than children whose parents had a university degree, which might be associated with cultural codes. 
One can compare this passive-exposure to loud music with passive smoking. Actually, the same applies to exposure to fireworks, firecrackers and extremely loud music from concerts and parties. If children are exposed to those loud sounds by their family, even when they clearly manifest their dislike with loud sounds,  wouldn't it be expected that they consider it "normal" and part of the adult life?
Parent's educational level did not influence children's knowledge about the effects of noise on the auditory system, their risk perception or hearing preferences, as it also happens with different health issues. ,
[Table 1] also shows significant statistical differences regarding attendance to Mardi Gras parties and children's allowance to set the volume of the music, but there is no clear tendency of increasing or decreasing its frequencies according to parents' educational level.
However, parent's educational level had significant influences on their children's knowledge about HPD [Figure 3]. That was the only finding that agrees with the notion that the higher the socioeconomic status, the higher was the individual's worry about noise and the use of hearing protection. 
Children's knowledge about the effects of noise on the auditory system and hearing protection strategies did not vary according to gender [Table 3] and [Table 4]. Furthermore, girls tend to involve themselves (or to be involved) in risky behaviors just as much as their male counterparts [Table 2], as also reported by Bohlin and Erlandsson. 
The only significant difference according to gender was the higher vulnerability awareness among girls, since they were significantly more conscious that children can lose their hearing than boys [Table 3]. Maybe it could be an early sign of young women's tendency to judge certain risk behaviors (including attendance to discotheques and rock concerts) as more risky than young men. , This is an important point, since according to the health belief model  the ones with a sense of susceptibility or vulnerability are more likely to have health-related behavior. Furthermore, it has been shown that adolescents who reported being worried prior to noise exposure were more likely to use hearing protection than those who did not report any worry.  Similar studies indicated that most children would intend to use hearing protective strategies if they were aware of hearing loss risks. ,
Older children were much more aware of what could harm the ears than the younger ones, including the risks related to exposures to loud sounds, and were better informed about HPD [Table 3] and [Figure 2]. We consider that this may be a positive influence of the mass media. Interestingly, only 18.4% of the younger children and 65.3% of the older ones said that the volume of the music was set by them [Table 1]. It agrees with the observation that children have less control over their environments, and daily situations than adults have.  At this point, we suggest the term "passive-exposure to loud sounds," comparable to passive smoke.
Most children said they do not like loud noises (67%) or loud music (48.3%) at all, although some like it sometimes (30.5% and 33% respectively). However, the percentage of older children who said that they like loud noise and loud music was significantly higher than the percentage of younger children [Table 4]. Following the same trend, older children were clearly much more exposed to hazardous levels of sounds than the younger ones,  and the only inverted condition is for churches with loud music, probably not because older children go to quieter religious services [Table 1], but perhaps because at younger ages many children have to go to churches with their parents.
It seems that as children get older, there is a clear tendency towards preferences and behaviors that involve loud sounds and loud music. Of course, there are developmental changes within the child that do not depend on the parents. As explained by Bohlin and Erlandsson,  adolescents may engage in risky activities as these activities give them higher status among peers, intense feelings, pleasure and satisfaction.
Our results are coherent with studies of adolescents, ,, that report that a great number of them are aware of the risks of loud sound exposure, but continue to expose themselves indiscriminately to risky situations. It endorses the impression that knowledge about the relationship between noise and hearing loss is not enough to facilitate a behavior change.  We certainly should consider that adolescents have mixed feelings of threat and desire related to risk-taking. 
Many researchers have discussed about the best solution for hearing conservation for children and adolescents. We fully agree that an overall reduction of sound levels in society is more than desired. ,, In many countries, the rise of sound pollution has fostered the reinforcement of public policies concerning noise issues. However, we are unsure about the success of simply imposed restrictions and laws about the production of noise to face the problem. Bijsterveld  coined the expression "paradox of control," related to the rise of noise that overlaps noise regulations. According to the author observation, experts and politicians intend to control some noise, such as aircraft noise, but left other noise problems up to the responsibility of citizens themselves. As noticed by Gilliver et al.,  noise reduction in leisure environments is likely to remain particularly reliant on personal regulation, which deeply depends on individuals' motivations to monitor and regulate their own behavior and exposure.
Safe listening should be encouraged at an early age.  We agree with Bistrup et al.  that children of a certain age and maturity are competent and active about their own situation, but younger ones depend on adults to guide them in protecting their hearing or prohibiting them from being exposed to hearing-damaging sounds. If we combine it with our data and with the recommendations by the World Health Organization  that focused on protecting children against loud noise exposure, we come to the conclusion that adults should be part of any educational hearing conservation program for children. In our opinion, passive loud sound exposure should be treated with the same seriousness as passive smoke, for example. We also defend that health risks associated with loud sounds as social and political problems.  Hence, hearing conservation programs and campaigns must be part of the public health agencies goals.
While the drop-out range was 40.4%, it was similar in private and public schools and did not change the general age and gender distribution. The reliance on self-reported measures of noise exposure and the lack of data about how frequent or infrequent the exposures were are limitations of the study. History of noise exposure was based on self-report, so it might be possible that children under or over reported noise exposure.
Our data may reflect the reality of Brazilian children living in a large and industrialized city in the Southeast of Brazil. We cannot generalize our data to different population strata in other geographic regions of Brazil or in other countries. Although differences like climate, regional culture and particular recreational activities could imply in different results, up to the current body of knowledge we consider that our study offers insight on how cultural issues can contribute to an increase or decrease loud sound stimulation.
Contributions and future directions
Data from our study may contribute to alerting parents, educators and authorities about their highest role as models for future generations and their importance into educational, preventive measures against NIHL in children and adolescents. It is unlikely that children and adolescents learn better habits and behaviors without the supposed social coherency and consistency that an environmental education about noise pollution and hearing conservation requires. Moreover, we hope that the education of an entire generation could have a long-term influence on the decreasing of the voluntary exposure to loud sounds.
Finally, our findings could be used to guide health policies on hearing conservation programs and campaigns for the whole family and environmental policies strategies to control noise pollution.
| Conclusion|| |
Children do not have a full understanding of the risks associated with exposure to loud sounds, but there is a consensus that it can be harmful to the hearing. However, children are exposed by their older family members to potentially harmful sounds in several recreational activities. Although most of the children do not like loud noise or loud music, younger children have very little autonomy to avoid exposures to leisure activities with potentially harmful sounds, which confirms their vulnerability. Hearing conservation programs are an urgent need for children, and it should include parents and the society as a whole.
This work was supported by the Fundação de Amparo à Pesquisa de São Paulo (Fapesp 2009/15825-0). The funding organizations had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
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Dr. Keila Alessandra Baraldi Knobel
Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Rua: Tessália Vieira de Camargo, 126, Cidade Universitária "Zeferino Vaz", 13083-887 Campinas, São Paulo
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]