Evaluation of Noise-Induced Hearing Loss in Young People

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DOI: 10.1542/peds.2004-01732005;115;861Pediatrics

Jeannie H. Chung, Catherine M. Des Roches, John Meunier and Roland D. Eavey

Survey TechniqueEvaluation of Noise-Induced Hearing Loss in Young People Using a Web-Based

http://pediatrics.aappublications.org/content/115/4/861.full.html

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Evaluation of Noise-Induced Hearing Loss in Young PeopleUsing a Web-Based Survey Technique

Jeannie H. Chung, MD*; Catherine M. Des Roches, PhD; John Meunier, MS; and Roland D. Eavey, MD*

ABSTRACT. Objective. Many adolescents and youngadults consciously expose themselves to loud music forentertainment. We hypothesized that these individualsmight not be aware that exposure to loud music couldresult in hearing loss. Furthermore, we wished to assessthe feasibility of a web-based survey to collect healthinformation from this group.

Methods. A 28-question survey was designed to tar-get adolescents and young adults. The survey containedquestions about views toward general health issues, in-cluding hearing loss, and was presented to random visi-tors at the MTV web site.

Results. In 3 days, 9693 web surveys were completed.

Hearing loss was defined on a Likert scale as a very bigproblem by 8% of respondents compared with otherhealth issues: sexually transmitted diseases, 50%; alco-hol/drug use, 47%; depression, 44%; smoking, 45%; nu-trition and weight issues, 31%; and acne, 18%. Notably,most respondents had experienced tinnitus or hearingimpairment attending concerts (61%) and clubs (43%).Only 14% of respondents had used earplugs; however,many could be motivated to try ear protection if theywere aware of the potential for permanent hearing loss(66%) or were advised by a medical professional (59%).

Conclusions. A majority of young adults have expe-rienced tinnitus and hearing impairment after exposureto loud music. Fortunately, many of these individualscould be motivated to wear ear protection. This novelweb-based survey technique rapidly generated a largedatabase and is a feasible method to obtain health datafrom this group. Pediatrics 2005;115:861867; noise-in-duced hearing loss.

ABBREVIATION. NIHL, noise-induced hearing loss.

Noise-induced hearing loss (NIHL) is a signif-icant social and public health problem. Muchof the efforts to reduce NIHL have concen-

trated on reducing risks from occupational noise ex-posure in adults. However, several studies have re-

ported an increasing trend of NIHL in children andadolescents. In the first large, national, population-

based study, Niskar et al1 estimated that 12.5% ofchildren aged 6 to 19 years have noise-inducedthreshold shifts. In 1985, Lees et al2 reported that 40%of students aged 16 to 25 years had audiometricevidence of NIHL, and in 1996, Blair et al3 reportedthat 1% of all school-aged children have some degreeof NIHL. Studies from the United Kingdom,4,5

France,6 Sweden,7 and China8 have also reportedevidence of NIHL in children and young adults.

NIHL in children and young adults has beenlinked to recreational noise and leisure activities. In1985, Axelsson and Jerson9 evaluated noisy toys aspossible sources of NIHL in children. They foundthat squeaky toys could produce sound levels of 78to 108 dBA at a distance of only 10 cm, whereasfirecrackers produced sound levels of 125 to 156 dBAat a distance of 3 m. Other leisure activities involvingwoodworking, recreational vehicles, and power toolsmay produce sounds 85 dBA.10 Classrooms alsoharbor potentially dangerous levels of noise. Onestudy measured sound levels in band and industrialtechnology classrooms at 80 to 110 dB.11 Further-more, adolescents who lived on farms had greaterprevalence of hearing loss compared with their peersfrom their exposure to sound levels 95 dBA.12

In todays society, adolescents and young adultsconsciously expose themselves to loud music, oftenfor hours at a time. Loud music from concerts, clubs,and personal audio systems pose a potentially dan-gerous source of recreational noise. Sound levels atrock concerts have been recorded at 120 dB to 140 dB,and the sound levels in bars can reach 95 dB on aweekend night.4,13 Lee et al14 found that transientthreshold shifts 10 db could be seen after listeningto headphones for 3 hours at normally used outputlevels. Despite evidence of hazardous noise exposureamong adolescents and young adults, no safety stan-dards or guidelines exist for nonoccupational noiseexposure.

Although short periods of exposure to amplifiedsound may be experienced without permanent hear-ing loss, the damage from chronic exposure to thesesound levels is cumulative so that a slight hearingloss in childhood can eventually become a substan-tial one in adulthood. The prevention of such hearingloss begins with education with hearing conserva-tion programs ideally targeting children and youngadults.

In 2002, Folmer et al15 performed a comprehensivereview of hearing conservation education programsfor children. They reviewed 29 organizations with

From the *Department of Otolaryngology, Pediatric Otolaryngology Ser-

vice, Massachusetts Eye and Ear Infirmary, and Department of Otology and

Laryngology, Harvard Medical School, Boston, Massachusetts; Center for

Survey Research, Harvard School of Public Health, Boston, Massachusetts;

and Cogent Research, Cambridge, Massachusetts.

Accepted for publication Jul 27, 2004.

doi:10.1542/peds.2004-0173

No conflict of interest declared.

Reprint requests to (R.D.E.) Massachusetts Eye and Ear Infirmary, 243

Charles St, Boston, MA 02114. E-mail: [email protected]

PEDIATRICS (ISSN 0031 4005). Copyright 2005 by the American Acad-

emy of Pediatrics.

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curricula in place to produce and disseminate hear-ing conservation materials suitable for children.Some of the organizations and programs reviewedincluded Crank It Down! (National Hearing Conser-vation Association), Stop That Noise! (League for theHard of Hearing), and Wise Ears (National Institute

on Deafness and Other Communication Disorders).Wise Ears is one of the most comprehensive curriculaavailable for children and includes lesson plans forteachers, videos, and interactive programs on theirweb site. In their review, Folmer et al15 found thatthe various hearing conservation programs had ef-

Fig 1. Survey created by researchers at the Massachusetts Eye and Ear Infirmary, the Harvard School of Public Health, and CogentResearch, Inc.

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fective program materials and resources but that dis-semination of these materials to the schools was in-adequate.

Although concerned professionals can implementaudiometric screenings and promote educationabout NIHL in schools, influence for behavior mod-ifications may be achieved perhaps more effectivelyif we could understand the perceptions about hear-ing and NIHL. What do adolescents and youngadults know about hearing loss? How do young

patients feel about the use of hearing protection?Which interventions might influence preventive be-havior? These are some of the questions that wewished to address. The objectives of this report wereto evaluate awareness of NIHL among young adults,to examine perceptions of hearing protection, and toidentify factors that might influence behavior in apositive way. In addition, we wished to determinethe utility of a web-based survey technique to gatherhealth information from this group.

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METHODS

A 28-question survey was created by researchers at the Massa-chusetts Eye and Ear Infirmary, the Harvard School of PublicHealth, and Cogent Research, Inc (Fig 1). The survey was designedto target adolescents and young adults and contained initial ques-tions about views toward several general health issues, includinghearing loss. The survey further directed 16 questions at specifichearing issues such as the use of hearing protection, factors thatmight increase use of hearing preservation, and personal exposureto loud recreational music. The survey also collected demographicdata such as age and occupational and socioeconomic status (Ta-

ble 1). The survey format included multiple choice, multichoto-mous, and open-ended questions designed to be completed easily.The survey contained 4 questions with multiple subquestions thatrequired the respondents to prioritize the significance of answersabout a health issue on a Likert scale such as a very big problem,somewhat of a problem, not too much of a problem, or nota problem at all.

The survey was administered anonymously as a randompop-up survey to every 30th visitor to the MTV.com web site for3 consecutive days. The MTV web site was chosen because of thelarge congruence of visitors (400 000 visits per day) with theproject requirements. MTV is accepted as a leading authority inmusic and is specifically geared toward 15- to 34-year-olds. In 3days, 49 800 visitors received the pop-up survey and 9693 surveyswere completed (19% cooperation rate). Of the surveys that werenot completed (81%), the number of participants who withdrewfrom the survey versus the number of incomplete surveys was notrecorded. Respondents between the ages of 13 and 65 years were

included in the study. Those who were between the ages of 35 and65 years constituted 0.2% of the study respondents. The result-ing study population consisted of 3310 (35%) male and 6148 (65%)female respondents, with an average age of 19.2 years. The re-sponses to each question are reported in percentages. Informedconsent was not obtained given the inherent, voluntary nature ofcompleting an anonymous web-based survey.

RESULTS

Hearing loss was defined as a very big problemby 8% of respondents compared with the following:sexually transmitted diseases, 50%; alcohol/druguse, 47%; depression, 44%; smoking, 45%; nutritionand weight issues, 31%; and acne, 18%. Female re-

spondents were statistically more likely to considerdrug and alcohol use, sexual issues, nutrition andweight-loss issues, and depression as a very bigproblem compared with male respondents (Table2). A respondent was more likely to consider hearing

loss a very big problem or somewhat of a bigproblem when they had previous education on hear-ing loss (41% vs 29%; P .05).

The majority of respondents had attended a con-cert, club, or party with loud music in the last 6months (Table 3), and 61% and 43% reported expe-riencing tinnitus or temporary hearing impairment,respectively, while attending loud music venues.Only 14% of respondents reported wearing ear pro-tection in places where loud music was being played,

but 39% reported that suggestions had been made towear earplugs; suggestion to wear earplugs wasmade to 29% of all respondents15 years, to 38% ofrespondents 15 to 18 years, to 35% of respondents 19to 21 years, and to 44% of respondents 21 years.Parents (55%) were the most likely group to haverecommended the use of earplugs. Physicians hadrecommended the use of hearing protection to 22%of respondents. Before this survey, only 16% of re-spondents had heard, read, or seen anything publiclyrelated to the issue of hearing loss, with 9% receivingeducation at school.

Only 20% of respondents reported the personalintention to use earplugs at a future concert or club

with loud music. However, this number increased(Table 4) when the respondents were made aware ofthe potential for permanent hearing loss (66%) orwere encouraged by a medical professional (59%).The respondents also would be inclined to wearhearing protection if they knew that earplugs protecthearing without decreasing enjoyment (57%). Whenasked by open-ended question about the perceptionsof peers who wear earplugs in a social situation withloud noise, 41% responded negatively and 59% werepositive or equivocal. As to the availability, 68% ofrespondents knew that ear plugs could be purchasedin a drug store.

DISCUSSION

The results of this study indicate the low priorityof hearing loss relative to other health issues. Ironi-cally, a 61% majority of respondents have experi-enced hearing loss and tinnitus at rock concerts. Thehealth issues that are considered to be of concern forour group, such as alcohol and drug use, smoking,sexually transmitted diseases, and depression, areconsistent with results drawn from an original sur-vey on Americans views toward childrens healthissues designed by the Harvard School of PublicHealth Survey Research Center.16 Unlike such issues

as alcohol and drug use, which may have immediatelife-threatening consequences, hearing loss does notpose a concern for youths as the detrimental effectsmay not manifest for years. Furthermore, they areunable to appreciate fully the significant impact thathearing loss may have on future quality of life.

Given the low priority to hearing loss, the infre-quent use of hearing protection is not unexpected.Expecting individuals to modify behavior requires asignificant amount of education at many levels insociety. A small number of respondents (16%) re-ported any exposure to or education about issuessurrounding hearing health; significantly, this groupwas more likely to consider hearing loss an impor-

TABLE 1. Demographic Data

Respondents, %

Female gender 65Age

Mean age 19 y15 161518 41

1921 1921* 23

Education levelIn high school 40High school graduate or higher 60

Employment statusStudent 63Employed part-time, full-time,

homemaker, other37

Family income in 2001Above average 34

Internet use/wk03 h 234 h or more 77

* Respondents between the ages of 35 and 65 constitute 0.2% ofthe study sample.



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tant health concern. Experts advocate that educa-tional programs must begin early in life and havesuggested well-child physician visits and annualschool examinations throughout elementary and

high school as possible opportunities.1,13,17,18

The substantial positive behavioral response (59%)to a doctor or nurse telling you that you shouldwear ear plugs indicates that we in the medicalcommunity have failed to communicate an effectivemessage but that we still do have a significant op-portunity to have an impact on hearing behaviors.Importantly, only 9% of respondents reported receiv-ing any education about hearing in school, anotheropportunity for change. Several studies have shownthe positive impact of hearing conservation pro-grams on behavior modification of school-aged chil-dren and young adults.11,18,19 A survey by Lass et

al

18

examined high school students knowledgeabout hearing health. They found deficiencies in thestudents knowledge about normal hearing mecha-nism and hearing loss and about the effect on hear-ing of overexposure to noise. Although only 14% ofthe study groups have worn hearing protection, thesubjects report a positive influence to wear hearingprotection if educated about the potential for perma-nent hearing loss (66%) and if known that hearingprotection would not decrease enjoyment (57%). Astudy by Lewis19 also exemplifies the power of edu-cation. He evaluated 1529 students at 5 Ohio highschools before and after a hearing conservation-edu-cation program. Pretesting showed that 87% of stu-

dents had never worn protective earplugs; posttestresults showed that 15% to 20% more studentswould wear them. These classic public health tech-niques of information and persuasion seem highly

promising regarding hearing preservation at enter-tainment venues and are certainly easier to imple-ment than the legislation-intensive techniques of re-striction and/or prohibition.

Parents were the group most likely to recommendthe use of hearing protection. However, other groupsshould also play an allied role in convincing childrenand adolescents to protect hearing as individuals inthis age group may typically engage in rebellious

behavior against parental authority. Our respon-dents reported that social influences such as peers(39%), public role models (46%), and television (24%)could also influence behavior to use hearing protec-

tion.This study attests to the accessibility and feasibilityof a web-based survey as shown by the overwhelm-ing response to the survey. The World Wide Web hasemerged as a powerful tool in which to collect dataand allows unprecedented access to the population.Although the Internet and the use of the web is notyet as ubiquitous as the conventional telephone sur-vey technique, Internet survey methodology is in-creasing.20 Most of the respondents (77%) spend 4 ormore hours per week on the Internet. In fact, a study

by the Kaiser Family Foundation revealed that teensspend a considerable amount of web time visitinghealth sites.21 The study report GenerationRX.comwas a national, random, telephone survey of 1209young people aged 15 to 24 years. The GenerationRx.com survey reported that 75% of teens and youngadults who have used the Internet most often havesearched for health information compared with play-ing games (72%), downloading music (72%), shop-ping (50%), or checking sports scores (46%). Of thosewho have accessed health information online, themajority (55%) have done so only a few times a year,

but 39% do so at least once a month. The survey alsofound that 39% of respondents have changed theirpersonal behavior because of the health informationthat they obtained on-line.21 As a significant portion

TABLE 2. Relative Priority of Health Concerns Considered a Very Big Problem

Health Concern Considered aVery Big Problem, %*

Gender, % Age, %

15 Years 1518 Years 1921 Years 21 Years

Hearing loss 8 Male: 10 9 8 8 9Female: 8

Sexually transmitted diseases 50 Male: 47 44 50 57 54Female: 54

Alcohol/drug use 47 Male: 40 40 48 44 52Female: 51

Depression 44 Male: 37 40 45 50 42Female: 59

Smoking 45 Male: 39 37 43 46 44Female: 45Nutrition and weight issues 31 Male: 23 23 26 37 41

Female: 36Acne 18 Male: 14 19 23 14 9

Female: 18

* Percentage of the total number of respondents. Percentage of all male or all female respondents. Percentage of respondents within a corresponding age group.

TABLE 3. Number of Attendances at Concerts or Clubs in thePast 6 Months

No. of Attendances Respondents, %

Concert

0 3419 6010 6

Club0 3419 441019 1020 13



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of adolescents and young adults spend time surfingthe net for health information, health researchersand educators should extract the full potential of theWorld Wide Web as a powerful communication me-dium. Examples of web sites that are dedicated toNIHL are www.hearinghealth.net (The NationalCampaign for Hearing Health Online) and www.hearnet.com (Hearing Education and Awareness forRockers).

The World Wide Web has been used in surveyresearch, and these studies have compared tradi-tional, mailed questionnaires, personal interviews,and e-mail surveys for differences in response ratesand response effects.22,23A recent study also assessed

the feasibility of collecting health risk behavior datafrom undergraduate students using a web-based sur-vey.20 Undergraduate students were randomized toreceive a traditional paper survey in the mail or aweb-based survey. There were no statistical differ-ences for demographics, response rates, item com-pletion, and item completion errors. However, thestudy found that the web group participants weremore inclined to reveal potentially embarrassing orsensitive information than were participants in themail survey group.

Web-based surveys offer advantages and distinctdesign elements such as checkboxes, radiobuttons,

pop-up questions, and text-entry boxes that limitdata entry errors. Software now exists that allowsraw data to be entered directly into a statistical da-tabase, which allows for immediate data analysissuch as for this survey. Furthermore, the survey may

be designed in such a manner that maximizes thequestion completion rate and decreases the comple-tion time with such features as skip patterns.

Traditional surveys pose numerous methodologi-cal problems and are costly and time-consuming.Furthermore, surveys that allow contact between therespondent and the surveyor may lead to biasedoverreporting of socially desirable responses, espe-

cially when sensitive information is being asked.

20

Self-administered, anonymous surveys are less likelyto overreport socially desirable responses, but re-sponse rates and item completion rates may be low.

Although this study had a large number of respon-dents, there are several shortfalls in the study. First,

by virtue that the survey was linked to the soleMTV.com web site, respondents were not a randomsample taken from the population. Second, the inher-ent nature of a web survey excludes those without acomputer or access to the Internet. Third, the volun-tary nature of the respondents participation mayinfluence data by self-selection of those who are bi-ased in a certain opinion.

CONCLUSION

This study shows that NIHL has a low level ofawareness priority among adolescents and youngadults. Fortunately, many would be persuaded towear hearing protection with adequate educationand counseling. Hearing conservation educationmust be implemented on many fronts in society toeducate our youths about hearing health. The WorldWide Web is powerful medium to collect health datafrom this group, and with additional experience, sur-vey result interpretations hopefully will refine evenfurther.

ACKNOWLEDGMENTS

We sincerely thank Shari Redstone of National Amusementsand Viacom for wise and gracious guidance and enthusiasticassistance. Sumner Redstone of Viacom and several individuals atMTV should be recognized for invaluable aid to this project: MarkRosenthal, Stephen Friedman, Allison Reidy, Jeannette Prymas,Ahna Biddle, Matthew Catapano, and Jeffrey Kaufman as well asthe members of the MTV technical crew in Cancun. Kathy Peckfrom H.E.A.R. along with Gwendaline Mazarra and DJ Polywogprovided on-site experience and provided earplugs from Aero.Elizabeth Thorpe from the Deafness Research Foundation andPeter Venner of Macks Ear Plugs generously provided advice andear protection plugs, respectively, for the Cancun audience. DrFelipe Santos greatly assisted with the paper survey in Cancun. Dr

Jose Ignatio Santos provided Mexican educational media oppor-tunities. Betty Treanor provided excellent manuscript preparation.

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TABLE 4. Factors That Are Likely to Influence the Use of Hearing Protection

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Finding out that limited exposure to very loud music canpermanently damage hearing

66

A doctor or nurse telling you that you should wear ear plugs 59Finding out that many musicians and performers wear

earplugs while performing46

Finding out that friends wear ear plugs 39Learning about earplugs on television 24



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DEVICE ALLOWS DOCTORS TO PRACTICE DELIVERIES

It does not look like anyones mother, and the baby it delivers has none of theemotional appeal of a newborn. But a life-like birth simulator developed at JohnsHopkins University may provide some important new information about problemdeliveries in real mothers and infants. The birth simulator, which started out as aresearch project in engineering, has now been used to determine the best way todeliver a baby whose shoulders become stuck in the birth canal, a condition calledshoulder dystocia. . . . The researchers found that the Rubins maneuver produced

less than half the force of the McRoberts method, suggesting that it might be safer.The findings, being published . . . in American Journal of Obstetrics and Gynecology,still require further validation through additional research and clinical evaluation,so recommendations for a change in practice may not come for some time. But theevidence is mounting. . . . There are commercially available birthing simulators,Dr. Edith D. Gurewitsch said in a telephone interview, but really theyre just dolls.None have instrumentation like ours that actually tells you what kind of forceyoure exerting on the head, neck, and nerves of the infant.

Bakalar N. New York Times. January 4, 2005

Noted by JFL, MD



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DOI: 10.1542/peds.2004-0173

2005;115;861PediatricsJeannie H. Chung, Catherine M. Des Roches, John Meunier and Roland D. Eavey

Survey TechniqueEvaluation of Noise-Induced Hearing Loss in Young People Using a Web-Based

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