Objective. Many adolescents and young adults consciously expose themselves to loud music for entertainment. We hypothesized that these individuals might not be aware that exposure to loud music could result in hearing loss. Furthermore, we wished to assess the feasibility of a web-based survey to collect health information from this group.
Methods. A 28-question survey was designed to target adolescents and young adults. The survey contained questions about views toward general health issues, including hearing loss, and was presented to random visitors 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 big problem” by 8% of respondents compared with other health issues: sexually transmitted diseases, 50%; alcohol/drug use, 47%; depression, 44%; smoking, 45%; nutrition and weight issues, 31%; and acne, 18%. Notably, most respondents had experienced tinnitus or hearing impairment attending concerts (61%) and clubs (43%). Only 14% of respondents had used earplugs; however, many could be motivated to try ear protection if they were aware of the potential for permanent hearing loss (66%) or were advised by a medical professional (59%).
Conclusions. A majority of young adults have experienced tinnitus and hearing impairment after exposure to loud music. Fortunately, many of these individuals could be motivated to wear ear protection. This novel web-based survey technique rapidly generated a large database and is a feasible method to obtain health data from this group.
Noise-induced hearing loss (NIHL) is a significant social and public health problem. Much of the efforts to reduce NIHL have concentrated on reducing risks from occupational noise exposure in adults. However, several studies have reported an increasing trend of NIHL in children and adolescents. In the first large, national, population-based study, Niskar et al1 estimated that 12.5% of children aged 6 to 19 years have noise-induced threshold shifts. In 1985, Lees et al2 reported that 40% of students aged 16 to 25 years had audiometric evidence of NIHL, and in 1996, Blair et al3 reported that 1% of all school-aged children have some degree of NIHL. Studies from the United Kingdom,4,5 France,6 Sweden,7 and China8 have also reported evidence of NIHL in children and young adults.
NIHL in children and young adults has been linked to recreational noise and leisure activities. In 1985, Axelsson and Jerson9 evaluated noisy toys as possible sources of NIHL in children. They found that squeaky toys could produce sound levels of 78 to 108 dBA at a distance of only 10 cm, whereas firecrackers produced sound levels of 125 to 156 dBA at a distance of 3 m. Other leisure activities involving woodworking, recreational vehicles, and power tools may produce sounds >85 dBA.10 Classrooms also harbor potentially dangerous levels of noise. One study measured sound levels in band and industrial technology classrooms at 80 to 110 dB.11 Furthermore, adolescents who lived on farms had greater prevalence of hearing loss compared with their peers from their exposure to sound levels >95 dBA.12
In today's society, adolescents and young adults consciously expose themselves to loud music, often for hours at a time. Loud music from concerts, clubs, and personal audio systems pose a potentially dangerous source of recreational noise. Sound levels at rock concerts have been recorded at 120 dB to 140 dB, and the sound levels in bars can reach >95 dB on a weekend night.4,13 Lee et al14 found that transient threshold shifts >10 db could be seen after listening to headphones for 3 hours at normally used output levels. Despite evidence of hazardous noise exposure among adolescents and young adults, no safety standards or guidelines exist for nonoccupational noise exposure.
Although short periods of exposure to amplified sound may be experienced without permanent hearing loss, the damage from chronic exposure to these sound levels is cumulative so that a slight hearing loss in childhood can eventually become a substantial one in adulthood. The prevention of such hearing loss begins with education with hearing conservation programs ideally targeting children and young adults.
In 2002, Folmer et al15 performed a comprehensive review of hearing conservation education programs for children. They reviewed 29 organizations with curricula in place to produce and disseminate hearing conservation materials suitable for children. Some of the organizations and programs reviewed included Crank It Down! (National Hearing Conservation Association), Stop That Noise! (League for the Hard of Hearing), and Wise Ears (National Institute on Deafness and Other Communication Disorders). Wise Ears is one of the most comprehensive curricula available for children and includes lesson plans for teachers, videos, and interactive programs on their web site. In their review, Folmer et al15 found that the various hearing conservation programs had effective program materials and resources but that dissemination of these materials to the schools was inadequate.
Although concerned professionals can implement audiometric screenings and promote education about NIHL in schools, influence for behavior modifications may be achieved perhaps more effectively if we could understand the perceptions about hearing and NIHL. What do adolescents and young adults know about hearing loss? How do young patients feel about the use of hearing protection? Which interventions might influence preventive behavior? These are some of the questions that we wished to address. The objectives of this report were to evaluate awareness of NIHL among young adults, to examine perceptions of hearing protection, and to identify factors that might influence behavior in a positive way. In addition, we wished to determine the utility of a web-based survey technique to gather health information from this group.
A 28-question survey was created by researchers at the Massachusetts Eye and Ear Infirmary, the Harvard School of Public Health, and Cogent Research, Inc (Fig 1) . The survey was designed to target adolescents and young adults and contained initial questions about views toward several general health issues, including hearing loss. The survey further directed 16 questions at specific hearing issues such as the use of hearing protection, factors that might increase use of hearing preservation, and personal exposure to loud recreational music. The survey also collected demographic data such as age and occupational and socioeconomic status (Table 1). The survey format included multiple choice, multichotomous, and open-ended questions designed to be completed easily. The survey contained 4 questions with multiple subquestions that required the respondents to prioritize the significance of answers about a health issue on a Likert scale such as “a very big problem,” “somewhat of a problem,” “not too much of a problem,” or “not a problem at all.”
The survey was administered anonymously as a random pop-up survey to every 30th visitor to the MTV.com web site for 3 consecutive days. The MTV web site was chosen because of the large congruence of visitors (>400000 visits per day) with the project requirements. MTV is accepted as a leading authority in music and is specifically geared toward 15- to 34-year-olds. In 3 days, 49800 visitors received the pop-up survey and 9693 surveys were completed (19% cooperation rate). Of the surveys that were not completed (81%), the number of participants who withdrew from the survey versus the number of incomplete surveys was not recorded. Respondents between the ages of 13 and 65 years were included in the study. Those who were between the ages of 35 and 65 years constituted <0.2% of the study respondents. The resulting study population consisted of 3310 (35%) male and 6148 (65%) female respondents, with an average age of 19.2 years. The responses to each question are reported in percentages. Informed consent was not obtained given the inherent, voluntary nature of completing an anonymous web-based survey.
Hearing loss was defined as “a very big problem” by 8% of respondents compared with the following: sexually transmitted diseases, 50%; alcohol/drug use, 47%; depression, 44%; smoking, 45%; nutrition and weight issues, 31%; and acne, 18%. Female respondents were statistically more likely to consider drug and alcohol use, sexual issues, nutrition and weight-loss issues, and depression as a “very big problem” compared with male respondents (Table 2). A respondent was more likely to consider hearing loss a “very big problem” or “somewhat of a big” problem when they had previous education on hearing loss (41% vs 29%; P < .05).
The majority of respondents had attended a concert, club, or party with loud music in the last 6 months (Table 3), and 61% and 43% reported experiencing tinnitus or temporary hearing impairment, respectively, while attending loud music venues. Only 14% of respondents reported wearing ear protection in places where loud music was being played, but 39% reported that suggestions had been made to wear earplugs; suggestion to wear earplugs was made to 29% of all respondents <15 years, to 38% of respondents 15 to 18 years, to 35% of respondents 19 to 21 years, and to 44% of respondents >21 years. Parents (55%) were the most likely group to have recommended the use of earplugs. Physicians had recommended the use of hearing protection to 22% of respondents. Before this survey, only 16% of respondents had heard, read, or seen anything publicly related to the issue of hearing loss, with 9% receiving education at school.
Only 20% of respondents reported the personal intention to use earplugs at a future concert or club with loud music. However, this number increased (Table 4) when the respondents were made aware of the potential for permanent hearing loss (66%) or were encouraged by a medical professional (59%). The respondents also would be inclined to wear hearing protection if they knew that earplugs protect hearing without decreasing enjoyment (57%). When asked by open-ended question about the perceptions of peers who wear earplugs in a social situation with loud noise, 41% responded negatively and 59% were positive or equivocal. As to the availability, 68% of respondents knew that ear plugs could be purchased in a drug store.
The results of this study indicate the low priority of hearing loss relative to other health issues. Ironically, a 61% majority of respondents have experienced hearing loss and tinnitus at rock concerts. The health issues that are considered to be of concern for our group, such as alcohol and drug use, smoking, sexually transmitted diseases, and depression, are consistent with results drawn from an original survey on Americans' views toward children's health issues designed by the Harvard School of Public Health Survey Research Center.16 Unlike such issues as alcohol and drug use, which may have immediate life-threatening consequences, hearing loss does not pose a concern for youths as the detrimental effects may not manifest for years. Furthermore, they are unable to appreciate fully the significant impact that hearing loss may have on future quality of life.
Given the low priority to hearing loss, the infrequent use of hearing protection is not unexpected. Expecting individuals to modify behavior requires a significant amount of education at many levels in society. A small number of respondents (16%) reported any exposure to or education about issues surrounding hearing health; significantly, this group was more likely to consider hearing loss an important health concern. Experts advocate that educational programs must begin early in life and have suggested well-child physician visits and annual school 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 should wear ear plugs” indicates that we in the medical community have failed to communicate an effective message but that we still do have a significant opportunity to have an impact on hearing behaviors. Importantly, only 9% of respondents reported receiving any education about hearing in school, another opportunity for change. Several studies have shown the positive impact of hearing conservation programs on behavior modification of school-aged children and young adults.11,18,19 A survey by Lass et al18 examined high school students' knowledge about hearing health. They found deficiencies in the students' knowledge about normal hearing mechanism and hearing loss and about the effect on hearing of overexposure to noise. Although only 14% of the study groups have worn hearing protection, the subjects report a positive influence to wear hearing protection if educated about the potential for permanent hearing loss (66%) and if known that hearing protection would not decrease enjoyment (57%). A study by Lewis19 also exemplifies the power of education. He evaluated 1529 students at 5 Ohio high schools before and after a hearing conservation-education program. Pretesting showed that 87% of students had never worn protective earplugs; posttest results showed that 15% to 20% more students would wear them. These classic public health techniques of information and persuasion seem highly promising regarding hearing preservation at entertainment venues and are certainly easier to implement than the legislation-intensive techniques of restriction and/or prohibition.
Parents were the group most likely to recommend the use of hearing protection. However, other groups should also play an allied role in convincing children and adolescents to protect hearing as individuals in this age group may typically engage in rebellious behavior against parental authority. Our respondents reported that social influences such as peers (39%), public role models (46%), and television (24%) could also influence behavior to use hearing protection.
This study attests to the accessibility and feasibility of a web-based survey as shown by the overwhelming response to the survey. The World Wide Web has emerged as a powerful tool in which to collect data and allows unprecedented access to the population. Although the Internet and the use of the web is not yet as ubiquitous as the conventional telephone survey technique, Internet survey methodology is increasing.20 Most of the respondents (77%) spend 4 or more hours per week on the Internet. In fact, a study by the Kaiser Family Foundation revealed that teens spend a considerable amount of web time visiting health sites.21 The study report GenerationRX.com was a national, random, telephone survey of 1209 young people aged 15 to 24 years. The GenerationRx.com survey reported that 75% of teens and young adults who have used the Internet most often have searched for health information compared with playing games (72%), downloading music (72%), shopping (50%), or checking sports scores (46%). Of those who have accessed health information online, the majority (55%) have done so only a few times a year, but 39% do so at least once a month. The survey also found that 39% of respondents have changed their personal behavior because of the health information that they obtained on-line.21 As a significant portion of adolescents and young adults spend time “surfing the net” for health information, health researchers and educators should extract the full potential of the World Wide Web as a powerful communication medium. Examples of web sites that are dedicated to NIHL are www.hearinghealth.net (The National Campaign for Hearing Health Online) and www.hearnet.com (Hearing Education and Awareness for Rockers).
The World Wide Web has been used in survey research, and these studies have compared traditional, mailed questionnaires, personal interviews, and e-mail surveys for differences in response rates and response effects.22,23A recent study also assessed the feasibility of collecting health risk behavior data from undergraduate students using a web-based survey.20 Undergraduate students were randomized to receive a traditional paper survey in the mail or a web-based survey. There were no statistical differences for demographics, response rates, item completion, and item completion errors. However, the study found that the web group participants were more inclined to reveal potentially embarrassing or sensitive information than were participants in the mail survey group.
Web-based surveys offer advantages and distinct design elements such as checkboxes, radiobuttons, pop-up questions, and text-entry boxes that limit data entry errors. Software now exists that allows raw data to be entered directly into a statistical database, which allows for immediate data analysis such as for this survey. Furthermore, the survey may be designed in such a manner that maximizes the question completion rate and decreases the completion time with such features as skip patterns.
Traditional surveys pose numerous methodological problems and are costly and time-consuming. Furthermore, surveys that allow contact between the respondent and the surveyor may lead to biased overreporting of socially desirable responses, especially when sensitive information is being asked.20 Self-administered, anonymous surveys are less likely to overreport socially desirable responses, but response rates and item completion rates may be low.
Although this study had a large number of respondents, there are several shortfalls in the study. First, by virtue that the survey was linked to the sole MTV.com web site, respondents were not a random sample taken from the population. Second, the inherent nature of a web survey excludes those without a computer or access to the Internet. Third, the voluntary nature of the respondents' participation may influence data by self-selection of those who are biased in a certain opinion.
This study shows that NIHL has a low level of awareness priority among adolescents and young adults. Fortunately, many would be persuaded to wear hearing protection with adequate education and counseling. Hearing conservation education must be implemented on many fronts in society to educate our youths about hearing health. The World Wide Web is powerful medium to collect health data from this group, and with additional experience, survey result interpretations hopefully will refine even further.
We sincerely thank Shari Redstone of National Amusements and Viacom for wise and gracious guidance and enthusiastic assistance. Sumner Redstone of Viacom and several individuals at MTV should be recognized for invaluable aid to this project: Mark Rosenthal, Stephen Friedman, Allison Reidy, Jeannette Prymas, Ahna Biddle, Matthew Catapano, and Jeffrey Kaufman as well as the members of the MTV technical crew in Cancún. Kathy Peck from H.E.A.R. along with Gwendaline Mazarra and DJ Polywog provided on-site experience and provided earplugs from Aero. Elizabeth Thorpe from the Deafness Research Foundation and Peter Venner of Mack's Ear Plugs generously provided advice and ear protection plugs, respectively, for the Cancún audience. Dr Felipe Santos greatly assisted with the paper survey in Cancún. Dr Jose Ignatio Santos provided Mexican educational media opportunities. Betty Treanor provided excellent manuscript preparation.
- Accepted July 27, 2004.
- Reprint requests to (R.D.E.) Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114. E-mail:
No conflict of interest declared.
- ↵Niskar AS, Kieszak SM, Holmes AE, Esteban E, Rubin C, Brody DJ. Estimated prevalence of noise-induced hearing threshold shifts among children 6 to 19 years of age: the Third National Health and Nutrition Examination Survey, 1988–1994, United States. Pediatrics.2001;108 :40– 43
- ↵Blair JC, Hardegree D, Benson PV. Necessity and effectiveness of a hearing conservation program for elementary students. J Educ Audiol.1996;4 :12– 16
- ↵Sadhra S, Jackson CA, Ryder T, Brown MJ. Noise exposure and hearing loss among student employees working in university entertainment venues. Ann Occup Hyg.2002;46 :455– 463
- ↵Axelsson A, Jerson T. Noisy toys: a possible source of sensorineural hearing loss. Pediatrics.1985;76 :574– 578
- ↵Gallagher G. Hot music, high noise, and hurt ears: are teens and young adults trading hearing ability for high volume? Hear J.1989;42 :7– 11
- ↵Harvard School of Public Health, Cogent Research, Inc. Attitudes Towards Children's Health Care Issues Survey. Boston, MA: Harvard School of Public Health; 2002
- ↵Lass NJ, Woodford CM, Lundeen C, Lundeen DJ, Everly-Myers D. A survey of high school students' knowledge and awareness of hearing, hearing loss, and hearing health. Hear J.1987;June:15– 19
- ↵Lewis DA. A hearing conservation program for high-school-level students. Hear J.1989;42 :29– 24
- ↵Pealer LN, Weiler RM, Pigg RM Jr, Miller D, Dorman SM. The feasibility of a web-based surveillance system to collect health risk behavior data from college students. Health Educ Behav.2001;28 :547– 559
- ↵Kaiser Family Foundation, Generation Rx.com: How young people use the Internet for health information. Menlo Park, CA: Kaiser Family Foundation. December 2001. Available at: www.kff.org/content/2002/20011211a/GenerationRx.pdf
- Copyright © 2005 by the American Academy of Pediatrics