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

METHODS

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.”

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Fig 1.

Survey created by researchers at the Massachusetts Eye and Ear Infirmary, the Harvard School of Public Health, and Cogent Research, Inc.

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.

RESULTS

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.

DISCUSSION

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.

CONCLUSION

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.