# Presentation: 880642

## APPLICATION OF HEALTH 

**Mark Stephenson, Ph.D.**
**Carol Merry Stephenson, Ph.D.**

**National Institute**
**for Occupational Safety**
**and Health**

**APPLICATION OF HEALTH **
**COMMUNICATION THEORIES**

## NIOSH HIERARCHY OF CONTROLS

**NIOSH HIERARCHY OF CONTROLS**

**Remove the hazard**
**Remove the worker**
**Protect the worker**

## OVERVIEW

**  ****Overview of the problem**
**  ****Current issues associated with hearing protectors**
**  ****Health communication models**
**  ****Using health communication theory to positively**
**    ****influence hearing health behaviors**

## THE PROBLEM:

_**THE PROBLEM**_**:**

## PREVALENCE OF PROGRAM ASPECTS

**PREVALENCE OF PROGRAM ASPECTS**
**BY COMPANY SIZE**

## Percentage of Time Hearing Protectors are Worn “Most of the Time” When Working in Loud Noise

## How much of a problem is there?

**Hearing loss from noise is the most common occupational illness (NIDCD), and the 2nd-most self-reported occupational illness for American workers (NCHS).**
**NIHL accounts for about 1 in 5 losses severe enough for a person to report trouble hearing (ASHA).**
**Preventing NIHL would do more to reduce the societal burden of hearing loss than medical and surgical treatment of all other ear diseases combined (Dobie, 1993).**

## How many people are affected?

**30 million people are occupationally exposed to hazardous noise.**
**10 million people have NIHL - nearly all from occupational exposures.**
**Hearing problems shot up 26% from 1971 to 1990 among those between 18 to 44 years old.**
**Today, 15% of those between 6-19 show signs of HL. **

## Slide 9

## Even by age 60, the average healthy person does not have impaired hearing!!

**The amount of “material hearing impairment” for a non-noise exposed 60 year old male is **_**16.75 dB**_**.  Re ASHA (Avg. of 1, 2, 3, & 4 kHz) and ANSI S3.44-1996, data base A**

**normal**
**hearing**

**Even by age 60, the average healthy person does not have impaired hearing!!**

## Hearing Levels in 60 Year Old Males as

**At 90 dBA, material hearing impairment > 25 dB.**

**Hearing Levels in 60 Year Old Males as**
**a Function of Noise Exposure**

## Hearing Loss Among Male Carpenters

**Hearing Loss Among Male Carpenters**
**as a Function of Age**

## The Average 25 Year Old Carpenter

**The Average 25 Year Old Carpenter**
**Has 50 Year Old Ears!**

## RESULTS OF FOCUS GROUPS

**Workers may be less **
**concerned about getting**
**a hearing loss then about **
**developing tinnitus.**
**“****I expected to lose my **
**hearing.  But, I thought**
**it would be quiet.”**

## Percent of People With Tinnitus

**Percent of People With Tinnitus**

## Murphy was right!

- <date/time>

**Without proper training, any hearing protector that can be worn wrong,**
** ****will be worn wrong!**

**Murphy was right!**

**Even when noise hazards are clearly identified,**
**you can’t just set out boxes of hearing **
**protectors and expect workers to use them.**

## Slide 17

## Effect of inconsistent use of hearing protection

**Effect of inconsistent use of hearing protection**
**on the amount of effective noise reduction**

## Hearing Protector Issues:

**Methods for Estimating Actual Performance**

**   ****FIT-TEST METHOD**
**Fit-test system feasible for field use**
**Using fit-test enabled workers to learn to correctly fit a new plug**
**Knowledge gained and consciousness raised**

## Can we take what we

**Can we take what we**
**have learned in the laboratory**
**out to the field?**
**Can we influence hearing loss**
**prevention behaviors among**
**noise exposed workers?**

## Factors Affecting Behavioral Change:

**     ****Individual Level**
- Knowledge/beliefs
- Attitudes/values
- Stage of change
- Decisional balance
- Self-efficacy

**Organizational Level**
- Norms- safety culture
- Union and management priorities
- Modeling by trainers
- OSH curricula in the apprentice centers
- Environmental support

**Notes:**
In addition to looking at individual factors from a socio-behavioral perspective, we also made a commitment to examine and emphasize the importance of work organizational factors.  
1.  The UBC made prevention of noise-induced hearing loss a national priority by publicizing the issue in newsletters and at their meetings.

2.  The UBC trainers participated in training workshops targeting hearing loss prevention and made the commitment to model good hearing health.  Many of the trainers are retired craftsmen who suffer tinnitis and/or NIHL, several prominent spokesmen came forward offering credible testimonials.

3.  A hearing loss prevention module is under development for use in the centers.  The module includes written and video educational materials, as well as instructor led sessions teaching apprentices skills necessary to identify noise hazards, take corrective noise control action when possible, and correctly use a variety of HPDs when appropriate.  

4.  Centers will also structure their environment to support hearing health behavior-for example, convenient access to HPDs.

## Health Promotion Can Learn From Marketing

**Health Promotion Can Learn From Marketing**

## INFLUENCING HEARING  HEALTH

**BEHAVIOR AMONG WORKERS**

**Studies utilizing a health communication/ promotion**
**approach indicate that your education and training **
**must address two concepts:**

**Remove Barriers**

**Develop Self-Efficacy**

## People have MANY reasons for not using hearing protectors.  (AKA:  You can lead a person to hearing protectors, but you can’t get him/her to wear them.)

**People have MANY reasons for not using hearing protectors.  (AKA:  *****You can lead a person to hearing protectors, but you can’t get him/her to wear them*****.)**

** **_**THE FOUR C’s**_
**Comfort**
** ****Convenience**
** ****Cost **
** ****Communications / hear**
**   ****important**** ****sounds**

**THERE ARE OVER 200 DIFFERENT HEARING PROTECTORS. EVERYONE CAN FIND A PROTECTOR THAT MEETS THEIR NEEDS.**
**  **
**THE BEST HEARING PROTECTOR IS THE ONE THAT’S WORN!**

## To effectively influence

**workers’ hearing health **
**behaviors, you need to**
**apply health communica-**
**tion theory as you develop**
**and use training and **
**educational materials.**

## “One way to cut confusion surrounding the selection of a theory...is to combine elements of successful and well-tested theories into a single framework.  A framework pools the best available knowledge...”-- Witte (1995)

**Notes:**
Armed with this information, we sat down with UBC management, associated contractors, academic consultants, and NIOSH staff and discussed approaches to take.  We wanted a theory driven, systematic approach and chose a framework under which we would design, implement, and evaluate an intervention.

## Applying these and similar models can 

**effectively help shape workers’ attitudes, **
**beliefs, and behaviors.**** **

**HEALTH PROMOTION AND **
**HEALTH COMMUNICATION MODELS**

## THEORY OF REASONED ACTION 

**THEORY OF REASONED ACTION**** **

**Health Promotion Models Help Identify **
**Variables That Predict Behaviors**** **

## I plan to wear hearing protectors when I work 

- Strongly
- Agree

- Agree

- Strongly
- Disagree

- Disagree

- Neither

**I plan to wear hearing protectors when I work **
**around loud noise.**

## Health Belief Model:Attitudes, Beliefs, Social Norms

**Susceptibility**
**Seriousness**
**Benefits**
**Barriers**
**Self-efficacy**

**Notes:**
First-- the Health Belief Model and the related Theory of Reasoned Action guided the development of our initial formative research. Using focus groups, key informant interviews, onsite observation, and a UBC survey we attempted to understand carpenter culture with regard to the elements of the health belief model.  We queried carpenters about their knowledge, beliefs, attitudes, behavioral intentions, and current worksite behaviors relating to hearing health and prevention of noise-induced hearing loss.  Let me share some of those results with you.

6.  Carpenters believe they use HPDs correctly on themselves, but were less sure they could help a coworker use them correctly...indicating a need to boost training in HPD use.
7.  Carpenters report they use HPD more than their coworkers-- but they don’t!

## Health Belief Models Help Identify 

**Health Belief Models Help Identify **
**Cognitive Variables That Predict Behaviors**** **

**HEALTH BELIEF MODEL**** **

## How do you know what the workers’ concerns and beliefs are?     

**Just ask me.**
**I’ll tell you**
**what I need.**

**Barriers cited by coal miners**
**for not wearing HPDs:**
**Comfort                 Poke Out Eardrum**
**Communication    Cords Get Caught**
**Convenience          Earcup Too Big**
**Roof “Talk”          Warning Sounds**

## I believe exposure to loud noise can hurt my hearing.

- Strongly
- Agree

- Agree

- Strongly
- Disagree

- Disagree

- Neither

**I believe exposure to loud noise can hurt my hearing.**

**Notes:**
Susceptibility:   Carpenters know noise causes hearing loss

## I think my hearing is being hurt by exposure 

- Strongly
- Agree

- Agree

- Strongly
- Disagree

- Disagree

- Neither

**I think my hearing is being hurt by exposure **
**to loud noise.**

**Notes:**

So.. What stage were most of these carpenters in?  In fact, many are actively concerned about NIHL-- it is on their radar screen!  They are at least in the contemplation stage, if not further along. 

Other questions and focus groups revealed that many carpenters know friends and family members suffering the physical and social effects of NIHL.  

## I think it would be a big problem if I lost my hearing.

- Strongly
- Agree

- Agree

- Strongly
- Disagree

- Disagree

- Neither

**I think it would be a big problem if I lost my hearing.**

**Notes:**

Seriousness:  The overwhelming majority of carpenters believe hearing loss would seriously affect their lives--  however 15% were unsure

## I am convinced I can prevent hearing loss by wearing

- Strongly
- Agree

- Agree

- Strongly
- Disagree

- Disagree

- Neither

**I am convinced I can prevent hearing loss by wearing**
**hearing protectors whenever I’m in loud noise. **

**Notes:**

Benefits question:  carpenters had knowledge and beliefs that hearing protectors would offer benefit in prevention of NIHL  

## I don’t think I have to wear hearing protectors 

- Strongly
- Agree

- Agree

- Strongly
- Disagree

- Disagree

- Neither

**I don’t think I have to wear hearing protectors **
**every time I’m working in loud noise. **

## Wearing hearing protectors is annoying.

- Strongly
- Agree

- Agree

- Strongly
- Disagree

- Disagree

- Neither

**Wearing hearing protectors is annoying.**

## I think it will be hard to hear warning signals (like 

- Strongly
- Agree

- Agree

- Strongly
- Disagree

- Disagree

- Neither

**I think it will be hard to hear warning signals (like **
**back-up beeps) if I am wearing hearing protectors.**

## Stages of Change Model Predicts  When Behavioral Change Will Occur

_**Precontemplation**_**- typically 40 % of workforce for a new behavioral request**
_**Contemplation**_**- may do in next 6 months**
_**Preparation**_**- may do in next 30 days**
_**Action**_**- trying out the behavior now**
_**Maintenance**_**- have been doing behavior for 6 months+**

**Notes:**
The next step was to take the information we had gathered about carpenters attitudes, beliefs, and intentions, and assess where they were in relation to Prochaska’s stages of change theory.  This theoretical perspective is useful in helping one to “frame the message” in an appropriately persuasive manner.  Past research has indicated that typically only 20 % of a population of potential changers is ready to take action, so much of the emphasis in an intervention program early on must often target people in stages 1-3: 
 precontemplators (not even on their radar screen), 
contemplators (aware of the problem, but not sure if they want to do anything about it), 
and preparers (in the process of choosing a course of action).

Understanding where people are along the stages of change continuum may be critical to successful interventions that require people to adopt an active behavioral change.  Recent research by Prochaska and others has indicated that if your program only concentrates on messages appropriate for those in the ACTION stage, you can expect 1-2% behavior change with the first round of your intervention.  However, if you carefully segment your audience and target your messages with a stage based approach, you can expect 12-18% behavior change after the first delivery of your program. 

## Identify and Target A Desired Behavior

- Carpenters will use hearing protectors consistently and correctly whenever they are exposed to hazardous noise

**Notes:**
In partnership with the UBC leadership, we examined the pilot data and chose to first address the issue of effective and appropriate hearing protector use.

Having conducted a systematic evaluation of the safety culture and hearing loss prevention behavioral norms of carpenters, we initially expected that we would simply design an educational intervention program that could cover the gamut from apprentices through experienced journeymen.  We were soon to learn that this would be impractical-- elements of the program that resonated with the journeymen seemed inappropriate for the apprentices, and thus a staged approach targeting first apprentices, then journeymen was designed.

## On my current job, I seldom wear hearing protectors

- Strongly
- Agree

- Agree

- Strongly
- Disagree

- Disagree

- Neither

**On my current job, I seldom wear hearing protectors**
**when I work around loud noise.**

**Notes:**

BUT-- despite their expressed attitudes, beliefs, and knowledge, few carpenters report consistently wearing HPDs while working in noise.  Why?

In this sample, before the pilot intervention using one exposure to a carefully framed video, 54% reported seldom wearing HPDs or were non-committal.

(After viewing the video, this was essentially unchanged...and should be!)

## What are precontemplators like?

**Sometimes**** ****lack knowledge about issue**
**Have no interest in changing their behavior or beliefs**
**Have no intention of changing **
** ****even in a future time frame**

## How to move precontemplators to contemplation

**Get their attention**
**Raise their consciousness **
**Create environments to help people do the right thing**

## Slide 45

## What moves Contemplators to the Preparation stage?

**Emotional arousal helps here too!**
**Direct Consequences for Self & others**
**    ****1.  Imagery- “imagine your life if...”**
**    ****2.  Consequences to family and friends**
**    ****3.  Thinking actively about solutions**
**    ****4.  Case studies & testimonials**

## It’s Really Pretty Simple.....

**Wear this now...**

**Or wear this later!**

## What are Preparers Like?

**Increasing belief in “pro’s”**
**Decreasing concern about “con’s”**
**Start taking small steps toward new behavior (do a sound survey, read up on HPDs)**
**Increased confidence about making changes**
**Make a plan or “intend” to adopt new, safer behavior**

## What Moves Preparers to Action?

**Setting reasonable goals**
**Making specific plans to overcome specific barriers**
**Making public pledges**
**Continuing to believe there are more pro’s than con’s for the new behaviors**

## What Are People in the Action Stage Like?

**Firmly believe benefits of new, safer behavior**
**Have a consistent plan for action and have been following it for several months**
**“****Intend” to maintain the behavior **
**Recognize success of small steps**
**                         **
**                          **

## Prospect Theory:  How you frame the message does count!

- Loss versus Gain
- Prevention versus Detection
- Loss vs. Gain

**Notes:**
Let me describe just two of the message framing interactions we found to be relevant to our study:
We know from studies in social psychology that people are generally willing to face uncertainty and accept risk when considering loss or negative results, but if the same thing is worded according to gains or positive results we are less likely to accept risk.  Here’s an example:
If I say to you-- You have responsibility to protect the hearing of 600 workers and can take several courses of action:  next slide
a) If you take action A, 200 of the workers will keep their hearing
b) If you take action B, there is a 1/3 probability that 600 will keep their hearing, and a 2/3 probability that no one will keep their hearing.  
*********************************************************

## Gain Framing

- 2)  If you take action B, there is a 1/3 probability that 600 will keep their hearing, and a 2/3 probability that no one will keep their hearing.

**Notes:**
72% will pick A because when we talk about gains or “health saved” , we all tend to prefer “no risk” courses of action.

## Loss Framing

- 4)  If you choose action D, there is a 1/3 probability that no one will lose their hearing, and a 2/3 probability that 600 will lose their hearing.

**Notes:**
But what if I word your choices through loss or negative framing-keep in mind this is arithmetically identical to the first set: 
c) If you choose action C, 400 workers will lose their hearing
d) If you choose action D, there is a 1/3 probability that no one will lose their hearing and a 2/3 probability that 600 will lose their hearing.  

**78% will pick d) when phrased in terms of “health lost”--because when dealing with possible losses, we are more willing to tolerate risk.

## Does this touchy-feely stuff work?  You bet it does!

**Does this touchy-feely stuff work?  You bet it does!**

## Positively influencing beliefs about using hearing protectors -

**Positively influencing beliefs about using hearing protectors -**

**Comfort**

**Consistent use**

**Behavioral**
**intentions**

**Ability to hear**
**warning sounds**

## The Effect of Removing Barriers (Comfort and Convenience) Which Workers Stated Prevented Them From Wearing Plugs

**Replacing foam ear plugs with custom-molded ear plugs nearly doubled the rate of use**

## Removing Barriers and

**Removing Barriers and**
**Developing Self-Efficacy**
**is an Iterative Process**

**How Do You Remove Barriers & Develop Workers’**
**Self-Efficacy?**

## Education and Training Must NOT Just

**Blah, blah, blah...**
**Blah, blah, blah...**

**Education and Training Must NOT Just**
**Fill a Square**

## Wise-Ears Web Links

- www.nih.gov/nidcd/health/wise/
- www.cdc.gov/niosh/noise
- www.aearo.com
- www.3m.com
- www.howardleight.com
- www.hearnet.com
- www.hearingconservation.org

## ANY QUESTIONS?

**ANY QUESTIONS?**