Communicating Hearing Loss

Information to Young Children

Effectiveness of Lecture and Printed Materials

by Robert F. Randolph, MS, Roberta L. Hudak, RN, BSN, and Charles Vaught, PhD

ABOUT THE AUTHORS

Mr. Randolph is a Research Psychologist, Ms. Hudak is an

Occupational Health Nurse, and Dr. Vaught is a Research Sociologist at

the National Institute for Occupational Safety and Health Pittsburgh

Research Laboratory, Pittsburgh, PA.

Abstract

Developing positive attitudes and behaviors

toward hearing loss prevention is more effective

the earlier it begins. This study evaluated two

training techniques for educating young children

about noise and hearing loss. Third grade students from seven Pennsylvania elementary

schools received either no intervention between

the pre-tests and post-tests, a lecture about hearing loss, or an informational bookmark along with

the same lecture. A 10 item quiz was administered

as a pre-test and post-test to assess changes in

knowledge. Scores on the quiz improved the most

for the lecture intervention groups regardless of

whether they received the bookmark. Adding the

bookmark did not have a significant effect on

knowledge gain. The findings reinforce the value

of providing an educational foundation along with

communication products.

ty and Health (NIOSH) is performing e

Effective prevention of hearing loss, as with other

health risks, should begin prior to exposure to the

hazard. The National Institute for Occupational Safextensive research

and outreach for hearing loss prevention for all ages and

demographic groups consistent with the goals of the

Healthy People 2010 initiative (U.S. Department of Health

and Human Services, 2000). Although children are unlikely to be exposed directly to occupational health hazards,

they can use prevention techniques when they are exposed

to similar hazards in nonoccupational settings. They can

also share their prevention attitudes and skills with their

working parents. Finally, they will need effective prevention strategies when they eventually enter the work force.

Research in other public health domains has shown

the value of educating children about issues, especially

cardiovascular health, that affect all family members

(Arbeit, 1992; Vega, 1988). Occupational health nurses

and other occupational health professionals can make use

of a variety of opportunities for hearing loss outreach to

children, including plant tours, school visits, and informational materials sent home with workers but targeted

toward all family members.

Even before they enter the workplace, children often

have measurable noise induced hearing loss. For

instance, Niskar (2001) reported 12.5% of 6 to 19 year

old children in the United States have a noise induced

threshold shift based on data from the Third National

Health and Nutrition Examination Survey (NHANES).

Montgomery (1992) showed the rates of hearing loss

among children have increased during time. Specifically,

they found that from 1979 to 1989, 2.8 times as many
second graders and 4 times as many eighth graders

showed a hearing level of 25 decibels (dB) or worse at 2

kilohertz (kHz), 4 kHz, or 8 kHz.

Some possible reasons for the higher rates include

more prevalent use of portable audio systems, motorized

recreational equipment, and other environmental exposures. Even when these losses are relatively mild, they

may eventually accumulate with losses later in life to

become disabling. Consequently, hearing conservation

should begin before any losses occur to be most effective

during an individual’s life span.

Hearing conservation programs for school children

have been shown to be an effective prevention strategy.

Lass (1986) showed increases in hearing loss prevention

knowledge resulting from an educational hearing conservation program that included a film, lecture, and handouts. Chermak (1996) found an increase in hearing conservation knowledge and behavioral intentions for fourth

grade students given two 1 hour sessions of instruction.

They noted scores were higher in a class that performed

more extensive participatory activities.

Bennett (1999) also found differences in effectiveness

based on the instructional approach. They observed higher

post-test scores on a hearing conservation knowledge test

when students were given more interactive “hands on”

lessons rather than traditional lectures. However, the current intervention differed from these educational programs

because the duration was much shorter and it was conducted outside the classroom as part of a field trip.

The National Institute for Occupational Safety and

Health (NIOSH) Pittsburgh Research Laboratory is a popular field trip destination for local school children who tour

its coal mine and extensive engineering and behavioral

research facilities. During a tour of the hearing loss prevention facilities, children are given information about protecting their own hearing. This study was conducted to evaluate the effectiveness of these information presentations.

During the presentations, two main concepts were

communicated—noise is a well known, measurable hazard

and noise induced hearing loss can be avoided by taking

specific preventive actions. Referring to the decibel scale

and identifying the increasing level of hazard greater than

85 decibels, A-weighted (dBA) emphasized the objective

nature of the noise hazard. While there is some risk of hearing loss at lower levels, NIOSH recommends 85 dBA as the

level at which sound becomes hazardous (NIOSH, 1998).

This level is reflected in Occupational Safety and Health

Administration (OSHA) and Mine Safety and Health

Administration regulations in which exposure to 85 dBA

more than 8 hours triggers hearing conservation efforts.

The simplicity and brevity of the studied intervention is potentially very important to health educators.

Hearing conservation education is rare in U.S. elementary schools (Chermak, 1996; Lass, 1986). A significant

barrier to adoption of hearing conservation curricula is

the resource intensive nature of the more effective training approaches. The individualized, interactive approach

that has shown some success (Bennett, 1999, Chermak,

1996) may be impractical for resource strapped schools

making an attempt to address many other high priority

public health concerns. In these settings, the simpler and

less costly the intervention, the more likely it is to reach

a large population of students. Consequently, a major

purpose of this study was to determine whether a brief

lecture and demonstration along with a simple informational handout generates meaningful increases in hearing

loss prevention knowledge. Such a finding would alert

educators that, while an elaborate interactive hearing

conservation curriculum might be ideal, even a very

modest program was worth implementing.

What Does This Mean for

Workplace Application?

The debilitating and costly effects of noise induced

hearing loss continue to occur at alarmingly high rates

despite efforts at prevention. Any tool that can add to

the effective prevention should be considered,

including thinking beyond workers to their families. In

many cases, occupational health professionals have

routine contact with employee families at open houses,

wellness fairs, school visits, and other settings, which

provide excellent teaching opportunities. This study

shows how even a brief lesson about hearing loss can

have an effect with school children. The lessons they

learn can be brought to bear on their working parents,

and will help the children establish effective preventive

habits now and into their working years.

METHOD

Participants

Participants were elementary school children at seven

schools in the Pittsburgh region: 565 students participated

in the pre-test phase and 546 participated in the post-test.

The slight discrepancy in numbers between the pre-tests

and post-tests is most likely because of student absences.

To preserve anonymity, names or other tracking identifiers

were not used to strictly relate the pre-test and post-test

participants. The NIOSH presenters were invited by the

schools to deliver a workshop on hearing loss prevention.

Design

This study followed a variation on the pre-test–posttest control group design (Campbell, 1966). Each visiting

tour group, consisting of one or more classrooms from an

individual school, was treated as a group for random

assignment to the experimental conditions. Individual students were not tracked to avoid confidentiality issues and

to allow for slight changes in class composition caused by

of student absences. A total of 565 students participated in

the pre-test, and 546 completed the post-test. The number

of students participating from each school ranged from 61

to 97 (two or three classrooms). The seven participating

schools were randomly assigned to one of three groups:

● No intervention group.

● Lecture only group.

● Lecture and bookmark group.
Noise Lecture Components

Definition of noise. Noise was defined simply as unwanted sound. This was to introduce the fact that some noise, although

unpleasant, may not be dangerous. However, any dangerous sound can be considered noise because of the potentially

negative effects.

Assessment item: Noise is unwanted sound.

Range of noisy environments. Occupational noise was described, but students were also informed that modern society contains

many more noisy environments. They are at risk from loud music, lawn mowers, vacuum cleaners, and other sources they may

not have considered. While the workplace is regulated and often professionally noise controlled, other settings are not. They

should be equally concerned about noise at work as well as away from work.

Assessment item: Noise only happens where people work.

Noise and hearing damage. The direct relationship between noise and hearing loss was presented. Specifically, different causes

and types of hearing loss were reviewed, but noise was singled out as the most common cause.

Assessment item: Noise will not hurt my hearing.

Objective measurement of noise. The basic instruments used to measure noise were described, including dosimeters and sound

pressure level meters. It was explained that these are in widespread standardized use, and the readings provide an accurate,

reliable index of actual risk of hearing damage.

Assessment item: There is no way to measure noise.

Noise level measurement units. The widespread use of decibels as the most common single measure of sound pressure level was

explained. The scaling of decibels was compared to other familiar scales, including rulers to measure distance in inches and

thermometers to measure temperature in degrees. The exponential nature of decibels was touched upon, but was not a major

focus. Different weighting schemes (“A”, “C,” etc.) were not discussed.

Assessment item: A “decibel” measures loudness.

Negative effects of loud noise. Specific and general effects of noise were explained. The discussion started with an explanation of

how noise affects the hair cells in the inner ear, and it has long term effects including hearing loss in the speech frequencies and

tinnitus. Several quality of life effects were reviewed, including difficulty communicating with family, friends, and coworkers, and

difficulty sleeping and concentrating as a result of oppressive tinnitus.

Assessment item: Very loud noises may hurt my ears.

Risk threshold. Students were told the risk for hearing damage begins at sound levels around 85 A-weighted decibels (dBA). The

“85 dBA more than 8 hours” standard was discussed, along with the use of hearing protection to bring sound levels down to a

safer range. Examples of hearing protection devices were shown, along with a demonstration of how and when to wear each one.

Assessment item: Noises above 85 decibels cause harm.

Permanence of hearing loss. This was a critical portion of the lecture. The permanent, irreversible, usually painless nature of

sensori-neural hearing damage was described. To reinforce this concept, hearing damage was contrasted with a typical bodily

injury resulting from a fall. In the case of bodily injury, the victim may have pain, bleeding, swelling, bruising, and other obvious

symptoms. The symptoms of hearing damage are much harder to detect.

Assessment item: If noise makes me lose my hearing, I will get it back soon.

Efficacy of hearing protection strategies. A variety of time, distance, and barrier self protection strategies were described or

demonstrated, specifically, these involved using some combination of reducing time of exposure, increasing distance from noise,

and using hearing protection or some other protective barrier. Examples of these strategies included leaving noisy areas, covering

the ears with hands or hearing protection devices, and lowering the volume on electronic devices.

Assessment item: I should always protect my ears from loud noises.

Self exposure assessment. Temporary tinnitus is one of the few warning signs of overexposure to noise. The typical nature of this

high pitched “ringing” was described and students were asked if they had ever experienced it. They were told this ringing

indicates the sound was too loud. If they were to continue their exposure, instead of temporary ringing or hearing loss, they

would be in danger of permanent damage. They were also told how to “listen” for a temporary threshold shift that is another good

indicator of potentially damaging noise exposure.

Assessment item: It is good if my ears ring after I leave a noisy place.
Figure 1. NIOSH hearing loss informational bookmark intended for elementary school children.

90

88

86

84

82

80

78

76

74

72

Percent Correct

Pre-test Post-test

No Intervention

Lecture and Bookmark

Lecture Only

Figure 2. Changes in hearing loss knowledge test scores

from pretest to posttest for no intervention, lecture only,

and lecture and bookmark groups.

No intervention group. The students in the no intervention group were given a knowledge pre-test 3 months

prior to the post-test, with no intervention between the

two tests. These students participated in an educational

tour and received information materials, but only after

completion of the post-test. Because the tour and other

information dissemination occurred after both the preand post-tests, it served just an outreach function and

would not have affected the test results.

Lecture only group. Lecture only students received a

pre-test 6 weeks prior to attending a tour and educational lecture at the NIOSH facility. They received a post-test

6 weeks after the tour and lecture. After the post-test, a

member of the research team gave the students an informational bookmark during a classroom visit.

Lecture and bookmark group. Students in the lecture

and bookmark group also received a pre-test 6 weeks prior

to a combined intervention consisting of an informational

lecture and presentation of the bookmark. This was followed by a post-test 6 weeks after the intervention.

A short (30 minute) informative lecture was delivered by one of the authors, an occupational health nurse.

The lecture contained information about the nature of

hazardous noise, causes of hearing loss, hearing damage

resulting from noise, and prevention strategies. Points

covered in the lecture were directly reflected in the

knowledge assessment instrument, “Things About

Noise.” The main components of the lecture are detailed
in the Sidebar on page 435, along with the corresponding assessment item.

An informational bookmark was developed based on

the suggestions of educators who had participated in earlier communications efforts. The bookmark used in this

study contained a general message that “your hearing is

worth protecting” and a listing of common noise or sound

levels. Sounds louder than 85 dBA were flagged as being

hazardous (see Figure 1).

RESULTS

Total scores for hearing loss knowledge increased

between the pre-tests and post-tests regardless of intervention treatment. Figure 2 shows that both intervention

groups (i.e., lecture only, lecture and bookmark) experienced greater improvements in knowledge test scores than

the no intervention group. The no intervention group

increased its scores by 4.99% while the lecture only group

increased by 15.1% and the lecture and bookmark groups

increased by 13.6%. Also, the percentage of students in all

groups who answered every question correctly increased

from 8.1 in the pre-test to 22.2 in the post-test. An analysis of variance showed there was a significant difference

between pre-test and post-test scores (F = 40.020, p =

.000), between the intervention groups (F = 3.64, p =

.027), and for the interaction between test and intervention

(F = 16.902, p = .000). Although the improvement in test

scores for the lecture only group was greater than that of

the lecture and bookmark group, this difference was too

small to reach statistical significance at the p = .05 level.

Individual Test Items

Separate results were combined for each of the 10

test items. Because the items assess different concepts,

these results provide some clues about the relative

strengths of the interventions.

The Table shows changes in percent correct for each

test question, along with the overall percent correct for all

pretests. For some of the items, pretest scores were very

high, which limited how much improvement was possible.

For instance, 96.5% of the students correctly answered the

question, “Very loud noises may hurt my ears,” and subsequent improvements in this score were small.

While the no intervention group increased its rate of

correct answers for 8 of the 10 questions, the scores for

“Noise is unwanted sound” declined substantially. This

group also performed slightly worse on the item, “It is

good if my ears ring after I leave a noisy place.”

The two intervention groups showed their greatest

gains for two measurement questions, “There is no way

to measure noise” and “A ‘decibel’ measures loudness.”

These points were covered in detail in the lecture, along

with demonstrations of the measurement instruments.

The lecture and bookmark scores generally improved

within a few percentage points of the lecture only group

with the exception of the item, “If noise makes me lose

my hearing, I will get it back soon.”

Table

Initial Average Pre-test Scores for all Groups and Changes

in Percentage Correct by Intervention Group

Changes by Intervention Group

All

Pre-tests

None Lecture

only

Lecture and

Question Bookmark

Noise is unwanted sound 51.2% –12.4% 8.5% 3.2%

Noise happens only where people work 94.9% 1.9% 1.2% 1.6%

Noise will not hurt my hearing 71.0% 17.2% 22.0% 19.4%

There is no way to measure noise 43.0% 15.2% 39.2% 32.0%

A “decibel” measures loudness 60.0% 12.4% 31.6% 31.3%

Very loud noises may hurt my ears 96.5% .8% 3.5% 1.7%

Noises above 85 decibels cause harm 83.9% 11.4% 10.0% 12.0%

If noise makes me lose my hearing, I will get it back soon 86.5% 3.1% 6.1% 17.2%

I should always protect my ears from loud noises 91.7% 1.9% 9.2% 5.7%

It is good if my ears ring after I leave a noisy place 77.3% –1.5% 19.6% 11.8%

Overall 75.6% 5.0% 15.1% 13.6%

DISCUSSION

The results show a clear improvement in knowledge resulting from the informational interventions.

While the study did not address changes in behavior or

other public health outcomes, it does indicate that carefully selected and presented messages can influence

understanding of health risks and appropriate preventive

measures. These results should encourage occupational

health nurses and other public health professionals to

use even brief encounters with children to deliver a
focused hearing loss message. While the intervention in

the current study took place in a government facility, it

bears strong resemblance to factory tours that are a popular field trip destination and the results should generalize to those broader industrial settings. The results

would also likely generalize to brief presentations in a

school setting for occupational health nurses who perform community outreach activities.

The lack of additional effect from the bookmark

intervention may be attributable to its design. The bookmark contained several messages, but none were clearly emphasized. Also, the hazardous sound levels were

indicated with a small star rather than a more “eye

catching” layout device. Because of these limitations,

new educational materials are under development. The

new materials are based on a more focused communication theory and will be subjected to evaluations with

both children and adults.

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