NIOSH tools for hearing loss 

prevention programs

A.S. Azman, R.F. Randolph and R.L. Hudak 

Research audiologist, research psychologist and occupational health nurse, respectively, National 

Institute for Occupational Safety and Health, Pittsburgh, Pennsylvania

Abstract

The mining workforce experiences high rates of hazardous noise exposure and hearing loss. However, 

previous studies have identified specific behavioral and attitudinal barriers that keep miners from effectively acting to prevent their own hearing loss. The National Institute of Occupational Safety and Health 

(NIOSH) has developed several new hearing loss prevention tools and interventions that specifically 

target these barriers to prevention. The NIOSH Hearing Loss Simulator addresses motivation to take 

action and knowledge about the consequences of noise exposure. The QuickFit earplug test device and 

QuickFitWeb online hearing protection tester address barriers to effective earplug and earmuff use by 

verifying at least 15 decibels of protection. The NIOSH Roll-Pull-Hold technique helps miners obtain 

better protection through an easy-to-remember set of steps that improves attenuation by nine decibels. 

The “Inquiring Ears Want to Know” fact sheet helps miners to understand audiograms and to use them 

to maintain their hearing health. Each of these interventions can be used within the context of a comprehensive hearing loss prevention program.

Introduction

The mining workforce experiences high levels of noise 

exposure and in turn suffers from high rates of noise-induced 

hearing loss (NIHL). The mining sector has the highest prevalence of hazardous workplace noise exposures (76%) among 

all industrial sectors (Tak et al., 2009). Although most miners 

use hearing protection and diligent effort is put forth both by 

manufacturers and researchers to quiet mining machinery, 

miners continue to exhibit a high prevalence (24%) of hearing difficulty (Tak and Calvert, 2008). Most U.S. miners are 

exposed to noise levels that mandate their enrollment in a 

hearing conservation program (HCP) through their employers. 

The U.S. Mine Safety and Health Administration’s (MSHA) 

1999 Health Standards for Occupational Noise Exposure,

codified in 30 CFR 62 (commonly called the “Noise Rule”), 

requires this step for most miners. The mandatory HCP includes 

exposure monitoring, annual audiometry, access to hearing 

protectors, training and recordkeeping. NIOSH recommends 

additional components beyond those mandated to provide 

procedural audits, worker motivation, program evaluation and 

integration of engineering and administrative controls as part 

of the program. These programs that go beyond the standard 

hearing conservation program requirements are referred to as 

hearing loss prevention programs (HLPP) to reflect the more 

comprehensive and proactive approach (NIOSH, 1996). To 

enable mines to implement an effective HCP or HLPP the 

NIOSH mining hearing loss research program has developed 

a variety of tools and resources. In particular, several tools 

have been developed to address the need for worker education and motivation to play a critical role in preserving their 

own hearing.

Previous studies have identified attitudinal and behavioral 

barriers that prevent miners from acting to effectively protect 

their own hearing. Virtually all of these studies examine the 

use or non-use of hearing protection, although noise controls 

are the preferred method of hearing loss prevention. A positive 

association has been identified between attitudes regarding 

hearing protection and behavioral intentions to wear hearing 

protection (Quick et al., 2008). Also, workers who believe that 

hearing protectors are effective at preventing NIHL are more 

likely to use HPDs in noisy situations, while those who do not 

believe that HPDs are effective do not use them consistently. 

Other factors that reduce hearing protector use include workers’ perceptions that they already have poor hearing, that the 

devices are uncomfortable and that HPDs can interfere with 

communications, job performance and the ability to hear warning signals (Morata, 2002). Additional barriers, such as lack of 

motivation, lack of hearing protector fitting skills and lack of 

knowledge, can undermine even the most employee-centered 

hearing loss prevention programs. NIOSH has developed several hearing loss intervention tools targeting specific barriers 

to effective hearing loss prevention which can be implemented 

into a comprehensive hearing loss prevention program.

Motivation

Workers may not take action to protect their hearing because 

they lack the motivation to do so. Without understanding the 

consequences of noise exposure on hearing, a worker may 
have little reason to take any action for protection against noise 

exposure. The NIOSH Hearing Loss Simulator was developed 

to motivate miners to protect their ears from noise-induced 

hearing loss. It is a software training and communication tool 

that allows for self-experience of the impact of NIHL. Selfexperiences of symptoms have been found to be positively 

associated with anti-noise attitudes and behaviors (Widen et 

al., 2009). The purpose of this tool is to motivate workers to 

protect their own hearing by allowing them to experience the 

potential hearing loss they may incur with conditions very 

similar to their “real life” work environment. The main screen 

of the Hearing Loss Simulator is shown in Fig. 1.

Figure 1 — NIOSH Hearing Loss Simulator main screen.

A user of the Hearing Loss Simulator can adjust various 

parameters to estimate the hearing loss one would experience 

given a specific level of noise exposure over a specific number 

of years. The effects are shown visually on a frequency band 

control panel while the user listens to audio playback. Additionally, frequency band sliders are available that allow users 

to manually input hearing thresholds, from an audiogram, for 

example, so that a specific hearing loss can be demonstrated. 

Because hearing in background noise is a more difficult task 

than hearing in quiet, the Hearing Loss Simulator also offers 

a variety of background noise conditions for demonstration. 

Users can select from several recorded mining worksite sounds 

(continuous mining machine, bulldozers, processing machines), 

as well as standard generic background noises, such as multitalker babble. Customized sounds may be recorded using a 

high-quality microphone for further individualization of workplace noise conditions. Through manipulation of these various 

conditions, a user can experience a range of estimated hearing 

impairments in a variety of background noise conditions. This 

variety allows for demonstration of noise conditions that are 

very similar to a user’s own noise exposures and, therefore, an 

increased understanding of how their own working conditions 

may negatively impact their hearing ability.

The Simulator gains realism by basing its approximation 

of the NIHL experience on models derived from hearing impaired populations. The software performs calculations based 

on the ANSI standard S3.44, Determination of Occupational 

Noise Exposure and Estimation of Noise-Induced Hearing 

Impairment (ANSI, 2006). This standard provides algorithms 

for predicting hearing loss based on age and noise exposure. 

These algorithms were derived from studies of large populations, including some groups with no exposure to hazardous 

noise and other groups that experienced various levels and 

durations of noise exposure. The Simulator can demonstrate 

the individual variability in susceptibility to NIHL by using 

its population quartile adjustment. For instance, it can show 

how much additional NIHL is experienced by individuals in 

the most susceptible quartiles versus those at the population 

median. Although no individual user can predict their own 

susceptibility, the program can show the range of possible 

expected NIHL. By doing so, the Simulator provides realistic 

examples of the negative impact of repeated or prolonged noise 

exposure with data from a large subject pool. 

The NIOSH Hearing Loss Simulator functions on systems 

with Windows 98 or higher and standard Windows sound support and speakers. Projectors and/or headphones may be used 

for certain training applications. The NIOSH Hearing Loss 

Simulator and the Hearing Loss Simulator Instruction and 

Training guide are available for download from the internet 

at: www.cdc.gov/niosh/mining/products/product47.htm. Additionally, these tools can be ordered by calling 1–800–CDC–

INFO (1–800–232–4636). 

Hearing protector fitting skills

Lack of hearing protector fit skills is another barrier that 

impedes workers’ attempts to prevent noise-induced hearing 

loss. Hearing protection devices (HPDs) marketed in the U.S. 

are tested in laboratories to determine their Noise Reduction 

Rating (NRR). This rating is intended to represent the amount 

of noise protection that the protector can provide. However, 

the attenuation values obtained at work sites are often much 

less than those achieved in the laboratory (Berger et al., 1996). 

With incorrect HPD fit, as often occurs with untrained users, 

little or no protection from noise may be obtained. NIOSH 

has developed two tools to aid users of HPDs in achieving 

adequate fit. The Roll-Pull-Hold method and QuickFit earplug 

fit tester are NIOSH products aimed to alleviate two specific 

issues with fitting earplugs.

Figure 2 — NIOSH Roll-Pull-Hold method for insertion of 

foam earplugs.

Roll-Pull-Hold. It can be difficult to understand and remember the instructional wording and small print that is often 

found on the packaging of soft foam earplugs. Additionally, 

the directions for earplug insertion can be inconsistent between 

manufacturers or the packaging may be discarded before the 

directions are read and comprehended. NIOSH has developed 
and published the Roll-Pull-Hold method to simplify the insertion of soft foam earplugs by standardizing the instructions to 

focus on three words essential to the insertion task. By breaking 

the instructions into three simple steps, each linked to a single 

word, users of foam earplugs are able to remember the insertion 

procedure without referring the packaging, and in turn achieve 

a better plug fit. The most critical departure from standard 

instructions is the use of the term “pull” to remind users that 

they need to pull the pinna of the ear outward and upward to 

facilitate insertion. Prior to this, most earplug instructions used 

the word “insert” or other non-specific terms to describe this 

crucial step. Figure 2 is a visual representation of the NIOSH 

Roll-Pull-Hold method.

An unpublished pilot study of 308 coal miners was conducted 

to determine the benefits of the Roll-Pull-Hold technique. Subjects who were observed to complete none of the three steps 

attained an average of only 15 dB of attenuation at 1,000 Hz. 

Subjects who completed all three steps attained an average of 

24 dB of attenuation, a 9 dB improvement.

QuickFit.Personal fit testing is an effective and proven way 

to determine the amount of protection a worker is receiving 

from their hearing protection; however, fit-test systems can be 

expensive and impractical to implement at worksites. NIOSH 

has developed the QuickFit as an affordable, simpler fit-testing 

device for use in classroom training and at the worksite. 

The NIOSH QuickFit is a highly simplified variation of 

laboratory fit evaluations such as the procedure specified in 

ANSI S12.6 (ANSI/ASA, 2008). The simplicity and low cost of 

the device result from its design. The electrical components are 

derived by using off-the-shelf MP3 player components, with a 

few other parts, housed in the shell of a standard earmuff style 

hearing protector. In contrast to most other fit-test systems, only 

one critical test frequency is used with the QuickFit, which 

saves time and allows for a simple three-step procedure that 

can be done at the worksite.

The QuickFit does not replace more complex systems that 

provide users with a personal attenuation rating (PAR), by 

testing hearing protector fit at several frequencies. Instead, 

the QuickFit tests only one octave band, 1,000 Hz, in a “go” 

or “no-go” paradigm designed to determine whether a user 

has achieved at least 15 dB of attenuation with earplugs. To 

arrive at this 1,000-Hz octave band, a digital bandpass filter 

was used to process a sample of random noise, limiting the 

band to the region between 500 and 2,000 Hz. This specific test 

signal was chosen for three reasons. It is part of the standard 

set of frequencies used in fit testing procedures, as well as 

audiometric testing; it is the most audible of those signals to 

the most people, because it is not typically masked by lower 

frequency sounds or impacted by noise-induced or age-related 

hearing loss and it is not affected by A-weighting. The test 

signal was then processed to pulse at one-second intervals. 

The QuickFit also streamlines testing by checking for just one 

attenuation value: 15 decibels. If a protector is poorly fitted, it 

will usually provide far less than 15 decibels of attenuation. This 

simplified method of fit testing proves more time-effective for 

use at busy worksites and is simple enough for workers to use 

without much training. A three-step process is followed that 

can be completed for both ears in less than five minutes. Figure 

3 shows a miner using the QuickFit to assure that his earplugs 

are properly inserted. 

Figure 3 — Worker adjusting the volume control on the 

QuickFit device to set his hearing threshold prior to inserting an earplug.

The user first holds the QuickFit to their 

ear and adjusts the output to their hearing threshold (where 

they can just barely detect the output). The user then inserts an 

earplug following the NIOSH Roll-Pull-Hold method or other 

method suited to the type of earplug being used. After insertion, 

the user will again hold the QuickFit over the protected ear 

and press the “boost” button, which raises the level of the test 

tone by 15 dB. If the user cannot hear the boosted signal, they 

have successfully achieved at least 15 dB of hearing protection. 

However, if the signal is still audible, they have not achieved 

enough attenuation from the earplug and should re-insert or 

try another style of earplug. 

QuickFitWeb is an online application that uses the same test 

tone as the handheld device, except that the sounds are played 

through computer speakers. This application, available to those 

with access to a computer and the internet, allows for testing 

of earmuff style protectors as well as plugs. The web version 

eliminates the need for the handheld device, but does not allow 

for testing earplug fit separately for left and right ears. The 

QuickFitWeb is available through the NIOSH website: www.

cdc.gov/niosh/mining/topics/hearingloss/quickfitweb.htm.

Figure 4 — Front pages of English and Spanish versions 

of “Inquiring Ears Want to Know” fact sheet.

Hearing test knowledge

Audiometric testing is the standard monitoring method 

in hearing conservation programs. Yet, audiograms remain 

misunderstood by most workers, leading to confusion and 
indifference regarding their hearing status and necessary steps 

for hearing protection. NIOSH developed the “Inquiring Ears 

Want to Know” fact sheet to increase worker knowledge about 

their own hearing status. This one-page (front and back) flyer 

is designed to augment the verbal information provided to 

workers after an audiometric test, with written information 

and visual images for a greater retention of the most salient 

points. An explanation of test results is provided, along with 

tips for preventing future hearing loss, a list of non-noise 

related causes of hearing loss, as well as a reminder of the 

Roll-Pull-Hold method for earplug insertion. The document 

is appropriate for all noise-exposed workers through simple 

wording and vivid images intended to convey complex messages. A Spanish translation is also available to accommodate 

the growing Spanish-speaking segment of the workforce. Figure 

4 shows the front page of the English and Spanish versions 

of the fact sheet. The purpose of the document is not only to 

increase worker knowledge about their hearing, but to motivate 

proactive behaviors towards hearing loss prevention efforts.

The “Inquiring Ears Want to Know” fact sheet has been 

field-evaluated with public health professionals as well as 

miners to assure the clarity and simplicity of the intended 

messages. Suggestions from the public health professionals 

regarding content and images were implemented to make the 

fact sheet as useful yet simple as possible. The document was 

also pilot-tested with a group of mining trainees to confirm that 

the text and images were communicated in a way that could be 

understood by the target audience. The “Inquiring Ears Want 

to Know” fact sheet is available online for download at: www.

cdc.gov/niosh/mining/pubs/pdfs/2008-102.pdf or by calling 

1–800–CDC–INFO (1–800–232–4636).

Conclusion

The Hearing Loss Simulator, QuickFit, Roll-Pull-Hold 

method and “Inquiring Ears Want to Know” fact sheet can 

be implemented in hearing loss prevention programs individually or as a suite of interventions. Worker motivation 

can be addressed through specific examples with the Hearing 

Loss Simulator. Hearing protector fit skills can be improved 

through hands-on training using the Roll-Pull-Hold method 

and the QuickFit. For improved comprehension of hearing 

test results and basic hearing knowledge, the “Inquiring Ears 

Want to Know” fact sheet provides practical, easily understood 

information. Workers can carry the sheet away from the test 

and retain it with their test results for future reference. By 

targeting specific behavioral barriers, hearing loss prevention 

programs are likely to yield greater success in reducing NIHL 

and improve worker acceptance through understanding of the 

purpose of the program. 

Disclaimer

The findings and conclusions in this report are those of the 

author(s) and do not necessarily represent the views of the 

National Institute for Occupational Safety and Health. Reference to specific brand names does not imply endorsement by 

the National Institute for Occupational Safety and Health.

References 

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