Health Service Applications Adolescent Hearing Behavior: A School Health Promotion Program Judith Wuest, Grace Getty
T
hough noise-induced hearing loss associated with occupational hazards is widely discussed in the literature, little is written about adolescent hearing status or patterns of exposure to hearing hazards in this age group. Concern about risk factors for hearing loss of adolescents attending a large regional high school resulted in development of an individualized health promotion program implemented during the 1990-91 academic year. Program goals included individualized teaching and counseling about hearing protection, assessment of hearing status, and gathering information about adolescent hearing health behavior. This paper describes the program and findings about adolescent hearing status and patterns of exposure to risk factors for hearing loss.
THE HEALTH PROMOTION PROGRAM Third-year nursing students in the undergraduate baccalaureate program and faculty from the University of New Brunswick initiated the program as part of a Primary Health Care course. Each student entering their first year at the high school could participate in a hearing screening, health counseling program. Student nurses visited each classroom, explained the service, and answered questions. Interested pupils took home and completed a health history that asked questions about general health status, family history of hearing problems, history of ear infections, present difficulties hearing, patterns of exposure to music with and without headphones, patterns of exposure to other loud noise (chain saws, motorcycles, power tools), ear protection worn, experiences with threshold shifts, and smoking habits. Health histories were collected before the actual screening and individual appointments were made with adolescents by nursing students for screening and counseling during class time at the high school. Student nurses reviewed the health history with each participant, dicussing current risk factors for noise-induced hearing loss inherent in each adolescent’s lifestyle. Health teaching focused on structure Judith Wuesl, RN, BScN, MN, Associate Professor; and Grace Getty, RN, BN, MN, Faculty of Nursing, University of New Brunswick, Box 4400, Fredericton, New Brunswick, Canada E3B 5A3. This article is based on a paper presented at the International Health Promotion Conference, Helsinki, Finland, June 1991. This article was submitted January 21, 1992. and revised and accepted for publication May 26, 1992.
and function of the ear, correct ear cleaning practices, and effects of noise on hearing. Efforts were made to build on knowledge teen-agers already had acquired from health and biology courses. Nurses and clients then collaborated to identify acceptable strategies for hearing protection the adolescent actually might implement. Such strategies included reducing volume, changing from headphones to stereo speakers, reducing time and frequency of exposure, wearing earplugs or ear protectors, and recognizing and avoiding situations that resulted in temporary threshold shifts. Physical and otoscopic examination of the ears, Weber and Rinne tuning fork tests, and a pure tone sweep check of frequencies 1000,2000,4000 Hz at 20 db and 500,60oO, and 8000 Hz at 25 db (because ambient noise levels in the screening setting resulted in over referral at 20db) were conducted on all clients. If the sweep check was failed, threshold audiometry was carried out and clients were retested in two weeks. Clients who failed the retest sweep check were referred to an audiologist and the family physician for further testing. Written findings were given to the adolescent.
RESULTS OF THE PROGRAM One hundred eighty teens, ages 14 to 21, participated. Of the 111 girls and 69 boys tested, 15% required retesting and 7.8% were referred for further testing. Seven girls and seven boys were referred: a referral rate of 10.3% for boys and 6.3% for girls. Twenty-eight students indicated on their histories they had difficulty hearing and eight of these were referred after screening. Chi square test on rate of referral for those who perceive they have difficulty hearing was higher than can be expected by chance variation at a 0.01 significance level. This finding is not surprising. However, only one of these students had previously been formally assessed with hearing loss though two others indicated continuing problems with ear infections. Apparently, degree of hearing loss was not sufficient to motivate the teen-agers or their families to seek assessment. Forty-three percent of teen-agers tested reported a history of ear infections. A family history of hearing loss was reported by 8.3% of the clients. When asked “Have you ever found it hard to ~
436
Journal of School Health
November 1992, Vol. 62, No. 9
hear for a time after exposure to loud noise?,’’ 51.7% (93 students) said yes. By gender, 57.3% of the girls and 45.5% of the boys reported experiencing a threshold shift. In a 1987 British study where 1,443 11-18 year olds were asked about temporary hearing loss, 40% of those attending live concerts or dances reported tinnitus and 39% reported temporary hearing loss. Rates of those who listened to recorded music through headphones were 19% reporting temporary hearing loss and 27% reporting tinnitus.’ Findings from this program indicate a higher rate of temporary threshold shift. Though only six students reported frequent threshold shift or tinnitus, many reported this occurrence after exposure to loud music at school dances, teen clubs, and at rock concerts. The experience was described either as a ringing in the ears or a muffling of sounds. Duration of impaired hearing varied from a few minutes to overnight. Verbally, many teens indicated music at dances and concerts and even in the school cafeteria was often so loud they found it hard to enjoy. However, at the same time, they felt powerless to change the situation because they perceived most of their peers liked it that way. West and Evans2 noted that exposure to intense sounds of rock music is for most young people the only significant threat to their hearing and recommended those who had experienced either tinnitus or temporary threshold shift associated with such exposure should avoid such high level sounds. Danenberg et al’ found that temporary threshold shift in response to rock music most often affects frequencies 4000 and 6OOO Hz, frequencies initially most affected by noise-induced hearing loss. This fact suggests more than 50% of students in this study are experiencing warning signs of possible noise-induced Table 1 Subjects’ History of Hearing Screening and Hearlng Loss
n
Tohi Screened
180
Retested
27
Referred
14
7.8
History Hearing Dilficully Ear Inlections
28 70
15.6 43.3
15
8.3
93
51.7
41 160 35
22.8 89 19.4
Family History 01 Hearing Loss Temporary Threshold Shill or Tlnnitus Music Listening Headphones Speakers Smoke
15
Table 2 Classification of Music Volume bv Gender Mutic Volume Female Male
PuY
Moderam
Loud
10%
51%
34%
5%
6%
31%
49%
14%
Vt~Loud
hearing loss and that irreversible damage may occur if these warnings are not heeded. In addition, about one-half the students referred had a hearing loss at 4OOO or 6OOO Hz. Some students cited power tools, gun shots, and airplane noise as causative factors of threshold shifts. Many reported regular exposure to these sources of noise as well as motorcycles and snowmobiles. Only a few students reported using any ear protection, a finding consistent wth other studies.‘ Information about practices of listening to music in leisure time was collected. Only 22.8% (41 students) said they listened to music through headphones, a lower rate than other studies of adolescent use. In Great Britain, 37% of 1,443 students;) in Italy, 61.3% of 259 adolescents;’ and in Hong Kong, 81TOof 487 teen-aged reported using headphones. In this program, the mean weekly listening time for headphone users was 6.44 hours, a higher rate than the mean weekly use of adolescents in Hong Kong (4.5 hours)6 and Italy (3.3 hours).J Many students in this program said they had stopped using headphones because they had heard reports they could damage hearing. One hundred sixty-one students reported listening to music without headphones daily with the mean number of listening hours being 2.5. When asked to classify the volume of the music they listened to as quiet, moderate, loud, or very loud, 51% of girls and 31% of boys listen to moderate music, 34% of girls and 49% of boys listen to loud music, and 5% of girls and 14% of boys listen to very loud music. These findings are consistent with those of the British study.’ When thevolume of music played by 25 of their subjects was measured, males used considerably higher levels than females. Using the Chi square test no significant difference occurred in referral rates between groups who reported listening to music at the four different volumes. An unexpected finding was the high rate of referral among smokers. Only 19.4% of students smoked, 23 girls and 12 boys, but eight of the students referred were smokers. The Chi square test indicates this rate of referral is higher than could be expected by chance at a significance rate of .01. This finding suggests a relationship between smoking and hearing loss in young people and further studies should be conducted. Studies of older populations exposed to industrial noise indicated smoking is associated with increased risk of hearing loss.’ If this trend also exists in young people, adolescents who smoke may be at a higher risk for noise-induced hearing loss.
IMPLICATIONS OF THE PROGRAM This health promotion program was useful for heightening the awareness of potential risks for individual students. That many students indicated a reduction in use of headphones might be a positive indicator of desire to preserve hearing in this target group. One implication of the findings is that teenagers who smoke may be at higher risk for noiseinduced hearing loss. Though further study is requir-
Journal of School Health
November 1992, Vol. 62, No. 9
437
ed, this possibility needs to be considered by health professionals working with adolescents. The reported occurrence of temporary threshold shift is worrisome. Though no significant difference existed in referral rates between those who have temporary threshold shifts and those who have not, this finding cannot be ignored because irreversible noiseinduced hearing loss develops over time with repeated exposure to noxious levels of n0ise.O Individual students may have benefited from the individual counseling; however, prevention of noise-induced hearing loss cannot only be dealt with on an individual level. In keeping with the philosophy of primary health care, some sociopolitical responsibility exists to establish safe levels of noise exposure beyond the industrial workplace. School boards need information about the status of risk factors within individual schools so responsible policies can be established. Additional studies are required to gather information about adolescent hearing status and hearing behaviors.
References 1. Bradley R, Fortnum H, Coles R. Research note: Patterns of exposure of schoolchildren to amplified music. Br J Audiol. 1987;2 1:119- 125. 2. West P, Evans E. Early detection of hearing damage in
young listeners resulting from exposure to rock music. Br J Audiol. 199O;24:89- 103. 3 . Danenberg M, Loos-Cosgrove M, Loverde M. Temporary
hearing loss and rock music. Lung Speech Hear Services in Schools. 1987; 18~250-256. 4. Lass NJ, Woodford CM, Lundeen C, Lundeen DJ, EverlyMyers D. A survey of high school students knowledge and awareness of hearing, hearing loss, and hearing health. Hearing J. 1987;4O: 15- 19. 5 . Rice CG, Rossi G, Olina M. Damage risk from personal cassette players. Br J Audiol. 1987;21:279-288. 6. Wong TW. Van Hasselt CA, Tang LS, Yiu PC. The use of personal cassette players among youths and its effects on hearing. Public Health. 1990;104:327-330. 7. Barone J, Peters J, Garabrant D, Bernstein L, Krebsbach R. Smoking as a risk factor in noise-induced hearing loss. J Occup Med. 1987;29:141-145. 8 . Lass NJ, Woodford CM, Lundeen C, English P, Schmitt J, Pannabacker M. Health educators' knowledge of hearing, hearing loss, and hearing health practices. Lung Speech Hear Services in Schools. 199O;21:85-90.
NOW AVAILABLE
IMPLEMENTAnON GUIDE FOR THE
STANDARDS OF SCHOOL NURSING PRACTICE The &page Implementation Guide pairs each of the eight Standardsof School Nursing Practice with "how to" suggestions to assist school nurses develop, enhance, standardizeand evaluate school health programs in their schools and communities. Contemporary Issues in School Nursing are also explored, including: 0 H IV in the School Setting LiabilityIssues School-based Clinics 0 Future of School Nursing The 27-page appendix contains more than 10 forms that can be used immediately in your school health office. They include a sample "Accident Report"; "Daily Log of Treatment Administered";"School Nursing Summary Sheet"; and a "Daily Medication Log". A two-page "School Nursing Activity Calendar" and a "Position Description of the School Nurse" are also included for reference. 1991. $10.95 for ASHA members and $12.50 for nonmembers, contact: PublicationsDept., ASHA, 7263 State Route 43, P.O. Box 708, Kent, OH 44240. Convenient telephone ordering with MasterCard or VISA at (216)678-1601.
Add $3.00 shipping Q handling, make checks payable to ASHA, and include your shipping address.
438
Journal of School Health
November 1992, Vol. 62, No. 9
T
hough noise-induced hearing loss associated with occupational hazards is widely discussed in the literature, little is written about adolescent hearing status or patterns of exposure to hearing hazards in this age group. Concern about risk factors for hearing loss of adolescents attending a large regional high school resulted in development of an individualized health promotion program implemented during the 1990-91 academic year. Program goals included individualized teaching and counseling about hearing protection, assessment of hearing status, and gathering information about adolescent hearing health behavior. This paper describes the program and findings about adolescent hearing status and patterns of exposure to risk factors for hearing loss.
THE HEALTH PROMOTION PROGRAM Third-year nursing students in the undergraduate baccalaureate program and faculty from the University of New Brunswick initiated the program as part of a Primary Health Care course. Each student entering their first year at the high school could participate in a hearing screening, health counseling program. Student nurses visited each classroom, explained the service, and answered questions. Interested pupils took home and completed a health history that asked questions about general health status, family history of hearing problems, history of ear infections, present difficulties hearing, patterns of exposure to music with and without headphones, patterns of exposure to other loud noise (chain saws, motorcycles, power tools), ear protection worn, experiences with threshold shifts, and smoking habits. Health histories were collected before the actual screening and individual appointments were made with adolescents by nursing students for screening and counseling during class time at the high school. Student nurses reviewed the health history with each participant, dicussing current risk factors for noise-induced hearing loss inherent in each adolescent’s lifestyle. Health teaching focused on structure Judith Wuesl, RN, BScN, MN, Associate Professor; and Grace Getty, RN, BN, MN, Faculty of Nursing, University of New Brunswick, Box 4400, Fredericton, New Brunswick, Canada E3B 5A3. This article is based on a paper presented at the International Health Promotion Conference, Helsinki, Finland, June 1991. This article was submitted January 21, 1992. and revised and accepted for publication May 26, 1992.
and function of the ear, correct ear cleaning practices, and effects of noise on hearing. Efforts were made to build on knowledge teen-agers already had acquired from health and biology courses. Nurses and clients then collaborated to identify acceptable strategies for hearing protection the adolescent actually might implement. Such strategies included reducing volume, changing from headphones to stereo speakers, reducing time and frequency of exposure, wearing earplugs or ear protectors, and recognizing and avoiding situations that resulted in temporary threshold shifts. Physical and otoscopic examination of the ears, Weber and Rinne tuning fork tests, and a pure tone sweep check of frequencies 1000,2000,4000 Hz at 20 db and 500,60oO, and 8000 Hz at 25 db (because ambient noise levels in the screening setting resulted in over referral at 20db) were conducted on all clients. If the sweep check was failed, threshold audiometry was carried out and clients were retested in two weeks. Clients who failed the retest sweep check were referred to an audiologist and the family physician for further testing. Written findings were given to the adolescent.
RESULTS OF THE PROGRAM One hundred eighty teens, ages 14 to 21, participated. Of the 111 girls and 69 boys tested, 15% required retesting and 7.8% were referred for further testing. Seven girls and seven boys were referred: a referral rate of 10.3% for boys and 6.3% for girls. Twenty-eight students indicated on their histories they had difficulty hearing and eight of these were referred after screening. Chi square test on rate of referral for those who perceive they have difficulty hearing was higher than can be expected by chance variation at a 0.01 significance level. This finding is not surprising. However, only one of these students had previously been formally assessed with hearing loss though two others indicated continuing problems with ear infections. Apparently, degree of hearing loss was not sufficient to motivate the teen-agers or their families to seek assessment. Forty-three percent of teen-agers tested reported a history of ear infections. A family history of hearing loss was reported by 8.3% of the clients. When asked “Have you ever found it hard to ~
436
Journal of School Health
November 1992, Vol. 62, No. 9
hear for a time after exposure to loud noise?,’’ 51.7% (93 students) said yes. By gender, 57.3% of the girls and 45.5% of the boys reported experiencing a threshold shift. In a 1987 British study where 1,443 11-18 year olds were asked about temporary hearing loss, 40% of those attending live concerts or dances reported tinnitus and 39% reported temporary hearing loss. Rates of those who listened to recorded music through headphones were 19% reporting temporary hearing loss and 27% reporting tinnitus.’ Findings from this program indicate a higher rate of temporary threshold shift. Though only six students reported frequent threshold shift or tinnitus, many reported this occurrence after exposure to loud music at school dances, teen clubs, and at rock concerts. The experience was described either as a ringing in the ears or a muffling of sounds. Duration of impaired hearing varied from a few minutes to overnight. Verbally, many teens indicated music at dances and concerts and even in the school cafeteria was often so loud they found it hard to enjoy. However, at the same time, they felt powerless to change the situation because they perceived most of their peers liked it that way. West and Evans2 noted that exposure to intense sounds of rock music is for most young people the only significant threat to their hearing and recommended those who had experienced either tinnitus or temporary threshold shift associated with such exposure should avoid such high level sounds. Danenberg et al’ found that temporary threshold shift in response to rock music most often affects frequencies 4000 and 6OOO Hz, frequencies initially most affected by noise-induced hearing loss. This fact suggests more than 50% of students in this study are experiencing warning signs of possible noise-induced Table 1 Subjects’ History of Hearing Screening and Hearlng Loss
n
Tohi Screened
180
Retested
27
Referred
14
7.8
History Hearing Dilficully Ear Inlections
28 70
15.6 43.3
15
8.3
93
51.7
41 160 35
22.8 89 19.4
Family History 01 Hearing Loss Temporary Threshold Shill or Tlnnitus Music Listening Headphones Speakers Smoke
15
Table 2 Classification of Music Volume bv Gender Mutic Volume Female Male
PuY
Moderam
Loud
10%
51%
34%
5%
6%
31%
49%
14%
Vt~Loud
hearing loss and that irreversible damage may occur if these warnings are not heeded. In addition, about one-half the students referred had a hearing loss at 4OOO or 6OOO Hz. Some students cited power tools, gun shots, and airplane noise as causative factors of threshold shifts. Many reported regular exposure to these sources of noise as well as motorcycles and snowmobiles. Only a few students reported using any ear protection, a finding consistent wth other studies.‘ Information about practices of listening to music in leisure time was collected. Only 22.8% (41 students) said they listened to music through headphones, a lower rate than other studies of adolescent use. In Great Britain, 37% of 1,443 students;) in Italy, 61.3% of 259 adolescents;’ and in Hong Kong, 81TOof 487 teen-aged reported using headphones. In this program, the mean weekly listening time for headphone users was 6.44 hours, a higher rate than the mean weekly use of adolescents in Hong Kong (4.5 hours)6 and Italy (3.3 hours).J Many students in this program said they had stopped using headphones because they had heard reports they could damage hearing. One hundred sixty-one students reported listening to music without headphones daily with the mean number of listening hours being 2.5. When asked to classify the volume of the music they listened to as quiet, moderate, loud, or very loud, 51% of girls and 31% of boys listen to moderate music, 34% of girls and 49% of boys listen to loud music, and 5% of girls and 14% of boys listen to very loud music. These findings are consistent with those of the British study.’ When thevolume of music played by 25 of their subjects was measured, males used considerably higher levels than females. Using the Chi square test no significant difference occurred in referral rates between groups who reported listening to music at the four different volumes. An unexpected finding was the high rate of referral among smokers. Only 19.4% of students smoked, 23 girls and 12 boys, but eight of the students referred were smokers. The Chi square test indicates this rate of referral is higher than could be expected by chance at a significance rate of .01. This finding suggests a relationship between smoking and hearing loss in young people and further studies should be conducted. Studies of older populations exposed to industrial noise indicated smoking is associated with increased risk of hearing loss.’ If this trend also exists in young people, adolescents who smoke may be at a higher risk for noise-induced hearing loss.
IMPLICATIONS OF THE PROGRAM This health promotion program was useful for heightening the awareness of potential risks for individual students. That many students indicated a reduction in use of headphones might be a positive indicator of desire to preserve hearing in this target group. One implication of the findings is that teenagers who smoke may be at higher risk for noiseinduced hearing loss. Though further study is requir-
Journal of School Health
November 1992, Vol. 62, No. 9
437
ed, this possibility needs to be considered by health professionals working with adolescents. The reported occurrence of temporary threshold shift is worrisome. Though no significant difference existed in referral rates between those who have temporary threshold shifts and those who have not, this finding cannot be ignored because irreversible noiseinduced hearing loss develops over time with repeated exposure to noxious levels of n0ise.O Individual students may have benefited from the individual counseling; however, prevention of noise-induced hearing loss cannot only be dealt with on an individual level. In keeping with the philosophy of primary health care, some sociopolitical responsibility exists to establish safe levels of noise exposure beyond the industrial workplace. School boards need information about the status of risk factors within individual schools so responsible policies can be established. Additional studies are required to gather information about adolescent hearing status and hearing behaviors.
References 1. Bradley R, Fortnum H, Coles R. Research note: Patterns of exposure of schoolchildren to amplified music. Br J Audiol. 1987;2 1:119- 125. 2. West P, Evans E. Early detection of hearing damage in
young listeners resulting from exposure to rock music. Br J Audiol. 199O;24:89- 103. 3 . Danenberg M, Loos-Cosgrove M, Loverde M. Temporary
hearing loss and rock music. Lung Speech Hear Services in Schools. 1987; 18~250-256. 4. Lass NJ, Woodford CM, Lundeen C, Lundeen DJ, EverlyMyers D. A survey of high school students knowledge and awareness of hearing, hearing loss, and hearing health. Hearing J. 1987;4O: 15- 19. 5 . Rice CG, Rossi G, Olina M. Damage risk from personal cassette players. Br J Audiol. 1987;21:279-288. 6. Wong TW. Van Hasselt CA, Tang LS, Yiu PC. The use of personal cassette players among youths and its effects on hearing. Public Health. 1990;104:327-330. 7. Barone J, Peters J, Garabrant D, Bernstein L, Krebsbach R. Smoking as a risk factor in noise-induced hearing loss. J Occup Med. 1987;29:141-145. 8 . Lass NJ, Woodford CM, Lundeen C, English P, Schmitt J, Pannabacker M. Health educators' knowledge of hearing, hearing loss, and hearing health practices. Lung Speech Hear Services in Schools. 199O;21:85-90.
NOW AVAILABLE
IMPLEMENTAnON GUIDE FOR THE
STANDARDS OF SCHOOL NURSING PRACTICE The &page Implementation Guide pairs each of the eight Standardsof School Nursing Practice with "how to" suggestions to assist school nurses develop, enhance, standardizeand evaluate school health programs in their schools and communities. Contemporary Issues in School Nursing are also explored, including: 0 H IV in the School Setting LiabilityIssues School-based Clinics 0 Future of School Nursing The 27-page appendix contains more than 10 forms that can be used immediately in your school health office. They include a sample "Accident Report"; "Daily Log of Treatment Administered";"School Nursing Summary Sheet"; and a "Daily Medication Log". A two-page "School Nursing Activity Calendar" and a "Position Description of the School Nurse" are also included for reference. 1991. $10.95 for ASHA members and $12.50 for nonmembers, contact: PublicationsDept., ASHA, 7263 State Route 43, P.O. Box 708, Kent, OH 44240. Convenient telephone ordering with MasterCard or VISA at (216)678-1601.
Add $3.00 shipping Q handling, make checks payable to ASHA, and include your shipping address.
438
Journal of School Health
November 1992, Vol. 62, No. 9
