International Journal of Audiology 2014; 53: 209–218

Original Article

Development and evaluation of a questionnaire to assess knowledge, attitudes, and behaviors towards hearing loss prevention

Int J Audiol Downloaded from informahealthcare.com by Baylor University on 06/27/14 For personal use only.

Gabrielle H. Saunders*,†, Serena M. Dann*, Susan E. Griest*,† & Melissa T. Frederick* *National Center for Rehabilitative Auditory Research (NCRAR), Portland VA Medical Center, Portland, USA, and †Department of Otolaryngology, Oregon Health and Science University, Portland, USA

Abstract Objective: To develop and evaluate a questionnaire assessing knowledge, attitudes, and behaviors (KAB) as they pertain to hearing conservation, using the constructs of the health belief model (HBM). Design: The KAB was completed by 235 participants. Relationships between knowledge and attitudes about hearing and hearing conservation, participation in noisy activities, and use of hearing protection were examined. Study sample: 117 males and 118 females aged between 18 and 80 years (mean ⫽ 42.3, SD ⫽ 4.1) recruited from the Portland VA Medical Center, local universities, and a community college. Results: Knowledge scores ranged from 15.6% to 93.8%. Factor analyses revealed six attitude factors, interpreted as measuring perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, and cues to action. Over 95% of participants routinely participated in at least one noisy activity but few used hearing protection while doing so. The attitude scores of individuals who used hearing protection differed significantly from the scores of those who did not. Conclusions: Significant relationships between use of hearing protection and scores on the KAB provide validation that the HBM is a valuable framework for understanding hearing health behaviors, and evidence that the KAB is a valid tool for assessing these attitudes and behaviors.

Key Words: Hearing conservation; health behaviors; health belief model; questionnaires Exposure to hazardous levels of noise is the most common cause of preventable hearing loss (Feldman & Grimes, 1985). Many people, however, are not aware that high levels of sound can cause irreversible hearing loss (Crandell et al, 2004; Shah et al, 2009) or they choose to engage in risky behaviors associated with noise exposure despite being aware of the damage it may cause (Widén & Erlandsson, 2007; Widén, 2013). Data also show that people underestimate the impacts hearing loss has on communication and quality of life (Saunders et al, 2013). As a result hearing protection and other strategies to avoid noise damage to the auditory system are underutilized (Crandell et al, 2004; Bogach et al, 2005). These issues are not specific to hearing. People are generally resistant to changing health behaviors (Rollnick et al, 1992) – even when extensive public health messages bring awareness of the dangers of those behaviors, and when individuals know they can lessen the impacts of a chronic health condition by doing so (Newson et al, 2012). In fact, even in matters of life versus death people are resistant to changing their behaviors – as illustrated by McGinnis & Foege (1993) who report that up to 50% of deaths in the US annually can be attributed to lifestyle decisions. It has been noted that factual information alone is insufficient to induce behavior change (Kreuter & Strecher, 1996); it is necessary to also change attitudes and beliefs (Elder et al, 1999). This is illustrated

by a recent hearing-related study by Gilles et al (2012) in which 145 university students were surveyed about the frequency with which they visited night club/parties and whether or not they experienced tinnitus. Almost 15% of respondents reported permanent tinnitus, and 89.5% reported having experienced transient tinnitus at least once after listening to loud music; further, almost 66% of participants reported a decrease in their hearing at least sometimes after having spent 30 minutes listening to loud music. In addition, despite the fact that almost 70% of individuals surveyed agreed with the statement ‘Exposure to loud music can damage my hearing,’ only 11% routinely used hearing protection, 25% indicated they would use it in the future, and 36% said they would consider using it. Notably, knowledge about the risks of noise induced hearing loss (NIHL) from loud music was not a significant predictor of intent to use hearing protection – but rather attitudes, peer influences, and behaviors were. Similarly, Rawool and ColligonWayne (2008) reported that despite 90% of the 248 students in their study being aware that loud music could damage hearing, 18% said they sat near or next to the speakers when attending concerts, 44% used noisy equipment (e.g. power tools) without hearing protection, and of those who worked in a noisy place, 85.5% never wore hearing protection. The use of hearing protection among this group was associated more closely with their beliefs than with their knowledge.

Correspondence: Gabrielle H. Saunders, National Center for Rehabilitative Auditory Research, Portland VA Medical Center, 3710 SW US Veterans Hospital Road, Portland, OR 97239, USA. E-mail: [email protected] (Received 19 June 2013; accepted 25 October 2013) ISSN 1499-2027 print/ISSN 1708-8186 online © 2014 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.3109/14992027.2013.860487

210

G. H. Saunders et al.

Abbreviations

Int J Audiol Downloaded from informahealthcare.com by Baylor University on 06/27/14 For personal use only.

ANOVA HBM KAB NIHL PCA SD

Analysis of variance Health belief model Knowledge, attitudes, and behaviors questionnaire Noise induced hearing loss Principle components analysis Standard deviation

Health behavior models can be applied to understand attitudes and behaviors towards health, including hearing conservation (Sobel & Meikle, 2008; Redding et al, 2000; Widén, 2013). These models aim to guide current and future understanding of health behavior, and provide direction for research and intervention development leading to behavior change. Many such models have been proposed. The four most common are the health belief model (Rosenstock, 1966), the theory of planned behavior (Ajzen, 1991), the transtheoretical stages of change model (Prochaska & Velicer, 1997), and social cognitive theory (Bandura, 1986). In this research, the health belief model (HBM) was applied because of the relevance of its constructs to hearing loss prevention. According to the HBM, the likelihood an individual will engage in a health behavior is influenced by the interplay between six factors: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy and cues to action. The HBM has been used in previous studies examining hearing-conservation related behaviors, and indeed significant associations have been shown between perceived susceptibility and behaviors towards loud noise (Bogach et al, 2005; Chung et al, 2005; Ferrari & Chan, 1991; Rawool & Collogon-Wayne, 2008), perceived severity of hearing loss and hearing conservation-related behaviors (Rawool & Collogon-Wayne, 2008), perceived barriers and the use of hearing protection (Bogach et al, 2005; Chung et al, 2005; Rintelmann & Borus, 1968), perceived self-efficacy, peer pressure, and tolerance of loud noise (Wuest & Getty, 1992), and between intentions to use hearing protection and cues to actions (i.e. symptoms of hearing loss; Bogach et al, 2005; Widén & Erlandsson, 2004a,b). Likewise, Beach et al (2012), who conducted interviews with twenty individuals who regularly wore hearing protection when attending loud music events, revealed that perceived severity/susceptibility, barriers/benefits, self-efficacy and cues to action each played a role in motivating use of hearing protection, although other factors, such as internal locus of control and self-image, also influenced behavior. To our knowledge, none of the above studies attempted to develop a psychometrically-validated questionnaire to assess attitudes and beliefs; rather they relied on informal questions and interviews. However, Widén and colleagues did develop and evaluate scales to examine hearing-related beliefs. Their scales assessed perceived susceptibility to noise, risk perception, individual norms, normative ideals, and attitudes towards loud noise. The content of the scales were selected based on interviews conducted with sixteen young adults aged between 17 and 28 years who regularly attended concerts and discothèques (Widén & Erlandsson, 2007; Widén et al, 2011). In later work, Widén (2013) added items to assess the HBM constructs of cues to action and perceived barriers. Widén et al (2011) examined the relationship between beliefs and hearing protective behaviors of 543 youths (age range 16 to 20 years). They determined that attitudes towards noise and degree of perceived risk from noise explained 15% of the variance in use of hearing protection

at discothèques/dances, and that the combination of perceived susceptibility to noise, the norm of being invulnerable and degree of perceived risk explained 36% of the variance in use of hearing protection at concerts. Landälv et al (2013) then collected data from a further 281 individuals aged 15–19 years and determined that attitudes to loud music were associated with being prepared to take risks, risk judgment, the norm of being invulnerable, as well as the presence of sound sensitivity and tinnitus. Together these variables explained 48% of the variation in attitudes. In his most recent study, Widén (2013) examined variables associated with intention to use and actual use of hearing protection among a sample of 242 adolescents aged 15 to 19 years. He determined that intention to use hearing protection was associated with norms about hearing protection, perceived barriers to its use, perceived control over the environment, and attitudes towards noise, while use of hearing protection was associated with norms about hearing protection, perceived barriers to its use, the presence of tinnitus and of noise sensitivity. In light of these studies showing that the HBM is applicable to understanding hearing conservation-related behaviors, the aim of this study was to develop a psychometrically sound questionnaire, known as the knowledge, attitudes, and behaviors questionnaire (KAB) that assessed the constructs of the HBM as they pertain to hearing conservation. A second aim was to evaluate the relationship between scores on the KAB and reported hearing conservationrelated behaviors. The study addressed the question ‘how do the constructs of the HBM as measured by the questionnaire relate to reported behaviors associated with hearing conservation, and to age and gender?’ The KAB was developed for use as one of three outcome measures in a randomized controlled trial comparing the effectiveness of two hearing conservation interventions: a computerized hearing loss prevention program (see Folmer et al, 2012 for more details), and a printed brochure (http://www.ncrar.research.va.gov/ForVets/ Documents/hearing_conservation.pdf). Outcomes following use of these interventions were compared with outcomes following no intervention (control condition). Participants in that study completed the KAB at baseline (pre-intervention) and then again after having used the intervention (post-intervention) to which they were randomized. The pre- to post-differences in KAB scores of individuals in the no intervention control group relative to those of individuals randomized to the computerized hearing loss prevention program or printed brochure are used here to examine stability of KAB responses and KAB sensitivity.

Part 1. Instrument development Methods The KAB consists of three sections. Section 1 assesses knowledge about the auditory system, NIHL and hearing conservation (‘K’). Section 2 assesses attitudes towards hearing, hearing loss and hearing conservation using HBM constructs (‘A’), and section 3 assesses behaviors associated with participation in noisy activities and use of hearing protection (‘B’). Each section was developed by the threeperson research team, as follows.

SECTION 1: KNOWLEDGE Each member independently developed questions to assess hearing-related knowledge that might influence hearing conservation behaviors, such as knowledge about sound levels and sources that are damaging, and about use of hearing protection. Members were

Knowledge Attitudes and Behaviors Questionnaire instructed to construct statements with which respondents would rate their agreement on the scale (a) I know this is true, (b) I think this is true, (c) I’m not sure, (d) I think this is false, (e) I know this is false.

Int J Audiol Downloaded from informahealthcare.com by Baylor University on 06/27/14 For personal use only.

SECTION 2: ATTITUDES Each member independently developed items to assess attitudes towards and beliefs about hearing, hearing loss and hearing conservation using the constructs of the HBM. Table 1 provides a definition of each factor in the HBM, and an explanation of how each is factor is thought to influence behaviors associated with hearing conservation. Members of the team were instructed that each item should consist of a statement to which respondents would rate their agreement on the scale (a) I strongly agree, (b) I agree, (c) I’m not sure, (d) I disagree, or (e) I strongly disagree. At least four items for each of the six HBM constructs were developed by each team member.

SECTION 3: BEHAVIORS Each member independently developed a list of common activities associated with exposure to loud sounds, along with questions to assess how often individuals engaged in the activity, whether and why they used hearing protection while doing so, and whether they experienced tinnitus after engaging in the activity. Together the research team discussed each proposed item. Items that were repetitive, complex, ambiguous or difficult to interpret were excluded or reworded. These changes were incorporated into the questionnaire and shared with ten hearing professionals and ten laypersons, who were asked to provide further feedback. This feedback, such as the recommendation to simplify vocabulary, exclude double negative items, and add items of importance, was also incorporated into the questionnaire.

Participants Two groups of participants completed the questionnaire. Group 1 was comprised of 146 individuals with a mean age of 46.9 years

211

(SD: 14.4, range: 21–80), 66% of whom were female. They were recruited from among friends and family of the research team. This data collection was given Institutional Review Board exemption by the Portland VA Medical Center (VAMC) Institutional Review Board, and Research and Development committee since no personal health information were collected. Data from 15 individuals with incomplete questionnaires and from 14 individuals who worked in an audiology-related profession (and therefore possessed knowledge and attitudes unrepresentative of the general population) were excluded from the analyses, leaving 116 complete questionnaires. Group 2 consisted of 119 individuals (mean age: 37.8 years; SD: 12.4; range: 18–55; 35% female) enrolled in the randomized controlled trial (See last paragraph in the introduction, above). Individuals in this group signed an IRB-approved informed consent form. All participants had a pure-tone average (mean of thresholds at 0.5, 1.0, and 2.0 kHz) less than or equal to 55 dB HL in one or both ears, an age and educationally appropriate score on the mini mental state exam (MMSE; Folstein et al, 1983; Crum et al, 1993), and a broad reading score of grade 5 or above on the Woodcock-Johnson III tests of achievement letter-word identification, reading fluency and passage comprehension subtests (Schrank et al, 2001). None of the participants had a conductive hearing loss or used hearing aids, nor did any work in an audiology-related profession. For the analyses the data from both datasets were combined in order to obtain a larger sample with a broader range of ages than either dataset alone (range ⫽ 18–80 years), and in which there are an equal number of male and female participants (117 males, 118 females).

Procedures Group 1 completed the KAB using a web-based survey program (Survey Monkey). They were invited to participate via an email in which there was a hyperlink that took them to the survey. Group 2 completed the KAB using a computer-based survey program (SurveyGold) in the laboratory. They completed it immediately after signing the informed consent form and completing inclusion-

Table 1. Health belief model: Definition of factors and influences on hearing-conservation related behaviors. Factor Perceived susceptibility Perceived severity

Perceived benefits

Perceived barriers

Perceived self-efficacy

Cues to action

Definition An individual’s assessment of the risk of acquiring a condition An individual’s assessment of the seriousness of the consequences of a condition if it is acquired An individual’s assessment of the positive consequences of adopting a health behavior An individual’s assessment of the influences that discourage adoption of a health behavior An individual’s assessment of his/her ability to successfully adopt a health behavior External influences that promote a health behavior (e.g. symptoms, media communications, or information from a healthcare provider).

Attitude likely to lead to positive behaviors associated with hearing-conservation Feeling vulnerable to hearing loss Believing that a hearing loss would have negative consequences

Explanation Individual is likely to take action to prevent hearing loss Individual is motivated to protect his/her hearing

Believing that hearing well is important

Individual is motivated to protect his/her hearing

Perceiving few negative influences to protecting hearing

Individual is likely to protect his/ her hearing

Believing one has the knowledge and abilities to protect hearing

Individual feels capable of taking action to prevent hearing loss

Receiving prompts from others about protecting hearing

Individual is ready to take action to prevent hearing loss

G. H. Saunders et al.

212

exclusion testing, but prior to being randomized to an intervention in the trial. The KAB for Group 1 consisted of 21 knowledge questions and 34 attitude items. The KAB for Group 2 consisted of 16 of the original 21 knowledge items, 26 of the original 34 attitude items, and 10 behavior activity questions. The five knowledge and 11 attitude items excluded for Group 2 were items to which Group 1 participants had mean scores at ceiling, and items that showed little variance in responses across the group. Participants in Group 1 did not complete the behavior questions because of branching limitations in the software.

Int J Audiol Downloaded from informahealthcare.com by Baylor University on 06/27/14 For personal use only.

Statistical analyses Data collected via SurveyMonkey and SurveyGold were saved to an Excel spreadsheet. Statistical analyses were conducted using Statistical Package for the Social Sciences (SPSS) v21. As is typical for questionnaire development (Rattray & Jones, 2007), principle components analysis (PCA) and reliability analyses were used to extract psychometrically valid KAB scales and to develop the final version of the KAB. Analyses of variance (ANOVAs) were used to examine the relationships between KAB scores, demographic variables, and hearing conservation behaviors.

Results

KNOWLEDGE QUESTIONS Data from the sixteen knowledge questions common to both datasets were combined and analysed together. The distribution of answers across each response category was examined. About 21% of responses were in the ‘I’m not sure’ category, almost 55% were in the ‘I think this is true/false’ categories, and 24% were in the ‘I know this is true/false’ categories, confirming that participants used the full range of response options. There were no questions to which more than 37% of participants knew the correct answer, but there were five questions to which more than 50% of participants thought they knew the correct answer. Participants were least knowledgeable about the following three questions, with less than 50% of the participants answering each correctly: • • •

Sounds measuring 70 dB can damage human hearing. (False) A good way for people to protect their hearing from loud sounds is to put cotton or tissue in their ears. (False) When people wear earplugs correctly they will not hear the difference in the loudness of the noise when they cover their ears. (True)

Participants were most knowledgeable about the following three questions, with more than 80% of participants answering correctly: • • •

The background sound is too loud if you can’t hear someone speaking who is 3 feet (1 metre) away. (True) Hearing protection isn’t as useful for people with hearing loss. (False) Hearing an extremely loud sound just once can cause someone to lose some hearing. (True)

An overall knowledge score was generated by awarding 1-point for a correct response (either ‘I KNOW this is true/false’ or “I THINK this is true/false”), and 0-points for an incorrect response (either “I THINK this is true/false” or “I KNOW this is true/false”). Points were summed for all 16 questions and the percentage correct computed. The average score obtained was 57.6% (SD ⫽ 15.2) with scores ranging from 15.6% to 93.8%. The total number of “I’m not

sure” responses for each participant was totaled. This ranged from 0 to 9 (mean ⫽ 3.1, SD ⫽ 1.7).

ATTITUDE ITEMS Data from the 26 attitude questions common to both datasets were combined and analysed together. PCA using equamax rotation with Kaiser normalization was conducted to evaluate the factor structure of these items. PCA explores the inter-item correlations to group the items into factors (Rattray & Jones, 2007). The items in each factor have stronger relationships to each other than they do to the items in other factors. Scree plots, in which sorted eigenvalues for each factor are plotted in order of decreasing magnitude, are often used to determine the number of factors to retain by determining how many factors there are before the break point or bend in the plot line. Another approach is to select factors with eigenvalues greater than 1 (Watson, 1998). In this analysis, the scree plot showed the break point to occur after the sixth factor (eigenvalue ⫽ 1.148), and that the 7th factor had an Eigenvalue below 1 (0.985), thus six factors were retained for further analysis. Factor loadings are used to determine the strength of the relationship between the item and the scale within which it falls. According to Costello & Osborne (2005), a factor loading of 0.4 or greater is one attribute required for a stable factor structure. Therefore, only items with factor loadings of greater than 0.4 were considered for inclusion in each factor. Reliability analyses were then used to examine the six factors. Reliability analysis evaluates the intercorrelations between the items in each factor, and, with Cronbach’s α as the metric, the extent to which the items measure the same underlying construct. For the reliability analyses, any items with a negative factor loading were reverse scored, and items that lowered the Cronbach’s α-value within a factor were excluded. Table 2 shows the Cronbach’s α-value for each factor, along with the items in each, the factor loadings of each item, our interpretation of the construct they measure, and the percentage of variance that each explains. Two items appear in more than one factor because they had factor loadings of greater than 0.4 in both (“Protecting my hearing is not worth the cost” and “The advantages of protecting my hearing are greater than the disadvantages”). According to George & Mallery (2003), Cronbach’s α-values of 0.8–0.9 are ‘good,’ values between 0.7 and 0.8 are ‘acceptable’, and those between 0.6 and 0.7 are ‘questionable,’ thus all but one factor had acceptable α-values. However, as noted by Kline (1999), when questionnaires are dealing with psychological constructs, such as those being assessed here, values below 0.7 can be expected because of the diversity of the constructs being measured. Together the six factors explain 55.8% of the variance which is typical of studies in which exploratory factor analyses are conducted (Peterson, 2000). The final attitudes scale consists of 22 items in six factors which, based on our interpretation, measure: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy and cues to action. The number of items in each factor ranges from two to seven. Individual attitude items were scored by awarding ⫹ 2 points for an attitude that is highly likely to lead to positive behaviors associated with hearing-conservation (see Table 1), ⫹ 1 point for an attitude that is likely to lead to positive behaviors associated with hearingconservation, 0-points for a neutral attitude, ⫺ 1 point for an attitude that is unlikely to lead to positive behaviors associated with hearingconservation, and ⫺ 2 points for an attitude that is highly unlikely to lead to positive behaviors associated with hearing-conservation. Total scores on each factor were computed and transformed onto a scale ranging from ⫺ 50 to ⫹ 50 so that for all factors, a higher score

Knowledge Attitudes and Behaviors Questionnaire

213

Table 2. KAB attitude factors derived from PCA and reliability analyses. Construct

Item

Perceived susceptibility

Perceived severity

Perceived barriers

Perceived self-efficacy

Cues to action

% variance explained Cronbach alpha

⫺ 0.646 ⫺ 0.607

10.4 0.753

0.596 0.473 ⫺ 0.451 ⫺ 0.722 0.706 0.657 0.566 0.530 ⫺ 0.433 0.674 0.579

7.3 0.542 11.3 0.795

0.574 0.418 ⫺ 0.736 ⫺ 0.723 ⫺ 0.493

9.3 0.708

⫺ 0.745 ⫺ 0.501 ⫺ 0.705 ⫺ 0.796

9.3 0.722

0.702 0.736

8.2 0.727

* ⫽ Reverse scored item.

reflects an attitude that is more likely to result in positive behaviors around hearing conservation. Means and SD error bars for each factor are plotted in Figure 1. It is seen that scores on all factors were greater than 0, indicating attitudes likely to lead to positive behaviors associated with hearingconservation. This is especially the case for scores on the perceived

50 40 30 20 Score

Int J Audiol Downloaded from informahealthcare.com by Baylor University on 06/27/14 For personal use only.

Perceived benefits

*Hearing loss from noise isn’t such a big deal. *I’m used to loud noises, so I’m not worried that more time in noisy places will harm my hearing. The advantages of protecting my hearing are greater than the disadvantages. It would be easy to carry earplugs with me whenever I go somewhere noisy. *Protecting my hearing is not worth the cost. *People with hearing loss do just fine. Good hearing is needed for good communication. Having a hearing loss will limit my social activities. I see value in spending money to protect my hearing. Protecting my hearing is important to me. *Protecting my hearing is not worth the cost. If hearing protection was around when I needed it, I would use it. If I didn’t have hearing protection when I needed it I would try to move away or turn down the volume. Spending time learning about hearing loss and protecting my hearing would be valuable to me. The advantages of protecting my hearing are greater than the disadvantages. *Earplugs are uncomfortable. *Earplugs are difficult to put in my ears. *It’s too much trouble to remember to wear hearing protection. (alpha ⫽ 0.732 if item omitted) *I am often around sounds that are loud enough to damage my hearing. *It’s difficult for me to protect my hearing even when I know it’s too loud. *My lifestyle makes it difficult for me to protect my hearing. *It’s difficult for me to stay away from loud sounds (music, machine noise, etc.) even when I think it’s too loud. I know where to go to buy hearing protection. I am confident that I know how to use hearing protection properly.

Factor loading

10 0 –10 –20 –30 –40 –50 Susceptibility Self-efficacy Benefits Severity Barriers Cues to Action

Figure 1. Mean score and standard deviation on each attitude scale.

susceptibility and perceived benefits factors. However, note that no participant scored at ceiling on all six factors, and only 13 participants (5.5%) scored at ceiling on four or five factors. In other words, the attitudes of all participants can change for the positive.

BEHAVIORS Table 3 presents data regarding use of hearing protection during each activity. Column 2 shows the number and percentage of individuals who engaged in each of the ten activities at least occasionally. Between 60% and 95% of participants listened to music, used power tools, and/or worked in noise, thus awareness of NIHL and hearing conservation is relevant to almost all participants. For activities where use of hearing protection was appropriate (all except listening to music in the car or with an MP3 player), participants were asked whether or not they used hearing protection while engaging in the activity. These data are shown in columns 3, 4, and 5 of Table 3. They were also asked to select from a list of options their reasons for doing so or not doing so. These data are summarized in Tables 4 and 5. Table 3 reveals that hearing protection is used by the majority of individuals when target shooting and hunting, but not for other activities, with less than one third of people using hearing protection for most activities. The most common reason for using hearing protection was that it ‘helps protect hearing,’ although a requirement to do so, and help with concentration were also cited (Table 4). The most common reasons for not using hearing protection were

214

G. H. Saunders et al. Table 3. Percentage of individuals who participate in each activity by use of hearing protection. Use of hearing protection Activity

Int J Audiol Downloaded from informahealthcare.com by Baylor University on 06/27/14 For personal use only.

Listen to music in car Listen to music (MP3 player) Attend concerts Use power tools Work in noise Play musical instruments/sing Target shoot Ride motorbikes/ATVs Hunt Attend car/motorbike/truck races

Percentage and number of total sample engaging in activity

Yes

Sometimes

No

95.8% (n ⫽ 114) 85% (n ⫽ 101) 75.8% (n ⫽ 90) 69.2% (n ⫽ 82) 60.0% (n ⫽ 71) 35.8% (n ⫽ 43) 27.5% (n ⫽ 33) 26.7% (n ⫽ 32) 13.3% (n ⫽ 16) 10.0% (n ⫽ 12)

N/A N/A 13.2% 30.1% 25.0% 7.0% 84.9% 18.8% 75.0% 41.7%

N/A N/A 26.4% 41.0% 22.2% 16.3% 12.1% 12.5% 6.3% 25.0%

N/A N/A 60.4% 28.9% 52.8% 76.4% 3.0% 68.8% 18.8% 25.0%

N/A ⫽ Not applicable.

not thinking about it, and perceiving the activity as not being loud enough to warrant protection (Table 5). Many participants checked the option ‘other’ for why they did and did not use hearing protection. Unfortunately the questionnaire did not offer participants the opportunity to specify what those reasons were. Omitted from Table 5 are the options of cost and that hearing protection is ineffective, because no one gave cost as a reason for non-use of hearing protection, and only one participant said he/she thought hearing protection was ineffective.

using attitude factor as the within subject variable and intervention (yes vs. no) as the between subjects factor, showed a significant effect of intervention (F ⫽ 4.26, p ⫽ 0.041), such that the scores of participants who did not receive an intervention changed significantly less than the scores of those who did. Thus, not only did knowledge and attitude responses show stability when no intervention was provided, but also they show change following an intervention.

Relationships between age, gender, and KAB scores Part 2. Instrument evaluation Information about the stability of KAB responses was obtained from participants in Group 2. As noted above, these individuals completed the KAB at baseline and then again 7 to 36 days later (mean ⫽ 9.6 days, SD ⫽ 4.5 days). Those in the control group did not receive an intervention between baseline and follow-up, while those in the intervention group did. On the knowledge scale, the mean score of the control group remained almost unchanged between baseline and follow-up (mean change ⫽ 1.9%, SD ⫽ 12.2%), while the mean score of participants who received an intervention increased by 11.8% (SD ⫽ 16.1%). This difference in change is statistically significant (F ⫽ 11.62, p ⬍ 0.001). Similarly, as is illustrated in Figure 2, the attitude scores of the control participants changed less than the attitude scores of the participants who received an intervention on all but the perceived self-efficacy factor. A repeated measures ANOVA,

Pearson correlations were used to examine the relationships between age and scores on the knowledge, attitude and behavior scales. There were statistically significant positive correlations between age and scores on all but the knowledge scale, and cues to action factor ranging from r ⫽ 0.150 to r ⫽ 0.210. That is, the attitudes of older individuals were more likely to increase behaviors associated with hearing-conservation than the attitudes of younger individuals. However, the highest r-value was 0.210, thus at most age explained only 4% of the variance in scores. ANOVAs were used to examine whether the knowledge and attitude scores of participants differed as a function of gender. Relative to males, females had significantly lower perceived susceptibility, perceived benefits, perceived barriers and cues to action scores than males. The activities engaged in by males and females differed, with fewer women than men using power tools (χ2 ⫽ 17.3, p ⫽ 0.002) and working in a noisy environment (χ2 ⫽ 10.0, p ⫽ 0.041). Further, significantly fewer women than

Table 4. Reasons for use of hearing protection by behavior (% participants). Reasons for using hearing protection

Activity Attending concerts (n ⫽ 36) Using power tools (n ⫽ 59) Working in noise (n ⫽ 42) Playing musical instrument/singing in band (n ⫽ 10) Target shooting (n ⫽ 32) Riding motorbikes/ATVs (n ⫽ 10) Hunting (n ⫽ 13) Attending car/motorbike/truck races (n ⫽ 1)

It’s required

It helps protect my hearing

It helps me concentrate

Other

0.0% 23.7% 26.2% 0.0% 40.6% 0.0% 30.8% 0.0%

86.1% 94.9% 42.9% 100.0% 100.0% 90.0% 100.0% 0.0%

8.3% 35.6% 23.9% 0.0% 50.0% 30.0% 30.8% 0.05

30.6% 20.3% 7.1% 0.0% 18.8% 30.3% 7.7% 100.0%

Note: Participants selected all applicable reasons, thus totals can be greater than 100%.

Knowledge Attitudes and Behaviors Questionnaire

215

Table 5. Reasons for non-use of hearing protection by behavior (% participants). Activity Attending concerts (n ⫽ 79) Using power tools (n ⫽ 58) Working in noise (n ⫽ 54) Playing musical instrument/singing in band (n ⫽ 40) Target shooting (n ⫽ 5) Riding motorbikes/ATVs (n ⫽ 26) Hunting (n ⫽ 4) Attending car/motorbike/truck races (n ⫽ 7)

I don’t think about it

Not worth the time/effort

Don’t hear well enough with it

Not loud enough

Doesn’t seem worth it for a short time

Use stereo headphones instead

59.5% 69.0% 53.7% 32.5%

2.5% 12.1% 16.7% 2.5%

22.8% 5.2% 22.2% 40.0%

25.3% 46.6% 35.2% 57.5%

6.3% 36.2% 16.7% 5.0%

0.0% 10.3% 3.7% 5.0%

23.6% 8.3% 21.1% 18.2%

100.0% 65.4% 75.0% 71.4%

0.0% 0.0% 0.0% 0.0%

0.0% 11.5% 25.0% 14.3%

0.0% 46.2% 0.0% 28.6%

20.0% 19.2% 25.0% 14.3%

0.0% 15.4% 0.0% 14.3%

0.0% 31.8% 25.0% 25.0%

Other

men who worked in a noisy environment used hearing protection (χ2 ⫽ 6.0, p ⬍ 0.049). This is perhaps because high-noise work environments typically encountered by women are schools and daycare centers in which use of hearing protection would be problematic.

Relationships between knowledge, attitudes, and behaviors In order to assess the construct validity of the KAB, ANOVAs comparing attitude and knowledge scores for individuals who said ‘yes’, ‘no’ or ‘sometimes’ to using hearing protection were conducted for the three activities (use of power tools, attending concerts, and working in noise) for which there were at least ten participants in each of the ‘yes’, ‘no’ and ‘sometimes’ response categories. These data are presented in Table 6. Knowledge scores did not differ across use of hearing protection categories, although for all three activities, the scores of individuals who said ‘yes’ to use of hearing protection were highest, and the scores of those who said ‘no’ were lowest, with the scores of those who said ‘sometimes’ part way between. The same pattern of results was seen for the majority attitude scores on all three activities. Individuals who used hearing protection had attitudes more likely to increase behaviors associated with hearingconservation, and individuals who did not use hearing protection had attitudes least likely to increase behaviors associated with hearingconservation. The scores of individuals who sometimes used hearing

Change in score (range 0-100)

Int J Audiol Downloaded from informahealthcare.com by Baylor University on 06/27/14 For personal use only.

Note: Participants selected all applicable reasons, thus totals can be greater than 100%. ATV: All terrain vehicles.

20

No intervention Intervention

15 10 5 0 –5

Susceptibility Severity

Benefits

Self-efficacy Cues to Action Barriers

Figure 2. Change in attitude scores as a function of intervention use.

protection were generally in between the scores of users and nonusers but were more similar to the scores of users.

Discussion This paper describes the development and evaluation of a questionnaire—the KAB—which assesses knowledge, attitudes, and behaviors associated with hearing and hearing conservation within the constructs of the HBM. It has 16 items that assess knowledge, 22 items that assess attitudes, and 10 that assess behaviors. PCA and reliability analyses revealed six factors among the attitude items that were interpreted to be assessing: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived selfefficacy, and cues to action. To our knowledge, the only similar questionnaire available is that developed by Widén and colleagues (Widén & Erlandsson, 2007; Widén et al, 2011; Widén, 2013). That questionnaire was also developed based on theoretical principles, but it does not directly assess all HBM constructs. Without an intervention, knowledge scores ranged from 15.6% to 93.8% (mean ⫽ 57.6%, SD ⫽ 15.2), suggesting that the knowledge of the majority of participants can be improved. Indeed, knowledge scores increased in 67% of participants in Group 2 who received a hearing education intervention. Baseline knowledge did not differ as a function of use of hearing protection. That is, knowing about the dangers of NIHL and hearing protection was not directly associated with behaviors towards hearing protection. Others have reported similar findings (Crandell et al, 2004; Rawool & Colligon-Wayne, 2008; Gilles et al, 2012). Nonetheless, knowledge scores were correlated with perceived self-efficacy (r ⫽ 0.160, p ⫽ 0.014) and cues to action (r ⫽ 0.161, p ⫽ 0.014) scores, which were also associated with behaviors, such that users of hearing protection had higher perceived self-efficacy and cues to action scores than non-users (see Table 6). Further work is needed to determine whether this relationship is causal, and whether increasing knowledge can lead to attitude and behavior change. Scores on all but the perceived severity and perceived self-efficacy factors were significantly associated with use of hearing protection (Table 6), such that favorable attitudes as defined by the HBM were associated with use of hearing protection, while less favorable attitudes were associated with non-use of hearing protection. These statistically significant relationships provide validation that the HBM is a valuable framework for understanding hearing health behaviors, and show that the KAB has construct validity and is thus a valid tool for assessing these attitudes and behaviors. It is not obvious

216

G. H. Saunders et al. Table 6. Knowledge and attitude scores by hearing protection use, and results of between group comparisons. Mean scores with standard deviations in parentheses. Do you use hearing protection when using power tools? Sometimes (n ⫽ 34)

Yes (n ⫽ 25) Knowledge Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Perceived self-efficacy Cues to action

59.5 (15.1) 45.6 (6.7)* 34.3 (18.2) 45.3 (6.4)* 25.6 (25.8)* 14.3 (21.1) 29.5 (27.0)*

55.5 (13.4) 43.4 (8.2)** 27.7 (16.8) 41.6 (7.6) 22.5 (22.3)** 5.3 (23.4) 29.0 (19.1)**

No (n ⫽ 23)

F

p

50.3 (18.1) 38.0 (12.6)*,** 27.1 (19.5) 37.1 (13.8)* 5.4 (23.8)*,**

2.17 4.21 1.26 4.46 5.08 2.07 3.16

n.s. .018 n.s. .015 .008 n.s. .048

1.1 (24.8) 13.6 (31.1)*,**

Int J Audiol Downloaded from informahealthcare.com by Baylor University on 06/27/14 For personal use only.

Do you use hearing protection when attending concerts? Sometimes (n ⫽ 24)

Yes (n ⫽ 12) Knowledge Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Perceived self-efficacy Cues to action

60.4 (13.6) 44.6 (7.5) 30.5 (25.0) 47.3 (3.1)* 16.6 (28.6) 18.2 (14.5) 30.2 (23.5)

59.5 (10.0) 42.1 (10.7) 32.6 (12.0) 40.3 (11.3) 16.6 (27.6) 7.6 (21.6) 28.1 (23.7)

No (n ⫽ 53) 55.0 (14.6) 38.9 (12.0) 30.8 (16.6) 47.9 (10.9)* 11.9 (22.1) 9.3 (24.2) 16.8 (27.8)

F

p

1.43 1.61 0.11 4.04 0.39 0.97 2.29

n.s. n.s. n.s. .021 n.s. n.s. n.s.

Do you use hearing protection when using working in noise?

Knowledge Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Perceived self-efficacy Cues to action

Yes (n ⫽ 18)

Sometimes (n ⫽ 16)

No (n ⫽ 38)

F

p

56.6 (15.1) 47.2 (4.6)* 33.8 (15.5) 45.4 (6.2)* 28.7 (22.9)*

56.4 (11.9) 44.4 (6.3)** 24.4 (20.3) 44.8 (6.5)** 27.6 (20.6)**

55.5 (16.5) 37.4 (13.2)*,** 30.9 (17.3) 37.9 (12.5)*,** 11.4 (26.2)*,**

9.7 (18.7) 34.7 (18.0)*

9.0 (22.0) 33.6 (16.9)**

3.8 (26.6) 12.8 (28.4)*,**

0.05 6.39 1.25 4.52 4.30 0.50 7.14

n.s. .003 .n.s. .014 .017 n.s. .002

*Significant difference (p ⬍ 0.05) in score between participants who said ‘yes’ and ‘no’ to use of hearing protection. **Significant difference (p ⬍ 0.05) in score between participants who said ‘sometimes’ and ‘no’ to use of hearing protection.

why perceived severity and perceived self-efficacy scores were not associated with use of hearing protection, since some others have shown this relationship (Lusk et al, 1994, 1999; Widén & Erlandsson, 2007; Widén, 2013). Since scores in this study were in the expected direction, it might be a reflection of the relatively small data set available. Unfortunately, test-retest reliability was not formally examined in the present study. In the future it will be. However, the limited data available showed knowledge scores to be stable across administrations when no intervention took place. Attitude scores were less stable, nonetheless, the scores of individuals who did not receive an intervention changed significantly less than the scores of individuals who did receive an intervention. The reasons for this difference in stability of scores may be because questionnaire completion is unlikely to provide new knowledge, however it has been shown that simply asking people about their intentions and attitudes towards a behavior increases the probability of their subsequently engaging in that behavior (Levav & Fitzsimons, 2006; Jeffery et al, 2006). While ideally study outcomes would not be impacted by simply completing the study outcome measures, it is unclear how this can be avoided in social science research. On a positive note, in this study at least, if

attitudes and behaviors are changed simply by completing the questionnaires, the effects on the participants would likely be positive – that is they might begin to think more about protecting their hearing. The attitudes of the individuals who received a hearing education intervention became more likely to be associated with positive behaviors towards hearing-conservation on all but the perceived self-efficacy factor. On this factor, attitudes became less likely to be associated with positive behaviors towards hearing-conservation. This may be an initial reaction to having gained knowledge about the many sources of leisure noise that can damage hearing, thus individuals became less confident about their capacity to protect their hearing. It may be that with time, individuals’ self-efficacy scores will increase. Data from the participants in the clinical trial (Group 2) who will complete the KAB again six months following use of the intervention will provide further insight on this matter. Females in this study had significantly lower perceived susceptibility than males. This is in contrast to other data (Widén et al, 2011; Bohlin & Erlandsson, 2007). It may be because younger individuals such as those who participated in the studies of Widén et al (2011) and Bohlin & Erlandsson, (2007), and males, are more likely to engage in risky behaviors than older individuals and females (Turner

Knowledge Attitudes and Behaviors Questionnaire & McClure, 2003). This may also explain the finding that the attitudes of older individuals were more likely to increase behaviors associated with hearing-conservation than the attitudes of younger individuals. Another explanation may be associated with cultural differences between Swedish and US populations in noise-related attitudes and behaviors (Widén et al, 2006).

Int J Audiol Downloaded from informahealthcare.com by Baylor University on 06/27/14 For personal use only.

Limitations Data for this study were collected from two groups of participants. This is a limitation in as much as the versions of the KAB completed by each group differed slightly. However, it is an advantage in as much the combined sample had greater age variability than each sample alone and an equal number of male and female participants. In addition to not formally examining test-retest reliability, as discussed above, it is unfortunate that participants were not given the option to provide ‘other’ reasons for using and not using hearing protection (Tables 4 & 5). This will be addressed in future administrations of the KAB. Further, additional work must be done to confirm the underlying factor structure of the KAB and to add items to the perceived severity factor with a view to increasing the reliability of that scale. Despite these limitations, this study revealed significant relationships between use of hearing protection and scores on a newly developed questionnaire that assess knowledge, attitudes, and behaviors within the constructs of the HBM.

Summary The KAB has been shown to be a valid and reliable tool for assessing knowledge, attitudes, and behaviors toward hearing loss and hearing protection within the framework of the HBM. The KAB not only provides an increased understanding of the attitudes underlying hearing conservation behaviors, it can also be used to evaluate the effectiveness of hearing conservation programs by identifying attitudes that have or have not been impacted by a program. Further, a standardized outcome measure such as the KAB can help direct the content of future hearing conservation education programs and be used to compare intervention effectiveness. A copy of the KAB can be obtained from the first author.

Acknowledgements This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Rehabilitation Research and Development Service Grant # #C7214R. Aspects of these data were presented at the National Hearing Conservation Association (NHCA), Mesa, USA, February 24 – 26, 2011, at the Academy of Rehabilitative Audiology Institute, San Francisco, USA, September 12 – 14, 2010. Declaration of interest: The authors report no conflicts of interest and are alone are responsible for the content and writing of the paper.

References Ajzen I. 1991. The theory of planned behavior. Organ Behav Hum Decis Process, 50, 179–211. Bandura A. 1986. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, USA: Prentice-Hall.

217

Beach E.F., Williams W. & Gilliver M. 2012. A qualitative study of earplug use as a health behavior: The role of noise injury symptoms, selfefficacy, and an affinity for music. J Health Psychol, 7, 237–246. Bogach I.I., House R.A. & Kudla I. 2005. Perceptions about hearing protection and noise-induced hearing loss of attendees of rock concerts. Can J Public Health, 96, 69–72. Bohlin M.C. & Erlandsson S.I. 2007. Risk behaviour and noise exposure among adolescents. Noise Health, 9 (36), 55–63. Bohlin M.C., Sorbring E., Widén S.E. & Erlandsson S.I. 2011. Risks and music: Patterns among young women and men in Sweden. Noise Health, 13, 310–319. Chung J.H., Des Roches C.M., Meunier J., Eavey R.D. 2005. Evaluation of noise-induced hearing loss in young people using a web-based survey technique. Pediatrics, 115, 861–867. Costello A.B. & Osborne J.W. 2005. Best practices in exploratory factor analysis: Four recommendations for getting the most from your analysis. Practical Assessment, Research & Evaluation, 10, 7. Available online at http://pareonline.net/pdf/v10n7.pdf Crandell C., Mills T.L. & Gauthier R. 2004. Knowledge, behaviors, and attitudes about hearing loss and hearing protection among racial/ethnically diverse young adults. J Natl Med Assoc, 96, 176–86. Crum R., Anthony J., Bassett S. & Folstein M. 1993. Population-based norms for the mini-mental state examination by age and educational level. J Am Med Assoc, 18, 2386–2391. Elder J.P., Ayala G.X. & Harris S. 1999. Theories and intervention approaches to health-behavior change in primary care. Am J Prev Med, 17, 275–284. Feldman A.S. & Grimes C.T. 1985. Hearing Conservation in Industry Baltimore: Williams & Wilkins. Ferrari J.R. & Chan LM. 1991. Interventions to reduce high-volume portable headsets: “Turn down the sound”! J Appl Behav Anal, 24, 695–704. Folstein M., Robins L. & Helzer J. 1983. The mini-mental state examination. Arch Gen Psychiatry, 40, 812. George D. & Mallery P. 2003. SPSS for Windows Step by step: A Simple Guide and Reference. 11.0 update (4th ed.). Boston: Allyn & Bacon. Gilles A., De Ridder D., Van Hal G., Wouters K., Kleine Punte A. et al. 2012. Prevalence of leisure noise-induced tinnitus and the attitude toward noise in university students. Otol Neurotol, 33, 899–906. Jeffery A., Jinks C. & Jordan K. 2006. The influence of completing a health-related questionnaire on primary care consultation behaviour. BMC Health Serv Res, 6, 101. Kreuter M.W. & Strecher V.J. 1996. Do tailored behavior change messages enhance the effectiveness of health risk appraisal? Results from a randomized trial. Health Educ Res, 11, 97–105. Landälv D., Malmström L. & Widén S.E. 2013. Adolescents, reported hearing symptoms and attitudes toward loud music. Noise Health, 66(15), 347–354. Levav J. & Fitzsimons G.J. 2006. When questions change behavior: The role of ease of representation. Psychol Sci, 17, 207–213. Lusk S.L., Ronis D.L., Kerr M.J. & Atwood J.R. 1994. Test of the health promotion model as a causal model of construction workers’ use of hearing protection. Nurs Res, 43, 151–157. Lusk S.L., Kerr M.J., Ronis D.L. & Eakin B.L. 1999. Applying the health promotion model to development of a worksite intervention. Am J Health Promot, 13, 219–227. McGinnis J.M. & Foege W.H. 1993. Actual causes of death in the United States. JAMA, 270, 2207–2212. Newson J.T., Huguet N., Ramage-Morin P.L., McCarthy M.J., Bernier J. et al. 2012. Health behaviour changes after diagnosis of chronic illness among Canadians aged 50 or older. Health Rep, 23, 49–53. Peterson R.A. 2000. A meta-analysis of variance accounted for and factor loadings in exploratory factor analysis. Marketing Letters, 11, 261–275. Prochaska J. & Velicer W. 1997. The transtheoretical model of health behavior change. Am J Health Promot, 12, 38–48. Ramma L. 2011. Vuvuzela media coverage during the 2010 FIFA soccer world cup tournament: Impact on raising awareness of noise-induced hearing loss. Noise Health, 13, 415–422.

Int J Audiol Downloaded from informahealthcare.com by Baylor University on 06/27/14 For personal use only.

218

G. H. Saunders et al.

Rattray J. & Jones M.C. 2007. Essential elements of questionnaire design and development. J Clin Nurs, 16 (2), 234–243. Rawool V.W. & Colligon-Wayne L.A. 2008. Auditory lifestyles and beliefs related to hearing loss among college students in the USA. Noise Health, 10, 1–10. Redding C.A., Rossi J.S., Rossi S.R., Velicer W.F. & Prochaska J.O. 2000. Health behavior models. Int Electron J Health Educ, 3 (special issue), 180–193. Rintelmann W.F. & Borus J.F. 1968. Noise-induced hearing loss and rock and roll music. Arch Otolaryngol, 88, 377–385. Robinson R., Carriere K.C., Young T.K., Roos L.L. & Gelskey D.E. 2000. Health-care seeking behavior following a health survey: Impact on prevalence estimates of chronic diseases. J Clin Epidemiol, 53, 681–687. Rollnick S.R., Heather N. & Bell A. 1992. Negotiating behaviour change in medical settings: The development of brief motivational interviewing. J Ment Health, 1, 25–37. Rosenstock I. 1966. Why people use health services. Milbank Mem Fund Q, 44 (Suppl. 3), 94–127. Saunders G.H., Frederick M.T., Silverman S. & Papesh M. 2013. Application of the health belief model: Development of the hearing beliefs questionnaire (HBQ) and its associations with hearing health behaviors. Int J Audiol, 52(8), 558–567. Schrank F.A., McGrew K.S. & Woodcock R.W. 2001. Technical Abstract (Woodcock-Johnson III Assessment Service Bulletin No. 2). Itasca, USA: Riverside Publishing. Shah S., Gopal B., Reis J. & Novak M. 2009. Hear today, gone tomorrow: An assessment of portable entertainment player use and hearing acuity in a community sample. J Am Board Fam Med, 22, 17–23.

Sobel J. & Meikle M. 2008. Applying health behavior theory to hearingconservation interventions. Sem Hear, 29, 81–89. Turner C. & McClure R. 2003. Age and gender differences in risktaking behaviour as an explanation for high incidence of motor vehicle crashes as a driver in young males. Inj Control Saf Promot, 10 (3), 123–130. Vogel I., Brug J., van der Ploeg C.P. & Raat H. 2007. Young people’s exposure to loud music: A summary of the literature. Am J Prev Med, 33, 124–133. Watson R. 1998. Publishing the results of factor analysis: Interpretation and presentation. J Adv Nurs, 28(6), 1361–1363. Widén S.E. & Erlandsson S.I. 2004a. The influence of socio-economic status on adolescent attitude to social noise and hearing protection. Noise Health, 7, 59–70. Widén S.E. & Erlandsson S.I. 2004b. Self-reported tinnitus and noise sensitivity among adolescents in Sweden. Noise Health, 7, 29–40. Widén S.E. & Erlandsson S.I. 2007. Risk perception in musical settings: A qualitative study. Int J Qualitative Studies Health Well-being, 2, 33–44. Widén S., Bohlin M. & Johansson I. 2011. Gender perspectives in psychometrics related to leisure time noise exposure and use of hearing protection. Noise Health, 13 (55), 407–414. Widén S.E. 2013. A suggested model for decision-making regarding hearing conservation: Towards a systems theory approach. Int J Audiol, 52, 57–64. Wuest J. & Getty G. 1992. Adolescent hearing behavior: A school health promotion program. J Sch Health, 62, 436–438.