Sekhar DL, Clark SJ, Davis MM, Singer DC, Paul IM. Parental Perspectives on Adolescent Hearing Loss Risk and Prevention. JAMA Otolaryngol Head Neck Surg. 2014;140(1):22-28. doi:10.1001/jamaoto.2013.5760
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Data indicate that 1 in 6 adolescents has high-frequency hearing loss, which is typically noise related and preventable. Parental participation improves the success of adolescent behavioral interventions, yet little is known about parental perspectives regarding adolescent noise-induced hearing loss.
To perform a survey to determine parental knowledge of adolescent hearing loss and willingness to promote hearing conservation to discern information that is critical to design adolescent hearing loss prevention programs.
Design, Setting, and Participants
A cross-sectional, Internet-based survey of a nationally representative online sample of parents of 13- to 17-year-olds.
A survey conducted with the C.S. Mott Children’s Hospital National Poll on Children’s Health, a recurring online survey.
Main Outcomes and Measures
Parental knowledge of adolescent hearing loss and willingness to promote hearing conservation.
Of 716 eligible respondents, 96.3% of parents reported that their adolescent was slightly or not at all at risk of hearing problems from excessive noise, and 69.0% had not spoken with their adolescent about noise exposure, mainly because of the perceived low risk. Nonetheless, to protect their adolescents’ hearing, more than 65.0% of parents are either willing or very willing to consider limiting time listening to music, limiting access to excessively noisy situations, or insisting on the use of hearing protection (earplugs or earmuffs). Higher parental education increased the odds of promoting hearing-protective strategies. Parents were less likely to insist on hearing protection for older adolescents. Parents who understood that both volume and time of exposure affect hearing damage were more likely to have discussed hearing loss with their adolescent (odds ratio [OR], 1.98; 95% CI, 1.29-3.03). The odds of discussing hearing loss were also increased for those who were willing or very willing to limit time listening to music (OR, 1.88; 95% CI, 1.19-2.26) and to insist on hearing protection (OR, 1.92; 95% CI, 1.15-3.18) compared with parents who were very unwilling, unwilling, or neutral.
Conclusions and Relevance
Despite the rising prevalence of acquired adolescent hearing loss, few parents believe their adolescent is at risk. Those with higher education are more willing to promote hearing conservation, especially with younger adolescents. To create effective hearing conservation programs, parents need better education on this subject as well as effective and acceptable strategies to prevent adolescent noise exposure.
The prevalence of adolescent hearing loss, 19.5%, is even higher than the 18.4% prevalence of obesity among 12- to 19-year-olds, and obesity is considered a national epidemic.1,2 Most adolescents demonstrate high-frequency hearing loss (HFHL), which is often related to noise exposure.1 Large-scale surveys of adolescents indicate that they often exceed the current occupational safety standard for noise exposure, with common exposures being personal listening devices and concerts.3 Hearing loss related to noise is irreversible but highly preventable, particularly if noise exposures are minimized or hearing loss is identified early.4,5
Based on studies of occupational noise exposure, noise-induced hearing loss (NIHL) can have significant negative effects on the quality of life.6 As individuals continue to expose themselves to sound-hazardous environments, hearing loss will progress, with long-term negative consequences on speech, communication, and quality of life.5 Early detection of even mild HFHL has the potential to prevent long-term morbidity for adolescents.4,5
To our knowledge, no studies have examined parental concern and knowledge of hazardous noise exposures and hearing loss for adolescents. However, numerous studies have examined parents’ positive impact in reducing adolescent risk-taking behaviors.7,8 For example, parental involvement has been shown to decrease substance abuse and risky sexual behavior in teenagers.7,8 Specific to hearing and noise exposure, a study of hearing loss from use of personal listening devices among adolescents rated parents as an important party to prevention efforts but raised concerns regarding lack of parental knowledge about hazardous noise exposures.9 The goals of the present study were to evaluate current parental knowledge and concerns regarding adolescent hearing loss and to assess parental willingness to make changes to preserve adolescent hearing. These are key elements in designing prevention programs for adolescent hearing loss.
In September 2011, we conducted a cross-sectional, Internet-based survey of a nationally representative sample of the US population regarding adolescent hearing loss. This survey was conducted as part of the C.S. Mott Children’s Hospital National Poll on Children’s Health (NPCH), a recurring online survey of parents and nonparents. Funding for the NPCH is provided by the University of Michigan Health System and the Department of Pediatrics and Communicable Diseases. The study was approved by the University of Michigan Medical School and the Penn State College of Medicine Institutional Review Boards.
The NPCH is conducted using the GfK Custom Research, LLC (GfK) Group’s web-enabled KnowledgePanel, a probability-based panel designed to be representative of the US population. Potential participants are chosen scientifically by a random selection of telephone numbers and residential addresses and then invited by telephone or by mail to participate in the web-enabled KnowledgePanel. If individuals agree to participate but do not already have Internet access, GfK provides them a laptop and ISP connection at no cost. Those with an existing personal Internet connection will have their bill paid by GfK. Panelists then receive unique log-in information for accessing surveys online and then are sent e-mails throughout each month inviting them to participate in research. Completion of the survey once enrolled in KnowledgePanel constituted panelists’ consent to participate in this study.
The NPCH was pilot tested by GfK in August 2011 with a separate convenience sample of 126 KnowledgePanel members. A unique KnowledgePanel sample was drawn for the NPCH that contained the survey items for this study. The introductory e-mail invited participation in a survey about child health. No additional incentive participation was offered beyond the usual KnowledgePanel participation points. The participation points are analogous to a “frequent flyer” program. Respondents are credited with points in proportion to their participation in the surveys. Panelists receive cash-equivalent checks every 4 to 6 months depending on their level of panel participation, which commonly results in distributions in the range of $4 to $6 per month. KnowledgePanel has found that the incentives successfully increase the survey completion rates in general. To ensure adequate representation, parents (defined as having children aged ≤17 years living in the household) and racial/ethnic minorities were oversampled.
KnowledgePanel provided deidentified data, along with census-based poststratification weights used to match the US population distribution on sex, age, race/ethnicity, education, census region, and urbanicity.
Frequency distributions were calculated on all weighted items. Descriptive statistics were calculated for all participants. Bivariate analysis was done of weighted items using χ2 and Cochran-Mantel-Haenszel tests to determine the relationships between survey responses and demographic variables. Logistic regression was used to analyze the odds of parents engaging in hearing-protective strategies and discussing hearing loss with their adolescent.
Of the 1626 parents surveyed, 725 (44.6%) had adolescents aged 13 to 17 years. Nine respondents were excluded as their teenager had been diagnosed with hearing loss by a medical professional, leaving 716 respondents eligible for inclusion. Demographics of the 716 parent respondents are detailed in Table 1. Respondents had equal numbers of male and female teenagers.
Table 2 details the survey questions and responses. More than two-thirds of parents had not discussed hearing loss related to noise with their adolescent, mostly because they believed their teenager was not at risk for hearing loss. For the few parents who did discuss hearing loss, their primary impetus was thinking that their teenager played music too loudly. More than half of parents understood that both high-volume sounds and time exposed may be equally damaging to hearing. However, when presented a list of potential hearing-hazardous activities, only headphone use with a personal listening device was considered a high-risk hearing activity by most parents (Table 3). More than 65.0% of parents were willing or very willing to take steps to protect their adolescent’s hearing. Less than half knew about volume-limiting headphones, and most thought that their teenager would be unlikely to use these devices. Many parents believed that adolescent hearing screening was best conducted at a physician’s visit.
Parental demographic factors as well as teenagers’ age and sex were subsequently examined in relation to parents’ willingness to engage in various hearing-protective strategies. There were no differences in parental survey responses based on the sex of the teenager, parent age, ethnicity, or Internet access. Parents who had completed college or had a bachelor’s degree had increased odds of being willing or very willing to insist on use of hearing protection (earplugs or earmuffs), limit access to excessively noisy situations, or purchase volume-limiting headphones and believe that their teenager would wear such headphones. Higher-income parents were more likely to insist on the use of hearing protection and purchase volume-limiting devices. Parents had decreased odds of engaging in hearing-protective strategies for older teenagers (15-17 years) (Table 4). Mothers had almost twice the odds (odds ratio, 1.89; 95% CI, 1.27-2.79; P = .002) of correctly answering that both volume and time exposed to noise may damage hearing.
Knowledge of hearing loss and willingness to engage in hearing-protective strategies was subsequently examined in relation to recently talking to a teenager regarding hearing loss (Table 5). Parents who understood that both volume and time exposed to noise may damage hearing had almost twice the odds of having discussed hearing loss with their adolescent. Odds of discussing hearing loss were also almost doubled for parents who were willing or very willing to limit time listening to music and to insist on hearing protection. The odds of discussing hearing loss were 3 times higher for parents who were very likely or likely to purchase volume-limiting headphones.
Although recent national data show that 1 in 6 adolescents has HFHL,1 the results of this study demonstrate that most parents do not think their teenager is at risk for hearing loss caused by noise exposure. Furthermore, parents do not recognize common potential causes of teenage hearing loss. Although most parents report that their teenager is at low risk for hearing loss, those with higher education, higher income, and younger teenagers were more willing to take measures to limit noise exposure for their children. Most parents support national requirements for adolescent hearing screening. This information is key to informing hearing loss prevention programs for adolescents.
Different individuals experiencing the same hazardous noise exposure may have different degrees of hearing loss or none at all. Some of this variation depends on an individual’s genetic susceptibility to hearing-related damage.10,11 With continued exposure to sound-hazardous environments, HFHL will progress, having negative consequences for speech, communication, and educational success.5 Research has demonstrated that hearing loss as a result of occupational NIHL has a significant negative effect on quality of life.6 Audiologic damage caused by excessive sound exposure is irreversible, although it is the most preventable type of hearing loss and can be prevented by avoiding sound-hazardous environments.4,5 Avoidance of such environments is more important in individuals who have been identified as having early indications of HFHL. This simple strategy can allow adolescents to achieve their full academic potential as well as a better quality of life.
When given a list of common adolescent noise exposures with the potential to cause hearing loss, most parents did not consider these activities to be high risk. Many of the listed activities could be a routine part of a teenager’s day. The musicians are known to experience NIHL, although fewer studies have been done among high school musicians.10 Certainly, many of the hearing-hazardous activities in which adolescents partake are also important components of their education, growth, and development. The goal is not to eliminate these activities but to approach them with some knowledge of the potential hearing risks and take the appropriate steps for hearing conservation. For example, the Centers for Disease Control and Prevention lists common adolescent school noise exposures with estimated decibel levels and times of maximum recommended exposure durations without hearing protection.12 However, it seems that this information is not widely used by parents and high schools, considering the lack of parental knowledge on this topic.
Although most parents reported that their teenager was at low risk of hearing loss, these same parents were very much in support of measures to prevent hearing loss. Theories of behavior change, such as the health belief model, indicate that individuals are unlikely to modify behavior in response to a perceived low-risk threat.13 It is doubtful that parents would strictly enforce rules on limiting time listening to music, wearing hearing protection, and avoiding sources of hazardous noise if they believe that their teenagers are at low risk of hearing loss. The survey results suggest that targeting less well-educated parents of younger teenagers may be a good starting point for an intervention. This is an important consideration in planning adolescent hearing conservation programs. Parents are known to be key elements in the success of adolescent behavioral interventions for other risk-taking behaviors.7,8 Vogel et al9 rate parents as an important party to teenage hearing conservation but raised concern about the lack of parental knowledge on this topic. For adolescent hearing loss prevention programs to be successful, parents must first understand that their teenager is at risk for hearing loss and have a basic understanding of what risks are involved.
Many parents also supported national requirements for hearing screening of teenagers. There is no national standard for adolescent hearing screening, with some individuals receiving screening in the school setting and others being tested at individual physician visits. Others may not be tested during the teenage years at all.14 A national standard for adolescent hearing screening may raise community awareness of adolescent hearing loss. Increasing awareness and changing social norms is another possible way to increase the success of health behavior interventions.13
Our study did not find a difference in survey responses based on sex. Although boys have historically had higher rates of noise-related hearing loss reported than girls, more recent data suggest that the gap in hearing loss prevalence between the sexes may be diminishing.1,15 The fact that parents do not discriminate in risk of hearing loss based on the sex of their child lends support to this finding. It is logical that parents who believed that their children were at higher risk of hearing loss were more likely to have discussed the topic. Furthermore, those with a better understanding of the mechanisms of hearing loss were logically more likely to discuss the topic, and those who had spoken to their teenager about hearing loss were more willing to purchase volume-limiting devices.
Our survey was limited by its multiple-choice format. Although we attempted to account for additional responses in our pilot testing, there may be other reasons parents did or did not discuss hearing loss with their teenager. The list of potential activities causing adolescent hearing loss might have been missing relevant exposures. Furthermore, in questioning the best approach for hearing testing of teenagers, it is a possibility that, if given the opportunity, parents would have had suggestions other than those included in the survey. Finally, a parental history of hearing loss was not directly asked about and may have affected the survey responses. This study was conducted using a nationally representative web-enabled panel. The makeup of the panel is affected by the willingness to participate in survey research when initially contacted. However, when given the opportunity to participate in individual surveys, participants are not informed of the content. Because parents were not invited to participate in our survey based on interest in adolescent hearing loss, the results should not have been biased in this way. The NPCH has been conducted on a variety of subjects and has been important in informing numerous topics in the medical literature.16,17
In conclusion, few parents believe that their teenager is at risk of hearing loss and most parents have a poor understanding of hazardous noise exposures for adolescents. Parental support of adolescent behavioral interventions can be an important piece of their success. In designing adolescent hearing conservation programs, the results suggest that a focus on parents with lower educational attainment and younger teenagers may be most helpful. Preventing progression of NIHL among adolescents has significant implications for future quality of life. Improved education on hearing loss must be combined with effective and acceptable strategies for hearing loss prevention.
Submitted for Publication: June 4, 2013; final revision received July 19, 2013; accepted September 27, 2013.
Corresponding Author: Deepa L. Sekhar, MD, MSc, Department of Pediatrics, Penn State College of Medicine, 500 University Dr, Mail Code HS83, Hershey, PA 17033 (email@example.com).
Published Online: November 21, 2013. doi:10.1001/jamaoto.2013.5760.
Author Contributions: Dr Sekhar had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Sekhar, Clark, Singer, Paul.
Acquisition of data: Clark, Davis, Singer.
Analysis and interpretation of data: Sekhar, Clark, Paul.
Drafting of the manuscript: Sekhar, Singer.
Critical revision of the manuscript for important intellectual content: Sekhar, Clark, Davis, Paul.
Statistical analysis: Clark.
Obtaining funding: Sekhar.
Administrative, technical, and material support: Clark, Davis, Singer, Paul.
Study supervision: Clark, Paul.
Conflict of Interest Disclosures: None reported.
Funding/Support: This project was supported by a grant from the Children’s Miracle Network.
Role of the Sponsors: The funding agency had no role in design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
Additional Contributions: Amy Butchart, MPH, and Achamyeleh Gebremariam, MS, provided statistical support and analysis; both received salary support for their work analyzing data from the NPCH.