Abstract
Objective: The goal of this study was to explore the awareness, knowledge and habits of UKM students towards recreational noise-induced hearing loss (RNIHL).
Methods: A cross-sectional study was performed through online survey and a Malay version of Knowledge, Awareness, and Behaviors (KAB) questionnaire was given to the health science and non-health science undergraduate UKM students. Two-way ANOVA was conducted to compare knowledge and awareness between health science and non-health science students while the spearman coefficient was conducted to correlate knowledge and awareness with their habits.
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Results: A total of 96 questionnaires were completed. UKM students demonstrated having positive awareness and low knowledge towards recreational noise-induced hearing loss. Health sciences and non-health sciences students reported no significant difference on their awareness and knowledge towards recreational noise-induced hearing loss. There was no correlation between knowledge, awareness and the use of hearing protective device.
Conclusion: In general, our study showed UKM students have low level of knowledge but positive awareness towards recreational noise-induced hearing loss. However, that did not promote the use of hearing protection.
Introduction
According WHO (2015), 1.1 billion young people aged between 12–35 years are at risk of hearing loss due to exposure to noise in recreational settings. Exposure to excessive noise is one major cause of hearing disorders. It can affect people of all ages, including children, teenagers, and young adults. Noise not necessarily come from workplaces, it also can be resulted from recreational activities which one intentionally exposed themselves to (Roberts et al., 2018). Some of the common source of recreational noise among young adults includes personal audio devices, nightclubs, bars, live music concerts and sporting events.
Noise-induced hearing loss (NIHL), defined as a permanent decrement in hearing threshold levels (HTLs) with the characteristics of reduction in hearing sensitivity at the frequencies of 3, 4 and, 6 kHz and with relatively better hearing sensitivity in surrounding frequencies (2 or 8 kHz) (Roberts et al., 2018). NIHL can happen when the sound is too loud, even for a very brief single exposure, or when they are both loud and long-lasting which can potentially damage the sensory hair cells and surrounding supporting cells of the inner ear, and ultimately degeneration of associated auditory nerve fibers (NIDCD, 2017). This condition can be temporary or permanent and it can affect one ear or both ears (NIDCD, 2017). Prolonged exposure to the noise levels regularly above 70 decibels (dBA) can cause hearing loss over time, leading to a permanent threshold shift (permanent hearing loss) (ASHA, 2017).
In recent years, there has been an increase among the younger generation of loud noise exposure which can lead to noise-induced hearing problems (Le Clercq et al., 2016). Entertainment venues contributed to the risk of NIHL, with a three-fold increase in those exposed to loud sounds in social settings over the past twenty years (Sliwinska-Kowalska and Davis, 2012). Beach et al. (2014) has reported that young adults between the age of 18-35 years were being involved in high-noise activities including playing an instrument, attending a nightclub or a pop concert which were measured to have noise levels >100 dB. A study of recreational noise exposure from outdoor football stadiums has also found out that 96% of the workers and fans sampled were overexposed to noise level which exceeded the American Conference of Governmental Industrial Hygienists (ACGIH) criteria (≥85 dBA, 3 dB exchange rate), with mean maximum personal noise exposure level of 116-120 dB (Engard et al., 2010).
Almost 50% of all portable music device users are listening to music in an unsafe manner (WHO, 2015). According to Scenihr (2008), 5-10% of listeners are likely to develop hearing loss in the future due to their personal preferences of volume levels and duration of listening. Vogel at al. (2011) conducted a study on adolescents risky MP3-player listening and its psychosocial correlates and indicated that among participants, 90% reported listening to music through earphones on MP3 players; 28.6% were categorized as listeners at risk for hearing loss due to estimated exposure of 89 dBA for >1 hour per day. The study had concluded that habit strength is the strongest correlate of risky listening behaviour. Besides, hearing thresholds in the 3 to 8 kHz frequency range were found significantly increased in personal listening device listeners (Peng, Tao, & Huang, 2007). These studies showed that recreational noise can place individuals at equal risk of noise-induced hearing loss caused by occupational noise, given equivalent loudness and time exposure. However, the potential risk from recreational noise exposure does not bring about the same degree of concern by the public as compared to occupational noise exposure. For instance, a regulation was established by the Malaysia Factories and Machinery Act 1967 to protect workers from excessive or prolonged exposure to occupational noise in order to reduce the risk of NIHL (FMA, 2015). But, there is hardly any safety standards or regulations concerning recreational noise exposure despite evidence of hazardous effect from non-occupational noise exposure among young people.
A study conducted by Balanay et al. (2015) included 2,151 college students and the findings revealed students with negative attitudes (noise is perceived as harmful) comprised the highest percentage, followed by neutral attitude (unaware of the possible consequences of loud noise) and positive attitude (noise is not perceived as dangerous). The study had also associated perceived hearing symptoms with attitude towards noise and hearing protection habits whereby those with more severe hearing symptoms generally have a more negative attitude towards noise and reported the use of hearing protection more than those with no hearing symptoms. However, a more recent study was conducted to explore attitudes and behaviours towards leisure noise and use of hearing protection among young adults and it was concluded that there was a lack of knowledge and concern over the impact of noise exposure and hearing problems (Hunter, 2018). This may be due to the lack of awareness and knowledge on the mechanism of normal hearing and hearing loss among young people (Lass et al, 1990). Thus, this study could be used to increase awareness about recreational noise-induced hearing loss among university students and may provide a greater understanding of university students’ knowledge and habits towards recreational noise exposure, particularly in Malaysia.
Understanding the awareness and habits towards recreational noise-induced hearing loss among university students can be served as an evidence to enhance the promotion of hearing conservation programs specifically for this population. The aim was to explore the awareness, knowledge and habits of undergraduates from The National University of Malaysia (UKM) towards recreational noise-induced hearing loss. The specific objectives of this study were to (1) measure the awareness and knowledge of UKM students towards recreational noise induced-hearing loss, (2) compare the awareness and knowledge between UKM health sciences and non-health sciences students towards recreational noise-induced hearing loss, (3) and identify the correlation between UKM students' awareness and knowledge of recreational noise-induced hearing loss and their habits towards the recreational noise.
Methodology
The participants in this study were first year to fifth year health sciences and non-health sciences undergraduates students at The National University of Malaysia (UKM). A total of 96 students were involved in this study, 48 of them were health sciences students and 48 of them were non-health sciences students. A self-administered online questionnaire was designed to explore the awareness, knowledge and habits of students from UKM towards recreational noise-induced hearing loss.
The Knowledge, Awareness, and Behaviors (KAB) questionnaire is a valid and reliable tool for assessing knowledge, attitudes, and behaviors towards noise-induced hearing loss and hearing protection (Saunders, Dann, Griest, & Frederick, 2014). In this study, the Malay version KAB questionnaire is used to evaluate the aforementioned domains. Cronbach’s alpha for the entire scale was α=0.79.
The questionnaire utilized in this study comprised of four sections. The questionnaires have 70 questions and will take approximately 15 minutes to complete. Section 1 is to obtain information about the demographic profile of respondents. The demographic questions focused on respondent’s hearing status and understanding of recreational noise-induced hearing loss.
Section 2 consists of 16 items and assesses knowledge about noise-induced hearing loss (NIHL) and hearing conservation. Respondents would rate their agreement with the statement on the scale (a) Saya TAHU ini adalah BENAR, (b) Saya RASA ini adalah BENAR, (c) Saya TIDAK PASTI, (d) Saya RASA ini adalah SALAH, (e) Saya TAHU ini adalah SALAH. 11 items were reversely worded and required reverse scoring.
Section 3 consists of 22 items to investigate participants’ attitude towards hearing, hearing loss and recreational noise-induced hearing loss. A 5-point Likert scale with response options from ‘Sangat Tidak Setuju’ to ‘Sangat Setuju’ is used. 11 items were reversely worded and required reverse scoring.
Section 4 is designed to measure the degree to which the individual participates in noisy activities and in addition whether hearing protection is used or not. It consists of two parts, the first part is on how often are respondents involved in the recreational activities whereas second part assesses on their frequency of using hearing protection device on those activities. The respondents were given a list of 11 recreational activities which might have the risk of noise exposure. Examples of recreational activities including attend concerts, ride motorbikes and play musical instruments.
Results
Demographic Data
There were 50% (n=48) health sciences students and 50% (n=48) non-health sciences students participated in this study. 77% (n=74) of them were females and 23% (m=22) were males. 92% (n=88) of the students have no hearing loss and 8% (n=8) reported of hearing loss. 88% (n=84) of them reported they have no family member with hearing loss not due to aging. A total number of 49% (n=47) students reported no changes in hearing due to sound exposure in different places. However, 24% (n=23) students reported their hearing change due to sound exposure after attending concert.
Awareness
The distribution of total awareness scores among UKM students was examined. Majority of respondents (92.70%) were having positive awareness. Respondents showed more awareness towards the following four questions, with at least 90.6% of respondents agree and very agree with it:
- Q4- Melindungi pendengaran saya adalah penting bagi saya. [S =35.4%, SS=57.3%]
- Q5- Mengalami masalah pendengaran akan menghadkan aktiviti sosial saya. [S =33.3%, SS =57.3%)
- Q8- Kebaikan melindungi pendengaran adalah lebih banyak berbanding keburukan. [S =35.4%, SS =57.3%]
- Q20- Pendengaran yang baik diperlukan untuk komunikasi yang baik. [S=32.3%, SS =57.3%]
55.2% of the respondents were neutral towards Question 14, that was “Sukar untuk memakai alat pelindung telinga ke dalam telinga saya.” and 50.0% of them were neutral towards Question 12, “Alat pelindung telinga adalah tidak selesa dipakai.”
Each question was scored by awarding 2 points for sangat setuju, 1 point for setuju, 0 point for tidak pasti, -1 point for tidak setuju, and -2 points for sangat tidak setuju. Reverse scoring was carried for Question 1,2, 6, 10-14, and 16-18. Total scores of each respondent’s awareness were computed followed by the mean of overall scores obtained by all the respondents. Positive score means positive awareness while negative score means negative awareness. The mean obtained was 14.30 (SD=9.04) indicating that UKM students have positive awareness towards recreational noise-induced hearing loss.
Knowledge
Data from the sixteen knowledge questions was summed and analyzed. Respondents were most knowledgeable about the following three questions, with ≥ 62.5% of respondents answering correctly:
- Q4- Bunyi dari mesin basuh baju boleh merosakkan pendengaran manusia. (Salah) (n=60, 62.5%)
- Q7- Bunyi yang terlalu kuat boleh menyebabkan kerosakan pada koklea. (Benar) (n=66, 68.8%)
- Q10- Bunyi bising di sekitar anda adalah sangat kuat sekiranya anda tidak dapat mendengar percakapan seseorang yang berada pada jarak 1 meter (panjang lengan) dari anda. (Benar) (n=67, 69.8%)
- Respondents were least knowledgeable about the following three questions, with ≥ 74.0% of the respondents answering each incorrectly:
- Q2- Pendengaran manusia boleh rosak jika mendengar bunyi sekuat 70 desibel. (Salah) (n=83, 86.5%)
- Q8- Seseorang yang telah kehilangan pendengaran akibat terdedah kepada bunyi yang kuat boleh mendengar seperti biasa sekiranya mereka memakai alat bantu dengar. (Salah) (n=73, 76.0%)
- Q9- Seseorang yang telah kehilangan pendengaran akibat terdedah kepada bunyi yang kuat boleh mendengar seperti biasa jika mereka meningkatkan 'volume' suara alat bantu dengar. (Salah) (n=71, 74.0%)
An overall knowledge score was generated by awarding 1-point for a correct response (either “Saya TAHU ini adalah BENAR/ SALAH” or “Saya RASA ini adalah BENAR/ SALAH” ), and 0-points for an incorrect response (either “Saya TAHU ini adalah BENAR/ SALAH” or “Saya RASA ini adalah BENAR/ SALAH” or “Saya TIDAK PASTI” ). Points were summed for all 16 questions and the percentage correct based on total score was computed. The average score obtained by each respondent was 43.8% which is equivalent to 7 marks (SD= 18.8 which is equivalent to 3 marks) with scores ranging from 6.3% which is equivalent to 1 mark to 81.3% which is equivalent to 13 marks. By using a cut off point of 75% to be considered as satisfactory knowledge level (Sawmill, Towards, Loss, & Kota, 2008), results showed that UKM students with the mean score of 43.8% has low knowledge towards recreational noise induced hearing loss.
Habit
Table 1 presents data regarding the percentage of individuals who participate in each of the activity. Data showed that 100% (n=96) of students participated in listening to music using headphone or earphone either “kerap”, “kadang-kadang” or “jarang-jarang”. For the participation of “kerap” and “kadang-kadang”, the highest percentage was shown by listening to music (88.5%), followed by listening to high volume of radio (42.7%) and then going to karaoke (32.2%). One of the item (listening to music using earphone or headphone) was selected to know how many hours in a week that the respondents involved in that activity. The data collected is in numerical form. The mean obtained was 9.38 hours per week (SD=11.01) indicating low period of time spent by UKM students in listening to music either using earphone or headphone in a week.
Meanwhile, table 2 showed the percentage and number of hearing protection use for each activity. In this part, the scoring for each item ranged from 1 to 3 (1=Tidak pernah, 2=Jarang-jarang, 3=Kerap). As we can see, the highest percentage of hearing protection usage was shown by shooting activity (10.5%). However, it was still considered remarkably low. Most of the students ranging from 88% to 100% never use any hearing protection when they were participating in the activities.
Table 1. Percentage and number of individuals who participate in each activity.
Aktiviti
Peratusan dan bilangan individu melakukan aktiviti berkaitan
Tidak pernah
Jarang-jarang
Kadang-kadang
Kerap
Bermain mercun
12.5% (n=12)
78.1% (n=75)
9.4% (n=9)
0% (n=0)
Menembak (senapang/paintball)
78.1% (n=75)
19.8% (n=19)
1.0% (n=1)
1.0% (n=1)
Menunggang motosikal
36.5% (n=35)
39.6% (n=38)
14.6% (n=14)
9.4% (n=9)
Menyaksikan perlumbaan kereta atau motosikal
75.0% (n=72)
21.9% (n=21)
1.0% (n=1)
2.1% (n=2)
Pergi ke konsert rock
61.5% (n=59)
30.2% (n=29)
5.2% (n=5)
3.1% (n=3)
Pergi berkaraoke
17.7% (n=17)
50.0% (n=48)
26.0% (n=25)
6.3% (n=6)
Mendengar muzik (headphone/earphone)
0% (n=0)
11.5% (n=11)
25.0% (n=24)
63.5% (n=61)
Mendengar radio dengan kuat
16.7% (n=16)
40.6% (n=39)
28.1% (n=27)
14.6% (n=14)
Bermain alat muzik/sertai band/koir
35.4% (n=34)
39.6% (n=38)
14.6% (n=14)
10.4% (n=10)
Mesin permainan arked
45.8% (n=44)
40.6% (n=39)
12.5% (n=12)
1.0% (n=1)
Duduk/kerja di tempat bising
18.8% (n=18)
55.2% (n=53)
20.8% (n=20)
5.2% (n=5)
Table 2. Percentage and number of use of hearing protection in each activity.
Aktiviti
Peratusan dan bilangan penggunaan alat pelindung pendengaran semasa melakukan aktiviti berkaitan
Tidak pernah
Kadang-kadang
Sentiasa
Bermain mercun
100% (n=96)
0% (n=0)
0% (n=0)
Menembak (senapang/paintball)
89.6% (n=86)
6.3% (n=6)
4.2% (n=4)
Menunggang motosikal
96.9% (n=93)
3.1% (n=3)
0% (n=0)
Menyaksikan perlumbaan kereta atau motosikal
97.9% (n=94)
2.1% (n=2)
0% (n=0)
Pergi ke konsert rock
96.9% (n=93)
1.0% (n=1)
2.1% (n=2)
Pergi berkaraoke
97.9% (n=94)
2.1% (n=2)
0% (n=0)
Mendengar muzik (headphone/earphone)
N/A
N/A
N/A
Mendengar radio dengan kuat
97.9% (n=94)
2.1% (n=2)
0% (n=0)
Bermain alat muzik/sertai band/koir
99.0% (n=95)
1.0% (n=1)
0% (n=0)
Mesin permainan arked
100% (n=96)
0% (n=0)
1.0% (n=1)
Duduk/kerja di tempat bising
88.5% (n=85)
10.4% (n=10)
1.0% (n=1)
N/A = Not applicable
Comparison of the Awareness and Knowledge between UKM Health Sciences and Non-health Sciences Students
In term of knowledge, more than fifty percent of both health science (72.9%) and non-health science students (64.6%) knew that loud noise can cause damage to the cochlea. Higher number of non-health science students (60.4%) have knowledge on hearing an extremely loud sound just once can cause someone to lose some hearing than health science students (45.8%). Further, non-health science students (14.6%) had poorer knowledge in terms of the function of hearing aid than the health science students (33.3%) of which they think hearing aid can help to restore hearing.
Regarding awareness on recreational noise-induced hearing loss, from a total of 22 items, health science students had a greater awareness (mean=34.5) than non-health science students (mean=27.9). In particular, in fifteen of the 22 items, health science students had higher scores. Health science students (51) scored higher than non-health science students (29) for item “Meluangkan masa untuk mempelajari masalah pendengaran serta cara melindungi / menjaga pendengaran adalah penting bagi saya.”.
In all, two-way ANOVA demonstrated no significant interaction between health science and non-health science students on their awareness and knowledge towards recreational noise-induced hearing loss (p> .025).
Table 3. Comparison of the Awareness and Knowledge between UKM Health Sciences and Non-health Sciences Students
Dependent Variable
F
p
Knowledge
.998
.320
Awareness
2.810
.097
Correlation between UKM Students’ Awareness and Knowledge of Recreational NIHL and Their Habits
Spearman correlations were used to examine the relationships between scores on the knowledge, awareness, and use of hearing protection device. There was no significant relationship between knowledge score and the use of hearing protection device among UKM students (p > .05). Besides, there was also no significant relationship between awareness score and the use of hearing protection device (p > .05).
Table 4. Correlation between knowledge, awareness and the use of hearing protection device among UKM students.
Knowledge
Awareness
p
r
p
r
Use of Hearing Protection Device
.286
0.110
.723
-0.037
Discussion
Nowadays, we can easily get health-related information from government agencies, national advocacy organizations, and health care systems on the Internet (Medlock et al., 2015). In our study, we found out that most of the respondents are aware that protecting their hearing is important and there are more pros than cons in protecting their hearing. This might due to the increment of hearing conservation programs which had promoted hearing health (Chermak, 1996). Most of them are also aware that hearing is important in communication and social activities as they noticed that difficulty to hear clearly will lead to physical and emotional exhaustion and can cause communication problem which leads to social isolation, feeling of loneliness, stigmatization, depression and increase dependency on others (Shield 2006). Around half of the respondents were in the neutral view towards the difficulties in wearing hearing protection devices and the uncomfortableness in using it. This could be due to they are not sure on how to use hearing protection devices.
According to Crandell, Mills, & Gauthier (2004), there remains a paucity of empirical evidence on the knowledge of noise exposure and hearing protection devices (HPDs) for young adults, particularly those of diverse racial/ethnic backgrounds. Consequently, our study was interested in identifying the knowledge level towards recreational noise-induced hearing loss among students who are studying at UKM in Malaysia. In whole, results indicated that UKM students have low knowledge level on recreational noise-induced hearing loss with a mean score of 43.8%. The findings provides evidence that there should be concern about educating UKM students in particular about the severity and risk of exposure to excessive noise. According to Erlandsson (2006), providing information and knowledge regarding recreational noise exposure can be important factors in inducing behavioral change. Therefore, there is a need to improve the knowledge of UKM students perhaps that it will translate into higher usage of HPDs and effective hearing protection.
Based on our findings, health science and non-health science students reported no significant difference on their awareness and knowledge towards recreational noise-induced hearing loss. This finding is in contrast to some other studies which found higher health awareness and knowledge of health versus non-health science students (Tirodimos et al., 2009; Peltzer et al., 2016). One possible explanation for the relatively equal awareness and knowledge level among health science and non-health science students may be related to the usage of internet among youth in obtaining health information (Victoria Rideout, 2001). It seems plausible that rapid diffusion of internet technology within the public sphere has placed an unprecedented amount of health information within reach of general consumers.
From our findings, there was no correlation between the knowledge, awareness, and the use of hearing protection device among UKM students. Our result revealed an inconsistent finding from previous studies from, where the attitude towards noise was an important influence on hearing protection use (Widén et al., 2006; Balanay & Kearney, 2015). Our study revealed many of the students agree with the statement “earplugs are uncomfortable”. Thus, the possible reasons for not wearing the hearing protective devices may include discomfort or the danger of not using hearing protection device is not apparent (Maisarah & Said, 1993). However, there are another study showed that, although the participants knew that the hearing protective device can protect the hearing, most of them never wear it before due to the limited knowledge and they thought earplugs would distort the sound (Alzahrani, Alzahrani, & Alghamdi, 2018). This is similar to our result where UKM students have low knowledge and low usage of hearing protection devices despite having positive awareness of recreational noise-induced hearing loss.
Limitation
We have identified and acknowledged a few limitations in this study. First, data were collected through a self-administered, anonymous online survey and thus rely on self-reporting which may be subjected to recall bias. Another limitation is the length of the survey. The online survey consists of 70 items which may result in the possibility of respondents providing random responses towards the end of the survey. A further limitation is that factors that may contribute to the low usage of hearing protective devices were not addressed in the survey. This is important to understand the reluctance on usage of hearing protection devices among young adults and thus provides useful information on planning hearing conservation campaigns.
Conclusion
In general, our study showed low level of knowledge but positive awareness towards recreational noise-induced hearing loss among UKM students. However, the positive awareness did not promote hearing protection as shown by the low percentage of participants using hearing protection devices. This indicates that increased awareness does not necessarily increase use of hearing protection devices (Keppler et al., 2015) and thus the purpose of encouraging hearing protective behaviour among the public through education and hearing conservation programs remains challenging. In order to bring about any significant change in hearing behaviour towards recreational noise in young adults, it is crucial for hearing conservation programs to not only provide information on noise exposure, hearing loss and hearing protection devices, but also focus self-experience symptoms such as tinnitus after recreational noise exposure as well as societal norms and regulations (Keppler et al., 2015; Hunter, 2018).
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