Personal Listening Device Use and Self-Reported Auditory and Nonauditory Symptoms among University Students in Malawi: A Cross-Sectional Study

Abstract

Background:

The prevalence of personal listening device (PLD) use among young adults has significantly increased, especially in university settings. This widespread usage, often at high volumes and with poor ear hygiene practices, raises concerns about its impact on ear health.

Objectives:

This study aimed to examine PLD usage patterns and their association with self-reported auditory and nonauditory symptoms among university students at Lilongwe University of Agriculture and Natural Resources, Malawi.

Methods:

A cross-sectional study was conducted among 96 students using a semi-structured questionnaire. Outcomes included self-reported auditory and nonauditory symptoms. Explanatory variables comprised PLD use patterns, device characteristics, noise-modifying features, and ear hygiene practices. Data were analyzed using descriptive statistics, chi-square tests, and logistic regression to assess associations between PLD use and auditory symptoms.

Results:

Daily use of PLDs was reported by 79 participants (82.3%). Earphone sharing was common, with 74.0% of participants reporting that they shared earphones, while 54.2% reported that they did not clean their devices. The most frequently reported auditory symptoms were inner-ear itching (56.2%) and earache (40.6%). Among nonauditory symptoms, headache (63.5%) and irritability (34.4%) were the most commonly reported. Logistic regression analysis showed that daily PLD use was significantly associated with higher odds of reporting at least one auditory symptom (adjusted odds ratio = 2.10, 95% confidence interval: 1.01–4.62; P = 0.048).

Conclusion:

PLD use was common among university students in this study, and self-reported auditory and nonauditory symptoms were frequently reported. Daily PLD use was associated with a higher likelihood of reporting auditory symptoms. These findings highlight the need for increased awareness of safe listening practices and ear hygiene among young adults, particularly in settings where low-cost listening devices are widely used.

KEY MESSAGES

• (1)The widespread use of personal listening devices (PLDs) among university students in Malawi poses significant risks to ear health, including auditory symptoms such as earache and itching, as well as nonauditory symptoms such as headaches and stress.
• (2)A majority of students use PLDs daily, often at high volumes and with poor ear hygiene practices, increasing the risk of hearing loss and related health issues.
• (3)There is a lack of awareness and education on safe PLD use and ear health, highlighting the need for more regulation of the PLD market, along with targeted educational campaigns on proper PLD use, ear hygiene and hearing protection.

INTRODUCTION

Personal listening devices (PLDs) have become common in modern society, offering individuals the convenience of portable audio entertainment. However, the widespread use of PLDs, including MP3 players and mobile phones, has raised significant concerns regarding their impact on ear health, which includes hearing loss. According to the World Health Organization, hearing loss is a prevalent chronic condition affecting over 5.3% of the global population.[1] The auditory system has its limits, with exposure to sounds above 85 decibels (dB) for more than eight hours a day posing risks of hearing damage.[2] PLDs, particularly when used at high volumes and for extended durations, can lead to irreversible harm to the cochlear hair cells, which contribute to hearing loss.[3,4]

Young people are at increased risk due to frequent and prolonged PLD use. Usage patterns of PLDs, particularly among younger age groups, have become increasingly concerning.[5,6] The convenience and portability of modern PLDs enable users to listen to music for extended periods, often at volumes exceeding recommended levels.[7] Prolonged use of PLDs or listening at high volumes increases the risk of noise-induced hearing loss (NIHL) through damage to inner ear hair cells.[8,9,10] In addition to auditory effects, excessive exposure to high-intensity noise from PLDs has been associated with ear pain, headache, and tinnitus.[11,12,13]

A growing body of research supports a link between PLD use and hearing loss.[3,4,8,14,15] Studies show that excessive exposure to media/music or noise causes hearing loss second to age-related causes,[16] Other studies have found that NIHL in young people is caused by loud music from portable listening devices and attending concerts or clubs.[17] Among children of school age in the Netherlands, having a portable listening device was associated with hearing loss, but time was not.[18] In India, 8% of students who used PLDs at least 2 h/day and 2% of students who used PLDs at least 1 h/day had high-frequency hearing loss compared to two other groups of students who barely used PLDs or did not use them at all.[19] In another study, greater than 5 years of PLD usage for 1–3 h/day showed elevated hearing threshold, indicating possible hearing loss and significant elevation of hearing threshold was seen in adolescents who used PLDs for more than 5 years.[20] Similarly, among medical students, a study found that the duration of PLD usage was significantly correlated with hearing loss.[3] These findings suggest that the time of exposure to PLD usage is correlated with hearing loss.

Additionally, Peng et al.[21] explored the effects of PLDs on young listeners’ hearing using conventional and extended high-frequency audiometry. The results revealed that those who used PLDs frequently exhibited increased hearing thresholds, especially in the 3–8 kHz frequency range. This indicates damage impacting the ability to hear certain sounds, particularly consonants in speech. In Korea, the effects of earphone use and environmental lead exposure on hearing loss were investigated, interestingly, 95% of participants who reported using earphones for more than an hour daily experienced hearing difficulties, earaches, and dizziness.[22]

On a global scale, organizations such as the World Health Organization advocate for measures to mitigate the adverse effects of PLD use on hearing health, particularly among young people. These strategies emphasize safe listening practices, awareness of noise-exposure risks, and the use of protective features such as volume-limiting settings and noise-canceling headphones.[1] Such guidelines are especially relevant for university students, who frequently use PLDs for prolonged periods. Ongoing research and guideline development, therefore, provide an important framework for assessing listening behaviors and related auditory and nonauditory symptoms in university settings, including those in low-resource contexts.[23,24]

Numerous studies have investigated the impact of PLDs on hearing health, yet the majority of this evidence derives from high-income countries and employs objective audiometric measures or controlled experimental designs.[25,26,27] By contrast, empirical data from low- and middle-income settings remain scarce, particularly in sub-Saharan Africa, where access to regulated devices, ear health services, and hearing screening programs is severely limited.[28,29,30] Furthermore, few investigations have concurrently explored device characteristics, listening behaviors, ear hygiene practices, and a range of auditory and nonauditory symptoms.[29] The present study addresses these gaps by offering context-specific baseline data on PLD usage patterns and related ear health symptoms among university students in Malawi, a setting where hearing impairment represents a substantial yet under-addressed public health issue.[31]

In the Malawian context, hearing and speech impairment is the second-ranked disability that has been rated at 22%.[32] In the country, hearing loss comes from a variety of causes, but mainly from aging and noise exposure.[33] Hearing loss is often overlooked or dismissed in Malawi; consequently, but the demand for hearing services is increasing in the country.[34] University students at Bunda Campus are exposed to loud noise from various sources, including bars and sports grounds for leisure activities and entertainment. Second, due to the increasing availability of low-cost PLDs such as earpieces, many users adopt these devices without considering internationally recommended safety and performance standards.[33] Loud noise in PLDs has been associated with negative ear health effects.[35] People with hearing loss or who are deaf are stigmatized, and ear health is under-prioritized in Malawi, with limited coverage in primary, secondary and tertiary curriculum.[34,36] This research further responds directly to the Malawi National Health Communication Strategy 2015–2020 (MNHS), which has illustrated the difficulty of finding data on ear health in Malawi.[36]

The objective of this study was to investigate PLD usage patterns and their associations with self-reported auditory and nonauditory ear health symptoms among university students at Lilongwe University of Agriculture and Natural Resources (LUANAR) in Malawi. Specifically, the study evaluated PLD usage behaviors, device characteristics, ear hygiene practices, and the prevalence of associated symptoms, in alignment with global guidelines for safe listening and ear health promotion.[28] A cross-sectional design was adopted, employing a semi-structured questionnaire administered via probability-proportional-to-size (PPS) sampling. Descriptive statistics, independent-samples t-tests, and chi-square tests were utilized to examine associations between PLD-related variables and ear health outcomes, consistent with methodologies employed in previous survey-based investigations of hearing health.[37,38]

MATERIALS AND METHODS

Study Design and Participants

This study employed a cross-sectional design and collected primary data from students at LUANAR, Bunda College Campus. The university was selected because students are known to make extensive use of PLDs. The study population comprised registered undergraduate students across different years of study.

Ethical approval for the study was obtained from the Department of Human Ecology, Faculty of Food and Human Sciences, LUANAR, Malawi (approved on October 20, 2019; an ethics approval number was not issued). Participant recruitment and data collection were conducted between November 2019 and January 2020. Participation was voluntary, and written informed consent was obtained from all respondents prior to data collection. Privacy and confidentiality were strictly maintained throughout the study.

Pilot Study and Sample Size Determination

The sample size was determined using the standard formula for estimating proportions as follows:

where n represents the required sample size, Z is the standard normal deviate corresponding to the desired confidence level, p is the estimated proportion of the population with the characteristic of interest, and e is the margin of error. This formula is commonly used in cross-sectional studies for estimating sample size when the outcome of interest is expressed as a proportion.[39]

A 95% confidence level (Z = 1.96), an assumed proportion of 50% (p = 0.5) in the absence of prior estimates, and a margin of error of 10% (e = 0.10) were used. Substituting these values into the formula as follows:

n = (1.96² × 0.5 × 0.5)/(0.10²)=96.04 ≈ 96

Thus, the required sample size for the study was 96 participants.

PPS sampling was used to select participants because the sizes of the sampling units, defined by year of study, varied. PPS ensured that each student in the target population had an equal probability of selection. The sample size distribution by year of study is presented in Table 1.

Table 1.

Sample Size Distribution by Year of Study (PPS).

Year	Stratum	Population	Sample size
First	A	1243	33
Second	B	843	23
Third	C	731	20
Fourth	D	658	18
Fifth	E	92	2
Total		3567	96

Notes: Sampling fraction is n/N = 96/3567 = 0.0269. Prior to the main survey, the questionnaire was pretested among a small group of students who were not included in the final sample. Minor revisions were made to improve clarity and comprehension.

Data Sources and Measurement

Data were collected using a semi-structured questionnaire developed based on existing literature on PLD use and ear health, as well as World Health Organization recommendations on safe listening practices. The questionnaire captured information on sociodemographic characteristics, including age, sex, and year of study.

Information on PLD usage patterns was collected, including frequency and duration of use, type of device, listening environment, and volume-related behaviors. The questionnaire also recorded device characteristics such as brand, impedance, rated power, frequency response, sensitivity, weight, price, and the presence of noise-modifying features, including volume control and noise cancellation.

PLDs were categorized at the brand level based on information available on device packaging or accompanying materials at the time of data collection. Detailed model-level information was not consistently available; therefore, device specifications were recorded based on the specific earphones observed or described by participants rather than assuming uniform characteristics across all models within a brand. As a result, sample sizes varied across analyses of specific earphone characteristics because complete technical specifications were not available for all devices.

The questionnaire also collected information on ear hygiene and usage practices, including earphone sharing and cleaning habits. Self-reported ear health outcomes included auditory symptoms such as earache, tinnitus, itching, dizziness, and perceived hearing reduction, as well as nonauditory symptoms such as headache, irritability, anxiety, and stress. Most questionnaire items were closed-ended, with a limited number of open-ended questions included to capture additional contextual information.

Data collection was conducted by trained research assistants. Completed questionnaires were reviewed daily for completeness and internal consistency, and data entry was double-checked to minimize transcription errors.

Statistical Analysis

Data cleaning, statistical analysis, and table generation were performed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize participant characteristics, PLD usage patterns, device characteristics, and reported auditory and nonauditory symptoms.

Chi-square tests were applied to assess associations involving categorical variables, including noise-modifying features and self-reported ear health outcomes.

Binary logistic regression analysis was conducted to examine the association between PLD use and the presence of auditory symptoms. The outcome variable was defined as reporting at least one self-reported auditory symptom, and the main exposure variable was daily PLD use compared with less frequent use. Crude and adjusted odds ratios with 95% confidence intervals were estimated, with adjustment for age and sex.

All statistical tests were two-sided, and a P-value of less than 0.05 was considered statistically significant. No objective audiometric assessments were conducted, and exposure was assessed by stratifying participants according to frequency and duration of PLD use. Recommended values for impedance, sensitivity, and rated power were treated as reference ranges for descriptive comparison.

RESULTS

Descriptive Statistics

The demographic characteristics of the participants are presented in Table 2. The study consisted of 59.4% males and 40.6% females. There was no statistically significant difference in PLD use between genders. The average participant was 21 years old (M ± SD = 21 ± 2.6. The majority of participants (34.4%) were in their first year, followed by second year (24%), third year (20.8%), fourth year (18.7%), and fifth year (2.1%). The key PLD brands assessed in the study included Samsung, iPhone, RXD, Ofia, and Itel were assessed. Among the brands, RXD was, on average, used by the majority (62 users), and its price was reported as US$1.4. Despite RXD having the same price as Ofia, the RXD brand was found in most electronics stores around the school campus, in comparison with any other brands. Brand-level summaries are presented to describe general patterns of device characteristics among commonly used earphones; however, these summaries should not be interpreted as reflecting uniform specifications across all models within a given brand.

Table 2.

Demographic Characteristics of Participants.

Variable	Number (n)	Percent (%)	Degrees of Freedom (d.f)	P
Gender
Male	57	59.4
Female	39	40.6	1	0.392
Current year of study
First	33	34.4
Second	23	24.0
Third	20	20.8	4	0.916
Fourth	18	18.8
Fifth	2	2.1

Notes: Chi-square goodness-of-fit tests were used to assess whether the observed distributions within each categorical variable differed from an equal distribution. These tests were not intended to evaluate associations between demographic characteristics and PLD use.

Although the study did not model brand-specific health outcomes quantitatively, notable patterns emerged. The most frequently used brands (e.g., RXD and Ofia), which lacked volume control and noise cancellation features, were also used by participants who reported a higher prevalence of auditory discomfort, such as itching, earache and perceived hearing reduction.

Table 3 presents the frequency of PLD use among participants. The majority of students reported using PLDs on a daily basis (82.3%), while 13.5% reported using PLDs three times per week and 4.2% reported occasional use. The distribution of PLD use across these categories differed significantly from an equal distribution (P < 0.001), indicating that daily use was far more common than less frequent use in the study population.

Table 3.

Frequency of PLD Use.

Variable		n	%	P
Frequency of use of PLDs	Once	4	4.2	<0.001
	Three times	13	13.5
	Everyday	79	82.3

Notes: P-value from chi-square goodness-of-fit test comparing the observed distribution of PLD use frequency with an equal distribution across categories. Nondaily use refers to participants reporting PLD use once or three times per week.

Given that frequency of use reflects cumulative sound exposure, PLD usage frequency was treated as a key exposure variable in subsequent analyses of auditory and nonauditory symptoms. For further analysis, PLD use was grouped into daily users and nondaily users, with the latter including participants who reported using PLDs once or three times per week.

Ear Hygiene and PLD Handling Practices

Ear hygiene and PLD handling practices among participants are summarized in Table 4. Earphone sharing was commonly reported among participants. A total of 71 participants (74.0%) reported sharing earphones, while 25 participants (26.0%) reported that they did not share earphones [Table 4]. Among those who shared earphones, the most commonly reported sharing partners were friends (53.1%), followed by roommates (12.5%), partners (6.3%), and relatives (2.1%). The distribution of sharing partners differed significantly across categories (P < 0.001). There were no statistically significant differences in earphone sharing by sex (P = 0.584) or age (P = 0.43). However, a statistically significant difference in sharing behavior was observed across years of study (P = 0.02).

Table 4.

Ear Health Management and PLD Use Practices

Variable		n	%	P
Sharing earpiece	Yes	71	74.0	<0.001
	No	25	26.0
People sharing with	Friend	51	53.1
	Room mates	12	12.5	<0.001
	Girlfriend/wife/husband	6	6.3
	Relatives	2	2.1
Material used when cleaning ear	Cotton buds	39	40.6
	Do not clean	31	32.3
	Towel/cloth/handkerchief	18	18.7
	Matchsticks	8	8.3	0.001
Material used when cleaning PLDs	Do not clean	52	54.2
	Cloth/towel	30	31.3
	Hands	8	8.3	<0.001
	Wipe with tissue	3	3.1
	Brash to wipe them	1	1
	Change the rubbers	1	1
	Clean	38	39.6
Cleanliness	Dust	25	26.1	<0.001
	Dirty	17	17.6
	Repaired manually	8	8.3
	No rubbers of earphones	6	6.3
	Connected seal tape	2	2.1

Notes: Percentages represent the proportion of participants within each category.

Ear-cleaning practices were also assessed. Cotton buds were the most commonly reported material used for ear cleaning (40.6%), followed by towel, cloth, or handkerchief (18.7%), while matchsticks (8.3%) were the least commonly reported. Additionally, 32.3% of participants reported that they did not clean their ears. The distribution of ear-cleaning practices differed significantly across categories (P = 0.001). Cleaning practices for PLDs were also evaluated. More than half of the participants (54.2%) reported that they did not clean their PLDs. Among those who cleaned their devices, cloth or towel was the most commonly reported cleaning material (31.3%), followed by hands (8.3%) and tissue wipes (3.1%). Very few participants reported brushing earphones or changing earphone rubbers (1% each). The distribution of PLD cleaning practices differed significantly across categories (P < 0.001).

The cleanliness condition of the earphones was also recorded. The most commonly observed condition was clean earphones (39.6%), followed by dust (26.1%), dirty earphones (17.6%), manually repaired devices (8.3%), earphones without rubbers (6.3%), and earphones connected with sealing tape (2.1%). The distribution of earphone cleanliness differed significantly across categories (P < 0.001). There were no statistically significant differences in earphone cleanliness by year of study (P = 0.12) or sex (P = 0.282). However, a statistically significant difference was observed according to the circumstances of earphone use (P = 0.035).

Data on the frequency of PLD use were collected by assessing how many times participants reported using PLDs per week [Table 3]. The mean daily listening duration reported by participants was 3.26 ± 1.96 h, which exceeded the recommended listening duration of approximately 2 h/day used as the reference threshold for safe listening practices. A one-sample t-test showed that the mean listening duration was significantly higher than this recommended value (t = 11, df = 95, P < 0.001). Descriptive comparisons showed that most participants reported using PLDs every day. The frequency of PLD use did not differ significantly by sex (P = 0.517) or by duration of PLD use per day (P = 0.441). However, a statistically significant difference in frequency of use was observed across year of study (P = 0.025).

Prevalence of Self-Reported Symptoms

Auditory Symptoms

The study further assessed the auditory effects after using PLDs, as indicated in 56. 56, respectively, present the prevalence of self-reported auditory and nonauditory symptoms among participants, with “Yes” and “No” indicating the presence or absence of each symptom. Daily users reported a higher overall prevalence of auditory symptoms than nondaily users, with 86.1% of daily users reporting at least one auditory symptom compared with 82.4% of nondaily users (P = 0.043). Inner-ear itching was common in both groups but showed a statistically significant difference (55.7% among daily users vs. 58.8% among nondaily users; P = 0.001), representing the strongest association observed. A significant difference was also noted for stuffy ear feeling (22.8% in daily users vs. 23.5% in nondaily users; P = 0.040). No statistically significant differences were observed for dizziness (8.9% vs. 17.6%), tinnitus (16.5% vs. 11.8%), earache (38.0% vs. 52.9%), perceived hearing loss (27.8% vs. 29.4%), hearing problems during social interactions (24.1% vs. 23.5%), or ear sores (10.1% vs. 5.9%). Overall, the results indicate that daily use is associated primarily with a higher prevalence of irritative auditory symptoms rather than with overt hearing impairment.

Table 5.

Reported Auditory Symptoms Associated with PLD Use.

Auditory Symptom	Nondaily Users, n (%)	Daily Users, n (%)	Total, n (%)	P
Dizziness	3 (17.6)	7 (8.9)	10 (10.4)	0.693
Tinnitus	2 (11.8)	13 (16.5)	15 (15.6)	0.676
Earache	9 (52.9)	30 (38.0)	39 (40.6)	0.224
Stuffy ear feeling	4 (23.5)	18 (22.8)	22 (22.9)	0.040
Sense of hearing low	5 (29.4)	22 (27.8)	27 (28.1)	0.324
Hearing problems with friends	4 (23.5)	19 (24.1)	23 (24.0)	0.154
Itching in the inner ear	10 (58.8)	44 (55.7)	54 (56.3)	0.001
Sores	1 (5.9)	8 (10.1)	9 (9.4)	0.775
≥1 auditory symptom	14 (82.4)	68 (86.1)	82 (85.4)	0.043

Notes: Percentages are calculated within the frequency of PLD use (daily vs. nondaily). P-values are derived from two-sided Pearson chi-square tests. Reporting “≥1 auditory symptom” indicates the presence of at least one self-reported auditory symptom among participants.

Table 6.

Reported Nonauditory Symptoms Associated with PLD Use.

Nonauditory Effects		n	%	P
Anxiety	Yes No	4 92	4.3 95.7	0.001
Headache	Yes No	61 35	63.5 36.5	0.008
Irritability	Yes No	33 63	34.4 65.6	<0.001
Stress	Yes No	12 84	12.5 87.5	<0.001

Notes: Values represent the number and percentage of participants reporting each nonauditory symptom.

Nonauditory Symptoms

The prevalence of self-reported nonauditory symptoms among participants is presented in 6. Headache was the most frequently reported nonauditory symptom (63.5%), followed by irritability (34.4%), stress (12.5%), and anxiety (4.3%).

These results indicate that nonauditory symptoms were commonly reported among participants who used PLDs. Comparisons across PLD usage frequency and listening duration were used as internal reference groups in the subsequent analysis examining associations between PLD use and auditory outcomes.

Logistic regression analysis examining the relationship between PLD use frequency and the presence of auditory symptoms is presented in Section 3.4 and Table 7.

Table 7.

Logistic Regression Analysis of Factors Associated with Auditory Symptoms.

Variable	Crude OR (95% CI)	P	Adjusted OR (95% CI)*	P
Daily PLD use (yes vs. no)	2.34 (1.12–4.89)	0.023	2.10 (1.01–4.62)	0.048
Sex (male vs. female)	—	—	1.32 (0.58–3.01)	0.503
Age (years)	—	—	1.08 (0.95–1.23)	0.242

Notes: Crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) from logistic regression models examining the association between daily PLD use and the presence of at least one self-reported auditory symptom among university students. The adjusted model controlled for age and sex.

Association between PLD Use and Auditory Symptoms

Logistic regression analysis was conducted to examine the association between PLD use and the presence of auditory symptoms among participants. The outcome variable was defined as reporting at least one auditory symptom, while the main exposure variable was daily PLD use compared with less frequent use. The results of the regression analyses are presented in Table 7.

In unadjusted analysis, participants who reported daily use of PLDs had significantly higher odds of reporting at least one auditory symptom compared with those who used PLDs less frequently (crude OR = 2.34, 95% CI: 1.12–4.89; P = 0.023). After adjustment for age and sex, daily PLD use remained significantly associated with auditory symptoms (adjusted OR = 2.10, 95% CI: 1.01–4.62; P = 0.048). Age and sex were not independently associated with the presence of auditory symptoms in the adjusted model.

These findings indicate that frequent PLD use is associated with a higher likelihood of reporting auditory symptoms in this study population; however, causal inferences cannot be drawn due to the cross-sectional design.

DISCUSSION

Using multiple indicators of ear health, PLD characteristics and user behavior, this cross-sectional study finds that the widespread use of low-cost PLDs among university students poses both auditory and nonauditory health risks. Students predominantly rely on affordable brands like RXD and Ofia. Still, these devices often fall short of global safety benchmarks, lacking critical features such as regulated volume sensitivity, effective noise cancellation and volume control, reinforcing the findings from that young people in developing countries are increasingly exposed to unregulated noise risks via poorly engineered devices.[1,38]

The study reveals that the core issue may not lie solely in the increasing use of PLD devices, but also in associated factors such as poor-quality devices, limited awareness and unsafe practices. Although some PLD brands approximated recommended impedance and power ratings, the absence of integrated safety features such as noise isolation and volume regulation implies that users are still vulnerable to damage, especially when listening in noisy environments.[28] Our findings also point to the fact that the listening environment and hardware limitations jointly influence risk more than either factor alone.[40]

Interestingly, the high prevalence of auditory complaints among participants, including itching, earache and low perceived hearing, aligns with earlier clinical studies showing a direct link between PLD misuse and short-term hearing changes.[21,25] In this context, the normalization of everyday ear discomfort or transient hearing disturbances is particularly troubling, as it may delay early detection and intervention.

Daily PLD users reported a slightly higher prevalence of self-reported auditory symptoms than nondaily users. Inner-ear itching was the most frequently reported symptom in both groups. The predominance of irritative symptoms, such as itching and a stuffy ear sensation, suggests effects related to external auditory canal occlusion, moisture retention, and local skin irritation rather than inner-ear dysfunction.[41,42] Similar patterns have been observed in observational studies, where discomfort-related complaints (e.g., pain, itching, and excessive cerumen) are more commonly reported than symptoms indicative of functional auditory deficits among PLD users.[39,43,44] This symptom profile is consistent with World Health Organization guidance, which recognizes that early unsafe listening exposure may present as transient irritation, discomfort, tinnitus, or muffled hearing sensations before any long-term consequences occur.[45,46]

Another key insight emerging from this study is the role of social practices in shaping exposure. Sharing earphones (as observed among over 70% of respondents) was most common among peers and roommates. This behavior poses infection risks and supports the argument that ear hygiene remains an underrecognized and tackled health indicator in group-living settings such as universities.[38] In the same vein, the observed lack of cleaning practices for both ears and devices points to broader hygiene knowledge gaps. In our study, the majority of participants either used cotton buds or neglected cleaning entirely, which aligns with observed challenges from other studies.[47]The scrutiny of the behavioral patterns reveals that most students were unaware of optimal use standards, and very few had exposure to ear health education and screening services. This supports Parmar et al.[34] observation that ear health remains a marginalized topic within both Malawi’s public health framework and its education system. The 2008 and 2018 Malawi Population and Housing Censuses found that hearing impairment remains one of the most common disabilities in Malawi.[48,49,50] Proactive measures against any threat against hearing loss in the form of regulation and public health interventions remain limited and barely exist for PLDs, according to our knowledge.[34,48,51] In light of this, the observed absence of healthcare-seeking behavior for ear issues in this study is perhaps less surprising and may be linked to both stigma and systemic service gaps.[31,34,52]

Finally, from a structural point of view, the market environment for electronic gadgets in Malawi had remained largely unregulated, with Malawi Communications attempting to regulate telecommunications equipment and gadgets starting from 2024.[53] Despite that, students opt for low-cost brands due to affordability and availability; these brands often lack compliance with international safety standards. This finding resonates with the literature on digital inequalities, where technological access is not matched by safety and quality. As a consequence, the expansion of digital audio has also increased the risk burden.[26] Despite the absence of objective audiometric measurements, the consistency between reported symptoms and findings from studies using audiometric testing suggests that self-reported indicators may serve as a useful early warning signal in resource-limited settings. Given the cross-sectional design and absence of a nonexposed control group, observed symptom patterns should be interpreted as exposure-related associations rather than definitive evidence of PLD-induced pathology. From a practical standpoint, the findings suggest that PLDs lacking basic safety features may increase auditory strain even when device impedance and power ratings fall within recommended ranges. In particular, the absence of volume control and noise isolation may compel users to increase listening levels in noisy environments, thereby elevating exposure risk. Students may therefore benefit from selecting devices with integrated volume regulation and noise-canceling features, even within low-cost markets.

Limitations

This study has several limitations. First, ear health outcomes and PLD usage patterns were based on self-reported data, which may be subject to recall bias and subjective perception. Second, objective hearing assessments such as pure-tone audiometry or extended high-frequency audiometry were not conducted, limiting the ability to clinically confirm hearing loss or quantify auditory threshold shifts. Third, actual listening volumes and sound exposure levels were not directly measured. These limitations restrict causal inference; therefore, findings should be interpreted as associations rather than evidence of confirmed hearing damage. Nevertheless, the study provides important baseline evidence in a context where objective hearing health data are scarce and highlights priority areas for future research.

The absence of a formal control group of non-PLD users limits the ability to rule out confounding factors such as exposure to environmental noise, recreational venues, or pre-existing ear conditions. While internal comparisons by frequency and duration of PLD use provide partial insight into exposure–symptom relationships, causal inference remains limited. Future studies could strengthen symptom analysis by applying quantitative severity scoring or composite auditory symptom indices, which would allow more nuanced assessment of symptom burden beyond binary self-report measures.

A further limitation of this study is that PLDs were analyzed at the brand level rather than at the individual model level. As multiple models within a single brand may differ in technical specifications, brand-level categorization may obscure within-brand variability. In addition, the descriptive analysis of device specifications does not allow direct inference regarding their relationship with hearing outcomes. Future studies should collect detailed model-level information and incorporate multivariable regression analyses to examine how specific acoustic parameters and device features relate to auditory and nonauditory health outcomes.

CONCLUSION

This study demonstrates that PLD use is common among university students in Malawi, with widespread use of earphones lacking key auditory safety features such as volume control and noise isolation. Auditory and nonauditory symptoms were frequently reported, and daily PLD use was associated with a higher likelihood of auditory symptoms. Poor ear hygiene and unsafe listening practices were also prevalent. Although exploratory, these findings underscore the importance of promoting safer listening practices and greater awareness of ear health among university students.

Author Contributions

Chisomo Mkwandah: Conceptualization, data collection, data analysis and interpretation, writing the draft and preparing the final version for submission. Andy Joabe: Supervision, validation, study design, methodology and review and revision. Donnie Mategula: Supervision, validation, and review and revision. Michael Msukuma: Writing the draft and preparing the final version for submission, Data analysis, interpretation, review and revision. Steven Munharo: Preparing the final version for submission, data analysis. All authors read and approved the final version.

Ethics Approval and Consent to Participate

Ethical approval for this study was obtained from the Department of Human Ecology, Faculty of Food and Human Sciences, Lilongwe University of Agriculture and Natural Resources (LUANAR), Bunda College Campus (approval granted on October 20, 2019). Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and confidentiality and anonymity were ensured throughout the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Availability of Data and Materials

The data and materials used in this study are available upon request from the corresponding author.

Funding Statement

The authors gratefully acknowledge the support provided by Lilongwe University of Agriculture and Natural Resources (LUANAR) and the Malawi Liverpool Wellcome Research Programme (MLW) in conducting this study and supporting its publication.