More to Lose? Noise-Risk Perceptions of Young Adults with Hearing Impairment

Abstract

This study investigated the attitudes and behaviors of young adults with hearing impairment (HI), in relation to leisure noise. It was hypothesized that young people with HI would have more negative perceptions of noise exposure than their peers with nonimpaired (normal) hearing (NH) and would engage more frequently in self-protective behaviors. Questionnaires were administered as part of a larger study of young Australians with: (1) preadult onset HI and (2) NH. Data from adults (age range 18 to 24 years; n  = 79 with HI, n  = 131 with NH) were selected for the current analysis. Attitudes data for HI and NH groups were compared using chi-square tests, and the reported use of hearing aids and personal hearing protectors (PHPs) in leisure environments was quantified. Most participants with HI and NH regarded leisure noise as a health hazard but rated their own noise-injury risk as lower than that of their peer group. The use of PHPs was low overall, and many participants with HI reported using hearing aids (switched on) during noisy leisure activities. An equal and substantial proportion of participants with HI and NH reported dislike and avoidance of loud activities. Systematic noise management in leisure environments would address noise-injury risk and also enhance social participation.

Learning Outcomes: As a result of this activity, the participant will be able to discuss the attitudes and behaviors of young people, particularly those with hearing impairment (HI), towards noise-injury risk.

Some leisure activities (e.g., attending night clubs, rock concerts, and using power tools or firearms) involve sound pressure levels (SPLs) sufficient to cause noise-induced hearing loss (NIHL). ^{1 2 3 4 5} It has been estimated that approximately 14% of 18- to 35-year-old Australians may be at risk of NIHL relating to their leisure activities. ⁴ Recently, Carter et al estimated that nearly one in four 18- to 24-year-olds with clinically normal hearing (NH) had experienced noise above a widely agreed acceptable exposure criterion for age. ^{6 7} There have been many studies of the attitudes and behaviors of young people with respect to leisure-noise exposure, focused on populations with a NH baseline. ^{8 9 10 11 12 13 14 15 16 17 18} Reluctance to use personal hearing protectors (PHP) in leisure (and work) situations has been observed. ¹⁹ For example, in a Canadian survey of attendees of rock concerts, 80.2% of young people (mean age 20.6 years) said they never wore PHP to events. ²⁰ In a very large Web-based survey of health issues (n ∼ 10,000), only 14% of respondents reported any use of PHP. ²¹ Vogel et al also reported that adolescents attending discotheques not only reported little use of PHP, but also reported standing close to speakers and taking few breaks during loud music listening. ²² Furthermore, self-protective behavior tends to be very limited, even when young people are cognizant of the potential for noise injury during leisure activity. ^{3 8} Weichbold and Zorowka reported that following an educational intervention fewer than 4% of participants took advice to use earplugs. ²³ Rawool and Colligon-Wayne found that although 75% of 238 college students surveyed were aware that exposure to loud sounds could cause hearing loss (HL), ¹² 50% of the students appeared to be exposing themselves to potentially harmful loud music. Furthermore, 46% of these students reported not using PHP during loud musical activities. In contrast, Gilles and Paul surveyed 547 14- to 18-year-olds before and after a government hearing health campaign and reported that, overall, attitudes toward noise were more negative and attitudes toward PHP were more positive postcampaign. ²⁴ Intended and actual PHP use were reported to increase as a result of the intervention; however, the need for study of the longer-term effects of preventative campaigns was highlighted.

Although the evidence base pertaining to leisure noise and protective behaviors is extensive, prior to the current investigation there had been no published research involving cohorts of young people with hearing impairment (HI). This is a serious gap in knowledge, given the adverse impacts early HI is known to have on life opportunities. ²⁵ In the face of risks for NIHL, young people already disadvantaged by HI potentially have more to lose than their peers with NH. Without adequate remediation, deteriorating hearing can degrade communication fluency, social interaction, and educational progress. ²⁶ In some cases, it is difficult to prevent or medically remediate hearing deterioration; however, NIHL is preventable. It is therefore critical that the evidence base pertaining to the effects of noise exposure on individuals with early HI is increased.

The current research probed the attitudes and behaviors of young adults with HI, with respect to leisure-noise exposure, and compared findings with those from a cohort of age-matched participants with NH. In view of the deleterious impacts that hearing deterioration may impose and the professional attention that is therefore given to monitoring the hearing levels of young people with HI, it was hypothesized that the sense of personal risk of noise injury would be greater for participants with HI than those with NH.

Protocols for this study were approved by the Australian Hearing Human Research Ethics Committee, the Human Research Ethics Committee, University of Sydney, and the New South Wales Department of Education and Training, Student Engagement and Program Evaluation Bureau. Participation was voluntary and there were no individual incentives for taking part.

Methods

As reported in Carter et al and Carter and Black, ^{6 26} young people with permanent HI were surveyed during the second phase of a large-scale study of hearing health, attitudes and behaviors of young Australians aged 11 to 35 years ( n  = 1,326) [HI + NH survey respondents]. This study was initiated because of widespread concern that leisure-noise exposure may be associated with increased prevalence of hearing injury. The details of the first study phase, in which most participants had NH, have been described previously. ^{6 27 28 29 30} Participants with NH were recruited from a wide range of schools and workplaces in metropolitan and regional New South Wales. In addition to completing hearing health questionnaires, the NH group received a comprehensive audiological evaluation. In the second study phase, the majority of participants (with HI) were recruited via Australian Hearing, which provides hearing services to citizens under the age of 26 years.

Participants

For the current study, data from 79 participants with HI and 131 participants with NH aged 18 to 24 years were extracted from the extensive data set of the larger study (see Table 1 ). The majority of participants in the HI group had a diagnosis of HI prior to school age and almost all by adolescence. As shown in Table 1 , the degree of hearing loss varied. NH group participants had a four-frequency average hearing level (4FAHL) at 500, 1,000, 2,000, and 4,000 Hz ≤ 20 dB HL in both ears. Participants included in the HI and NH subsets had no disabling conditions apart from HI (i.e., physical, intellectual, or sensory) or other severe health problems.

Table 1. Participant Details.

	HI Group	NH Group
18- to 24-y-olds ( n )	79	131
Mean age	21.1	22.4
Sex, n (%)  Female:  Male:	56 (70.9%) 23 (29.1%)	78 (59.5%) 53 (40.5%)
Degree of pure tone hearing loss*	Mild (21–39 dB): 13 (16.5%)
	Moderate (40–59 dB): 25 (31.6%)
	Severe (60–89 dB): 18 (22.8%)
	Profound (90+ dB): 13 (16.5%)
Reported hearing aid/cochlear implant use	Hearing aids only: 58 (73.4%)
	Cochlear implant: 16 (20.3%)
	Not fitted/devices no longer used: 5 (6.3%)

Abbreviations: HI, hearing impairment; NH, normal hearing.

*Better ear four-frequency average hearing level 500, 1,000, 2,000, and 4,000 Hz.

Note: Total does not equal 100% due to cases with better ear four-frequency average hearing level < 21 dB (mainly cases of asymmetrical hearing loss). Some cochlear implant wearers also used a conventional hearing aid in the opposite ear.

Questionnaires

The instruments used in this research were developed by the National Acoustic Laboratories and are publicly available. ^{6 27} The questionnaires were developed specifically for the research aims and were informed by an extensive review of the previous literature pertaining to NIHL in young populations. ⁵ Previous hearing health surveys, especially as reported by Serra et al and Biasonni et al, ^{31 32} influenced the questionnaire design. Instruments were piloted and input was sought from a range of professionals during the development process. The format was self-report, but parents could assist where appropriate. The questionnaires included detailed sections about history of ear and hearing problems, general health, leisure and work activity participation, attitudes to noise, and protective behaviors. Seven questionnaire items probing young adults' attitudes to noise risk were fixed-choice, using 5-point Likert response scales and various anchor descriptions, as shown in Table 2 . ³³ Three items examined participants' perception of risk to self and the remaining four items examined perceptions of risk in relation to other young people. Preliminary analysis indicated that the two extreme response categories were infrequently chosen. Therefore, to increase power, raw ratings were collapsed to a 3-point scale prior to analysis as follows: negative (1 and 2), neutral (3), positive (4 and 5).

Table 2. Young Adult Risk Perceptions in Relation to Self and in General.

		Responses (%)
Risk to self		Negative	Neutral	Positive
1. Are you worried or concerned about the possibility of YOUR hearing getting worse in the future? [not at all → very much]	HI	26.6	24.1	49.4
	NH	15.3	22.1	62.6
2. How likely do you think it is that your hearing will change in future? * [not at all likely → very likely]	HI	35.9	21.8	42.3
	NH	9.2	38.5	52.3
3. In terms of hearing damage from loud sound exposure: How risky do you think your own activities are? [very low risk → very high risk]	HI	44.3	34.2	21.5
	NH	33.3	34.1	32.6
Risk to peers/in general		Negative	Neutral	Positive
4. In terms of causing hearing damage: On average, how risky do you believe the leisure activities of other people your own age are? [very low → very high]	HI	11.4	36.7	51.9
	NH	5.4	23.8	70.8
5. How risky do you think using a personal stereo (iPod, MP3 player) is for most young people? [very low risk → very high risk]	HI	7.6	20.3	72.2
	NH	3.1	21.4	75.6
6. In general, how risky do you think activities such as night-clubbing or loud concerts are? [very low risk → very high risk]	HI	3.8	13.9	82.3
	NH	2.3	12.2	85.5
7. In general, how much do you think exposure to loud sound during leisure activities contributes to people's hearing getting worse, or to developing a hearing loss later in life? [very little → very much]	HI	13.9	22.8	63.3
	NH	6.1	26.0	67.9

Abbreviations: HI, hearing impairment; NH, normal hearing.

^*Statistically significant difference using chi-square test.

Information about hearing-protective behavior was obtained from leisure participation items included in the questionnaire (example shown in Fig. 1 ). Participants were asked about their involvement in 25 specific activities, most of which provide the opportunity for loud-sound exposure. These included music events (concerts in large and small venues, festivals, pubs and clubs), music performance (playing musical instruments, bands, singing), sports activities (large stadium events, gym/exercise classes, motor sports, firearms use), and working with power tools. More in-depth questions about use of personal stereo players, home stereo, and nightclub attendance were included, and participants also were probed about any work-related noise exposure. For participants with HI, wearing hearing aids switched off during noisy activities was accepted as a form of PHP, because the earmold of the hearing aid can provide some attenuation of noise. ^{34 35} Other strategies to reduce noise exposure (apart from PHP use), such as avoiding or leaving loud situations, were also explored in other questions.

Figure 1.

Example of a leisure participation item from the questionnaire. CI, cochlear implant.

Throughout the questionnaire, participants had the opportunity to describe their individual experiences and provide general comments, for example: “describe the situation(s) or activity(s) you have tended to avoid” and, “do you have any other comments about your hearing or exposure to loud sound, particularly in terms of having a hearing loss?” A selection of verbatim responses are included in the Discussion to illuminate the quantitative findings that follow.

Statistical Analysis

IBM SPSS Statistics, version 22, was used for statistical analyses (IBM, Armonk NY). Pearson chi-square tests were used to compare the responses of the HI and NH groups for the seven fixed-choice attitudes items and the items relating to hearing-protective behaviors. To correct for multiple comparisons, the Holm-Bonferroni procedure was applied with an initial p value of 0.05.

Results

Attitudes to Leisure Noise

The attitudes items and related findings are presented in Table 2 . Less than one-third of participants (HI = 21.5%; NH = 32.6%) believed themselves to be at risk for leisure-related noise injury. In contrast, the majority of participants believed their peer group to be at risk, in general terms (HI = 63.3%; NH = 67.9%) and from nightclubs or loud concerts (HI = 82.3%; NH = 85.5%). For these items, a statistically significant difference between groups was only observed for question 2, which asked participants about the perceived likelihood of their hearing changing in future. Around one-third (35.9%) of the HI group expected no future change in their hearing compared with 9.2% of those in the NH group (chi-square = 23.235; df = 2; p  < 0.001).

Protective Behaviors

Figs. 2 and 3 show the reported PHP use of participants with HI and participants with NH, respectively. Reported use of hearing protectors (or switching off hearing aids in loud environments) was low among both groups of participants. PHP use was most frequently reported during several of the highest-noise activities (nightclubbing, firearms, and power tool use).

Figure 2.

Personal hearing protector (PHP) use, hearing impairment group (PHP includes active hearing aids in situ). Numbers in parentheses indicate the total number of respondents who participated in each activity.

Figure 3.

Personal hearing protector (PHP) use, normal hearing (NH) group. Numbers in parentheses indicate the total number of respondents who participated in each activity.

Responses to additional questions regarding noise-related behaviors are shown in Table 3 . Approximately half of all respondents reported some avoidance of loud activities (HI = 50.6%; NH = 52.7%). Many participants also reported having left or stopped an activity at least occasionally because it was too loud (HI = 55.7%; NH = 66.4%). In this context, the most commonly cited activity was nightclub attendance. There were no statistically significant differences between the HI and NH groups for these two items. Of the participants who reported avoidance of loud leisure situations, the reason most frequently selected was that it is “too hard to hear conversation” (HI = 43%; NH = 37%). This was followed by experience of “pain/discomfort” (HI = 32%; NH = 29%) and, finally, “the risk of hearing damage” (HI = 15%; NH = 28%). Note that more than one reason could be recorded. Apart from these three fixed-choice options, participants could nominate “other” reasons for avoiding loud activities. HI group participants cited: lack of interest in activities, poor sound quality of hearing aids, noise-induced symptoms (e.g., tinnitus, headaches), self-consciousness, and “feeling dumb.” Parental discouragement to participate also was mentioned by one participant. Only a small number of respondents with NH (∼7%) described other reasons for avoiding leisure noise. These included music being distorted (and hence not enjoyable) when played too loud, preference for classical music, religious reasons, and the type of other people attending the activity.

Table 3. Participant Responses to Questions about Avoidance of Loud/Noisy Activities.

Questions		Responses (%)
Do you prefer to avoid some places (e.g., clubs, dance parties), or activities (e.g., motor sports) because they are too loud?
			No	Yes, Somewhat	Yes, Very Much
		HI	48.1	35.4	15.2
		NH	46.6	41.2	11.5
Have you ever left a place, or stopped doing an activity, because it was too loud?
			Never	Occasionally	Often
		HI	44.3	49.4	6.3
		NH	32.1	52.7	13.7

Abbreviations: HI, hearing impairment; NH, normal hearing.

As shown in Fig. 1 , participants with HI were asked to indicate whether hearing aids were used, switched on, during each of the leisure activities described. As shown in Fig. 4 , a significant proportion of respondents wore active hearing aids during a wide range of activities. Hearing aid use during potentially high-noise activities such as music concerts (small and large venues and festivals) and motor sports was reported by more than 50% of respondents. Hearing aid use during nightclubbing was also reported by around half of those who reported participation.

Figure 4.

Hearing aid use during leisure activities. Numbers in parentheses indicate total number of respondents who participated in each activity.

The results presented in Figs. 2 , 3 , and 4 , although informative, do not capture the diverse combinations of activity participation, hearing device, and PHP use reported by the participants with HI. Table 4 presents a summary of hearing aid, cochlear implant, and PHP use and other details for five individuals, previously determined to have the highest whole-of-life noise exposure among HI group participants. ⁶ As described by Carter et al, ⁶ whole-of-life exposure was estimated based on leisure activity data from the hearing health questionnaire, according to a method described previously. ^{7 36} It is notable that none of these highly noise-exposed individuals reported consistent use of PHP, although in the second case (female, 19 years), noise exposure was not a critical issue, because the only hearing device used was a cochlear implant and the signal provided is therefore nonacoustic. Furthermore, all three participants using hearing aids reported always wearing their devices during the loud activities nominated.

Table 4. Overview of Personal Data for Five HI Participants with the Highest Whole-of-Life Noise Exposure.

Gender/Age	Exposure (Pa 2 h) approximate	4FAHL Left/right	Etiology	Devices	Exposure Source ≥Once/Month	Exp. Years	Devices Worn	Hearing Protection Used
Male 20.5 y	13,910 HTL shift *  = yes HF shift †  = no	23/39	Chronic middle ear infection	Air and bone conduction hearing aids (LT & RT) Not worn currently First HA fit 7 years	Nightclubs	2	Never	Never
					Motorsports	14	Never	Never
					Shooting	8	Never	Mostly/always
					Power tools	10	Never	Sometimes
					Farm worker	10	Never	Sometimes
Female 19 y	9,325	116/116	Meningitis	Cochlear implant RT First HA fit 2 years	Nightclubs	<1	Mostly Always	Never
					Orchestra (woodwind)	8	Always	Never
					Choir	3	Always	Never
					Gym/dance class	6	Always	Never
					Nil occupational noise: Customer service
Female 24.3 y	8,270	90/90	Familial	Bimodal (HA + CI) First HA fit ∼ 6 years	Nightclubs	3	Sometimes	Never
					Live music	16	Always	Never
					Gym/dance class	3	Mostly	Never
					Play drums	17	Never	Never
					Play piano	16	Always	Never
					Garage band	12	Always	Never
					Nil occupational noise: Nurse assistant/student
Female 23 y	6,560 HTL shift = yes HF shift = yes	63/66	Post-typhoid	Hearing aids LT & RT First HA fit ∼ 6 years	Nightclubs	3	Always	Sometimes
					Orchestra (woodwind)	4	Always	Never
					Gym/dance class	7	Always	Never
					Personal stereo	10	Earphones	N/A
					Nil occupational noise: Researcher. Reports exposure to solvents
Male 23 y	5,820 HTL shift = yes HF shift = no	59/53	Prematurity	Hearing aids LT & RT First HA fit 5 years	Nightclubs	4	Always	Sometimes
					Live music	4	Always	Never
					Pubs/clubs	4	Always	Never
					Shooting	8	Always	Sometimes
					Power tools	8	Always	Sometimes
					Builder	8	Always	Sometimes

Abbreviations: 4FAHL, four-frequency average hearing level; CI, cochlear implant; HA, hearing aid; HF, high frequency; HI, hearing impairment; HTL, hearing threshold level; LT, left; N/A, not applicable; Pa ² h, Pascal squared hours; RT, right.

Notes: All exposures were above the acceptable criterion for the individual's age.

Cochlear implantation surgery often results in HTL shift, therefore no analysis of occurrence of shift made for CI wearers.

^*HTL shift refers to two criteria for significant change: (1) a downward shift (i.e., increase) in HTL of ≥10 dB at any of the adjacent air conduction frequency pairs: 250/500, 500/1,000, 1,000/2,000, and 2,000/4,000 Hz, and (2) a downward shift in HTL of ≥15 dB at one or more of the following individual frequencies: 250, 500, 1,000, 2,000, or 4,000 Hz.

^† HF shift refers to downward shift of ≥15 dB at 2,000 and/or 4,000 Hz in either or both ears. ²⁵

Discussion

The hypothesis that young adults with HI have a greater sense of personal risk of noise injury than their peers with NH was not confirmed by the current analysis. Most participants (with HI and NH) perceived activities such as night-clubbing, loud concerts and personal stereo player use as risks for hearing injury. Both groups similarly rated their own noise-injury risk as lower than that of others their own age. The observed tendency for participants to rate their own noise risk as lower than the risk to others mirrors parental attitudes to children's risk detailed in a previous publication relating to this study and the findings of other health behavior research. ^{37 38}

Slightly more than a third of the HI group expected no future change in their hearing compared with just under one-tenth of the NH group. A previous examination of noise exposure data from the same group of young adults showed the median whole-of-life noise exposure of the HI group was significantly lower than for the NH group (710 Pa ² h and 1,615 Pa ² h, respectively). Furthermore, relatively few participants with HI (∼9%) reported exposures exceeding an acceptable criterion for age. ⁶ In contrast, almost one in four young adults with NH had whole-of-life noise exposure above the stated risk criterion. The lower concern of the HI group about future hearing change may therefore be realistic if considered only in the context of noise-related hearing deterioration. However, HI can often be a progressive condition for reasons unrelated to noise injury. ²⁶ In a complementary analysis of adolescent participant attitudes data (HI n  = 46, NH n  = 165), 17% of the HI group believed their hearing would get better and one third believed hearing would fluctuate, ⁶ despite the fact that almost every participant had sensorineural (permanent) HI. These findings suggest that a proportion of young people with HI may have limited knowledge of the likely prognosis of their HI.

It is plausible that the participants' lack of awareness of the possibility of HTL shift could relate to an underplaying of this risk during information counseling provided to young people (and their parents). This may arise from professional motivation to reduce client anxiety in the face of uncertainty. Prior to the current research, there was scant evidence about the incidence of progressive HL (of any etiology) in young people with HI, which may account for professional reticence toward providing prognostic advice about HTL shift. Another possibility is that some participants have been influenced by hearing health messages, despite the fact that most hearing health messages assume, and are directed toward, an audience with NH. The following comments from participants with HI attest to the likely influence of hearing health education:

Growing up I have always been wary that loud sounds damage hearing, even if that's not what caused my own hearing loss. I try and avoid loud situations if I can, mainly because it is frustrating for me to have a conversation with someone in a louder setting, but otherwise because I try and discourage my friends from damaging their hearing.

I feel like trying to preserve your hearing in today's society is fighting a losing battle. . . . The music and noise levels my peers are subjecting themselves to is bridging the gap between my hearing loss and their hearing levels.

Consistent with previous reports of hearing health attitudes and behavior, ^{8 19 20 21 22} reported PHP use was very low in both the HI and NH groups, as illustrated in Figs. 2 and 3 . No statistically significant difference between groups was observed. This provides further evidence that risk awareness does not necessarily motivate young people to take protective action. A 17-year-old participant with HI stated:

Young people listen to music through headphones/ear buds a lot and at high volumes, however it doesn't bother me (or others I know) that it could have a detrimental impact on my hearing. We know about the effects of loud noise on our level of hearing as well as how to protect it, but (generally) we don't care and will continue to do this anyway.

Avoidance of loud activities was reported by approximately half of all respondents (both with HI and NH), which was a very interesting finding. Reluctance to participate in noisy leisure activities was not primarily related to concern about noise injury. A range of other factors including physical discomfort, difficulty communicating, dislike of the social environment, tinnitus, and vocal strain, also were relevant. Although these reasons were cited by participants in both groups, only those with HI reported feeling “self-conscious” or feeling “dumb” as reasons why they avoided noisy leisure activities.

Among the HI group, use of hearing aids (switched on) in a range of noisy situations was quite frequently reported, even during activities such as using power tools and, in a few cases, using firearms (as illustrated in Fig. 4 ). Case details presented in Table 4 illustrate the fact that some individuals consistently wear hearing aids in loud environments, including nightclubs and when using power tools and firearms. This is a very concerning finding given previous evidence that use of hearing aids in loud environments can contribute to hearing deterioration. ³⁹ It is possible that hearing aids are sometimes worn in combination with earmuffs. However, given the low reported PHP use overall, it appears this would not frequently be the case, supporting the speculation that hearing aids and earmuffs are sometimes worn together. A 14-year-old participant with HI noted:

I wear my hearing aids at all times. When it comes to loud sounds or metal work/wood work at school when I need to use the earmuffs I still leave my aid on.

An association between whole-of-life noise exposure and HTL shift was not observed in the group data, as reported previously. ^{6 25} However, the case profiles provided in Table 4 draw attention to the fact that some individuals are placing themselves at risk of noise injury. The last two profiles (female participant, 23 years; male participant, 23 years) are particularly apposite. Both these individuals reported frequent participation in noisy activities and consistent use of hearing aids in these situations. Unfortunately, both participants also have experienced deterioration in hearing over time. The final participant reported significant occupational noise (working as a builder) in addition to recreational noise (including 8 years of firearms use), but only sometimes taking measures to protect hearing. Clinical case notes attested to repeated professional advice about the risk of NIHL. The participant, however, presumably placed the need for audibility above the risk of noise injury.

The finding that many young people wear their hearing aids in high-noise environments may trouble audiologists, who generally take responsibility for delivering HL prevention messages to this group. However, the frequent use of hearing aids and low use of PHP in noisy situations probably reflects the reality that people with HI depend on amplification to communicate effectively (regardless of the environment) and also need to hear warning sounds in a range of situations. The following comment from a participant with HI highlights the importance of audibility:

Occasionally I find it hard at work (preschool) with all the children yelling, at times screaming. When talking all at once it can cause me headaches and ringing in my ears. Sometimes I've worn earplugs although this isn't good for safety.

Another comment about the use of hearing aids in noise speaks to the viewpoint that hearing aids may have a protective function, rather than increase the risk of noise injury:

I find that if the sound is too loud, the hearing aid often blocks it anyway because it does not have the capacity to take in sounds at that level (this is my belief).

Given the advanced signal processing features in current digital hearing aids, this may be a valid observation. However, there is currently insufficient systematic evidence to be certain of the extent of protective functions of signal processing. Furthermore, features such as automatic gain control can compromise sound quality for some wearers and so may not be widely appreciated, as evident in the following participant statement:

To be honest I hate getting new hearing aids, as the sound is always different and it's unnatural that the technology in the new hearing aids increases the volume of the soft sound and lowers the volume of the loud sounds. I would prefer to hear like everyone else and hear the sounds the way they are naturally.

Perhaps one of the most interesting results to emerge from the questionnaire was that many young people (both with HI and NH) do not enjoy the experience of loud sound during leisure. The entertainment and hospitality industries may do well to consider their patrons' preferences, rather than adhere to the stereotypic assumption that all young people love loud, hard music. It is possible that patronage of music and social venues may increase if environmental noise levels were lowered, and thus listening comfort and social interaction among attendees were improved. Challenging the social norms regarding loud music in venues is clearly a major undertaking, as noted previously. ⁶ However, given sufficient determination and cooperation between the health and entertainment sectors, positive outcomes could be achieved. The successful banning of tobacco smoking in eating and entertainment venues in many developed countries sets an encouraging precedent. It is also essential that more effective and practical technologies are developed that allow individuals with HI to communicate effectively in loud environments, while controlling exposure to harmful levels of noise. Refining assistive technology is a critical factor in providing equal access for young people with HI, across a wide range of social venues and environments.

Limitations of the Study

In generalizing the results of the current study, certain limitations must be taken into account. Considerable effort was made to ensure a representative participant sample, for example, by recruiting and collecting data in country, regional, and urban locations. Nevertheless, the participation rate for individuals with HI was relatively low. ⁶ The difficulty in involving young people with disability in research has been noted by previous authors. ³⁹ Another factor to consider is that the test–retest reliability of the questionnaire was unknown at the time of the analysis.

Conclusions

Despite awareness that leisure noise can pose a risk to hearing health, few participants reported PHP use, and many participants in the HI group reported wearing hearing aids during noisy activities. This study revealed that many young people would prefer lower sound levels in clubs and other social venues. Systematic noise reduction in leisure environments may ultimately be more effective in reducing the risk of NIHL than traditional approaches that have attempted to modify individual noise-related behavior. Importantly, noise reduction would also enhance the comfort and social participation of patrons—regardless of their hearing status.