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Evaluating the Impact of a Hearing Conservation Program on Noise-Induced Hearing Loss (NIHL) among Racially Diverse Children

Permanent Link: http://ufdc.ufl.edu/UFE0044874/00001

Material Information

Title: Evaluating the Impact of a Hearing Conservation Program on Noise-Induced Hearing Loss (NIHL) among Racially Diverse Children
Physical Description: 1 online resource (114 p.)
Language: english
Creator: Dell, Shawna M
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2012

Subjects

Subjects / Keywords: children -- noiseinducedhearingloss
Speech, Language and Hearing Sciences -- Dissertations, Academic -- UF
Genre: Communication Sciences and Disorders thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The prevalence ofnoise-induced hearing loss (NIHL) among children has been reported to have increasedfrom 12% to 16%. The prevalence of NIHL among Caucasians, African Americans,and Hispanics showed no significant differences between groups, although theAfrican American children showed the lowest prevalence of NIHL. When examiningthe prevalence of NIHL among the adult population, there are significantdifferences across groups, and the African American group had the lowestprevalence of NIHL. An evidence-basedpractice in combating NIHL includes the use of hearing conservation programs(HCPs). HCPs provide information about the auditory system, hazardous soundsources, and methods to protect one from acquiring NIHL. The purpose of thisresearch was to measure the prevalence of NIHL and to examine the efficacy of aHCP on increasing the knowledge and changing pro-noise attitudes among children. One hundred andseventy nine racially diverse children participated in this study. Thesechildren were recruited from two elementary schools located in Osceola County,FL and from O2Bkids and the Boys and Girls Clubs of Alachua County, FL. Participantsreceived an audiometric screening battery. Two surveys presented at twodifferent times were used to measure their knowledge and attitudes towards loudsounds. The participants were separated into a control group that received theaudiometric screening and completed the survey measures; and an experimentalgroup that received the additional HCP between the surveys. Focus groups wereperformed after the test measures were completed. In this currentstudy the prevalence of children with NIHL, defined as a loss from 3k to 6k Hzwas 16.8% on the initial hearing screening with no significant difference amongthe racial groups. However, the prevalence rate dropped to 4.6% after thechildren were retested. The experimental group showed a significant reductionof the pro-noise attitudes and an increase in knowledge regarding the effectsof loud sounds. There was a significant relationship between the increase inknowledge and the reduction in positive attitudes towards noise. This current studyfound a lower prevalence rate compared to the literature, so priorepidemiologic studies may have over-estimated the prevalence of NIHL amongchildren. /* Style Definitions */ table.MsoNormalTable{mso-style-name:"Table Normal";mso-tstyle-rowband-size:0;mso-tstyle-colband-size:0;mso-style-noshow:yes;mso-style-priority:99;mso-style-qformat:yes;mso-style-parent:"";mso-padding-alt:0in 5.4pt 0in 5.4pt;mso-para-margin:0in;mso-para-margin-bottom:.0001pt;mso-pagination:widow-orphan;font-size:11.0pt;font-family:"Calibri","sans-serif";mso-ascii-font-family:Calibri;mso-ascii-theme-font:minor-latin;mso-fareast-font-family:"Times New Roman";mso-fareast-theme-font:minor-fareast;mso-hansi-font-family:Calibri;mso-hansi-theme-font:minor-latin;mso-bidi-font-family:"Times New Roman";mso-bidi-theme-font:minor-bidi;}
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Shawna M Dell.
Thesis: Thesis (Ph.D.)--University of Florida, 2012.
Local: Adviser: Holmes, Alice E.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2012
System ID: UFE0044874:00001

Permanent Link: http://ufdc.ufl.edu/UFE0044874/00001

Material Information

Title: Evaluating the Impact of a Hearing Conservation Program on Noise-Induced Hearing Loss (NIHL) among Racially Diverse Children
Physical Description: 1 online resource (114 p.)
Language: english
Creator: Dell, Shawna M
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2012

Subjects

Subjects / Keywords: children -- noiseinducedhearingloss
Speech, Language and Hearing Sciences -- Dissertations, Academic -- UF
Genre: Communication Sciences and Disorders thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The prevalence ofnoise-induced hearing loss (NIHL) among children has been reported to have increasedfrom 12% to 16%. The prevalence of NIHL among Caucasians, African Americans,and Hispanics showed no significant differences between groups, although theAfrican American children showed the lowest prevalence of NIHL. When examiningthe prevalence of NIHL among the adult population, there are significantdifferences across groups, and the African American group had the lowestprevalence of NIHL. An evidence-basedpractice in combating NIHL includes the use of hearing conservation programs(HCPs). HCPs provide information about the auditory system, hazardous soundsources, and methods to protect one from acquiring NIHL. The purpose of thisresearch was to measure the prevalence of NIHL and to examine the efficacy of aHCP on increasing the knowledge and changing pro-noise attitudes among children. One hundred andseventy nine racially diverse children participated in this study. Thesechildren were recruited from two elementary schools located in Osceola County,FL and from O2Bkids and the Boys and Girls Clubs of Alachua County, FL. Participantsreceived an audiometric screening battery. Two surveys presented at twodifferent times were used to measure their knowledge and attitudes towards loudsounds. The participants were separated into a control group that received theaudiometric screening and completed the survey measures; and an experimentalgroup that received the additional HCP between the surveys. Focus groups wereperformed after the test measures were completed. In this currentstudy the prevalence of children with NIHL, defined as a loss from 3k to 6k Hzwas 16.8% on the initial hearing screening with no significant difference amongthe racial groups. However, the prevalence rate dropped to 4.6% after thechildren were retested. The experimental group showed a significant reductionof the pro-noise attitudes and an increase in knowledge regarding the effectsof loud sounds. There was a significant relationship between the increase inknowledge and the reduction in positive attitudes towards noise. This current studyfound a lower prevalence rate compared to the literature, so priorepidemiologic studies may have over-estimated the prevalence of NIHL amongchildren. /* Style Definitions */ table.MsoNormalTable{mso-style-name:"Table Normal";mso-tstyle-rowband-size:0;mso-tstyle-colband-size:0;mso-style-noshow:yes;mso-style-priority:99;mso-style-qformat:yes;mso-style-parent:"";mso-padding-alt:0in 5.4pt 0in 5.4pt;mso-para-margin:0in;mso-para-margin-bottom:.0001pt;mso-pagination:widow-orphan;font-size:11.0pt;font-family:"Calibri","sans-serif";mso-ascii-font-family:Calibri;mso-ascii-theme-font:minor-latin;mso-fareast-font-family:"Times New Roman";mso-fareast-theme-font:minor-fareast;mso-hansi-font-family:Calibri;mso-hansi-theme-font:minor-latin;mso-bidi-font-family:"Times New Roman";mso-bidi-theme-font:minor-bidi;}
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Shawna M Dell.
Thesis: Thesis (Ph.D.)--University of Florida, 2012.
Local: Adviser: Holmes, Alice E.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2012
System ID: UFE0044874:00001


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1 EVALUATING THE IMPACT OF A HEARING CONSERVATION PROGRAM ON NOISE INDUCED HEARING LOSS (NIHL) AMONG RACIALLY DIVERSE CHILDREN By SHAWNA MARLANA DELL A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2012

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2 2012 Shawna M. Dell

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3 To My Mom and My Little Jimmy

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4 ACKNOWLEDGMENTS I would like to thank my heavenly Father for blessing, guiding, protecting, and giving me the strength to fulfill my dreams and in return to be a blessing to others. I have been fortunate and blessed to be taught by extraordinary professors and I sincerely appreciate my illustrious committee members. I have l earned s o much from each and every one. I would like to thank my Ph D mom and Chair, Dr. Alice E. Holmes, for all her endless support, repeated efforts to make my dissertation awesome, and her advice and guidance throughout my journey as a graduate studen t. I greatly app reciate Dr. Patricia Kricos who has taught me to be an advocate for those living with hearing loss and to be fearless in my pursuits to prevent the ill effects of hearing loss. I would also like to thank Dr. Colleen LePrell for all her guid ance and advice especially when it came to methodology and hearing conservation. I would like to thank my external members, Dr. Lawrence Winner and Dr. Barbara Curbow. Dr. Winner had great patience as he guided me through the trials and tribulations that I like to call s tatistics so that I could accurately analyze all of my data Dr. Barbara Curbow introduced me to my new passion, the world of public health. I thank her for her endless positive regard and encouragement. Last and not least, I want to expre ss my gratitude to Dean Kenneth Gerhardt for introducing me to the audiologic area of hearing conservation and occupational health. I still remember the words that he spoke to me and my fellow classmates during my first cla ss in my Doctor of Audiology prog ram in 2004; he said that as students we should see him and the faculty as a golden net that is there to catch us if we stumble or fall. Thus, I would like to thank him, my committee, and all my professors (clinical and academic) for being my golden net.

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5 I have been part of the gator nation for 12 years and I have meet wonderful people as I navigated my way from a fresh faced freshman to a glorious graduate. This was made possible through the McKnight Fellowship provided by the Florida Education Fund. I wou ld like to thank Dr. Lawrence Morehouse, Mr. Charles Jackson, the Florida Education Fund, and the extended McKnight Family. I would also like to acknowledge Ms. Idella King, the graduate secretary, who was there to assist me with everything from registerin g for classes to navigating the process of graduation. In addition, she lent an ear so I could par take in one of my favorite pas time s chatting. I would also like to thank Sarah Traylor and the Office of Graduate Minority Programs for all their help with t he allocation of my funding. I would like to acknowledge Ms. Carol Mills, Ms. Sharla Alexander, and the endless staff members that worked in the past and currently within the Department of Speech, Language, and Hearing Sciences for their support and encour agement. To my mother and fath er, Mr. and Mrs. James and Cecelia Dell, that always told me to work hard, do my best, an I thank you for providing every opportunity for me to excel in life when you both did not have the same opportunity. I love you both dearly. I would like to thank my big sister, Mrs. Sheree McGee, for all her generosity, love, and understanding. You are on e of my biggest cheerleaders, a loyal supporter and I love and thank you so much. Many more thanks to m y brother, James, my brother in law, Kenny, and all my other family members that support and care for me. I especially want to recognize my little girls, Laurynn and Lay l a for providing Auntie with laughs, love, and fun. My second family, Drs. Kenneth

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6 Pod lenski, Ronald Kelley, Kathlee n Read, Shari Kwon, Amy Selvaraj, and Devon Weist thank you so much for your support. To Freda Coleman Jackson and all my closest friends from the Coleman Jacksons to the Selvarajs, I want to thank you for the endless friends hip, laughs, and free food I would also like to extend my thanks to all the participants, students, teachers and staff at Neptune and Reedy Creek elementary schools. I would also like to thank Ms. Diane Nichols, Ms. Linda Harwood, Ms. Julie Wilson, and M s. Dianne Dinkins of Osceola County School District. In addition, I would like to thank the Boys and Girls Clubs of Alachua County and O2Bkids of Gainesville. I would like to thank Dr. Brittany Hensley for her assistance with my study. Lastly, I was fortun ate to have two wonderful Doctor of Audiology students, Jennie Allen and Laura Davidson, to assist me with data collection, data entry, and transcription. I greatly appreciate all the work that these ladies offered me with pleasant smiles and positive atti tudes.

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7 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 9 LIST OF FIGURES ................................ ................................ ................................ ........ 11 ABSTRACT ................................ ................................ ................................ ................... 12 CHAPTER 1 INTRODUCTION AND LITERATURE REVIEW ................................ ..................... 14 Effects of Noise on the Audit ory System ................................ ................................ 15 Associated Health Consequences of NIHL ................................ ............................. 18 Gender Differences Among NIHL ................................ ................................ ........... 21 Occupational HCP versus Educational HCP ................................ ........................... 22 Educational HCPs and Resources for Children ................................ ...................... 25 Racial/Ethnic Group Disparit ies and NIHL ................................ .............................. 34 Purpose ................................ ................................ ................................ .................. 37 2 METHODS ................................ ................................ ................................ .............. 40 Participants ................................ ................................ ................................ ............. 40 Ethics of working with Special Populations ................................ ............................. 40 Sampling and Recruitment ................................ ................................ ...................... 41 Measures and Mat erials ................................ ................................ .......................... 42 Procedures ................................ ................................ ................................ ............. 43 3 RESULTS ................................ ................................ ................................ ............... 49 Prevalence Data ................................ ................................ ................................ ..... 49 Prevalence of Hearing Loss in Audiometric Data ................................ ............. 49 Attitudes and Knowledge towards Noise ................................ ................................ 52 ................................ ................................ 52 ................................ ............................. 55 Effects of Hearing Conservation Program ................................ ............................... 57 Hearing Conservation Training Effects on Attitudes ................................ ......... 57 Hearing Conservation Training Effects on Knowledge ................................ ..... 60 Main Themes of Focus Groups ................................ ................................ ............... 63 4 DISCUSSION ................................ ................................ ................................ ......... 81 Prevalence of the Study Population ................................ ................................ ........ 81 Effects of the Hearing Conservation Program ................................ ......................... 90

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8 Influence of Gender and Race ................................ ................................ ................ 92 Consensus of Focus ................................ ............................... 93 Limitations of the Study ................................ ................................ ........................... 94 Future Aims ................................ ................................ ................................ ............ 96 Conclusi on ................................ ................................ ................................ .............. 97 APPENDIX A PRE TEST QUESTIONNAIRE ................................ ................................ ............... 99 B POST TEST QUESTIONNAIRE ................................ ................................ ........... 103 LIST OF REFERENCES ................................ ................................ ............................. 107 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 114

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9 LIST OF TABLES Table page 3 1 Sample demographics ................................ ................................ ...................... 67 3 2 Count and Prevalence of Hearing Screening Failure of Study Participants that either passed or failed pure tone screening or tympanometry ..................... 68 3 3 Count and Prevalence of Hearing Screening Failure of Study Participants at any frequency (1 6k Hz) in either ear ................................ ................................ 69 3 4 Count and Prevalence of failed high frequency (3k, 4k, or 6k Hz) in either ear ................................ ................................ ................................ ...................... 70 3 5 Count and Prevalence of Hearing Screen of Study Participants after second hearing test ................................ ................................ ................................ ......... 71 3 6 DPOAE results of each frequency and overall results for each ear based on race ................................ ................................ ................................ .................... 72 3 7 P values of Chi Square Analysis of DPOAE results at 2000, 3000, and 4000 Hz based on Gender and Race (n=174 for right ear; n=173 for left ear) ............ 72 3 8 Comparison of the DPOAE results with high frequency hearing loss status (n=167) ................................ ................................ ................................ ............... 73 3 9 Descriptive statistics on the YANS measure (n=179). ................................ ...... 73 3 10 ANOVA Results for the Entire YANS and sub factors without presentation of a HCP. ................................ ................................ ................................ ................ 74 3 11 Percentages of Participants Exposure to Dangerous Sounds in Daily Living ... 75 3 12 ratio, and Level of Significance for each Factor ................................ .................. 75 3 13 based on Gender and Race ................................ ................................ ................ 75 3 14 Level of Significance for each Factor ................................ ................................ .. 76 3 15 on Gender and Race ................................ ................................ .......................... 76 3 16 Participants Responses to Opinion/Behavioral Questions on Knowledge and Hearing Protection Usage ................................ ................................ ............ 76

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10 3 17 Correlation Table of Knowledge and YANS responses ................................ .... 77

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11 LIST OF FIGURES Figure page 3 1 Participants Reported Experience of Tinnitus ................................ ................... 78 3 2 Mean scores from the Knowledge Questions based on Race and Gender (N=179) ................................ ................................ ................................ .............. 79 3 3 Participants Anticipated Use of Hearing Protection within the next month ....... 80

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12 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy EVALUATING THE IMPACT OF A HEARIN G CONSERVATION PROGRAM ON NOISE INDUCED HEARING LOSS (NIHL) AMONG RACIALLY DIVERSE CHILDREN By Shawna Marlana Dell December 2012 Chair: Alice E. Holmes Major: Communication Sciences and Disorders The prevalence of noise induced hearing loss (NIHL) among children has been reported to have increased from 12% to 16% The prevalence of NIHL among Caucasians, African Americans, and Hispanics show ed no significant difference s betwe en groups, although the African American child ren showed the lowest prevalence of NIHL. W hen examining the prevalence of NIHL among the adult population, there are significant difference s across group s and the African American group had the lowest prevalence of NIHL. An evidence based practice in com bating NIHL include s the use of hearing conservation programs (HCPs) HCPs provide information about the auditory system, hazardous sound sources, and met hods to protect one from acquiring NIHL. The purpose of this research was to measure the prevalence of NIHL and to examine the efficacy of a HCP on increasing the knowledge and changing pro noise attitudes among children One hundred and seventy nine racially diverse children participated in this study. These children were recruited from two elementary sch ools located in Osceola County FL and from O2Bkids and the Boys and Girls Clubs of Alachua County, FL. Parti ci pants

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13 received an audiometric screening batter y Two surveys presented at two different times were used to measure their knowledge and attitudes towards loud sounds. The participants were separated into a control group that received the audiometric screening and completed the survey measures; and an experimental group that received the additional HCP between the surveys F ocus groups were performed after the test measures were completed. In this current study t he prevalence of children with NIHL defined as a loss from 3k to 6k Hz was 16.8 % on the initial hearing screening with no significant difference among the racial groups. However, the prevalen ce rate dropped to 4.6% after the children were retested. The experimental group showed a significant reduction of the pro noise attitudes and a n increase in knowledge regarding the effects of loud sounds. There was a significant relationship between the i ncrease in knowledge and the reduction in positive attitudes towards noise. This current study found a lower prevalence rate compared to the literature, so prior epidemiologic studies may have over estimated the prevalence of NIHL among children.

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14 CHAPTE R 1 INTRODUCTION AND LIT ERATURE REVIEW The number of Americans living with hearing loss has soared to 30 million individuals ( Kochkin, 2009 ) losses can be ascribed to exposure to high intensity sounds from occupational and/or recr eational settings ( Crandell, Mills, & Gauthier, 2004 ) Hearing loss ( especially in the high er frequencies of 2k present in this frequency range) attributed to high intensity sounds is classified as noise induced hearing loss (NIHL). Hearing loss, including NIHL, is known to cause detrimental health effects, such as depression, anxiety, reduced cognition, and poor psycho social function ( Bess, Dodd Murphy, & Parker, 1998 ; Bloom, 2006 ; Co ll, Cutler, Thobro, Haas, & Powell, 2009 ; Davis, Shepard, Stelmachowicz, & Gorga, 1981 ) Since the mid 1930s, the dangers of noise on the auditory system within occupational settings have been recognized among professionals. This recognition has lead to regulations and laws, such as the Walsh Healey Act and the Hearing Conservation Amendment to reduce the number of American workers that would suffer from NIHL ( Berger, Royster, Royster, Driscoll, & Layne, 2003 ; Lusk, 1997 ; Suter, 2009 ) These laws require the implementation of hearing conservation programs (HCPs). However, there are no regulations against NIHL caused by recreational noise within the U.S. unlike other countries (i.e. Sweden) ( Ryberg, 2009 ) Thus, many America ns, including children and adolescents are being exposed to noise that has the potential to cause NIHL among various diverse groups without any protective regulation. One group that seems to have less vulnerability NIHL is African Americans. African Amer ican adults, compared to Caucasians and Hispanics, have the lowest

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15 prevalence of high frequency hearing loss ( Agrawal, Platz, & Niparko, 2008 ) On the other hand, African American children compared to other groups show no significant differences in the occurrence of NIHL ( Niskar et al., 2001 ) This generational difference between African Americans may be due to the change in hearing related behaviors, especially pro noise behaviors like listening to extremely loud music for e xtended periods of time. NIHL is preventab le and prevention would be accomplished by avoiding the initiation of risky hearing behaviors ( Caitlin, 1986 ; Dobie, 1995 ; Rogers et al., 2009 ) Ultimately, positive hearing health behaviors are dependent upon knowledge and attitudes toward noise. HCPs educate individuals about t he risks associated with noise and are effective in prevention of NIHL among all age groups ( Crandell et al., 2004 ) Therefore, the purpose of this study is to examine the differences in the prevalence of NIHL, and the attitudes and behaviors towards noise among African American Hispanic, and Caucasian children. This study also seeks to examine the correlation between measured NIHL and attitudes/ behavior towards noise among the study population. In addition, this study will examine the effectiveness of HCPs in changing knowledge, beliefs, and pro noise behaviors. Effects of Noise on the Auditory System NIHL, a term used to describe hearing loss af ter noise includes temporary threshold shifts (TTS) and permanent threshold shifts (PTS) that are caused by a variety of high intensity sounds ( Gunderson, Molinem, & Catalano, 1997 ) TTS and PTS are the products of the changes that high intensity sounds (which will be referred to as noise within this manuscript) produce within the auditory system, including mechanical damage, excitotoxicity or overstimulation of the hair cells, and oxidative stres s and

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16 production of free radicals. Mechanical damage to the auditory system from noise is generally caused by loud impulse noise or transient sound stimuli (i.e. gunshots) that cause physical damage to the sensitive anatomical structures. This damage inclu des but is not limited to ty mpanic membrane rupture, ossicular disarticulation, and the death of hair cells, especially the outer hair cells due to the intense vibrations of the noise ( Berger et al., 2003 ; D. Henderson, Bielefield, Harris, & Hu, 2006 ; LePrell, Yamashita, Minami, Yamasoba, & Miller, 2007 ) For insta nce, when loud transient noise enters the external auditory canal the sound vibrates the tympanic membrane The vibrations of the tympanic membrane set the ossicles in motion that disturbs the inner ear fluids, which causes a traveling wave along the basi lar membrane that causes damage to the hair cells that reside in the Organ of Corti. Further, the force of this wave has the potential to create a large shearing motion of the stereocilia of the outer hair cells due to the extreme movement of the tectorial membrane that results in the stereocilia bending and breaking away from the outer hair cells which results in the subsequent demise of the outer hair cells ( D. He nderson et al., 2006 ; Jahn & Santos Sacchi, 2001 ; LePrell et al., 2007 ; Tanaka, 2009 ) Once the outer hai r cells (also referred to as auditory system amplifiers ) die, they do not regenerate With repeat ed exposure to intense noise the resulting hair cell death produces an irreversible and measurable permanent hearing loss ( Hu, Henderson, & Yang, 2008 ; Jahn & Santos Sacchi, 2001 ; Kopke et al., 1999 ) In addition, consta nt exposur e to continuous noise has detrimental effects on the cochlea. This process through which noise induced pathology develops within the cochlea incorporates a series of complex and intricate mechanisms that ultimately cause irreversible damage within the coch lea.

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17 One of the mechanisms of cell trauma is neural excitotoxicity due to the release of the excitatory neurotransmitter glutamate. With excessive noise exposure, the hair cells dendritic terminals of the auditory nerve afferent fibers can swell; this sw elling is due to the release of large amounts of glutamate into the synapse of type I fibers of the auditory nerve by hi ghly active inner hair cells responding to loud noise exposure ( D. Henderson et al., 2006 ; Kopke et al., 1999 ) Glutamate also cau ses large sodium and potassium ion fluctuations that cross to post synaptic structures creating osmotic imbalance, which results in the entry of fluid within the cells pr oducing swelling and rupturing of cell membranes and cell degeneration ( LePrell et al., 2007 ) Excitotoxicity is related to another mechanism that produces NIHL within the cochlea which is oxidative stress and the formation of free radicals ( Harrison, 2008 ) Free radicals are molecules with one or more unpaired electrons that can cause instability in the electron arrangements of stable molecules for reviews see D. Henderson et al. (2006 ); LePrell et al. (2007 ) The cochlea has numerous tissue types that are metabolically active ; reactive oxygen specie s (ROS) are produced during cell energy metabolism These molecules act as free radicals and/or are capable of creating fr ee radicals, such as : superoxide, hydroxyl radical, and hydrogen peroxide ( D. Henderson et al., 2006 ; Jahn & Santos Sacchi, 2001 ; Kopke et al., 1999 ) Sound exposure increases metaboli c activity wi thin the cells in the Organ of Corti, especially in the outer hair cells and the strial cells. The literature has shown that noise exposure specifically increases the mitochondrial free radical formation ( D. Henderson et al., 2006 ; Kopke et al., 1999 ; LePrell et al., 2007 ) According to Henderson et al. ( 2006 ) ROS (i.e. superoxide) are created as the byproducts of the mitochondria efforts to

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18 provide energy to the hair cells in the presence of acoustic overstimulation due to hazardous noise exposure. Hence, as sound intensity increases, cochlear blood flow, endolymph oxygenation, and glucose uptake decreases generating an optimal environment for free radical production. Free radicals, such as hydroxyl radicals, damage DNA, especially within the marginal cells of the stria vas cularis and the outer hair cells ( LePrell et al., 2007 ) s initiated ( Cheng, Cunningham, & Rubel, 2005 ) Associated Health Consequences of NIHL NIHL, like other hearing losses with varying etiologies (i.e. pre sbycusis or hearing loss due to old age), causes negative health consequences, such as communication breakdown s, depression, and other psycho social problems ( Tharpe, 2 008 ; Tharpe & Bess, 1999 ) Depression among individuals with hearing loss is also a prevalent psychological dilemma that affects the quality of life and enjoyment ( Daniel, 2007 ; Fausti, Wilmington, Helt, Helt, & Konrad Martin, 2005 ; Stansfeld & Matheson, 2003 ) Children with minimal and mild unilateral or bilateral hearing loss often have difficulties in communication, emotions, and psychosocial function ( Tharpe & Sladen, 2008 ) According to Tharpe and Bess ( 1999 ) hearing loss may result in of poor psychosocial function includ ing common break downs in family communication that may lead to family tension and social isolation. Loneliness is an effect that adolescents that self identify as having a hearing loss report more compared to normal hea ring adolescents ( Kent, 2003 ) This trend is due to the num erous communication breakdowns caused by poor speech perception caused by hearing loss. Hearing loss also increases dysfunction in self esteem, behavior, energy, stress management, performance, and

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19 social competence among children ( Stansfeld & Matheson, 2003 ; Tharpe & Bess, 1999 ; Tharpe & Sladen, 2008 ) Behavioral pr oblems present in children and adolescents with hearing loss also include social withdrawal, uncooperative behaviors (i.e. lack of participation in group activities) and aggression. Coll, Cutler, Thobro, Haas, and Powell ( 2009 ) reported hard of hearing/deaf adolescents demonstrate more risk to self (i.e. risk of suicide, self harm, and victimization) and aggression toward people and animals compared to normal hearing peers The high rates of aggression can be attributed to frustration due to the inability to communicate effectively between peers and family members. In addition, noise can cause impaired cognitive function. excessive exposure to noise affects central process ing, language comprehension, and attention in the form of being less able to multitask in the presence of noise (i.e. background noise caused by multiple talkers) ( Dani el, 2007 ; McFadden & Pittman, 2008 ; Stansfeld & Matheson, 2003 ) A study evaluating students with hearing loss in Iowa schools found that children with minimal hearing loss had language measures that illustrated a gap between the instance, the vocabulary of 8 year old children with hearing loss was as much as 3 years behind their normal hearing peers at that age ( Davis et al., 1981 ; McFadden & Pittman, 2008 ) The typical classro om setting tends to be a noisy and reverberant place. Children with minimal hearing loss will have a greater difficulty maintaining performance on a secondary task (e.g. taking notes in class) while performing the primary task of listening (e.g. listening to lecture). This, in turn will affect their academic performance,

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20 due to poor speech perception and an inability to allocate cognitive resources needed for learning ( McFadden & Pittman, 20 08 ) W ith deficits in language comprehension and other cognitive function, children with minimal hearing loss have an obstacle to overcome when it comes to learning and attaining an education. Educationally significant hearing losses, including NIHL, ca n Hearing loss is often related to the diminished academic performance among this population ( Kawada, 2004 ; McFadden & Pittman, 2008 ; Tharpe, 2008 ) Hearing loss at high tive sounds (e.g. / f / or / s / ) which can lead to decreased speech discrimination for differentiation of words and overall performance in school. Bess et al. ( 1998 ) reported that young children with minimal sensorineural hearing loss (MSHL) scored significantly lower on the Comprehensive Tes t of Basic Skill (4 th edition), displayed more behavioral problems and had lower self esteem compared to normal hearing children. Also, 37% of the children with MSHL were reported to have failed at least one grade level a striking difference compared to the school district average of 8% failing at least one grade Noise also affects children by creating psychological vulnerability in the form of anxiety and annoyance C hildren may perceive noise as menacing and may have a greater inability to habituat e to loud sounds within their environments ( Erlandsson, Holmes, Widen, & Bohlin, 2008 ; Lusk, 1997 ; Stansfeld & Matheson, 2003 ) Some of the poor outcomes associated with NIHL or hearing loss mentioned previously (i.e. poor academic performance, low self esteem, poor social competence and family

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21 dysfunction) may lead to other risky health behaviors, such as greater likelihood of smoking or abuse of alcohol or drugs ( Kent, 2003 ; Spear & Kulbok, 2001 ) Noise can also cause various other (non auditory) physiologi cal ailments that poorly affect quality of life for individuals of all ages. These non auditory problems include increased stress, inability to concentrate, lack of sleep, eleva ted blood pressure, and increased heart rate ( Daniel, 2007 ; Erlandsson et al., 2008 ; Kawada, 2004 ; Stansfeld & Matheson, 2003 ) Noise has a great effect on blood pressure in which workers in hazardous noise environments of continuous noise levels of 85 decibels A we ighted (dBA) have higher blood pressure that those not exposed to noise, which can increase the risk of mortality for these workers ( Stansfeld & Matheson, 2003 ) Gender Differences Among NIHL There is a clear gender di fference in the prevalence of NIHL. Niskar et al. ( 2001 ) estimated the prevalence of noise induced hearing threshold shift (NITS) among children 6 to 19 years of a ge in the United States. The overall prevalence of NITS in one or both ears was 12.5% ( approximately 5.2 million children based on population of the US ) A higher prevalence was observed in males than females and a higher prevalence of NITS was observed in children aged 12 to 19 years compared to 6 to 11 year olds Shargorodsky, Curhan, Curhan, and Eavey (2010 ) showed that females had lower prevalence of high f requency hearing loss (10.1%) compared to males (15.3%) when they repeated the NHANES analysis and extended it to more recent sampling years. Recently E. Henderson, Testa, and Hartnick (2011 ) reported the odds of NITS and the odds of HFHL were less for females compared to males; however, the odds or rate of NITS among females increased faster compared to males.

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22 Young males are more likely to engage in hea ring related risk behaviors than young females ( Vogel, Brug, van der Ploeg, & Raat, 2007 ; Vogel, Verschuure, van der Ploe g, Brug, & Raat, 2009 ) A study by Widen, et al. ( 2006 ) examined the differences between American and Swedish young adults regarding attitude towards noise and th e use of hearing protection at concerts. U.S. men held the most positive attitudes towards noise (pro noise), and women from Sweden held the most negative attitudes towards noise. In both cultural groups, females were more likely to express negative attitu des toward noise than their male counterparts. Occupational HCP versus Educational HCP There are numerous laws and regulations that are enacted for the protection of American adult workers from work related noise hazards that include: the Walsh Healey No ise standard and the Occupational Safety and Health Administration (OSHA) 1983 Hearing Conservation Amendment. The Hearing Conservation Amendment requires the use of permissible exposure level (PEL) or the maximum noise exposure of 90 dBA during an 8 hour workday (Walsh Healey standard) and/or an action level of 85 dBA during an 8 hour workday and the implementation of hearing conservation programs (HCPs) and the use of hearing protective devices in the workplace ( Berger et al., 2003 ; Lusk, 1997 ; Rogers et al., 2009 ) OSHA requires that Occupational HCPs include noise measure ment and monitoring, audiometric testing, use of hearing protection devices, employee education and training, record keeping, and program evaluation for effectiveness ( Berger et al., 2003 ; National Institute of Occupational Safety and Health, 2009 ; Rogers et al., 2009 ) Unlike Occupational HCPs, Educational HCPs are targeted to children and focus on education and training rather than monitoring and record keeping E ducation and

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23 motivation of children regarding positive hearing health behaviors toward noise is the key focus of E ducational HCPs. When comparing the education component of Occupational HCP versus an Educational HCP, multiple differences exists. There are seven required topics that should be included during the implementation of the education component of an Occupatio nal HCP that include the following: (1) requirements of and rationale for the occupational noise standard, (2) effects of noise of hearing protection devices, (6) audio metric testing, and (7) importance of individual responsibilities for preventing hearing loss ( National Institute of Occupational S afety and Health, 1998 ) The main components of an Occupational HCP that are similar to HCPs targeted to children and adolescents include: (1) characteristics of noise and the sources of noise, (2) anatomy and physiology of the ear and noise damage, (3) effects of noise, (4) warning signs of NIHL, and (5) hearing protection devices ( Rogers et al., 2009 ) The awareness and precautions of NIHL are well known for adults compared to children due to their exposure to hazardous noise within the work environment. The t prevalent irreversible work in hazardous noise environments that may eventually result in NIHL for some individuals ( Robertson, Kerr, Garcia, & Halterman, 2007 ; Smith, 1998 ) Important laws and regulations were enacted to protect employees f rom hazardous noise exposure in industries that have noise, such as agriculture, mining, manufacturing, and the military ( Berger et al., 2003 ; Rogers et al., 2009 ) However, there are no regulations that

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24 specifically protect individuals from recreational noise, such as noise from hunting or attending clubs or discotheques within the United States. The re is great uncertainty of how to ass ess the dangers of recreational noise exposure among young populations because of the great difference in how one is exposed to recreational noise and the variety of this type of noise versus occupational noise. Occupat ional noise regulations set by OSHA or stricter measures recommended by NIOSH have been used as proxies for establishing safe exposure levels for recreational noise from toys, MP3 players, urban areas, and transportation sounds. Specific assumptions must b e made when predicting noise. For instance, within the literature of MP3 players and NIHL, the risk for NIHL is often treated as equivalent to exposure to occupational noise ( Keppler et al., 2010 ; Vogel, Brug, Hosli, van der Ploeg, & Raat, 2008 ) For example, it is assumed that a MP3 player delivering sound at a particular exposure level (i.e. 90 dBA) has the same potential for causing NIHL as if the exposure were an occupational exposure Because many exposures are shorter and less frequent some authors think that NIHL is very unlikely. However, there is no knowledge of the possible rep ercussions of listening to MP3 players for 10 years of varied amounts of time throughout the day and how that will C urrent noise standards and/or regulations may not be the best measure of prevention, bu t it is the best available guide for designing Educational HCP for children. Thus, what is needed is for audiologists, hearing scientists, and those in the profession of preserving hearing to be proactive when it comes to NIHL. What is known is that the effects of NIHL are detrimental; even

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25 though, the acquisition of NIHL can be presumptuous in some cases, yet there are effective preventative measures, such as educational HCPs. T here are no regulations for the implementation of Educational HCPs within th e school setting E ven though over the past 30 years the recommendation of implementing Educational HCPs within the school setting has been stressed numerous times, little action has been taken to integrate Educational HCPs within school systems nationwide ( Chermak, Curtis, & Seikel, 1996 ; Folmer, 2008 ; Roeser, Coleman, & Adams, 1983 ; Weichbold & Zorowka, 2007 ) NIHL is completely preventable with proper instruction on the means to combat the effects of noise Fortunately, there are now several Educational HCPs with curr iculum targeted to children and adolescents. Educational HCPs and Resources for Children There are various agencies and organizations that have created resources for the prevention of NIHL among children of all ages. Some of the resources are complete HCP s aimed at NIHL prevention Others provide information regarding anatomy and physiology of the auditory system, types and degrees of hearing loss, and the risks of noise O ne must be very careful when researching Educational HCPs targeted to children. HCPs are often incorrectly considered to be synonymous with early identification and intervention programs within the public school setting or public arena. Various states, such as Montana (Montana Office of Public Instruction) and California (California Depar tment of Health Care Services and Children Medical Services) have statewide HCPs that are simply hearing loss screening, testing, and monitoring programs without the aspect of educating students about hearing loss, prevention measures, and the poor hearing related health outcomes caused by noise exposure

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26 ( Anderson, 1992 ; Californi a Department of Health Care Services, 2009 ; Montana Office of Public Instruction, 2008 ) One created b y the National Hearing Conservation Association (NHCA). The Crank It Down education for children and adolescents (HCECA) ( Meinke, 2009 ) protection was to start young by instilling an appreciation for hearing so that use of hearing protection would be akin to wearing se atbelts or bicycle helmets. By 1999, the NHCA had provided more than 250 copies of Crank It Down training videos. The Crank video by the Sight and Hearing Association, a nd audio demonstrations of hearing loss and hearing protection. Dangerous Decibels is another Educational HCP that was created from the collaboration between the Oregon Museum of Science and Industry (OMSI), Oregon Health and Science University, and the Or egon Hearing Research Center. This partnership created an Educational HCP that has curriculum that can be modified for children grades K 12 with numerous videos, games, and hands on activities ( Dangerous Decibels, 2009 ; Martin, 2008 ) These activities are also provided in educator kits for purchase. Au diologists, teachers, and other health educators may also attend workshops geared to the effective teaching of this program for a nominal fee. In addition, the OMSI, a partner of Dangerous Decibels, houses a permanent exhibition of this program with a life size ear. Dangerous Decibels has been tested for efficacy in changing attitudes/behaviors, but the latter has not been formally evaluated ( Griest,

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27 2008 ) partners ( House Ear Institute, 2009 ) This program is based on an online program which targets middle and high school students. The program engages teens with audio visual demonstrations on NIHL and NIHL prevention measures. Also, student participants are provided flyers, earplugs, and opportunities to Know Noise is a HCP that is targeted to younger children in grades 3 6. This hat includes: 26 lesson plans, transparencies, learning activities, technical information, supplemental articles and resources, audio and video, and earplugs ( Sight and Hearing Association, 2009 ) Another comprehensive program by the Military Audiology Association targeted to young children in grades 2 to 5 is titled Operation BANG (Be Aware of Noise Generation). It was initially created to be hour long presentations covered over a period of three days for 5 th graders only. Fifth grade was chosen because most states require he aring screenings at this grade level ( Roeser, 1980 ; Roeser et al., 1983 ; Waldo, 2009 ) This program can be modified into a 45 minute presentation for all elementary grade of effects of noise on hearing and the importance of protecting hearing). Supplemental items like pencils, pens, and stickers are also available. The S ound Sense HCP comes from our neighbors to the north, the Hearing Foundation of Canada. This bilingual program comes in English and French versions

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28 and is ( Hearing Foundation of Canada, 2009 ) This Educational HCP focuses on teaching t weens or preteens about the hazards of over exposure to noise. The Educational HCP can be taught in 30 minute increments or an hour long presentation. Sound Sense consists of a 10 minute video, evaluation forms. This program is the only program that has a built in method of measuring the effectiveness of the program by providing means of evaluating the HCP. Further, this program suggested student projects for teachers to assign to students as pre paration for the topic of hearing and NIHL or post program homework or class assignment. Wise Ears! is another bilingual program that comes in English and Spanish versions. Wise Ears! was created by the National Institute on Deafness and Other Communicativ e Disorders (NIDCD) and targets children and adolescents in grades 3 to 8 ( National Institute on Deafness and Other Communicative Disor ders, 2009b ) This HCP provides resources for kids, teachers, parents, and the public. There are age appropriate information materials, activities, and videos that teachers can modify for their students. The objective of Wise Ears! is to increase awarene ss regarding NIHL among all audiences and motivate these audiences to take action in preventing NIHL. Recently, the NIDCD targets children between the ages of 8 to 12 years. This campaign also provides resources for kids, parents, and the community. There may be a limited amount of currently available Educational HCPs targeted for children, yet a myriad of resources for NIHL awareness and prevention exists free of charg e or for a small nominal fee. The American Academ y of Audiology (AAA) provides

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29 excellent resource s for everything related to the ear from information on vestibular camp aign, an internet based resource ( American Academy of Audiology, 2009 ) The about NIHL, hearing los s in children, and audiologists. In addition, this campaign provides various worksheets on a number of topics such as the anatomy of the auditory system and posters. The American Speech Language and Hearing Association (ASHA) also has an internet based res ( American Speech Language and Hearing Association, 2009 ) The campaign has two mascots, the buds, which represent the earbuds that are commonly used to lis ten to MP3 players. This campaign provides an interactive website that children, parents, and educators may visit. This site has numerous factoids and games regarding NIHL, NIHL prevention, the auditory system, and proper MP3 usage. ASHA has also partnered with NIDCD to provide an Campaign website ( National Institute on Deafness and Other Communicative Disorders, 2009a ) Another excellent resource is provided by the National Aeronautics and Space Administration (NASA) acoustical testing laboratory ( National Aeronautics and Space Administration, 2009 ) educational resources that promote NIHL preventio n. Single copies of their media (auditory demonstrations and animations), games, and activity sheets are provided free of charge for the purpose of use in HCPs.

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30 It may be easy for health care providers, especially audiologists, to advise adolescents to avo id loud sounds and reduce time spent in those environments due to the knowledge audiologists have already attained. But would children recognize a sound as too loud or know how long of a listening period is dangero us to the auditory system? Hearing educat ion programs must provide truthful information so that children may feel empowered with their knowledge that will increase their confidence and self efficacy to make changes to their behaviors. For instance, a common topic covered in hearing conservation p rograms for adults and hearing education pr ograms for children is the noise exposure limit guideline s of NIOSH. NIOSH has created permissible noise exposure levels using a limit of 85 dB for 8 hrs and an exchange rate of 3 dB, to predict maximum time of e xposure before permanent damage will take place if repeated ( Berger et al., 2003 ; Katbamna & Flamme, 2008 ; Lusk, 1997 ) For instance, a sound environment of 91 dB equals a maximum listening per iod of two hours. If children listen to their MP3 players at 91 dB (many MP3 players produce sounds exceeding 90 dB) and listen to their music for longer than two hours at a time daily over several years they may caus e irreversible damage to their auditory systems ( Roeser et al., 1983 ) Thus, educating children is imp erative because many children may simply be unaware that their recreational listening habits may cause damage to their hearing. Educational HCPs have certain components to be effective. According to Lass et al. ( 1987 ) instruction regarding normal auditory mechanism s, 2) types of hearing loss and their causes, 3) noise and its effect on hearing, 4) warning signs of NIHL, and lastly 5) specific recommendations for preventing noise

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31 components were reiterated by Anderson (1992 ) who suggests that NIHL curriculum should provide information on how the ear works, how noise can damage hearing, describe hearing loss and how hearing loss affects quality of life, illustrate the types of noise and noisy activities that are risks to hearing, provide warning signs of NIHL and components are modeled from successful Occupational HCPs for employees. If all these essential components are incorporated, then an Educational HCP for children has the potential to be an effective health prevention program. For instance, Operation BANG provides information on the physics of s ound and the function of the auditory system, the identification of warning signs of hearing loss, the effects of noise on hearing, and prevention of NIHL. By having these components, Operation BANG fulfills several goals of an effective Educational HCP; h owever, the method in which the HCP is given is also as important as the information provided. Weichbold and Zorowka ( 2007 ) implemented a variety of didactic approaches to ensure that the topic of hearing conservation was as attractive as possible for the high school students enrolled in their Educational HCP. The dynamic approaches included multi media presentations, role play, demonstrations of protective devices and hearing aids, group work, questionnaires, and discussions with persons with hearing loss and tinnitus. These were all used loud sounds. Thus, the mentioned Educational HCP has a multimedia component (either audio and/or visual demonstrations). Further, Folmer ( 2008 ) stated that Educational HCPs for children/adolescents must be as interactive as possible, and the use of a variety of media and activities are necessary for successful programs.

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32 Chermak et al. ( 1996 ) recommend that instruction of Educational HCPs should not rely only on information based on textbooks or class instruction in the traditional lecture format. Instead, the use of peer teaching to promote peer leadership or the use of supplemental activities (games, posters, and multimedia) should be steps to make a pro gram more interactive. These researchers found that students gained more knowledge from an Educational HCP taught in a more interactive format compared to a traditional lecture format ( Chermak et al., 1996 ; Folmer, 2008 ) Also, an effective program must have knowledgeable instructors of the course and the material. According to Rogers et al. ( 2009 ) instructors of the Educational HCP must be qualified to teach the material, confident and able to present content appropriately; therefore, an ill trained instructor will not be able to convey the importance of the material or gain respect from participants. Audiologists are more than qualified to instruct Educational HCPs in the school s etting with their extensive knowledge of hearing /hearing loss and their constant skills in relaying information to parents, patients, teachers, and other health care providers. In a pilot study, Dell and Holmes (2012 ) found that a single presentation of an educational HCP was effective in significantly reducing pro noise attitudes among adolescents. Thus, over the years the literature has revealed that E ducational HCPs are effective by changing knowledge, awareness, and motivation ( Borchgrevink, 2003 ; Chermak et al., 1996 ; Daniel, 2007 ; Roeser et al., 1983 ; Weichbold & Zorowka, 2007 ) Effectiveness was generally mea sured by three methods : 1) by examining if the Educational HCP contains all the essential components necessary for an effective Educational HCP mentioned previously 2) by examining the change in knowledge,

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33 awareness, and intentions to change behavior thr ough qualitative (i.e. focus groups) and/or quantitative (i.e. surveys or questionnaires) methods and 3) by measuring the actual change in behavior (e.g. wearing earplugs at a concert) or a significant decrease in hearing acuity from baseline audiometric measures. Weichbold and Zorowka ( 200 7 ) stress the third method of evaluation for effectiveness should be the true measure of Educational HCP effectiveness. This is due to a general lack of studies using this method as the criteria for effectiveness. These researchers assert this belief bec ause the ultimate goal of Educational HCP is the prevention of NIHL; subsequently, only a reduction in NIHL will prove the effectiveness of an Educational HCP. Conversely, there are studies that report changes in behavior, especially in the form of adolesc ents increasing their use of hearing protective devices ( Borchgrevink, 2003 ; Knobloch & Broste, 1998 ) Weich theoretical viewpoint. Many health care experts follow and believe in a particular theoretical framework to explain certain health behaviors. In contrast to Weichbold and Zorowka (2007 ) other researche rs that use a change in knowledge, awareness, or motivation as the measure of effectiveness follow ing the constructs of the Health Belief Model ( Daniel, 2007 ; Rosenstock, Strecher, & Becker, 1988 ) Based on this model, individuals must first acquire awareness and knowledge This knowledge allows them to perceive their susceptibility to acquiring hearing loss, under stand that the effects of NIHL can be severe, and understand the perceived benefits and barriers of taking preventative actions before a change in behavior is made. Even though Weichbold and Zorowka make a valid point, it is unfair to reduce the importance of changing knowledge

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34 as a measure of effectiveness because researchers differ in their selection of a theoretical framework that may guide their research. Racial/Ethnic Group Disparities and NIHL The beginning of the 21 th century marked a substantial gro wth in the diversity of people within the United States with approximately 25% of the population being part of a minority group based on the 2000 Census ( U.S. Census Bureau, 2000 ) It is projected by the year 2050, that the United States will become a majority minority nation in which Caucasians will make up less than 50% of the population ( LaVeist, 2005 ) Hence, it is becoming more imperative that as a nation we examine and understand the health status of racia l minorities within this nation. T hese groups tend to present more health disparities, such as having higher rates of health conditions such as diabetes, heart disease, and respiratory diseases ( LaVeist, 2005 ) Health Disparities are the adverse health conditions that exist among specific popu lation groups in the United 2004; LaVeist, 2005). Hispanics represent 16.3% of the U.S. population making Hispanics the largest minority group in the U. S. ( U.S. Census Bureau 2010 ) This r acial group has grown rapidly from approximately 15 million in 1980 to over 50 million in 2010. This minority group present with lower mortality rates than non Hispanics, such as in males aged 55 or older, which is paradoxica l due to lower socio economic s tatus ( SES ) and lower access to health care services (LaVeist, 2005). A recent epidemiolog ical study by Shargorodsky et al. (2010 ) using NHANES data reported that Hispanic children

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35 presented with the lowest prevalence of NIHL (14.8%) compared to Caucasians (17.6%) and African Americans (17.2%) African Amer icans make up approximately 13.6 % of the U.S. population, which makes them the third largest racial/ethni c group in the count r y, which more than half of the African American population lives in the southern regions ( U.S. Census Bureau, 2000 ) African Americans, compared to other racial groups, have higher mortality rates and higher rates for serious health conditions. For instance, African Americans have the highest infant mort ality rate with approximately 13.4 deaths per 1,000 live births compared to an infant mortality rate of 4.6 deaths per 1,000 live births among Asians ( LaVeist, 2005 ) Also, the prevalence of health conditions, such as HIV/AIDs, hypertension, and diabetes, are higher among African Americans. This racial group also has the highest poverty rates with those living at or below the federal p overty level with 25.8%, 25.3%, 12.5%, and 12.3 %, for African Americans, Latinos, Asians, and Caucasians, respectively ( U.S. Census Bureau, 2009 ) Thus, high poverty rates and low SES may facilitate higher rates of mortality and morbidity among African Americans and other groups due to the lack of resources (i.e. educa tion and economic) that limit the access to healthcare when compared to other groups with more resources ( LaVeist, 2005 ) There is v ery little literature regarding racial/ethnic differences among African Americans Hispanics, and other groups regarding NIHL. However, from the limited research, it can be gleamed that African Americans, both adults and children, have a lower prevalence o f NIHL. In the Third National Health and Nutrition Examination Survey (NHANES III), African American children had the lowest prevalence (11.7%) of

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36 high frequency hearing loss or NIHL compared to Caucasian children (12.3%) and Latino children (15.1%) ( Niskar et al., 2001 ) yet there is no statistical differences between these groups. Additionally, data from the National Health and Nutrition Examination Survey (1999 200 4) revealed that African American adults had significantly lower prevalence of high frequency hearing loss in one or both ears compared to Caucasians and Latinos ( Ag rawal et al., 2008 ; Lee, Gomez Marin, Lam, & Zheng, 2004 ) The overall prevalence of high frequency hearing loss among African Americans was 19% compared to 36% among Caucasians and 27% among Latinos. Recent research showed that Hispan ic children present with a lowest prevalence of hearing loss compared to other racial groups, but Hispanic adults presented with higher prevalence of hearing compared to African Americans. Thus, one c ould assume that African Am ericans have specific knowledge and behaviors regarding the protection of the auditory system from noise. However, a study by Crandell, Mills, and Gauthier ( 20 04 ) examined differences in knowledge, behaviors, and attitudes of African American students compared to Caucasian students at the University of Florida. The data revealed that African American students were consistently less likely to correctly identify symptoms of excessive noise and the risk of hearing damage compared to their Caucasian counterparts, yet these students knew that excessive noise could cause damage to the auditory system. Thus, how does this paradox exists? African Americans generally te nd to show disparities in health, which can be seen in the high morbidity and mortality rates, but when it comes to NIHL, the African American adult population has seemed to have escaped this health condition. On the other hand, NIHL also depends on an susceptibility; African

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37 American children may have an auditory protection mechanism in the form of increased membrane, modialus, and the vestibular org ans ( Barrenas & Lindgren, 1991 ) Conversely, no significant differences in hearing have been reported between Caucasian Hispanic, and African American children. Could the lack of differe nces in risk behaviors between these groups of children be causing the gap between groups to decrease? Purpose The danger of NIHL is a great concern among adults; now NIHL is a great concern among children and adolescents. NIHL among children and adolescen ts causes negative consequences that affect their quality of life ( Lusk, 1997 ) The risk of acquiring NIHL among children that are exposed to noise is due to effects of recreational noise on their vulnerable auditory systems, the effect of enga ging in risky hearing health behaviors, and the effect of their perceptions of noise. Thus, individuals from different racial/ethnic groups with varying socio economic status ( SES ) levels hold different beliefs and life experiences. These beliefs and expe riences may or may not include information regarding hearing. There is limited research regarding the racial/ethnic differences in attitudes and behaviors towards noise among children that may lead to differences in the prevalence of NIHL and hearing prote ctive behaviors among racial/ethnic diverse children. Hence, the purpose of this study is to investigate possible differences in attitudes, knowledge, behaviors (protective and risky), and the presenc e of NIHL among African American, Hispanic, and Caucasia n children. In addition, the influence of s everal social determinants ( gender, age, etc.) on the attitudes towards noise and hearing related

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38 behaviors that prevent or lead to NIHL w as examined to possibly rectify the paradox of knowledge of NIHL and prevalence of NIHL. Thus, to what extent does race/ethnicity play a role in the attainment of positive or negative attitudes and beliefs towards noise, use of hearing protective behaviors, and the development of NIHL among African Ame rican Hispanic, and Caucasian children? As a result, the following research hypotheses were created. First, attitudes and knowledge of NIHL will vary with race in African American Hispanic, and Caucasian children W ithin group difference s based on gender (i.e. African American males versus African American females) are also expected. Thus, African American children especially African American males will have more positive attitudes towards noise (pro noise) and a lower prevalence of NIHL compared to Cauc asian and Hispanic count erparts. This is due to the so cial and cultural situation (i.e. cultural identity of the African American and Hispanic children who may promote more pro noise attitudes and risky behaviors Further, Caucasian children, e specially females will display the most conservative attitudes toward noise compared to African American and Hispanic children. This will be attributable to the higher likelihood that the Caucasian parents are have attained higher education, and may unders tand the risk of noise and may l ive in quieter, more affluent physical environments. In addition, Caucasian females will also be more knowledgeable than the other racial groups. Caucasian children will be the most knowledgeable compared to the other race/e thnic groups. Second, an educational HCP will be found to be an effective method in changing knowledge, attitudes, and behaviors among diverse groups of children. Within the literature,

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39 Educational HCPs are very effective in changing knowledge and attitude s, yet change in behavior is rarely accessed.

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40 CHAPTER 2 METHODS Participants Racially diverse children in the fourth and/or fifth grades (aged eight to twelve years) were selected to participate in this project. This age bracket was chosen due to two r easons (1) the ability to complete the pre and post test measures and (2) the health or positive health messages has greater influence on children if they are exposed to these messages earlier in life (before adolescence) versus later in childhood. For example, the health promotion of wearing sun protection (i.e. sunscreen) to prevent skin cancer among children is more effective in younger children in which various research of sun protection inte rvention programs show that the most effective intervention programs are targeted to children at younger ages. According to Olsen et al. (2007), the creation of the SunSafe Program for children aged 2 to 10 years old was highly effective in promoting healt hy sun protective beliefs and behaviors. When children are exposed at a younger age to hearing protective education and behaviors, the more likely they will NOT engage in risky hearing behaviors ( Folmer, 2008 ; Howarth, 2008 ) Ethics of working with Special Populations When working with vulnerable populations, such as children, researchers must ensure the safety and c onfidentiality of the participants. The Institutional Review Board (IRB) approved this protocol before study initiation (IRB protocol #592 2010). This protocol involves no more than minimal risk ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests. All the data collected was de identified for the confidentiality of

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41 each participant. The informatio n is stored in a locked secured room that will be only accessible to core investigators and graduate students. All focus groups were audio taped and transcribed for content analysis. Further, during transcription of the focus groups no participant identifi ers were recorded with transcribed data. Only de identified text files were shared with investigators and graduate students. Parental consent was obtained via participant. Written consent was obtained in the letter format based on IRB 1 written informed concept form template on University of the informed consent for his/her records and to return one signed copy to the investigators. The children signed assent consent f or participation in the study. The parental consent form and assent form specified the purpose of the research, the study protocol, and the time length required for participation. All partici pants had the right to withdraw from the study at any time. Sampl ing and Recruitment Study participants were recruited from two elementary schools within Osceola County located near Kissimmee, FL and the Boys and Girls Club of Alachua County and the O2Bkids within Alachua County in Gainesville, FL based on access to div erse populations. The two elementary schools that were chosen for participant recruitment included Neptune and Reedy Creek elementary schools. Participants from Neptune elementary were recruited from the fourth and fifth grades compared to the participants recruited from the fifth grade from Reedy Creek elementary. Neptune elementary is an A receives free/reduced lunch in the 2011/2012 school year. The racial make up of the students in the fourth grade

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42 was as follows: Caucasian children 27%, African American children 11%, and Hispanic children 59%. The racial make up of the students in the fifth grade was as follows: Caucasian children 19%, African American children 10%, and Hispanic children 69% ( Florida Department of Education, 2012 ) Reedy Creek elementary school is also an A rated school that had 70.16% of the student popula tion receives free/reduced lunch during the 2011/2012 school year. The racial make up of Reedy Creek elementary fifth grade students were 18% were Caucasian children, 20% were African American children, and 57% were Hispanic children. The racial/ethnic gro up populations at both the percentage of Caucasians equal to 43.2%, African Americans equal to 22.9%, and Hispanics equal to 27.9% Measures and Materials Materials th at were used in this study include the following equipment: Welch Allan otoscope, Grason Stadler (GSI) 17 a udiometer, GSI 37 Auto Tymp T ympanometer, GSI AudioScreener+ distortion product otoacoustic emission machine, a hearing conservation program, and cas e history and questionnaire forms (pre and post). The hearing conservation program was a modification of the Dangerous Decibels program. Dangerous Decibels is a highly interactive and evidence based program targeted to children in grades K 12 ( Folmer, 2008 ; Martin, 2008 ) The pre measure comprised of a case history section and questionnaire that included questions pe rtaining to demographics (5 questions), children habits and knowledge (14 questions modified from Dangerous Decibels 4 th grade questionnaire), and the Youth Attitudes to Noise Scale ( S. E. Widen et al., 2006 ) (YANS, 19 questions modified for age level). The post measure include the same case history and questionnaire questions as mentioned

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43 previously with the exception of having 13 questions to measure children habits and knowledge (modified also from the Dangerous Decibels 4 th questionnaire). The case occupation. The questions from the Dangerous Decibels 4 th grade questionnaire ( Griest, 2008 ) related behaviors. The YANS have four main categories of questions that include: attitudes towards noise associated with youth culture (8 items), attitudes to wards daily noises (3 items), intention to influence sound environment (4 items), and attitudes towards the ability to concentrate in noisy environments (4 items). These four categories had a four factors solution performed and the alpha values are alpha 78 for attitudes towards noise associated with youth culture, alpha .72 for attitude towards daily noises, alpha .53 for intention to influence sound environment, and alpha .66 for attitudes towards the ability to concentrate in noisy environments ( S. E. Widen & Erlandsson, 2004 ) Procedures All of the participants were randomly divided into two groups con trol and experimental The two groups were cross balanced by the order in which they received the pre measure and the audiometric testing. Thus, t he participants in the control group either received the audiometric testing prior to receipt of the pre measu re or they received the pre measure prior to the audiometric testing. Cross balance of the order may identify any possible modification to pre measure answers due to the awareness of NIHL that audiometric testing in itself may arise. The experimental group was also cross balanced for test order ; and they received a 50 minute interactive presentation of

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44 the hearing conservation program. The control and experimental groups both received the post measure four to seven weeks after completing the pre measure. A ll participants received an audiometric test in a quiet room in their elementary schools or community center. The audiometric protocol include d hearing tests with otoscopy, tympanometry, otoacoustic emissions, and pure tone audiometric screening. The audio logic test took approximately 15 20 minutes to complete. Universal health precautions were executed for each and every hearing test. Otoscopy was performed on each participant to examine the external ear canals for excessive cerumen, infection, and irritat ion and inspection of the tympanic membrane If a participant had excessive cerumen, infection, irritation, or inflamed tympanic membrane, the participant was provided a parental notification letter for further medical follow up or was referred to the scho ol nurse. Once the external ear canal was deemed free of cerumen or the tympanic membrane free of any abnormalities, tympanometry was performed to evaluate the middle ear function. The tympanometric descriptive system was used to classify the middle ear r esults; therefore, any participants with a Type B or Type C tympanogram was also provided a parental notification letter for further medical follow up or was referred to the school nurse. Distortion Product Otoacoutic Emissions (DPOAEs) tests were used to measure the integrity of the outer hair cells cells that are highly sensitive to high intensity sounds. The otoacoustic emissions device was set in a screening mode for the high frequencies (2000, 3000, and4000Hz) at 65/55 dB levels. The next testing measu re for the participants was an audiometric screening that was given at 1000, 2000, 3000, 4000, and 6000 Hertz (Hz) in the right and left ears. Each participant was asked to indicate when he or she heard the tone by stating that he or

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45 she heard a tone by sa ying yes or raising his or her hand. Hearing will be screened at 15 dB HL. In the event that a child does not respond at that intensity, a modifie d Hughson having hearing loss. Thus, these participants were retested at least two weeks l ater to access permanency of the elevated thresholds. In the advent, a participant with retested results of greater than 20 dB at any frequency during the second hearing test was provided a parental notification letter for further medical follow up for a c omplete audiologic evaluation and/or was referred to the educational audiologist of the Osceola County school district for a full audiologic evaluation Children in the after school programs (i.e. Boys and Girls) were provided referral letters to notify pa rents of the results and the recommendation of medical follow physician Participants enrolled in the Deaf and Hard of Hearing program were excluded from the study. The hearing conservation program included information ab out the anatomy and physiology of the auditory system, the causes of noise induced hearing loss using conservation program started with an introduction of the investigator and the purpose of the HCP and an explanation of the importance of taking part in the HCP. Various activities via the use of the Virtual exhibit of Dangerous Decibels program and hands on activities were performed during the 50 minute program that included sev eral topics that were given in the following order: What is Sound How Do We Hear Sound How Loud is too Loud and Save Your Ears During the topic of What is

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46 Sound the participants were informed about what is sound and was given a visual representation of sound waves with the use of a tuning fork and a ping pong ball tied to a string. How Do We Hear section discussed the anatomy and physiology of the auditory system from the external ear canal to the cochlea. Participants were e ither given the physical props of two marshmallows and angel hair pasta or the use of pipe cleaners. These props represented the movement of the tectorial membrane and stereocilia of the outer hair cells, and how the damage of the stereocilia is irreversib le due to loud sounds. The third topic covered was in which this activity is a virtual game that simulates a hearing loss. Therefore, the goal of the game is for an individual to correctly identify a sound presented with hearing loss. A fter the game was completed a short dialogue of the psychosocial effects of hearing loss was discussed with the participants. The fourth topic discussed was How Loud is too Loud which covered the identification of dangerous sounds based on the NIOSH exp osure level recommendations. The virtual game of How Loud is too Loud had the individual choose a tile that represented a sound (i.e. a rock concert) and determine if the sound is a safe sound or a dangerous sound. After the participants were given in formation regarding dangerous sound levels, the three methods of hearing protection were discussed. The first method of hearing protection of NIHL was to turn it down (turn down the volume on the sound he sound source. An actual activity of using a sound level meter, tape measure, and radio illustrated the effectiveness of walking away from a source would decrease the volume emitted from the sound source or the radio which was used in this activity The third method is the

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47 use of hearing protection and the corresponding activity included the use of a sound level meter, bubble wrap, and a radio. Participants used the bubble wrap to block the sound waves from the radio; therefore, demonstrating how an ear p lug would limit sounds from entering in the ear canal. The final topic covered was Save Your Ears which was a virtual game in which the participants had to correctly use the three methods of hearing protection in a specified situation. If the correct he aring health behavior was performed the participants won the game. Therefore, at the end of the HCP, the three methods of hearing protection were re iterated to the participants. After all the post test measures, a randomly selected group of participants f rom experimental group participated in focus groups to investigate the knowledge, beliefs, and behaviors related to noise and hearing health behaviors among these children. The focus groups were used to investigate various themes related to noise exposure, such as invulnerability to hearing loss among the young. Two focus groups were established after the completion of all post test measures. Participants for the focus groups were solicited from the experimental group who were given permission by parents an d/or guardians and agreed to participate in the focus group. Each focus group had 3 5 participants with similar representation of male and female participants; therefore, 8 participants participated in the focus groups. Each focus group had one experience d group leader and a research assistant and lasted for approximately 1 to 1 and1/2 hour s each. The same focus gro up guidelines and themes were discussed in each group. Participants will be asked to further explore their hearing related beliefs and behavio rs, change in hearing health knowledge, and thoughts on the hearing conservation

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48 program. All sessions were recorded and transcribed and evaluated for the important themes.

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49 CHAPTER 3 RESULTS This investigation was completed in two public schools in Osceo la County, FL and in two afterschool programs in Gainesville, FL. The results discussed include the overall population that received the surveys initial and follow up audiometric screenings (prevalence data) and the results from participants that receiv ed a HCP Prevalence Data Over 450 children were solicited to participate in this study; 201 students received parental permission for participation. Of the 201 participants, 22 either failed to initiate study participation due to moving away and/or multi ple absences or they were dropped from the study since they were enrolled in the Deaf and Hard of Hearing Program at Neptune elementary. Of the remaining 179 participants, 73 were male and 106 were female. There were 46 Caucasian children, 49 African Ameri can children, and 84 Hispanic children that participated and the gender makeup of each group is shown in Table 3 1. Prevalence of Hearing Loss in Audiometric Data Table 3 2 shows the count and prevalence of the participants who failed tympanometry and/or t he audiometric/pure tone screening by race and gender. In the total study population, 29.6% failed either the pure tone or tympanometry sc reenings in at least one ear. Because a failure in tympanometry is indicative of middle ear pathology, the 12 partic ipants who failed this screening in at least one ear were immediately referred to the school nurse for medical follow up and are excluded from further prevalence analyses. The prevalence of middle ear pathology among Caucasians was 2% (n= 3/Males=0 and Fem ales=3), among African Americans was 2%

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50 (n=3/Males=2 and Females=1), and among Hispanics was 3% (n=6/Males=2 and Females=4). Table 3 3 shows the count and prevalence of those that passed the pure tone screening or failed the pure tone screening at any fre quency from 1000 to 6000 Hz in at least one ear (excluding all participants that failed tympanometry). Twenty four and a half percent failed the pure tone screening. However, it should be noted that 1000 Hz was highly susceptible to background noise (i.e air conditioning fans in screening rooms) in which participants found it hard to hear the presented tone at 15 dB HL; therefore, the results at 1000 Hz was considered invalid and these children were considered a pass for re screening purposes All of th e remaining participants passed at 2000 Hz with the exception of one participant that failed at 2000 Hz in the right ear and he or she was lost to follow up testing. High frequency hearing loss was defined as having failed at any frequency in at least one ear for the following frequencies: 3000, 4000, and 6000 Hz. Table 3 4 shows the count and prevalence of those that passed the pure tone screenings and those that presented with loss in the higher frequencies. Therefore, based on this classification, 30 pa rticipants were classified as having high frequency hearing loss. The remaining 137 participants that passed tympanometric and audiometric screening measures were classified as having normal hearing acuity in both ears. The prevalence of high frequency hea ring loss at the first screening among Caucasians was 4.1%, among African Americans was 3.6%, and among Hispanics was 10.1%. A chi square analysis was performed to measure any possible differences in the prevalence of hearing disorders among the racial gro ups. There were no statistical differences between any of

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51 the groups (p=0.796, Pearson Chi Square=1.671). A chi square test was also used to analyze if there were any gender differences in the prevalence of hearing disorders in which none were found (p=0.8 17; Pearson Chi Square=0.405). The total study population (n=179) had 137 (76.5%) participants with normal hearing acuity, 12 (6.7%) participants had a middle ear pathology, and 30 (16.8%) participants had a high frequency hearing loss. The study protocol included retesting participants that did not pass the initial pure tone screening, and were classified as failing the pure tone screening. Out of the 30 participants only 18 children were able to be retested due to time and availability of the participants (i.e. multiple absences on scheduled retest days), so 12 participants were lost to follow up. Of the 18 participants (11.6% of the study population, n=155) classified as having high frequency loss, only 7 participants or 4.6% of the study population prese nted with high frequency hearing loss after the retest evaluation. Therefore, 11 participants passed the audiometric screening on the second pure tone screening. Table 3 5 shows the count and prevalence of the remaining population (n=155) of those that pas sed the pure tone screenings and those that presented with loss in the high frequencies after being retested. DPOAEs were obtained at 2000, 3000, and 4000 Hz in both ears from most of the study population depending on the integrity of their middle ear sys tem, and background noise. Only five participants did not complete DPOAE testing due to excessive background noise; as a result, 174 participants completed DPOAE testing. The GSI AudioScreener+ reported a Pass result if DPOAEs were present at two out of th e three frequencies or a Refer result if DPOAEs were present only at one frequency (which the other frequencies were reported as having too much noise or absent/reduced

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52 DPOAEs). DPOAEs results were reported for each frequency and the overall result for eac h ear. The prevalence of the participants that passed overall in the right ear was 159 students (88.8%). Fifteen students (8.4%) failed DPOAE testing in the right ear. Participants that passed overall in the left ear were 162 students (90.5%) and 11 studen ts (6.1%) failed DPOAE testing in the left ear. It should be noted that one participant did not have his left ear tested due to an inability to maintain proper probe fit in the external ear canal. A chi square analysis showed no gender differences in the o verall right ear (p=0.608, Pearson Chi square=0.262) and overall left ear (p=0.349, Pearson Chi square=0.878) results. In addition, chi square analysis showed no racial differences for overall right ear (p=0.480, Pearson Chi square=1.468) and overall left ear (p=0.315, Pearson Chi square=2.310). In addition, Table 3 6 shows the DPOAE pass and refer rates for each ear at each frequency by race. Chi square analysis of each frequency also showed no statistically significant gender or racial differences, and Ta ble 3 7 displays the p values of each frequency based on race and gender. Examination of overall results in at least one ear of the DPOAEs in relation to pure tone screening showed the DPOAEs with a sensitivity equal to 13.3% (proportion of true positives in those classified with high frequency loss) and specificity equal to 91.9% (proportion of true negatives in those classified with normal hearing acuity); Table 3 8 displays the comparison of the DPOAE results with high frequency hearing loss status. Atti tudes and Knowledge towards Noise In addition to the audiometric screening, each participant (n=179) was asked to complete a survey on attitudes and knowledge. The Youth Attitudes to Noise ( YANS )

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53 portion of the measure provided the information regarding the attitudes towards noise by the participants. The YANS provides an overall score and four sub scores that include the following: Entire YANS, Factor One or Youth Culture, Factor Two or Concentration in Noisy Situation s, Factor Three or Daily Noises, and Factor Four or Intent to Influence the Sound Environment. The YANS measure is based on a Likert type scale (1 5), which the higher a person scores on this measure the more pro noise attitudes he or she hold; therefore, a person with a mean score of 4.5 has a more positive attitude toward noise compared to a person that has a mean score of 3. (Table 3 9) revealed a mean of 3.23 (standard deviation [SD] = 0.639) for Caucasians, a mean of 3.23 (SD= 0.586) for African Americans, and a mean score of 3.18 (SD= 0.621) for Hispanics. The mean scores for Factor One for Caucasians was 3.46 (SD= 0.767), for African Americans was 3.42 (SD= 3.702), and for Hisp anics was 3.32 (SD=0.780). Factor Two mean scores for Caucasians was 2.85 (SD=1.001), African Americans was 2.80 (SD=1.09), and Hispanics was 2.80 (SD= 0.979). The mean scores for Factor Three was 3.40 (SD= 0.926) for Caucasians, 3.55 (SD= 0.921) for Afric an Americans, and 3.26 (SD=0.895) for Hispanics. Lastly, mean scores for Factor Four was 2.89 (SD=0.760) for Caucasians, 2.84 (SD=0.778) for African Americans, and 2.82 (SD= 1.001). Five two way analysis of variance (ANOVA) was used to evaluate gender and race on the entire YANS and each factor using the model of 179 participants in three groups (Caucasian, African American, and Hispanic) by two genders (male and female). Table 3 10 displays the ANOVA results for the Entire YANS and four sub factors.

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54 The A NOVA evaluation of the entire YANS revealed no gender and race interactions with the following F ratio, F [2, 172] (between groups degrees of freedom, within groups degrees of freedom) =0.909, p=0.405. The main effect of gender for the Entire YANS was not significant between the males and females (F [1,172]=2.537, p=0.113). There was no significant main effect of race/ethnicity for the Entire YANS among Caucasians, African Americans, and Hispanics (F [2,172]=1.113, p=0.331). Factor One or Youth Culture show ed no significant interaction of gender and race (F [2,172]=1.325, p=0.268). The main effect of gender on youth culture was no t significant between males and females (F [1,172]=1.898, p=0.170). There was no significant main effect of race/ethnicity differe nces among Caucasians, African Americans, and Hispanics (F [2,172]=0.999, p=0.370). Evaluation of Factor Two or Concentration in Noise revealed no significant gender and race interactions (F [2,172]=1.418, p=0.245). Also, there was no significant gender m ain effect between the sexes (F [1,172]=1.066, p=0.303). The main effect of the variable race/ethnicity was not significant present in the study population (F [2,172]=0.332, p=0.713). Factor Three or Daily noises showed no significant gender and race inter actions (F [2,172]=0.472, p=0.625). There was a significant gender main effect on Daily noises that showed that females scored significantly lower than males, so males have more pro noise attitudes regarding daily noises (F [1,172]=5.352, p=0.022) There wa s no significant main effect of race/ethnicity among the racial groups (F [2,172]=1.489, p=0.228). Factor Four on Intent to Influence the Sound Environment showed no significant gender and race interaction (F [2,172]=2.461, p=0.088). There was also no si gnificant

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55 gender main effect between the males and females (F [1,172]=0.070, p=0.792). Finally, there was no significant main effect of race among Caucasians, African Americans, and Hispanics ( F [ 2,172 ] = 0.332, p=0.725). e Participants also answered questions modified from the Dangerous Decibels 4 th grade questionnaire ( Griest, 2008 ) that include questions regarding reported prevalence, efficacy, and knowledge questions for a combined total of 14 questions on the pre test measure and 13 questions on the post test measure. Seven questions from and perceived knowledge and efficacy, which there were no correct or in correct answers. T able 3 11 illustrates the number of participants that reported exposure to hazardous sound sources. A large proportion of participants (84.9%) reported use of Mp3 players. Participants also reported that they had fired a gun (19%), used a gas lawn mower (2 2.9%), gone to a concert (34.1%), played in a band (8.4%), rode on a motorcycle (27.4%), or gone to car race (17.9%). Participants were questioned if the used hearing protection around loud sounds ; only 2.8% reported that they always use hearing protection compared to 34.6% that reported they sometimes use hearing protection and 62.6 % who reported they never use hearing protection. Thirty four percent of the participants reported that they attended a concert, yet only 32.4% reported using hearing protecti on when attending a concert. Figures 3 1 shows the tinnitus, 27.37% reported that they were no sure they ever experienced tinnitus, and 35.20% reported that they did not ex perience tinnitus.

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56 The remaining eight questions focused on knowledge of NIHL and associated hearing protective behaviors. Three out of the eight knowledge questions had multiple e divided into single answers, which created 23 separate answers. Hence, the highest score that a participant could achieve was 23. The mean scores and standard deviations on the knowledge questions for racial groups were as follows: 16.45 (SD=3.59) for Ca ucasians, 15.12 (SD=3.56) for African Americans and 15.27 (SD=3.63) for Hispanics. The mean scores and standard deviations on the knowledge questions based on gender were 14.93 (SD=3.72) for males and 15.95 (SD=3.50) for females. Another two way ANOVA was used to examine the influence of gender and race on the knowledge questions implementing the model of 179 participants in three race/ethnic groups by two genders. There was a race and gender interaction (F[2,173]=4.019, p=0.014) present among the populati on, therefore the individual post hoc anal yses were completed. Figure 3 2 shows this interaction of race and gender. Post hoc analysis using Bonfferoni tests indicated a significant difference between the genders for African Americans (p=0.008) and non s ignificant differences for the Caucasian (p=.065), and Hispanics (p=0.395). In the male sample the African American students were significantly less knowledgeable than the Hispanic students (t= 2.098, df=55, p=0.041), but not significantly different from the Caucasian students (t=1.330, df=35, p=.192) and the Caucasian students were not significantly different than the Hispanic students (t= .152, df=98, .880). For the female sample, the Caucasian students were significantly more knowledgeable than the Af rican American students (t=2.485, df= 77, p=.015) and the Hispanic students (t=2.469; df=112, p=.015),

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57 but the African American females were not significantly more knowledgeable than the Hispanic group. Therefore, the Caucasian females were the most knowle dgeable whereas the African American males were the least knowledgeable. The order in which the participants received the hearing test or the pre test measure was cross balanced. An independent t test was also used to evaluate if an order effect existed a mong the participants, which no order effect was seen for the Entire YANS (p=0.750), Factor One (p=0.343), Factor Two (p=0.272), Factor Three (p=0.517), and Factor Four (p=0.772). In addition, Pearson correlation analysis was completed on the entire YANS s core and the knowledge measure for all participants (n=179). A significant negative correlation (r= 0.256, p=0.001) indicating that with higher knowledge participants reported lower pro noise attitudes. Effects of Hearing Conservation Program Hearing Conse rvation Training E ffects on Attitudes The hearing conservation program was provided to 112 participants (experimental group). Due to the small n umber of subjects per cell when looking at both gender and Race/ethnicity, separate analyses were completed for each of these variables. Five ANOVA s with repeated measures procedures (analysis of entire YANS and 4 Sub factors) were used to examine any possible differences in attitudes before and after the HCP looking at gender differences. The statistical model w as 112 participants in 2 genders (males and females) by two test administrations (Pre and Post HCP Measures). Table 3 12 displays the pre and post HCP means, standard deviations, F ratios, and significance levels for the Entire YANS, Factor One or Youth C ulture, Factor Two or Concentration in Noise, Factor Three or Daily Noise, and Factor Four or Intent to

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58 Influence. There were no significant interactions of gender by pre and post measures for the entire YANS or any of the sub factors. There was a signifi cant main effect of test administration with attitudes for the entire YANS (p=0.004) and Factor One or Youth Culture (p<0.01) being significantly less pro noise after the HCP. The main effect of test administration for the entire YANs and Factor One had an effect size of 0.07 and 0.13 respectively. Therefore, the students overall attitudes towards noise and attitudes of youth culture towards noise explained variance s of 7% and 13 %, respectively. The se effect sizes for eta squared exceed or are close to a m oderate effect size of 0.09. The magnitude of the effect size that is greater than a small effect size of 0.01 and is greater than or equal to a moderate effect size (0.09) ; specifically on differences between pre and post HCP survey s support a practical s ig nificance due to the program being easily feasible, inexpensive, and can affect a large number of individuals ( Osteen & Bright, 2010 ) Ther e were no statistically significant main effects of test administration for the remaining factors: Factor Two (Concentration in Noise; p=0.533 effect size= 0 ), Factor Three (Daily Noises; p=0.835 effect size= 0 ), and Factor Four (Intent to Influence; p=0.0 71 effect size= .0 ). All other main effects of gender for all ANOVAs were not significant (P> 0.05). Effect sizes for the main effect of gender were the follow ing: entire YANS ( 0 ), Factor One ( 0 ), Factor Two ( 0 ), Factor Three ( .03 ), and Factor Four (0). Fi ve ANOVA with repeated measures procedures (analysis of entire YANS and 4 Sub factors) were also used to examine any possible differences in attitudes before and after the HCP looking at race/ethnicity variable. The statistical model was also 112 particip ants in three race/ethnic groups (Caucasians, African Americans, and Hispanics) by two test administrat ions (Pre and Post Measures). Table 3 13 displays the F ratio

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59 and level of significance for gender and race/ethnicity for all of factors of YANS. There w ere no significant interactions of race by test administration for the entire YANS, Factor One, Factor Two, Factor Three analysis. However, there was a significant interaction (p=0.035, effect size= .06 ) of race and Factor Four or Intent to Influence the Sound Environment with Hispanics being significantly less likely than African American and Caucasians to aspire to influence their sound environment. The effect size of this interaction is higher than the minimum effect size of 0.01. There was a significant main effect of test administration with attitudes for the entire YANS (p=0.004 effect size= 0.07 ) and Factor One or Youth Culture (p<0.01 effect size= 0.13 ) being participants being less pro noise after the HCP. There were no other significant main effec ts of test administration for the Factor 2, Factor 3, and Factor 4 with effect size less than 0.03 All other main effects of race/ethnicity for all ANOVAs were not significant (P> 0.05). Effect sizes for the main effect of race/ethnicity were the follow ing: entire YANS ( 0.01 ), Factor One (0.01 ), Factor Two (0.04 ), Factor Three ( 0 ), and Factor Four ( 0.06 ). Another group of participants were placed in a control group (N=37) to evaluate the efficacy of the HCP. The control group received the second/post tes t measure commensurate with the time span of the experimental group. Table 3 14 displays the pre and post test means, standard deviations, F ratio, and significance levels for the Entire YANS, Factor One or Youth Culture, Factor Two or Concentration in Noi se, Factor Three or Daily Noise, and Factor Four or Intent to Influence for the control and experimental groups. Five ANOVA with repeated measures were used to evaluate any differences in pre and post measures among the sexes. The statistical model was 37

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60 participants in 2 genders (males and females) by two test administrations (Pre and Post test Measures). There were no statistically significant gender and test administration interactions. Also, there were no significant main effects (p> 0.05) of test adm inistration The effect size for the main effect of test administration for the control group was the following: entire YANS= 0.03 Factor One= 0.01 Factor Two= 0.07 Factor Three= 0 and Factor Four = 0.03 There were no significant main effects of gender on any measures for the YANS: Entire YANS (p=0.290 effect size= 0 ), Factor One (p=0.623 effect size=0 ), Factor Two (p=0.127 effect size=0 ), Factor Three (p=0.885 effect size= 0.03 ), and Factor Four (p=0.338 effect size=0 .01 ). Five ANOVA with repeated measu res analyses were used to examine differences in pre and post test measures among three race/ethnic groups. The statistical model was 37 participants in three race/ethnic groups (Caucasians, African Americans, and Hispanics) by two test administrations (Pr e and Post Measures). Table 3 15 shows the F score and level of significance for Gender and Race for all of factors of YANS. There were no significant interactions or main effects of test administration or race /ethnicity for the entire YANS and sub facto rs ( p > 0.05). The effect sizes for the main effect of race ethnicity were the following: entire YANS ( .03 ), Factor One ( 0.04 ), Factor Two ( 0 ), Factor Three ( 0.0 2 ), and Factor Four ( 0.02 ). Hearing Conservation Training Effects on Knowledge Four questions

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61 hearing protec tive beliefs, knowledge, and efficacy among the participants after receiving the HCP (Table 3 16). An ANOVA with repeated measure was also used to evaluate the effectiveness of ctive behaviors among males and females. The statistical model was 112 participants in two genders (males and females) by two test administrations (Pre and Post test Measures). No significant interaction between gender and test administration (F[1,110]=0.2 94, p= 0.589 effect size= 0 ). There was a significant main effect of test administration (F[1,110]= 26.373, p<0.01 effect size= 0. 18 ) and a practical significance evident, so there is an improvement in the knowledge regarding hearing protection among the p articipants after HCP There was no significant main effect of gender on the test administrations (F[1,110]=3.46,p=0.065 effect size= 0.0 3 ). Another ANOVA with repeated measure was also used to evaluate the effectiveness of the HCP effects on the particip hearing protective behaviors among the race/ethic groups. The statistical model was 112 participants in three race/ethnic groups (Caucasians, African Americans, and Hispanics) by two test administrations (Pre and Post tes t Measures). No significant interaction between race and test administration (F[2,109]=0.118, p= 0.889 effect size= 0 ) was found There was a significant main effect of test administration (F[2,109]= 26.373, p<0.01 effect size= 0.20 ) and a significant m ain effect of race/ethnicity on the test administrations (F[2,109]=4.404, p=0.014 effect size= 0.08 ). These effect sizes represent a practical significance among these test results. Hence, the Caucasian

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62 participants were the most knowledgeable regarding N IHL and hearing protective behaviors; African American participants were the second most knowledgeable, and the Hispanic participants were the least knowledgeable. knowledge regardi ng NIHL and hearing protective behaviors among males and females in the control group. The statistical model was 37 participants in two genders (males and females) by two test administrations (Pre and Post test Measures). There were no significant interact ion between gender and test administration (F [1 35] = 0.089, p= 0.768 effect size= 0) There was no significant main effect of test administration (F [1, 35]= 1.588, p=0.216 effect size= 0.0 4 ). There was no significant main effect of gender on the test ad ministrations (F [1, 35]=1.250, p=0.271 effect size= 0.0 3 ). ANOVA with repeated measure was also used to evaluate the effectiveness of the behaviors among the race/ethic grou ps. The statistical model was 37 participants in three race/ethnic groups (Caucasians, African Americans, and Hispanics) by two test administrations (Pre and Post test Measures). There was no significant interaction between race and test administration (F [2, 34] =0.308, p= 0.737 effect size= 0.02 ). Also, there was no significant main effect of test administration (F [1, 34] = 0.277, p=0.602 effect size= 0.01 ); and no significant main effect of race/ethnicity on the test administrations (F[2,34]=0.336, p=0. 717 effect size= 0.02 ) The order in which the participants received the hearing test or the pre test measure was cross balanced. An independent t test was used to evaluate if an order

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63 effect existed among the participants, which no order effect was seen fo r the post HCP results (p=0.113). Correlations were also measured to evaluate any association between the attitudes and knowledge measures after receiving a HCP. There were significant positive associations between the pre and post Entire YANS scores (r=0. 692, p<0.01), and the pre and post knowledge answers (r=0.610, p<0.01). There was a significant negative association between the YANS and knowledge measures (r= 0.334 / p<0.01) increased knowledge and reduced positive regard of noise. Table 3 17 shows the correlation table between the YANS and knowledge measures. Figure 3 3 the next month. Only 9.46% of the participants reported that they would not use hearing protection within the next month compared to 22.30% that reported that they were not sure if they would use hearing protection or 68.24% reported that they would use hearing protection within the next m onth. Main Themes of Focus Groups Two focus groups (n=7) were assembled to evaluate what information was retained after receiving HCP and their opinions of the intervention program. Several main factors were discussed in the focus groups that included: (1) knowledge of their individual susceptibility to NIHL, (2) knowledge of the consequences of NIHL, (3) knowledge of the protective hearing behaviors and efficacy to perform these behaviors, and (4) their opinion of the positive and negative aspects of the H CP. All of the

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64 one repeatedly exposed themselves to loud sounds he or she would not be able to hear normally in the future. Prior to participating in the research stud y, the participants reported that they knew a limited amount of the information presented in the HCP ahead of time, mainly learned from their teachers in school or parental guidance. One participant learned about NIHL the majority reported that they learned about the dangers of NIHL due to the intervention program. The participants were already aware of the several sources of hazardous sounds, including traffic, motorcycles, lawnmowers, fireworks/firecrackers, motor b ikes, airplanes, space shuttles, and football games. The participants further reported their individual susceptibility to hazardous sound sources present in school, which included the cafeteria, classrooms (due to noisy students), the music room, physical education classes, and/or doors are being slammed around the school campus. The participants reported enjoying certain loud activities, such as going to the park, attending music concerts, playing basketball, playing with their friends, attending sporting events, and listening to music. As a result, the participants reported that they became aware of their own IPod volumes and the potential that listening at higher levels can decrease their hearing. All the focus groups participants learned from the HCP tha t the level which is considered dangerous is at 85 dB A. The participants identified the consequences to loud sounds to include hearing loss and ringing in their ears. Further, one participant reported that any person of any age could have hearing loss, i ncluding babies. The participants agreed that children their same age could easily get hearing loss, and that they knew a friend with a hearing

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65 come back. Also, a few participants reported other consequences of acquiring NIHL in daily living included reduced ability to converse with other people, and that NIHL can cause a safety hazard because one would have difficulty alerting to warning signals and alarms. Every part icipant recalled the three ways to protect their hearing, which included (1) wearing hearing protection, (2) moving away from the sound source, and (3) turning the volume down. The Dangerous Decibels program taught them these strategies; and that using the se strategies they can protect their hearing. However, all agreed that it could be difficult for some children to protect their hearing at some times, because they may fail to remember when to practice positive hearing habits. Two participants also believe d if they used earplugs to protect their hearing, they may not be able to enjoy an activity (i.e. listening to music) as much; however, remaining participants disagreed. However, the participants reported a high level of self efficacy to perform these hear ing protective behaviors. They felt that the HCP convinced them they had the ability to protect their hearing and teach their friends and family members about what they learned. Several participants expressed that the HCP was really helpful and taught them immensely. They also reported that they were able to retain most of the facts that they learned from the, such as that the loudness of a sound could be measured in order to determine how hazardous the sound could be to hearing through the use of a sound l evel meter. The most memorable portion of the HCP was how to protect their hearing lowering the music on their stereos, participating in the tuning fork demonstrat ions, the

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66 sound sources. The least effective information provided was the information regarding the auditory system. The participants further reported that they would have liked fewer survey questions and more hands on activities and group interaction, and to learn about what kind of physical side effects occurred after obtaining hearing loss. The focus groups also stated they would have liked more information concerning the life of those living with hearing loss. For instance, to receive a real world account from those living with hearing loss on their usage of lip reading and social compensation strategies to interact with others on a daily basis. Otherwise, the participants rea lly liked the program. One emergent theme not asked, yet was brought up by the participants was the importance of completing the audiometric screening. Reportedly, hearing and eye exams are given annually to the focus group participants. They further disc ussed that hearing tests can be very scary for some children, especially younger ones. One participant expressed being nervous and scared during the hearing test because she was worried about having hearing loss due to her previous hearing behaviors.

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67 Tab le 3 1 Sample d emographics Total Participants (n=179 ) Percentage of Sample Sex Male 73 41% Caucasian 16 22% African American 21 29% Hispanic 36 49% Female 106 59% Caucasian 30 28% African America n 28 26% Hispanic 48 45% Race Ethnici ty Caucasian 46 26% African American 49 27% Hispanic 84 47% Age 8 1 1% 9 23 13% 10 83 46% 11 65 36% 12 7 4%

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68 Table 3 2. Count and Prevalence of Hearing Screening Failure of Study Participants that either passed or failed p ure tone scre ening or tympanometry Pure tone and Tympanometry(n=179) Passed (P) Failed (P) Total count Caucasian Male 14 (7.8%) 2 (1.1%) 16 Female 19 (10.6%) 11 (6.1%) 30 Total 33 (18.4%) 13 (7.2%) 46 African American Male 16 (8.9%) 5 (2.8%) 21 Female 24 (13.4%) 4 (2.2%) 38 Total 40 (22.3%) 9 (5.0%) 49 Hispanic Male 25 (13.9%) 11 (6.1%) 36 Female 28 (15.6%) 20 (11.2%) 47 Total 53 (29. 6%) 31 (17.3%) 84 Total Sample Male 55 (30.7%) 18 (10.0%) 73 Female 71 (39.7%) 35 (1 9.6%) 106 Total 126 (70.4%) 53 (29.6%) 179

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69 Table 3 3. Count and Prevalence of Hearing Screening Failure of Study Participants at any frequency (1 6k Hz) in either ear Pure tone Screening (n=167) Passed (P) Failed (P) Total count Caucasian Male 14 (8.4%) 2 (1.2%) 16 Female 19 (11.4%) 8 (4.7%) 27 Total 33 (19.8%) 10 (5.9%) 43 African American Male 16 (9.6%) 3 (1.8%) 19 Female 24 (14.4%) 3 (1.8%) 27 Total 40 (24.0%) 6 (3.6%) 46 Hispanic Male 25 (15.0%) 9 (5.4%) 34 Female 28 (16.7%) 16 (9.6%) 44 Total 53 (31.7%) 25 (15.0%) 78 Total Sample Male 55 (33.0%) 14 (8.4%) 69 Female 71 (42.5%) 27 (16.1%) 98 Total 126 (75.5%) 41 (24.5%) 167

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70 Table 3 4. Count and Prevalence of failed high frequen cy (3k, 4k, or 6k Hz) in either ear High Frequencies (n=167) Passed (P) Failed (P) Total count Caucasian Male 14 (8.4%) 2 (1.2%) 16 Female 22 (13.1%) 5 (2.9%) 27 Total 36 (21.5%) 7 (4.1%) 43 African American Male 16 (9.6%) 3 (1.8%) 19 Female 24 (14.3%) 3 (1.8%) 27 Total 40 (23.9%) 6 (3.6%) 46 Hispanic Male 27 (16.2%) 7 (4.2%) 34 Female 34 (20.3%) 10 (5.9%) 44 Total 61 (36.5%) 17 (10.1%) 78 Total Sample Male 57 (34.1%) 12 (7.2%) 69 Female 80 (47.9%) 18 (10.8%) 98 Total 137 (82.0%) 30 (18.0%) 167

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71 Table 3 5. Count and Prevalence of Hearing Screen o f Study Participants after second hearing test High Frequencies (n=155) Passed (P) Failed (P) Total count Caucasian Male 15 (9.7%) 1 (0.6%) 16 Female 25 (1 6.1%) 1 (0.6%) 26 Total 40 (25.8%) 2 (1.2%) 42 African American Male 17 (11.0%) 1 (0.6%) 18 Female 24 (15.5%) 3 (2.0%) 27 Total 41 (26.5%) 4 (2.6%) 45 Hispanic Male 28 (18.1%) 1 (0.6%) 29 Female 39 (25.1%) 0 (0%) 39 Total 67 (43.2% ) 1 (0.6%) 68 Total Sample Male 60 (38.7%) 3 (2.0%) 36 Female 88 (56.7%) 4 (2.6%) 92 Total 148 (95.4%) 7 (4.6%) 155

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72 Table 3 6 DPOAE results of each frequency and overall results for each ear based on race 2000 Pass Refer 3000 Pass Refer 4000 Pass Refer Overall Pass Refer Caucasian Right Ear 33 12 41 4 37 8 40 5 Left Ear 36 9 41 4 38 7 40 5 African American Right Ear 33 12 42 3 36 9 4 0 5 Left Ear 34 10 42 2 36 8 42 2 Hispanic Right Ear 67 17 79 5 75 9 79 5 Left Ear 69 15 79 5 77 7 80 4 Table 3 7. P values of Chi Square Analysi s of DPOAE results at 2000, 3000, and 4000 Hz based on Gender and Race (n=174 for right ear; n=173 for left ear) 2000Hz 3000Hz 4000Hz Right Left Right Left Right Left Gender p=0.765 p=0.474 p=0.485 p=0.762 p=0.131 p=0.364 Race p=0.6 07 p=0.803 p=0.819 p=0.687 p=0.305 p=0.227

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73 Table 3 8. Comparison of the DPOAE results with high frequency hearing loss status (n=167) Results High Frequency Loss No High Frequency Loss Total (+) Refer 4 11 15 ( ) Pass 26 126 152 30 137 167 Sensit ivity= 13.3% (4/30) and Specificity=91.9% (126/137) Table 3 9. Descriptive statistics on the YANS measure (n=179) Entire YANS Factor One Factor Two Factor Three Factor Four Mean, [SD] Mean, [SD] Mean, [SD] Mean, [SD] Mean, [SD] Caucasian Mal e 3.52 [0.617] 3.76 [0.859] 3.24 [0.877] 3.50 [0.944] 3.02 [0.700] Female 3.12 [0.628] 3.31 [0.681] 2.67[1.017] 3.36 [0.930] 2.83 [0.791] Total 3.25 [0.647] 3.46 [0.767] 2.85[1.001] 3.40 [0.926] 2.89 [0.760] African American Male 3.27 [0.63 2] 3.38 [0.689] 2.79[1.293] 3.77 [1.054] 2.91 [0.803] Female 3.19 [0.558] 3.45 [0.723] 2.80[0.953] 3.39 [0.788] 2.78 [0.768] Total 3.23 [0.647] 3.42 [0.702] 2.80[1.099] 3.56 [0.922] 2.84 [0.778] Hispanic Male 3.14 [0.667] 3.38 [0.845] 2.77[ 1.060] 3.54 [0.928] 2.57 [0.907] Female 3.10 [0.613] 3.28 [0.734] 2.83[0.925] 3.06 [0.821] 3.01 [1.036] Total 3.12 [0.633] 3.32 [0.780] 2.80[0.979] 3.27 [0.895] 2.82 [1.001] Total Male 3.27 [0.654] 3.46 [0.809] 2.87[1.101] 3.60 [0.962] 2.76 [0.851] Female 3.13 [0.599] 3.33 [0.713] 2.77[0.952] 3.23 [0.851] 2.90 [0.903] Total 3.18 [0.624] 3.38 [0.754] 2.82[1.013] 3.38 [0.913] 2.84 [0.882]

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74 Table 3 10. ANOVA Results for the Entire YANS and sub factors without presentation of a HCP. Source Type III Sum of Squares Df Mean Square F Sig. Entire YANS Analysis Gender 0.980 1 0.980 2.537 0.113 Race/Ethnicity 0.860 2 0.430 1.113 0.331 Gender x Race 0.702 2 0.351 0.909 0.405 Factor One Analysis Gender 1.080 1 1.080 1.898 0.17 0 Race/Ethnicity 1.137 2 0.568 0.999 0.370 Gender x Race 1.507 2 0.754 1.325 0.268 Factor Two Analysis Gender 1.105 1 1.105 1.066 0.303 Race/Ethnicity 0.703 2 0.351 0.339 0.713 Gender x Race 2.941 2 1.470 1.418 0.245 Factor Three Analysis Gender 4.312 1 4.312 5.353 0.022* Race/Ethnicity 2.399 2 1.200 1.489 0.228 Gender x Race 0.760 2 0.380 0.472 0.625 Factor Four Analysis Gender 0.054 1 0.054 0.070 0.792 Race/Ethnicity 0.498 2 0.249 0.322 0.725 Gender x Race 3.815 2 1.907 2.461 0.088 *= Significant p<0.05

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75 Table 3 11. Percentages of Participants Exposure to Dangerous Sounds in Daily Living Activity Participation Non participation Used a Mp3 Player 84.9% 15.1% Fired a Gun 19% 81% Use a Gas Lawn Mower 22.9% 77.1% Went to a Concert 34.1% 65.9% Played in a Band 8.4% 91.6% Rode a Motorcycle, etc. 27.4% 72.6% Went to a Car Race 17.9% 82.1% Table 3 12. ratio, and Level of Significance for each Factor Factors Pre test Mean, [SD] Post test Mean, [SD] F Significance Entire YANS 3.19 [0.557] 3.07 [0.589] 8.667 p = 0.004 Factor One 3.37 [0.733] 3.12 [0.815] 16.072 p < 0.001 Factor Two 2.79 [0.872] 2.83 [0.921] 0.391 p = 0.533 F actor Three 3.44 [0.891] 3.43 [0.849] 0.043 P = 0.835 Factor Four 2.87 [0.774] 2.80 [0.728] 3.314 P = 0.071 *= Significant p<0.05 Table 3 13. based on Gender and Race YANS Factors R ace Gender F p value F p value Entire YANS 0.865 0.424 0.703 0.404 Factor One 0.265 0.768 0.126 0.723 Factor Two 2.483 0.088 0.162 0.688 Factor Three 1.580 0.211 3.617 0.060 Factor Four 4.314 0.731 0.000 0.994

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76 Table 3 and Post Means and Standard Deviations, F ratio, and Level of Significance for each Factor Factors Pre test Mean, [SD] Post test Mean, [SD] F Significance Entire YANS 3.21 [0.852] 3.12 [0.661] 1.154 p = 0.290 Factor One 3.45 [0.954] 3.39 [0.777] 0.2 45 p = 0.623 Factor Two 3.13 [1.255] 2.83 [0.958] 2.442 p = 0.127 Factor Three 3.18 [0.998] 3.18 [1.095] 0.021 p = 0.885 Factor Five 2.81 [1.212] 3.29 [0.994] 0.904 p = 0.348 Table 3 15. cores based on Gender and Race YANS Factors Gender Race F p value F p value Entire YANS 0.095 0.760 0.462 0.634 Factor One 0.058 0.812 0.759 0.476 Factor Two 0.002 0.963 0.033 0.968 Factor Three 0.979 0.329 0.405 0.670 Factor Four 0.293 0.592 0.39 3 0.678 Table 3 16. Participants Responses to Opinion/Behavioral Questions on Knowledge and Hearing Protection Usage Questions Always Sometimes Never Pre test 2.8% 34.6% 62.6% Post test 3.3% 49.3% 47.3% Pre test 42.5 17.9 39.7 Post test 49.7 13.4 36.9 Pre test 6 1.5 8.9 29.6 Post test 70.7 8.0 21.3 Pre test 32.4 31.3 36.3 Post test 43.3 18.7 38.0

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77 Table 3 17. Correlation Table of Knowledge and YANS responses Pre Entire YANS Post Ent ire YANS Pre Knowledge Post Knowledge Pre Entire YANS Pearson Correlation Sig. (2 tailed) N 1 140 0.692** 0.000 112 0.255** 0.007 112 0.172 0.070 112 Post Entire YANS Pearson Correlation Sig. (2 tailed) N 0.692** 0.000 112 1 112 0.292** 0.00 2 112 0.334** 0.000 112 Pre Knowledge Pearson Correlation Sig. (2 tailed) N 0.255** 0.007 112 0.292** 0.002 112 1 112 0.610** 0.000 112 Post Knowledge Pearson Correlation Sig. (2 tailed) N 0.172 0.070 112 0.334** 0.000 112 0.610** 0.00 0 112 1 112 **Correlation is significant at the 0.01 level (2 tailed).

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78 Figure 3 1 Participants Reported Experience of Tinnitus

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79 Figure 3 2 Mean scores from the Knowledge Questions based on Race and Gender (N=179) 15.125 13.524 15.667 17.167 16.321 14.979 10 11 12 13 14 15 16 17 18 Caucasian African American Hispanic Knowledge Score Male Female

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80 Figure 3 3 Part icipants Anticipated Use of Hearing Protection within the next month

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81 CHAPTER 4 DISCUSSION NIHL is insidious and it poor psycho social effects, such as loneliness, depression, and overall poor qu ality of life. Hearing loss among children can produce reduced academic function and reduced social competence among peers. Identification of hearing loss is important to provide timely (re)habilitation services among children to ensure normal and on level academic performance. The nexus of NIHL can be avoided based on positive health behaviors, such as charged with the responsibility to provide adequate NIHL prevention servi ces. Adequate prevention of NIHL involves hearing health professionals identifying and understanding the risk and prevalence of the problem (NIHL) among the target population (i.e. children); and implemen ti ng of hearing conservation services, such as provi ding information regarding use of hearing protective devices (i.e. ear plugs). T he current study sought to gain novel information regarding the prevalence of NIHL among racially diverse children and determine the efficacy of evidenced based HCP in racially diverse children. Eventually this information can be implemented into primary prevention measures. Prevalence of the Study Population One hundred and seventy nine children between the ages of 8 and 12 years received an initial hearing screening. From this 1 st screening, the prevalence of hearing loss in at least one ear was 22.9%; and more specifically 16.8% f or high frequency hearing loss. T he prevalence rates obtained from this project are consistent with the

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82 reported increases of hearing loss and high f requency hearing loss among children reported by Shargorodsky et al. (2010 ) study. Shargorodsky compared the data from the singular testing in the National He alth and Nutrition Examination Survey (NHANES) 2005 2006 to the NHANES III (1988 1994) data. Shargorodsky et al. (2010 ) found a 30% increase in hearing loss T he prevalence of hearing loss increased from 14.9% to 19.5%; and the prevalence of high frequency hearing loss increased from 12.8% to 16.4%. E. Henderson et al. (2011 ) also completed a similar comparative study of the data obtained from NHANES III to NHANES 2005 2006 This study excluded tympanometric data, and found that there was no reliable increase in hearing loss unlike the earlier report from the Shargorodsky et al. (2010 ) study. Twelve (6.7%) students in the current study failed tympanometry in at least one ear. Maw, Hall, Pothier, Gregory, and Steer (2011 ) completed a longitudinal study of children (n=6569, 8 11 years old) to identify the number of tympanic membrane abnormalities and related middle ear pathology. Retraction of the tympanic membrane on the pars tensa (located inferior or lower section of the tympanic membrane) was seen in 6.1% in at l east one ear, which is consistent with the rate found in the current study. The Niskar et al. (2001 ) and Shargorodsky et al. (2010 ) prevalence studies did not report tympanometric results, yet they reported the study participants reported history of three ear infections or more and the reported prevalence was 20.8% (n=2928 ) or 26.3% (n=1771), respectively ( Niskar et al., 2001 ; Shargorodsky et al., 2010 ) The lower prevalence of mi ddle ear pathology seen in the current study is expected in the older child population compared to young children due to the maturation of the anatomical structures (i.e.Eustachian tubes).

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83 The current study evaluated the hearing status, especially high fre quency loss among the participants. In the prevalence calculations for hearing loss those that failed tympanometry were excluded. Results of the initial hearing test showed, Hispanic participants presented with the highest prevalence of high frequency loss equal to 10.1%, Caucasian participants presented with the second highest prevalence of high frequency loss equal to 4.1%, and African American participants presented with the lowest prevalence of high frequency loss equal to 3.6%, yet there was no statist ically reliable effect of race/ethnicity. Taken together, the trend in which African American participants presented with the lowest prevalence of high frequency hearing loss that is consistent with the results from the Niskar et al. (1998 ) NHANES anal ysis which showed that African Americans had the lowest prevalence of high frequency hearing loss (11.7%) compared to other racial groups. However, in the Shar gorodsky et al. (2010 ) study, Hispanic children had the lowest prevalence rate (14.8%) compared to the other racial groups, African Americans (17.2%) and Caucasian (17.6%). The noted intrinsic protection (i.e. melanin) from hearing loss for African Ameri cans was not seen in this project, yet those within the Hispanic culture (due to the darker pigmentation, i.e. dark brown eyes and olive skin) also have the potential to benefit from similar protection. The literature has also shown a gender difference in the prevalence of high frequency hearing loss, which females present with lower prevalence rates (10.1% 13.4%) compared to males (15.3% 19.4%) ( Shargorodsky et a l., 2010 ) However, in the current study there were no gender differences in the presence of high frequency hearing loss.

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84 Children classified with high frequency hearing loss in the current study were retested; and the prevalence rate greatly reduced fro m 16.8% to 4.6%. Therefore, one can speculate that the previous reported prevalence rates from Niskar et al. (2001 ) or Shargorodsky et al. (2010 ) studies could be an over estimation of high frequency hearing loss among children. An article by Schlauch and Carney (2012 ) examined t he epidemiologic studies of Niskar and Shargorodsky to access the challenge of detecting minimal hearing loss. They found that there was an over estimation of minimal hearing loss (false positives) due to several study limitations, such as only testing the what was reported in the established literature. The lower prevalence rate of 4.6% found in the current study is still too high of a rate among children. Participan their audiometric screenings. Prior to the audiometric screenings, none of the participants expressed any concerns of hearing problems in which a few participants stated to the investigator that the y had normal hearing. However, seven children (4.6%) presented with high frequency hearing loss after the re test. A study by Le Prell, Hensley, Campbell, Hall, and Guire (2011 ) found a prevalence of hearing loss as low as 7% and as high as 12% (based on the classification/description of hearing loss) among college students (n=56, mean age=21 years) that self reported as having normal hearing in both ears. Using the conservative prevalence of 7% would mean that approximately 4 college students out of the 56 students presented with a hearing loss. Hence, the final prevalence found in the current study is more consistent with the conservative prevalence rate reported in the Le Prell et al. (2011 ) study; however, a

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85 prevalence of 4.6% still warrants attention and prevention among children and young adults. Pure on the other hand, pure tone audiometry is sensitive to variabi lity. Sources of this equipment ( Schlauch & Carney, 2012 ; Shargorodsky et al., 2010 ) In the current study, many of the children that failed the initial audiometric screening can be attributed to malingering or presenting with a non organic hearing loss, reduced attenti on to the task of the hearing screening, or not understanding how to perform the task of the hearing screening. Schlauch and Carney (2012 ) made the following recommendations: (1) multiple measurements of threshold s, (2) use of insert head phones, (3) use of 20 or 25 dBHL as the pass fail criterion, and (4) use of a clinical diagnostic evaluation to improve detection of hearing loss in large scale audiometric screenings. They promoted completion of multiple testing of thresholds to ensure reliability of the test results among participants. The use of insert headphones reduces the risk of collapse of the external ear canal and/or the possible calibration error at 6000 and 8000 Hz when a TDH style headphone is calibrat ed using a NBS 9A coupler (which would make thresholds at the those higher frequencies approximately 5 dB poorer). In addition, the use of a 20 25 dBHL pass fail criterion to counter the limited time to obtain thresholds and the reduced care in obtaining t hresholds, because with more time and care yields higher participant motivation and lower thresholds. Also, Schlauch and Carney (2012 ) reported the importance of use of a clinical test method to include air and b one conduction to obtain more accurate results.

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86 Based on these recommendations and the current results, the limitations present in the Niskar and Shargorodsky epidemiologic studies are evident. For instance in both studies, participants were only tested o nce by trained volunteers NOT clinical audiologists, so the reliability of the thresholds may be poor due to inexperience of the examiner. In the current investigation, audiometric testing was completed by a licensed audiologist and two second year Doctor of Audiology (Au.D.) students that assisted in supervision. These AuD students had completed two years of clinical training versus the trained volunteers. Schlauch and Car ney advocated for the use insert headphones. However, in this study TDH 39 headphones were used in the current study due to the ability to maintain Universal Health Precautions. Further, the effect of collapsed ear canals shows as an increase in threshold for low frequencies (less than 1000 Hz), which no low frequencies were tested in the current study. Distortion Product Otoacoustic emi ssions (DPOAEs) were used to ass ess the otoacoustic emissions of the outer hair cells. DPOAE is a measure of cochlear fun ction of the outer hair cells. Outer hair cells are highly sensitive to noise exposure and once these cells are damaged, the result is hearing loss. Pure tone audiometry cannot measure this damage of the outer hair cells until a approximately 30 50% of the se cells are damaged ( Daniel, 2007 ) and a permanent he aring loss has occurred. This study found 8.4% children failed DPOAE testing in the right ear, and 6.1% children failed DPOAE testing in the left ear. Nonetheless, in relation to the audiometric screening the sensitivity of identifying high frequency heari ng loss (prior to retesting) was poor at 13.3%. The specificity of those with normal hearing was great at 91.9%. DPOAE testing

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87 is vulnerable to participant artifact and background noise, so the child participant had to remain entirely still and quiet for a t least five minutes, which may be difficult for some children. Also, background noise can influence DPOAE test results by also creating too much noise in which the probe is unable to accurately pick up and measure the otoacoustic emission. This may be the cause of the false positives of the DPOAE outputs. The sensitivity of DPOAE testing in relation to the retest hearing results was poor (0%) because all of the students who failed the second hearing screening passed DPOAE testing. Therefore, the validity o f the DPOAEs testing in this study is in question. The poor sensitivity found in this study may be attributed to the high noise and patient artifact. Hence, DPOAE testing may not be an effective test measure to use in a real world mass screening situation. The GSI Audioscreener+ used in this study to acquire the DPOAEs from participants was highly sensitive to patient artifact and noise, which ultimately lead to an extended time period for obtaining results. Thus, it took on average 15 minutes to obtain DPO AE results. When one compares the time it took to obtain audiometric results to the time it took to obtain DPOAE results, it was much quicker to obtain the audiometric results (testing took 5 10 minutes to complete). As a result, the use of pure tone audio DPOAEs from participants. Although tinnitus was not the main focus in the current investigation, 34% of the study population reported tinnitus. Commonly characterized as a ringing or buzzing in the e ars, tinnitus may occur in one or both ears, and can be perceived as originating either inside or outside the ear ( Axelsson & Ringdahl, 1989 ) Tinnitus is often one of the

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88 first signs of NIHL and i ts major co morbid symptom. Tinnitus affects 50 million individuals or approximately 16% of the United States population ( American Tinnitus Association, 2009 ) Similarly, results from a Swedish study of 1,285 adolescents between the ages of 13 and 19, 8.7 % reported tinnitus and the symptoms were more common in the 16 to 19 age group (10.3%) versus the 13 to 15 age group (6.8%) ( Olsen Widen & Erlandsson, 2004 ) The 34% prevalence rate of tinnitus reported in the current project may differ from the reported rates seen in Olsen Widen and Erlandsson study due to the wording of the ing the past year, I have been around loud sounds that made my ears hurt or gave me Based on the current study one can speculate that a par ticipant may have had an episode of tinnitus within a year instead of constant permanent tinnitus. Approximately a third of the study population reported tinnitus. In addition, tw o participants out of the seven participants classified with high frequency hearing loss reported tinnitus. This is to be expected due to the reported noise exposures of the study population. The vast majority of the 179 students reported participation in hazardous noisy activities, such as use of a Mp3 player (84.9%), attendance at a concert (34.1%), firing of a gun (19%), riding on a motorcycle (27.4%), and/or use of a gas lawn mower (22.9%) that may contribute to NIHL without use of hearing protective b ehaviors (i.e. use of hearing protection). Even with the reported noise exposures only

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89 2.8% reported always using hearing protection or 34.6% sometimes using hearing protection. Half of the study population received either the audiometric screening or the survey first to determine if the process of receiving a hearing test had any effect on a ledge towards Participants reported a moderate appreciation of noise with a mean score of 3.21 on a scale of one to five (which a score of five would equal the highest appreciation of noise/highly pro noise). The participants also reported a moderate appreciation for each sub factor of YANS (Youth Culture, Concentration in Noise, Daily Noise, and Intent to Influence). Erlandsson et al. (2008 ) showed that American young adults were more pro noise compared to Swedish young adults. Thus, it could be speculated that Americans hold higher appreciation of noise. In addition, the participants (n=179) presented with fair knowledge regarding NIHL and hearing protection behaviors. The mean score was 15.61 out of the highest possible score of 23. One study by Crandell et al. (2004 ) examined differences in knowledge, behaviors, and attitudes of African American students compared to Caucasian students. The data revealed that African American students were consistently less likely to correctly identify symptoms of excessive noise and the risk of hearing damage, therefore less knowledge compared to their Caucasian counterparts. In addition, o ne of the knowledge qu

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90 yes to this question. According to Kochkin (2009) many young individuals believe that hearing loss is only a concern of elders and that they do not need to worry about acquiring hearing loss. Thus, a number of children are not aware of the potential difficulties that may affect their ability to hear and communicate, and their overall quality of life. Effects of the Hearin g Conservation Program The evidence based practice to combat the ill effects of hazardous sound is through the use of HCPs, which the use of HCPs is effective in increasing the knowledge and awareness of NIHL among children ( Borchgrevink, 2003 ; Chermak et al., 1996 ; Daniel, 2007 ; Folmer, 2008 ; Weichbold & Zorowka, 2007 ) Thus, the results of the current study indicated that a HCP was effective in reducing positive noise (pro noise) attitudes and increasing knowledge a mong the participants that were randomly selected into the experimental group. The participants in the control group did not have a change in their attitudes or an increase in their knowledge regarding NIHL. The Health 8) constructs of perceived susceptibility, perceived severity, perceived benefits, and cues to action relate to the study population of children. First, this population did not perceive themselves at risk for acquiring hearing loss at a young age believing that hearing loss is only a concern for elderly people. Second, the children did not perceive the severity of hearing loss and feel that NIHL is not that serious and can be simply solved by hearing aids. Prior to the HCP, the participants did not realize that NIHL can affect their academic performance in school (Kawada, 2004; Tharpe & Sladen, 2003; McFadden & Pittman, 2008, & Tharpe, 2008) or their interactions with family and friends (Tharpe & Sladen, 2008; & Tharpe & Bess, 1999). Third, the goal of imple mentation of the HCP would allow participants to

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91 understand the benefits of using hearing protection (i.e. earplugs) and hearing protective practices that will ultimately protect them from hazardous noise (NIOSH, 2009). Fourth, cue to action stimuli were t he messages provided within the HCP and the hearing screening. The overall score of YANS showed a significant reduction in pro noise attitudes. There was also a great reduction in the factor of youth culture. Youth culture questions included questions, su can be modified by a hearing conservation program. There were no significant reduction for the sub factors of Concentration in Noise, Daily Noises, and Intent to Influence. It was expected to see minor or no changes in the response for these sub factors. For while doing to make it less likely for a person to believe that listening to music while doing homework is a danger to him or her, yet a HCP may influence the level at which the person plays the music. The HCP greatly improved the knowledge of NIHL and hearing protective behaviors. With increased knowledge a person beliefs and positive attitudes towards noise w hich will hopefully change any poor hearing health behaviors Based on the health belief model, the HCP and audiometric screening results served as cue to action to make a change in the thoughts regarding NIHL. This change in

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92 knowledge wil l affect the perception of susceptibility and severity of the risk of NIHL, and the participants would appreciate having the benefit of normal hearing Influence of Gender and Race There was an effect of gender on initial YANS sub factor of Daily noises. Specifically, females scored significantly lower than males on accepting daily loud sounds. Within the literature females tend to be more conservative and less risky in actions compared to males ( Vogel et al., 2007 ; Vogel et al., 2009 ) There were no other gender effects within the experimental group or the control group. On the initial knowledge survey, there was a race a nd gender interaction, so there was a significant difference between African American males and females. Thus, African American females were much more knowledgeable than African American males. Also, Caucasian females were the most knowledgeable among all the other groups; and African American males were the least knowledgeable of all the other racial groups. for the sub factor of Intent to Influence the Sound Environment. Cau casians were most likely to make an effort to change his or her sound environment. African Americans were also willing to influence a change in their sound environment, but not as much as Caucasians. Hispanics were significantly less likely to aspire to in fluence t heir sound environment. One can hypothesize that this may be due to the cultural norms of Hispanics in which they are taught obedience and respect to elders and authority figures, so these children may be less likely to challenge authority figures (i.e. Parent listening to loud music) to ensure a safe sound environment ( LaVeist, 2005 ; Rivera & Rogers Adkinson, 1997 )

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93 Racial/ethnic differences were also seen in the knowledge measures. Caucasian participants were the most knowledgeable compared to the other racial groups; and Hispanics were the least knowledgeable. These racial/ethnic differences may be due to the difference in the parental knowledge and SES level. Caucasians generally have higher levels of SES and higher SES is often based on attainment of higher education and the ab ility to move upward in society ( LaVeist, 2005 ) These results are not surprising and would be expected because different racial/ethnic groups hold different beliefs and attitudes, so these differences in belie fs would also be seen in attitudes towards noise. The responses from the focus groups support the use of a didactic and interactive teaching of a HCP. Rogers et al. (2009 ) reported that the effective implementation of a HCP is dependent on the instructor. The instructor m ust be knowledgeable of material, and present the material in an interactive and didactic manner. Every focus group participant provided positive feedback regarding the hands on activities and games within the program. For example, the focus group particip ants reported enjoying the interaction with the instructor in the tuning fork demonstrations. In this specific task, participants were given the opportunity to use a tuning fork to set a ping pong ball in motion, which demonstrated a visual representation of sound created by vibrations. Exposing children to audiometric testing as an integral part of HCP is a necessity based on the responses of focus group participants. The focus groups members reported that the audiometric exams were memorable and made the importance of protecting their hearing once they understood their hearing status. Thus, by including audiometric testing in an educational HCP would allow the program to similar to a modified

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94 occupational HCP targeted to children. Also, by implementing au diometric tests allowed children to relate what they have learned in the HCP to real world consequences of a potential high frequency hearing loss. Limitations of the Study Upon completing this project, several limitations became evident. There were three major challenges to this study that included (1) accessibility to the study partici pants, (2) background noise, (3) consistency of the HCP group interactions (4) possible peer interaction between the control and experimental group (5) student self report of race/ethnicity and (6) possible language issues. First, accessibility to the study population was dependent on participants being present at school on the scheduled study days. For instance, several participants had moved away or were absent during th e scheduled study days set aside for retests of audiometric screenings. Thus, the frequency hearing loss among those first identified as having high frequency hearing loss. In addition, 29 participants were unable to complete the post test measure that affected the total number of participants in each racial group, which may have affected the statistical analyses for interactions for the variable of race. Another chall enge to accessibility was the various school schedule requirements placed on the children. The participating schools implemented team/co teaching in which students were taught by two teachers in which they would switch between during the course of the day. A typical participants could not be pulled for their audiometric screenings during reading time (90 minutes within the school day), math and/or science classes for fourth and fifth grades

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95 (90 minutes within the school day); lunch (30 minutes of the school day); and/or if the teacher stated that the child could not be pulled at the requested time. Second, background noise due to the ambient noise, such as the fans of the air c onditioning units or more commonly due to the extraneous background noise caused by the other study participants affected the ability for some participants to pass at 1000 Hz. Three to five participants were pulled at once due to accessibility to participa nts, and because of the number of participants in the designated testing room, it was difficult to maintain complete silence from the participants. Third, the consistency of HCP interactions among participants varied greatly. The same lesson plan was cover ed for each HCP group within the experimental group; however, each group was allowed to interrupt with questions and following the presentation there was an additional five minutes allocated for questions. Thus, each group presented novel thoughts and ques tions which lead to various group interactions that differed from one other. Fourth, the issue of peer interactions of the control and experimental group Because, participa nts in both groups had the same lunch period, same physical education classes, and rode on the same school buses, they had an opportunity to share and discuss the material covered in the HCP. Therefore, the non statistically significant reductions seen in control group could be an outcome of the sharing of material within a peer group. Another possible limitation was the researcher was dependent on the participants self report of race/ethnicity. Some participants may not have been aware of their race/ethnic background. This may have been a problem for students from multi cultural

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96 families. For example, children with interracial parents may not have a specific ethnic identity. Several races can represent the Hispanic ethnicity, which may have resulted in vary ing cultural differences. Finally, some of the children had Spanish as their first language. Thus, the researcher was dependent on the translation of teachers and fellow students for both the survey and the HCP. Ideally, these both should have been done i n their native language. Future Aims A future investigation would be to implement a comparative study to measure the consistency between the diagnosis of hearing loss using the audiometric methods used from the Niskar and Shargorodsky studies compared to t he suggestions made by Schlauch and Carney. Schlauch and Carney (2012 ) suggested recommendations that included the following: (1) use of a clinical method to obtain threshold (i.e. modified Hughson Westlake proced ure), (2) use of insert headphones versus TDH style headphones to reduce potential issues, such as collapse of the external ear canal, (3) completion of multiple audiometric tests or retesting thresholds (to compensate for patient reliability), and (4) use of a 20 dBHL as the new pass/fail criterion. With implementation of these study recommendations would ultimately reduce the number of false positive diagnoses of high frequency hearing loss seen in children. Thus, a more accurate account of the risk of hi gh frequency hearing loss could be obtained for this population. Another future aim of this study would be make this study into a longitudinal study in which participants would have the same protocol completed twice, once in middle school and once in high school. Thus, one may determine if attitudes remain less pro

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97 noise and if participants remain knowledgeable regarding NIHL and protective hearing behaviors. Thus, it woul d be the ultimate measure to ass ess if providing primary prevention programs at young er ages is more beneficial than presenting primary prevention programs later in life. Further, completed audiometric testing would provide information on the permanence of identified hearing loss (permanent threshold shift versus a temporary threshold shif t) and if there is the presence of hearing loss how stable is the loss. Conclusion The results of this study supported some of the study hypotheses. Most importantly, a 45 minute HCP was effective in modifying attitudes and knowledge among those that recei ved the HCP. Therefore, the implementation of an educational HCP in a school setting was beneficial to the HCP participants. Second, there were differences between the racial groups for knowledge after receiving a HCP. Therefore, Caucasians were shown to b e the most knowledge compared to the other racial/ethnic groups. Also, there was a racial/ethnic difference in the participants' willingness to influence their sound environment, so Hispanics were least likely to make a change in their sound environment. P rior, to the HCP there were gender differences in the of these daily noises. Also, the hypothesis of white females being the most knowledgeable was true prior to receip t of a HCP (which afterwards there was no influence of gender). However, it was not expected to have an absence of racial/ethnic differences in the attitudes towards noise among the children. The HCP made a significant influence in changing the overall pos itive attitudes toward noise. Thus, with an increase in knowledge there was a reduction in pro noise

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98 attitudes; so the participants learned that noise is hazardous. The information from a HCP presented in less than an hour was retained more than a month af ter the HCP was presented. Thus, implementation of a HCP should receive the same resources that other education programs (i.e. anti smoking or anti drug) within the school systems and other community institutions ( Dell & Holmes, 2012 ; Folmer, Griest, & Martin, 2002 ) Thus, hearing health professional should take up the charge and implement HCP programs that benefit child ren regardless of racial/ethnic or gender differences.

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99 APPENDIX A PRE TEST QUESTIONNAIRE Thank you for participating in this program. This questionnaire collects information about your thoughts about loud noises and this class. Remember your responses wi ll remain private. 1. Sex (Please circle): Male Female 2. Age (Please circle): 08 09 10 11 12 3. Race/Ethnicity: 4. 5. Please circle the number that shows how you agree with the statement. 5 STRONGLY AGREE with the statement 4 AGREE with the statement 3 NEUTRAL with the statement 2 DISAGREE with the statement 1 STRONGLY DISAGREE with the statement 6. I think that sounds at parties, concerts, and sporting events, in general, are too loud. 1 2 3 4 5 7. Listening to music whil e doing homework helps me concentrate. 1 2 3 4 5 8. I am prepared to do something to make the school quieter 1 2 3 4 5 9. I would think about leaving a party or sporting event if the sound level is too loud. 1 2 3 4 5 10. I can concentrate even if t here are many different sounds around me. 1 2 3 4 5 11. I think it is unnecessary to use earplugs when I am at music concert, party, or sporting event. 1 2 3 4 5 12. It is important for me to make the sounds around me more comfortable. 1 2 3 4 5 13. 1 2 3 4 5

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100 14. The sound level at parties, concerts, or sporting events is not a problem. 1 2 3 4 5 15. Noise and loud sounds are natural parts of our world. 1 2 3 4 5 16. Traffic noise is not disturbing. 1 2 3 4 5 17. The sounds should be lowered at concerts, parties, or sporting events. 1 2 3 4 5 18. I think it should be quiet and calm in the classroom. 1 2 3 4 5 19. Sounds from fans, refrigerators, computers, etc. do not bother me. 1 2 3 4 5 20. I am prepared to give up activities where the sound level is too loud. 1 2 3 4 5 21. The sound level at my school is comfortable. 1 2 3 4 5 22. It is easy for me to ignore traffic noise. 1 2 3 4 5 23. There should be more rules or regulations for the s ound levels in society. 1 2 3 4 5 24. When I cannot get rid of sounds that bother me, I feel helpless. 1 2 3 4 5 Please answer the following questions 25. During the past year, I have done the following (check all that apply): a. Used MP3 player or CD player b. Fire d a gun c. Used a gas powered lawn mower or leaf blower d. Went to a concert e. Played in a band f. Rode on a motorcycle, ATV, jet ski g. Went to a car race

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101 26. During the past year, I have been around loud sounds that made my ears hurt or rs. a. Yes b. No c. Not Sure 27. I wear earplugs or earmuffs whenever I am around loud sounds. a. Always b. Sometimes c. Never 28. Which of the following types of sound can be loud enough to damage your hearing? a. MP3 player or CD player b. Fireworks c. Gunfire d. Dishwasher e. Washing Machin e f. Concert 29. Which of the following are good ways to protect your hearing when you are around loud sound? (Check all that apply): a. Walk away from the loud sound b. Turn down the volume c. Make yourself listen to loud sounds for longer periods of time so your ears w ill get use to it d. Spend less time around loud sounds whenever possible e. Put cotton or Kleenex in your ears f. Use earplugs or ear muffs 30. I know a lot about the types of sound that cause hearing loss a. True b. False c. Not sure 31. I know a lot about how to protect my he a. True b. False c. Not sure 32. Hearing an extremely loud sound even one time can cause you to lose some of your hearing. a. True b. False c. Not sure

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102 33. Sound that is too loud can damage tiny hair cells of the inner ear. a. True b. False c. Not sure 34. H earing loss is only a problem for elderly people. a. True b. False c. Not sure 35. People with hearing loss often have problems with the following (check all that apply): a. Hearing alarms, the doorbell, or the telephone ringing b. Understanding road signs c. Understanding wh at is said in a group d. Getting to work e. Understanding what is said at movies, plays or on TV f. Understanding what is said in class 36. Having hearing loss is not a big deal a. Agree b. Disagree c. Not sure 37. hearing loss, so I a. Agree b. Disagree c. Not Sure 38. If I go to a loud concert, I will wear hearing protection. a. Yes b. No c. Not Sure

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103 APPENDIX B POST TEST QUESTIO N NAIRE Thank you for participating in this program. This questionnaire collects information about your thoughts about loud noises and this class. Remember your responses will remain private. 6. Sex (Please circle): Male Female 7. Age (Please circle): 08 09 10 11 12 8. Race/Ethnicity: 9. 10. ation: Please circle the number that shows how you agree with the statement. 5 STRONGLY AGREE with the statement 4 AGREE with the statement 3 NEUTRAL with the statement 2 DISAGREE with the statement 1 STRONGLY DISAGREE with the statement 6. I think tha t sounds at parties, concerts, and sporting events, in general, are too loud. 1 2 3 4 5 7. Listening to music while doing homework helps me concentrate. 1 2 3 4 5 8. I am prepared to do something to make the school quieter 1 2 3 4 5 9. I would think about leaving a party or sporting event if the sound level is too loud. 1 2 3 4 5 10. I can concentrate even if there are many different sounds around me. 1 2 3 4 5 11. I think it is unnecessary to use earplugs when I am at music concert, party, or sp orting event. 1 2 3 4 5 12. It is important for me to make the sounds around me more comfortable. 1 2 3 4 5 13. 1 2 3 4 5

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104 14. The sound level at parties, concerts, or sporting events is not a problem. 1 2 3 4 5 15. Noise and loud sounds are natural parts of our world. 1 2 3 4 5 16. Traffic noise is not disturbing. 1 2 3 4 5 17. The sounds should be lowered at concerts, parties, or sporting events. 1 2 3 4 5 18. I think it should be quiet and calm in the classroom. 1 2 3 4 5 19. Sounds from fans, refrigerators, computers, etc. do not bother me. 1 2 3 4 5 20. I am prepared to give up activities where the sound level is too loud. 1 2 3 4 5 21. The sound level at my school is comfortable. 1 2 3 4 5 22. It is easy for me to ignore traffic noise. 1 2 3 4 5 23. There should be more rules or regulations for the sound levels in society. 1 2 3 4 5 39. When I cannot get rid of sounds that bother me, I feel helpless. 1 2 3 4 5 Please answer the following questions 25 Which of the following are good ways to protect your hearing when you are around loud sound? (Check all that apply): a. Walk away from the loud sound b. Turn down the volume c. Make yourself listen to loud sounds for longer periods of time so your ea rs will get use to it d. Spend less time around loud sounds whenever possible e. Put cotton or Kleenex in your ears f. Use earplugs or ear muffs

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105 26 Hearing loss is only a problem for elderly people. g. True h. False i. Not sure 27. I wear earplugs or earmuffs whenever I am around loud sounds. a. Always b. Sometimes c. Never 28. I know a lot about the types of sound that cause hearing loss a. True b. False c. Not sure 29. Which of the following types of sound can be loud enough to damage your hearing? a. MP3 player or CD player b. Fireworks c. Gunfire d. Dish washer e. Washing Machine f. Concert 30. a. True b. False c. Not sure 31. Hearing an extremely loud sound even one time can cause you to lose some of your hearing. a. True b. False c. Not sure 32. Sound that is too loud can damage tiny hair cells of the inner ear. a. True b. False c. Not sure

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106 33. People with hearing loss often have problems with the following (check all that apply): a. Hearing alarms, the doorbell, or the telephone ringing b. Understanding road signs c. Understanding what is said in a group d. Getting to work e. Understanding what is said at movies, plays or on TV f. Understanding what is said in class 34. Having hearing loss is not a big deal a. Agree b. Disagree c. Not sure 35. a hearing loss, a. Agree b. Disagree c. Not Sure 36. If I go to a loud concert, I will wear hearing protection. a. Yes b. No c. Not Sure 37. During the next month, if I am around loud sound, I would be likely to try to somet hing to protect my hearing. a. Yes b. No c. Not Sure

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107 LIST OF REFERENCES Agrawal, Y., Platz, E. A., & Niparko, J. K. (2008). Prevalence of hearing loss and differences by demographic characteristics among US adults: data from the National Health and Nutrition Examination Survey, 1999 2004. Arch Intern Med, 168 (14), 1522 1530. American Academy of Audiology, A. (2009). Turn It to The Left Retrieved November 1, 2009, from www.turnittotheleft.org American Speech Language and Hearing Association, A. (2009). Listen to Your buds Retrieved November 2, 2009, from www.listentoyourbuds.org American Tinni tus Association, A. (2009). Frequently asked questions Retrieved April 8, 2009 from http://www.ata.org/about tinnitus/patient faq1 Anderson, K. L. (1992). Keys to effective hearing conservation programs: Hearing status of school age children. American Speech and Hearing Associtation Reports, 21 38 47. Axelsson, A., & Ringdahl, A. (1989). Tinnitus: A study of its prevalence and characteristics. British Journal of Audiology, 23 53 62. Barrenas, M., & Lindgren, F. (1991). The influences of eye colour on susceptibility to TTS in Humans. British Journal of Audiology, 25 303 307. Berger, E. H., Royster, L. H., Royster, J. D., Driscoll, D. P., & Layne, M. (Eds.). (2003). The noise manual (5th ed.). Fairfax, VA: American Industrial Hygiene Association. Bess, F. H., Dodd Murphy, J., & Parker, R. A. (1998). Children with minimal sensorineural hearing loss: Prevalence, educational performance, and functional status. Ear and Hearing, 19 (5), 339 354. Bl oom, S. (2006). New hearing conservation initiatives: small steps with great potential. Hearing Journal, 59 (1), 23. Borchgrevink, H. M. (2003). Does health promotion work in relation to noise? Noise Health, 5 (18), 25 30. Caitlin, F. I. ( 1986). Noise induced hearing loss. The American Journal of Otology, 7 (2), 141 149. California Department of Health Care Services, D. (2009). Hearing conservation programs Retrieved October 30, 2009, from http://www.dhcs.ca.gov/services/hcp/Pages/default.aspx

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108 Cheng, A. G., Cunningham, L. L., & Rubel, E. W. (2005). Mechanisms of hair cell death and protection. Otolaryngology, Head, Neck, and Surgery, 13 343 348. Chermak, G. D., Curtis, L ., & Seikel, J. A. (1996). The effectiveness of an interactive hearing conservation program for elementary school children. Language, Speech, & Hearing Services in Schools, 27 (1), 29 39. Coll, K. M., Cutler, M. M., Thobro, P., Haas, R., & Powell, S. (2009 ). An exploratory study of psychosocial risk behaviors of adolescents who are deaf or hard of hearing: comparisons and recommendations. Am Ann Deaf, 154 (1), 30 35. Crandell, C., Mills, T. L., & Gauthier, R. (2004). Knowledge, behaviors, and attitudes abou t hearing loss and hearing protection among racial/ethnically diverse young adults. J Natl Med Assoc, 96 (2), 176 186. Dangerous Decibels, D. (2009). Dangerous Decibels Retrieved November 1, 2009, from www.dan gerousdecibels.org Daniel, E. (2007). Noise and hearing loss: a review. J Sch Health, 77 (5), 225 231. Davis, J. M., Shepard, N. T., Stelmachowicz, P. G., & Gorga, M. P. (1981). Characteristics of h earing impaired children in the public schools: part II -psychoeducational data. Journal of Speech and Hearing Disorders, 46 (2), 130 137. Dell, S., & Holmes, A. (2012). The effect of a hearing conservation program on adolescents' attitudes towards noise. Noise Health, 14 (56), 39 44. Dobie, R. A. (1995). Prevention of noise induced hearing loss. Arch Otolaryngol Head Neck Surg, 121 (4), 385 391. Erlandsson, S. I., Holmes, A. E., Widen, S. E., & Bohlin, M. (2008). Cultural and so cial perspectives on attitudes, noise, and risk behavior in children and young adults. Seminars in Hearing, 29 (1 ), 29 41. Fausti, S. A., Wilmington, D. J., Helt, P. V., Helt, W. J., & Konrad Martin, D. (2005). Hearing health and care: the need for improv ed hearing loss prevention and hearing conservation practices. Journal of Rehabilitation Research & Development, 42 (4), 45 61. Florida Department of Education. (2012). Student Membership by School by Race, Grade, Gender, 2011 12. Data Publications and Rep orts Retrieved September 11, 2012, from http://www.fldoe.org/eias/eiaspubs/pubstudent.asp Folmer, R. L. (2008). Hearing loss prevention practices should be taught in schools. Seminars in Hear ing, 29 (1), 67 80.

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109 Folmer, R. L., Griest, S. E., & Martin, W. H. (2002). Hearing conservation education programs for children: a review. J Sch Health, 72 (2), 51 57. Griest, S. E. (2008). Evaluation of a hearing loss prevention program. Seminars in Hearin g, 29 (1), 122 136. Gunderson, E., Molinem, J., & Catalano, P. (1997). Risks of Developing Noise Induced Hearing Loss in Employees of Urban Music Clubs. Americal Journal of Industrial Medicine, 31 75 79. Harrison, R. V. (2008). Noise induced hearing loss in children: A 'less than silent' environmental danger. Paediatr Child Health, 13 (5), 377 382. Hearing Foundation of Canada, H. (2009). Sound Sense Retrieved November 2, 2009, from www.soundsense.ca Henderson, D., Bielefield, E. C., Harris, K. C., & Hu, B. H. (2006). The role of oxidative stress in noise induced hearing loss. Ear & Hearing (01960202), 27 (1 19). Henderson, E., Testa, M. A., & Hartnick, C. (2011). Prevalence of noise induced hearing threshold shifts and hearing loss among US youths. Pediatrics, 127 (1), e39 46. House Ear Institute, H. (2009). Sound Partners Retrieved November 1, 2009, from http://www.hei.org/edu cation/soundpartners/sp.htm Howarth, L. C. (2008). Coordinating a hearing health education program: Challenges and strategies. Seminars in Hearing, 29 (1), 111 121. Hu, B. H., Henderson, D., & Yang, W. P. (2008). The impact of mitochondrial energetic dysf unction on apoptosis in outer hair cells of the cochlea following exposure to intense noise. Hearing Research, 236 (1 2), 11 21. Jahn, A. F., & Santos Sacchi, J. (Eds.). (2001). Physiology of the Ear (Second ed.). Canada: Singular Thomson Learning. Katbam na, B., & Flamme, G. A. (2008). Acquired hearing loss in adolescents. Pediatric Clinics of North America, 55 (6), 1391 1402. Kawada, T. (2004). The effect of noise on the health of children. Journal of Nippon Medical School, 71 (1), 5 10. Kent, B. A. (2003 ). Identity Issues for Hard of Hearing Adolescents Aged 11, 13, and 15 in Mainstream Setting. J Deaf Stud Deaf Educ, 8 (3), 315 324. Keppler, H., Dhooge, I., Maes, L., D'haenens, W., Bockstael, A., Philips, B., Vinck, B. (2010). Short tern Auditory Effects of Listening to an MP3 Player. Arch Otolaryngol Head Neck Surg, 136 (6), 538 548.

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110 Knobloch, M. J., & Broste, S. K. (1998). A hearing conservation program for Wisconsin youth working in agriculture. Journ al of School Health, 68 (8), 313 318. Kochkin, S. (2009). Hearing Loss: The prevalence of hearing loss. Better Hearing Institute Retrieved from www. Betterhearing.org/hearing_loss/prevalence.cfm Kopke, R., Allen, K. A., Henderson, D., Hoffer, M., Frenz, D ., & Van der Water, T. (1999). A radical demise: Toxins and trauma share common pathways in hair cell death. Annals New York Academy of Sciences, 884 171 191. hearing, hearing loss, and hearing health. Hearing Journal 15 19. LaVeist, T. (2005). Minority Populations and Health: An introduction to health disparities in the United States San Francisco: Jossey Bass. Le Prell, C. G., Hensley, B. N., Campbell, K. C. M., Ha ll, J. W., & Guire, K. (2011). student population. International Journal of Audiology, 50 (S1), S21 S31. Lee, D. J., Gomez Marin, O., Lam, B. L., & Zheng, D. D. ( 2004). Trends in hearing impairment in United States adults: the national health interview survey, 1986 1995. J Gerontol A Biol Sci Med Sci, 59 (11), 1186 1190. LePrell, C. G., Yamashita, D., Minami, S. B., Yamasoba, T., & Miller, J. M (2007). Mechanisms of noise induced hearing loss indicate multiple methods of prevention. Hearing Research, 226 22 43. Lusk, S. L. (1997). Noise exposures. Effects on hearing and prevention of noise induced hearing loss. AAOHN J, 45 (8), 397 408; quiz 4 09 310. Martin, W. H. (2008). Dangerous decibels: Partnership for preventing noise induced hearing loss and tinnitus in children. Seminars in Hearing, 29 (1), 102 110. Maw, A. R., Hall, A. J., Pothier, D. D., Gregory, S. P., & Steer, C. D. (2011). The Pre valence of Tympanic Membrane and Related Middle Ear Pathology in Children: A Large Longitudinal Cohort Study Followed From Birth to Age Ten. Otology & Neurotology, 32 (8), 1256 1261 McFadden, B., & Pittman. (2008). Ef multitask in quiet and noise. Language, Speech, and Hearing Services in Schools, 39 342 351. Meinke, D. (2009). Crank It Down update Retrieved October 31, 2009, from www.hearingconservation.org Montana Of fice of Public Instruction, M. (2008). Hearing conservation programs Retrieved October 30, 2009, from www.opi.state.mt.us/specED/audio2.html

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114 BIOGRAPHICAL SKETCH Shawna M. Dell received her Bachelor of Arts degree in communication sciences and d isorders from the University of Florida. She continued her education at the University of Florida to receive her Doctor of Audio logy degree in 2008. A year later, Dr. Shawna M. Dell received her certification in public h ea lth with specialization in social behavioral s cience She recently received her Doctor of Philosophy in the major of communication sciences and disorders Dr. Del include: incorporation of the aims of public health among the world of audiology, hearing conservation, prevention and education of hearing loss among diverse populations, and audiologic rehabilitation Dr. Dell is a licensed clinic al audiologist in the State of Florida since 2008. She also holds her certificate of Clinical Competence in Audiology issued by the American Speech and Hearing Association. Dr. Dell has supervised students in various clinical settings at the Speech and Hea ring Clinics at the University of Florida and she has worked with Veterans at the Veteran Administration in Gainesville, FL.