Factors influencing use of hearing protection among farmers: a test of the pender health promotion model

Leisure noise exposure and hearing outcomes among Canadians aged 6 to 79 years

OBJECTIVE

To examine the association between individual and cumulative leisure noise exposure in addition to acceptable yearly exposure (AYE) and hearing outcomes among a nationally representative sample of Canadians.

DESIGN

Audiometry, distortion-product otoacoustic emissions (DPOAEs) and in-person questionnaires were used to evaluate hearing and leisure noise exposure across age, sex, and household income/education level. High-risk cumulative leisure noise exposure was defined as 85 dBA or greater for 40 h or more per week, with AYE calculations also based on this occupational limit.

STUDY SAMPLE

A randomised sample of 10,460 respondents, aged 6-79, completed questionnaires and hearing evaluations between 2012 and 2015.

RESULTS

Among 50-79 year olds, high-risk cumulative leisure noise was associated with increased odds of a notch while high exposure to farming/construction equipment noise was associated with hearing loss, notches and absent DPOAEs. No associations with hearing loss were found however, non-significant tendencies observed included higher mean hearing thresholds, notches and hearing loss odds.

CONCLUSION

Educational outreach and monitoring of hearing among young and middle-aged populations exposed to hazardous leisure noise would be beneficial.

Effectiveness of Motivational Interviewing in Increasing Use of Hearing Protection Devices Among Agricultural Producers

BACKGROUND

Agricultural producers are frequently exposed to noise that is hazardous to their hearing and cardiovascular health, and have among the highest rates of noise-induced hearing loss of all occupations. However, despite information-sharing approaches, few producers wear sufficient hearing protection. There is a need to develop effective methods of protecting producers from their noise exposure.

METHODS

We provided a series of 2 to 3 short (30-minute) telephone-based motivational interviewing (MI) sessions to noise-exposed agricultural producers. We assessed intervention effectiveness through changes in measuring hearing protector use pre- and post-intervention using a one-group pre/posttest design.

RESULTS

The sample (N = 29) predominantly consisted of crop producers from Michigan. The mean percentage of time hearing protection was used increased from 44.9% to 51.8% after the intervention, approximately a 7% increase (p =.105). Regression analysis suggested the relationship between intervention dose and use of hearing protection was not correlative.

DISCUSSION/CONCLUSION

There was a marginal increase in the use of hearing protection after the intervention, although setting-specific increases in use were uneven. Intervention dose did not correlate with a change in hearing protection use. Further research is warranted to determine the effectiveness of MI, how it compares to information sharing, and to identify intervention dose parameters that promote efficiency.

Augmented Hearing of Auditory Safety Cues for Construction Workers: A Systematic Literature Review

Safety-critical sounds at job sites play an essential role in construction safety, but hearing capability is often declined due to the use of hearing protection and the complicated nature of construction noise. Thus, preserving or augmenting the auditory situational awareness of construction workers has become a critical need. To enable further advances in this area, it is necessary to synthesize the state-of-the-art auditory signal processing techniques and their implications for auditory situational awareness (ASA) and to identify future research needs. This paper presents a critical review of recent publications on acoustic signal processing techniques and suggests research gaps that merit further research for fully embracing construction workers' ASA of hazardous situations in construction. The results from the content analysis show that research on ASA in the context of construction safety is still in its early stage, with inadequate AI-based sound sensing methods available. Little research has been undertaken to augment individual construction workers in recognizing important signals that may be blocked or mixed with complex ambient noise. Further research on auditory situational awareness technology is needed to support detecting and separating important acoustic safety cues from complex ambient sounds. More work is also needed to incorporate context information into sound-based hazard detection and to investigate human factors affecting the collaboration between workers and AI assistants in sensing the safety cues of hazards.

Towards a Holistic Model Explaining Hearing Protection Device Use among Workers

Offering hearing protection devices (HPDs) to workers exposed to hazardous noise is a noise control strategy often used to prevent noise-induced hearing loss (NIHL). However, HPDs are used incorrectly and inconsistently, which explains their limited efficiency. Numerous models based on social cognition theories identify the significant factors associated with inconsistent HPD use and aim to improve HPD training programs and to increase HPD use. However, these models do not detail (dis)comfort aspects originating from complex interactions between characteristics of the triad “environment/person/HPD” while these aspects are known to largely influence HPD (mis)use. This paper proposes a holistic model explaining HPD (mis)use, based on the integration of a comfort model adapted to HPDs into an existing behavioral model already developed for HPDs. The model also takes into account the temporal dimension, which makes it possible to capture the scope of change in HPD-related health behaviors. This holistic description of HPD use could be used as a tool for stakeholders involved in HPD use to effectively prevent NIHL among workers.

Prevalence of hearing protection device non-use among noise-exposed US workers in 2007 and 2014

BACKGROUND

This study estimated the prevalence of hearing protection device (HPD) non-use among US workers exposed to hazardous workplace noise and provided risk estimates.

METHODS

Self-reported data from the National Health Interview Survey in 2007 (15,852 workers) and 2014 (23,656 workers) were examined. Weighted prevalence and adjusted prevalence ratios of HPD non-use (using HPDs half the time or less when exposed to hazardous noise) were estimated by demographic, industry, and occupation. Differences in the prevalences of non-use were estimated and compared.

RESULTS

The prevalence of HPD non-use was 53% among all noise-exposed workers in 2014. Workers in the Accommodation and Food Services industry had the highest prevalence (90%) and risk (PR: 2.47, 95% confidence interval: 1.54-3.96) of HPD non-use. The industries with the lowest prevalences of noise exposure, including Finance and Insurance (2%) and Health Care and Social Assistance (4%), had some of the highest prevalences of HPD non-use (80% and 83%, respectively). There were no statistically significant changes in HPD non-use among industries between 2007 and 2014. Among occupations, HPD non-use increased 37% in Arts, Design, Entertainment, Sports and Media, and decreased 39% in Architecture and Engineering.

CONCLUSION

The prevalence of HPD non-use remains high; especially within industries and occupations with fewer noise-exposed workers. These groups need targeted attention to increase awareness and compliance. Employers should require HPD use and trainings among noise-exposed workers and provide an assortment of HPDs tailored to noise level and type, workplace environment, communication and audibility needs, and individual comfort and convenience.

Risk Perception & Risk-Reduction Behavior Model for Blue-Collar Workers: Adapted From the Health Promotion Model

This study examined the health promotion model (HPM) as a framework for assessing perceptions and health-related behaviors related to cardiovascular disease (CVD) risk among blue-collar workers. This was done with the aim of providing time-sensitive educational and training materials for workers while on the job or functioning in their communities. The revised HPM was evaluated in the above context using specific criteria developed by Chinn and Kramer (2008) and scoping literature review. Specifically, we assessed the model based on five criteria such as its clarity, simplicity, generality, accessibility, and importance. The revised HPM showed strengths in both accessibility and generality. That is, it applied to all populations and chronic illnesses through clearly defined and specified major concepts. However, there were several weaknesses in areas of clarity and consistency; the model included three new concepts (i.e., activity-related affect, commitment to a plan of action, and immediate competing demands and preference) that actually decreased these elements. In this context, situational influences require adequately reflected external variables. Nevertheless, the revised HPM showed predictive power among this study's target population. The HPM was modified to address deficiencies in regard to the concept of risk perception. Work-related situational influences were also restructured based on individual and environmental characteristics. The modified framework can be used to clarify health-related behaviors among blue-collar workers.

An overview of occupational noise-induced hearing loss among workers: epidemiology, pathogenesis, and preventive measures

Occupational noise-induced hearing loss (ONIHL) is the most prevalent occupational disease in the world. The goal of this study was to review the epidemiology, pathogenesis, and preventive measures of ONIHL among workers and provide evidence for the implementation of control measures. Literature studies were identified from the MEDLINE, PubMed, Embase, Web of Science, and Google Scholar using the search terms “noise-induced hearing loss” “prevalence”, “pathogenesis”, and “preventive measures”. The articles reviewed in this report were limited from 2000 to 2020. Articles that were not published in the English language, manuscripts without an abstract, and opinion articles were excluded. After a preliminary screening, all of the articles were reviewed and synthesized to provide an overview of the current status of ONIHL among workers. The mechanism of ONIHL among workers is a complex interaction between environmental and host factors (both genetic and acquired factors). The outcomes of noise exposure are different among individual subjects. Clinical trials are currently underway to evaluate the treatment effect of antioxidants on ONIHL. Noise exposure may contribute to temporary or permanent threshold shifts; however, even temporary threshold shifts may predispose an individual to eventual permanent hearing loss. Noise prevention programs are an important preventive measure in reducing the morbidity of ONIHL among workers.

Hearing Difficulties and Tinnitus in Construction, Agricultural, Music, and Finance Industries: Contributions of Demographic, Health, and Lifestyle Factors

High levels of occupational noise exposure increase the risk of hearing difficulties and tinnitus. However, differences in demographic, health, and lifestyle factors could also contribute to high levels of hearing difficulties and tinnitus in some industries. Data from a subsample (n = 22,936) of the U.K. Biobank were analyzed to determine to what extent differences in levels of hearing difficulties and tinnitus in high-risk industries (construction, agricultural, and music) compared with low-risk industries (finance) could be attributable to demographic, health, and lifestyle factors, rather than occupational noise exposure. Hearing difficulties were identified using a digits-in-noise speech recognition test. Tinnitus was identified based on self-report. Logistic regression analyses showed that occupational noise exposure partially accounted for higher levels of hearing difficulties in the agricultural industry compared with finance, and occupational noise exposure, older age, low socioeconomic status, and non-White ethnic background partially accounted for higher levels of hearing difficulties in the construction industry. However, the factors assessed in the model did not fully account for the increased likelihood of hearing difficulties in high-risk industries, suggesting that there are additional unknown factors which impact on hearing or that there was insufficient measurement of factors included in the model. The levels of tinnitus were greatest for music and construction industries compared with finance, and these differences were accounted for by occupational and music noise exposure, as well as older age. These findings emphasize the need to promote hearing conservation in occupational and music settings, with a particular focus on high-risk demographic subgroups.

Noise Exposure on Mixed Grain and Livestock Farms in Western Australia

Noise presents an ongoing occupational health and safety issue, which despite numerous studies still presents a significant risk in agriculture with high exposures prevalent. In this study, we measured noise exposures associated with significant activities on 42 mixed grain and livestock farms in Western Australia. Employing a mixture of personal noise measurements using dosimeters, noise measurements using sound level meters, and a validated survey, we identified that 32% of farm workers were exposed to noise levels above the LAeq,8h 85 dB(A) limit, before considering extended shifts. We also noted that extended shift lengths, of up to 16 h in some cases, were possible. In addition, we found that 37% of workers were exposed to noise peak of 140 dB(C) or greater. It was further noted that hearing protection is not typically worn for the duration of an activity and is only for a small number of tasks. However we did find some evidence that farmers had begun to implement some form of noise management practice, usually in the form of buying quieter equipment or separating noisy tasks from quiet tasks. Improved education for farmer and farm workers in terms of the risks posed by noise, identifying noisy tasks, is recommended, as well as a programme to encourage better and consistent use of hearing protection.

Nursing Assistants' Use of Personal Protective Equipment Regarding Contact With Excreta Contaminated With Antineoplastic Drugs

PURPOSE

To examine the feasibility of observing and interviewing nursing assistants about handling of antineoplastic drugs contaminated with excreta, acceptability of a measure of personal protective equipment (PPE) use with nursing assistants, and predictors of PPE use.

PARTICIPANTS & SETTING

27 nursing assistants in an inpatient hematology-oncology unit at an academic medical center in the southeastern United States.

METHODOLOGIC APPROACH

This was an exploratory, multimethod study using observation, verbally administered questionnaires, and interviews. Research variables included recruitment rates, acceptability of observation, and understandability of a safe-handling instrument.

FINDINGS

Observed use of double gloves, chemotherapy gowns, and face shields was low; use of plastic-backed pads when flushing excreta was high.

IMPLICATIONS FOR NURSING

Nursing assistants are willing to participate in research. Standardized training and education about PPE use are needed.

Iranian experiences in terms of consumption of disposable single- use plastics: Introduction to theoretical variables for developing environmental health promotion efforts

In recent years, the consumption of disposable plastic items such as single-use plastic bags, plates, cutlery and so on has rapidly increased in Iran. Present study explored the Iranians' experiences in terms of the consumption of disposable single-use plastics. A qualitative content analysis study was conducted in Delfan, Lorestan, Iran in 2017. Thirty semi-structured in-depth interviews were done with citizens who resided in Delfan. Participants were asked about their experiences of single-use plastics consumption. After the first interview, continuous analysis of data began and continued up to data saturation. Three main themes including perceived barriers for less consumption of disposable single-use plastics, decisional balance and structural factors emerged as the Iranians' experiences in terms of the consumption of disposable single-use plastics. Health promotion practitioners should increase public awareness about the harmful outcomes of high consumption of disposable single-use plastic items through mass media. In addition, they should convince policymakers to enact laws for increasing the production of recyclable single-use items.

A Preliminary Study of a Spanish Graphic Novella Targeting Hearing Loss Prevention

PURPOSE

This preliminary study developed a digital graphic novella targeting hearing protection beliefs of Spanish-speaking agricultural workers. Researchers used pretest-posttest interview surveys to establish if the novella had an immediate influence on the participants' beliefs about noise-induced hearing loss and usage of hearing protection devices.

METHOD

Researchers developed a digital graphic novella directed to increase knowledge about noise-induced hearing loss and increase the proper use of hearing protection devices. The novella was tailored to meet the specific linguistic and literacy needs of Spanish-speaking agricultural workers. Thirty-one Spanish-speaking farmworkers of Mexican nationality participated. This study included an interview survey with specific questions on noise-induced hearing loss, myths, and hearing protection device usage. A pretest-posttest design was applied to measure the graphic novella's immediate influence on workers.

RESULTS

The posttest scores on Hearing Protection Beliefs statements were significantly better than pretest scores, with a large effect size observed.

CONCLUSION

Digital media may be an effective way to overcome language and literacy barriers with Spanish-speaking workers when providing health education and prevention efforts.

Breakfast consumption determinants among female high school students of Yazd Province based on Pender's Health Promotion Model

BACKGROUND AND AIM

Despite the importance of breakfast, especially for students, unfortunately, this meal is usually ignored in daily routine. The aim of this study was to identify determinants among female high school students of Yazd province based on the Pender Health Promotion Model.

METHODS

This was a cross-sectional study conducted to examine 200 female high school students of Yazd, selected by cluster sampling method in 2016. A researcher-made questionnaire, based on Pender's Health Promotion Model, was used as a data collection tool. A panel of experts and Cronbach's alpha coefficient were used to confirm the questionnaire validity and reliability. In order to analyze descriptive data, SPSS version 22 was used. AMOS software (v.23) was employed for path analysis.

RESULTS

Direct impact of activity -related affect (0.300), interpersonal influences (0.276), and perceived barriers to eating breakfast (-0.223) were approved at significance level p<0.000. By influencing perceived barriers, perceived self-efficacy and previous related behavior indirectly affected breakfast consumption. These components determined 33% of breakfast consumption.

CONCLUSION

By planning to create a positive feeling in students to have breakfast, to involve family and friends to encourage students to eat breakfast, to reduce barriers to have breakfast by increasing students' self-efficacy, the behavior of having breakfast among students can be improved.

Predictors of Hearing Protection Use Among Industrial Workers

Promoting the use of hearing protection devices (HPDs) can prevent noise-induced hearing loss (NIHL) among workers who are exposed to excessive noise. In the present study, the authors examine factors that may explain HPD use among industrial workers from 15 manufacturing plants in Thailand. Participants consisted of 268 randomly selected workers exposed to harmful noise levels for which routine HPD use was required. Logistic regression analysis of study variables revealed the most powerful predictors of HPD use were perceived hearing status ( b = 0.66, p < .001) and interpersonal factors (i.e., role modeling and interpersonal support; b = 0.20, p < .001). Together, these variables correctly classified 63.4% of the cases. These findings have implications for interventions aimed at motivating workers to use HPDs regularly.

Reported bed net ownership and use in social contacts is associated with uptake of bed nets for malaria prevention in pregnant women in Ghana

Background

Despite progress made in the last decades, malaria persists as a pressing health issue in sub-Saharan Africa. Pregnant women are particularly vulnerable to infection and serious health outcomes for themselves and their unborn child. Risk can be mitigated through appropriate use of control measures such as insecticide-treated bed nets. Although social networks can influence uptake of preventive strategies, the role of social influence on bed net ownership has not been explored. During an evaluation of a bed net distribution programme, the influence of non-health care advisors on ownership and use of bed nets by pregnant women in Kumasi, Ghana was examined.

Methods

Data were collected through in-person interviews with 300 pregnant women seeking antenatal care in an urban hospital in Kumasi, Ghana. Participants were asked about their bed net ownership, bed net use, and information about three personal contacts that they go to for pregnancy advice. Information about these advisors was combined into an influence score. Logistic regression models were used to determine the association between the score and bed net ownership. Those who owned a bed net were further assessed to determine if interpersonal influence was associated with self-reported sleeping under the bed net the previous night.

Results

Of the 294 women in the analysis, 229 (78%) reported owning bed nets. Of these bed net owners, 139 (61%) reported using a bed net the previous night. A dose response relationship was observed between the interpersonal influence score and bed net ownership and use. Compared to the lowest influence score, those with the highest influence score (>1 SD above the mean) were marginally more likely to own a bed net [OR = 2.37, 95% CI (0.87, 6.39)] and much more likely to use their bed net [5.38, 95% CI (1.89, 15.25)] after adjusting for other factors.

Conclusions

Interpersonal influence appears to have modest impact on ownership and use of bed nets by pregnant women in an urban area of Ghana. Further investigations would need to be conducted to determine if the relationship is causal or if individuals who associate are simply more likely to have similar practices.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-016-1660-4) contains supplementary material, which is available to authorized users.

Gender differences in use of hearing protection devices among farm operators

Purpose:

Although farm operators have frequent exposure to hazardous noise and high rates of noise-induced hearing loss, they have low use of hearing protection devices (HPDs). Women represent about one-third of farm operators, and their numbers are climbing. However, among published studies examining use of HPDs in this worker group, none have examined gender-related differences. The purpose of this study was to examine gender-related differences in use of hearing protection and related predictors among farm operators.

Materials and Methods:

Data previously collected at farm shows and by telephone were analyzed using t-tests and generalized linear model with zero inflated negative binomial (ZINB) distribution.

Findings:

The difference in rate of hearing protector use between men and women farm operators was not significant. There was no difference between men and women in most hearing protector-related attitudes and beliefs.

Conclusion:

Although men and women farm operators had similar rates of use of hearing protectors when working in high-noise environments, attitudes about HPD use differed. Specifically, interpersonal role modeling was a predictor of HPD use among women, but not for men. This difference suggests that while farm operators of both genders may benefit from interventions designed to reduce barriers to HPD use (e.g., difficulty communicating with co-workers and hearing warning sounds), farm women have unique needs in relation to cognitive-perceptual factors that predict HPD use. Women farm operators may lack role models for use of HPDs (e.g., in peers and advertising), contributing to their less frequent use of protection.

Knowledge, attitudes, behaviors, and noise exposure of baristas

OBJECTIVE

To examine the daily noise exposure of baristas working in cafés, and to measure their knowledge, attitudes, and behaviors regarding hearing conservation and perceptions of noise in their work environment.

DESIGN

Fifteen baristas from six cafés in Portland completed the Knowledge, Attitudes and Behaviors questionnaire, a sound disturbance survey, and a structured interview to document perceptions of noise in the work environment. To measure daily noise exposure, a subset of eight participants wore a personal dosimeter for three different work shifts.

STUDY SAMPLE

A total of 11 females and four males, aged between 19 and 36 years old (mean: 26.3, SD: 4.6) recruited from independently owned cafés in the Portland metro area.

RESULTS

Dosimetry measurements revealed Leq measurements between 71 and 83 dBA, with noise doses ranging from 4% to 74%, indicating that baristas are not exposed to sound levels above the regulatory criterion. Questionnaire results indicated that baristas have low awareness about the hazards of noise, are not opposed to hearing conservation, and rarely use hearing protection when engaged in noisy activities.

CONCLUSIONS

Baristas here lacked the pertinent education and motivation to commit to invaluable hearing conservation practices.

Effects of interventions on use of hearing protectors among farm operators: A randomized controlled trial

OBJECTIVE

The purpose of this study was to compare the effectiveness of three interventions designed to promote hearing protector device (HPD) use.

DESIGN

Randomized controlled trial.

STUDY SAMPLE

Farm operators (n = 491) were randomly assigned to one of five intervention groups: (1) interactive web-based information with mailed assortment of HPDs; (2) Interactive web-based information only; (3) static web-based information with mailed assortment of HPDs; (4) Static web-based information only; or (5) mailed assortment of HPDs only. Data were analysed using a mixed model approach.

RESULTS

HPD use increased among all participants, and increased more among participants receiving the mailed HPDs (with or without information) compared to participants receiving other interventions. Participants receiving the interactive web-based information had comparable increased use of HPDs to those receiving the static web-based information. Participants receiving the mailed HPDs had more positive situational influences scale scores than other participants. Program satisfaction was highest among mailed and web-based information groups.

CONCLUSIONS

A mailed assortment of hearing protectors was more effective than information. Interactive and static information delivered via web were similarly effective. Programs interested in increasing HPD use among farmers should consider making hearing protectors more available to farmers.

Predictive factors of occupational noise-induced hearing loss in Spanish workers: A prospective study

The purpose of our study was to identify the main factors associated with objective noise-induced hearing loss (NIHL), as indicated by abnormal audiometric testing, in Spanish workers exposed to occupational noise in the construction industry. We carried out a prospective study in Tenerife, Spain, using 150 employees exposed to occupational noise and 150 age-matched controls who were not working in noisy environments. The variables analyzed included sociodemographic data, noise-related factors, types of hearing protection, self-report hearing loss, and auditory-related symptoms (e.g., tinnitus, vertigo). Workers with pathological audiograms had significantly longer noise-exposure duration (16.2 ± 11.4 years) relative to those with normal audiograms (10.2 ± 7.0 years; t = 3.99, P < 0.001). The vast majority of those who never used hearing protection measures had audiometric abnormalities (94.1%). Additionally, workers using at least one of the protection devices (earplugs or earmuffs) had significantly more audiometric abnormalities than those using both protection measures simultaneously (Chi square = 16.07; P < 0.001). The logistic regression analysis indicates that the use of hearing protection measures [odds ratio (OR) = 12.30, confidence interval (CI) = 4.36-13.81, P < 0.001], and noise-exposure duration (OR = 1.35, CI = 1.08-1.99, P = 0.040) are significant predictors of NIHL. This regression model correctly predicted 78.2% of individuals with pathological audiograms. The combined use of hearing protection measures, in particular earplugs and earmuffs, associates with a lower rate of audiometric abnormalities in subjects with high occupational noise exposure. The use of hearing protection measures at work and noise-exposure duration are best predictive factors of NIHL. Auditory-related symptoms and self-report hearing loss do not represent good indicators of objective NIHL. Routine monitoring of noise levels and hearing status are of great importance as part of effective hearing conservation programs.

Social Desirability Bias in Self-Reporting of Hearing Protector Use among Farm Operators

OBJECTIVE

The purposes of this study were (i) to examine the relationship between reported hearing protector use and social desirability bias, and (ii) to compare results of the Marlowe-Crowne social desirability instrument when administered using two different methods (i.e. online and by telephone).

METHODS

A shortened version of the Marlowe-Crowne social desirability instrument, as well as a self-administered instrument measuring use of hearing protectors, was administered to 497 participants in a study of hearing protector use. The relationship between hearing protector use and social desirability bias was examined using regression analysis. The results of two methods of administration of the Marlowe-Crowne social desirability instrument were compared using t-tests and regression analysis.

RESULTS

Reliability (using Cronbach's alpha) for the shortened seven-item scale for this sample was 0.58. There was no evidence of a relationship between reported hearing protector use and social desirability reporting bias, as measured by the shortened Marlowe-Crowne. The difference in results by method of administration (i.e. online, telephone) was very small.

CONCLUSIONS

This is the first published study to measure social desirability bias in reporting of hearing protector use among farmers. Findings of this study do not support the presence of social desirability bias in farmers' reporting of hearing protector use, lending support for the validity of self-report in hearing protector use in this population.

Noise-induced hearing loss: an occupational medicine perspective

PURPOSE OF REVIEW

Up to 30 million workers in the United States are exposed to potentially detrimental levels of noise. Although reliable medications for minimizing or reversing noise-induced hearing loss (NIHL) are not currently available, NIHL is entirely preventable. The purpose of this article is to review the epidemiology and pathophysiology of occupational NIHL. We will focus on at-risk populations and discuss prevention programs. Current prevention programs focus on reducing inner ear damage by minimizing environmental noise production and through the use of personal hearing protective devices.

RECENT FINDINGS

NIHL is the result of a complex interaction between environmental factors and patient factors, both genetic and acquired. The effects of noise exposure are specific to an individual. Trials are currently underway evaluating the role of antioxidants in protection from, and even reversal of, NIHL.

SUMMARY

Occupational NIHL is the most prevalent occupational disease in the United States. Occupational noise exposures may contribute to temporary or permanent threshold shifts, although even temporary threshold shifts may predispose an individual to eventual permanent hearing loss. Noise prevention programs are paramount in reducing hearing loss as a result of occupational exposures.

Farm and rural adolescents' perspective on hearing conservation: reports from a focus group study

This study explored the attitudes, beliefs, and behaviors of rural and farm adolescents regarding hearing conservation strategies. This qualitative study took place at two high schools in rural Michigan. Twenty-five adolescents living and working on farms or living in rural areas participated in one of two focus groups. Interviews were audio-recorded and transcribed verbatim. Transcripts were coded and analyzed by two researchers and checked by an additional researcher to ensure reliability. Noise exposure was ubiquitous among participants, both in farm-related (e.g., equipment, livestock) and non-farm-related (e.g., music, firearms) activities. Perceived barriers to use of hearing protection devices outweighed perceived benefits, resulting in uncommon use of protection. When hearing protection was used, it was usually earmuffs or earplugs. Participants indicated a lack of training in noise hazards and protective strategies. Despite their acknowledged risk of hearing loss, participants did not associate their use of hearing protection today with their hearing ability later in life. Categories emerging that relate to hearing protector use included: Barriers, benefits, self-efficacy, situational influences, impersonal influences, cues to action, susceptibility, and severity. Farm and rural adolescents are at risk for noise exposure and hearing loss. The findings stress the significance of work environment and adult modeling in facilitating hearing conservation behaviors. As indicated by the youths' recommendations, school-based interventions may be an effective approach to address this health concern. Intervention studies are needed to test various approaches that can effectively promote use of hearing conservation strategies among rural and farm adolescents.

Protocol of a randomized controlled trial of hearing protection interventions for farm operators

Background

Hearing loss and tinnitus are prevalent in America, and noise-induced hearing loss is a leading cause of hearing loss. Noise-induced hearing loss has negative impact on quality of life, physical and emotional functioning, social life, and employment. In addition, noise-induced hearing loss results in heavy social and economic burdens on families and communities from all ethnic and socioeconomic groups. Farmers are a group that is particularly high risk for noise-induced hearing loss, and is underserved by programs designed to limit that risk. They are among the most noise-exposed group of workers, and experience the second highest prevalence of noise-induced hearing loss among all occupational categories. In agriculture, 1.5 million workers (43.3%) report exposure to hazardous noise. Although use of hearing protection devices (HPDs) would protect them from noise-induced hearing loss, use among farmers is low.

Methods/Design

The purpose of this project is to compare the effectiveness of several approaches to influencing hearing protector use. Approaches include: a) an interactive, predictors-based intervention delivered via the Internet; b) a static informational web site; and c) a mailed sampler of hearing protectors. The goals are to further develop an intervention to promote farmers’ use of HPDs, and compare the effectiveness of the interventions delivered in various combinations. Participants will include 701 farmers. Sites will be affiliates of a major farmer organization. Data will be collected at baseline, 6, and 12 months. A random intercept mixed model will be used to explore the fixed effects of the three NIHL prevention interventions over time while adjusting for age and gender. This project will involve a partnership between the University of Michigan and a major farmer organization to accomplish project aims.

Discussion

Results of this study will be used to inform future research-to-practice studies to increase hearing protector use. Increased use of hearing protectors is expected to reduce rates of noise-induced hearing loss and other negative effects of high noise exposure, and improve quality of life in this high-risk and underserved group.

Trial registration

Clinicaltrials.gov NCT01454895 Registered 14 October, 2011.

DEFENS - Drug Exposure Feedback and Education for Nurses' Safety: study protocol for a randomized controlled trial

BACKGROUND

Three decades of research findings have documented the health effects of handling hazardous drugs. Oncology nurses are vulnerable due to frequent administration of antineoplastics, low adherence to equipment use, reported barriers to use, and perceived low risk of health effects. No interventions have been tested in a controlled, multi-site trial to increase nurses' use of protective equipment when handling hazardous drugs. The Drug Exposure Feedback and Education for Nurses' Safety (DEFENS) study will compare the efficacy of education (control) versus an audit and feedback intervention (treatment) on nurses' self-reported use of personal protective equipment when handling hazardous drugs. The treatment intervention will include tailored messages based on nurses' reported barriers to protective equipment use.

METHODS/DESIGN

The DEFENS Study is a cluster randomized controlled trial. We are enrolling cancer centers and will recruit nurse participants in April 2015. Eligible cancer centers employ at least 20 eligible registered nurses in the chemotherapy infusion setting and have on-site phlebotomy resources. Eligible participants are nurses who work at least 0.40 full-time equivalent hours in the chemotherapy infusion setting and have not received an antineoplastic drug for a health problem in the past year. An encrypted, user-authenticated website will administer surveys and deliver control and treatment interventions. The primary endpoint is the change in score on nurses' reports of the Revised Hazardous Drug Handling Questionnaire between baseline and approximately 18 months later. A baseline survey is completed after informed consent and is repeated 18 months later. Nurses in all sites who experience a drug spill will also report incidents as they occur; these reports inform the treatment intervention. Plasma will be obtained at baseline, approximately 18 months later (the primary endpoint), and with drug spill occurrences to measure hazardous drugs levels and to inform the treatment intervention. Potential mediators include knowledge of hazardous drug handling and perceived risk of drug exposure. We will examine whether personal factors and organizational factors moderate the intervention effects.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02283164 , registered 31 October 2014.

Predictors of hearing protection behavior among power plant workers

PURPOSE

This study aimed to identify factors affecting the use of the hearing protection devices (HPDs) among workers exposed to noise using the Pender Health Promotion Model.

METHODS

The 222 subjects came from thermal power plants with similar noise levels, which are between 80 dB and 90 dB in South Korea. Data were collected with self-administered questionnaires designed to measure concepts from the Health Promotion Model.

RESULTS

Mean percent times of using the HPDs at their most recent job site were 50.9%, and 20.3% had never the HPDs. The predictors of HPD use were social modeling (OR = 1.380), perceived benefits (OR = 1.150), and working at noisy worksites (OR = 4.925) when the outcome was based on the "non-use" versus "used at least once". However, the predictors of HPD use were social modeling (OR = 1.795) and perceived benefits (OR = 1.139) based on the "less than half-of-the-time-use" versus "more than half-of-the-time-use".

CONCLUSION

Social modeling and perceived benefits of using the HPDs are important for workers to keep minimal or certain level of using the HPDs.

Strategies to enhance participant recruitment and retention in research involving a community-based population

Challenges associated with recruiting and retaining community-based populations in research studies have been recognized yet remain of major concern for researchers. There is a need for exchange of recruitment and retention techniques that inform recruitment and retention strategies. Here, the authors discuss a variety of methods that were successful in exceeding target recruitment and retention goals in a randomized clinical trial of hearing protector use among farm operators. Recruitment and retention strategies were 1) based on a philosophy of mutually beneficial engagement in the research process, 2) culturally appropriate, 3) tailored to the unique needs of partnering agencies, and 4) developed and refined in a cyclical and iterative process. Sponsoring organizations are interested in cost-effective recruitment and retention strategies, particularly relating to culturally and ethnically diverse groups. These approaches may result in enhanced subject recruitment and retention, concomitant containment of study costs, and timely accomplishment of study aims.

Review of interventions to increase hearing protective device use in youth who live or work on farms

AIMS AND OBJECTIVES

To identify and compare hearing protection interventions for youth working and living on farms.

BACKGROUND

Noise-induced hearing loss represents a significant risk factor for injury, disability and death in agricultural populations due to an inability to receive sensory information that can indicate dangerous situations. Despite the availability of hearing protection devices, rates of utilisation remain low, while rates of noise-induced hearing loss are high within the agricultural youth population.

DESIGN

Comprehensive review of the literature.

METHOD

Electronic database searches were conducted to identify research studies of hearing protection interventions for youth living or working on farms.

RESULTS

Three intervention studies were identified as meeting the review criteria, with additional reanalysis studies based on the original intervention studies. The intervention studies demonstrated increased use of hearing protection devices among youth who received the interventions compared to the control groups although audiometry testing results were not improved as a result of the intervention.

CONCLUSIONS

The findings of this review highlight the need for additional research into the effectiveness of hearing protection device use as a noise-induced hearing loss preventative measure in youth who live or work on farms and the creation of effective interventions to increase hearing protection device use and decrease Noise-induced hearing loss risk.

RELEVANCE TO CLINICAL PRACTICE

It is recommended that nurses be educated in the areas of health promotion relevant to farming communities to be able to effectively meet their rural clients' needs in relation to noise-induced hearing loss. Working with youth, families, and schools, as well as developing community partnerships, can facilitate the dissemination of hearing protection promotion.

Beliefs and attitudes among Swedish workers regarding the risk of hearing loss

The beliefs and attitudes regarding the risk of hearing loss and their impact on hearing protector use were investigated among Swedish workers. A questionnaire, developed by the US National Institute for Occupational Safety and Health (NIOSH), was used. The study objective was to assess workers' attitudes towards using hearing protection devices (HPDs) and to enhance the ability of workers to protect themselves from occupational hearing loss. Ninety-five per cent of the respondents were aware that loud noise could damage their hearing, 90% considered that a hearing loss would be a serious problem, and 85% believed that HPDs could protect their hearing. However, lower percentages of workers always used the HPDs when they were noise-exposed. Fifty-five per cent of the workers indicated that they could not hear warning signals when using HPDs, and 45% of the workers indicated that they considered HPDs to be uncomfortable. These issues must be addressed to make HPD use more effective.

Factors influencing oncology nurses' use of hazardous drug safe-handling precautions

PURPOSE/OBJECTIVES

To examine relationships among factors affecting nurses' use of hazardous drug (HD) safe-handling precautions, identify factors that promote or interfere with HD precaution use, and determine managers' perspectives on the use of HD safe-handling precautions.

DESIGN

Cross-sectional, mixed methods; mailed survey to nurses who handle chemotherapy and telephone interviews with managers.

SETTING

Mailed invitation to oncology centers across the United States.

SAMPLE

165 nurses who reported handling chemotherapy and 20 managers of nurses handling chemotherapy.

METHODS

Instruments measured the use of HD precautions and individual and organizational factors believed to influence precaution use. Data analysis included descriptive statistics and hierarchical regression. Manager interview data were analyzed using content analysis.

MAIN RESEARCH VARIABLES

Chemotherapy exposure knowledge, self-efficacy, perceived barriers, perceived risk, interpersonal influences, and workplace safety climate.

FINDINGS

Nurses were well educated, experienced, and certified in oncology nursing. The majority worked in outpatient settings and administered chemotherapy to an average of 6.8 patients per day. Exposure knowledge, self-efficacy for using personal protective equipment, and perceived risk of harm from HD exposure were high; total precaution use was low. Nurse characteristics did not predict HD precaution use. Fewer barriers, better workplace safety climate, and fewer patients per day were independent predictors of higher HD precaution use. HD handling policies were present, but many did not reflect current recommendations. Few managers formally monitored nurses' HD precaution use.

CONCLUSIONS

Circumstances in the workplace interfere with nurses' use of HD precautions.

IMPLICATIONS FOR NURSING

Interventions should include fostering a positive workplace safety climate, reducing barriers, and providing appropriate nurse-patient ratios.

Research to practice in occupational health nursing

Occupational health nursing research has gained a significant place in national and international nursing programs and has advanced occupational health nurses' understanding of the most effective ways to prevent occupational illness and injury, provide access to quality care for workers, and manage occupational injuries and return to work. This article describes the history of nursing research in general and highlights the current national shortages that must be addressed to ensure that nurses continue to impact the field. Occupational health nursing priorities are described and examples are given of nurse scientists who have established the foundation of occupational health nursing research and who illustrate varied expertise and the interdisciplinary context in which the work is conducted.

Noise exposures of rural adolescents

PURPOSE

This project was conducted to characterize the noise exposure of adolescents living in rural and agricultural environments.

METHODS

From May to October, 25 adolescents ages 13 through 17, living either on a farm or a rural nonfarm, were enrolled in the study. Subjects received training on the correct operation and use of personal noise dosimeters and the proper way to record their daily tasks on activity cards. Subjects completed 4 days of self-monitoring noise dosimetry, 2 days in the first round (May-July) and 2 days in the second round (August-October). In addition to dosimetry, subjects completed activity logs of their daily tasks.

RESULTS

The mean daily noise exposures of adolescents living on farms and in nonfarm rural homes were between 55.4 dBA (A-weighted decibels) and 103.5 dBA, with 44% of the daily measurements greater than the National Institute of Occupational Safety and Health Recommended Exposure Level of 85 dBA. Task-based analysis of noise exposures found that activities involving mechanized equipment resulted in the highest exposures, while activities in the home resulted in the lowest exposure. No particular demographic group had a statistically higher noise exposure; therefore, specific factors apart from activities and noise sources could not be identified as risk factors for exposure to hazardous noise levels.

CONCLUSIONS

The results of this project indicate that rural adolescents complete a variety of activities and are exposed to noise sources with a broad range of decibel levels. While the exposures may change from day to day, there are occasions when exposure to noise exceeds the recommended levels.

Effects of a low intensity intervention to increase hearing protector use among noise-exposed workers

BACKGROUND

Farm operators experience exposure to high noise and high prevalence of noise-induced hearing loss, but use of hearing protection in this worker group is low. The purpose of this study was to test a brief intervention to increase farm operators' use of hearing protection.

METHODS

In this one-group pre- and post-test study, a random sample of 32 members of a farmers' organization was supplied a variety of hearing protectors. Participants received an assortment of hearing protectors by mail with manufacturer's instructions for use.

RESULTS

Mean pre-intervention hearing protector use when in high noise in this group was 23% (SD 29). Of the 32 participants, 27 (84%) were exposed to hazardous noise during the study period. Post-intervention mean use of HPDs was 64%, an increase of 41% (t = 5.26, P < 000).

CONCLUSION

Results of this study suggest that overall, hearing protectors were acceptable to farm operators, and that a brief mailed intervention is feasible.

Factors affecting Thai workers' use of hearing protection

This study used an ecological model to examine Thai workers' beliefs and attitudes toward using occupational hearing protection. Data collection involved focus group sessions with 28 noise-exposed workers at four factories in Chiang Mai Province and an interview with a safety officer at each organization. Detailed content analysis resulted in the identification of three types of factors influencing the use of hearing protection: intrapersonal, including preventing impaired hearing, noise annoyance, personal discomfort, and interference with communication; interpersonal, including coworker modeling, supervisor support, and supervisor modeling; and organizational, including organizational rules and regulations, provision of hearing protection devices, dissemination of knowledge and information, noise monitoring, and hearing testing. Effective hearing protection programs depend on knowledge of all of these factors. Strategies to promote workers' use of hearing protection should include the complete range of factors having the potential to affect workers' hearing.

Health, medication use, and agricultural injury: A review

BACKGROUND

Agricultural work in the United States and Canada continues to be one of the most dangerous vocations. Surveillance evidence suggests that older farmers (>60 years of age) are at greater risk of serious injury than their younger counterparts. The purpose of this article was to outline illnesses and medications that may contribute to older farmers' increased risk of agricultural injury and to determine a minimum set of health-related covariates that could be used in farm injury studies.

METHODS

A review of English language literature in Medline, CINAHL, and NIOSH databases was conducted examining disease and medication factors related to farm injury.

RESULTS

Health- and disease-related factors most commonly reported as significantly contributing to agricultural injury included previous injury, hearing problems, depression, arthritis, and sleep deprivation. The use of "any medication" was identified as a significant risk factor for injury in a number of studies. The use of sleep medication was significantly related to injury in two studies.

CONCLUSIONS

Based on the findings, it is recommended that at a minimum, researchers collect information on the prevalence of previous injury, hearing problems, depression, arthritis/muscular-skeletal problems and sleep disturbance as these have been identified as significant risk factors in a number of studies. In addition, where subjects that identify any of these afflictions, further information should be sought on any medications used in their treatment which can add data on disease severity. More research and surveillance activities need to be focused on the older farm worker. This population is critical to the maintenance of the agricultural base in North America and health and safety research initiatives need to address this. By integrating research from the fields of gerontology, occupational health and safety, and injury prevention, innovative interventions could be constructed to assist the aging farmer in the continuation of safe farming.

Determinants of use of hearing protection devices in Canadian lumber mill workers

BACKGROUND

In a cohort study of lumber mill workers' exposure to noise and incidence of heart disease, initial noise estimates were likely overestimated because they did not account for reductions afforded by the use of hearing protection. As such information was seldom available for individual workers, modeling was necessary to predict hearing protection use and derive adjusted noise measures.

OBJECTIVE

To develop a multilevel model of the likelihood of use of hearing protection devices (HPDs) for British Columbia (Canada) lumber mill workers.

METHOD

The study population included 13,147 workers in 14 sawmills for whom we had information on HPD use. Subjects self-reported their use of hearing protectors during routine hearing tests over their work history period. Separate multilevel logistic regression models with increasing complexity were developed for a subcohort of workers with complete information (n = 1493) and for a subcohort comprised subjects with hearing tests coinciding with their jobs (n = 10 203). The models included random intercepts for worker and for sawmill.

RESULTS

HPD use was associated in both subcohorts with factors such as noise exposure and age. We also showed that specific jobs (such as sawfiling) and departments (planer, in particular) were strongly associated with the use of HPDs. The model illustrates the quantitative importance of including a hierarchical structure which allows for explaining potential sources of outcome variability.

CONCLUSIONS

We developed a hierarchical model to predict hearing protection use to enable correction of exposure assessments for use in retrospective epidemiological studies. We showed that this was feasible even in the absence of complete determinant information.

Predictors of hearing protection use in construction workers

OBJECTIVES

Although noise-induced hearing loss is completely preventable, it remains highly prevalent among construction workers. Hearing protection devices (HPDs) are commonly relied upon for exposure reduction in construction, but their use is complicated by intermittent and highly variable noise, inadequate industry support for hearing conservation, and lax regulatory enforcement.

METHODS

As part of an intervention study designed to promote HPD use in the construction industry, we enrolled a cohort of 268 construction workers from a variety of trades at eight sites and evaluated their use of HPDs at baseline. We measured HPD use with two instruments, a questionnaire survey and a validated combination of activity logs with simultaneous dosimetry measurements. With these measurements, we evaluated potential predictors of HPD use based on components of Pender's revised health promotion model (HPM) and safety climate factors.

RESULTS

Observed full-shift equivalent noise levels were above recommended limits, with a mean of 89.8 +/- 4.9 dBA, and workers spent an average of 32.4 +/- 18.6% of time in each shift above 85 dBA. We observed a bimodal distribution of HPD use from the activity card/dosimetry measures, with nearly 80% of workers reporting either almost never or almost always using HPDs. Fair agreement (kappa = 0.38) was found between the survey and activity card/dosimetry HPD use measures. Logistic regression models identified site, trade, education level, years in construction, percent of shift in high noise, and five HPM components as important predictors of HPD use at the individual level. Site safety climate factors were also predictors at the group level.

CONCLUSIONS

Full-shift equivalent noise levels on the construction sites assessed were well above the level at which HPDs are required, but usage rates were quite low. Understanding and predicting HPD use differs by methods used to assess use (survey versus activity card/dosimetry). Site, trade, and the belief that wearing HPD is not time consuming were the only predictors of HPD use common to both measures on an individual level. At the group level, perceived support for site safety and HPD use proved to be predictive of HPD use.

Exposure to hazardous workplace noise and use of hearing protection devices among US workers--NHANES, 1999-2004

BACKGROUND

To estimate the prevalence of workplace noise exposure and use of hearing protection devices (HPDs) at noisy work, NIOSH analyzed 1999-2004 data from the National Health and Nutrition Examination Survey (NHANES).

METHODS

A total of 9,275 currently employed workers aged > or =16 years were included in the weighted analysis. Hazardous workplace noise exposure was defined as self-reported exposure to noise at their current job that was so loud that the respondent had to speak in a raised voice to be heard. Industry and occupation were determined based on the respondent's current place and type of work.

RESULTS

Twenty-two million US workers (17%) reported exposure to hazardous workplace noise. The weighted prevalence of workplace noise exposure was highest for mining (76%, SE = 7.0) followed by lumber/wood product manufacturing (55%, SE = 2.5). High-risk occupations included repair and maintenance, motor vehicle operators, and construction trades. Overall, 34% of the estimated 22 million US workers reporting hazardous workplace exposure reported non-use of HPDs. The proportion of noise-exposed workers who reported non-use of HPDs was highest for healthcare and social services (73.7%, SE = 8.1), followed by educational services (55.5%).

DISCUSSION

Hearing loss prevention and intervention programs should be targeted at those industries and occupations identified to have a high prevalence of workplace noise exposure and those industries with the highest proportion of noise-exposed workers who reported non-use of HPDs.

Too late smart: farmers' adoption of self-protective behaviors in response to exposure to hazardous noise

Farmers are exposed to hazardous noise from equipment and livestock and experience high rates of noise-induced hearing loss (NIHL); however, their use of hearing protection devices (HPDs) is low. The purpose of this study was to describe farmers' personal experiences using HPDs, influencing others' use of HPDs, and overcoming barriers to the use of HPDs. A purposive sample of farmers who reported a high frequency of HPD use was selected for face-to-face interviews. Findings indicated that farmers have frequent exposure to hazardous noise. They described their motivation to adopt protective behaviors to avoid hearing loss, noise annoyance, or tinnitus. Many tried to influence others' use of HPD, particularly family members. These farmers have developed a variety of methods to ensure convenient access to HPDs when needed, and have developed effective techniques for overcoming common barriers to protection. Findings from this study will be used to form the foundation for future studies aimed at developing and testing an intervention to increase HPD use and decrease rates of NIHL among farmers.

Ethnic, racial, and gender variations in health among farm operators in the United States

PURPOSE

The purpose of this study was to collect baseline prevalence data on the health problems faced by minority, white, and female farm operators.

METHODS

An occupational health survey of farm operators was conducted by the U.S. Department of Agriculture, National Agricultural Statistics Service between February and August 2000. A stratified random sample of farm operators from 50 U.S. states based on the 1997 Census of Agriculture was selected for telephone interview. Interviews were primarily conducted using a computer assisted telephone instrument system.

RESULTS

Population prevalences were calculated for 7137 farm operators. Prevalences were greatest for musculoskeletal discomfort, followed by respiratory problems, hearing loss, and hypertension. Generally, Latino and Asian American operators had lower prevalences for health problems than white non-Latino and white operators, respectively. African-American operators had greater prevalences for hypertension, and osteoarthritis, but lower prevalences for hearing loss, skin problems, heart problems, and cancer than white operators. American Indian or Alaska Native operators had higher prevalences for musculoskeletal problems, skin problems, and hypertension.

CONCLUSIONS

Prevalences for the different ethnicity and race groups are not the same. Studies that combine racial and ethnic groups, or study only white and non-Latino farm operators may overestimate or underestimate the prevalence of health conditions in the entire farm operator population.

Testing and developing the health promotion model in low-income, Korean elderly women

This study was conducted to test Pender's health promotion model in low-income, Korean elderly women. A total of 389 low-income, Korean elderly women completed the interviews focused on the concepts in health promotion model. Seventy-three percent of the variance in health-promoting behaviors was accounted for by prior health-related behavior, biological, psychological, and sociocultural factors, behavior-specific cognitions and affect, environmental influences, commitment to a plan of action, and health-promoting behavior variables in a modified health promotion model. Findings from this study may support the conceptual framework for future nursing practice and research studies in this vulnerable population.

Development and pilot test of hearing conservation training for construction workers

BACKGROUND

Hearing conservation efforts in construction frequently rely on use of hearing protection devices (HPDs): however, training on HPDs is often not provided, and usage rates remain low. In this study, a hearing conservation training program was developed and pilot tested.

METHODS

A theoretical model was selected as the basis for the program, and program contents and delivery methods were selected to optimize the effectiveness and flexibility of the training. Two evaluation measures were selected to assess training-related changes in self-reported HPD use. The first was a validated method using concurrent work-shift noise dosimetry, and the second was a survey concerning workers beliefs and attitudes towards HPDs and HPD use.

RESULTS

The training program was pilot tested on a single construction site. Complete assessment data were available for 23 workers. The percent of time when hearing protection was used during noise levels above 85 dBA nearly doubled post-training, and the change was statistically significant.

CONCLUSIONS

Pre- and post-training data from participating workers demonstrated that HPD use can be increased significantly with basic model-based training, even in industries with complex noise exposures such as construction.