THE KNOWLEDGE AND ATTITUDES REGARDING NOISE-INDUCED HEARING
LOSS AMONG ADOLESCENTS

By

Mary K. Bulger, B.A.
King’s College

A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of
Master of Science in Communication Sciences and Disorders
to the Office of Graduate and Extended Studies of East Stroudsburg University of
Pennsylvania

August 6, 2021

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ABSTRACT
A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of
Master of Science in Communication Sciences and Disorders to the Office of Graduate
and Extended Studies of East Stroudsburg University of Pennsylvania.

Student’s Name: Mary K. Bulger
Title: The Knowledge and Attitudes Regarding Noise-Induced Hearing Loss Among
Adolescents
Date of Graduation: August 6, 2021
Thesis Chair: Susan Dillmuth-Miller, Au. D., CCC-A
Thesis Member: Akila T. Rajappa, Ph.D., CCC-SLP, BCS-S
Thesis Member: Elaine M. Shuey, Ph.D., CCC-SLP

Abstract
The risk of noise-induced hearing loss (NIHL) increases with age due to
engagement in loud activities and beginning work. Thirty-five students within grades 5,
6, 7, and 8 participated in this 100% online/asynchronous hearing conservation program
(HCP) at a New Jersey K-8 public school. This program included a pre-survey, a 27minute online education, a post-survey, and a 3-month post-survey. Participants were
randomized into treatment and control groups. All participants received the surveys. Only
the treatment group received the HCP. No significant differences were found between
treatment and control groups when comparing knowledge and attitude scores on the pre-,
post, and 3-month post-surveys. However, significant differences were found within the
post-survey knowledge questions without any significant change in the attitude questions
for the treatment group, which indicated that students who participated in the HCP had a
positive increase in knowledge of NIHL although their attitudes toward prevention did
not change.

DEDICATION

This work is completely dedicated to my grandmother, Mary R. Cestone. She was always
interested in learning new information throughout her life, and she encouraged me to do
the same.

ACKNOWLEDGEMENT

I would like to thank my thesis advisor, Dr. Susan Dillmuth-Miller, and my thesis
committee members, Dr. Akila Rajappa, and Dr. Elaine Shuey for helping me throughout
my entire thesis. I would like to thank my statistician, Dr. David Rheinheimer, for
assisting me while interpreting the data. I would like to thank Mr. Robert Magnuson and
his K-8 school for their willingness to participate in my study. I would like to thank Dr.
Lu-Ann Batson Magnuson for assisting me during the initial steps of my thesis process. I
would like to thank Dr. Rachel Wolf and her Test and Measurement class for
participating in my thesis defense. I would like to thank my friends and classmates at East
Stroudsburg University for supporting me throughout my thesis. Lastly, I would like to
thank all my family members for being incredibly understanding and supportive
throughout this time.

TABLE OF CONTENTS

LIST OF TABLES ............................................................................................................vii
Chapter
I. INTRODUCTION......................................................................................................1
II. METHODS................................................................................................................8
III. RESEARCH DESIGN...........................................................................................14
IV. RESULTS..............................................................................................................16
V. DISCUSSION.........................................................................................................20
VI. CONCLUSION......................................................................................................24
APPENDICES ..................................................................................................................26
REFERENCES .................................................................................................................38

v

LIST OF TABLES
Table
1. Total participation on all forms ..............................................................................16
2. Total pre-survey participation..................................................................................16
3. Total post-survey participation................................................................................17
4. Total 3-month post-survey participation..................................................................17
5. Summary statistics for the pre- and post-survey total scores by group...................17
6. Summary statistics for the pre-survey knowledge and attitude scores....................18
7. Summary statistics for the post-survey knowledge and attitude scores...................18
8. Summary statistics for the 3-month post-survey knowledge and attitude
scores by group........................................................................................................19
9. Summary statistics for the 3-month post-survey knowledge and attitude
scores by gender......................................................................................................19

vii

CHAPTER 1
INTRODUCTION
Anyone, at any age could be affected by noise-induced hearing loss (NIHL).
Although everyone is exposed to noise every day, some studies have demonstrated that
adolescents have the potential to learn about NIHL while attending school and prevent
hearing loss before it becomes a life-long hearing impairment. Schlauch (2013) reported
that 6% of teenagers (ages 12-19) have noise-induced hearing loss and this percentage
has remained stable. Agrawal (2008) found that the prevalence of NIHL to be 8.5%
among young adults (ages 20-29). Furthermore, Phillips et al. (2010) found that the risk
of noise-induced hearing loss (NIHL) increases with age due to engagement in loud
activities and beginning work. According to the National Institute on Deafness and Other
Communication Disorders (2019), NIHL is believed to be 100% preventable. Therefore,
adolescents may be the ideal age group to teach about NIHL as well as safe hearing
practices since they are young enough to stop poor listening practices and old enough to
retain the information throughout adulthood.
Several studies were conducted to evaluate the attitudes and awareness of NIHL
among the adolescent and young adulthood population. Chung et al. (2005) conducted an

1

online survey evaluating the amount of noise exposure adolescents and young adults
experience on a daily basis. The data for this study was collected within the pop-up
survey that was presented to every 30th MTV website visitor for three consecutive days.
Surveys were collected from 9458 total participants where 99% were aged 15-34 years
and 35% of the participants were male and 65% were female. Only 8% of participants
indicated hearing loss as a serious health issue. Sixty percent of participants indicated that
they have already attended 1-9 concerts. However, 44% indicated that they have already
attended 1-9 clubs. Over half of the responses indicated that a major factor for using
hearing protection would be if information was provided regarding how even short
exposure to loud music can still impact hearing. This study revealed that most young
people have already experienced events in which there was loud noise exposure.
However, over half of the population indicated that knowledge of NIHL would motivate
them to use hearing protection during the loud events.
Alnuman et al. (2019) conducted a similar study which utilized the survey
originally created by Chung et al. (2005). However, Alnuman et al. (2019) slightly
altered the survey and administered the study in person at three different universities in
Jordan rather than over the internet. This study added questions that involved the
frequency of hearing loss symptoms, attitude towards the use of ear plugs, and the current
use of hearing protection. In contrast to the study completed by Chung et al. (2005), 64%
of the 245 participants indicated hearing loss as a serious health issue. Similar to the
study conducted by Chung et al. (2005), this study revealed that most young people
attend events or expose themselves to environments that involve loud noise. However,
2

Alnuman et al. (2019) reported that over half of the population selected hearing loss as a
serious health issue but less than 10% of the population reported using hearing protection
and only 2% of the population indicated positive attitudes towards ear plugs. Although
many participants acknowledged hearing loss as a serious health issue, the awareness of
hearing loss that can be caused from noise exposure was low. Keppler et al. (2015)
conducted a study similar to Alnuman et al. (2019) and Chung et al. (2005) which
analyzed the attitudes and beliefs of participants aged 18-30 in regard to noise exposure,
hearing loss, and hearing protection devices (HPDs). The survey featured questions from
the Youth Attitude to Noise Scale (YANS) by Widen and Erlandsson (2004), which
addressed self-reported tinnitus and noise sensitivity among adolescents in Sweden. In
addition, an audiological test battery was administered to each participant. This study
revealed that the participants who indicated that noise exposure was not problematic had
worse hearing thresholds at 6.0 kHz than the participants who indicated noise exposure as
problematic. Alnuman et al. (2019), Chung (2005), and Keppler et al. (2015) concluded
that there is a need for quality and engaging hearing educational programs in order to
change the attitudes of those who find noise exposure not problematic and influence
positive attitudes towards hearing protection.
Khan et al. (2018) reported the efficacy of hearing protection programs within a
systematic review. Only 10 studies published between 2010-2018 fit the criteria for this
systematic review. The interventions reviewed incorporated educationally based learning,
increasing knowledge of hearing loss, reducing the risk of hearing loss, and influencing
the usage of hearing protection. One strength across the hearing conservation programs
3

was that two studies showed considerable efficacy, in which hearing protection usage
was significantly increased after the intervention. Another strength reported was how
technology was integrated into the programs. This study revealed that there is a need for
more hearing conservation programs with significant efficacy in order to increase the
usage of hearing protection to reduce NIHL.
Is knowing that excessively loud noise exposure can cause NIHL enough to
change the behavior? Johnson et al. (2016) conducted a study in which students from 2
different universities completed a survey modified from the YANS (Widen &
Erlandsson, 2004) regarding hearing protection use and attitudes about loud sounds.
Results of the study revealed that both Communication Sciences and Disorders (CSD)
majors and non-CSD display similar attitudes toward use of hearing protection despite
the additional training CSD majors have acquired. The results of the questionnaire
revealed that students who received hearing conservation education were significantly
more likely to agree that loud environments can damage their hearing; however, they
were not any more likely to use hearing protection when in excessively loud
environments. The researchers concluded that young adults, even those that have chosen
the speech and hearing field and have received additional knowledge, have already
established their attitudes toward use of hearing protection (Johnson et al., 2016). They
recommended educating students before they are young adults so that their attitudes will
match their knowledge regarding NIHL.
However, some schools have already provided their students with NIHL
education by utilizing companies and groups outside of the school system. Three hearing
4

conservation programs which have been commonly utilized among public school systems
throughout the last thirteen years are Dangerous Decibels® by Meinke et al. (2008), the
American Speech-Language-Hearing Association (ASHA) Listen to your Buds campaign
(2021), and Sound Sense by Neufeld et al. (2011). Phillips et al (2010) identified that the
risk of NIHL increases with age due to engagement in loud activities and the beginning
of work. Therefore, the program targeted elementary and middle school students.
Dangerous Decibels® has been successful because it is a multi-component program
which considers the interests of the target audience, utilizes interactive instruction,
highlights appropriate scientific content for students, provides skills-based learning as
well as repetition within the program. Essential components of Dangerous Decibels®
included the program’s DVD, stereocilia model, “physics of sound” demonstration,
“sound is vibration” demonstration, “how loud is too loud” game, sound level meter
activity, hearing education handouts, free ear protection, proper ear plug instruction, and
review of the noise reduction rating (NRR) from packaging (Meinke et al., 2008).
Currently, Dangerous Decibels is one of the leading hearing conservation programs for
students in elementary and middle schools.
Griest et al. (2008) analyzed the effectiveness of Dangerous Decibels® when
taught to 4th and 7th grade students. The results of the study indicated that the 4th grade
students found improvements in their knowledge and attitudes after the program and
maintained their knowledge and attitudes after three months, while the 7th grade students
only found immediate improvements in knowledge and attitudes (Griest et al., 2008).

5

This study revealed that young students can change their attitudes about NIHL and
maintain them 3 months after a hearing conservation program.
Similar to the study by Griest et al. (2008), Dell & Holmes (2012) analyzed the
efficacy of hearing conservation programs (HCP) that change the knowledge and
attitudes of adolescents. The participants included 64 students, ages 12-14. The HCP
analysis involved a pretest which utilized the YANS (Widen & Erlandsson, 2004).
Following the pretest, the Dangerous Decibels® HCP was performed by a licensed
audiologist for 1 hour. At the end of the program, the students completed a post-test. The
results of this study revealed that the HCP had a statistically significant effect in reducing
the pro-noise attitude among adolescents (Dell & Holmes, 2012).
Another program targeting young children was the American Speech-LanguageHearing Association (ASHA) Listen to your Buds campaign in which audiologists visited
schools to educate elementary and middle school students about safe listening practices in
an interactive, fun way. However, no information regarding the current state of the
campaign has been published since 2014 (ASHA, 2021).
Neufeld et al. (2011) created a hearing conservation program (HCP), Sound
Sense, which was presented to 846 students in grade 6 within 16 Vancouver School
Board schools in Canada. The study analyzed personal music player (MP3, iPod, Smart
Phone) habits and exposure to excessive noise. The HCP involved a 10-minute video and
a 45-minute interactive session which educated students on the hearing anatomy and
physiology, causes of NIHL, symptoms of NIHL, consequences, and prevention. At the
end of the program, students received ear plugs and stickers. All students participated in
6

the program and there was no control group. Students were assessed before the program,
2 weeks after the program, and 6 months after the program. The results of this study
revealed that participants who participated in Sound Sense increased their long-term
earplug use in loud environments (Neufeld et al., 2011). This study revealed rewards
acted as positive reinforcement which increased the use of ear protection.
Although the three commonly utilized HCPs are effective, there is a need for an
online uncommercialized program, which is more cost effective, within a speechlanguage pathologist’s scope of practice, as well as more accessible to schools. The
COVID-19 pandemic changed the way schools are providing education. Many schools
are continuing to educate students in an online or hybrid (online and in-person classes
available to all students) manner. There needs to be an online option for HCPs so that this
information can still reach all students if schools continue to provide online education or
bring students back into the classroom full time. In addition, there is a heightened need
for younger students to participate in the HCPs, as it could benefit them more than the
older students. Therefore, the purpose of the current study is to increase the knowledge
regarding NIHL and improve attitudes of adolescents toward ear protection and excessive
noise exposure through an HCP. The importance of hearing protection education is to
learn how NIHL can affect everyday life and how to prevent NIHL. This study will
evaluate if there is a significant difference in the knowledge and attitudes about noiseinduced hearing loss (NIHL) measured before and after an uncommercialized, online
hearing conservation program for middle school students.

7

CHAPTER 2
METHODS
Thirty-five students within grades 5, 6, 7, and 8 voluntarily participated in an
uncommercialized 100% online/asynchronous hearing conservation program developed
by this lead investigator at a New Jersey K-8 public school. This study was approved by
East Stroudsburg University’s Instructional Review Board (IRB). A parental consent
form was distributed to the consenting parents of students in grades 5, 6, 7, and 8 via
Google Forms. Students in grades 5 and 8 were in the treatment group. Students in
grades 6 and 7 were in the control group. Participants did not know whether they were in
the treatment group or the control group. The control and treatment groups were
determined by grade using a random generator within Microsoft Excel. Participants in
both the control and treatment groups had access to all electronic surveys via Google
Forms. Only participants in the treatment group had access to the pre-recorded hearing
conservation program via Screencast-O-Matic.
A pre-survey was electronically distributed and completed by students in grades 5
(n=12, 7 males, 5 females), 6 (n=6, 3 males, 3 females), 7 (n=10, 6 males, 4 females), and
8 (n=7, 2 males, 5 females). After 40 days, the hearing conservation program link was
8

electronically distributed to the treatment group. After 39 days, a post-survey was
electronically distributed and completed by students in grades 5 (n=11, 5 males, 6
females), 6 (n=8, 3 males, 5 females), 7 (n=12, 10 males, 2 females), and 8 (n=4, 2 males,
2 females). After all data was collected, the hearing conservation program link was sent
to students in grades 6 and 7 so all could benefit from the program. Ninety-days after the
post-survey closed, a 3-month post-survey was electronically distributed and completed
by students in grades 5 (n=2, 0 males, 2 females), 6 (n=3, 2 males, 1 females), 7 (n=5, 3
males, 2 females), and 8 (n=0, 0 males, 0 females).
The superintendent of a New Jersey public school was contacted via email
requesting for the school’s participation in a NIHL conservation program. See Appendix
B for NIHL Conservation Program Permission Letter for School. Students in grades 5, 6,
7, and 8 were asked to participate. All participants passed school hearing screenings, had
the ability to read fluently as well as comprehend age-appropriate directions. Teachers
were contacted regarding their roles and responsibilities throughout the program which
included forwarding information from the lead investigator to parents and students as
well as reminding students of completion deadline for each stage of the program (signed
content form, pre-survey, video, and post-survey). See Appendix C for more information
regarding Noise-Induced Hearing Loss Conservation Program Directions to Teachers. A
parental consent form was sent out to all parents and caregivers of all students in grades
5, 6, 7, and 8. Parental consent forms were signed and returned prior to beginning the
study. See Appendix D for Noise-Induced Hearing Loss Conservation Program Informed
Consent. All participants had access to a computer in order to participate in the study.
9

As a result of the COVID-19 pandemic, this study was conducted in an
asynchronous manner, in which the surveys were sent out electronically via Google
Forms. The pre-, post-, and 3-month post-surveys utilized the questionnaire created by
Johnson et al. (2016), which is a modified version of the YANS (Widen & Erlandsson,
2004). Questions were modified for middle school students and reflected age-appropriate
vocabulary and syntax. The surveys contained questions relating to the knowledge and
attitudes regarding NIHL and prevention. The surveys included 10 questions, with 2
questions addressing knowledge of NIHL and 8 questions addressing attitudes towards
NIHL prevention. Participants had 3 options when answering each question; agree,
neutral (sometimes agree/sometimes disagree), or disagree. The surveys were used to
collect participant responses for data analysis of the treatment group as well as the control
group. All participants had access to the pre-survey 40 days before the program link was
available. See Appendix E for Noise-Induced Hearing Loss Conservation Program PreSurvey Link and Appendix F Noise-Induced Hearing Loss Conservation Program PreSurvey. The post-survey was available to all participants 39 days after the program link
was available. See Appendix G for Noise-Induced Hearing Loss Conservation Program
Post-Survey Link and Appendix H for Noise-Induced Hearing Loss Conservation
Program Post-Survey.
The NIHL conservation program, which included information regarding NIHL
and prevention, was a 27-minute pre-recorded video developed and delivered online by
the lead investigator using Microsoft PowerPoint and Screencast-O-Matic. See

10

Appendix I for Noise-Induced Hearing Loss Conservation Program Link. The
asynchronous, online hearing conservation program shared many of the same premises
that Meinke et al. (2008) outlined when creating Dangerous Decibels, the successful
hearing conservation program for children from ages 6-19. Dangerous Decibels catered
to the attention span of a target audience as well as providing interactive instruction,
skills-based learning opportunities, and repetition of information (Meinke et al., 2008). In
order to effectively engage students in grades 5, 6, 7, and 8, the lead investigator limited
this presentation to 27 minutes and presented via PowerPoint in order to share concise
information and incorporate multiple infographics.
The program was separated into four sections. The first section included NIHL
background information (9.5 minutes) which featured the anatomy and physiology of the
hearing process, causes of NIHL, noise levels, exposure limits, as well as types of hearing
loss. The second section provided interactive instruction and skills-based learning
opportunities as it included a video, hearing loss simulation, as well as application to
everyday life (7.5 minutes). This section featured a Fred Flintstone video simulation of
types of hearing loss by Shaw (2016), explanation of how hearing loss affects speech,
explanation of sound level apps (iOS vs Android), the Support Success For Children with
Hearing Loss (2016) version of the iconic 1970s Unfair Spelling Test simulation/check
answers, as well as a reflection of Unfair Spelling Test. Participants were provided with
the opportunity to download and utilize one of two different free sound measurement
applications on a smartphone during the simulation portion of the program. Both

11

applications were selected after viewing a sound-level-meter software application list, for
iOS and android devices, created by Dr. Tina Childress (n.d.), an educational audiologist.
Among all the applications listed, the two applications selected were free, and had the
highest ratings and accuracy. The National Institute for Occupational Safety and Health
(NIOSH) Sound Level Meter (SLM) application was available to iOS devices. The
Decibel X application was available to Android devices. Both applications were used to
teach the participant about identifying the amount of noise produced in any listening
environment and which environments suggest limited exposure as well as utilizing
hearing protection. The Unfair Spelling Test (Support Success For Children with
Hearing Loss, 2016) was utilized within the program to simulate taking a spelling test
with a mild hearing loss. This section of the program required students to record their
responses using a pencil and a piece of paper. The third section provided skills-based
learning opportunities and repetition as it included prevention of NIHL (8 minutes) which
featured strategies and ear plug demonstration as well as check your knowledge questions
(3 true/false questions). The last section provided repetition as it included a review of the
presentation (2 minutes). See Appendix J for Noise-Induced Hearing Loss Conservation
Program Outline. After the completion of the study, the control group was given the
option to experience the entire hearing conservation program. Three months after the
post-survey closed, all participants were provided with a 3-month post-survey to
complete. See Appendix K for Noise-Induced Hearing Loss Conservation Program 3Month Post-Survey Link and Appendix L for Noise-Induced Hearing Loss Conservation
Program 3-Month Post-Survey. This survey was nearly identical to the post-survey and
12

analyzed the retention of participants in terms of their knowledge and attitudes regarding
NIHL. Statistical analysis is discussed in the next section.

13

CHAPTER 3
RESEARCH DESIGN
Surveys were collected from a sample of students in an elementary school in
northern New Jersey. The students were in grades 5-8 and ranged in ages from 10-14.
Students in grades 5 and 8 were in the treatment group and received the NIHL
conservation program. The students in grades 6 and 7 served as the control group and
received no training.
Data were extracted from the surveys, coded, and analyzed with the IBMÒ
Statistical Package for the Social Sciences (SPSS)Ò (Version 27) software platform.
After the surveys were collected and scored by the lead investigator, surveys were
analyzed by a statistician. Parametric and nonparametric procedures were utilized to
compare the groups (treatment vs. control, gender). Independent variables included the
knowledge and attitude scores on the surveys. The dependent variables included the total
survey scores. Parametric procedures included multivariate analyses of variance
(MANOVAs) and summary statistics, which were used to analyze the pre- and post-survey
data. Because of the small sample size for the 3-month post-survey, these data were

14

analyzed with the Mann-Whitney U test, a nonparametric procedure. This quasiexperimental study maintained anonymity of all research study participants, which
precluded the use of repeated measures procedures for the analyses of survey data.

15

CHAPTER 4
RESULTS
Thirty-five students participated in the study. Table 1 shows total
participation throughout all survey responses.
Grade Level

Pre-Survey

Post-Survey

5

12

11

6

6

8

7

10

12

8

7

4

35

35

Total:
Table 1 – Total participation on all forms

Table 2 shows the total pre-survey participation.
Grade Level

n

Male

Female

5

12

7

5

6

6

3

3

7

10

6

4

8

7

2

5

Table 2 – n = sample size; total: 35 participants

16

Table 3 shows the total post-survey participation.
Grade Level

n

Male

Female

5

11

5

6

6

8

3

5

7

12

10

2

8

4

2

2

Table 3 – n = sample size; total: 35 participants

Table 4 shows the total 3-month post-survey participation.
Grade Level

n

Male

Female

5

2

0

2

6

3

2

1

7

5

3

2

8

0

0

0

Table 4 – n = sample size; total: 10 participants

There were no significant differences found between the pre- and post-survey
knowledge and attitude factor scores within the control and treatment groups after
treatment group participation in the hearing conservation program. Table 5 shows
summary statistics for the pre- and post-survey total scores by group.
Variable

n

M

SD

95% CI

Pre-survey: Treatment group

19

2.03

0.26

[1.91, 2.16]

Pre-survey: Control group

16

2.05

0.45

[1.81, 2.29]

Post-survey: Treatment group

15

1.95

0.34

[1.76, 2.13]

Post-survey: Control group

20

2.03

0.47

[1.80, 2.25]

Table 5 – n = sample size; M = mean; SD = Standard Deviation; CI = Confidence Interval

17

There were no significant differences found when comparing the knowledge and
attitude scores of the treatment and control groups. There were 2 knowledge questions
(numbers 9 and 10) and 8 attitude questions (numbers 1-10) on the pre-survey (Appendix
F). Questions Table 6 shows the summary statistics for the pre-survey knowledge and
attitude scores.
Variable

n

M

SD

95% CI

Pre-Knowledge Score: Treatment

19

1.58

0.51

[1.33, 1.82]

Pre-Knowledge Score: Control

16

1.59

0.52

[1.31, 1.87]

Pre-Attitude Score: Treatment

19

2.14

0.32

[1.99, 2.30]

Pre-Attitude Score: Control

16

2.16

0.49

[1.90, 2.43]

Table 6 – n = sample size; M = mean; SD = Standard Deviation; CI = Confidence Interval

However, significant differences were found within the post-survey responses
when comparing the knowledge and attitude scores within the treatment group, with
significantly lower scores for the knowledge factor. No significant differences were
found when comparing treatment and control group knowledge and attitude scores. There
were 2 knowledge questions (numbers 3 and 9) and 8 attitude questions (numbers 1, 2, 48, and 10) on the post-survey (Appendix H). Table 7 shows the summary statistics for the
post-survey knowledge and attitude scores.
Variable

n

M

SD

95% CI

Post-Knowledge Score: Treatment

15

1.43

0.42

[1.20, 1.66]

Post-Knowledge Score: Control

20

1.68

0.59

[1.40, 1.95]

Post-Attitude Score: Treatment

15

2.08

0.38

[1.86, 2.29]

Post-Attitude Score: Control

20

2.11

0.49

[1.88, 2.34]

Table 7 – n = sample size; M = mean; SD = Standard Deviation; CI = Confidence Interval

18

There were no significant differences found when comparing the knowledge and
attitude scores of the treatment and control groups on the 3-month post-survey. There
were 2 knowledge questions (numbers 3 and 9) and 8 attitude questions (numbers 1, 2, 48, and 10) on the 3-month post-survey (Appendix L). Table 8 shows the summary
statistics for the 3-month post-survey knowledge and attitude scores by group.
Variable

n

Mean Rank

3-month Knowledge Score: Treatment

2

8.75

3-month Knowledge Score: Control

8

4.69

3-month Attitude Score: Treatment

2

7.50

3-month Attitude Score: Control

8

5.00

p-Value
.09

.40

Table 8 – n = sample size; total score = mean of items 1-10; knowledge score = mean of items 3 and 9; attitude
score = mean of items 1, 2, 4 to 8, and 10

There were no significant differences found when comparing the knowledge and
attitude scores between male and female participants on the 3-month post-survey. Table 9
shows the summary statistics for the 3-month post-survey knowledge and attitude scores
by gender.
Variable

n

Mean Rank

3-month Knowledge Score: Female

5

7.10

3-month Knowledge Score: Male

5

3.90

3-month Attitude Score: Female

5

7.10

3-month Attitude Score: Male

5

3.90

p-Value
.10

.10

Table 9 – n = sample size; total score = mean of items 1-10; knowledge score = mean of items 3 and 9; attitude
score = mean of items 1, 2, 4 to 8, and 10

19

CHAPTER 5
DISCUSSION
There was a significant difference between post-survey knowledge and attitudes
scores of the treatment group, which indicated that students who participated in the
hearing conservation program had a positive increase in knowledge of NIHL although
their attitudes toward protecting hearing did not change. Middle school training may not
be early enough. In Griest et al. (2008) study, the 4th and 7th grade students both benefited
from the hearing conservation program; however, the 7th grade students did not maintain
their change in attitudes when assessed after 3 months. In this current study, there was
still no significance between the 5th and 8th grade treatment group when analyzing the 3month post-survey retention of knowledge. Similar effects were found by Johnson et al.
(2016) when comparing collegiate CSD students with collegiate non-CSD students, as
there was no difference in the behavior of ear protection use even with knowledge
regarding harmful effects of excessive noise exposure. It is possible that older middle
school students may have already formed their opinions, like young adults. Younger
children are more impressionable and can be more willing to consider other viewpoints
(Meinke et al., 2008). They are less influenced by peers, therefore, there is a possibility

20

that their attitudes may be able to change before they have already formed their opinions
about NIHL prevention and protection.
This study found that there was no overall significant difference between the pre-,
post-, and 3-month post-surveys. However, Dell and Holmes (2012) found statistically
significant effects in reducing the pro-noise attitude among adolescents and Neufeld et al.
(2011) found statistically significant effects in increasing long-term earplug use in loud
environments (Neufeld et al., 2011). One of the possible reasons why there was no
significance found in this current study was that this program was different from Dell and
Holmes (2012) and Neufeld et al. (2011) as it was delivered in a 100% online and
asynchronous format. Dangerous Decibels® by Meinke et al. (2008) provided multiple
skills-based learning activities within the program. Although there were a few skillsbased learning opportunities embedded into this study’s online video, there was no way
to make sure students were practicing the skills in the correct manner. There was a time
delay of 39-40 days between surveys and program. Therefore, there was a possibility of
limited retention of information. Dell and Holmes (2012) found significant results in
reducing the pro-noise attitude among adolescents and provided their participants with
their post-survey immediately after the HCP. The asynchronous and online format made
it very difficult to maintain anonymity and track students. Therefore, students were not
matched on the pre-, post-, and 3-month post-surveys.
Since the program was asynchronous, the home environments of the participants
could have played a role in their performance and participation. Family members or
friends could have assisted the participants during the program. Although there was no
21

specific tracking mechanism to see which participant watched the program, there was a
mechanism within the program which counted the number of times the video was
watched. In total, the video was watched 10 times and 19 participants were in the
treatment group which means that not everybody watched the video. Due to the online
delivery manner, there was no way to distribute ear protection (ear plugs) during the
program. Due to the age of the participants, they needed to rely on their parents or family
members to provide them with ear protection whereas Dell and Holmes (2012) provided
their participants with ear plugs at the end of their program. Another reason why
significance may not have been found between the pre-, post-, and 3-month post-surveys
could be because the same survey was given for all grades, and students in grades 5-8
have different reading comprehension and vocabulary levels, which could have led to
confusion and impacted their responses. For example, this survey might have been the
first survey they completed which utilized a rating scale for their responses. The options
included the terms agree, disagree, and neutral. In addition, the term hearing protection
was utilized often. If the participants did not know what those terms meant, that would
greatly affect the accuracy of their responses. In addition, a substantial amount of
development occurs between grades 5 and 8, which can affect participant attention,
motivation, and interest.
One major reason why there might not have been significant differences found in
the 3-month post-survey would be that there were only 10 total participants with only 2
participants in the treatment group. Perhaps the timing of this survey was related to the

22

low participation rate as this survey was available during the last two weeks of the
participants' school year.
Due to the nature of COVID-19, this study was presented with challenges. Only
one school chose to participate, which limited the possible number of participants.
Although there was a total of 129 students in grades 5, 6, 7, 8, only 35 agreed to
participate. Different delivery methods were utilized when contacting the participants and
their parents. Sometimes the superintendent sent the information from the lead
investigator to parents and participants, and other times, the health teachers were the
main form of contact. This study had limited free resources and there was a lack of
funding. There were no incentives provided to the participants and no physical reward
system was present. In a previous study by Neufeld et al. (2011), the 6th grade participants
changed their long-term behavior and received stickers at the end of the program. There
is a possibility that the participants of this study might have changed their attitudes if
there was a physical reward system present.

23

CHAPTER 6
CONCLUSION
There was a significant difference between post survey knowledge and attitude
scores, which indicated that students who participated in the hearing conservation
program had a positive increase in knowledge of NIHL although their attitudes did not
change. Although this program had a positive increase in knowledge, presenting this HCP
in the same online and asynchronous manner to younger children in grades 3-5 might
have a greater impact of behavior change toward the use of ear protection. Researchers
should alter presentation style and interest suitable for grades 3-5 and utilize a program
which tracks student activity to hold students more accountable. There should be an
increase in communication among teachers/participating schools as well as an increase in
the number of participants. Another possibility is conducting a longitudinal study which
would track how knowledge and attitudes change throughout the years, beginning in
younger grades such as kindergarten to 2nd grade. If the program is repeated in a
synchronous manner to participants in grades 3-5, an in-class facilitator with a CSD
background should be utilized to distribute the surveys and present the program. Since
NIHL is 100% preventable (National Institute on Deafness and Other Communication

24

Disorders, 2019), further study is warranted to find effective HCP programs that will both
educate and result in positive behavioral changes.

25

APPENDICES
Appendix A

East Stroudsburg University Institutional Review Board
Human Research Review
Protocol # ESU-IRB-015-2021
Date: August 11, 2020
To:
Mary Bulger and Susan Dillmuth-Miller
From: Shala E. Davis, Ph.D., IRB Chair
Proposal Title: “Knowledge and Attitudes Regarding Noise-Induced Hearing Loss Among
Adolescents Pre and Post Conservation Program”
Review Requested:
Exempted
Expedited X
Full Review
Review Approved:
Exempted
Expedited X
Full Review
FULL RESEARCH
____ Your full review research proposal has been approved by the University IRB (12 months).
Please provide the University IRB a copy of your Final Report at the completion of your
research.
____ Your full review research proposal has been approved with recommendations by the
University IRB. Please review recommendations provided by the reviewers and submit
necessary documentation for full approval.
____ Your full review research proposal has not been approved by the University IRB. Please
review recommendations provided by the reviewers and resubmit.
EXEMPTED RESEARCH
____ Your exempted review research proposal has been approved by the University IRB (12
months). Please provide the University IRB a copy of your Final Report at the completion of
your research.
____ Your exempted review research proposal has been approved with recommendations by the
University IRB. Please review recommendations provided by the reviewers and submit
necessary documentation for full approval.
____ Your exempted review research proposal has not been approved by the University IRB.
Please review recommendations provided by the reviewers and resubmit, if appropriate.
EXPEDITED RESEARCH
_X__ Your expedited review research proposal has been approved by the University IRB
(12months). Please provide the University IRB a copy of your Final Report at the completion
of your research.
____ Your expedited review research proposal has been approved with recommendations by the
University IRB. Please review recommendations provided by the reviewers and submit
necessary documentation for full approval.
____ Your expedited review research proposal has not been approved by the University IRB.
Please review recommendations provided by the reviewers and resubmit, if appropriate.
______________________________________________________________________________
Please revise or submit the following:

26

Appendix B
NIHL Conservation Program Permission Letter for School
July 28, 2020
Dear Superintendent of New Jersey School:
I am a graduate student under the direction of Professor Susan Dillmuth-Miller in the Department of
Communication Sciences and Disorders at East Stroudsburg University. I am conducting a research study
to investigate the knowledge and attitudes regarding noise-induced hearing loss (NIHL) among adolescents.
Would you please consider allowing your school to participate in this study?
The purpose of the NIHL Conservation Program is to determine if there is a significant difference in the
knowledge and attitudes about noise-induced hearing loss (NIHL) measured before and after a hearing
conservation program for middle school students. The NIHL Conservation Program includes a slide
presentation about NIHL as well as a NIHL simulation which will feature the interactive components so
that students may deepen their understanding of what NIHL is and how to prevent it.
This study will include an online pre-survey, an online hearing conservation program, and an online postsurvey, which will be completed by students in grades 5, 6, 7, and 8. The NIHL Conservation Program
Pre-Survey will take up to ten minutes for a student to complete. The actual hearing conservation program
is approximately 20-25 minutes long. The NIHL Conservation Program Post-Survey will take about ten
minutes to complete. In order to measure the effectiveness of the program, half of the students participating
will view the hearing conservation program while the other half will not.
Each student’s participation in this study is voluntary. If parents choose for their children not to participate,
there will be no penalty. Parents can choose to have their children discontinue the study at any time. The
pre and the post-surveys will not collect any identifying information. The results of the study may be
published but the participant names will not be disclosed.
I am kindly requesting your school’s participation. The potential benefits of the study include education
regarding the harmful effects of excessive noise. In addition, this research may encourage other school
systems to provide electronic NIHL programs for the teenage population each year, as they are at a greater
risk for developing NIHL. There are no risks involved in participating in this study.
Following my research study, the hearing prevention program will be available to all students.
If you have any questions concerning the research study, please email me at mbulger@live.esu.edu or my
faculty advisor at sdmiller@esu.edu.
Thank you for considering your school’s participation in this valuable study.
Sincerely,
Mary K. Bulger
mbulger@live.esu.edu
(908)455-0538
Dr. Susan Dillmuth-Miller
Associate professor/clinical audiologist
sdmiller@esu.edu
(484)330-9022

27

Appendix C
Noise-Induced Hearing Loss Conservation Program Directions to Teachers
September 27, 2020
Dear Teachers:
I am a graduate student under the direction of Professor Susan Dillmuth-Miller in the Department of
Communication Sciences and Disorders at East Stroudsburg University. I am conducting a research study
to investigate the knowledge and attitudes regarding noise-induced hearing loss (NIHL) among adolescents.
Would you consider participating in this study?
This study will include an online pre-survey, an online hearing conservation program, and an online postsurvey, which will be completed by the students. The NIHL Conservation Program Pre-Survey will take up
approximately ten minutes for your students to complete. The hearing conservation program is
approximately 20-25 minutes long and the NIHL Conservation Program Post-Survey will take
approximately ten minutes to complete. In order to measure the effectiveness of the program, half of the
students will view the hearing conservation program while the other half will not.
The potential benefits of the study include education regarding the harmful effects of excessive noise. In
addition, this research can encourage other school systems to provide electronic NIHL programs for the
teenage population each year, as they are at a greater risk for developing NIHL. There are no risks involved
in participating in this study.
Each student’s participation in this study is voluntary. If parents choose for their children not to participate,
there will be no penalty. Parents can choose to have their children discontinue the study at any time. The
both the pre- and the post-surveys will not collect any identifying information. The results of the study may
be published but participant names will not be known.
Following my research study, the hearing prevention program will be available to all students.
I have outlined the following steps in order so that the study can be as accurate as possible:
1. When instructed, forward email #1 to all parents in your homeroom which will include informed
consent.
2. When instructed, forward email #2 with pre-survey link to either parents or participants, depending
on class format.
3. I will randomize students by homeroom to determine who will view the hearing conservation
program. If your class is chosen to watch the hearing conservation program, then I will ask you to
forward email #3 to all parents or participants in your homeroom. This is the email in which students
will click on the link and participate in activities during the online program. If your class is not
chosen to watch the hearing conservation program, you will not receive email #3 to forward to
parents or participants, as your class will not participate in this step.
4. When instructed, forward email #4 to all parents or participants in your homeroom which will include
post-survey link. This is the email in which students will complete the post-survey.
I will be in touch with you via email every step of the way, reminding you of which email to send to
parents and when. Thank you for considering participating in this valuable study. If you have any questions
concerning the research study, please email me at mbulger@live.esu.edu or my faculty advisor at
sdmiller@esu.edu.
Sincerely,
Mary K. Bulger
mbulger@live.esu.edu

28

Appendix D
Noise-Induced Hearing Loss Conservation Program Informed Consent
October 6, 2020
Dear Parents/Guardians:
I am a graduate student under the direction of Professor Susan Dillmuth-Miller in the Department of
Communication Sciences and Disorders at East Stroudsburg University. I am conducting a research study
to investigate the knowledge and attitudes regarding noise-induced hearing loss (NIHL) among adolescents.
Would you consider allowing your child to participate in this study?
This study will include an online pre-survey, an online hearing conservation program, and an online postsurvey, which will be completed by students in grades 5, 6, 7, and 8. The NIHL Conservation Program
Pre-Survey will take up approximately ten minutes for your child to complete. The hearing conservation
program is approximately 20-25 minutes long and the NIHL Conservation Program Post-Survey will take
approximately ten minutes to complete. In order to measure the effectiveness of the program, half of the
students participating will view the hearing conservation program while the other half will not.
The potential benefits of the study include education regarding the harmful effects of excessive noise. In
addition, this research can encourage other school systems to provide NIHL programs for the teenage
population each year, as they are at a greater risk for developing NIHL. There are no risks involved in
participating in this study
Your child’s participation in this study is voluntary. If you choose for your child not to participate, there
will be no penalty. Know that you can choose to have your child discontinue the study at any time. Both the
pre- and the post-surveys will not collect any identifying information. The results of the study may be
published but your child’s name will not be known.
Following my research study, the hearing prevention program will be available to all students.
Thank you for considering participating in this valuable study. Please click on the link below in order to
provide consent for your child to participate in this study.
https://docs.google.com/forms/d/e/1FAIpQLSfCBNjsmYthiaMw2KddkCvxUPpRCv9uGcVl2RTOVFVW
UZDHGg/viewform?usp=sf_link
If you choose to have your child participate in this study, an email will be sent to either you or your child
(depending on your child’s class format) with the NIHL Conservation Program Pre-Survey link for your
child to complete.
If you have any questions concerning the research study, please email me at mbulger@live.esu.edu or my
faculty advisor at sdmiller@esu.edu.
Sincerely,
Mary K. Bulger
mbulger@live.esu.edu

29

Appendix E
Noise-Induced Hearing Loss Conservation Program Pre-Survey Link
October 22, 2020
Dear Parents/Guardians:
Please have your child complete the Noise-Induced Hearing Loss Conservation Program Pre-Survey:
https://docs.google.com/forms/d/e/1FAIpQLScPsU8foVUnXhbHoYj_sKCn5ihdA0u9WBvErJdFW2gf7nIyw/viewform?usp=sf_link
If you have any questions concerning the research study, please email me at mbulger@live.esu.edu or my
faculty advisor at sdmiller@esu.edu.
Thank you so much for your child’s participation in my study!
Sincerely,
Mary K. Bulger
mbulger@live.esu.edu

30

Appendix F
Noise-Induced Hearing Loss Conservation Program Pre-Survey
Age:______

Grade: ______ Gender: Male______ Female ______
Agree

1.

I enjoy music when it is played very
loud.

2.

Sound levels at concerts, sporting
events, or other loud places are NOT
a problem to me.

3.

I would leave the room if sounds
were too loud.

4.

I often use hearing protection at
concerts, sporting events, or other
loud places.

5.

I think people are too concerned
about loud sounds.

6.

I find it uncomfortable to use
hearing protection.

7.

I plan to wear hearing protection at
concerts, sporting events, or other
places where there are loud sounds.

8.

If my friends used earplugs at
concerts, sporting events, or other
loud places, I would use them.

9.

Sound levels at concerts, sporting
events, or other loud places may
cause damage to my hearing.

10.

I have already learned information
about how loud sounds can affect
my hearing and ways to prevent
hearing loss.

31

Neutral
(Sometimes
agree/sometimes
disagree)

Disagree

Appendix G
Noise-Induced Hearing Loss Conservation Program Post-Survey Link
January 8, 2021
Dear Parents/Guardians:
Please have your child complete the Noise-Induced Hearing Loss Conservation Program Post-Survey:
https://docs.google.com/forms/d/e/1FAIpQLSduocq3qPmPpyO4fsav7gYQtIlLCNBGH2gKKLWgEI0m_K
RjHw/viewform?usp=sf_link
If you have any questions concerning the research study, please email me at mbulger@live.esu.edu or my
faculty advisor at sdmiller@esu.edu.
Thank you so much for your child’s participation in my study!
Sincerely,
Mary K. Bulger
mbulger@live.esu.edu

32

Appendix H
Noise-Induced Hearing Loss Conservation Program Post-Survey
Age:______

Grade: ______ Gender: Male______ Female ______
Agree

1.

I think people are too concerned
about loud sounds.

2.

I plan to wear hearing protection
at concerts, sporting events, or
other places where there are loud
sounds.

3.

Sound levels at concerts, sporting
events, or other loud places may
cause damage to my hearing.

4.

If my friends used earplugs at
concerts, sporting events, or other
loud places, I would use them.

5.

I enjoy music when it is played
very loud.

6.

I would leave the room if sounds
were too loud.

7.

Sound levels at concerts, sporting
events, or other loud places are
NOT a problem to me.

8.

I often use hearing protection at
concerts, sporting events, or other
loud places.

9.

I have learned information about
how loud sounds can affect my
hearing and ways to prevent
hearing loss.

10.

I find it uncomfortable to use
hearing protection.

33

Neutral
(Sometimes
agree/
sometimes
disagree)

Disagree

Appendix I
Noise-Induced Hearing Loss Conservation Program Link
12/01/2020
Dear Parents/Guardians:
I am requesting your child’s participation in the NIHL Conservation Program. Noise-induced hearing loss
(NIHL) is the only preventable type of hearing loss, yet it is prevalent among adolescents and young adults.
There is a heightened need to increase the awareness and research concerning the knowledge and attitudes
of adolescents regarding NIHL.
The purpose of the NIHL Conservation Program is to determine if there is a significant difference in the
knowledge and attitudes about noise-induced hearing loss (NIHL) measured before and after a hearing
conservation program for middle school students. The NIHL Conservation Program includes a 30-minute
slide presentation about NIHL as well as a NIHL simulation which will feature the interactive components
so that students can deepen their understanding of what NIHL is and how to prevent it.
Please have your child view the NIHL Conservation Program Link:
https://screencast-o-matic.com/watch/cYXijiMF18
If you have any questions concerning the research study, please email me at mbulger@live.esu.edu or my
faculty advisor at sdmiller@esu.edu.

Sincerely,
Mary K. Bulger
mbulger@live.esu.edu

34

Appendix J
Noise-Induced Hearing Loss Conservation Program Outline

27-minute pre-recorded video
● NIHL background information (9.5 mins)
○ Facts, anatomy of the ear
○ Causes of NIHL
○ Noise levels
○ Exposure limits
○ Types of hearing loss
● Video, simulation, and application (7.5 mins)
○ Fred Flintstone video simulation of types of hearing loss
○ How hearing loss affects speech
○ Sound level apps (iOS vs Android)
○ Unfair Spelling Test simulation/check answers
○ Reflection of Unfair Spelling Test
■ (Support Success For Children with Hearing Loss, 2016)
● Prevention of NIHL (8 mins)
○ Strategies and ear plug demonstration
○ Check your knowledge questions (3 true/false questions)
● Review of presentation (2 mins)

35

Appendix K
Noise-Induced Hearing Loss Conservation Program 3-Month Post-Survey Link
June 1, 2021
Dear Parents/Guardians:
Please have your child complete the Noise-Induced Hearing Loss Conservation Program 3-Month PostSurvey:
https://docs.google.com/forms/d/1eNlotFmP24C7qeGrTwrONVwh6tcpqNrKiuol4QavwlA/edit
This survey will be available until Friday, June 11, 2021.
If you have any questions concerning the research study, please email me at mbulger@live.esu.edu or my
faculty advisor at sdmiller@esu.edu.
Thank you so much for your child’s participation in my study!
Sincerely,
Mary K. Bulger
mbulger@live.esu.edu

36

Appendix L
Noise-Induced Hearing Loss Conservation Program 3-Month Post-Survey
Age:______

Grade: ______ Gender: Male______ Female ______
Agree

1.

I think people are too concerned
about loud sounds.

2.

I plan to wear hearing protection at
concerts, sporting events, or other
places where there are loud sounds.

3.

Sound levels at concerts, sporting
events, or other loud places may
cause damage to my hearing.

4.

If my friends used earplugs at
concerts, sporting events, or other
loud places, I would use them.

5.

I enjoy music when it is played very
loud.

6.

I would leave the room if sounds
were too loud.

7.

Sound levels at concerts, sporting
events, or other loud places are
NOT a problem to me.

8.

I often use hearing protection at
concerts, sporting events, or other
loud places.

9.

I have learned information about
how loud sounds can affect my
hearing and ways to prevent hearing
loss.

10.

I find it uncomfortable to use
hearing protection.

37

Neutral
(Sometimes
agree/
sometimes
disagree)

Disagree

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