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Hearing Loss Prevention

Health Behavior Change Models to Prevent Noise-Induced Auditory Dysfunction

Lewis, M. Samantha PhD

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doi: 10.1097/01.HJ.0000719800.96632.d5
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It is well established that exposure to sounds of sufficient duration and intensity can cause damage to the auditory system.1-2 This exposure may occur in occupational and in non-occupational settings. Preventing or limiting this exposure could obviate or minimize noise-induced auditory dysfunction.

Public health, hearing conservation, noise.
Table 1
Table 1:
Illustrative Examples for Promoting Hearing Conservation Using Model-Based Components.

Practices that protect one's hearing (e.g., using hearing protection devices [HPD], reducing sound levels) may require a change in one's established behavior. Identifying factors that can facilitate these behavior changes may enhance the effectiveness of hearing conservation efforts and, ultimately, help prevent noise-induced auditory dysfunction. Major health behavior change models—including the Transtheoretical Model, Health Belief Model, Theory of Planned Behavior, and Health Promotion Model—have been used by researchers to understand the acceptance of hearing conservation behaviors and, in some cases, to enhance hearing conservation efforts. While this article is not a comprehensive, systematic review on the topic, it provides overview for readers interested in learning more.


The Transtheoretical (Stages-of-Change) Model (TTM)3-4 describes the stages of making a behavior change: pre-contemplation, contemplation, preparation, action, maintenance, and termination, which is when a person has completely adopted the behavior. This model does recognize, however, that these stages are not static; a person can fall back to an earlier stage in the process. Beyond the stages, the TTM considers 10 processes that may move an individual through the stages, such as consciousness-raising and the establishment of helping relationships. The Ida Institute's circle tool5 applies the TTM stages and processes to hearing rehabilitation. Research evaluating the TTM in regard to other health behaviors has demonstrated that behavior change typically takes place when the pros of the targeted behavior outweigh the cons.3,6 Support for this finding in terms of hearing conservation practices is also available.7-8 Another key component of this model is self-efficacy, which that refers to an individual's confidence in his or her own ability to accomplish a skill or set of skills related to a targeted goal*.3-4,9-10 As one might imagine, self-efficacy is higher in later stages of adoption of hearing conservation practices.7-8


The Health Belief Model (HBM)11,12 considers the individual's perceptions about the likelihood of contracting a given health condition (e.g., hearing loss, tinnitus) and the consequences of that health condition. It also considers an individual's perceptions regarding the pros (benefits) and cons (barriers) of the health behavior needed to protect against acquiring the health condition. Other major elements include events or signs that encourage a person to initiate the behavior change (also known as cues to action) and self-efficacy.

Researchers have explored the HBM for its applicability in understanding hearing conservation behaviors and evaluated its components in regards to the TTM stages of change.13-14 Gilliver, Beach, and Williams13 reported that subjects in the pre-contemplation stage perceived less susceptibility and severity for noise-induced hearing loss, as well as fewer benefits for hearing conservation behaviors compared with those perceived by subjects in later stages of change. These subjects also reported more barriers to hearing conservation than those who had adopted such practices. Divani and colleagues14 also found more pros and fewer cons to hearing conservation practices at later stages. They found higher self-efficacy in the action stage than in the contemplation stage, and more cues to action (i.e., experiences of auditory difficulties after being around loud noise) in the contemplation stage versus pre-contemplation. In a qualitative study on musicians,15 auditory difficulties were reported to be the reason for HPD use by the majority of participants. Rawool and Colligon-Wayne16 also found a relationship between prior experiences with auditory difficulties and HPD use in occupational settings, but not with hearing conservation practices in non-occupational settings. They found that barriers to HPD use were related to riskier listening behavior but knowledge and beliefs about hearing loss were not. Saunders and colleagues17-19 used the HBM constructs to create a computerized educational program that demonstrated statistically significant improvements in perceived severity, perceived benefits, cues to action, and knowledge immediately after the training. Readers may be interested in suggestions for promoting hearing conservation practices to musicians using the HBM.20


The Theory of Planned Behavior (TPB)21 considers one's intentions and postulates that three constructs influence one's intention to implement the behavior change. These constructs are (1) one's attitude regarding the behavior (attitudes), (2) one's perception of how those around him or her view the behavior (subjective norms), and (3) how much the person believes in his or her ability to perform and control the behavior (perceived control). One's intention and perception of control in turn direct one's behavior.

Concerning hearing conservation, Gopal, Champlin, and Phillips22 found that positive attitudes but not subjective norms or perceived control were significantly associated with safe music listening practices, while Quick and colleagues23 reported a significant relationship between subjective norms and HPD use by coal miners. While not specifically studying the TPB, Melamed, et al.,24 also found support for subjective norms and HPD use by those who worked in manufacturing. Keppler, Dhooge, and Vink25 and Widén26 combined the TPM with elements of the HBM. Keppler, et al.,25 found young adults who did not use HPD during high-noise non-occupational activities were more positive in their attitudes about noise and reported significantly more barriers to using HPD. Gilles and Paul27 created a campaign to raise negative feelings regarding noise and positive feelings regarding HPD use, and found that HPD use increased after the campaign. Widén26 found that how others around them view using HPD (subjective norms), cues to action (i.e., noise sensitivity, tinnitus), and the cons of using HPD to be related to HPD use by teens at concerts. Kotowski, Smith, Johnstone, and Pritt28 created brochures designed to increase awareness of the threat of hearing loss and the effectiveness of the use of HPD around hazardous noise for protecting one's hearing and over-the-ear headphones over earbuds for listening to MP3 players, and found that the use of headphones (but not HPD use) increased.


The Health Promotion Model (HPM)29 postulates that two factors influence one's thoughts and feeling regarding a behavior, which in turn influence whether or not a health-promoting action will occur. These two factors are an individual's past experiences with prior related behaviors, as well as personal factors. Personal factors include biological, psychological, and sociocultural factors. Many of these thoughts and feelings include factors already discussed like the perceived benefits of and barriers to behavior change, self-efficacy, and feelings about the behavior. It also includes interpersonal and situational influences, immediate competing demands and preferences, and commitment to a plan of action.

Research using this model has found a relationship between worker's use of HPD and personal factors,30-33 perceived benefits,33-34 perceived barriers,31,34, self-efficacy,33-36 the value one places on HPD,34-36 interpersonal influences,8 and situational influences.31,33,37 The work by Vogel and colleagues38-39 on habit strength concerning music listening practices supports the construct of prior experiences with related behaviors. Kerr, Lusk, and Ronis33 determined that significant predictors of HPD use by those who worked in a factory were the benefits of using HPD, the barriers to using HPD, seeing others using HPD (social modeling), and situational influences. Edelson and colleagues40 found significant predictors for HPD use in construction workers to be a low rating of the time required to use HPD (barriers) and perceived support for HPD use. Lusk and colleagues41 created an individualized multimedia hearing conservation education program based on components shown to be predictive of HPD use using an earlier version of the HPM model and the responses from participants. While HPD use increased after the training, the results were not significantly different from the control group, who watched material that met the Occupational Safety and Health Administration requirements.


Researchers have not limited themselves to using just one of the above health behavior change models to improve hearing conservation practices. Neitzel and colleagues42 used components derived from both the HBM and the HPM to create a hearing-conservation-education program for construction workers, which resulted in greater use of HPD in high-noise environments. Stephenson and colleagues43-44 used the TTM, HBM, HPM, and the Theory of Reasoned Action (a precursor to the TPB) as a guide to creating a hearing conservation education program for carpenters, and found positive changes in knowledge, attitude, and intentions regarding appropriate HPD use after the training. The Dangerous Decibels® program,2 a hearing conservation education program designed for children, also drew from the TTM, the HBM, the TPB, and Social Cognitive Theory.45 This program's training outcomes were more robust when presented by an older peer or nurse educator in a classroom environment versus at a museum exhibit or over the internet. This may further support the construct of interpersonal influence promoted by the HPM.

While the models’ approaches and effectiveness vary depending on the situation, some illustrative examples based on the models reviewed are listed in Table 1.

The health behavior change models described in this article may help hearing care professionals better understand the adoption (or lack thereof) of hearing conservation behaviors by their patients, and provide strategies that may help facilitate the adoption of these behaviors.


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