Music students need and benefit from education on hearing protection
Hearing loss has been reported as the third most common chronic health problem in the United States.1 In particular, noise-induced hearing loss (NIHL) from exposure to high-intensity sounds during work or in leisure activities is a major health problem in the United States for both adolescents and adults.2-4 Estimates suggest that approximately 15% of people ages 20 to 69, or 26 million Americans, have high-frequency NIHL.5 Other changes in auditory function, such as tinnitus (ringing or buzzing in the ears), hyperacusis (loudness intolerance), and diplacusis (difficulty in pitch perception), also may occur due to excessive exposure to high-intensity auditory stimulation.
Prevention of hearing loss, as well as promotion of hearing screenings, should be encouraged in young adulthood. Although the presence of hearing loss increases with age, 8.5% of people ages 20-29 exhibit hearing loss.4 However, in general, many young adults display a lack of concern regarding potential risks to the auditory system.6,7 In a survey of college students,6 the majority (75%) of respondents reported awareness of noise exposure and associated hearing loss; however, half of the surveyed students reported potentially harmful exposure to loud music.
Young adult musicians display an increased risk for hearing loss, with recent evidence indicating that the overall prevalence of NIHL in student musicians (ages 18-25) is 45%, with the large majority of hearing loss in the high frequencies (particularly above 6000 Hz).8 Those students who indicated more than 2 hours a day of personal instrument practice time displayed significantly more hearing loss than other musicians; however, instrument groups and outside recreational noise exposures were not significant factors in increased hearing loss.8
When attitudes of college students majoring in music were compared to non-music majors, the musicians exhibited a healthier attitude toward sound.9 Music majors were more likely to perceive noise that may damage hearing as negative and were more aware of and attentive to noise; therefore, music majors were more likely to take measures to decrease personal exposure.9
Although many music majors may display a healthy attitude toward music, this population exhibits greater declines in hearing than the general population of college students.10 During a 3-year period of study in a university setting, over half of undergraduate music students displayed declines in high-frequency hearing. Individual differences in susceptibility along with behavioral resistance to music overexposure were determined to be the most critical factors when examining the hearing loss in the student musicians.10 Noise exposure in non-music majors from sources such as personal listening devices, recreational shooting, and the use of chain saws, snowmobiles, or motorcycles has been examined, with only 28% of students displaying reductions in high-frequency auditory thresholds.11
Declines in hearing in college music students may be related to inconsistent use of hearing protection devices. For example, although many student musicians (74%) reported receiving information about noise and hearing health, when exposed to potentially harmful sound levels, none reported wearing hearing protection devices (HPDs) all of the time and only 22% reported any use of hearing protection.12 Similar results were found in freshman college music majors, with 95% reporting never using HPDs when performing in concerts, 85% never using HPDs during rehearsals, and 64% never using HPDs in other environments, such as when attending rock concerts and using lawn mowers.13
Thorough documentation supports the fact that musicians’ auditory systems are at risk of damage from noise/music exposure.14-16 Although collegiate music programs are not regulated by the Occupational Safety and Health Administration (OSHA)17 or the National Institute for Occupational Safety and Health (NIOSH),18 previous studies have documented that all tested student musicians, regardless of instrument type, were exposed to daily noise doses that exceeded both OSHA and NIOSH standards.12
Similar results were documented in a group of collegiate musicians where sound levels exceeding OSHA standards were obtained in 10 of 15 dosimeter measurements recorded from the trumpet, trombone, saxophone, and rhythm sections of a jazz ensemble.19 Although student musicians are not defined as an “at risk” population, a hearing conservation program would be required by OSHA criteria given these noise level measurements.17 Since 2006, the Health Promotion in Schools of Music (HPSM) project20 has sought to increase awareness of the health-related problems associated with playing music, including the potential risks of noise/music exposure to students. The initial recommendations state:
“…schools of music should recognize that Noise Induced Hearing Loss is a widespread and serious health issue and that music is always implicated as a causal factor. This problem receives little or no recognition in schools of music. A high priority strategy is needed for informing all music students about the risks for noise-induced hearing loss.”20
Specifically, recommendation III in the HPSM project is to educate music students about hearing loss during “ensemble-based” instruction, including goals to encourage hearing health along with raising concern for hearing loss, to promote “healthy beliefs” about prevention of hearing loss, and to provide education on reducing the risk of hearing loss.21
It appears that schools of music across the country are adopting noise-induced hearing loss education and hearing conservation as part of the HPSM program.22-24 In addition to an educational component, a hearing conservation policy—including baseline audiograms and monitoring of hearing for all students entering concentrated music programs—is recommended.25
The main objective of the following study was to explore college student musicians’ perception of an NIHL education program containing the proposed elements in the HPSM project. This study also aimed at determining music students’ general knowledge of and attitudes toward hearing health both prior to and after attending the seminar. In addition, it also provides insight into the reasoning behind students’ non-use of hearing protection and their specific knowledge of hearing protection before and after attending the lecture. Suggestions for increasing the effectiveness of information delivery were also solicited.
Self-reported noise exposure and attitudes toward hearing protection were first examined through a survey of 129 college student musicians during the initial meeting of a Music Convocation series in the Division of Music at West Virginia University (WVU). Students majoring in music were asked to complete a researcher-generated questionnaire aimed at assessing baseline knowledge of select facts about hearing loss/tinnitus prevention, as well as attitudes toward hearing loss/tinnitus and hearing protection. All procedures are on file with and approved by the WVU Institutional Review Board for the Protection of Human Subjects (IRB).
Approximately 2 months after the initial survey was completed, a 50-minute educational program designed by the researchers was given to the same group of music majors through the Music Convocation series. Topics included the following areas: overview of the importance of hearing; characterization of NIHL; a description of measurements that determine status of hearing and risk for hearing loss (eg, overview of audiometric evaluation of hearing status, specific sound levels of musical instruments, and risk criteria per time-weighted average); characterization of the effects of hearing loss; facts of risk; and methods for reducing the risk and preventing hearing loss.21 During the educational program, students also were encouraged to receive free full audiometric evaluations and annual monitoring of hearing through the university’s hearing clinic. The use of custom musicians hearing protection also was discussed and encouraged.
In an effort to evoke interest in the audience of college students, the presentation incorporated multimedia, such as audio and video clips demonstrating hearing loss and perceptions of tinnitus, as well as quotations from famous musicians regarding effects of hearing loss. Students also were provided with a “Music and Hearing Fact Sheet” generated by the researchers containing a list of Web sites and supplemental reading materials with additional information about music/noise exposure. Selected preliminary data relating to the students’ attitudes and knowledge of hearing loss (which were obtained during the first meeting of the course) also were incorporated into the presentation.
After the seminar, students were given a questionnaire similar to the initial survey completed at the first Music Convocation meeting. In addition, the post-seminar survey asked about planned changes in behavior resulting from attending the lecture. Six additional questions examining the perceived effectiveness of the program were included in the post-seminar survey. The educational component and all data collection were completed at WVU.
Pre- vs post-seminar responses. The music students’ knowledge of hearing loss and hearing protection along with attitudes and beliefs about hearing health were examined during the preliminary questionnaire and again after attending the seminar. Only those students who completed both the pre- and post-surveys were included in the analysis. The investigation included participants ages 18 to 25 with a gender distribution of 47.3% female and 52.7% male. The college ranks of students were: 28.7% freshman, 31.0% sophomores, 27.9% juniors, 10.9% seniors, 0.8% graduate, and 0.8% transfer student.
Music students’ knowledge of hearing loss and hearing protection improved in the pre- vs post-seminar surveys, with more students correctly answering questions about the permanent nature of NIHL, treatment of NIHL, and effectiveness of HPDs (Table 1). For example, in the pre-seminar survey, when responding to the statement “Music-induced hearing loss can be treated with medicine/surgery,” 64.5% reported that they did not know whether the statement was true or false. However, after attending the seminar, 55.8% of students correctly indicated that this statement was false while only 36.0% reported the answer was still unknown. Students also improved their knowledge about advantages of wearing HPDs in the post-seminar condition, with 94.3% reporting that wearing HPDs can preserve hearing, 89.8% said HPD use will reduce tinnitus, 80.7% indicating that the use of HPDs will help to make loud sounds more comfortable, and 79.5% reporting that HPD use will help to prevent fatigue (Figure 1). In addition, students were more accurately able to predict the cost of custom musicians’ HPDs and were able to note where to purchase custom devices (Figures 2 & 3).
Attitudes about hearing conservation. Students consistently reported more positive attitudes and beliefs about hearing health in the post-seminar condition as shown in Table 2. For example, more student musicians (80.6%) either “agreed” (54.5%) or “strongly agreed” (26.1%) with the statement “I am worried about hearing loss” in the post-seminar condition. In addition, the majority of respondents (67.0%) either “agreed” (51.1%) or “strongly agreed” (15.9%) with the statement “I am worried about tinnitus,” and almost all (90.9%) either “disagreed” (42.0%) or “strongly disagreed” (48.9%) with the statement “I believe that hearing loss does not happen from listening to loud music.” The statement “I believe that the noise/music exposure that I have now will not damage my hearing until I am older” also received a high percentage (80.5%) of “strongly disagree” (36.8%) and “disagree” (43.7%) responses in the post-seminar condition.
Responses about HPDs and baseline hearing tests. After attending the noise-induced hearing loss seminar, overall expectation of HPD use was assessed. About one-quarter (27.3%) reported that they were “very likely” and 61.4% reported being “somewhat likely” to start using some form of HPD when exposed to potentially hazardous noise levels. When asked specifically about exposure from music, over half (55.7%) of students reported that they planned to use HPDs “sometimes” during practice/rehearsal, while only 4.5% reported that they planned to wear HPDs at all times during practice/rehearsal. When participating in a performance, 31.4% indicated that they would “sometimes” plan to wear HPDs and only 1.1% reported that they would “always” wear HPDs when performing.
The most commonly reported types of HPD that students planned to use after attending the seminar were custom musicians’ HPDs (40.5%) and foam plugs/flange (25.9%). Additional reported types of HPDs were wax/molded types (6.9%), music (non-custom) quality headsets (6.0%), ear muffs (4.3%), and “other” (1.7%). Some students (14.7%) indicated that they did not know which type of HPD that they would plan to use.
The inability to hear environmental sounds (16.0%), along with the cost (15.3%), hassle (11.1%), comfort (9.7%), and inability to communicate (9.7%), were the most common reasons that students remained unwilling to use HPDs. All reported reasons for unwillingness to wear HPDs are shown in Figure 4. When asked if they were interested in purchasing custom musicians’ quality HPDs, 71.4% of students reported “yes.”
After attending the informational session, 39.8% of students reported that they were “very likely” to get a hearing test, while 46.6% reported that they were “somewhat likely” to receive a hearing test. Only 13.6% of students reported no interest in receiving an audiologic evaluation.
Recommendations on NIHL seminar. The majority of students (96.6%) reported that the 50-minute seminar was of sufficient depth. When asked about preferred formats for future education in noise exposure and hearing loss, students were encouraged to select multiple choices from a list of 10 different formats (Figure 5). Almost half of the students (47.7%) selected live demonstrations. Traditional face-to-face lectures were requested by 44.3% of students and print materials by 31.8% of students. Formats such as “YouTube” videos (23.9%), e-mail (20.5%), Web sites (15.9%), and social networking sites (14.8%) ranked as the most commonly reported electronic responses.
When asked to “select all” of the potential speakers from whom participants would like to receive NIHL education, 80.7% chose audiologists, followed by instructors and faculty in music (59.1%), and speech and/or hearing scientists (59.1%). Physicians (35.2%) and peers (33.0%) were less frequently requested in this category.
In general, the music students’ knowledge of hearing loss and hearing protection improved from the pre- vs post-seminar surveys, with more students correctly answering questions about the permanent nature of NIHL, treatment of NIHL, and effectiveness of HPDs. Students also improved their knowledge of the benefits of using hearing protection in the post-seminar condition. The results support the need for continuing efforts to raise awareness in college student musicians through educational programs that outline the risks of excessive noise/music exposure.
Information delivery by audiologists was requested by the majority of students. Faculty in the music department as well as other college staff in speech and/or hearing science were requested to provide additional information about music and hearing loss by over half of respondents.
The majority of students indicated that the program was of sufficient depth and the suggested formats included both live demonstrations and traditional face-to-face lectures. Although many resources about noise/noise-induced auditory damage are available on the Internet,28-30 electronic formats were not as often requested by the respondents when compared to traditional lectures and live demonstrations. Efforts to incorporate face-to-face seminar programs should be encouraged in schools of music across the country. In addition, electronic formats and print handouts may serve as supplemental information.
Furthermore, music programs should encourage annual audiometric evaluations of students to monitor changes in hearing throughout their course of study. The large majority of students in the present study indicated that they were either “very likely” or “somewhat likely” to receive a hearing evaluation after attending the seminar. If declines in hearing are noted on annual audiometric evaluations, students may be more likely to incorporate recommendations to prevent excessive noise exposure into practice and playing time. Previous studies of adult orchestra musicians found that the more hearing disorders (including self-reported hearing loss, tinnitus, hyperacusis, sound distortion, and diplacusis) that musicians perceived, the more concern they reported about hearing, and thus the more often hearing protection was worn at rehearsals and performances.26
Overcoming resistance to HPDs. Although students’ knowledge of hearing health increased and their attitudes about hearing loss became more favorable, many students were still resistant to using HPDs during practice and performance. The most frequently reported reason for not planning to wear hearing protection after the seminar was that they were “unable to hear environmental sounds.”
Negative perceptions of wearing hearing protection while playing music has been previously documented, with student musicians reporting difficulty hearing themselves and others while playing and also decreased ability to perform music and communicate musically.27 The student population surveyed appeared most interested in custom musicians’ hearing protection; however, cost of the devices was a concern. Hassle, comfort, and inability to communicate also were frequently reported reasons for resistance to wearing HPDs.
Improving settings and exposure times. In the workplace, NIOSH recommends that HPDs should be used as a last resort, while the most effective way to prevent NIHL is to apply engineering controls to reduce sound levels or to remove the worker from excessive noise exposures.31 Similar recommendations should apply to music students, with exploration of other ways to reduce potential risks to hearing, such as decreasing exposure time and implementing environmental modifications rather than solely relying on HPD use.
Environmental musical instrument playing conditions should be examined for both practice rooms and concert halls. When designing performance and rehearsal spaces, large physical volume rooms with optimal sound reflection, sound distribution, and reverberation characteristics should be incorporated to decrease the amount of noise exposure in student musicians.32 Moreover, in already existing playing facilities, options such as using environmental treatments in practice facilities and concert halls, changing the location of specific instruments in the orchestra or band, and relocating the speaker/amplifier systems can aid in reducing excessive levels of music.33
Future research. Future studies combining data from multiple settings with larger and more diverse populations would increase the applicability of the data to general populations of musicians. Future research also may examine the effectiveness of similar hearing loss education programs on other populations of college students who have the potential for noise exposure from activities performed to meet requirements for degree completion, from participation or attendance in sporting events, or other collegiate activities.
Audiologist-provided, lecture-format seminar programs outlining the risks of noise-induced hearing loss can be effective in promoting immediate changes in student musicians’ attitudes and beliefs regarding hearing loss and hearing protection. Promotion of noise-induced hearing loss prevention programs with collaboration between audiology and music departments, along with recommendations for annual audiometric evaluations, safe listening habits, and appropriate use of hearing protection, may greatly reduce the risk of noise-induced hearing loss in college musicians.
The authors thank Keith Jackson, John Hendricks, Sandra Schwartz, Chris Nichter, and the Creative Arts Center faculty at West Virginia University for their support in establishing this program.
Correspondence can be addressed to HR or Dr Callahan at:
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