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|Year : 2012
: 14 | Issue : 59 | Page
|Hearing protection use in manufacturing workers: A qualitative study
Ravi K Reddy1, David Welch1, Peter Thorne1, Shanthi Ameratunga2
1 Section of Audiology, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, NewZealand
2 Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, NewZealand
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|Date of Web Publication||18-Aug-2012|
Occupational noise is a significant contributor to disabling hearing loss worldwide. Noise-induced hearing loss (NIHL) has resulted in huge human and economic consequences costing New Zealand approximately $53M annually and rising. A high proportion of hearing loss claims are made by workers in the manufacturing sector. Hearing protection devices (HPDs) are used together with engineering and administrative controls to minimize noise exposure and to prevent hearing loss. Unfortunately, inconsistent and improper use of HPDs has hindered efforts to prevent NIHL. The purpose of this study was to understand the factors that influence the use of HPDs amongst a group of manufacturing workers in New Zealand. A purposive sample of twenty-five workers was recruited to take part in semi-structured interviews. The open-ended questions were aimed at exploring the participants' knowledge, attitude, beliefs, and behavior towards noise and HPDs. The data were analyzed using conventional content analysis and key themes emerged in relation to HPD use. Themes that emerged from the interviews either supported good hearing protection behavior or acted as barriers against it. Five major themes, (perception of noise, hearing preservation, reluctance to use HPDs, workplace interaction, and value of hearing) and sub-themes described various factors that influence hearing protection use. Both personal and environmental factors influence the use of HPDs. Based on this study, personal and environmental factors need to be targeted for further research using ecological models to develop interventions that promote HPD use amongst workers.
Keywords: Barriers, behavior, hearing protection devices, noise-induced hearing loss, supports
|How to cite this article:|
Reddy RK, Welch D, Thorne P, Ameratunga S. Hearing protection use in manufacturing workers: A qualitative study. Noise Health 2012;14:202-9
| Introduction|| |
Occupational noise-induced hearing loss (NIHL) costs people many years of healthy life. Worldwide, 7-21% of disabling hearing loss is estimated to be caused by occupational noise  and it is considered to affect approximately 17% in the New Zealand population. This has a high personal and societal cost. For example, in New Zealand, claims for occupational NIHL rehabilitation (provision of hearing aids) is costing the Accident Compensation Corporation approximately $53M annually.  Further, given that the overall direct burden of hearing loss is estimated at 1.6-3% of GDP,  the impact of occupational noise exposure is a significant cost to society.
Engineering and administrative controls, such as eliminating noise at source and isolating workers from noise source, are primary measures to reduce noise exposure. These measures must be encouraged to reduce noise levels at work. However, hearing protection devices (HPDs) are also used in addition to these controls. However, improper and inconsistent use of HPDs has been of concern to preventive approaches to NIHL.  Several factors are reported to influence the wearing of hearing protection: Health beliefs, perceived risk, perceived probability of risk, perceived benefits, and comfort of wearing the device. ,,, New Zealand data suggest that a high proportion of hearing loss claims come from the manufacturing sector and plant and machine operators. 
Previous New Zealand research into of occupational exposure found that just half the plant and machine operators, assemblers, and elementary workers who worked in noisy environments reported hearing protection use.  Although international studies have looked at factors that influence the use of HPDs, ,,, no such study has been found in New Zealand manufacturing workers. The purpose of this study was to understand the factors that influence the use of HPDs amongst a group of manufacturing workers in New Zealand.
| Methods|| |
Ethics approval was obtained from the University of Auckland Human Participants Ethics Committee (Ref: 2010/214). Companies defined as "manufacturing" by The Australian and New Zealand Standard Industrial Classification (ANZSIC) 2006  were approached. A purposive sample of twenty-five workers was recruited from 11 companies to take part in semi-structured face-to-face interviews in August, 2010. The participants were plant and machine operators and assembly line workers from factories in Auckland, New Zealand. Regulation 11 of the Health and Safety in the New Zealand Employment Regulations 1995 require employers to take all practicable steps to ensure that no employee is exposed to noise above 85 dBA for an 8-hour period.  Participants were recruited from workers who reported noise levels greater than 85 dBA for an 8-hour period. They predominantly conducted molding works, sheet metal fabrication, and joinery. This sample included one female participant. Demographics were not the focus of this research; however, one participant was female, age ranged between 19 and 60, and 17 were New Zealanders, 8 were immigrants, of whom 6 were Pacific Islanders, 1 was European and 1 was South American. Four workers approached refused to be interviewed. The interview questions were developed from a literature review of NIHL and the use of HPDs. The semi-structured interview consisted of five items. The open-ended questions [Table 1] were aimed at exploring the participants' knowledge, attitude, beliefs, and behavior towards noise and HPDs. In addition, the interviews aimed to establish supports for and barriers against HPD use.
Permission was sought from employers to engage their workers in this study. Recruitment of participants for this study ceased after the twenty-fifth participant was interviewed. This was the point of saturation where no new information was being recorded. Six workers from five different companies were recruited at a training workshop organized by the local workers union. All participants were informed that participation was voluntary and given a participant information sheet outlining information about the research. Each participant was asked to sign a letter of consent. Interviews took approximately 10 minutes to complete, and the participants were gifted a $10 voucher for their time and assistance. The interviews were digitally recorded using an Olympus digital voice recorder and transcribed verbatim (RKR). The data were exported to QSR NVivo 8 software for analysis. The data were analyzed using conventional content analysis. 
Conventional content analysis aims to describe a phenomenon without having preconceived themes, instead allowing themes to emerge from raw data.  Transcripts were read thoroughly, words that described a concept related to workers and their views were highlighted. Notes were made to capture a keyword that described the highlighted texts. After coding six transcripts, a set of codes based on emerging themes were determined. The rest of the transcripts were read, and key ideas were assigned to preliminary codes. Data that did not fit existing codes were assigned to new codes. Once the coding was completed, the data were checked in each code, and a review (RKR and DW) was undertaken to decide if some codes could be collapsed or expanded. There were further discussions between the investigators about the order of the categories and sub-categories. These discussions led to changes in the make-up of categories and themes and its hierarchy.
| Results|| |
Themes that emerged from the interviews either supported good hearing protection behavior or acted as barriers against it. Some themes are further divided into sub-themes to explain different views and concepts.
Theme 1: Perception of noise in the workplace:
Sub-theme 1.1: Acceptance of noise as part of work - fatalism
A theme of fatalistic acceptance was observed. There is the suggestion of accepting noise as part of work and that work could not be done without making noise.
"You can't work and not make noise, so it's just part of the job."
"Because of the nature of the work, they ( noise levels) are very high."
Because of this belief, noise was regarded as something that has to be accepted.
"You can't really help it ( noise). Welding makes noise, fabricating makes noise, and cutting makes noise."
"But it (noise) is unavoidable...it is the nature of our machinery...it (noise) is just one of those things you've got to live with."
Even though all participants worked in places where noise would be considered to be hazardous (i.e. greater than 85 dB Leq for an eight-hour shift) under the Health and Safety in Employment Regulations,  some workers described noise levels as low. This could be taken as further evidence of the acceptance and normalization of high noise levels within this workforce. There is also the suggestion that some workers may feel that they have become used to being in noisy environments.
"It's ( the noise level) not that loud..."
"I have got quite accustomed (to noise)."
Sub-theme 1.2: Noise annoyance:
Noise was reported to be annoying, and that it causes undue stress and discomfort. Some participants view noise to be bothering and frustrating and that working in constant noise had a negative effect on their mood, level of attention, and health. They also report that noise causes them to experience headaches and migraines.
"It ( noise) can stress you out. It is frustrating sometimes being in all the noise."
"Sometimes you get a migraine…headaches."
"It (noise) can start to get on your nerves after a while…all the banging and hammering."
Sub-theme 1.3: Fear of Hearing Loss:
There was knowledge that high levels of noise can damage ears and cause hearing loss. Part of this knowledge was the understanding that hearing loss is gradual and damage to hearing may not be felt until later in life.
"It ( noise) makes you deaf."
"You may not see it (hearing loss) straight away but in time…"
"Loud noise all day will affect your hearing in the long run."
Theme 2: Hearing protection use:
Sub-theme 2.1: Hearing preservation
The participants discussed reasons why workers used HPDs at work. They acknowledged that HPDs help prevent damage to hearing. They talked about how loud levels of noise can damage their ears if unprotected.
"To ( wear HPD) obviously protect my ears from damage."
"It (HPD) protects my ear drums."
Sub-theme 2.2: Work Requirement
Interestingly, some participants also reported that they use hearing protection because it is the law and a company requirement. This demonstrates an acceptance of HPDs, an attitude similar to noise acceptance, due to enforcement of rules and regulations. There is suggestion that HPD use is part of their work process, similar to punching in their time cards when they start and finish work.
"Because it is law, we have to wear hearing protection."
"It's ( to wear HPD) an employee requirement by the company."
"I wear ear muffs because the rules in the factory you have to wear your safety gear."
These responses suggest an acceptance of instructions about HPDs by employers or health and safety officials. However, they may also indicate lack of thought given to why hearing preservation is important to an individual.
This is highlighted by the suggestion that even though there are company rules, the workers may choose not to wear them.
"It ( wearing HPD's) really comes down to the own person. You cannot force it."
"I know it is put on us to wear hearing protection, it is supplied to us, but it is up to us."
Sub-theme 2.3: Reduce noise annoyance
Some participants used HPDs to counter the annoying effects of occupational noise. They described relief and concentration to carry out work in a less noisy environment.
"To keep the noise out. It gets very noisy in the workshop."
"I wear the ear muff...when it is too loud, I feel unhappy."
The suggestion that HPDs help workers experience some peace in frustrating conditions is seen as another strong motivator for HPD use.
"You want a little bit of peace and quiet."
Theme 3: Reluctance to use HPDs:
The participants accept the use of HPDs to protect hearing, avoid noise annoyance, and conform to workplace rules. However, they report unwillingness to use HPDs for varying reasons. These include the mechanics of HPDs and the inability to communicate when using HPDs.
Sub-theme 3.1: Bulky
The participants described earmuffs as being bulky and inconvenient to use. Some workers found it difficult to wear earmuffs with other safety equipment such as helmets, safety shields, and goggles.
"If you have the earmuffs, you cannot get the helmets on. You cannot get your goggles, your glasses, you cannot get anything on."
Sub-theme 3.2: Uncomfortable
In addition to being a problem to wear with other safety equipment, the participants reported a degree of discomfort when wearing HPDs, particularly given the hot and humid conditions of most manufacturing workshops. Some workers also find earplugs to be painful when inserted in the ear canal. "It's (HPD) uncomfortable. You know if you use the plugs, it tends to hurt the inside of your ears when it expands. And when we use the earmuffs, it tends to press against your head and it sweats."
"They get sweaty around their ears. Just feels uncomfortable."
Sub-theme 3.3: Communication problems
The participants felt that the wearing of hearing protection blocked off sounds, and it was difficult to communicate with other workers or hear what was going around in their work environment.
"You know you cannot hear the other co-workers and you cannot communicate properly with them."
In addition, the need to communicate can make workers to constantly remove hearing protection devices. This can be frustrating, and workers may abandon wearing hearing protection altogether
"Every time you got to talk to someone, it's ( HPD) in out in out."
Furthermore, there is suggestion that workers value communication and interaction with each other. Their inability to carry this out makes them feel demoralized and unhappy.
"I've got to wear hearing protection at work and when you are wearing ear muffs, basically you are in your own little world."
"You can't really talk to anybody, so you are by yourself sort of. It makes a long shift."
Sub-theme 3.4: Quality and Availability
There were suggestions from the workers that the type of HPDs provided are of inferior quality, and thus workers are not keen on wearing them.
"…the company provided a cheap one ( HPD)…they (workers) do not want to use it."
It was also suggested that workers have different preferences about which HPD to use. Some workers prefer earplugs while others liked earmuffs. However, in the absence of their preferred type of HPD, workers may be unmotivated to use the available HPD.
"We have to wear them ( ear plugs) because we don't have ear muffs. Ear muffs would be lot better."
Sub-theme 3.5: Habits
The participants also suggested that some workers are habitual non-users of HPD and that those workers who have not regularly used HPDs are more likely not to regard HPD use as an important protective behavior.
"They have worked here for 30 plus years and think that it (noise) does not do any damage."
"Probably habits…It is like old dog, new tricks sort of thing. Like my father for instance, builder for years, he is deaf as a door post…If only he had worn hearing protection. He never did, still does not."
Theme 4: Workplace influence:
Sub-theme 4.1: Peer Mentality
It was reported that some workers may find the wearing of HPDs as a ridiculous and socially inappropriate behavior. The workers as a group may not necessarily value the importance of HPDs and find wearing them funny. While this may all be light-hearted workplace banter, some workers may be discouraged from using HPDs.
"The way I'm thinking they make fun of me. Especially when I put the green ear plug, it looks funny to me."
Sub-theme 4.2: Peer Modeling
On the other hand, co-workers support each other at work and remind them of safety practices. This gives workers added encouragement and motivation to adopt positive HPD use behavior.
"Everyone is treated the same, so we all support each other. Remind each other ( to wear HPD)."
Sub-theme 4.3: Self-image
Some participants thought that some workers considered themselves as stronger and not vulnerable to the harmful effects of high levels of noise. This may also mean that some workers think that this bravado earns them the respect of their peers.
"Maybe they are too staunch and think it (noise) doesn't hurt them."
"Some of the guys got, 'I'm the man' type of attitude, you know. 'It's not going to hurt me,' but it will in the long run."
Sub-theme 4.4: Proper enforcement of rules
Some participants reported that the practice of wearing hearing protection was encouraged when employers effectively enforced policies and regulations.
"My boss is also our safety inspector and makes sure that we do wear them ( HPDs)."
"I think the boss can make people wear it (HPD)."
Sub-theme 4.5: Training
The participants thought regular training at workplaces on noise and hearing protection encouraged workers to wear HPDs and increased workers' awareness of issues around noise and hearing protection.
"We have regular courses at work that remind us; refresh us about hazards at work and why we should wear hearing protection."
Theme 5: Value of hearing:
There is a suggestion that good hearing ensures a normal life with loved ones and being able to appreciate the everyday joys of life. The idea moves beyond just protecting ears. It is about valuing hearing as an important part of life.
"I love going out to the beach. I do a lot of diving. My hearing is very precious to me.
I love the sound of my grandkids."
On the other hand, it appears that some workers may not see noise as an issue at all whether at or away from work. This may imply that noise is not regarded as a serious hazard in the community: An attitude, which may produce a barrier against safety behavior.
"I have got 2 subwoofers ( for loud music ) at the back of my car, so I don't really care."
| Discussion|| |
The findings suggest that a combination of factors influence the use of HPDs. Five major themes: Perception of noise, hearing protection use, reluctance to use HPDs, workplace interaction, and value of hearing influence hearing protection use.
There is a fatalist belief among workers that noise is an acceptable and unavoidable part of the job. This attitude suggests that workers feel that noise is a given and will always be present in their line of work. A possible consequence of this may be acceptance of hearing loss as an unavoidable condition of the work environment. Fatalistic beliefs such as this can influence workers' risk perception and make them ignore safety procedures.  In addition, noise levels were reported to be low by some workers. Since we know that, according to an external (legal) frame of reference, the noise levels were high for all those interviewed; the presence of an opposing theme may be taken to represent an acceptance and internalization of the idea that, within the manufacturing sector, noise levels cannot be avoided. The presence of the contrary theme, that noise was high and continuous, suggests that workers may not have completely accepted high-level noise as the norm. If workers are able to identify noise as a hazard, it will support the idea of the importance of HPD to keep out noise. Previous research showing that those who felt they were exposed to high levels of noise wore hearing protection more often supports this idea.  This implies that workers' attitudes to noise may be influenced by the perspective from which they perceive it. For example, a worker who views the noise in his factory as being average for his industry may not be careful around it. On the other hand, another worker who views the noise level as high in comparison to the rest of the world may take more care in noise.
Exposure to noise in industrial settings is known to annoy workers,  and evidence suggests that workers who accept noise as part of everyday work are less likely to be annoyed by noise.  In addition, noise can also cause annoyance indirectly by interfering with performance and communication as well as impairing hearing  However, workers' perceived susceptibility to NIHL and the perceived severity of NIHL varies. 
The participants indicated that HPDs were beneficial in efforts to protect hearing. However, there was a contrary theme that company requirements are the primary reason to wear hearing protection; not a personal desire for hearing protection. This may indicate that the workers possibly do not understand the benefits of HPDs. Furthermore, the workers reported using HPDs to reduce the annoying effects of noise. It is not uncommon for workers to use HPDs to reduce the annoying aspects of noise. , This belief can be seen as a motivator to use hearing protection in noisy workplaces. While the use of HPDs was acknowledged as a means of preventing hearing loss and reducing noise annoyance, there were barriers that hindered this protective behavior. HPDs are known to be uncomfortable,  and workers in this study described them to be bulky, painful, and sweaty. The workers also found HPDs to interfere with other safety equipment. In addition, workers reported having different preferences in relation to the type of hearing protection they choose to use. When there is limited choice, workers could start developing unfavorable attitudes towards HPDs. These factors may cause dissatisfaction and frustration that could lead to the compromised use of HPDs. An ineffective and improper use of HPDs will in turn reduce hearing protection.  The use of hearing protection is further impacted by the inability of workers to communicate effectively when using them. , The workers felt that using HPDs cut them off from others and made them lonely. In addition, it was difficult and a hassle to remove hearing protection every time to communicate and then put them back on. It may also be necessary to hear machine sounds for workers to carry out their tasks properly. 
Peers can be seen to exhibit behavior that either can act as support for or as barriers against HPD use. An earlier study did not find any evidence of people being ridiculed or joked at for wearing hearing protectors, but the authors accept that it did not mean peer pressure did not exist but operated rather subtly.  A more recent study involving construction workers did, however, provide evidence that workers did not wear personal protective equipment because they feared being teased by their peers.  There were suggestions by workers in this study that HPDs may become the subject of jokes in workplaces. On the other hand, it has been shown that workers were motivated to wear HPDs after seeing co-workers carry out this behavior. There is evidence that collective behavior of a work group may function as a social modeling stimulus for HPD use.  Our study also found that workers were motivated to wear hearing protection because they reminded each other to wear HPDs at work.
Participants believed that some workers thought that noise was not a problem for them, and that they were tough enough to negate the effects of noise. The idea that some workers may not feel the need to wear HPDs because they can physically cope with noise is interesting. It contains an implicit assumption that invulnerability is a manly trait, and implies that this view is believed to be misguided. It may be that an 'ideal' man would be invulnerable, but it is acknowledged that nobody meets this ideal. In terms of developing intervention, this ideal man image may be a useful straw man. This finding is consistent with the findings of another study where workers did not wear HPDs to appear strong and macho for their peers and employers.  This kind of attitude may also be driven by the need to be popular among peers. It is likely that some workers think that by demonstrating negative safety behavior they will earn the respect of peers of being a tough worker.
Poor enforcement of safety law and rules can make the workers complacent and possibly trivialize the importance of HPD use. The workers acknowledge that enforcement of HPD use helps them sustain this behavior. While, rules and regulations alone cannot influence behavior, they are important to observe and when combined with strategies at other levels, should have a positive influence on HPD use behavior. The attitude of being an ideal worker who follows company rules can be viewed as an added motivation to observe workplace safety procedures. It appears that workers who think that they are provided with inferior quality HPDs are not raising this with their employers. However, the suggestion that the HPDs provided are of inferior quality could just be a justification to not wear them. In addition, training is an important organizational factor that increases workers' ability to use HPDs effectively. It raises the question about the effectiveness of training methods on how to use earplugs. Improper use of earplugs will most likely cause discomfort to the ears of workers. Training needs to be effective to facilitate any increase in knowledge and initiate the process of behavioral change. Training needs to go further than the fact that HPDs help protect hearing. It must scratch beyond the surface and stimulate thinking about why hearing is precious and how it would affect different aspects of workers lives.
Social support networks such as family and peers influence HPD use behavior. Preservation of hearing to maintain a good quality of life was reported as one of the reasons to wear HPDs. Hearing loss may contribute to isolation, loss of intimacy, communication impairment, self-pity, and diminished quality of life. , The thought that hearing is necessary to maintain and enjoy the little joys in life with family members is a very powerful driver to support HPD use. On the other hand, of concern is the attitude demonstrated by the worker who appears to be fond of loud sounds, ("...subwoofer at the back of the car..."), and is not bothered by noise at work. This suggests a culture of accepting loud sounds and noise in our communities, and could explain the relaxed attitude to noise in the workplace. Workers may not relate to the hazardous nature of noise because they have not experienced hearing loss and possibly have an internal belief of low susceptibility to hearing loss. Future research may consider investigating possible association between community perception of loud sounds and noise and its subsequent influence on workers' hearing protection behavior.
Our findings suggest that two types of factor influence hearing protection behavior: Personal and environmental. Both are important to consider when looking at hearing protection behavior. The themes of this study fit in well with the ecological model for health promotion [Table 2].  The model theorizes that there are different levels of influence (intrapersonal, interpersonal, organizational, community, and public policy) that interact with each other and that personal, socio-cultural, and physical environmental factors cut across each level to influence behavior.  The personal and environmental factors in this study cut across different levels of the ecological model, suggesting that factors in each level and across levels of influence interact with each other to impact HPD use [Table 2]. This supports findings of other studies that have used ecological models to explain hearing protection behavior amongst workers. , An important consideration for an ecological model is the community level. There were suggestions in this study that workers did not care about noise and enjoyed loud sounds outside of work, suggesting a community culture of not thinking of noise as a hazard. However, a contrary theme of valuing hearing to enjoy life, the environment, and family is seen as a motivator for HPD use at work. These two themes suggest that how noise is perceived in the community may influence hearing protection behavior at work.
|Table 2: Personal and environmental factors that influence the use of HPDs at different levels of the ecological model|
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Our study has some limitations. While we recruited workers from manufacturing companies, this study is qualitative and exploratory, with limited generalizability. Our study was not designed to consider demographic factors, but to understand underlying motivations and barriers to HPD use amongst manufacturing workers. The findings strengthen the need for ecological models to be used as a theoretical framework in developing health-promoting interventions. Future research using a mixed methodology (quantitative questionnaires and focus group discussions) would provide important context-dependent information that informs the development of focused and targeted interventions. This study provides baseline information that will be used to inform the formulation of a quantitative questionnaire as part of a larger study looking to develop targeted intervention aimed at positively influencing the behavior of workers towards the use of HPDs.
| Acknowledgment|| |
This study was made possible through a Health Research Council of New Zealand administered Accident Compensation Cooperation of New Zealand doctoral scholarship awarded to the lead author (HRC:10/094). We would also like to thank the workers, companies, the Engineering, Printing and Manufacturing Union (EPMU), and the Employers and Manufacturers Association (EMA) for assisting in the data collection process.
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Ravi K Reddy
Section of Audiology, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland
[Table 1], [Table 2]