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|Year : 2008 | Volume
| Issue : 38 | Page : 1--10
Auditory lifestyles and beliefs related to hearing loss among college students in the USA
Vishakha W Rawool1, Lynda A Colligon-Wayne2,
1 Department of Speech Pathology and Audiology, West Virginia University, Morgantown WV 26505, USA
2 Princeton Otolaryngology Assoc., 457 North Harrison Street Suite 101, Princeton, NJ 08540, USA
Vishakha W Rawool
Department of Speech Pathology and Audiology, PO Box 6122, West Virginia University, Morgantown, WV 26505
The purpose of this study was to evaluate the auditory life styles and beliefs of college students with reference to exposure to loud sounds in the context of the health belief model. A survey was administered to 238 (40 men, 198 women) students in the USA. Results suggest that 44% of the students use noisy equipment without ear protection and 29% (69/238) of the students work in noisy environments. Of the 69 who worked in noisy surroundings, only ten reported wearing hearing protection devices although 50 (72.46%) reported tinnitus. The use of hearing protection devices (HPDs) was associated with previous experience with hearing loss and tinnitus. Although 75% of the students were aware that exposure to loud sounds could cause hearing loss, 50% of the students appeared to be exposing themselves to potentially harmful loud music. Furthermore, 46% of the students reported not using HPDs during loud musical activities because they felt that the music was difficult to hear with HPDs. Most students in this study considered hearing loss to be serious but 76% of the students believed that they would not lose their hearing until a greater age. Although 66% of the students had experienced tinnitus, 58% of these students reported not being concerned about it. These results suggest a critical need for promoting healthy hearing behavior among college students. Possible strategies could include improved education, experience with simulated hearing loss for extended periods and availability of cosmetically appealing or invisible HPDs with uniform attenuation across the frequency range.
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Rawool VW, Colligon-Wayne LA. Auditory lifestyles and beliefs related to hearing loss among college students in the USA.Noise Health 2008;10:1-10
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Rawool VW, Colligon-Wayne LA. Auditory lifestyles and beliefs related to hearing loss among college students in the USA. Noise Health [serial online] 2008 [cited 2023 Feb 4 ];10:1-10
Available from: https://www.noiseandhealth.org/text.asp?2008/10/38/1/39002
Young adults may expose themselves to harmfully loud sounds without any regard to the consequences they may face as adults. It has been suggested that 17% of teens may have lost some of their hearing probably due to noise exposure and are not aware of it.  This is unfortunate as hearing loss from exposure to loud sounds can be minimized by using appropriate hearing protection devices (HPDs) such as earplugs or earmuffs and by recognizing and avoiding harmfully loud situations.
Although college-age adults can be exposed to harmfully loud sounds in a variety of ways, three avenues appear most obvious. One is exposure related to occupational noise. In the USA, construction labor is the second most common occupation during the school year and the most common summer occupation among male youths who are 18 years old.  The frequency of the use of HPDs among young adults who work in such noisy environments is unknown. It is also not known if the lack of use of HPDs is associated with lack of adequate knowledge about noise-induced hearing loss or if it is associated with risk-taking behavior.
A second avenue for potentially damaging noise exposure among young adults is the use of noisy equipment without ear protection. Many young adults use noisy equipment such as lawn mowers, snowmobiles, snow blowers, dirt bikes, power tools, chain saw etc. The prevalence of such use without ear protection among young adults is unknown.
Another obvious way that many young adults are exposed to excessively loud sounds is exposure to loud music from personal walkmans or stereo systems, iPODs, MP3 players, compact disc (CD) players, car sound systems, aerobic music and attendance at music concerts and nightclubs. It appears that exposure to harmfully loud sounds through personal listening systems or other leisure activities may be associated with a lack of knowledge about the potential harmful effects of exposure to excessively loud sounds.  Furthermore, young individuals with 'tender ears' who are exposed to high sound levels during musical leisure activities including personal stereo systems and attendance at discos can suffer from permanent hearing loss. 
Several studies suggest the possibility of damage to the cochlea from personal listening systems at least in some individuals. The free field equivalent sound pressure levels (SPLs) from personal stereo systems can vary from 91 to 121 dBA at the highest volume control settings; some peaks in music samples can be as high as 139 dB SPL.  As many as 31% of college students may be at high risk for hearing loss from the use of portable radios or cassette players.  Lee et al.  asked 16 volunteers who regularly used personal listening systems to listen to "rock" or "fusion" music for a period of three hours at their usual maximum level. Six of the 16 participants (37.5%) had a temporary threshold shift (TTS) of 10 dB at one or more frequencies with an average headphone output of 99 dB SPL. One listener who had a headphone output of 104 dB SPL sustained a 30 dB temporary threshold shift. The early elevation of thresholds caused by amplified music may be better detected by high-resolution Bekesy tracking (extending over a range of 2-8 kHz) than by conventional fixed-frequency audiometry. This is because the notches may first appear at frequencies other than those evaluated during conventional audiometry  or the elevation of thresholds may occur at higher frequencies such as 14 and 16 kHz.  Thus, depending on the measures used, all investigations may not always reveal an effect of exposure to loud music. 
The maximum sound levels from music measured in automobiles can be as high as 154.7 dBA.  The average sound pressure level of a typical nightclub in the UK is reportedly 96 dBA and the levels can be as high as 106 dBA in some nightclubs.  The average sound levels in nightclubs in Brazil can range from 93.2 to 109.7 dBA  and those in USA can range from 94.9 to 106.7 dBA.  In French discotheques, the levels are closer to 105 to 110 dBA,  in Hong Kong, the average level on the dance floor is 97 dBA,  in Montreal, the levels range from 98 to 101 dBA  and in Argentina, the levels in discos range from 104.3 to 112.4 dBA.  Exposure to such high levels suggests the potential for hearing loss from car stereos and/or regular attendance at nightclubs.
The sound levels at rock concerts can range from 100 to 115 dBA  and 70 to 80% of the concert attendees may not be wearing any hearing protection. , Dey  exposed participants to music and noted that 16% of the listeners showed significant thresholds shifts with two hours of music exposure at 110 dB SPL. Ulrich and Pinheiro  reported significant threshold shifts in all participants exposed to pop music with average levels of 110-115 dB SPL. In one of the participants, this threshold shift appeared to be permanent even five months after the exposure. An investigation of 505 college students found statistically significant hearing losses in the group that admitted frequent attendance at pop-music concerts when compared to a control group.  Yassi et al.  reported TTS of 10 dB or more in 81% of the rock attendees 5 to 25 minutes after exposure and 76% showed continued temporary threshold shift at 40 to 60 minutes. Opperman et al.  requested 29 volunteers to attend three concerts featuring pop, rock and heavy metal music in the same concert hall. Average sound levels were 99.8 dBA and the maximum level was 125.6 dBA. Sixty-four percent (9/14) of the participants without earplugs and 27% (4/14) of those using earplugs suffered from significant threshold shifts. Some patients can develop hearing loss with just one-time exposure at a rock or pop concert.  Tinnitus is also commonly reported after attending concerts. , These studies collectively suggest the possibility of cochlear damage after attendance at concerts at least in some individuals.
The reported levels in American health clubs can range from 78 to 106 dBA with 79% (92/127) of the measures showing levels between 90 and 98 dBA.  The reported range can vary from 89 to 96 dBA in aerobics centers in England. A significant temporary threshold shift was noted in all the individuals attending these aerobics classes two minutes after being present in the class and 50% of the participants reported tinnitus following the exposure.  Mirbod et al.  reported a range of 93-96 dBA in three different Japanese aerobics studios during peak exercise periods. Thus, college students who attend aerobic sessions regularly may be exposed to potentially harmful sound levels.
Dannenberg et al.  studied students (aged 12-17 years) and adults (aged 37-43 years) before and after a school dance. Pure tone air conduction thresholds were evaluated at 2000, 4000 and 6000 Hz. All students but one and all teachers with the exception of one showed worsening of hearing following exposure. Fifteen of the nineteen students and all the adults that experienced the threshold shift also experienced slight tinnitus. Thus, students can be exposed to loud sounds in a variety of ways. Martin and Church  conducted pure tone hearing screenings on 18,424 university students. Sixty one percent of the hearing loss found in males and 20% of the hearing loss found in women was only noted at 4000 Hz suggesting the possibility of noise-induced hearing loss.
In order to protect hearing among youth, basic education about noise and its effects must be offered in school settings. According to Frager,  38-90 minutes are being spent on educating students in schools about hearing conservation. If such education is effective, students entering college or first year college students can be expected to be knowledgeable about noise-induced hearing loss. Two previous studies have surveyed college students with reference to noise-induced hearing loss and the use of hearing protection.
Widen et al.  surveyed the attitudes of 17-21 year-old Swedish and American students towards noise and the use of hearing protection at concerts. The Swedish population consisted of 230 students from upper secondary schools in Boras, Sweden and the American population consisted of 251 students from a community college in Gainsville, Florida. Participants with negative attitudes towards noise were 12.45 times more likely to report the use of hearing protection compared to individuals with a positive attitude towards noise. Men from the USA had more positive attitudes towards noise than men from Sweden and men in general had a slightly more positive attitude towards noise than women. Fifty percent of the variance in the use of hearing protection in this study could be explained by attitudes and the country of origin.
Another study examined the knowledge, behavior and attitudes of college students in the USA with reference to noise-induced hearing loss.  More specifically, a survey was administered to students at a major university in Southeastern USA. The study revealed that 85% of the participants knew that there is no cure for sensorineural hearing loss. Seventy percent of the participants had knowledge of HPDs but 72% reported that they never wore HPDs. The investigators suggested the need to offer greater knowledge about the effects of noise and hearing protection devices to young people. One of the reported limitations of the study was that the findings could be generalized only to students enrolled in a very large university setting. The authors suggested the need to conduct future studies in other geographic regions and university settings.
Although offering more knowledge may be the first step towards hearing conservation, the above study reveals that knowledge itself is insufficient to promote healthy hearing behavior such as the use of HPDs. For example, it is possible that even though students have the knowledge of the harm caused by loud sounds, they may continue to listen to loud music suggesting risk-taking tendencies. Such risk-taking behavior is common among college students. For example, 95% of bicyclists do not consistently wear helmets and 25% report driving a vehicle after consuming alcohol.  Under such circumstances, in addition to offering greater knowledge about hearing conservation, other strategies need to be explored that will foster healthy hearing behavior. Such strategies can only be devised with better understanding of the underlying issues.
A Health Belief Model has been previously applied to preventative health in other contexts  and also in the context of noise-induced hearing loss.  The model  proposes that the likelihood of taking recommended preventive health action depends on three major elements: 1. Individual perceptions based on perceived susceptibility to disease and perceived seriousness of disease. 2. Modifying factors such as perceived threat of disease and demographic variables such as gender. 3. Perceived benefits of preventive health action minus perceived barriers to preventive action. The model also postulates that a relevant stimulus or "cue to action" must occur to trigger the appropriate preventive health behavior. The stimulus can be internal ( e.g ., symptoms resulting from not taking the preventive action) or it can be external ( e.g ., mass media campaigns).
The health belief model can be applied to noise-induced hearing loss as shown in [Figure 1]. According to this model, the likelihood that young adults will take preventive actions such as minimizing noise exposure or using HPDs will depend on individual perceptions about noise-induced hearing loss. This includes perceived invulnerability to noise-induced hearing loss, modifying variables such as previous experience with hearing loss or tinnitus and perceived barriers to the use of HPDs such as reduced loudness sensation.
The current investigation was designed to examine certain elements of the Health Belief Model with reference to the auditory lifestyles of college students. More specifically, the study was designed to answer the following questions: 1. What is the reported prevalence of occupational noise exposure with and without the use of ear-protection among college students? 2. What percentage of students uses noisy equipment without ear protection? 3. What percentage of college students exposes themselves to excessively loud music? 4. Do internal triggers such as experience with tinnitus, hearing loss and/or ear infections encourage healthy hearing behavior and/or HPD use during occupational noise exposure? 5. Is knowledge or belief about hearing loss associated with healthy hearing behavior? 7. Is reduced loudness sensation resulting from the use of HPDs perceived as a barrier to the use of HPDs during loud musical activities? 8. Do college students consider themselves relatively invulnerable or less susceptible to hearing loss due to young age and is this belief associated with lack of experience with hearing loss or ear infections? 8. What is the perceived effectiveness of treatment for hearing loss? 9. What is the perceived seriousness of hearing loss?
Materials and Methods
A questionnaire was developed as no standardized instrument existed to address the questions raised in the current investigation. The various questions included in the survey, the response choices and the areas assessed by the various questions are listed in [Table 1]. In designing the survey, we initially interviewed a different group of college students (not included in the study) informally to determine their beliefs, attitudes and behaviors related to noise-induced hearing loss. We also reviewed the literature to determine the potential major sources of noise-induced hearing loss among young adults. Based on this information, a draft questionnaire was developed and pretested on another small group of students not included in the current study. Following qualitative assessment of responses to the questionnaire, the questions were refined.
The final survey was administered to a large class consisting mostly of first year college students from a small urban university in the eastern part of the USA. The Institutional Review Board of the University approved the study. The study was explained to all participants and each participant was then asked to sign a consent form. Two hundred forty six students enrolled in the General Psychology class completed the survey after signing consent forms. The General Psychology class was selected because it is one of the larger classes at the University and it consists of mostly first year college students, which allowed us to control variability related to age and the education level. Eight of the surveys were eliminated from the data analyses due to several missing responses. Thus, this report is based on surveys completed by 238 (40 men, 198 women) students.
The prevalence was determined using descriptive statistics. Any effect of gender was assessed using the Chi-square statistics. The contingency coefficient was used to determine the association between the different variables. A probability level of P Occupational noise exposure
Twenty nine percent (69) of the college students reported working in noisy surroundings. Only ten (14.5%) of these students reported wearing ear protection. Thus, 59 (85.5%) students were exposed to occupational noise without ear protection. There was a gender effect related to occupational noise exposure ([Table 3], row 1) and use of hearing protection devices. Men (52.5%) were twice as likely (24.24%) to work in noisy surroundings compared to women. However, women (4.17%) were less likely to wear hearing protection compared to men (38.10%). Any gender effects in the current study should be viewed with caution due to the unequal distribution of men (40) and women (198).
Use of noisy equipment without ear protection
Approximately 44% of the students either moderately (21%) or strongly (22.69%) agreed about using noisy equipment without ear protection. Men (74.36%) were twice as likely to do so compared to the women (34.39%).
Exposure to loud music and sensation-seeking
Approximately 50% of the students either moderately (43.7%) or strongly (7.14%) agreed to the statement that when they were listening to their headphones, people next to them could hear their music. In addition, 18% of the students either moderately (13.45%) or strongly (3.78%) admitted to sitting near the speakers when attending concerts. Contingency coefficients revealed a significant correlation (r = 0.40, P = 0.000) in the responses to the two statements related to loud music exposure.
Association between experience with tinnitus, hearing loss and/or ear infections and hearing behaviors
No significant associations were found between experience with tinnitus (question 5) and some of the hearing behaviors (questions 2, 3 and 4). Similarly, no significant association was found between experience with hearing loss (question 6) and hearing behavior (questions 2, 3 and 4: [Table 2]). The same was true for experience with ear infections (question 6) and hearing behavior (questions 2, 3 and 4).
There was a significant association (Contingency coefficient = 0.249, P = 0.05) between the use of hearing protection during occupational noise exposure and experience with hearing loss. Out of 59 students who had not used any hearing protection during occupational noise exposure, only five (8.47%) had previously experienced hearing loss. Out of ten who wore hearing protection, two (20%) had experienced hearing loss. Similarly, there was a significant association between any history of tinnitus and the use of HPDs (contingency coefficient = 0.260, P = 0.027). Out of ten individuals who had worn ear protection during occupational noise exposure, six (60%) strongly agreed with the statement " I have had, in the past, ringing in my ears". Out of 59 who had not worn ear protection, 16 (27%) strongly agreed with the same statement.
Association between knowledge or beliefs about hearing loss and hearing behavior
There were no significant associations between hearing behavior (Questions 1b, 2, 3 and 4) and knowledge/beliefs about hearing loss (questions 9,10,11 and 12). For example, only 10% of the students agreed with the statement "I believe that hearing loss does not occur because of loud music", suggesting that most of the students were aware of the potential of hearing loss due to exposure to loud music (Question 11, [Table 2]) and yet 50% of the students were exposing themselves to potentially loud music (Question 3, [Table 2]).
Perceived barrier to the use of HPDs during exposure to loud music
Approximately 46% of the students agreed with the statement "I don't wear hearing protection during loud activities such as a concert because I feel the music is more difficult to hear with hearing protection". In addition, responses to this statement were significantly associated with responses to statement 3, "when I am listening to my headphones, people next to me can hear my music" (contingency coefficient = 0.335, P = 0.022) and statement 4, "When I go to concert, I sit near a speaker" (contingency coefficient = 0.323, P = 0.036).
Perceived susceptibility, seriousness and effectiveness of treatment
The majority (75.62%) of the students surveyed believed that they would not lose their hearing until they were older. Such a belief was significantly associated with lack of experience with hearing loss (contingency coefficient = 0.415, P = 0.0000) and ear infections (contingency coefficient = 0.418, P = 0.000). In addition, approximately 58% of the students agreed with the statement "Although my ears ring after a social activity, the ringing goes away and I feel that I do not have to worry". Women (62.24%) were more likely to hold this belief than men (43.59%). Only 4% of the students agreed with the statement "I don't mind having a hearing loss." Approximately 44% of the students believed that hearing loss could be "fixed" with hearing aids.
Prevalence of reported experience with hearing loss and/or ear-infections
Approximately 10% of the students disagreed with the statement "I have not had any previous history of hearing impairment" and approximately 35% of the students disagreed with the statement "I have not had many ear infections in the past". There was a significant association (contingency coefficient = 0.40, P = 0.000) between history of hearing loss and ear infections. Out of the 208 students who had not experienced hearing loss, 65 (31%) reported history of ear infections. Out of the 24 who reported experience with hearing loss, 18 (75%) students had experienced ear-infections.
Findings related to tinnitus
Approximately 66% of the student agreed with the statement "I have had, in the past, ringing in my ears". There was a significant association (contingency coefficient = 0.331, P = 0.026) between tinnitus and reported hearing loss. In addition, tinnitus was also associated with working in noisy environments (contingency coefficient = 0.202, P = 0.038). Out of 69 who were exposed to occupational noise, 50 (72.46%) reported tinnitus. There was also a significant (contingency coefficient = 0.375, P = 0.001) association between tinnitus and responses to the statement "although my ears ring after a social activity, it goes away and I feel that I do not have to worry".
Overall, the results suggest that several college-students are at risk for developing hearing loss due to occupational noise exposure, exposure to the use of noisy equipment and/or exposure to loud music. There is a critical need for devising strategies to reduce the risk of this type of hearing loss among college students.
The results suggest that about 29% of the college students work in noisy environments. As indicated in [Table 2], the length of such work can vary from a few days to several years. Some students work only during the summer in noisy environments probably due to school-breaks but also because more construction work may occur during summer. An alarming trend is that only 14.5% (10/69) of the students reported the use of hearing protection.
It should also be noted that noise and hearing loss can compromise personal safety in the workplace. , The results also suggest that experience with tinnitus or hearing loss can promote the use of HPDs during work. Bogoch et al.  similarly reported that concert attendees' use of hearing protection was significantly associated with previous experience with hearing disturbances. In the context of the Health Belief Model,  hearing loss and tinnitus probably serve as internal triggers for cuing preventive action.
Approximately 44% of the students reported using noisy equipment without ear protection and men were twice as likely to do so as women. Although any gender-related effects in the current study should be viewed with caution due to the greater number of women (198) than men (40) in this study, this finding is similar to other research findings that suggest that college men are more likely than college women to engage in risky activities. ,
Exposure to loud music and sensation-seeking
The current results suggest that as many as 50% of the students are exposing themselves to potentially harmful, loud music although 75% of the students seemed to be aware of the fact that exposure to loud music could cause hearing loss. In addition, 18% of the students admitted sitting near the speakers during concerts. It appears that some of the students may be seeking enhanced loudness sensation for arousal; this possibility needs to be further explored in future studies. Sensation seeking has been defined as a trait characterized by the seeking of varied, novel, complex and intense sensations and experiences and the willingness to take risks for the sake of gaining the experience.  It has also been conceptualized as the need for individuals to reach and maintain an optimal level of arousal.  With respect to music-induced hearing loss, sensation seeking can be defined as a trait characterized by listening to intense music at the risk of experiencing hearing loss and/or tinnitus following the listening experience. Higher sensation seeking has been associated with spending more time listening to punk music. 
Hetu and Fortin  suggested that feeling music through one's body parts is a type of proprioceptive sensation that may be sought by listeners as part of the "listening" experience. A study conducted in nightclubs by Royster and Royster  reported that teens like the music better when it is turned to its fullest; when the average levels fell below 95 dBA, the audience perceived the sound as being too "wimpy". In another study, although 60% of the bar patrons experienced tinnitus, most of them were not in favor of imposing any restriction on the volume of the music.  Wilson and Herbstein  reported that participants in aerobics classes found 80 dBA music too soft while the levels of 89 to 97 dBA resulted in the perception of comfortable listening. Furthermore, at these levels, the participants reported that they enjoyed the class more and that the music made them work harder. Florentine et al.  suggested the possibility of behavioral patterns consistent with a subjective sense of being addicted to loud music in 8/90 (9%) of their participants. These studies collectively suggest that at least some individuals are willing to take the risk of suffering from hearing disturbances to feel the sensation of loud music.
Beliefs/knowledge related to hearing loss
In a previous study, only 42% of the college students felt that listening to their favorite music at high levels was potentially damaging to their hearing.  In contrast, the majority (76%) of the students in the current study were aware of the potential of hearing loss resulting from exposure to loud music. This may be the result of campaigns such as Wise Ears.  Nonetheless, increased awareness may still be necessary in this area since some students seem to be unaware of the potential risk associated with the exposure to loud music. In this context, it is noteworthy that some investigators have questioned the effectiveness of campaigns. For example, Weichhold and Zorowka  reported an increase in the frequency of discotheque attendance following a campaign although there was also an increase in the number of regeneration breaks during the attendance.
Perceived invulnerability to and perceived effectiveness of treatment of hearing loss
The majority (75.62%) of the students surveyed in the current study believed that they would not lose their hearing until they were older suggesting a sense of being less vulnerable to hearing loss due to youth. According to the Health Belief Model, perceived vulnerability is one of the factors related to taking appropriate preventive actions.  For example, perceived susceptibility to skin cancer and sun damage is the strongest predictor of teenagers' use of sunscreen.  Perceived invulnerability is also associated with the failure to adopt preventive behavior such as testicular self-examinations.  Students who see themselves as being less vulnerable may not be motivated to reduce their exposure to loud sounds. Approximately 44% of the students in the current study believed that hearing loss can be "fixed" with hearing aids. Such beliefs may reduce the perceived threat from hearing loss and further reduce motivation to take preventive actions.
Prevalence of reported experience with hearing loss and/or ear infections
The results suggest that 10% of the students have experienced hearing loss, 75% of reported hearing loss is connected to some history of ear infections and 25% of the loss is related to causes other than ear infections. Other studies have revealed a prevalence rate of approximately 9% of ear infections among college students.  Our results suggest that 35% of college students have experienced ear infections. The difference in these two numbers is probably because our question asked about any previous experience with ear infections and not just experience within the college environment. Many individuals may have experienced ear infections in childhood, which probably resulted in the higher percentage reported in the current study.
Findings related to tinnitus
In the current study, approximately 66% of the students reported experiencing ringing and there was a significant association between tinnitus and hearing loss. In this context, it should be noted that Davis et al.  showed some evidence suggesting that the auditory function of young individuals who report tinnitus and have significant social noise exposure may differ from those who do not report tinnitus and have not experienced similar leisure noise.
Strategies for reducing the risk of hearing loss from exposure to loud sounds
Long-term school-based education programs may effectively increase the use of hearing protection among students.  One of the reported barriers to students obtaining healthcare is the lack of perceived susceptibility.  Current results suggest that students need to understand that hearing loss can result from causes other than aging and noise exposure can result in significant hearing loss even at a young age. College students also need to understand that although hearing aids can help, they do not "fix" hearing loss and that the best strategy is to prevent the occurrence of hearing loss. Furthermore, students need to be informed that the occurrence of tinnitus after a noisy activity is highly associated with hearing loss and several instances of temporary hearing loss can lead to permanent hearing loss.
College students appear to be more concerned about how their health affects their physical appearance than with their overall physical health.  Hearing loss is an invisible disability and does not affect physical appearance. Furthermore, noise-induced hearing loss has an insidious onset and it may not be perceived as disabling at the onset, thus students may not take an active interest in minimizing hearing loss. In the context of the health-belief model, current results suggest that allowing students to experience simulated hearing loss over extended periods may serve as an external trigger for urging the use of hearing protection devices. Future studies are necessary for evaluating the effectiveness of such a strategy.
One of the reported barriers to students obtaining healthcare is the need to conceal vulnerability.  Therefore, future studies need to explore the effectiveness of cosmetically "cool" (appealing) HPDs or HPDs that are not obviously visible when worn. Furthermore, 46% of the students in the current study reported not using HPDs during loud musical activities because they felt that the music was difficult to hear with HPDs. The effectiveness of earplugs with uniform attenuation across the frequency range should be explored in future studies as such earplugs may reduce the muffled sensation caused by conventional HPDs. 
Other possible strategies may include recommendations of maximum levels during activities that involve loud music such as aerobics, nightclubs and concerts. Partial success has been reported with the use of warning signs posted near elevators and the request from a peer to reduce the volume in reducing the volume of portable headsets.  Peer pressure may be an effective tool for college populations and needs to be explored in future studies for reducing the volume and using ear protection.
Limitations of the study
In an attempt to limit the length of the questionnaire to avoid fatigue, only limited factors related to healthy hearing behavior were explored in the current study. Due to the preliminary nature of the study, a sample of students from a small university in a specific northeastern area was used in the current study. Thus, the generalization of findings to other college students may be somewhat limited. All students included in the current study were Caucasian due to the prevalence of such a population at the University and thus current findings cannot be generalized to culturally diverse populations. Further studies are necessary to allow generalizations to a large group of students including culturally and geographically diverse groups. In terms of geographical regions, the use of hearing protection can vary depending on the country.  Another variable that may be explored in future studies is the socioeconomic status. Adolescents from families with high socioeconomic status may use hearing protection to a greater extent when compared to those with lower socioeconomic status.  The current study focused on college students who had at least a high school level education. Results from individuals in similar age groups who do not have similar educational backgrounds may vary considerably.
The results suggest that 29% of college students may be currently exposed to occupational noise without ear protection, 44% of the students may be using noisy equipment without ear protection and 50% of the students may be exposing themselves to potentially harmful levels of music. Although each factor alone may put students at risk for hearing loss, a combination of such exposures may further increase the risk. Such exposure seems to be occurring although most students perceive hearing loss as serious and many are aware that exposure to loud music can cause hearing loss. These results suggest a critical need for promoting healthy hearing behavior among college students. Previous experience with hearing loss and tinnitus is associated with the use of HPDs during occupational noise exposure. Future studies should explore provision of experience with simulated hearing loss as a strategy to promote the use of HPDs. In addition, improved education about causes of hearing loss, limitations of hearing aids and significance of the occurrence of tinnitus following loud activities can be provided. Effectiveness of HPDs that provide uniform attenuation across the frequency range during musical leisure activities also needs to be explored in future studies.
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