Mark Stephenson, Ph.D.Mark Stephenson, Ph.D.

Carol Merry Stephenson, Ph.D.Carol Merry Stephenson, Ph.D.

National InstituteNational Institutefor Occupational Safetyfor Occupational Safety

and Healthand Health

APPLICATION OF HEALTH APPLICATION OF HEALTH COMMUNICATION THEORIESCOMMUNICATION THEORIES

NIOSH HIERARCHY OF CONTROLSNIOSH HIERARCHY OF CONTROLS

Remove the hazardRemove the hazard

Remove the workerRemove the worker

Protect the workerProtect the worker

OVERVIEWOVERVIEW

• Overview of the problemOverview of the problem

• Current issues associated with hearing protectorsCurrent issues associated with hearing protectors

• Health communication modelsHealth communication models

• Using health communication theory to positivelyUsing health communication theory to positively influence hearing health behaviorsinfluence hearing health behaviors

I tell ya,noise-induced hearing

loss don’t get norespect.

THE PROBLEMTHE PROBLEM::

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Audiometry Monitoring HPDs

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PREVALENCE OF PROGRAM ASPECTSPREVALENCE OF PROGRAM ASPECTSBY COMPANY SIZEBY COMPANY SIZE

Percentage of Time Hearing Percentage of Time Hearing Protectors are Worn “Most of the Protectors are Worn “Most of the

Time” When Working in Loud NoiseTime” When Working in Loud Noise

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100 Hearing ConservationProfessionalsCarpenter SafetyTrainersCarpenters

How much of a problem is there?How much of a problem is there? Hearing loss from noise is the most common Hearing loss from noise is the most common

occupational illness (NIDCD), and the 2nd-most self-occupational illness (NIDCD), and the 2nd-most self-reported occupational illness for American workers reported occupational illness for American workers (NCHS).(NCHS).

NIHL accounts for about 1 in 5 losses severe enough NIHL accounts for about 1 in 5 losses severe enough for a person to report trouble hearing (ASHA).for a person to report trouble hearing (ASHA).

Preventing NIHL would do more to reduce the Preventing NIHL would do more to reduce the societal burden of hearing loss than medical and societal burden of hearing loss than medical and surgical treatment of all other ear diseases combined surgical treatment of all other ear diseases combined (Dobie, 1993).(Dobie, 1993).

How many people are affected?How many people are affected?

30 million people are occupationally exposed to 30 million people are occupationally exposed to hazardous noise.hazardous noise.

10 million people have NIHL - nearly all from 10 million people have NIHL - nearly all from occupational exposures.occupational exposures.

Hearing problems shot up 26% from 1971 to 1990 Hearing problems shot up 26% from 1971 to 1990 among those between 18 to 44 years old.among those between 18 to 44 years old.

Today, 15% of those between 6-19 show signs of HL. Today, 15% of those between 6-19 show signs of HL.

So what…People lose their hearing

anyway as they age.

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ring

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s 40 Y.O.50 Y.O.60 Y.O.

The amount of “material hearing impairment” for a non-noise exposed 60 year old male is 16.75 dB. Re ASHA (Avg. of 1, 2, 3, & 4 kHz) and ANSI S3.44-1996, data base A

normalhearing

Even by age 60, the average healthy Even by age 60, the average healthy person does not have impaired hearing!!person does not have impaired hearing!!

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95 dBA

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At 90 dBA, material hearing impairment > 25 dB.

Hearing Levels in 60 Year Old Males asHearing Levels in 60 Year Old Males asa Function of Noise Exposurea Function of Noise Exposure

Hearing Loss Among Male CarpentersHearing Loss Among Male Carpentersas a Function of Ageas a Function of Age

The Average 25 Year Old CarpenterThe Average 25 Year Old CarpenterHas 50 Year Old Ears!Has 50 Year Old Ears!

RESULTS OF FOCUS GROUPSRESULTS OF FOCUS GROUPS

Workers may be less Workers may be less concerned about gettingconcerned about gettinga hearing loss then about a hearing loss then about developing tinnitus.developing tinnitus.

““I expected to lose my I expected to lose my hearing. But, I thoughthearing. But, I thoughtit would be quiet.”it would be quiet.”

94%

6%

Tinnitus

No Tinnitus

21%

79%

Tinnitus

No Tinnitus

Non-Noise Exposed WorkerNon-Noise Exposed Worker

Noise Exposed WorkersNoise Exposed Workers

Percent of People With TinnitusPercent of People With Tinnitus

Without proper training, any hearing Without proper training, any hearing protector that can be worn wrong,protector that can be worn wrong,

will be worn wrong!will be worn wrong!

Murphy was right!Murphy was right!

Even when noise hazards are clearly identified,Even when noise hazards are clearly identified,you can’t just set out boxes of hearing you can’t just set out boxes of hearing protectors and expect workers to use them.protectors and expect workers to use them.

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Plug A Plug B Plug C Plug D Plug E Plug F Plug G

Available protection vs. the amount of protection obtained by untrained workers.

Likely protection as worn by untrained worker

Amount of protection listed on the box

Effect of inconsistent use of hearing protectionEffect of inconsistent use of hearing protectionon the amount of effective noise reductionon the amount of effective noise reduction

Hearing Protector Issues:Hearing Protector Issues:Methods for Estimating Actual PerformanceMethods for Estimating Actual Performance

FIT-TEST METHODFIT-TEST METHOD• Fit-test system feasible for Fit-test system feasible for

field usefield use

• Using fit-test enabled Using fit-test enabled workers to learn to workers to learn to correctly fit a new plugcorrectly fit a new plug

• Knowledge gained and Knowledge gained and consciousness raisedconsciousness raised

Can we take what weCan we take what wehave learned in the laboratoryhave learned in the laboratoryout to the field?out to the field?

Can we influence hearing lossCan we influence hearing lossprevention behaviors amongprevention behaviors amongnoise exposed workers?noise exposed workers?

Factors Affecting Behavioral Change:

Individual LevelIndividual Level

• Knowledge/beliefs• Attitudes/values• Stage of change• Decisional balance• Self-efficacy

Organizational LevelOrganizational Level

• Norms- safety culture

• Union and management priorities

• Modeling by trainers

• OSH curricula in the apprentice centers

• Environmental support

Health Promotion Can Learn From MarketingHealth Promotion Can Learn From Marketing

INFLUENCING HEARING HEALTHINFLUENCING HEARING HEALTHBEHAVIOR AMONG WORKERSBEHAVIOR AMONG WORKERS

Studies utilizing a health communication/ promotionStudies utilizing a health communication/ promotionapproach indicate that your education and training approach indicate that your education and training must address two concepts:must address two concepts:

Remove BarriersRemove Barriers Develop Self-EfficacyDevelop Self-Efficacy

People have MANY reasons for not using hearing protectors. (AKA: You can lead a person to hearing protectors, but you can’t get him/her to wear them.)

THE FOUR C’s•Comfort• Convenience• Cost • Communications / hear important sounds

THERE ARE OVER 200 DIFFERENT HEARING PROTECTORS.

EVERYONE CAN FIND A PROTECTOR THAT MEETS THEIR NEEDS. THE BEST HEARING PROTECTOR IS THE ONE THAT’S WORN!

To effectively influenceTo effectively influenceworkers’ hearing health workers’ hearing health behaviors, you need tobehaviors, you need toapply health communica-apply health communica-tion theory as you develoption theory as you developand use training and and use training and educational materials.educational materials.

“One way to cut confusion surrounding the selection of a

theory…is to combine elements of successful and well-tested

theories into a single framework. A framework

pools the best available knowledge…”-- Witte (1995)

Applying these and similar models can Applying these and similar models can effectively help shape workers’ attitudes, effectively help shape workers’ attitudes, beliefs, and behaviors.beliefs, and behaviors.

HEALTH PROMOTION AND HEALTH PROMOTION AND

HEALTH COMMUNICATION MODELSHEALTH COMMUNICATION MODELS

Theory of Reasoned ActionTheory of Reasoned Action

Health Belief ModelHealth Belief Model

Stages of Change ModelStages of Change Model

Behavioral beliefs andoutcomeevaluations

Normative beliefs &motivation tocomply

Attitude towardsbehavior

Subjective normconcerningbehavior

Intention toperformbehavior

BEHAVIOR

THEORY OF REASONED ACTIONTHEORY OF REASONED ACTION

Health Promotion Models Help Identify Health Promotion Models Help Identify

Variables That Predict BehaviorsVariables That Predict Behaviors

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I plan to wear hearing protectors when I work around loud noise.

Health Belief Model:Attitudes, Beliefs, Social Norms

• Susceptibility

• Seriousness

• Benefits

• Barriers

• Self-efficacy

Belief inbenefitsor effec-tiveness

Amountof controlover theissue

Beliefsaboutbarriers

Perceivedsuscep-tibility

Perceivedconse-quencesofinaction

Behaviors to avoid a health risk

Health Belief Models Help Identify Health Belief Models Help Identify

Cognitive Variables That Predict BehaviorsCognitive Variables That Predict Behaviors

HEALTH BELIEF MODELHEALTH BELIEF MODEL

How do you know what How do you know what the workers’ concerns the workers’ concerns and beliefs are?and beliefs are?

Just ask me.I’ll tell you

what I need.

Barriers cited by coal minersBarriers cited by coal miners

for not wearing HPDs:for not wearing HPDs:

Comfort Poke Out EardrumComfort Poke Out Eardrum

Communication Cords Get CaughtCommunication Cords Get Caught

Convenience Earcup Too BigConvenience Earcup Too Big

Roof “Talk” Warning SoundsRoof “Talk” Warning Sounds

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I believe exposure to loud noise can hurt my hearing.

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I think my hearing is being hurt by exposure to loud noise.

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I think it would be a big problem if I lost my hearing.

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I am convinced I can prevent hearing loss by wearinghearing protectors whenever I’m in loud noise.

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I don’t think I have to wear hearing protectors every time I’m working in loud noise.

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Wearing hearing protectors is annoying.

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I think it will be hard to hear warning signals (like back-up beeps) if I am wearing hearing protectors.

Stages of Change Model Predicts When Behavioral Change Will Occur

• Precontemplation- typically 40 % of workforce for a new behavioral request

• Contemplation- may do in next 6 months

• Preparation- may do in next 30 days

• Action- trying out the behavior now

• Maintenance- have been doing behavior for 6 months+

Identify and Target A Desired Behavior

• Carpenters will use hearing protectors consistently and correctly whenever they are exposed to hazardous noise

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On my current job, I seldom wear hearing protectorswhen I work around loud noise.

What are precontemplators like?What are precontemplators like?

•SometimesSometimes lack knowledge about issuelack knowledge about issue

•Have no interest in changing their Have no interest in changing their behavior or beliefsbehavior or beliefs

•Have no intention of changing Have no intention of changing even in a future time frameeven in a future time frame

How to move precontemplators to How to move precontemplators to contemplationcontemplation

• Get their attentionGet their attention

• Raise their consciousness Raise their consciousness

• Create environments to help people do Create environments to help people do the right thingthe right thing

This is your ear.This is your ear. This is your ear on noise.This is your ear on noise.Any questions?Any questions?

What moves Contemplators to the What moves Contemplators to the Preparation stage?Preparation stage?

• Emotional arousal helps here too!Emotional arousal helps here too!• Direct Consequences for Self & othersDirect Consequences for Self & others

1. Imagery- “imagine your life if…”1. Imagery- “imagine your life if…”

2. Consequences to family and friends2. Consequences to family and friends

3. Thinking actively about solutions3. Thinking actively about solutions

4. Case studies & testimonials4. Case studies & testimonials

It’s Really Pretty Simple…..It’s Really Pretty Simple…..

• Wear this now...Wear this now... • Or wear this later!Or wear this later!

What are Preparers Like?What are Preparers Like?

• Increasing belief in “pro’s”Increasing belief in “pro’s”• Decreasing concern about “con’s”Decreasing concern about “con’s”• Start taking small steps toward new behavior Start taking small steps toward new behavior

(do a sound survey, read up on HPDs)(do a sound survey, read up on HPDs)• Increased confidence about making changesIncreased confidence about making changes• Make a plan or “intend” to adopt new, safer Make a plan or “intend” to adopt new, safer

behaviorbehavior

What Moves Preparers to What Moves Preparers to Action?Action?

• Setting reasonable Setting reasonable goalsgoals

• Making specific plans Making specific plans to overcome specific to overcome specific barriersbarriers

• Making public pledgesMaking public pledges

• Continuing to believe Continuing to believe there are more pro’s there are more pro’s than con’s for the new than con’s for the new behaviorsbehaviors

What Are People in the Action What Are People in the Action Stage Like?Stage Like?

• Firmly believe benefits of Firmly believe benefits of new, safer behaviornew, safer behavior

• Have a consistent plan for Have a consistent plan for action and have been action and have been following it for several following it for several monthsmonths

• ““Intend” to maintain the Intend” to maintain the behavior behavior

• Recognize success of small Recognize success of small stepssteps

Prospect Theory: How you frame the message does count!

Loss versus Gain

Prevention versus Detection

Loss vs. Gain

1) If you take action A, 200 workers will keep their hearing.

2) If you take action B, there is a 1/3 probability that 600 will keep their hearing, and a 2/3 probability that no one will keep their hearing.

Gain Framing

3) If you choose action C, 400 workers will lose their hearing.

4) If you choose action D, there is a 1/3 probability that no one will lose their hearing, and a 2/3 probability that 600 will lose their hearing.

Loss Framing

Does this touchy-feely stuff work? Does this touchy-feely stuff work? You bet it does!You bet it does!

Positively influencing beliefs about using Positively influencing beliefs about using hearing protectors -hearing protectors -

ComfortComfort

Consistent useConsistent use

BehavioralBehavioralintentionsintentions

Ability to hearAbility to hearwarning soundswarning sounds

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The Effect of Removing Barriers (Comfort The Effect of Removing Barriers (Comfort and Convenience) Which Workers Stated and Convenience) Which Workers Stated

Prevented Them From Wearing PlugsPrevented Them From Wearing Plugs

Replacing foam ear plugs with custom-molded Replacing foam ear plugs with custom-molded ear plugs nearly doubled the rate of useear plugs nearly doubled the rate of use

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uoGp

uoEssaenLl

ORDB

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MFTN

A YD

Conduct FocusGroups

MeasureSPLs & HTLs

ObserveBehaviors

Analyze Audio-metric Data

AdministerSurvey

Analyze Data

Develop Training

Re-administerSurvey

Analyze Data

Modify Training

Removing Barriers andRemoving Barriers andDeveloping Self-EfficacyDeveloping Self-Efficacyis an Iterative Processis an Iterative Process

How Do You Remove Barriers & Develop Workers’How Do You Remove Barriers & Develop Workers’Self-Efficacy?Self-Efficacy?

Blah, blah, blah…Blah, blah, blah...

Education and Training Must NOT JustEducation and Training Must NOT JustFill a SquareFill a Square

Wise-Ears Web Wise-Ears Web LinksLinks

www.nih.gov/nidcd/health/wise/

www.cdc.gov/niosh/noise

www.aearo.com

www.3m.com

www.howardleight.com

www.hearnet.com

www.hearingconservation.org

This is your ear.This is your ear. This is your ear on noise.This is your ear on noise.

ANY QUESTIONS?ANY QUESTIONS?NIOSH Toll-Free Number: (800) 35-NIOSHNIOSH Toll-Free Number: (800) 35-NIOSH

http://www.cdc.gov/niosh/homepage.htmlhttp://www.cdc.gov/niosh/homepage.html

Mark R. Stephenson Carol Merry StephensonMark R. Stephenson Carol Merry Stephenson(513) 533-8144 (513) 533-8144 (513) 533-8581 (513) 533-8581mos9@cdc.govmos9@cdc.gov cem3@cdc.gov cem3@cdc.gov