In 1999, the National Institute on Deafness and Other Communication Disorders (NIDCD) and the National Institute for Occupational Safety and Health (NIOSH) joined forces with public and private partners to launch WISE EARS!, a national campaign to prevent noise-induced hearing loss. The campaign’s objectives were to educate the general public about the risks of noise-induced hearing loss and to motivate individuals and organizations to increase awareness about preventing noise-induced hearing loss. Central to the effort was the development and distribution of free educational materials, available both online and through a toll-free information clearinghouse. The materials included bilingual fact sheets and other publications, promotional items, multimedia presentations, an activity book for third through sixth graders, and an in-depth, Web-interactive curriculum for seventh- and eighth-grade students. In 2006, NIDCD evaluated WISE EARS! to determine how well the campaign was meeting its objectives and to make recommendations for the future direction of the campaign. Based on the evaluation’s key findings, NIDCD plans to retool its noise-induced hearing loss campaign by focusing on children ages nine to 13, forging more mutually beneficial partnerships, and making use of delivery channels with the highest potential to attract and engage the target audience.
Keywords: public health education, program evaluation, target audience, curriculum
Acronyms: National Institute on Deafness and Other Communication Disorders (NIDCD), National Institute for Occupational Safety and Health (NIOSH), National Institutes of Health (NIH), noise-induced hearing loss (NIHL)
Yogi Berra once said, "If you don’t know where you’re going, you might end up somewhere else." Such wisdom certainly rings true for ongoing national efforts to educate the public about health issues such as noise-induced hearing loss.
For a health campaign to be successful—and to make sure we don’t "end up somewhere else"—campaign efforts must be monitored continually. In this way, we can determine if the program’s goals and objectives are being met and, if not, what adjustments need to be made to achieve them. Key questions that should be addressed when evaluating a campaign are:
- What information is currently available on the topic?
- How effective is the prevention message for the target audience?
- What audience not already targeted by current campaigns is most in need of this information?
- What messages and delivery channels most effectively can reach — and influence the behavior of — individuals who are most at risk?
Such questions were considered by the National Institute on Deafness and Other Communication Disorders (NIDCD) during a recent evaluation of WISE EARS!, a national campaign to prevent noise-induced hearing loss.
WISE EARS! Background
The effects of loud noise on hearing have been a primary area of focus for NIDCD since its beginning in 1988. In 1990, NIDCD took part in a National Institutes of Health (NIH) consensus conference on noise and hearing loss. The outcome of the conference was a consensus statement that addressed the characteristics of noise-induced hearing loss, dangerous sound levels, individual susceptibility, prevention strategies, and directions for research. Congress also expressed concern about the number of Americans whose hearing is impacted by loud noise. Following the 1998 Senate Appropriations Committee Report, NIDCD sponsored an noise-induced hearing loss conference in December 1998 in collaboration with the National Institute for Occupational Safety and Health (NIOSH), the National Institute of Environmental Health Sciences, and the private sector. The outcome of this conference was the development of the WISE EARS! educational program. For seven years, NIDCD has led the WISE EARS! effort by building a coalition of partner organizations and by disseminating information and promotional materials through the media, at professional conferences and health fairs, and on the NIDCD website.
The objectives for WISE EARS! have been to educate all audiences (e.g., workers, employers, health professionals, teachers, parents, children, unions, industry, state and local government workers, and the general public) about noise-induced hearing loss and to motivate them to learn more about hearing health and hearing protection. The broadness of the objectives reflects the missions of the two sponsoring agencies as well as those of the nearly 90 public and private organizations that have been involved in campaign efforts. Whereas NIDCD’s mission is to prevent disease and promote health through research, training, and education in the normal and disordered processes of hearing, balance, smell, taste, voice, speech, and language, NIOSH is charged with conducting research and making recommendations for the prevention of work-related injury and illness, including hearing loss. Current campaign partners vary in their interests and audiences, from advocacy groups (e.g., American Speech-Language-Hearing Association [ASHA]) to industry (e.g., Howard Leight Industries) to research organizations (e.g., Deafness Research Foundation) to special-interest groups (e.g., AARP and Farm Safety Just 4 Kids).
WISE EARS! Materials
The central source for WISE EARS! campaign materials and other information is the NIDCD website. The site contains bilingual educational and promotional materials developed specifically for WISE EARS! and is supplemented by other relevant NIDCD and NIOSH publications. These materials can be downloaded from the site or ordered without charge through the NIDCD Information Clearinghouse. Each year, the clearinghouse receives roughly 3,000 requests for WISE EARS! publications, while NIDCD distributes additional quantities at conferences and health fairs. Prominently displayed on WISE EARS! materials is the logo—a colorful cartoon owl representing a succession of noise levels, from tranquil (quiet) to highly agitated (too loud)—along with the phrase "Hearing matters!".
The WISE EARS! website also contains interactive features and classroom materials for teachers and students. The "I Love What I Hear" classroom activity and video, designed for grades three through six, educates young children about hearing and sound and introduces them to the concept of hearing protection. Seventh and eighth graders can access "How Your Brain Understands What Your Ear Hears," a middle school curriculum supplement developed by NIDCD in collaboration with the NIH Office of Science Education. The supplement, which describes how we hear and how to develop healthy hearing habits, combines cutting-edge scientific research discoveries with state-of-the-art instructional materials and is consistent with state and national science education standards.
The 2006 evaluation included two parts: an "environmental scan," or real-time snapshot of existing programs, resources, and media coverage on noise-induced hearing loss, and informal discussions with campaign partners.
The environmental scan consisted of several interrelated components, each designed to contribute insight into the type and scope of information about noise-induced hearing loss that is currently available and the organizations that are most involved with communicating this information to the public. The components and their purpose include:
- Literature/media review of recent published literature to discover issues, trends, and potential target audiences and to assess media coverage of noise-induced hearing loss.
- Materials audit of WISE EARS! materials to determine the extent to which campaign materials are current and useful.
- Publications distribution analysis to identify organizations that request WISE EARS! materials most frequently and the most popular materials.
- General assessment of competing and complementary campaigns to identify overlap and gaps in messages and target audiences.
For the second part of the evaluation, researchers conducted informal discussions with campaign partners. These discussions were structured to determine the extent to which the partners, through the use of WISE EARS! materials, were reaching target audiences and influencing their behavior. Researchers also solicited partners’ opinions about the future direction of the campaign.
Noise-induced hearing loss is completely preventable. Yet approximately 22 million Americans between 20 and 69 years of age have experienced permanent damage to their hearing from overexposure to loud noises at work or during leisure activities.1 More than 30 million Americans are exposed to dangerous levels of noise on a regular basis. In addition, smoking may adversely affect hearing, both as a single factor and in synergy with age and noise exposure.2, 3 Research suggests that men suffer noise-induced hearing loss at a 2:1 ratio compared to women.4
Noise-induced hearing loss among combat veterans appears to be on the rise.5 Out of a group of more than 5,000 soldiers returning from Afghanistan and Iraq during 2004, about one-third were referred to audiologists for hearing evaluations due to acute acoustic blast exposure; 72 percent were identified with hearing loss.6
Noise-induced hearing loss among children and adolescents is perceived as an important public health issue, and continued investigation of statistical evidence is needed to determine the extent of the problem. Studies by Niskar et al. suggest that approximately 13 percent of youth between the ages of six and 19, or 5.2 million children, may already have experienced some type of hearing loss, including temporary hearing loss.7 A comparison of the National Health and Nutrition Examination Surveys from 1963 to 1970 and from 1988 to 1994 by Hoffman et al., however, indicates that noise-induced hearing loss among children actually may be declining.8
Noise-induced hearing loss is receiving increasing coverage in mainstream media, primarily due to the risk to hearing posed by portable music players and other personal electronic devices. Eighty-five percent of noise-induced hearing loss-related citations from June 2005 to June 2006 were found in daily newspaper and consumer magazines. By contrast, only 55 percent of articles related to noise-induced hearing loss-related appeared in mainstream media during the preceding year. The WISE EARS! campaign materials were not included in the recent media coverage, however, indicating that the campaign’s visibility in the general population is low.
The potential risk to hearing posed by MP3 players and similar devices has inspired broad-based organizations to become involved in raising public awareness about noise-induced hearing loss causes and prevention, particularly among children and young adults. Two new national campaigns, both sponsored by WISE EARS! partners, target the music-listening behavior of young people. "Listen to Your Buds", sponsored by ASHA, targets children ages five to 10; "It’s How You Listen That Counts", sponsored by the House Ear Institute, targets older children and young adults, ages 12 to 22. These campaigns are complemented by Dangerous Decibels, an Oregon-based program for children ages five to 14 that takes a science-based approach to preventing noise-induced hearing loss and tinnitus. Also of note is the Don't Lose the Music campaign in the UK, by the Royal National Institute of the Deaf (now called Action on Hearing Loss).
Despite the availability of information about noise-induced hearing loss, most American youth appear uninformed. According to a Web-based survey conducted through the MTV website, only 16 percent of adolescent and young adult respondents reported that they had heard, read, or seen anything related to the issue of hearing loss.9 Only nine percent received this information through their school, even though researchers and health professionals have advocated for 30 years for the addition of hearing conservation education in school curricula and the availability of materials for classroom use.10
There also is an apparent gap between what young people know about noise-induced hearing loss and the choices they make based on that knowledge. A study by Crandell et al. found that 72 percent of college students demonstrating a high degree of knowledge about noise-induced hearing loss reported that they never wore hearing protection.11 Based on this behavioral gap and the prevailing view that children may be at increased risk of noise-induced hearing loss, the majority of WISE EARS! partners recommended that NIDCD focus future campaign efforts on youth.
Key findings about the WISE EARS! campaign specifically presented a mixed review. The majority of coalition members have not promoted the campaign aggressively. Some organizations pointed to a lack of information about new materials as their reason for not participating more actively. Other organizations indicated that the broadness of the WISE EARS! materials decreased their usability. Although many partners praised WISE EARS! materials and said they frequently referred others to the WISE EARS! website, several organizations with narrow constituencies (e.g., musicians or military personnel) have developed and are distributing their own targeted materials in lieu of broader WISE EARS! materials.
Campaign partners also noted that WISE EARS! has lacked a recent call to action to stimulate a united effort. Most coalition members indicated that their organizations would like to partner with NIDCD to promote future health messages and would welcome information about opportunities to be involved.
New Approaches to a New Campaign
NIDCD will use findings from the WISE EARS! evaluation to strengthen its noise-induced hearing loss campaign. One key strategy will be to target youth for future campaign efforts. Although the NIDCD’s ultimate goal is to prevent noise-induced hearing loss among all audiences, an all-purpose campaign cannot realistically achieve that goal. By focusing primarily on youth, NIDCD can design materials that directly address the attitudes, interests, and behaviors of this age group. This more focused approach is supported by current health communication theory, which questions a broad-brush approach to public health education. According to the National Cancer Institute’s communications planning guide, Making Health Communication Programs Work, "trying to reach everyone with one message or strategy may result in an approach that does not effectively reach those most able or ready to change."12
A more targeted approach also may help expand outreach by increasing the number of visitors to the WISE EARS! website. In 2005, the WISE EARS! website recorded 18,670 user sessions, a 47 percent growth in user sessions from 2004. In comparison, millions of users have been drawn to the targeted multimedia site for the noise-induced hearing loss campaign "It’s How You Listen That Counts". Participating in the "Earbud" campaign are the MTV Network, MTV.com, and five Yahoo! websites including Yahoo!Music.com (a.k.a. Launch.com). According to the House Ear Institute, which launched the campaign, these sites plus the campaign website and its educational spot have garnered nine million impressions to date.13 Although numbers reached is not a reliable measure of overall program effectiveness and behavioral changes, they do indicate that the target audience is at least being introduced to the message.
NIDCD will focus campaign development on youth ages nine to 13, also referred to as "tweens." NIDCD selected this age range because it offers two opportunities:
- to influence children’s attitudes and behaviors before and during the time that they develop listening, leisure, and working habits; and
- to complement existing campaigns aimed at youth. NIDCD plans to maximize available resources by building upon other campaigns rather than investing time and resources in duplicative efforts. Its new program will help fill a target audience gap by addressing children at the boundaries of the "Listen to Your Buds" and "Earbud" campaigns. In this manner, NIDCD will reinforce and provide continuity of information as children develop and grow.
NIDCD will continue to educate the general public on noise-induced hearing loss. By working through parents, teachers, and others who influence the behavior of youth, NIDCD can continue to reach out to a broader audience as well.
In addition, NIDCD will continue to support the mission and programs of other organizations, such as NIOSH’s workplace safety efforts, as a way to reach other audiences. As part of the NIH communications community, NIDCD can tap into NIH-sponsored multimedia outlets, such as NIH Radio, a 24-hour audio service designed to provide radio stations with the latest information about NIH research findings, highlights of press conferences, and health campaigns, and the National Library of Medicine’s new health magazine, NIH MedlinePlus, to engage the medical and scientific community in outreach efforts.
NIDCD also will give its campaign more attention and visibility within NIDCD’s communication efforts. NIDCD director James F. Battey, Jr., M.D., Ph.D., strongly endorses the new youth-oriented direction of the campaign. In February 2004, Dr. Battey wrote a member of Congress that "Young people live in a loud and noisy world. In this age of the escalating use of personal stereo systems, hands-free cell phones, and portable movie/game systems, youth worldwide are exposed to harmful levels of noise every day."
NIDCD also will conduct regular, comprehensive evaluations of future campaign efforts and will be developing evaluation measures from the planning stage onward so that future efforts can be measured against communication objectives. Two such objectives, both part of Healthy People 2010, call for a reduction in the number of children, teenagers, and adults suffering from noise-induced hearing loss.
NIDCD intends to make greater use of media channels and technology to expand campaign outreach. Use of the Internet may be particularly relevant to educating a younger target audience about hearing protection. A GenerationRX.com survey of teens and young adults who frequently use the Internet found that this group regularly turns to the Internet for health-related information. According to the survey, 75 percent of participants searched for health information online. Comparatively, 72 percent downloaded music; 50 percent shopped; and 46 percent checked sports. Thirty-nine percent of respondents reported a change in personal behavior because of health information obtained online.14
Next Steps Toward a New Campaign
Developing a new noise-induced hearing loss prevention campaign targeted at youth will involve:
- Tailoring materials to appeal to youth.
- Pretesting concepts, messages, and materials.
- Developing collaborative partnerships.
NIDCD envisions employing a new multimedia approach to convey the basic message that hearing is valuable and can be protected. The institute will conduct formative research to identify creative opportunities to engage the target audience, inform them about the causes of noise-induced hearing loss, and encourage them to take action to prevent it. NIDCD will look at how individuals in this age group access health information (e.g., through school programs, health care providers, and the Internet), what sources of information they find most reliable, and how they prefer to learn (e.g., interactive and entertaining activities versus traditional methods). The age of the target audience will substantially affect message development in that younger children depend on adults to initiate some protective measures for them, such as purchasing earplugs. The Dangerous Decibels message, for example, emphasizes protective measures that are within a child’s power: turning it down, walking away, protecting the ears.
NIDCD will explore multiple opportunities to promote noise-induced hearing loss education and prevention through the schools. School settings present an unparalleled opportunity to promoting hearing wellness among youth and adults. Roughly 52 million students attend more than 114,000 schools in the United States. When combined with the six million adults who work at those schools, that adds up to nearly one-fifth of the nation’s population who pass through our schools on any given school day.15 In addition, numerous studies of hearing conservation programs conducted in elementary, middle, and high schools point to positive increases in hearing knowledge and noise awareness among students exposed to this information.16
NIDCD also will be concentrating on engaging and maintaining active, committed partners. NIDCD cannot conduct the most successful campaign possible on its own. The involvement of other committed organizations to broaden campaign outreach and impact is needed. Therefore, the institute plans to put considerable effort into rebuilding and reinvigorating campaign partnerships.
As with all good partnerships, those involved will have both responsibilities and benefits. One of the lessons learned from the evaluation of WISE EARS! was that NIDCD needs to establish clearer roles and expectations for campaign partners. Future partners will contribute toward meeting campaign objectives through such tangible actions as:
- Providing resources and support of program activities and materials development.
- Disseminating messages and materials through existing channels.
- Supporting message and product testing.
- Providing feedback on use and impact of program messages and materials.
In addition, to maintain continuous improvement, NIDCD will engage its partners in regular reviews and reassessments of campaign efforts. This will include the use of benchmarks to gauge the involvement of campaign partners and the effectiveness of their activities. Future partners will be asked to participate in annual evaluations of their contributions toward campaign success.
At the same time, campaign partners will be able to realize greater program outreach and visibility for their organizations as they contribute to protecting the hearing of children. Potential benefits from participating in a new national noise-induced hearing loss prevention campaign include opportunities to:
- Combine relevant resources and core messages under the campaign umbrella.
- Extend outreach and campaign communication channels.
- Use campaign materials in support of their own outreach efforts.
- Receive recognition through the campaign’s media outreach efforts.
- Raise national awareness of their organization
The involvement of any organization may depend on the organization’s current programs, available resources, and infrastructure and outreach.
WISE EARS!, NIDCD’s national public health education campaign to protect against noise-induced hearing loss, can become a strong, successful program through the application of sound health communication principles. These principles include narrowing the program’s scope to a more specific target audience, conducting regular assessments on campaign objectives, and nurturing the cooperation of committed partners. Retooling the WISE EARS! campaign in this way could help produce a generation of individuals with healthy hearing now and for a lifetime.
Prepared by Patricia Blessing, NIDCD. Thanks to Charlotte A. Ball, NIDCD Information Clearinghouse, and Jennifer Wenger, Office of Health Communication and Public Liaison, NIDCD, for their contributions to this article.
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