Cultural Adaptation and administration of public awareness questionnaire on hearing health and hearing loss in Karnataka: A cross-sectional study

Background

Hearing is a unique and measured sense because it allows us to relate to the world for various essential purposes, the most crucial of which will enable us to communicate with others. Our ability to interact with one another is highly reliant on our ability to comprehend speech, which is difficult for an individual with hearing loss. In India, over 65 million people have hearing loss, which affects 6% of the population (Healthy Ear District in India: Sound Hearing 2030, n.d.).

A few factors that affect hearing health include the present lifestyle, trauma, illness, genetic disorders, age, leisure time activities, exposure to noise, and hearing loss induced by ototoxic drugs. Leaving these factors unattended can lead to hearing loss (Alsudays et al., 2020). The lack of execution of hearing health programs and the absence of awareness also makes individuals more vulnerable to hearing loss (Fausti et al., 2005).

A persistent ear infection is one of the most prevalent reasons for hearing loss, and it is possible to prevent and treat it with medication and surgical procedures. Hearing loss that goes untreated can have various consequences in the workplace and social situations. Therefore, many people with hearing loss are unjustly denied promotions or forced to work at a level below their abilities, expertise, and experience (National Research Council, 2002).

The Global Burden of Disease study showed an increased hearing loss burden, which is now alarmingly high (Wilson et al., 2017). They reported that hearing loss is the fourth leading cause of disabilities worldwide. Hearing health is about adopting safe listening habits and avoiding excessive loudness and other loud noises during leisure time; hence, proper hearing health is required to communicate and stay associated with the surroundings.

According to WHO statistics, about one billion young people worldwide may be at risk of hearing loss because of harmful listening habits involving personal devices such as earbuds, headphones, speakers, and other similar devices. The rise in these devices has highlighted the need to address improper earphone use among youth and encourage effective hearing protection measures (Mohammadpoorasl et al., 2018; Di Berardino et al., 2013).

Another common unsafe practice seen among the global population is self-ear cleaning (Khan et al., 2017), which is the insertion of items like matchsticks, hairpins, application of hot or cold oil, herbal remedies, and liquids such as kerosene into the ear canal to clean it based on the assumption that removing excess cerumen is required for ear hygiene. Using such items to remove wax, blood, or any foreign body in the ear canal can lead to a perforated eardrum, ear discharge, and infection in the ear.

Many educated and illiterate people engage in unhygienic practices and are thus unaware that poor aural hygiene can lead to several problems. Hearing and balance may be compromised by engaging in harmful or unclean personal practices (Khan et al., 2017). So, it is important to educate individuals about good auditory hygiene. Firdose and Poduval (2015) did a study in India to assess public understanding of proper aural hygiene procedures and concluded that misconceptions about the same are related to the socio-economic profile of the community and widespread unawareness. These behaviours can cause hearing loss and alienation, separating people from their activities and society. As a result, knowing such measures might help individuals become more conscious of their hearing status, recognize early warning signals, and learn about aural hygiene practices. Corrective action can be taken when a risk is identified with this information, and it can also be used to educate others about hearing health care.

Certain medications like gentamicin, streptomycin, erythromycin, ibuprofen, and anti-cancer drugs which are ototoxic can damage the nerves and the cells involved in hearing (Arslan et al., 1999). Hence, routine monitoring is essential if any medications are prescribed; thus, no drugs should be taken without the doctor’s advice.

Routine hearing tests for persons of all ages are essential to detect any medical condition, identify potential problems, prevent potential impairment, and begin early intervention (Ferguson et al., 2016). Mainly audiologists and otolaryngologists provide specialized audiological services, such as hearing evaluations, hearing aid selection and fitting, and auditory rehabilitation. Several studies on hearing awareness have been undertaken, and it has been discovered that people with awareness of the risks of ear infections, continuous noise exposure and aural hygiene have less of an understanding of the audiology profession (Joubert et al., 2017).

Hearing loss can strike at any age. Moreover, hearing loss in one’s early stage can affect their developmental and educational achievements, harming their social and emotional quality of life. Any amount of loss of hearing at any age should not be ignored. Early identification in newborns is crucial, as there could be a chance of undetected conditions due to complications during pregnancy. As a result, diagnosing and treating hearing impairments as soon as possible is critical since they can harm a child’s speech and language development, social skills, and educational outcomes.

Sensorineural hearing loss is permanent; hence, early detection and treatment, such as amplification devices on the recommendation of a trained medical professional, are essential. As a result, the progression of hearing loss can be delayed, resulting in a higher quality of life (Galhotra & Sahu, 2019). A simple awareness program could help diminish these problems, reducing morbidity and needing specialist care (Firdose & Poduval, 2015; Alshehri et al., 2019).

Karnataka is the sixth largest state in south India, with diverse communities across districts. According to a survey by the National Program for Prevention and Control of Deafness (2017), 5.3% of the state’s population suffers from hearing problems due to a lack of awareness and early detection.

Hence this study aims to assess public awareness of hearing health and hearing loss to initiate early prevention and intervention of hearing loss in Karnataka.

Methods

Results

In our study, 658 participants answered the online survey out of a total sample size of 720 persons. Thus, a response rate of 91.4% was obtained. Underlying data are publicly available (Bhargavi, 2023).

Demographic data

Of the 658 individuals, 54.9% were female (n =361), and 45.1% were male (n =297). The responses were collected from people aged 20 to 60 years old in a 10-year age bracket. There was representation from seven different districts of Karnataka state with literacy levels from 8^th grade to undergraduate. The demographic characteristics of the samples are presented in Table 2, and the age-wise distribution of responses obtained in each district is shown in Figure 1. Figure 2 shows the age-wise responses obtained from each district.

Table 2. Demographic characteristics of the sample.

Demographic details	Frequency	Percentage (%)
Age
20-30	345	52.40
30-40	127	19.30
40-50	74	11.20
50-60	112	17
Gender
Female	361	54.90
Male	297	45.10
Education
General literate (up to 8th grade)	16	2.40
Basic literate (up to 10th grade)	40	6.10
Secondary level (up to 12th)	39	6.00
Diploma	20	3.00
Bachelors & above	543	82.50

Figure 1. Percentage of responses obtained among the different districts.

Figure 2. Age-wise responses obtained from each district.

Estimates of knowledge score

Knowledge scores are summarized as Median and Interquartile ranges (Q₁, Q₃) as the data violates the normality assumption. The overall and domain-wise average score is below in Figure 3.

Figure 3. Knowledge score in each domain.

Awareness in each domain

Figure 4 depicts the awareness percentage depicted through the number correct answers for all four domains’ questions. In domain one regarding the knowledge about infant hearing loss, the percentage score was 72.5%. In domain two, which was related to cleaning and treating the ear the highest percentage of correct score was 73.8%. Domain three, which provided information regarding the effect of overexposure to noise and loud sounds had correct response percentage of 68% and fourth domain - diagnostic delay had correct response of 66.5%.

Figure 4. Percentage of correct responses in each domain.

Discussion

This online survey presented public awareness of hearing health and hearing loss from 658 respondents from various districts of Karnataka. Many of the responses were obtained from individuals in the Udupi district, which accounts for around 54% of the total responses, whilst the Davangere district received fewer responses due to difficulties in collecting participants.

A link between age and awareness level in the current study was discovered. Participants between 20 and 30 were most likely to answer the questions correctly (73.8 %), while those aged 40 and over were the least likely to do so (63.5%).

The responses for the cleaning and treating the ear domain had the highest rate of correct answers (73.8%), while the responses for the diagnostic delay domain remained the lowest (66.7%). The study’s findings demonstrate that many responses were correct (70.1%). The question about hearing rehabilitation administered by ENTs, audiologists, or both had the most significant correct-answer percentage (83.11%). Participants who were aware of the audiologists and ENT professions’ rehabilitative services said they learned about them via other healthcare providers and word of mouth (Gabriel et al., 2015). An unexpected observation was made concerning the knowledge section, i.e., lack of knowledge concerning the ringing sensation affecting one’s daily activities. Most participants (36.76%) were not aware of the existence and impact of tinnitus (Bagwandin & Joseph, 2017).

Lack of public knowledge about the effects of extended listening to music via earphones and recommended duration of noise exposure (50.23%) show people have a poor approach towards factors which can lead to the prevention of hearing loss in terms of their attitudes.

The younger group responded better than, the older population when comparing the findings. The results revealed that the public had a decent understanding of hearing problems. However, numerous critical concerns with early detection and prevention of hearing loss were inadequate. When asked about their knowledge of infant hearing loss, almost 73.74% of participants correctly stated that hearing loss might be diagnosed shortly after birth. In contrast, only 56.2% knew the availability of specialized audiological services for a hearing evaluation. However, it was noted that about 77.63% of the individuals responded correctly about the need for correct fitting of hearing aid for maximum benefit.

However, early detection and effective management of hearing impairment (e.g., hearing aids and aural rehabilitation) may influence the quality of life of individuals with hearing loss (Olusany et al., 2014). In coastal Karnataka, putting oil to cure an itching ear or an ear infection is also believed to be a common practice (Dosemane et al., 2015). Participants were aware of the risks associated with cotton earbuds and ear infections.

In our study, we found a lack of understanding about ringing sensations and their impact on an individual’s daily activities and the usage of cotton buds, with the mistaken belief that it is beneficial. The medical recommendation against cleaning one’s ears is not well understood. As a result, it is suggested that health education for both urban and rural populations focus on ear hygiene, including why cotton buds should not be used.

There was a lack of public understanding about the risks of physical agents, particularly slaps/hits to the ear, which can cause hearing loss. Furthermore, it was surprising that most participants were unaware of tables recommending a reduction in exposure duration to high-intensity noises. It is feasible to conclude that a lack of understanding of the hazards of noise exposure might lead to higher exposure. Hence these findings support the need for noise reduction informative initiatives.

According to qualitative research conducted in India on healthcare personnel and parents of afflicted children, parents were less likely to recognize delayed speech or any other communication disorder in their children which would be affecting their school performance, even if they were well educated in other subjects (Merugumala et al., 2017). However, in our study, 81.51% of individuals knew how hearing loss could affect a child’s school performance.

Many studies have shown associations between elderly deafness, especially if untreated, and diminished physical ability and activity (Chen et al., 2014), life satisfaction (Solheim et al., 2011), quality of life (Kelly & Atcherson, 2011), and mortality (Karpa et al., 2010). Similarly, our study discovered a dearth of awareness concerning the relationship between hearing loss and behaviour in the elderly (50.23%).

On the other hand, education is also a crucial factor that impacts the awareness level among individuals (Merugumala et al., 2017). Individuals with a high level of education (> bachelor 82.5%) among the total participants showed a higher rate of correct responses in the True/False questionnaire (72.8%), and individuals with poor literacy (2.4%) showed the lowest rate of correct responses (53.1%). However, our study did not show any changes concerning the number of correct responses correlating with a person’s education. Studying the influence of education level would also have implications for estimating awareness in small towns and rural areas.

Furthermore, because the study was carried out through an online platform, the age distribution of the data was biased toward younger individuals, which might impact the accuracy of our estimations of awareness.

Finally, the association concerning the occupation (medical or non-medical) was not carried out since there was no equal distribution among the responses obtained. Studies that include medical individuals and a more representative number of non-medical individuals and their families might clearly show how awareness distribution can be among them. Hence, there is a need to accurately assess the effect of awareness on hearing health.

Conclusion

Hearing loss may affect anyone, although it is less often known and discussed than other disabilities. Hearing loss affects many people, directly or indirectly, at some point in their lives. Hearing health awareness and early detection of hearing problems are two of the most under-addressed medical issues in the world. As a result, it is essential to build awareness so that individuals of all ages may learn about their hearing health and take steps to ensure that it remains at its best.

In our study, we found a lack of understanding about ringing sensations and their impact on an individual’s daily activities and the usage of cotton buds, with the mistaken belief that it is beneficial. The medical recommendation against cleaning one’s ears is not well understood. As a result, it is suggested that health education for both urban and rural populations focus on ear hygiene, including why cotton buds should not be used.

There was a lack of public understanding about the risks of physical agents, particularly slaps/hits to the ear, which can cause hearing loss. Furthermore, it was surprising that most participants were unaware of tables recommending a reduction in exposure duration to high-intensity noises. It is feasible to conclude that a lack of understanding of the hazards of noise exposure might lead to higher exposure. Hence these findings support the need for noise reduction informative initiatives.

The study’s strength is that the data collected is not concentrated on a single region but was distributed across several districts. The survey data, with a sample size of 658 respondents, does provide an estimated clear picture of hearing health and hearing loss awareness. However, the responses were skewed toward younger participants. Hence the results were insufficient to generalize to the entire population.

To obtain better clarity and to analyze a better awareness among the population, it would be best if the study could be carried out across the entire country rather than state-wise. Future research should also explore variables such as the difference in awareness between rural and urban areas and between the medical and non-medical populations.

In conclusion, this audiological questionnaire appeared to be a simple, practical, and reliable tool; the results obtained in this study were generally positive; additionally, more comprehensive hearing conservation programs focusing on hearing aid management and early infant hearing loss detection, as well as noise exposure prevention, will be necessary to continue developing.

Authors’ contribution

Jincy Cherian: Data Curation, Investigation, Project Administration, Writing – Original Draft Preparation

Bhargavi P.G: Conceptualization, Methodology, Supervision, Validation, Writing – Review & Editing