The Relationship Between Noise-Induced Hearing Loss Awareness and the Use of Personal Listening Devices in Makkah Region, Saudi Arabia

Introduction Noise-induced hearing loss (NIHL) is one of the most common avoidable reasons for hearing impairment worldwide. Work-related, genetic, infectious, and environmental factors all have a part in defining the level of hearing impairment. Nevertheless, the use of personal listening devices (PLDs) is popular nowadays, particularly among younger people. Healthy behaviors are needed to prevent them from developing hearing loss. Our objective is to evaluate the knowledge level of NIHL among the people of Makkah, Saudi Arabia, and understand its association with PLDs. Methods A cross-sectional survey was performed in December 2022 by sending an online survey on various social media applications. An electronic Arabic questionnaire with a total of 37 questions was designed to explore the participants' demographic data, history of hearing loss, risk factors, attitudes, and awareness of NIHL. Results Almost 22% of the study had mild-to-severe hearing impairment. Hearing issues were especially common among male individuals. A higher incidence of hearing impairments was seen in individuals who were utilizing a sound degree of more than 80%. The causes for NIHL comprised exposure to occupational noise, duration of the listening session per day, and the level to which the sound of the television or the broadcasting was raised. Approximately 77% of the participants preferred to reduce the sound of their personal audio devices (PADs) to prevent NIHL. Conclusion According to this study, there is a high prevalence of hearing problems in the Saudi population. Most of the respondents understood the risk factors linked to NIHL. There is a need for more NIHL awareness campaigns to educate the Saudi population and reinforce positive, healthy listening habits.


Introduction
Hearing loss (HL) affects the ability of people to differentiate between sounds appropriately, making it difficult to understand basic conversations and daily life situations. Also, hearing loss in early childhood can have a considerable negative effect on both development and educational growth, adversely impacting emotional health and social well-being [1]. HL is a critical issue worldwide, affecting 6.1% of the global population [2,3]. Previously published studies have shown that the occurrence rate of HL increased from 15% to nearly 19% in a group of young people aged between 12 and 19 years old [4]. HL can occur at any age, and the reasons for HL vary between adults and children. The causes in children are a first-degree relative history of HL or infection, while in adults, HL is probably due to increased age and prolonged noise exposure [5]. Noise-induced hearing loss (NIHL) happens as a consequence of exposure to loud sounds; these sounds affect the sensory hair cells in the inner ear, which is one of the most common causes of HL [6][7][8]. The source of loud noise differs and can be either occupational or recreational [9,10]; although noise related to work can be more serious, recreational noises are more frequent in the current period. NIHL has become an international issue in the last two decades due to the growing use of smartphones [6]. Additionally, there has 1 1 1 1 been a rise in the use of personal listening devices (PLDs), which involve headphones and earphones [11,12]. Misuse of these devices can lead to difficulty in understanding speech, tinnitus, unsteadiness, and reduced hearing capability [13]. For this reason, many articles have been written to explore people's beliefs and attitudes regarding NIHL and PLD use. Thus, our survey aims to assess the awareness level of NIHL and the use of PLDs and determine the risk factors, signs, and symptoms associated with HL among the general population in the Makkah region of Saudi Arabia.

Materials And Methods
A cross-sectional survey was performed in December 2022 by distributing an online questionnaire on social media platforms to collect information on participants' demographics, history of hearing loss, risk factors, beliefs, and knowledge about NIHL as well as to assess society's awareness of NIHL from PLDs among the general population in the Makkah region of Saudi Arabia, using a validated version of a self-administered questionnaire in the Arabic language [14].
The sample size was decided by using a Raosoft calculator to be more than 380 subjects, with a confidence interval of 95% and a level of significance (P-value) of 5%. The questionnaire was completed by 384 people at random.
We involved only participants from the Makkah region who were ≥18 years old and who agreed to participate in this survey. Partially filled questionnaire submissions were eliminated from the study.
The questionnaire included a total of 37 items distributed into six categories. The initial section consisted of six items to collect personal data.

Results
A total of 384 individuals were surveyed: 56.5% were women, 97% were under 50 years old, 90.9% were Saudi, 44.5% had a college degree, 85.2% were nonsmokers, and 91% had no chronic diseases. Of the participants, 77.9% did not exhibit any signs of hearing impairments. However, mild, moderate, and severe hearing loss was found in nearly 13.8%, 5.7%, and 2.6% of the individuals, respectively. Furthermore, a family history of hearing impairments was described by about 51.8% ( Table 1).

TABLE 1: Bio-demographic data of the sampled population, Makkah Region, Saudi Arabia
The risk factors for NIHL involved work-related noise (40.4%), choice of using earphones (63.5%), and a high frequency of sessions (6 to ≥10; 62.2%) where the individual was exposed to a loud noise sound corresponding to the following parameters: >3 h per session (31%) and a sound degree in the range of 80%-100% (23.4%). Forty-nine percent of the study participants engaged in more than 10 sessions weekly where they would listen to a noise sound for <1 h/day ( Table 2). A considerable number of the individuals in this study also suffered tinnitus (44.5%), whereas others described that people occasionally complained that they spoke too noisily (38%). Others reported the occasional need to raise the sound of the television or radio (53.6%). This study found that 89.3% of participants needed one hour to adjust to the level of loudness produced by the noise sound ( Table 3).

Frequency Percent
Exposure to occupational noise

TABLE 3: Signs and symptoms associated with noise-induced hearing loss in Makkah Region, Saudi Arabia
An assessment of individual beliefs regarding the risk factors of NIHL showed fascinating findings. Most of the individuals in this study were aware that high sound degrees could lead to hearing impairments (87.2%) and that staying in a noisy setting could also adversely impact hearing (83.9%). They also identified that a prior hearing problem could get worse by sustained exposure to loud sound (79.4%) ( Table 4). Furthermore, about 48% of the study individuals assumed that daily dialog becoming harder to follow was a sign of hearing loss. Likewise, 26.6% of the study individuals believed that tinnitus could also be a sign of hearing loss. Curiously, 70.6% of the individuals in this study understood that hearing impairments caused by noise are avoidable, and almost half of them believed that they had adequate knowledge about the risks of loud sounds on their hearing capability. Yet, a considerable number of study individuals did not understand the minimum duration (35.2%) or the minimum level (45.3%) that can adversely affect hearing capability (

TABLE 4: Knowledge and beliefs about noise-induced hearing loss
The attitudes and practices correlated to NIHL suggest that a significant number of the study individuals (74.6%) favored decreasing the level of several audio devices as a preventive plan, and a considerable number (81%) suggested that the manufacturer must set sound-warning features on devices ( Table 5). Furthermore, most of the study individuals (92.7%) advised fixing an alarm feature in devices to restrict the sound level, whereas 15.9% favored the use of a system to limit sound output. Approximately 35.2% said that their source of information about NIHL was hospitals.

Variables Frequency Percent
Typically  Subgroup evaluations relating to the recognition of independent variables implied that older age was associated with a higher number of hearing issues, though this association was not statistically significant (P = 0.063). A higher percentage of males (26.3%) reported experiencing hearing problems as compared to females (18.9%). However, this was not statistically significant (P = 0.081). Additionally, the study did not find any statistically significant associations between educational level, smoking, chronic diseases, and family history ( Table 6). The risk factors associated with NIHL included exposure to occupational noise (P = 0.000), increased sound degrees originating from a television or radio (P = 0.000), and >5 h of being exposed to a noise sound (P = 0.013) ( Table 7).

Discussion
The negative impacts on human well-being due to loud sound exposure are not instantly perceivable [15]. This study assessed the hearing impairment awareness among the individuals of Makkah, Saudi Arabia, and its association with PLDs.
Those who describe symptoms of hearing issues, such as tinnitus and sound sensitivity, are more likely to accept protective hearing behaviors [16,17]. There is evidence of increased knowledge among adults about the danger of NIHL. Nevertheless, people may be unaware that they are at risk and hence deem it pointless to modify their listening behaviors [18].
A study performed previously revealed that 60.6% of participants used media devices with high-sound settings on a daily basis [19]. In agreement with our study, 49.2% of the participants reported more than 10 hearing sessions weekly. An additional difference is that only 35.2% of the individuals in our study were hearing a sound of less than 50%. This result does not necessarily suggest that the Saudi participants had better listening habits. Approximately 54% of the individuals in our study stated ringing in the ears as compared to 21% of the participants in a study done in Jordan [19].
In the current study, 22.1% of the participants complained of hearing loss. These results were higher than the results described in a previous study [10], where nearly 10% of the participants stated a history of hearing loss. Another study showed a lower prevalence of hearing impairment than the participants who took place in this survey. The study revealed that only 7.3% of the participants reported hearing loss, whereas most of them showed mild hearing impairment only [19,20].
In the present survey, 40.4% of the subjects were exposed to work-related noise. In contrast, a study published in Saudi Arabia revealed that 16.9% of the participants were exposed to occupational noise [21].
In this study, 63.5% chose to use earphones. A comparable finding has been noted in a previous study, where they were utilized by 51% [20]. In the current study, 43.2% of the individuals listened to a noise-emitting sound for <1 h/session. This agrees with a study carried out in Saudi Arabia [21]. In contrast, a higher mean listening time was documented in Malaysia (1.5-3.2 h) [22]. Social and spiritual aspects may have influenced the shorter durations of usage of personal audio devices (PADs) in Saudi society.
Of the participants, 26.6% stated that sometimes the sound of their device was high enough to be heard by the individuals around them. This number is lower than that of the Saudi Arabian study, where 41% of participants reported a similar experience [21].
Our study noticed that more than two-thirds of the participants reported difficulty in listening to others, which is a finding higher than described in the previous study [21].
Of the participants, 87.2% understood that high sound degrees could harmfully impact their hearing. This is in agreement with the survey carried out in Saudi Arabia [21].
This study has some limitations. First, the cross-sectional study proves only association. Second, the limit to a particular region might affect the generalization of the findings. Third, the lack of a standardized questionnaire about the attitudes and knowledge related to NIHL could have limited the comparability of the study results. Fourth, linear regression analysis was not performed.

Conclusions
The present study has recognized that there is a high prevalence of hearing loss in Saudi society. Most of the individuals were aware that such hearing issues were avoidable. However, many of them were unaware of the minimum duration of exposure to a noise or sound or the sound degree that could lead to hearing damage. The positive attitude of the individuals regarding modifying their lifestyle suggests that there is a need for NIHL awareness campaigns to increase the educational level of society. Our recommendation for future studies is to explore the role of occupation in NIHL.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. The Biomedical Research Ethics Committee of Umm Al-Qura University issued approval HAPO-02-K-012-2023-03-1515. The Biomedical Research Ethics Committee has evaluated and examined the above-mentioned research proposal and has found it to be in accordance with the specifications and conditions of the ethics of scientific research. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.