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Keywords:

  • agricultural health;
  • community health;
  • farm youth;
  • health education;
  • health promotion;
  • injury prevention;
  • noise-induced hearing loss;
  • public health nursing;
  • rural nursing;
  • rural youth

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aims
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Relevance to clinical practice
  10. Contributions
  11. References

Aims and objectives

To identify and compare hearing protection interventions for youth working and living on farms.

Background

Noise-induced hearing loss represents a significant risk factor for injury, disability and death in agricultural populations due to an inability to receive sensory information that can indicate dangerous situations. Despite the availability of hearing protection devices, rates of utilisation remain low, while rates of noise-induced hearing loss are high within the agricultural youth population.

Design

Comprehensive review of the literature.

Method

Electronic database searches were conducted to identify research studies of hearing protection interventions for youth living or working on farms.

Results

Three intervention studies were identified as meeting the review criteria, with additional reanalysis studies based on the original intervention studies. The intervention studies demonstrated increased use of hearing protection devices among youth who received the interventions compared to the control groups although audiometry testing results were not improved as a result of the intervention.

Conclusions

The findings of this review highlight the need for additional research into the effectiveness of hearing protection device use as a noise-induced hearing loss preventative measure in youth who live or work on farms and the creation of effective interventions to increase hearing protection device use and decrease Noise-induced hearing loss risk.

Relevance to clinical practice

It is recommended that nurses be educated in the areas of health promotion relevant to farming communities to be able to effectively meet their rural clients' needs in relation to noise-induced hearing loss. Working with youth, families, and schools, as well as developing community partnerships, can facilitate the dissemination of hearing protection promotion.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aims
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Relevance to clinical practice
  10. Contributions
  11. References

Noise-induced hearing loss (NIHL) is a serious concern for the agricultural community due to the associated increased risk of injury and death from agricultural accidents and the decreased quality of life. Individuals who live or work on farms are continuously exposed to noise from equipment, large animals and other sources that are associated with high rates of NIHL. The aetiology for NIHL lies in the vibratory damage done to the sensory cells of the cochlea. These cells consist of one inner and three outer rows of hair cells that serve as amplifiers. Exposure to noise at or above 85 decibels traumatises the outer hair cells resulting in high-frequency hearing loss. As the exposure continues, the trauma persists and the hearing loss progresses to other frequencies. Initially, the hearing loss manifests itself as an inability or difficulty in understanding speech in the presence of background noise. Typically, the loss begins in the 4000–6000 Hz range. If the loss progresses to involve frequencies in the 500–3000 Hz range, the affected individual will have difficulty with simple conversation. NIHL is exacerbated by normal age-related hearing changes over time, known as presbycusis, which may worsen the individual's ability to hear and communicate. NIHL is permanent, untreatable and irreversible (Thelin & Donham 2006). Farmers with NIHL are at an increased risk of injury and death due to their inability to hear signals that would indicate a potentially dangerous situation because of their altered sensory perception (Hager 2002). NIHL also creates quality-of-life issues in the agricultural community, including difficulty communicating resulting in impaired social interaction, interrupted family processes and risk for social isolation (McCullagh et al. 2002).

While many industries are subject to noise standards and assessment by the Occupational Safety and Health Administration (OSHA 1999), many family farms are exempt because they employ fewer than 10 nonimmediate family members (Roka et al. 2009). In addition, individuals can develop NIHL from nonoccupational noise exposures, and many individuals attribute a loss in hearing to age-related changes instead of noise exposure. Therefore, the impact and extent of the NIHL problem in the agricultural community, and American society as a whole, is difficult to discern. However, several studies have attempted to describe the scope of the problem. A prospective cohort study conducted in a rural Iowa county measured the hearing of rural residents through pure tone audiometry at multiple thresholds. Of 1972 participants, only 1% had normal hearing, 93% of participants did not meet expected standards in one audiometric threshold, and 6% did not meet standards in two thresholds (Flamme et al. 2005).

One of the challenges in describing NIHL is isolating hearing loss to agriculture rather than to nonfarm exposure or presbycusis. However, evidence shows that agriculture is a major source of hearing loss independent of nonfarm exposures and age-related changes. In a study comparing the outcomes of hearing screening of 161 farmers and 75 office workers, higher rates of farmers aged 45–54 failed the audiometric testing across all frequencies compared to office workers in the same age group (42·98% vs. 22·8%, respectively) (Thelin et al. 1983). Through the use of an extensive case history questionnaire to examine a sample that excluded adults with a potential nonfarm aetiology for hearing loss, researchers found that 10% of farmers age 30 had a hearing handicap, 30% of age 40 farmers had a hearing handicap, and 50% of farmers age 50 had a hearing handicap (Plakke & Dare 1992). Another study found that 25% of farming participants had a communication handicap as a result of hearing loss by the age of 30 (Karlovich et al. 1988).

Youth who live or work on farms are of particular concern regarding noise exposure as hearing loss in youth can interfere with learning, communication and behaviour (Renick et al. 2008). Early onset of NIHL indicates an early exposure to high rates of noise, which may be exacerbated with age and increased exposure on the farm as well as in other settings. Evidence suggests similar patterns of hearing loss in the farm youth population as in the general agricultural population. The exact rate of NIHL is difficult to discern due to the fact that youth on family farms are often exposed to occupational noise that is not subject to regulations required in industrial facilities and larger agricultural operations. Because regulatory agencies do not have a presence in the facilities where most rural youth are exposed to noise, data are not tracked and reported in a consistent manner. However, researchers have conducted several studies designed to estimate the prevalence of the problem. Studies of audiometric threshold testing in vocational agriculture students have found higher rates of NIHL in students who actively participated in farm activities than students who were not involved in farm work (Broste et al. 1989, Renick et al. 2008). The most recent study assessed audiometry results to assess for and follow-up NIHL among a subset of youth of the Ohio Farm Family Health and Hazard Study. At the six- to 10-year follow-up, the researchers found an increase in hearing loss by 22·5% such that 33·1% of participants had some hearing loss compared to the 14·9% national prevalence rate (Renick et al. 2008).

The risk of developing NIHL is a function of noise volume and duration of noise exposure. Strategies to prevent NIHL include engineering controls to prevent the generation of noise, separating the individual from the noise source, planning the work to reduce exposure to loud volumes and using hearing protective devices (HPD). The use of HPD has been found to be an effective strategy when costs and limited technology prevent the use of other strategies (Thelin & Donham 2006), such as is often the case with family farms where youth live or work. Various devices are available to fit individual needs, but farmers continue to have low utilisation of HPD despite the evidence that supports their effectiveness (Gates & Jones 2007, McCullagh et al. 2010). In addition to adult farmers, it has also been documented that adolescents in farming activities refrain from using HPD while being exposed to noise. A study of farming youth found that 90% of the male adolescent participants reported working with noisy farm equipment, while only 29% reported using hearing protection (Reed et al. 2006). Also, 61·4% reported that they had experienced tinnitus (ringing of the ears), which is associated with NIHL. Results for the female participants were similar; 86·8% reported working with noisy machinery and only 28·8% used hearing protection, and 53·4% reported experiencing tinnitus (Reed et al. 2006).

Despite the significance of the problem, the literature provides minimal evidence-based guidance in providing HPD use interventions to farm youth. While there are no systematic reviews or national clinical guidelines addressing interventions to increase the use of HPD in youth who live or work on farms, there are two reviews of interventions to increase HPD use in general workers (El Dib et al. 2007, 2011) and a review of interventions to prevent childhood farm injuries, including hearing loss (Hartling et al. 2004).

Aims

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aims
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Relevance to clinical practice
  10. Contributions
  11. References

Because of the potential for permanent disability and injury associated with NIHL and the low utilisation rates of HPD, the development and implementation of effective interventions aimed at improving the use of HPD is important for farm youth. The purpose of this review is to identify and compare hearing protection interventions for youth working and living on farms based on search and inclusion criteria.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aims
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Relevance to clinical practice
  10. Contributions
  11. References

A comprehensive literature search of interventions aimed at reducing NIHL among farm youth in North America was conducted in PubMed without restriction of year of publication or type of study using various combinations of the following search terms: ‘youth, farm, noise-induced hearing loss’; ‘student, hearing loss, rural, intervention’; ‘student, hearing loss, rural, prevention’; ‘student, deafness, agriculture, intervention’; ‘student, hearing, agriculture, intervention’; ‘youth, hearing, agriculture, education’; and ‘youth, hearing, agriculture, screening’. These searches yielded 29 hits. Additional searches were conducted using EbscoHost to search CINHAL, the Education Resources Information Center (ERIC) of the United States Department of Education, and AGRICOLA. AGRICOLA is the database of the National Agricultural Library, which is the repository of the collections of the United States Department of Agriculture (United States Department of Agriculture 2006). These databases were searched for intervention studies in the English language without date restriction, although no additional pertinent studies were found. Snowballing was then conducted using related citations in PubMed, the studies listed in three systematic reviews and the bibliographies of all included studies yielding nine additional relevant studies. Snowballing is a technique used to generate additional studies of interest by evaluating the citations in known articles and evaluating them for inclusion in the review (Sayers 2007). The criteria for inclusion in the review were as follows: (1) an intervention that wholly or in part was designed to increase HPD use, (2) population consisted of youth who live or work on farms in North America, and (3) English language publication. Three studies met the inclusion criteria. Furthermore, three nonintervention secondary data analysis and reanalysis studies based on the original intervention studies were identified. The nonintervention studies were identified in the original search strategy noted above, but were separated from the intervention studies because they were extrapolations of the three original interventions and did not represent a new approach to the problem. Due to their relevance and enrichment of the intervention study findings, they were included in the overall discussion.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aims
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Relevance to clinical practice
  10. Contributions
  11. References

Search of the literature yielded three intervention studies that fit the criteria: a randomised controlled trial by Knobloch and Broste (1998), a cluster randomised controlled trial by Lee et al. (2004), and a quasi-experimental crossover study by Reed et al. (2001) (Table 1). Nonexperimental studies based on the randomised controlled trial and the quasi-experimental crossover studies were conducted and will be presented as information augmenting the review of the intervention studies (Table 2).

Table 1. Review of hearing protection intervention programs for agricultural youth
Author (year)ObjectiveParticipantsDesignInterventionResults
Knobloch and Broste (1998)Investigated the effects of a hearing conservation intervention for youths on farms753 high school students in 34 schools of whom 375 were in the experimental group and 378 were in the control groupRandomised controlled trialUse of a four-year, in-depth, multifaceted hearing conservation educational intervention

At three years postintervention, 87·5% of the intervention group reported that they use HPD at least sometimes (23·2% at baseline) vs. 45% of the control group (24·1%) at baseline. Statistical significance of findings not provided

Three top educational strategies that facilitated HPD use were access to free devices (94%), annual hearing tests (90%) and mailed reminders (77%). Statistical significance not provided

Audiometric testing was conducted, but changes in results were not reported

Lee et al. (2004)Evaluated a rural youth health and safety initiative used in FFA programs nationwide8068 participants in 123 FFA chapters of whom 2955 were assigned to a control group, 2427 to the intervention group, and 2686 to an enhanced intervention groupCluster randomised controlled trialUse of a rural health and safety curriculum that included extensive training and support materials

No statistically significant differences were noted between groups in any of the study's parameters

Audiometry testing was not conducted

Reed et al. (2001)Developed and tested a farm health injury prevention educational intervention for high school agriculture students based on the Transtheoretical Model of Change790 high school agriculture students in 21 high schools of whom 417 were in the experimental group and 373 were in the control groupQuasi-experimental crossover studyUse of the AgDARE educational intervention based on the Transtheoretical Model of change utilizing experiential learning techniques

Intervention groups showed improvement in their attitudes (LS Mean = 32·1) and readiness to adopt healthy behaviours (LS Mean = 31·1) compared to the control group (Attitude LS Mean = 31·3; Behaviour change LS Mean = 21·4). Both findings had a statistical significance of p = <0·001

Audiometric data was not collected

Table 2. Summary of auxiliary nonintervention studies
Author (year)ObjectiveParticipantsDesignResults
Berg et al. (2009)Reanalysed data from Knobloch and Broste (1998) using more contemporary statistical techniquesNo additional participants were recruited for this study. Based on data from the 753 high school students in 34 schools of whom 375 were in the experimental group and 378 were in the control groupStatistical reanalysis

67·6% of intervention group increased HPD use when in noisy area vs. 19·1% of control group (p = <0·001)

30·9% of intervention group increased HPD use when using firearms vs. 13·2% of control group (p = <0·001)

No statistically significant changes were noted between groups in audiometric test results

Marlenga et al. (2011)Evaluated the long-term effects of the intervention by Knobloch and Broste (1998) 16 years after the original intervention was conducted392 participants from the original trial, 200 from the intervention group and 192 from the control groupFollow-up study

25·9% of the intervention group reported using HPD when exposed to agricultural noise vs. 19·6% of the control group (p = 0·015)

56·2% of the intervention group reported using HPD when using firearms vs. 41·6% of the control group (p = 0·02)

No statistically significant difference between the groups was noted in audiometric thresholds at the time of follow-up

Reed et al. (2003)Observed a subset of the Reed et al. (2001) study's sample for the adoption of safety behaviours and compared with baseline data from the 2001 study29 students who were participants in the Reed et al. (2001) studyObservational

96·3% (n = 26 of 27) reported that they worked in noisy environments at baseline

96·2% (n = 25 of 26) reported that they worked in noisy environments at the farm visit

18·5% (n = 5 of 27) reported that they wore HPD at baseline

36·0% (n = 9 of 25) were observed to wear hearing protection at the farm visit

Statistical significance was not provided

Reed et al. (2006)Reported the use of personal protective equipment, self-protective work behaviours, and selected risk exposures of adolescents who perform farm work593 high school students enrolled in agriculture class in Kentucky, Iowa, and Mississippi who were part of the Reed et al. (2001) studyDescriptive

90·0% of males and 86·8% of females performed farm work with noisy equipment (OR = 1·38, 95% CI: 0·76–2·48)

29·0% of males and 28·8% of females use HPD while farming (OR = 1·01, 95% CI: 0·63–1·64)

61·4% of males and 53·4% of females have experienced ringing in the ears (OR = 1·39, 95% CI: 0·90–2·15)

Participants who stated that a doctor recommended HPD use were 2·4 times more likely to use HPD (OR = 2·42, 95% CI: 1·27–4·61)

Randomised controlled trial and its follow-up

Knobloch and Broste (1998) investigated the effects of a hearing conservation intervention for youths on farms in a randomised controlled trial. In this study, 34 Wisconsin high schools were randomly assigned to a control group or intervention group. Students were recruited from these high schools to create a sample of 734 participants. The intervention group received an in-depth multi-faceted educational intervention modelled on an evidence-based industrial hearing conservation programme, while the control group received no intervention. Compared to baseline data, by three years, the self-reported use of HPD increased for the intervention group from 23·2-87·5% and for the control group from 24·1-45·0% (statistical significance of this finding was not provided). While audiometry tests were conducted, the results were not reported. In the multivariate model, the factors found to significantly predict the odds of using HPD included lawn tractor use (p = 0·04), farm tractor use (p = 0·03) and male gender (p = 0·02). The investigators also found that the top three educational strategies that facilitated HPD use among the intervention group were access to free devices, annual hearing tests and mailed reminders (statistical significance not provided).

Additionally, a reanalysis of the data from the randomised controlled trial by Knobloch and Broste (1998) was conducted (Berg et al. 2009) as well as a follow-up study (Marlenga et al. 2011). Berg et al. (2009) performed a reanalysis of the original data using more contemporary measures of analysis, although no additional intervention was conducted. The investigators supported the original findings that the intervention was associated with an increased use of HPD that persisted over three years for the intervention group compared to the control group in noisy agricultural areas (67·6% vs. 19·1%, p = <0·001) and with firearm use (30·9% vs. 13·2%, p = <0·001). There was no significant difference in the audiometry results between the intervention and control groups.

Marlenga et al. (2011) continued to examine the effect of Knobloch and Broste's (1998) intervention by evaluating the effect of the intervention 16 years later. Researchers located and enrolled approximately half of the original participants to complete an audiometric examination and survey examining exposure to occupational and recreational noise, chemical exposure, smoking and HPD use during high-risk activities. The study found that rates of HPD use was significantly higher in the intervention group compared to the control group for those who worked in agriculture (25·9% vs. 19·6%, p = 0·015) and for those who participated in recreational activities with firearms (56·2% vs. 41·6%, p = 0·020). There was no significant difference between the groups in audiometric thresholds at the time of follow-up.

Quasi-experimental crossover study with subset observation

Reed et al. (2001) developed a farm health and injury prevention educational intervention evaluated in a quasi-experimental crossover study. The intervention offered experiential learning for high school agriculture students based on the theoretical framework of the Transtheoretical Model of Change, as further described in another published article by the research team (Kidd et al. 2003). The sample consisted of 790 participants who attended 21 high schools in Iowa, Kentucky and Mississippi. The schools were assigned to either the intervention group who received a simulation-based intervention or the control group. The study assessed the usefulness of the Transtheoretical Model in relation to HPD use in high school students, as part of a more encompassing AgDARE intervention. The study measured changes in attitudes towards safe work behaviours and readiness to adopt healthy behaviours. HPD use was one component of this intervention. The intervention group showed improvement in their attitudes (LS Mean = 32·1, p = <0·001) and readiness (LS Mean = 31·1, p = <0·001) defined by ‘stages of change’ towards safe work behaviours compared to the control group (attitude LS Mean = 31·3, readiness LS Mean = 21·4). A study by Reed et al. (2006) examined the demographic data obtained in the baseline surveys from Reed et al. (2001). They found that adolescents who are educated about NIHL and the use of HPD by their healthcare providers were 2·4 times more likely to use the devices (Reed et al. 2006). Additionally, a small subset of the study involving 29 students was observed for safe behaviour changes (Reed et al. 2003), although this subset of the study was not included in the review as a distinct intervention study due to the observational nature. At the farm visit, 36·0% of participants were observed wearing hearing protection, an increase from 18·5% self-reported at baseline. None of these studies included audiometric measurement to determine whether the behavioural changes impacted health outcomes.

Cluster randomised controlled trial

Lee et al. (2004) conducted a cluster randomised controlled trial that assessed the effectiveness of a rural youth health and safety programme that was conducted in FFA (formerly Future Farmers of America) chapters nationwide and included nurse participation in the programme implementation. The sample consisted of 8068 participants in 123 FFA chapters who were assigned to a control group, an intervention group or an enhanced intervention group. The study found no significant differences between the groups following the intervention on the examined variables of safety knowledge, attitudes, activities, leadership, community participation or injury. Approximately two-thirds of the nurses considered the programme to be valuable. There were reports of inconsistency in the implementation of the programme among the different locations throughout the nation, although further explanation regarding the reasons for programme ineffectiveness is needed. The researchers explained that such agricultural health education initiatives alone have been found to be insufficient at creating behavioural changes.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aims
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Relevance to clinical practice
  10. Contributions
  11. References

The three intervention studies represent foundational and informational work in the area of hearing protection promotion among agricultural youth, contributing to the limited body of knowledge. Each of the studies included a large sample of youth and strong research designs, thereby strengthening the reliability and validity of the studies and enabling generalisation to larger farm youth populations, although there were some potential risks of reporting bias and inconsistency in implementation of the interventions. Some of the intervention studies were enhanced by auxiliary nonexperimental studies. In general, the overall use of HPD has been noted to be low, with improvements in HPD use and readiness to use HPD following educational interventions for youth.

The original intervention study by Knobloch and Broste (1998) and by Berg et al. (2009) showed a three-year improvement in HPD use. Berg et al. (2009) found that there was no significant difference in audiometric results in the three-year period. It should be noted that NIHL develops over an extended period of time. Therefore, three years may not have been enough time for differences in audiometric results to develop. While HPD use differences between groups were sustained in the long term of 16 years as demonstrated by Marlenga et al. (2011), the follow-up study showed no difference in NIHL between the groups. Thus, Marlenga et al. (2011) suggested that the educational intervention had limited long-term effectiveness in hearing protection. HPD use plays a foundational role in OSHA's guidelines for effective industrial hearing conservation programmes (OSHA n.d.). However, the findings of Berg et al. (2009) suggest that increased use of HPDs does not correlate with decreased rates of NIHL. Berg et al. (2009) and the studies included in this review relied upon self-reported measures of HPD use. Therefore, future research should include a more rigorous design that controls for inflated self-report of HPD use or improper use of HPD use as this might account for no change in NIHL rates in the presence of increased HPD use. If more stringent research designs support the contention that increased HPD use is not correlated to decreased rates of NIHL, further research needs to be conducted to determine to what extent HPD use is an effective strategy in preventing NIHL in agricultural populations or to identify nonagricultural sources of noise that are causing NIHL.

Reed et al. (2001) used the Transtheoretical Model of Change to measure changes in attitudes and behaviour. Their study demonstrated that the use of the theoretically based educational intervention was associated with increased intention and report of HPD use. The observational study following the intervention that involved 29 farm visits at one to three years postintervention observed that 36·0% of participants used HPD, an increase from the self-reported 18·5% at baseline (Reed et al. 2003). Follow-up on the intervention by Reed et al. (2001) should be conducted to examine the long-term outcomes of the intervention on behaviours and on audiometric results as was carried out by Marlenga et al. (2011). In addition, researchers found the Transtheoretical Model of Change to be useful in individualising interventions to increase HPD use in industrial workers (Raymond & Lusk 2006), which may indicate the need for further development and testing of interventions with farm youth based on this model.

While Lee et al. (2004) found moderate improvements in safety knowledge, attitudes and behaviours were largely unchanged despite an intervention that benefited from ample financial support and educational resources. The authors cite the fact that the intervention was not uniformly administered across the sample groups, which may have hindered the ability of the intervention to achieve the desired effect.

Despite the sound basic research designs, strong theoretical frameworks and large sample sizes, the studies faced challenges with validity related to the samples. The study by Knobloch and Broste (1998) was conducted over time, but lacked an account of maturation of the subjects. In addition, the subjects had ample time to have been exposed to information about the need for HPD use from outside sources as well as to be exposed to noise contributing to NIHL from sources other than agricultural environments. The original educational interventions addressed agricultural settings, while participants are often exposed to noise in nonagricultural occupational and recreational settings. Marlenga et al. (2011) point out a possible reporting bias that participants might have inflated their reporting of HPD use to please the research staff, which threatens many studies that employ behavioural self-report. This phenomenon is known as the Social Desirability Effect and commonly affects research that requires participants to self-report behaviours. A 2008 review of 14,275 question-based studies found that only 0·2% (31) measured the amount of influence the Social Desirability Effect had on participants. However, the review found that 43% of the studies that assessed Social Desirability Effect found that it influenced study outcomes (Van de Mortel 2008). The use of observation of behavioural changes would reduce the risk of reporting bias associated with self-report. While the Social Desirability Effect is cited by Marlenga et al. (2011) as a limitation of the study, other studies have refuted the phenomenon's effect on the reliability of outcomes. Lusk et al. (1995) found that self-report was a valid measurement of hearing protective device use, with a <8% deviation from observed use. Limitations of the study by Reed et al. (2001) include nonrandom assignment to group following convenience sampling method, potentially lending to a sampling bias and a threat to internal validity. The study did not address controls for a history of exposure to information regarding NIHL. In addition, the authors state that the control group was older than the treatment group, which would indicate that whatever history and maturation issues may exist are not evenly distributed across the sample. Therefore, it is difficult to discern the true impact of the intervention on behaviour change.

Reed et al. (2006) found that adolescents who receive information about NIHL from their healthcare providers were more likely to use HPD, suggesting a need for nurses and nurse practitioners working in rural communities to educate youth and their families about the importance of NIHL prevention strategies. Lusk (2002) delineates the role of the nurse as having three parts: assessing clients for noise exposure as part of a health history; educating clients on effects of noise on hearing; and training clients on the appropriate use of HPD. Therefore, it is important to incorporate information about NIHL and HPD use in the paediatric portions of preparatory curricula for entry into practice as well as to create continuing education programs for providers already in practice who may influence youths' use of HPD. Another aspect to consider is the effect on the parents and other family members. Knobloch (1999) found that following the intervention for the high school students, the parents of the participants in the intervention had a significant increase in their reported HPD use compared to the control group. A quasi-experimental study aimed at increasing knowledge of safety information and behaviours for farm youth who attend the English as a second language (ESL) programme at high school as well as their parents (Teran et al. 2008). The researchers sought to educate nonEnglish speaking farm workers, who would not typically be served by 4-H, FFA and other traditional resources for farm safety information, through the integration of farm safety information into the ESL high school curriculum. The study found significant increases knowledge, improvement in attitudes and safety behaviours among youth, with modest improvements in knowledge among the parents. These studies suggest the importance of family inclusion in programmes targeted at increased safety behaviours among youth.

Limitations of the review are related to the paucity of published hearing protection interventions for farm youth. Additionally, the three intervention studies did not consistently use the dependent variable of audiometry results, which is important in evaluating the effectiveness of the intervention at conserving hearing, not only in self-reporting HPD use behaviours. As the three interventions demonstrated positive changes in HPD use behaviour, evaluation research should analyse the successful components of the interventions to serve as the basis for developing educational hearing loss curricula that will have an impact of longer duration on behaviour and hearing outcomes. Replication of the interventions and follow-up studies of behaviour and hearing outcomes may better highlight the ability of the interventions to achieve their desired goals.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aims
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Relevance to clinical practice
  10. Contributions
  11. References

While NIHL is a condition that dramatically raises the risk of injury, disability and death due to agricultural unintentional injuries and evidence supports that the condition begins in adolescence or earlier, very little evidence exists to guide nurses in how to promote the use of HPD in rural adolescent populations. However, formal educational interventions in a classroom setting using a standardised curriculum have demonstrated effectiveness in increasing HPD use, but failed to decrease NIHL rates in adulthood.

Relevance to clinical practice

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aims
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Relevance to clinical practice
  10. Contributions
  11. References

This review highlights the need for the development of educational interventions to increase HPD use in youth to prevent the development of NIHL later in life. Furthermore, to promote consistency among interventions, more effort should be put forth to develop similar outcome measures that would examine behavioural changes in HPD use, attitudinal changes and audiometric changes. Based on the findings suggesting that youth were more likely to use HPD when recommended by their healthcare providers (Reed et al. 2006), programmes should also be developed for effective delivery of hearing protection messages by providers, especially those nurses and nurse practitioners working with rural populations. Nursing education programmes also need to include this topic in their paediatric curricula, especially those preparing nurses for entry and advanced rural practice. In addition, nurse administrators of public and community health organisations should be encouraged to include NIHL in their community needs assessments and to search for grant funds to support interventions to prevent NIHL. Finally, it is vital that the integration of these findings be integrated across the entirety of nursing practice to ensure that all nurses who address the needs of rural communities are informed and able to intervene in this vital issue.

The intervention studies reviewed were time and resource intensive, challenging the sustainability of such interventions outside of the general vocational agriculture curricula for which they were designed. While the inclusion of safety education interventions into vocational agriculture curricula represents an appropriate and timely opportunity to elicit a long-term behaviour change, it precludes access to youth who are not enrolled in these classes. Therefore, it is vital that shorter, high impact interventions be developed that can be used with 4-H clubs, farm safety day camps and short-term educational events, with options of brief refresher programs, also known as booster interventions (Lusk et al. 2004), and follow-up evaluations. There were challenges to consistency of HPD programme delivery, beckoning development of evidence-based programmes with clear curricular approaches for nurses to use in delivery of the message regarding hearing protection. Such programmes necessitate partnerships between community agencies and organisations that serve rural youth and public health nurses who are experienced in health promotion and injury prevention programming to jointly develop and implement effective evidence-based interventions. These recommendations constitute a research agenda that has the ability to improve hearing health and reduce injury, disability and death among farm youth.

Contributions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aims
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Relevance to clinical practice
  10. Contributions
  11. References

Study design: CRS, IRAC; data collection and analysis: CRS, IRAC and manuscript preparation: CRS, IRAC.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aims
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Relevance to clinical practice
  10. Contributions
  11. References
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