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Survey of College Students on iPod Use andHearing HealthDOI: 10.3766/jaaa.20.1.2

Jeffrey L. Danhauer*

Carole E. Johnson{Anne Byrd*

Laura DeGood*

Caitlin Meuel*

Angela Pecile*

Lindsey L. Koch{

Abstract

Background: The popularity of personal listening devices (PLDs) including iPods has increased

dramatically over the past decade. PLDs allow users to listen to music uninterrupted for prolongedperiods and at levels that may pose a risk for hearing loss in some listeners, particularly those using

earbud earphones that fail to attenuate high ambient noise levels and necessitate increasing volume foracoustic enjoyment. Earlier studies have documented PLD use by teenagers and adults, but omitted

college students, which represent a large segment of individuals who use these devices.

Purpose: This study surveyed college students’ knowledge about, experiences with, attitudes toward,

and practices and preferences for hearing health and use of iPods and/or other PLDs. The study wasdesigned to help determine the need, content, and preferred format for educational outreach

campaigns regarding safe iPod use to college students.

Research Design: An 83-item questionnaire was designed and used to survey college students’

knowledge about, experiences with, attitudes toward, and practices/preferences for hearing healthand PLD use. The questionnaire assessed Demographics and Knowledge of Hearing Health, iPod

Users’ Practices and Preferences, Attitudes toward iPod Use, and Reasons for iPod Use.

Results: Generally, most college students were knowledgeable about hearing health but could use

information about signs of and how to prevent hearing loss. Two-thirds of these students usediPods, but not at levels or for durations that should pose excessive risks for hearing loss when

listening in quiet environments. However, most iPod users could be at risk for hearing loss given acombination of common practices.

Conclusions: Most of these college students should not be at great risk of hearing loss from their iPodswhen used conscientiously. Some concern is warranted for a small segment of these students who

seemed to be most at risk because they listened to their iPods at high volume levels for long durationsusing earbuds, and reported that they may already have hearing loss due to their iPods.

Key Words: College students, iPods, nonoccupational noise exposure, personal listening devices,recreational noise exposure, young adults

Abbreviations: IRB 5 Institutional Review Board; NISNHL 5 noise-induced sensorineural hearing

loss; PLDs 5 personal listening devices; PLDHQ 5 Personal Listening Device and Hearing Question-naire; PLLs 5 preferred listening levels; UCSB 5 University of California, Santa Barbara

Jeffrey L. Danhauer, Ph.D., Department of Speech and Hearing Sciences, 1476 N. Fairview Ave., University of California, Santa Barbara, Goleta,CA 93117; Phone: 805-683-5322; Fax: 805-683-4302; E-mail: [email protected]

Portions of this work were presented as a Research Poster session at AudiologyNow!, April 2007, Denver, CO.

This work was partially funded by a University of California, Santa Barbara, Faculty Research Assistance Program grant.

*Department of Speech and Hearing Sciences, University of California, Santa Barbara; {Department of Communication Disorders, AuburnUniversity

J Am Acad Audiol 20:5–27 (2009)

5

In recent years, health care experts have been

concerned about recreational noise exposure caus-

ing hearing loss in adolescents and young adults

(Rabinowitz et al, 2006). Sources of recreational noise

exposure include noisy toys, firearms, and listening to

music. Several studies have investigated the amount of

risk for hearing loss resulting from personal listening

devices (PLDs). In the 1990s, attention was focused on

personal cassette players or Walkmans. For example, a

study from Hong Kong found that although about 81

percent of young adults listened to personal cassette

players, most did so at levels and durations that did

not expose them to a significant risk of hearing loss

(Wong et al, 1990). Similarly, Turunen-Rise and

colleagues (1991) measured output levels from five

personal cassette players and evaluated temporary

threshold shifts in young adults. They concluded that

moderate use of the devices posed minimal risk of

hearing loss. In addition, Mostafapour and colleagues

(1998) conducted prospective audiologic evaluations on

college students who were grouped according to their

noise profiles, which revealed that this population was

at a relatively low risk of noise exposure from use of

Walkman-style PLDs.

Innovations in popular electronics have resulted in

new options for PLDs including computers with

headphones, MP3 players, portable compact disc

players, and iPods. These new PLDs have powerful

memory capabilities, which enable the storage of

thousands of entries on a single device and provide

listeners endless opportunities to enjoy their favorite

songs without interruption. As a result, new concerns

about risks of hearing loss have been voiced due to

the possibility of extended listening time for users.

Moreover, Fligor and Cox (2004) investigated the

output levels of commercially available portable

compact disc players and their potential risk for

causing hearing loss. They found that some PLDs

were capable of producing outputs in excess of

130 dB SPL and concluded that use of PLDs with

supra-aural headphones should be limited to no more

than 60 percent of full volume for 60 minutes per

day. This recommendation has been dubbed the ‘‘60-

60 Rule.’’

In 2007, the most popular PLD was the iPod,

manufactured by Apple. A lawsuit filed against Apple

in 2006 by a Louisiana man who claimed to have

sustained a hearing loss from iPod use (Goodin, 2006)

resulted in considerable controversy on this topic in

professional organizations like the American Academy

of Audiology (AAA, 2007) and the American Speech-

Language-Hearing Association (ASHA, 2007) as well

as in the mass media. Indeed, the iPod possesses

several characteristics that could potentially increase

its risk for causing hearing loss, particularly in young

people. The iPod’s extended memory capability allows

users to listen to uninterrupted series of their favorite

songs for indefinite amounts of time, and the stock

earbuds that accompany most models do not block out

ambient noise, which necessitates an increase in the

volume for preferred listening by many users. Fligor

and Ives (2006) hypothesized that if all variables are

held constant, then listeners using earbuds might set

their preferred volumes higher when in background

noise than users wearing headphones having better

sound attenuation. For example, they found significant

differences between mean output levels in participants’

ear canals when they wore iPod earbuds (89 dBA)

versus in-the-ear Etymotic Research ER-6i earphones

(78 dBA) in a background of 80 dBA airplane noise.

However, there were no significant differences in

output levels for different sets of headphones in quiet

environments. These findings caused Portnuff and

Fligor (2006) to estimate that listeners using earbuds

could listen to iPods at 70 percent of full volume for

4.6 hours per day without any substantial risk for

hearing loss, which would be a more liberal revision of

the 60-60 Rule.

More recently, Hodgetts and colleagues (2007)

evaluated normal-hearing young adults’ preferred

listening levels (PLLs) for a musical passage presented

through an MP3 player via earbuds, over-the-ear

headphones, and over-the-ear with noise reduction

headphones in backgrounds of quiet, street noise, and

multitalker babble. The average PLLs of listeners

using earbuds were higher than those for the other

headphones; and street noise produced higher PLLs

than the multitalker babble, and both exceeded those

for quiet. Generally, the authors concluded that the

subjects’ PLLs were quite conservative, which should

have allowed them to listen safely for long periods of

time. They also measured the maximum output levels

of the MP3 player through the three headphones at the

ear canal and found that the earbuds produced the

highest levels. The authors concluded that earbuds,

which are the most popular style of headphones, are

most susceptible to ambient noise that can cause users

to increase their PLLs, resulting in more sound

pressure level being directed to the eardrum. Never-

theless, the conservative PLLs for the subjects in that

study caused the authors to conclude that the listening

levels of MP3 players may not be as important a

concern as has been presented in the media. Consid-

ering the somewhat conflicting issues raised in these

studies and the media, it would be important to

determine exactly how many people are at risk for

hearing loss from use of PLDs. Further, it should be

noted that the participants in the study by Hodgetts

and colleagues (2007) were young professionals in their

academic departments and were non-MP3 users, who

did not own the devices under investigation. Clearly,

there is a need for more far-reaching investigations

Journal of the American Academy of Audiology/Volume 20, Number 1, 2009

6

that would include participants from across the

country and result in information about the numbers

of present PLD users and their listening habits.

Aside from potential risks of hearing loss, other

possible concerns about the use of popular electronics

include users being unaware of their environmental

surroundings and creating a public safety hazard for

themselves and others. For example, Beede and Kass

(2006) found that drivers using cell phones were

distracted to the point that their performance on

strategic skills became impaired, possibly making

them public safety risks. Moreover, ‘‘iPod oblivion,’’ a

term used to describe the condition that individuals

find themselves in when they listen to these devices so

attentively that they lose contact with what is going on

around them, was attributed to two pedestrian deaths

in New York within a four-month period (Kuntzman,

2007). Clearly, it is also important to determine how

many iPod users may be creating public safety hazards

due to the use of these devices in potentially dangerous

situations.

The survey method is one of the best ways of

determining whether potentially risky behaviors exist

and if there is a need for public outreach campaigns to

deal with them (Chung et al, 2005). For example,

ASHA partnered with Zogby International (2006) to

survey high school students’ and adults’ use of

popular electronics including cell phones, iPods,

computers with headphones, and other PLDs. Briefly,

they found that both groups used these devices

heavily and that they were not particularly concerned

about risks of hearing loss. However, college students

constitute an obvious group that was overlooked in

that national survey. College students probably use

iPods more than any other age group due to their

tendency to listen to loud music, abundance of leisure

time, and involvement in various activities like

studying compared to the rest of the population. The

purpose of this study was to survey college students’

knowledge about, experiences with, attitudes toward,

and practices and preferences for hearing health and

use of iPods and/or other PLDs. The results of this

survey will help determine the need, content, and

preferred format for educational outreach campaigns

regarding safe iPod use, particularly directed to

college students.

METHOD

Participants

During the spring of 2006, potential participants

were recruited to complete either an online or an

identical paper-and-pencil version of a questionnaire

about PLDs and hearing health. The online survey was

directed to college students from 40 universities (listed

in item 5 of Table 1) that were selected because of

their membership in conferences (i.e., Big East, Big

Ten, Big West, Pac-10, and Southeastern) with broad

geographical representation of the 48 contiguous

states. The paper-and-pencil survey was completed

by students in undergraduate courses at the Univer-

sity of California, Santa Barbara (UCSB). The UCSB

Institutional Review Board (IRB) approved this

project as ‘‘exempt’’ from needing any informed

consent from the participants due to the survey

nature of the study.

The Questionnaire

The survey instrument used was the Personal

Listening Device and Hearing Questionnaire (PLDHQ),

a comprehensive 83-item questionnaire developed for

this study. The questions are presented in Tables 1

through 5 along with the participants’ responses. The

entire questionnaire was developed through an exhaus-

tive iterative process using input from college students,

colleagues, and experts in the field. The survey was

designed to elicit information pertaining to college

students’ knowledge about, experiences with, attitudes

toward, and practices and preferences for hearing

health behaviors and iPods and/or other PLDs. The

questionnaire was developed to be administered (1)

online through Survey Monkey and (2) by hand via

paper and pencil.

The questionnaire contains four sections: (1) Demo-

graphics and Knowledge of Hearing Health, (2) iPod

Users’ Practices and Preferences, (3) Attitudes toward

iPod Use, and (4) Reasons for iPod Use. Aside from the

few mechanical, noncontent formatting exceptions

described below, the sections on both versions of the

questionnaires were identical. Some items on the

questionnaire were for both iPod users and nonusers,

and others were specifically designated for iPod users

only. For example, all participants respond to items 1

through 31. Item 31 asked respondents whether they

were iPod users; if so, they were then instructed to

complete items 32 through 56, which probed informa-

tion about their practices and preferences. Non-iPod

users were instructed to skip to item 57, which was the

first question on the section surveying attitudes

toward iPod use. Likewise, item 68 again asked

respondents whether they used an iPod, after which

iPod users were instructed to answer items 69 through

82 concerning reasons for iPod use, while nonusers

were instructed to skip to item 83, the final question of

the questionnaire. The online version automatically

directed participants to appropriate sections of the

questionnaire based on their responses to items 31 and

68, while those completing the paper-and-pencil format

physically turned the pages to the appropriate sec-

tions.

College Students, iPod Use, and Hearing Health/Danhauer et al

7

Table 1. Demographics (Number Responding and Percent)

Item/Question Response Number %

(1) What is your age in years? 17 years or younger 11 1.8

18 years 146 24.1

19 years 194 32.0

20 years 108 17.8

21 years 76 12.5

22 years 41 6.8

23 years 14 2.3

24 years 6 1.0

25 years 3 0.5

26 years 2 0.3

27 years 1 0.2

28 years 0 0.0

29 years 2 0.3

30 years or older 3 0.5

Total 607 100.0

N/A 2

(2) What is your gender? Male 223 40.0

Female 334 60.0

Total 557 100.0

N/A 52

(3) What is your ethnic background? Asian/Pacific Islander 98 17.6

Hispanic/Latino 74 13.3

Native American 1 0.2

Black/African 22 3.9

White/Caucasian 321 57.6

Other 30 5.4

Rather not answer 11 2.0

Total 557 100.0

N/A 52

(4) What state do you currently live in?

(Listed by number responding)

California 401 72.1

Iowa 13 2.3

Florida 11 2.0

Oregon 9 1.6

Michigan 9 1.6

Illinois 8 1.4

Kansas 8 1.4

Ohio 8 1.4

South Dakota 7 1.3

Minnesota 7 1.3

Indiana 7 1.3

Alabama 6 1.1

Arizona 5 0.9

Connecticut 5 0.9

Washington 5 0.9

Kentucky 5 0.9

Louisiana 5 0.9

New Jersey 4 0.7

Wisconsin 4 0.7

Tennessee 3 0.5

Arkansas 3 0.5

Texas 3 0.5

Missouri 3 0.5

Pennsylvania 3 0.5

West Virginia 3 0.5

Georgia 2 0.4

North Carolina 2 0.4

South Carolina 2 0.4

Virginia 1 0.2


8


Maryland 1 0.2

District of Columbia 1 0.2

New Hampshire 1 0.2

New York 1 0.2

Total 556 99.9

N/A 53

(5) What university do you currently attend?

(Listed by number responding)

University of California, Santa Barbara 374 67.9

Stanford University 13 2.4

University of Iowa 13 2.4

University of Southern California 9 1.6

University of Kansas 8 1.5

University of Alabama 8 1.5

+South Dakota State University 8 1.5

University of Florida 7 1.3

Purdue University 6 1.1

University of Cincinnati 6 1.1

Michigan State University 6 1.1

University of Oregon 5 0.9

University of Washington 5 0.9

University of South Carolina 4 0.7

University of Notre Dame 4 0.7

University of Connecticut 4 0.7

University of Minnesota 4 0.7

Louisiana State University 4 0.7

University of Louisville 4 0.7

University of California, Berkeley 4 0.7

Indiana University 3 0.6

University of Georgia 3 0.6

+University of Tennessee 3 0.6

Rutgers University 3 0.6

Georgetown University 3 0.6

University of Michigan 3 0.6

DePaul University 3 0.6

Penn State University 3 0.6

West Virginia University 3 0.6

University of Arizona 2 0.4

University of South Florida 2 0.4

University of Kentucky 2 0.4

University of Arkansas 2 0.4

Ohio State University 2 0.4

+University of Illinois, Urbana-Champaign 2 0.4

+University of Minnesota Twin Cities 2 0.4

Oregon State University 2 0.4

+California State University, Los Angeles 2 0.4

Arizona State University 2 0.4

+George Washington University 1 0.2

University of Illinois 1 0.2

+Western Kentucky University 1 0.2

+University of Minnesota, Morris 1 0.2

University of California, Los Angeles 1 0.2

+Loyola University, New Orleans 1 0.2

Marquette University 1 0.2

University of Wisconsin 1 0.2

2San Diego State University 0 0.0

2Vanderbilt University 0 0.0

Total 551 101.1

N/A 58

Table 1. Continued

Response


9

PROCEDURES

The data collection procedures used for each version

(i.e., paper and pencil and online) of the question-

naire are discussed below. The two versions were

designed to be used interchangeably to collect data

from a large number of college students in a short

period of time.

Online Questionnaire

Using the advertising capability on Facebook.com,

a widely used Web site (which at the time of this

study required subscribers to be enrolled in a college

or university to be a member of an institution-

specific, online community), a ‘‘flyer’’ was randomly

shown for a 72-hour period on the UCSB network and

a 24-hour period on all the other university sites. The

flyers were viewable when Facebook.com members

loaded new Web pages. The flyers were randomly

shown 30,000 times within the three-day period on

the UCSB network and 2500 times within the one

day for the other universities’ sites. If students

noticed the flyers and felt inclined to participate,

they simply clicked on the advertisement, which

linked them directly to the first page of the

questionnaire on Survey Monkey. As an incentive

for participation, the online respondents were offered

a chance to win $100.00 for completing the question-

naire. Thus, all online respondents self-selected their

participation in the study.

Paper-and-Pencil Questionnaire

During spring quarter 2006, instructors of under-

graduate courses offered at UCSB (not in our depart-

ment) were contacted for permission to recruit partic-

ipants (they were unknown to us) to complete a

questionnaire on iPods. Investigators visited the

classrooms at either the beginning or the end of the

instructional periods, distributed the questionnaires,

answered any questions, and then collected the

surveys. Because UCSB’s IRB did not permit the use

of financial incentives in the classrooms to get students

to respond to questionnaires, the respondents com-

pletely voluntarily self-selected their participation for

the paper-and-pencil format.

Data Preparation and Analysis

Participants’ responses to the online version of the

questionnaire were already tallied by Survey Mon-

key, which also calculated the percentages answer-

ing in each category for each item. Returned paper-

and-pencil questionnaires were numbered and placed

into a notebook, and then participants’ data were

entered into Survey Monkey via a separate but

identical database, and tallies and percentages were

calculated the same way as for the online survey.

Data entry and analysis were completed indepen-

dently and then verified by us as two sets of

reliability judges. Two judges double-checked the

data that were transferred from the individual

paper-and-pencil questionnaires to Survey Monkey.

Similarly, two judges double-checked the compiling

of responses from both survey databases for each

item on the questionnaire to determine the numbers

of participants who responded to each category. Data

were then used to calculate the numbers and

percentages shown here in the tables, which were

also triple-checked for accuracy.

RESULTS AND DISCUSSION

A total of 609 college students responded to either

the online or paper-and-pencil versions of the

questionnaire. Although 322 participants completed

the online questionnaire, it was not feasible to

calculate a response rate for this version, because

the Web-based self-selection process made it impossi-

ble to know exactly how many students might have

actually seen the flyers. Although 320 students were

recruited to complete the paper-and-pencil version of

the survey, 33 were eliminated because they failed to

complete the questionnaire. Thus, the paper-and-

pencil version of the questionnaire was completed by

287 participants, yielding a response rate of 89.6

percent.


(6) What is your present college status? Freshman 186 33.8

Sophomore 163 29.6

Junior 112 20.3

Senior 71 12.9

Graduate Student 19 3.4

Total 551 100.0

N/A 58

Note: N/A 5 no response or not applicable. For item 5, + 5 not solicited, but someone responded; 2 5 solicited, but no one responded.

Table 1. Continued

Response


10

The issues of pooling the data from the paper-and-

pencil and online versions of the survey and the use

of an incentive for one and not the other were

considered. Previous research had shown that pre-

senting health-related questionnaires to adolescents

via online and paper-and-pencil surveys produced

equivalent results (e.g., Mangunkusumo et al, 2005;

Raat et al, 2007) and that financial incentives had no

effect on response rates (e.g., Moses and Clark, 2004;

Roberts et al, 2004). Further, even though two

sampling methods were used, as seen below, the

majority of the respondents (i.e., all 287 of the paper

and pencil and 87 of the 322 online) were from UCSB.

With 67.8 percent of the sample being UCSB

students, it seemed unlikely that the remaining

32.2 percent from the other universities would

represent a substantially different population. Thus,

no differences were expected to result from the two

sampling methods, and the data were pooled for

analysis. The results are presented in Tables 1

though 5. The items on the tables match those on

the questionnaire and are numbered consecutively.

In addition, because the discussion of the results does

not necessarily follow the order of the items as listed

on the tables, the item numbers on the table

(corresponding to those on the questionnaire) are

placed in parenthesis along with the percent value

for clarity as each concept is presented. For most of

the items, the number responding was 609; however,

either some participants did not respond to or a

response was not applicable for certain questions

(i.e., if they were not iPod users), which is indicated

by N/A on the tables. The total number responding

for a few of the questions was greater than 609 if

participants were asked to respond to all choices that

were appropriate.

Demographics

Table 1 shows the results of the first segment of the

questionnaire (items 1 through 6), which surveyed

college students’ demographic information. As expect-

ed considering that they were all college students, most

of the respondents (1: 86.4%) were only about four

years apart in age (i.e., 18 to 21). The sample was

composed of slightly more females than males (2: 60 vs.

40%). Neither age nor gender was expected to be a

factor considering that advertising is generally direct-

ed to all persons of college age. Recall that one

rationale for the study was to focus on college-age

students as a group because they were not well

represented in the Zogby International (2006) survey.

Moreover, it was hypothesized that most college

students, regardless of age or gender, had more time

and/or involvement in situations and activities that

were conducive to using PLDs than would persons in

other age groups. Therefore, the population sampled

here may be at more risk for noise-induced sensori-

neural hearing loss (NISNHL) by listening to PLDs

than others, which was a compelling reason for

surveying this group.

Although more than half (3: 57.6%) of the respon-

dents said that White or Caucasian was their ethnic

background, a proportion of the sample was reportedly

Asian/Pacific Islander (3: 17.6%) and Latino (3: 13.3%).

Although differences have been found or suggested for

different ethnic groups on similar topics (Crandell et

al, 2004; Zogby International, 2006), these analyses

were not conducted here, but this will be addressed in a

later study. The students wrote in their responses for

items 4 and 5, which revealed that they represented 47

different universities, from 33 states (including the

District of Columbia). Interestingly, responses were

received from 47 universities when the Facebook.com

ads were only placed on 40 universities’ Web sites. This

may mean that students from universities on the list

shared the ads with friends at additional schools,

which should have had no effects on the overall results,

aside from enhancing the number of institutions

sampled. Generally, item 6 showed that although there

was a fairly wide representation across college class

ranks, the percent of underclassmen (freshmen and

sophomores 5 63.4%) was almost double that of

upperclassmen (juniors and seniors 5 33.2%).

Knowledge about, Experiences with, and

Attitudes toward Hearing Health and Hearing

Health Behaviors

Table 2 shows the results for the second segment of

the questionnaire (items 7 through 19), which sur-

veyed college students’ knowledge about, experiences

with, and attitudes toward hearing health and hearing

health behaviors. Over a third (7: 34.2%) of the

students reported being in noisy settings frequently

or always, while about half (7: 49%) said sometimes.

This means that many of the students were in settings

that may have exposed them to loud noise levels for

potentially dangerous periods of time. This finding

becomes even more relevant when considering that

other studies have shown that PLD users tend to set

the volume higher when listening in backgrounds of

noise (e.g., Williams, 2005). These issues are covered

and discussed in more detail later for the students’

responses to subsequent items on the present ques-

tionnaire, which suggest a need for educational

outreach programs directed to college students.

Fortunately, items 8 through 10 showed that most of

these students knew that preexisting hearing loss does

not reduce the worry about future hazardous noise

levels and that hearing loss may be prevented. Even

so, the results suggest that college students could


11

Table 2. Knowledge about, Experiences with, and Attitudes toward Hearing Health and Hearing Health Behaviors(Number Responding and Percent)


(7) How often are you in noisy settings (e.g., concerts, jet skiing, work

environments)?

Never 5 0.9

Rarely 88 15.9

Sometimes 272 49.0

Frequently 167 30.1

Always 23 4.1

Total 555 100.0

N/A 54

(8) Do you think that people who have preexisting hearing loss do not have

to worry about future hazardous noise levels because the damage has

already been done?

Yes 45 8.1

No 410 74.0

Maybe 56 10.1

I don’t know 43 7.8

Total 554 100.0

N/A 55

(9) Do you think that using cotton in the ears can protect people from

hearing loss due to loud noises?

Yes 91 16.4

No 220 39.7

Maybe 179 32.3


Total 554 100.0

N/A 55

(10) Do you think that hearing loss caused by noise can be prevented? Yes 455 82.3

No 19 3.4

Maybe 66 11.9


Total 553 100.0

N/A 56

(11) Do you think that ringing in the ears is a warning sign for overexposure

to potentially hazardous sound?

Yes 415 75.0

No 23 4.2

Maybe 84 15.2


Total 553 100.0

N/A 56

(12) How often do you have ringing in your ears? Never 84 15.2

Rarely 327 59.1

Sometimes 129 23.3

Frequently 9 1.6

Always 4 0.7

Total 553 100.0

N/A 56

(13) Are saying ‘‘huh,’’ or ‘‘what,’’ or asking for repeats signs of

hearing loss?

Yes 107 19.4

No 181 32.8

Maybe 242 43.9


Total 551 100.0

N/A 58

(14) How often do you say ‘‘huh,’’ ‘‘what,’’ or ask for repeats because

you do not hear others clearly?

Never 17 3.1

Rarely 190 34.4

Sometimes 250 45.2

Frequently 91 16.5

Always 5 0.9

Total 553 100.0

N/A 56

(15) Is ‘‘voices sounding muffled or mumbled’’ a sign of hearing loss? Yes 224 40.5

No 69 12.5

Maybe 221 40.0


Total 553 100.0

N/A 56


12

benefit from information about effective methods of

hearing conservation because only 40 percent of the

respondents were reasonably certain that using cotton

in the ears could not protect people from hearing loss

due to loud noises. These findings were consistent with

earlier investigations regarding college students’

knowledge about the effectiveness of hearing protec-

tion devices (Johnson et al, 1997).

Understanding college students’ knowledge about

and experience with symptoms of overexposure to

noise and/or hearing loss is useful for assessing the

need for and content of educational outreach programs.

Therefore, it is of concern that many (11: ,25%) of

these students either were mistaken about, did not

know, or were unsure whether ringing in the ears is an

early warning sign for overexposure to potentially

hazardous sound levels. College students need to be

reminded of the fact that ringing in the ears during or

after exposure to loud sounds is a clear sign that

overexposure has occurred and that such experiences

should be avoided in the future (e.g., Bray et al, 2004;

Holgers and Pettersson, 2005). Fortunately, most of

these respondents reported that their ears never (12:

15.2%) or rarely (12: 59.1%) ring; however, several (12:

23.3%) said they did sometimes.

Fewer than half of these students knew that saying

‘‘huh’’ or ‘‘what’’ or asking for repeats (13: 19.4%),

‘‘voices sounding muffled or mumbled’’ (15: 40.5%), and

having to turn the volume up on TVs or radios (17: 36.9%)

are signs of hearing loss. These results suggest that most

college students should be educated on signs and

symptoms of hearing loss and how to recognize them in

themselves and in others, which may indicate a need for

referral for an audiologic evaluation. This is particularly

important because items 14, 16, and 18 revealed that a

large portion of the college students sampled here

reported experiencing these signs and symptoms either

sometimes or frequently, while only 3.1 to 19.8 percent of

them reported never having experienced any of these

signs or symptoms of hearing loss.


(16) How often do other people’s voices sound muffled or mumbled to you? Never 109 19.8

Rarely 284 51.5

Sometimes 136 24.7

Frequently 21 3.8

Always 1 0.2

Total 551 100.0

N/A 58

(17) Is having to turn up the volume on TVs or radios a sign of hearing loss? Yes 202 36.9

No 126 23.0

Maybe 203 37.0


Total 548 100.0

N/A 61

(18) How often do you have to turn up the volume on the TV or radio in order

to hear better?

Never 32 5.8

Rarely 204 37.2

Sometimes 236 43.1

Frequently 70 12.8

Always 6 1.1

Total 548 100.0

N/A 61

(19) Rate your hearing on a 1–10 scale below, where 1 5 the worst possible

hearing and 10 5 the best possible hearing.

1 (worst possible hearing) 0 0.0

2 1 0.2

3 8 1.4

4 16 2.9

5 22 4.0

6 32 5.8

7 128 23.1

8 205 36.9

9 119 21.4

10 (best possible

hearing)

24 4.3

Total 555a 100.0

N/A 59

aFive responded to more than one level.

Response

Table 2. Continued


13

Table 3. Personal Listening Device Ownership and Preferences (Number Responding and Percent)


(20) If you own a personal listening device, which one(s)? Walkman 46 8.5

MP3 player 82 15.2

Computer with headphones 152 28.1

iPod 358 66.2

None 33 6.1

Other (please specify) 6 1.1

Total 541 100.0

N/A 68

(21) If you own personal listening devices, how did you obtain your main

(or favorite) one?

Given to me, but I chose it 180 33.2

Given to me, but I did not choose it 98 18.1

I purchased it 231 42.6

Do not own one 29 5.4


Total 542 100.0

N/A 67

(22) Given your present financial status, do you consider an iPod to be

easily affordable?

Yes 158 28.8

No 310 56.6

Maybe 80 14.6

Total 548 100.0

N/A 61

(23) What percentage of your friends use personal listening devices? Less than 25 25 4.5

26–50 46 8.4

51–75 167 30.4

76–100 312 56.7

Total 550 100.0

N/A 59

(24) What percentage of your friends use iPods? Less than 25 39 7.1

26–50 101 18.3

51–75 216 39.2

76–100 195 35.4

Total 551 100.0

N/A 58

(25) If you could choose, would you pick an iPod over all the other devices

available on the market for your own use?

Yes 379 68.9

No 74 13.5

Maybe 72 13.1


Total 550 100.0

N/A 59

(26) Should personal listening device manufacturers build output limiters

in their players to prevent hearing losses?

Yes 221 40.3

No 150 27.3

Maybe 143 26.0


Total 549 100.0

N/A 60

(27) Are you aware that on 3/29/06, Apple announced availability of a

software update permitting iPod users to set their own maximum

volume limits and a Web page that describes how the ear processes

sound loudness, cautions against listening for long periods of time at

loud levels, ways to prevent hearing loss from iPod use, and how parents

can limit and lock the volume wheel of their children’s iPod use?

Yes 94 17.2

No 454 82.8

Total 548 100.0

N/A 61

(28) Would you use Apple’s or any other volume-limiting output software

for yourself or your children?

Yes 253 45.9

No 91 16.5

Maybe 187 33.9


Total 551 100.0

N/A 58


14

Finally, item 19 (borrowed from Solodar et al, 2005)

asked the participants to rate their hearing on a 1

(worst possible hearing) to 10 (best possible hearing)

scale. More than 90 percent of all of the respondents

rated their hearing as a 6 or better (mode 5 8); note

that five of the students responded to two levels.

Further analysis of these data using the filtering

feature in Survey Monkey revealed that over 80

percent of both iPod users and nonusers rated their

hearing at 7 or better. If these self-ratings were

accurate, then we believe that most of these students

probably did not have to worry much about their

hearing, but nearly 10 percent of them may already

have or be at a higher risk for developing hearing loss.

They should be counseled about NISNHL, especially if

they happen to be among those iPod users who listen at

intense levels for prolonged periods, as will be

discussed later.

Personal Listening Device Ownership

and Preferences

Table 3 shows the results for the third section of the

questionnaire (items 20 through 31), which assessed

the students’ responses regarding PLD ownership and

preferences. Clearly, the type of PLD owned by most of

these college students was iPods (20: 66.2%), and only

6.1 percent said that they did not own any device. An

initial concern in conducting this study was whether

this sample might have had a greater prevalence of

iPod users than the general population of college

students because the Facebook.com advertisement

flyer specifically asked potential participants if they

would like to respond to a survey about iPods, which

could have attracted more iPod than other PLD users.

However, this did not seem to be an issue because the

percents of iPod owners were essentially the same for

the paper-and-pencil (66.1%) and the online (66.3%)

versions of the questionnaire. Interestingly, the pro-

portion of college students who owned iPods was

appreciably higher than for either the high school

students (36%) or the adults (11%) reported in the

Zogby International (2006) survey. This confirmed one

of our initial rationales for conducting the study and

supported our contention that iPod use by college

students, as a group, was worthy of a separate

investigation.

Most of the respondents either purchased their main

or favorite PLD themselves (21: 42.6%) or selected it as

a gift (21: 33.2%). Most of the respondents (23: 87.1%)

estimated that over half of their peers used PLDs and

that more than half of those actually used iPods (24:

74.6%). Although more than half (22: 56.6%) of the

respondents did not consider an iPod to be easily

affordable, the popularity of these devices among

college students is evident, as most of the participants

stated that if they could choose, they would pick an

iPod over all the other devices available on the market

(25: 68.9%).

Generally, these respondents did not seem to be

aware of or too concerned about the possibility of iPods

causing hearing loss or ways to prevent it, such as

Apple’s software that permits users to set their own

maximum output volume limits on their iPods (27:

82.8%). A little less than half (28: 45.9%) of the

respondents reported that they would use such

software for themselves or their children or that

manufacturers should build them into their players


(29) Do you agree with experts who recommend a ‘‘60-60 Rule’’

saying that iPod use should be restricted to no more than 60% of

the volume level for no more than 60 minutes a day?

Agree 207 37.6

Strongly 33 6.0

Moderately 174 31.6

Neutral 232 42.2

Disagree 111 20.1

Strongly 25 4.5

Moderately 86 15.6

Total 550 100.0

N/A 59

(30) Do you think advisories like a ‘‘60-60 Rule’’ are an invasion of

people’s privacy?

Yes 110 20.3

No 306 56.6

Maybe 94 17.4


Total 541 100.0

N/A 68

(31) Do you use an iPod? Yes 377 67.9

No 178 32.1

Total 555 100.0

N/A 54

Table 3. Continued

Response


15

Table 4. Habits and Preferences of iPod Users (Number Responding and Percent)


(32) Which iPod do you use? iPod (20gb, 30gb, 40gb, 60gb) 179 53.9

iPod Nano 59 16.2

iPod Mini 88 24.1

iPod Shuffle 21 5.8

Total 365 100.0

N/A 244

(33) Prior to using your iPod, which personal listening system(s) did you use? Walkman 165 41.6

MP3 player 68 17.0

Computer with headphones 104 26.1

None 46 11.5


Total 359 99.9

N/A 250

(34) How do you usually listen to your iPod? Earbuds 278 76.0

Headset 47 12.8

Custom ear pieces 23 6.3


Total 366 100.0

N/A 243

(35) Would you consider buying custom ear pieces for your iPod to reduce

background noise?

Yes 201 54.9

No 92 25.1

Maybe 73 19.9

Total 366 100.0

N/A 243

(36) How much would you be willing to pay for custom ear pieces? Under $25 144 40.0

$26–$50 174 48.3

$51–$100 29 8.1

Over $100 14 3.6

Total 360 100.0

N/A 249

(37) How long have you been using your iPod? Less than 1 year 174 47.3

1 to 2 years 134 36.6

More than 2 years 60 16.3

Total 368 100.1

N/A 241

(38) Do you think you have any hearing difficulties? Yes 44 12.0

No 230 62.5

Maybe 74 20.1


Total 368 100.0

N/A 241

(39) If you have hearing difficulties, what caused them? Do not have any 174 51.6

Ear infections 26 7.6

Fever 4 1.2

Noise 39 11.5

Trauma 4 1.2

Drugs 4 1.2

Birth defects 3 0.8

iPod use 20 5.9

Unknown 60 17.6


Total 317 99.8

N/A 292

(40) How many DAYS A WEEK do you usually use your iPod? 1 27 7.4

2 32 8.8

3 45 12.3

4 65 17.9

5 72 19.8


16


6 42 11.5

7 81 22.3

Total 364 100.0

N/A 245

(41) How many HOURS do you use your iPod continuously in a single

session?

Less than J 36 9.8

J to K 83 22.6

K to 1 130 35.3

1 to 2 99 26.9

3 to 4 12 3.3

More than 4 7 1.9

Total 367 100.0

N/A 242

(42) On days you use your iPod, how many HOURS do you usually use

it in total for the day?

Less than J 10 2.7

J to K 27 7.4

K to 1 109 29.9

1 to 2 142 38.9

3 to 4 56 15.3

More than 4 21 5.8

Total 365 100.0

N/A 244

(43) How may times A YEAR do you listen to your iPod for LONGER THAN

4 HOURS AT ONE SITTING (e.g., traveling)?

1 to 3 204 57.6

4 to 6 72 20.3

7 to 10 37 10.5

11 to 20 21 5.9

21 or more 19 5.4

Total 353 100.0

N/A 256

(44) Indicate the number representing where you typically set the volume

on your iPod?

1 2 0.6

2 5 1.4

3 11 3.0

4 32 8.8

5 54 14.9

6 76 20.9

7 90 24.8

8 65 17.9

9 21 5.9

10 7 1.9

Total 363 100.0

N/A 246

(45) What do you consider your typical iPod listening level to be? Very soft 5 1.4

Soft 25 6.8

Medium 209 57.1

Loud 113 30.9

Very loud 14 3.8

Total 366 100.0

N/A 243

(46) Do you set your iPod at higher volume levels for your favorite songs? Yes 172 47.0

No 71 19.5

Sometimes 122 33.5

Total 364 100.0

N/A 245

(47) Do you set your iPod at higher volume levels when you are in noisy

backgrounds?

Yes 284 78.2

No 18 5.0

Sometimes 61 16.8

Total 363 100.0

N/A 246

Table 4. Continued

Response

(40) Cont.


17


(48) Do you set your iPod at higher volume levels when you are exercising? Yes 222 61.3

No 72 20.0

Sometimes 68 18.8

Total 362 100.1

N/A 247

(49) During which activities (indicate all that apply) do you use your iPod? Studying 197 54.1

Walking/Jogging 296 81.3

Driving 113 31.0

Biking 142 39.0

Skiing/snowboarding 43 11.8

Working 97 26.6

Exercising 278 76.4

During class 49 13.5

Relaxing 201 55.2

Riding on planes, buses, etc. 284 78.0

Other 22 6.0

Total 364 473.1

N/A 245

(50) Can other people around you usually hear your iPod? Yes 29 8.0

No 206 56.9

Maybe 75 20.7


Total 362 100.0

N/A 247

(51) People (e.g., family, friends, strangers, police) caution/reprimand

me to turn down the volume on my iPod.

Never 227 62.2

Rarely 85 23.3

Sometimes 41 11.2

Frequently 11 3.0

Always 1 0.3

Total 365 100.0

N/A 244

(52) My ears ring after using my iPod. Never 273 74.8

Rarely 67 18.4

Sometimes 23 6.3

Frequently 2 0.5

Always 0 0.0

Total 365 100.0

N/A 244

(53) My ears feel full or fuzzy after using my iPod. Never 216 59.2

Rarely 100 27.4

Sometimes 39 10.7

Frequently 8 2.2

Always 2 0.5

Total 365 100.0

N/A 244

(54) I have to turn up the volume on the TV or radio in order to hear better

after using my iPod?

Never 251 69.1

Rarely 84 23.1

Sometimes 22 6.1

Frequently 5 1.4

Always 1 0.3

Total 363 100.0

N/A 246

(55) I notice that people’s ‘‘voices sound mumbled or muffled’’ after

using my iPod.

Never 266 73.2

Rarely 74 20.4

Sometimes 20 5.5

Frequently 3 0.8

Table 4. Continued


18

to prevent hearing loss (26: 40.3%). However, inspec-

tion of their answers indicated that about a third of the

participants were not necessarily against these mea-

sures but were ‘‘unsure,’’ which might indicate that

they could be influenced through appropriate educa-

tional outreach. In addition, only less than a quarter

(29: 20.1%) of the respondents disagreed with the ‘‘60-

60 Rule’’ and felt that it was an invasion of people’s

privacy (30: 20.3%). These results were in fair

agreement with the Zogby survey findings that an

appreciable segment of high school students (47%) and

adults (48%) were not concerned about the risks of

hearing loss posed by PLD use.

Habits and Preferences of iPod Users

Table 4 shows the results of the fourth section of the

questionnaire (items 32 through 56), which assessed

the habits and preferences of iPod users only. Item 32

revealed that the standard iPod was used by far more

(53.9%) of these students than Minis, Nanos, or

Shuffles, which may be because it has been on the

market the longest and has extended memory for

storing thousands of songs. Item 33 revealed that other

types of PLDs were used by most of these students

prior to obtaining their iPods.

An important expected finding was that most (34:

76%) of the respondents listened to their iPods using

earbuds. Other studies (Fligor and Cox, 2004; Hodgetts

et al, 2007) have shown that earbuds do not attenuate

background noise levels as well as other types of

headphones, which may cause users to increase the

volume to listen to their favorite songs at a satisfying

level. Recall that Fligor and Ives (2006) found

significant differences in mean output levels in

participants’ ear canals in 80 dBA of airplane noise

when using Apple iPod earbuds (89 dBA) versus in-

the-ear Etymotic Research ER-6i earphones (78 dBA).

This suggested that many of the students using

earbuds in the present study might have had to adjust

their iPods to potentially unsafe levels in noisy

environments. Clearly, more studies need to be

conducted to determine safe uses of iPods with ear-

buds, particularly in backgrounds of noise.

Interestingly, more than half of the participants (35:

54.9%) said that they would be willing to purchase

custom earpieces for their iPods to reduce background

noise and were willing to spend more than $25.00 for

them (36: 60.0%). The large majority (37: 83.9%) of these

respondents had used their iPods for less than two years.

Items 38 and 39 revealed that only 12 percent of

these students believed that they had any hearing

difficulties, about 25 percent were unsure, and about 6

percent attributed problems to iPod use. These find-

ings were consistent with the fact that the respon-

dents’ reported listening behaviors in typical situations

would not seem to predispose most of them to hearing

loss from iPod use. Recall that Portnuff and Fligor

(2006) updated the ‘‘60-60 Rule’’ and estimated that

typical listeners could use their iPods safely at 70

percent of full volume for 4.6 hours a day when using

the supplied earphones without greatly increasing

their risk of hearing loss. Nevertheless, as will be

discussed later, a relatively small number of the

college students in this study may still have been at

risk when listening in noisy environments and/or for

long periods of time, which indicates a need for

outreach especially directly to them.

Items 40 through 43 revealed that more than half of

the respondents said they listened to their iPods for

five or more days a week and for more than one hour

per day. A few (42: 21.1%) listened for three hours or

more per day, for durations exceeding three hours

during a single session (41: 5.2%); however, the

frequency of these sessions was three times or less

per year by a little over half (43: 57.6%) of the

participants. Even more important, though, was the

fact that a small number of these students said that

they used their iPods for seven days a week, more than

four hours either in a single session or combined per

day, over 20 times per year. It is this subgroup that

may be at greatest risk of developing recreational

NISNHL and for whom educational outreach is

probably most critical. Further, although most of these


Always 0 0.0

Total 363 100.0

N/A 246

(56) I find myself saying ‘‘what’’ or ‘‘huh’’ or asking for repeats after

using my iPod.

Never 246 67.6

Rarely 83 22.8

Sometimes 27 7.4

Frequently 6 1.6

Always 2 0.5

Total 364 100.0

N/A 245

(55) Cont.

Table 4. Continued

Response


19

Table 5. Attitudes toward iPods and Their Use (Number Responding and Percent)


(57) What is the youngest age that you believe regular

iPod use is acceptable for children?

Younger than 5 years 7 1.3

5 to 10 years 78 14.8

11 to 13 years 207 39.2

14 to 16 years 162 30.7

Older than 16 years 46 8.7


Total 528 100.0

N/A 81

(58) Use of an iPod in some situations may be dangerous

(e.g., driving, biking, jogging, snowboarding, etc.).

Agree 407 76.8

Strongly 177 33.4

Moderately 230 43.4

Neutral 74 14.0

Disagree 49 9.3

Strongly 11 2.1

Moderately 38 7.2

Total 530 100.1

N/A 79

(59) Using an iPod at loud listening levels may damage hearing. Agree 458 86.6

Strongly 254 48.0

Moderately 204 38.6

Neutral 61 11.5

Disagree 10 1.9

Strongly 2 0.4

Moderately 8 1.5

Total 529 100.0

N/A 80

(60) It is not important to obey manufacturers’ warnings

regarding safe use of personal listening devices.

Agree 107 20.1

Strongly 40 7.5

Moderately 67 12.6

Neutral 99 18.7

Disagree 324 61.2

Strongly 128 24.2

Moderately 196 37.0

Total 530 100.0

N/A 79

(61) Scientific proof that using iPods at high volume levels can

cause hearing loss would not lead me to change

my own iPod use.

Agree 171 32.3

Strongly 42 7.9

Moderately 129 24.4

Neutral 120 22.7

Disagree 238 45.0

Strongly 77 14.6

Moderately 161 30.4

Total 529 100.0

N/A 80

(62) All iPods should be labeled with warnings (like on cigarettes)

that use at high volumes can cause hearing loss.

Agree 287 54.1

Strongly 95 17.9

Moderately 192 36.2

Neutral 139 26.2

Disagree 104 19.6

Strongly 40 7.5

Moderately 64 12.1

Total 530 99.9

N/A 79

(63) People should turn down the volume on their iPods rather

than limit listening times to reduce risks of hearing loss.

Agree 348 65.8

Strongly 113 21.4

Moderately 235 44.4

Neutral 158 29.9

Disagree 23 4.3


20


Strongly 7 1.3

Moderately 16 3.0

Total 529 100.0

N/A 80

(64) Do you think the media have exaggerated the risks of

hearing loss from iPod use?

Yes 111 21.1

No 169 32.1

Maybe 142 27.0


Total 526 100.0

N/A 83

(65) Would you like more information about iPod use and

potential hearing loss?

Yes 207 39.2

No 321 60.8

Total 528 100.0

N/A 81

(66) If you would like additional information on iPods and

hearing loss, how would you prefer to receive it?

E-mail 87 17.0

Web sites 82 16.0

From doctors, friends, family, others 72 14.1

TV 103 20.2

Radio 24 4.7

Manufacturer labeling/warnings 87 17.0

Print 30 5.9

Other 26 5.1

Total 511 100.0

N/A 254

(67) From which of these persons would you follow advice

given regarding iPod use and hearing loss?

Doctors 296 35.0

Manufacturers 101 12.0

Audiologists 139 16.4

Experts 165 19.5

Family 64 7.6

Friends 51 6.0

Others 6 0.7

None 24 2.8

Total 846 100.0

N/A 93

(68) Do you use an iPod? Yes 357 67.2

No 174 32.8

Total 531 100.0

N/A 78

(69) If you think you already have a hearing loss, do you

think your iPod use could have contributed to it?

Yes 30 6.2

No 168 29.1

Maybe 80 11.8


Total 323 55.4

N/A 287

(70) Would you rather turn down the volume on your iPod

than limit your listening times to avoid hearing loss?

Yes 259 73.1

No 37 10.5

Maybe 43 12.1


Total 354 100.0

N/A 255

(71) I sometimes get so focused on listening to my iPod

that I become so unaware of my surroundings that

I may be a hazard or danger to myself or others

(e.g., while driving in a car or walking/jogging

in an unsafe area).

Agree 82 23.1

Strongly 17 4.8

Moderately 65 18.3

Neutral 67 18.9

Disagree 206 57.9

Strongly 112 31.5

Moderately 94 26.4

Total 355 100.0

N/A 254

Table 5. Continued

Response

(63) Cont.


21


(72) I have been in a dangerous situation at least once while

using my iPod (e.g., crossing a street or driving and being

unaware of traffic).

Agree 86 24.3

Strongly 15 4.2

Moderately 71 20.1

Neutral 49 13.9

Disagree 218 61.7

Strongly 138 39.0

Moderately 80 22.7

Total 353 100.8

N/A 256

(73) The main reason I use my iPod is for listening to music. Agree 334 95.4

Strongly 267 76.3

Moderately 67 19.1

Neutral 11 3.1

Disagree 5 1.4

Strongly 0 0.0

Moderately 5 1.4

Total 350 100.0

N/A 259

(74) I sometimes use my iPod because it helps me to relax. Agree 264 75.4

Strongly 110 31.4

Moderately 154 44.0

Neutral 59 18.9

Disagree 27 7.7

Strongly 11 3.1

Moderately 16 4.6

Total 350 100.0

N/A 259

(75) I sometimes use my iPod to isolate myself from others. Agree 192 55.0

Strongly 68 19.5

Moderately 124 35.5

Neutral 55 15.8

Disagree 102 29.3

Strongly 47 13.5

Moderately 55 15.8

Total 349 100.0

N/A 260

(76) I sometimes use my iPod because it is fashionable. Agree 74 21.1

Strongly 22 6.3

Moderately 52 14.8

Neutral 69 19.7

Disagree 208 59.3

Strongly 134 38.2

Moderately 74 21.1

Total 351 100.0

N/A 258

(77) I sometimes use my iPod because it helps me to concentrate. Agree 163 46.4

Strongly 52 14.8

Moderately 111 31.6

Neutral 70 19.9

Disagree 118 33.6

Strongly 54 15.4

Moderately 64 18.2

Total 351 100.0

N/A 258

(78) I sometimes use my iPod as a form of rebellion. Agree 14 4.0

Strongly 3 0.9

Moderately 11 3.1

Neutral 32 9.1

Table 5. Continued

Response


22

students (45: 57.1%) described their typical iPod

listening levels as ‘‘medium,’’ over a third (45: 34.7%)

said ‘‘loud’’ or ‘‘very loud.’’ These results agree with

levels described by both high school students and

adults in the Zogby survey. For even more specific

estimations of listening levels, item 44 asked respon-

dents to indicate the number on a bar labeled from 1 to

10 representing where they typically set the volume of

their iPods. Interestingly, 71.4 percent of them listened

at 60 percent of full volume or higher, levels that could

exceed the ‘‘60-60 Rule’’ if listening sessions exceed one

hour per day. More in-depth analysis using the filter

feature in Survey Monkey revealed that, indeed, 34.6

percent of those students said that they actually

listened for more than one hour per day. Further,

49.6 percent reported listening at 70 percent of full

volume or higher, which would potentially exceed even

the less conservative recommendation for safe listen-


Disagree 304 86.9

Strongly 232 66.3

Moderately 72 20.6

Total 350 100.0

N/A 259

(79) I sometimes use my iPod so I will not bother others

with my music.

Agree 270 77.2

Strongly 108 30.9

Moderately 162 46.3

Neutral 49 14.0

Disagree 31 8.9

Strongly 17 4.9

Moderately 14 4.0

Total 350 100.0

N/A 259

(80) I sometimes use my iPod when I am bored. Agree 258 73.5

Strongly 99 28.2

Moderately 159 45.3

Neutral 48 13.7

Disagree 45 12.8

Strongly 24 6.8

Moderately 21 6.0

Total 351 100.0

N/A 258

(81) I sometimes use my iPod because it is convenient. Agree 318 90.8

Strongly 180 51.4

Moderately 138 39.4

Neutral 21 6.0

Disagree 11 3.1

Strongly 4 1.1

Moderately 7 2.0

Total 350 100.0

N/A 259

(82) I use my iPod because I am a ‘‘high-tech or gadget junkie.’’ Agree 71 20.2

Strongly 21 6.0

Moderately 50 14.2

Neutral 67 19.1

Disagree 213 60.7

Strongly 133 37.9

Moderately 80 22.8

Total 351 100.0

N/A 258

(83) How honest were you in answering the questions

in this survey.

Completely honest 497 95.8

Partially honest 22 4.2

Total 519 100.0

N/A 90

Table 5. Continued

Response

(78) Cont.


23

ing proposed by Portnuff and Fligor (2006). Of this

subgroup, 23.9 percent said that they listened for three

hours or more per day, placing them at even greater

risk of developing recreational NISNHL.

The risk of developing NISNHL may be compounded

for individuals using their iPods in noise or other types

of listening situations. Almost half (46: 47.0%) of these

students reported that they turned the volume up on

their iPods when listening to their favorite songs;

another 33.5 percent said that they did so sometimes.

Even more of the participants turned the volume up

when listening in noise (47: 78.2%) or when exercising

(48: 61.3%). Therefore, these results suggest that all

college students could probably benefit from informa-

tion about potential dangers of hearing loss from iPods,

particularly when used in excessive noise that could

conceivably require setting the level at full volume for

satisfactory PLLs, which is dangerous for periods even

as short as five minutes at full volume with earbuds

(Portnuff and Fligor, 2006). Item 49 revealed that a

high percentage of these students listened to their

iPods in a variety of activities from traveling to

relaxing to exercising, which confirmed that these

devices were being used in situations that could be

continuous or overlapping in time, increasing the

chances for overexposure.

In spite of the fact that some of these college students

may have been at risk for recreational NISNHL from

listening in certain situations, most of their responses to

items 52 through 56 revealed that very few of them

(about 7 to 13%) reported experiencing signs/symptoms

of hearing loss sometimes or more frequently after iPod

use. These results were similar to those reported in the

Zogby International (2006) survey on high school

students and adults. Other signs that these college

students’ iPod listening levels may not have been

excessively high were that only a small segment

reported receiving cautions/reprimands from others to

turn down the volume (51: 14.5%) or that their iPods

could be heard by people around them (50: 8%).

Hearing loss caused by listening to iPods at

excessively high levels is just one of the potential

dangers posed by these devices. The ‘‘iPod oblivion’’

(Kuntzman, 2007) described earlier may pose even

greater dangers for PLD users. Most of these college

students reported listening to iPods in situations that

should require their auditory attention to avoid

possible dangers. For example, as noted earlier, item

49 revealed that many of these students said they wore

their iPods while walking, jogging, biking, or driving,

which could preclude awareness of hazards like

automobiles or muggers and could possibly interfere

with their safety and that of others. These results

indicate that educational outreach campaigns should

include information beyond just the risks of hearing

loss from iPod use.

Attitudes toward iPods and Their Use

The fifth and final section of the questionnaire (items

57 through 83) assessed the participants’ attitudes

toward iPods and their use, and the results are shown in

Table 5. The previous section demonstrated that some

of these college students had listening habits and

preferences that could have placed them at risk for

hearing loss or injury from an accident. However, the

development of effective educational outreach programs

requires an understanding of the attitudes of the target

group toward iPod use. Recall that only iPod users

completed the previous section of the questionnaire.

Because educational outreach programs should focus on

both present and potential iPod users, the final section

of the questionnaire included some items that were to be

answered by all of the participants (items 57 through 67

and item 83) as well as others that were specifically for

iPod users (items 68 through 82).

Only about 16% of these college students (57: 16.1%)

believed that regular iPod use was acceptable for

children under 11 years of age, perhaps because they

believed that using an iPod at loud listening levels may

damage hearing (59: 86.6%) or be dangerous in some

situations (58: 76.8%). About half of the respondents

thought that it was important to obey manufacturers’

warnings regarding safe use of PLDs (60: 61.2%), would

change their own behavior if scientific proof existed that

using iPods at high volume levels can cause hearing loss

(61: 45.0%), and believed that iPods should be labeled

with warnings like those on cigarette packages that use

at high volumes can cause hearing loss (62: 54.1%). In

order to decrease risk, most of them (63: 65.8%) indicated

that people should turn down the volume on their iPods

rather than limit listening times to reduce risks of

hearing loss, which suggests that they understood the

connection between safe use and risk. Only about a fifth

(64: 21.1%) of the respondents thought that the media

had exaggerated the risks of hearing loss from iPod use.

About three-fifths (65: 60.8%) of these college students

did not want any additional information, which might

signify a reluctance of receiving pejorative warnings

about iPod use and potential hearing losses. Further,

item 66 revealed that there was no consistent form in

which those who wanted more information wished to

receive it. Previous research has shown that young

people may be open to taking steps to protect their

hearing, given an appropriate message and medium

(Chung et al, 2005). Again, although there was no

consistent source, item 67 showed that these college

students would most likely follow the advice of doctors

(35.0%), ‘‘experts’’ (19.5%), audiologists (16.4%), and

manufacturers (12.0%). Young people should be in-

formed that audiologists are hearing health care

experts. Clearly, audiologists, physicians, and manufac-

turers should work together in developing effective


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educational outreach campaigns to this population.

Further analysis of the data using the filtering feature

in Survey Monkey revealed that both iPod users and

nonusers responded similarly on items 57 through 67

regarding their attitudes toward iPod use. The only

exception was for item 57, on which iPod users believed

that regular iPod use for children was acceptable at

slightly younger ages than did nonusers.

Results on the last segment of the questionnaire

provided information about psychosocial issues sur-

rounding iPod use that may be helpful in designing

educational outreach campaigns for college students.

Item 68 again was used to direct iPod users to item 69

and nonusers to item 83, the last question of the

questionnaire. Recall that few of the respondents had

or believed that they had a hearing loss. Because only a

very small segment of this sample (69: 6.2%) thought

that iPod use had contributed to their current hearing

difficulties, we believe that educational messages should

encourage either limiting listening time or turning down

the volume, which was the personal preference for nearly

three-fourths (70: 73.1%) of these iPod users. Further, we

believe that consciousness-raising messages should

suggest that college students not use their iPods in

situations requiring their attention (e.g., driving a

car) because less than a quarter of them believed that

they ever got so focused on listening that they may

have been a hazard to themselves or others (71:

23.1%) or they had ever been in a dangerous

situation like crossing a street or driving and being

unaware of traffic while using their iPods (72:

24.3%). Recall that most of the iPod users surveyed

here indicated earlier on item 49 that they had

listened while being involved in such activities.

Finally, designing effective educational outreach

campaigns requires an understanding of the reasons

behind college students’ iPod use. As expected, items

73 through 82 revealed that most of these college

students used their iPods for listening to music (73:

95.4%), helping them relax (74: 75.4%), isolating

themselves from others (75: 55.0%), concentrating

(77: 46.4%), keeping from bothering others with their

music (79: 77.2%), and easing boredom (80: 73.5%).

Also, some of the respondents said that they used their

iPods as a fashion statement (76: 21.1%), a form of

rebellion (78: 4.0%), or because they were ‘‘high-tech or

gadget junkies’’ (82: 20.2%). Finally, nearly all (81:

90.8%) of the respondents agreed that they used their

iPods because they were convenient.

Further analysis using the filter capability of the

Survey Monkey revealed that of the 377 students in this

nationwide study who said that they were iPod users, 93

(24.7%) of them reported that they usually listen at

volume level 8 or higher. Of these 93 students, 66

(71.0%) used standard earbuds and 79 (83.9%) consid-

ered their typical listening level to be loud or very loud.

Also, 56 (60.2%) said that they set the volume higher for

their favorite songs, 80 (86.0%) did so when in noise, and

71 (76.3%) did so while exercising. Fortunately, only 26

(27.9%) of them said that they listened for three hours or

more a day. Although impossible to prove from a survey

such as this, these individuals appeared to be extreme

users. Because students in this group may be the most

at risk for hearing loss and other injury, they might

benefit from educational outreach programs that are

conducted appropriately for them.

Further, many athletic enthusiasts like runners,

snowboarders, and aerobic sports participants, who like

to exercise to music played very loudly either via

soundfield speakers or directly to the ear through earbuds

and headphones, may also be at higher risks for hearing

loss and other injuries. The combined effects of noise and

aerobic activity have been investigated previously, and

some results have suggested that their synergistic effects

may compound the risk of hearing loss (Nassar, 2001;

Wilson and Herbstein, 2003). This topic requires further

investigation with modern PLDs and headphones.

Item 83 revealed that nearly all (95.8%) of the

participants reported that they were completely honest

in providing information on this survey. If this was true

and these data can be generalized to the greater

population, then their responses should be useful in

helping to determine how many college students are at

risk and for designing effective educational outreach

campaigns promoting safe iPod use and hearing health.

SUMMARY AND CONCLUSIONS

Undeniably, iPods have become a major part of our

culture, especially among persons of college age,

and a source of entertainment and medium for informa-

tion transmission in today’s society. Indeed, judging by

their present popularity, iPod and other PLD use will

continue to grow in the next few years and will

encompass even more aspects of everyday life. For

example, college students may be using these devices to

receive classes via podcasting, and at least three

manufacturers have already developed hearing aids that

incorporate wireless PLD and other broadband stream-

ing capabilities and deliver them directly to the ears of

persons with hearing loss. Apple’s introduction of

iPhones provided users with all the features of iPods

plus telephone reception, Internet access, and movie-

viewing downloads, all through standard earbuds,

further increasing the likelihood that greater numbers

of individuals will use these devices for increasingly

longer periods of time. Although the technological

innovations and possibilities for PLDs are exciting and

seem almost limitless, the comforts and conveniences

provided by them may be offset somewhat for a few users

who are unaware of and/or unwilling to recognize

potential risks and who ignore safe practice guidelines.


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Unless personal responsibility comes with having the

ability to listen to a wide variety of auditory inputs from

numerous sources for hours on end at PLLs delivered

directly to the ear canals, many users of PLDs could

encounter undesirable consequences. Indeed, the per-

sonal privacy provided by PLDs makes it almost

impossible for persons or agencies outside of the

individual to monitor or dictate how they are used.

Based on the subjective results of this comprehensive

national survey of college students and those from the

Zogby International (2006) study of high school stu-

dents and adults, coupled with objective sound pressure

level measurements from PLDs using earbuds and

other types of headphones in conditions of quiet and

background noise (Williams, 2005), it appears that most

users listen in relatively safe ways. However, the results

presented here indicate that there might be a small

segment of the college-aged PLD-using community that

listens to these devices at levels and for durations that

could pose a risk for hearing loss. Further, some

individuals, perhaps unknowingly, use their PLDs in

environments, situations, and activities that may be

hazardous to their own safety and well-being and/or to

that of others around them.

This new technology can provide users with almost

limitless personal access to auditory stimulation for

prolonged periods of time and at PLLs that might

contribute to NISNHL. Several recent investigations

have tried to estimate the risks of hearing loss from

listening to iPods using different types of earphones

(Williams, 2005; Hodgetts et al, 2007). Portnuff and

Fligor (2006) provided warnings stating that users

could listen to iPods safely at 70 percent of full volume

for 4.6 hours per day using the Apple earbuds that come

with these devices. Moreover, these investigators

cautioned that the real risks of hearing loss posed by

iPod listening depend on the type of earphone used and

the level of ambient noise. The riskiest scenario is use of

an earphone like the Apple iPod earbud in noisy

listening situations because these output transducers

do not block out ambient noise, which may cause

listeners to increase the volume to unsafe PLLs in order

to enjoy music. Although it is difficult to determine

exactly how many people are at risk for hearing loss

from iPod use, the results presented here suggest that

there is a small segment of college students who may be

particularly susceptible. Thus, it is important for

professionals to design effective, ‘‘age-appropriate’’

educational outreach programs that are likely to result

in compliance with recommendations for safe use,

particularly for students who may have a high risk for

incurring NISNHL. In addition, other risks include loss

of auditory awareness causing undue distraction in

certain situations (e.g., snowboarding or driving a car)

that may pose dangers to both iPod users and those

around them.

One way to estimate the number of people at risk to

the potential dangers of iPod use is to survey different

segments of the population to determine the need, type,

and content of educational outreach efforts. The Zogby

International (2006) survey of high school students’ and

adults’ use of PLDs precluded generalization to the vast

majority of iPod users, namely, college students who

might have greater risk for hearing loss from extensive

iPod listening compared to other age groups. Moreover,

their questionnaire did not focus specifically on iPod

use. The present nationwide survey of college campuses

produced 609 responses from students who completed

either an online or a paper-and-pencil version of the 83-

item PLDHQ. This study found that approximately two

out of every three college students surveyed here owned

an iPod. Few of these college students seemed to be

using iPods at levels for durations that should dispose

them for excessive risks for hearing loss when listening

in quiet. However, because the majority of iPod users

surveyed used earbud-type earphones and tended to

turn the volume up in noisy situations or when listening

to their favorite songs, all of them could be considered to

be at some potential risk for hearing loss, given the right

combination of these factors. Of even greater concern is

the small subgroup of college students who seemed to be

most at risk because they listened at level 8 or higher for

long durations using earbuds, said that they played

their iPods loud or very loud, and reported that they

may already have had hearing loss that they believed

might be caused by their iPods. Even though many of

the students said that they wore their iPods during the

activities listed in questionnaire item 48 or 49 and some

activities with iPod use may be dangerous (item 58),

responses from item 71 reveal that most disagreed with

the idea that these activities can endanger themselves

or others. Thus, this subgroup should be targeted for

educational campaigns pointing out these risks.

The data presented here are probably representative

of the larger population of college students in the

United States, of which only a small segment is at risk

for hearing loss from iPod use. However, a unique and

synergistic combination of factors (e.g., high ambient

noise levels, increased PLLs while exercising, and use

of earbuds) could increase the likelihood of hearing

loss and/or other injury from iPod use, unless college

students are made aware of these possibilities. The

responses to this questionnaire seemed to indicate

that these students wished to exercise personal

responsibility in choice regarding hearing health care

and that educational outreach campaigns sensation-

alizing the fact that young people should decrease the

volume of their iPods to avoid hearing loss may not

work. Because the majority of these students did not

want additional information about iPods and hearing

loss, the message, messenger, and medium must be

carefully considered in any educational programs


26

directed to them. For example, although most of thesecollege students said that they had listened to their

iPods in dangerous situations, many denied having

done so when asked directly. Our data suggest that

respectful public service announcements made by

physicians and other experts via TV or Internet

directed toward raising young people’s awareness of

possible dangers from iPod use should be employed

rather than lecturing them. Young people also needinformation about the critical role that audiologists

play in hearing health care.

Research on the risks of hearing loss from iPod use is

relatively new. Undoubtedly, researchers around the

world are investigating this issue from many angles

that should lead to more definitive recommendations

for safe iPod use and new methods for estimating the

number of individuals at risk for hearing loss (AAA,2007; ASHA, 2007). Members of affected groups should

participate in the design and dissemination of effective

educational outreach campaigns, especially for the

relatively small subset of users who would be consid-

ered to be most at risk.

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