BMJ Manuscript Hearingloss RicardoXMtz PDF

BMJ Global Health
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Prevalence and global estimates of unsafe listening
practices in adolescents and young adults: A systematic
review and meta-analysis
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Journal: BMJ Global Health

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Manuscript ID bmjgh-2022-010501.R1
Article Type: Original research

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Date Submitted by the
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Author:
Complete List of Authors: Dillard, Lauren; Medical University of South Carolina, Department of
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Otolaryngology Head & Neck Surgery

Arunda, Malachi Ochieng; Lund University, Clinical Sciences
Lopez-Perez, Lucero; World Health Organization, Cluster of Healthier
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Populations
Martinez, Ricardo ; World Health Organization, Cluster of Healthier
Populations
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Jiménez, Lucía; Octoma

Chadha, Shelly; World Health Organization, Department on
Noncommunicable Diseases
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Health policy < Health policies and all other topics, Prevention strategies
< Health policies and all other topics, Public Health < Health policies and
Keywords:
all other topics, ENT diseases < Infections, diseases, disorders, injuries,
Systematic review < Study design
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BMJ Global Health Page 2 of 79
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3 Prevalence and global estimates of unsafe listening practices in adolescents and
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6 young adults: A systematic review and meta-analysis
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10 Lauren K. Dillard, PhDa, Malachi Arunda, PhDb, Lucero Lopez-Perez, PhDc, Ricardo X.
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Martinez, PhDc, Lucía Jiménezd, Shelly Chadha, PhDe
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18 aDepartment of Otolaryngology- Head & Neck Surgery, Medical University of South
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21 Carolina, Charleston, SC, USA
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bDepartment of Clinical Sciences, Lund University, Lund, Sweden
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25 cCluster of Healthier Populations, World Health Organization, Geneva, Switzerland

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dOctoma, México
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eDepartment on Noncommunicable Diseases, World Health Organization, Geneva,
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32 Switzerland
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All correspondence should be addressed to: Lauren K. Dillard, Walton Research
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38 Building, 39 Sabin Street, Charleston, SC 29425, USA. Email: dillalau@musc.edu
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41 Declarations of interest: None

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43 Word count: 4050183
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3 ABSTRACT
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6 Introduction: This study aimed to a) determine prevalence of unsafe listening practices
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8 from exposure to personal listening devices (PLD) and loud entertainment venues in
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10 individuals aged 12-34 years, and b) estimate the number of young people that could be
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at risk for hearing loss from unsafe listening worldwide.
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15 Methods: We conducted a systematic review and meta-analysis to estimate prevalence
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17 of unsafe listening practices from PLDs and loud entertainment venues. We searched 3
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databases for peer-reviewed articles published between 2000 and 2021 that reported
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22 unsafe listening practices in individuals aged 12-34 years. Pooled prevalence estimates
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24 (95% confidence interval [CI]) of exposed populations were calculated via random
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26 effects models or ascertained from the systematic review. The number of young people
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29 that could be at risk for hearing loss worldwide was estimated from the estimated global
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31 population aged 12-34 years, and best estimates of exposure to unsafe listening
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33 ascertained from this review.
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Results: Thirty-three studies (corresponding to data from 35 records and 19,046
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38 individuals) were included. Seventeen and eighteen records focused on PLD use and
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40 loud entertainment venues, respectively. The pooled prevalence estimate of exposure
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to unsafe listening from PLDs was 23.81% [CI 18.99 – 29.42]. There was limited
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45 certainty (p>0.50) in our pooled prevalence estimate for loud entertainment venues.
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47 Thus, we fitted a model as a function of intensity thresholds and exposure duration to
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49 identify the prevalence estimate as 48.20%. The global estimated number of young
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52 people that could be at risk of hearing loss from exposure to unsafe listening practices
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54 ranged from 0.67 – 1.35 billion.
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59 2
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3 Conclusions: Unsafe listening practices are highly prevalent worldwide and may place
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6 over one billion young people at risk for hearing loss. There is an urgent need to
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8 prioritize policy focused on safe listening. The World Health Organization provides
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10 comprehensive materials to aid in policy development and implementation.
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15 KEYWORDS: hearing loss, noise-induced hearing loss, global health, policy
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3 KEY MESSAGES
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7 What is already known on this topic
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10 Voluntary recreational noise exposure, or unsafe listening, is a modifiable risk factor for
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13 hearing loss in young people and may increase risk of hearing loss in aging. Estimates
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15 of the prevalence of unsafe listening practices or of the global caseload of young people
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17 engaging in unsafe listening practices are not available in published literature although
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such estimates are needed to promote policy implementation to reduce risk of hearing
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22 loss in young people.

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25 What this study adds

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29 Results from this study indicate that unsafe listening practices from use of personal
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31 listening devices and attendance of loud entertainment venues are common
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33 (prevalence estimates 23.81%, 48.20%, respectively) and may place up to 1.35 billion
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36 young people at risk for hearing loss worldwide.
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39 How this study might affect research, practice or policy
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These data will be used to communicate the urgent need to implement policy that
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45 promotes safe listening habits to governments, industry, civil society, and other relevant
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47 stakeholders. The World Health Organization has publicly available standards,
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recommendations, and toolkits to aid in development and implementation of policy and
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52 public health initiatives to promote safe listening worldwide.
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3 INTRODUCTION
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6 Hearing loss is a public health concern that deserves global recognition and
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8 prioritization. The World Health Organization (WHO) estimates over 430 million people
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10 worldwide have disabling hearing loss and that its prevalence may almost double if
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hearing loss prevention is not prioritized.[1] Recreational noise exposure is a modifiable
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15 risk factor for hearing loss, and in 2015, the WHO estimated 1.1 billion adolescents and
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17 young adults were at potential risk of hearing loss from voluntary recreational noise
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exposure, referred to henceforth as ‘unsafe listening practices.’[2] This exposure is
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22 largely attributable to use of personal listening devices (PLD; e.g., mobile phones, mp3
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24 players) and/or from attendance of loud entertainment venues (e.g., discotheques, bars,
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26 clubs).[3] Importantly, unsafe listening behaviors are likely modifiable with
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29 implementation of existing policy recommendations and known public health
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31 practices.[3]
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33 Recurrent or even single instances of unsafe listening may cause physiological
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damage to the auditory system, presenting as transient or permanent tinnitus and/or
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38 changes to hearing.[4-6] Damage from unsafe listening can compound over the life
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40 course, and noise exposure earlier in life may make individuals more vulnerable to age-
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related hearing loss.[7-8] Importantly, hearing loss, when it is unaddressed, has sizable
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45 economic costs estimated at almost 1 trillion annual US dollars,[1] and has serious
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47 impacts on individuals and families. In children, hearing loss and/or noise exposure has
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49 been associated with poorer academic performance and reduced motivation and
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52 concentration,[9-10] which may lead to a trajectory of limited economic mobility later in
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54 life. In adults, hearing loss has been associated with poorer psychosocial well-being,
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3 lower income, and serious co-morbid health conditions such as cognitive
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6 impairment.[11]. Tinnitus also has important impacts on the health and well-being of
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8 individuals and is associated with poorer quality of life.[12]
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10 Unsafe listening practices are common worldwide, particularly among
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adolescents and young adults, given high availability of PLDs and scarce enforcement
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15 of regulatory measures for PLDs and entertainment venues.[13] Risk of hearing loss
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17 depends on the loudness, duration, and frequency of noise exposure. Permissible levels
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of recreational noise exposure are The maximum permissible level of leisure noise
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22 exposure is often calculated from equivalent occupational noise exposure limits (e.g., 80
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24 decibels [dB] for 40 hours a week or 85 dB for 40 hours a week)[4], which vary slightly
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26 by region and/or by regulatory agencies or organizations.[14] the equivalent of 80
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29 decibels (dB) for 40 hours a week,[4] and exposures that exceed these levels place
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31 individuals at higher risk of hearing loss. Sound intensity (dB) is measured on a
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33 logarithmic scale and thus there is a time-intensity tradeoff (tradeoff exchange rate) (3
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dB increase for halving the time) for permissible levels and duration of exposure,
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38 meaning that permissible levels change drastically by sound level. For example, based
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40 on a maximum permissible level of noise exposure of 80 dB for 8 hours a day (40
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hours/week) with a 3 dB exchange rate, the the permissible exposure time of a 920 dB
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45 sound is 2.5.5 hours, of a 985 dB sound is 47 minute38 minutess, and of a 1010 dB
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47 sound is only 195 minutes.[4,15] PLD users commonly choose volumes as high as 105
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49 dB and average sound levels at entertainment venues range from 104 to 112 dB,[164]
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52 therefore exceeding permissible levels even for very short periods of time. These
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54 findings suggest that many young people are likely at risk for developing permanent
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3 hearing loss. Some systematic reviews on unsafe listening practices have been
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6 conducted although estimates of prevalence and global burden of exposure are not
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8 available in published literature.[175-197] Global prevention efforts would benefit from
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10 data on the prevalence and global burden of unsafe listening practices to effectively
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communicate the need for preventative intervention to governments, industries, and
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15 other stakeholders responsible for implementing policy.
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17 The importance of hearing loss prevention is gaining traction on the global
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agenda,[1, 2018] making now a particularly important time to prioritize interventions to
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22 prevent hearing loss. The aims of this systematic review and meta-analysis were to a)
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24 determine the prevalence of unsafe listening practices from PLD use and attendance of
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26 loud entertainment venues in adolescents and young adults, and b) create a global
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29 estimate of the number of adolescents and young adults likely to be at risk of hearing
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31 loss from unsafe listening practices.
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METHODS
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38 Search strategy and selection criteria
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40 This systematic review and meta-analysis was conducted under the Preferred
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Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
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45 guidelines.[1921] Peer-reviewed manuscripts published in English, Spanish, French, or
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47 Russian languages between years 2000 and 2021 that were case-control cross-
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49 sectional or cohort studies were eligible for inclusion.
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52 Manuscripts must have contained information on human subjects aged from 12-
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54 34 years. Studies focused on PLDs must have reported objectively measured device
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59 7
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3 output levels and time of exposure. This information was used to define prevalence of
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6 unsafe listening practices (or risk of hearing loss) as equivalent to exceeding
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8 permissible levels (e.g., >80 dB(A) for 40 hours a week).[4] Sound output levels
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10 measured at a single time point were presented as equivalent continuous levels (LAeq),
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which is the integrated, normalized sound pressure divided by the duration of the signal,
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15 representing the average total energy of the measured sound. The LAeq is presented
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17 corresponding to daily or weekly maximum permissible levels (e.g., >80 or >85 dB).
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Studies focused on loud entertainment venues must have reported participants’
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22 attendance to venues at least one time per month. Study samples must have been
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24 representative of the general population. For example, studies focused only on staff
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26 members working at loud entertainment venues were not eligible for inclusion.
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29 The databases PubMed, Web of Science (core collection) and Scopus were
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31 searched in English in December 2021 using a combination of MeSH terms and key
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33 words (Supplement 1). Two separate searches were conducted, one for PLD use and
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one for entertainment venues. Reference lists of included articles were searched for
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38 potentially eligible articles, and studies that cited included articles (listed on Google
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40 Scholar) were considered for eligibility.
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Studies in Spanish, French and Russian were ‘hand-searched’ using translated
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45 search terms and were assessed for eligibility by speakers of those languages. Trial
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49 Selection process and data extraction
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52 Several reviewers extracted papers from the three databases (based on
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54 language of papers) and a single reviewer removed duplicates and completed the title
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3 and abstract screen based on eligibility criteria. References were exported to Mendeley,
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6 and full text articles were shared with all study team members. The study team agreed
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8 on inclusion of all articles and any differences in inclusion/exclusion were reconciled via
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Data extraction tables were developed by WHO biostatisticians. Extracted data
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15 included a) meta-study information (e.g., authors, year of publication, journal, country,
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17 country income level), b) sample characteristics (e.g., age, sex, population, sample
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size), c) prevalence of exposure to PLDs or loud entertainment venues that exceeded
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22 permissible sound levels, and d) definitions of noise exposure and related

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24 measurements. Data were extracted by multiple reviewers and verified for accuracy by
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26 a separate reviewer. If duplicate data were included in eligible studies, we used the
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29 study with the best available data (i.e., fit best with outcome of interest and target
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31 population). The primary outcome was the prevalence of the study population exposed
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(e.g., >80 dB LAeq for PLDs; attendance of loud entertainment venues ≥1 time per
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38 month).
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40 Risk of bias assessment
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A modified version of the Quality Assessment of Diagnostic Accuracy Studies
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45 (QUADAS) scale was used to assess risk of bias for each study, based on the following
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47 categories: selection, study design, performance of data collection tools, completeness,
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49 and reporting bias. For each study, these categories were ranked as strong, moderate,
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52 or weak, which corresponded to presenting a low, moderate, or high risk of bias,
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54 respectively. Studies were assigned an overall rating of a) weak if they were ranked as
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3 weak in at least one category, b) moderate if they had 0 rankings of weak and <2
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6 rankings of strong, and c) strong if they had 0 rankings of weak and ≥2 rankings of
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8 strong. Sensitivity analyses evaluated pooled prevalence estimates after a) excluding
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10 each study, individually, from analyses, b) excluding studies considered to be weak (i.e.,
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high risk of bias), and c) excluding studies considered to be weak and that defined risk
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15 with a definition classified as ‘other.’
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17 Data analysis
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Subgroup analyses by age category (adults: 18-34 years, minors: 12-19 years,
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22 mixed: 12-34 years), region and country income level were undertaken. Age was
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24 categorized based on age categories defined in included studies. Region was defined
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26 by the WHO classification,[2022] and country income level was defined by the World
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29 Bank.[231] Two categories of income were applied, 1) high income: ≥$12,696 gross
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31 national income (GNI) per capita, or 2) middle- income (including low-middle and high-
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33 middle income countries): between $4,096 to $12,695 GNI per capita.
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Following the corresponding Cochrane’s Q (chi-square) and I2 statistics
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38 suggesting a large dispersion of effect sizes and a large amount of heterogeneity
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40 (between studies), we used random effects estimates to determine pooled prevalence
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of exposure and corresponding 95% confidence intervals (95% CI). Varying but
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45 considerable heterogeneity was found in all subsequent subgroup analyses, warranting
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47 use of random effects estimates for all subgroup analyses. Analysis was conducted with
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49 Comprehensive Meta-Analysis software (CMA 3.3). The study protocol was not
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52 registered prior to study completion.
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59 10
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3 Global estimate of individuals at risk of hearing loss from unsafe listening
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6 practices
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8 The global number of individuals that could be at risk of developing hearing loss
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10 from exposure to PLDs or loud entertainment venues (i.e., unsafe listening practices)
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was estimated by considering a) the estimated global population aged 12-34 in year
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15 2022,[242] and b) the best estimates of exposure to unsafe listening practices from
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17 PLDs or loud entertainment venues ascertained from this systematic review. We
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present the estimated global population of individuals at risk of hearing loss from unsafe
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22 listening practices as a range, utilizing prevalence estimates of exposure to both unsafe

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26 Patient and public involvement statement
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29 Patients or the public were not involved in the design, conduct, or reporting of this
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31 systematic review and meta-analysis.
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RESULTS
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38 A total of 389 non-duplicate citations were identified by using the selected
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40 keywords. After the final review, 33 articles were eligible for inclusion in this study. The
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study selection process is shown in Figure 1.
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45 Pertinent study characteristics are displayed in Table 1. A total of 35 records
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47 from 33 studies corresponding to data from 19,046 individuals were included.[5, 253-
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49 553] Seventeen records focused on PLD use (n=8,987 participants) and 18 records
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52 focused on loud entertainment venues (n=9,702 participants). Studies were from 21
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54 countries corresponding to representation from African (n=1), Americas (n=12),
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59 11
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3 European (n=15), Middle East (n=2) South-East Asian (n=1) and Western Pacific (n=4)
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6 regions. Twenty-six and 9 study records were from high income and middle-income
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8 (upper or lower) countries, respectively. Sixteen study records focused on adults, 10
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10 focused on minors, and 9 focused on mixed age groups (adults and minors). The
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pooled samples had even distributions by gender (49% females, 51% males).
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15 Table 1. Pertinent study characteristics for all studies in the systematic review.
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Country
18 Age Number, Number,
First author (year) (Income Risk criteria
19 category sample size exposed
Level)
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21 Personal Listening Devices
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23 Israel Daily (LAeq
Muchnik (2012) Minors 74 22
24 (High) >80dB)
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26 Germany Weekly (LAeq
Twardella (2017) Minors 2143 579
27 (High) >80dB)
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29 Netherlands Weekly (LAeq
Vogel (2010a) Minors 1510 487
(High) >80dB)
or
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Malaysia Daily (LAeq
32 Sulaiman (2013) Minors 177 15
(Middle) >80dB)
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34 Malaysia Daily (LAeq

35 Sulaiman (2015) Adults 282 22
(Middle) >80dB)
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37 United States
38 Weekly (LAeq
Fligor (2014) of America Adults 110 72
>80dB)
39 (High)
40
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41 Canada Daily (LAeq

Lévesque (2010) Minors 124 52
42 (High) >85dB)
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44 Singapore Daily (LAeq

Lee (2014) Mixed 1928 316
45 (High) >85dB)
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Chile Daily (LAeq
47 Breinbauer (2011) Mixed 562 67
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(High) >85dB)
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49 United States
50 Hussain (2018) of America Adult 50 11 Other1
51 (High)
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53 Kaplan-Neeman Israel Daily (LAeq
Adult 40 9
54 (2017) (High) >85dB)
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59 12
1
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3
4 United States
Hutchinson Marron
5 of America Adult 164 7 Other1
(2015)
6 (High)
7
Orozco Medina Mexico
8 Adult 40 22 Other1
(2017) (Middle)
9
10 Republic of
11 Daily (LAeq
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Kim (2021) Korea Adult 40 9
12 >85dB)
(High)
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14 India
Kumar (2017) Mixed 100 41 Other1
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15 (Middle)
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Vogel (2014) Mixed 943 287
18 (High) >80dB)
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20 Switzerland
Mercier (2002) Mixed 700 121 Other1
21 (High)
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Loud Entertainment Venues
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≥1x / month;
25 Netherlands
Vogel (2014) Mixed 943 454 LAeq ≥80 dB for
26 (High)
≥56 hour / week
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28 ≥1x / week;
29 Switzerland
Mercier (2002) Mixed 700 553 LAeq ≥87 dB for
(High)
or
30 ≥40 hour / week

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32 United States
33 LePrell (2013) of America Adults 87 36 ≥1x / month
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34 (High)
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36 United States
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38 (High)
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Figueroa México
40 Mixed 205 159 ≥1x / month
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Hernández (2011) (Middle)

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42 Canada
43 Ahmed (2007) Mixed 150 46 ≥1x / month
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(High)
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45 ≥1x / month;
46 Netherlands
Vogel (2010b) Minors 1512 267 LAeq ≥85 dB for
47 (High)
≥40 hour / week
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49 Argentina
Serra (2005) Minors 106 67 ≥1x / month
50 (Middle)
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52 Rosanowski Germany
Adults 88 69 ≥1x / month
53 (2006) (High)
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Sweden
55 Widén (2004) Minors 1238 350 ≥1x / month
(High)
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59 13
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4 Finland
Jokitulppo (2005) Adults 1054 437 ≥1x / month
5 (High)
6
South Africa
7 Deegest (2014) Adults 151 54 ≥1x / month
(Middle)
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9 Austria
10 Weichbold (2012) Minors 1294 787 ≥1x / month
(High)
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12 Argentina
13 Serra (2014) Minors 172 58 ≥1x / month
(Middle)
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15 Belgium
Gilles (2012) Adults 145 92 ≥1x / month
16 (High)
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18 Serbia
Budimčić (2014) Adults 780 609 ≥1x / week
19 (Middle)
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Slovakia
21 Filova (2020) Adults 1003 437 ≥1x / month
nt
(High)
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23 United
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Johnson (2014) Kingdom Adults 357 165 ≥1x / week

25 (High)
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27
:F
28 Table Note. Adults (18-34 years); Minors (12-19 years); Mixed (12-34 years). LAeq=
29 equivalent continuous sound pressure level is the constant noise level that would result
or
30 in the same total sound energy being produced over a given period.
31 1Studies specified duration of exposure and objectively measured intensity but did not
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explicitly state a standard permissible exposure limit.
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Personal Listening Devices
36
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37 The pooled prevalence estimates of exposure to excessive noise from PLDs was
38
39 23.81% [CI 18.99 – 29.42]. Figure 2 is a forest plot showing point estimates from each
40
w
41
study and the pooled prevalence estimate. Table 2 displays the pooled prevalence
42
43
On
44 estimates of exposure to excessive noise from PLDs, overall, and by subgroups age
45
46 category, income group and details of risk criteria. Prevalence estimates were similar for
47
ly
48 age categories (adult: 23.10% [CI 8.90 – 48.03]; minors: 27.10% [CI 21.25 – 33.88];
49
50
51 mixed: 21.55% [CI 14.65 – 30.53]) and income group (high: 24.51% [CI 19.35 – 30.53];
52
53 middle: 22.12% [CI 7.15 – 51.17]) although the middle-income group showed
54
55 substantial variability. Prevalence estimates were (non-significantly) highest in studies
56
57
58
59 14
1
2
3 using definitions of weekly exposure LAeq > 80 dB (36.37% [CI 29.18 – 44.22] as
4
5
6 compared to definitions measuring daily exposure (LAeq > 80 dB (12.95% [CI 5.10-
7
8 29.20]; LAeq > 85 dB (21.36% [CI 13.50 – 32.09]) or using other definitions (23.15% [CI
9
10 11.28 – 41.67]).
11
Co
12
13
14
nf
15 Table 2. Pooled prevalence estimates of exposure to excessive noise from personal
16 listening devices (PLDs). Estimates are presented overall and stratified to age, income
17 level, and risk criteria definition.
ide
18
19
21
nt
22 Effect size, 95% confidence interval Test of null (2-Tail)

23 Number,
24 records Point estimate Lower limit Upper limit P-value
ial
25
26 Pooled prevalence 17 23.81% 18.99% 29.42% p < 0.01
27
:F
28 Age Category
29
or
30 Adults 7 23.10% 8.90% 48.03% p < 0.01

31
32
33 Minors 5 27.10% 21.25% 33.88% p < 0.01
Re
34
35
36 Mixed 5 21.55% 14.65% 30.53% p < 0.01
vie
37
38 Income group
39
40
w
High income 13 24.51% 19.35% 30.53% p < 0.01

41
42
43 Middle income (upper
On
4 22.12% 7.15% 51.17% p < 0.01

44 + lower middle)
45
46 Risk criteria definition
47
ly
48 Daily (LAeq >80dB) 3 12.95% 5.10% 29.20% p < 0.01

49
50
51 Daily (LAeq >85dB) 5 21.36% 13.50% 32.09% p < 0.01
52
53
54 Weekly (LAeq >80dB) 4 36.37% 29.18% 44.22% p < 0.01
55
56
57
58
59 15
1
2
3
4 Other1 5 23.15% 11.28% 41.67% p < 0.01
5
6
7 Table Note. Adults (18-34 years); Minors (12-19 years); Mixed (12-34 years). High
8
9
income: ≥ $12,696 gross national income (GNI) per capita; middle- income (including
10 low-middle and high-middle income countries): between $4,096 to $12,695 GNI per
11 capita, according to World Bank Income group classification FY22.[231] LAeq=
Co
nf
15
16
17
ide
18
19 Our risk of bias assessment revealed that for the 17 studies focused on PLDs, 5
20
21 (29%) were rated as strong, 8 (47%) as moderate and 4 (24%) as weak (Supplement
nt
22
23
24
2). Sensitivity analyses evaluated changes in pooled prevalence estimates after
ial
25
26 removing each study, individually, from analyses. The prevalence estimates and
27
:F
28 confidence intervals were stable (<2% change) after removal of each study, indicating
29
or
30 pooled prevalence estimates were insensitive to individual study inclusion. Sensitivity

31
32
33 analyses removing a) studies with a high risk of bias (i.e., rated as ‘weak’), and b)
Re
34
35 studies with a high risk of bias and with a risk criterion classified as ‘other’ did not return
36
vie
37 substantially different estimates as compared to the estimate using data from all studies
38
39
40 (23.81% [CI 18.99- 29.42]) (results not shown).
w
41
42 Loud Entertainment Venues
43
On
44 The pooled prevalence estimate for exposure to excessive noise from loud
45
46
entertainment venues was calculated from the 18 studies in the systematic review but
47
ly
48
49 there was limited certainty (p>0.50) in our estimate. Thus, estimates (including
50
51 subgroup analyses) calculated from the 18 studies are not presented.
52
53 The risk of bias assessment revealed that for the 18 studies focused on loud
54
55
56 entertainment venues, 2 (11%) were rated as strong, 12 (67%) as moderate and 4
57
58
59 16
1
2
3 (22%) as weak (Supplement 2). Sensitivity analyses that removed a) studies with a high
4
5
6 risk of bias (i.e., rated as ‘weak’), and b) studies with a high risk of bias and with risk
7
8 criteria classified as ‘attending a loud entertainment venue at least once a week’ were
9
10 conducted but also yielded estimates with limited certainty (results not shown).
11
Co
12
13
Therefore, ad hoc analyses aimed to reduce heterogeneity across studies by
14
nf
15 considering only studies that equated intensity and duration of sound levels to LAeq
16
17 values. There were three studies that met this criterion,[275, 4038, 4139] all of which
ide
18
19
used slightly different definitions to define risk (LAeq ≥80 dB for ≥56 hours/week; LAeq
20
21
nt
22 ≥90 dB for ≥40 hours/week; LAeq ≥87 for ≥40 hours/week). Several steps were taken to
23
24 select the preferred prevalence estimate used to compute the global estimate of
ial
25
26 individuals at risk from unsafe listening practices (described in Supplement 3).
27
:F
28
29 The chosen quadratic model was a very good fit for all the studies, with a higher
or
30
31 quadratic dependence on intensity than on duration (Figure S3b of supplement 3);
32
33 Prev(x,y) = -5.3E-0.5x2+6.2E-05xy+0.003y2-0.56y+25.85. The model was then used to
Re
34
35
36
approximate a prevalence of 48.20% for an intensity threshold of 80 dB and duration
vie
37
38 threshold of 40 hours per week.
39
40 Thus, to estimate the number of individuals at risk of hearing loss from unsafe
w
41
42
listening, we utilized the estimated prevalence of 48.20% of exposure to excessive
43
On
44
45 noise from loud entertainment venues given that this estimate: a) accounts for duration
46
47 and level of exposure, b) was consistent (of the studies in Supplement 3) with the WHO
ly
48
49 definition of excessive noise exposure based on permissible sound pressure levels of
50
51
52 80 dB for 40 hours per week (WHO, 2015), and c) that prevalence estimates for the
53
54 three studies that had values of duration and intensity were commensurate.
55
56
57
58
59 17
1
2
3 Heterogeneity & publication bias
4
5
6 The I2 statistics for studies on PLD use and loud entertainment venues were 96.2
7
8 and 98.8, respectively, indicating a high amount of heterogeneity among studies. Funnel
9
10 plots of standard error by logit event rate (not shown) were symmetric and thus did not
11
Co
12
13
suggest publication bias.
14
nf
16
17 practices
ide
18
19
Estimates are shown in Table 3. In 2022, the estimated global population aged 12-34
20
21
nt
22 years was 2.8 millionbillion.[242] We utilized the pooled prevalence estimate of

23
24 exposure to excessive noise from PLDs ascertained from this systematic review and
ial
25
26 meta-analysis (23.81% [CI 18.99 – 29.42]). For loud entertainment venues, we utilized
27
:F
28
29 the prevalence estimate (48.20%) described above. Therefore, the global estimated
or
30
31 number of adolescents and young adults at risk of hearing loss from voluntary exposure
32
33 to unsafe listening practices ranges from 0.67 – 1.35 billion.
Re
34
35
36
Table 3: Estimated global population of individuals exposed to recreational noise from
vie
37 personal listening devices or entertainment venues

38
39 Number, exposed
Prevalence (95% number, exposed Prevalence,
40 Global population to loud
CI), exposed to to personal exposure to loud
w
41 aged 12-34 yrs entertainment

personal listening listening devices entertainment
42 (billions) venues
devices (billions) venues
(billions)
43
On
23.81%
44 2.795 0.665 48.20% 1.347
(18.99 - 29.42)
45
46 Table Note. Global population data are from the United Nations World Population
47 Prospects 2019.[242]
ly
48
49 DISCUSSION
50
51 Results from this systematic review and meta-analysis demonstrate that unsafe
52
53
54 listening practices are highly prevalent among adolescents and young adults and that
55
56 an estimated 0.67 – 1.35 billion individuals worldwide may be at risk for hearing loss
57
58
59 18
1
2
3 from voluntary unsafe recreational listening practices. These findings highlight the
4
5
6 urgent need to implement policy focused on safe listening habits worldwide in order to
7
8 promote hearing loss prevention.
9
10 Increased exposure to unsafe listening practices may be one cause of increasing
11
Co
12
13
prevalence of hearing loss in children.[564-575] However, previous studies have
14
nf
15 reported inconclusive findings on associations between unsafe listening practice and
16
17 permanent changes to hearing.[586] Evidence showing consistent associations of
ide
18
19
adolescent recreational noise exposure and permanent hearing loss is sparse, and the
20
21
nt
22 potential dose-response relationship of recreational noise exposure and associated

23
24 hearing loss is not understood. While some studies have not observed associations
ial
25
26 between recreational noise exposure and permanent hearing loss,[597-6058] others
27
:F
28
29 have indicated that use of PLD for extended periods of time can result in changes to
or
30
31 hearing thresholds.[6159] Inconsistencies in existing research are likely in part because
32
33 hearing loss is incremental and progressive, thus making it difficult to capture short-term
Re
34
35
36
effects of noise exposure in adolescents. Well-designed epidemiological studies are
vie
37
38 needed to evaluate effects of early-life recreational noise exposure on hearing
39
40 throughout the life course and to identify relevant risk factors associated with unsafe
w
41
42
listening practices.
43
On
44
45 Despite some inconsistent research on associations of recreational noise
46
47 exposure and permanent changes to hearing in adolescence, studies conducted in
ly
48
49 animals and human subjects have provided compelling evidence for the biological
50
51
52 plausibility of associations, demonstrated by the physiological impacts of loud noise
53
54 exposure on the auditory system. Studies have indicated that repeated or even single
55
56
57
58
59 19
1
2
3 instances of loud noise exposure may lead to physiological damage that present as
4
5
6 temporary hearing loss (temporary threshold shifts) that resolve within several hours or
7
8 days, or acute tinnitus, both of which may be predictive of permanent hearing
9
10 damage.[5, 6, 497, 620, 631] Similarly, repeated or single exposures to noise and
11
Co
12
13
temporary threshold shifts have been tied to the presence of ‘hidden hearing loss’ also
14
nf
15 known as cochlear synaptopathy, which can be defined as damage to or a loss of
16
17 synaptic contacts between cochlear hair cells and auditory nerve fibers that can exist
ide
18
19
without permanent changes to audiometric thresholds.[642] Temporary threshold shifts
20
21
nt
22 and hidden hearing loss likely serve as predictors for irreversible, permanent hearing
23
24 loss and may present as difficulties hearing in challenging listening environments, such
ial
25
26 as in background noise. Studies have indicated that mechanisms of noise-induced
27
:F
28
29 hearing loss include damaged synapses, destruction of the sensory cells in the cochlea,
or
30
31 and intense metabolic activity at the cellular level which leads to raised levels of
32
33 cochlear free radicals, eventually leading to programmed and/or necrotic cell
Re
34
35
36
death.[642-675] These physiological changes likely result in progressive and
vie
37
38 incremental, yet permanent, changes to hearing thresholds and/or the onset of
39
40 tinnitus.[6668]
w
41
42
The detrimental impacts of noise exposure on auditory and non-auditory health
43
On
44
45 have been described and unsafe listening practices are recognized as an important
46
47 global public health problem.[4] In 2015, the WHO launched the ‘Make listening safe’
ly
48
49 initiative to ensure people of all ages can enjoy listening with full protection of their
50
51
52 hearing.[697] This initiative aims to modify unsafe listening behaviors and regulate and
53
54 limit (when necessary) voluntary exposure to loud sounds from PLDs and other loud
55
56
57
58
59 20
1
2
3 recreational settings, including from entertainment venues. Make listening safe
4
5
6 prioritizes educating the general population, policymakers, health professionals, and
7
8 manufacturers about the importance of safe listening practices that are needed to
9
10 prevent hearing loss. The WHO and its partners have released several publicly
11
Co
12
13
available resources in multiple languages that can be adapted to specific settings,
14
nf
15 including awareness materials for individuals,[2] a depository of open-access resources,
16
17 and the standards and toolkits briefly discussed below. The WHO offers support to
ide
18
19
Member States, private sector entities and civil society in adopting and implementing
20
21
nt
22 these standards and toolkits, and promotes partnerships that will encourage
23
24 implementation of make listening safe.
ial
25
26 In 2018, the WHO and International Telecommunication Union (ITU) released
27
:F
28
29 global standards for safe listening devices and systems to define suitable exposure
or
30
31 limits and safety standards for listening devices/systems and this resource also details
32
33 implementation strategies.[6870] Some recommendations for device safety standards
Re
34
35
36
include use of, a) sound measurement functions to track the level and duration of sound
vie
37
38 exposure, b) individualized listening profiles to inform users of their listening practices
39
40 and provide relevant cues to action, and c) device volume limiting options such as
w
41
42
automatic volume reduction and password-protected controls. Other recommendations
43
On
44
45 include information provision via packaging and advertising, and use of earphones that
46
47 provide some attenuation of ambient noise (i.e., so volume is not increased by users to
ly
48
49 overcome ambient noise levels). The WHO toolkit for safe listening devices and
50
51
52 systems provides a user-friendly summary and a stepwise approach for governments,
53
54 industry, and civil society to implement these standards.[3]
55
56
57
58
59 21
1
2
3 This year, the WHO released the gGlobal standard for safe listening venues and
4
5
6 events, which .[13] This standard aims to protect hearing of audience members at
7
8 recreational venues such as discotheques, bars, concerts, and festivals by providing
9
10 standardized, evidence-based recommendations and implementation strategies to
11
Co
12
13
reduce risk of unsafe noise exposure.[13] Six The ‘features’ are detailed in this
14
nf
15 standard that can be implemented through governmental legislation or regulation,
16
17 and/or by voluntary adoption by venue owners or managers. The first feature specifies
ide
18
19
that venues should have an upper limit of 100 dB LAeq and the second feature
20
21
nt
22 recommends active sound level monitoring to ensure compliance with this limit. The
23
24 third feature recommends optimization of venue acoustics and sound systems to ensure
ial
25
26 safe listening. The fourth and fifth features recommend provision of hearing protection
27
:F
28
29 (e.g., earplugs) and designated quiet zones at the venue/event. The sixth feature
or
30
31 recommends provision of educational trainings and information aimed at staff and
32
33 audiences on the importance of safe listening and practical steps to achieve it.
Re
34
35
36
Also this year, the WHO released the mSafeListening handbook, which provides
vie
37
38 details needed to develop, integrate, implement, and evaluate a national
39
40 mSafeListening program to promote hearing loss prevention and promotes the use of
w
41
42
digital interventions.[6971] The mSafeListening program is part of the ‘Be He@lthy, Be
43
On
44
45 Mobile’ (BHBM) initiative, which promotes use of digital interventions to strengthen
46
47 health systems. Governmental leadership is needed to develop mSafeListening
ly
48
49 programs, which should be incorporated into national or sub-national digital health
50
51
52 programs. The BHBM provides support to governments in creating and implementing
53
54
55
56
57
58
59 22
1
2
3 mSafeListening programs by, for example, providing guidance on program design,
4
5
6 fundraising and evaluation, and providing topic-specific toolkits and technical support.
7
8 In addition to recommendations and standards for governments, industry, and
9
10 civil society, the WHO provides educational resources that can be used by the general
11
Co
12
13
public.[2, 7072] Recommendations for safe listening focus on reducing sound levels and
14
nf
15 duration of exposure, monitoring listening levels (i.e., through device settings), use of
16
17 hearing protection, and heeding the early signs of hearing loss, such as tinnitus and
ide
18
19
difficulties understanding in background noise.
20
21
nt
22 Findings from this study support the need to implement the above policy
23
24 recommendations. Prevalence estimates of exposure to excessive noise from PLD use
ial
25
26 and loud entertainment venues were high. However, high study heterogeneity was
27
:F
28
29 present and was particularly salient in studies focused on loud entertainment venues.
or
30
31 The heterogenous methodologies and definitions used in these studies likely
32
33 contributed to the low confidence (i.e., higher p-values) in pooled prevalence estimates
Re
34
35
36
that were created using all studies in the systematic review (data not shown). These
vie
37
38 results highlight the need to reduce heterogeneity of measurement and outcome
39
40 definitions in studies focused on exposure to unsafe listening. Thus, it is recommended
w
41
42
that future studies focused on unsafe listening practices use internationally standardized
43
On
44
45 definitions of excessive recreational noise exposure and measure sound exposure
46
47 using standardized methodology.
ly
48
49 There are likely demographic (e.g., by gender, age, rurality) and personal
50
51
52 differences in risk perception and preferences and engagement in risky behaviors,
53
54 including voluntary recreational noise exposure.[520, 731, 742] This notion is supported
55
56
57
58
59 23
1
2
3 by pooled prevalence estimates of exposure to excessive noise from PLDs stratified to
4
5
6 age group, which suggest that minors (versus adults) may be slightly more likely to be
7
8 exposed to unsafe listening from PLDs. We were unable to evaluate potential
9
10 differences across other demographic strata, such as gender or rurality given the
11
Co
12
13
limitations of data reported in the studies included in the systematic review. Our
14
nf
15 estimate of the global population likely exposed to unsafe listening levels was crude yet
16
17 was created with the most current and best available data.
ide
18
19
Strengths and limitations
20
21
nt
22 To our knowledge, this review is the first published article to estimate prevalence
23
24 of exposure to unsafe listening practices in adolescents and young adults and its global
ial
25
26 burden. These estimates are needed to communicate the urgency of prioritizing hearing
27
:F
28
29 loss prevention to governments, industries, and other stakeholders responsible for
or
30
31 implementing policy. However, some limitations exist. This systematic review and meta-
32
33 analysis are limited by the heterogeneity and lack of standardized research
Re
34
35
36
methodology of the studies included. As mentioned above, there was particularly high
vie
37
38 heterogeneity in studies focused on loud entertainment venues. Although we conducted
39
40 the literature search in four languages, there may be published articles in other
w
41
42
languages that were not captured in this systematic review. Most studies were from
43
On
44
45 European and American regions and thus may not be reflective of unsafe listening
46
47 practices in other regions. There were not studies from low-income countries eligible for
ly
48
49 inclusion in the meta-analysis and therefore the estimates of prevalence or global
50
51
52 burden may not capture unsafe listening practices in low-income countries. However, it
53
54 is likely that the prevalence of unsafe listening practices is high in low-income countries
55
56
57
58
59 24
1
2
3 given limited policies and regulations on noise exposure limits.[13] Our global estimate
4
5
6 of exposed individuals was crude and did not account for some potentially influential
7
8 factors, such as demographic factors and recent changes to policy on safe listening in
9
10 some countries/regions.
11
Co
12
13
14
nf
15 CONCLUSION
16
17 Exposure to unsafe listening practices from voluntary use of PLDs and
ide
18
19
attendance of loud entertainment venues is highly prevalent in adolescents and young
20
21
nt
22 adults. It is estimated that 0.67 – 1.35 billion adolescents and young adults worldwide
23
24 may be at risk for hearing loss from exposure to unsafe listening practices. There is an
ial
25
26 urgent need for governments, industry, and civil society to prioritize global hearing loss
27
:F
28
29 prevention by promoting safe listening practices. WHO global standards,
or
30
31 recommendations and toolkits are available to aid in development and implementation
32
33 of policy and public health initiatives to promote safe listening worldwide.
Re
34
35
36
vie
37
38
39
40
w
41
42
43
On
44
45
46
47
ly
48
49
50
51
52
53
54
55
56
57
58
59 25
1
2
3
4
5
6
7
8
9
10
11
Co
12
13
14
nf
15
16
17
ide
18
19
20
21
nt
22 FIGURE CAPTIONS
23
24 Figure 1: Flow diagram (PRISMA 2020) summarizing the article screening process.
ial
25
26
27
:F
28
29 Figure 2: Forest plot displaying study-specific and overall prevalence estimates of
or
30
31 exposure to PLDs for the 17 studies included in the meta-analysis.
32
33
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34
35
36
ACKNOWLEDGEMENTS
vie
37
38 Thank you to Artem A. Shchepilov for translating the studies from Russian to English,
39
40 and to Juan J. Lopez Perez for extracting the studies in Spanish.
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43
On
44
45 COMPETING INTERESTS
46
47 Authors have no competing interests to declare.
ly
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49
50
51
52 FUNDING
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54
55
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57
58
59 26
1
2
3 This research did not receive any specific grant from funding agencies in the public,
4
5
6 commercial, or not-for-profit sectors.
7
8
9
10
11
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12
13
14
nf
15
16
17
ide
18
19
20
21
nt
22
23
24 REFERENCES
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26 1. World Health Organization. World Report on Hearing. World Health Organization;
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43 bank-country-and-lending-
On
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47 20with%20a%20GNI%20per
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3 23.25. Muchnik C, Amir N, Shabtai E, et al. Preferred listening levels of personal
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8 Int J Audiol. 2012;51(4):287-93.
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10 24.26. Twardella D, Raab U, Perez-Alvarez C, et al. Usage of personal music
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players in adolescents and its association with noise-induced hearing loss: A
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15 cross-sectional analysis of Ohrkan cohort study data. Int J Audiol. 2017;56(1):38-
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26 26.28. Sulaiman AH, Seluakumaran K, Husain R. Hearing risk associated with
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33 27.29. Sulaiman AH, Husain R, Seluakumaran K. Hearing Risk among Young
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38 Frequency Audiogram Thresholds. J Int Adv Otol. 2015;11(2):104-9.
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40 28.30. Fligor BJ, Levey S, Levey T. Cultural and demographic factors influencing
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45 environment. J Speech Lang Hear Res. 2014;57(4):1535-47.
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47 29.31. Lévesque B, Fiset R, Isabelle L, et al. Le baladeur numérique: une
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3 30.32. Lee GJ, Lim MY, Kuan AY, et al. The music listening preferences and
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6 habits of youths in Singapore and its relation to leisure noise-induced hearing
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8 loss. Singapore Med J. 2014;55(2):72-7.
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10 31.33. Breinbauer H, Anabal JL, Gutierrez D, et al. Estimación de riesgos y
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15 población chilena. Rev. Otorrinolaringol. Cir. Cabeza Cuello 2011; 71: 31-38
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3 37.39. Kumar P, Upadhyay P, Kumar A, et al. Extended high frequency
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8 2017;38(2):163-7.
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10 38.40. Vogel I, van de Looij-Jansen PM, Mieloo CL, et al. Risky music listening,
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permanent tinnitus and depression, anxiety, thoughts about suicide and adverse
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15 general health. PLoS One. 2014;9(6):e98912.
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17 39.41. Mercier V, Hohmann BW. Is Electronically Amplified Music too Loud?
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What do Young People Think? Noise Health. 2002;4(16):47-55.
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22 40.42. Le Prell CG, Spankovich C, Lobariñas E, et al. Extended high-frequency

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26 noise. J Am Acad Audiol. 2013;24(8):725-39.
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29 41.43. Le Prell CG, Siburt HW, Lobarinas E, et al. No Reliable Association
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31 Between Recreational Noise Exposure and Threshold Sensitivity, Distortion
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33 Product Otoacoustic Emission Amplitude, or Word-in-Noise Performance in a
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38 42.44. Figueroa Hernández DD, Sánchez DF. Relation between hearing loss and
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40 exposure to recreational noise. Anales de Otorrinolaringología Mexicana 2011
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(Vol. 56, No. 1, pp. 15-21).
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45 43.45. Ahmed HO, Ali WJ. Noise levels, noise annoyance, and hearing-related
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47 problems in a dental college. Arch Environ Occup Health. 2017;72(3):159-65.
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49 44.46. Rosanowski F, Eysholdt U, Hoppe U. Influence of leisure-time noise on
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52 outer hair cell activity in medical students. Int Arch Occup Environ Health. 2006
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54 Oct;80(1):25-31.
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3 45.47. Widén SE, Erlandsson SI. Self-reported tinnitus and noise sensitivity
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6 among adolescents in Sweden. Noise Health. 2004;7(25):29-40.
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8 46.48. Jokitulppo J. Estimated leisure-time noise exposure and hearing
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10 symptoms in a finnish urban adult population. Noise Health. 2003;5(17):53-62.
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47.49. Degeest S, Corthals P, Vinck BM, et al. Prevalence and characteristics of
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15 tinnitus after leisure noise exposure in young adults. Noise Health.
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17 2014;16(68):26-33.
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48.50. Weichbold V, Holzer A, Newesely G, et al. Results from high-frequency
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22 hearing screening in 14- to 15-year old adolescents and their relation to self-
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24 reported exposure to loud music. Int J Audiol. 2012;51(9):650-4.
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26 49.51. Serra MR, Biassoni EC, Hinalaf M, et al. Hearing and loud music exposure
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29 in 14-15 years old adolescents. Noise Health. 2014;16(72):320-30.
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31 50.52. Gilles A, De Ridder D, Van Hal G, et al. Prevalence of leisure noise-
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33 induced tinnitus and the attitude toward noise in university students. Otol
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Neurotol. 2012;33(6):899-906.
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38 51.53. Budimčić M, Seke K, Krsmanović S, et al. Auditory risk behaviours and
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40 hearing problems among college students in Serbia. Med Glas (Zenica).
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2014;11(2):361-6.
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45 52.54. Filova A, Jurkovicova J, Hirosova K, et al. Social Noise Exposure in a
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47 Sample of Slovak University Students. Int J Environ Res Public Health.
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3 53.55. Johnson O, Andrew B, Walker D, et al. British university students' attitudes
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6 towards noise-induced hearing loss caused by nightclub attendance. J Laryngol
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8 Otol. 2014;128(1):29-34; quiz 3-4.
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10 54.56. Shargorodsky J, Curhan SG, Curhan GC, et al. Change in prevalence of
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hearing loss in US adolescents. JAMA. 2010;304(7): 7728.
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15 55.57. Cone BK, Wake M, Tobin S, et al. Slight-mild sensorineural hearing loss in
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17 children: audiometric, clinical, and risk factor profiles. Ear Hear. 2010.
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1;31(2):202-12.
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22 56.58. Śliwińska-Kowalska M, Zaborowski K. WHO environmental noise

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24 guidelines for the European region: a systematic review on environmental noise
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26 and permanent hearing loss and tinnitus. Int J Environ Res Public Health. 2017,
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29 14(10), 1139.
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31 57.59. Keppler H, Dhooge I, Vinck B. Hearing in young adults. Part II: The effects
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33 of recreational noise exposure. Noise Health, 2015. 17(78), 245.
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58.60. Grinn SK, Wiseman KB, Baker JA, et al. Hidden hearing loss? No effect of
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38 common recreational noise exposure on cochlear nerve response amplitude in
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40 humans. Frontiers Neuroscience. 2017 Sep 1;11:465.
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59.61. Kim MG, Hong SM, Shim HJ, et al. Hearing threshold of Korean
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45 adolescents associated with the use of personal music players. Yonsei Medical
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47 Journal 2009, 50(6), 771-776.
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49 60.62. Axelsson A, Prasher D. Tinnitus induced by occupational and leisure
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52 noise. Noise Health. 2000;2(8):4754.
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59 34
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3 61.63. Chung JH, Des Roches CM, Meunier J, et al. Evaluation of noise-induced
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6 hearing loss in young people using a web-based survey technique. Pediatrics.
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8 2005;115(4):8617.
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62.64. Kujawa SG, Liberman MC. Adding insult to injury: Cochlear nerve
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13 degeneration after “temporary” noise-induced hearing loss. J Neurosci. 2009 Nov
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15 11;29(45):14077-85.
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17 63.65. Le Prell CG, Yamashita D, Minami SB, et al. Mechanisms of noise-
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20 induced hearing loss indicate multiple methods of prevention. Hear Res.
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22 2007;226(12):2243.
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24
ial
64.66. Kopke RD, Coleman JKM, Liu J, et al. Mechanisms of noise- induced
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27 hearing loss and otoprotective strategies. In: Van De Water TR, Staecker H,
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29 editors. Otolaryngology: basic science and clinical review. New York: Thieme;
or
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31 2006:395408.
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34 65.67. Kurabi A, Keithley EM, Housley GD, et al. Cellular mechanisms of noise-
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36 induced hearing loss. Hearing research. 2017 Jun 1;349:129-37.
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38 66.68. Hong O, Kerr MJ, Poling GL, Dhar S. Understanding and preventing
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41 noise-induced hearing loss. Dis Mon. 2013;59(4):1108.

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43 67.69. World Health Organization. Make Listening Safe; 2015. Accessed from:
On
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45 https://apps.who.int/iris/bitstream/handle/10665/177884/WHO_NMH_NVI_15.2_e
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47
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48 ng.pdf.
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50 68.70. ITU. Series H: Audiovisual and multimedia systems. E-health multimedia
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52 systems, services and applications – Safe listening. Guidelines for safe listening
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devices/systems. 2018.
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59 35
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3 69.71. World Health Organization. A handbook on how to implement
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6 mSafeListening; 2022.
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8 70.72. World Health Organization, 2022. Media brief on #safelistening; 2022
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10 71.73. Washnik NJ, Russell JA, Bhatt I, et al. University Marching Band
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Members’ Noise Dosages and Hearing Health-Related Knowledge. Int J Env Res
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15 Public Health. 2021 Nov 1;18(21):11497.
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17 72.74. Ji-Su K. Association between tinnitus and mental health among Korean
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adolescents: the Korea National Health and Nutrition Examination Survey. Cent
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22 Eur J Public Health. 2018 Mar 30;26(1):65-70.

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3 Prevalence and global estimates of unsafe listening practices in adolescents and
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6 young adults: A systematic review and meta-analysis
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10 Lauren K. Dillard, PhDa, Malachi Arunda, PhDb, Lucero Lopez-Perez, PhDc, Ricardo X.
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Martinez, PhDc, Lucía Jiménezd, Shelly Chadha, PhDe
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18 aDepartment of Otolaryngology- Head & Neck Surgery, Medical University of South
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21 Carolina, Charleston, SC, USA
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bDepartment of Clinical Sciences, Lund University, Lund, Sweden
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25 cCluster of Healthier Populations, World Health Organization, Geneva, Switzerland

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dOctoma, México
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eDepartment on Noncommunicable Diseases, World Health Organization, Geneva,
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32 Switzerland
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All correspondence should be addressed to: Lauren K. Dillard, Walton Research
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38 Building, 39 Sabin Street, Charleston, SC 29425, USA. Email: dillalau@musc.edu
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41 Declarations of interest: None

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59 1
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3 ABSTRACT
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6 Introduction: This study aimed to a) determine prevalence of unsafe listening practices
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8 from exposure to personal listening devices (PLD) and loud entertainment venues in
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10 individuals aged 12-34 years, and b) estimate the number of young people that could be
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at risk for hearing loss from unsafe listening worldwide.
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15 Methods: We conducted a systematic review and meta-analysis to estimate prevalence
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17 of unsafe listening practices from PLDs and loud entertainment venues. We searched 3
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databases for peer-reviewed articles published between 2000 and 2021 that reported
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22 unsafe listening practices in individuals aged 12-34 years. Pooled prevalence estimates
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24 (95% confidence interval [CI]) of exposed populations were calculated via random
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26 effects models or ascertained from the systematic review. The number of young people
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29 that could be at risk for hearing loss worldwide was estimated from the estimated global
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31 population aged 12-34 years, and best estimates of exposure to unsafe listening
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33 ascertained from this review.
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Results: Thirty-three studies (corresponding to data from 35 records and 19,046
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38 individuals) were included. Seventeen and eighteen records focused on PLD use and
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40 loud entertainment venues, respectively. The pooled prevalence estimate of exposure
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to unsafe listening from PLDs was 23.81% [CI 18.99 – 29.42]. There was limited
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45 certainty (p>0.50) in our pooled prevalence estimate for loud entertainment venues.
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47 Thus, we fitted a model as a function of intensity thresholds and exposure duration to
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49 identify the prevalence estimate as 48.20%. The global estimated number of young
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52 people that could be at risk of hearing loss from exposure to unsafe listening practices
53
54 ranged from 0.67 – 1.35 billion.
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59 2
1
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3 Conclusions: Unsafe listening practices are highly prevalent worldwide and may place
4
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6 over one billion young people at risk for hearing loss. There is an urgent need to
7
8 prioritize policy focused on safe listening. The World Health Organization provides
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10 comprehensive materials to aid in policy development and implementation.
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15 KEYWORDS: hearing loss, noise-induced hearing loss, global health, policy
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59 3
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3 KEY MESSAGES
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7 What is already known on this topic
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10 Voluntary recreational noise exposure, or unsafe listening, is a modifiable risk factor for
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13 hearing loss in young people and may increase risk of hearing loss in aging. Estimates
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15 of the prevalence of unsafe listening practices or of the global caseload of young people
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17 engaging in unsafe listening practices are not available in published literature although
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such estimates are needed to promote policy implementation to reduce risk of hearing
21
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22 loss in young people.

23
24
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25 What this study adds

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:F
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29 Results from this study indicate that unsafe listening practices from use of personal
or
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31 listening devices and attendance of loud entertainment venues are common
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33 (prevalence estimates 23.81%, 48.20%, respectively) and may place up to 1.35 billion
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36 young people at risk for hearing loss worldwide.
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39 How this study might affect research, practice or policy
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These data will be used to communicate the urgent need to implement policy that
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45 promotes safe listening habits to governments, industry, civil society, and other relevant
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47 stakeholders. The World Health Organization has publicly available standards,
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recommendations, and toolkits to aid in development and implementation of policy and
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52 public health initiatives to promote safe listening worldwide.
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59 4
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3 INTRODUCTION
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6 Hearing loss is a public health concern that deserves global recognition and
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8 prioritization. The World Health Organization (WHO) estimates over 430 million people
9
10 worldwide have disabling hearing loss and that its prevalence may almost double if
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hearing loss prevention is not prioritized.[1] Recreational noise exposure is a modifiable
14
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15 risk factor for hearing loss, and in 2015, the WHO estimated 1.1 billion adolescents and
16
17 young adults were at potential risk of hearing loss from voluntary recreational noise
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exposure, referred to henceforth as ‘unsafe listening practices.’[2] This exposure is
20
21
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22 largely attributable to use of personal listening devices (PLD; e.g., mobile phones, mp3
23
24 players) and/or from attendance of loud entertainment venues (e.g., discotheques, bars,
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26 clubs).[3] Importantly, unsafe listening behaviors are likely modifiable with
27
:F
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29 implementation of existing policy recommendations and known public health
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31 practices.[3]
32
33 Recurrent or even single instances of unsafe listening may cause physiological
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damage to the auditory system, presenting as transient or permanent tinnitus and/or
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38 changes to hearing.[4-6] Damage from unsafe listening can compound over the life
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40 course, and noise exposure earlier in life may make individuals more vulnerable to age-
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related hearing loss.[7-8] Importantly, hearing loss, when it is unaddressed, has sizable
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45 economic costs estimated at almost 1 trillion annual US dollars,[1] and has serious
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47 impacts on individuals and families. In children, hearing loss and/or noise exposure has
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49 been associated with poorer academic performance and reduced motivation and
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52 concentration,[9-10] which may lead to a trajectory of limited economic mobility later in
53
54 life. In adults, hearing loss has been associated with poorer psychosocial well-being,
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59 5
1
2
3 lower income, and serious co-morbid health conditions such as cognitive
4
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6 impairment.[11]. Tinnitus also has important impacts on the health and well-being of
7
8 individuals and is associated with poorer quality of life.[12]
9
10 Unsafe listening practices are common worldwide, particularly among
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adolescents and young adults, given high availability of PLDs and scarce enforcement
14
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15 of regulatory measures for PLDs and entertainment venues.[13] Risk of hearing loss
16
17 depends on the loudness, duration, and frequency of noise exposure. Permissible levels
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of recreational noise exposure are often calculated from equivalent occupational noise
20
21
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22 exposure limits (e.g., 80 decibels [dB] for 40 hours a week or 85 dB for 40 hours a
23
24 week)[4], which vary slightly by region and/or by regulatory agencies or
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26 organizations.[14] Sound intensity (dB) is measured on a logarithmic scale and there is
27
:F
28
29 a time-intensity tradeoff (exchange rate) for permissible levels and duration of exposure,
or
30
31 meaning that permissible levels change drastically by sound level. For example, based
32
33 on a maximum permissible level of noise exposure of 80 dB for 8 hours a day (40
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36
hours/week) with a 3 dB exchange rate, the permissible exposure time of a 92 dB sound
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38 is 2.5 hours, of a 98 dB sound is 38 minutes, and of a 101 dB sound is only 19
39
40 minutes.[4,15] PLD users commonly choose volumes as high as 105 dB and average
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sound levels at entertainment venues range from 104 to 112 dB,[16] therefore
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45 exceeding permissible levels even for very short periods of time. These findings suggest
46
47 that many young people are likely at risk for developing permanent hearing loss. Some
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49 systematic reviews on unsafe listening practices have been conducted although
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52 estimates of prevalence and global burden of exposure are not available in published
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54 literature.[17-19] Global prevention efforts would benefit from data on the prevalence
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59 6
1
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3 and global burden of unsafe listening practices to effectively communicate the need for
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6 preventative intervention to governments, industries, and other stakeholders
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8 responsible for implementing policy.
9
10 The importance of hearing loss prevention is gaining traction on the global
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agenda,[1, 20] making now a particularly important time to prioritize interventions to
14
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15 prevent hearing loss. The aims of this systematic review and meta-analysis were to a)
16
17 determine the prevalence of unsafe listening practices from PLD use and attendance of
ide
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loud entertainment venues in adolescents and young adults, and b) create a global
20
21
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22 estimate of the number of adolescents and young adults likely to be at risk of hearing
23
24 loss from unsafe listening practices.
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29 METHODS
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31 Search strategy and selection criteria
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33 This systematic review and meta-analysis was conducted under the Preferred
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Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.[21]
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38 Peer-reviewed manuscripts published in English, Spanish, French, or Russian
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40 languages between years 2000 and 2021 that were case-control cross-sectional or
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cohort studies were eligible for inclusion.
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45 Manuscripts must have contained information on human subjects aged from 12-
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47 34 years. Studies focused on PLDs must have reported objectively measured device
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49 output levels and time of exposure. This information was used to define prevalence of
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52 unsafe listening practices (or risk of hearing loss) as equivalent to exceeding
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54 permissible levels (e.g., >80 dB(A) for 40 hours a week).[4] Sound output levels
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59 7
1
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3 measured at a single time point were presented as equivalent continuous levels (LAeq),
4
5
6 which is the integrated, normalized sound pressure divided by the duration of the signal,
7
8 representing the average total energy of the measured sound. The LAeq is presented
9
10 corresponding to daily or weekly maximum permissible levels (e.g., >80 or >85 dB).
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Studies focused on loud entertainment venues must have reported participants’
14
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15 attendance to venues at least one time per month. Study samples must have been
16
17 representative of the general population. For example, studies focused only on staff
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members working at loud entertainment venues were not eligible for inclusion.
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21
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22 The databases PubMed, Web of Science (core collection) and Scopus were
23
24 searched in English in December 2021 using a combination of MeSH terms and key
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26 words (Supplement 1). Two separate searches were conducted, one for PLD use and
27
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28
29 one for entertainment venues. Reference lists of included articles were searched for
or
30
31 potentially eligible articles, and studies that cited included articles (listed on Google
32
33 Scholar) were considered for eligibility.
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Studies in Spanish, French and Russian were ‘hand-searched’ using translated
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38 search terms and were assessed for eligibility by speakers of those languages. Trial
39
40 registries or unpublished studies were not included.
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41
42
Selection process and data extraction
43
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44
45 Several reviewers extracted papers from the three databases (based on
46
47 language of papers) and a single reviewer removed duplicates and completed the title
ly
48
49 and abstract screen based on eligibility criteria. References were exported to Mendeley,
50
51
52 and full text articles were shared with all study team members. The study team agreed
53
54
55
56
57
58
59 8
1
2
3 on inclusion of all articles and any differences in inclusion/exclusion were reconciled via
4
5
6 discussion among team members.
7
8 Data extraction tables were developed by WHO biostatisticians. Extracted data
9
10 included a) meta-study information (e.g., authors, year of publication, journal, country,
11
Co
12
13
country income level), b) sample characteristics (e.g., age, sex, population, sample
14
nf
15 size), c) prevalence of exposure to PLDs or loud entertainment venues that exceeded
16
17 permissible sound levels, and d) definitions of noise exposure and related
ide
18
19
measurements. Data were extracted by multiple reviewers and verified for accuracy by
20
21
nt
22 a separate reviewer. If duplicate data were included in eligible studies, we used the
23
24 study with the best available data (i.e., fit best with outcome of interest and target
ial
25
26 population). The primary outcome was the prevalence of the study population exposed
27
:F
28
29 to unsafe listening practices, defined as noise exceeding permissible exposure levels
or
30
31 (e.g., >80 dB LAeq for PLDs; attendance of loud entertainment venues ≥1 time per
32
33 month).
Re
34
35
36
Risk of bias assessment
vie
37
38 A modified version of the Quality Assessment of Diagnostic Accuracy Studies
39
40 (QUADAS) scale was used to assess risk of bias for each study, based on the following
w
41
42
categories: selection, study design, performance of data collection tools, completeness,
43
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44
45 and reporting bias. For each study, these categories were ranked as strong, moderate,
46
47 or weak, which corresponded to presenting a low, moderate, or high risk of bias,
ly
48
49 respectively. Studies were assigned an overall rating of a) weak if they were ranked as
50
51
52 weak in at least one category, b) moderate if they had 0 rankings of weak and <2
53
54 rankings of strong, and c) strong if they had 0 rankings of weak and ≥2 rankings of
55
56
57
58
59 9
1
2
3 strong. Sensitivity analyses evaluated pooled prevalence estimates after a) excluding
4
5
6 each study, individually, from analyses, b) excluding studies considered to be weak (i.e.,
7
8 high risk of bias), and c) excluding studies considered to be weak and that defined risk
9
10 with a definition classified as ‘other.’
11
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12
13
Data analysis
14
nf
15 Subgroup analyses by age category (adults: 18-34 years, minors: 12-19 years,
16
17 mixed: 12-34 years), region and country income level were undertaken. Age was
ide
18
19
categorized based on age categories defined in included studies. Region was defined
20
21
nt
22 by the WHO classification,[22] and country income level was defined by the World
23
24 Bank.[23] Two categories of income were applied, 1) high income: ≥$12,696 gross
ial
25
26 national income (GNI) per capita, or 2) middle- income (including low-middle and high-
27
:F
28
29 middle income countries): between $4,096 to $12,695 GNI per capita.
or
30
31 Following the corresponding Cochrane’s Q (chi-square) and I2 statistics
32
33 suggesting a large dispersion of effect sizes and a large amount of heterogeneity
Re
34
35
36
(between studies), we used random effects estimates to determine pooled prevalence
vie
37
38 of exposure and corresponding 95% confidence intervals (95% CI). Varying but
39
40 considerable heterogeneity was found in all subsequent subgroup analyses, warranting
w
41
42
use of random effects estimates for all subgroup analyses. Analysis was conducted with
43
On
44
45 Comprehensive Meta-Analysis software (CMA 3.3). The study protocol was not
46
47 registered prior to study completion.
ly
48
50
51
52 practices
53
54
55
56
57
58
59 10
1
2
3 The global number of individuals that could be at risk of developing hearing loss
4
5
6 from exposure to PLDs or loud entertainment venues (i.e., unsafe listening practices)
7
8 was estimated by considering a) the estimated global population aged 12-34 in year
9
10 2022,[24] and b) the best estimates of exposure to unsafe listening practices from PLDs
11
Co
12
13
or loud entertainment venues ascertained from this systematic review. We present the
14
nf
15 estimated global population of individuals at risk of hearing loss from unsafe listening
16
17 practices as a range, utilizing prevalence estimates of exposure to both unsafe listening
ide
18
19
practices from PLDs and loud entertainment venues.
20
21
nt
22 Patient and public involvement statement

23
24 Patients or the public were not involved in the design, conduct, or reporting of this
ial
25
26 systematic review and meta-analysis.
27
:F
28
29
or
30
31 RESULTS
32
33 A total of 389 non-duplicate citations were identified by using the selected
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34
35
36
keywords. After the final review, 33 articles were eligible for inclusion in this study. The
vie
37
38 study selection process is shown in Figure 1.
39
40 Pertinent study characteristics are displayed in Table 1. A total of 35 records
w
41
42
from 33 studies corresponding to data from 19,046 individuals were included.[5, 25-55]
43
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44
45 Seventeen records focused on PLD use (n=8,987 participants) and 18 records focused
46
47 on loud entertainment venues (n=9,702 participants). Studies were from 21 countries
ly
48
49 corresponding to representation from African (n=1), Americas (n=12), European (n=15),
50
51
52 Middle East (n=2) South-East Asian (n=1) and Western Pacific (n=4) regions. Twenty-
53
54 six and 9 study records were from high income and middle-income (upper or lower)
55
56
57
58
59 11
1
2
3 countries, respectively. Sixteen study records focused on adults, 10 focused on minors,
4
5
6 and 9 focused on mixed age groups (adults and minors). The pooled samples had even
7
8 distributions by gender (49% females, 51% males).
9
10 Table 1. Pertinent study characteristics for all studies in the systematic review.
11
Co
12
13 Country
Age Number, Number,
14 First author (year) (Income Risk criteria
category sample size exposed
nf
15 Level)
16
17
ide
18
Israel Daily (LAeq
19 Muchnik (2012) Minors 74 22
(High) >80dB)
20
21 Germany Weekly (LAeq
nt
22 Twardella (2017) Minors 2143 579

(High) >80dB)
23
24
ial
Netherlands Weekly (LAeq

Vogel (2010a) Minors 1510 487
25 (High) >80dB)
26
27 Malaysia Daily (LAeq
:F
Sulaiman (2013) Minors 177 15

28 (Middle) >80dB)
29
Malaysia Daily (LAeq
or
30 Sulaiman (2015) Adults 282 22

31 (Middle) >80dB)
32
United States
33 Weekly (LAeq
Re
Fligor (2014) of America Adults 110 72

34 >80dB)
(High)
35
36 Canada Daily (LAeq
vie
37 Lévesque (2010) Minors 124 52

(High) >85dB)
38
39 Singapore Daily (LAeq
Lee (2014) Mixed 1928 316
40 (High) >85dB)
w
41
42 Chile Daily (LAeq
Breinbauer (2011) Mixed 562 67
43 (High) >85dB)
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44
45 United States
46 Hussain (2018) of America Adult 50 11 Other1
47 (High)
ly
48
Kaplan-Neeman Israel Daily (LAeq
49 Adult 40 9
(2017) (High) >85dB)
50
51 United States
52 Hutchinson Marron
of America Adult 164 7 Other1
53 (2015)
(High)
54
55
56
57
58
59 12
1
2
3
4 Orozco Medina Mexico
Adult 40 22 Other1
5 (2017) (Middle)
6
Republic of
7 Daily (LAeq
Kim (2021) Korea Adult 40 9
8 >85dB)
(High)
9
10 India
11 Kumar (2017) Mixed 100 41 Other1
Co
(Middle)
12
Vogel (2014) Mixed 943 287
14 (High) >80dB)
nf
15
16 Switzerland
Mercier (2002) Mixed 700 121 Other1
17 (High)
ide
18
20
21 ≥1x / month;
Netherlands
nt
22 Vogel (2014) Mixed 943 454 LAeq ≥80 dB for

(High)
23 ≥56 hour / week
24
ial
≥1x / week;
25 Switzerland
Mercier (2002) Mixed 700 553 LAeq ≥87 dB for
26 (High)
≥40 hour / week
27
:F
28 United States
or
30 (High)
31
32 United States
Re
34 (High)
35
36 Figueroa México
Mixed 205 159 ≥1x / month
vie
37 Hernández (2011) (Middle)

38
39 Canada
Ahmed (2007) Mixed 150 46 ≥1x / month
(High)
40
w
41 ≥1x / month;
42 Netherlands
Vogel (2010b) Minors 1512 267 LAeq ≥85 dB for
43 (High)
On
≥40 hour / week

44
45 Argentina
(Middle)
47
ly
48 Rosanowski Germany
Adults 88 69 ≥1x / month
49 (2006) (High)
50
51 Sweden
Widén (2004) Minors 1238 350 ≥1x / month
52 (High)
53
54 Finland
Jokitulppo (2005) Adults 1054 437 ≥1x / month
(High)
55
56
57
58
59 13
1
2
3
4 South Africa
Deegest (2014) Adults 151 54 ≥1x / month
5 (Middle)
6
Austria
7 Weichbold (2012) Minors 1294 787 ≥1x / month
(High)
8
9 Argentina
(Middle)
11
Co
12 Belgium
13 Gilles (2012) Adults 145 92 ≥1x / month
(High)
14
nf
15 Serbia
Budimčić (2014) Adults 780 609 ≥1x / week
16 (Middle)
17
ide
18 Slovakia
Filova (2020) Adults 1003 437 ≥1x / month
19 (High)
20
United
21
nt
Johnson (2014) Kingdom Adults 357 165 ≥1x / week
22
(High)
23
24
ial
25 Table Note. Adults (18-34 years); Minors (12-19 years); Mixed (12-34 years). LAeq=
27
:F
in the same total sound energy being produced over a given period.
29
or
30
31
33
Re
34 The pooled prevalence estimates of exposure to excessive noise from PLDs was
35
36 23.81% [CI 18.99 – 29.42]. Figure 2 is a forest plot showing point estimates from each
vie
37
38
39 study and the pooled prevalence estimate. Table 2 displays the pooled prevalence
40
w
41 estimates of exposure to excessive noise from PLDs, overall, and by subgroups age
42
43 category, income group and details of risk criteria. Prevalence estimates were similar for
On
44
45
46
age categories (adult: 23.10% [CI 8.90 – 48.03]; minors: 27.10% [CI 21.25 – 33.88];
47
ly
48 mixed: 21.55% [CI 14.65 – 30.53]) and income group (high: 24.51% [CI 19.35 – 30.53];
49
50 middle: 22.12% [CI 7.15 – 51.17]) although the middle-income group showed
51
52
substantial variability. Prevalence estimates were (non-significantly) highest in studies
53
54
55 using definitions of weekly exposure LAeq > 80 dB (36.37% [CI 29.18 – 44.22] as
56
57
58
59 14
1
2
3 compared to definitions measuring daily exposure (LAeq > 80 dB (12.95% [CI 5.10-
4
5
6 29.20]; LAeq > 85 dB (21.36% [CI 13.50 – 32.09]) or using other definitions (23.15% [CI
7
8 11.28 – 41.67]).
9
10
11
Co
12
13
Table 2. Pooled prevalence estimates of exposure to excessive noise from personal
14 listening devices (PLDs). Estimates are presented overall and stratified to age, income
nf
15 level, and risk criteria definition.
16
17
ide
18
19 Effect size, 95% confidence interval Test of null (2-Tail)
20 Number,
21
nt
records Point estimate Lower limit Upper limit P-value
22
23 Pooled prevalence 17 23.81% 18.99% 29.42% p < 0.01
24
ial
25 Age Category
26
27
:F
28 Adults 7 23.10% 8.90% 48.03% p < 0.01

29
or
30
31 Minors 5 27.10% 21.25% 33.88% p < 0.01
32
33
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Mixed 5 21.55% 14.65% 30.53% p < 0.01

34
35
36 Income group
vie
37
38 High income 13 24.51% 19.35% 30.53% p < 0.01
39
40
w
Middle income (upper

41 4 22.12% 7.15% 51.17% p < 0.01
+ lower middle)
42
43
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Risk criteria definition

44
45
46 Daily (LAeq >80dB) 3 12.95% 5.10% 29.20% p < 0.01
47
ly
48
49 Daily (LAeq >85dB) 5 21.36% 13.50% 32.09% p < 0.01
50
51
Weekly (LAeq >80dB) 4 36.37% 29.18% 44.22% p < 0.01
52
53
54 Other1 5 23.15% 11.28% 41.67% p < 0.01
55
56
57
58
59 15
1
2
3
4
5
Table Note. Adults (18-34 years); Minors (12-19 years); Mixed (12-34 years). High
6 income: ≥ $12,696 gross national income (GNI) per capita; middle- income (including
7 low-middle and high-middle income countries): between $4,096 to $12,695 GNI per
8 capita, according to World Bank Income group classification FY22.[23] LAeq=
11
Co
1Studies specified duration of exposure and objectively measured intensity but did not
12
13
14
nf
15
16 Our risk of bias assessment revealed that for the 17 studies focused on PLDs, 5
17
ide
18 (29%) were rated as strong, 8 (47%) as moderate and 4 (24%) as weak (Supplement
19
20
21 2). Sensitivity analyses evaluated changes in pooled prevalence estimates after
nt
22
23 removing each study, individually, from analyses. The prevalence estimates and
24
ial
25 confidence intervals were stable (<2% change) after removal of each study, indicating
26
27
:F
28
pooled prevalence estimates were insensitive to individual study inclusion. Sensitivity
29
analyses removing a) studies with a high risk of bias (i.e., rated as ‘weak’), and b)
or
30
31
32 studies with a high risk of bias and with a risk criterion classified as ‘other’ did not return
33
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34
substantially different estimates as compared to the estimate using data from all studies
35
36
vie
37 (23.81% [CI 18.99- 29.42]) (results not shown).

38
40
w
41 The pooled prevalence estimate for exposure to excessive noise from loud
42
43
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44 entertainment venues was calculated from the 18 studies in the systematic review but
45
46 there was limited certainty (p>0.50) in our estimate. Thus, estimates (including
47
ly
48 subgroup analyses) calculated from the 18 studies are not presented.

49
50
51
The risk of bias assessment revealed that for the 18 studies focused on loud
52
53 entertainment venues, 2 (11%) were rated as strong, 12 (67%) as moderate and 4
54
55 (22%) as weak (Supplement 2). Sensitivity analyses that removed a) studies with a high
56
57
58
59 16
1
2
3 risk of bias (i.e., rated as ‘weak’), and b) studies with a high risk of bias and with risk
4
5
6 criteria classified as ‘attending a loud entertainment venue at least once a week’ were
7
8 conducted but also yielded estimates with limited certainty (results not shown).
9
10 Therefore, ad hoc analyses aimed to reduce heterogeneity across studies by
11
Co
12
13
considering only studies that equated intensity and duration of sound levels to LAeq
14
nf
15 values. There were three studies that met this criterion,[27, 40, 41] all of which used
16
17 slightly different definitions to define risk (LAeq ≥80 dB for ≥56 hours/week; LAeq ≥90
ide
18
19
dB for ≥40 hours/week; LAeq ≥87 for ≥40 hours/week). Several steps were taken to
20
21
nt
22 select the preferred prevalence estimate used to compute the global estimate of
23
24 individuals at risk from unsafe listening practices (described in Supplement 3).
ial
25
26 The chosen quadratic model was a very good fit for all the studies, with a higher
27
:F
28
29 quadratic dependence on intensity than on duration (Figure S3b of supplement 3);
or
30
31 Prev(x,y) = -5.3E-0.5x2+6.2E-05xy+0.003y2-0.56y+25.85. The model was then used to
32
33 approximate a prevalence of 48.20% for an intensity threshold of 80 dB and duration
Re
34
35
36
threshold of 40 hours per week.
vie
37
38 Thus, to estimate the number of individuals at risk of hearing loss from unsafe
39
40 listening, we utilized the estimated prevalence of 48.20% of exposure to excessive
w
41
42
noise from loud entertainment venues given that this estimate: a) accounts for duration
43
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44
45 and level of exposure, b) was consistent (of the studies in Supplement 3) with the WHO
46
47 definition of excessive noise exposure based on permissible sound pressure levels of
ly
48
49 80 dB for 40 hours per week (WHO, 2015), and c) that prevalence estimates for the
50
51
52 three studies that had values of duration and intensity were commensurate.
53
54 Heterogeneity & publication bias
55
56
57
58
59 17
1
2
3 The I2 statistics for studies on PLD use and loud entertainment venues were 96.2
4
5
6 and 98.8, respectively, indicating a high amount of heterogeneity among studies. Funnel
7
8 plots of standard error by logit event rate (not shown) were symmetric and thus did not
9
10 suggest publication bias.
11
Co
12
13
Global estimate of individuals at risk of hearing loss from unsafe listening
14
nf
15 practices
16
17 Estimates are shown in Table 3. In 2022, the estimated global population aged 12-34
ide
18
19
years was 2.8 billion.[24] We utilized the pooled prevalence estimate of exposure to
20
21
nt
22 excessive noise from PLDs ascertained from this systematic review and meta-analysis
23
24 (23.81% [CI 18.99 – 29.42]). For loud entertainment venues, we utilized the prevalence
ial
25
26 estimate (48.20%) described above. Therefore, the global estimated number of
27
:F
28
29 adolescents and young adults at risk of hearing loss from voluntary exposure to unsafe
or
30
31 listening practices ranges from 0.67 – 1.35 billion.
32
33 Table 3: Estimated global population of individuals exposed to recreational noise from
Re
34
personal listening devices or entertainment venues
35
36
Number, exposed
vie
37 Prevalence (95% number, exposed Prevalence,

Global population to loud
38 CI), exposed to to personal exposure to loud
aged 12-34 yrs entertainment
39 personal listening listening devices entertainment
(billions) venues
40 devices (billions) venues
(billions)
w
41 23.81%
42 2.795 0.665 48.20% 1.347
(18.99 - 29.42)
43 Table Note. Global population data are from the United Nations World Population
On
44
45
Prospects 2019.[24]
46
47 DISCUSSION
ly
48
49 Results from this systematic review and meta-analysis demonstrate that unsafe
50
51 listening practices are highly prevalent among adolescents and young adults and that
52
53
54 an estimated 0.67 – 1.35 billion individuals worldwide may be at risk for hearing loss
55
56 from voluntary unsafe recreational listening practices. These findings highlight the
57
58
59 18
1
2
3 urgent need to implement policy focused on safe listening habits worldwide in order to
4
5
6 promote hearing loss prevention.
7
8 Increased exposure to unsafe listening practices may be one cause of increasing
9
10 prevalence of hearing loss in children.[56-57] However, previous studies have reported
11
Co
12
13
inconclusive findings on associations between unsafe listening practice and permanent
14
nf
15 changes to hearing.[58] Evidence showing consistent associations of adolescent
16
17 recreational noise exposure and permanent hearing loss is sparse, and the potential
ide
18
19
dose-response relationship of recreational noise exposure and associated hearing loss
20
21
nt
22 is not understood. While some studies have not observed associations between
23
24 recreational noise exposure and permanent hearing loss,[59-60] others have indicated
ial
25
26 that use of PLD for extended periods of time can result in changes to hearing
27
:F
28
29 thresholds.[61] Inconsistencies in existing research are likely in part because hearing
or
30
31 loss is incremental and progressive, thus making it difficult to capture short-term effects
32
33 of noise exposure in adolescents. Well-designed epidemiological studies are needed to
Re
34
35
36
evaluate effects of early-life recreational noise exposure on hearing throughout the life
vie
37
38 course and to identify relevant risk factors associated with unsafe listening practices.
39
40 Despite some inconsistent research on associations of recreational noise
w
41
42
exposure and permanent changes to hearing in adolescence, studies conducted in
43
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44
45 animals and human subjects have provided compelling evidence for the biological
46
47 plausibility of associations, demonstrated by the physiological impacts of loud noise
ly
48
49 exposure on the auditory system. Studies have indicated that repeated or even single
50
51
52 instances of loud noise exposure may lead to physiological damage that present as
53
54 temporary hearing loss (temporary threshold shifts) that resolve within several hours or
55
56
57
58
59 19
1
2
3 days, or acute tinnitus, both of which may be predictive of permanent hearing
4
5
6 damage.[5, 6, 49, 62, 63] Similarly, repeated or single exposures to noise and
7
8 temporary threshold shifts have been tied to the presence of ‘hidden hearing loss’ also
9
10 known as cochlear synaptopathy, which can be defined as damage to or a loss of
11
Co
12
13
synaptic contacts between cochlear hair cells and auditory nerve fibers that can exist
14
nf
15 without permanent changes to audiometric thresholds.[64] Temporary threshold shifts
16
17 and hidden hearing loss likely serve as predictors for irreversible, permanent hearing
ide
18
19
loss and may present as difficulties hearing in challenging listening environments, such
20
21
nt
22 as in background noise. Studies have indicated that mechanisms of noise-induced

23
24 hearing loss include damaged synapses, destruction of the sensory cells in the cochlea,
ial
25
26 and intense metabolic activity at the cellular level which leads to raised levels of
27
:F
28
29 cochlear free radicals, eventually leading to programmed and/or necrotic cell death.[64-
or
30
31 67] These physiological changes likely result in progressive and incremental, yet
32
33 permanent, changes to hearing thresholds and/or the onset of tinnitus.[68]
Re
34
35
36
The detrimental impacts of noise exposure on auditory and non-auditory health
vie
37
38 have been described and unsafe listening practices are recognized as an important
39
40 global public health problem.[4] In 2015, the WHO launched the ‘Make listening safe’
w
41
42
initiative to ensure people of all ages can enjoy listening with full protection of their
43
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44
45 hearing.[69] This initiative aims to modify unsafe listening behaviors and regulate and
46
47 limit (when necessary) voluntary exposure to loud sounds from PLDs and other loud
ly
48
49 recreational settings, including from entertainment venues. Make listening safe
50
51
52 prioritizes educating the general population, policymakers, health professionals, and
53
54 manufacturers about the importance of safe listening practices that are needed to
55
56
57
58
59 20
1
2
3 prevent hearing loss. The WHO and its partners have released several publicly
4
5
6 available resources in multiple languages that can be adapted to specific settings,
7
8 including awareness materials for individuals,[2] a depository of open-access resources,
9
10 and the standards and toolkits briefly discussed below. The WHO offers support to
11
Co
12
13
Member States, private sector entities and civil society in adopting and implementing
14
nf
15 these standards and toolkits, and promotes partnerships that will encourage
16
17 implementation of make listening safe.
ide
18
19
In 2018, the WHO and International Telecommunication Union (ITU) released
20
21
nt
22 global standards for safe listening devices and systems to define suitable exposure
23
24 limits and safety standards for listening devices/systems and this resource also details
ial
25
26 implementation strategies.[70] The WHO toolkit for safe listening devices and systems
27
:F
28
29 provides a user-friendly summary and a stepwise approach for governments, industry,
or
30
31 and civil society to implement these standards.[3] This year, the WHO released the
32
33 global standard for safe listening venues and events, which aims to protect hearing of
Re
34
35
36
audience members at recreational venues such as discotheques, bars, concerts, and
vie
37
38 festivals by providing standardized, evidence-based recommendations and
39
40 implementation strategies to reduce risk of unsafe noise exposure.[13] The features
w
41
42
detailed in this standard can be implemented through governmental legislation or
43
On
44
45 regulation, and/or by voluntary adoption by venue owners or managers. Also this year,
46
47 the WHO released the mSafeListening handbook, which provides details needed to
ly
48
49 develop, integrate, implement, and evaluate a national mSafeListening program to
50
51
52 promote hearing loss prevention and promotes the use of digital interventions.[71]
53
54
55
56
57
58
59 21
1
2
3 In addition to recommendations and standards for governments, industry, and
4
5
6 civil society, the WHO provides educational resources that can be used by the general
7
8 public.[2, 72] Recommendations for safe listening focus on reducing sound levels and
9
10 duration of exposure, monitoring listening levels (i.e., through device settings), use of
11
Co
12
13
hearing protection, and heeding the early signs of hearing loss, such as tinnitus and
14
nf
15 difficulties understanding in background noise.
16
17 Findings from this study support the need to implement the above policy
ide
18
19
recommendations. Prevalence estimates of exposure to excessive noise from PLD use
20
21
nt
22 and loud entertainment venues were high. However, high study heterogeneity was
23
24 present and was particularly salient in studies focused on loud entertainment venues.
ial
25
26 The heterogenous methodologies and definitions used in these studies likely
27
:F
28
29 contributed to the low confidence (i.e., higher p-values) in pooled prevalence estimates
or
30
31 that were created using all studies in the systematic review (data not shown). These
32
33 results highlight the need to reduce heterogeneity of measurement and outcome
Re
34
35
36
definitions in studies focused on exposure to unsafe listening. Thus, it is recommended
vie
37
38 that future studies focused on unsafe listening practices use internationally standardized
39
40 definitions of excessive recreational noise exposure and measure sound exposure
w
41
42
using standardized methodology.
43
On
44
45 There are likely demographic (e.g., by gender, age, rurality) and personal
46
47 differences in risk perception and preferences and engagement in risky behaviors,
ly
48
49 including voluntary recreational noise exposure.[52, 73, 74] This notion is supported by
50
51
52 pooled prevalence estimates of exposure to excessive noise from PLDs stratified to age
53
54 group, which suggest that minors (versus adults) may be slightly more likely to be
55
56
57
58
59 22
1
2
3 exposed to unsafe listening from PLDs. We were unable to evaluate potential
4
5
6 differences across other demographic strata, such as gender or rurality given the
7
8 limitations of data reported in the studies included in the systematic review. Our
9
10 estimate of the global population likely exposed to unsafe listening levels was crude yet
11
Co
12
13
was created with the most current and best available data.
14
nf
15 Strengths and limitations
16
17 To our knowledge, this review is the first published article to estimate prevalence
ide
18
19
of exposure to unsafe listening practices in adolescents and young adults and its global
20
21
nt
22 burden. These estimates are needed to communicate the urgency of prioritizing hearing
23
24 loss prevention to governments, industries, and other stakeholders responsible for
ial
25
26 implementing policy. However, some limitations exist. This systematic review and meta-
27
:F
28
29 analysis are limited by the heterogeneity and lack of standardized research
or
30
31 methodology of the studies included. As mentioned above, there was particularly high
32
33 heterogeneity in studies focused on loud entertainment venues. Although we conducted
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35
36
the literature search in four languages, there may be published articles in other
vie
37
38 languages that were not captured in this systematic review. Most studies were from
39
40 European and American regions and thus may not be reflective of unsafe listening
w
41
42
practices in other regions. There were not studies from low-income countries eligible for
43
On
44
45 inclusion in the meta-analysis and therefore the estimates of prevalence or global
46
47 burden may not capture unsafe listening practices in low-income countries. However, it
ly
48
49 is likely that the prevalence of unsafe listening practices is high in low-income countries
50
51
52 given limited policies and regulations on noise exposure limits.[13] Our global estimate
53
54 of exposed individuals was crude and did not account for some potentially influential
55
56
57
58
59 23
1
2
3 factors, such as demographic factors and recent changes to policy on safe listening in
4
5
6 some countries/regions.
7
8
9
10 CONCLUSION
11
Co
12
13
Exposure to unsafe listening practices from voluntary use of PLDs and
14
nf
15 attendance of loud entertainment venues is highly prevalent in adolescents and young
16
17 adults. It is estimated that 0.67 – 1.35 billion adolescents and young adults worldwide
ide
18
19
may be at risk for hearing loss from exposure to unsafe listening practices. There is an
20
21
nt
22 urgent need for governments, industry, and civil society to prioritize global hearing loss
23
24 prevention by promoting safe listening practices. WHO global standards,
ial
25
26 recommendations and toolkits are available to aid in development and implementation
27
:F
28
29 of policy and public health initiatives to promote safe listening worldwide.
or
30
31
32
33
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36
vie
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38
39
40
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On
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46
47
ly
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52
53
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57
58
59 24
1
2
3 FIGURE CAPTIONS
4
5
6 Figure 1: Flow diagram (PRISMA 2020) summarizing the article screening process.
7
8
9
10 Figure 2: Forest plot displaying study-specific and overall prevalence estimates of
11
Co
12
13
exposure to PLDs for the 17 studies included in the meta-analysis.
14
nf
15
16
17 ACKNOWLEDGEMENTS
ide
18
19
Thank you to Artem A. Shchepilov for translating the studies from Russian to English,
20
21
nt
22 and to Juan J. Lopez Perez for extracting the studies in Spanish.

23
24
ial
25
26 COMPETING INTERESTS
27
:F
28
29 Authors have no competing interests to declare.
or
30
31
32
33 FUNDING
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36
This research did not receive any specific grant from funding agencies in the public,
vie
37
38 commercial, or not-for-profit sectors.
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40
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59 25
1
2
3 REFERENCES
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43 69. World Health Organization. Make Listening Safe; 2015. Accessed from:
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47
ly
48 ng.pdf.
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50 70. ITU. Series H: Audiovisual and multimedia systems. E-health multimedia
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52 systems, services and applications – Safe listening. Guidelines for safe listening
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54
55
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57
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59 33
1
2
3 71. World Health Organization. A handbook on how to implement mSafeListening;
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6 2022.
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8 72. World Health Organization, 2022. Media brief on #safelistening; 2022
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10 73. Washnik NJ, Russell JA, Bhatt I, et al. University Marching Band Members’ Noise
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Dosages and Hearing Health-Related Knowledge. Int J Env Res Public Health.
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15 2021 Nov 1;18(21):11497.
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17 74. Ji-Su K. Association between tinnitus and mental health among Korean
ide
18
19
adolescents: the Korea National Health and Nutrition Examination Survey. Cent
20
21
nt
22 Eur J Public Health. 2018 Mar 30;26(1):65-70.

23
24
ial
25
26
27
:F
28
29
or
30
31
32
33
Re
34
35
36
vie
37
38
39
40
w
41
42
43
On
44
45
46
47
ly
48
49
50
51
52
53
54
55
56
57
58
59 34
1
2 Identification of studies via databases and registers Identification of studies via other methods
3
4
Co
5
Identification
6 Records identified from: Records removed before Records identified from:

7 PubMed (n = 153) screening: Search in Spanish, French,
nfi
8 Web of Science (n=151) Duplicate records removed or Russian (n = 9)
9 Scopus (n=365) (n = 280) Citation searching (n = 36)
de
10
11
12
nti
13
14
Records excluded (did not match
al:
15 Records screened
eligibility criteria)
16 (n = 389)
(n = 308)
17
Fo
18
19
rR
20 Reports sought for retrieval Reports sought for retrieval Reports not retrieved
Reports not retrieved
21 (n = 81) (n = 3) (n = 45) (n = 0)
Screening
ev
22
23
24
iew
25 Reports excluded:
26 Reports assessed for eligibility Did not include outcome of Reports assessed for eligibility
(n = 78) interest, repeated data (n = 39) (n = 45)
27 Reports excluded:
Not representative of target
On
28 Did not include outcome of
population (n = 8) interest, repeated data (n = 38)
29 Incorrect article type or other Incorrect article type (n =2)
30 language (n=3)
ly
31
32
33
34 Studies included in review
Included
35 (n = 28)
36 Reports of included studies
(n = 5)
37 A total of n=33 studies were
38 included in synthesis.
39
40
41
42
44
45
46
nf
id
Personal
Page 73 of 79Listening Devices BMJ Global Health
First author (year) Event Rate (95% CI)
2 Twardella
en
1 Muchnik (2012)
(2017)
0.30 (0.20 – 0.41)
0.27 (0.25 – 0.29)
tia
3 Vogel (2010a) 0.32 (0.30 – 0.35)
4 Sulaiman (2013) 0.08 (0.05 – 0.14)
l: F
5 Sulaiman (2015) 0.08 (0.05 – 0.12)
6 Fligor (2014) 0.65 (0.56 – 0.74)
7 Lévesque (2010) 0.42 (0.34 – 0.51)
or
8
Lee (2014) 0.16 (0.15 – 0.18)
9
Breinbauer (2011) 0.12 (0.09 – 0.15)
10
Re
11Hussain (2018) 0.22 (0.13 – 0.36)
12Kaplan-Neeman (2017) 0.23 (0.12 – 0.38)
13Hutchinson Marron (2015) 0.04 (0.02 - 0.09)
vie
14Orozco Medina (2017) 0.55 (0.40 – 0.69)
15Kim (2021) 0.23 (0.12 – 0.38)
16Kumar (2017) 0.41 (0.32 – 0.51)
w
17
Vogel (2014) 0.30 (0.28 – 0.33)
18
Mercier (2002) 0.17 (0.15 – 0.20)
19
On
20Pooled Estimate 0.24 (0.19 – 0.29)
21 -1.00 -0.50 0.00 0.50 1.00
22
24
25
1
2
3 Supplement 1: Search strings for each database. Searches were conducted December
4
5
16, 2021.
6
7 Search string 1: Personal listening devices
8
9 1. PubMed
10
Advanced search
11
Co
12 n= 92
13 Filters: English, years 2000-2021
14
nf
15 (“sound” OR “listen*” OR “noise” OR “decibel level”) AND (“risk” OR “odds” OR
16 “prevalence” OR “incidence” OR exposure”) AND (“adolescent*” OR “youth*” OR “young
17
ide
adult*” OR “student*” OR “juvenile*” OR “teenage*”) AND (”audio device” OR "personal
18
19 listening device" OR "mp3 player" OR “Ipod” OR “personal music devices” OR “music
20 player”)
21
nt
22 2. Web of Science core collection

23 Advanced search
24
ial
25
n= 80
27
:F
28 (“sound” OR “listen*” OR “noise” OR “decibel level”)

29 AND (“risk” OR “odds” OR “prevalence” OR “incidence” OR “exposure”) AND
or
30 (“adolescent*” OR “youth*” OR “young adult*” OR “student*” OR “juvenile*” OR

31
32
“teenage*”) AND (”audio device” OR "personal listening device" OR "mp3 player" OR
33 “Ipod” OR “personal music devices” OR “music player”)
Re
34
35 3. Scopus
36 Advanced search
vie
37
n=198
38
40
w
41 TITLE-ABS-KEY ( ( "sound" OR "listen*" OR "noise" OR "decibel level" ) AND (

42 "audio device" OR "personal listening device" OR "mp3 player" OR "Ipod" OR
43 "personal music devices" OR "music player" ) AND ( "risk" OR "odds" OR
On
44
"prevalence" OR "incidence" OR "exposure" ) ) AND ALL ( ( "adolescent*" OR
45
46
"youth*" OR "young adult*" OR "student*" OR "juvenile*" OR "teenage*" ) )
47
ly
48 Search string 2: Entertainment venues

49
50 1. PubMed
51
Advanced search
52
53 n= 61
55
56
57
58
59
1
2
4
5
“prevalence” OR “incidence” OR “exposure”) AND (“adolescent*” OR “youth*” OR
6 “young adult*” OR “student*” OR “juvenile*” OR “teenage*”) AND ("entertainment
7 venue*" OR “night club” OR “concert” OR “discotheque*” OR “bar” OR “disco” OR
8 “nightclub”)
9
10 2. Web of Science core collection
11
Co
12
Advanced search
13 n= 71
nf
15
17
ide
“prevalence” OR “incidence” OR “exposure”) AND (“adolescent*” OR “youth*” OR
18
19
“young adult*” OR “student*” OR “juvenile*” OR “teenage*”) AND ("entertainment
20 venue*" OR “night club” OR “concert” OR “discotheque*” OR “bar” OR “disco” OR
21 “nightclub”)
nt
22
23 3. Scopus
24
ial
Advanced search
25
26 n= 167
:F
28
29 TITLE-ABS-KEY ( ( "sound" OR "listen*" OR "noise" OR "decibel level" ) AND
or
30 ("entertainment venue*" OR “night club” OR “concert” OR “discotheque*” OR “bar” OR

31
“disco” OR “nightclub”) AND ( "risk" OR "odds" OR "prevalence" OR "incidence"
32
33 OR "exposure" ) ) AND ALL ( ( "adolescent*" OR "youth*" OR "young adult*" OR
Re
34 "student*" OR "juvenile*" OR "teenage*" ) )

35
36
vie
37
38
39
40
w
41
42
43
On
44
45
46
47
ly
48
49
50
51
52
53
54
55
56
57
58
59
1
2
3 Supplementary Materials 2. Details for risk of bias assessment.
4
5
7
Performance of data collection tools
Completeness and reporting bias

8
9
10
11
Co
12
Overall Rating
Selection Bias
Study Design
13
14
nf
15 First author (year)
16
Muchnik (2012) + + +
17
ide
18 Twardella (2017) +
19
20 Vogel (2010a) +
21
nt
Sulaiman (2013) +
22
23 Sulaiman (2015) + + +
24
ial
Fligor (2014) + + +
25
26 Lévesque (2010) +
27
:F
Lee (2014) + + +
28
29 Breinbauer (2011) +
or
30
31 Hussain (2018) + + +
32 Kaplan-Neeman (2017) - -
33
Re
34 Hutchinson Marron (2015)
35 Orozco Medina (2017) - - -

36
vie
37 Kim (2021) - -
38
Kumar (2017) - - +
39
40 +
w
Vogel (2014)
41
Mercier (2002)
42
43
On
44
+ Strong Moderate - Weak
45
46
47 Overall Rating 5 8 4
ly
48 Selection Bias 3 12 2
49
50 Study Design 3 13 1
51
Performance of data collection tools 9 7 1
52
53 Completeness and reporting bias 2 14 1
54
55 0 2 4 6 8 10 12 14 16 18
56 Number of studies
57
58
59
1
2
4
Performance of data collection tools

5
Completeness and reporting bias

6
7
8
9
Overall Rating
Selection Bias
10
Study Design
11
Co
12 First author (year)
13
14 Vogel (2014)
nf
15
Mercier (2002)
16
17
ide
LePrell (2013)
18
LePrell (2018) - -
19
20 Figueroa Hernández (2011) - - -
21
nt
Ahmed (2007)
22
23 Vogel (2010b) +
24
ial
25 Serra (2005) + + +
26 Rowsanowski (2006) +
27
:F
28 Widen (2004) + + + +
29 Jokitulppo (2005) - - + +
or
30
31 Deegest (2014)
32 Weichbold (2012) +
33
Re
34 Serra (2014) - - +
35 Gilles (2012)
36
vie
37 Budimčić (2014)
38
Filova (2020) +
39
40 Johnson (2014) +
w
41
42
+ Strong Moderate - Weak
43
On
44
45 Overall Rating 2 12 4
46 Selection Bias 5 10 3
47
ly
48 Study Design 18
49
Performance of data collection tools 5 12 1
50
51 Completeness and reporting bias 3 14 1
52
0 2 4 6 8 10 12 14 16 18
53
Number of studies
54
55 Note. Studies were assigned an overall rating of weak if they were ranked as weak in ≥1 category, moderate if they
56 had 0 weak ratings and <2 strong ratings, and strong if they had 0 weak ratings and ≥2 strong ratings.
57
58
59
1
2
3 Supplement 3: Details on the quadratic model evaluating the relationship of prevalence
4
5
of exposure to excessive noise from loud entertainment venues as a function of
6 loudness intensity and duration thresholds.
7
8 Table S3. Studies from systematic review that equated intensity and duration of sound
9 levels to LAeq values for exposure to loud entertainment venues. These studies were
10 used to build and evaluate the quadratic model.
11
Co
13
14 First author Number, Number, Prevalence
Risk criteria
nf
15 (year) sample size exposed estimate (%)
16
17 LAeq ≥ 80 dB for
ide
18 943 454 48.1%
19 ≥56 hours/week
20
LAeq ≥ 85 dB for
21 Vogel (2014)a 943 171 18.1%
nt
22 ≥56 hours/week
23
ial
25 943 68 3.1%
26 ≥56 hours/week
27
:F
LAeq ≥ 85 dB for
28 Vogel (2010b)b 1512 267 17.7%
29 ≥40 hours/week
or
30
32 Mercier (2002)b 700 68 9.7%
33 ≥40 hours/week
Re
34
35 aPrevalence estimates for several different risk criteria definitions were provided in this
36
publication and thus it was chosen to build the first quadratic model.
vie
37 bPrevalence estimate from studies were used to evaluate consistency of estimates

38
39 across populations and eventually added to the second model.
40
w
41 As a first step, we produced a quadratic spline model, which approximates the

42 relationship of prevalence of exposure to excessive noise from loud entertainment
43 venues as a function of the exposure thresholds of loudness/intensity. The quadratic
On
44
45
model was fitted to data points from Vogel (2014), which was chosen because authors
46 report the prevalence of exposure for several cut points of intensity level (LAeq ≥80 dB;
47 ≥ 85 dB; ≥ 90 dB) and several data points from the same population are needed to fit
ly
48 the model.
49
50 Next, we compared the estimates of the other two studies that defined risk of exposure
51 to excessive noise from loud entertainment venues using LAeq (Supplement 3) and the
52
53
values predicted by the quadratic model to evaluate consistency of prevalence
54 estimates among the relevant studies. All three studies lie closely on the estimated
55 quadratic, indicating that prevalence estimates among these studies are commensurate
56 (see Fig. S3a).
57
58
59
1
2
3 Figure S3a: Quadratic model showing the prevalence of excessive noise exposure from
4
5
loud entertainment venues as a function of loudness intensity. The model was built with
6 estimates from Vogel (2014). Estimates from Vogel (2010b), and Mercier (2002) were
7 plotted on the model and results indicate that prevalence estimates across risk criteria
8 definitions are consistent.
9
10
11
Co
12
13
14
nf
15
16
17
ide
18
19
20
21
nt
22
23
24
ial
25
26
27
:F
28
29
or
30
31
32
33
Re
34
35 As last step, we produced a quadratic model for the prevalence as a function of both the
36
loudness intensity and duration thresholds that fitted very well all five studies, (see Fig
vie
37
38 S3b).
39
40
w
41
42
43
On
44
45
46
47
ly
48
49
50
51
52
53
54
55
56
57
58
59
1
2
3 Figure S3b: Quadratic model showing the prevalence of noise exposure from loud
4
5
entertainment venues as a function of y = Intensity (dB) and x = Duration (hours per
6 week). The model was built with estimates of Table S3, the fitting equation Prev (x,y) is
7 shown below the 3D figure.
8
9
10
11
Co
12
13
14
nf
15
16
17
ide
18
19
20
21
nt
22
23
24
ial
25
26
27
:F
28
29
or
30
31
32
33
Re
34
35
36
vie
37
38
39
40
w
41
42
43
On
44
45
46
47
ly
48
49
50
51
52
53
54
55
56
57
58
59

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BMJ Global Health

Journal: BMJ Global Health

Article Type: Original research

Otolaryngology Head & Neck Surgery

Jiménez, Lucía; Octoma

25 cCluster of Healthier Populations, World Health Organization, Geneva, Switzerland

41 Declarations of interest: None

22 loss in young people.

25 What this study adds

22 permissible sound levels, and d) definitions of noise exposure and related

22 listening practices as a range, utilizing prevalence estimates of exposure to both unsafe

34 Malaysia Daily (LAeq

41 Canada Daily (LAeq

44 Singapore Daily (LAeq

30 ≥40 hour / week

37 LePrell (2018) of America Adults 74 45 ≥1x / month

Hernández (2011) (Middle)

Johnson (2014) Kingdom Adults 357 165 ≥1x / week

22 Effect size, 95% confidence interval Test of null (2-Tail)

30 Adults 7 23.10% 8.90% 48.03% p < 0.01

High income 13 24.51% 19.35% 30.53% p < 0.01

4 22.12% 7.15% 51.17% p < 0.01

48 Daily (LAeq >80dB) 3 12.95% 5.10% 29.20% p < 0.01

30 pooled prevalence estimates were insensitive to individual study inclusion. Sensitivity

22 years was 2.8 millionbillion.[242] We utilized the pooled prevalence estimate of

37 personal listening devices or entertainment venues

41 aged 12-34 yrs entertainment

22 potential dose-response relationship of recreational noise exposure and associated

22 Laryngol, 2018. 127(10), 703-709.

22 40.42. Le Prell CG, Spankovich C, Lobariñas E, et al. Extended high-frequency

22 56.58. Śliwińska-Kowalska M, Zaborowski K. WHO environmental noise

41 noise-induced hearing loss. Dis Mon. 2013;59(4):1108.

22 Eur J Public Health. 2018 Mar 30;26(1):65-70.

25 cCluster of Healthier Populations, World Health Organization, Geneva, Switzerland

41 Declarations of interest: None

22 loss in young people.

25 What this study adds

22 Patient and public involvement statement

22 Twardella (2017) Minors 2143 579

Netherlands Weekly (LAeq

Sulaiman (2013) Minors 177 15

30 Sulaiman (2015) Adults 282 22

Fligor (2014) of America Adults 110 72

37 Lévesque (2010) Minors 124 52

22 Vogel (2014) Mixed 943 454 LAeq ≥80 dB for

37 Hernández (2011) (Middle)

≥40 hour / week

28 Adults 7 23.10% 8.90% 48.03% p < 0.01

Mixed 5 21.55% 14.65% 30.53% p < 0.01

Middle income (upper

Risk criteria definition

37 (23.81% [CI 18.99- 29.42]) (results not shown).

48 subgroup analyses) calculated from the 18 studies are not presented.

37 Prevalence (95% number, exposed Prevalence,

22 as in background noise. Studies have indicated that mechanisms of noise-induced

22 and to Juan J. Lopez Perez for extracting the studies in Spanish.

22 4. World Health Organization. Environmental noise guidelines for the European

environmental danger. Paediatr Child Health. 2008;13(5):37782.

41 8. Kujawa SG, Liberman MC. Acceleration of age-related hearing loss by early

48 on health. Lancet. 2014;383:132532.

24. United Nations. Population Division, World Population Prospects; 2019.

Int J Audiol. 2012;51(4):287-93.

30 (“adolescent” OR “youth” OR “young adult” OR “student” OR “juvenile*” OR

30 ("entertainment venue" OR “night club” OR “concert” OR “discotheque” OR “bar” OR

34 "student" OR "juvenile" OR "teenage*" ) )