 Hi everyone. Today I'm talking about hearing loss prevention and how we need to approach this challenge from a number of different angles. When I talk about hearing loss prevention I'm talking specifically about noise-induced hearing loss. And we know that that risk of noise-induced hearing loss can come from two sources essentially, from the workplace and also from leisure environments, at least in the pre-COVID era when we were still allowed to go to nightclubs and attend music concerts. Research at NAL and many other labs around the world over the past few years has shown very clearly how sound levels at recreational events can be just as loud as they are in more traditional industrial workplaces. In this graph the pink lines, the pink bars represent recreational sound levels while the green bars are workplace levels. And you can see for example that a nightclub is just as loud as the sound level that you get from a chainsaw. Similarly the sound level that you experience in a fitness class is just as loud as the sound level in a sheet metal workshop. And while there hasn't been an epidemic of hearing loss from recreational sources, the research clearly demonstrates that the more recreational noise that a person is exposed to, the more likely they are to exhibit signs and symptoms of hearing damage. And that's particularly true for tinnitus. In the lower graph you can see that people who report always having tinnitus are very likely to have higher levels of recreational noise doses. And so there's essentially three ways that we can approach a hearing loss prevention. The first approach is to take an upstream view. So this means working at the government level to change policy, to change regulations and legislation. It means working with international organisations to try and make change at a systemic level so that you can create safer environments for a really large group of people, whether that's like a national population or even an international population. At the midstream activities include approaching schools, doing work in the workplace, disseminating information via the media, basically community driven activities where you can still reach large groups of people but not quite as large a group as you would be reaching in the upstream sort of scenario. And then there's also downstream activity that you can do. So downstream refers to reaching individuals on a one-on-one basis and trying to change the behaviour of individuals. And clearly this is a fairly ineffective way to go about trying to change the dial on hearing loss prevention. It's much more effective to try and work at the upstream level where you can make really major changes that affect the health of really large groups of people. However, even though upstream work is effective, it's also really labour-intensive and it involves a lot of stakeholders and reaching agreement from a lot of people who have very diverse views. So it can be really time consuming and it can take many years to reach an outcome. What I'm going to talk about today is some of the lessons that we've learned from the work that we've done at both the upstream, the midstream and the downstream level. So the first lesson I want to talk about is the fact that we've learnt that international cooperation can make a difference. So NAL has been involved in the World Health Organisation's group called Make Listening Safe since it was formed in 2015. And the World Health Organisation estimated that 1.1 billion young people were exposed to unsafe sound levels through their headphones. And so they formed this Make Listening Safe group to try and see if we could come up with some international agreed standards for how we can better protect people's hearing while they're listening through headphones on their personal listening devices. And after four years of work and many meetings and a lot of effort from a lot of people from a wide range of disciplines, the group came up with some international guidelines. So the Safe Listening Guidelines for devices and systems is a joint publication between the World Health Organisation and the International Telecommunications Union. And it sets out some minimum standards that we think should be included for people who are listening through to sound through their headphones. It includes ways for devices to measure sound levels and monitor them and then provide that information to the user. And so this is a really good example of how work at the upstream level can actually lead to tangible differences. One of the really important aspects of this work was that Apple has been involved in the working group discussions. And so if you look at the latest updates in Apple software, you can see that they've actually incorporated these standards into their devices. They allow for monitoring of headphone levels and they provide messages when people are listening at unsafe levels. So this is a great example of how you can really make a difference when you're working upstream. The next agenda on the item for the Make Listening Safe Group is to try and tackle the concept of developing standards for music venues. And we've been heavily involved in this work. We developed a background paper collating all the evidence from the countries which currently have standards for their music venues. So there's quite a few countries in Europe that already impose standards on their music venues. They require them to meet limits on the sound level. They require their sound engineers to monitor the sound levels of their music. They also need to make sure that they're listening to the environment concerts. They require venues to provide earplugs for patrons and they also require rest areas. So that people take a break from loud listening. And so the aim from now on for the Make Listening Safe Group is to try and see if we can emulate what we've done for the personal listening devices and try and create some international standards to create safe listening is it relates to workplace behaviours and how these can translate into leisure environments. So we conducted a survey of 8,000 people and we asked them about their workplace. Did they experience noise at the workplace and did they use hearing protectors in the workplace? And what we found was that those people who'd been exposed to noise at work who'd learned about noise exposure at work or understood the risks of noise exposure and who had used earmuffs or earplugs at work were much more likely to then translate that information, translate that learning, translate that knowledge to their leisure environments. And they're up to five times more likely to use hearing protectors in leisure environments whether that was at concerts or when using tools around the house. So this is a really great example of how activity in the midstream can have an even wider effect than you might think initially because those behaviours can be translated beyond the workplace into other aspects of a person's life. We've also learned that online tools can be a really effective way of reaching a large number of individuals. So while it might be really expensive and time consuming to reach individuals and try and change behaviour on a one-on-one basis, the internet provides a fantastic platform to reach large numbers of individuals for a relatively low cost. So back in 2014 we developed a tool called the Know Your Noise Risk Calculator and we've had many thousands of users log on since that time and what Know Your Noise is is a personalised risk calculator. It's an interactive tool where people enter information about the noise activities that they do, how often they do them and how long they spend doing each one and then the noise risk calculator calculates that individual's personalised risk profile. It presents that information in relation to their peers so it compares where they're sitting on the risk parameter. So in this example this person is at very high risk, they've got a noise risk level of 2.5 and then we demonstrate that when you compare that to the group, the group sitting more around one. So this person's obviously at high risk and most importantly what the noise risk calculator does is it provides information about the source of that risk. So in this example this person's risk is mostly coming from attending concerts and so the person is encouraged to actually go back and change their initial answers and find out what would happen if they changed their behaviour. So for example perhaps this person goes to concerts on a fortnightly basis and so they can go in and say okay well what if I only attended concerts on a monthly basis how would this change in behaviour change my risk profile. And so there's a very real, tangible, personalised demonstration of how that person's behaviour can alter their risk profile. And we know that providing this information to people is useful and then does change people's motivation. So we've conducted a before and after survey and found that before starting the noise risk calculator about 60% of people told us that they either sometimes or always act to protect their hearing and reduce their noise exposure but after doing the noise risk calculator this number jumped from 60% to 88%. So that's a really significant increase in the level of motivation for people doing this tool. We've also learnt that giving access to tools is a more effective strategy than providing information. So we studied a group of clubbers and we invited them to come and meet us and receive a pair of high fidelity earplugs to wear at our clubs and we had two groups. There was Control Group who simply received the earplugs and then another group that received the earplugs plus they were given some information and some training about noise exposure and risks and so on. And what we found was that there was actually no difference between the groups. Both groups were equally likely to change their behaviour to wear earplugs more often and both sustained their intention to protect their hearing 12 weeks after the initial time that we interviewed them. And so what this study has shown us is that giving people the tools that they need to act and to protect their hearing is a more effective strategy and it's really all that you need if people are motivated already to protect their hearing. Giving them information is likely to make a very small difference if at all. Over the years we've done a lot of qualitative work talking to people who protect their hearing and trying to find out exactly why they protect their hearing, what are the insights that we can learn, what are the themes there, what can we find out about what motivates these people and then the idea is that we can then use that information to design tools and campaigns to convince other people to take protective action as well. And what we've found through these qualitative interviews is that tinnitus can be a really salient trigger for people and also people who have a really strong love of music and those who can take a long-term view of their hearing are really likely to be the ones who have been proactive about taking action to protect their hearing. So we often find that if we talk to someone who's a regular earplug user they will relay a story about how they decided to start using earplugs when their tinnitus got too bad or when they spoke to a friend who had really bad tinnitus and they realised that they didn't want to end up in the same situation. So tinnitus can be a really strong emotional motivator to get people to take real action. And we also found that people who are regular earplug users often identify very strongly as music lovers. They see it as part of their identity and it's something that they want to maintain for the long term. And so these people who can see themselves in 10, 20, 30 years time and they realise that they want to maintain their hearing so that they continue their love of music, these are the people that are more likely to be the regular protectors of hearing. And so these things are really important for us because they're sort of emotional triggers that help us to design tools and activities and interventions to help other people also take action. We've also found throughout the years that the media is a really important partner for promoting hearing health and it's a really good way of reaching a large number of people. So these examples come from World Hearing Day from 2018. The ABC published a number of studies looking at music exposure and the risks that come with that. And what we found was that reading the comments was really useful for us. And in particular we found that there were a bunch of comments where people were indicating that they were taking action as a result of reading these media stories. So there were people who were talking to their friends, tagging their friends, talking about getting earplugs for a concert they were about to go to, reminding their friends to get earplugs, offering to buy earplugs for their friends. And so this was a really encouraging sign that promoting your work through the media can actually have downstream effects and affect behaviour in individuals and really you can see sort of the effect of what you're trying to promote. And even more encouraging was one comment in particular which pointed out that this was the first feed on this person had ever read where other people are saying they wear earplugs at concerts. And this gives us a really great sense of encouragement because it suggests that there might be a time when wearing earplugs and protecting hearing and being aware of noise levels will actually become the norm. And we know that people are much more likely to listen to their friends, listen to their peers and take notice of the example of their friends rather than listening to scientists or academics telling them what to do. And so the fact that promoting your work in the media can have this effect and can suggest that the norms can be changed is a really positive thing for us to be able to see. And so I guess if you take all of our work and look at it as a whole, what's very clear to us is that it aligns really well with the COMB model. So the COMB model is a popular health behaviour change model. It's used in lots of different areas of health, not just hearing. And what it says is that in order to change behaviour, what we need to do is enhance and improve and change a person's capability, opportunity and motivation. And it's these three things which will drive behaviour change. What we need to do is to resist the urge to educate and instruct and inform. And instead, what we need to do is look for opportunities to try and help people be capable of protecting their hearing, knowing the risks, understanding the relationship between noise level and duration, giving that capability and the know-how to insert earplugs. These things are all about enhancing capability and they are the type of things that are going to lead to real behaviour change. Equally, providing opportunities for people to change their behaviour. So if we take the example of earplugs at a music venue, it means having the earplugs visible. It means having them available on the counter, not hidden in the back room. It means making them available at a reasonable price, so that people can purchase them easily. And of course, motivation is essential. We've seen in our qualitative work that motivating people, appealing to their love of music, appealing to their desire to be able to listen to music for a really long period of time. Those are the types of things that are really strong and salient and emotional and are much more likely to create behaviour change than giving people handouts and information and scientific material. So this leads me to the final piece of work I want to talk about. And this is some recent work that we've been asked to do by the Department of Health and they asked us to look at how we can change hearing health behaviours across the entire population. So not just young people in a music setting, but across the whole population. How can we motivate people to change their hearing health behaviours? And so we've done a big analysis, a big deep dive, if you like, looking at the needs and gaps of the Australian population in terms of their capability, their opportunity and their motivation to engage in hearing health behaviours. And yeah, if this is something that you're interested in, please reach out to me after this talk and I'll be happy to tell you more about it. And so finally, to conclude, if we're going to prevent noise induced hearing loss and make a difference, what we need to do is a whole lot of different activities. We need to think about what we can do at the upstream level. We need to keep active in the midstream, engage with the media and also think about what we can do in the downstream and try and reach individuals on their level. To do that, personalised online tools are a really good way for reaching young adults and motivating them to change their behaviour. At the midstream, we know that the workplace is a really good place to talk to people about noise exposure because it has more widespread effects than just the workplace. It goes beyond that into leisure and recreational settings as well. We know that giving people tools to act is much more important than giving them knowledge and we know that we need to keep engaging with the media because it's a really good way to generate peer-to-peer advice, motivate action and perhaps even create some new norms. Finally, my main message, prevention campaigns, interventions and activities need to be based on trying to enhance a person's capability, opportunity and motivation. By changing these three things, we'll be able to make effective changes in terms of behaviour. Finally, I'd like to finish by thanking my colleague, Megan Gilbert, who has been an instrumental partner in all of the work that I've talked about here today. Of course, I'd like to acknowledge our funders for all of this work. That includes the Hearing CRC and also the Department of Health, which funds much of the work that is done at now.