2013 Vol.8 No.

JOURNAL OF

OTOLOGY
NOISE INDUCED HEARING LOSS IN CHINA: A POTENTIALLY COSTLY PUBLIC HEALTH LSSUE
Shi Yongbing , William Hal Martin
Abstract
Hearing loss and tinnitus are among the most common consequences of long term noise exposure and remain an under-addressed heath issue in most developing nations including China. The rapid industrialization and life style changes in China increase the concern over noise exposure and noise induced hearing loss
(NIHL). Research on NIHL in China is limited. The current paper reviews studies published in English and
Chinese language literatures regarding noise exposure and NIHL in China. Their implication on the Chinese population is discussed. The possible utility of a research model such as the Dangerous Decibels as a
means to increase understanding of the scope of NIHL among the Chinese population, to educate the general public in China (especially the young) about NIHL and its prevention, and to study effects of language
and cultural factors on international information dissemination and behavioral interventions is proposed.
Key words: noise, noise-induced hearing loss, China

Introduction

family history and salt use[2].

China is going through probably the fastest change in
its recent history, with rapid growth in economy and dramatic alterations in ordinary peoples life styles. Such
changes have significantly changed individual Chineses
exposure to noise levels on a daily basis among many
other changes, involving his/her working environment,
transportation and leisure time activities. Tens of millions of immigrant workers in Chinese cities are mostly
involved in labor-intense trades including construction
and manufacturing, often subjecting themselves to noise
levels higher than typical office environment. As millions of Chinese now commute to work and move
around in motor vehicles instead of bicycles, streets in
most Chinese cities and towns are getting increasingly
noisy. Entertainment activities among young Chinese
are drastically different than former generations and often involve loud sound exposures, including music, sport
events, computer games and other loud hobbies. The increased noise exposure levels of the Chinese population
inevitably raise the questions on its impact on hearing
and hearing disorders in China.

Noise hazard can cause many health problems. Hearing loss and tinnitus are among the most common consequences of long term noise exposure. Other health issues such as anxiety and hypertension have also been reported to be related to noise exposure. While noise hazard has been extensively studied in industrialized countries, it remains an under-addressed heath issue in most
developing nations including China. China is the largest
developing country in the world. As it is rapidly industrialized in the past few decades, occupational noise exposure and noise exposure in daily life among its population are on the rise and there is an increasing concern
over the potential health consequences of such exposures. In recent studies, in addition to other environmental factors such as lack of relaxation and physical exercise, frequent extra work shifts and air pollution, noise
pollution is ranked number four to contribute to a
sub-healthy status in the Chinese population[1]. Noise exposure has also been shown to be a significant determinant of hypertension prevalence in China, trailing only

Affiliation:
Oregon Hearing Research Center NRC04
3181 SW Sam Jackson Park Road, Portland, OR 97239,
USA

Corresponding authors:
SHI Yong-bin
Emailshib@ohsu.edu

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Hearing loss in China

have played a major role in the process since China

changed its economic policies that traditionally favored
state-owned large enterprises. From 1978 to 1991, the
number of small scale enterprises in China increased
11.5 times and the number of employees in such enterprises increased 2.4 times. Many of such new enterprises are privately owned, located in traditionally rural areas and not tightly regulated. Most township enterprises
do not provide basic occupational health services. A
study showed that the coverage of five occupational
health service activities routinely provided for Chinese
workers was very limited in township enterprises, from
1.4 to 36%[10]. The same study showed that 82.69% of rural industrial enterprises had at least one type of occupational hazard in their work environments. Workers engaged in at least one type of hazardous working environment accounted for 33.91% of the blue-collar workers.
The total detectable rate of the seven types of occupational diseases was 4.4% among these workers. In addition,
11% had illnesses suspected of being (though not proven
to be) caused by occupational exposures.
Currently available study data on NIHL in China published in Chinese language literatures appear to confirm
the impact by noise in the occupational environment.
The prevalence rates of noise related deafness among Chinese workers from various industries, including manufacturing, textile, metal works, railroad and packing, range
from 12.15 to 49.02% in reported Chinese studies [11-20].
The incidence of NIHL increases as the duration of exposure increases[11, 16, 19-21]. Prevalence of NIHL as high as
80.7% has been reported in railroad workers with a working career longer than 10 years[15].
However, industrial noises are no more the only
source of noise exposure in modern day China. In the
past 10 years, China has seen the largest scale of road
construction and fastest increase in the number of automobiles. Road noise is increasingly a source of noise exposure for urban Chinese[22]. A recent study showed that
the average day-to-night noise level was 79.2 dB (A) in
rooms facing main traffic in Beijing, Chinas capital
with fast growth in population and road traffic, dangerously approaching OSHA safety limit especially given
that this is a non-stop constant exposure[23]. As economical conditions for the Chinese people improve, increasing amount of time is spent on entertainment, especially
among young Chinese. Many of these leisure activities
involve exposure to loud sounds, including music and
sports events. Some of the Chinese traditional music instruments are loud and believed to be able to affect hearing. In fact, an earlier study suggested that the incidence
of hearing impairment among musicians of Chinese opera was even higher than among those of popular music
or rock and roll music[24]. Peak sound levels from Chi-

Systematic study data on the prevalence of hearing

loss in China are scarce. For the purpose of this review,
some non-peer reviewed online data are quoted in conjunction with those from peer-reviewed academic journals.
Hearing-related disabilities have been reported to be
among the most common disabilities in China, affecting
16.8% of the population[3]. A recent survey in the southwest province of Sichuan that involved 126,876 randomly selected individuals suggested an overall hearing loss
prevalence of 3.28%, with 73% of the cases being sensorineural[4]. In the same province, the rate of profound
deafness had been reported to be at 0.186%, with 35.6% of
these cases being attributed to environmental factors[5].
Among senior Chinese populations, prevalence of hearing impairment appears to be higher. In a study conducted at the beginning of the 21st century in Suzhou, a
mid-size city in southeastern China, prevalence of hearing loss was reported to be at 66.5% among urban seniors and 50.5% among their rural counterparts. While
the rate of disease-related hearing impairment was similar in the two groups, the rates of presbycusis and
noise-induced hearing loss (NIHL) were significantly different: 55.8% versus 43.4% and 6.5% versus 0.8% respectively, with the rate in the urban group being higher
than that in the rural group[6].
Little data are available concerning hearing disorders
in young Chinese. About 0.3% of newborns in China
are reported to have hearing disorders[7, 8]. A Sino-Japanese group studied hearing impairment among school
age (7-17 years) children in a rural area in a northern
Chinese province (Shandong) in 1996. Of the 282 children studied, 56 (20% ) were found to have abnormal
hearing and more than half of the hearing loss ears either
demonstrated a 4000 Hz notch or were dominated by
high frequency loss. The prevalence of hearing loss in
this group of Chinese children is significantly higher
than young Japanese or even the normal data of young
people in the same province in 1987[9].
NIHL in China
Data regarding epidemiology of NIHL in China are
very limited. A thorough literature search of English language biomedical databases yielded only 9 published papers regarding NIHL among the Chinese population in
peer reviewed journals. More epidemiological studies
are published in the Chinese language literature and the
vast majority of these works are concerned with occupational NIHL in China.
The past three decades have witnessed rapid industrialization in China. Small scale factories and enterprises
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nese firecrackers have been measured at more than 160

dB even at a distance of 2 meters[25]. A recent web-based
survey involving residents from the UK, France, Sweden
and China showed that 8% of respondents reported hearing loss as "a very big problem" on a Likert scale. Most
of these respondents had experienced tinnitus or hearing
impairment attending concerts (61% ) and/or clubs
(43% ). Only 14% of respondents had used earplug[26].
With improving economic conditions and increasing recreational activities for the ordinary Chinese, it can be predicted that average noise exposure levels related to leisure time activities in China will continue to increase.

and can be a devastating condition in some cases. Studies in mostly developed countries suggest that prevalence of tinnitus among the general population is about
15% and increasing[30, 31]. It is reasonable to assume similar or worse tinnitus prevalence in China. Tinnitus will
likely become a significant problem for China if hearing
loss continues to increase in the country.
The Significance of NIHL in China
The significance of NIHL in China is probably greater
than in some other countries, considering Chinas population of 1.3 billion and its efforts to develop its economy and to improve living conditions for its people. In
addition to the loss of productivity and life quality to NIHL, the cost of rehabilitation for hearing-impaired individuals can be un-proportionally heavy for China as a
large developing country. Of major hearing aid brands
sold in China, the Oticon hearing aids carry relatively
low prices. Prices of Oticon hearing aids in China range
from $240 to $3,400 per piece depending on the model,
with a median price at $919[32]. Assuming that 0.186% of
the 1.3 billion Chinese population have profound hearing
loss that require hearing assistance 5, more than $ 4.4 billion will be needed to just fit the 2,418,000 people each
with two median price Oticon hearing aids. The real
cost to help these people is certainly higher since some
of these people will not be able to benefit from hearing
aids due to the severity of their hearing loss and will likely need more costly solutions such as cochlear implants.
Albeit China has enjoyed probably the fastest economic
growth in its history for the past couple of decades, personal wealth in China remains far behind compared to
major developed countries, mainly due to the size of its
population and wealth distribution patterns. The International Monetary Fund estimated that China's annual per
capita income in 2008 was equivalent to $3,180[33]. Providing appropriate care for increasing numbers of individuals with hearing loss can be a significant drag on
Chinas economic development. In addition to financial
burdens, the significance of loss of employment and productivity due to hearing impairment can be tremendous
to China as a country that needs to support 20% of the
world
s population, which is also rapidly aging.

NIHL in Chinese Children

The increase of noise-related hearing impairment
among young Chinese is probably more alarming, although systematic studies in this area are extremely rare.
Since noise and NIHL research has traditionally focused
on workers in hazardous environment, little systematic
research efforts have been directed to studying effects of
noise exposure on children in China. However, some information seems to indicate increasing hearing problems
among young Chinese populations. From a report by the
Tianjin Occupational Disease Prevention Hospital, as
much as 80% of the young people disqualified for employment were due to hearing problems. They suspected
that this was related to use of personal listening devices
and frequent visits to loud places such as discos and internet caf[27]. A study conducted in Baise City, Guangxi
(a southwest province less urbanized than coastal cities
and towns), attests to a similar problem. In this study, 1,
156 young people between 13-22 years of age were studied with questionnaires and pure tone audiometry. The
results showed that 64.2% of the sample listened to their
MP3 players for more than 10 hours/week. Tinnitus and/
or hearing impairment following MP3 player listening
were reported by 12.3% of the subjects, of whom 31.7%
showed hearing loss on audiometric tests. The authors
also concluded that MP3 player use at inappropriate levels was likely the cause of their observation[28]. In another study conducted in Hong Kong that involved 487
youths aged 15-24 years, 394 (81% ) reported using the
personal cassette player on a regular basis, with a mean
duration of 2.8 years and a mean time of listening of 4.5
hours/week. The mean ear canal sound level was found
to be at 70.4 dB A. In one child, the ear canal sound level was found to reach 116 dB A and he was found to
have a 4000 Hz dip on his audiogram[29].
Little is known about the prevalence and incidence of
tinnitus among the Chinese workers and general population, except for the few reports mentioned above. However, tinnitus is commonly associated with hearing loss

What Is Being Done in China for NIHL

While there have been government regulations in China, they have not always been strictly followed or enforced. This is especially true in small size privately
owned enterprises in China, which counted for 60% of
the Chinese manufacturing industries in 2005[34] and now
employ a major portion of Chinas labor force. To make
the matter worse, little attention has been paid to non-in53

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Research That May Help Prevent and Decrease NIHL in China

dustrial noise levels in Chinas national standards and

recommendations. Compared to western nations, little
research efforts have been made to understand the scope
of NIHL among the Chinese population. This is especially true with non-occupational NIHL. Information on
prevalence of NIHL is of great importance as it can provide incentives for relevant legislation and fiscal investment, and guide future research and regulation efforts.
Currently, several legislations governing environmental noise issues, including the Environmental Protection
Law of The Peoples Republic of China and Environmental Noise Pollution Prevention and Control Law, are
in place, although enforcement of these laws varies greatly from region to region. They are better aware of and
implemented in large cities such as Beijing and Shanghai, and are largely ignored in smaller municipal jurisdictions and rural areas. The relatively lack of research and
information on noise exposure and associated health issues have provided little incentive for more effective regulation on the part of the authority, nor does it encourage
changes in practice patterns by business owners or behavioral changes among the general public. Considering
the size of the Chinese population and potential cost of
NIHL to the Chinese society, there is a great need for active research and effective intervention to reduce likely
increasing impact of NIHL on the Chinese population.
In recent years, there appears an effort in China to
raise public awareness of the danger of noise exposure.
Whether this is related to increased contact between China and other developed nations in the world is not clear
but possible. As a result, the third day in March is now
set to be a National Ai Er (Love the Ear) Day in China.
The Chinese media usually increase coverage on ear diseases, noise exposure and prevention and treatment of
common hearing disorders, on this day[35-37]. In recent
years, there has been an increasing concern over hearing
problems and noise exposure levels among the young
population in China[38, 39]. There also seems to be an effort in China to educate the young about noise hazards.
A group of middle school students actually conducted
a study on noise levels at a wide range of public locations frequented by the youth. Their data were published
on the web in 2003, in which they registered a range of
averaged noise levels from 44.6 dB in a quiet office to
sustained 83.1 dB at entertainment places such as gaming halls and discos[40]. They concluded that most public
places were noisy, including supermarkets (>70 dB) and
market streets (>82 dB). The report cited crowding and
inappropriate use of loud speakers as some of the causes
of these high level noises. The group also expressed concerns over increasing traffic noises (66-78 dB) and their
effects on commuting school age children and residential
areas neighboring main traffic.

Despite the above-mentioned efforts, systematic research is needed to comprehend the scope of the problem, develop effective intervention instruments, assess
impact of interventions, and monitor trends of NIHL for
the Chinese population. Constant surveillance of noise
exposure and NIHL among the population is needed as
social and industrial lives constantly change. In addition
to obtaining updated information on the prevalence and
incidence of NIHL, it is important to understand factors
that contribute to NIHL. To achieve this goal, appropriate research tools need to be developed and updated to
ensure acquisition of accurate and relevant information.
The tools must also be appropriate to the Chinese language and culture for them to be effective in the countr
As previous studies have suggested, noise exposure in
modern society is no longer limited to occupational activities. As a result, research on noise exposure and NIHL
must not simply focus on workers in manufacturing enterprises, but include the general population and their environment. Young people including children of various
ages especially need to be studied, as early identification
of problems provides an opportunity for early intervention and potentially improved outcomes, and is consistent with principles of preventive medicine. Successful
control of noise exposure will be the most cost-effective
intervention for NIHL. Research of noise exposure in
children is especially important as they are in a period
critical for developing long term behavior patterns. This
is probably the best opportunity to nurture behaviors that
may lead to lasting voluntary protection against NIHL.
As indicated in previous studies, in addition to social and
demographic factors, behavior patterns can also affect an
individuals attitude to noise exposure[41]. Information
regarding non-occupational noise exposure is especially
important also because such environments are more dynamic and difficult to regulate than in industrial settings.
How Research Models Such As Dangerous Decibel May Be Useful in China
Dangerous Decibel is a hearing health promotion
partnership initiated by a group of hearing scientists at
the Oregon hearing Research Center (OHRC), which focuses on noise exposure, NIHL and its prevention in
school age children and the general public. It is a joint
effort by the OHRC, the Oregon Health & Science University Department of Public Health and Preventive Medicine, Oregon Museum of Science and Industry, Portland
State University and the University of Northern Colorado. The project takes a non-traditional approach that
combines efforts from research institutions, the public ed54

2013 Vol.8 No.1

ucation system and public museums to reach the target

populations. Innovative technologies such as video
games and disguised sound level meters are used to engage subjects for data acquisition and intervention at
public locations. Data from over 56,000 individuals
have been collected[42]. As part of the project, efficacy of
structured curricula intervention at schools in reducing
risky behaviors is studied[43]. The project has been
shown to be effective in improving knowledge levels on
noise and NIHL among teenagers[44].
Similar research may also prove to be helpful in China, although modification and changes are likely needed
to make it language- and culture-appropriate. Compared
to traditional approach to noise-related research efforts
which are usually conducted exclusively by either engineering personnel or hearing scientists, the Dangerous
Decibel model incorporates school system and public
education and entertainment facilities. It also allows direct intervention among school age children and information dissemination to the general public in both organized and informal environments. This research model
is not a passive observation of the study subjects, as in
most existing noise-related studies in China, but seeks intervention and evaluation of intervention efficacy as an
integrated part of the research efforts. Information from
studies like Dangerous Decibel will likely provide new
directions of noise research as well as practical guidance
for NIHL intervention. In addition, the research model
also serves to study and monitor noise-related issues
among the population as other traditional noise studies
do. If successful, a Dangerous Decibel-like project in
China will help increase the information body on prevalence of NIHL in China and provide an opportunity for
early intervention in NIHL among the worlds largest
population. In addition, testing a new research model in
the Chinese language and culture itself is of great significance. Experience from such endeavor will help promote similar research efforts in other nations. It also provides an opportunity to study impact of language and cultural differences on behavioral research. Considering
the potential society burden of NIHL in China and increasing noise hazards around the world, such studies
should be of high priority and urgency.

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(Received July 25, 2013)

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