Patterns and Perceived Risks of Personal Auditory Device Use Among Medical Students: A Cross-Sectional Study

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The use of these devices has grown exponentially, placing young adults at high risk of recreational NIHL. This study aimed to explore PAD usage patterns among medical students, identify perceived health problems, and analyse the association between usage patterns and these issues. Methods A cross-sectional study was conducted among medical students at a private university in western India. A sample size of 152 students was determined. Data on PAD usage and perceived health effects were collected using a pre-tested, self-administered questionnaire after obtaining written informed consent. Data were analysed using descriptive statistics, and associations were examined using the chi-squared test. Results Ninety-two percent of students reported using PADs. A majority used them daily, with an average duration of nearly five hours. Many participants reported listening at high volumes and perceived health problems as a result. Notably, almost half of the users felt unable to discontinue their PAD use despite acknowledging potential adverse effects. There was a significant association between the daily duration of PAD use and the perception of adverse effects. Conclusions The continuous, prolonged, and high-intensity use of PADs among medical students is a significant issue that could escalate into a public health concern. Interventions focused on awareness, behavioural change, and the adoption of safe listening practices are crucial to mitigate these potential hazards. NIHL Personal Auditory Devices Hearing loss Medical students Public health Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Personal Auditory Devices (PADs), ranging from headphones to wireless earbuds, are now an integral part of daily life for millions who use them to consume a variety of audio content. The World Health Organization (WHO) has identified unsafe listening as a major public health threat, estimating that 1.1 billion young people worldwide are at risk of developing preventable noise-induced hearing loss (NIHL) [ 1 ]. The U.S. Centers for Disease Control and Prevention (CDC) has established occupational noise exposure guidelines, which can be adapted for recreational contexts, suggesting that daily permissible exposure at 90 dB is limited to 150 minutes [ 2 ]. To provide a more practical guideline for PAD users, Portnuff suggested the "80–90 rule": listening at no more than 80% of the device's maximum volume for no more than 90 minutes a day [ 3 ]. Studies globally report high prevalence of PAD use among young adults. In a study in India PAD usage prevalence was found to be 81.3% among medical students, with over three-quarters of them using the devices for one hour or more per day [ 4 ]. Similarly, a study among university students in Nigeria revealed that 93.8% used PADs, with over half listening for 1–3 hours daily [ 5 ]. These figures underscore that heavy and prolonged PAD use is a global issue among university students. Self-reported listening volume is a key risk factor. A study in New York found that over one-third of adult PAD users reported listening at volumes exceeding 75% of the maximum [ 6 ]. Sulaiman et al. in Malaysia used objective measurements and found that a significant portion of young users listened at an average level of 83 dB, with some reaching levels as high as 96 dB, well above safe limits [ 7 ]. The preference for high volumes is often linked to the listening environment. Users tend to increase the volume to overcome background noise, a practice known as auditory masking. This was highlighted in a study by Hodgetts et al., who found that individuals on public transit listened at levels 10–15 dB higher than they did in quiet environments [ 8 ]. The use of noise-cancelling headphones, which can mitigate this effect, was found to be relatively low in our study population at only 16.4%, though another study noted usage at 26.9% [ 7 ]. There is often a significant disconnect between knowledge of risks and personal behaviour. The study by Basu et al. among medical students in Delhi found that while a majority were aware of the risks, this did not translate into safer practices [ 10 ]. While many adolescents are aware that loud noise can damage hearing, they exhibit "auditory optimistic bias," believing they are personally less vulnerable than their peers [ 11 ]. Several studies have documented the prevalence of auditory symptoms among PAD users. Hoover and Krishnamurti, in their survey of US college students, reported that 11.2% had experienced hearing loss and 15.9% had experienced tinnitus (ringing in the ears) [ 12 ]. Tinnitus is a particularly important early warning sign, as it often suggests overexposure and cochlear stress. A study by Thompson et al. in the USA observed pedestrians and found that those using earphones were significantly less likely to look for traffic before crossing the road [ 13 ]. It was also noted that nearly one in ten students admitted to the possibility of crossing the road while distracted by music on their PADs [ 10 ]. This behavior creates a state of "inattentional blindness," where the user is physically looking but not cognitively processing their environment, dramatically increasing accident risk. Methodology Study Design and Participants A cross-sectional study was carried out in January-February 2023 among medical students enrolled in the MBBS program at a private university in Western India. The total study population was approximately 600 students across four academic batches. Any student, aged > 18 years regardless of their PAD usage status, was eligible to participate. The cross-sectional design was chosen as it is efficient for assessing the prevalence of behaviors and perceptions in a defined population at a single point in time. Sample Size Determination Based on a pilot study of 102 students where the prevalence of PAD usage was found to be 82%, the sample size was calculated to be 228. This was determined using Cochrane’s formula for prevalence studies, with a 95% confidence level and a 5% margin of error. This sample size was deemed sufficient to provide statistically meaningful results for the primary objectives of the study. Data Collection Instrument A pre-tested, self-designed questionnaire was developed based on a review of existing literature on PAD usage patterns and perceived health issues. The questionnaire was administered via Google Forms. It included sections on sociodemographic details, patterns of PAD use (frequency, duration, type of device), listening habits (volume preference), purpose of use (leisure, study, driving), and hygiene practices (sharing and cleaning). It also explored perceptions of safe usage, awareness of health risks, and experience with adverse effects (e.g., headache, earache, hearing difficulty). The questionnaire's content validity was established through consultation with subject matter experts in Public Health and ENT. Sampling and Data Collection Procedure A convenience sampling method was used to recruit participants. A total of 57 students were selected from each of the four academic batches to ensure representation across different years of medical training. The principal investigator approached potential participants in common university areas like the library, cafeteria, and college buildings. The purpose of the study was explained to each student, and written informed consent was obtained prior to participation. For each participant, the investigator read the questions aloud and filled in the Google Form based on their responses to ensure clarity and completeness of the data. Ethical Considerations The informed consent was procured prior to taking responses from the participants. It was ensured that participants understood the study's purpose, the voluntary nature of their involvement, and that their data would be kept confidential and anonymous. Statistical Analysis Data were exported from Google Forms into an auto-generated google sheet for cleaning and analysis which was exported to MS Excel. Descriptive statistics, including frequencies and proportions for categorical data and means with standard deviations for continuous data, were calculated to summarize the sample characteristics and usage patterns. The chi-squared test was employed to assess associations between categorical variables, such as daily usage duration and the presence of perceived adverse effects. Significance level for all the results were set to be 95% ( p-value < 0.05). Results Sociodemographic Profile and Prevalence of PAD Usage The study included 228 participants with a mean age of 19.9 ± 2.2 years. An initial analysis of 152 participants for demographic data showed that 52.6% were female and 76.97% were hostel residents. The prevalence of PAD usage within the student population was extremely high, with 92.1% of participants reporting that they use devices such as earphones, headphones, or earbuds. The duration of use was extensive; about half of the users (50.3%) had been using PADs for more than three years. Specifically, 24.4% reported using them for 3–5 years, and a significant 25.9% had been using them for more than 5 years. This indicates that PAD use is a long-standing habit for a substantial portion of this young adult population. Patterns of PAD Usage Daily usage was the norm for the majority of users (61.4%). When analyzed by daily duration, almost 5 hours per day was the average. A gender disparity was noted in high-duration usage; for daily use exceeding 3 hours, male subjects were more than three times as likely as female subjects to be in this category. The most common types of devices were earbuds and other in-ear or canal-type PADs, which were used by more than three-quarters of the participants. Only 16.4% of students reported using noise-cancelling PADs, which are designed to reduce the need for high volumes in noisy environments. Purpose of Use and High-Risk Behaviours The primary purpose of PAD usage was for leisure activities, such as listening to music, watching audio-visual content, or scrolling through social media, as reported by nearly 80% of users. A notable 64.2% of subjects also used PADs while studying, though the specific use for educational content versus entertainment during study was not differentiated. Several high-risk behaviours were identified. A significant portion of participants (71%) used PADs while engaged in activities requiring situational awareness, such as walking on the road or exercising. More alarmingly, 22.6% of subjects admitted to the high-risk behaviour of using PADs while driving. Figure 2 illustrates the various purposes for which the study participants (n = 228) reported using personal auditory devices (PADs). A notable proportion of students used PADs for both leisure and academic purposes, with 34.5% falling into this dual-use category. Exclusive use for leisure was reported by 28.4% of participants, while study-only usage accounted for 14.7%. A smaller subset reported using PADs solely for driving purposes (2.5%). Combined categories also emerged: 5.1% used PADs for both leisure and driving, 1.8% for study and driving, and 13.2% used PADs across all three domains leisure, study, and driving. These patterns highlight the multifunctionality of PADs in students' daily routines, with academic and entertainment use being the most prominent. Perceptions of Safe Usage and Volume There was considerable variation and misinformation regarding what constitutes safe daily usage. While 33% of participants believed 1 hour per day was a safe duration, 31% believed 2 hours was safe, and a worrying 13% of participants perceived 3 hours or more of daily usage to be safe. A significant discrepancy was observed between device-generated warnings about high volume and users' self-perception of their listening habits. Among the subjects who reported "Always" getting the alert from their device to "Keep the volume low," very few of them actually perceived that they were listening at a loud volume. This suggests a normalization of high-volume listening, where users become accustomed to potentially damaging sound levels. Perceived Health Issues and Side Effects A majority of users (60%) perceived some kind of issue resulting from their PAD use. The most commonly reported problems were headache (30.50%) and earache (29.90%). Other notable issues included itching in the ear (23.40%), hearing difficulty (12.20%), lack of concentration (11.70%), and insomnia (10.70%). Regarding beliefs about side effects, 67% of respondents believed that PADs cause them. However, there was a split opinion on the permanence of these effects. A slight majority (55.1%) believed the side effects were reversible, while a substantial minority (44.9%) believed they were irreversible, indicating concern about long-term damage. Despite this, when asked if they could stop their habit of excessive PAD usage, nearly half (50.3%) either thought they could not or were unsure, highlighting a potential dependency. Hygiene Practices Ear hygiene practices were suboptimal among the participants. One-third (33.5%) admitted to sharing their PADs with others, a practice that can transmit bacteria and lead to ear infections. Furthermore, only 53.4% of users reported cleaning their PADs regularly. Discussion This study highlights the near-universal use of personal auditory devices (PADs) among medical students, with usage characterized by prolonged exposure and behaviours that pose significant risks to auditory health. The 92% prevalence observed in our sample aligns with findings from both Indian and international contexts, where PAD usage among university students ranges from 81% to over 90% [4 13]. More critically, the data reveal that this usage is not casual or occasional but rather a deeply ingrained daily habit. On average, students used PADs for nearly five hours per day, and over half reported using them for more than three years. This sustained exposure is concerning in light of World Health Organization (WHO) estimates suggesting that individuals using PADs unsafely for five or more years are at significantly increased risk of developing noise-induced hearing loss (NIHL) [ 1 ]. Alarmingly, over one-quarter of our respondents had already surpassed this risk threshold. Gender-based patterns of PAD use, particularly the tendency for male students to use devices for longer durations, mirror trends seen in prior studies [ 9 ]. Interestingly, our study did not find significant gender differences in preferred volume levels, diverging from earlier research [ 6 ]. This may reflect evolving cultural norms or population-specific behaviors. A central finding of this study is the disconnect between risk awareness and behavioral change. While two-thirds of participants acknowledged the potential adverse effects of PADs and 60% reported experiencing symptoms such as headaches, earaches, or hearing discomfort, few made meaningful changes to their usage patterns. This gap between knowledge and action is consistent with the concept of “auditory optimistic bias,” where individuals believe that the risks of loud listening apply more to others than themselves [ 11 ]. For example, many respondents believed that daily exposure of two to three hours was “safe,” despite expert recommendations like Portnuff’s “80–90 rule,” which suggests limiting listening to 80% of maximum volume for no more than 90 minutes per day [ 3 ]. Another troubling pattern is the normalization of high listening volumes. Despite receiving frequent device-generated volume warnings, many users did not perceive their listening habits as excessive. This phenomenon reflects a process of perceptual adaptation, where sustained exposure to high volumes recalibrates the user’s threshold for what is considered “loud,” potentially creating a dangerous feedback loop that leads to increased volume and faster cochlear damage. The widespread preference for in-ear and canal-type devices further compounds the risk, as these deliver sound directly to the tympanic membrane and increase exposure to potentially harmful sound pressure levels [ 7 ]. Risk is also elevated by poor hygiene practices. Many participants reported sharing devices or cleaning them infrequently, behaviors known to increase the risk of external ear infections, such as otitis externa [14 15]. Moreover, PAD usage during high-risk activities, such as walking along roads (reported by over 70%) or driving (over 20%), poses serious safety concerns. These practices impair situational awareness by reducing the user’s ability to hear critical auditory cues such as vehicle horns or emergency sirens. This phenomenon, referred to as inattentional blindness, has been documented in observational studies and underscores a largely overlooked public safety risk [ 13 ]. The presence of self-reported symptoms such as hearing difficulties (12.2% of students) aligns closely with Hoover and Krishnamurti’s findings in a similar population [ 12 ]. While self-reported symptoms are not diagnostic, they are important early indicators of underlying auditory pathology. Symptoms such as mental irritability and insomnia may also reflect the presence of tinnitus, an early sign of auditory system stress and a precursor to long-term hearing loss [ 16 ]. Given the severity and complexity of the issue, a multi-pronged strategy is required. Educational institutions and public health bodies should develop targeted awareness campaigns that translate technical decibel thresholds into relatable terms, for example, comparing certain volume levels to industrial noise sources. Campaigns should feature clear, actionable messages, such as the “80–90 rule” [ 3 ], and be supported by screening initiatives that provide baseline audiometric assessments for students. Furthermore, hearing conservation should be integrated into medical curricula to prepare future healthcare professionals to recognize and counsel patients on the risks of PAD usage. On the policy front, government and regulatory agencies should implement the WHO and International Telecommunication Union (ITU) global standard for safe listening devices, which includes real-time monitoring of sound exposure and default volume limits [ 17 ]. Packaging for PADs should carry standardized labeling to indicate maximum safe listening times at various volume levels, much like nutritional information on food products. National campaigns should also address risky behaviors like listening while driving or walking in traffic, using social and mass media to engage young adults. PAD manufacturers must share in the responsibility. Devices should default to safe listening modes, requiring users to opt-in for higher volume levels only after being presented with clear health warnings. User interfaces should include visual indicators for cumulative sound exposure, similar to step counters in fitness trackers. In addition, manufacturers should more actively promote noise-canceling technology, which can help users maintain lower volume levels even in noisy environments. Future research should prioritize longitudinal studies with larger and more diverse populations to assess the long-term auditory impact of PAD use. These studies should incorporate objective measures such as device-based dosimetry and extended audiometric testing to better establish dose–response relationships between sound exposure and hearing loss [ 18 ]. The widespread and often unsafe use of PADs among medical students represents a serious and preventable public health issue. The disconnect between awareness and action, normalization of high-risk behavior, and early signs of auditory damage highlight the need for urgent and coordinated interventions across education, policy, and industry. Limitations of the Study There are certain limitations of this research, which we need to acknowledge. First, as a cross-sectional study conducted at a single private medical college, the findings may not be generalizable to all students in India or other populations. Medical students may have a higher baseline knowledge of health risks, which could influence their responses, although our data suggests this knowledge does not always translate to behaviour. Second, the study relied on self-reported data, which is subject to recall bias and social desirability bias. Students may have underreported behaviours they perceived as undesirable, such as listening at high volumes or using PADs while driving. Third, the study lacked objective measures. We did not measure the actual listening levels of the PADs nor did we perform audiometric examinations to assess the students' hearing thresholds. Such objective data would be needed to conclusively link usage patterns with actual hearing loss. Conclusions The findings of this study demonstrate that the continuous, prolonged, and intensified usage of Personal Auditory Devices is a deeply embedded behavior among medical students. This habit, characterized by high-risk practices such as listening at loud volumes for extended periods and using devices in attention-critical situations, poses a significant and immediate threat to their auditory health and personal safety. The observed disconnect between the awareness of risk and the adoption of safe behaviors indicates that simple knowledge-based interventions are insufficient. A comprehensive public health response is required, involving education, policy, regulation, and technological solutions. Without concerted action, we risk a future where a substantial portion of the population suffers from preventable, permanent hearing loss, a condition that diminishes quality of life and has significant societal costs. Declarations Ethical Approval and Consent to Participate: Ethical approval for this study was obtained from the Institutional Ethics Committee prior to data collection. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee. Informed consent was obtained from all individual participants included in the study. Participation was voluntary, and confidentiality of the data was assured throughout the research process. Consent for Publication: Not applicable. Availability of Data and Materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests: The authors declare that they have no competing interests. Funding: Not applicable. Authors’ Contributions: PS conceptualized the idea and developed the manuscript, PD made the analysis plan, LD reviewed the study and prepared the final draft, US supervised the study and prepared the outline of the research, NB carried out the analysis and obtained all the ethical approval required for the study. References World Health Organization. (2015). Make listening safe: A WHO initiative. Retrieved from https://www.who.int/activities/making-listening-safe Centers for Disease Control and Prevention. (n.d.). Occupational noise exposure guidelines. Retrieved from https://www.cdc.gov/niosh/topics/noise/ Portnuff, C. D. F. (2016). The 80-90 rule: Safe listening guidelines for personal listening devices. Hearing Review, 23(2), 24. Rekha, S., Unnikrishnan, B., Mithra, P., Kumar, N., Kulkarni, V., & Holla, R. (2016). Perceptions and practices regarding use of personal audio devices and their associated health risks among medical students in coastal South India. Journal of Clinical and Diagnostic Research, 10(1), CC17–CC20. MGBE, E. K., MGBE, C. G., AJARE, C. E., & NNAMANI, A. O. (2020). Awareness and Perception of Undergraduate Students towards Risk Associated with Wireless Electromagnetic Field Radiation Exposure in Enugu, South-East Nigeria: A Cross-sectional Study. Journal of Clinical & Diagnostic Research , 14 (7). Levey, S., Levey, T., & Fligor, B. J. (2011). Noise exposure estimates of urban MP3 player users. Journal of Speech, Language, and Hearing Research, 54(1), 263–277. Sulaiman, A. H., Husain, R., Seluakumaran, K., Satar, N., & Mohamad, A. (2013). Evaluation of early hearing damage in personal listening device users using extended high-frequency audiometry and otoacoustic emissions. Noise & Health, 15(66), 346–352. Hodgetts, W. E., Rieger, J. M., & Szarko, R. A. (2007). The effects of listening environment and earphone style on preferred listening levels of normal hearing adults using an MP3 player. Ear and Hearing, 28(3), 290–297. Vogel, I., Verschuure, H., van der Ploeg, C. P., Brug, J., & Raat, H. (2011). Adolescents and MP3 players: Too many risks, too few precautions. Pediatrics, 127(6), e1547–e1552. Basu, S., Garg, S., Singh, M. M., Kohli, C., & Mishra, R. (2019). Knowledge, attitude and practices of personal audio device use and its health effects among medical students in Delhi. Indian Journal of Community Health, 31(1), 134–139. Danhauer, J. L., Johnson, C. E., & Caudle, J. M. (2009). Survey of adolescent attitudes toward noise, hearing loss, and hearing protection. Hearing Journal, 62(6), 32–38. Hoover, A., & Krishnamurti, S. (2010). Survey of college students’ MP3 listening: Habits, safety issues, attitudes, and education. American Journal of Audiology, 19(1), 73–83. Thompson, L. L., Rivara, F. P., Ayyagari, R. C., & Ebel, B. E. (2013). Impact of social and technological distraction on pedestrian crossing behaviour: An observational study. Injury Prevention, 19(4), 232–237. Okpala, E. C., & Chinazom, L. Awareness and Knowledge of The Adverse Effects of Ear-Piece Use Among University Undergraduates in Anambra State. IJRISS, 768-774. Fasunla, J., Ogunkeyede, S., & Lasisi, A. (2012). Perception and practice of ear hygiene among undergraduate students of a Nigerian University. International Journal of Pediatric Otorhinolaryngology , 76(11), 1641–1645. Wang, S., Cha, X., Li, F., Li, T., Wang, T., Wang, W., ... & Liu, H. (2022). Associations between sleep disorders and anxiety in patients with tinnitus: A cross-sectional study. Frontiers in psychology , 13 , 963148. World Health Organization & International Telecommunication Union. (2019). Safe listening devices and systems: WHO-ITU global standard . Retrieved from https://www.who.int/publications/i/item/9789241515276 Punch, J. L., Elfenbein, J. L., & James, R. R. (2011). Targeting hearing health messages for users of personal listening devices. International Journal of Audiology , 50(Suppl 1), S22–S30. Tables Table 1: Background characteristics of the study participants Age (Mean +- SD) 19.05+-2.04 years Gender Male 72 47.4 Female 80 52.6 Residence Home 35 23 Hostel 117 77 Usage of personal audio device (Earphones, headphones, Earbuds etc) No 12 7.9 Yes 140 92.1 Total 152 100 Table 2: Duration of PAD usage (n=152): Time duration of usage (Years) Frequency(n=228) Percentage 5 52 (25.9%) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Nov, 2025 Read the published version in BMC Research Notes → Version 1 posted Editorial decision: Revision requested 08 Aug, 2025 Reviews received at journal 07 Aug, 2025 Reviews received at journal 05 Aug, 2025 Reviews received at journal 02 Aug, 2025 Reviews received at journal 24 Jul, 2025 Reviewers agreed at journal 21 Jul, 2025 Reviewers agreed at journal 20 Jul, 2025 Reviewers agreed at journal 16 Jul, 2025 Reviewers agreed at journal 16 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviewers invited by journal 15 Jul, 2025 Editor invited by journal 07 Jul, 2025 Editor assigned by journal 01 Jul, 2025 Submission checks completed at journal 01 Jul, 2025 First submitted to journal 27 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Bharadva","email":"data:image/png;base64,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","orcid":"","institution":"Parul Institute Medical Sciences \u0026 Research","correspondingAuthor":true,"prefix":"","firstName":"Niraj","middleName":"","lastName":"Bharadva","suffix":""}],"badges":[],"createdAt":"2025-06-27 07:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6989177/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6989177/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13104-025-07541-4","type":"published","date":"2025-11-03T15:57:32+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87360389,"identity":"6fd71b07-204f-4c79-9fdf-560d2727d306","added_by":"auto","created_at":"2025-07-23 05:46:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30596,"visible":true,"origin":"","legend":"\u003cp\u003eGender wise distribution of daily usage of PADs (n=152):\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6989177/v1/3da3b4afbf9565374ff08aa3.png"},{"id":87362160,"identity":"1428a785-7e1f-4277-8101-8a46c47a3489","added_by":"auto","created_at":"2025-07-23 05:54:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":180562,"visible":true,"origin":"","legend":"\u003cp\u003ePerceived safe duration for usage (per day) (n=152)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6989177/v1/60204299afe9af9b4fbe03a7.png"},{"id":87360390,"identity":"3a897ac1-de1a-41e8-97af-03a8aa20edc5","added_by":"auto","created_at":"2025-07-23 05:46:54","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":88043,"visible":true,"origin":"","legend":"\u003cp\u003eIssues perceived due to PADs\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6989177/v1/85e30ac8a4f3932673f5cffb.png"},{"id":87360393,"identity":"aa3c8e44-45ae-47a9-a96f-654e14a1bf23","added_by":"auto","created_at":"2025-07-23 05:46:54","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":78858,"visible":true,"origin":"","legend":"\u003cp\u003eLoud volume: Perception v/s Alert by system (n=228).\u003c/p\u003e\n\u003cp\u003eAlertness of the participants to loud volume, (Self-perception v/s Alert by system) (n=152)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6989177/v1/4b85302efdd2fadbb209d09b.png"},{"id":87360395,"identity":"0b1c8f90-ad2e-4060-9171-fdbf5b989d47","added_by":"auto","created_at":"2025-07-23 05:46:54","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":75450,"visible":true,"origin":"","legend":"\u003cp\u003ePerception of the participants regarding Side-effects (n=152)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6989177/v1/f3f75f9eee44347b92b41e63.png"},{"id":95564134,"identity":"6c16dade-a7a1-4b3b-af03-bc970da7b3f3","added_by":"auto","created_at":"2025-11-10 16:08:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":969580,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6989177/v1/59b75031-fb3c-4744-b3c6-d1c3f20b87d9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patterns and Perceived Risks of Personal Auditory Device Use Among Medical Students: A Cross-Sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePersonal Auditory Devices (PADs), ranging from headphones to wireless earbuds, are now an integral part of daily life for millions who use them to consume a variety of audio content. The World Health Organization (WHO) has identified unsafe listening as a major public health threat, estimating that 1.1\u0026nbsp;billion young people worldwide are at risk of developing preventable noise-induced hearing loss (NIHL) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The U.S. Centers for Disease Control and Prevention (CDC) has established occupational noise exposure guidelines, which can be adapted for recreational contexts, suggesting that daily permissible exposure at 90 dB is limited to 150 minutes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. To provide a more practical guideline for PAD users, Portnuff suggested the \"80–90 rule\": listening at no more than 80% of the device's maximum volume for no more than 90 minutes a day [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStudies globally report high prevalence of PAD use among young adults. In a study in India PAD usage prevalence was found to be 81.3% among medical students, with over three-quarters of them using the devices for one hour or more per day [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Similarly, a study among university students in Nigeria revealed that 93.8% used PADs, with over half listening for 1–3 hours daily [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These figures underscore that heavy and prolonged PAD use is a global issue among university students.\u003c/p\u003e\u003cp\u003eSelf-reported listening volume is a key risk factor. A study in New York found that over one-third of adult PAD users reported listening at volumes exceeding 75% of the maximum [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Sulaiman et al. in Malaysia used objective measurements and found that a significant portion of young users listened at an average level of 83 dB, with some reaching levels as high as 96 dB, well above safe limits [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The preference for high volumes is often linked to the listening environment. Users tend to increase the volume to overcome background noise, a practice known as auditory masking. This was highlighted in a study by Hodgetts et al., who found that individuals on public transit listened at levels 10–15 dB higher than they did in quiet environments [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The use of noise-cancelling headphones, which can mitigate this effect, was found to be relatively low in our study population at only 16.4%, though another study noted usage at 26.9% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere is often a significant disconnect between knowledge of risks and personal behaviour. The study by Basu et al. among medical students in Delhi found that while a majority were aware of the risks, this did not translate into safer practices [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While many adolescents are aware that loud noise can damage hearing, they exhibit \"auditory optimistic bias,\" believing they are personally less vulnerable than their peers [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Several studies have documented the prevalence of auditory symptoms among PAD users. Hoover and Krishnamurti, in their survey of US college students, reported that 11.2% had experienced hearing loss and 15.9% had experienced tinnitus (ringing in the ears) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Tinnitus is a particularly important early warning sign, as it often suggests overexposure and cochlear stress. A study by Thompson et al. in the USA observed pedestrians and found that those using earphones were significantly less likely to look for traffic before crossing the road [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It was also noted that nearly one in ten students admitted to the possibility of crossing the road while distracted by music on their PADs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This behavior creates a state of \"inattentional blindness,\" where the user is physically looking but not cognitively processing their environment, dramatically increasing accident risk.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cem\u003eStudy Design and Participants\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA cross-sectional study was carried out in January-February 2023 among medical students enrolled in the MBBS program at a private university in Western India. The total study population was approximately 600 students across four academic batches. Any student, aged \u0026gt; 18 years regardless of their PAD usage status, was eligible to participate. The cross-sectional design was chosen as it is efficient for assessing the prevalence of behaviors and perceptions in a defined population at a single point in time.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSample Size Determination\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBased on a pilot study of 102 students where the prevalence of PAD usage was found to be 82%, the sample size was calculated to be 228. This was determined using Cochrane’s formula for prevalence studies, with a 95% confidence level and a 5% margin of error. This sample size was deemed sufficient to provide statistically meaningful results for the primary objectives of the study.\u003c/p\u003e\u003cp\u003e\u003cem\u003eData Collection Instrument\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA pre-tested, self-designed questionnaire was developed based on a review of existing literature on PAD usage patterns and perceived health issues. The questionnaire was administered via Google Forms. It included sections on sociodemographic details, patterns of PAD use (frequency, duration, type of device), listening habits (volume preference), purpose of use (leisure, study, driving), and hygiene practices (sharing and cleaning). It also explored perceptions of safe usage, awareness of health risks, and experience with adverse effects (e.g., headache, earache, hearing difficulty). The questionnaire's content validity was established through consultation with subject matter experts in Public Health and ENT.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSampling and Data Collection Procedure\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA convenience sampling method was used to recruit participants. A total of 57 students were selected from each of the four academic batches to ensure representation across different years of medical training. The principal investigator approached potential participants in common university areas like the library, cafeteria, and college buildings. The purpose of the study was explained to each student, and written informed consent was obtained prior to participation. For each participant, the investigator read the questions aloud and filled in the Google Form based on their responses to ensure clarity and completeness of the data.\u003c/p\u003e\u003cp\u003eEthical Considerations\u003c/p\u003e\u003cp\u003e The informed consent was procured prior to taking responses from the participants. It was ensured that participants understood the study's purpose, the voluntary nature of their involvement, and that their data would be kept confidential and anonymous.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData were exported from Google Forms into an auto-generated google sheet for cleaning and analysis which was exported to MS Excel. Descriptive statistics, including frequencies and proportions for categorical data and means with standard deviations for continuous data, were calculated to summarize the sample characteristics and usage patterns. The chi-squared test was employed to assess associations between categorical variables, such as daily usage duration and the presence of perceived adverse effects. Significance level for all the results were set to be 95% ( p-value \u0026lt; 0.05).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eSociodemographic Profile and Prevalence of PAD Usage\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study included 228 participants with a mean age of 19.9 ± 2.2 years. An initial analysis of 152 participants for demographic data showed that 52.6% were female and 76.97% were hostel residents.\u003c/p\u003e\n\u003cp\u003eThe prevalence of PAD usage within the student population was extremely high, with 92.1% of participants reporting that they use devices such as earphones, headphones, or earbuds. The duration of use was extensive; about half of the users (50.3%) had been using PADs for more than three years. Specifically, 24.4% reported using them for 3–5 years, and a significant 25.9% had been using them for more than 5 years. This indicates that PAD use is a long-standing habit for a substantial portion of this young adult population.\u003c/p\u003e\n\u003cp\u003ePatterns of PAD Usage\u003c/p\u003e\n\u003cp\u003eDaily usage was the norm for the majority of users (61.4%). When analyzed by daily duration, almost 5 hours per day was the average. A gender disparity was noted in high-duration usage; for daily use exceeding 3 hours, male subjects were more than three times as likely as female subjects to be in this category.\u003c/p\u003e\n\u003cp\u003eThe most common types of devices were earbuds and other in-ear or canal-type PADs, which were used by more than three-quarters of the participants. Only 16.4% of students reported using noise-cancelling PADs, which are designed to reduce the need for high volumes in noisy environments.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePurpose of Use and High-Risk Behaviours\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe primary purpose of PAD usage was for leisure activities, such as listening to music, watching audio-visual content, or scrolling through social media, as reported by nearly 80% of users. A notable 64.2% of subjects also used PADs while studying, though the specific use for educational content versus entertainment during study was not differentiated.\u003c/p\u003e\n\u003cp\u003eSeveral high-risk behaviours were identified. A significant portion of participants (71%) used PADs while engaged in activities requiring situational awareness, such as walking on the road or exercising. More alarmingly, 22.6% of subjects admitted to the high-risk behaviour of using PADs while driving.\u003c/p\u003e\n\u003cp\u003eFigure 2 illustrates the various purposes for which the study participants (n = 228) reported using personal auditory devices (PADs). A notable proportion of students used PADs for both leisure and academic purposes, with 34.5% falling into this dual-use category. Exclusive use for leisure was reported by 28.4% of participants, while study-only usage accounted for 14.7%. A smaller subset reported using PADs solely for driving purposes (2.5%). Combined categories also emerged: 5.1% used PADs for both leisure and driving, 1.8% for study and driving, and 13.2% used PADs across all three domains leisure, study, and driving. These patterns highlight the multifunctionality of PADs in students' daily routines, with academic and entertainment use being the most prominent.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePerceptions of Safe Usage and Volume\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere was considerable variation and misinformation regarding what constitutes safe daily usage. While 33% of participants believed 1 hour per day was a safe duration, 31% believed 2 hours was safe, and a worrying 13% of participants perceived 3 hours or more of daily usage to be safe.\u003c/p\u003e\n\u003cp\u003eA significant discrepancy was observed between device-generated warnings about high volume and users' self-perception of their listening habits. Among the subjects who reported \"Always\" getting the alert from their device to \"Keep the volume low,\" very few of them actually perceived that they were listening at a loud volume. This suggests a normalization of high-volume listening, where users become accustomed to potentially damaging sound levels.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePerceived Health Issues and Side Effects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA majority of users (60%) perceived some kind of issue resulting from their PAD use. The most commonly reported problems were headache (30.50%) and earache (29.90%). Other notable issues included itching in the ear (23.40%), hearing difficulty (12.20%), lack of concentration (11.70%), and insomnia (10.70%).\u003c/p\u003e\n\u003cp\u003eRegarding beliefs about side effects, 67% of respondents believed that PADs cause them. However, there was a split opinion on the permanence of these effects. A slight majority (55.1%) believed the side effects were reversible, while a substantial minority (44.9%) believed they were irreversible, indicating concern about long-term damage. Despite this, when asked if they could stop their habit of excessive PAD usage, nearly half (50.3%) either thought they could not or were unsure, highlighting a potential dependency.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHygiene Practices\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEar hygiene practices were suboptimal among the participants. One-third (33.5%) admitted to sharing their PADs with others, a practice that can transmit bacteria and lead to ear infections. Furthermore, only 53.4% of users reported cleaning their PADs regularly.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights the near-universal use of personal auditory devices (PADs) among medical students, with usage characterized by prolonged exposure and behaviours that pose significant risks to auditory health. The 92% prevalence observed in our sample aligns with findings from both Indian and international contexts, where PAD usage among university students ranges from 81% to over 90% [4 13]. More critically, the data reveal that this usage is not casual or occasional but rather a deeply ingrained daily habit. On average, students used PADs for nearly five hours per day, and over half reported using them for more than three years. This sustained exposure is concerning in light of World Health Organization (WHO) estimates suggesting that individuals using PADs unsafely for five or more years are at significantly increased risk of developing noise-induced hearing loss (NIHL) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Alarmingly, over one-quarter of our respondents had already surpassed this risk threshold.\u003c/p\u003e\u003cp\u003eGender-based patterns of PAD use, particularly the tendency for male students to use devices for longer durations, mirror trends seen in prior studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Interestingly, our study did not find significant gender differences in preferred volume levels, diverging from earlier research [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This may reflect evolving cultural norms or population-specific behaviors.\u003c/p\u003e\u003cp\u003eA central finding of this study is the disconnect between risk awareness and behavioral change. While two-thirds of participants acknowledged the potential adverse effects of PADs and 60% reported experiencing symptoms such as headaches, earaches, or hearing discomfort, few made meaningful changes to their usage patterns. This gap between knowledge and action is consistent with the concept of \u0026ldquo;auditory optimistic bias,\u0026rdquo; where individuals believe that the risks of loud listening apply more to others than themselves [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. For example, many respondents believed that daily exposure of two to three hours was \u0026ldquo;safe,\u0026rdquo; despite expert recommendations like Portnuff\u0026rsquo;s \u0026ldquo;80\u0026ndash;90 rule,\u0026rdquo; which suggests limiting listening to 80% of maximum volume for no more than 90 minutes per day [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAnother troubling pattern is the normalization of high listening volumes. Despite receiving frequent device-generated volume warnings, many users did not perceive their listening habits as excessive. This phenomenon reflects a process of perceptual adaptation, where sustained exposure to high volumes recalibrates the user\u0026rsquo;s threshold for what is considered \u0026ldquo;loud,\u0026rdquo; potentially creating a dangerous feedback loop that leads to increased volume and faster cochlear damage. The widespread preference for in-ear and canal-type devices further compounds the risk, as these deliver sound directly to the tympanic membrane and increase exposure to potentially harmful sound pressure levels [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRisk is also elevated by poor hygiene practices. Many participants reported sharing devices or cleaning them infrequently, behaviors known to increase the risk of external ear infections, such as otitis externa [14 15]. Moreover, PAD usage during high-risk activities, such as walking along roads (reported by over 70%) or driving (over 20%), poses serious safety concerns. These practices impair situational awareness by reducing the user\u0026rsquo;s ability to hear critical auditory cues such as vehicle horns or emergency sirens. This phenomenon, referred to as inattentional blindness, has been documented in observational studies and underscores a largely overlooked public safety risk [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe presence of self-reported symptoms such as hearing difficulties (12.2% of students) aligns closely with Hoover and Krishnamurti\u0026rsquo;s findings in a similar population [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. While self-reported symptoms are not diagnostic, they are important early indicators of underlying auditory pathology. Symptoms such as mental irritability and insomnia may also reflect the presence of tinnitus, an early sign of auditory system stress and a precursor to long-term hearing loss [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGiven the severity and complexity of the issue, a multi-pronged strategy is required. Educational institutions and public health bodies should develop targeted awareness campaigns that translate technical decibel thresholds into relatable terms, for example, comparing certain volume levels to industrial noise sources. Campaigns should feature clear, actionable messages, such as the \u0026ldquo;80\u0026ndash;90 rule\u0026rdquo; [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and be supported by screening initiatives that provide baseline audiometric assessments for students. Furthermore, hearing conservation should be integrated into medical curricula to prepare future healthcare professionals to recognize and counsel patients on the risks of PAD usage.\u003c/p\u003e\u003cp\u003eOn the policy front, government and regulatory agencies should implement the WHO and International Telecommunication Union (ITU) global standard for safe listening devices, which includes real-time monitoring of sound exposure and default volume limits [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Packaging for PADs should carry standardized labeling to indicate maximum safe listening times at various volume levels, much like nutritional information on food products. National campaigns should also address risky behaviors like listening while driving or walking in traffic, using social and mass media to engage young adults.\u003c/p\u003e\u003cp\u003ePAD manufacturers must share in the responsibility. Devices should default to safe listening modes, requiring users to opt-in for higher volume levels only after being presented with clear health warnings. User interfaces should include visual indicators for cumulative sound exposure, similar to step counters in fitness trackers. In addition, manufacturers should more actively promote noise-canceling technology, which can help users maintain lower volume levels even in noisy environments.\u003c/p\u003e\u003cp\u003eFuture research should prioritize longitudinal studies with larger and more diverse populations to assess the long-term auditory impact of PAD use. These studies should incorporate objective measures such as device-based dosimetry and extended audiometric testing to better establish dose\u0026ndash;response relationships between sound exposure and hearing loss [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The widespread and often unsafe use of PADs among medical students represents a serious and preventable public health issue. The disconnect between awareness and action, normalization of high-risk behavior, and early signs of auditory damage highlight the need for urgent and coordinated interventions across education, policy, and industry.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations of the Study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThere are certain limitations of this research, which we need to acknowledge. First, as a cross-sectional study conducted at a single private medical college, the findings may not be generalizable to all students in India or other populations. Medical students may have a higher baseline knowledge of health risks, which could influence their responses, although our data suggests this knowledge does not always translate to behaviour. Second, the study relied on self-reported data, which is subject to recall bias and social desirability bias. Students may have underreported behaviours they perceived as undesirable, such as listening at high volumes or using PADs while driving. Third, the study lacked objective measures. We did not measure the actual listening levels of the PADs nor did we perform audiometric examinations to assess the students' hearing thresholds. Such objective data would be needed to conclusively link usage patterns with actual hearing loss.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe findings of this study demonstrate that the continuous, prolonged, and intensified usage of Personal Auditory Devices is a deeply embedded behavior among medical students. This habit, characterized by high-risk practices such as listening at loud volumes for extended periods and using devices in attention-critical situations, poses a significant and immediate threat to their auditory health and personal safety. The observed disconnect between the awareness of risk and the adoption of safe behaviors indicates that simple knowledge-based interventions are insufficient. A comprehensive public health response is required, involving education, policy, regulation, and technological solutions. Without concerted action, we risk a future where a substantial portion of the population suffers from preventable, permanent hearing loss, a condition that diminishes quality of life and has significant societal costs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate:\u003c/strong\u003e Ethical approval for this study was obtained from the Institutional Ethics Committee prior to data collection. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee. Informed consent was obtained from all individual participants included in the study. Participation was voluntary, and confidentiality of the data was assured throughout the research process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u003c/strong\u003e The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions:\u003c/strong\u003e PS conceptualized the idea and developed the manuscript, PD made the analysis plan, LD reviewed the study and prepared the final draft, US supervised the study and prepared the outline of the research, NB carried out the analysis and obtained all the ethical approval required for the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. (2015). Make listening safe: A WHO initiative. Retrieved from https://www.who.int/activities/making-listening-safe\u003c/li\u003e\n\u003cli\u003eCenters for Disease Control and Prevention. (n.d.). Occupational noise exposure guidelines. Retrieved from https://www.cdc.gov/niosh/topics/noise/\u003c/li\u003e\n\u003cli\u003ePortnuff, C. D. F. (2016). The 80-90 rule: Safe listening guidelines for personal listening devices. Hearing Review, 23(2), 24.\u003c/li\u003e\n\u003cli\u003eRekha, S., Unnikrishnan, B., Mithra, P., Kumar, N., Kulkarni, V., \u0026amp; Holla, R. (2016). Perceptions and practices regarding use of personal audio devices and their associated health risks among medical students in coastal South India. Journal of Clinical and Diagnostic Research, 10(1), CC17\u0026ndash;CC20.\u003c/li\u003e\n\u003cli\u003eMGBE, E. K., MGBE, C. G., AJARE, C. E., \u0026amp; NNAMANI, A. O. (2020). Awareness and Perception of Undergraduate Students towards Risk Associated with Wireless Electromagnetic Field Radiation Exposure in Enugu, South-East Nigeria: A Cross-sectional Study. \u003cem\u003eJournal of Clinical \u0026amp; Diagnostic Research\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(7).\u003c/li\u003e\n\u003cli\u003eLevey, S., Levey, T., \u0026amp; Fligor, B. J. (2011). Noise exposure estimates of urban MP3 player users. Journal of Speech, Language, and Hearing Research, 54(1), 263\u0026ndash;277.\u003c/li\u003e\n\u003cli\u003eSulaiman, A. H., Husain, R., Seluakumaran, K., Satar, N., \u0026amp; Mohamad, A. (2013). Evaluation of early hearing damage in personal listening device users using extended high-frequency audiometry and otoacoustic emissions. Noise \u0026amp; Health, 15(66), 346\u0026ndash;352.\u003c/li\u003e\n\u003cli\u003eHodgetts, W. E., Rieger, J. M., \u0026amp; Szarko, R. A. (2007). The effects of listening environment and earphone style on preferred listening levels of normal hearing adults using an MP3 player. Ear and Hearing, 28(3), 290\u0026ndash;297.\u003c/li\u003e\n\u003cli\u003eVogel, I., Verschuure, H., van der Ploeg, C. P., Brug, J., \u0026amp; Raat, H. (2011). Adolescents and MP3 players: Too many risks, too few precautions. Pediatrics, 127(6), e1547\u0026ndash;e1552.\u003c/li\u003e\n\u003cli\u003eBasu, S., Garg, S., Singh, M. M., Kohli, C., \u0026amp; Mishra, R. (2019). Knowledge, attitude and practices of personal audio device use and its health effects among medical students in Delhi. Indian Journal of Community Health, 31(1), 134\u0026ndash;139.\u003c/li\u003e\n\u003cli\u003eDanhauer, J. L., Johnson, C. E., \u0026amp; Caudle, J. M. (2009). Survey of adolescent attitudes toward noise, hearing loss, and hearing protection. Hearing Journal, 62(6), 32\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eHoover, A., \u0026amp; Krishnamurti, S. (2010). Survey of college students\u0026rsquo; MP3 listening: Habits, safety issues, attitudes, and education. American Journal of Audiology, 19(1), 73\u0026ndash;83.\u003c/li\u003e\n\u003cli\u003eThompson, L. L., Rivara, F. P., Ayyagari, R. C., \u0026amp; Ebel, B. E. (2013). Impact of social and technological distraction on pedestrian crossing behaviour: An observational study. Injury Prevention, 19(4), 232\u0026ndash;237.\u003c/li\u003e\n\u003cli\u003eOkpala, E. C., \u0026amp; Chinazom, L. Awareness and Knowledge of The Adverse Effects of Ear-Piece Use Among University Undergraduates in Anambra State. IJRISS, 768-774.\u003c/li\u003e\n\u003cli\u003eFasunla, J., Ogunkeyede, S., \u0026amp; Lasisi, A. (2012). Perception and practice of ear hygiene among undergraduate students of a Nigerian University. \u003cem\u003eInternational Journal of Pediatric Otorhinolaryngology\u003c/em\u003e, 76(11), 1641\u0026ndash;1645.\u003c/li\u003e\n\u003cli\u003eWang, S., Cha, X., Li, F., Li, T., Wang, T., Wang, W., ... \u0026amp; Liu, H. (2022). Associations between sleep disorders and anxiety in patients with tinnitus: A cross-sectional study. \u003cem\u003eFrontiers in psychology\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e, 963148.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization \u0026amp; International Telecommunication Union. (2019). \u003cem\u003eSafe listening devices and systems: WHO-ITU global standard\u003c/em\u003e. Retrieved from https://www.who.int/publications/i/item/9789241515276 \u003c/li\u003e\n\u003cli\u003ePunch, J. L., Elfenbein, J. L., \u0026amp; James, R. R. (2011). Targeting hearing health messages for users of personal listening devices. \u003cem\u003eInternational Journal of Audiology\u003c/em\u003e, 50(Suppl 1), S22\u0026ndash;S30.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"275\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 275px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1: Background characteristics of the study participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e(Mean +- SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 125px;\"\u003e\n \u003cp\u003e19.05+-2.04 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 61px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 61px;\"\u003e\n \u003cp\u003e47.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 61px;\"\u003e\n \u003cp\u003e52.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eHome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 61px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eHostel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 61px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 275px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUsage of personal audio device\u003c/strong\u003e (Earphones, headphones, Earbuds etc)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e92.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable 2:\u0026nbsp;\u003cu\u003eDuration of PAD usage (n=152):\u003c/u\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"599\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTime duration of usage (Years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eFrequency(n=228)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026lt;=1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e(13.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e2-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e(36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e3-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e(24.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026gt;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e(25.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"NIHL, Personal Auditory Devices, Hearing loss, Medical students, Public health","lastPublishedDoi":"10.21203/rs.3.rs-6989177/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6989177/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe World Health Organization estimates that 1.1\u0026nbsp;billion people are at risk of developing noise-induced hearing loss (NIHL) from the unsafe use of Personal Auditory Devices (PADs). The use of these devices has grown exponentially, placing young adults at high risk of recreational NIHL. This study aimed to explore PAD usage patterns among medical students, identify perceived health problems, and analyse the association between usage patterns and these issues.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted among medical students at a private university in western India. A sample size of 152 students was determined. Data on PAD usage and perceived health effects were collected using a pre-tested, self-administered questionnaire after obtaining written informed consent. Data were analysed using descriptive statistics, and associations were examined using the chi-squared test.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eNinety-two percent of students reported using PADs. A majority used them daily, with an average duration of nearly five hours. Many participants reported listening at high volumes and perceived health problems as a result. Notably, almost half of the users felt unable to discontinue their PAD use despite acknowledging potential adverse effects. There was a significant association between the daily duration of PAD use and the perception of adverse effects.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe continuous, prolonged, and high-intensity use of PADs among medical students is a significant issue that could escalate into a public health concern. Interventions focused on awareness, behavioural change, and the adoption of safe listening practices are crucial to mitigate these potential hazards.\u003c/p\u003e","manuscriptTitle":"Patterns and Perceived Risks of Personal Auditory Device Use Among Medical Students: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 05:46:49","doi":"10.21203/rs.3.rs-6989177/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-08T12:28:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-08T03:46:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-05T05:24:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-02T10:49:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-24T06:53:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9706898051476187184001325290338795804","date":"2025-07-21T06:10:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192414149037395134312284207889501629921","date":"2025-07-20T11:40:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139506398765367055023573377484581843707","date":"2025-07-16T23:58:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223815473720222609854959742719552939387","date":"2025-07-16T07:46:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26992647436179245235585718292092136935","date":"2025-07-16T03:14:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312870814668429150876116302017584864154","date":"2025-07-16T02:23:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-16T02:07:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-07T11:07:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-02T00:50:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-02T00:49:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Research Notes","date":"2025-06-27T07:41:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"efd22ed4-ac8d-4b32-9552-fce3287cb18b","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:04:22+00:00","versionOfRecord":{"articleIdentity":"rs-6989177","link":"https://doi.org/10.1186/s13104-025-07541-4","journal":{"identity":"bmc-research-notes","isVorOnly":false,"title":"BMC Research Notes"},"publishedOn":"2025-11-03 15:57:32","publishedOnDateReadable":"November 3rd, 2025"},"versionCreatedAt":"2025-07-23 05:46:49","video":"","vorDoi":"10.1186/s13104-025-07541-4","vorDoiUrl":"https://doi.org/10.1186/s13104-025-07541-4","workflowStages":[]},"version":"v1","identity":"rs-6989177","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6989177","identity":"rs-6989177","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}