Use Of Hearing Protection Research Articles

An Adult with Congenital Aural Atresia, Amplification, and Exaggerated Hearing Difficulty with Use of Hearing Protection

An Adult with Congenital Aural Atresia, Amplification, and Exaggerated Hearing Difficulty with Use of Hearing Protection

Prevalence and Factors Associated With Occupational Noise-Induced Hearing Loss Among Palm Oil Mill Workers in Selangor, Malaysia.

Introduction Occupational noise-induced hearing loss (NIHL) continues to be a significant public health issue globally, with Malaysia being no exception. In Malaysia, the majority of NIHL cases are reported from the manufacturing sector, with Selangor among the states with the highest number of confirmed cases. This study aimed to assess the prevalence of and factors associated with occupational NIHL among palm oil mill workers in Selangor, Malaysia. Methods A cross-sectional study was conducted to analyze the data from the data collection form, noise risk assessment reports, and audiometric test results done between 2021 and 2022 with a comparable baseline audiometric test. Results A total of 143 participants from three palm oil mills joined this study. The prevalence of NIHL was 42.7% (n = 61). Following the logistic regression model, NIHL was significantly associated with a duration of employment of 10 years and above, a history of occupational noise exposure at the previous workplace, and the use of personal hearing protectors at the current workplace with an adjusted OR of 2.41 (95% CI (1.14, 5.07)), 5.89 (95% CI (2.38, 14.53)), and 0.36 (95% CI (0.16, 0.83)), respectively. Conclusion The prevalence of NIHL among the study participants was high, and the associated factors are modifiable factors that can be prevented with a comprehensive hearing conservation program in the palm oil mills.

Music to Define a Generation: Factors Associated With Hearing Protection Use at Music Venues.

Excessive noise levels in music venues can negatively impact long-term hearing health. We investigated the prevalence, characteristics, and factors associated with hearing protection use among music event attendees. Cross-sectional cohort. Adult participants (2,352) from online music forums completed a questionnaire assessing attendance at music events, hearing protection (HP) usage, type, and frequency, along with history of hearing-related symptoms and medical history. Primary outcome was defined as HP use at music venues. Data were characterized using descriptive statistics, paired t tests, and Pearson's chi-squared tests. Multivariable regression analysis elicited factors associated with any and regular HP use. Our 2,352 respondents were primarily male (61.3%) and on average 28.7 years old (SD = 7.0). Of the respondents, 60.6% reported using HP, and 33.2% reported regular use; high-fidelity earplugs were the most used HP type (57.5%). HP use was associated with significantly fewer reports of negative hearing-related symptoms. In a multivariable regression model, factors associated with less likelihood of HP use included being female (vs male, OR = 0.74, CI = [0.55-0.98]), less concern about effects on hearing (OR = 0.53, CI = [0.45-0.61]), and pop music event attendance (vs EDM, OR = 0.40, CI = [0.22-0.72]). Increased attendance frequency in the past year was associated with higher likelihood of regular HP use (OR = 1.07, CI = [1.04-1.09]). Decreased attendance duration was associated with decreased likelihood (OR = 0.09, CI = [0.03-0.33]). HP use prevalence was high, while frequent use remained low. HP use was significantly associated with reduced hearing-related symptoms. Demographic factors, otologic symp-tomology, and attendance-related characteristics were associated with HP use. These findings may guide interventions to increase adoption at music venues. 4.

PROFILE OF RISK FACTORS FOR ACOUSTIC TRAUMA IN 105 HOWITZER CANNON SHOOTER STUDENTS AT THE PUSAT PENDIDIKAN ARTILERI MEDAN-CIMAHI

Acoustic Trauma is hearing loss caused by short period high frequency noise. Hearing loss can occur in military, because it uses the main tools of the weaponry system, such as guns, military vehicles, and explosions. This research aims to determine the description of risk factors for acoustic trauma, patterns of hearing protector use, and ear complaints among students of Pusdik Armed who perform 105 Howitzer Cannon shooting practice. This study used a descriptive method with a cross sectional design on the students of Pusdik Armed who perform 105 Howitzer Cannon shooting practice. The sampling technique used total sampling with 103 population. The research instrument was secondary data from the public dedication questionnaire of Dr Asti Kristianti, Sp.THT-BKL, M.Kes. The results showed a description of the risk factors for acoustic trauma in Pusdik Armed Students who perform Howitzer 105 Cannon shooting practice mostly due to high noise exposure (64.1%), smoking history (60.2%), using PLDs (59.2%), a minority do not wear hearing protectors (12.6%), and the use of ototoxic drugs (1.9%), and no one has hypertension and a family history of hearing loss. The pattern of using hearing protectors during 105 Howitzer Cannon shooting practice is from students who use ear protectors (87.4%), some use ear protectors during training (72.8%). The description of ear complaints before doing Howitzer 105 Cannon shooting practice mostly did not experience ear complaints either before (82.5%) or after (76.6%). Therefore, it is necessary to require the use of ear protective equipment for cannon shooters.

A Simulation Study of Noise Exposure in Sledge-Based Cable Yarding Operations

Ensuring the safety of forestry workers is a key challenge, particularly when working with partly mechanized harvesting systems. Cable yarding is typically used in steep terrain timber harvesting. For long-distance extraction, one of the few alternatives is to use sledge yarders, but these machines may expose workers to high doses of noise. The goal of this study was to model haulers’ exposure to noise in sledge-based cable yarding operations, based on a simulation approach that considered variable factors such as the yarding distance, lateral yarding distance, and average skyline height. Taken into consideration were 165 scenarios developed by examining the variation in yarding distance (500 to 1500 m, with a step of 100 m), lateral yarding distance (10 to 50 m, with a step of 10 m), and average skyline height above the ground (10, 15, and 20 m). The simulations assumed an 8-h working day with a break of 1 h. The models and statistics published by other studies were used to calculate the time consumption and number of work cycles completed within a working day. These data were used to compute the equivalent exposure to noise (LAeq) for each scenario, as well as for those work elements that were likely to expose the haulers to noise the most. The presented findings indicated that (i) the exposure to noise was higher than 100 dB(A), irrespective of variation in the considered factors; (ii) the trend in exposure was characterized by polynomials in relation to the extraction distance, and the magnitude of exposure was consistently affected by variation in the considered factors; and (iii) without hearing protection, the empty and loaded turns exposed workers to noise over the permissible limits. These findings strongly suggest the use of hearing protection when working in close proximity to sledge-based cable yarding operations. The methods proposed in this study in the form of simulation may help benchmark other forest operations.

'Cultural Insights into Adults' Hearing Awareness and Personal Listening Device Habits: A Survey Study.

The aim of this study was to investigate adults' habits regarding personal listening devices (PLDs), associated factors such as tinnitus and hearing threshold shift, and their knowledge of safety measures, including the use of hearing protectors in noisy environments. A cross-sectional survey was designed and distributed online. Participants between the ages of 18 and 40 years were invited to complete the survey. The online survey was filled out by 274 individuals with an average age of 24.2 years (SD= 5.1 years). Based on age, the participants were grouped into young adults (18-23 years old, 151 participants) and adults (24-40 years old, 123 participants). The estimation of noise exposure was calculated based on self-reported responses of PLD use. Two categories emerged from this calculation: the participants with exposure lower than 80 dB were in the low exposure category (N: 196, 62.9 dB), while the participants with exposure higher than 80 dB were in the high exposure category (N: 78, 89.9 dB). Based on the age categories, most of the questionnaire answers were similar between the young adults and the adults, revealing similar habits in using their PLDs. However, the investigation based on exposure revealed differences, as the participants with high exposure levels were more likely to have hobbies that involved noise, and they were less likely to obtain hearing evaluations. Among the participants, 30% used their devices at the maximum volume level and on a daily basis. 33.5% reported experiencing worsening in hearing, 2.4% reported persistent tinnitus, 94.1% knew that hearing protectors were available but only 20.7% reported using hearing protectors. The study concludes that adults are at risk of hearing loss due to unsafe listening habits. A discrepancy between knowledge and practice is apparent and needs to be addressed in young adults by increasing awareness of hearing loss, hearing protection and annual hearing evaluation.

Attitudes towards hearing, hearing loss, and hearing protection in university students

Objective Young adults are at risk for hearing loss caused by exposure to loud music. Intervention at this stage provides opportunities to support lifelong hearing protection use. This study explores attitudes related to hearing, hearing loss, and hearing protection among university students. Design Qualitative interview design, supplemented by quantitative questionnaire data. Study sample 18 university students, aged 18–24 years. Results Students were uncertain about mechanisms of noise-induced hearing loss, did not feel vulnerable to permanent hearing damage from loud music, were unconvinced of hearing protection efficacy, and reported barriers to hearing protection use. Students emphasised the positive effects of loud music and reported an increased likelihood of using hearing protection were it used by peers. Music students appeared more aware of the negative effects of loud music exposure. Students reported conflicting attitudes regarding government regulation of hearing protection use. Conclusion Young adults require education about hearing protection from multiple, credible sources and need to understand the mechanisms behind noise-induced hearing loss in a way that makes it of high personal relevance.

New Paradigm of Music Listening: Hearing Protection Perceptions and Treatment Decision-Making Among Music Venue Attendees.

Investigate the prevalence of hearing protection (HP) use and behavioral motivations and barriers among adults attending music venues. Cross-sectional online survey study. Noise exposure levels at popular social music venues often exceed national guidelines. Surveys were distributed on online music communities. Respondents (n = 2352) were asked about demographics, HP use at music venues, knowledge about noise exposure impact, and perceptions of HP use. Data were characterized through descriptive statistics. Multivariable regression analysis explored differences in knowledge and perception between HP users and nonusers. In this cohort (mean age 29 ± 7 years, 61% male), HP users were significantly more aware of the impact of music venues on hearing (P < .01), believed their hearing ability had decreased after attending music venues (P < 0.01), and believed HP could protect from hearing loss (P < .01) than non-HP users. HP nonusers most frequently cited never considering HP (14.45%) and apathy about it affecting music quality (12.71%). Common sources of HP information were recommended by a friend/peer. Multivariable regression analysis accounting for demographics, medical history, and attendance characteristics found belief that HP use at music venues could protect from hearing loss (β = 0.64, 95% confidence interval [CI] = [0.49-0.78]) and HP use (β = 1.73, 95% CI = [1.47-1.98]) were significantly associated with increased subjective enjoyment while wearing HP. HP users and nonusers have significantly different perceptions of HP use and its impact. Our findings have implications for understanding motivations and barriers related to HP use and developing strategies to promote HP use at music venues.

Awareness of Noise-Induced Hearing Loss among the General Population in the Eastern Province of Saudi Arabia

Abstract Introduction: Noise-induced hearing loss (NIHL) is a common work-related hazard that can affect employees and can lead to multiple health problems, and the use of hearing protection devices has been proven to reduce the possibility of developing NIHL. This study aims to construct useful knowledge that can be used to increase awareness campaigns and promote social acceptance of the use of hearing protection devices among the general population in the Eastern Province of Saudi Arabia. Materials and Methods This is a descriptive, cross-sectional study, and the convenience sampling technique was followed in this study, in which the questionnaire was distributed electronically through social media platforms. The questionnaire contained 18 items to evaluate NIHL and awareness of the effects of loud sounds on hearing and health. Results: Of the 416 respondents involved in the study, it was observed in this study that gender, level of education, and age were not significantly associated with a higher or lower perception of hearing loss. Forty-three percent of the study participants have not heard anything about hearing loss at all, and surprisingly, among the participants who have heard about it, only 4.8% of the participants stated that they obtained their information from medical campaigns, which is the least informative site for hearing loss information. Finally, it is shown that the majority of the participants, 52.2%, have not heard any information regarding earplugs. Conclusion: This paper provides data on noise exposure and its associations with the risk of hearing impairment and attitudes toward earplugs among the Saudi population in the eastern region. The results explicitly showed that the young age group demonstrated a low level of knowledge and a low level of awareness of NIHL and the importance of earplugs. As a result, we strongly advocate for more health campaigns to raise community awareness of NIHL.

The Effect of a Web-Based Occupational Noise-Induced Hearing Loss Prevention Program on Hearing Protection Device Behavior Among Thai Navy Officers: A Quasi-Experimental Study

Navy officers working on the coastal guard vessels risk hearing loss due to repeated exposure to high noise levels from ship engines. Therefore, proper use of hearing protection devices is important. In this study, a web-based hearing loss prevention program was developed to promote the behavior of the use of hearing protection devices among Thai navy officers working on coastal guard vessels. In total, 152 navy personnel were recruited based on selection criteria and randomly assigned to the experimental (n = 76) and control groups (n = 76). The participants in the experimental group received the hearing loss prevention program via a website over four weeks. After completing the program, hearing protection device behavior was evaluated by a self-report questionnaire immediately after and at eight weeks follow-up. The results showed significantly increasing scores of the use of hearing protection devices behavior within the experimental group, both immediately and eight weeks after the program completion. However, there were no significant differences in the scores when comparing between groups, even though the scores of the experimental group were better than those in the control group. The restrictions could be explained by some emerging events during the implementation period, including the COVID-19 pandemic followed by a massive oil spill incident at sea. These put an extra workload on the study participants. Most importantly, there was a problem with the network connection that might have affected the continuation of participant attention to the program. Although this study found no effective results of the developed program due to some limitations, nurses can adopt this protective intervention to reduce the risk of occupational noise-induced hearing loss among Navy officers. Therefore, a recommendation for further study is to develop an intervention program that considers both the working context of the coastal vessels and appropriate participation methods that require more challenging efforts.

Parameters influencing auditory fatigue among professionals working in the amplified music sector: noise exposure and individual factors

Objective Hearing disorders are common among music professionals, as they are frequently exposed to sound levels exceeding 100 dB(A). By assessing auditory fatigue, situations that are deleterious for hearing could be identified, allowing the deployment of preventive measures before permanent impairment occurs. However, little is known about the factors contributing to auditory fatigue. The objective is to determine the exposure parameters most influencing auditory fatigue during occupational exposure to amplified music. Design Auditory fatigue was defined as variations of both pure tone auditory (ΔPTA) and efferent reflex thresholds (ΔER) during the workday. Noise exposure was monitored and information on the volunteers was gathered using a questionnaire. Study sample The population consisted of 43 adult volunteers exposed to amplified music (sound, light or stage technicians, security agents, barmen) and 24 unexposed administrative agents. Results ΔPTA and ΔER were positively correlated with the energy of noise exposure and its stability over time, i.e a steady noise tends to create more auditory fatigue. Conclusion In addition to a global decrease of music levels and a systematic use of hearing protection, our results advocate for the provision of quiet periods within noise exposures as they reduce auditory fatigue accumulation and long-term risks for hearing.

Preventing Occupational Hearing Loss: 50 Years of Research and Recommendations from the National Institute for Occupational Safety and Health.

For more than 50 years, the National Institute for Occupational Safety and Health (NIOSH), part of the United States (U.S.) Centers for Disease Control and Prevention (CDC), has been actively working to reduce the effects of noise and ototoxic chemicals on worker hearing. NIOSH has pioneered basic and applied research on occupational hearing risks and preventive measures. The Institute has issued recommendations and promoted effective interventions through mechanisms ranging from formal criteria documents to blogs and social media. NIOSH has conducted surveillance and published statistics to guide policy and target prevention efforts. Over the past five decades, substantial progress has been made in raising awareness of noise as a hazard, reducing the risk of occupational hearing loss, improving the use of hearing protection, and advancing measurement and control technologies. Nevertheless, noise remains a prevalent workplace hazard and occupational hearing loss is still one of the most common work-related conditions. NIOSH continues to work toward preventing the effects of noise and ototoxicants at work and has many resources to assist audiologists in their hearing loss prevention efforts.

The development and evaluation of an online hearing loss prevention program

Recent studies underline the need for research on approaches to encouraging healthy listening habits. This study aims to develop and evaluate an online hearing loss prevention program; and examine its influence on the participants’ use of hearing protection, hearing loss prevention knowledge, attitude towards noise, and program useability and adherence.The study was conducted in the county of Västra Götaland, Sweden, from March through October 2021. The program included four modules focused on hearing and hearing loss prevention and was accessible to the participants for four weeks. In total, 75 participants completed the program which was evaluated using the Youth Attitude to Noise Scale and four additional self-designed questionnaires. The questionnaires were deployed before and immediately after program completion.The findings indicate that the program may influence the participants’ attitudes toward noise and the use of hearing protection. The participants who completed the program perceived high useability and increased hearing loss prevention knowledge. This program is most needed to promote healthy hearing. Future studies should target specific groups with this program and evaluate its long-term effects.

Occupational noise exposure and tinnitus: the HUNT Study

Objective We aimed to assess the association between occupational noise exposure and tinnitus. Further, to assess whether the association depends on hearing status. Design In this cross-sectional study, tinnitus (>1 h daily) was regressed on job exposure matrix (JEM)-based or self-reported occupational noise exposure, adjusted for confounders. Study sample The 14,945 participants (42% men, 20–59 years) attended a population-based study in Norway (HUNT4, 2017-2019). Results JEM-based noise exposure, assessed as equivalent continuous sound level normalised to 8-h working days (LEX 8 h), over the working career or as minimum 5 years ≥85 dB) was not associated with tinnitus. Years of exposure ≥80 dB (minimum one) was not associated with tinnitus. Self-reported high noise exposure (>15 h weekly ≥5 years) was associated with tinnitus overall and among persons with elevated hearing thresholds (prevalence ratio (PR) 1.3, 1.0–1.7), however not statistically significantly among persons with normal thresholds (PR 1.1, 0.8–1.5). Conclusions Our large study showed no association between JEM-based noise exposure and tinnitus. This may to some extent reflect successful use of hearing protection. High self-reported noise exposure was associated with tinnitus, but not among normal hearing persons. This supports that noise-induced tinnitus to a large extent depends on audiometric hearing loss.

Prevalence of hearing protection use and subjective auditory symptoms among Spanish classical orchestral musicians

IntroductionSensorineural hearing loss caused by exposure to noise is one of the most frequent causes of deafness. Professional musicians have significant occupational exposure to high levels of noise. Use of hearing protection among musicians could substantially prevent hearing damage, though the rate of use is quite low. Methods and materialA questionnaire on the use of protective hearing devices, hearing care, and subjective judgments of hearing difficulties was completed by a group of classical musicians from Spain. We analysed the frequency of device use by instrument based on contingency tables analysed by χ2 tests. ResultsOne hundred and ninety-four Spanish classical orchestral musicians voluntarily completed the questionnaire. The percentage of musicians who reported using hearing protection in our survey was very low and varied with the type of instrument played. However, we found a high prevalence of subjective auditory disorders within this group. ConclusionFew Spanish musicians use hearing protection. Training on hearing-loss prevention in this field and better protective devices could increase device use and improve the auditory health of this group.

Development and initial validation of questionnaire on predictors for the use of hearing protection devices among noise exposed manufacturing workers in Tanzania: A methodological study.

The use of hearing protection devices (HPDs) has been an intervention of choice in many workplaces such as in the construction industry for quite some time due to impractical effects of engineering and administrative interventions. Questionnaires for assessment for HPDs use among construction workers have been developed and validated in developed countries. However, there is limited knowledge of the same, among manufacturing workers in developing countries that are assumed to have a different culture, work organizations and production processes. We conducted a stepwise methodological study to develop a questionnaire to predict the use of HPDs among noise exposed workers in manufacturing factories in Tanzania. The questionnaire included 24 items and was developed through rigorous and systematic procedures involving three steps; (i) item formulation that involved two experts, (ii) expert content review and item rating that involving eight experts with vast experience in the field, and (iii) a field pre-test that involved 30 randomly selected workers from a factory with similar characteristics as a planned study site. A modified Pender's Health Promotion Model was adopted in the questionnaire development. We analyzed the questionnaire in terms of content validity and item reliability. The 24 items were categorized into seven domains i.e., perceived self-efficacy, perceived susceptibility, perceived benefits, perceived barriers, interpersonal influences, situational influences and safety climate. The score for content validity for each item was satisfactory as the content validity index ranged between 0.75 to 1.00 for clarity, relevance, and essentiality criteria. Similarly, the scores for the content validity ratio (for all items) were 0.93, 0.88 and 0.93 for clarity, relevance, and essentiality, respectively. In addition, the overall value for Cronbach's alpha was 0.92 with domain coefficients: perceived self-efficacy 0.75; perceived susceptibility 0.74; perceived benefits 0.86; perceived barriers 0.82; interpersonal influences 0.79; situational influences; 0.70; and safety climate 0.79. The mean inter-item correlation was 0.49 suggesting good internal consistency. The developed and preliminary validated questionnaire can be used to predict the HPDs use among noise exposed manufacturing factory workers. Future surveys using this questionnaires warranted for further validation of the scale developed.

Impulse noise measurement in view of noise hazard assessment and use of hearing protectors

Experience shows the occurrence of situations when the measurements of impulse noise parameters are made with measurement equipment unsuitable for such conditions. The results of using such equipment were compared with the results of using equipment with a sufficiently large upper limit of the measurement range. The analysis was carried out on the example of noise generated during shots from a Mossberg smooth-bore shotgun and AKM rifle, as well as produced in the forge. The use of the unsuitable equipment allowed to indicate the exceeding of the exposure limit value of the peak value of the signal (LC peak), but this is not always possible when determining the energy properties of the signal (L EX,8h). While the inadequate properties of the measurement equipment will generally not prevent the conclusion that noise in a particular workplace is hazardous to hearing, the results of measurements cannot be used to select hearing protectors.

Effectiveness of Motivational Interviewing in Increasing Use of Hearing Protection Devices Among Agricultural Producers.

Agricultural producers are frequently exposed to noise that is hazardous to their hearing and cardiovascular health, and have among the highest rates of noise-induced hearing loss of all occupations. However, despite information-sharing approaches, few producers wear sufficient hearing protection. There is a need to develop effective methods of protecting producers from their noise exposure. We provided a series of 2 to 3 short (30-minute) telephone-based motivational interviewing (MI) sessions to noise-exposed agricultural producers. We assessed intervention effectiveness through changes in measuring hearing protector use pre- and post-intervention using a one-group pre/posttest design. The sample (N = 29) predominantly consisted of crop producers from Michigan. The mean percentage of time hearing protection was used increased from 44.9% to 51.8% after the intervention, approximately a 7% increase (p =.105). Regression analysis suggested the relationship between intervention dose and use of hearing protection was not correlative. There was a marginal increase in the use of hearing protection after the intervention, although setting-specific increases in use were uneven. Intervention dose did not correlate with a change in hearing protection use. Further research is warranted to determine the effectiveness of MI, how it compares to information sharing, and to identify intervention dose parameters that promote efficiency.

Translation, adaptation, and cross-cultural validation into Brazilian portuguese of the hearing protection assessment questionnaire (HPA)

The aim of the present study is to translate, adapt, and cross-culturally validate the Brazilian Portuguese version of the questionnaire Hearing Protection Assessment Questionnaire (HPA). The original instrument, developed in English, seeks to assess barriers and supports related to the use of hearing protection devices (HPD), as well as workers' knowledge, habits and attitudes towards occupational noise. The translation, adaptation, and cross-cultural validation of the questionnaire consisted of five steps: Translation of the questionnaire from English to Portuguese; 2) Reverse translation from Portuguese to English; 3) Analysis of the instrument by three experts in the field; 4) Pre-test of the questionnaire with ten workers; 5) Application of the instrument to 509 workers in a meatpacking industry after the pre-employment medical exam. The results indicate the construction and content validity of the Brazilian Portuguese version for use with a working population and its internal consistency. This study resulted in the translation, cultural adaptation, and validation of the Hearing Protection Assessment Questionnaire (HPA), in order to be used to assess the use of individual hearing protection in the occupational field, called Hearing Protection Assessment Questionnaire (HPA).

Tradução, adaptação e validação transcultural para o português brasileiro do questionário de Avaliação da Proteção Auditiva (APA)

ABSTRACT Purpose The aim of the present study is to translate, adapt, and cross-culturally validate the Brazilian Portuguese version of the questionnaire Hearing Protection Assessment Questionnaire (HPA). Methods The original instrument, developed in English, seeks to assess barriers and supports related to the use of hearing protection devices (HPD), as well as workers' knowledge, habits and attitudes towards occupational noise. The translation, adaptation, and cross-cultural validation of the questionnaire consisted of five steps: Translation of the questionnaire from English to Portuguese; 2) Reverse translation from Portuguese to English; 3) Analysis of the instrument by three experts in the field; 4) Pre-test of the questionnaire with ten workers; 5) Application of the instrument to 509 workers in a meatpacking industry after the pre-employment medical exam. Results The results indicate the construction and content validity of the Brazilian Portuguese version for use with a working population and its internal consistency. Conclusion This study resulted in the translation, cultural adaptation, and validation of the Hearing Protection Assessment Questionnaire (HPA), in order to be used to assess the use of individual hearing protection in the occupational field, called Hearing Protection Assessment Questionnaire (HPA).