Loud, hazardous noise exposure is ubiquitous and unavoidable in the Defence Force. As a result, it has the unfortunate but foreseeable effect of inducing early-onset hearing loss and/or tinnitus among service members. In Australia, Australian Defence Force (ADF) members and veterans can receive fully subsidised hearing care under the Commonwealth Hearing Services Program (HSP). While the HSP has its own limitations for the Defence/veteran community, as a clinical audiologist, this author has assisted numerous actively serving personnel and veterans through the HSP and is aware of the number of individuals who have benefited from this service.
Currently, to access these hearing services, ADF members are first referred to an audiologist for the following reasons: (1) to confirm abnormal screening audiogram results; (2) to monitor known hearing loss; (3) to investigate clinical presentations of hearing difficulty, asymmetrical hearing loss and/or tinnitus; or (4) provision/management of hearing aids. While these are excellent trigger points for a referral, many members appear to be presenting at their audiology appointment, reporting years of untreated, long-standing hearing difficulties and/or severe, debilitating or intrusive tinnitus. Conversations with numerous ADF members and veterans have led this author to identify common reasons for why this is occurring:
1. The culture among Defence personnel of not wanting to appear ‘weak’ or ‘letting their teams down’ or having a health consideration that may limit postings and/or promotions. It is known that fitness-for-duty requirements can affect members’ willingness to disclose hearing problems or the presence and/or impact of tinnitus on their personal and professional lives. At times, this under-reporting was allegedly supported by military medical officers. For this reason, many members may ‘reverse malinger’, with veterans later reporting that they have denied, concealed or trivialised their hearing symptoms to maintain their status or obtain special jobs.
‘I personally knew my hearing was deteriorating for several years, especially in my left ear so whenever I went for my annual hearing test, I would put the headphones on backwards when the left-ear beeps started. This allowed me to do the entire hearing test with my right ear, thereby appearing “normal”. This was clearly not the smartest thing to do, but at the time, it seemed to be the only thing I could do not to risk my ongoing employment. I have seen countless others conceal injuries or illnesses for other similar reasons. With regards to tinnitus though, I have read how people in the past took drastic action to try to make it stop.’ –Veteran
‘People will not ask if it is normal to have a noise in your head and if there is any treatment. Saying you have a noise in your head suggests you have a mental health issue because the noise is not real. This then pulls into question your deployability, security clearance and career and financial stability.’ –Veteran
2. Misinformation or lack of knowledge regarding tinnitus across the Defence community – both among service members and across leadership, managerial and medical ranks.
‘When I first knew that the noise was called tinnitus in 2022, I was told nothing could be done to treat tinnitus. I’ve asked a heap of people since if they have tinnitus, and it seems to be quite prevalent, but there is misinformation either from medical officers or perpetuated within ranks that it is an issue that can’t be alleviated or treated. There seems to be an urban legend that nothing can be done so it is not worth seeking at least alleviation of tinnitus when it is annoying you.’ –Veteran
‘It has even been put to me that not educating us on labelling or specifically asking if we hear a high-frequency noise in our ears was a way of evading the burden it would place on ADF medical to treat.’ –Veteran
‘When I first experienced “ringing in my ears”, I didn’t know what it was. When it became intrusive, I started reporting it at all my hearing screens and my annual Defence medicals. I was told it was tinnitus and that it was normal or fine. Action was not taken on it.’ –Veteran
3. Existing cultural challenges within Defence where stigma remains associated with ‘help-seeking’. This may be particularly so for hearing-related issues which are ‘invisible’ and may not be socially condoned, justified or considered ‘legitimate’. As quoted by a veteran,
‘Many won’t seek treatment as it is embarrassing to whinge about a high-pitched noise when a mate has died of an IED blast, has a disfigurement or has lost a limb.’
In addition, increasing research indicates that noise-induced damage can still occur without causing a detectable change in the audiogram.1 This phenomenon is termed hidden hearing loss, an auditory dysfunction with the hallmarks of speech intelligibility deficits despite normal or near-normal hearing levels.2 Aside from reduced speech clarity, hidden hearing loss can also contribute to tinnitus development and the acceleration of age-related hearing loss across the lifespan.3,4 Anecdotally, ADF members and veterans who have presented with symptoms of ‘hidden hearing loss’ reported feeling inadequate, embarrassed and frustrated by their hearing inadequacies despite acing consecutive hearing screenings.
‘I felt stupid for constantly having to ask for repeats when I supposedly have normal hearing. In the end I just gave up listening at meetings and would later ask a colleague if I had missed anything important.’ –Active ADF member, exhibiting symptoms of hidden hearing loss.
As a result of the above, a vast majority of ADF members and veterans likely struggle with untreated auditory dysfunction for many years. While hearing loss and tinnitus are not life-threatening conditions, it is the impact of suppressing, concealing and masking one or both of these conditions that is of greatest concern. Hearing loss compromises one’s ability to communicate and, in turn, the ability to partake in daily activities, relate to others and deeply connect with people, both professionally and personally. Hearing loss can cause individuals to withdraw by avoiding or tuning out at social events, as it can be upsetting when everyone appears to be having a good time, yet, hearing difficulties prevent one from joining the conversation or catching the punchline of a joke. Although misunderstandings can sometimes be humorous, they can also be embarrassing, frustrating and disengaging when one’s contribution does not align with the conversation. It is not unusual for veterans to report that their hearing loss, which has sometimes been concealed for decades, has led to conflict with family/friends, significant mental exhaustion, fatigue and feelings of loneliness, low self-confidence/self-worth and insecurity.
‘After running my own meetings or briefing senior committees on my multi-billion dollar project, I would be mentally exhausted from attempting to lip read or embarrassed by how many times I would ask for the question or answer to be repeated. Eventually, I really pushed to be referred to an audiologist in one of my annual Defence medicals and was able to be fitted with hearing aids through the Hearing Services Program. However, as they were Bluetooth enabled (as most hearing aids are these days), they were often not permitted to be worn within secure working spaces, compounding the exhaustion and embarrassment even further.’ –Ex-Senior Officer, medically retired May 2023.
While some ADF members adapt to their tinnitus over time, those who do not and are repeatedly reinforced by medical staff or colleagues that ‘nothing can be done’ may go on to experience other health comorbidities compounded by the perceived impact of their tinnitus and/or the hopelessness of the situation. This includes conditions such as depression, anxiety, sleep disorders, substance abuse and, in extreme cases, suicide. There is indeed significant evidence that psychological disorders that are paired with a hearing impairment, such as tinnitus, can exacerbate each other.5,6 In the military arena, such consequences can impact on job performance and operational missions (ironically, the reason for concealing any hearing issues in the first place), which could be costly in terms of mission effectiveness and even survivability.7
According to the Department of Veterans’ Affairs, hearing loss and tinnitus are two of the most common conditions experienced by former ADF members. However, of greater concern is the high and increasing number of claims for both conditions over the years (Table 1). These figures may not include veterans reluctant to seek help or talk about their tinnitus in their efforts to ‘soldier on’ and not complain.8
Table 1: Percentage of sensorineural hearing loss and tinnitus claims accepted under the Military Rehabilitation and Compensation Act 2004
| Condition | Percentage of claims accepted under the MRCA (2004) | ||
| 2014–2015 | 2019–2020 | 2021–2022 | |
| Sensorineural hearing loss | 7.1% 556 accepted claims 90% acceptance rate |
11% 2,458 accepted claims 98.5% acceptance rate |
16.8% 4,163 accepted claims 99.2% acceptance rate |
| Tinnitus | 9.1% 710 accepted claims 96% acceptance rate |
27% 5,935 accepted claims 96.3% acceptance rate |
18.2% 4,526 accepted claims 94.6% acceptance rate |
While the ADF has come a long way in improving and providing hearing protection, there are many situations where hearing protection is impossible (e.g. during active combat) or impractical for continuous use. The unpredictability of gunfire and explosive detonations is also another factor that can catch an individual unprepared without hearing protection.
In light of this, it could be argued that the detection and mitigation of hearing loss must not only include effective noise control, hazard assessments and audiometric monitoring but for a hearing conservation program that aims to educate, train, identify, monitor and intervene.
The goals of such a program would be to:
- Promote healthy hearing through adequate and relatable hearing education
- Reduce the impact of occupational and, at times, unavoidable, loud noise exposure through timely and intentional hearing monitoring
- Maintain fitness-for-duty and mission readiness of all personnel, including retention of skilled and experienced members in speciality jobs, through early intervention
- Normalise the currently serving ADF members seeking help for hearing conditions so the requisite medical, audiological and management responses can be put into place.
Hearing conservation program: A proposed framework
1. Hearing loss prevention education
According to Beamer et al. (2020), ‘If hearing protection is the cornerstone of hearing loss prevention, it is hearing health education that serves as the foundation for successful hearing loss prevention efforts’ (p.685).7 The authors added that without appropriate education, military personnel are unaware of the harmful effects of noise on hearing, the impact of noise-induced hearing loss on job performance and daily living, how to correctly use hearing personal protective equipment (PPE) and hearing protection measures for off-duty noise-hazardous activities.
In August 2010, Safe Work Australia published a paper investigating the obstacles and enablers that play a role in effective noise control and hearing loss prevention.11 Infrequent and improper use of hearing protectors, insufficient knowledge of the effects of loud noise, a belief that hearing loss ‘will not happen to me’ (optimism), low confidence about being able to do anything about noise (self-efficacy) and work cultures that are resistant to change were among the barriers identified by the study. The report’s highly favoured recommendation was education. This sentiment was later echoed by Elsey & Jennings in 2014, who affirmed that ‘a lack of understanding about a subject matter will not induce any action to be taken at the workplace’.12
Conversations between this author and ADF personnel/veterans indicate a desire for greater understanding and knowledge.
‘When I was first posted to a flying unit back in 2011, there was an element of raising awareness for the use of hearing PPE but long-term health effects of hearing loss/tinnitus were not discussed in detail on the course. From an aviation point of view, I would say the most effective time to raise awareness of the effects of hearing loss/tinnitus is at the delivery of said safety familiarisation courses. –Active Defence Member
‘I was, for example, told to wear hearing protection when things were noisy but no detail was ever given regarding the degree of protection to wear for different noises, how to wear it or how to even access it in many cases. Additionally, I was never taught what would happen if I didn’t do this other than not wearing it was “bad for you”. Education is one thing, but the quality of that education and the acceptance of it is critically important, as is the tailoring of it to suit individual employment. Had the teaching been more explanatory, then I (and others) may have taken more care, as may many others.’ –Veteran
‘If I knew more about my hearing and the impact of hearing loss/tinnitus from the beginning, I would have 100% openly discussed it with medical staff. If more Defence members did this and actually reported through their workplaces, Defence would gain a better appreciation of how much this is actually affecting their workforce. –Veteran
‘Every year, we do mandatory training ranging from heat illness, records management, alcohol, equity and diversity and occasionally, a token form of mental health preservation. If we want to change the culture of hearing loss and mental health, it needs to be featured in our annual training and normalised within our management culture. Today, we are far from it.’ –Ex Senior officer, medically retired May 2023.
It would therefore seem prudent that the provision of hearing PPE be accompanied by information on the real and relatable risks of loud noise exposure and the real and relatable impact hearing loss and/or tinnitus can have on quality of life
A list of potential topics that could be considered in the planning of a hearing conservation program include, but are not limited to:
- How? Simplified explanation of how hearing works, the impact of loud noise on the auditory system, phenomenon of hidden hearing loss.
- Who? Noise-induced hearing loss does not discriminate by age, gender or health status.
- What? What might occur after noise exposure? What does ‘cotton wool’ hearing and ‘ringing ears’ mean? Recovery of symptoms does not mean no hearing damage.
- Why? Repeated noise exposure leads to irreversible damage through permanent hearing loss and/or tinnitus. Inclusion of a veteran with lived experience may be beneficial to ‘strike at the core’ of listeners and ensure information is memorable, believable and relevant.12
- When? When and how to use hearing protection and, more importantly, its fit and suitability (e.g. earmuffs are impossible to use in a confined space like performing maintenance under armoured vehicles). Training on how to care for, maintain and store hearing PPE.
- Where? Where to seek help or advice for defective hearing PPEs. There was a common theme among interviewed veterans of not knowing where to go or who to consult regarding this. Reduced accessibility reduces compliance.
Material sources could include technical guides, brochures, factsheets, websites, videos, in-person demonstrations, computer-based training and presentations for mobile device platforms. Participant satisfaction and feedback on educational materials should be solicited to improve the quality of material overtime. Longitudinal studies of learning effects should also be included in future research.
2. Timely and intentional hearing monitoring
Hearing screening should continue routinely, with perhaps an increased test frequency for those in higher noise exposure roles. Post-deployment hearing screenings should also be mandated promptly, with personnel screened for tinnitus and particular attention given to those with blast-related injuries/concussion, traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). This is due to findings that auditory pathways are susceptible to injury and/or dysfunction after a TBI, with a higher proportion of veterans with comorbid TBI perceiving their tinnitus as ‘very severe’.13 Research also found that soldiers with blast-related injuries are twice as likely to develop hearing loss, with audiometric patterns varying from typical ‘noise-induced audiograms’.14-17 While one condition does not cause the other, tinnitus may exacerbate any pre-existing mental health symptoms, subsequently reducing an individual’s overall coping abilities.18 Research has found that even partial PTSD was associated with an increased incidence of tinnitus progression among a group of active-duty Marine and Navy personnel.17
Given what we know about hidden hearing loss, self-reported auditory problems should not be ignored despite the presence of a normal audiogram. To support this, blast-exposed US veterans were found to show significantly more hearing handicap and poorer central auditory processing than their non-blast-exposed peers despite presenting with ‘normal hearing’.19 The study showed that the reported hearing difficulties caused challenges in many environments where social interaction was necessary, which significantly impacted the emotional health of these veterans.19 More recently, a longitudinal study on the UK Armed Forces showed that self-reported hearing problems with tinnitus were associated with increased odds of mental health issues and alcohol misuse 7 years later.20.
3. Early intervention as a preventative strategy
Misconceptions or the lack of knowledge about tinnitus are often reasons for developing a maladaptive response to the condition or the progression of its severity.21 This was frequently observed among the Australian Veterans this author has seen, with the following anecdotal quotes obtained from veterans with significant tinnitus.
‘The only way I knew how to get relief from my tinnitus was to be around noise that was louder than my tinnitus. So I would intentionally work next to very loud sources of noise, like engines and stuff, to mask my tinnitus. I didn’t realise that would only make it worse.’
‘I didn’t know what tinnitus was until I had it. “Present me” wishes I could go back to “past me” and say the ringing in your ears means you need to take your hearing more seriously.’
‘We were told to have a drink (alcohol) at night if the tinnitus kept us from falling asleep. We were given no coping information. It would have helped if I knew more about it.’
It would, therefore, appear reasonable to deduce that educating ADF members on their tinnitus and empowering them with basic self-management skills would be significantly beneficial. Research supports this and has shown that knowledge about tinnitus can facilitate habituation, mitigate severity levels and increase resilience towards the condition.22,23 Similarly, a study investigating the impact of tinnitus on US Military Service members and veterans suggested that ‘tinnitus should be addressed earlier in the military’ to maximise functioning and quality of life among personnel.24
To cater to the time and operational constraints of the ADF, tinnitus education could be introduced as group sessions at ADF health centres and offered to personnel who experience persistent tinnitus, comorbid risk factors or who would like to learn self-management strategies. These sessions could perhaps cover the foundations of tinnitus neurophysiology, basic cognitive coping skills, sound therapy benefits and the greater importance of proper hearing protection, and provide an opportunity to problem-solve frequent hearing/tinnitus-related problems. Aside from information giving, a group construct may also foster a sense of social connectedness through the shared experience of an otherwise private and rarely discussed condition. Rather than playing the role of a patient, sufferer or, in some cases, victim, group attendees can assume the role of a proactive and coping individual.23 Personnel continuing to struggle can then be fast-tracked or referred to an audiologist (under the HSP), tinnitus specialist, psychologist and/or tinnitus support group for further individualised treatment.
An example of group training has been observed at the Walter Reed National Military Medical Center in the United States. The centre has provided a modified version of Progressive Tinnitus Management (PTM) group education over the past 8 years. It includes two 2-hour group appointments and is available to active-duty members, veterans and their dependents. A recent retrospective assessment revealed that group education was effective and significantly reduced self-reported tinnitus awareness and annoyance two months post-session. The study also found that modifications to the content (greater emphasis on sound management vs cognitive education) had no significant effect on outcomes.22 This suggests there can be some level of flexibility in the protocol.
4. Development of a safe climate/culture that would promote behavioural change
While not explored in detail, there remains an undercurrent of stigma associated with help-seeking among ADF members. Although scientific and medical advances are improving capabilities, stigma reduction will continue to act as a barrier to early preventative and stabilising care and must be prioritised and addressed.
‘The message that it is not weak to speak should be applied to all injuries, not just mental health because physical or sensory injuries untreated or poorly treated can be the last drop that breaks the surface tension and sends veterans to suicide.’ –Veteran
‘The ADF has all the policies, posters and polish that people are first and that it’s not weak to speak up about physical or mental health considerations. The reality is that current culture suppresses speaking up about yourself or your subordinates due to a disproportionate volume of senior leaders being too focused on themselves and painting a positive picture of everybody around them.’ –Ex-Senior Officer, medically retired May 2023.
Conclusion
Hearing loss and tinnitus are long-standing, service-connected disabilities for members of the ADF that not only prevail but appear to be on the rise. While mortality is not a direct consequence of auditory dysfunction, unidentified and untreated hearing loss and tinnitus can compound and exacerbate associated health conditions that burden the individual, their families and larger community. Given this, there is an urgent call for a well-rounded hearing conservation program to retain and rehabilitate serving ADF members and improve quality-of-life outcomes for those who dedicate themselves to protecting this nation.
Disclaimer
The views expressed in this article are those of the author and do not necessarily reflect the position of the Australian Defence Force, Department of Veterans’ Affairs or the Australian Government.
Corresponding Author: Yan Ling Chia, yanlingc18@gmail.com
Authors: Y L Chia1
