WHO-ITU stakeholders’ consultation on the Make Listening Safe initiative

MEETING REPORT

17-19 February 2020 WHO headquarters, Geneva, Switzerland

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EXECUTIVE SUMMARY

WHO-ITU stakeholders’ consultation on the Make Listening Safe Initiative was held in Geneva, Switzerland on 17-19 February 2020 with the following objectives: • Revise the current text of the WHO-ITU Standard for safe listening devices, and discuss ITU compliance testing process • Share the progress in online approaches for raising awareness among different target audiences such as a media brief on safe listening, a Be Healthy, Be Mobile mHealth tool for safe listening • Initiate discussions on the development of a novel WHO school-based module for safe listening • Share progress and discuss the development of a regulatory framework for control of recreational exposure in entertainment venues • Finalize the research protocol for determining the incidence of noise-induced loss in recreational settings

Meeting participants included representatives from all relevant stakeholders in the field, including experts in , , , sound engineering and measurement, sound system and manufacturers, members of standardization organizations; consumer organizations; youth groups; and associations of musicians and venue managers.

The Key outcomes and next steps with respect to different areas are: • Suggested amendments to the text of the WHO-ITU standards on safe listening devices will be embedded and more changes will be discussed in online ITU hosted meetings during the next months. In addition, inputs on the ITU compliance testing document have been requested as the document is expected to be finalized and presented in ITU by June. • WHO media brief and mHealth message database will be revised according to the comments provided during the meeting. Both documents are expected to be finalized during the second half of 2020. • Based on the ideas and perspectives gained during the meeting, WHO will initiate the development of a school-based programme on safe listening in the coming months. • All evidence and perspectives presented during the meeting on the WHO regulatory framework for control of loud in entertainment venues will be collated and used for drafting the document. • The research protocol for determining the incidence of noise-induced in recreational settings was finalized. It will be reviewed by WHO and field tested in multiple locations later this year.

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INTRODUCTION

It is estimated that over a billion young people worldwide are at risk of hearing loss due to unsafe listening practices (https://www.who.int/activities/making-listening-safe). In response to this growing public health problem, WHO launched the Make Listening Safe initiative in 2015. The initiative aims to reduce the risk of hearing loss posed by unsafe listening behaviour. In order to facilitate safe listening, WHO has identified the following three strategies:

• Implementation of WHO-ITU global standard for safe listening devices • Undertaking a public health campaign for listening behaviour change • Develop a regulatory framework for control of recreational sound exposure

To advance this agenda, WHO and ITU adopted a consultative approach. Since 2015, WHO has been regularly organizing stakeholders’ consultation meetings with experts in audiology, public health, acoustics, sound engineering and measurement, sound system manufacturers, members of standardization organizations; consumer organizations; youth groups; and associations of musicians and venue managers.

The 2020 meeting had the following objectives: • Revise the current text of the WHO-ITU standard for safe listening devices, and discuss ITU compliance testing process • Share the progress in online approaches for raising awareness among different target audiences such as a media brief on safe listening, a Be Healthy, Be Mobile mHealth tool for safe listening • Initiate discussions on the development of a novel WHO school-based module for safe listening • Share progress and discuss the development of a regulatory framework for control of recreational sound exposure in entertainment venues • Finalize the research protocol for determining the incidence of noise-induced hearing loss in recreational settings

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SUMMARY OF PROCEEDINGS FEBRUARY 17

Three pre-meeting workshops were held on this day on: 1. WHO-ITU standards for safe listening devices 2. School based programmes for safe listening 3. Research protocol on assessment of incidence of noise-induced hearing loss

School based programmes for safe listening

Alarcos Cieza explained the need of ideas to explore and develop a school-based programme, since the target audience of the Make Listening Safe initiative has always been children and adolescents. Dr Cieza highlighted how important it would be to provide information in any school setting, which would promote behavioural change not only among the children but also in initiating a culture of safe listening practices among the people around them.

William Hal Martin and Deanna Meinke introduced Dangerous programme as an evidence-based programme intended to reduce the incidents of noise-induced hearing loss and . Dangerous Decibels is an international partnership between experts in hearing sciences, public health, noise, evaluation, and education. The classroom programme consists of 9 modules intended to be delivered in a limited 30 participant setting equipping low tech, portable, low cost consumables. The training of the trainers is done through a 2 day workshop.

Joseph Cerquone presented the work of the American Speech-Language-Hearing Association on the Listen to your buds campaign. The target audience of the campaign are children and youth aged 5 to 18 years. The campaign consists of different activities including a concert and fun activities for the kids to deliver the safe listening messages, e.g. by using music enhancers () if the music is too loud. The planning of the concerts begins at least nine months prior and includes selection of schools, talking to the musicians and ensuring they understand the context of the campaign along with the messages they will be delivering.

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Demonstration of Dangerous Decibels programme

William Hal Martin demonstrated the classroom programme of the Dangerous decibels to the meeting participants and the WHO colleagues. It was an interactive session which included basic knowledge of the physiology of the ear and process of hearing, and what happens as a result of listening to loud sounds. Session included pictograms and live demonstration of few daily activities that could be harming the ears.

WHO-ITU Standards for safe listening devices

Masahito Kawamori opened the session providing updates on the WHO-ITU standard for safe listening devices. Mr Kawamori introduced the proposed new features of the text, including new types of personal audio system devices, gaming devices, sensitivity range and frequency response of , profiles for different categories of personal audio system, implementation points

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and volume limit. Mr Kawamori also introduced the topic of conformance testing specification for WHO-ITU standard that is planned to be discussed during the day. Roxana Widmer-Iliescu briefed on the implementation of the WHO-ITU standard. Till date, over 4,000 stakeholder representatives in more than 10 thematic regional and global events have been made aware of the standard through advocacy and awareness raising. The implementation toolkit is also being translated in all UN official languages. As a step forward, further information dissemination will be implemented through 2020 World Summit on the Information Society. Simao De Campos said that the technical committee of ITU at present is working on two documents - a version two of the approved standard with some revisions included and a test checklist of aspects on how to test the implementation. Mr Campos highlighted that two features need to be tested - dose measurement and messaging. These are two essential elements for the conformance testing. Shelly Chadha added to the discussion by introducing the purpose of the conformance testing, namely, to have an informal yet standardized and ITU-approved approach for accessing conformance with the standard. The conformance testing document would need to define what is that needs to be tested, how will it be tested, and the criteria for conformance. During the full day of discussions, it was decided that participants in the meeting will provide comments and suggestions on the compliance testing document through the ITU system and those will be discussed in a subsequent meeting in April. In addition, different amendments of the text were provisionally accepted by ITU and will be finalized in an online meeting in April.

Research Protocol on assessment of hearing loss

The working group on the research protocol for assessment of incidence of noise-induced hearing loss in entertainment venues gathered and spent the day working on the document. The document was finalized and sent to Dr Chadha for inputs and revision, prior to internal review.

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FEBRUARY 18

The consultation was opened by Ren Mingui, Assistant Director General, WHO, who welcomed all participants with great pleasure. Dr Mingui stressed the importance of the work WHO does on safe listening and emphasized that the aim of the initiative is to ensure that people keep enjoying the pleasure of music and listening throughout their life in a safe manner. Dr Mingui also highlighted the importance of having such a broad group of experts and practitioners from all fields in the meeting. Nishan Perera shared his personal experience of suffering from tinnitus and hearing loss. He began his story by highlighting how important music is in his life and the hearing problems caused by listening loud sounds during adolescence. He emphasized the importance of safe listening practices and WHO’s role in providing proper guidance and information to young people. Shelly Chadha briefed about the work of WHO with specific regard to ear and hearing care. WHO’s main initiatives by the ear and hearing care team are: 1. celebrated on 3 March every year; 2. World Report on Hearing to be launched in May 2020; 3. World Hearing Forum; 4. Make Listening Safe initiative. Dr Chadha then focused on the Make Listening Safe initiative which was started in 2015 and gave details on the three main streams of work in this respect. Mark Laureyns and Amarilis Melendez introduced the work of the World Hearing Forum with regard to the Make Listening Safe working group. The group consists of 36 members representing academic institutions, NGOs, professional associations, and cochlear implant users. The main purpose of such group is to mobilize the messages developed by WHO to the larger audience. Simao De Campos and Denis Andreev shared the updates on and compliance testing process for the WHO-ITU standard for safe listening devices. Mr Campos explained that there are two areas of work ITU has been undertaking - a future revision of the standard and a conformance testing specification which will allow those who want to implement the product to have a check-list on what they need to do. Mr Andreev explained the concept of compliance testing and highlighted the importance of having a test specification, which shows what needs to be tested and how it should be tested. He shared information on the ‘ITU product conformity database’, where a list of devices compliant with the WHO-ITU standard could be created in future. Fiona Salter outlined the WHO media brief on safe listening. A media toolkit is being developed for the media and journalist population so as to have a greater impact in information dissemination, creating a greater positive public opinion, boost awareness and change behaviour, which will include the media brief along with available WHO materials, as a means for creating more insightful coverage on the work related to safe listening. Matt Howick briefed about the development of a message database as part of WHO mHealth tool on safe listening. He outlined the methodology behind the development of the messages

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and explained that his company will not only develop messages that are appealing to young people and parents, but also provide guidance on how best to convey them in order to influence the adolescents and young adults across the world. Mr Howick showed some preliminary examples of messages and invited the audience to comment on them. Ricky Kej introduced the music maker’s pledge that he has been working on during the last year. The idea of musician’s pledge is to drive awareness towards action by all music makers. Mr Kej presented the pledge in front of the audience and invited participants to comment on it. Participants were then divided into five groups to work on the following topics and reported back upon the discussion and steps forwards.

Group work

WHO-ITU standard for safe listening devices: The working group on the WHI-ITU standard for safe listening devices discussed several amendments of the text. A consensus was reached to further discuss and potentially accept these amendments during the next ITU meeting on the topic. In terms of next steps, e-meetings in April and June were set. Media Brief: The working group on the media brief concluded that the content and language of the document were good, but there are several things that need to be addressed: more case stories from different regions need to be included, the document needs to be more visual and include different graphs or pictures, and finally – a new table with hearing loss grading needs to be inserted. It was suggested that Fiona Salter will work on revising the document and share it with WHO for final approval. mHealth tool: The group discussed in detail the methods for developing the messages. It was highlighted that a guidance on how to deliver the messages in different cultural settings is crucial. The involvement of young people with different ethnic background in the development of the messages was seen as something positive. Different suggestions on the length and content of the messages were given. As next steps, Mr Howick and his team will implement the suggested changes in their work and provide first draft of the messages to WHO within the next few months. School-based programme: Discussion looked into the issues of the right age for an educational intervention, and whether the intervention should be school system directed. It was agreed that as next steps, WHO will study existing models in this space for different age groups, and also try to get lessons learned from other domains which have a school behaviour component or a school awareness component to see how they are delivering the content. WHO will engage with teachers, students and experts in the field, and work on determining the key messages that need to be delivered, and consequently outline the structure and content which will be further discussed with different stakeholders.

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Music Maker’s Pledge: The working group suggested rephrasing, rewording, and shortening the pledge. The concept of how a pledge would work and be beneficial and should not demean an artist was strongly considered. As a next step, it was suggested to look out for people in the target population through contacts and build a group to take the message forward.

Stakeholder’s perspective on the Regulatory Framework

Kaloyan Kamenov shared WHO perspective on the Regulatory framework for control of loud sounds in entertainment venues. He emphasized that it is always an individual’s choice to visit a club and be exposed to , but as a public health agency, WHO has a duty and responsibility to provide necessary information to everyone to make an informed decision and choices. It is also essential to create a safe environment for everyone by providing the necessary tools and guidelines. WHO encourages representation and involvement of different stakeholders. Raphael Elmiger put forward the government perspective on the regulatory framework. Switzerland is the first country to have comprehensive legislation for entertainment venues. The Ordinance to the Federal Act for protection against non-ionizing radiation and sound was achieved after political consensus in 1996 and had several revisions after that. Mr Elmiger presented the components of the regulation and shared that it is well accepted by venue owners in the country. He emphasized that it is essential to consider the restricted resource availability in smaller venues. Daniel Fink represented the civil society’s perspective on the regulatory framework. He started by emphasizing the importance of civil society and shared his personal experience with tinnitus. Dr Fink highlighted the need for a change in the social norm to be able to adapt the preventive measures like use of earplugs. The definition of entertainment venues needs to be elaborated and should consider including outdoor venues and restaurants. Max Reichen and Ronnie Madra shared the venue owners’ perspective on the regulatory framework. Mr Reichen represented the Swiss perspective on the matter. He mentioned that the ordinance in Switzerland is well-established as venues do not face liability if they adhere to the regulations, which, however, remains an issue for the smaller venue owners. He also said that it is extremely important for the industry and owners to have a say in the development of the regulation, and that individual responsibility needs exist. Mr Madra had taken initiative in his own venues to identify the exposure to loud noise among his staff. He emphasised the need to protect the staff and the costumers from such exposure. The venues should take the responsibility of creating awareness about the impact of unsafe listening and protecting hearing among the consumer and the staff. Adam Hill shared the audio engineering society’s perspective on the regulatory framework. He stressed the importance of a multi-stakeholder approach that involves the target groups. Awareness among sound engineers is vital and consideration of exposure to all staff is important.

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Dr Hill emphasized that a good sound system design can be fundamental for preserving the hearing of patrons in events. He also presented some relevant results from a recent report that the Audio Engineering Society had published on managing sound exposure and noise pollution at outdoor events. Esha Sajjanhar as a young person shared her perspective. The idea of safe listening initiative which promotes informed decision making is highly valuable for a teenager as it is not a one-way dialogue which is patronizing and hence more likely to be acceptable to the adolescents and young adults. The concept of daily or weekly allowance is also empowering to the music lovers which does not restrict listening to music. Information provision to all in a way that it is accessible and available is vital. FEBRUARY 19

Alarcos Cieza thanked everyone for their input during the previous day and set the agenda for the day by introducing the WHO regulatory framework for control of loud sounds in entertainment venues. Shelly Chadha provided an overview of the current status of the framework and all the work that has been done in the previous year. Dr Chadha introduced all the aspects that are considered in the framework:

• Sound management which includes sound distribution, placement of sound sources, sound absorbent surfaces, and sound level limiting • Quiet spaces - a quite or noise free space with particular specification • Provision of ear protection in the form of earplugs • Information to the users in terms of announcements and printed materials Dr Chadha said that several literature reviews have been commissioned to study these various aspects in depth and explore the evidence behind them.

Literature reviews

Johannes Mulder presented the results of a literature review that he and his team have undertaken to study sound limits and sound measurement. He highlighted the differences between venues based on their size, sound systems, space and dynamics and shared evidence that smaller venues are not always capable of implementing existing recommendations in countries because of affordability and acoustics issues. Dr Mulder shared some interesting findings from two large scale sound studies carried out in Melbourne and Norway. In his recommendations, Dr Mulder emphasized that measurement of sound across venues needs to be consistent and reliable, best practices should be shared globally, training on safe listening

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needs to be provided to audio engineers, musicians and venue managers, and local support should be argued for small venues. Ian Wiggins presented the results of a systematic review on sound distribution. Dr Wiggins shared evidence on the design of modern sound systems emphasizing common practices and considerations that need to be taken. He continued by giving details on the variability of sound across a venue, place of sound measurement, and requirements for a minimum separation between the loud speaker and the audience. Dr Wiggins emphasized the importance of good acoustics in a venue and shared that he and his team are currently undertaking a study with a controlled measurement of sound in a real performance space the results of which he will soon share with WHO. Cory Portnuff presented results and recommendations for hearing protection based on a literature review highlighting the variety of types of hearing protection that are available. He focused specifically on the earplugs designed for music and their level of attenuation. Dr Portnuff recognised the limitations as well as importance of earplugs in hearing protection. He also commented on the changing attitudes and behaviour of people towards larger use of earplugs and stressed the need for proper instruction in their use.

In-depth interviews with experts and survey with users

Kaloyan Kamenov presented the results of series of interviews conducted in the past months with sound engineers, manufacturers of earplugs and sound systems, musicians, venue mangers, event organizers, and musicians. The interviews highlighted certain key considerations:

• Sound limiting: there is a significant variation across venues with respect to size, duration of the event and other dynamics. Overall, 100dBA average for an hour was suggested as a possible limit. A maximum cut-off threshold was discussed but it was agreed to explore this further and align with existing guidelines/standards • Sound measurement: with respect to measurement device, class one sound meters provide accurate data but their use is limited due to higher costs. The site of measurement was explored and front of the house was considered as suitable in most venues • Sound distribution: suggestions from experts included elevating speakers and subwoofers above the floor or stage, and ensuring a maximum sound attenuation of 6dB at different points in a venue • Earplugs: should be made freely available at entertainment venues. Various types of earplugs were discussed but no clarity on type was obtained • Quiet rooms: were considered a valid option by most stakeholders. Owners of small venues expressed their concern in complying with such a requirement due to limitation of space. Hence, special consideration is required for such venues

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• Communication and Education: warning signs, printed brochures with information, as well as announcements were considered necessary. In addition, it is important to launch an overall public health campaign to sensitize people about safe listening Nicola Diviani presented preliminary results of an online survey designed to understand users’ knowledge, beliefs and attitude towards loud sounds and the implementation of preventative measures in venues. The survey was made available in English, French, Spanish, Russian and Chinese and was distributed through informal channels. The majority of the 3000 respondents perceived the sound in entertainment venues as loud. Three- quarters experienced tinnitus in their life. More than half of the respondents perceived themselves at risk or susceptible to hearing loss, which indicates higher awareness among public. In general, users were in favour of preventive measures, especially those related to sound limiting, provision of information and quiet rooms. However, the attitudes were not that positive towards use of hearing protection. Kelly Tremblay presented existing mobile apps for safe listening. According to her, there are more than 40 existing mobile applications in market with different layout and purpose. It is important to distinguish those which aim to achieve behaviour change and safe listening environment. Dr Tremblay then presented an app that she has developed some years ago called iHEARu. This app has two main purposes - it can be used as a sound level meter to capture noise levels, and also as an accessibility tool. Dr Tremblay went on to present different features of the tool and the data collected from more than 10,000 users. Group work

Participants were divided into four groups to discuss and provide comments on the topics of Sound Limit/Sound Measurement/Sound Distribution and Earplugs/Information provision. Sound Limit/Sound Measurement/Sound Distribution • 100dBA sound level limit: o Advantages: it can stop the extreme exposure of loud sounds, it is an evidence-based limit adopted in most current regulations, and has the ability to maintain dynamic range. o Disadvantages: compliance may be impractical in small venues; measuring over 60 minutes alone may not be ideal for sound engineers who need shorter integration periods; in case of certain types of music it could restrict artistic expression. • Sound distribution: The groups discussed the feasibility and practical limitations of achieving a ‘maximum 6dB variation of sound’ across different venues. The location of speakers and subwoofers was discussed. While ideally they should be elevated above the stage, it may be more appropriate to provide best-practice advice as part of WHO recommendations, that allows venues to do what is best in their individual circumstances.

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• Sound measurement: while there was overall agreement on mandatory sound measurement, clarity on the type of sound meters to be recommended was lacking - class 1 provides more accurate information but it might be too expensive for low-income settings, whereas class 2 is affordable but may not be as accurate. The site of measurement was discussed and the options of front of house or worst-exposed location accessible to the audience were suggested. In addition, C-weighted measurement was also discussed but the overall agreement was that the lack of clear evidence on the impact of low frequencies on hearing does not allow for making strong recommendations. Earplugs/Information provision • Minimum requirements for earplugs: o correct labelling – SNR (single number ratings) and NRR (Noise Reduction Rating) and 15/15/15 HML dB attenuation (9/11/12 Hf/Mf/Lf* (HML in dB) minimum attenuation should be provided; o environmentally friendly; o laboratory-tested. • Where to be provided: owners should use innovate and creative ways of promoting earplugs, and strategic points should be used for provision of hearing protection e.g. on a tray if drinks are served, at the bar, close to the entrance or in bathrooms. • How to improve use of hearing protection: some good practices in this respect may be highlighted, e.g. a video that can be projected with information on how to use earplugs, a QR code, or social media messages. In addition, information on safe listening and relevance of hearing protection should be visibly displayed and supplemented with announcements where appropriate. • Display of sound levels to audience: no agreement was reached on this.

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NEXT STEPS

The following next steps were outlined:

• Suggested amendments to the text of the WHO-ITU standards on safe listening devices will be embedded and more changes will be discussed in online ITU hosted meetings during the next months. In addition, inputs on the ITU compliance testing document have been requested as the document is expected to be finalized and presented in ITU by June. • WHO media brief and mHealth message database will be revised according to the comments provided during the meeting. Both documents are expected to be finalized during the second half of 2020. • Based on the ideas and perspectives gained during the meeting, WHO will initiate the development of a school-based programme on safe listening in the coming months. • All evidence and perspectives presented during the meeting on the WHO regulatory framework for control of loud sounds in entertainment venues will be collated and used for drafting the document. • The research protocol for determining the incidence of noise-induced hearing loss in recreational settings was finalized. It will be reviewed by WHO and field tested in multiple locations later this year.

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More photos are available here: https://photos.app.goo.gl/xkUyZpzBQ9e1RSQC9

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