Cognitive skills and the effect of noise on perceived

effort in employees with aided hearing impairment

and normal hearing

Håkan Hua1,2, Magnus Emilsson1,2, Rachel Ellis1,2, Stephen Widén1,3,

Claes Möller1,3,4, Björn Lyxell1,2

Linnaeus Centre HEAD, Swedish Institute for Disability Research, 2Department of Behavioural Sciences and Learning, Linköping University,
1

School of Health and Medical Sciences and Örebro University, 4Audiological Research Centre, Örebro University Hospital, Örebro, Sweden
3

Abstract
The aim of the following study was to examine the relationship between working memory capacity (WMC), executive
functions (EFs) and perceived effort (PE) after completing a work-related task in quiet and in noise in employees with
aided hearing impairment (HI) and normal hearing. The study sample consisted of 20 hearing-impaired and 20 normally
hearing participants. Measures of hearing ability, WMC and EFs were tested prior to performing a work-related task
in quiet and in simulated traffic noise. PE of the work-related task was also measured. Analysis of variance was used
to analyze within- and between-group differences in cognitive skills, performance on the work-related task and PE.
The presence of noise yielded a significantly higher PE for both groups. However, no significant group differences were
observed in WMC, EFs, PE and performance in the work-related task. Interestingly, significant negative correlations
were only found between PE in the noise condition and the ability to update information for both groups. In summary,
noise generates a significantly higher PE and brings explicit processing capacity into play, irrespective of hearing. This
suggest that increased PE involves other factors such as type of task that is to be performed, performance in the cognitive
skill required solving the task at hand and whether noise is present. We therefore suggest that special consideration in
hearing care should be made to the individual’s prerequisites on these factors in the labor market.

Keywords: Adverse conditions, cognitive skills, hearing impairment, labor market, normal hearing, perceived effort

Introduction participating in noisy sound environments is more cognitively

demanding for people with HI[6-9] and one could speculate
Statistics Sweden[1] reports that people with hearing that physical tension might originate from these situations as
impairment (HI) have an unfavorable position at the labor more cognitive effort is required from this population.
market. This group report bad health more frequently and
Working memory refers to a system that processes and
estimate their own health to be worse than peers in their
stores information over a period of time. When working
age group. Increased unemployment, early health-related
with complex cognitive tasks, working memory capacity
retirement and sick leave are also more common for people
(WMC) is often of crucial importance because it determines
with HI compared to the population at large. Research
the resources available to the individual to process the
has confirmed these disadvantages in the labor market[2-5]
information necessary for the task at hand and to temporarily
and Danermark and Gellerstedt[2] demonstrated that neck
store and handle the needed information.[10] Studies have
problems are most frequently reported by employees with HI.
confirmed that performance declines if a task is performed
Furthermore, previous studies have shown that listening and in competing background noise.[6,11] Baddeley’s[10] multi-
component model includes a central control called the
Access this article online
central executive, which is considered to be responsible
Quick Response Code: Website:
www.noiseandhealth.org
for the control and regulation of cognitive processes
called executive functions (EFs). Executive functioning
DOI:
refers to inhibition of unwanted responses, updating with
10.4103/1463-1741.132085
new incoming information and shifting between different
PubMed ID:
sources of information. It has been demonstrated that it is
***
possible to distinguish between the different subcomponents

79 Noise & Health, March-April 2014, Volume 16:69, 79-88

 Hua, et al.: Cognitive skills and PE in employees with HI

of EF according their relative contribution to performance Methods

in different cognitive tasks.[12,13]
Participants
Moreover, studies have shown that perceived effort (PE)
Data were collected in 2010-2012 and is a part of a larger
increases in challenging listening conditions and that noise
study about working life and hearing loss and participants in
affect working memory (WM) in different ways.[6-9] For
this study are the same individuals reported in Hua et al.[15]
example, Larsby et al.[8] have examined how different speech
Forty participants (21 men and 19 women) with a mean age
noises interfere with cognitive processing in individuals with
of 44.3 years old (18-64 years old) were recruited to take part
HI and normal hearing. Four study groups were included in
in the study. The study sample consisted of both hearing-
the study and the sample consisted of both young/elderly
impaired (n = 20) and normally hearing (n = 20) participants.
with normal hearing and young/elderly with HI. Cognitive
All participants were either students, part-time or full-time
speech understanding tests (presented either as text, auditory
employees in Örebro County, Sweden. The hearing-impaired
or visual-auditory) and PE were administered and rated,
participants were recruited from the Department of Audiology,
respectively, in four background conditions: Quiet and three
Örebro University Hospital. They were selected based on the
types of speech or speech-like noise. The results demonstrated
following criteria: 18-65 years old, mild to moderate binaural
that the presence of noise compared with quiet clearly had
sensorineural hearing loss, undergone aural rehabilitation and
a negative effect on accuracy, speed of performance in
frequent hearing aid (HA) users with at least 3 months HA
the speech processing tasks and PE for the group with HI
experience. Exclusion criteria were: Retirement, long-term
compared to the group with normal hearing.
sick leave, moderate-severe tinnitus, hyperacusis, psychiatric
illnesses, dyslexia and/or other diseases/disabilities. Air and
In another study by Jahncke et al.,[14] cognitive, emotional
bone conduction thresholds were measured using standard
and physiological effects of two open-plan office noises (low
audiological procedures in a sound-treated booth. Pure tone
and high noise levels at 39 dBA and 51 dBA) were examined
averages (PTA) were calculated for the 0.5, 1, 2 and 4 kHz for
during work in a simulated open-plan office. The study
each ear. Table 1 gives the demographic information of the
sample comprised of 47 participants with normal hearing.
participants. The two study groups were matched according
In each session, the participants were instructed to work for
to age and education level and did not differ significantly on
2 h on tasks involving basic WM processes. Physiological
these two variables (P > 0.05).
measures of stress (cortisol and catecholamine) and self-
reported ratings of fatigue and mood were also obtained.
Measurements
The results showed that short-term exposure to the high
level noise negatively affected WM performance, tiredness Demographic questionnaire
and motivation to a greater extent than the low level noise In order to control for background factors a demographic
and reduction of noise level can reduce the negative effects questionnaire was used. This questionnaire included questions
of background noise. However, there was no effect of noise regarding the respondents’ age, sex, education, profession,
on the physiological measures. The authors concluded employment status and working tasks. The participants were
that the effect of short-term noise exposure on cognitive also instructed to identify all types of disabilities (including
performance might not be mediated by change in physiology. physical, psychological and sensory) and medication that
In a follow-up study, the same procedure and tasks were
used to test participants with aided HI.[7] The results showed Table 1: Summary of demographic data
that participants with HI were more affected by high noise Variable Normally hearing Hearing-impaired
than participants with normal hearing. Participants with HI Sex (n)
reported higher levels of fatigue and tended to have a higher Female 9 10
stress hormone levels in the high noise level. The authors Male 11 10
concluded that the impact of noise varied with the hearing Age (years)
characteristics of the study participants. Mean (SD) 40.5 (14.0) 48.0 (12.0)
Education level (n)
Taken together, studies indicate that it might be important Junior high school — 1
High school 6 9
to examine the effects of background noise and hearing
University 14 10
loss on measures reflecting the effort required during the
Work status (n)
performance of different cognitive tasks. To date, only a Student 3 1
few studies have investigated cognitive abilities and PE Part-time 4 4
in noise in employees with HI. Therefore, the aim of the Full-time 13 15
present study was to examine the possible relationship Pure tone average (HTL)
between WMC, EFs and PE after completing a work-related Right ear (SD) 5.2 (6.3) 36.5 (6.0)
task in quiet and in traffic noise in employees with aided HI Left ear (SD) 7.0 (7.2) 36.0 (7.0)
and normal hearing. SD = Standard deviation, HTL = Hearing threshold level

Noise & Health, March-April 2014, Volume 16 80

 Hua, et al.: Cognitive skills and PE in employees with HI
they were currently using. If they had HI they were instructed
to answer questions regarding etiology, duration of hearing
loss, HA experience, uni- or bi-lateral fitting and current
HA model.
Cognitive tests
All tasks were administered through a computer and the
instructions were presented in written form and complemented
with oral instructions by the test leader. Three of the cognitive
tests, lexical decision-making, rhyme-judgment and reading
span, are part of a cognitive test battery. The test battery has
previously been described in detail in Rönnberg et al.[16] and
the tests included in the test-battery are all well-established
in the literature of cognitive psychology.[17-21] A condensed
description follows below:
Lexical decision-making: The lexical decision-making test
was used as a measure of lexical access. The task was to
decide whether a combination of three letters constituted
a real word or not. Six items were initially presented for
practice and after that 40 items in total were presented and
used for scoring. Half of the items were real words and they
were all familiar Swedish three-letter words.
Rhyme-judgment: A rhyme-judgment test was used as
a measure of phonologic ability. The task was to decide
whether two simultaneously presented words rhymed or not.
Words were presented lexically on the computer screen. Four
items were used for practice and after that 32 items were
presented and used for scoring of the measurement. The
outcome measures of the lexical decision-making and rhyme-
judgment were the proportion of correct responses.
Reading span: The reading span test was used as a measure of
WMC. The test used in the current study was a short version
of the reading span test created by Rönnberg et al.[15] based
on the original test created by Daneman and Carpenter.[22]
The task was to read 24 sentences and to decide whether the
sentences were absurd or not and after reading sets of three,
four or five sentences, to recall either the first or the final
words of the sentences in correct serial order. The sets were
always presented in the ascending order and the participants
were cued to recall the first/last words post-stimulus
presentation. The outcome measure was the proportion of
correctly recalled items.
The keep track task: The keep track task, adapted from
Miyake et al.,[12] was used as a measure of updating of
information. Each trial began with the presentation of four
target categories at the top of the computer screen. After this,
15 (mono- or disyllabic) words including 1-4 exemplars from
each of six possible categories (countries, colors, metals,
fruits, relatives and animals) were presented one at a time.
Words were presented for 3000 ms with an interstimulus
interval of 500 ms. At the end of each trial, the participants
81
were asked to type in (in a dialogue box appearing on the
screen) the last item from each of the four target categories.
The target categories remained on the screen during the
whole of each trial. Each trial required three updates for
one of the categories (for example, four exemplars of this
category were presented) and two, one and no update for the
remaining three categories, respectively. By the presentation
of the seventh word in each trial, at least one exemplar of
each of the four target categories had been presented (i.e.,
during the presentation of words 8-15, the participants were
required to hold four items active in working memory). Two
practice trials were followed by six main trials. The outcome
measure was the proportion of correctly recalled items.
The sustained attention to response test (SART): SART
was used as a measure of inhibition.[23] One digit at a time
was presented at the center of the computer screen. The
task was to press the space bar as fast as possible when a digit
was detected. However, if the digit was “3”, the participants
were to withhold their response and await the next stimuli.
Each digit remained on the screen until a response had been
given or until 1000 ms had passed. Trials were separated by
an interstimulus interval of 500 ms. Of the 120 presented
digits, 21 were the digit “3”. The outcome measure was the
number of failures to withhold a response.
The number-letter task: The number-letter task, adapted from
Miyake et al.,[12] was used as a measure of shifting ability.
In this task, pairs consisting of one digit and one letter (for
example: 7G) were presented in one of the four corners of the
computer screen. The pairs were presented one at a time and
in a clockwise manner. The task was to decide whether the
digit was odd or even when a pair was presented in the upper
half of the screen and whether the letter was a lower case or
upper case when a pair was presented in the lower half of the
screen. The participants responded by pressing one of four
buttons marked with the words “odd”, “even”, “lower” and
“upper”. Stimuli remained on the screen until a response had
been given or until 10 s had passed. Twelve practice trials
were followed by 38 main trials. Scoring was based upon the
difference in reaction time between two consecutive trials:
1. When the present trial was a shift trial and the preceding
trial was a no-shift trial and
2. when the present trial was a no-shift trial and the preceding
trial was a shift trial. The outcome variable reported to
as “shifting” was thus the mean difference between trials
1 and 2.
Work-related task and rating of PE
An information extraction task was used as a work-related
task. In this task, tables of 15 numbered items belonging to a
semantic category (for example fruits) and both categorical
(for example place of origin) and continuous (for example
price) information about the items were presented on a
computer screen. In each trial, the participants were asked
Noise & Health, March-April 2014, Volume 16
 Hua, et al.: Cognitive skills and PE in employees with HI
to identify one target item based on a question presented
below the table. The participants responded by typing the
number (1-15) corresponding to the target item in a box
appearing at the bottom of the screen. The tables remained
on the screen until a response had been given, or until
60 s had passed. The level of difficulty was manipulated
by using one constraint in the easy condition (“Which fruit
has the highest price per kilogram?”) and three constraints
in the difficult condition (“Which Portuguese fruit of which
at least 14,000 kg has been sold has the highest price per
kilogram?”). There were 16 easy and 16 difficult trials in
total and proportions of correct responses were used as
outcome measures of performance.
After the extraction of information task was completed, the
participants were immediately asked to rate how effortful
they found the task to be using the Borg CR-10 scale on
the computer.[24] This scale is a combination of ratio and
category scaling where verbal expressions and numbers are
used congruently on a scale ranging from 0 (none at all) to
10 (extremely great). The scale was given on a sheet of paper
next to the computer to help the participants with ratings and
the participants had to type in the number corresponding to
the degree of effort perceived in the work-related task. One
question was asked for each level of difficulty of the working
task. The Borg CR-10 scale was used as a measure of PE
because this measure has shown to be sensitive enough to
identify differences between different background conditions
in a previous study where it has been used (c.f., Larsby et al.[8]).
The noise used in the experiment was recorded at a crossroads
in Örebro during morning traffic using a microphone
employing the Ambisonics surround sound technique.[25]
From the original recording, 19.6 min of traffic noise was
extracted, edited and reproduced in an anechoic chamber
(5.5 m × 5.5 m × 4.5 m). Six loudspeakers were used to
reproduce the noise and they were placed in the circle around
the participants (sitting in the middle of the room with a
computer performing the work-related task) with a spread of
60° between each speaker. To ensure a realistic noise level, the
sound was reproduced with an equivalent A-weighted sound
pressure level of 73 dBA, matching the level of the original
recording location. In order to avoid dynamic variation of the
noise level, quiet parts of the recording file were removed
so that a consistent traffic noise was played in every test
trial. The final output of the noise was also looped and hence
that it could be played continuously until the work-related
task was completed by each participant. Figure 1 shows the
experimental set up in the anechoic chamber.
Procedure
Data collection occurred on two separate sessions. Sessions
were completed within 4 weeks of each other. At the first
appointment, the demographic questionnaire, auditory and
cognitive tests were administrated. As the data is part of a
Noise & Health, March-April 2014, Volume 16
larger project, several other work-related tasks were included
in the project in a counterbalanced order meaning that the
extraction of information task could be performed either in
the first or second session. The task was always performed in
quiet or in noise in the anechoic chamber and the group with
HI always wore their HAs during this task.
Statistical analysis
The SPSS software was used for statistical analysis.
A Kolmogorov-Smirnov test for normality was first
conducted to ensure a normal distribution and the results
of the test  showed that the variables were non-significant
(P > 0.05). Initially, a one-way analysis of variance
(ANOVA) was performed on the results of all the cognitive
tasks between the two groups (normally hearing vs. hearing
impaired). The reason for this was to check whether both
study groups went into the quiet and noise conditions on
similar cognitive level when performing the work-related
task. Secondly, Pearson’s correlation coefficients between
each of the cognitive scores and demographic variables
were calculated for the total sample. Thirdly, to analyze
for within-group and between-groups differences in
performance on the work-related task and PE, two-way
ANOVA with repeated measures was performed. This
was followed with Bonferroni-adjusted post-hoc pairwise
comparisons. Finally, Pearson’s correlation coefficients
were used to examine the possible relationship between
cognitive abilities and PE after completing the work-related
task in quiet and in noise. All tests were two tailed and
conducted at a 5% significance level.
Ethics
Participants received vouchers for cinema tickets or flowers
for taking part in the study. The study was approved by the
Regional Ethics Committee in Uppsala (Dnr: 2010/072).
Figure 1: The experimental set-up. The participants were seated
in the middle of an anechoic chamber with a computer and
there were six loudspeakers surrounding them in a circle. The
loudspeakers reproduced the traffic noise at 73 dBA and had a
spread of 60° between them
82
 Hua, et al.: Cognitive skills and PE in employees with HI

Results P = 0.04) and positively with education (r = 0.37, P = 0.02).

A positive correlation also emerged between updating and
In the first part, we will report the test results of the cognitive education (r = 0.44, P = 0.005). This means that decreased
measurements between the two study groups. In the second cognitive performance was observed with increasing age
part, the correlational analyzes between the cognitive tasks and increased performance was related to higher education.
and the demographic variables are described. In the third part,
Performance in the work-related task and PE
we examined the performance of the work-related task and
PE after completing the task in quiet and in noise, between Figure 2 shows the mean performance on the work-related
and within-group. Finally, correlational analyzes between the task for both groups in quiet and in noise. Both groups scored
cognitive tasks and PE in the two conditions are reported. relatively highly in the easy tasks in quiet, 90% (SD = 0.1)
for the group with HI and 92% (SD = 0.1) for the group with
Cognitive performance between groups normal hearing. A similar level of performance was seen
in the noise condition, where the hearing-impaired group
Table 2 shows the performance of the cognitive tests for each
scored 89% (SD = 0.1) and the normally hearing group 91%
group. As can be seen, both groups scored relatively high
(SD = 0.1) in the easy task. In the difficult task, the groups
in recall and accuracy. A one-way ANOVA conducted on
differed in performance. The group with HI scored 67%
the mean scores showed no significant differences (P > 0.05) (SD = 0.2) and 68% (SD = 0.2) and the group with normal
between the groups, indicating that both groups performed hearing scored 80% (SD = 0.2) and 82% (SD = 0.1) in the
similarly on the cognitive tasks. quiet and the noise condition, respectively. A two-way
repeated measures ANOVA revealed a statistical significant
Correlations between cognitive tasks and demographic main effect of condition (F(3, 114) = 27.0, P = 0.001,
variables ηp2 = 0.4) and between-group effect (F(1, 38) = 5.5, P =
A series of Pearson product-moment correlation coefficients 0.02, ηp2 = 0.13). However, no significant interaction effect
were computed to assess the relationship between the between condition and the group was observed (F(3, 114) =
background demographic variables and performance on the 3.3, P = 0.23). Post-hoc analysis showed that both groups
cognitive tasks [Table 3]. The strongest correlation was found performed significantly lower in the difficult task (P < 0.05)
between education and rhyme-judgment accuracy (r = 0.63, compared with the easy task in both conditions, meaning
P < 0.001). WMC correlated negatively with age (r = −0.34, that task difficulty and not the presence of noise, affected
their performance.
Table 2: Mean performance and SDs of the cognitive tasks for
the normally hearing group and the hearing-impaired group Figure 3 shows the mean PE scores for both groups in the
Cognitive task (SD) Normally Hearing- One-way ANOVA quiet and the noise conditions. A higher rating indicates
hearing (%) impaired (%) higher PE. The normally hearing group reported a mean PE
Lexical decision- 97 (0.03) 96 (0.04) F (1, 38)=1.1, P=0.29 score of 2.1 points (SD = 1.3) and 4.1 points (SD = 1.5) for
making
the easy and difficult task in quiet, respectively, whereas
Rhyme-judgment 93 (0.05) 90 (0.12) F (1, 38)=1.2, P=0.24
the group with HI showed a mean score of 2.7 points
Reading span 60.5 (0.13) 57 (0.11) F (1, 38)=0.9, P=0.40
SART errors* 2.2 (2.3) 3.1 (3.2) F (1, 38)=−1.0, P=0.40
(SD = 1.4) for the easy and 4.1 (SD = 1.3) points for the
The keep track task 79 (0.13) 70 (0.15) F (1, 38)=2.0, P=0.06 difficult task. In noise, the group with normal hearing
The number-letter task 97 (0.38) 97 (0.42) F (1, 38)=−0.4, P=0.70 reported a mean score of 2.7 points (SD = 1.3) for easy and
Shifting 769 ms (320) 707 ms (444) F (1, 38)=0.5, P=0.62 5.0 points (SD = 1.8) for the difficult task and group with
*Total errors. SD = Standard deviation, SART = Sustained attention to response test HI reported 3.5 points (SD = 1.5) for the easy and 5.3 points

Table 3: Pearson correlation coefficients between demographic variables and cognitive skills in the total group of participants (n = 40)
Demographic variable Education PTA R PTA L Lexical Rhyme- Reading SART The keep The number- Shifting
match judgment span errors track task letter task
Age −0.21 0.39* 0.42** 0.25 −0.04 −0.34* −0.06 −0.18 −0.13 0.10
Education −0.22 −0.31 −0.04 0.63** 0.37* 0.14 0.44** −0.08 0.14
PTA R 0.95** −0.16 −0.13 −0.11 0.10 −0.30 0.04 −0.06
PTA L −0.14 −0.28 −0.14 0.06 −0.41** −0.02 −0.03
Lexical decision-making −0.16 −0.16 −0.22 −0.10 0.11 0.11
Rhyme-judgment 0.19 0.22 0.50** −0.07 0.06
Reading span 0.22 0.48** −0.08 0.09
SART errors 0.14 −0.10 0.06
The keep track task −0.29 0.13
The number-letter task −0.31*
*Correlation is significant at the 0.05 level, **Correlation is significant at the 0.01 level. PTA = Pure tone average, SART = Sustained attention to response test

83 Noise & Health, March-April 2014, Volume 16

 Hua, et al.: Cognitive skills and PE in employees with HI

(SD = 1.5) for the difficult task. A two-way repeated
measures ANOVA revealed a statistical significant main
effect of condition (F(3, 114) = 65.4, P = 0.001, ηp2 = 0.6).
No significant main effect between groups (F(1, 38) = 1.3,
P = 0.27) and interaction effect between condition and group
(F(3, 114) = 1.4, P = 0.25) were observed, meaning that no
significant differences in PE were observed between groups
in all conditions. Post-hoc analysis revealed however, that
both groups reported a statistical significantly higher PE
(P < 0.001) when noise was present when compared with
the quiet condition and this effect was observed for both the
easy and difficult task. These findings demonstrate that the
presence of noise generated a significantly higher PE for
both groups, regardless of task difficulty.
Correlations between cognitive tasks, performance in the
work-related task and PE
A series of Pearson product-moment correlation coefficient
tests were used to analyze the relationship between
performance on each of the cognitive tasks and PE in quiet
and in noise after performing the work-related task for each
group [Table 4]. In general, no significant correlations were
found between the cognitive tasks and PE in quiet and in
noise. Only updating was found to correlate significantly
with PE in noise for both groups, with PE being negatively
correlated with the easy task (r = −0.55, P = 0.02) for the
group with normal hearing and with the difficult task (r =
−0.46, P = 0.04) for the group with HI [Figure 4]. That is, the
updating skill of both groups was significantly correlated with
PE in noise, where lower performance in the updating task
generated a higher PE. Interestingly, a difference between
groups emerged where the updating skill was only correlated
in the easy task for people with normal hearing and in the
difficult task for people with HI. Nonetheless, it is important
to point out that PE in noise was trending toward statistical
significant correlation with updating for the group with HI
(r = −0.44, P = 0.057) in the easy task as well.
In order to rule out the possibility that the participants rated
their performance instead of PE, an additional correlation
analysis was performed between the performance of the work-
related task and PE for both groups. The analysis showed
no significant correlations between performance and rated
PE in the group with HI in quiet (easy: r = −0.18, P = 0.46;
difficult: r = −0.18, P = 0.45) and noise (easy: r = 0.07, P =
0.76; difficult: r = −0.25, P = 0.29). Likewise, no significant
correlations were observed in the group with normal hearing
in the quiet (easy: r = −0.13, P = 0.60; difficult: r = −0.12,
P = 0.62) and noise (easy: r = −0.10, P = 0.68; difficult:
r = −0.20, P = 0.41) condition.

Figure 2: Mean performance in the work-related task in quiet Figure 3: Means scores of perceived effort in quiet and in traffic
and in traffic noise for each group (error bars denote the 95% noise for each group (error bars denote the 95% confidence
confidence interval) interval)

Table 4: Pearson correlation coefficients between cognitive skills and perceived effort in the different conditions for both groups
Cognitive task Normally hearing (n = 20) Hearing impaired (n = 20)
Quiet Noise Quiet Noise
Easy Difficult Easy Difficult Easy Difficult Easy Difficult
Lexical decision-making −0.34 0.01 −0.11 −0.20 0.37 0.12 0.05 −0.07
Rhyme-judgment −0.12 0.17 −0.27 −0.22 −0.33 −0.03 −0.36 −0.32
Reading span −0.05 −0.22 −0.10 0.14 0.00 0.27 −0.11 0.11
SART errors −0.39 −0.44 −0.34 −0.08 −0.06 0.11 −0.02 −0.20
The keep track task −0.28 −0.24 −0.55** −0.19 −0.28 −0.14 −0.44 −0.46*
The number-letter task 0.13 0.15 0.20 0.22 −0.14 −0.34 0.18 −0.10
Shifting −0.16 −0.07 −0.20 −0.27 0.06 0.07 −0.07 0.03
*Correlation is significant at the 0.05 level, **Correlation is significant at the 0.01 level. SART = Sustained attention to response test

Noise & Health, March-April 2014, Volume 16 84

 Hua, et al.: Cognitive skills and PE in employees with HI
Figure 4: Scatter plots showing the significant relationship
between the keep track task performance and perceived effort
in noise for both groups
Discussion
The present results show that both groups performed at a
similar cognitive level and this finding was expected since
there was no indication to as why both groups were to differ
on cognitive performance (c.f., Hällgren et al.[19]). Significant
correlations between some of the demographic variables
and cognitive tasks emerged in line with previous research.
That is, decreasing cognitive performance (WMC) with
increasing age,[20,26,27] and increased performance (WMC,
rhyme-judgment and updating) with higher education.[28] No
significant group differences were found when comparing PE
in quiet and in noise in the easy and difficult task, meaning
that both groups rated PE similarly in both conditions,
although there was a tendency for listeners with HI to rate
PE slightly higher in the easy conditions. When analyzing
for within-group differences, significant differences emerged
between the quiet and the noise condition for each level of
difficulty of the task, meaning that the presence of noise
yielded a significantly higher PE for both groups, regardless
of task difficulty. Performance in the work-related task
further showed that the noise did not affect performance
for both groups. Interestingly, significant correlations were
found between PE in noise and updating ability, but not in
quiet, where the ability to update information and PE in noise
was significantly correlated with the easy task for the group
with normal hearing and difficult task for the group with HI.
85
PE in quiet and in noise
The current results demonstrate no statistical significant
differences between groups in PE in quiet and in noise.
Previous studies have shown, however, that people with
HI usually do report a higher PE than normally hearing
controls.[7-9] There are a number of possible explanations
for the difference between our results and previous studies.
Firstly, the exclusion criteria in the present study had a wide
range of conditions that had to be fulfilled (early retirement,
sick leave and other diseases/disabilities) for participation
in the study and this resulted in two relatively healthy
groups with the main difference being the mild-moderate
HI. Secondly, the present study recruited relatively young
employees that were group matched on age and education
and the group with HI had already undergone aural
rehabilitation with at least 3 months of HA experience
and this might have contributed to the similar ratings in
PE. This finding clearly demonstrates that employees with
aided HI with no other diseases/disabilites perceive the
task to be as effortful to perform as their normally hearing
peers, irrespective of hearing and task difficulty. Noise does
generate a higher PE for both groups, but here we can extend
this finding showing that young and healthy employees with
mild-moderate HI using HAs report a similar PE in noise
and in quiet as their normally hearing peers.
Performance in the work-related task
No statistical significant differences between groups were
observed in performance in the work-related task regardless
of task difficulty and whether noise was present. This was
somewhat expected as both groups performed on a similar
cognitive level, rated effort equally in all conditions and
that cognitive performance showed statistical significant
correlations with some of the demographic variables
according to our expectations. However, it should be noted
that there was a larger difference between the groups in the
difficult task, where employees with HI scored, although
not statistical significant, slightly lower in quiet and in
noise. One reason for this larger difference between-group
might be due to the updating ability as the performance of
the keep track task [Table 2] was trending toward statistical
significant difference (P = 0.06) and that the extraction of
information task was highly dependent on one’s ability to
update new information. The additional correlation analysis
between PE and performance of the work-related task further
showed that these two outcome variables were dissociated,
meaning that a larger difference in performance does not
necessarily generate a significantly higher PE. Moreover,
the trending difference in performance in the difficult work-
related task could also be due to differences in performance
in other cognitive skills that were not examined with
the cognitive test battery used in the present study. Future
research focusing on additional cognitive skills and their
contribution to performance in different working tasks
would be of interest.
Noise & Health, March-April 2014, Volume 16
 Hua, et al.: Cognitive skills and PE in employees with HI
Correlations between PE in noise and updating
Statistical significant negative correlations were found, but
not in quiet, between updating ability and PE of the work-
related task in noise for both groups. This demonstrates that
with lower ability to update new information, a higher PE
in noise is generated regardless of hearing ability. Previous
studies have shown that in challenging situations, such as in
noise, people with HI have to rely more on cognitive skills.[29,30]
Further, both objective and subjective measures indicate that
background noise forces hearing-impaired individuals to
exert more effort in different listening tasks.[6,8,9] However,
it is important to remember that the current study employed
a non-auditory extraction of information task and it is not
apparent whether the detrimental effects from background
noise also applies to visual tasks for people with HI. The
current findings suggest that there is a correlation between
PE and cognitive skills in noise in both employees with HI
and with normal hearing, even when the task is visual.
Interestingly, the current results showed that updating skill
was only negatively correlated with the PE in the easy task
for people with normal hearing. By itself, one might think
that a more difficult work-related task would generate a
higher PE for the group with normal hearing. This might
not be the case according to Lavie’s[31] perceptual load
theory. This theory postulates that distractor perception
can be prevented when processing of task-relevant stimuli
involves high perceptual load. In other words, when high
perceptual load engages full capacity in relevant processing
this would leave no spare capacity for perception of the
noise. Conversely, in situations of low perceptual load,
any capacity not taken up in perception of task-relevant
stimuli would involuntarily “spill over” to the perception
of task-relevant distractors. This means that the easy task
left more room for processing of noise and based upon the
assumption that explicit processing capacity are brought
into play in noise, updating skills were therefore involved
in the easy task instead of the difficult task that yielded a
higher perceptual load. These predictions have previously
been tested in a series of experiments that assessed the effect
of varying perceptual load in task-relevant processing.[32,33]
If this theory were to apply to employees with aided HI,
a significant correlation should have emerged between PE
in the easy task in noise and updating and not between the
difficult task and updating observed in the current results.
There might be some explanations as to why there was a
group difference in this finding and why the perceptual load
theory does not apply on employees with aided HI. From
an audiological perspective, a HI may be advantageous
when performing visual tasks in noise, as the noise is not as
intelligible for the group with HI. Moreover, all participants
in our study were frequent HA users and they always wore
their HAs when performing the work-related task, which
could have amplified the noise to a normal hearing level.
However, Jahncke and Halin[7] have proposed that the
Noise & Health, March-April 2014, Volume 16
HAs may still distort incoming signals which may lead
to an even greater distraction for people with HI as more
cognitive resources are required to process the input. The
authors further propose that recruitment of the HI may also
lead to the perception of sharp onsets of sound that capture
attention away from focal tasks. Therefore, for participants
with aided HI there could still be an additional demand of
resisting attention capture that causes disruption or less
efficient focal task processing when noise is present. If this
argument was true, disruption of task processing should still
have been observed between PE in the easy task in noise and
updating, as the HAs were worn in both levels of difficulty.
In the present study, a trending, but non-significant,
correlation (r = −0.44, P = 0.057) was indeed observed in
our results between the PE in the easy task in noise and
updating for the group with HI. This means that participants
with HI could still be distracted by the noise in the easy task
due to HA and that explicit processing capacity could still
be involved in noise for this group even when performing
an easy task. The current statistical significant correlations
should however be interpreted with caution as the strength
of the correlation was relatively small when judged against
the standard criteria proposed by Cohen.[34] Future studies
replicating the present findings would therefore be of
interest to conduct.
In addition, despite the multiple correlations, a Bonferroni
correction was not applied as it was felt that the increase in
the risk of a Type 2 error occurring outweighed the potential
benefits of reducing the risk of a Type 1 error. Exact P values
are provided in order to enable the reader to evaluate whether
applying a correction for multiple comparisons would have
affected the outcome of the analyzes. We argue that the
statistical significant correlations between PE in noise and
updating skill are valid because: The task is highly based
upon updating skills and no other statistical significant
correlations emerged with the different cognitive tasks and
the involvement of updating was only observed in the noise
conditions for both groups. In other words, regardless of
hearing ability, the employees at work have to actively think
about the task and devote cognitive resources to it during the
presence of noise, even if the task is non-auditory, which
involves executive processes. The presence of noise does
not affect performance, further confirmed by the additional
analysis where no significant correlations were observed
between PE and performance of the task, but it affected both
groups differently due to the aided HI. More specifically, it
affects how and when explicit processing capacity is engaged
to solve the task at hand and that a decreased performance
relying on that specific process may lead to a greater PE
for the individual in adverse conditions. Furthermore, our
results are also in agreement with those Jahncke and Halin[7]
reported regarding visual tasks for people with HI in noise.
An effect of noise was observed in their study where high
noise affected the hearing-impaired participants’ recall
of semantic information and subjective effort negatively,
86
 Hua, et al.: Cognitive skills and PE in employees with HI
whereas statistical significant correlations between PE in
noise and updating skills were observed in our study for
employees with aided HI and normal hearing.
The current results are important because they demonstrate
that a higher PE is generated by noise and that it affects
both employees with normal hearing and with HI. Practical
implication on where the present results are applicable could
be working environments at inventories where a lot of traffic
noises are constantly present and where the employees need
to update themselves with new information (e.g., fill out
forms, check invoices, read documents, etc.). In addition,
previous research has shown that neck problems are most
frequently reported by hearing-impaired men and women
with a mild to moderate HI and this might be due to listening
and participating in general challenging communication
situations at work.[2] This study further demonstrates that the
effects of noise are highly influenced by which task that is
to be performed and that the chosen task relies on specific
aspects of cognitive skills, especially when noise is present.
We therefore suggest that special consideration should be
made in hearing care and occupational health services to the
individual’s prerequisites in the labor market, such as hearing
ability, cognitive skills and the sound environments where the
working tasks are being performed. At this stage, little is still
known about the interaction between cognitive processes,
hearing and PE and more research is needed to unravel this
complex area of research for employees in the labor market.
Future studies comparing different work-related noises and
working tasks would add valuable knowledge for both study
populations.
Conclusion
The results from the present study demonstrate that the
presence of noise generated a significantly higher PE for
employees with HI and normal hearing compared to quiet
and that noise brings explicit processing capacity into play
irrespective of hearing. However, a group difference was
observed on how and when explicit processing capacity is
involved to solve the work-related task in adverse condition
and this difference might be due to the aided HI. We
therefore suggest that special consideration in hearing health
care and occupational health services should be made to the
individual’s prerequisites on these factors in the labor market.
Future studies focusing on different tasks and comparing
different work-related noises would add valuable knowledge
for this study population.
Acknowledgments
The authors would also like to thank Jonas Birkelöf, Arvid Björndal,
Kristina Ingvall, Jennie Hjaldahl, Johannes Olsson and Tobias
Åslund who carried out some of the tests and recorded the different
sound environments. Thanks are also due to Gitte Keidser for
providing valuable comments on the manuscript.
87
Address for correspondence:
Mr. Håkan Hua,
Department of Behavioural Sciences,
Linköping University,
SE-581 83, Linköping, Sweden.
E-mail: huahakan@aol.com
References
1. Statistics Sweden. Disabled 1988-1999. Surveys on living conditions,
Report 97:2003.
2. Danermark B, Gellerstedt LC. Psychosocial work environment, hearing
impairment and health. Int J Audiol 2004;43:383-9.
3. Grimby A, Ringdahl A. Does having a job improve the quality of life
among post-lingually deafened Swedish adults with severe-profound
hearing impairment? Br J Audiol 2000;34:187-95.
4. Kramer SE, Kapteyn TS, Houtgast T. Occupational performance:
Comparing normally-hearing and hearing-impaired employees using the
Amsterdam Checklist for Hearing and Work. Int J Audiol 2006;45:503-12.
5. Nachtegaal J, Kuik DJ, Anema JR, Goverts ST, Festen JM, Kramer SE.
Hearing status, need for recovery after work, and psychosocial work
characteristics: Results from an internet-based national survey on
hearing. Int J Audiol 2009;48:684-91.
6. Rudner M, Lunner T, Behrens T, Thorén ES, Rönnberg J. Working
memory capacity may influence perceived effort during aided speech
recognition in noise. J Am Acad Audiol 2012;23:577-89.
7. Jahncke H, Halin N. Performance, fatigue and stress in open-plan
offices: The effects of noise and restoration on hearing impaired and
normal hearing individuals. Noise Health 2012;14:260-72.
8. Larsby B, Hällgren M, Lyxell B, Arlinger S. Cognitive performance and
perceived effort in speech processing tasks: Effects of different noise
backgrounds in normal-hearing and hearing-impaired subjects. Int J
Audiol 2005;44:131-43.
9. Zekveld AA, Kramer SE, Festen JM. Cognitive load during speech
perception in noise: The influence of age, hearing loss, and cognition on
the pupil response. Ear Hear 2011;32:498-510.
10. Baddeley A. Working memory: Theories, models, and controversies.
Annu Rev Psychol 2012;63:1-29.
11. Kjellberg A, Ljung R, Hallman D. Recall of words heard in noise. Appl
Cogn Psychol 2008;22:1088-98.
12. Miyake A, Friedman NP, Emerson MJ, Witzki AH, Howerter A,
Wager TD. The unity and diversity of executive functions and their
contributions to complex “Frontal Lobe” tasks: A latent variable
analysis. Cogn Psychol 2000;41:49-100.
13. Kjellberg A, Sköldström B. Noise annoyance during the performance of
different nonauditory tasks. Percept Mot Skills 1991;73:39-49.
14. Jahncke H, Hygge S, Halin N, Green A, Dimberg K. Open-plan office
noise: Cognitive performance and restoration. J Environ Psychol
2011;31:373-82.
15. Hua H, Karlsson J, Widén S, Möller C, Lyxell B. Quality of life, effort
and disturbance perceived in noise: A comparison between employees
with aided hearing impairment and normal hearing. Int J Audiol
2013;52:642-9.
16. Rönnberg J, Arlinger S, Lyxell B, Kinnefors C. Visual evoked potentials:
Relation to adult speechreading and cognitive function. J Speech Hear
Res 1989;32:725-35.
17. Baddeley A, Wilson B. Phonological coding and short-term memory in
patients without speech. J Mem Lang 1985;24:490-502.
18. Daneman M, Merikle PM. Working memory and language
comprehension: A meta-analysis. Psychon Bull Rev 1996;3:422-33.
19. Hällgren M, Larsby B, Lyxell B, Arlinger S. Evaluation of a cognitive
test battery in young and elderly normal-hearing and hearing-impaired
persons. J Am Acad Audiol 2001;12:357-70.
20. Hertzog C, Dixon RA, Hultsch DF, MacDonald SW. Latent change
models of adult cognition: Are changes in processing speed and working
memory associated with changes in episodic memory? Psychol Aging
2003;18:755-69.
Noise & Health, March-April 2014, Volume 16
 Hua, et al.: Cognitive skills and PE in employees with HI
21. Shoben E. Semantic and lexical decisions. In: Puff CR, editor. Handbook
of Research Methods in Human Memory and Cognition. New York:
Academic Press; 1982.
22. Daneman M, Carpenter PA. Individual differences in working memory
and reading. J Verbal Learning Verbal Behav 1980;19:450-66.
23. Manly T, Robertson IH, Galloway M, Hawkins K. The absent
mind: Further investigations of sustained attention to response.
Neuropsychologia 1999;37:661-70.
24. Borg G. Psychophysical scaling with applications in physical work and
the perception of exertion. Scand J Work Environ Health 1990;16 Suppl
1:55-8.
25. Malham DG, Myatt A. 3-D sound spatialization using ambisonic
techniques. Comput Music J 1995;19:58-70.
26. Fisk JE, Sharp CA. Age-related impairment in executive functioning:
Updating, inhibition, shifting, and access. J Clin Exp Neuropsychol
2004;26:874-90.
27. Salthouse TA. Aging and measures of processing speed. Biol Psychol
2000;54:35-54.
28. Gathercole SE, Pickering SJ, Knight C, Stegmann Z. Working memory
skills and educational attainment: Evidence from national curriculum
Noise & Health, March-April 2014, Volume 16
assessments at 7 and 14 years of age. Appl Cogn Psychol 2004;18:1-16.
29. Pichora-Fuller MK. Perceptual effort and apparent cognitive decline:
Implications for audiologic rehabilitation. Semin Hear 2006;27:289-93.
30. Pichora-Fuller MK, Souza PE. Effects of aging on auditory processing
of speech. Int J Audiol 2003;42 Suppl 2:2S11-6.
31. Lavie N. Distracted and confused? Selective attention under load.
Trends Cogn Sci 2005;9:75-82.
32. Lavie N. Perceptual load as a necessary condition for selective attention.
J Exp Psychol Hum Percept Perform 1995;21:451-68.
33. Forster S, Lavie N. Harnessing the wandering mind: The role of
perceptual load. Cognition 2009;111:345-55.
34. Cohen J. Statistical Power Analysis for the Behavioral Sciences. New
York: Academic Press; 1978.
How to cite this article: Hua H, Emilsson M, Ellis R, Widén S, Möller C,
Lyxell B. Cognitive skills and the effect of noise on perceived effort in
employees with aided hearing impairment and normal hearing. Noise
Health 2014;16:79-88.
Source of Support: Nil, Conflict of Interest: None declared.
88
Copyright of Noise & Health is the property of Medknow Publications & Media Pvt. Ltd. and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.