British Journal of Audiology

ISSN: 0300-5364 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ijap20

Effect of Hearing Impairment on Educational

Outcomes and Employment up to the Age of 25
Years in Northern Finland

Marjo–Riitta Järvelin, Elina Mäki–torkko, Martti J. Sorri & Paula T. Rantakallio

To cite this article: Marjo–Riitta Järvelin, Elina Mäki–torkko, Martti J. Sorri & Paula T. Rantakallio
(1997) Effect of Hearing Impairment on Educational Outcomes and Employment up to
the Age of 25 Years in Northern Finland, British Journal of Audiology, 31:3, 165-175, DOI:
10.3109/03005364000000019

To link to this article: http://dx.doi.org/10.3109/03005364000000019

Published online: 03 Mar 2011.

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 British Journal of Audiology, 1997,31, 165-175

Effect of hearing impairment on educational out-

comes and employment up to the age of 25 years in
northern Finland
Marjo-Riitta Jarvelin’, Elina M&i-Torkko*, Martti J. Sorri*and
Paula T. Rantakallio’
’Department of Public Health Science and General Practice and zDepartment of Otolaryngology,
University of Oulu, Finland

(Received 29 June 1995, accepted 11 July 1996)

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Abstract
The association between hearing impairment in adolescence and school performance and the outcome of
education was studied among 25-year-old subjects followed since pregnancy in the Northern Finland
birth cohort. The series, 395 subjects with abnormal hearing and 977 randomly selected controls, was
based on a questionnaire on hearing and school achievement sent to 11780 members of the cohort alive at
the age of 14 years, and on audiometric screening test requested from health centres. Hearing loss was
defined as ‘clinically significant’ if the pure tone average (PTA; mean of the thresholds at 0.5, 1 and
2 kHz) exceeded 25 dB in the better ear; a threshold of 2 30 dB at 4 kHz and a PTA of I 25 dB as ‘4kHz
loss’; and as ‘slightly abnormal’ if any of the thresholds exceeded 20 dB at any frequency and the case did
not belong to the above two categories. The more severe the hearing impairment, the poorer was the
child’s performance a t elementary school. Those with normal hearing and those with a slightly abnormal
or 4 kHz loss were equally often accepted for intermediate education (88%), while those with a clinically
significant loss had the lowest acceptance figures (64%). When adjusting for neurological and social con-
founders, excluding mental disability, the risk of not qualifying from intermediate or higher education at
all was twice as high among those with a clinically significant loss as among the controls (OR 2.1,95% CI
1.13-3.8), and was still elevated after adjustment had been made for all the relevant perinatal, neurologi-
cal and social factors (OR 1.9,95% CI 1.02-3.6). 14% of those with a clinically significant hearing loss,
9% of the subjects with a 4 kHz loss and 7% of those with normal hearing were unemployed at the age of
25 years. Hearing impairment appears to have effects on both the outcome of education and employment
status.

Introduction 1985; Axelsson et al., 1987; Sorri et al., 1990).

Severe early childhood hearing loss is relatively
rare, the incidence being about 1 per 1000 (Barr
et al., 1978; Simmons 1980; Parving 1983; Fein-
messer et al., 1986), but milder hearing disorders
a r e far m o r e common a n d their incidence
increases with age, averaging 14% a t the age of
15 years (Barr et al., 1973; Sorri and Rantakallio
Correspondence to: Majc-Riitta Jg-rvelin, Department of
Public Health Science and General Practice, University of
Oulu, 90220 Oulu, Finland. E-mail: mrj@cc.oulu.fi
Even mild hearing impairment may adversely
affect school performance and the later outcome
of education (Klee a n d Davis-Dansky 1986;
Bovo et al., 1988). The aim here is to evaluate the
association of hearing disorders with school per-
formance, the outcome of education and
employment, in the Northern Finland birth
cohort of 1966. T h e framework of t h e birth
cohort study allows perinatal, neonatal, medical
and social factors t o b e taken into account as data
on this series have been collected prospectively
ever since pregnancy.

0300-5364/97/310165+10 $03.5010 0 1997 British Society of Audiology

 166
Material and methods
Educational system in Finland
Ordinary primary and secondary schools (ele-
mentary schools) are defined here in the manner
shown in Fig. 1. A child can also be granted post-
ponement, or before 1985 exemption, from these
levels of education if suffering from delayed
development or mental disability. In addition to
this ordinary elementary schooling, there are
special schools for children with hearing disabili-
ties and mentally or otherwise disabled children.
The compulsory basic schooling normally lasts
from the age of 7 until 16 years (Fig. 1).
M-R. Jarvelin
Upon completing their basic education, all
adolescents are advised to take part in the
national application system for intermediate
level education, including the upper secondary
schools and the vocational schools. Higher edu-
cation includes the universities and the upper lev-
els of vocational school, now commonly known
as polytechnics (Fig. 1).
Population
The source of the population to be studied here
consisted of 12068 pregnant women who gave
birth to 12058live-born children in the two north-

Number of
school
Yam
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18

16
17
5
9 Universities
7
15 3
High
14 2
grade
13 I
(Tertiary
education)
t I
Polytechnic, 4

12
grade
I1 2 secondary
schools equivalent (Upper
10 schools secondary
education)
I .....
9 9 Secondary
school -
8 B Elementary
schools
1 7 Primary
6 6
stage
and
5 5 special (Basic
schools
4 4 education)
3 3 Primary -
school
2 2

1 1
.....
F're-primary education in daycare centres and primary Prcprimary
school stage

Fig. 1. The Finnish educational system. The corresponding nomenclature according to the International
Standard Classification of Education is given in brackets. The boxes indicate the number of years taken
to complete each stage. (Modifiedfrom Statistics Finland, 1992)
 Hearing impairment and educational outcomes
ernmost provinces of Finland in 1966
(Rantakallio, 1969). This cohort accounts for
96% of all pregnancies in the area with an
expected date of delivery in that year. Of these
children, 11780 were alive at the age of 14 years,
when a questionnaire was sent out to each child
or family, dealing with social standing, schooling
and hearing. This achieved an exceptionally high
response rate of 97%.
The questionnaire replies indicated that 425
children were suffering from hearing loss. The
latest audiograhs were requested for these chil-
dren from primary care, with a 97% response
rate, and for a random sample of 1000 children
reported to have normal hearing, the response
rate being 96% (Sorri and Rantakallio, 1985).
The correspondence between audiometry and
reported hearing was good, and the audiometric
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screening results were taken into account when
defining the eventual groups for the present sur-
vey. There were two totally deaf children, based
on the parent’s report (three categories in ques-
tionnaire: totally deaf, severely impaired or
slightly impaired), six with severely impaired and
four with slightly impaired hearing who were
excluded because no audiogram was available for
them. Nine out of these 12 children had an IQ of
less than 71. The final material for evaluation
consists of 395 cases with abnormal hearing in
audiometry and 977 random controls. The mean
age at the time of the audiometric examination
was 15.0years (SD 1.8).
Data collection
Social and biological characteristics of the
mother and family of each cohort member were
recorded by questionnaire at the antenatal clinics
and from the hospital records at the time of the
pregnancy and delivery. Data on the child up to
the age of 28 days were obtained in connection
with the mother’s follow-up examination at the
postnatal clinic. Later health and development
were recorded continuously from birth onwards
from various morbidity and mortality registers
and hospital records (Rantakallio, 1988).
Information on school performance in the
form of the average mark in all subjects and
school class at the age of 14 was sought in the
questionnaire. For those who did not supply this
information the class that the child was attending
was ascertained from the school offices. All exist-
ing reports on intelligence tests were collected
from institutions for disabled children in the area,
167
and from the child guidance centres and hospi-
tals. Only a few of those in the class appropriate
for their age were tested, while a half of those in a
lower class and 95% of those in special schools or
not at school at all were tested (Rantakallio and
von Wendt, 1986).
All applications and preferences for intermedi-
ate education are stored in national registers
maintained by the Ministry of Education, data
from which were added to the records of the birth
cohort. Of the adolescents in this cohort, 95%
took part in the national application system,
almost half of them more than once.
The highest qualification obtained was ascer-
tained from Statistics Finland, as was employ-
ment status.
Specifications of the outcomes variables
Basic education (Fig. 1):
1. Attending an elementary school in the appro-
priate class for his or her age. The four sub-
classes of this category were based on the
average mark on the child’s school report at
the age of 14; i.e. <6.5,6.5-7.4,7.5-8.4, S . 5
(theoretical minimum 4, which means the
worst performance, theoretical maximum 10).
2. Attending elementary school in a class lower
than appropriate, i.e. a child had deferred or
repeated a class.
3. Special school for the disabled, i.e. for those
with hearing impairment or otherwise handi-
capped.
4. Not attending school at all at the age of 14
years.
Intermediate level education: Application or
acceptance for intermediate level education
before the age of 19 was classified into:
1. did riot apply to vocational school or upper
secondary school,
2. applied, but was not accepted,
3. accepted.
Intermediate level educational qualifications
were classified according to the Finnish Standard
Classification of Education (Statistics Finland,
1992), which covers all levels and fields of educa-
tion. The principle is essentially consistent with
the International Standard Classification of Edu-
cation (see Statistics Finland, 1992), the lower
 168 M-R. Jarvelin

level comprising about 10-11 years’ education PTA was >25 dB in the better ear. As the last
and the upper level about 12years (Fig. 1). group was small (n = 55), they were analysed
mostly as one entity. The impaired hearing in
Highest level of education (Finnish Standard Table 1 comprises the above three categories
Classification of Education, 1992): combined. Bone conduction thresholds were not
taken into account as they were not measured in
1. The lowest level of tertiary education, about many cases. This classification differs from the
13-14 years of total schooling (vocational conventional grading, but the intention was to
school, polytechnic or equivalent level, pro- include even minimal losses, because their possi-
grammes lasting 4-5 years at vocational ble effect on learning could not be ignored until
schools, e.g. high national certificate engineer, analysed.
HNC). Epilepsy was considered to have been present if
2. Lower basic degree in tertiary education (low- there had been at least one episode of paroxysmal
est true university level or the equivalent), disturbances of consciousness,sensation or move-
about 15 years of total schooling (e.g. BSc, ment, primarily cerebral in origin, not associated
nursery school teacher). with acute febrile episodes (von Wendt et al.,
3. Higher basic degree in tertiary education, a 1985a).The definition of cerebralpalsy formulated
total of about 16 years (e.g. honours degree, by the Little Club of London (Pharoah, 1981) was
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MD, MSc). followed, with the exception that children with

4. Doctorate or equivalent (e.g. PhD, specialist postnatally acquired cerebral palsy or progressive
doctor), about 20 years of total schooling. neurological disease as the primary causative
5. N o information in the national education reg- agent were alsoincluded (von Wendt etal., 1985b).
ister, but elementary or special school com- The intelligence quotient (IQ) was classified as sub-
pleted. normal if it was 71-84, and the person was defined
as mentally disabled if the IQ was 70 or less. There
Main occupational activity in 1990: had been an average of 2.4 tests per child
(Rantakallio and von Wendt, 1986).
1. employed,
2. unemployed, Statistical analysis
3. still studying, Proportions and their 95% confidence intervals
4. sickness pension, were used to illustrate the differencesbetween the
5. others, including housewives, persons living in groups with normal and impaired hearing.The chi-
institutions, etc., square test or Fisher’s exact probability test was
6. not known (Statistics Finland, 1992). used for contingency tables. Stratification by IQ
classes was used to control the confounding.The
Specification of the explanatory and confounding independent effect of hearing impairment on the
variables outcome of education was analysed using a multi-
The specifications and categorizations of most ple logistic regression model (Breslow and Day,
explanatory and confounding variables are 1980),adjustingfinally for:
shown in Table 1. Hearing loss was here defined
on the basis of air-conduction pure tone thresh- 1. sex,
olds at frequencies of 0.25,0.5,1,2,3,4,6 and 8 2. mother’s age,
kHz, although the lowest threshold measured 3. mother’s education,
was 15 or 20 dB in many cases. The audiometers 4. social class,
were calibrated according to the I S 0 389 stan- 5. family type,
dard (1991).A findingwas interpreted as ‘slightly 6. birth weight under the 10th percentile,
abnormal’ for the present purpose if any of the 7. gestational age <37 weeks,
thresholds exceeded 20 dB and the case did not 8. signs of neurological injury, i.e. epilepsy, CP,
belong to either of the following two groups. A perinatal brain damage, later neurological
threshold of 2 30 dB at 4 kHz and a pure tone trauma or mental disability (a new variable
average (PTA; mean of the thresholds at 0.5,l was formed to ensure that each youngster hav-
and 2 kHz) of 5 25 dB was called ‘4 kHz loss’, ing one of the above diseases or forms of dam-
while in the case of ‘clinically significant loss’ the age was noted only once) (Table 1).
 Hearing impairment and educational outcomes 169

Table 1. Specifications of the variables and association of perinatal and certain medical and social
factors with hearing impairment. OR = odds ratio, CI = confidence interval.
Normal hearing Impaired hearing’ Fisher’s
(total 997) (total 395) exact test
n % n % O R CI P
Birth weight under 86 8.8 54 13.7 1.6 0.01
10th percentile 1.1-2.4
Birth weight <2500g 30 3.1 23 5.8 2.0 0.02
1.1-3.4
Gestational age 68 7.0 52 13.2 2.0 <0.001
<37 weeks 1.4-3.0
Epilepsy 10 1.o 11 2.8 2.8 0.02
1.2-6.6
Perinatal brain damage2 8 0.8 14 3.5 4.5 <0.001
1.9-10.7
Other neurological injury’ 24 2.5 18 4.6 1.9 0.04
1.0-3.5
Cerebral palsy 2 0.2 3 0.8 3.7 0.2
0.6-22.4
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Mother’s smoking during 137 14.0 65 16.5 1.2 0.3

pregnancy (after second 0.9-1.7
month of pregnancy)
Mother’s age <20 yrs 75 7.7 21 5.3 0.7 0.1
(at the delivery) 0.4-1.1
Mother’s age 35 yrs 181 18.5 81 20.5 1.1 0.4
or over 0.8-1.5
Mother’s marital status 30 3.1 20 5.1 1.7 0.08
not married 0.9-3 .O
Mother’s education, 331 33.9 111 28.1 0.8 0.04
8 yrs and at least half 0.6-1.0
a year vocational schooling or more
Father’s social class 1+114 285 29.2 100 25.3 0.8 0.2
0.6-1.1
Father’s social class IV 250 25.6 120 30.4 1.3 0.07
1.0-1.6
Rise in social class’ 261 28.7 107 30.7 1.1 0.5
(birth to 14 years) 0.8-1.4
Fall in social classS 170 18.7 71 20.3 1.1 0.5
(birth to 14 years) 0.8-1.5
Family type6 180 18.4 89 22.5 1.3 0.08
non-standard 1.0-1.7
Mental disability 9 0.9 6 1.5 1.7 0.4
(IQ<71) 0.64.7

‘Includes: (a) slightly abnormal, if any of the thresholds exceed 20 dB and the case does not belong to the
next groups; (b) 4 kHz loss, threshold 230 dB at 4 kHz and a pure tone average in the better ear 125 dB;
(c) clinically significant loss, pure tone average >25 dB in the better ear.
21ncludesneonatal asphyxia, cerebral lesion or intracranial haemorrage, Apgar 0 at 1 min or <5 at 15 min,
neonatal convulsions (Rantakallio et al., 1987).
)Cranial fractures, contusion or concussion, spinal cord and other nervous damage (excluding perinatal brain
damage).
Social group was based on the father’s occupation at the time of the child’s birth and the common apprecia-
tion of different professions (Sosiaaliryhmitys, 1954; Alestalo and Uusitalo, 1978). Children without a known
father were classified into group IV. For analysis purposes, social class was classified as (1) I or I1 versus oth-
ers or missing; (2) class IV (unskilled labourers, persons on a disability pension, farmers with less than 8
hectares of land) versus others or missing.
5Missing 113.
6Upto the child‘s 14th birthday; standard = original complete family, i.e. both parents from birth to 14 years
versus non-standard = one or no parents at the age of 14, mostly because of divorce (Isohanni et al., 1991).
 170 M-R. Jarvelin

The numbers of missing values for the biological 2. Forty-seven of the children with normal hearing
and social background variables varied by up to (4.8%) were in a class lower than was appropriate
5.3%, and these were added to the reference class, for their age at a normal elementary school or were
with the exception of social mobility, for which the in a special school for disabled children, the corre-
113 missing values were excluded. Data were lack- sponding figure among those with slightly abnor-
ing in the national register on the eventual educa- mal hearing being 15out of205 (7.3%), that for the
tional qualifications of 244 subjects, mostly children with a4 kHz loss 11out of 135 (8.1%),and
because they were abroad (n = 70), but using the that for those with aclinically significantloss 18out
other available data set it was possible to find out 55 (32.7%). Likewise, Fig. 2 shows that the more
that 94% of these had completed at least elemen- severe the hearing impairment, the poorer was the
tary school and 6% had been at a special school at child's performance at elementary school, espe-
the age of 14. The other educational data sug- cially when considering poorer than average per-
gested that the most appropriate group in which to formance (mean score 7.4 or less).
include all those with missing information on their Mental subnormality or disability (IQ 5 84)
final education was the reference group in the was observed more often among those with hear-
logistics regression analysis, i.e. those who had ing impairment. Twenty-three of the 977 controls
completed elementary or special school. (2.4%) were either of subnormal intelligence or
mentally disabled, as were 20 of the 395 with a
Results hearing disorder (5.1%; P < 0.015). Only one
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Social background and perinatal outcome child with an IQ of 71 and a 4 kHz loss was inte-
The associations of perinatal and social factors grated into the class appropriate for his age, while
with hearing impairment are presented in Table 1. the rest were in a lower class or at a school for
Even a modest decrease in the birth weight to handicapped children, with the exception of one
below 2500g or intrauterine growth retardation child with and IQ of 54 and normal hearing, who
denoted a risk of hearing impairment, and perina- was not at school at all (Table 2).
tal brain damage, later brain injuries and epilepsy
were more often reported among the subjects with Application and entrance to intermediate level
hearing impairment. Of the social variables, a low education
level of education on the part of the mother had the The young people with normal hearing, slightly
most significantassociation with impaired hearing. abnormal hearing or a 4 kHz loss were equally
often accepted into intermediate education pro-
Elementary school performance (Basic education) grammes (about SSYo)), but those who had a
The type of schooling at the age of 14 years is pre- clinically significant disorder had the lowest fig-
sented in relation to hearing impairment in Table ure (64%), and a large proportion of them
Table 2. Type of schooling at the age of 14, by hearing impairment

Hearing impairment'

Normal Slightly 4 kHz Clinically Total

hearing abnormal loss significant
loss
n % n YO n % n % n

Normal school, class

-appropriate for age 929 95.0 190 92.7 124 91.8 37 67.3 1280
-lower than appropriate for age 29 3.0 10 4.9 7 5.2 4 7.3 50
Special school for disabled 18 1.8 5 2.4 4 3.0 14 25.4 41
Not at school 1 0.1 0 0.0 0 0.0 0 0.0 1
Total 997 100.0 205 100.0 135 100.0 55 100.0 1372
'Slightly abnormal, if any of the thresholds exceed 20 dB and the case does not belong to the following
groups; 4 kHz loss, threshold 230 dB at 4 kHz and a pure tone average in the better ear 125 dB; Clinically
significant loss, pure tone average >25 dB in the better ear.
 Hearing impairment and educational outcomes 171

I I I I I I I I

i L
Mean scores on

school repmi

87.5-0.4

8 6 . 5 - 7.4

8 <6.5 (wont

Normal SlQhnY 4 CHz loss Clinicolv

hearing abnormal n = 119 signincant
n.887 n = 181 lossn=43
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Fig. 2. Elementary school performance at the age of 14 years among adolescents with normal and
impaired hearing, expressed as mean school grades in four categories. For definitions of groups, see
footnotes to Table I .
(32.7%) did not apply at all (Table 3). Twenty- ment, as was also the case with elementary
two of the 128 who did not apply (17.2%) had an school. Even the upper level of this education, i.e.
IQ of less than 85, and 9 of these had a hearing the matriculation examination or at least 3 years
disorder. Vocational school programmes were of vocational school, was more common among
chosen by the youngsters with hearing impair- the control subjects. A university degree was
ment more often than upper secondary school more common among those with normal hearing
enrolment. than with impaired hearing (4.7% versus 2.3%,
P = 0.04). To evaluate the effect of hearing on the
Outcome of education by the age of25 years outcome of education, the latter was stratified by
The lowest level of intermediate education both IQ and hearing impairment, but mental dis-
(10-11 years of schooling, i.e. vocational pro- ability did not affect the figures noticeably, so
gramme of less than 3 years) was more often the that the percentages in Table 4 are presented
final achievement of those with a hearing impair- without stratification.
Table 3. Application and entrance to intermediate level education
Hearing impairment'
Normal Slightly 4 kHz Clinically Total
hearing abnormal loss significant
loss
n % n % n % n % n
Did not apply 81 8.3 17 8.3 12 8.9 18 32.7 12802
Applied, not accepted 19 2.0 6 2.9 4 3.0 2 3.6 50
Accepted forvocational school 437 44.7 113 55.1 68 50.3 21 38.2
Accepted for upper secondary school 440 45.0 69 33.7 51 37.8 14 25.5 41
Total 977 100.0 205 100.0 135 100.0 55 100.0 1372

'See footnotes in Table 2.

21ncludes62 who had emigrated and whose application was not known.
 172 M-R. Jarvelin

Table 4. Extent of education up to the age of 25 years (most recent qualification)

Hearing impairment'

Normal Slightly 4 kHz Clinically Total

hearing abnormal loss significant
loss
n % n % n % n % n

Elementary or special school* 165 16.9 37 28.1 25 18.5 17 30.9 244

Upper secondary education
(intermediate level education)
-Lowerlevel(about 10-11 years) 320 32.8 83 40.5 50 37.0 18 32.7 471
-Upperlevel(about 12years) 387 39.6 67 32.7 47 34.8 17 30.9 518
Tertiary education
Vocational school, polytechnic or
equivalent
-Lowest level (about 13-14years) 51 5.2 12 5.9 8 5.9 1 1.8 72
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University level or equivalent

-Lowerdegree (about 15 years) 26 2.7 3 1.5 2 1.5 0 0.0 31
-Higherdegree(about16years) 18 1.8 1 0.5 2 1.5 1 1.8 22
- Doctorate or equivalent 2 0.2 0 0.0 0 0.0 0 0.0 2
Deaths by the age of 25 8 0.8 2 1.0 1 0.7 1 1.8 12
Total 977 100.0 205 100.0 135 100.0 55 100.0 1372
'See Table 2 footnotes.
21ncludesall those for whom data on higher education were not available from the national education
register.

Logistic regression was fitted first with hear-
ing and outcome (reference: basic education, i.e.
elementary school or special school) in the
model to explore the risk of not obtaining inter-
mediate or higher level education at all. Slightly
abnormal hearing or a 4 kHz loss did not signifi-
cantly affect the outcome of education, but a
clinically significant impairment did have an
effect (crude OR 2.3, 95% CI 1.3-4.2). When
allowing for social background factors, with or
without neurological disability but excluding
mental disability, the risk of not obtaining an
intermediate or higher level education was simi-
larly twofold (OR 2.1,1.13-3.8). When mental
disability was also added to the model, the risk
was about the same as in the full model, which
showed that clinically significant hearing loss
still carried an elevated risk after adjustment
had been made for all the significant perinatal
and social factors (OR 1.9, 95% CI 1.02-3.5).
Social factors such as low social class (OR 1.5,
95% CI 1.l-2.1), non-standard family status
(OR 1.6, 95% CI 1.2-2.3) or a young mother
(OR 2.0, 1.2-3.2) were found to be indepen-
dently equally important for the outcome of
education as a hearing impairment.
The group with clinically significant hearing
loss was further divided into 28 (51%) with a
PTA of 26-40 dB, 15 (27%) with a PTA of 41-80
and into 12 (22%) with a PTA of 281. Among
them there was a trend for a worse educational
outcome associated with the increasing grade of
hearing impairment after allowing for the above
confounders (OR for the subgroup with a PTA of
281 was 4.6, 95% CI 1.4-15.8; normal hearing as
the reference and slightly impaired hearing and
4 kHz loss combined in the model).
Main occupational activity and employment at 25
years
Altogether 7% of the subjects with normal hear-
ing were unemployed, the corresponding figures
for those with a 4 kHz loss and a clinically signifi-
cant impairment being 9 and 14%, respectively.
17% of the controls and those with a slightly
abnormal hearing or a 4 kHz loss were still study-
ing, compared with only 6% of those with a clini-
cally significant hearing impairment (Fig. 3).
 Hearing impairment and educational outcomes
Normal Slightly
hearing abnormal
n = 917 n = 205
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Fig. 3. Main occupational activity at the age of 24 years by hearing ability (for definitions of groups, see
footnotes to Table I ) . The group ‘other’ includes housewives, etc. and ‘unknown’ those on the register
but of unknown activity and those not on the register at all.
Discussion
The present analysis is based on a large sample of
unselected young people, with or without hearing
loss, drawn from a total birth cohort in a defined
geographical area and followed up to the age of
25 years. These strengths and the good results
achieved in tracing the subjects increase the relia-
bility of interpretation of both the early
anamnestic data and the later information on
education. In the Finnish health care system, the
child’s hearing is screened by audiometry at pri-
mary health care at the age of 4-5,7,10 and 15
years of age. In the case of any abnormality,
audiometry should be repeated regularly every
year and the child should be referred to an appro-
priate hospital for test, so that all the children
with hearing impairment should have been found
by the age of 15 years (Haapaniemi, 1992).
One weakness in the present analysis could be
that the definition of hearing impairment is often
based on audiological screening measurements
rather than clinical audiometry, and another the
time interval of 10 years between the screening
and the final outcome of education, as there
could be some cases among the controls who
developed a hearing impairment later and some
existing impairments may have disappeared or
some even progressed. It is unlikely, however,
that this could have biased our results to any con-
siderable extent. There was no marked delay
between the hearing examination and the appli-
173
mother
.Sick pension
Bunemployed
W Student
4 kHz Clinically
loss significant
n = 135 loss n = 55
cation for intermediate education. Another
source of misclassification could be the fact that
those whose highest educational achievement
was not known were classified in the reference
group, i.e. as if they had completed only the com-
pulsory elementary school, while some of these
may in fact have had a higher level of education.
The effect on the results is obviously that it may
reduce the difference between the groups, as it is
likely to have happened more often among the
controls. Another small dilution effect is also
introduced by those subjects with a hearing disor-
der who were excluded because of missing
audiometry.
This survey indicates that perinatal events such
as pre-term birth, low birth weight, i.e. below
2500 g, and perinatal brain damage serve as risk
factors for hearing impairment, and in this
respect confirms earlier findings (Newton, 1985;
Astbury et al., 1990; Veen et al., 1993). On
account of low incidence of both marked hearing
impairment and perinatal disadvantages, consid-
erable problems are encountered, especially in
many cohort studies when examining the associa-
tion of prenatal and perinatal factors with hear-
ing impairment. In addition, the subjects are
often hospital patients, which leads to a selection
bias (Anagnostakis et al., 1982; Bergman et al.,
1985; Mauk et al., 1991). In the present study, it
was possible to examine the role of later brain
injuries in hearing impairment without the influ-
 174 M-R. Jarvelin
ence of early perinatal brain damage, and a clear
association was observed, which points to the
importance of checking a child’s hearing after a
brain injury.
Our analysis shows that the young people with
a hearing impairment had both a poorer basic
school performance and a more modest later out-
come of education, which is partly connected
with the higher incidence of associated handicaps
such as mental disability and perinatal brain
damage. With few exceptions, the mentally dis-
abled children, including those of subnormal
intelligence, attended special schools, so that the
stratification by type of school reduced this con-
founding effect. After adjusting for social and
medical factors, it was also found that hearing
impairment had an independent untoward effect
on the final outcome of education. It has been
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pointed out in the literature (Bess et al., 1986;
Bovo et al., 1988) that even a mild hearing loss
may affect school ability and result in poorer per-
formance by these children, as was shown in the
present analysis by the lower than average school
marks gained by all the groups with hearing dis-
orders, even by those with only slightly abnormal
hearing. An effect was also seen in that the more
severe the hearing impairment was, the poorer
the elementary school performance. The multi-
variate model revealed that, allowing for the
important confounders affecting education, only
a clinically significant hearing loss (PTA >25 dB)
had an independent adverse effect on the final
outcome of education, and further in this group
there was a trend for a worse educational out-
come associated with the increasing grade of
hearing impairment.
Entrance to the intermediate level of education
was equally common for the cases as for the con-
trols, with the exception of those with clinically sig-
nificant hearing loss.The fact that all the case took
part in compulsory education reflects that it is
quite possible for disabled people to achieve at
least and intermediate-level education. Educabil-
ity is not bound to normal elementary school per-
formance. On the contrary, a certain number of
places in intermediate education are specifically
allocated for pupils coming from schools for the
mentally or otherwise disabled. This can be seen in
the present study in that slightly abnormal hearing
or 4 kHz loss did not appreciably affect the out-
come of education, which shows that the education
system is relatively well able to take care of these
children and young people.
The most marked difference between the cases
and the controls was seen in the completion of
higher education, as also observed by Parving
and Christensen (1993). Without a doubt, the
combined difficulties caused by a hearing impair-
ment and associated disabilities have affected
their performance at this level. In addition, any
delay in the diagnosis of hearing impairments,
even mild ones, may detract from language skills
and primary school performance, and also from
the later outcome, as has been suggested earlier
(Tharpe and Bess, 1991).
The results show that even though the statu-
tory schooling system offers possibilities for edu-
cation, youngsters with hearing disorders did not
exploit these effectively, and this may have led to
poorer occupational activity in later life. This
could also be due to attitudes of employers, espe-
cially with the present high level of unemploy-
ment in Finland. Diagnostic and rehabilitation
efforts should be focused on these children and
their families as early as possible to guarantee
optimal language skills in order to allow each
individual to increase his or her chances of lead-
ing and independent adult life.
Acknowledgements
Financial support was received from the Medical
Research Council of the Finnish Academy.
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