The Relationship Between Cigar

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How to cite this thesis
Surname, Initial(s). (2012). Title of the thesis or dissertation (Doctoral Thesis / Master’s
Dissertation). Johannesburg: University of Johannesburg. Available from:
http://hdl.handle.net/102000/0002 (Accessed: 22 August 2017).
The relationship between cigarette smoking and occupational noise
induced hearing loss among employees working at the Royal Swaziland
Sugar Corporation, Swaziland, 2018/19
A mini-dissertation submitted to the
Faculty of Health Sciences,
University of Johannesburg,
In partial fulfilment of the requirement for the degree of Master of Public Health
By
Mbuso Patrick Mdluli
(Student number: 218089024)
Supervisor: 24-04-2020
Prof SA Feresu Date
Declaration
I declare that this dissertation is my own, unaided work. It is being submitted for the Master of
Public Health degree at the University of Johannesburg. It has not been submitted before for
any degree or examination at any other University.
24-04-2020
Signature Date
i
Acknowledgements
I would like to pass my sincere gratitude to RSSC Public Affairs Department for granting me
permission to conduct the study in the organisation. I would also like to thank the occupational
health clinic for providing the necessary records for data abstraction. Heartfelt gratitude also
goes to my family for their un-ending support during the course of the study. Lastly, I would
like to thank Professor S. Feresu for her guidance and support as I was conducting the study.
ii
Abstract
Occupational noise induced hearing loss (occupational NIHL) is one of the leading causes of
permanent hearing impairments not only in developing countries since developed countries
such as the US also have a large number of employees who are at risk of occupational NIHL.
A number of epidemiological studies have found a positive association between smoking and
hearing loss while others show a negative association. Furthermore, in some other studies,
no relationship between smoking and hearing loss was found, presenting conflicting evidence
of this relationship. This study aimed to exemine the relationship between the exposure which
in this case is smoking and the outcome which is occupational NIHL. The study was conducted
at the Royal Swaziland Sugar Corporation (RSSC), located in the north-eastern Lowveld of
the Kingdom of Eswatini. The goal was to add to the existing knowledge while creating a
foundation for further studies in understanding the risk factors of hearing loss which will enable
authorities to plan and implement interventions accordingly.
The study was done among permanent, contract and seasonal employees at RSSC.
Secondary data was collected from occupational health medical records, a total of 1440 data
extraction forms were completed, of which 350 were cases and 1090 were controls. The data
was then analysed by running frequencies and descriptive statistics. Frequency distributions
tables were computed, means, standard deviations and standard errors were used to compute
central tendency and dispersion of the data, then logistic regression was used to compute
measures of association and confidence intervals. Results of the study have confirmed that
smokers, ex-smokers, those with history of ear infection and those exposed to occupational
noise are more likely to be diagnosed with NIHL.
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Contents
Declaration ........................................................................................................................................ i
Acknowledgements .......................................................................................................................... ii
Abstract ............................................................................................................................................iii
Contents .......................................................................................................................................... iv
List of Figures..................................................................................................................................vii
List of Tables .................................................................................................................................. viii
List of abbreviations ........................................................................................................................ ix
Definition of terms ............................................................................................................................ x
Chapter 1.......................................................................................................................................... 1
1.1 Introduction............................................................................................................................. 1
1.2 Background ............................................................................................................................ 2
1.2.1 Aging ............................................................................................................................... 3
1.2.2 Solvent exposures ........................................................................................................... 3
1.2.3 Recreational noise........................................................................................................... 3
1.2.4 Ototoxic medications ....................................................................................................... 3
1.2.5 Presbycusis ..................................................................................................................... 4
1.2.6 Ear infection..................................................................................................................... 4
1.3 Problem statement ................................................................................................................. 5
1.4 Feasibility of the study............................................................................................................ 5
1.5 Significance of the study ........................................................................................................ 5
1.6 Rationale for the study ........................................................................................................... 6
1.7 Purpose of the study .............................................................................................................. 6
1.8 Justification............................................................................................................................. 6
1.9 Research questions ............................................................................................................... 7
1.9.1 Overall research question ............................................................................................... 7
1.9.2 Specific research questions ............................................................................................ 7
1.10 Study objectives ................................................................................................................... 7
1.10.1 Broad objective.............................................................................................................. 7
1.10.2 Specific Objective .......................................................................................................... 7
iv
1.11 Research Hypothesis ........................................................................................................... 8
1.11.1 Overall hypothesis ......................................................................................................... 8
1.11.2 Specific hypothesis........................................................................................................ 8
1. 12 Delimitation of the study...................................................................................................... 9
Summary and transition ................................................................................................................... 9
Chapter 2: ........................................................................................................................................ 9
2.1 Conceptual Framework .......................................................................................................... 9
2.1.1 Health Belief Model (HBM).............................................................................................. 9
2.1.2 Effects of smoking: ........................................................................................................ 11
2.2 Literature Review ................................................................................................................. 12
2.2.1 Occupational noise induced hearing loss ..................................................................... 12
2.2.2 Cigarette smoking ......................................................................................................... 18
2.2.3 Cigarette smoking and occupational noise induced hearing loss................................. 19
Summary and transition ................................................................................................................. 21
Chapter 3........................................................................................................................................ 21
3.1 Study design......................................................................................................................... 21
3.2 Study area ............................................................................................................................ 22
3.3 Study Population .................................................................................................................. 23
3.4 Inclusion criteria ................................................................................................................... 23
3.5 Exclusion criteria .................................................................................................................. 23
3.6 Sampling method ................................................................................................................. 23
3.7 Sample size estimation ........................................................................................................ 23
3.8 Data types ............................................................................................................................ 24
3.9 Sources of data .................................................................................................................... 26
3.10 Instrumentation .................................................................................................................. 26
3.11 Pilot study ........................................................................................................................... 27
3.12 Data collection.................................................................................................................... 27
3.13 Data analysis ...................................................................................................................... 27
3.13.1 Data analysis for each objective ................................................................................. 27
3.14 Ethical Consideration ......................................................................................................... 28
v
3.15 Timelines ............................................................................................................................ 28
3.16 Budget ................................................................................................................................ 29
Summary and transition ................................................................................................................. 29
Chapter 4........................................................................................................................................ 30
4.1 Introduction........................................................................................................................... 30
4.2 Report on the findings .......................................................................................................... 30
4.2.1 Descriptive analysis....................................................................................................... 30
4.2.2 Inferential analysis ...................................................................................................... 35
4.3 Summary .............................................................................................................................. 38
Chapter 5........................................................................................................................................ 38
5.1 Introduction........................................................................................................................... 38
5.2 Discussion of results ............................................................................................................ 39
5.2.1 Descriptive analysis....................................................................................................... 39
5.2.2 Inferential analysis......................................................................................................... 40
5.3 Strengths of the study .......................................................................................................... 42
5.4 Limitations of the study ........................................................................................................ 42
5.5 Public Health Implications .................................................................................................... 42
5.6 Conclusion............................................................................................................................ 43
5.7 Recommendations ............................................................................................................... 43
References: .................................................................................................................................... 44
Appendices .................................................................................................................................... 47
Appendix A: Data extraction form .............................................................................................. 47
Appendix B: Ethics Approval Letter ........................................................................................... 49
Appendix C: HDC Approval Letter ............................................................................................. 50
Appendix D: Permission letter from RSSC ................................................................................ 51
Appendix E: Research Project Gantt Chart ............................................................................... 52
Appendix F: Research Project Budget....................................................................................... 53
Appendix G: Letter from Language Editor ................................................................................. 54
Appendix H: TurnitIn Digital Receipt .......................................................................................... 55
vi
List of Figures
Figure 1: Heath Belief Model………………………………………………………………..10
Figure 2: Sample size estimation using EPI INFO 7.2……………………………………25
Figure 3: Age distribution graph…………………………………………………………….33
Figure 4: Comparison of NHIL by smoking………………………………………………..34
Figure 5: Comparison of NIHL by noise exposure………………………………………..35
Figure 6: Comparison of NIHL by years in employment………………………..............35
Figure 7: Year in employment distribution graph………………………………..............36
Figure 8: Comparison of NIHL by ear infection…………………………………………..36
vii
List of Tables
Table 1: Studies of noise exposures & hearing impairment in selected
Countries……………………………………………………………………………12
Table 2: Selected variables…………………………………………………………………26
Table 3: Distribution of diseased & non-diseased by socio-demographic

characteristics……………………………………………………………………...31
Table 4: Crude & Adjusted odds ratios for being diagnosed with occupational NIHL by
socio-demographic characteristics………………………………………………37
viii
List of abbreviations
UJ : University of Johannesburg
NIHL : Occupational noise induced hearing loss
RSSC : Royal Swaziland Sugar Corporation
OR : Odds Ratio
RD : Risk Difference
RR : Relative Risk
CI : Confidence Interval
dB A : A-weighted decibel
DALYs : Disability-Adjusted Life Year
TWA : Time Weighted Average
CDC : Centers for Disease Control
WHO : World Health Organisation
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Definition of terms
Hearing loss : Hearing loss, also known as hearing impairment, is a partial or total
inability to hear
Noise : Noise is unwanted sound judged to be unpleasant, loud or disruptive

to hearing
Public Health : Public health is the science of protecting and improving the health of
people and their communities. This work is achieved by promoting
healthy lifestyles, researching disease and injury prevention, and
detecting, preventing and responding to infectious diseases
x
Chapter 1
1.1 Introduction
According to the World Health Organisation (2012), there are approximately 360 million
individuals in the world with disabling hearing loss, out of which 91% are adults, and only 9%
are children. According to Taneja (2014), occupational NIHL is the second leading cause of
permanent hearing impairment after age-related hearing loss. Occupational NIHL is among
the major problems among workers in developing countries. However, this only does not affect
the developing countries as in the United States of America, 30 million workers are at risk of
occupational NIHL. Occupational NIHL has a negative impact on the health of individuals. This
results in poor quality of life as a result of poor communication and loss of livelihood. For
instance, in a study conducted by Kurabi et al (2017), it was concluded that veterans who
worked in noise dominant sites had significant hearing loss resulting in loss of quality of life,
psychological status and employability. The study also revealed that occupational noise
induced hearing loss may result in disability and rehabilitation expenses.
Bomela (2006) says that excessive noise exposure is also prevalent in developing countries,
such as Africa, in the formal sector ; (e.g. mining and construction) and informal occupational
sector (e.g. vehicle repair) as well as the non-occupational sector (urban, environmental and
leisure) (WHO, 2007). The WHO estimates that 18% of adult-onset hearing losses in the 20
southern most countries in Africa (AFR-E region), including South Africa, might be due to
occupational NIHL in the workplace. In South Africa, mining is the country’s largest industry
employing 5.1% of all workers in the non-agricultural, formal sectors of the economy, a
reported total of 458 600 employees in 2006. The processes associated with mining generate
tremendous noise as a result of activities including percussion drilling, blasting and crushing
of ore which is often exacerbated by confined and reflective spaces.
The results of a recent study investigating the profiles of noise exposure in South African
mines indicate that the mean noise exposure levels in the South African mining industry range
from 63.9 A-weighted decibels (dB A) to 113.5 dB A and that approximately 73.2% of miners
in the industry are exposed to noise levels of above the legislated threshold (Bomela, 2006).
Because occupational NIHL is a significant source of potentially avoidable morbidity, it has
been categorised as a compensable disease in South Africa in terms of Schedule three of the
Compensation for Occupational Injuries and Diseases Act 1993 (COIDA, 1993). It is reported
that 3 849 new cases of occupational NIHL were submitted to the South African Mining
Occupational Disease Database (SAMODD) in 2004 and compensation to the amount of ZAR
77 067 521 was paid to the victims (Bomela, 2006).
1
1.2 Background
Studies have shown that occupational noise induced hearing loss is influenced by a number
of factors, among which are genetic and environmental factors. The genetic factors include
age, sex and race. On the other hand, environmental factors include level of noise exposure
and behaviour patterns which include cigarette smoking (Strauss et al 2014).
Smoking has an adverse effect on occupational noise induced hearing loss among workers
exposed to a high level of industrial noise (Tao et al 2013). The frequency of occupational
noise induced hearing loss is also higher among smokers compared to non-smokers as per
finding by Mohammadi et al (2010).
According to Freuler (2014), various statistics in recent years showed that smokers are 70%
more likely to develop some form of hearing loss than non-smokers, if all other factors are
accounted for. Freuler (2014) further says that smoking affects hearing in that firstly, the
nicotine and carbon monoxide that result from smoking tighten your blood vessels, including
the ones in your ears. This restricts the blood flow and thus the life-giving oxygen in the inner
ear. The tiny hair cells in the cochlea that are responsible for translating sound vibrations into
electrical impulses for the brain, can thus be damaged due to this type of
asphyxiation.Secondly, nicotine can affect the chemical messengers (or neurotransmitters) in
the auditory nerve and thus would not be able to accurately tell the brain what kind of sound
is really being processed. Thirdly, smoking unleashes free radicals in our bodies. If these
radicals speed into the tissue and hair cells in our inner ear, it can result in permanent damage.
An important implication is the effect that smoking has on those around us. Studies have
shown clear correlations between hearing loss and second-hand smoke. This is particularly
troubling when it concerns children since the auditory system is usually not fully developed
until late adolescence (Freuler, 2014).
Epidemiology studies such as studies by: Barone et al (2009) have found a positive
association between smoking and hearing loss, and others such as studies by: Starck et al
(1999) and Talebi et al (2017) show a negative association. In some other studies, no relation
between smoking and hearing was reported (Talebi et al, 2017). No study has been found in
Swaziland where the relationship between smoking and occupational noise induced hearing
loss was evaluated.
Abel (2004), says that the assessment of hearing loss from occupational noise exposure may
be confounded by a number of factors. Studies reported in the literature have focused on the
interaction with aging, exposure to potentially ototoxic organic solvents (e.g., toluene and
styrene), exposure to high-level sound from non-occupational sources (i.e., leisure noise), and
the use of ototoxic drugs.
2
1.2.1 Aging
The two main causes of hearing loss are aging and noise exposure. Difficulty in separating
the effect of the noise arises when the attempt is made to match control and experimental
groups on all but the noise exposure. Matching variables must include but are not limited to a
history of ear disease, preventative measures such as the use of hearing protection,
educational background and socio-economic level. Isolation of a pure aging effect is equally
difficult because it is rare to find subjects who have not had some form of noise exposure. In
spite of these problems, several databases that describe the effects of aging on hearing that
may be used as a baseline against which to judge the effects of noise exposure have been
published (Abel, 2004).
1.2.2 Solvent exposures

The risk to hearing of inhalation of organic solvents is not well understood. Results of studies
conducted in animal models and human subjects have raised the possibility that certain
aromatic hydrocarbons, particularly toluene, xylene and styrene, may be ototoxic. It has been
demonstrated that rats who inhaled toluene on a daily basis for five weeks sustained a high-
frequency hearing loss. Morphologic examination of the cochlea indicated a pattern of hair cell
damage that was consistent with this outcome.
There is ample evidence that in the workplace, the combination of organic solvents and noise
is pervasive. According to a survey conducted by the National Institute for Occupational Safety
and Health in the U.S., occupational sectors that are implicated include agriculture, oil and
gas extraction, construction, transportation, electric and gas services, automotive dealers and
repair services, gasoline service stations and a wide range of manufacturing industries such
as textiles, paper products, printing and publishing (Abel, 2004).
1.2.3 Recreational noise

There has been increasing concern in recent years about the damaging effect of high-level
sound exposure during leisure activities. The sources are diverse and include amplified music
at rock concerts and disco/dance bars, motorcycles, snowmobiles, firearms, power and chain
saws, and impulse generating toys such as cap pistols. Levels from such sources can be in
excess of 100 dBA (Abel, 2004).
1.2.4 Ototoxic medications

The effects of noise exposure may also interact with the effects of medication. Agents that
result in high-frequency hearing loss include aminoglycoside antibiotics (antibacterial agents)
such as kanamycin and neomycin and antineoplastic agents such as cisplatin. The dosage
will determine whether these drugs will produce hearing loss and whether they will act
synergistically with noise exposure. To date, drug and noise interactions have not been
studied in detail on human subjects (Abel, 2004).
3
1.2.5 Presbycusis
Presbycusis is caused by the aging of the auditory system experienced by many elderly adults.
Presbycusis is the most common type of Sensorineural Hearing Loss caused by the natural
aging of the auditory system. It occurs gradually and initially affects the ability to hear higher
pitched (higher frequency) sounds. Over time, it can result in individuals being unable to clearly
hear sounds at progressively lower frequencies. People with Presbycusis often notice that
speech is loud enough, but not clear – as if the talker is mumbling. Unlike Noise-induced
Hearing Loss, Presbycusis is the cumulative result of the normal aging process on your ears.
However, Noise-Induced Hearing Loss can compound the effects of Presbycusis, which can
result in the onset of hearing loss earlier in life. There are many factors that can cause it but
most commonly it’s the loss of nerve hair cells in the Cochlea – the organ that senses sound
– caused by repeated daily exposure to noise over a lifetime. Pre-existing health conditions
and use of some medicines can also contribute to the hearing loss associated with
Presbycusis (Staff, 2007).
1.2.6 Ear infection

According to Staff (2007), an ear infection may sometimes cause a temporary or reversible
hearing loss. This generally occurs because the infection blocks sound from passing through
the ear canal or middle ear to the inner ear. When sound is blocked like this, it is known as
conductive hearing loss. You may hear sounds as muffled or indistinct.
Types of infection that may cause temporary or reversible hearing loss according to Staff
(2007) include:
i) Inflammation or infection of the ear canal (otitis externa). This condition is often
referred to as "swimmer's ear," though too much water in the ear is not the only cause.
Inflammation, swelling, or build-up (exudate) in the ear canal may block sound from
moving to the middle ear. Hearing usually returns on its own after the infection goes
away.
ii) Middle ear infection (otitis media). Swelling and pus may block sound from moving to
the inner ear. Hearing usually returns on its own after the infection goes away.
Untreated middle ear infections may cause permanent damage to the structures of the
middle ear that results in permanent hearing loss. But this is rare. Most ear infections
get better on their own, but sometimes antibiotics may be needed. And few ear
infections cause permanent damage.
iii) Fluid build-up in the space behind the eardrum (otitis media with effusion). This may
occur with or without infection. Fluid build-up may distort sound or block its passage to
4
the inner ear. Fluid behind the eardrum usually clears on its own, although the eardrum
may burst if the fluid in the middle ear becomes infected.
iv) Viral infection of the cochlea (the main sensory organ of hearing). This causes sudden
hearing loss. The viruses that cause this type of hearing loss are thought to be the
same ones that cause upper respiratory infections such as influenza or a cold. Hearing
may not return, may partially return, or may be completely restored.
1.3 Problem statement

There is insufficient evidence that smoking increases the risk of occupational noise induced
hearing loss (occupational NIHL) since some studies have shown a positive association
between smoking and occupational NIHL among workers exposed to occupational noise,
others have shown a negative association while others have shown no association at all.
Since Swaziland has a number of industries, employees are therefore exposed to occupational
noise yet there is insufficient information from literature on prevalence of occupational NIHL
in the country. No literature has been found where the association between smoking and
hearing loss has been evaluated among workers in Swaziland. In light of the contradicting
findings from literature and unavailability of previous studies in Swaziland, additional research
is needed to better understand the effect of smoking on hearing.
1.4 Feasibility of the study

The study was feasible because it was done at the researcher’s workplace hence the
researcher did not need to dedicate specific time to conduct the research but was done during
normal hours. The occupational health clinic already conducts medical examination on
employees hence the necessary medical records were easily accessible for data collection.
1.5 Significance of the study

Cigarette smoking has become a common tendency worldwide. In general, tobacco is
consumed by approximately 1.3 billion of the world’s population (Shafey et al 2003).
Most of tobacco’s damage to the human health does not become evident until years or even
decades after the onset of its use. While tobacco use is the leading cause of preventable death
in the world, this epidemic can be stopped by proper measures (WHO, 2003). Studies have
shown that occupational noise induced hearing loss is influenced by a number of factors which
among them are genetic and environmental factors. The genetic factors include age, sex and
race. On another note, environmental factors include level of noise exposure and behaviour
patterns which among others include cigarette smoking (Strauss et al 2014).
There have been different views on the effects of smoking on the hearing abilities. Also, most
of the studies had been done in the western and Asian population, with some studies favouring
5
it, while some hadn’t found any association. This study is unique in the sense that was
conducted in Swaziland where very little data is available regarding the smoking effects on
hearing loss. It is hoped that this study can pave the way for large scale studies which could
be carried out further in Swaziland and Southern Africa at large. Findings from this study may
result in actions taken for early screening in smokers to identify any hearing impairment and
for carrying out a timely intervention to correct it.
1.6 Rationale for the study

According to Taneja (2014), occupational noise induced hearing loss is the second leading
cause of permanent hearing impairment after age-related hearing loss. Occupational noise
induced hearing loss is among the major problems among workers in developing countries.
Swaziland as one of the developing countries with high poverty rate and high rate substance
abuse including tobacco, is not spared from the impact of disabling hearing loss. However,
there has not been any study done in Swaziland to investigate the relationship between
cigarette smoking and hearing loss. Studies that have been done mainly in western and Asian
populations have either shown a positive relationship, a negative relationship while some have
shown no relationship between smoking and hearing loss. This study will add to the existing
knowledge while creating a foundation for further studies in understanding the relationship
between cigarette smoking and hearing loss which will enable authorities to plan and
implement interventions accordingly.
1.7 Purpose of the study

The purpose of this case control study was to investigate the relationship between smoking
and noise induced hearing for employees exposed to occupational noise at the Royal
Swaziland Sugar Corporation (RSSC). The independent variable which is cigarette smoking
was separated into three categories namely: non-smoker, smoker and ex-smoker and the
participants were classified accordingly. Furthermore, smokers were classified according to
the number of cigarettes they smoke per day (e.g. less than 5 and more than 5). The
dependent variable which is noised induced hearing loss is defined generally as a permanent
hearing impairment resulting from prolonged exposure to high levels of noise, and the
intervening variables are: age, race, length of exposure, hearing infections/diseases and use
of hearing protection were statistically controlled in the study.
1.8 Justification
This research investigated the relationship between cigarette smoking and occupational noise
induced hearing loss (occupational NIHL) at the Royal Swaziland Sugar Corporation (RSSC).
This is because occupational noise induced hearing loss is the major problem among workers
in developing world, (WHO, 2003). This study therefore explored if smoking is a risk factor for
noise induced hearing loss among workers in the sugar production industry. The study findings
6
will assist in the development of preventative programs in alleviating induced hearing loss at
RSSC. This will include programs aimed at smoking cessation and promoting non-smoking
behaviours among workers. This in turn will aid in reducing the occurrence of induced hearing
loss among workers. The study will also form a basis for other studies in other different work
environments in the country thus will assist companies to develop better preventative
measures including rising awareness on the danger of smoking thus promoting smoker free
environments. This in turn will help companies in making the necessary interventions of cost
reduction for employee’s treatment and also compensation costs of rehabilitating already sick
employees.
1.9 Research questions

1.9.1 Overall research question
i) What is the relationship between cigarette smoking and hearing loss among workers
exposed to occupational noise at RSSC?
1.9.2 Specific research questions

i) What is the prevalence of occupational noise induced hearing loss among smokers
and non-smokers at RSSC?
ii) What is the association between employees with history of smoking and occupational
noise induced hearing loss among employees at RSSC?
iii) What is the association between employees with history of smoking and occupational
noise induced hearing loss among employees at RSSC after controlling for socio-
demographic characteristics?
iv) What is the association between all the covariates and occupational NIHL among
employees working at RSSC?
1.10 Study objectives

1.10.1 Broad objective
i) To investigate the relationship between cigarette smoking and occupational noise-
induced hearing loss among employees at RSSC.
1.10.2 Specific Objective

i) To quantify the prevalence of occupational noise induced hearing loss among smokers
and non-smokers at RSSC
ii) To ascertain the association between history of smoking and occupational noise
induced hearing loss among employees at RSSC
7
iii) To determine the association between history of smoking and occupational noise
induced hearing loss among employees at RSSC after controlling for socio-
demographic characteristics
iv) To assess the association of all the covariates and occupational noise induced hearing
loss among employees working at RSSC
1.11 Research Hypothesis

1.11.1 Overall hypothesis
The overall hypothesis is that there is a relationship between cigarette smoking and
occupational noise induced hearing loss among employees at RSSC
1.11.2 Specific hypothesis

and non-smokers at RSSC
H0: The prevalence of occupational noise induced hearing loss is the same between
smokers and non-smokers at RSSC
HA: The prevalence of occupational noise induced hearing loss is not the same
between smokers and non-smokers at RSSC
H0: There is no association between history of smoking and occupational noise

HA: There is an association between history of smoking and occupational noise

H0: There is no association between history of smoking and occupational noise

HA: There is an association between history of smoking and occupational noise

8
iv) To assess the combined effect of smoking and noise exposure on employees working
at RSSC
H0: There are no combined effect of smoking and noise exposure on employees
working at RSSC
HA: There are combined effect of smoking and noise exposure on employees working
at RSSC
1. 12 Delimitation of the study

There are a lot factors that cause hearing loss and this study only focused on how smoking
contributes to hearing loss in workers who are exposed to noise. The study focused on
Simunye Factory employees who are either employed as permanent, seasonal or contract
employees. The researcher is confident that the results of the study can be generalized to
other sugar factory settings of similar size as Simunye Factory. The study utilized data already
collected by the RSSC Occupational Health Unit through their routine medicals and was
confined to the tests done during such routine medicals.
Summary and transition

Occupational NIHL is one of the leading causes of permanent hearing impairments not only
in developing countries, since developed countries such as the US also have a large number
of employees who are at risk of occupational NIHL. A number of factors can influence
occupational NIHL and these include: age, race, level of noise exposure and smoking. This
study focused on the effects of smoking on occupational NIHL among employees exposed to
noise. A number of epidemiological studies have found a positive association between
smoking and hearing loss while others show a negative association. Furthermore, in some
other studies, no relation between smoking and hearing loss was found. No studies were found
to have been done in Swaziland and Southern Africa as a whole on the relationship between
smoking and occupational NIHL hence this study will form a baseline on which further studies
on this subject can be developed and explored.
Chapter 2:
2.1 Conceptual Framework
2.1.1 Health Belief Model (HBM)
The HBM suggests that a person's belief in a personal threat of an illness or disease together
with a person's belief in the effectiveness of the recommended health behaviour or action will
predict the likelihood the person will adopt the behaviour.
9
The HBM derives from psychological and behavioural theory with the foundation that the two
components of health-related behaviour are: 1) the desire to avoid illness, or conversely get
well if already ill; and, 2) the belief that a specific health action will prevent, or cure, illness.
Ultimately, an individual's course of action often depends on the person's perceptions of the
benefits and barriers related to health behaviour. There are six constructs of the HBM. The
first four constructs were developed as the original tenets of the HBM. The last two were added
as research about the HBM evolved (Glanz, Rimer, & Lewis, 2002 & 2008).
1. Perceived susceptibility - This refers to a person's subjective perception of the risk of

acquiring an illness or disease. There is a wide variation in a person's feelings of
personal vulnerability to an illness or disease.
2. Perceived severity - This refers to a person's feelings on the seriousness of contracting

an illness or disease (or leaving the illness or disease untreated). There is wide
variation in a person's feelings of severity, and often a person considers the medical
consequences (e.g., death, disability) and social consequences (e.g., family life, social
relationships) when evaluating the severity.
3. Perceived benefits - This refers to a person's perception of the effectiveness of various

actions available to reduce the threat of illness or disease (or to cure illness or
disease). The course of action a person takes in preventing (or curing) illness or
disease, relies on consideration and evaluation of both perceived susceptibility and
perceived benefit, such that the person would accept the recommended health action
if it was perceived as beneficial.
4. Perceived barriers - This refers to a person's feelings on the obstacles to performing a

recommended health action. There is wide variation in a person's feelings of barriers,
or impediments, which lead to a cost/benefit analysis. The person weighs the
effectiveness of the actions against the perceptions that it may be expensive,
dangerous (e.g., side effects), unpleasant (e.g., painful), time-consuming, or
inconvenient.
5. Cue to action - This is the stimulus needed to trigger the decision-making process to
accept a recommended health action. These cues can be internal (e.g., chest pains,
wheezing, etc.) or external (e.g., advice from others, illness of family member,
newspaper article, etc.).
6. Self-efficacy - This refers to the level of a person's confidence in his or her ability to
successfully perform a behaviour. This construct was added to the model most recently
10
in mid-1980. Self-efficacy is a construct in many behavioural theories as it directly
relates to whether a person performs the desired behaviour (Glanz et al, 2002 & 2008).
Figure 1: Health Belief Model
The HBM is applicable in this study when looking at behaviour change for employees who
smoke cigarettes and are exposed to occupational noise. For these employees to change their
behaviour, they first need to understand that they can be susceptible to occupational NIHL
and appreciate the seriousness of this disease. They then need to accept the benefits of all
the control measures in place to prevent occupational NIHL and also overcome barriers that
prevent them from accessing or using the controls, which can be to quit smoking and use
hearing protection in noise designated work areas. Internal or external factors can make the
employees to take action to avoid or control the disease and finally they will need to develop
confidence that they can indeed succeed in the prevention and control of occupational NIHL.
2.1.2 Effects of smoking:

Smoking has an adverse effect on occupational noise induced hearing loss among workers
exposed to high level of industrial noise (Tao et al 2013). The frequency of occupational noise
induced hearing loss is also higher among smokers compared to non-smokers as per finding
by Mohammadi et al (2010).
11
Smoking affects hearing in that firstly, the nicotine and carbon monoxide that result from
smoking tighten your blood vessels, including the ones in your ears. This restricts the blood
flow and thus the life-giving oxygen in the inner ear. The tiny hair cells in the cochlea that are
responsible for translating sound vibrations into electrical impulses for the brain, can thus face
damage due to this type of asphyxiation. Secondly, nicotine can affect the chemical
messengers (or neurotransmitters) in the auditory nerve and thus would not be able to
accurately tell the brain what kind of sound is really being processed. Thirdly, smoking
unleashes free radicals in our bodies; if these radicals speed into the tissue and hair cells in
our inner ear, permanent damage can result (Freuler, 2014).
Abel (2004) says that the assessment of hearing loss from occupational noise exposure may
be confounded by a number of factors, such as the interaction with aging, sex and race,
exposure to potentially ototoxic organic solvents (e.g., toluene and styrene), exposure to high-
level sound from non-occupational sources (i.e., leisure noise), ear infections, presbycusis
and the use of ototoxic drugs.
Assuming that other things are constant during the performance of the study, it will be possible
to relate these two variables and confirm that indeed, cigarette smoking increases the
prevalence of occupational noise induced hearing loss.
2.2 Literature Review

2.2.1 Occupational noise induced hearing loss
Noise-induced hearing loss is a permanent hearing loss caused by prolonged exposure to
high levels of noise. The hearing deteriorates gradually from the noise exposure. A noise-
induced hearing loss is also called occupational NIHL. Excessive noise exposure is one of the
most common causes of hearing loss. When you have a noise-induced hearing loss
(occupational NIHL), the hair cells in your inner ear have been damaged by the exposure to
noise. The hair cells’ ability to pick-up and transmit sound to the brain is therefore reduced. A
noise-induced hearing loss is therefore a type of sensorineural hearing loss (Nelson et al
2005).
Nelson et al (2005) state that excessive noise is a global occupational health hazard with
considerable social and physiological impacts, including noise-induced hearing loss.
Excessive noise is a pervasive occupational hazard with many adverse effects, including
elevated blood pressure, reduced performance, sleeping difficulties, annoyance and stress,
tinnitus, noise-induced hearing loss and temporary threshold shift. Of these, the most serious
health effect is occupational NIHL resulting from irreversible damage to the delicate hearing
mechanisms of the inner ear. Occupational NIHL typically involves the frequency range (pitch)
of human voices, and thus interferes with spoken communications. Worldwide, 16% of the
12
disabling hearing loss in adults (over 4 million daily adjusted life years) is attributed to
occupational noise, ranging from 7% to 21% in the various sub-regions. The effects of the
exposure to occupational noise are larger for males than females in all sub-regions and higher
in the developing regions.
In the US alone, about 9 million workers are exposed to time-weighted average (TWA) sound
levels of 85 dBA and above (Simpson and Bruce, 1981, quoted in Suter, 2000), and about 10
million have occupational NIHL >25 decibels (dB) (USDOL-OSHA, 2002). In the European
Union, 28% of workers surveyed reported that at least one-fourth of the time, they are
occupationally exposed to noise loud enough that they would have to raise their voices to hold
a conversation (corresponds to approximately 85 - 90 dBA) (EASHW, 2000). Summary
statistics on noise exposure are not available for most industrializing and non-industrialized
countries; however, high occupational noise exposure levels were reported in 17 studies
conducted in 12 countries in South America, Africa, and Asia. These high noise levels
occurred in a wide range of workplaces, including manufacture of foods, fabrics, printed
materials, metal products, drugs, watches, and in mining (see Table I). Many of these studies
reported hearing losses in exposed workers.
Adult-onset hearing loss has been described as the “fifteenth most serious health problem” in
the world, with profound effects ranging from social isolation and stigmatization of individuals
to serious national economic burdens (Smith, 2004). Estimates of the number of people
affected worldwide by hearing loss increased from 120 million in 1995 (WHO, 1999; WHO,
2001) to 250 million worldwide in 2004 (Smith, 2004). Much of this impairment may be caused
by exposure to noise on the job.
Table I: Studies of noise exposures and hearing impairment in selected developing countries
Country Facility / job Sound levels Hearing loss Notes Source
Brazil Rotogravure printing Continuous Some 49% of 124 Morata et

workers noise level workers exposed to al. 1997
from 71 to 93 noise an organic
dBA solvent had hearing
loss (>25 dB) in the
high frequencies,
significantly
associated with age.
13
Egypt Road traffic Average 97 About 20-dB loss at all Kamal et
policemen in Cairo dBA with frequencies compared al. 1989
horns, 85 to office policemen.
without; 97 at
railway
crossings
Egypt Textile factory 78-91 dBA in Compared to non- Hearing Moselhi et

wool sorting exposed controls, impairment was al. 1979
and combing workers exposed to defined as
units ≤85 dBA had only 1% average of left
increase in hearing and right ear
impairment after 12 thresholds at 0.5,
years. In workers 1 and 2 kHz, >25
exposed to >85 dBA dB.
the increased risk was
9.6%
Hong Kong Five industries Leq (8-hour Compared to controls, No evidence was Evans and
weaving, bottling, time-weighted noise-exposed found for any Ming 1982
metal working, average, dBA); workers had ethnic differences
spinning, airport weaving 102; significantly higher between western
bottling 94; thresholds in most age groups and
metal working groups and in all five Cantonese
96; spinning industries, closely Chinese, either in
97; airport 80 – matching predicted general hearing
90 values. ability or in
response to long-
term noise
exposure.
India Heavy Engineering Ranged from Mean hearing Hearing Raja and
industry: machine 83-116 dBA. threshold: 40 controls impairment was Ganguly
shop and press At selected 4-24 dB; 53 machine progressive with 1983.
divisions work sites: shop employees 14 – age for all groups.
press 94-110; 40 dB; 60 press Use of hearing
machine shop employees 19-70 dB.
14
83-92; foundry protection was
86-116 recommended.
India Textile mill weavers 102-104 dBA 120 weavers, exposed Bhattacha
1-15 years, in the age rya et al.
range 30-34 years 1981
median threshold of
audibility in the
right/left ear was 55/55
compared to 15/15 for
controls; for 35-39
year-olds the
threshold was 60/55
compared to 15/15 for
controls
India Drug and Noise levels in - Authors Bhattacha

pharmaceutical dBA: recommended rya et al.
company fermentation engineering 1990
100-105; air controls and
compressor hearing
95-102; conservation
ammonia programme
compressor including the use
93-97; Primary of hearing
air filter 104- protection.
106. Night shift
levels were 1-3
dBA higher
India Watch factory in Maximum - Mukherjee

Bangalore noise levels et al. 1995
ranged from 74
in assembly to
99 dBA in the
diesel
15
generator
room.
Nigeria Car assembly 94-108 dB Hearing threshold of Oleru et al.

165 workers were 1990
significantly higher
than non-exposed
controls and
correlated significantly
with employment
duration.
Nigeria Textile workers in Continuous Hearing threshold of No hearing Oleru

five factories in noise levels of 61 noise-exposed protection worn. 1980
Lagos 95- 115 dBA. workers were Exposed workers
significantly higher did not display
than 90 non-exposed 4000-Hz notch,
controls. After 7 years and the shape of
of employment, the audiogramsa
exposed workers lost was convex
2-12 dB per year, upwards,
compared to 0.6-1.8 indicating lower
dB per year in losses at the
controls. middle
frequencies.
(Typical
audiograms with
NHL display a
convex downward
shape, indicating
higher losses at
the middle
frequencies).
Pakistan Polyester fibre plant Average noise - Typical exposure Shaikh

levels: filament is 48 hours per 1996
take-up unit week in these
areas. Author
16
93.2 dBA; recommended
texturizing unit engineering
controls and
94.8 dBA;
hearing
compressor
conservation,
house
including use of
99.5 dBA hearing
protection.
Saudi 78 factories 86% exceeded - None of the Alidris et

Arabia producing food, 85 dBA, at factories al. 1990
chemicals, plastics, least in part of practiced noise
metals, paper and the factory. In protection
other products 12%, all of the
factory
exceeded 85
dBA.
Singapore Audiometric testing Noise 127 cases of NID Author stated that Tay 1996
of noise-exposed dosimetry on identified from 1985- NID is the leading
workers is 46 of these 1994. On average, occupational
mandatory in cases showed after 24 years of disease in
Singapore. Most a mean time- exposure, the mean Singapore, with
cases of noise- weighted hearing threshold at 1, >500 new cases
induced deafness exposure of 90 2 and 3 kHz was 62 per year.
(NID) are in those dBA. dB.
employed in
shipping and metal
manufacturing, the
remainder in
transport, quarrying
and other
manufacturing.
South Gold mining (cross- Authors quoted Hearing impairment

Africa sectional survey of a noise survey was defined as
in which the average hearing loss
majority of of >25 dB for 500,
17
2667 workers in underground 1000 and 2000 Hz,
Johannesburg and surface with 5 times weighting
gold mining of better ear.
occupations
None of the miners
were exposed
<22 years old had
above
hearing impairment,
85 dBA rising progressively to
22% of those ≥58
years old.
Sudan Cotton ginning 99 – 107 dB - Newly Khogali

mechanized 1970
facility
United Textile industry (EI- Average of 98 92% (60/73) of Audiometric test Noweir et
Arab Mehalla EI-Kobra dB in 1200- workers exposed to methods not al. 1968
Republic 4800 Hz noise for ≥10 years in described;
weaving departments hearing
range; up to
had mean hearing impairment not
103 dBA
impairment of 60dB defined.
compared to
20 dB for control
group.
Zambia Copper mines “Continuous 100 miners tested No hearing Obiako

(based on author’s noise” audiometrically. Of protection worn by 1979
experiences as ear, those with over 20 miners.
nose and throat years, 23% were
specialist in completely deaf.
Zambian copper belt
in 1975-1977)
Source: Nelson et al (2005)
2.2.2 Cigarette smoking

Cigarette smoking is among the most important modifiable risk factors for adverse health
outcomes and a major cause of morbidity and mortality. Current cigarette smoking prevalence
among all adults aged ≥18 years has decreased 42.4% since 1965 but, declines in current
18
smoking prevalence have slowed during the past 5 years (declining from 20.9% in 2005 to
19.3% in 2010) and did not meet the Healthy People 2010 (HP2010) objective to reduce
cigarette smoking among adults to ≤12%. Targeted workplace tobacco control interventions
have been effective in reducing smoking prevalence and exposure to second-hand smoke;
therefore, CDC analysed National Health Interview Survey (NHIS) data for 2004-2010 to
describe current cigarette smoking prevalence among currently working U.S. adults by
industry and occupation. This report describes the results of that analysis, which found that
overall, age-adjusted cigarette smoking prevalence among working adults was 19.6% and was
highest among those with less than a high school education (28.4%); those with no health
insurance (28.6%), those living below the federal poverty level (27.7%), and those aged 18-
24 years (23.8%). Substantial differences in smoking prevalence were observed across
industry and occupation groups. By industry, age-adjusted cigarette smoking prevalence
among working adults ranged from 9.7% in education services to 30.0% in mining; by
occupation group, prevalence ranged from 8.7% in education, training, and library to 31.4% in
construction and extraction. Although some progress has been made in reducing smoking
prevalence among working adults, additional effective employer interventions need to be
implemented, including health insurance coverage for cessation treatments, easily accessible
help for those who want to quit, and smoke-free workplace policies (CDC, 2011).
2.2.3 Cigarette smoking and occupational noise induced hearing loss

According to WHO (2012), there are approximately 360 million individuals in the world with
disabling hearing loss, out of which 91% are adults, and only 9% are children. According to
Taneja (2014), occupational noise induced hearing loss is the second leading cause of
permanent hearing impairment after age-related hearing loss. Occupational noise induced
hearing loss is among the major problems among workers in developing countries. However,
this only does not affect the developing countries as in the United States of America, 30 million
workers are at risk of occupational noise induced hearing loss. Occupational noise induced
hearing loss has a negative impact of the health of individuals. This results to poor quality of
life as a result of poor communication and loss of livelihood. For instance, in a study conducted
by Kurabi et al (2017), it was revealed that veterans who worked in noise dominant sites had
significant hearing loss resulting to loss of quality of life, psychological status and
employability. The study also revealed that occupational noise induced hearing loss results in
disability and rehabilitation expenses.
Bomela (2006) says that excessive noise exposure is also prevalent in developing countries,
such as Africa, in the formal (e.g. mining and construction) and informal occupational sector
(e.g. vehicle repair) as well as the non-occupational sector (urban, environmental and leisure)
(WHO, 2007). In South Africa, mining is the country’s largest industry employing 5.1% of all
19
workers in the non-agricultural, formal sectors of the economy, a reported total of 458 600
employees in 2006. The processes associated with mining generate tremendous noise as a
result of activities including percussion drilling, blasting and crushing of ore which is often
exacerbated by confined and reflective spaces.
The results of a recent study investigating the profiles of noise exposure in South African
mines indicate that the mean noise exposure levels in the South African mining industry range
from 63.9 dB A to 113.5 dB A and that approximately 73.2 per cent of miners in the industry
are exposed to noise levels of above the legislated. Because occupational NIHL is a significant
source of potentially avoidable morbidity it has been categorised as a compensable disease
in South Africa in terms of Schedule three of the Compensation for Occupational Injuries and
Diseases Act 1993 (COIDA, 1993). It is reported that 3 849 new cases of occupational NIHL
were submitted to the South African Mining Occupational Disease Database (SAMODD) in
2004 and compensation to the amount of ZAR 77 067 521 was paid (Bomela, 2006)
Studies have shown that occupational noise induced hearing loss is influenced by a number
of factors among which are genetic and environmental factors. The genetic factors include
age, sex and race. On the other hand, environmental factors include level of noise exposure
and behaviour patterns which among others include cigarette smoking (Strauss et al 2014).
For the purpose of this study, the focus will be on the relationship between smoking and
occupational noise induced hearing loss. Smoking has an adverse effect on occupational
noise induced hearing loss among workers exposed to high level of industrial noise (Tao et al
2013). The frequency of occupational noise induced hearing loss is also higher among
smokers compared to non-smokers as per finding by Mohammadi et al (2010).
According to Freuler (2014), various statistics in recent years showed that smokers are 70%
more likely to develop some form of hearing loss than non-smokers, if all other factors are
corrected for. Smoking affects hearing in that firstly, the nicotine and carbon monoxide that
result from smoking tighten your blood vessels, including the ones in your ears. This restricts
the blood flow and thus the life-giving oxygen in the inner ear. The tiny hair cells in the cochlea
that are responsible for translating sound vibrations into electrical impulses for the brain, can
thus face damage due to this type of asphyxiation.
20
Secondly, nicotine can affect the chemical messengers (or
neurotransmitters) in the auditory nerve and thus would not be
able to accurately tell the brain what kind of sound is really
being processed. Thirdly, smoking unleashes free radicals in
our bodies. If these free radicals speed into the tissue and hair
cells in our inner ear, permanent damage can result. An
important implication is the effect that smoking has on those
around us. Studies have shown clear correlations between
hearing loss and second-hand smoke. This is particularly
troubling when it concerns children, since the auditory system
is usually not fully developed until late adolescence.Summary
and transition
Occupational noise induced hearing loss also called occupational NIHL is caused by
continuous exposure to high levels of noise. The noise cause irreversible damage in the inner
ear components thus resulting in hearing loss. Statistics from studies done in South America,
Africa and Asia have shown that there were high levels of occupational noise in workplaces
such as manufacturing, metal industries and mining to mention but a few. Furthermore, cases
of hearing loss were reported among the exposed employees in these studies.
On the other hand, smoking is one of the major causes of morbidity and mortality globally.
Smoking prevalence globally is still high and does not meet the Health People (2010)
objective. Data from a survey in the US show that industries such as mining, construction and
extraction have the highest prevalence of smoking. At the same time, these are the industries
which also have high levels of occupational noise.
Some studies have found a positive association between smoking and hearing loss while
others show a negative association. However, in some other studies, no relation between
smoking and hearing loss was found. Hearing loss from occupational noise exposure have
been found to be confounded by a number of factors including aging, exposure to toxic
solvents, ototoxic medication, ear infections and presbycusis.
Chapter 3
3.1 Study design
This was a case control study to examine the relationship between smoking and occupational
NIHL. According to Alexander et al (2017), case-control studies are used to determine if there
is an association between an exposure and a specific health outcome. These studies proceed
from effect (e.g. health outcome, condition, disease) to cause (exposure). Case-control
21
studies assess whether exposure is disproportionately distributed between the cases and
controls, which may indicate that the exposure is a risk factor for the health outcome under
study. In this study, participants will be selected with respect to the presence (cases) or
absence (controls) of disease (occupational NIHL) and then inquiries are made about past
exposure. The diseased (cases) and non-diseases are compared to find out the level of
exposure and the exposure status is traced backward in time. Odds ratio will then be used to
compute the odds of exposure to cigarette smoking among cases.
This study design was chosen because it is relatively quicker and economical to conduct.
Because of time constraints, available data from RSSC clinics was used to classify participants
to cases (those who have occupational NIHL) and controls (those who are free from
occupational NIHL). Since case control studies can be used to retrospectively determine the
exposure to the risk factor of interest from the cases and controls, it will therefore be
particularly useful in informing the planning and allocation of the limited health resources at
RSSC in dealing with cigarette smoking and occupational NIHL. This study will also be an
important first step in assessing the possibility of a relationship between smoking and
occupational NIHL, before more costly and complex case-control or cohort studies can be
undertaken.
3.2 Study area

The study was conducted at the Royal Swaziland Sugar Corporation (RSSC), located in the
north-eastern Lowveld of the Kingdom of Eswatini. The company employs over 3 500 people
and produces two-thirds of the country’s sugar and 35.3 million litres of ethanol a year. RSSC
has two sugar mills namely, Simunye and Mhlume Sugar Mills. RSSC manages 22 000
hectares of irrigated sugar cane on two estates leased from the Swazi Nation and manages a
further 5 018 hectares on behalf of third parties, which collectively deliver approximately 3.6
million tonnes of cane per season to the Group’s two sugar mills. RSSC also provides
accommodation for their employees in the two estates. RSSC also provides medical services
to their employees and the local community at three static clinics based at Simunye, Mhlume
and Ngomane estates which provide outpatient, limited inpatient, radiology, laboratory,
dispensing, occupational health, community health, TB and HIV/AIDS services (RSSC, 2017).
RSSC has a fully-fledged hearing conservation programme which can be broken down into
five parts:
a) Installation and maintenance of equipment to ensure they do not emit excessive noise
b) Conducting two yearly noise surveys to collect data on the noise levels from each area
in order to take appropriate actions
c) Conducting base line, routine and exit audiometric tests for all employees
22
d) Provision of hearing protection to all employees exposed to noise levels above 85dBA
e) Monitoring to ensure that all elements of the hearing conservation programme is
properly implemented
The study area was chosen because it was easy to get authority to conduct the study, the
medicals records and study participants will also be easily accessible. Lastly, there were no
travelling costs and the study could be done during normal working hours.
3.3 Study Population

The research population for this study comprised permanent, fixed term contact and seasonal
RSSC employees for both cases and controls.
3.4 Inclusion criteria

 participants who were current or former RSSC employee
 participants who were either be employed on permanent or seasonal basis
 participants who had done baseline, periodic and/ exit medicals with RSSC
3.5 Exclusion criteria

 participants who did not have full medical records in the RSSC clinic
 participants who were employed on casual basis
 participants who were working for sub-contractors
3.6 Sampling method

Purposive sampling was used to identify the cases and controls from the study population
which is 3500 employees (Royal Swaziland Sugar Corporation, 2019). In this study, medical
records from the Occupational Health Unit were used to select participants and classify them
to cases and controls based on their status of occupational NIHL disease.
3.7 Sample size estimation

The sample size was calculated using The Centres for Disease Control and Prevention
(CDC), EPINFO version 7.2.2.6, for a case-control study.
23
Figure 2: Sample Size Estimation Using EPINFO 7.2.2.6
The sample size was determined using OR of 1.6, 90% study power, 95% CI, the ratio of
controls to cases of 1:3 and percentage of cases exposed at 40.7%. The study will therefore
include 1158 participants, 290 participants with history of disabling hearing loss and 868
participants with no history of disabling hearing loss. A 25% contingency plan was added,
hence the total number of participate is 1440 (350 cases and 1090 controls).
3.8 Data types

Variables measured in this study were: cigarette smoking, noise exposure, employment type
(permanent/seasonal), period of employment, age, sex, race, ear infections, and occupational
noise induced hearing loss.
Table 2: Selected variables

Level of Measurement
Variable Type Variable Name Variable Source
Independent Variable cigarette smoking Extracted from the Nominal

personal and medical
history file
Dependent Variable occupational noise Extracted from the Continuous

induced hearing loss annual audiogram
results
Covariates employment type Extracted from the Categorical

(permanent/seasonal) personal and medical
history file
Covariates race Extracted from the Categorical

history file
24
Covariates sex Extracted from the Dichotomous
history file
Covariates age Extracted from the Continuous

history file
Covariates period of employment Extracted from the Continuous

history file
Covariates ear infections Extracted from the Nominal

history file
Independent Variable noise exposure Extracted from Continuous

occupational hygiene
survey reports
Description of the selected variables for the research project or study

 Cigarette smoking – this was used to analyse if the participants are smokers or non-
smokers or ex-smokers. This is the independent variable for this study
 Noise exposure – this was used to assess the levels of noise to which the participants
have been exposed to during their employment. This was also an independent variable
for this study.
 Occupational noise induced hearing loss – this is the outcome of interest (dependent
variable) in this study. This was measured as the percentage shift from the baseline
audiograms for each participant.
 Employment type – this was used to assess if the participants are employed on a
permanent or seasonal basis as a covariate to hearing loss
 Race – this was used to assess the race of the participants (either black or white) as
a covariate to hearing loss
 Sex – this was used to classify the participants as males or females to assess the
effects of smoking in relation to hearing loss on each group
 Age – this was used to classify the participants according to their ages and age groups
and assess the effects of smoking in relation to hearing loss of each group
25
 Period of employment – this is the number of years each participant has been in
employment with RSSC
 Ear infections – this was used to assess if participants have or have had or does not
have ear infection as a covariate to hearing loss
 Noise exposure – this was used to assess if participants have or are exposed to noise
levels exceeding 85dB.
3.9 Sources of data

Data was collected from secondary data sources. According to Sørensen et al (1996),
secondary data in research are data which have not been collected with a specific research
purpose. Such data are often collected for; management, claims, administration and planning,
evaluation of activities within health care, control functions and surveillance or research.
Sources of secondary data can include: disease registries which are a centralized database
for collection of information about a disease, health behaviour and risk data e.g. from HIV
surveys and demographic health surveys, reportable disease statistics e.g. from infectious
and communicable diseases and notifiable diseases defined by local and state health
departments, mass diagnostic and screening surveys, vital registration statistics such as birth
and mortality statistics, study data collected for other research purposes and private data
collected by health care organizations (hospitals, HMOs, but also unions, companies).
Secondary data collected largely by health care organisations and in this case it’s the RSSC
clinic. The records from which the data was extracted are participants’ occupational health
medical records including pre-employment and routine medicals and also factory occupational
hygiene survey reports. Data extraction form was then used to extract data from these records
on the following variables: cigarette smoking, noise exposure, occupational noise induced
hearing loss, employment type, race, sex, age, period of employment and ear infections.
3.10 Instrumentation
For this study, a form of data extraction form was used for data collection. The data extraction
form was used to ensure that all the data required for the study is extracted from the medical
records at the Occupational Health Unit and other relevant documents such as occupational
hygiene survey reports. This was primarily used to obtain the cases and controls and also
obtain data on other variables relevant to the study. According to Kelsey, Whittemore, Evans
and Thompson (1996), records are often used in clinical research and epidemiology to obtain
information about exposures and outcomes. Most common use is to establish that a person
had disease(s) under study, especially in case-control studies.
26
3.11 Pilot study
A pilot test was done on the data collection instrument to get feedback regarding how easy or
hard the measure is and information about how the testing environment affected their
performance. The researcher extracted the data himself from the medical records. When
collecting data for the study, the researcher ensured that the data was double-checked for
accuracy. All data entry for computer analysis was "double-punched" and verified. This means
that data was entered twice, the second time having the data entry machine check that the
exact same data was being typed as in the first time. The researcher also checked to ensure
that the measurements on the medical records were taken by the use of highly precise and
calibrated instruments and were taken under controlled conditions. The use of computer
software for data processing and statistical analysis and applying appropriate statistical
techniques was employed to minimise measurement error.
3.12 Data collection

A data extraction form was used for to abstract data from records. The data extraction form
was used to ensure that all the data required for the study is extracted from the medical records
at the Occupational Health Unit and other relevant documents such as occupational hygiene
survey reports. This was primarily used to obtain the cases and controls and to obtain data
on all the variables relevant to the study.
3.13 Data analysis

Occupational health medical records from both Simunye and Mhlume clinics were used to
extract data for 350 cases and 1090 controls who are either employed on permanent, seasonal
or fixed term contract. Variables measured in this study were: cigarette smoking, noise
exposure, employment type (permanent/seasonal), period of employment, age, sex, race, ear
infections, and occupational noise induced hearing loss. Data was then be entered into SPSS
version 25 for analysis as pre-coded in the data extraction form. Double checking of data was
done to check for missing data. Data was then transformed and recoded as appropriate such
as age into age groups.
Data was analysed by running frequencies and descriptive statistics. Frequency distributions
tables were computed, means, standard deviations and standard errors were used to compute
central tendency and dispersion of the data. Odds ratio and 95% confidence interval was then
calculated to ascertain the association between cigarette smoking and occupational noise
induced hearing loss. Table shells were also prepared for Univariate and bivariate analysis.
3.13.1 Data analysis for each objective

and non-smokers at RSSC - Frequency distributions tables were computed, means,
27
standard deviations and standard errors were used to compute central tendency and
dispersion of the data, then produce graphs.
induced hearing loss among employees at RSSC – The logistic regression was used
to determine the association of smoking and occupational noise induced hearing loss
and then test the significance of this association. The odds of occupational NIHL
between smokers, ex-smokers and non-smokers, were the estimated and 95%
confidence interval used to test for statistical significance.
demographic characteristics – Multiple logistic regression was used determine if
cigarette smoking is a predictor of occupational NIHL. Socio-demographic
characteristics (age, type of employment, occupation, marital status, noise exposure,
department and ear infections) were then added into the model as covariates to
establish their contribution.
iv) To assess the association of all the covariates and occupational noise induced hearing
loss among employees working at RSSC – A multivariate analysis was done by
including all the variables in the model at the same time to obtain the odds ratio and
respective confidence interval (CI)
3.14 Ethical Consideration

Permission to conduct the research was sought from RSSC Public Affairs Department as per
the company policy. The study used secondary data with no identifications by name of the
participant. Occupational health medical reports for data collection were accessed in the
presence of the Occupational Health Nurse and no records will be taken away from the clinic.
Identification number was given to the participants to protect the identity of the participants.
Since data was collected through the use of records, neither the cases nor the controls were
denied treatment or be exposed to harmful substances in ascertaining the relationship
between cigarette smoking and occupational NIHL. Finally, the results of this study will only
be used for academic purposes and will not be published without prior consent from all
concerned parties.
3.15 Timelines
The whole project took about 61 working days. Data extraction from the Occupational Health
Unit commenced on the 26th Aug 2019 and took about 15 working days to collect data for the
research sample size. Verification of the collected data was done to check if all the required
fields in the data extraction forms are completed, this took 5 working days. Thereafter, the
data was captured into SPSS version 25 for analysis as pre-coded in the data extraction form.
28
Verification was also done to ensure the data is entered correct. All this took about 20 working
days. The data was then analysed by running frequencies and descriptive statistics.
Frequency distribution tables were computed. Statistical tests were done to ascertain the
association between cigarette smoking and occupational noise induced hearing loss. This took
about 20 working days. An additional 15 days was taken to interpret the results from this
analysis. Discussion of the results and report writing was then done, and it took about 10
working days. The draft report was submitted to the research supervisor for perusal.
Final report preparation was then done, and mini dissertation submitted to examiners on 26
January 2020.
3.16 Budget
The total budget for this project was E8 400. The first cost was printing of the
questionnaires/data extraction forms. The sample size was 1440 hence 1440 copies were
printed at a cost of E5/per copy, each copy had two pages. Data collection, capturing, analysis
and interpretation was done by the researcher. The data was collected at the RSSC
occupational health units and there was no travelling involved. Printing of the draft report for
submission cost E600 since it was done on colour print, and two reports were printed. The
report was 60 pages at E10/page. The same applied to the final report once corrections were
made.
Summary and transition

This was a case control study to examine the relationship between the exposure which in this
case is smoking and the outcome which is occupational NIHL. This study design was chosen
because it is relatively easy and economical to conduct. Because of time constraints, available
data from RSSC clinics was used to classify participants to cases (those who have
occupational NIHL) and controls (those who are free from occupational NIHL). The study
population was all permanent and seasonal employees at RSSC and purposive sampling was
used to identify the cases and controls from the study population. A data extraction form was
used to collect data from medical records at RSSC occupational health clinic. Data analysis
was done using SPSS version 25 by running frequencies and descriptive statistics and also
doing statistical tests. Permission to conduct the research was sought from RSSC Public
Affairs Department as per the company policy and the study results will be used for academic
purposes only and will not be revealed to any third party without prior authorisation by RSSC.
29
Chapter 4
4.1 Introduction
This chapter discusses the data analysis and findings of the study. The purpose of this case
control study was to investigate the relationship between smoking and noise induced hearing
for employees exposed to occupational noise at the Royal Swaziland Sugar Corporation
(RSSC). The overall hypothesis is that there is a relationship between cigarette smoking and
occupational noise induced hearing loss among employees at RSSC.
A data extraction form was used for data collection. The data extraction form was used to
ensure that all the data required for the study is extracted from the medical records at the
Occupational Health Unit and other relevant documents such as occupational hygiene survey
reports. The data was then analysed using SPSS version 25 by performing descriptive and
inferential statistical analysis.
4.2 Report on the findings

4.2.1 Descriptive analysis
A total of 1440 data extraction forms were completed, of which 350 were cases and 1090 were
controls, giving a ratio of 1:3, 1 case to about 3 controls. Table 3 shows the distribution of
socio-demographic characteristics of the study participants.
Table 3: Distribution of diseased and non-diseased by socio-demographic characteristics

Total Cases Controls
(N=1440) (n=350) (n=1090)
Variables n % n % n %
Age groups
20 – 30 years 118 8.2 8 2.3 110 10.1
31 – 40 years 417 29.0 43 12.3 374 34.3
41 – 50 years 363 25.2 60 17.1 303 27.8
51 - 70 years 542 37.6 239 68.3 303 27.8
Marital Status
Single 505 35.1 119 34.0 386 35.4
Married 851 59.1 207 59.1 644 59.1
Divorced/ Widowed 84 5.8 24 6.9 60 5.5
Gender
Male 1228 85.3 324 92.6 904 82.9
Female 212 14.7 26 7.4 186 17.1
Education
None 0 0 0 0 0 0
Primary 34 2.4 24 6.9 10 0.9
Secondary 283 19.7 102 29.1 181 16.6
High school 669 46.5 149 42.6 520 47.7
Tertiary/post grad 454 31.5 75 21.4 379 34.8
Employment type
Permanent 929 64.5 239 68.3 690 63.3
Seasonal 432 30.0 105 30.0 644 30.0
Contract 79 5.5 6 1.7 60 6.7
30
Occupation
Unskilled 410 28.5 175 50.0 235 21.6
Semi-skilled 533 37.0 96 27.4 437 40.1
Skilled 221 15.3 30 8.6 191 17.5
Supervisor/manager 276 19.2 49 14.0 227 208
Smoker
Yes 255 17.7 165 47.1 90 8.3
No 1185 82.3 185 52.9 1000 91.7
Exposed to noise
Yes 853 59.2 242 69.1 611 56.1
No 587 40.8 108 30.9 479 43.9
Ear infection
Yes 128 8.9 83 23.7 45 4.1
No 1312 91.1 267 76.3 1045 95.9
Yrs in Employment
0 to 10 727 50.5 132 37.7 595 54.6
11 to 20 265 18.4 46 13.1 219 20.1
21 to 30 203 14.1 62 17.7 141 12.9
31 to 41 245 17.0 110 31.4 135 12.4
Ex-smoker
Yes 79 5.5 38 10.9 114 10.5
No/Not applicable 1361 94.5 312 89.1 886 89.5
#of cig per day
Less than 5 162 11.3 103 29.4 59 5.4
More than 5 93 6.5 62 17.7 31 2.8
None 1185 82.3 185 52.9 1000 91.7
Department
Factory production 498 34.6 74 21.1 424 38.9
Factory maintenance 183 12.7 55 15.7 128 11.7
Distillery 103 7.2 0 0 103 9.4
Agric production 146 10.1 82 23.4 64 5.9
Agric services 245 17.0 49 14.0 196 18.0
Water resources 131 9.1 52 14.9 79 7.2
Admin 134 9.3 38 10.9 96 8.8
4.2.1.1 Age group

From table 3, it can be observed that a majority of the participants 37.6% fall in the age group
51 – 71 years, 25.2% are in the age group 41 – 50 years, 29.0% in the age group 31 – 40
years, while age group 20 – 30 years constituted the least participants, 8.2%.
With regards to the normality test, age distribution has a mean of 45.36 years and standard
deviation of 10.45. From the graph below and the normal distribution curve, it can be
concluded that this data is symmetric/normal distribution.
31
Figure 3: Age distribution graph
4.2.1.2 Marital Status

A majority of the participants 59.1% are married whilst 35.1% are single and the remaining
5.8% are either divorced or widowed.
4.2.1.3 Gender
The sugar manufacturing industry is largely dominated by males and this is evident since
85.3% of the participants are males and only 14.7% females.
4.2.1.4 Employment Type
The participants were most made up of permanent employees 64.5% whilst seasonal workers,
formed 30.0% and 5.5% were contract employees.
4.2.1.5 Occupation
When it comes to occupation, semi-skilled employees formed the majority of the participants
at 37% followed by un-skilled employees at 28.5%, then supervisors/managers at 19.2%, with
skilled employees being the least at 15.3%.
4.2.1.6 Education
When looking at the level of education, 46.5% of the participants had high school education
while 31.5% had either tertiary/post-graduation education. A very small proportion of the
participants 2.4% had primary education and the remaining 19.7% had secondary education.
4.2.1.7 Department
Most of the participants came from the factories, with 34.6% coming from factory production,
12.7% from factory maintenance and 7.2% from distillery. From agriculture, 17.0% cam e from
agriculture production whilst 10.1% and 9.1% came from agriculture services and water
resources respectively. The remaining 9.3% of the participants came from administration.
32
4.2.1.8 Comparison of occupational NIHL by smoking
When comparing the frequency distribution between two groups in terms of smoking, it can
be noted that 47.1% of the cases are smokers and 52.9% are non-smokers whilst for controls,
8.3% are smokers and 91.7% are non-smokers.
Figure 4: Comparison of NHIL by smoking graph
4.2.1.9 Comparison of occupational NIHL by exposure to noise

69.1% of the cases are exposed to noise and 30.9% are not while on the other hand 56.1%
of the controls are exposed to noise and 43.6% are not.
Figure 5: Comparison of NHIL by noise exposure
33
4.2.1.10 Comparison of occupational NIHL by number of years in employment
In terms of the number of years in employment, most cases 37.7% fall between the 0 – 10
years category, followed by 31.4% in the 31 – 41 years category, 17.7% in the 21 – 30 years
category and lastly 13.1% in the 11 – 20 years category. On the other hand, 54.6% controls
are in the 0 – 10 years category, 20.1% in 11 – 20 years, 12.9% in 21 – 30 years and lastly
12.4% in 31 – 41 years in employment.
Figure 6: Comparison of NHIL by years in employment
Years in employment distribution has a mean of 14.56 and standard deviation of 12.14. From
the graph below and the normal distribution curve, it can be concluded that this data is right
skewed and there are outliers
Figure 7: Years in employment distribution graph
34
4.2.1.11 Comparison of occupational NIHL by history of ear infection
It was also found that 23.7% of the cases and 4.1% of the controls had history ear infections
while 76.3% of the cases and 95.9 of the controls did not have history of ear infections.
Figure 8: Comparison of NHIL by ear infection
4.2.2 Inferential analysis

Binary logistic regression was used to calculate both the crude and adjusted odds ratios (OR)
and their respective confidence intervals (CI). OR and CI were first computed by comparing
the cases and controls within each independent variable to obtain the crude odds ratios. After
which, controlling for possible confounding between the variables was done to compute
adjusted odds ratios. Adjustment was done specifically for: age, marital status, gender,
education level, employment type, occupation, cigarette smoking, exposure to noise, history
of ear infection, years in employment, being an ex-smoker, number of cigarettes smoked per
day and the participant’s department. All the thirteen independent variables were included
simultaneously in the model comparing the cases and controls.
Table 4: Crude and adjusted odds ratios for being diagnosed with occupational NIHL by socio
Crude Odds Adjusted
95% CI 95% CI
ratio Odds ratio
Variable N= % N= N=
Age groups
20 – 30 years Reference
31 – 40 years 1.58 0.72 – 3.46 1.40 0.50 – 3.90
41 – 50 years 2.72 1.26 – 5.88 5.03 1.54 – 16.39
51 - 70 years 10.85 5.19 – 22.67 72.63 20.24 – 260.61
35
Marital Status
Single 0.96 0.74 – 1.24 4.93 2.72 – 8.92
Married Reference
Divorced/
1.24 0.77 – 2.05 0.96 0.44 – 2.10
Widowed
Gender
Male 2.56 1.67 – 3.94 2.49 1.29 – 4.80
Female Reference
Education
Primary Reference
Secondary 0.24 0.11 – 0.51 0.28 0.08 – 0.96
High school 0.12 0.06 – 0.26 1.17 0.34 – 4.03
Tertiary/post
0.08 0.04 – 0.18 3.86 0.83 – 17.97
grad
Employment type
Permanent Reference
Seasonal 0.93 0.71 – 1.21 3.24 1.44 – 7.29
Contract 0.24 0.10 – 0.55 3.71 1.02 – 13.43
Occupation
Unskilled 3.45 2.39 – 4.97 7.99 2.80 – 22.80
Semi-skilled 1.02 0.70 – 1.49 2.41 0.96 – 6.04
Skilled 0.73 0.44 – 1.19 0.64 0.28 – 1.42
Supervisor/man
Reference
ager
Smoker
Yes 9.91 7.33 – 13.39 2.38 1.11 – 5.10
No Reference
Exposed to noise
Yes 1.76 1.36 – 2.27 4.70 2.88 – 7.67
No Reference
Ear infection
Yes 7.22 4.90 – 10.63 10.26 5.52 – 19.07
No Reference
Years in
Employment
0 to 10 Reference
11 to 20 0.95 0.65 – 1.37 1.44 0.60 – 3.42
21 to 30 1.95 1.39 – 2.82 1.10 0.45 – 2.65
31 to 41 3.67 2.68 – 5.03 1.43 0.60 – 3.41
Ex-smoker
Yes 3.12 1.97 – 4.93 4.76 2.48 – 9.14
No/Not
Reference
applicable
#of cig per day
Less than 5 11.95 8.01 – 17.81 8.00 3.24 – 19.71
More than 5 32.40 15.15 – 69.30 20.23 6.25 – 65.50
None Reference
Department
Factory
Reference
production
Factory
2.46 1.65 – 3.68 3.11 1.67 – 5.79
maintenance
36
Agric
7.34 4.87 – 11.06 8.11 4.08 – 16.14
production
Agric services 1.43 0.96 – 2.13 1.02 0.55 – 1.89
Water resources 3.77 2.46 – 5.79 6.37 3.19 – 12.72
Admin 2.27 1.45 – 3.56 10.18 4.74 – 21.86
4.2.3.1 Findings for age

The results of the logistic regression analysis showed that except for the age-group 31 – 40
years, all other age groups were statistically significant at 95% CI using the 20 – 30 years age
group as reference even after adjusting for socio-demographic characteristics. The odds of
occupational NIHL for participants in age group 41 – 50 years and 51 – 70 years were 5.0 and
72.6 times higher respectively than the odds of occupational NIHL for participants in the 20 –
30 years age group.
4.2.3.2 Findings by marital status

Being single was statistically significant at 95% CI (AOR: 4.93, 95% CI 2.72 – 8.92) with being
married used as the reference group. This means that the odds of developing occupational
NIHL in single participants were 4.9 times higher than the odds of developing occupational
NIHL in married participants.
4.2.3.3 Findings by gender

Regarding gender, being a male was statistically significant at 95% CI (AOR: 2.49, 95% CI
1.29 – 4.80), meaning the odds of male participants developing occupational NIHL were 2.5
times higher than the odds of developing occupational NIHL in females.
4.2.3.4 Findings by employment type and occupation

Both being employed as a seasonal and contract employee were statistically significant at
95% CI (AOR: 3.24, 95% CI 1.44 – 7.29) and (AOR: 3.71, 95% CI 1.02 – 13.43) respectively,
using permanent employees as a reference. This means that the odds of developing
occupational NIHL for seasonal and contract employees were 3.2 and 3.7 times higher
respectively than the odds of developing occupational NIHL for permanent employees.
When it comes to the type of occupation, the analysis showed that none of the occupations
were statistically significant at 95% CI except for unskilled (AOR: 7.99, 95% CI 2.80 – 22.80),
using supervisor/manager as a reference. This tells us that the odds of occupational NIHL for
unskilled employees was 8.0 times higher than the odds of occupational NIHL for
supervisors/managers.
4.2.3.5 Results by cigarette smoking and number of cigarettes smoked per day
Cigarette smoking was statistically significant at 95% CI (AOR: 2.38, 95% CI 1.11 – 5.10),
meaning the odds of developing occupational NIHL for smokers was 2.4 times higher than the
odds of developing occupational NIHL for non-smokers.
37
When looking at the number of cigarettes smoked per day, both those who smoked less than
5 and more than 5 cigarettes showed statistically significant results at 95% CI (AOR: 8.00,
95% CI 3. 24 – 19.71) and (AOR: 20.23, 95% CI 6.25 – 65.50) respectively, using non-smokers
as a reference. This means that the odds of occupational NIHL for employees who smoked
less than five cigarettes per day and those who smoked more than five cigarettes per days
were 8.0 and 20.2 times higher respectively than the odds of occupational NIHL for employees
who did not smoke.
Being an ex-smoker was statistically significant at 95% CI (AOR: 4.76, 95% CI 2.48 – 9.14),
meaning the odds of occupational NIHL for ex-smokers were 4.8 times higher than the odds
of occupational NIHL for employees who have never smoked.
4.2.3.6 Findings by exposure to occupational noise

When it comes to exposure to noise, the analysis was statistically significant at 95% CI (AOR:
4.70, 95% CI 2.88 – 7.67), meaning the odds of developing occupational NIHL for employees
exposed to noise were 4.7 times higher than the odds of developing occupational NIHL for
employees who were not exposed to noise.
4.2.3.7 Findings by history of ear infection

Having ear infection was also statistically significant at 95% CI (AOR: 10.26, 95% CI 5.52 –
19.07), meaning the odds of occupational NIHL for employees who had history of ear infection
were 10.3 times higher than the odds of occupational NIHL for employees who did not have
history of ear infection.
4.3 Summary
The data analysis was presented in this chapter. The chapter started with the descriptive
analysis, followed by inferential analysis where the crude and adjusted odds ratios were
presented focusing on statistically significant results at 95% CI. The next chapter will discuss
and interpret the results, re-iterate the strengths and limitations of the study and thereafter
propose some recommendations.
Chapter 5
5.1 Introduction
This chapter discusses and interprets the results, re-iterate the strengths and limitations of the
study and thereafter recommendations are proposed. The broad objective of this study was to
investigate the relationship between cigarette smoking and occupational noise induced
hearing loss among employees at RSSC. The overall hypothesis was that there is a
relationship between cigarette smoking and occupational noise induced hearing loss among
employees at RSSC.
38
5.2 Discussion of results
5.2.1 Descriptive analysis
It was observed that a majority of the participants were males, this is understandably so
because the sugar manufacturing industry is generally dominated by males. Most of the
participants were married and a very small proportion was either divorced/widowed. In terms
of age group, a majority of the participants were between 51 – 71 years old and this is also
the age group that had the highest number of cases in terms of NIHL. It was also found that
more than half of the participants are employed on permanent basis and a very small number
is employed on contract basis. This is in line with a survey conducted in 2013 by EFFAT
(2015), which found that workers aged 55 or more accounted for a very significant proportion,
25%, of the sugar industry workforce younger workers (aged 24 or less) represented a mere
5%. The same survey also found that men represent approximately 80% of the permanent
workforce in the sugar sector. The situation is similar across the different age groups although
women are particularly under-represented among the young (16%) and the older (15%)
workers groups EFFAT (2015). Furthermore, EFFAT (2015) says that permanent employment
is the norm in the EU sugar sector with 80% of all staff being under a permanent contract. The
sugar industry being a seasonal sector, it employs supporting workers during the 3-4 months
of the beet processing campaign. Seasonal workers represent about 11% of the total. The
category ‘other staff’ (9% of the total) covers other forms of fixed-term employment, temporary
work agencies and posted workers among others. The sugar industry is very labour intensive,
and this was evident since a majority of the participants were semi-skilled and followed by un-
skilled labour.
There were more smokers among the cases as compared to smokers among the controls. A
large number of cases had a history of ear infections while a very small number of controls
had history of NIHL. A significantly large number of cases are exposed to occupational noise
as compared to controls. Lastly, it was surprising that a majority of the cases had been
employed between 0 – 10 years, however this group was followed by those who had been
employed for 31 – 41 years. The explanation for the latter is that they had been exposed to
occupational noise for an extended period of time and they are part of the aged group (age
group 51 – 71 years). A study by Wang et al (2017) also found that the prevalence of hearing
loss among all participants was 61.5% (72.9% for male and 52.1% for female). We observed
pronounced differences in hearing loss prevalence by demographic characteristics.
Prevalence of hearing loss was higher among men, aged over 70, current drinkers and
subjects with hypertension, diabetes mellitus, coronary heart disease, myocardial infarction,
and stroke. Current smokers and those exposed to occupational noise for 20 years or more
were more inclined to have hearing loss.
39
5.2.2 Inferential analysis
5.2.2.1 Results by Age
It was observed from the analysis that participants aged between 51 – 70 years were the most
likely to suffer from NIHL followed by those aged 41 – 50 years. This can be explained by the
fact that these participants are aged and have been working for a number of years and have
been exposed to noise for a long time. Azizi (2010) says that research has shown that after
the age of 40 years, there was an additive interaction between smoking and development of
NIHL at high frequencies, mostly at 8 kHz. It has been shown that age was an important factor
for development of NIHL, particularly among those workers exposed to noise levels below 98
dB.
5.2.2.2 Results by gender

When looking at gender of the participants, males were found to be more likely to be diagnosed
with NIHL compared to females as reported by other studies Nelson (2005). This is generally
because the sugar manufacturing industry is dominated by males and they perform work that
expose factors that contribute to NIHL such as occupational noise while the small number of
females in such an industry perform mainly office work and they are less exposed to noise.
Nelson (2005) found that a heavier burden of NIHL is borne by males (2.8 million DALYs) as
compared to females (1.4 million DALYs). The study further says that worldwide, males enter
the work force at an earlier age than females and remain there at higher participation rates
than females throughout their lives in all regions of the world. Males are also represented at
higher rates in economic sectors with high noise exposures: mining, manufacturing, utilities,
and construction.
5.2.2.3 Results by employment type and occupation

Seasonal employees and contract employees were found to be almost equally likely to be
diagnosed with NIHL compared to permanent employees. When looking at the type of
occupation, unskilled employees were found to be the most likely to be affected by NIHL. This
can be attributed to the fact that most unskilled employees have low levels of education and
are likely not to adhere to ear protection precautions, they mainly perform tasks that expose
them to factors that contribute to NIHL such as occupational noise and lastly they belong to
the low socio-economic group and are vulnerable to habits such as smoking. This is supported
by a study done by (Concha Barrientos et al, 2004) which found that there is a strong
association between occupational noise and NIHL, an effect that increased with the duration
and magnitude of the noise exposure. This was shown by comparing the risk for “blue-collar”
construction workers which was found to be 2 to >3.5-fold greater than that for “white-collar”
workers in other industries.
40
5.2.2.4 Results by cigarette smoking
Cigarettes smokers and ex-smokers were found to be more likely to be diagnosed with NIHL
which has also been reported by a study conducted on the effect of smoking on development
of NIHL among 504 workers in a large wagon manufacturing company exposed to risky noise
level (>85 dB). The results revealed a higher prevalence of hearing loss in smoker workers in
comparison to non-smokers (Azizi, 2010). Smokers who smoked more than five cigarettes per
day were found to be at more risk of suffering from NIHL than those who smoked less than
five cigarettes per day. This is in agreement with a study conducted in the United States and
published in the Journal of the American Medical Association, June 1998, which concluded
that the risk of hearing impairment often increases with the number of cigarettes smoked
(Cruickshanks et al, 1998). In many cases, hearing problems increase proportionately with the
intensity and duration of exposure to cigarette smoke. In general, smokers are 1.69 times
more likely to damage their hearing ability (Cruickshanks et al, 1998). Heavy smokers are
more than 1.30 times as likely to have a hearing loss in all age groups but the oldest. The
greater prevalence of hearing loss among smokers remains the same after adjusting for
factors such as occupational noise exposure, age and lifestyle (Cruickshanks et al, 1998). A
study by Kumar et al (2013) also concurs that smoking was found to be statistically associated
with the hearing impairment, with 65.7% of the smokers and 15% of the non-smokers having
hearing impairment. Furthermore, the same study found that the severity of the hearing loss
in the smokers increased with an increase in the number of bidis/cigarettes which were
smoked, and the duration of smoking and this association was found to be significant
statistically (Cruickshanks et al, 1998). Results from multiple logistic regression from another
study by Sung et al (2013) also found that for smoking status (reference: non-smokers)
showed that the adjusted odds ratios of current smokers were 1.291 (95% confidence interval
[CI]: 1.055–1.580), 1.180 (95% CI: 1.007–1.383), 1.295 (95% CI: 1.125–1.491), and 1.321
(95% CI: 1.157–1.507) at 1 k, 2 k, 3 k, and 4 kHz, respectively. Based on smoking amount,
the adjusted odds ratios were 1.562 (95% CI: 1.013–2.408) and 1.643 (95% CI: 1.023–2.640)
for the 10–19.9 and ≥30 pack-years group, respectively, at 1 kHz (reference: 0.05–9.9 pack-
years).
5.2.2.5 Results by exposure to occupational noise and history of ear infections

Participants who are exposed to noise were found to have higher chances of suffering from
NIHL compared to those who are not exposed to noise finding reported by other studies
(Concha-Barrientos, 2004). This study found that it is generally accepted that the link between
occupational noise and hearing loss is biologically obvious (i.e. there is a clear mechanistic
pathway between the physical properties of noise and damage to the hearing system). The
same study also showed a strong association between occupational noise and NIHL, an effect
that increased with the duration and magnitude of the noise exposure. (Concha-Barrientos,
41
2004) further says that this link is also supported by other epidemiological studies that
compared the prevalence of hearing loss in different categories of occupations, or in
particularly noisy occupations.
Similarly, participants who have a history of ear infections were found to be more likely to
suffer from NIHL than those who do not have history of ear infections. This is supported by
Staff (2007), who said that an ear infection may sometimes cause a temporary or reversible
hearing loss. This generally occurs because the infection blocks sound from passing through
the ear canal or middle ear to the inner ear. When sound is blocked like this, it is known as
conductive hearing loss wherein one may hear sounds as muffled or indistinct.
5.3 Strengths of the study

Since the study was conducted at Royal Swaziland Sugar Corporation, the researcher was
easily granted permission to conduct the study. It was cheaper and less time consuming to
conduct the study since the researcher works at the study site. Also, secondary data was used
hence it was cheaper and quicker to collect the data. The sample size was scientifically
derived using EPI Info version 7.2.2.6 hence making it possible and easy to find significant
relationships from the data using statistical tests. This study was the first one in Swaziland
hence it will create a foundation for further studies in understanding the relationship between
cigarette smoking and hearing loss which will enable authorities to plan and implement
interventions accordingly.
5.4 Limitations of the study

Secondary data was used for this study i.e. occupational health medical records which had
been collected for a different purpose. Such records maybe improperly completed, not legible,
not easily accessible or missing. Lastly, the limitation in the number of cases made it
impossible to increase the sample size in order to have a higher prediction power.
5.5 Public Health Implications

According to WHO (2003), occupational noise induced hearing loss is the major problem
among workers in the developing world. This study therefore will explore if smoking is a risk
factor for induced hearing loss among workers in the sugar production industry. The study
findings will assist in the development of preventative programs in alleviating induced hearing
loss at RSSC. This will include programs aimed at smoking cessation and programs aimed at
promoting non-smoking behaviours among workers. This in turn will aid in reducing the
occurrence of induced hearing loss among workers. The study will also form the basis for other
studies in other different work environments in the country thus assisting companies to
develop better preventative measures, including raising an awareness on the dangers of
smoking thus promoting smoking free environments. This in turn will help companies in
reducing costs incurred in the treatment of sick employees and rehabilitation of already sick
42
employees in terms of workmen compensation costs. Since this study was the first to be
conducted in Swaziland, it will create a foundation for further studies in understanding the
relationship between cigarette smoking and hearing loss which will enable authorities to plan
and implement interventions accordingly.
5.6 Conclusion
The purpose of this study was to investigate the relationship between smoking and noise
induced hearing for employees exposed to occupational noise at the Royal Swaziland Sugar
Corporation (RSSC). From the results of the study, it can be concluded that indeed cigarette
smoking and exposure to noise increase the likelihood of being diagnosed with occupational
NIHL. The effects of smoking to noise on occupational NIHL exist even after controlling for
covariates.
5.7 Recommendations
Based on the findings of the study, the following is recommended:
i) Further studies be conducted in other industries to ascertain the relationship between

cigarette smoking and occupational NIHL
ii) Health education should be enforced both at the workplace and occupational health
clinic on the health effects of smoking
iii) Establish policies that discourage smoking and establish facilities that assist in quitting
smoking and prevent relapse thereof
iv) Organisations should develop effective hearing protection programmes to prevent,
control and eliminate occupational NIHL
43
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demographic analysis of the European Sugar Sector: challenges and opportunities for
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46
Appendices
Appendix A: Data extraction form
DATA EXTRACTION FORM (for the pre-coded questions, circle on the correct
number)
1. General Information
a) Name of person collecting the data :
b) Date of data collection :
c) Location of data record :
2. Demographic Information
a) Participant code :
b) Date of birth :
c) Age :
d) Sex:
Male :1
Female :2
e) Education level:
No formal education :1
Primary education :2
Secondary education :3
High School education :4
Tertiary education :5
Post graduate education :6
f) Marital status:
Single :1
Married :2
Divorced :3
Widowed :4
3. Employment Information
a) Participant’s occupation:
General Labourer (unskilled) :1
Operator (semi-skilled) :2
Artisan (Skilled) :3
Supervisor :4
Manager :5
47
b) Employment type:
Permanent :1
Seasonal :2
Contract :3
c) Department:
Factory Production :1
Factory Maintenance :2
Distillery :3
Agric Production :4
Agric Services :5
Water Resources :6
Administration :7
d) Years in current occupation :
e) Exposed to occupational noise:
Yes :1
No :2
4. Lifestyle
a) Does the participant smoke:
Yes :1
No :2
b) If yes, how many cigarettes per day:
Less than 5 :1
More than 5 :2
c) If no to a), is the participant an ex-smoker
Yes :1
No :2
d) If yes to c), when did the participant stop :
5. Medical history
a) Has the participant been diagnosed with NIHL?
Yes :1
No :2
b) PLH Shift:
c) History of ear infections:
Yes :1
No :2
48
Appendix B: Ethics Approval Letter
49
Appendix C: HDC Approval Letter
50
Appendix D: Permission letter from RSSC
51
Appendix E: Research Project Gantt Chart
RESEARCH PROJECT GANTT CHART

DATA COLLECTION 15
5
DATA CAPTURING 20
20
INTERPRETATION OF RESULTS 15
10
SUBMISSION OF DRAFT REPORT 10
5
PREPARATION OF FINAL REPORT 5
5
Submissi Preparati Correctio Submissi

Interpret Data Data Data
on of on of n of on of Report Data
ation of capturin verificati collectio
final final draft draft writing analysis
results g on n
report report report report
START DATE 24-Feb-2017-Feb-2010-Feb-2027-Jan-2013-Jan-2011-Nov-1914-Oct-1923-Sep-1916-Sep-1926-Aug-19
DURATION (Days) 5 5 5 10 10 15 20 20 5 15
52
Appendix F: Research Project Budget
Task By Who Unit Cost Total Cost

Printing questionnaires (1440 copies) Researcher E5 E7200
Data collection Researcher - -
Data capturing Researcher - -
Data analysis Researcher - -
Data Interpretation and report writing Researcher - -
Printing draft report (100 pages) Researcher E5 E500
Printing final report (100 pages) Researcher E5 E500
Total E8200
53
Appendix G: Letter from Language Editor
P.O BOX 39 Nsoko. Cell: 76132530, email: thobiledlmn@gmail.com
Appendix G
Department of Environmental health
University of Johannesburg
26 January 2020
To whom it may concern,
Confirmation of editing
This is to confirm that this dissertation was proofread and edited by me as an

independent language specialist. The University reserves the right to accept or reject
the suggestions and corrections made on this dissertation.
Yours Sincerely
Thobile Singwane
54
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A mini-dissertation submitted to the

Faculty of Health Sciences,

Mbuso Patrick Mdluli

(Student number: 218089024)

List of Tables .................................................................................................................................. viii

List of abbreviations ........................................................................................................................ ix

Definition of terms ............................................................................................................................ x

1.2 Background ............................................................................................................................ 2

1.2.1 Aging ............................................................................................................................... 3

1.2.2 Solvent exposures ........................................................................................................... 3

1.2.3 Recreational noise........................................................................................................... 3

1.2.4 Ototoxic medications ....................................................................................................... 3

1.2.5 Presbycusis ..................................................................................................................... 4

1.2.6 Ear infection..................................................................................................................... 4

1.3 Problem statement ................................................................................................................. 5

1.4 Feasibility of the study............................................................................................................ 5

1.5 Significance of the study ........................................................................................................ 5

1.6 Rationale for the study ........................................................................................................... 6

1.7 Purpose of the study .............................................................................................................. 6

1.9 Research questions ............................................................................................................... 7

1.9.1 Overall research question ............................................................................................... 7

1.9.2 Specific research questions ............................................................................................ 7

1.10 Study objectives ................................................................................................................... 7

1.10.1 Broad objective.............................................................................................................. 7

1.10.2 Specific Objective .......................................................................................................... 7

1.11.1 Overall hypothesis ......................................................................................................... 8

1.11.2 Specific hypothesis........................................................................................................ 8

1. 12 Delimitation of the study...................................................................................................... 9

Summary and transition ................................................................................................................... 9

2.1 Conceptual Framework .......................................................................................................... 9

2.1.1 Health Belief Model (HBM).............................................................................................. 9

2.1.2 Effects of smoking: ........................................................................................................ 11

2.2 Literature Review ................................................................................................................. 12

2.2.1 Occupational noise induced hearing loss ..................................................................... 12

2.2.2 Cigarette smoking ......................................................................................................... 18

2.2.3 Cigarette smoking and occupational noise induced hearing loss................................. 19

Summary and transition ................................................................................................................. 21

3.1 Study design......................................................................................................................... 21

3.2 Study area ............................................................................................................................ 22

3.3 Study Population .................................................................................................................. 23

3.4 Inclusion criteria ................................................................................................................... 23

3.5 Exclusion criteria .................................................................................................................. 23

3.6 Sampling method ................................................................................................................. 23

3.7 Sample size estimation ........................................................................................................ 23

3.8 Data types ............................................................................................................................ 24

3.9 Sources of data .................................................................................................................... 26

3.10 Instrumentation .................................................................................................................. 26

3.11 Pilot study ........................................................................................................................... 27

3.12 Data collection.................................................................................................................... 27

3.13 Data analysis ...................................................................................................................... 27

3.13.1 Data analysis for each objective ................................................................................. 27

3.14 Ethical Consideration ......................................................................................................... 28

3.16 Budget ................................................................................................................................ 29

Summary and transition ................................................................................................................. 29

4.2 Report on the findings .......................................................................................................... 30

4.2.1 Descriptive analysis....................................................................................................... 30

4.2.2 Inferential analysis ...................................................................................................... 35

4.3 Summary .............................................................................................................................. 38

5.2 Discussion of results ............................................................................................................ 39

5.2.1 Descriptive analysis....................................................................................................... 39

5.2.2 Inferential analysis......................................................................................................... 40