According to the Veterans Benefits Administration, more than 672,000 Veterans were service-connected for hearing loss and more than 744,000 Veterans were service-connected for tinnitus as of fiscal year 2010 . Hearing loss and tinnitus are the most prevalent disabilities experienced by Veterans who served during peacetime, Operation Iraqi Freedom/Operation Enduring Freedom, World War II, and the Korean war. In fiscal year 2010, the Department of Veterans Affairs (VA) provided 561,212 hearing aids at an estimated cost of $196.7 million and audiological services to Veterans at a cost of $227.4 million. * Therefore, hearing loss and tinnitus prevention should be a priority for the VA. At least one type of hearing loss--noise-induced hearing loss (NIHL)--can be prevented if appropriate protective strategies are implemented.
Citing the high prevalences of hearing loss and tinnitus among Veterans, Fausti et al. concluded that programs aimed at preventing hearing loss should include education concerning the effects of both occupational and recreational noise exposures, as well as counseling on the hearing protection methods available to individuals at risk for NIHL . Subsequently, authors Saunders and Griest worked with a video production company (Craftmaster Productions; Portland, Oregon) to implement this recommendation by developing a computer-based hearing loss prevention program (HLPP) for Veterans that could be accessed by patients in VA medical clinics .
HEARING LOSS PREVENTION PROGRAM
The HLPP uses the constructs described in the Health Belief Model (HBM) developed by Rosenstock  to explain individual differences in decisions to practice particular health behaviors. To varying degrees, the HBM predicts health-related behaviors, such as prenatal care visits , breast cancer self-examination , continued enrollment in diabetes-related pharmaceutical services , and hepatitis B vaccination . The principles outlined in the HBM were described by Folmer et al. [9, p. 12] as follows:
1. "Perceived Susceptibility: The feeling of being vulnerable to a condition and the extent to which the individual believes he/she is at risk of acquiring the condition.
2. Perceived Severity: Belief in the seriousness of the consequences incurred if [a person is] affected by the condition both medically (e.g. death, disability, pain) and socially (e.g. effects on family life, personal relations).
3. Perceived Benefits: The belief that intervention will result in positive benefits.
4. Perceived Barriers: The barriers an individual believes he/she needs to overcome in order to effectively conduct some form of intervention. This includes costs, negative side effects, social stigma, and time needed for implementation.
5. Perceived Efficacy: Belief the individual has that he/she can successfully use the intervention.
6. Cue to Action: A cue that prompts an individual to take action. This could be internal, such as symptoms of a health problem, or external, such as media communications, interpersonal communications, or information from healthcare providers."
One goal of the HLPP is to increase participants' knowledge about auditory system damage that can be caused by loud sounds and methods of hearing protection, which in turn would change participants' understanding and attitudes about noise exposure and hearing protection. The ultimate goal of this, and all HLPPs, is to motivate participants to change their behaviors in noisy situations so they implement appropriate hearing protection strategies. Most Veterans were exposed to loud sounds during their military service. Additional unprotected noise exposure will contribute to hearing loss in this population. Indeed, evidence exists that ears with prior noise damage age differently than those without significant noise exposure. Specifically, hearing loss progresses more quickly in noise-exposed ears than in ears not exposed to noise and loud sounds cause greater damage to already-exposed ears . Given this knowledge, it follows that Veterans, whose ears were probably exposed to high levels of noise during military service, must now protect their ears to avoid exacerbating cochlear damage and thus accelerating the progression of age-related hearing loss. The VA does not provide a hearing loss prevention education program for Veterans, although such instruction would be beneficial.
The HLPP is a self-administered, multimedia, computer-based program developed for Veterans and designed …