Occupational noise induced hearing loss in the 2 mining sector in South Africa : How are mineworkers 3 trained-perspective from occupational health 4 personnels 5

The aim of this study was to explore perspectives of occupation health personnels (OHPs) regarding education and training of mineworkers on occupational noise induced hearing loss (ONIHL) and its impact on mineworkers’ hearing. Qualitative, in-depth telephonic and face-to-face interviews were conducted with 16 OHPs comprising representatives from the state, employer and labour as well as audiologists and occupational health hygienists.  Purposive and snowball sampling were utilized to recruit participants. Data were analysed using inductive thematic analysis. Findings revealed that mineworkers have a superficial awareness and knowledge of the impact of noise on their hearing and health. Moreover, OHPs are not knowledgeable on how mineworkers are educated on ONIHL and its latent consequences. Furthermore, language, low levels of education and literacy as well as the financial constraints were factors that had a negative impact on raising awareness and training mineworkers. There is a need to prioritize health literacy among mineworkers. Additionally, audiologists need to play an active role in educating mineworkers about the effects of excessive exposure to noise. There is a need to take into account literacy levels and language barriers in planning training material for mineworkers.


Introduction
Occupational noise induced hearing loss (ONIHL) has received little, if any, attention especially in the period preceding 1994 in the South African mining industry.Historically, occupational health concerns associated with mining, particularly ONIHL was ignored by the mining sector, policy makers, and academic researchers [1].Consequently, mineworkers were not aware of the latent effects of excessive exposure to hazardous noise and the resultant hearing loss thereof.
A literature search into ONIHL in the mining sector in South Africa prior to 1994 revealed only one study [2] which was conducted on White mineworkers, to the exclusion of Black workers who formed the majority of the mines' workforce.It was only in 1994, at the apartheid-democracy twilight that a study was conducted on Black mineworkers [3].This study explored knowledge and attitudes of Black mineworkers regarding ONIHL and the use of hearing protection devices (HPDs).
Findings revealed that mineworkers were firstly, not aware that noise was a health hazard.Secondly, their knowledge was based on personal experiences and observations, rather than formal educational input.Thirdly, mineworkers were self-motivated to protect themselves from acquiring a hearing loss and to learn more about the effects of noise.Lastly, mineworkers complained about discomfort, feelings of insecurity due to inadequate communication and inability to hear when using HPDs.
Findings of this study are consistent with Simon's [4] assertions that Black workers were not given instruction on occupational health and safety issues as they were seen as incapable to learn.Two decades later in 2015, a study exploring the use of HPDs among mineworkers was conducted in mines in South Africa [5].Findings revealed mineworkers still complain about comfort, design and work-related communication due to HPDs.However, in this particular study, participants were reportedly knowledgeable regarding noise exposure levels, ONIHL and appropriate use of HPDs.
In the same year, 2015, a descriptive survey was conducted to evaluate ONIHL awareness training programmes in six mines in South Africa [6].Findings suggested, firstly, there is a lack of prioritization of commitment to awareness training by management.Secondly, a large majority of mines lacked a solid and consolidated theoretical basis for their awareness training programmes.
Lastly, there were challenges with the language used during awareness training.
In 2018, a study conducted on the management of ONIHL in the mining sector revealed awareness training of mineworkers as one of the successes realized by the mining sector [7].
Despite these reported successes, the fact that there is a mismatch between findings in the studies by Ntlhakana, [5] and Edwards, [6] raises questions into how mineworkers are informed about the latent and subsequent sequel of ONIHL.Arguably, data for both these studies were obtained from different sites and contexts, therefore, differences in results should be expected.Nevertheless, education and awareness are part of hearing conservation programmes (HCP) which all South African mines were mandated to implement in 1996 [8].Therefore, it may be logical to expect similarities in how the programmes were implemented in the mines.
Currently, awareness on ONIHL may be overshadowed by the increased burden of disease, particularly HIV/AIDS and tuberculosis, the most prevalent diseases in the South African mining industry [9,10].Relying on anecdotal evidence and findings presented by Edwards et al [6], it appears that mineworkers are not well informed about the effects of ONIHL.Moreover, the mining industry's efforts in targeting education are not yet successful.Therefore, the is a need to conduct studies to ascertain how mineworkers are educated on ONIHL and its consequences.Therefore, the current study explored perspectives of occupation health personnels (OHPs) regarding educating mineworkers on ONIHL and its impact on their health.Obtaining perspectives and opinions of mineworkers, as individuals exposed to noise, regarding their training is preferred and ideal.Due to difficulties in gaining access into the mining sector for data collection purposes [11], it was not possible to obtain this information from mineworkers.

Materials and Methods
Methods followed in this study have already been described previously; however, the reference is not mentioned to ensure a blind review.This study is nested on a PhD study titled "Occupational Noise Induced Hearing Loss in South African Mines: From Policy Formulation to Implementation and Monitoring".This current study aims to explore perspectives of OHPs on awareness and training of mineworkers on ONIHL and its impact on their health.
This study sought to understand perspectives of OHPs on the awareness and training of mineworkers on ONIHL and impact on health.A qualitative design, which uses a naturalistic approach in seeking to understand a phenomena in context-specific settings, without the influence of the researcher, thereby eliminating the manipulation of and allowing the phenomena of interest to unfold naturally was employed in this study [12,13].
Purposive snowball sampling was utilized to recruit possible participants identified from websites of companies affiliated with the South African mining industry.Participants were contacted via emails and telephonically.Furthermore, they were requested to identify and request other participants on behalf of the researcher to participate.Therefore, snowball sampling, as discussed by Penrod [14] was necessary in this study because of the challenges experienced by the researcher in identifying and recruiting participants.Ultimately, 16 participants were obtained and interviewed.
Participants compromised six representatives from the Mine Health and Safety Council of South Africa seven audiologists and two Ventilation and Occupational Health Engineers, and one occupational hygienist, herein referred to as OHPs.Participants were required to be involved in the management of ONIHL in the mining industry for 6 months and more.
Data were collected through in-depth face-to-face and telephonic interviews.The interview structure followed recommendations by Rubin [15] where the interviewer possesses a plan of inquiry as well as a set of questions.All the interviews were conducted in English and were audio recorded for analysis.Research questions focused on the OHPs perspectives on awareness and training of mineworkers on ONIHL and its effects.
Procedures contributing to this work comply with the ethical standards of national and institutional guidelines on human experimentation.Ethical approval was obtained from the University's Medical Ethics Committee (Protocol number M160264) and the work adhered to the Helsinki Declaration of 1975, as revised in 2008 [16].Furthermore, ethical aspects such as confidentiality, right to withdraw from the study were discussed with the participants.Anonymity; however, could not be guaranteed as snowball sampling was utilized.
Reflexivity and bracketing were applied to guard against any bias from the researcher.A peer reviewer served as a mirror and assisted in reflecting on the researcher's responses to the interviews.Also, current authors made use of the "community of practice" as described by Rossman [17] to share the process and findings of the study with a group of colleagues familiar with ONIHL and policies governing noise management in the mines.Furthermore, after transcribing the interviews, the researcher conducted member or participant checks to "learn from the interviewee how well the researcher's interpretations reflect the interviewee's meaning" [18].
Inductive thematic analysis, an analytic process which allows for the coding of data without attempting to fit it into a pre-existing coding frame, or the researcher's analytic preconceptions, thus allowing the themes to emerge from the data themselves was used in this study [19].Data were analysed using six steps namely: familiarization with the data, generate initial codes, search for themes, review themes, define themes, and write-up [19].Representative verbatim quotations were used in the write up of the study to provide examples of the themes.

Results
The following themes were identified and discussed below: seeing is believing, not my department, blame it on the language and compensation payouts.

Theme 1: Seeing is believing
Participants were asked to share their perspective on whether mineworker are aware of the impact of ONIHL and its latent consequences on their hearing.The majority indicated that the workers are superficially aware of the impact of noise.P11 felt that, although the miners are aware of the impact, they only fully appreciate the impact when they develop a hearing loss.
"I think so.Yes.But I don't think the fact that it is permanent (hearing loss), cannot be cured.I don't think that people realize that.I think at the back of their minds they think when they go away from the mines, back home, their hearing will get better again.I think they have this perception that while I'm in the noise, it's damaged but once I go home and I'm not working in the mines anymore my hearing will improve.P11 P1 believes that since hearing is insidious and is an abstract concept to grasp, some workers do not actually understand the implications of acquiring a hearing loss.

Theme 2: Not my department!
Participants were asked to elaborate on how workers are educated on the impact of ONIHL on their hearing.Responses highlighted that participants are ,0knowledgeable on how workers are trained.
It should be noted that these participants are occupational health personnels and they should either be involved in the education or be informed on whose role it is to inform workers regarding the effects of ONIHL.

P7stated that:
"I don't know.I'm not 100% sure.I'm sure that they get information on that.For example, at XXX mine there was a big… like a waiting area.And there is a tv that shows all these videos and information.I know there, they have something.But I'm not 100% sure. .

While P 1 admitted that:
"To be honest we haven't done a campaign solely on noise and I think this year, depending on funding we will look into such a campaign"

Theme 3: Barriers and facilitators to raising awareness
Two subthemes were identified with regard to barriers and facilitators to raising awareness.The first subthemes (blame it on the language) was on the part of the OHPs while the second subtheme (compensation pay-outs) was on the part of the mineworker.These barriers were also cited as facilitators, in that, if they are overcome, they can enable and positively contribute towards promoting awareness and education among the mineworkers.

Blame it on the language
Participants were asked to share possible barriers to teaching mineworkers about ONIHL and its effects.Language and levels of education were highlighted as the biggest barriers.P 8 admitted that language differences contribute to the difficulty in teaching:

"Obviously, I know that I'm lacking in my communication with my patients. I always feel that it is important to have good communication with all my patients that I see. Most of them can't even speak English or
Afrikaans.So that is a struggle for me.I really try my best P8.

Participant 5 shared a similar experience:
They do understand the basics because they have been getting screened for a very long time.But getting to the details… that is a struggle for me because I'm not able to communicate with them in a language that they understand P5" Participant 14 mentioned the levels of education as barrier as well.

3.3.2: Compensation pay-outs
Participants were asked, in their perspectives, why mineworkers still present with a high incidence of ONIHL if they are aware of ONIHL and its effects.Responses indicated that socio-economic factors may be at play.

"I definitely think that compensation plays a very big role. I definitely think that it plays a very big role because unfortunately we see a lot of people who pretend to have a hearing loss because they want compensation. It is something that in a very sad way motivates them not to look after their ears because they think they going to get money." P7
Participant 6 confirmed financial gain as a major contributor "…You know because there are production bonuses in the industry.Sometimes people feel… people then sacrifice Health and Safety because they are chasing production bonuses".
While participant 2 also shared her concern about the observed practice "…when we intervene, then the exposed individual says 'I can hear" because there are incentives for high production and you know so and so is strong.That same individual will go back to drilling because he knows that his team depends on him.So there are those dynamics".

P2 further elaborated:
"So then the discussion shifted to should there not be indicators of health and safety that are included in the bonus.So… you know, sort of be remunerated or rewarded for high production but also at the same time keeping or maintaining health and safety".

Discussion
Perceptions of OHPs indicated that mineworkers have limited and superficial knowledge regarding noise exposure and its effects on them.Mineworkers do not fully grasp that ONIHL, due to its latency and painless nature is irreversible and permanent and that once acquired, there are no guaranteed benefits from rehabilitation [ [20][21][22].These findings are consistent with studies reporting medical information presented at the time of diagnosis can be misunderstood or easily forgotten [23,24].This may be the case with the mineworkers.These findings have implications for how information is presented to the mineworkers.This becomes particularly important when we consider levels of education for most mineworkers in South Africa.Although, literacy levels have improved among mineworkers [28] in the past few years, especially with the advent of millennials in the mining sector.Nevertheless, to promote health literacy among mineworkers, literacy levels of mineworkers is important.For instance, Edwards [6] indicated that the material content used to train workers was the same as that used for managers and other levels of workers.These findings shed light on some of the reasons mineworkers have superficial knowledge on ONIHL and its impact.
Therefore, address literacy and language barriers, information must be matched to the worker's levels of understanding by utilizing a range of modalities such as verbal, visual and printed material to enhance learning and improve awareness while observing literacy, cultural, and linguistic relevance.In this way, even complex concepts can be understood if appropriate communication skills are [25].It is known that physicians explanations and the level of patients' understanding significantly affect treatment adherence, treatment outcome, and patients' satisfaction [26].The same argument applies to OHPs, if trainers explain concepts at the level of mineworker's understanding, workers will have deep knowledge and understanding of the consequences of excessive exposure to noise in the workplace, and they will be more likely to adopt and practice change in behaviour in the workplace.Ultimately, this will improve and promote health literacy among mineworkers [27].
Education and motivation are a priority in minimizing hearing loss in the mines as they create opportunities for both management and employees to discuss and agree on commitments, communication lines and cooperation [28].If individuals understand the reasons and the benefits of a HCP, they are more likely to participate, especially if training addresses the specific needs of individuals exposed to excessive noise.
Findings also indicated that OHPs believe mineworkers are informed regarding ONIHL and its effects.However, OHPs were not aware or knowledge on how mineworkers were informed or trained on ONIHL.These findings raise questions on how and who is responsible for the training of the workers.Byrne [28] asserts that before implementing HCPs, mines should address administrative issues; where company regulations as well as individuals' responsibilities and roles are identified and enforced.From the responses above, itis not clear who is responsible for educating mineworkers on ONIHL.Interestingly, even audiologists who participated in this study did not seem involved in raising and training of mineworkers.
The scope of practice for audiologists include, among other responsibilities, includes prescription of and counselling for the use of hearing protection as well as education and training of employees [29].Audiologists are responsible for educating and training mineworkers on the negative impact of ONIHL.However, in South Africa, evidence indicates that there are a few audiologists employed in the mining sector as mines prefer services of audiometrists who are considered more cost effective [30].Edwards [6] commented that mines have a lack of qualified professionals, who possess knowledge and skills on how to teach adults to achieve health promotion and behaviour change.Therefore, these findings highlight the important role of audiologists in actively participating in educating and training mineworkers regarding the impact of ONIHL on their hearing and health.
Audiologists are trained to provide programmes tailored to the needs of the workers; develop or recommend appropriate educational materials; instruct in-house staff in effective methods of motivating and educating workers; contribute to management education by preparing articles for publication or speaking before trade and management groups and maintain up-to-date knowledge of pertinent local, state, and federal regulations in order to provide management with accurate information concerning these matters [31].There is therefore a need for audiologists to play an active role in providing direction on the material and strategies in teaching mineworkers and management on ONIHL and its effects on individuals exposed to excessive noise.This study also brought to the fore issues of language in the training of mineworkers.Nelson Mandela, the late former president of South Africa accurately captures the importance of language when engaging with people."If you talk to a man in a language he understands, that goes to his head.
If you talk to him in his language that goes to his heart" [32].This quote rings true in this context where language seems to be a barrier in achieving the desired results in the training of workers.
Edward [6] also highlighted language as a barrier in a study conducted in the mines in South Africa.
South Africa is a multilingual country with 12 official languages.Consequently, for instance, using English as a chosen mode of communication excludes workers who may not be efficient in the English.In the 2011 Census, results indicated that Zulu is the most spoken language however, not everyone is fluent in this language.Moreover, Africa is a developing continent and South Africa is viewed as the richest developing country in Africa due to its infrastructure, it has led to people from neighbouring countries migrating to South Africa to seek better job opportunities in the mining industry.This has resulted in a culturally and linguistically rich and diverse environment.OHPs therefore, need to take language and culture into account when planning worker-training initiatives within the mining sector.
Workers may be aware of ONIHL and its effects; nevertheless, socioeconomic difficulties may play a role in health practices of mineworkers.South Africa as a whole is faced with high levels of unemployment, high burden of disease as well as increased cost of living.Historically, mineworkers were unskilled and uneducated and were refused skill training to improve their skills and their salaries [31].Salaries for unskilled mineworkers are low, particularly when considering the high cost of living in South Africa.For instance, in 2003, the average salary for a mineworker in a gold mine was approximately R5000 at entry level, rising to R8000 with the inclusion of housing and food allowance.Overtime and bonuses improved the salaries to R11 000 a month [33].In 2012, it was rumoured that "the salaries of chief executives in the mining sector have quadrupled over the past few years despite the global economic crisis and are 150 times higher than the pay of an average mineworker" [34].To put this into perspective, South Africa has dominated the mining industry for about 120 years, reaching its peak in 1970, although in 2004 there was a slight decline in production, South Africa nevertheless remains the biggest producer of gold globally, maintaining its growth economically [35].This is, however, not consistent with the income levels of those that work in the mines.Although, these findings are based on OHPs speculations, nonetheless, they highlight the plight faced by workers in meeting their financial obligations.It is sad that some miners may resort to exposing themselves to excessive noise for financial gain.However, it is also comforting that the mining industry is aware of this predicament, hence the attempt to balance high production with maintaining health and safety as alluded to by P2.

Conclusions
One of the most important components of an effective HCP is the education and motivation of workers and management [31], consequently, "no cause can succeed without first making education its ally" [36].Furthermore, success of programmes rely on the involvement of all stakeholders to ensure that objectives and outcomes are identified and achievable [37].Additionally, stakeholders are likely to support initiatives if they are involved in the decision-making process [38], as without their support, initiatives may be ignored, criticized, resisted or even sabotaged [39].Mineworkers are primary stakeholders in the management of ONIHL; however, they seem excluded in the process.If the mining industry is committed in eliminating ONIHL, they should involve mineworkers in decision-making processes as to ensure active participation, empowerment, and support for the programme.Education and active participation of mineworkers will go a long way in achieving the desired results as far as eliminating ONIHL is concerned.Furthermore, audiologists also need to take an active role in educating and training mineworkers and other professionals on the impact on excessive noise in the workplace.
was injured and I saw the blood.I think hearing loss, because it is an invisible thing to them, I think it is a difficult thing to comprehend.
).When we tell people there is a hole in your eardrum, it's like what are you talking about!They don't see it.That's the problem.Our workers are people who want to see something.You know, when I break my arm and the bone is sticking out, I can see it you know.So next time, I'm gonna [going to] (sic) be careful doing that job because my colleague