Acceptability of the Wulira app in assessing occupational hearing loss among workers in a steel and iron manufacturing industry.

BACKGROUND: Industrial workers are at a high risk of acquiring noise induced hearing loss, yet there is minimal hearing loss screening of such groups of people. Pure Tone Audiometry (PTA), the gold standard for hearing loss screening, is expensive, and not readily available at health sites. Mobile audiometry can bridge this gap. However, there is limited knowledge on its acceptability in low-income countries like Uganda. We aimed to assess the acceptability of using the Wulira App, a validated mobile phone app, in assessing hearing loss among industrial workers in Kampala.
METHODS: We carried out a qualitative study in a steel and iron manufacturing industry in Kampala, in April 2021. Four Focus group discussions (FGDs) with 8 participants per FGD, and 12 In-depth Interviews (IDI), were conducted on the industrial workers. The industrial workers were first tested for hearing loss, then enrolled for the FGDs and IDI. A semi-structured interview guide was used. Audio recordings were transcribed verbatim. Themes were derived using thematic content analysis, borrowing from Sekhon's model of Acceptability of Health Interventions.
RESULTS: Industrial workers found the Wulira App user friendly, cheap, time saving, and an effective hearing loss assessment tool. However, barriers such as lack of smart phones, difficulty in navigating the app, and fear of getting bad news hindered the App's acceptability, as a hearing assessment tool.
CONCLUSION: Hearing loss assessment using Wulira App was acceptable to the industry workers. There is need of informing industrial workers on the essence of carrying out regular hearing loss screening, such that barriers like fear of getting screened are overcome.

Introduction

Hearing Loss is increasingly becoming a public health threat, and currently ranks as third among the non-fatal disabling conditions [1]. According to the World Health Organization (WHO), 466 million people suffer from disabling hearing loss, and a further projection of 630 million people by 2030 [2]. Hearing loss has been associated with deleterious consequences, including higher unemployment rates, poor health, social isolation, depression, dementia, and increased mortality [2-4].

Exposure to noise in recreation areas increases the risk of developing hearing loss by 7%, for every 5 years [5]. Noise induced hearing loss ranks among the leading causes of occupational illness among industrial workers [6,7] which subsequently results in unemployment [2,8]. Early detection and prevention of noise induced hearing loss is critical in addressing this occupational hazard.

Pure Tone Audiometry (PTA), which is the gold standard for hearing loss screening, is quite costly, requires a specialist audiologist to operate in a sound- proof room, and is not readily available at health (especially rural) sites in sub-Saharan Africa (SSA). On the other hand, Mobile Audiometry (hearing loss screening using mobile phones) has been shown to be as effective as PTA, and has great potential in improving access to hearing loss screening services [9-13]. This concept has been utilized in the general population to screen for hearing loss [9,10,14], thus providing evidence for its use in industrial workers.

One of the available mobile app-based hearing loss tools in sub-Saharan Africa is the Wulira app, which has been validated against the gold standard (Pure Tone Audiometry), and found to have a specificity of 93.2% (right ear, 95% CI (88.1–95.4%), 91.5% (left ear, 95%CI (87.2–94.7), sensitivity of 91.4% (right ear, 95% CI (88.9–93.5%), and 88.4% (left ear, 95% CI (85.6–80.9) [14]. This shows that the Wulira App can be used for hearing loss screening services, especially in settings with limited access to PTA [9,10,14]. Previous studies [12,15] have shown that effective utilization of technological health interventions is affected by their acceptance within the target group.

Although a study done in the United States of America, a high-income country, showed that mobile audiometry can easily be utilised among industrial workers [12], this has not been established in low-income countries such as Uganda, where phone ownership is still low [11].

In assessing acceptability of a particular health intervention, sekhon et al. suggested a theoretical framework with seven constructs [16], which we drew on, in guiding our presentation of study findings from a qualitative study. This was necessary, to understand the acceptability of mobile audiometry in assessing hearing loss among industrial workers using Wulira App.

As countries work towards Universal Health Coverage, prevention of disabilities should be at the centre of policy, and all programs. Evidence from our work will be able to guide policy in this regard. This study aimed at assessing acceptability of using Wulira App, in hearing loss screening among industrial workers.

Methods

Study design

We carried out an exploratory qualitative study, using Focus group discussions (FGDs) and in-depth interviews (IDI), with industrial workers at a steel and iron manufacturing industry.

Study population

The study was carried out in a steel and iron manufacturing industry in Kampala, in April 2021. Kampala is the capital city of Uganda, with over 1.5 million people. As of 2011, the steel and iron manufacturing industry employed the largest number of people in Kampala district, which was close to 8,233 people [17]. In Kampala, there are 3 steel and iron manufacturing industries, each employing more than 200 people [18]. One industry was selected among the three, by purposive sampling. The selected industry employed over 1,100 staff on permanent basis, thus having more than enough participants for our study.

We enrolled workers permanently employed by the industry.

Face to face approach of the participants was done.

Sample size

We did not decide in advance the sample size, but rather used the data saturation principle [19]. Thirty-two participants were recruited for the FGDs, of which 12 were invited for the IDI.

Participant selection

Participants for the FGDs were purposively sampled from the industry workers’ list, provided by the human resource manager, so that the industry’s daily production is not affected by absence of the workers participating in the study. Four mixed FGDs were carried out, with each FGD having eight participants. Furthermore, 3 of the most active participants (those that appeared to have more to say, but were not given enough time in the FGD, as observed by the moderator) in each FGD were invited to participate in the In-depth Interviews. Participant recruitment was not sex specific. The inclusion criteria included; permanent staff employed by the industry, who were above 18 years, and had consented to take part in the study. We excluded participants who had established history of hearing loss.

Data collection

Data was collected from a private room at the industry, to enable confidentiality and comfortability of the participants, while being engaged by a Ugandan male medical doctor, who was trained in qualitative research data collection. No third party, apart from the participants and data collection team, was allowed to be present. Each participant was first assessed for hearing loss using Wulira App, and then enrolled for the FGDs. The hearing assessment was done by a trained audiologist (FB), using Wulira App installed on the study tablet. The assessment results were not communicated to the participants prior to attending the FGD and IDI.

Each FGD lasted 60 minutes, and had the same moderator (AWS). Participants were on a round table, with the moderator seated among them. Before the start of each FGD, the moderator shared with participants the objectives of the study, and that the discussion will help in guiding the implementation of mobile audiometry in hearing assessment. Written informed consent was thereafter provided by the participants, and the moderator started the discussion.

A semi structured interview guide based on Sekhon’s Model of Acceptability of Health Interventions [16] was used for data collection (S1 FGD guide tool). All FGDs were audio recorded, and field notes taken by MN.

During the FGDs, the moderator noted the participants who gave more information, who were then invited for the IDI. Three participants from each FGD were recruited for the IDI. AWS carried out all the IDI, with the note-taker being MN. All IDI were audio recorded, as well with each IDI, lasting a minimum of 45 minutes, within the recommended time of similar IDI [20]. No repeat interviews were done.

The investigators underwent intensive training, before enrollment of participants for the FGDs and IDI. FGDs were conducted, until data saturation was reached. A total of 4 FGDs were carried out, with each FGD containing 8 participants, and 12 in-depth interviews. No participant refused to participate. After data collection and transcription, no transcript was returned to study participants.

Data analysis

All audio recordings were transcribed verbatim. The initial codebook was developed after carefully analyzing the text line-by-line of each transcript through coding, using de-identified respondent identification numbers. JM assigned codes to relevant segments of the text, and similar or related codes aggregated to form themes. Themes were derived using thematic content analysis, borrowing from Sekhon’s Theoretical Framework of Acceptability [16]. Words, sentences or paragraphs that conveyed a similar message were grouped as meaning units, which were then condensed and labelled with a code. JM aggregated similar codes to form categories. Categories were made to be mutually exclusive whenever that was possible, and to include all the information related to the content area being discussed. Categories were further analyzed, to form sub themes, and themes from their latent meanings [21,22].

The FGD findings were ratified and triangulated, with themes obtained from IDIs. A narrative was generated from the dominant themes. Some quotes are used to represent the narrative. Nvivo software was used to organize the analysis. Participants did not provide feedback on the findings. Findings of this study are reported according to consolidated criteria for reporting qualitative studies (COREQ) [23], as shown in S2 File.

Ethics statement

Ethical approval was granted by Makerere University School of Biomedical Sciences Institutional Review Board (SBS-862), and Uganda National Council of Science and Technology (HS1237ES). Each participant provided written informed consent.

Results

In this qualitative study, the majority of the participants were males (65.6%), with a median age of 27 years. Half of the participants had their highest education level being secondary school, with a majority of them (75%) working as machine operators (

Acceptability of hearing assessments using Wulira app

The results from the IDI and FGDs revealed themes that are presented using Sekhon’s framework, to understand the acceptability of the hearing assessment, using the Wulira app. Overall, the hearing assessment using Wulira app was acceptable to the industrial workers.

Affective attitude

Affective attitude denotes how an individual feels (either negatively or positively) about the intervention.

User friendliness:

Participants found using the Wulira app easy for them. The lay out of the app, and the guidelines for use were straightforward and intuitive. One participant stated

“To me using the Wulira App, the process of testing my ears was very easy. It was clear what was expected of me, it went on well” -(FGD 2)

Improved health seeking behavior:

Some of the participants in the in-depth interviews and FGDs said the use of the Wulira app was the first mobile based app they had encountered in hearing test.

“It was my first time to test my hearing. It was so sensitive, I got the sounds very well, it was comfortable during the testing. I recommend Wulira because it is the only gadget right now which I know and to me it was very sensitive that is number one.” (Interviewee 6)

For the rest who had tested their hearing, they had done so in the company clinic, although they could not remember how regularly they went there. This is illustrated by the quote:

“I have done a test in our clinic they also used the resonance tool. They hit it and then brought it next to my ear to test whether you can hear the disappearing sound” (FGD 4)

Fear of getting bad news from the hearing testing:

Fear of getting bad news among the participants was a major barrier for the acceptability of the hearing screening test. Many of the participants mentioned hesitancy in coming for the tests, despite working in high noise environments at the factory.

“According to the life we live, we are in a noisy area full day. However, I was fearing to even come for this testing. You never know what result I would get.” (Interviewee 10)

Another participant interestingly offered:

“I have been fearing to attend to medical personnel within the company for some tests. So when this new App (Wulira) testing came in, this new activity of testing came in. Everybody is just eager” (Interviewee 4)

Self-efficacy and burden

The next two themes within the Sekhon et al model were self-efficacy and burden. Self-efficacy is an individual’s confidence that they can perform the procedures of the intervention, while burden is how much effort an individual thinks is needed for the successful outcomes of the intervention, if they participate. For this analysis, the sub-themes for self-efficacy and burden constructs overlapped, and are reported jointly.

Self-efficacy

Easy to access:

Certain respondents felt that the Wulira app was easy to obtain and use for their own personal hearing assessments. They highlighted that the fact that they had smart phones and some internet access, they could download it on to their devices.

“I will manage to get the App and install it on my phone and then I will have to get headsets and I can do it at any time I want. I use it when am home and on different types of people.” (FGD 4)

Willing to test on their own:

Other participants felt that they would be able to perform the tests on their own in the future, if given appropriate training.

“…I can do the hearing testing myself if I am taught how to use it. I can do it as many times as possible since we work in noisy sections. There are departments where noise is too much whereby that kind of noise can affect my ear so I would prefer five to six times in a month.” (FGD 2)

Lack of smart phones:

The Wulira app’s compatibility with only smart phone or other smart devices, was seen as a major barrier for the performance of hearing testing at the home, or rural areas.

“… probably since it was just an application on the phone, someone may need to use the app, yet they do not have a smart phone which prevent them from testing” (Interviewee 8).

Technology literacy:

A few participants mentioned challenges in navigating and using the Wulira app to assess their hearing. They noted the need to have internet to download it, and an individual to train them on how to use the app. As one participant said:

“I would not know where to go to download the app and even I didn’t know what to do like me to do the testing but someone came here and helped me do the testing for free (Interviewee 6).

Burden

Time efficiency:

Maximizing the outputs at the factory is a key goal for any of the managers of a production facility. Therefore, any health procedure that does not take the participants away from their job for long rhymes does well with their values of effective use of time. The participants noted that the use of the Wulira app for the screening of the hearing loss fitted into their schedules, and they felt that they would easily be compensated for it on return to their job stations, as it was a faster procedure and led to little or no losses.

“…we used it (Wulira app) with its less effects, and this being a production company, it does not lead to time wastage so I would recommend the company to always use the Wulira app” (Interviewee 11) it did not affect my work as much because it was around ten to thirteen minutes and after the testing, I was able to make it up for the lost time of thirteen minutes” (Interviewee 3)

It is cheap:

While there were a few participants concerned about intervention costs, most appeared to feel that the intervention could bring cost savings. The cost of the procedure had prevented some of them from accessing hearing testing. They saw this an opportunity to test at a cheaper price. As one indicated:

“I thought if you are going for the hearing test you have to go to the hospital, and I even thought it was costly. However, this exercise was somehow very cheap and easy to access because most of the people have smart phones. If it comes and people can download and use it, it’s very good” (Interviewee 10)

Perceived effectiveness and intervention coherence

Sekhon et al define perceived effectiveness construct as the extent to which an intervention is expected to achieve its purpose [16]. On the other hand, intervention coherence is the extent to which participants understand the intervention, and how it works.

Perceived effectiveness

Had desired hearing testing qualities:

Several participants recognized the ability of the app to assess their hearing testing. The various frequencies that were generated in the app gave a range of results, for both high and low frequencies, unlike other hearing testing gadgets they had encountered.

“…I like the consistency of how results are being generated from the Wulira app. I could hear the low and high frequencies through the headsets.” -(Interviewee 2)

It is better technology:

To some participants who had ever experienced hearing testing, using the tuning fork and pure tone audiometry, the incorporation of new smart phone app technology in the Wulira app in screening for hearing loss, was viewed as an improvement, that would lead to better results of the testing. This would be crucial in areas where many participants need to be assessed and treated, if need arises.

“I think the Wulira App is a better technology because with the tongs, well I feel like even the frequencies in which the sounds come from the tongs it may differ depending on the strength at which it has been hit.” (Interviewee 12)

In addition, other participants appreciated the information technology invested in the Wulira app, which was faster and equivalent to previous analogue testing tools, like the tuning fork.

“Within the medical checkups, there is also testing for hearing capacity amongst our workers, and we basically have been using the analogue medical tools (not IT programmed like the Y shaped tuning fork), which were being handled by the medical team. But now having this tool which uses an App, it will ease the process of our medical checkups with our workers”- (Interviewee 2)

Potential benefits of Wulira app hearing screening test:

Some of the participants cited that the hearing testing using the Wulira app would provide information on the hearing status of their work colleagues. This may have future positive effects of the work environment noise protections and work place health policies. This is illustrated by the quote:

“We will get feedback on the hearing tests quickly about our work colleagues and I believe that it (Wulira app testing) will help us to assess whether we need to improve on the working conditions so that people don’t get hearing loss.” (Interviewee 5)

Intervention coherence

Testing procedure was comprehendible:

All the participants knew the details of how the intervention was performed. They described the use of headphones and different frequencies, sent by an assessor to their ears. After this, they made signals to show that they had heard the sounds.

“They started by checking our ears with a bright light to see whether I have wax and they asked if I have any problem with our hearing, after they connected the phone on to the Wulira App headset and then I would give signals in case I heard any sound like give a signal to the person who was interviewing. He would detect whether we can hear the low, high or mild, any sound or the high-pitched ones. However low it would be he told me that I had to give him a signal.” (FGD 3)

Opportunity cost and ethicality

Opportunity cost is defined as the potential loss or gain from other alternatives, when a choice is made, while ethicality is the extent to which the intervention is considered as a good fit with their values for these two constructs. The sub-themes overlapped, and are presented together.

Opportunity cost

Willing to leave work for hearing assessment:

Participants were willing to give up time they would have used for other activities, so that they would participate in the intervention. To most of the participants (10/12 in depth interviews), they did not lose much through their participation in the hearing test assessment:

“The exercise took me about 15 minutes. It did not affect my work schedule as I utilized the big lunch break since the procedure was not time consuming” (Interviewee 9)

Similar findings were found in the FGDs as shown:

“it (hearing assessment with Wulira app) took around four minutes which as just so small and it didn’t affect my work schedule because my schedule always takes longer than that "(FGD 1)

Lack of time to do testing:

Inadequate time to participate in the hearing was also a barrier to accepting the hearing assessment using the Wulira app, since they work in sections of the production plant, that keep running throughout the day.

“…I work in the very production section, and it is challenging to leave the station at any time I am on duty.” (Interviewee 11)

Ethicality

The use of the Wulira app to address the screening needs for hearing loss among the workers was viewed as suitable for their work lifestyle.

Personal relevance:

In the FGDs, the participants felt that the hearing assessment by the Wulira app was an intervention they could benefit from. They felt that they would be able to know their hearing status more frequently. One participant mentioned that:

“With the Wulira App I think I will be able to do frequent screening to determine my hearing performance because with this App I don’t have to go and see a doctor. I can do it any time I feel my ears have a problem or my hearing is not okay, and I think it’s necessary because hearing is a major sense to us as humans.” (FGD 4)

Willingness to do more frequent hearing tests:

Based on their current personal experiences, the study participants were willing to have routine hearing assessments at their workplace. They felt that this regularity might help them realize any hearing problems earlier, and seek faster and appropriate management. However, the frequency varied between participants, with ranges from once a month, to once a year.

“…I would advocate for it. I would advocate for frequent screening as long as the frequency for screening is determined, like if at all they have adjusted like maybe depending on our noise levels and environment, if at all we do like quarterly or maybe twice a year depending on the frequency of usage, I would advocate for the frequent screening” (Interviewee 2)

Interestingly to other participants, the frequency of routine screening would even be better, if dropped to biweekly clinic assessments, as shown in this quote:

“…because Wulira app wouldn’t incur very many costs, that would at least be two weeks….” (Interviewee 11).

Discussion

This current study showed that hearing assessment, using Wulira App is acceptable, in addition the Wulira App, is easy to use, and an effective hearing loss screening tool. However, challenges like technology illiteracy and lack of smart phones were mentioned, as the barriers that could hinder Wulira App usage.

A Study done by Sabur et al, revealed that Digital technologies introduction in medicine faces barriers like end user acceptance [24]. Contrary to that, our results show that Wulira App was acceptable to the industrial workers. A previous study has shown that Wulira App has a similar sensitivity and specificity, at detecting hearing loss, when compared to the conventional PTA [13], hence this could explain its acceptability. This current result shows that Wulira App is an effective hearing loss assessment tool. Audiometry access in Uganda being minimal, Wulira App gives the option of prevailing valid audiometer data.

Participants in this study revealed that Wulira app was easy to use, however, they had challenges in navigating and knowing how to use the app in assessing hearing loss. A Study performed by Zhenzhen et al, revealed that for promotion of mHealth interventions, they should be user friendly [25]. Other studies have shown that difficulty in use of mHealth technologies in terms of navigation and network reliability, compromised the efficiency and usability of the technologies [26-28]. Wulira App team took careful measures to overcome such challenges, like making the app accessible offline and online, and embedding directory messages on how to use the App.

Generally, most individuals do not desire to be informed that they are ill, and resent the idea that their work life and life-style will be endangered by their health state [29-31]. Similarly, participants in our study feared the prospect of getting bad news, hence limiting the App’s acceptability. Hearing loss is strongly linked to depression [32,33]. With this result, there should be an increase in education regarding the importance of screening for hearing loss. The decreased ability to hear is annoying in and of itself [34]. With screening, hearing loss is detected early enough, and treated appropriately [34]. The focus of screening is to separate individuals who have a potential hearing disorder, from those who don’t [35].

Our results revealed that Wulira App’s compatibility with only smartphones will be a major barrier for individuals in rural areas, or with no smart devices. In Uganda, 70.9% of the individuals own a mobile phone, however, of these, 15.8% have a smartphone, with more urban individuals in possession of these phones [11]. Primary inhibitor to the possession of smart devices is affordability of these devices [11,36]. With rapid changes and fall in smart phone prices, affordability of such devices will soon be solved, thus increasing usage of smart phone-based interventions. The employers could as well provide test personal hearing on a stand-alone smartphone on which the application is installed under the supervision of a technology skilled person to assist individual persons.

One of the challenges to getting hearing care is the cost of equipment and services [37,38]. A study done by Hussein et al., revealed that traditional diagnostic audiometers are expensive [37]. Contrary to that, participants in our study revealed that Wulira App is an intervention that could bring cost savings, when accessing for hearing testing. This finding conforms to the need to integrate low cost interventions, in countries that have limited health budgets [38,39].

Participants reported that Wulira App was effective in assessing hearing loss of both low and high frequencies, as it would give a range of results for both high and low frequencies, which was not the case with other testing gadgets they had interfaced with. This acceptance shows that Wulira App may be acceptable in assessing hearing loss of both low and high frequencies. In addition, participants revealed that Wulira App was faster in assessing hearing loss, thus being a time saver.

Limitation

Participants were initially screened for hearing loss using the Wulira App, before being recruited for the FGDs. Of those screened, none was found to be having hearing loss. This might have influenced the participants’ optimism and perceptions, when being later asked to describe their experience and their perceived acceptability of the App. However, this potential bias was reduced by making participants unaware of their results before the FGDs, and using open ended questions when conducting the FGDs.

Conclusion

The study suggests that Wulira App could be an acceptable, cost-effective, easy to use, and time saving tool in hearing assessment. However, challenges such as technology illiteracy, lack of smart phones, and fear of getting to know their test results, could hinder uptake. There is need of educating industrial workers on the essence of carrying out regular hearing loss screening, such that barriers like fear of getting screened are overcome.

FGD guide tool.

(DOCX)

Click here for additional data file.

Consolidated criteria for reporting qualitative research check list.

(DOCX)

Click here for additional data file.

13 Dec 2021

8 Feb 2022

Reviewer #1: Dear authors thank you for your research:

-I preferred to mention the detailed of the Sekhon’s framework of Acceptability tool of data collection in the method section.

Authors’ Response:

Thanks for the suggestion. We have addressed this.

-regarding the sample size: could you please give some information about data saturation principle.

Authors’ Response:

Participants were recruited until the point of saturation (54) was reached. We determined that we had reached saturation when no new themes were being derived from subsequent interviews. It was possible to determine the saturation since the analytical process was an on-going process, taking place alongside the data collection. We also determined saturation by varying our participants and determining whether any new themes came up.

2 you mention many limitations for the study that affect the validity of your results; what did you conduct to decrease the effect of them on your study results?

and you didn't ; why?

Authors’ Response:

The study had one notable limitation. Participants were initially screened for hearing loss using the Wulira App before being recruited for the FGDs. Of those screened, none was found to be having hearing loss. This might have influenced the participants’ optimism and perceptions, when being later asked to describe their experience and their perceived acceptability of the App. However, this potential bias was reduced by making participants not aware of their results before the FGDs and using open ended questions when conducting the FGDs.

Reviewer #2: General comments:

- Please avoid starting a sentence as "There is/was/are/were" in scientific writing.

Authors’ Response:

Thank you for this suggestion. We have addressed this.

- Do not use the full stop after the title of the section.

Authors’ Response:

Thank you for this observation. We have corrected this.

Abstract:

- Please say when and where the study was done.

Authors’ Response:

Thanks for the suggestion. We have addressed this. The study was conducted in a steel and iron manufacturing industry in Kampala during the month of April 2021.

- It is not clear which were the inclusion/exclusion criteria.

Authors’ Response:

Thank you for the observation. Due to the world limit, we had removed some of these aspects. The inclusion criteria included; permanent staff employed by the industry who were above 18 years and had consented to take part in the study. We excluded participants who had established history of hearing loss.

- It is not clear what was tested with the FGDs.

Authors’ Response:

FGDs explored group level perceptions regarding the Wulira app.

- The results are not specific (e.g., how many are considered friendly or cheap; what time-saving means, etc.)

Authors’ Response:

Qualitative results are not designed to be generalizable or to draw inference from the proportion within the sample that share a belief. As such, this information was not presented among our results.

Introduction:

- "has increased the risk of developing hearing loss" how considerable the risk is?

Authors’ Response:

The cited study done by Nondahl et al (5), on recreational firearm use revealed that, men (n=1538) who had ever regularly engaged in target shooting (odds ratio, 1.57; 95% confidence interval, 1.12-2.19) or who had done so in the past year (odds ratio, 2.00; 95% confidence interval, 1.15-3.46) were more likely to have a marked high-frequency hearing loss than those who had not. Risk of having a marked high-frequency hearing loss increased 7% for every 5 years (odds ratio, 1.07; 95% confidence interval, 1.03-1.12).

- Please also report the 95% confidence interval associated with Se and Sp.

Authors’ Response:

Thanks for the suggestion. Confidence intervals have been reported in the updated manuscript. Specificity of 93.2% (right ear, 95 % CI (88.1-95.4 %)) ,91.5% (left ear, 95 %CI (87.2-94.7)) and sensitivity of 91.4% (right ear, 95% CI (88.9-93.5%)), 88.4% (left ear, 95% CI (85.6-80.9)).

- "Previous studies" to which populations were these previously study conducted?

Authors’ Response:

Study by Meinke et al was carried out among industrial workers (manufacturing and administrative workers). The study population in this study was similar to ours. Study by Scheibe et al was carried out among diabetic patients aged 50 or older.

- "phone ownership is still low due to the cost" how low and how much does it cost relative to the income of persons who work in industries where hearing loss occurs?

Authors’ Response:

The Uganda National ICT Survey released in April 2018, revealed that 70.9% of individuals had a mobile phone. And of these, only 15.8% had smart phones. In terms of cost, most individuals on average spent UGX 14,500 per month on their phone. Among individuals that did not own a mobile phone, the cost of the mobile phone was the biggest barrier (cited by 88.9% of respondents), followed by the challenges of charging the phone battery (cited by 36.6% of respondents).

https://www.nita.go.ug/sites/default/files/publications/National%20IT%20Survey%20April%2010th.pdf

- "Literature on the acceptability of mobile audiometry for monitoring purposes in Africa and Uganda is scarce" Briefly present these studies and their results.

Authors’ Response:

From literature review, studies that were found assessing hearing loss screening using mobile audiometry were among the pediatric population in South Africa and Malawi. Due to a different study population between our study and the reviewed studies, this statement has been removed from the updated manuscript.

- It is not clear which is hearing loss among industrial workers in the target population.

Authors’ Response:

The WHO defines disabling hearing loss as to hearing loss greater than 40dB in the better hearing ear in adults.

- End this section with the aim of your study.

Authors’ Response:

Thank you. We have included the aim of the study as suggested.

Methods:

- It is not clear when the study was conducted.

Authors’ Response:

Thanks for the observation. This has been updated accordingly. The study was conducted in a steel and iron manufacturing industry in Kampala during the month of April 2021.

- "industrial workers at a steel and iron manufacturing industry" Are the steel and iron manufacturing industry the most prevalent industry where hearing loss can occur?

Authors’ Response:

A study performed in Tanzania assessing industrial workers at risk of occupational hearing loss revealed that steel and iron factory workers had a prevalence of 48%. Tanzania having similar settings like Uganda, we felt it necessary to carry out our study in a similar study population.

- Why was this particular city and industry was chosen?

Authors’ Response:

As of 2011, Kampala had 32% of the total number of manufacturing industries in Uganda. Steel and iron manufacturing industry employed the largest number of people in Kampala district which was close to 8,233 people. The selected industry employed over 1,100 staff on permanent basis thus having more than enough participants to meet the sample size of our study.

- The inclusion criteria are not sufficiently presented (e.g., how many years were they working in that industry, had the family history of hearing loss? etc.).

Authors’ Response:

Duration of work was not included in the inclusion but rather all permanent workers aged 18 years and above, and consented were included in the study.

- It is not clear how the participant was recruited and how the participants were decided.

Authors’ Response:

In selection of the participants, we discussed with the industry workers’ supervisor and selected those available, willing to participate, and working in a noisy section. Upon selection, they were then screened for hearing loss using the Wulira App. The screening was done by a trained audiologist who was part of the study team. After screening, the participants were then enrolled for the FGDs.

- Define "most active participants".

Authors’ Response:

“most active participants” were those that appeared to have more to say, but were not given enough time in the FGDs as observed by the moderator.

- Is there any reason why the participants were not evaluated for hearing loss by gold standard procedure?

Authors’ Response:

Wulira has already been validated against the gold standard and found to be as good (14). This current study was to explore acceptability of the Wulira App.

- It is not clear which questions were in the interviews.

Authors’ Response:

Thank you. The guide has been submitted as a supplementary to the manuscript. Some of the questions included;

a. In your opinion, what is occupational hearing loss?

b. Have you undergone testing for hearing loss? If so, where did you go and what did they use to test you for hearing loss?

c. Was the Wulira app used to test your hearing ability? If it was used, how did you find the exercise? Would you mind telling me how the exercise went? (Affective attitude).

d. Tell me about the duration of the screening exercise using Wulira App. How long did it take to start and end? Was there any inconvenience you felt during this exercise? (Burden).

- It is not clear if the participants used the App on their own phones or not.

Authors’ Response:

The participants did not use the App on their phones but rather one of the study team member (FB) carried out this assessment using the App installed on the study tablet. This has been updated accordingly in the revised manuscript.

- It is not clear if the participants were or not with phone/smartphone skilled.

Authors’ Response:

The participants did not use the App on their phones but rather one of the study team member (FB) carried out hearing assessment using the Wulira App installed on the study tablet.

Results:

- Put the results either in text or in Tables. Do not duplicate the results in text and tables/figures.

Authors’ Response:

Thank you for the constructive feedback. We have improved the presentation of our results in text and those in table.

- Do not include in the body of the table the units of measurements (e.g. %).

Authors’ Response:

Thanks for this observation. This has been updated accordingly.

- "The results from the IDI and FGDs revealed themes that are presented using Sekhon’s framework to understand the acceptability of the hearing assessment using the Wulira app" this information is duplicated; please delete it.

Authors’ Response:

Thanks for the suggestion. This has been revised as suggested.

- It is not clear how many participants agreed with the features presented in Table 2 as facilitator/barrier.

Authors’ Response:

Qualitative results are not designed to be generalizable or to draw inference from the proportion within the sample that share a belief. As such, this information was not presented among our results.

Discussion:

- Do not duplicate information (the aim of the study is already known).

Authors’ Response:

Thanks for this observation. This has been revised accordingly.

- It is useful to begin the discussion by briefly summarizing the main findings and explore possible mechanisms or explanations for these findings.

Authors’ Response:

Thank you for the suggestion. We have greatly improved the discussion of our results.

- Emphasize the new and important aspects of your study and put your findings in the context of the totality of the relevant evidence. State the limitations of your study, and explore the implications of your findings for future research and for clinical practice or policy.

Authors’ Response:

Thanks for the constructive feedback. We have greatly improved the discussion of our results.

- "Our results revealed that Wulira App’s compatibility with only smartphones will be a major barrier for individuals in rural areas or with no smart devices" a possible solution to this barrier is that the employer to provide the possibility to test personal hearing on a stand-alone smartphone on which the application is installed and why not with a supervision of a technology skilled person to assist individual persons.

Authors’ Response:

The authors appreciate the reviewer for this insightful feedback. The suggestion has been included in the revised manuscript.

- The main limitation of your study is the absence of performance evaluation of the used App since the respondent was disease-free and no standard gold diagnosis was made.

Authors’ Response:

Performance of the app was assessed elsewhere albeit in a different patient population. Wulira has already been validated against the gold standard and found to be as good (14). This current study was to explore acceptability of the Wulira App.

Conclusions:

- Not all sentences presented here are conclusions (e.g., 453-457).

Authors’ Response:

Thank you for the feedback. The conclusion has been updated to align with the results of the study.

- Please provide the date for ethics approval.

Authors’ Response:

The Uganda National Council for Science and Technology (UNCST) approved the research protocol on 22/02/2021. UNCST registration number is HS1237ES.

Reviewer #3: The reviewed article presents a qualitative evaluation of the acceptability of the Wulira App in assessing hearing loss among industrial workers in Kampala, Uganda.

Overall, this qualitative investigation produced a useful insight into both facilitating and hindering factors experienced by a sample of industrial workers after their hearing has been assessed using the evaluated App.

The evaluation involved 4 focus group discussions (FGD) with 8 participants per FGD and 12 in-depth interviews (IDI), conducted after all industrial workers were first tested for hearing loss using the evaluated App.

None of the investigated workers has been found to be suffering from hearing loss.

In this reviewer’s opinion, this might have influenced the participants’ optimism and perceptions, when being later asked to describe their experience and their perceived acceptability of the App.

Unless the audiometric test results were not communicated to participants until after their participation in the FGDs and IDIs (an aspect that should be clearly mentioned in the article), this represents a limitation that should also be mentioned by the authors, and which should be addressed by future studies, by including a larger number of participants which may ensure not only the qualitative-data saturation (which dictated sample size in this study), but also a reasonable number of participants with hearing problems to be detected by the App (thereby reflecting the prevalence of hearing loss in the targeted population of industrial workers).

Authors’ Response:

The authors thank the reviewer for this constructive feedback. This limitation has been included in the updated manuscript. Audiometric test results were not communicated to the participants prior to attending the FGDs. The results were communicated to them after the FGDs. This has been made clearer in the updated manuscript.

Despite the major conflict of interest that has been declared by 3 of the authors (who own, direct and/or have participated in the development of the evaluated App), other than this possibly important limitation of the study (which needs to be clarified or stated along with those already underlined in the Limitations section), the scientific approach appears to have been conducted using fairly objective methods (as described in the Methods part of the study and as reported in accordance to the COREQ guidelines).

Authors’ Response:

The authors thank the reviewer for this submission.

Also, lacking other evidence, the authors needed to rely on their own previous works when making accuracy/ sensitivity/ specificity claims about the investigated App. Given the aforementioned conflicts of interest, encouraging future independent studies of diagnostic accuracy and acceptability of the evaluated App would be desirable.

Authors’ Response:

The authors thank the reviewer for this suggestion.

Further improvements of the article manuscript may also be achieved by addressing the following issues:

Lines 73-75: please specify the gold standard against which the authors have determined the Se and Sp of the evaluated App in their previous work. Also, please specify the sample size and the 95% CI for Se and Sp.

Authors’ Response:

The gold standard was Pure Tone Audiometry (14). Confidence intervals have been reported in the updated manuscript. Specificity of 93.2% (right ear, 95 % CI (88.1-95.4 %)) ,91.5% (left ear, 95 %CI (87.2-94.7)) and sensitivity of 91.4% (right ear, 95% CI (88.9-93.5%)), 88.4% (left ear, 95% CI (85.6-80.9)).

Lines 129-130: please detail what “most active participants” means, since this may have been a highly subjective choice, leading to the selection of the most optimistic and favorably-oriented participants towards the evaluated App.

Authors’ Response:

“most active participants” were those that appeared to have more to say, but were not given enough time in the FGDs as observed by the moderator.

Lines 143-144: this reviewer suggests replacing “Before start of each FGD, moderator shared” with “Before the start of each FGD, the moderator shared”.

Thank you. The grammar in the statement has been rectified as suggested.

Line 150: this reviewer suggests replacing “moderator noted” with “the moderator noted”.

Thank you. The grammar has been rectified as suggested.

Line 172: this reviewer suggests replacing “FGD findings were ratified and triangulated themes got from IDI” with “The FGD findings were ratified and triangulated with themes got from IDI”.

Thank you. The grammar in the statement has been rectified as suggested.

Line 174: please specify which open code software was used to perform the analysis.

Thank you for this observation. Nvivo software was used to perform the analysis. This has been added in the updated manuscript.

Line 190: this reviewer suggests replacing “majority” with “the majority”.

Thank you. The grammar has been rectified as suggested.

Line 192: this reviewer suggests replacing “majority” with “a majority of them”.

Thank you. The grammar in the statement has been rectified as suggested.

Line 233: this reviewer suggests replacing “working high noise environments” with “working in high noise environments”.

Thank you. The grammar in the statement has been rectified as suggested

Line 235: there is an unlikely omission of a sense-giving verb in the verbatim transcription of Interviewee 10: “You never what result I would get.”

Thank you for this observation. The verb ‘Know’ was added in this verbatim transcription.

Line 290: this reviewer suggests replacing “prevented some of them for accessing” with “prevented some of them from accessing”.

Thank you. The grammar in the statement has been rectified as suggested

Lines 382-383: this reviewer suggests replacing “ranges from everyone month to once a year” with “ranges from once a month to once a year”.

Thank you. The grammar in the statement has been rectified as suggested.

Line 398: this reviewer suggests replacing “Study done” with “A study done”.

Thank you. The grammar has been rectified as suggested.

Lines 401-402: Once again, please specify the gold standard against which the Se and Sp of the App and of PTA have been determined, in order to reach a conclusion of “similarity” between the App and conventional PTA. Also, even if Se and Sp were indeed similar between the App and conventional PTA, it is not clear how that would influence or even “explain its acceptability”.

The gold standard was Pure Tone Audiometry (14). Confidence intervals have been reported in the updated manuscript. Specificity of 93.2% (right ear, 95 % CI (88.1-95.4 %)) ,91.5% (left ear, 95 %CI (87.2-94.7)) and sensitivity of 91.4% (right ear, 95% CI (88.9-93.5%)), 88.4% (left ear, 95% CI (85.6-80.9)).

Lines 406-407: this reviewer suggests replacing “Study done” with “A study performed”.

Thank you. The grammar has been rectified as suggested.

Line 420: this reviewer suggests replacing “to separate individuals with potential hearing disorder from those who don’t” with “to separate individuals who have a potential hearing disorder from those who don’t”.

Thank you. The grammar in the statement has been rectified as suggested.

Line 424: this reviewer suggests replacing “in possession with these phones” with “in possession of these phones”.

Thank you. The grammar in the statement has been rectified as suggested.

Line 435: please resolve the doubling in “would would”.

Thank you. The repeated word has been deleted.

Lines 476-478 and 480: There are several abbreviations in the list which do not appear in the text of this article: YLD, OHL, NIHL, MDR-TB. Those abbreviations might have been useful in previous publications of the authors, but should be removed from this article.

Thank you for this observation. The abbreviation list has been updated accordingly.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

28 Feb 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

1. Has the statistical analysis been performed appropriately and rigorously?

2. Have the authors made all data underlying the findings in their manuscript fully available?

The 

No

3. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

No

Generally the authord appropriated response to my comments and suggestions. However, some chnages are needed before publication:

- I am not a native English speaker bu I belive that your manuscript could benefit by English language professional service.

- Write the aim of the study at past tense.

- Some duplicated text exist in the revised manuscript (e.g. Affective attitude).

- Line 230-231 belongs to the methods section.

- Do not start a sentence with a number.

- Please avoid starting a sentence as "There is/was/are/were" in scientific writing.

- Do not use the full stop after the title of the section.

Abstract:

- Please say when and where the study was done.

- It is not clear which were the inclusion/exclusion criteria.

- It is not clear what was tested with the FGDs.

- The results are not specific (e.g., how many are considered friendly or cheap; what time-saving means, etc.)

Introduction:

- "has increased the risk of developing hearing loss" how considerable the risk is?

- Please also report the 95% confidence interval associated with Se and Sp.

- "Previous studies" to which populations were these previously study conducted?

- "phone ownership is still low due to the cost" how low and how much does it cost relative to the income of persons who work in industries where hearing loss occurs?

- "Literature on the acceptability of mobile audiometry for monitoring purposes in Africa and Uganda is scarce" Briefly present these studies and their results.

- It is not clear which is hearing loss among industrial workers in the target population.

- End this section with the aim of your study.

Methods:

- It is not clear when the study was conducted.

- "industrial workers at a steel and iron manufacturing industry" Are the steel and iron manufacturing industry the most prevalent industry where hearing loss can occur?

- Why was this particular city and industry was chosen?

- The inclusion criteria are not sufficiently presented (e.g., how many years were they working in that industry, had the family history of hearing loss? etc.).

- It is not clear how the participant was recruited and how the participants were decided.

- Define "most active participants".

- Is there any reason why the participants were not evaluated for hearing loss by gold standard procedure?

- It is not clear which questions were in the interviews.

- It is not clear if the participants used the App on their own phones or not.

- It is not clear if the participants were or not with phone/smartphone skiled.

Results:

- Put the results either in text or in Tables. Do not duplicate the results in text and tables/figures.

- Do not include in the body of the table the units of measurements (e.g. %).

- "The results from the IDI and FGDs revealed themes that are presented using Sekhon’s framework to understand the acceptability of the hearing assessment using the Wulira app" this information is duplicated; please delete it.

- It is not clear how many participants agreed with the features presented in Table 2 as facilitator/barrier.

Discussion:

- Do not duplicate information (the aim of the study is already known).

- It is useful to begin the discussion by briefly summarizing the main findings and explore possible mechanisms or explanations for these findings.

- Emphasize the new and important aspects of your study and put your findings in the context of the totality of the relevant evidence. State the limitations of your study, and explore the implications of your findings for future research and for clinical practice or policy.

- "Our results revealed that Wulira App’s compatibility with only smartphones will be a major barrier for individuals in rural areas or with no smart devices" a possible solution to this barrier is that the employer to provide the possibility to test personal hearing on a stand-alone smartphone on which the application is installed and why not with a supervision of a technology skilled person to assist individual persons.

- The main limitation of your study is the absence of performance evaluation of the used App since the respondent was disease-free and no standard gold diagnosis was made.

Conclusions:

- Not all sentences presented here are conclusions (e.g., 453-457).

- Please provide the date for ethics approval.

13 Mar 2022

Generally, the authors appropriated response to my comments and suggestions. However, some changes are needed before publication:

- I am not a native English speaker but I believe that your manuscript could benefit by English language professional service.

Authors’ Response:

Thanks for the suggestion. The manuscript has been proof read and has been remarkably improved regarding the grammar.

- Write the aim of the study at past tense.

Authors’ Response:

Thanks for this observation. This has been updated as suggested.

- Some duplicated text exists in the revised manuscript (e.g. Affective attitude).

Authors’ Response:

Thanks for this observation. We have proof read the manuscript. The updated manuscript has no duplicated text.

- Line 230-231 belongs to the methods section.

Authors’ Response:

Lines 230-231 have statements in the result section.

We believe you meant lines 440-441 in the limitation section. We acknowledge this statement should be in the methodology, however it was included here to explain the potential bias of our study and how we addressed this.

- Do not start a sentence with a number.

Authors’ Response:

Thanks for the suggestion. The sentence that was started with a number has been corrected as suggested.

Generally, the authors appropriated response to my comments and suggestions. However, some changes are needed before publication:

- I am not a native English speaker but I believe that your manuscript could benefit by English language professional service.

Authors’ Response:

Thanks for the suggestion. The manuscript has been proof read and has been remarkably improved regarding the grammar.

- Write the aim of the study at past tense.

Authors’ Response:

Thanks for this observation. This has been updated as suggested.

- Some duplicated text exists in the revised manuscript (e.g. Affective attitude).

Authors’ Response:

Thanks for this observation. We have proof read the manuscript. The updated manuscript has no duplicated text.

- Line 230-231 belongs to the methods section.

Authors’ Response:

Lines 230-231 have statements in the result section.

We believe you meant lines 440-441 in the limitation section. We acknowledge this statement should be in the methodology, however it was included here to explain the potential bias of our study and how we addressed this.

- Do not start a sentence with a number.

Authors’ Response:

Thanks for the suggestion. The sentence that was started with a number has been corrected as suggested.

Submitted filename: Responses to Reviewer.docx

Click here for additional data file.

15 Mar 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

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15 Mar 2022

Generally, the authors appropriated response to my comments and suggestions. However, some changes are needed before publication:

- I am not a native English speaker but I believe that your manuscript could benefit by English language professional service.

Authors’ Response:

Thanks for the suggestion. The manuscript has been proof read and has been remarkably improved regarding the grammar.

- Write the aim of the study at past tense.

Authors’ Response:

Thanks for this observation. This has been updated as suggested.

- Some duplicated text exists in the revised manuscript (e.g. Affective attitude).

Authors’ Response:

Thanks for this observation. We have proof read the manuscript. The updated manuscript has no duplicated text.

- Line 230-231 belongs to the methods section.

Authors’ Response:

Lines 230-231 have statements in the result section.

We believe you meant lines 440-441 in the limitation section. We acknowledge this statement should be in the methodology, however it was included here to explain the potential bias of our study and how we addressed this.

- Do not start a sentence with a number.

Authors’ Response:

Thanks for the suggestion. The sentence that was started with a number has been corrected as suggested.

Submitted filename: Responses to Reviewer.docx

Click here for additional data file.

29 Mar 2022

ACCEPTABILITY OF THE WULIRA APP IN ASSESSING OCCUPATIONAL HEARING LOSS AMONG WORKERS IN A STEEL AND IRON MANUFACTURING INDUSTRY.

PONE-D-21-32084R3

Dear Dr. twinamasiko,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

22 Apr 2022

PONE-D-21-32084R3

Acceptability of the Wulira app in assessing occupational hearing loss among workers in a steel and iron manufacturing industry

Dear Dr. Twinamasiko:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

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on behalf of

Dr. Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

Table 1

Socio-demographic characteristics of the participants.

Characteristics	N (%)
Sex
Male	21 (65.6)
Female	11 (34.4)
Age Median, IQR	27 (25–30)
Level of Education
Primary	02 (6.3)
Secondary	16 (50)
University	09 (28.1)
Others	05 (15.6)
Job Description
Management	06 (18.8)
Medical staff	02 (6.25)
Machine Operators	24 (75)
Duration of Work
Less than 6 months	03 (9.4)
Between 6 and 12 months	04 (12.5)
Between 12 and 24 months	09 (28.1)
More than 24 months	16 (50)
Hearing loss	00