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10.1371/journal.pone.0310953
PONE-D-24-06278
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Prevalence and risk factors of hearing loss in the Chinese population aged 45 years and older: Findings from the CHARLS baseline survey
Hearing loss prevalence and risk factors in Chinese adults aged 45+
Xu Xiaoli Conceptualization Data curation Methodology Resources Writing – original draft Writing – review & editing 1
Sun Gang Conceptualization Data curation Methodology Resources Writing – original draft Writing – review & editing 2
https://orcid.org/0000-0001-5698-7818
Sun Deping Conceptualization Data curation Formal analysis Investigation Project administration Resources Supervision Validation Writing – original draft Writing – review & editing 1 *
1 Department of Otorhinolaryngology Head and Neck Surgery, The Fourth Clinical College of Chongqing Medical University, Chongqing, People’s Republic of China
2 Department of Otorhinolaryngology Head and Neck Surgery, Shapingba District People’s Hospital of Chongqing, Chongqing, People’s Republic of China
Ilic Irena Editor
University of Belgrade: Univerzitet u Beogradu, SERBIA
Competing Interests: The authors have declared that no competing interests exist.

* E-mail: 800306@hospital.cqmu.edu.cn
23 9 2024
2024
19 9 e03109533 3 2024
29 8 2024
© 2024 Xu et al
2024
Xu et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Objective

This study aimed to determine the prevalence of hearing loss and identify associated risk factors in a Chinese population aged 45 years and older.

Study design

This study employed a cross-sectional research design. Data from the 4th wave survey of the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2018 were utilized. Participants were assessed using self-reported questionnaires, and various demographic and comorbidity factors were analyzed to elucidate the risk factors associated with hearing loss.

Methods

A total of 17,695 individuals from 10,257 households in 450 villages and urban settlements were included in the study. Hearing loss was assessed through self-reported questionnaires. Risk factors, including demographic characteristics and comorbidities, were analyzed to identify associations with hearing loss.

Results

The study population had a hearing loss prevalence rate of 17.9% (n = 3,179). Regional variations were observed, with highest rates in Chongqing (28.67%), Yunnan (25.12%), and Qinghai (24.36%), and lowest rates in Zhejiang (17.71%), Tianjin (10.56%), and Shanghai (9.26%). Age ≥70 was associated with higher risk (OR = 3, p<0.05), while being female was associated with reduced risk (OR = 0.81, p<0.05). Higher education level showed lower risk (OR<1, p<0.05). Non-agricultural workers had lower risk (OR = 0.67, p<0.05). Fewer social activities were correlated with decreased risk (OR = 0.89, p = 0.024). Ethnic minorities had slightly higher risk (OR = 1.23, p<0.05).

Conclusion

This study provides valuable insights into the prevalence and risk factors associated with hearing loss in the Chinese population aged 45 years and older. The findings emphasize the importance of early detection and intervention, particularly among older individuals and those residing in specific regions, for effective hearing loss management.

The author(s) received no specific funding for this work. Data AvailabilityWe confirm that all data necessary to reproduce our study's results are readily available. The source data is from the China Health and Retirement Longitudinal Study (CHARLS), which is publicly accessible via their website (http://charls.pku.edu.cn/). Detailed data usage guidelines are provided there. Specific data files and variables used in our analysis are detailed in the Supporting Information section of our manuscript, complete with descriptions and analysis methods. Additionally, the minimal data set for replication is available in Dryad with the DOI: https://doi.org/10.5061/dryad.mpg4f4r85, and is unrestricted for sharing.
Data Availability

We confirm that all data necessary to reproduce our study's results are readily available. The source data is from the China Health and Retirement Longitudinal Study (CHARLS), which is publicly accessible via their website (http://charls.pku.edu.cn/). Detailed data usage guidelines are provided there. Specific data files and variables used in our analysis are detailed in the Supporting Information section of our manuscript, complete with descriptions and analysis methods. Additionally, the minimal data set for replication is available in Dryad with the DOI: https://doi.org/10.5061/dryad.mpg4f4r85, and is unrestricted for sharing.
==== Body
pmc1 Introduction

Hearing loss is a significant global health issue, affecting a large number of individuals. In 2019, it was estimated that approximately 1.51 billion to 1.64 billion people worldwide, about one-fifth of the population, experienced hearing loss. These numbers are predicted to rise dramatically by 2050, with an estimated 2.35–2.56 billion individuals suffering from hearing loss. According to the Global Burden of Disease research, hearing loss ranks as the third leading cause of years lived with disability (YLDs) [1].

The impact of hearing loss extends beyond physical implications and affects an individual’s quality of life and communication abilities [2, 3]. Studies have found links between hearing loss and cognitive decline [4], increased risk of dementia in older adults, negative emotional experiences [5], and social isolation [6]. Moreover, individuals with hearing loss face higher rates of unemployment compared to those without hearing loss, emphasizing the importance of addressing this issue.

In China, the prevalence of hearing loss is on the rise due to the aging population. Understanding the prevalence and associated risk factors within the Chinese population is crucial for implementing effective prevention and intervention strategies. Previous studies have provided valuable insights into the prevalence of hearing loss among older adults in specific regions of China [7, 8]. However, these studies had limitations in terms of their limited coverage or outdated data.

Self-reported measures of hearing capacity, despite their subjective nature, have proven effective in identifying a wide range of individuals with significant hearing loss. This method offers a more detailed picture of real-world hearing ability, encompassing both the severity of impairment and its perceived effects on daily life. Large-scale epidemiological studies have utilized self-reported hearing loss to provide critical insights into the prevalence and distribution of hearing impairment across populations [9, 10].

To address the limitations of previous research, our study leverages data from the China Health and Retirement Longitudinal Study (CHARLS) to examine the incidence of hearing loss among the middle-aged and elderly. By tapping into the extensive and representative CHARLS dataset, we aim to obtain precise and contemporary data on the prevalence of hearing loss across the entire Chinese population. This research will not only deepen our understanding of the broader implications of hearing loss but also inform the creation of targeted interventions and policies to tackle this critical public health challenge.

2 Methods

2.1 Ethical approval

This study was conducted in accordance with the Declaration of Helsinki and was approved by the Biomedical Ethics Review Committee of Peking University (IRB00001052-11015). All participants provided informed consent prior to their inclusion in the study. The consent was obtained in written form, ensuring that participants were fully aware of the study’s purpose, procedures, and potential risks. The data were analyzed anonymously to protect the privacy and confidentiality of the participants.

2.2 Study population

The study utilized data from the fourth wave of the China Health and Retirement Longitudinal Study (CHARLS), conducted in 2018. The participants included in this wave were individuals aged 45 or above and their spouses, with one participant selected from each household. The CHARLS national baseline survey was first conducted in 2011 and included a total of 17,708 individuals from 10,257 households across 450 villages and urban settlements in 28 provinces [11]. The sampling method used was probability-proportional-to-size (PPS) random sampling, with a stratified multi-stage design based on per capita GDP of urban districts and rural counties [11]. Further details about the CHARLS survey, as well as the data utilized in the present study, can be accessed via the Dryad Digital Repository at the following DOI: https://doi.org/10.5061/dryad.mpg4f4r85.

The study included participants aged 45 years or older. The exclusion criteria consisted of: 1) individuals lacking a hearing questionnaire, 2) Excluding participants with missing survey weight data is crucial to ensure the representativeness of our epidemiological study and maintain the accuracy of our findings, as these weights correct for response bias and ensure our sample accurately reflects the broader population. A total of 17,695 eligible participants’ data were included in the statistical analysis. Fig 1 illustrates the flowchart of the data selection process.

10.1371/journal.pone.0310953.g001 Fig 1 Participant selection flow diagram.

2.3 Hearing loss

Participants with hearing loss (HL) self-reported their condition in our study. While objective tests such as audiometric testing were not included in the CHARLS survey, previous research has demonstrated the reliability of using questionnaires to identify individuals with hearing problems [12, 13]. Moreover, a validation study conducted in China showed that a single question had a sensitivity of 100% for detecting moderate or higher degrees of hearing impairment in older adults, defined as a pure-tone average at 0.5–4 kHz >40 dB, with a specificity of 84.5% [14]. Additionally, self-reported functional hearing capacity may capture a larger number of people with significant hearing loss and provide a more accurate assessment of real-world hearing ability [15–17].

To address the need for clarity in our assessment of hearing loss, we utilized a self-administered questionnaire that has been previously employed and validated in various research studies. [18–20]. While we acknowledged its use in prior research, we recognize the necessity for a more explicit description of the instrument in our manuscript. The questionnaire, adapted from a validated hearing assessment tool, included the following questions:

"Do you ever wear a hearing aid?" with responses categorized as ’Yes’ or ’No’.

"Would you say your hearing is excellent, very good, good, fair, or poor? Please assess your hearing with a hearing aid if you normally use one, and without if you normally don’t." with a Likert scale ranging from ’Excellent’ to ’Poor’.

Participants were classified as having hearing impairment based on meeting either criterion: the use of a hearing aid or a rating of ’fair’ or ’poor’ for their hearing status. This approach ensures a standardized assessment consistent with previously validated methods, allowing for a reliable determination of self-reported hearing loss [12, 13].

This methodology enabled a thorough capture of self-reported hearing capabilities, a significant measure for gauging the impact of hearing loss in everyday scenarios. The questionnaire was meticulously administered via face-to-face interviews by trained investigators, ensuring the precision and uniformity of the collected data.

2.4 Covariates

The covariates included in the analysis were: age (45–49, 50–59, 60–69, ≥70), gender (male or female), education level (illiterate, literate, primary, secondary, high school or above), marital status (married or other), residential area (rural or urban), health insurance (covered or not covered), household size (living alone, two people, three people, ≥four people), occupation type (agricultural, non-agricultural, retired/unemployed), alcohol consumption (drinkers or non-drinkers), current smoking habit (smokers or non-smokers), instrumental activities of daily living (IADLs) difficulty (with or without), any weekly contact with children in person, by phone, mail or E-mail (yes or no), social engagement (Have you done any of these activities in the last month?), nation (Han ethnicity or ethnic minorities).

2.5 Handling missing data for categorical variables

To address missing values in categorical variables, we employed the "missing" indicator variable method. This method involves creating a binary variable indicating the presence or absence of missing data. Both the original categorical variable and the "missing" indicator variable were included in the analysis to account for the various categories and the influence of missingness. Treating missing data as an additional category enables examination of its impact and a comprehensive understanding of the data.

2.6 Statistical analysis

To address potential bias, the prevalence estimations and risk factors analysis for hearing loss in this study were adjusted by incorporating weights that accounted for the study design, individual weight, and non-response adjustments at both the individual and household levels. All baseline variables in the study were categorical and expressed as absolute counts and percentages. To assess the variations in baseline variables according to the incidence rate of hearing loss, the Kruskal-Wallis test was employed for comparison.

In the multivariate logistic regression analysis, we calculated adjusted odds ratios (ORs) to identify the risk factors associated with hearing loss. The presence of hearing loss was considered the dependent variable in the logistic regression model. The independent variables included various categories such as age, gender, education, living region, health insurance, number of individuals in the household, work status, drinking habits, smoking habits, contact frequency, engagement in social activities, and nationality.

Data cleaning and analysis were conducted using R software (version 4.1.2, R Foundation for Statistical Computing, Vienna, Austria). A significance level of P < 0.05 was used to determine statistical significance.

3 Results

3.1 Demographic characteristics of the participants

Our analysis of 17,695 individuals revealed a 17.9% prevalence of hearing loss. We meticulously examined demographic characteristics, including age, gender, education level, residential area, marital status, and ethnicity. The age distribution across the cohorts was as follows: 9.2% were aged 45–49, 33.5% were 50–59, 34.4% were 60–69, and 22.9% were 70 or older. Regarding education, 24.9% were illiterate, while 11.1% had completed high school or advanced degrees. The majority of participants identified as Han ethnicity, accounting for 92.3% of the study population. These findings are summarized in Table 1.

10.1371/journal.pone.0310953.t001 Table 1 Summary descriptive table by groups of hearing status.

Characteristic	Total	No hearing loss	Hearing loss	
Respondents	17695	14516(82.03%)	3179(17.97%)	
Age:				
    45–49 years	1626(9.2%)	1471 (10.1%)	155 (4.88%)	
    50–59 years	5929(33.5%)	5261 (36.2%)	668 (21.0%)	
    60–69 years	6088(34.4%)	5016 (34.6%)	1072 (33.7%)	
    ≥70 years	4052(22.9%)	2768 (19.1%)	1284 (40.4%)	
Gender:				
    Male	8423(47.6%)	6961 (48.0%)	1462 (46.0%)	
    female	9272(52.4%)	7555 (52.0%)	1717 (54.0%)	
Education:				
    illiterate	4404(24.9%)	3272 (22.5%)	1132 (35.6%)	
    literate	2854(16.1%)	2248 (15.5%)	606 (19.1%)	
    primary education	5024(28.4%)	4241 (29.2%)	783 (24.6%)	
    middle-school	3441(19.4%)	2978 (20.5%)	463 (14.6%)	
    high-school or above	1972(11.1%)	1777 (12.2%)	195 (6.13%)	
marital status:				
    married	7258(41.0%)	5520 (38.0%)	1738 (54.7%)	
    separated,Divorced or others	10437(59.0%)	8996 (62.0%)	1441 (45.3%)	
Living region:				
    rural	10878(61.5%)	8688 (59.9%)	2190 (68.9%)	
    urban	6817(38.5%)	5828 (40.1%)	989 (31.1%)	
Health insurance:				
    no	658(3.7%)	516 (3.55%)	142 (4.47%)	
    yes	17027(96.2%)	13991 (96.4%)	3036 (95.5%)	
    miss	10(0.1%)	9 (0.06%)	1 (0.03%)	
Household size:				
    living alone	1543(8.7%)	1142 (7.87%)	401 (12.6%)	
    two individuals	8858(50.1%)	7231 (49.8%)	1627 (51.2%)	
    three individuals	3218(18.2%)	2718 (18.7%)	500 (15.7%)	
    ≥four individuals	4076(23.0%)	3425 (23.6%)	651 (20.5%)	
Work:				
    agricultural	6344(35.9%)	5124 (35.3%)	1220 (38.4%)	
    non-agricultural	4875(27.6%)	4400 (30.3%)	475 (14.9%)	
    retired or no work	6476(36.6%)	4992 (34.4%)	1484 (46.7%)	
Drinking:				
    no	11764(66.5%)	9471 (65.2%)	2293 (72.1%)	
    yes	5931(33.5%)	5045 (34.8%)	886 (27.9%)	
Current smoking habit:				
    no	13041(73.7%)	10635 (73.3%)	2406 (75.7%)	
    yes	3797(21.5%)	3216 (22.2%)	581 (18.3%)	
    miss	857(4.8%)	665 (4.58%)	192 (6.04%)	
IADLs difficulty:				
    no	11764(66.5%)	9471 (65.2%)	2293 (72.1%)	
    yes	5931(33.5%)	5045 (34.8%)	886 (27.9%)	
FCI:				
    no	1769(10.0%)	1396 (9.62%)	373 (11.7%)	
    yes	15605(88.2%)	12869 (88.7%)	2736 (86.1%)	
    miss	321(1.8%)	251 (1.73%)	70 (2.20%)	
Social engagement:				
    no	4236(23.9%)	3672 (25.3%)	564 (17.7%)	
    yes	13289(75.1%)	10728 (73.9%)	2561 (80.6%)	
    miss	170(1.0%)	116 (0.80%)	54 (1.70%)	
Nation:				
    Han	16333(92.3%)	13437 (92.6%)	2896 (91.1%)	
    Minorities	1362(7.7%)	1079 (7.43%)	283 (8.90%)	
IADLs: instrumental activities of daily living, FCI: Any weekly contact with children in person, by phone, mail or E-mail/ Frequent Child Interaction

3.2. Prevalence of hearing loss in 2018

The prevalence of hearing loss varied significantly across different demographic factors. Age exhibited a strong association, with higher rates observed as age advanced. Education level also showed a significant correlation. Other factors such as gender, living arrangement, marital status, health insurance coverage, living region, occupation, work status, alcohol consumption, smoking habits, difficulty in instrumental activities of daily living (IADLs), contact with children, engagement in social activities, and ethnicity demonstrated significant variations in hearing loss prevalence,(Table 2). Regional differences were identified, with Chongqing, Yunnan, and Qinghai having the highest rates, and Zhejiang, Tianjin, and Shanghai having the lowest rates (Fig 2).

10.1371/journal.pone.0310953.g002 Fig 2 The prevalence of hearing loss in diffrent province of China.

10.1371/journal.pone.0310953.t002 Table 2 The prevalence of hearing loss by diferent characteristics among people aged 45 and older.

Characteristic	Prevalence(%)	95%CI	P	
Respondents				
Age:			<0.001	
    45–49 years	9.533	0.08–0.11		
    50–59 years	11.267	0.11–0.12		
    60–69 years	17.608	0.17–0.19		
    ≥70 years	31.688	0.30–0.33		
Gender:			0.047	
    male	17.357	0.17–0.18		
    female	18.518	0.18–0.19		
Education:			<0.001	
    illiterate	25.704	0.24–0.27		
    literate	21.233	0.20–0.23		
    primary education	15.585	0.15–0.17		
    middle-school	13.455	0.12–0.15		
    high-school or above	9.8884	0.09–0.11		
Marital status:			<0.001	
    married	23.946	0.23–0.249		
    separated,Divorced or others	13.807	0.132–0.145		
Living region:			<0.001	
    rural	20.132	0.194–0.209		
    urban	14.508	0.137–0.154		
Health insurance:			0.041	
    no	21.581	0.185–0.249		
    yes	17.831	0.173–0.184		
    miss	10	0.003–0.445		
Household size:			<0.001	
    living alone	25.989	0.238–0.283		
    two individuals	18.368	0.176–0.192		
    three individuals	15.538	0.143–0.168		
    ≥four individuals	15.972	0.149–0.171		
Work:			<0.001	
    agricultural	19.231	0.1830–202		
    non-agricultural	9.744	0.089–0.106		
    retired or no work	22.915	0.219–0.24		
Drinking:			<0.001	
    no	19.492	0.188–0.202		
    yes	14.9382	0.14–0.159		
Current smoking habit:			<0.001	
    no	18.45	0.178–0.191		
    yes	15.302	0.142–0.165		
    miss	22.403	0.197–0.253		
IADLs difficulty:			<0.001	
    no	19.492	0.188–0.202		
    yes	14.938	0.14–0.159		
FCI:			<0.001	
    no	21.085	0.192–0.231		
    yes	17.533	0.169–0.181		
    miss	21.807	0.174–0.267		
Social engagement:			<0.001	
    no	13.314	0.123–0.144		
    yes	19.272	0.186–0.2		
    miss	31.765	0.248–0.393		
Nation:			0.005	
    Han	17.73	0.171–0.183		
    Minorities	20.778	0.187–0.23		
IADLs: instrumental activities of daily living, FCI: Any weekly contact with children in person, by phone, mail or E-mail.

3.3 Sociodemographic, geographic, and lifestyle factors associated with hearing loss

A multivariable logistic regression analysis identified significant risk factors for hearing loss, including age (60–69: OR = 1.57, p<0.05; 70 and above: OR = 3.03, p<0.05), gender (female: OR = 0.88, p<0.05), education level (primary/middle/high school and above: OR<1, p<0.05), work status (non-agricultural: OR = 0.67, p<0.01), without social activity (OR = 0.89, p = 0.024), (OR = 0.89, p = 0.024), and ethnicity (minorities: OR = 1.23, p<0.05) (Fig 3).

10.1371/journal.pone.0310953.g003 Fig 3 Factors associated with hearing loss: Multivariable logistic regression analysis results.

4 Discussion

According to the study conducted on HCARLS, which involved 17,695 individuals, the overall prevalence of hearing loss was found to be 17.9%. Similarly, the Korea National Health and Nutrition Examination Survey (KNHANES) reported a prevalence of 8% for unilateral hearing loss and 5.9% for bilateral hearing loss among 16,799 aging participants [21]. In the United States, the National Health and Nutrition Examination Survey (NHANES) found that approximately 26% of males and over 20% of females, aged 20 to 80+ years, self-reported trouble hearing [22]. Large-scale population studies such as HCARLS, KNHANES, and NHANES provide comprehensive data on the prevalence of hearing loss across different populations, ensuring reliable and representative results due to their substantial sample sizes. The modest number of participants, a mere 48, reporting hearing aid use in our study indicates a possible underdiagnosis and limited adoption of these devices. This could be due to heightened barriers such as lack of awareness, accessibility issues, or cultural stigma. The small sample underscores the need for further research to uncover the specific challenges faced by hearing aid users and to develop effective intervention strategies.

The study identified certain demographic factors associated with higher rates of hearing loss. These factors include older age groups (particularly 60–69 and ≥70), females, individuals with lower education levels, those who are separated, divorced, or have other marital statuses, and individuals living in rural areas. The highest prevalence rates were observed in the provinces of Chongqing (28.67%), Yunnan (25.12%), and Qinghai (24.36%). Conversely, the lowest rates were found in Zhejiang (17.71%), Tianjin (10.56%), and Shanghai (9.26%). These findings highlight the importance of targeted interventions for these high-risk demographic groups.

Multivariate analysis identified several primary risk factors for hearing loss among individuals aged 45 years and above. These factors include age (≥60 years), lower education level (middle-school education and below), being male, and engaging in agricultural work, retirement, or unemployment. The correlation between age and the prevalence of hearing loss aligns with previous studies [23–26], indicating an increased likelihood of hearing loss with advancing age. This trend is consistent in other countries [21, 27] as well, emphasizing the importance of understanding the cumulative effects [24, 28] of various factors on hearing loss as individuals age.

Men were found to have a 12% higher risk of hearing loss compared to women, which is consistent with previous research studies [21, 23, 29]. Hormonal differences [30], occupational noise exposure [31–33], and potential genetic factors [34] contribute to this gender disparity.

Low levels of education were identified as a risk factor for hearing loss, with illiterate individuals having a 14% higher risk compared to literate individuals. The risk increases with lower levels of education, indicating the importance of considering socioeconomic disparities [35] and limited access to healthcare [36] in understanding the relationship between education and hearing loss.

While the study suggests that non-agricultural work may be associated with a lower risk of hearing loss, further research is needed to establish causation and explore the complex relationships between occupational factors, lifestyle choices, and hearing outcomes.

We made an intriguing discovery: there was a slight correlation between decreased participation in social activities and a diminished risk of hearing loss (OR = 0.89, p = 0.024). However, additional investigation is required to examine the specific underlying factors.

Additionally, in line with other studies [37], consistent evidence indicates that minorities face a higher risk of hearing loss compared to the Han ethnic group. This increased risk can be attributed to various factors, including genetic variations (such as the GJB2 gene [38]), socioeconomic disparities, limited access to healthcare, cultural practices, environmental factors, and occupational hazards.

Our multivariable analysis points to several key strategies for preventing hearing loss, particularly among those at higher risk. For the elderly, routine hearing screenings coupled with educational programs on hearing preservation are vital. Ensuring gender-neutral access to hearing health resources is essential, as is raising awareness through community programs, especially for individuals with lower levels of education. In the workplace, mandatory hearing protection measures should be emphasized for all, but particularly for non-agricultural workers who may face different noise exposures. Additionally, the study indicates that reduced social activity is associated with a slightly decreased risk of hearing loss, highlighting the need for further research to understand the underlying mechanisms. For ethnic minorities, targeted initiatives that consider cultural nuances are crucial. Implementing these interventions can significantly reduce the prevalence of hearing loss in our targeted populations.

While our study provides valuable insights into the prevalence and risk factors of hearing loss among the Chinese population aged 45 years and older, there are inherent limitations that should be acknowledged. Firstly, the cross-sectional nature of our research design limits our ability to establish causality between the identified risk factors and hearing loss. Secondly, reliance on self-reported data through questionnaires, although validated, may introduce subjective bias, affecting the accuracy of hearing loss prevalence. Thirdly, the generalizability of our findings may be constrained by the regional representation of the CHARLS survey, which may not fully capture the diversity across all areas of China. Additionally, the lack of objective audiometric testing could potentially overlook nuances in the degree and type of hearing loss. Lastly, while we controlled for several variables, there may be residual confounding factors that were not accounted for in our analysis. Despite these limitations, our study offers a robust foundation for further research and underscores the need for early detection and intervention strategies to address hearing loss in the aging population.

The study’s robust methodology, characterized by its national scope and diverse participant demographics, significantly enhances the credibility of our findings. Nonetheless, we are mindful of the potential biases arising from the reliance on self-reported data for hearing loss within the CHARLS framework. To mitigate these biases, we advocate for the integration of objective auditory evaluations in subsequent research endeavors, thereby enhancing the precision of prevalence estimates. Our analysis, while revealing several key risk factors, also acknowledges the potential influence of additional variables such as occupational noise exposure, ear diseases, and genetic factors. The inclusion of these elements in future studies is crucial for a more nuanced comprehension of the multifaceted nature of hearing loss and its underlying causes.

5 Conclusion

The prevalence of hearing loss is increasing among middle-aged and elderly people in China. Risk factors for hearing loss include age, sex, education level, work, social engagement and ethnicity. These results can help to develop measures to protect hearing and prevent hearing loss.

For the CHARLS data and all the hard work that went into collecting and organizing it, Peking University has our deepest appreciation.

10.1371/journal.pone.0310953.r001
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Ilic Irena Academic Editor
© 2024 Irena Ilic
2024
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https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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PONE-D-24-06278Prevalence and Risk Factors of Hearing Loss in the Chinese Population Aged 45 Years and Older: Findings from the CHARLS Baseline SurveyPLOS ONE

Dear Dr. sun,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Dear Authors, thank you for submitting your work for consideration. Please, address the comments from the Reviewers. In particular, it is necessary to provide explanations regarding the used questionnaire, I understand that previous work that describes this study's methodology has been cited, but please specify whether the same questionnaire was used and that the mentioned validation studies are for the exact same questionnaire used and presented in your study.

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We look forward to receiving your revised manuscript.

Kind regards,

Irena Ilic, MD, PhD

Academic Editor

PLOS ONE

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. 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.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Author,

Thank you for submitting this paper to the PLOSONE journal.

-I have a question about the criteria to classify hearing impairment: reporting hearing problem, using a HA and having a poor hearing status (how this was evaluated?)

- What some of the suggestion to help those who are at higher risk to develop HL?

-what is your suggestions to reduce the prevalence of HL among the targeted population?

- What are the limitations to the study?

Reviewer #2: Title: Prevalence and risk factors of hearing loss in Chinese population aged 45 year and older: Findings from the CHARLS baseline survey

The manuscript describes the findings of a large scale survey of the Chinese population that was conducted on several waves and the results described is from the 4th .

The introduction section requires strengthening and adding more sections about self-reported hearing loss surveys and its use in large population studies. Many statements in the introduction lack referencing. The aims and objectives of study needs to be clearly outlined at the end of the introduction section.

In the methods section the exclusion criteria includes missing information on weights, this needs to be explained to show the significance of this.

The authors described the hearing loss based on self-reported questionnaire, the questionnaire itself was not fully described and was not included in the manuscript, the authors did mention that the questionnaire was previously used and validated in previous studies, but it was not clear if they used the same questionnaires or selected questions of these questionnaires.

The classification of hearing impairment was based on three categories, these categories (needs to be explained to the reader, for example, reporting a hearing problem how does this distinguish normal hearing individuals from individuals with hearing loss? What is meant by having poor hearing status? What criteria did the authors use to classify the patients into this category?

In the results section, Table 1 the terminology needs to be enhanced (for example, man replace with male, woman replace with female), Marry (replace with marital status). Also pay attention to the alignment of the subsections in the table. Similarly, IADL and HwKCNTPMA needs to be replaced with more relevant short terms). Furthermore, in text explanation of the terms is required (for example social engagement).

The results section does not show the results based on the classification of hearing impairment, for instance the participants using hearing aids are the ones with confirmed hearing loss as they would have gone through audiological evaluation prior hearing aid fitting, it would be interesting to see if the findings would be the same if only this group was evaluated?

All of the above suggestions needs to be reflected in the discussion section.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachment Submitted filename: PLOSONE Review.docx

10.1371/journal.pone.0310953.r002
Author response to Decision Letter 0
Submission Version1
14 Jul 2024

Dear Academic Editor,

Thank you for your thorough review and constructive feedback. Below are the streamlined responses to each of your inquiries:

Style and File Naming Requirements:

We have meticulously reviewed and adjusted our manuscript to comply with PLOS ONE's formatting and file naming guidelines, utilizing the provided LaTeX templates.

Data Availability Statement:

We confirm that the "minimal data set" necessary to replicate our study's findings is available in Dryad with the DOI: https://doi.org/10.5061/dryad.mpg4f4r85, and there are no restrictions on data sharing.

Ethics Statement Placement:

The ethics statement has been relocated to the Methods section of the manuscript, ensuring it is included appropriately for publication.

Copyright Concerns for Map Images:

In response to the copyright issue with Figure 2, we have replaced the copyrighted map images with a bar chart that is free from any copyright restrictions.

We trust that these revisions have adequately addressed your concerns and have further strengthened the quality of our submission. We look forward to your continued guidance and feedback.

Sincerely,

Deping Sun

2024-6-28

Dear Reviewer #1,

Thank you for your insightful comments and questions on our manuscript submitted to PLOS ONE. We have taken your feedback into careful consideration and have made the following revisions and clarifications in our manuscript:

Criteria for Classifying Hearing Impairment:

We have clarified our methodology for classifying hearing impairment using a validated self-administered questionnaire. The two key questions regarding the use of hearing aids and self-assessed hearing quality on a Likert scale have been detailed in the revised manuscript to ensure transparency and replicability.

Suggestions for Those at Higher Risk of Developing Hearing Loss (HL):

We have expanded the discussion section to include several strategies aimed at assisting individuals at higher risk of developing HL. These include routine hearing screenings, educational programs, gender-neutral access to resources, community outreach, workplace protection, social engagement, and targeted initiatives for ethnic minorities.

Strategies to Reduce the Prevalence of HL Among the Targeted Population:

The same recommendations listed above are proposed as strategies to reduce the prevalence of HL. These have been concisely summarized and integrated into the discussion to offer a comprehensive approach to prevention.

Limitations of the Study:

We have acknowledged and concisely summarized the key limitations of our study, including the cross-sectional design, reliance on self-reported data, potential lack of regional representation, absence of audiometric testing, and possible residual confounding factors. These limitations are discussed to provide a balanced view of our research findings and to highlight areas for improvement in future studies.

We trust that these revisions adequately address your questions and concerns, and we are grateful for the opportunity to enhance our manuscript based on your feedback.

Sincerely,

Deping Sun

2024-6-28

Dear Reviewer #2,

Thank you for your detailed review and constructive feedback on our manuscript, “Prevalence and Risk Factors of Hearing Loss in the Chinese Population Aged 45 and Older: Findings from the CHARLS Baseline Survey.” We have taken your suggestions seriously and have made the following revisions:

Introduction Enhancement:

We have expanded the introduction to discuss the significance of self-reported hearing loss surveys in large-scale studies and have clarified our study’s aims and objectives at the end of the section. Additionally, we have improved referencing to support our statements.

Exclusion Criteria Explanation:

We have provided a clear explanation of why participants with missing weight data were excluded, emphasizing its importance for the representativeness and accuracy of our findings.

Questionnaire Description:

We have revised the manuscript to confirm that the full, validated questionnaire was used, maintaining consistency with previous research.

Hearing Impairment Classification Clarification:

We have succinctly clarified the classification criteria for hearing impairment in the manuscript, ensuring that the distinctions between categories are clear to the reader.

Terminology and Table Revisions:

Table 1 and the manuscript text have been revised for enhanced clarity and terminology. Gender terms have been standardized, and abbreviations have been defined in the text.

Results Based on Hearing Impairment Classification:

We have included an analysis of the low prevalence of hearing aid use in our discussion, suggesting potential underdiagnosis and barriers to adoption.

We believe these revisions address your concerns and have significantly improved the quality and clarity of our manuscript. We appreciate the opportunity to refine our work based on your comments.

Sincerely,

Deping Sun

2024-6-28

Attachment Submitted filename: Response to Reviewers.docx

10.1371/journal.pone.0310953.r003
Decision Letter 1
Ilic Irena Academic Editor
© 2024 Irena Ilic
2024
Irena Ilic
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
5 Aug 2024

PONE-D-24-06278R1Prevalence and Risk Factors of Hearing Loss in the Chinese Population Aged 45 Years and Older: Findings from the CHARLS Baseline SurveyPLOS ONE

Dear Dr. sun,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Sep 19 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript: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,

Irena Ilic, MD, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear Authors, thank you for submitting your revised version and for providing answers to comments. However, it is not enough to only state that a validated questionnaire was used, one that was used in previous epidemiological studies, but it is necessary to provide citation for those studies, preferably to the validation study.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. 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.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: All of the comments were adequately addressed by the authors

Typo of CHARLS in the discussion line 202, and line 209.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

10.1371/journal.pone.0310953.r004
Author response to Decision Letter 1
Submission Version2
17 Aug 2024

Dear Irena Ilic, MD, PhD,

We would like to express our gratitude for the opportunity to revise our manuscript entitled "[Manuscript Title]" and for the constructive comments provided by the reviewers. We have taken the feedback seriously and have made the following revisions to our manuscript:

Financial Disclosure Statement: We have included an updated financial disclosure statement in our cover letter as requested, although no changes were necessary.

Figure File Resubmission: We have uploaded our figure files to the Preflight Analysis and Conversion Engine (PACE) and have incorporated the recommended modifications. Specifically, we have replaced Figure 1 and Figure 2 with the revised versions provided by PACE.

Laboratory Protocols: We have deposited our laboratory protocols on protocols.io to enhance the reproducibility of our results, as suggested. The protocols have been assigned their own identifiers (DOIs) for independent citation in the future. We have included the DOI link (https://doi.org/10.5061/dryad.mpg4f4r85) in our methods section, following the guidelines provided.

Reference List: We have meticulously reviewed and updated our reference list to ensure it is complete and accurate. We have confirmed that there are no citations of retracted articles in our manuscript. We have adhered to the "PloS" style for reference formatting and have made sure that all references are up to date.

Citation of Validation Studies: In response to the additional editor comments, we have now provided citations for the validation studies of the questionnaire used in our research. Three relevant studies have been added to the manuscript, ensuring that our use of the validated questionnaire is appropriately referenced.

Thank you again for your guidance. We look forward to the possibility of publication in PLOS ONE.

Sincerely,

Deping Sun

2024-8-17

Attachment Submitted filename: Response to Reviewers -second.docx

10.1371/journal.pone.0310953.r005
Decision Letter 2
Ilic Irena Academic Editor
© 2024 Irena Ilic
2024
Irena Ilic
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version2
30 Aug 2024

Prevalence and Risk Factors of Hearing Loss in the Chinese Population Aged 45 Years and Older: Findings from the CHARLS Baseline Survey

PONE-D-24-06278R2

Dear Dr. sun,

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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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. 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.

Kind regards,

Irena Ilic, MD, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

10.1371/journal.pone.0310953.r006
Acceptance letter
Ilic Irena Academic Editor
© 2024 Irena Ilic
2024
Irena Ilic
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
13 Sep 2024

PONE-D-24-06278R2

PLOS ONE

Dear Dr. sun,

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

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, 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.

If we can help with anything else, please email us at customercare@plos.org.

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

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Irena Ilic

Academic Editor

PLOS ONE
==== Refs
References

1 Collaborators GBDHL. Hearing loss prevalence and years lived with disability, 1990–2019: findings from the Global Burden of Disease Study 2019. Lancet. 2021;397 (10278 ):996–1009. Epub 2021/03/15. doi: 10.1016/S0140-6736(21)00516-X .33714390
2 Livingston G , Sommerlad A , Orgeta V , Costafreda SG , Huntley J , Ames D , et al . Dementia prevention, intervention, and care. Lancet. 2017;390 (10113 ):2673–734. Epub 2017/07/25. doi: 10.1016/S0140-6736(17)31363-6 .28735855
3 Golub JS , Brickman AM , Ciarleglio AJ , Schupf N , Luchsinger JA . Association of Subclinical Hearing Loss With Cognitive Performance. JAMA Otolaryngol Head Neck Surg. 2020;146 (1 ):57–67. Epub 2019/11/15. doi: 10.1001/jamaoto.2019.3375 .31725853
4 Slade K , Plack CJ , Nuttall HE . The Effects of Age-Related Hearing Loss on the Brain and Cognitive Function. Trends Neurosci. 2020;43 (10 ):810–21. Epub 2020/08/23. doi: 10.1016/j.tins.2020.07.005 .32826080
5 Leverton T. Depression in older adults: hearing loss is an important factor. BMJ. 2019;364 :l160. Epub 2019/01/17. doi: 10.1136/bmj.l160 .30647062
6 Saha R , Sharma A , Srivastava MK . "Psychiatric assessment of deaf and mute patients—A case series". Asian J Psychiatr. 2017;25 :31–5. Epub 2017/03/07. doi: 10.1016/j.ajp.2016.10.007 .28262170
7 Gong R , Hu X , Gong C , Long M , Han R , Zhou L , et al . Hearing loss prevalence and risk factors among older adults in China. Int J Audiol. 2018;57 (5 ):354–9. Epub 2018/02/06. doi: 10.1080/14992027.2017.1423404 .29400111
8 Li P , Pang K , Zhang R , Zhang L , Xie H . Prevalence and risk factors of hearing loss among the middle-aged and older population in China: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol. 2023;280 (11 ):4723–37. Epub 2023/07/13. doi: 10.1007/s00405-023-08109-3 .37439927
9 Tareque MI , Chan A , Saito Y , Ma S , Malhotra R . The Impact of Self-Reported Vision and Hearing Impairment on Health Expectancy. J Am Geriatr Soc. 2019;67 (12 ):2528–36. Epub 2019/08/15. doi: 10.1111/jgs.16086 .31411348
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