Starkey Research & Clinical Blog

On the prevalence of hearing loss and barriers to hearing aid uptake

Dawes, P., Fortnum, H., Moore, D., Emsley, R., Norman, P., Cruickshanks, K., Davis, A., Edmondson-Jones, M., McCormack, A., Lutman, M. & Munro, K.  (2014) Hearing in middle age: a population snapshot of 40- to 69-year olds in the United Kingdom. Ear & Hearing 35 (3), 44-51.

This editorial discusses the clinical implications of an independent research study and does not represent the opinions of the original authors.

The Biobank is a national program in the United Kingdom, aimed at longitudinal investigation of the prevention, diagnosis and treatment of diseases and health conditions affecting middle-aged individuals. Since 2006, the Biobank has recruited over half a million participants, who complete test procedures, provide biomedical samples and detailed health information and have their health followed over time, periodically providing updated information. One of the health conditions assessed in the Biobank study is hearing loss and over 160,000 participants have completed questionnaires, audiometric assessment and speech-in-noise testing.

Dawes and his colleagues used Biobank data to examine the prevalence of hearing impairment among 164,700 middle-aged respondents in the U.K., “hearing impairment” was defined as reduced or poor performance on a speech recognition in noise test. They assessed how audiologic and demographic factors relate to hearing impairment and the use of hearing aids among individuals in this age group.

For the Biobank database, hearing loss was assessed via audiometric testing and questionnaires covering lifestyle, environment and medical history, including associated symptoms such as tinnitus. Speech recognition in noise was assessed via the Digit Triplet Test (DTT; Smits et al., 2004). The DTT is a large-scale screening tool that can be administered via the telephone and internet.  The test includes 15 sets of monosyllable digit triplets, presented at a comfortable listening level. Noise levels are varied adaptively to arrive at the SNR required for 50% recognition. Speech recognition results were analyzed in relation to several demographic variables: age, work and music related noise exposure socioeconomic status, ethnicity and gender. 

10.7 % of participants had hearing impairment, as measured by the DTT. Tinnitus was reported by 16.9% of the subjects, which is consistent with previous reports (Davis 1995).  The results show, not surprisingly, that the prevalence of hearing loss increases with increasing age, with an acceleration of prevalence beginning in the 55-59 year old age group. The increase in prevalence with increasing age is consistent with previously published reports for this age group (Plomp & Mimpen, 1979; Wilson & Strouse, 2002; Smits et al., 2006). Tinnitus showed a more consistent increase with increasing age, without a steeper increase for respondents in their 50’s.  Hearing aid use was only 2% for the entire sample and increased with age.  Only 21% of the participants with Poor DTT scores reported using hearing aids.  Those who did use hearing aids had significantly higher socioeconomic status than those without hearing aids.

Only 2.0% of the middle-aged individuals in this study reported hearing aid use. This is similar to an earlier report in which hearing aid use for 41-70 year olds was 2.8% (Davis, 1995). The persistently low proportion of hearing aid use contrasts with the fact that 9.4% of the respondents in the current study had average pure tone thresholds of at least 35 dBHL in the better ear. There are many potential explanations for the low proportion of hearing aid use among hearing impaired individuals. Cost is a commonly cited explanation, though cost is not likely to have influenced the present report, as hearing aids are provided free in the United Kingdom and the participants included in this report probably did not purchase their hearing aids privately. Insufficient value and uncomfortable fit have also been reported as explanations for low hearing aid use (McCormack & Fortnum, 2013). Other proposed barriers to hearing aid use are related to motivation, expectations and attitudes toward hearing aids, with self-recognition of hearing handicap being the most consistently related factor to hearing aid use (Vestergaard-Knudsen et al., 2010).

One mechanism for addressing the concern of hearing aid cost is through the unbundling of the hearing aid and services provided. Bundled pricing (the packaging of hearing aid and services into one price) is typical in the U.S. Unbundling may encourage initial uptake because it allows hearing aid users to pay less at the outset and divide additional expenditures into smaller, more manageable amounts, paying fees at each visit after the initial service period. There is some concern that unbundled pricing will make hearing aid users less likely to obtain needed care, but this fear may be overstated. Hearing aid users generally indicate that verification measures and counseling increase satisfaction and perceived value of hearing aids (Kochkin, 2010; 2011), so follow-up care can be perceived by the patient as a valuable part of the rehabilitative process. Unbundling offers the additional benefit for private practices because fee-for-service appointments lead to more consistent monthly cash flow than bundled fees in which a large initial payment is received with free services for a long time thereafter.

The manner in which hearing aids are represented to the general public may further impact uptake. Hearing aids are best positioned as medical devices, prescribed by skilled professionals, in clinical settings where testing is performed in controlled acoustic environments. If price is prioritized, then testing, verification and follow-up care may be abbreviated to control costs. If cosmetic appeal is prioritized, patients may select the smallest devices, perhaps without adequate venting or directional microphones, though this might not be the best option for their loss and listening needs. The potential outcome of both scenarios is disappointment with the performance and comfort of the hearing instruments, resulting in either lack of use or return for credit.  Instead, hearing aid users need to be fully educated about the options that are available and counseled as to why some models are better for their needs than others. This cannot be achieved in an environment that emphasizes price over functionality and service.

As Dawes points out, hearing impairment may be better defined by speech recognition ability in everyday situations, rather than pure tone audiometry. Even so, it is arguable whether either of these measures alone should be used to define hearing aid candidacy. Instead, clinicians gain more insight into their patients’ motivation and readiness by examining how the hearing loss affects their ability to function in their regular activities. A mildly-impaired individual with a quiet, socially inactive lifestyle is less likely to be motivated for hearing aids than a similarly impaired individual who works full time and has an active social life. A thorough patient history and needs assessment, coupled with objective testing can more accurately identify hearing aid candidates than relying on degree of hearing loss alone. The authors of this article cite a study of Swiss hearing aid use and satisfaction, stating that in Switzerland, hearing aid candidacy is “based on the degree of social and emotional handicap due to hearing loss” and that the dispensing process focuses on ongoing counseling and care after the fitting.  This study reported high rates of long-term hearing aid use and satisfaction, where 97% of Swiss hearing aid owners reported using their hearing aids and only 3% were non-users (Bertoli, 2009).

It makes sense to advise unmotivated individuals to assess their difficulties, making note of every time they ask for repetition, misunderstand a word or sentence, or smile and “fake” their way through a conversation. I instruct patients to consider whether their hearing loss causes them to avoid places or situations that they might otherwise enjoy or if the hearing loss affects their ability to perform important work-related or social activities.  With a little patience and attention, most people can determine the point at which they are ready to proceed with a hearing aid purchase. Self-recognition of need is strongly associated with eventual hearing aid uptake and use (Vestergaard-Knudsen et al., 2010), meaning that a person who returns for a consultation after taking time to evaluate their difficulties is more likely to keep their hearing aids and follow through with proper use and care.

Even as testing techniques and prevalence data improve our ability to identify those with hearing impairment and those at risk, there remain barriers to hearing aid use. Consistent representation of hearing aids as medical devices that are fitted by clinical professionals may improve the perception and attitudes of the general public. Unbundled pricing may lower the cost barrier by making the initial purchase more affordable and concomitantly emphasizing the value of follow-up care. Finally, development and adherence to a thorough fitting protocol will ensure that those who do purchase hearing aids will receive a well-prescribed medical device and become an example of success to others.



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Kochkin, S. (2011). MarkeTrak VIII: Reducing patient visits through verification and validation. Hearing Review 18 (6), 10-12.

McCormack, A. & Fortnum, H. (2013). Why do people fitted with hearing aids not wear them? International Journal of Audiology 52, 360-368.

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Vestergaard-Knudsen, L., Oberg, M. & Nielsen, C. (2010). Factors influencing help seeking, hearing aid uptake, hearing aid use and satisfaction with hearing aids: A review of the literature. Trends in Amplification 14, 127-154.

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