Starkey Research & Clinical Blog

What motivates hearing aid use?

Jenstad, L. & Moon, J. (2011). Systematic review of barriers and facilitators to hearing aid uptake in older adults. Audiology Research 1:e25, 91-96.

This editorial discusses the clinical implications of an independent research study. The original work was not associated with Starkey Laboratories and does not reflect the opinions of the authors.

Though some causes of adult-onset hearing loss are treated medically or surgically, hearing aid use is by far the most common treatment. Yet 25% of adults who could benefit from hearing instruments actually wear them (Kochkin, 2000; Meister et al., 2008). A number of studies have examined the factors that prevent individuals from purchasing hearing aids and Jenstad and Moon’s objective was to systematically review the literature to identify the main barriers to hearing aid uptake in older adults.

They included subjective and objective reports, but limited this investigation to studies with more than 50 subjects over the age of 65, who had never used hearing aids, had at least mild to moderate sensorineural hearing loss and were in good general health. From an initial set of 388 abstracts, they eliminated studies about children, cochlear implants, medical aspects of hearing loss, auditory processing or hearing aid outcomes.  From the remaining 50 articles, the report focused on 14 papers that met the inclusion criteria. Hearing aid uptake was defined as a hearing aid purchase, but some studies included willingness to purchase.  Based on the literature review, Jenstad and Moon identified a set of predictors of hearing aid uptake in older adults. Some of the predictors they described may be helpful discussion points for clinicians counseling potential hearing aid users.

Self-reported hearing loss was evaluated in questionnaires and hearing-handicap indices that examined hearing-related quality of life as well as activity and participation limitation (Chang et al., 2009; Helvik et al., 2008; Garstecki & Erler, 1998; Meister et al., 2008; Palmer, 2009).  Not surprisingly, as self-reported hearing loss increased, study participants were more likely or willing to obtain hearing aids.  In other words, the more aware individuals were of their hearing-related difficulties, the more likely they were to purchase hearing aids. With this in mind, clinicians should instruct unmotivated hearing aid candidates to pay close attention to their hearing-related difficulties while determining need for amplification. Work together to identify activities that patients must do (e.g., work) or enjoy doing (e.g., dining out, going to the theater). Using this information to understand the extent to which hearing loss disrupts their communication ability in these situations will enlighten the patient to the extent of their own hearing handicap and point towards opportunities for treatment and counseling.

Stigma was predictive of hearing aid acceptance in some studies (Franks & Beckmann, 1985; Garstecki & Erler, 1998; Kochkin, 2007; Meister et al., 2008; Wallhagen, 2010), but overall was inconsistent in its effect on hearing aid uptake. In 1985, Franks & Beckmann found that stigma was the highest concern among their subjects, whereas in 2008, Meister and his associates found that stigma only accounted for 8% of the variability in hearing aid uptake. The negative stigma associated with hearing aids is assumed to relate to the appearance of the aid and the perception of hearing loss by other people. Therefore, hearing aid users with high concern desire small, discreet instruments. Improvements in technology allow for smaller, sleeker designs that make the hearing aid—and hearing loss—less noticeable. Therefore, hearing aid users no longer have to make an obvious acknowledgement of their hearing impairment.

Degree of hearing loss was a significant factor in the decision to obtain hearing aids, but the effect seems to be modified by gender. Garstecki & Erler (1998) found that degree of hearing loss was more likely to affect hearing aid uptake for females than males, but this finding was not reported in other studies. In general, as degree of hearing loss worsens people are more willing to wear hearing aids. Detailed discussion of audiometric findings, with visual references to speech and environmental sound levels helps to familiarize the patient and their family with degrees of hearing loss and the impact on speech perception.  Using tools like hearing loss simulators offer a convenient tool for educationing and motivating patients toward the acceptance of hearing aids.

Personality and psychological factors affected hearing aid uptake in three studies (Cox et al., 2005; Garstecki & Erler, 1998; Helvik et al., 2008). Cox and her colleagues found that hearing aid “seekers” were less neurotic, less open and more agreeable than those who did not seek hearing aids.  Internal locus of control predicted hearing aid acceptance in Cox’s study, but Garstecki and Erler found that it was only predictive for female subjects. Though locus of control is one among many factors influencing the decision, the choice to obtain hearing aids should be presented as a way to assume control of the hearing impairment and make proactive steps toward improving communication abilities.

Helvik (2008) found that subjects who reported using fewer maladaptive coping strategies, such as dominating conversations or avoid social situations, were less likely to accept hearing aids. Many hearing-impaired individuals use poor coping strategies without realizing it. It seems counterintuitive that reported use of maladaptive strategies would be inversely related to hearing aid acceptance, but the authors surmised that the study participants who rejected hearing aids may have been in denial about both the hearing loss and their use of poor communication strategies. Hearing impaired individuals may not be aware of the extent of their communication difficulties and may not realize how often they are misunderstanding conversation or requiring others to make extra efforts. Including family members in the discussion of hearing aid candidacy is critical, to make the hearing-impaired individual aware of how their loss affects others and how the use of poor or ineffective strategies may result in frustration for themselves and other conversational participants.

Cost was a barrier to hearing aid use in some studies but was not a significant factor in others (Meister et al., 2008). But Jenstad and Moon point out that cost may affect hearing aid acceptance in more than one way. Pointing out that Kochkin’s 2007 survey found that 64% of respondents reported that they could not afford hearing aids, whereas 45% of respondents said that hearing aids are not worth the expense. There are ways in which clinicians can address both of these issues with hearing aid candidates. First, improvements in technology have made quality instruments available at a wide range of prices. Most manufacturers offer a broad product line, with entry-level instruments in custom and BTE styles. Clients should be assured that their hearing loss, lifestyle and listening needs will determine a range of options to choose from. Lower-cost hearing aids might require more manual adjustment than aids with sophisticated automatic features, but with proper training and programming some lower cost options might work quite well. Additionally, unbundled pricing and financing options may help potential hearing aid users afford the purchase price. Together, these strategies make cost less of a barrier for many potential hearing aid candidates.

Kochkin’s finding that 45% of respondents felt hearing aids were not worth the expense is perhaps more difficult to address. Some of the bias against hearing aids is related to inappropriate hearing aid selection or inadequate training and follow-up care. Most clinicians have encountered clients with a friend or neighbor who doesn’t like their hearing aids. Negative experiences with hearing aids may be more likely related to selection, programming and follow-up care than the quality of the hearing instruments themselves. The finest hearing aid available will be rejected if it is inappropriate for the user’s hearing loss or lifestyle or is programmed improperly. Unfortunately, many people who have an unsuccessful experience have acquired their hearing aids through non-clinical channels. These people often blame their dissatisfaction on the quality of the hearing aid, contributing to a larger general perception that hearing aids are not worth the price. Clinicians must emphasize the importance of the care that they provide. Thorough verification, validation and follow-up care by well-trained, credentialed clinical specialists will affect patient’s perception and lead them toward success.

The effect of age on hearing aid uptake was unclear in Jenstad and Moon’s review. One study showed a slight increase in hearing aid uptake with increasing age (Helvik et al, 2008), whereas another showed a stronger increase with age (Hidalgo, 2009). In contrast, Uchida et al. (2008) found that hearing aid uptake decreased with increasing age. The effect of age, if any, on hearing aid acceptance will be confounded by other variables such as degree of loss, lifestyle, general health and financial constraints. Therefore, age should be a minor consideration with reference to hearing aid candidacy but remains highly relevant when discussing specific options such as manual controls, automatic features and hearing aid styles.

Gender affected the predictive value of several factors including stigma, degree of loss and locus of control. Hidalgo (2009) found that in general males were more likely to report a need for hearing aids than were females. Gender in itself might not be a strong predictor, so it probably should not be specifically considered in discussions with potential hearing aid users as other variables appear to have more impact on the decision to pursue hearing aids.

Franks and Beckmann reported that individuals who chose not to purchase hearing aids were more likely to report that hearing aids were inconvenient to wear. Though the study was done in 1985, their findings merit consideration today.  Since then, hearing aids have become smaller, more effective and less troublesome because of advances like feedback cancellation, directionality and noise reduction. However, the fact remains that hearing aids must be worn, cleaned and cared for daily and in most cases batteries must be changed on a weekly basis.  Use and care guidelines should be balanced by discussion of the likely benefits of hearing aid use and the positive effect they have on communication in everyday situations.  With the technological sophistication that today’s hearing aids offer the known benefits should outweigh any perceived inconvenience.

Jenstad and Moon have clarified some of the primary barriers to hearing aid uptake, providing useful information for clinicians working with hearing aid candidates. The predictors they discussed can be addressed systematically to quell concerns about and underscore the need for hearing instruments. Discussing these issues at the outset may encourage motivated clients to proceed with a hearing aid purchase and provide helpful considerations for those who are not yet ready to pursue amplification. With many potential places to purchase and limited information to guide patients toward qualified hearing care professionals, internet sales offer the appealing promise of quality hearing instruments at lower costs than may be found in a clinic.  But consumers must be educated that a key to successful hearing aid use is the support of the professional, not the quality of the device itself.  Anyone can “sell” a quality hearing aid but only a trained professional can make appropriate clinical decisions and recommendations.

References

Chang, H.P., Ho, C.Y. & Chou, P. (2009). The factors associated with a self-perceived hearing handicap in elderly people with hearing impairment – results from a community-based study. Ear and Hearing 30(5), 576-583.

Cox, R.M., Alexander, G.C. & Gray, G.A. (2005). Who wants a hearing aid? Personality profiles of hearing aid seekers. Ear and Hearing 26(1), 12-26.

Franks, J.R. & Beckmann, N.J. (1985). Rejection of hearing aids: attitudes of a geriatric sample. Ear and Hearing 6(3), 161-166.

Garstecki, D.C. & Erler, S. F. (1998). Hearing loss, control and demographic factors influencing hearing aid use among older adults. Journal of Speech, Language and Hearing Research 41(3), 527-537.

Helvik, A.S., Wennberg, S., Jacobsen, G. & Hallberg, L.R. (2008). Why do some individuals with objectively verified hearing loss reject hearing aids? Audiological Medicine 6(2), 141-148.

Hidalgo, J.L., Gras, C.B., Lapeira, J.T., Verdejo, M.A., del Campo, D.C. & Rabadan, F.E. (2009). Functional status of elderly people with hearing loss. Archives of Gerontology and Geriatrics 49(1), 88-92.

Jenstad, L. & Moon, J. (2011). Systematic review of barriers and facilitators to hearing aid uptake in older adults. Audiology Research 1:e25, 91-96.

Kochkin, S. (2000). MarkeTrak V: “Why my hearing aids are in the drawer”: the consumer’s perspective. Hearing Journal 53(2), 34-41.

Meister, H., Walger, M., Brehmer, D., von Wedel, U. & von Wedel, J. (2008). The relationship between pre-fitting expectations and willingness to use hearing aids. International Journal of Audiology 47(4), 153-159.

Palmer, C.V., Solodar, H.S., Hurley, W.R., Byrne, D.C. & Williams, K.O. (2009). Self-perception of hearing ability as a strong predictor of hearing aid purchase. Journal of the American Academy of Audiology 20(6), 341-347.