Hearing help-seeking, hearing aid uptake and outcomes in adults : barriers, enablers and over-the-counter hearing aids

Abstract

Hearing loss is a growing global health concern, with its prevalence increasing worldwide. In adults, unaddressed hearing loss can lead to various negative consequences, including reduced quality of life, cognitive decline, and economic disadvantages. Timely intervention with hearing aids can mitigate these consequences. However, despite their availability and effectiveness, help-seeking behaviors and hearing aid uptake have been notably low. In the past decade, significant efforts have been made to improve access to hearing healthcare, including establishing various types of direct-to-consumer (DTC) hearing devices, such as over-the-counter (OTC) hearing aids in the United States. Despite these advancements, the number of people seeking help for hearing difficulties and hearing aid uptake remains low. This may be due to various audiological and non-audiological factors that hinder or facilitate help-seeking behavior and the uptake of hearing aids. This project, therefore, explored factors influencing help-seeking behavior for hearing difficulties and the uptake of hearing aids, in addition to evaluating self-fitting OTC (OTC-SF) hearing aids for usability and effectiveness.

Study I analyzed factors influencing hearing help-seeking and hearing aid uptake in adults with hearing loss through a literature review. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 42 articles from January 2011 to February 2022 were reviewed. Factors included 70 audiological and 28 non-audiological for help-seeking and 159 audiological and 66 non-audiological for hearing aid uptake. Hearing aid uptake had strong predictors, such as hearing sensitivity, while others showed conflicting results, such as self-reported health. Hearing help-seeking had clear non-predictive factors, such as education, and conflicting factors, such as self-reported health. New factors included cognitive anxiety associated with increased help-seeking and hearing aid uptake and urban residency and access to financial support with hearing aid uptake. Most studies were rated low evidence (67%) and fair quality (86%). The findings suggest further research to understand conflicting factors and factors with limited evidence to effectively promote help-seeking and hearing aid uptake among adults with hearing loss.

Study II explored the main reasons for hearing aid uptake from a user perspective and provided recommendations for others with hearing difficulties. A cross-sectional survey gathered responses to an open-ended question, which were analyzed using qualitative content analysis. The study sampled 642 adult hearing aid users from the Hearing Tracker website and Lexie Hearing databases in the US. Participants cited reasons for hearing aid uptake in three domains: (a) personal impact, (b) social difficulties, and (c) auditory difficulties, encompassing 11 main categories and 48 sub-categories. Recommendations for others included eight main categories, such as timely help and affordability, with 32 sub-categories. The decision to take up hearing aids was influenced by intrinsic factors such as readiness to change and extrinsic factors such as financial availability. The most frequent recommendation was not to delay seeking hearing help. These findings may inform strategies to improve hearing aid adoption.

Study III explored user perspectives on the relationship between hearing aid cost and uptake, along with cost-related recommendations for others with hearing difficulties, among prescription and OTC hearing aid users. A secondary analysis of a cross-sectional survey to an open-ended question were analyzed using the qualitative content analysis. Study participants included 241 adults, 179 prescription hearing aid users from the Hearing Tracker website and 62 OTC users from the Lexie Hearing United States database. Three domains were identified: (a) perceived enablers to hearing aid uptake related to cost, (b) perceived barriers, and (c) cost-related recommendations. Both groups cited high costs and lack of insurance coverage as major barriers. Prescription users noted external financial support as an enabler, while OTC users emphasized the affordability of OTC devices. Prescription users recommended seeking professional support, whereas OTC users advised researching hearing aids before purchasing. The study concludes that cost and insurance coverage are primary barriers to hearing aid adoption, suggesting that initiatives should address these financial challenges to enhance accessibility. Further research is needed on the relationship between cost and uptake, particularly for OTC users and those requiring financial assistance.

Study IV compares the usability and performance of six OTC-SF hearing aids for individuals with mild-to-moderate hearing loss. In a cross-sectional study, 43 adults were pseudo-randomly assigned to self-fit two of the six devices using manufacturer instructions and smartphone apps. Usability was assessed through fitting time, Hearing Aid Skills and Knowledge (HASK) scores, ease of the self-fitting process, and the Post-Study System Usability Questionnaire (PSSUQ). Performance was evaluated using the Judgement of Sound Quality (JSQ) test, and speech-in-noise benefit was assessed through the Digits-In-Noise (DIN) and Quick Speech in Noise (QuickSIN) tests. Results showed fitting times ranged from 14.4 minutes (HP Hearing PRO) to 27.1 minutes (Lexie Lumen), with varied HASK scores, the highest being Soundwave Sontro (8.9/10) and the lowest HP Hearing PRO (6.8/10). While self-fitting ease and PSSUQ scores were similar across devices, sound quality ratings varied, with Lexie B2 scoring highest and HP Hearing PRO lowest. Speech-in-noise benefit did not significantly differ. Participants generally found the devices user-friendly, though issues with Bluetooth connectivity, handling, insertion, and sound quality were noted. These findings can aid consumers and healthcare professionals in choosing OTC-SF hearing aids, highlighting the need for further research on long-term usability and selection processes.

Study V compared in-situ audiometry and self-adjustment strategies for OTC-SF hearing aids in adults with mild-to-moderate hearing difficulties. Conducted as a cross-over, within-participant pseudo-randomized controlled trial, it involved 28 participants (mean age 60.2 years). Participants used both strategies for four weeks: self-adjustment with Lexie B2 hearing aids and in-situ audiometry with Lexie B2 Plus hearing aids. The primary outcome was the Abbreviated Profile of Hearing Aid Benefit (APHAB), with secondary outcomes including the International Outcome Inventory for Hearing Aids (IOI-HA), speech-in-noise tests (DIN and QuickSIN), and real-ear measurements (REMs). Results showed no clinically meaningful differences in APHAB benefit or overall IOI-HA satisfaction. However, self-adjustment users reported higher satisfaction and longer daily use. Both strategies produced similar results in speech-in-noise benefit and REMs. The findings suggest that self-adjustment may offer higher user satisfaction and engagement, indicating the potential benefits of active user involvement in the fitting process. Further research is needed to assess long-term outcomes.

From these studies, it is evident that numerous factors, both audiological and non-audiological, influence the help-seeking behavior and uptake of hearing aids among adults with hearing loss. While advancements such as OTC hearing aids have improved accessibility, significant barriers, especially financial constraints, impede widespread adoption. The user perspectives highlighted in these studies underscore the importance of timely intervention, affordability, and the effectiveness of both self-adjustment and professional support in promoting hearing aid uptake. Continued research is essential to address these barriers and optimize strategies for enhancing hearing healthcare accessibility and user satisfaction.