Socioeconomic position and hearing loss: current understanding and recent advances

Abstract

Purpose of review

The purpose of this review is to describe recent literature examining the relationship between socioeconomic position (SEP) and hearing loss, including the impact of hearing loss on several socioeconomic outcomes over the life course. Additionally, we highlight current policy advances in recent years and review alternative models of hearing care that aim to address disparities related to SEP and hearing healthcare.

Recent findings

Applying a social epidemiologic lens to hearing health gives insight into the role of material and social contexts in understanding and improving hearing health outcomes. Recent studies investigating the intersection of SEP and hearing health highlight the disparities that exist for individuals with low SEP as well as the influence of hearing loss on SEP. Individuals with hearing loss are more likely to be unemployed, have lower educational attainment, lower income, and are less likely to use hearing aids and access hearing care. Legislation addressing cost and access to hearing care as well as transforming the current landscape of hearing care, is essential to creating equitable care for individuals, especially older adults, with low SEP.

Summary

With the expected rise in prevalence of hearing loss over the next 40 years, hearing care that is affordable and accessible is a public health priority. As hearing loss is associated with negative outcomes for individuals with low SEP, advances in legislation and care delivery models are necessary in order to include populations traditionally unserved by current hearing healthcare.

INTRODUCTION

The prevalence of hearing loss has continued on an upward trajectory in the United States and globally, in part because of the aging population [1]. An estimated 44.1 million Americans over the age of 20 years [2] and approximately two-thirds of Americans over the age of 70years are living with clinically significant hearing loss [3]. The negative effects of hearing loss at a societal level have been recognized, prioritized as a public health challenge, and consequent legislation has followed [4,5]. The negative effects of hearing loss include an association of hearing loss with worse socioeconomic outcomes, such as income, as well as worse outcomes for those with hearing loss from lower socioeconomic positions [6–8]. Although legislation has largely focused on increasing access to hearing care, the influence of socioeconomic position among adults with hearing loss is likely to persist without a shift in the hearing care delivery model. This review will define socioeconomic position (SEP) from a social epidemiologic perspective, describe the current evidence on the socioeconomic impact of hearing loss on individuals, provide an overview of current legislation seeking to minimize the influence of SEP on hearing healthcare, and raise the importance of various models of hearing care delivery to address disparities related to SEP.

DEFINING SOCIOECONOMIC POSITION

Social epidemiology, or the study of factors in our social environment affecting patterns of disease, acknowledges the roles of structural and social elements at the macro level and mezzo level in society that contribute to changes in the development of disease and health outcomes in various populations [9,10▪]. Figure 1 provides a visual representation of the differing societal levels affecting health outcomes. The application of social epidemiology to hearing health includes a focus on SEP, which relates to an individual’s access to resources, such as money, assets, employment, education, and material items, as well as their social status and stability in society [11]. This differs from socioeconomic status (SES), which is more narrowly defined and only includes social status or class [9].

FIGURE 1.

Levels of social-structural factors (macro and mezzo) interacting with individual-function (micro) and biological processes to impact health and society. Adapted with permission from Nieman et al. [10▪].

Whenever considering SEP in hearing health research, either as a reader or investigator, one must critically evaluate the appropriateness of the selected measures, including the study population, the underlying theoretical framework, and the hypothesized mechanism for SEP’s effect on the measured outcome [10▪]. Examples of different SEP measures over the life course are shown in Fig. 2. In recent hearing-related literature involving older adults, SEP has been measured through education, home ownership, income, income-to-poverty ratio, occupation, unemployment/underemployment, and wealth [6,13▪,14,15▪]. Particularly among older adults, who may no longer be employed, measures of SEP related to wealth or accumulated assets may be more appropriate than income. For example, in a study assessing the relationship between hearing loss, SEP, and depression using data from the English Longitudinal Study of Aging, SEP was measured by educational level and wealth [16]. In this example, wealth was thought to be the most appropriate indicator for the older adult population’s SEP as it also captures retired individuals or those in later stages of active employment [16].

FIGURE 2.

Examples of measures for capturing socioeconomic position throughout the life course. Adapted with permission from Galobardes et al. [12].

Although participants’ stage of life influences SEP and the selection of associated measures, a life course perspective can also be important when considering hearing health. A life course approach seeks to capture the cumulative effects of various exposures from gestation to older adulthood on health and disease, including SEP over the life course. Within hearing health, higher cumulative SEP has been positively associated with hearing aid use, with childhood SEP serving as a stronger predictor of hearing aid use than SEP in older adulthood [15▪]. Although SEP measures between studies may vary based on the study population and aim, a robust understanding of SEP, including the strengths and limitations of selected measures, is imperative for measuring overall hearing health from a social epidemiologic perspective and informing subsequent interventions.

SOCIOECONOMIC POSITION AND HEARING LOSS

Communication is essential for many aspects of life and daily functioning. Hearing loss, especially when left untreated, can lead to impaired communication and create barriers to education, employment, income earning potential, and access to hearing care, all of which are related to SEP.

Education

Hearing loss can have negative effects on speech and language development in children and subsequently lead to low educational attainment. Large population-based studies in the United States and Finland have shown that individuals with hearing loss are at a higher risk for low educational attainment, including not finishing high school and being less likely to apply for further education [6,17,18]. A prospective population study in Norway estimated that individuals with hearing loss were 50% less likely to graduate from a college or university compared with individuals without hearing loss [17]. Treatment of hearing loss, including through hearing aids and cochlear implants, have improved greatly over the last decade. Although these devices have been shown to improve language development and academic performance in children with hearing loss, especially when implemented early, this may not always be true for children with different SEPs [19,20▪▪].

Children with hearing loss from lower SEPs may not have the same access to hearing care services or may have greater challenges compared with children from a family with higher SEP. Evidence indicates that children from families with higher income had better language performance prior to cochlear implantation and had faster progression of language comprehension after implantation [21]. Transportation to and from appointments and access to an audiologist close to home can create challenges to using and maintaining devices for children with low SEP. Private language services and tutors might be out of reach for many families with low SEP that have a child with hearing loss. The lack of adequate special education in rural areas, because of shortages in trained specialists, coupled with lack of funding, can create disparities in educational attainment [22]. These barriers can lead to children dropping out of school prior to graduating high school or deciding not to attend college for higher education.

SEP has also been associated with negative cochlear implant outcomes, including implantation rates, utilization, and speech outcomes [23,24,25▪]. Lower levels of parental education, especially maternal education, and lack of support for families with low SEP can create disparities in overall outcomes. Children with low SEP are less likely to receive early diagnosis and intervention, have lower levels of device use, and often attend schools with fewer resources or rehabilitation programs [23,26]. Studies investigating cochlear implant interventions have used insurance status as a proxy for SEP, where individuals with public insurance (e.g. Medicaid) or no insurance are classified as having low SEP [24,25▪]. These studies have shown mixed results as some have found having public insurance or no insurance to be significantly associated with worse cochlear implant outcomes, whereas others have found no association [24,25▪,27]. Authors have noted that depending on the state’s Medicaid coverage, insurance status may not be the best proxy for low SEP as states with comprehensive Medicaid coverage may not have the same disparities as those that do not [25▪,27].

Employment and income

Hearing loss has been consistently associated with lower levels of employment and income, as low educational attainment and difficulty communicating may decrease job prospects. Population-based studies have found that individuals with hearing loss are more likely to be unemployed [6,18,28], work part-time positions (underemployed) [6,18,28], and have low-income [6–8] compared with those without hearing loss. Employees with hearing loss often expend more effort listening, which may lead to increased stress, greater number of stress-related sick days, and ultimately individuals with hearing loss make less than those without hearing loss [7,29,30]. Adults with hearing loss are also more likely to retire earlier than their peers without hearing loss, which can lead to increased financial strain later in life [31]. Overall wealth and income may be affected by untreated hearing loss as evidence suggests these individuals spend on average $22 434 more in healthcare costs over 10 years than individuals without hearing loss [32].

Access to hearing healthcare

In the United States, hearing healthcare, specifically hearing aids, are often not covered by most private insurances and not every state has Medicaid coverage of hearing aids for low-income individuals [33]. This can create a barrier for individuals with low SEP in accessing services and treatment, where hearing care is unaffordable for 77% of Americans with hearing loss, as a healthcare cost over $2500 would be considered financially catastrophic [34]. With the average cost of a pair of hearing aids alone costing an average of $4700, many are left without an affordable treatment option [35].

Disparities related to hearing aid use exist among those with low SEP. Individuals with lower education and lower income (less than 100% of the federal poverty level) are less likely to use hearing aids and those who have hearing aids are less likely to use them on a regular basis [8,13▪,36–38,39▪]. Those with lower income and Medicare coverage who reported having a hearing loss were less likely to have gone to an audiologist than individuals with high incomes [40]. Individuals were also less likely to have a recent hearing test if they also had low educational attainment [40,41]. In a nationally representative sample from the United States from 2011 to 2018, although overall ownership and use of hearing aids increased in the general population by 23.3%, those with lower income showed a decrease in proportional ownership and use of hearing aids [36].

The current hearing care model may contribute to inequities in access to services, especially for individuals with low SEP. Hearing care and hearing aids have only been available in the United States through a licensed professional, specifically, centralized through audiologists and hearing aid dispensers. In 2021, there were an estimated 13240 audiologists and 10790 hearing aid dispensers providing hearing healthcare to 331.8 million Americans [42–44]. Audiologists predominately practice in urban areas and in areas with individuals with higher income, with fewer audiologists in Southern and Western states [45]. For example, out of 15 counties in the state of Arizona, there were no audiologists practicing in six of those counties [46]. As the United States population ages and the prevalence of hearing loss increases, the demand for hearing healthcare professionals will rise. This calls for a change in the hearing care delivery model and accompanying policies to create more equitable hearing care.

CURRENT LEGISLATION TARGETING DISPARITIES

The high prevalence and adverse societal impacts of hearing loss are a public health priority, and policy makers have begun to push for legislation to increase access to hearing care in the United States. Specifically targeted to increase access to hearing aids, the Over-the-Counter (OTC) Hearing Aid Act was passed in 2017 and allows for the purchase of hearing aids in conventional markets for those with mild-to-moderate hearing loss [5]. This legislation will allow for individuals to purchase hearing aids directly without the need for a hearing care professional to fit the device. The device regulatory guidelines set by the US Federal Drug Administration are expected to be released in 2022, and the development of a robust OTC device market is expected to follow.

Although the OTC Hearing Aid Act of 2017 will increase access to hearing technology, disparities in accessing hearing care services will likely persist. Currently, Medicare Part B covers the cost of diagnostic evaluations for hearing loss (unless evaluations are performed for the purpose of acquiring hearing aids specifically); however, typically Medicare beneficiaries do not have coverage for hearing aids [40]. Medicare Advantage Plans, which covers approximately a third of those with Medicare, include some limited benefits for hearing aids. The Biden administration introduced the Build Back Better Act in 2021, which proposed expanding Medicare coverage to include hearing aids to individuals with more severe hearing loss, as well as hearing treatment services, such as hearing aid support and aural rehabilitation [4]. For beneficiaries with more mild-to-moderate hearing loss, this legislation would have allowed those with fixed incomes and lower SEP to purchase an OTC device and receive covered services from a hearing healthcare professional if extra assistance is needed after purchasing an OTC device. The Build Back Better Act passed in the House of Representatives in November 2021 and included coverage of hearing aids once every 5years but it stalled in the US Senate [4]. Regardless of the legislation’s outcome, this legislation provided an important example of the type of legislation that is needed to advance coverage of hearing-related services and appropriately leverage the emerging OTC hearing aid market.

Although passage of this type of legislation and the debut of OTC hearing aids could be a step toward equitable access to hearing aids and associated services, there are concerns that barriers to the use of OTC hearing aids will remain for individuals with low SEP. The overall uptake and use of hearing aids are low, where only one in seven individuals with hearing loss wear hearing aids [47]. This number is even lower for those with low income [8,13▪]. Individuals using hearing aids are more likely to have access to technology, a stronger commitment to learning and using technology, and respective social support of family and friends [36,48▪,49]. For individuals with low SEP, lack of access to technology and outside support may be a challenge in light of the OTC device market and may exacerbate existing disparities if follow-up services remain uncovered.

ALTERNATIVE HEARING HEALTH DELIVERY MODELS

Limiting hearing healthcare to the conventional delivery model with hearing healthcare professionals as gatekeepers perpetuates disparities in hearing health and often excludes individuals with low SEP from needed care. With the development of OTC hearing aids and the use of other self-fit devices, such as Personal Sound Amplification Products (PSAPs), additional models of hearing care are needed to provide the respective education and support for realizing more inclusive and equitable hearing care. These models include, and are not limited to, community-based hearing care delivery through partnership with trained community members or community health workers who provide hearing care to individuals facing structural and social barriers to hearing care [50,51▪▪].

Community-based hearing care for adults provides an opportunity for individuals with hearing loss to receive high-quality culturally relevant hearing care in their communities. For this model of care to function, task sharing is necessary. Task sharing requires the reallocation of care delivery to other trained members of a healthcare team who often operate as paraprofessionals [51▪▪]. For hearing care, task sharing in partnership with community health workers, nurses, and technicians is essential for building capacity and delivering hearing care to individuals who may otherwise have limited access. For adults in the United States, several hearing care models in rural, urban, and telemedicine settings have used this model of care for improving access for individuals with low SEP [50,52,53].

CONCLUSION

The socioeconomic impact of hearing loss is widespread and affects individuals over the life course. In addition to the effects of hearing loss on SEP, low SEP is also associated with lower rates of hearing aid use and use of hearing services. As a public health priority, federal legislation and additional models of care are positioned to increase access to hearing aids and hearing services, in particular, benefiting individuals with low SEP.

KEY POINTS.

• Socioeconomic position impacts hearing health, including negative effects on the level of education, employment status, level of income, and access to hearing care.

• Recent legislation highlights the need for policy-driven solutions to address barriers to hearing care, including low socioeconomic position.

• Community-based models of hearing care creates an opportunity to reach individuals with hearing loss often left out of the traditional hearing care model based in clinical settings where licensed professionals often act as gatekeepers to hearing aids.