Abstract
Background of the Research: Higher prevalence of hearing loss is reported among older adults. Hearing aids have been proven to be a viable option to reduce the burden associated with hearing impairment. Despite these positive aspects, there is no increase seen in hearing aid adoption or usage among individuals with hearing impairment. Objective: To explore the aspects favoring hearing aid usage among individuals with hearing impairment based on hearing aid users’ and audiologists’ perspectives. Method: The present study used inductive thematic analysis. The participants were 12 hearing aid users and 12 Audiologists. The study was conducted in interview mode either face-to-face or telephonic mode. The verbatim of the participants was transcribed and different codes were assigned. The codes were used to derive the subthemes and themes. Results: Four major themes were obtained. The first and second themes were Client-centred and Clinician-centred aspects respectively. The third theme focussed on Hearing aid trial and service delivery aspects. The fourth theme discussed mainly Hearing aid-associated benefits and drawbacks. Conclusion: Audiologist should effectively address the challenges posted by hearing aid users, this in turn can favor the hearing adoption among the adults with hearing loss.
Keywords: Hearing aids, Audiologist, Hearing aid user
Introduction
Hearing loss in older adults can lead to a breakdown in information interchange, which can have a negative impact on daily living, leading to feelings of loneliness, isolation, dependence, and frustration, as well as communication problems [1, 2].
Hearing aids are the most used rehabilitative strategy offered to individuals with hearing loss [3]. Hearing aids are proven to be advantageous for improving communication as well as the psychological, social, and emotional well-being of individuals with hearing impairment [4, 5]. Hearing aid usage within three months has shown improvement in cognitive functions and decreased depressive signs [6].
Although the prevalence of hearing loss is high, there is a reluctance to adopt hearing aids, especially in developing countries. As per the literature, the reasons provided by individuals with hearing loss for not wearing a hearing aids includes, hearing aids are not effective in noisy situations, need assistance during hearing aid usage, feel uncomfortable, or experience side effects [7, 8].
A cross-sectional study performed in India on people aged above 60 years in an urban slum and a village area showed self-reported hearing loss by 63.1% of participants. However, the use of hearing aids was very low at approximately 1.47% [9]. Hearing aid adoption is very low in developing countries, and even if aid is purchased, it is abandoned by users [10, 11]. A better understanding of the factors contributing to the adoption and continued use of hearing aids among older adults can facilitate the development of appropriate strategies to promote the use of hearing aids [4].
Methodology
Approval
Approval for the current study was obtained from the Institutional Research Committee (IRC), Institutional Ethics Committee (IEC) (IEC No: 260/2022), and Clinical Trial Registry of India (CTRI) (CTRI/2022/11/047437) before recruitment of the participants for the study.
Participants
The study consisted of two groups, and each group had 12 participants [12]. Participants from each group were recruited using purposive sampling. Group 1 consisted of audiologists with more than two years of experience. Group 2 consisted of hearing aid users with a minimum of 6 months of hearing aid usage. Consent was obtained from all the participants before enrolling in the study. Details of the participants are given in Table 1.
Table 1.
Participant Details
| Audiologist- Group 1 | ||||
|---|---|---|---|---|
| Identifier | Gender | Age (years) | Experience in hearing aid dispensing (in yrs) | Qualification |
|
P111 P112 P113 P114 P115 P116 P117 P118 P119 P120 P121 P122 |
F F F F F F F M M M M M |
29 32 24 25 24 25 48 30 32 28 28 30 |
> 5 > 5 < 5 < 5 < 5 < 5 > 10 5 > 5 < 5 < 5 > 5 |
MASLP BASLP BASLP BASLP BASLP BASLP BASLP MASLP MASLP MSc Audiology MSc Audiology MSc Audiology |
| Hearing Aid User- Group 2 | ||||
| Identifier | Gender | Age (years) | Duration of Hearing aid usage (in years) | |
|
P211 P212 P213 P214 P215 P216 P217 P218 P219 P220 P221 P222 |
M F M F M M M F F M M M |
50 36 75 55 60 78 65 27 66 78 67 57 |
< 5 < 5 < 5 > 5 < 5 > 5 > 5 > 10 > 10 5 > 10 < 5 |
|
Note. MASLP- Masters in Audiology and Speech-Language Pathology, MSc Audiology- Master of Science in Audiology. MASLP and MSc Audiology are Postgraduate programs. BASLP- Bachelor in Audiology and Speech-Language Pathology. BASLP is an undergraduate program
Interview Question Guides
An extensive review of the literature regarding various aspects of hearing aid adoption and usage was performed, and a set of interview probes was prepared for each group, which was reviewed by a group of experienced audiologists who have been working under rehabilitative audiology for more than 2 years. Interview probes were used to elaborate on responses from the client.
Procedure
The participants were interviewed by the principal investigator. The interview was recorded using the mobile application Smart Voice Recorder on the Redmi A3 phone. The recorded data were later transcribed for further analysis.
Data Coding and Analysis
Data analysis was performed using thematic analysis [13]. An inductive (bottom-up) technique was utilized to find themes in the data study. Following the completion of the interview, the verbatim transcriptions of the participants were transcribed orthographically. The two groups were analyzed for the generation of the initial set of codes. The codes derived were put under a broader category of subthemes and then into themes. Finally, all the subthemes were explained using an analytic narrative supported by relevant extracts from the data.
Results
The analysis resulted in four major themes, mentioned in Table 2.
Table 2.
Themes and Subthemes
| Themes | Client-centered aspects | Clinician-centered aspects | Hearing aid trial and service delivery aspects | Hearing aid-associated benefits and drawbacks |
|---|---|---|---|---|
| Subthemes |
Client’s personality and attitude toward the device. Age, degree of loss and financial aspects. |
Knowledge and clinical experience of the clinician. Qualities of a clinician. Counseling skills. Follow-up monitoring. |
Clinical vs. home trial. Clinical setup and service aspects. Care and maintenance of the aid. |
Challenges faced with the hearing aid. Benefits of hearing aid. Technology aspects. |
Theme 1: Client-centered Aspects
There were two subthemes identified in this section. The first subtheme mainly talked about personality and attitude aspects, and the second subtheme explained the demographic aspects of the clients, such as age and financial aspects.
Client’s Personality and Attitude Toward the Device
As per the audiologist’s point of view client’s attitude toward his/her hearing loss, and the way they were willing to deal with it, the support system offered by his/her peers played a fundamental aspect when going ahead with an amplification device.
Some of the participants from the hearing aid user group were completely against hearing aids and other technological aspects. They have strongly associated hearing aids as a device that worsens the hearing loss of an individual. This mindset against hearing aids puts an end to hearing aid procurement.
The social support system of the client played a vital role in encouraging the client to go ahead with the hearing aid. One participant from the hearing aid user group stated that she loved to share her positive experiences with the device and recommend it to others who have hearing loss.
Audiologists have commented that if the client is positively motivated, they would go ahead with the suggestion of the family members or peers for procuring a hearing aid. On the other hand, when the client does not have the self-realization regarding his impairment, he/she feels that family is pressurizing them to get a hearing aid. Some of the hearing aid users themselves said that they had just bought hearing aid due to pressure from family members and did not wear hearing aid often.
Both groups of participants expressed concern regarding the size of the hearing aid being a hindrance to going ahead with a hearing aid. Many stigmas are associated with hearing aids. Some of the hearing aid users said they were embarrassed regarding others finding out about their hearing loss. This inhibited them from wearing the hearing aid after procurement. Audiologists commented on female clients being more bothered about the cosmetic part while buying an aid. Despite the severity of hearing loss, they preferred hearing aids that are invisible outside. One of the hearing aid users responded that she was frustrated with all the questioning and the way she was made fun of by society secondary to wearing the device.
Age, Degree of Loss and Financial Aspects
As per the audiologist, the degree of hearing loss along with its handicapping effects persuaded the individual to go ahead with the hearing aid. Age of the participant plays a key role in determining whether the client would go ahead with using the hearing aid. The elderly clients found it difficult to comprehend the advanced technology and handle the aid by themselves and therefore chose not to go for a hearing aid. Dexterity issues are seen as part of aging as well as along with certain health issues, which puts these users at a disadvantage. The miniature size of the hearing aid and changing hearing aid batteries are the other concerns where they fear mishandling the aid and do not want to go for it. Most audiologists have experienced conflicts with clients regarding hearing aid being too expensive and not having enough financial support to go for aid.
P118 “Definitely all the Individuals who come here are Looking for a Cheaper Hearing aid.”.
Some of the hearing aid users expressed concerns regarding the delay in government schemes that sanction the funding of hearing aid, which thereby resulted in a delay in the procurement of hearing aid. Participants from the hearing aid user group had also voiced their opinion on hearing aids being expensive, provided there is no other choice, they have to compromise with the cost of the aid.
P221 “Yes, I did have issues with the price of the aid, but there was no other choice”.
Theme 2: Clinician-centered Aspects
Four subthemes were identified in this section, which are mentioned below.
Knowledge and Clinical Experience of the Clinician
Audiologists have provided remarks regarding the importance of clinicians being knowledgeable in the field of audiology and updating themselves with the recent trends in hearing aid. They also commented that the clinical proficiency of the clinician played a significant role in device procurement and usage. A proficient clinician provides satisfactory hearing aid trials to the client. The satisfaction experienced during the first fitting determines whether the client will continue using the device.
Most of the hearing aid users had complained that the clinician never showed different hearing aids during the trial, and the hearing aid features were not explained.
Qualities of a Clinician
The audiologist group strongly stated that a clinician must stay within his professional boundary and not endorse the hearing aid like a retailer. A clinician must try different hearing aids, explain their features to the client and help the client reach a decision and not force a decision on them. The rapport built by the clinician with the client ensured the confidence of the client with the clinician, which made the client more comfortable sharing his/her problems. In this way, it helped the clinician program the hearing aid in a better manner.
Some hearing aid users have said that they have good rapport with their clinicians. The clinician was very approachable and quick to respond to their queries. This facilitated them to procure a hearing aid. One of the hearing aid users commented on hearing aid dispensing by a nonprofessional, leading to a very bad experience. The individual reported that if he had not approached the audiologist, he would have been conned by the dispenser.
Counseling Skills
Audiologists stressed the fact that counseling played a major role in hearing aid procurement. Before going for a hearing aid fitting, the clinician must counsel the client regarding the need for going for a hearing aid. They also stated that counseling must explain the aspects of what difficulties the client is going to face without aid along with difficulties experienced by the caretakers and family members. Prior to the purchase of the aid, the price of the aid along with maintenance expenditure must also be brought to the client’s attention.
P114 “Making them understand that they have hearing loss is a very big factor. Because it’s usually a stage where the caretaker or the kids are facing many difficulties.”
The high expectations from the client and the hearing aid not addressing those requirements caused the abandonment of the hearing aids. The client should be clearly informed of the benefits and limitations of hearing aids.
Follow-up and Monitoring
Audiologists have reported that hearing aid users needed a minimum of one month for acclimatization. During the period of acclimatization, the client must pay frequent visits for fine-tuning and other adjustments. The clinician must follow up with the client regarding whether the aid is functioning well enough to meet the client’s needs. Regular audiological evaluation helped in reprogramming the hearing aid based on the change in the threshold, especially in cases of fluctuating hearing loss. These sessions helped the client obtain the maximum benefit that met the patient’s needs. Thus, it helped the client to use the aid without any issues.
P122 “We should always follow up with the patient, like whether he is having optimal output from the hearing aid from his fitting if not, we should always call him back for a fine-tune session.”
Theme 3: Hearing aid Trial and Service-delivery Aspects
Three subthemes were identified under this theme.
Clinical vs. Home Trial
Both groups of participants in the study conveyed that hearing aid given for home trials acted as a convincing factor for hearing aid adoption. The advantage of a home trial stated by the participants was that it helped the client decide whether the aid matched the expected benefit in his/her natural environment. Some audiologists reported that if they incorporated the practice of giving hearing aid for a home trial prior to purchase, there are chances of the hearing aid not being returned to the clinic posttrial. However, hearing aid users were worried about the expenses to be covered in case of any damage to the aid occurred during the home trial period.
P115 “We gave him a home trial option, but the thing is most of the time they will not return the hearing aid on the day you asked them to bring it. There were many problems caused because of that.”
Clinical Setup and Service Aspects
Frequent complaints audiologists reported were that of lack of availability of hearing aids in stock for trial. Hence, different hearing aids cannot be tried on the client. Another major concern was that when the hearing aid was sent for servicing, the clinician did not have a backup hearing aid to be given to the client during this period. Both groups of participants talked about the unwillingness shown by the clients to give the aid for servicing, worrying about the expenditure involved, the delay in getting the hearing aids back, and the difficulty in managing without the aid when it is sent for servicing.
P118 “When we send the device for servicing, they will not be having a spare device here. That will be difficult for the patient. In addition, also, in some scenarios, servicing time will be much longer.”
Care and Maintenance of the Aid
Audiologists commented on training the client regarding the care and maintenance of the aid is necessary, which prevents chances of a client returning to the clinic with complaints against the susage of hearing aids.
Theme 4: Hearing aid-associated benefits and drawbacks
In this section, three main subthemes were identified.
Challenges Faced with Hearing Aids
The most frequent complaints faced by audiologists were hearing aid damage within a short span of time. Other major issues were frequent battery drainage, dissatisfaction with sound quality, and corrosion of hearing aid due to humidity factors, especially in coastal areas. Limitations reported by hearing aid users were annoyance from the continuous humming sound from the aid, itching in the canal due to the use of an earmold, and outside noises, especially vehicle sounds, becoming intolerable. All these require frequent visits to hearing aid clinic and results in troublesome for hearing aid users.
Benefits of a Hearing Aid
Both groups of participants reported that the advantage of using a hearing aid was improved hearing ability, reduction in tinnitus perception, ease of communication, and less reliance on lip reading or other visual cues. Most audiologists have also commented that the need to hear the voice of near and dear ones overrides the cosmetic concerns of the client.
P112 “They will ask for ‘I just want to hear my child’s voice,’ so we have to consider patients’ need.”
Technology Aspects
Audiologists stated that they have clients who had come in search of features such as noise reduction, Bluetooth accessibility, directional streaming, and rechargeable options. Clients were already aware of these aspects before they came to purchase aid. If the clinician had hearing aids with these features during the trial, it would help in easier decision-making for the client.
One hearing aid user reported 50–70% ease in the work environment after shifting to Bluetooth-supported hearing aids. Clients preferred hearing aids that were rechargeable over battery-worn hearing aids. Some of the very recent technological advancements, such as waterproof hearing aids, were another feature that was requested by the clients.
Discussion
Both groups of participants in the present study had similar views on hearing aid adoption and usage. The difference between the two groups was seen only at the level of codes used for inductive coding. For a better understanding of the results, the factors were discussed under the pre-fitting and post- fitting aspects. Audiologists obtain a better idea of the factors that are involved in the journey from hearing aid dispensing to postadoption aspects.
Pre-fitting
The major factor in hearing aid adoption was when the client himself was concerned about his hearing and was motivated to go for a hearing aid. A self-perceived hearing problem was the most important determinant of hearing aid usage [14]. When the desire to overcome the impact of hearing loss was stronger, there was greater acceptance of the aid [15].
Even if they were willing to go for a hearing aid, the price of the hearing aid was another stressing factor. Despite the need for aid, financial issues prevented them from procuring hearing aid. The literature also supported this finding. Based on a review performed on Marke Trak10, it was stated that if a person has a significant perception of hearing loss and knew they needed a hearing aid, the cost was the reason that they do not have one (Jorgensen & Novak, 2020).
Another factor in prefitting aspects was centered on the social stigma associated with the use of the device. Individuals with hearing impairment were worried about the visibility of the aid and the way it affected their appearance [16]. The use of a hearing aid was often associated with old age and diminishing cognitive capacity [17]. Thus, individuals with hearing loss do not want to be labelled as cognitively challenged because of wearing a hearing aid [16].
Counseling offered by the clinician was another aspect predominantly discussed by audiologists. Along with knowledge regarding hearing aid aspects, successful fitting of hearing aids can be achieved only when the audiologist was a good listener heeding to the client’s complaints and provide good counselling accordingly [18]. The clinician must counsel on the type and degree of hearing loss along with possible limitations experienced due to this impairment. This makes the client more convinced to go for a hearing aid as one of the possible management options.
Post-fitting
Under post-fitting factors, one of the challenging situations was related to their efficiency in occupation. This is because employers think that wearing a hearing aid is a sign of handicap and hence not fit for the job. This showed the lack of awareness existing in modern times regarding the use of a hearing aid that can assist the individual function more efficiently. This pointed toward the existence of negative societal attitudes toward a person with hearing loss [17].
Many other challenges were reported regarding the hearing aid being damaged within a short duration and annoyance related to the sound quality of the aid. These frequent troubles prevented them from continuing hearing aid usage. If the client follows proper care and maintenance of the hearing aid as per the guidelines from the audiologists, this can help reduce the frequent visits needed to the clinic for repair. Kochkin, in his review of Marke Trak V, discussed the abandonment of hearing aids due to problems faced with hearing aid post-purchase. The probable solutions for these as per the author were better evolution in technology, improved fitting provided during dispensing, and advanced fitting strategies that can help with providing better fit and comfort [19].
Factors with respect to pre- and post-fitting
The common problem encountered by the clinician in the clinical setup was the lack of hearing aid models available for trial. Lack of backup hearing aid available for use while the user’s aid is sent for service. These issues at the level of the clinic needed to be addressed such that clients can have the option to rely on them without compromising their day-to-day functioning during the absence of their hearing aid.
Most hearing aid users conveyed a great deal of assurance when approaching the specific clinician. The clinician was empathetic and considerate, which made the clients feel more comfortable discussing their concerns. The audiologist is supposed to provide a professional environment that is not only physically comfortable and accessible but also does not feel threatened or coerced into selecting hearing aids [18]. In accordance with this, the literature has stated that clinicians meeting the client’s needs, conveying device information, providing supporting choices, and taking part in shared decision-making favored hearing aid procurement [20].
Conclusion
Based on the detailed thematic analysis, factors that facilitate the use of hearing aids were categorized under client-centered aspects, clinician-centered aspects, hearing aid trial and service delivery aspects, and hearing aid-associated benefits and drawbacks. These aspects must be addressed to promote hearing aid usage and provide device-related satisfaction.
Future Directions and Implications
The outcomes of the study can be used by hearing aid manufacturers and audiologists to improve the design and functionality of hearing aids, as well as the services provided to clients. By understanding the factors that facilitate the use of hearing aids, they can create products and services that better meet the needs of clients and promote device-related satisfaction. Hearing aid manufacturers can be more aimed toward client-centered products that are tailored to individual needs, and audiologists could provide more comprehensive hearing aid trials and follow-up services to promote hearing aid usage.
Funding
This research did not receive any specific grant from any agency in the public, commercial or not -for- profit specific sector.
Declarations
Conflict of Interest
No conflicts of interest were reported.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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