Post‐COVID‐19 Pandemic Growth of National Hearing Aid Utilisation: A Population‐Based Study

ABSTRACT

Introduction

Hearing loss affects 538 million people globally. Untreated hearing loss may be compensated through speech reading. The COVID‐19 pandemic prompted face coverings, causing communication challenges. We aim to investigate the possible impact of the COVID‐19 outbreak era on hearing aid demand.

Study Design

Ecological time‐series study.

Settings

A health organisation with five million members.

Methods

We examined the number of patients referred for hearing aid fitting by an otolaryngologist from March 2018 to February 2024. The data were stratified into three main groups: pre‐pandemic (control group, 2018–2020), COVID‐19 pandemic (study group 1, 2020–2022) and post‐pandemic group (study group 2, 2022–2024).

Results

A total of 97 149 patients were included in the study. The yearly incidence rate of referrals for hearing aid fitting (per 100 000 patients) in all age groups increased in all study groups (during and post‐COVID) compared to the average incidence of the control group, with a notable increase in the second year of the COVID‐19 pandemic onward. The incidence rate ratio (IRR) for the 18–49 age group showed the largest and most significant increase 3.16 (95% CI: 2.74, 3.65) in the second post‐COVID year compared to the pre‐COVID period (p < 0.001). Significant increases were also observed in the 50–75 age group IRR: 2.10 (95% CI: 1.87, 2.36) and the 75–120 age group IRR: 1.53 (95% CI: 1.35, 1.74) (p < 0.001).

Conclusion

There is a significant increase in the demand for hearing aids following the COVID‐19 outbreak. Considering the possibility of future outbreaks and the everyday increase in face masking usage, health providers and patients should be further encouraged to pursue hearing rehabilitation.

Level of Evidence

Level 3.

Summary.

• Face coverings may have reduced speech‐reading cues, leading to heightened awareness of hearing loss.

• COVID‐19 pandemic restrictions increased demand for hearing aids across all age groups.

• Younger adults (18–49 years) showed the most significant rise in hearing aid referrals.

• Post‐pandemic hearing aid demand remained elevated, especially in elderly individuals.

• The study highlights the importance of hearing rehabilitation in future pandemic scenarios.

1. Introduction

Hearing loss is a common chronic impairment, particularly in older adults. According to estimates from the World Health Organisation (WHO), hearing loss affects approximately 538 million people around the globe [1]. Age‐related hearing loss impacts around 25% of individuals over the age of 65 [2].

Speech‐reading is the ability to use visual cues of lip movements and facial expressions in speech perception. It is a valuable skill when listening to speech in degraded auditory environments (e.g., listening in noise). Speech‐reading cues, when available, are inevitably processed, as proven in brain imaging works [3]. People with hearing loss heavily rely on speech‐reading to communicate, in comparison to people without hearing loss, and function significantly better when presented with audio‐visual cues rather than audio cues only [4, 5, 6]. Hearing aids are considered an effective conventional clinical option for patients with hearing loss [7, 8, 9]. Untreated hearing loss can lead to significant consequences, including social isolation, depression, cognitive decline and reduced quality of life [10]. As communication becomes increasingly difficult, individuals may withdraw from social interactions, leading to feelings of loneliness and potentially exacerbating mental health issues. Moreover, there is growing evidence linking untreated hearing loss to an increased risk of cognitive decline and dementia in older adults [10].

The COVID‐19 pandemic was declared a public health emergency of international concern in January 2020 by the WHO. In March 2022, the COVID‐19 outbreak was officially designated a pandemic [11]. Globally, nations responded to this pandemic with lockdowns, social distancing, and mandatory face masking [12].

Long‐term complications of COVID‐19 and COVID‐19 vaccines were widely researched and include a range of intra‐ and extrapulmonary manifestations. Some studies dealt with otologic symptoms and hearing loss [13, 14, 15]. A recent review found that hearing loss can be one of the complications of COVID‐19, but it is rare [16].

Although useful and important, face covering has far‐reaching impacts on communication in the general population [5, 6, 17]. A few studies have examined the acoustic impacts of face coverings and consistently illustrated that masks attenuate sound output by 2–20 dB, depending on mask type [5, 6]. In addition, face coverings remove visible cues from the mouth and lips, which are essential for speech reading, and limit the visibility of facial expressions [5, 6, 17], affecting mostly people with hearing loss [5].

In 2020, Ertugrul and Soylemez described their impression that the use of hearing aids would increase during the COVID‐19 outbreak [18]. This has led the authors to hypothesise that the COVID‐19 era may have influenced the demand for hearing aids, as it may have ‘reflected’ the hearing loss for patients relying on speech reading.

For this purpose, we designed a population‐based cohort, using one of the largest HMOs worldwide, encompassing over five million patients. The aim of this study was to investigate the association between the COVID‐19 virus outbreak era and the demand for hearing aids.

2. Materials and Methods

The study was approved by the National Helsinki Committee of CHS. The institutional Helsinki committee approved the lack of need for consent to participate due to the retrospective nature of the study.

This is an ecological study analysed by time‐series methodology, using the Clalit Health Services (CHS) database, covering the medical records of patients who were referred for hearing aid fitting by an otolaryngology doctor based on an audiological hearing test between March 2018 and February 2024. For all patients, this is the first referral for a hearing aid fitting.

The study's design was based on the COVID‐19 pandemic timeline. Every study year has been considered to run from March to February of the following year. The annual division thus ensured time intervals corresponding to key phases of the COVID‐19 pandemic. The study periods are classified into three main groups representing different study periods (divided into subgroups according to years), shown in Figure 1:

• Group 1—Control group: pre‐COVID‐19, years 2018–2020 (23 882 patients).

• Group 2—study group 1: during COVID‐19, years 2020–2022 (28 187 patients).

• Group 3—study group 2: post‐COVID‐19, years 2022–2024 (45 080 patients).

FIGURE 1.

Study population flow chart.

For each interval, hearing aid demand was sub‐analysed further by age, divided into three age groups: 18–49, 50–75 and 75–120 years.

We included all adult patients (18 years old and older) who were referred by an otolaryngology doctor for hearing aid fitting, using the specific organisation's codes for this referral, separating it from other referrals for audiometry testing. We excluded patients with partial medical backgrounds or patients who had hearing aids prior to the study years. As we reviewed the whole population, there was no need for sampling methods.

CHS is the largest health maintenance organisation (HMO)—an organisation that provides comprehensive health insurance and healthcare services to the country's residents, including primary care, specialist consultations, hospitalisation and medications. According to recent data, CHS insures more than five million members of the country's population. CHS information is entirely digitised and constantly fed into a central database. Data were extracted from CHS using Clalit's data‐sharing platform powered by MDClone (https://www.mdclone.com), including demographic data (date of birth, sex, ethnicity, socioeconomic status) and MDClone coding for hearing aid referral evaluation or fitting.

2.1. Statistical Analysis

We calculated episode rates of hearing aid referrals per 100 000 patients for each age group, and then compared monthly disease‐specific rates for each study year. We then modelled seasonal incidence rate ratios (IRRs) using interrupted time‐series analysis. Seasonality was considered by including harmonic terms (sines and cosines) with 12‐ and 6‐month periods to adjust for the annual and semi‐annual patterns. The time trend remaining after adjustment to seasonal fluctuations was further investigated for its association with the pandemic.

To examine the pandemic's impact, we delineated three distinct periods: pre‐COVID‐19 period, COVID‐19 and post‐COVID‐19 period. The goodness‐of‐fit of the quasi‐Poisson regression model was assessed by visual inspection of the correlograms (Autocorrelation and Partial Auto‐Correlation Functions) and residual analysis. All tests were two‐sided, and we considered a result statistically ‘significant’ when the p‐value was < 0.05. All statistical analyses involved using R v.3.6.1 (http://www.R‐project.org).

3. Results

During the study period, a total of 97 149 patients were referred for hearing aid fitting by an otolaryngology doctor and were divided into three main groups: Control (n = 23 882), during COVID‐19 (n = 28 187) and POST COVID‐19 (n = 45 080) (Figure 1).

The baseline characteristics of the study's population are presented in Table 1. Across all age groups, the male‐to‐female ratio was 1:1, and their average age was 72 ± 14 years during all COVID‐19 pandemic periods. The study population was mainly composed of individuals with medium socioeconomic status.

TABLE 1.

Demographics of hearing aid referral episodes, according to study interval.

Characteristic	Control group 1 03/18–02/19, N = 12 082	Control group 2 03/19–02/20, N = 11 800	COVID year 1 03/20–02/21, N = 12 183	COVID year 2 03/21–02/22, N = 16 004	Post COVID 1 03/22–02/23, N = 21 021	Post COVID 2 03/23–02/24, N = 24 059	p	Overall, N = 97 149
Yearly incidence rate per 100 000 patients	398	384	391	508	657	743
Age, years							< 0.001
Mean ± SD (N)	74 ± 13 (12 082)	73 ± 13 (11 800)	72 ± 14 (12 183)	72 ± 14 (16 004)	71 ± 14 (21 021)	71 ± 14 (24 059)		72 ± 14 (97 149)
Median (IQR)	75 (67, 83)	75 (67, 82)	73 (65, 82)	74 (65, 82)	73 (65, 81)	73 (64, 80)		74 (65, 82)
Range	18–109	18–114	18–105	18–106	18–107	18–106		18–114
Age group, n (%)							< 0.001
18–49 years	570 (4.7%)	667 (5.7%)	871 (7.1%)	1232 (7.7%)	1716 (8.2%)	2081 (8.6%)		7137 (7.3%)
50–74 years	5365 (44%)	5374 (46%)	5899 (48%)	7583 (47%)	9929 (47%)	11 645 (48%)		45 795 (47%)
75–120 years	6147 (51%)	5759 (49%)	5413 (44%)	7189 (45%)	9376 (45%)	10 333 (43%)		44 217 (46%)
Gender, n (%)							0.093
Female	6048 (50%)	6014 (51%)	6003 (49%)	7984 (50%)	10 508 (50%)	11 896 (49%)		48 453 (50%)
Male	6034 (50%)	5786 (49%)	6180 (51%)	8020 (50%)	10 513 (50%)	12 163 (51%)		48 696 (50%)
Socioeconomic score, n (%)							< 0.001
High	3036 (26%)	2695 (24%)	2692 (23%)	3300 (22%)	4550 (23%)	5163 (23%)		21 436 (23%)
Low	1031 (9.0%)	1098 (9.8%)	1293 (11%)	2000 (13%)	2779 (14%)	3297 (15%)		11 498 (13%)
Medium	7434 (65%)	7403 (66%)	7533 (65%)	9805 (65%)	12 468 (63%)	14 184 (63%)		58 827 (64%)

The incidence of hearing aid referrals and a negative control sensitivity analysis stratified by age groups is presented in Table 2 and Figure 2.

TABLE 2.

Incidence of hearing aids referrals by different time periods and a negative control sensitivity analysis. Results of time series analysis. ^a

Characteristic	All ages			18–49			50–75			75–120
	IRR	95% CI	p	IRR	95% CI	p	IRR	95% CI	p	IRR	95% CI	p
Period
Pre‐COVID 03/18–02/20	—	—		—	—		—	—		—	—
COVID year 1 03/20–02/21	1	0.87, 1.15	> 0.9	1.38	1.15, 1.64	< 0.001	1.08	0.94, 1.24	0.3	0.89	0.76, 1.04	0.14
COVID year 2 03/21–02/22	1.3	1.14, 1.48	< 0.001	1.92	1.64, 2.26	< 0.001	1.38	1.22, 1.57	< 0.001	1.15	1.00, 1.32	0.057
Post COVID year 1 03/22–02/23	1.68	1.49, 1.90	< 0.001	2.64	2.27, 3.06	< 0.001	1.8	1.60, 2.03	< 0.001	1.44	1.27, 1.64	< 0.001
Post COVID year 2 03/23–02/24	1.9	1.69, 2.14	< 0.001	3.16	2.74, 3.65	< 0.001	2.1	1.87, 2.36	< 0.001	1.53	1.35, 1.74	< 0.001

Abbreviations: CI, confidence interval; IRR, incidence rate ratio.

^a Adjusted for seasonality.

FIGURE 2.

Hearing aids referrals episodes fluctuations timeline.

For all age groups, hearing aid fitting referrals were significantly increased following COVID year 2–2021–2022 (p‐value < 0.001), but not COVID year 1–2020–2021 (p‐value > 0.9), when comparing incidence demand rates to the control group. The largest and most significant increase was noted in the 18–49 age group, demonstrating a higher IRR in all study periods compared with the other age groups (Table 2). Of note, the only group that did not demonstrate a significant increase in hearing aid demand incidence in the COVID second year was the elderly population (age group 75–120), with a significantly increased IRR demonstrated in the POST‐COVID period (p‐value < 0.001).

4. Discussion

While not studied formally, it is not uncommon for patients to refuse hearing aids and to rely on facial cues due to social concern and self‐perception [10, 19]. The current study aimed to investigate a possible association between face covering and hearing aid demand stratified by COVID‐19‐related time periods and age groups. Only one study with very limited information dealt with this subject, and this is the first big‐data study to investigate it.

We found that hearing aid demand increased among all age groups during the post‐COVID‐19 period, while the younger age group (18–49) showed the most significant increase. Since previous studies did not find a significant effect of COVID‐19 on hearing thresholds even among patients with additional COVID‐19 symptoms [20, 21, 22], we suggest that the increase in demand for hearing‐aid referrals reflects an increased self‐awareness of hearing loss. This is likely affected by the inability to use speech‐reading cues as a result of the face covering. The latter was shown to reduce sound levels by up to 20 dB [5]. Moreover, face coverings can limit the natural speech‐reading ability that unknowingly and unintentionally compensates for some degree of hearing loss or speech perception in challenging listening environments. The lack of this ability when face covers are applied may have led more patients to acknowledge their hearing disability and pursue assistance.

While taking a closer look at the COVID‐19 groups, in the age group of 18–49 years, there was a significant increase in demand in both COVID‐19 years compared to the other age groups, where the increase for hearing aid demand was only significant in the second COVID‐19 year.

It can be assumed that the reasons for the different data trends between the age groups mentioned, and the difference between the two COVID‐19 years with respect to the demand for hearing aids, potentially lie within the social effects of the initial COVID‐19 outbreak. At first, during COVID‐19 year 1, while the effects of COVID‐19 were still unclear for the general population, social distancing was widely embraced, and that was accompanied by more limitations including strict lockdowns, which have resulted in people not leaving their homes, minimising their visits to medical institutions of all kinds, and in general avoiding unnecessary contact with other people, mainly in the older population who were at risk. Moreover, non‐emergent medical services were significantly decreased, further reducing availability. In the second COVID year, as vaccinations were introduced and lockdowns became uncommon, social interactions using face masks have increased significantly as well. This, together with the increased availability of medical services and hearing aid providers, may explain the differences noted.

The elderly population was the only subgroup of patients that did not demonstrate a significant increase between the 2 years of COVID. This may be attributed to the unique characteristics of this population regarding the risk of infections and complications related to COVID. The introduction of the vaccines may have had a particular impact on the elderly patients by providing a safer environment for this population at risk, which is further supported in the results, as evidenced by the rise in hearing aid referrals among elderly populations during the second year of the COVID‐19 pandemic.

Hearing loss is still accompanied by many prejudices and can lead to avoidance of social interactions and self‐isolation [10, 19]. The study findings underscore the interplay of facial coverings, communication challenges and hearing health awareness and call for increased attention to hearing health at all ages, with special emphasis on situations in which there might be a reduced ability to use visual cues for communication.

4.1. Research Limitation

Our data was collected at an insufficient resolution that doesn't allow us to differentiate between types of hearing loss and their severity. Additionally, the study was confined to health care services provided within Clalit health clinics. Although this represents a high proportion of the population, it may still not capture the whole picture, and generalizability to other health systems or countries was limited. During the early stages of the COVID‐19 outbreak in Israel, the widespread caution and anxiety stemming from the unknown virus led to people staying isolated at home, delaying non‐essential appointments, including elective medical services. This delay might result in a lack of information regarding new cases of hearing loss. To address this limitation, the study spanned over different pandemic periods (pre‐COVID‐19, during COVID‐19 and post‐COVID‐19). This duration was chosen to more accurately capture the actual trajectory of the demand for hearing aids, potentially unaffected by underdiagnoses during the COVID‐19 lockdown period.

5. Conclusion

This study reveals a significant increase in the demand for hearing aids since the COVID‐19 outbreak, possibly due to its restrictions. Considering the possibility of future outbreaks and changes in face masking usage, health providers and patients should be further encouraged to pursue hearing rehabilitation.

Author Contributions

Data collection, Helsinki approval, drafting the article: Keren Oren. Statistical analysis, data collection, Helsinki approval, drafting the article: Itai Hazan. Study design, drafting, and revisions of the article: Stave Edri Abikasis. Data collection, audiological analysis, drafting the article: Liron Kariv. Statistical analysis: Tomer Kerman. Study design, drafting, and revisions of the article: Oded Cohen. Study design, drafting, and revisions of the article: Oren Ziv.

Ethics Statement

The study was approved by the institutional Helsinki Committee.

Consent

The institutional Helsinki committee approved the lack of need for consent to participate due to the retrospective nature of the study. All authors have given consent to publish the study.

Conflicts of Interest

Oded Cohen is an Editorial Board member of Clinical Otolaryngology and a co‐author of this article. To minimise bias, they were excluded from all editorial decision‐making related to the acceptance of this article for publication.

Oren K., Hazan I., Abikasis S. E., et al., “Post‐COVID‐19 Pandemic Growth of National Hearing Aid Utilisation: A Population‐Based Study,” Clinical Otolaryngology 51, no. 2 (2026): 262–268, 10.1111/coa.70048.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.