Help-seeking behaviour of older adults towards hearing loss based on the health belief model: a qualitative research study

Abstract

Background

Hearing loss is common among older adults in Singapore, yet many do not seek early assessment or adopt hearing aids despite the availability of community hearing screening services. This may lead to preventable consequences such as reduced quality of life and dementia. This study aimed to explore the health beliefs and help-seeking behaviour of older adults towards hearing loss.

Methods

The study leveraged the Health Belief Model (HBM) to develop a topic guide to field in-depth interviews (IDIs) on 16 Asian adults aged 65 years and older with diagnosed or self-reported hearing impairment in primary care. The interviews were audio-recorded, transcribed verbatim, audited and analysed to identify emerging themes based on the HBM.

Results

The identified themes were grouped under perceived susceptibility, severity, barriers and cues to action that enhanced self-efficacy. Older adults did not consider hearing loss as a disability, attributing it to natural ageing and being “untreatable” with minimal daily disruption. Few regarded it as a serious health condition unless they experienced significant social consequences or emotional distress, often seeking treatment only as a last resort. Cost to fit hearing aid was deemed a barrier, with devices perceived as ineffective or inconvenient. Cues to action that could enhance their self-efficacy include family support, greater awareness of available hearing aid financial subsidies and community hearing screening programmes.

Conclusion

Using the HBM, this study highlights that older adults commonly underestimate their susceptibility to and severity of hearing loss. Many seek help only when it causes significant impairment and are deterred by perceived cost or doubts about the usefulness of hearing aids. These findings underscore the importance of leveraging effective cues to action to enhance self-efficacy, thereby promoting timely help-seeking and better management of hearing loss.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-026-03274-w.

Background

Hearing loss is highly prevalent worldwide. According to the World Health Organization, it is estimated that by 2050, over 700 million of the global population will be affected by disabling hearing loss, defined as having hearing loss greater than 35 decibels (dB) in the better hearing ear [1]. The prevalence of hearing loss increases with age and roughly doubles with every decade of ageing [2]. The prevalence of hearing loss among Singapore residents aged 60 years and above was estimated to be 63.7% [3]. With the proportion of Singaporeans aged 65 years and older projected to reach 25% of the population by 2030, the burden of hearing loss is expected to rise significantly [4].

Despite its impact, hearing loss remains unassessed and untreated among older adults [5, 6]. Many regard it as an inevitable part of ageing and delay seeking help. International and local studies report that most individuals live with hearing loss symptoms for prolonged periods, often years or even decades before seeking treatment [7, 8].

Unaddressed hearing loss imposes a substantial burden on individuals and society. It can severely affect daily living by compromising safety and causing communication barriers, social isolation [9], depression [10] and decreased quality of life [11]. Beyond psychosocial consequences, hearing loss has been linked to cognitive decline and an increased risk of dementia [12, 13]. The economic impact is also significant, with the estimated annual global cost of unaddressed hearing loss ranging US$750–790 billion, stemming from healthcare costs, productivity loss and diminished quality of life [14, 15].

In Singapore, basic functional hearing screening is available at subsidized rate, yet it is often perceived as less important than other chronic disease screening [16]. Almost 90% of local patients on their first assessment at a mean age of 70 years were found to have disabling hearing loss [8]. In addition, hearing aid uptake remains low, with only 7.5% of older adults with disabling hearing loss using hearing aids [8], underscoring the urgent need to better understand their hesitancy towards intervention.

Early diagnosis and intervention for hearing loss are crucial for improving the quality of life and promoting healthy ageing among older adults [1]. Timely treatments, such as the use of hearing aids, can potentially delay the onset or progression of cognitive impairment and dementia [17]. These benefits empower older adults to maintain their independence and well-being while reducing the long-term societal and healthcare burdens associated with untreated hearing loss.

Understanding older adults’ views towards hearing loss and their hesitancy to seek help are key to addressing this care gap, which is increasingly pertinent in a rapidly ageing population. Local studies on hearing loss have primarily focused on demographic patterns, hearing aid uptake and usage [8, 18]. However, identifying factors that can potentially modify perceptions and help-seeking behaviour by deep-diving into the perspectives, experiences and enablement of older adults allows healthcare providers to design more person-centric interventions to address the barriers.

Therefore, this study aimed to explore the health beliefs and factors that influence the self-efficacy to manage hearing loss among community-dwelling older Asian adults in a developed nation. The findings will inform improvements in hearing screening interventions and public education initiatives to promote early detection and management of hearing loss among older adults in the local community.

Methods

Study design

A qualitative methodology was used to explore the beliefs and perceptions of older adults towards hearing loss and their help-seeking behaviour via in-depth interviews (IDIs). Participants were interviewed individually guided by a semi-structured interview guide.

This study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Annex A) [19].

Theoretical framework

A theoretical framework provides a structured approach to guide the study design, data collection and interpretation based on an existing theory or model. The Health Belief Model (HBM) is a behavioural model used to explain and predict health-related behaviours [20–22]. The HBM was adopted as the theoretical framework for this study, as it offers a structured lens to explore the health beliefs and help-seeking behaviour of older adults towards hearing loss [23]. The model comprises six key constructs (Fig. 1): perceived susceptibility (belief about the likelihood of getting a particular health condition); perceived severity (feelings of the seriousness or impact of the health condition); perceived benefits (perception of the advantages of taking a specific health-related action; perceived barriers (obstacles or costs associated with taking a particular health-related action); cues to action (internal or external triggers that prompt individuals to take action); and self-efficacy (belief in one’s ability to successfully perform a health-related behaviour) [20–22].

Fig. 1.

The HBM and its key constructs. (Adapted from Rosenstock 1988)

Research instrument

A semi-structured interview guide was developed by the study team, based on a review of the literature and the constructs of the HBM and was refined through discussion among the study team members (Annex B). The guide was available in both English and Mandarin and comprised open-ended questions that explored participants’ perceptions and experiences of hearing loss, beliefs about its risk and severity, perceived barriers and facilitators to seeking treatment, and suggestions for improving hearing care services. The interview guide was pilot-tested and iteratively modified based on data that emerged during both pilot and subsequent interviews.

Study site and period of study

The study was conducted from May to December 2024 at a polyclinic located in northeast Singapore. Polyclinics are public healthcare centres in Singapore that provide subsidised primary care, including management of acute and chronic conditions, maternal and child health services, preventive healthcare and health education [24]. The polyclinic provides comprehensive primary care services to approximately 199,400 residents, of whom about 9.8% are aged 65 and above [25].

Study team

The study team comprised three female family physicians (LKL, ASM and JFS) and one male family physician (NCT). The study team members are trained in qualitative research, and NCT is an experienced researcher in both qualitative and quantitative methods.

Study population

The inclusion criteria were multiethnic Asian older adults aged 65 years and above, including those with diagnosed or self-reported hearing loss, regardless of hearing aid use. Participants were identified as having hearing loss based on self-reported hearing difficulties and/or prior documentation of hearing assessment in their medical records. Purposive sampling was conducted to select older adults of varying ages and hearing status in order to gather diverse perspectives relevant to the research question [26]. Participants with impairments that prevented them from providing consent or meaningful participation in in-depth interviews, including those with profound hearing loss or those who identified as “deaf”, as well as those who were unable to speak or understand English or Mandarin, were excluded.

Recruitment

Potential participants were approached during their clinic visit by the study team and nurses at the study site, and the reasons for doing the study were explained to them. Participation was entirely voluntary and had no impact on their care. Participants were recruited if they met the eligibility criteria and provided written informed consent. They were given the Participant Information Sheet and any queries regarding the study were addressed. They were then notified of their interview date and time. Recruitment continued until data saturation was achieved, defined as the point at which no new code emerged [27].

Data collection

Before the interviews, demographic data and medical history of hearing loss were collated using a participant demographic questionnaire. Interviews were conducted individually in a quiet room at the study site, with participants unaccompanied to ensure privacy. As all participants had hearing impairment, specific communication strategies were implemented, including conducting the interviews at a moderate pace and volume, repeating or rephrasing questions when necessary, ensuring face-to-face communication to support lip-reading and encouraging participants to seek clarification at any point. These measures facilitated the interview process and enabled participants to share rich information in a private and comfortable setting, and allowed for a more personalized exploration and discussion of their insights and experiences [28]. The interviews were conducted in English or Mandarin, aided by the interview guide consisting of open-ended questions with follow-up probes. Field notes were taken during the interviews.

The interviews were conducted by the primary researcher (LKL) and supported by co-investigator (NCT). The interviews were audio-recorded and transcribed verbatim by a professional third-party transcriber proficient in both English and Mandarin. Interviews conducted in Mandarin were translated into English using a forward and backward translation process by bilingual translators. The original Mandarin transcripts and their back-translated versions were reviewed by study members proficient in both spoken and written Mandarin to ensure the accuracy of the final English transcripts.

Data analysis

The data was analyzed using thematic analysis. Thematic analysis is a systematic method used to identify, analyze and interpret themes within qualitative data, guided by the research question [29].

Two investigators (LKL and JFS) independently read the full transcripts and generated initial codes inductively from the data. Regular meetings were held to facilitate iterative refinement of the coding process and development of a preliminary coding framework, based on the first four transcripts. Recurring and common codes identified were cross-checked in subsequent IDIs. As more interviews were completed, additional codes were discussed and incorporated into the evolving coding framework. Differences in coding were discussed among the investigators and any discrepancies were resolved with discussion and consensus. Data analysis employed a hybrid inductive–deductive approach, with initial inductive coding followed by deductive organisation of codes into themes guided by the Health Belief Model. NVivo software version 10 was used to manage the qualitative data. The participants did not provide feedback on the transcripts or findings.

Reflexivity

As family physicians with clinical experience caring for older adults in the community, the researchers engaged in ongoing reflection on their clinical position to reduce potential biases during interviewing, data analysis and writing up. Potential preconceptions from clinical experience were acknowledged and regular discussions with the research team were held during coding and analysis to ensure a balanced interpretation of the data. Field notes were also used to document the investigators’ reflections and perspectives throughout the research process.

Ethics and funding

The study was approved by the SingHealth Centralised Institutional Review Board (CIRB) (2023/2637). All participants were reimbursed with grocery store vouchers worth SGD20 (~ US $15) each for their time and contribution to the study. The study was supported by the Family Medicine Academic Clinical Programme Collaborative Research Support Grant (FM ACP CRSG).

Results

A total of 20 participants were approached and 16 agreed to participate. Those who declined cited a lack of interest or time constraints. Four IDIs were conducted in Mandarin and the rest were in English. The interviews lasted between 22 and 45 min and there were no repeat interviews.

Table 1 shows the demographic characteristics of the participants. Participants were comprised of 8 males and 8 females with a median age of 73 years (ranging from 66 to 85 years). Most participants were of Chinese ethnicity (75%), had secondary education (62.5%) and lived with others (87.5%). The majority of participants (81.3%) did not own hearing aids.

Table 1.

Demographic characteristics of study participants (N = 16)

Characteristics	N (%)
Gender
Male	8 (50)
Female	8 (50)
Age (years)
65–69	5 (31.3)
70–79	9 (56.3)
80 and above	2 (12.5)
Ethnicity
Chinese	12 (75)
Malay	2 (12.5)
Indian	2 (12.5)
Education
Primary	2 (12.5)
Secondary	10 (62.5)
Post-secondary or diploma	2 (12.5)
University	2 (12.5)
Employment status
Retired	13 (81.3)
Working (full-time or part-time)	1 (6.3)
Homemaker	2 (12.5)
Living arrangement
Alone	2 (12.5)
With other(s)	14 (87.5)
Hearing status and hearing aids use
Completed hearing assessment with hearing aids ownership	3 (18.8)
Completed hearing assessment without hearing aids ownership	7 (43.8)
Self-reported hearing impairment	6 (37.5)

Findings

The key themes and subthemes are summarized in Fig. 2.

Fig. 2.

Factors affecting the help-seeking for hearing loss in older adults using the Health Belief Model (HBM)

Perceived susceptibility to hearing loss

1. Hearing loss is part of ageing

Many participants regarded hearing loss as a common issue among older adults and a natural part of the ageing process.

“So this thing (hearing loss) is slowly happening. This is part and parcel of being old. Because my parents also like that when they were old. It is normal, I would say, normal. It (hearing loss) will come sooner or later, as you age, right?”

(P03, 73-year-old male, self-reported hearing loss)

• b)Lack of self-awareness of hearing impairment

Some participants expressed that they were unaware that they had hearing difficulty until they were told by others. They attributed their reduced hearing to a lack of attention during conversations rather than actual hearing issues.

“ My experience is, actually I felt nothing. But my wife said sometimes I cannot hear when she talked to me. Not totally cannot hear, because sometimes I may be thinking of something else and I cannot hear them talking to me, (because) I did not concentrate enough, you see. ”

(P01, 84-year-old male, completed hearing assessment, fitted with hearing aids)

Perceived severity of hearing loss

1. Minimal impact on daily life with adaptive strategies

Many felt their hearing impairment was not severe and had not caused significant inconvenience in their daily activities, particularly if they spent most of their time at home or stayed alone.

“ If you talk to me like that, I’m fine, I can hear. The children go out to work early in the morning, so actually there’s nobody at home, so it doesn’t bother me at all. The phone ringing, all these, I can hear. ”

(P11, 69-year-old female, self-reported hearing loss)

Many reported that they could still manage their hearing difficulties with adaptive strategies such as lips reading, talking nearer or face-to face with others, increasing the volumes on televisions or phones and taking extra precautions when outside.

“It doesn’t affect my lifestyle now very much, I just have to sit in front and listen. And if my friend is (talking) too soft, I’ll just tell her to increase her volume. Because having a conversation across the table is still quite near to each other, so I can hear.” (P13, 76-year-old female, self-reported hearing loss)

“I like to sit in front or go nearer. If people talk with masks on, I can’t hear clearly. But if I see your mouth (lips movement), I can know roughly what you are talking.”

(P12, 75-year-old male, completed hearing assessment, fitted with hearing aids)

• b)Impact on communication and mental wellbeing

One of the major challenges of living with hearing loss was communication difficulty. Individuals with hearing loss often required others to raise their voices or repeat themselves, leading to frustrations and strained relationships with family and others. Many found it difficult to engage in conversations and social activities, which contributed to increased social isolation and disengagement.

“Sometimes when I talk to people, I cannot hear clearly and have to ask (them) to repeat, they may feel frustrated. Especially my wife, (even though) she knows that I have hearing loss, she still feels frustrated whenever I ask her to repeat.”

(P12, 75-year-old male, completed hearing assessment, fitted with hearing aids)

“You’ll miss out a lot, and you may feel isolated. Example like my friend, when we are in a small group talking, he doesn’t seem to contribute. That means people tend not to socialise because of this problem (hearing loss).”

(P15, 73-year-old male, completed hearing assessment, does not own hearing aids)

Participants also expressed frustration or stress when they could not hear people talking to them. Some felt embarrassed about speaking louder, asking others to speak up in public or requesting repetitions.

“Yah, sometimes you feel angry, or frustrated, because you can’t hear what they (the children) are talking. And next time they may ask and say, ‘I told you already, I told you so many times’. And you will get fed up. The one who can’t hear gets frustrated, they (the children) also get frustrated, when you ask them twice.”

(P11, 69-year-old female, self-reported hearing loss)

Many participants viewed help-seeking as a last resort, only considering it if the hearing loss significantly deteriorated and began to cause considerable inconvenience in daily life, particularly affecting communication and safety for themselves or those around them.

“Last resort, come and see the doctor. When the symptoms are there, like totally hard of hearing or causing more troubles, then we have to seek treatment.”

(P03, 73-year-old male, self-reported hearing loss)

“I think if my hearing is really that bad, I have to put on hearing aids, you can’t run away from certain things in life.”

(P15, 73-year-old male, completed hearing assessment, does not own hearing aids)

Perceived barriers to address hearing loss

1. Lower health priority

Participants perceived hearing loss as less important and less disabling for older adults when compared to vision loss or other health issues as it did not cause significant inconvenience or pain like other conditions that affected them.

“I think, for old people like us, hearing loss is amongst the lowest priority of concern, you know, in our health, compared to eyesight, knee pain, all these. These are more important than hearing problem. So for the old people, they don’t want to come (to see doctor) because they don’t find it as important. If the eyes are affected, then it’s different, they will tell you that they would come (to see doctor).”

(P02, 73-year-old male, self-reported hearing loss)

• b)Hearing loss cannot be treated

Hearing loss was also perceived as untreatable, with no effective treatment apart from wearing hearing aids, which discouraged people from seeking treatment.

“The ears cannot be treated, but eyes can. Like my eyes, now I don’t need to wear spectacles already. The ears (hearing loss) will deteriorate as we age, the only solution is to put on hearing aids. Hearing loss cannot be treated, no treatment.”

(P06, 71-year-old female, self-reported hearing loss)

• c)Cost concerns

Participants expressed concerns about the treatment costs, as they relied on their savings or were financially dependent on their family. While the functional screening was affordable, they were worried the subsequent specialist reviews would be expensive.

“See doctor also needs money. Not many people will want to go (to see doctors), especially those old ladies or men who are not earning well, or depending on their children. Unless they got money on their own.

Those five dollars check-ups (functional screening programme), after that they ask you to go hospital and do more checks, that is more than five dollars already. Consultations, tests, hearing apparatus (hearing aids), everything needs money.”

(P11, 69-year-old female, self-reported hearing loss)

• d)Perceived low acceptability and usefulness of hearing aids

Participants noted that many older individuals were generally reluctant to use hearing aids, even with reduced hearing. Some viewed hearing aids as unnecessary at the moment as they believed their hearing impairment was mild and that they could hear adequately without them. Others perceived hearing aids as uncomfortable and inconvenient to use, which deterred them from considering getting one or using it regularly. Hearing aids were also commonly perceived as ineffective in improving hearing, leading many to avoid using them regularly or refusing to adopt them altogether.

“Normally we don’t want to wear hearing aids, don’t want to wear that. You have to wear if you really can’t hear, like me, I don’t need to wear it. Like we talk like this, I can still hear, so don’t need that.”

(P07, 76-year-old male, self-reported hearing loss)

“None of my friends are using hearing aids, even though they cannot hear. I think, one is, not comfortable. Second, I think, maybe, using hearing aids is very inconvenient, they have to make sure that every time they go out, they have to wear it.”

(P02, 73-year-old male, self-reported hearing loss)

“ And at home, I put on (hearing aids), I always find that, it’s only a little bit difference only. Unless you have a very major difference, then maybe I’ll keep wearing it. ”

(P10, 70-year-old male, completed hearing assessment, fitted with hearing aids)

• e)Social stigma

Some older adults may feel embarrassed and hesitant to seek help due to the social stigma associated with hearing loss and the perception that hearing aids are a sign of old age or disability. Participants believed that certain older adults were reluctant to admit their hearing difficulties due to issues of pride.

“Some people don’t want to get or use (hearing aids), same like walking sticks. I see a lot of people with difficulty in walking, still don’t want to use walking sticks. I think pride, embarrassment. They find that, if I use this, I’m a handicap.”

(P15, 73-year-old male, completed hearing assessment, does not own hearing aids)

“ Some old folks, they have this kind of pride. ‘I can hear you, who said I cannot hear you?’ This is denial. But actually they can’t (hear). ”

(P08, 69-year-old female, completed hearing assessment, does not own hearing aids)

Cues to action that enhanced self-efficacy

1. Family support and encouragement

Participants primarily sought treatment for their hearing loss due to encouragement or concerns raised by their family members, as they often did not perceive a need for treatment themselves.

“My family advised me best to see doctor. Other than that, I never thought of seeing doctor (for hearing loss), because to me, I was thinking it is quite mild. Only off and on, I cannot hear. My son, my wife, all told me to better (go for a) check. So I think, okay, I’ll just go.”

(P01, 84-year-old male, completed hearing assessment, fitted with hearing aids)

• d)Misconstrued perception of long wait time for hospital-based hearing assessments

Participants shared that the need to visit hospitals for hearing assessments, coupled with long waiting time for specialist appointments, discouraged them from seeking treatment. They felt that improving the accessibility of hearing assessments could reduce delay in care and encourage more timely help-seeking.

“Actually, it is better if they have some easier places where we can test our hearing. Because if not, we have to still go to make appointment, which is months away, in the hospital. So it’s quite a long wait. If we have it like in polyclinic setting, it will be better for us.”

(P09, 66-year-old female, completed hearing assessment, does not own hearing aids)

• b)Availability of financial support or subsidies

The availability of financial support or government subsidies served as an important cue to action for some participants. Although cost was a concern for some, awareness of subsidy schemes reassured them that hearing aids were financially attainable and provided the impetus to pursue hearing assessments or adopt hearing aids.

“Wah I heard the hearing aid is very expensive, one costs a few thousand dollars. But I was told I’m covered (by subsidies) and have to pay a little bit only, because of my age.”

(P01, 84-year-old male, completed hearing assessment, fitted with hearing aids)

“This one (hearing aid), three thousand plus, they advised me to apply for CHAS [Community Health Assist Scheme (subsidies for medical and dental care)]. So when you get the CHAS card, I only have to pay 10%. Three thousands plus, I only have to pay three hundred over dollars.”

(P12, 75-year-old male, completed hearing assessment, fitted with hearing aids)

• c)Outreach failure of community hearing screening programmes to older adults

Participants reported that they had not heard of or attended any hearing or functional screening programmes in the community and would typically visit the polyclinics if necessary. They felt that the functional screening programmes could be better advertised to increase outreach to older adults.

“No, no. No resources (hearing screening programmes) we can find, the only resource is to see doctor in polyclinic.

(P03, 73-year-old male, self-reported hearing loss)

“ But that one (functional screening programmes) not many will go, because they put the poster in the HDB [Singapore’s public housing flats] lift lobby. Not many people will go and look at the poster, especially those who are not educated, and it was in English. I don’t know if they have other languages. Or maybe can send flyers to promote it. ”

(P09, 66-year-old female, completed hearing assessment, does not own hearing aids)

Discussion

This qualitative research study used the HBM to highlight the culturally contextual interplay between internal beliefs and external social and systemic factors in shaping help-seeking for hearing loss among older adults, with themes reflecting local sociocultural norms, family dynamics and healthcare system factors in Singapore’s primary care setting. Many appeared to underestimate its severity and delay help-seeking until it caused notable social or emotional consequences. Concerns about cost, stigma and doubts about the usefulness of hearing aids contributed to delayed help-seeking. Family support, awareness of community hearing screening and financial subsidies were identified as important cues to action that could enhance self-efficacy and promote earlier hearing care engagement.

Older adults had low perceived susceptibility to and severity of hearing loss as it was often regarded as a low priority for intervention compared to other health issues. A study in Malaysia by Mukari et al. reported that hearing impairment was often not considered life-threatening and was therefore ranked lower in priority for medical attention [30]. In some cultures, conditions that cause pain or negatively affect mobility are prioritized over hearing loss when seeking treatment [30].

Many viewed hearing loss as a natural part of ageing and often relied on coping strategies instead of seeking medical intervention, reducing their motivation to seek timely care [31, 32]. The belief that hearing loss was untreatable further discouraged treatment seeking, highlighting the need for improved public education on hearing health. Wang D et al. demonstrated that hearing health educational programmes, combining online and offline components such as digital messages, group discussions and health leaflets, effectively improved knowledge and self-efficacy, while counteracting misconceptions that hearing loss is untreatable [33].

A local study by Wu et al. reported that many older adults were unwilling to consider hearing aids despite the negative impact of hearing loss on their psychosocial well-being [34]. Previous studies have similarly shown that older adults are more likely to seek help for hearing loss when they perceive that the benefits of hearing aids outweigh the barriers to their adoption [35, 36]. Negative perceptions of hearing aids were often shaped by concerns about comfort or usability, doubts about their effectiveness and peers’ anecdotal experiences [31, 37]. These findings are consistent with our study, in which participants similarly perceived hearing aids as inconvenient, uncomfortable, or offering limited benefit, contributed to feelings that hearing aids were not worth the cost or effort and led to reluctance in adopting them even after professional recommendation [37]. However, awareness of available financial support or subsidies serves as an important cue to action by alleviating cost concerns and encouraging help-seeking for hearing loss [38, 39].

Family members played a key role as cues to action, often prompting help-seeking by noticing communication difficulties before the affected individual themselves [40]. This finding is consistent with prior research, including Pornprasit et al. highlighted the potential role of family and social networks in mitigating barriers to help-seeking for hearing loss among older adults [31]. Similarly, McKee et al. reported that support from family and friends, often through encouragement driven by frustration with communication lapses, was one of the key factors facilitating hearing aid adoption and use in this population [41]. These findings suggest the importance of raising public awareness and family involvement in hearing care outreach and intervention to prevent the adverse consequences of untreated hearing loss.

Implications to clinical practice

The findings underscore the need for a multi-pronged approach to addressing hearing loss, which remains an underrecognized health concern among older adults in Singapore. Healthcare providers should be equipped to address older adults’ misconceptions regarding hearing loss and encourage proactive screening during routine consultations to facilitate timely referrals. Integrating hearing health into routine geriatric and primary care [1], such as incorporating hearing screening into geriatric assessment [42] or preventive health screening, can further support early detection and intervention.

Our findings show that limited understanding of one’s own hearing loss and perceived lack of necessity for hearing aids may persist even after individuals seek assessment or undergo hearing-aid fitting, consistent with observations reported by Franks and Timmer [43]. This underscores the importance of addressing illness insight, perceived need, and expectations throughout the hearing care journey, including post-fitting. Targeted hearing health education can be delivered through written or digital media, such as multilingual patient information leaflets or short videos, to improve older adults’ awareness and understanding [44]. Engaging family members in these educational initiatives fosters shared understanding, encourages timely help-seeking and promotes sustained use of hearing aids through emotional and financial support [35, 38]. In addition, hearing-aid counselling should not only address device-related concerns such as comfort and usability but also focus on setting realistic expectations regarding adaptation and benefits. Self-management support and educational interventions, such as structured post-fitting counselling, communication strategy training, and follow-up support can enhance hearing aid use, self-efficacy, and communication outcomes [45].

These insights can also inform healthcare providers and policymakers in developing public health strategies to improve public awareness. Health campaigns that emphasize hearing loss as a treatable condition can help dispel misconceptions [1]. Furthermore, expanding the reach of functional screening programmes may encourage earlier detection and intervention [16]. Such initiatives can be delivered through community centres, including social recreational centres for seniors in residential and public housing areas, religious centres and public media platforms to maximize outreach. Mobile application-based hearing assessments can also be used as a means of hearing screening in the community to identify individuals who require further formal hearing evaluation [46].

As concerns about cost have been cited in both local and international studies as one of the major deterrents to seeking treatment for hearing loss [34, 41], this barrier could be mitigated by increasing awareness of and access to financial subsidies for hearing aids to reduce out-of-pocket expenses [38, 47]. Publicizing such information through public media platforms or community centres may further improve awareness and uptake.

Strengths and limitations

This study focused on hearing loss among older adults in Singapore, specifically exploring the health beliefs and factors influencing treatment seeking, an area that has been underexplored in the local context. Participants were recruited from the major ethnic groups in Singapore and included individuals who spoke either English or Mandarin, the two most commonly used languages among older adults locally [48]. This approach allowed the study to capture perspectives from a large proportion of the local older adult population.

This study has several limitations. Participants were recruited solely from the polyclinic setting, which may not fully reflect the perspectives of older adults seeking care from private general practitioners or tertiary hospitals. Participants with lower educational levels were likely to be under-represented, which may have limited the diversity of perspectives captured, as this group could have differing levels of awareness and attitudes towards hearing loss and its management. Nevertheless, purposive sampling was employed to identify a wide range of views and factors affecting older adults’ help-seeking towards hearing loss.

Hearing loss was identified primarily through self-report rather than objective audiometric testing, which may limit clinical characterisation of severity. However, as the study focused on perceptions and help-seeking behaviour, self-perceived hearing difficulty was considered appropriate. This study did not include participants who identified as “deaf” and primarily used sign language. As a result, the findings may not reflect the experiences, help-seeking pathways, and barriers specific to the “deaf” community, which may differ from those of older adults with age-related hearing loss. While participants with varying hearing care experiences were included, this study did not undertake a formal comparative analysis between hearing aid adopters and non-adopters. Another limitation was that member checking was not performed due to constraints related to the project timeline and logistical challenges in re-engaging participants.

Future directions

Future studies should focus on developing educational programmes that address common barriers to hearing care, facilitate access to appropriate resources for older adults, and evaluate the effectiveness of these interventions in raising public awareness and promoting value-based hearing loss management. Additionally, studies exploring the perspectives of family members and healthcare providers, such as primary care providers or audiologists, may reveal opportunities to enhance early detection and referral for hearing loss.

Conclusion

Older adults had a low perceived need for treatment for hearing loss, often viewing it as a normal part of ageing and manageable with adaptive strategies. Many delayed help-seeking due to concerns about cost or negative perceptions of hearing aids. The findings also highlight the role of cues to action, such as family support, which may help overcome perceived barriers and enhance self-efficacy in seeking timely treatment. Enhancing awareness among older adults, their families and communities, along with improved access to hearing screening and financial subsidies, could promote early intervention and improve hearing health outcomes in this population.

Authors’ contributions

LKL and NCT conceptualized, designed the study and conducted the interviews. LKL and JFS coded and analysed the data. LKL, ASM and NCT interpreted the results and drafted the manuscript. All authors reviewed, revised and finalized the manuscript.

Funding

The study was supported by the Family Medicine Academic Clinical Programme Collaborative Research Support Grant (FM ACP CRSG). The funder had no role in the conceptualization, design, data collection, analysis, decision to publish or preparation of the manuscript.

Data availability

The datasets analysed during the study are not publicly available to ensure participants’ identity and data confidentiality. The de-identified transcripts are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the declaration of Helsinki and approved by the SingHealth Centralised Institutional Review Board (CIRB) (2023/2637). Written informed consent was obtained from all participants prior to the interviews. All study procedures were conducted in accordance with relevant ethical guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.