Consumer preferences for hearing health care information and services as described by older adults surveyed in Australia, Canada, England, and the United States

Abstract

Background

Age-related hearing loss is a global public health concern and yet hearing health care (HHC) services remain underutilized. Understanding the HHC experiences of older adults is essential to addressing why existing systems are underutilized. Therefore, we surveyed older adults to determine their preferences for HHC service delivery. In this cross-sectional survey study, we report where they preferred to obtain HHC information, undergo hearing tests, and acquire hearing devices. We also examined whether these preferences varied by degree of hearing loss, help-seeking experience, survey mode (online or in person), age, or country.

Methods

Using survey questions that were co-created with consumers, responses were collected online and in person prior to the pandemic (2016–2018) in the United States (USA), Canada (CAN), Australia (AUS), and England (EN). Third-party firms recruited convenience samples from each region. Participants, aged 60 + and proficient in English, responded to three questions: “Where would you prefer to get information about HHC?” (8,151 respondents, 14 response options), “Where would you most like to get your hearing tested?” (8,035 respondents, 8 options), and “From which of the following places would you MOST like to get hearing aids (or other types of hearing devices) if you needed them?” (8,151 respondents, 11 options). Participants could select multiple options. Hearing thresholds were obtained from in-person respondents and used to impute hearing loss estimates for online respondents.

Results

Across all questions, respondents consistently preferred traditional medical over nonmedical locations when seeking HHC information, hearing tests, and hearing devices. Respondents consistently reported a preference for seeking HHC in-person, at provider-mediated medical settings (e.g., doctors’ and audiologists’ offices and hospitals) rather than through non-medical channels such as radio, internet advertisements, or retail stores. Preferences were consistent across degrees of hearing loss, survey modes, age bands, and countries.

Conclusions

Our survey results indicate that older adults preferred to seek and receive HHC through traditional medical settings. These data were collected prior to the pandemic and before some of the recent OTC policy changes; nonetheless, they align with more recent findings and capture the attitudes of individuals who are likely still making HHC decisions today. These findings, therefore, provide contextual evidence about older adults’ reported preferences against which future studies of hearing healthcare preferences may be compared.

Background

Age-related hearing loss (ARHL) is highly prevalent and the fourth-leading contributor to years lived with a disability worldwide [1–6]. Hearing loss also negatively affects a country’s human capital, the mainstay of human and economic development [7] and is a global public health concern [2, 8–12]. The primary clinical intervention for people with ARHL is hearing aids (HAs); however, only about 1 in 5 adults who might benefit from them use them [13]. Several factors have been identified as barriers to accessing hearing healthcare (HHC) services and technologies. They include stigma, a lack of trust in service providers, dissatisfaction with current HA technology, and limited affordability and accessibility of treatment (see Knoetze et al., 2023 for a review [14]; also [15] for cost as a frequently cited barrier).

To address this public health problem, several initiatives have been launched. The World Health Organization (WHO), for example, is working with various partners to promote the development of more cost-effective and accessible services that can reach underserved populations. These efforts include encouraging the integration of HHC into primary health and community-level systems and developing open-source hearing-screening and training materials [16, 17]. To address access and affordability issues, the United States (USA) Congress passed the Over-the-Counter (OTC) Hearing Aid Act in 2017, mandating that the Food and Drug Administration (FDA) establish a new hearing aid category for OTC hearing aids [18], thereby promoting the development of more affordable hearing assistive technologies. Since then, the term OTC is typically used to refer to the regulated category of hearing aids that adults can purchase without a prescription, medical examination, or fitting by a hearing care professional. The term direct-to-consumer (DTC) is used more broadly to describe hearing-related devices, information, or services that consumers can access directly, without first consulting a hearing health professional [19]. Thus, OTC hearing aids represent one form of DTC access, but the terms are not synonymous.

In 2022, the FDA authorized OTC hearing aids to be sold directly to consumers (DTC) without the need for consultation with a hearing care professional, making it easier for adults with perceived mild-to-moderate hearing loss to access these devices. As a result, HAs can now be purchased directly from stores or online retailers in the USA without a medical exam, prescription, or audiologist fitting [20]. New forms of self-fitting DTC amplification devices are also being sold online, as are new mobile apps. For example, in 2024, the FDA authorized the use of clinical-grade hearing-aid software to be used in commercially available Apple AirPods [21].

Despite these efforts to improve affordability and accessibility, the uptake of HHC worldwide remains low. Even after policy changes, in the USA, survey data from 2024 showed that only about 2% of adults aged 40 + with hearing difficulties had purchased an OTC device, and only 4% planned to do so within the next year [22]. Similar results were reported a few years later in the 2025 USA MarkeTrak survey, in which OTC devices accounted for only 1–2% of total hearing aids sold [23, 24]. Together, these insights suggest that recent policy changes have not yet stimulated changes in consumer behaviors in the USA, and a large portion of the population still has unmet hearing needs.

These early-adoption trends are not entirely surprising, given that help-seeking behaviors and HA adoption do not depend on price alone [25–28]. If cost were the only barrier, one would expect HA adoption to be significantly higher in countries where costs are subsidized, thereby reducing the financial burden on consumers. However, research findings suggest otherwise. In Australia, many older adults who meet eligibility criteria can access subsidized hearing services and devices through the government-funded Hearing Services Program. As described in the 2021 AustraliaTrak report, 80% of hearing-aid owners reported some form of third-party reimbursement, yet hearing-aid adoption among people with self-reported hearing loss was estimated at only 45% in 2021 and 2025 [29, 30]. In Canada (CAN), where only some seniors benefit from partial payment from public and private sources, the estimated HA adoption rate approximated 33% in 2019 [31]. In England (EN), where HA costs are often fully or partially covered by public programs such as the National Health Service (NHS) [32] the adoption rate among people with self-reported hearing loss was estimated at 50.5% in 2025 [33]. These adoption rates are not much higher than those in the USA, where the estimated HA adoption rate was 39% in 2025 (including OTC devices), and consumers incur significant out-of-pocket expenses [34]. This means that large portions of the populations in the AUS, CAN, EN, and the USA still had unmet HHC needs leading into 2025, despite having low-cost options available to them. Moreover, it reinforces the need to consider issues beyond price when designing new HHC systems.

These observations are timely given that other countries are currently considering adopting similar OTC-type policies. Parts of Canada (CAN), for instance, are considering altering their HHC services [35], and the UK recently granted certain hearing devices the ability to be sold directly to consumers without a prescription, although this is currently guidance rather than a fully codified regulatory category [36]. Also, the UK, CAN, and AUS recently approved the use of Apple AirPods Pro software [37].

To effectively position new products and services and encourage greater uptake of HHC, it is important to understand older consumers' preferences and how they may change over time. Moreover, when designing care models, it is essential to draw on the experiences and insights of older individuals at different stages of seeking help and with varying degrees of hearing loss [38]. Most existing surveys assess preferences for a single service type (e.g., self-testing or DTC) or compare online/DTC versus in-person care using binary or scalar measures, and do not contextualize these preferences relative to the broader set of available options in real-world situations [30, 39, 40]. Although some studies have examined HHC preferences in relation to the help-seeking stage, few have contextualized these preferences across help-seeking experience, degree of hearing loss, age, and geographic regions. Without understanding their perspectives, there is a risk of implementing new HHC services and products that remain underutilized.

Therefore, in this study, we took the opportunity to examine data collected between 2016 and 2018, prior to the pandemic and the 2022 OTC final hearing aid ruling, to learn more about older adults' HHC preferences. During this time, we held focus groups in four countries (AUS, CAN, EN, and the USA) and invited adults aged 60 and older to share their perceptions of and preferences for current and future HHC services. Despite participants being drawn from different healthcare systems and countries, a consistent theme emerged. Focus group participants expressed a preference for trustworthy HHC services integrated into traditional (i.e., medical) healthcare services [28]. To examine their preferences in more detail, the research team and focus group members co-created survey questions (and response options) to assess the types of HHC engagement and distribution channels this age group preferred when seeking HHC information, undergoing hearing testing, and acquiring hearing technologies. The purpose of this study, therefore, was to examine the survey responses and systematically characterize their preferences. A secondary goal was to determine whether these preferences varied by respondents’ degree of hearing loss, help-seeking experience, mode of participation (online or in-person), and geographic region.

Methods

Survey development

The survey questions and response options were co-created with focus group members in London (EN), Seattle (USA), Sydney (AUS), and Toronto (CAN) [28]. The methodology and findings from these focus groups have been reported previously [28]. In summary, English-speaking adults 60 years of age and older were invited to share their perceptions and preferences regarding current and future HHC services and to co-create questions (with corresponding response options) that would be used to survey their peers. Adults 60 years of age and older were included because of the high and increasing prevalence of hearing loss in this age group.

Focus group recruitment was conducted using a third-party London-based company with offices in the four cities. Participants with a) no self-reported hearing problems; b) hearing problems and HA use; and c) hearing problems and no HA use were recruited. Semi-structured focus groups were conducted in-person and facilitated by a locally based, professionally trained representative from the third-party company. The facilitator informed the participants of the purpose of the research and used a script designed to elicit their opinions on factors affecting consumer uptake of HHC services and their preferences for service improvements. The facilitator had no expertise in hearing loss. At least three members of the research team were present to observe each focus group. Real-time captioning (Communication Access Real-Time, CART) was used, and personal assistive listening solutions were available to all participants.

Results from the focus groups were used to develop questions for the survey. Preliminary questions were developed by the research team and vetted in a second round of focus groups were held in London, Sydney, Seattle, and Toronto, facilitated by the same third-party company, using the same inclusion criteria. The goal of this second round of focus groups was to determine if the content and wording of each survey question and response were understandable and reflected participants’ perspectives regarding HHC. Using cognitive interviewing methods, the facilitator encouraged participants to provide feedback on each question and response item, including what they liked or disliked and any needed wording changes. For example, participants provided their feedback on the relevance of items to their experiences, item wording that might be confusing or inappropriate, preferences for the wording of response options, and item content that was missing but should be included. Suggested modifications to items were discussed to reach group consensus on the preferred item content and wording. Scripted prompts were used to encourage consistency across focus groups.

Survey administration

The survey was administered online and in person at the same locations between 2016 and 2018. Similar to the focus group participants, survey participants were English-speaking adults aged 60 and older. In-person participants completed the survey on-site, where trained research staff were available to provide procedural support or answer questions as needed. The same third-party company assisted with participant recruitment, survey administration, data collection, and management. The study and its procedures were carried out as approved by the University of Washington Internal Review Board.

A total of 10,744 participants initiated the survey. Participants were not required to complete each question; therefore, the number of responses varied across questions. After accounting for missing or incomplete data, responses from 9,510 participants were eligible for analysis (Table 1). A total of 1003 (10.5%) female and 922 (9.7%) male adults participated in-person, while 3563 (37.5%) female and 4022 (42.3%) male adults participated online. Participants who completed the survey in-person had a mean age of 70.18 years (SD = 6.78, N = 1925), and those who completed it online had a mean age of 69.31 years (SD = 6.73, N = 7585). Age was reported in categories (e.g., 60–64, 65–69, etc.) and mean values were calculated using the midpoints of each category.

Table 1.

Demographic descriptors of all respondents (n = 9510) BEPTA = better-ear pure-tone average at four frequencies (0.5, 1, 2, 4 kHz), Inter-quartile range (IQR)

Age	Online		In-Person
	Female	Male	Female			Male
	N	N	N	PTA (dB HL)	± IQR BEPTA (dB HL)	N	PTA (dB HL)	± IQR BEPTA (dB HL)
Australia
60–64	205	163	51	13.1	18.6/7.7	38	19.4	27.2/11.6
65–69	151	192	58	18.8	25.6/11.9	59	23.8	34.7/12.8
70–74	210	243	53	22.5	30.9/14.1	51	26.9	35.5/18.3
75–79	94	102	33	26.3	35/17.5	33	27.5	35.6/19.4
80–84	78	114	23	39.4	47/31.7	26	30.0	36.6/23.4
85 +	21	39	14	33.1	38/28.3	16	38.1	45.9/30.3
Total	759	853	232			223
Canada
60–64	603	569	61	14.4	20.6/8.1	56	20.0	27.8/12.2
65–69	253	374	85	16.3	23.4/9.1	72	23.1	32.3/13.9
70–74	137	190	63	25.0	32.8/17.2	57	26.3	34.4/18.1
75–79	77	111	34	28.8	36.3/21.3	41	33.8	42.5/25
80–84	59	75	20	29.4	37.2/21.6	25	40.6	50.8/30.5
85 +	12	16	5	45.0	50/40	14	43.8	47.8/39.7
Total	1141	1335	268			265
England
60–64	327	303	79	17.5	26.1/8.9	57	20.0	29.4/10.6
65–69	274	306	66	24.4	32.5/16.3	51	25.0	32.8/17.2
70–74	290	301	41	30.0	38.8/21.3	67	27.5	33.8/21.3
75–79	83	126	20	33.1	47.3/18.9	18	36.3	45/27.5
80–84	111	146	5	28.8	30/27.5	7	31.3	33.8/28.8
85 +	29	53	3	45.0	50.9/39.1	5	51.3	58.1/44.4
Total	1114	1235	214			205
USA
60–64	29	30	57	14.4	22.8/5.9	41	20.0	26.3/13.8
65–69	304	278	96	18.8	25.6/11.9	79	25.6	38.6/12.7
70–74	146	194	77	26.9	36.7/17	49	27.5	38.9/16.1
75–79	44	62	40	33.8	44.7/22.8	34	37.5	48.1/26.9
80–84	20	25	12	40.6	49.4/31.9	14	46.9	58.4/35.3
85 +	6	10	7	37.5	47.8/27.2	12	50.6	55.3/45.9
Total	549	599	289			229

Self-reported ethnicity: White (88.77%), Asian (4.68%), Black (2.81%), Indigenous (0.34%), other (3.40%)

Of the 8,151 participants who answered the question: “Where would you prefer to get information about hearing health care?”, 6,242 were online respondents, and 1,909 were in-person respondents (Table 1). Of the 8,035 participants who answered the question: “Where would you most like to get your hearing tested?”, 6,134 completed the survey online and 1,901 in-person. Finally, when asked “From which of the following places would you most like to get hearing aids (or other types of hearing devices) if you needed them?”, 8,151 people responded (6246 online and 1,905 in-person).

To determine if participant preferences differed according to a participant’s degree of hearing loss, air-conduction thresholds were obtained from participants who completed the survey in-person using the Home Hearing Test ™ (HHT) [41, 42]. The HHT is an automated, validated, computer-based pure-tone audiometry tool that can be used to measure air-conduction thresholds in and outside of clinical settings. Our research and that of others [42, 43] have shown the HHT to be a reliable method for obtaining pure-tone thresholds comparable to those obtained with gold-standard clinical audiometry. The pure-tone average (PTA) threshold for four frequencies (0.5, 1, 2, 4 kHz) in the better ear was used to characterize a participant’s degree of hearing loss. Four categories of hearing loss were established [44]: normal hearing (PTA = 25 dB HL and below), mild hearing loss (PTA = 26 to 40 dB HL), moderate hearing loss (PTA = 41 to 55 dB HL), and > moderate hearing loss (PTA = 56 dB HL and greater). The greatest output of the HHT was 85 dB HL; when no response was obtained at 85 dB HL, a value of 90 dB HL was used for analyses. In some cases when manual audiometry was used instead of the HHT, actual thresholds levels were used if they exceeded 85 dB HL. Because hearing thresholds could not be obtained for online panel members, estimations of hearing category were imputed using ordinal regression modeling [45].

Each person was also asked to self-report their perceived hearing ability and help-seeking history by answering the question: “Which of the following statements best describes how you feel about your hearing ability?” Options were: 1) I do not know if I have a hearing problem; 2) I do not have any problems with my hearing and nobody has complained about my hearing; 3) I do not have any problems with my hearing, but sometimes other people tell me I have a hearing problem; 4) I do have a hearing problem, but I haven’t sought any kind of help for it; 5) I do have a hearing problem and I wear HAs or use other technology to help me hear. Participants who reported not knowing or not having a hearing problem (options 1–3) were categorized as not having a reported hearing problem. Participants who reported having hearing difficulties, but who chose not to seek help (option 4), were assigned to the “hearing loss without help seeking” category (HI-HA). Participants who described having hearing problems and who had sought help (option 5) were assigned to the “hearing loss with help seeking” category (HI + HA). Respondents who did not answer this question could not be assigned a category; therefore, their data were excluded from the analysis.

Results

Getting information

Participants were asked: “Where would you prefer to get information about hearing health care? Check all that apply.” There were 14 options, and participants could select as many as they wanted. Figure 1a displays the percentage of participants, tested online and in-person, who selected each response option, shown separately for all respondents combined and for each of the four countries. Overall, radio and internet advertisements were the least preferred method for obtaining HHC information, whereas receiving information from a “doctor” and other medical/government sources were most preferred. USA data show some differences compared to other countries, with a greater preference for medical/government websites and a lower preference for TV advertisements among participants who completed the survey onsite. USA respondents also reported that university-based websites and pamphlets in health care provider (HCP) offices were more preferable than those from other countries.

Fig. 1.

Responses to the question: “Where would you prefer to get information about hearing health care?” Total online survey (grey) and in-person (black) responses (n = 6242 and 1909 respectively) shown as percentages, for A all four countries. B degree of hearing loss, and C hearing help experience category

Because a person with no reported hearing loss might have preferences that differ from those of someone with hearing loss, data collapsed across countries were analyzed by degree of hearing loss (Fig. 1b) and by hearing and help-seeking experience (Fig. 1c). The results are remarkably similar regardless of the responder’s degree of hearing loss or hearing and help-seeking experience. Regardless of the degree of hearing loss or help-seeking category, radio and internet advertisements were the least preferred methods for obtaining HHC information, whereas receiving information from a “doctor” or a medical/government source was the most preferred option. These results were also similar regardless of mode of participation in the survey (online or in person) and geographic region.

Testing

When participants were asked: “We are thinking of providing hearing services to people in different ways. From which of the following places would you most like to get your hearing tested?” They could choose only one of the 8 options available. As shown in Fig. 2, participants consistently indicated a preference for medical settings (hospital, family doctor/general practitioner’s office, audiologist’s office) compared to non-medical settings (e.g., self-test, supermarket or pharmacy, community center, at home, technology retail store). Respondents from EN showed a greater preference for family doctor/general practitioner settings, whereas participants in other countries predominantly preferred to be tested in an audiologist’s office. Similar results were obtained when responses were examined according to a person’s degree of hearing loss. As shown in Fig. 3, medical settings were also preferred regardless of the participant’s hearing and help-seeking experience category. However, across all countries, there was a notable increase in preference for testing in an audiologist's office among individuals reporting hearing loss, possibly due to their greater previous experience with audiologists.

Fig. 2.

“From which of the following places would you most like to get your hearing tested?” Responses (n = 8035) from AUS, CAN, UK and US, of online and in-person survey respondents combined. Pie chart slices are grouped into medical (e.g., hospital, audiologist’s office) and non-medical (e.g., pharmacy, community center) categories, with non-medical slices slightly separated (expanded) for emphasis. The legend indicates which response options belong to each category

Fig. 3.

“From which of the following places would you most like to get your hearing tested?” Responses (n = 8035) separated by country and help seeking experience. Online and in-person survey responder preferences combined. Pie chart slices are grouped into medical (e.g., hospital, audiologist’s office) and non-medical (e.g., pharmacy, community center) categories, with non-medical slices slightly separated (expanded) for emphasis. The legend indicates which response options belong to each category

Obtaining devices

Participants were asked: “We are thinking of providing hearing services to people in different ways. From which of the following places would you most like to get hearing aids (or other types of hearing devices) if you needed them?” Participants could select more than one of 11 options.

Figure 4 displays the percentage of participants, tested both online and in-person, who chose each option. Technology stores and mail order options were the least preferred settings for acquiring hearing devices, while audiologist offices, doctors’ offices, and hospitals were the most favored choices across all four countries. When compared to responses from other countries, EN respondents showed a stronger preference for obtaining devices at doctors’ offices and hospitals rather than at an audiologist’s office. A preference for medical-type locations was similar across all three hearing and help-seeking experience categories, with medical settings (doctors’ and audiologists’ offices and hospitals) preferred over mail-order and technology stores (Fig. 5). Similar results were obtained when responses were examined according to a person’s degree of hearing loss.

Fig. 4.

From which of the following places would you most like to get hearing aids (or other types of hearing devices) if you needed them?”. Percentages of options selected from online survey (grey) and in-person (black) participants from all countries (n = 8151) in the left column and from AUS, CAN, UK and US individually in remaining columns

Fig. 5.

From which of the following places would you most like to get hearing aids (or other types of hearing devices) if you needed them?” Percentages of options selected from online survey (grey) and in-person (black) participants in the three categories based on their hearing help seeking experience

Discussion

Despite recent advances in HHC technology, policy, and services, HHC uptake and HA adoption remain low. In AUS, the HA adoption rate among people with self-reported hearing loss increased by only 4%, from 2017 (41%) to 2025 (45%); in the UK, it rose slightly, from 42.4% in 2015 to 50.5% in 2025 [30]. Even after the USA government implemented policy changes in 2017 and 2022, HA adoption over the past decade has been modest, 30.2% in 2015 to 39.1% in 2025, with the latter figure including OTC options [34]. These insights suggest that the recent FDA OTC rulings have not yet stimulated changes in consumer behavior in the USA, and many people still have unmet hearing needs. Therefore, much work remains, particularly as other countries consider adopting similar OTC policies.

Reviewing past and current consumer behaviors and preferences helps to identify gaps, evaluate effectiveness, and understand needs, thereby informing future research and action. Therefore, we took the opportunity to examine data collected during 2016–2018, around the same time the initial 2017(OTC) Hearing Aid Act passed, but prior to the COVID-19 pandemic and the official 2022 OTC hearing aid ruling, to learn more about what consumers were telling us back then. We found that older adults across all four countries strongly preferred to seek HHC information and services in traditional medical-type settings. Regardless of the participants’ hearing-loss severity, prior help-seeking, survey mode, or geographic location, they consistently preferred to seek help in person, in provider-mediated clinical settings (e.g., doctors’ and audiologists’ offices and hospitals) rather than through non-clinical channels such as radio, internet advertisements, or retail stores.

These insights are important, given that an aim of the 2022 OTC hearing aid ruling was to expand HHC delivery beyond traditional medical healthcare settings. It was thought that the availability of newer, low-cost amplification technologies, including OTC hearing aids, would improve access to HHC by reducing clinical barriers and attracting new technology companies to enter the market, thereby increasing competition and reducing prices. However, while policymakers in the USA assumed OTC channels would be preferable, consumers told us otherwise.

One could argue that the bias towards medical settings stems from participants’ unfamiliarity with some of the alternative forms of HHC delivery listed as response options (e.g., mobile apps, home services, self-testing, the Apple Store). However, the focus group participants in our study were familiar with the options currently available to them or under future consideration. This is certain because each survey question and response option was co-created with focus group participants. If a response option was present, it was because participants chose to include it. Participants were aware of alternative forms of HHC services because these have been available for decades. Hearing self-testing options, for example, have been around since the 1950’s (e.g., telephone hearing tests). Early digital personal sound amplifiers (PSAPs) reached consumers in the late 1990 s and 2000 s (e.g., Williams Sound), with more advanced smart, Bluetooth, and app-controllable, amplify-as-needed, ear-worn devices emerging a decade later [46]. Over 30 mobile apps offering self-administered, automated pure-tone hearing tests were available in the Google Play and Apple App stores between 2007 and 2015 [47]. There were also global discussions in the mainstream media about emerging hearables and the need for alternative solutions to address the affordability problems in hearing care, especially in the USA, ahead of the initial 2017 Executive Order, and the eventual 2022 OTC Hearing Aid ruling. And yet, despite having access to all these HHC resources in the past, respondents from all four countries still preferred HHC information and services to be provided in medical-type settings, such as hospitals, doctors’ offices, and audiologists’ offices.

Recent studies suggest consumer preferences have not changed over the years. In the 2022 USA MarkeTrak survey, 78% of respondents preferred to obtain future HAs through traditional, in-person medical channels, working with a hearing care professional rather than using remote or self-fitting options [48]. In 2025, 85% of the survey respondents who owned HAs indicated they would prefer to repurchase in person, with assistance from a hearing care professional. Even among OTC hearing aid owners planning to repurchase, over half indicated they would buy in person from a HHC provider. In comparable EuroTrak UK and AustraliaTrak (2025) studies [30], similar to our findings, survey respondents reported that doctors and HHC professionals were the most important sources of information, with print ads received in their mailboxes, and magazine and newspaper sources being the least preferred. In the UK, the NHS/hospital location was the most preferred place to obtain hearing aids, and online sources were the least preferred. When Australians were asked where they would prefer to get HAs, 93% of respondents identified Hearing aid clinics, ENT offices, and Hospitals, with only 2% selecting online. Therefore, based on our data and other recent studies, access to a HHC professional continues to be a key factor influencing consumer preferences.

An additional explanation for our survey respondents’ preference for medical-type settings may involve their established trust and familiarity with medical systems and providers. In a 2023 survey examining the attitudes and preferences of Americans older than 50 years of age, 84% of respondents indicated they would choose to pursue HHC via an in-person pathway that included direct interaction with a professional [40]. Complementary studies, including qualitative surveys and scoping reviews, support this by showing that users often lack trust in online retailers and value professional guidance when making hearing healthcare decisions [49, 50]. Trust is a topic that frequently comes up when discussing healthcare preferences, and there is substantial research describing how and why medical settings can be perceived as more trustworthy than other settings (e.g., retail outlets). Even though there is an abundance of research showing that HHC services can be reliably carried out in different settings, by different people, using different methods, there is also evidence to suggest that individuals perceive services delivered in clinical settings (e.g., audiology or medical clinics) as more trustworthy than those offered through retail or online channels, as clinical locations signal greater diagnostic rigor and professional oversight [26, 40, 49, 51, 52]. Whereas retail and OTC models improve accessibility and affordability, they are sometimes associated with lower perceived credibility and reduced patient confidence [40, 49, 53–55].

Another point to consider is that the participants in our study were older and likely experienced decades of health communication and services in traditional medical settings. Changing how healthcare is accessed can be difficult for older adults because trust and perceived quality of care are closely tied to long-standing relationships and shared decision-making [56]. Disrupting this continuity could generate uncertainty and reduce confidence in care [57, 58], making newer alternative options less attractive and less preferable. Unfamiliar systems and technologies can also increase anxiety and reduce trust and willingness to adopt new care models, especially for older adults [59].

Relying solely on medical channels for future HHC would be challenging, though, especially if help-seeking is limited to doctors, such as primary care physicians, because ARHL is not routinely addressed in primary care settings. ARHL is often dismissed by doctors as a typical consequence of aging rather than a remediable health concern [60, 61]. Fewer than 40% of the doctors surveyed in the USA reported screening for hearing loss during the patient’s initial visit [62]. Similar findings have been reported in AUS and EN [63, 64]. Even when hearing loss was identified, only about half of the doctors suggested that the patient schedule a comprehensive hearing evaluation [48], and even fewer counseled the patient on the possible causes of hearing loss or treatment options [48]. It is for these reasons that medical doctors have been described as a barrier to HHC help-seeking and HA adoption [65–70]. However, now that hearing loss has been identified as a potentially modifiable risk factor for dementia [4, 71], some countries, such as Canada, have introduced new geriatric guidelines recommending that primary care physicians conduct hearing screenings [72]. Some family physicians have begun engaging in HHC now that they can sell HAs themselves rather than refer to HHC professionals [73–75]. Despite these advancements, there remains a need to explore alternative ways to make HHC more accessible, as there are insufficient numbers of physicians and audiologists to address the growing problem of ARHL [76]. As the world’s population continues to age and the demand for services increases, there is a pressing need to train more healthcare professionals across disciplines to support HHC delivery. Even with the growing number of health services now being delivered online (e.g., telehealth), following the pandemic, efficacious HHC service delivery models for older adults are unfortunately not yet in place (for a review, see D’onfrio and Zeng 2022) [77–79].

One approach to increasing HHC uptake in medical settings is to raise awareness through public health campaigns and to engage non-physician healthcare professionals, especially rehabilitation professionals and trained community-level stakeholders. These roles can be highly effective when embedded in trusted medical settings, as they reinforce consumer confidence in the information and services provided. The WHO (ICOPE) handbook, for example, includes many different hearing screening and training tools so that person-centered care pathways can be established in primary care and community settings [78, 80–85]. There is also growing support for task-shifting hearing screening by trained lay personnel, including community health workers, volunteers, and retail staff, as a scalable strategy to expand early detection [86–89].

Employing trained personnel and offering complimentary in-person and remote services situated in medical-type settings, under the supervision of professional hearing care providers, may be a viable approach. We say this because participants in our earlier focus groups used the term “doctor” loosely. Although they had described going to the “doctor’s” office and preferring to go to a “doctor’s” office for future HHC services, they admitted to not always knowing the job titles of the people who treat them. Furthermore, while co-creating the survey questions, focus group participants focused more on “where” they would prefer to obtain HHC services (e.g., doctor’s office, hospital) rather than “who” they would prefer to serve them. Perhaps they assumed that medical-type clinics deliver professional, trustworthy care by a doctor or under a doctor's direction. For this reason, to reflect the perspectives of survey participants during co-creation, the generic term “doctor” was used in parts of the survey without defined credentials. Therefore, because older adults appear to prioritize where they receive services, one potential strategy to better engage them in HHC is to offer both in-person and OTC services within medical-type settings they perceive as trustworthy. These services could be delivered by audiologists alongside other trained, supervised hearing care personnel, with follow-up remote services introduced once trust and basic competencies have been established. Such an approach would satisfy the request to have HHC services provided in medical-type settings while also fostering continuity of care through alternative, scalable, follow-up pathways.

Future directions and study limitations

Results from our study and others show a continued preference for medically situated HHC services, a point that is important to consider as other countries contemplate adopting OTC HHC policies. Although these survey responses were collected several years ago, recent studies also report a persistent value for in-person care and support from hearing care professionals when seeking hearing aids or HHC information [23, 34, 40, 48]. This suggests that preferences for trusted, professionally supported services may remain relevant, even as alternative OTC devices and services become more available, but this interpretation should be tested directly in future follow-up studies.

A strength of this study is that the results reflect participants’ perspectives by using their own language to craft survey questions and response options, while also accounting for their degree of hearing loss and prior HHC experience. With that said, our participants reflect a convenience sample that is primarily composed of white respondents, which limits generalizability. In addition, the preferences reported in this study may partly reflect the hearing healthcare structures, service pathways, and consumer expectations to which participants were accustomed at the time of data collection. Therefore, these findings should not be interpreted as fixed or universally generalizable. Preferences could potentially change and generational differences may emerge, especially as telecare adoption increases following the pandemic. For these reasons, the authors encourage readers to use these same questions and responses to track changes in consumer preferences over time and to consider including additional measures to capture potentially mediating factors that influence trust and healthcare uptake. For example, examining one’s social media use, health literacy, geographic region (rural versus urban), and cultural background could provide a more comprehensive understanding of post-pandemic hearing healthcare help-seeking behaviors.

Conclusion

Older consumers prefer to seek HHC information, testing, and treatment in medical-type settings. This preference remained consistent regardless of the participant’s degree of hearing loss, prior hearing and help-seeking experience, survey participation mode (online or in person), and country. These results are important because they underscore the established demand for medically situated HHC services among older adults, including those who may be making HHC decisions today, and even as alternative care pathways are introduced.

Abbreviations

ARHL

Age-related hearing loss

AUS

Australia

CAN

Canada

dB HL

Decibels hearing level

HA

Hearing aid

HCP

Health care provider

HHC

Hearing healthcare

HHT

Home Hearing Test

HI + HA

Hearing loss with help seeking

HI-HA

Hearing loss without help seeking

NH

Normal hearing

OTC

Over-the-counter

PTA

Pure Tone Average

UK

United Kingdom

US

United States of America

WHO

World Health Organization

Authors’ contributions

KT, AD, CMM, AM and MP-F conceived and designed the program of research and attended focus groups. KT wrote the grant that funded this research as a former professor at the University of Washington. FA, ML, KT and MP-F analysed the data; KT, MP-F and FA wrote the paper; CMM, AM, CM and AD contributed to and edited the manuscript. CM assisted with data collection.

Funding

This study was supported by grants from the National Institutes of Health – NIDCD R21DC013161, R33DC013161.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the University of Washington Health Internal Review Board – Human Subjects Review Board; participants provided informed consent and were remunerated for their time. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

AD has received sponsorship from GN Resound to attend conferences, a fee from Natus for lecturing, and royalties paid to Manchester University for the intellectual property for Siemen’s HearCheck Screener. CLM provides audiological services to consumers. KT has received compensation for consulting with AAVAA, AgingIn, and the World Health Organization. She also serves on advocacy committees such as the Hearing Loss Association of America and the World Health Organization.