Burden of treatment associated with hearing aid use among older adults with hearing loss: a qualitative study

Abstract

Background

Treatment burden can affect patients’ ability to carry out tasks or follow healthcare providers’ recommendations. Evaluating the burden of using and maintaining hearing aids can help identify factors that affect patient compliance. This study also examined the support that older adults receive and prefer to overcome this burden. This enables healthcare providers to better understand the burden and promote improved adherence to hearing aid use among older adults.

Methods

We conducted a qualitative study using semi-structured interviews with older adults recruited from the Audiology Clinic at King Faisal Specialist Hospital and Research Center (KFSH&RC). Participants had been diagnosed with hearing loss and were using hearing aids. Data collection continued until thematic saturation was reached. The data were analyzed using thematic analysis.

Results

This study included 17 participants aged 62–80 years. Four main themes were identified from the interviews: experiencing hearing loss, barriers to hearing aid use, facilitators to hearing aid use, and support needs. The subtheme highlighted the burden associated with hearing loss and hearing aid use; physical, psychological, and financial burdens were cited, in addition to the perceived limitations of hearing aid use. On the other hand, the perceived benefit of hearing aids in terms of audibility and promoting social engagement was identified as a facilitator to effective use of hearing aids, as they act as motivators. Consistent use of hearing aids was found to help in acclimatization. Professional support for hearing aid use is preferred over family support to promote autonomy. Findings highlight the need for individualized support, improved device features, and accessible hearing healthcare to enhance hearing aid adoption and user satisfaction in older adults.

Conclusion

Our research has identified several factors that affect adherence to hearing aid use in older adults. The barriers identified included physical, psychological and financial burdens. Difficulty with hearing aid use and care was cited as a burden that can limit hearing aid use. Participants in our study preferred support from their healthcare providers over their family. The study highlighted the need for improved support and counselling in hearing healthcare. Furthermore, the study highlighted the need for improved hearing aid technology and for accessible, direct communication channels with their healthcare providers.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12877-026-07862-4.

Introduction

Individuals who have long-term health conditions such as diabetes, hypertension, heart disease, or cancer face not only the challenges of their illness but also the increasing responsibilities associated with managing their healthcare. Those responsibilities can include adhering to medication schedules, attending medical appointments, monitoring their health, undergoing laboratory tests, making lifestyle changes, using new devices, and other actions in addition to their typical daily responsibilities [1–3]. The burden of managing treatments can negatively affect patients’ quality of life, as they dedicate significant time, effort, and financial resources to maintain their well-being [1]. The term “burden of treatment” refers to the overall demand that medical care places on individuals and its effects on their functioning and well-being [1, 3, 4]. Understanding the burden of treatment is important in clinical practice because it can reduce adherence to recommended treatments and self-management [5]. Studies have shown that non-adherence is associated with adverse outcomes, such as increased hospitalizations, higher mortality rates, and lower quality of life [4]. Patients with a high burden of treatment struggle to adhere to their therapeutic care, regardless of their specific illness [6, 7]. Factors such as education, culture, beliefs, family and social support, financial resources, available support systems, and the healthcare environment all contribute to the patient’s capacity [2]. By evaluating the burden of treatment in clinical practice, healthcare professionals can become aware of the distress experienced by patients and caregivers. This awareness can help in building a collaborative relationship with the patient, working together to develop treatment strategies that are effective and acceptable for both the patient and caregiver [8]. Additionally, research in this area has shown that reducing treatment burden can promote patient well-being and improve quality of life [9]. The reduction in treatment burden can be achieved by reducing workload through simplified devices, increasing capacity through home services, and employing social support [10, 11].

Research in the Theory of Burden of Treatment shows that it extends beyond adherence to a specific regimen to encompass all the changes a patient must make to comply with treatment recommendations [8]. Additionally, it can add to the difficulties experienced by the patient caused by their primary condition [12]. For example, a patient newly diagnosed with hearing loss must make lifestyle changes and employ communication strategies in addition to using hearing aids to communicate effectively. This, in addition to the repeated clinic visits to adjust the hearing aid [13]. Employing this theory in clinical settings can empower patients to acknowledge the burden and advocate for their needs, which in turn will reduce the burden and improve adherence.

Hearing loss is a chronic health condition that affects approximately 430 million individuals worldwide [14]. Hearing loss prevalence in Saudi Arabia is reported to range from 1.7% to 16.8% [15]. Those experiencing hearing loss often feel embarrassed or frustrated by their communication difficulties, leading them to limit their social interactions [16]. This isolation can result in feelings of loneliness, anxiety, and even depression and fewer opportunities for effective communication [17]. Research has shown that hearing aids can improve hearing function and positively affect overall quality of life by enhancing communication [18]. Despite these advantages, hearing aid use remains low [19, 20]. The social stigma attached to hearing aids, coupled with the physical discomfort they may cause, often leads to avoidance behaviors or outright rejection of device use [21]. There is an increased likelihood of experiencing negative emotions immediately after receiving hearing aids due to the complex process of adapting to them, which involves practical obstacles and emotional challenges [22]. Enhancing our understanding of the precise factors that lead to positive and negative emotional responses in situations related to hearing loss and hearing aids would help improve the clinical evaluation and counselling skills of health care providers. It would also help to refine the focus of interventions and manage expectations more effectively [23, 24].

Qualitative evidence is needed to examine the treatment burden associated with prescribing hearing aids for older adults with hearing loss. The findings from this research will inform the development of clinical practice guidelines that incorporate the perceived burden into the management and counselling of patients eligible for hearing aid fitting. Without evidence in this area, patient-centered care may be compromised, leading to reduced compliance.

Methods

The study explored the perceived burden of treatment experienced by older adults with hearing loss who use hearing aids, using a qualitative research design. Data was collected using semi-structured interviews in King Faisal Specialists Hospital and Research Center (KFSH&RC). Qualitative methodology enables the exploration of patients’ perspectives and experiences, providing a deeper understanding of the factors that may exacerbate their treatment burden [25]. The research proposal was approved by the Research Advisory Council at KFSH&RC (RAC#2241084) as a non-interventional study.

Study setting and sample

Data collection took place at the Audiology clinic at KFSH&RC using convenience sampling. The recruitment targeted older adults aged 60 and above who were diagnosed with hearing loss and were using hearing aids. All patients attending their scheduled hearing aid follow-up appointments were considered eligible for inclusion in the study. All participants self-identified as active hearing aid users. To verify actual use patterns, we collected both subjective reports and objective measures of hearing aid wear time. Subjective estimates of daily use were obtained through structured interview questions, and objective verification was conducted using hearing aid data logging (Table 1).

Table 1.

Study participants’ characteristics

Age	60–65	4
	66–70	8
	71–75	3
	76–80	2
Gender	Male	11
	Female	6
Pure Tone Average of the better ear	25–40	4
	41–50	9
	51–70	3
	71 – >90	1
Years of hearing loss	< 1–4 years	6
	5–10 years	5
	> 10	6
Hearing aid type	Behind The Ear	5
	Receiver in The Canal	7
	Custom made	5
Monaural vs. binaural	Monaural	4
	Binaural	13
Average HA use per day (Data Log)	1–5 H	7
	6–12 H	5
	> 12 H	5

Eligible participants who met the criteria were invited by research coordinators to attend face-to-face interviews after their management was completed. Interested participants were given an information sheet explaining the study, their role in it, and any expected benefits and harms of participating. Informed consent was obtained and documented in the patient’s medical records.

The research coordinators, who are junior Audiologists trained by the principal investigator, conducted the interviews. We continued interviewing until we reached inductive thematic saturation. Thematic saturation was assessed after all interviews had been completed and the full dataset was available for analysis. Saturation was considered achieved when the analysis revealed recurring patterns across participants and no new themes, concepts, or insights related to treatment workload, patient capacity, or the healthcare system context emerged from the later interviews [25].

Topic guide

A topic guide was developed based on the literature on patients’ experiences with hearing aids [1, 11, 23]. The topic guide was influenced by the Theory of Burden of Treatment, which examines the demands placed on individuals in managing their healthcare, especially those with chronic conditions such as hearing loss [11]. The theory emphasizes that if the demand becomes too heavy, it can impact the quality of life and an individual’s ability to adhere to treatment.

The topic guide was developed for this study and included questions about participants’ overall experience with hearing loss and hearing aids, as well as factors that facilitate or hinder the use of hearing aids. The guide also included questions about participants’ suggestions for improving healthcare delivery to enhance their experiences and reduce any unnecessary burden associated with hearing aid use. Participants were free to discuss any relevant areas not covered by the guide. The topic guide is available in Supplementary Material 1.

Data analysis

The interviews were audio-recorded with participants’ consent and transcribed verbatim. Thematic analysis was used to identify and describe patterns derived from qualitative data [26]. After the transcription and familiarization with all interviews, all transcripts were coded using ATLAS.ti software by the lead author (SA¹) in the original language of the interviews (Arabic) to preserve cultural nuance and contextual meaning. SA is a senior Audiologist with 15 years of experience working with older adults using amplification. She is trained in qualitative research methodology. A sample of the data was double-coded by another researcher (SA²), who is a public health researcher with expertise in qualitative research. Meetings were conducted to discuss and amend the codes as needed.

Categories were developed by grouping codes into an analytical framework, which was continuously refined through discussions with the research team. All themes and sub-themes emerged from these collaborative discussions, enhancing both rigor and reliability. To ensure the integrity of the findings presented in English, a multi-stage translation process was employed for all quoted material. First, two bilingual authors independently translated the selected quotes. They then jointly reviewed and agreed upon the final translations, which were subsequently examined by a third bilingual author to enhance rigor and reduce individual bias. Finally, the research team compared the translations with the original transcripts to resolve discrepancies and ensure conceptual equivalence. This process safeguarded both linguistic accuracy and cultural context, thereby strengthening the credibility and trustworthiness of the findings.

Results

Seventeen participants, both male and female, aged 62–80 (mean age of 69.4 years), participated in this study. The characteristics of the participants are presented in Table 1. Four major themes were identified from the data (Table 2).

Table 2.

Themes and subthemes identified from the data

Themes	Sub-themes
Experiencing hearing loss	− Accepting hearing loss. − Hearing loss is a burden in itself. − Accessibility of Hearing Healthcare Services.
Barriers to effective hearing aid use	− Hearing aid is a burden: physical, psychological and financial − Ease of hearing aid − Perceived limitation of hearing aids: sound quality, telephone use, technology.
Facilitators to effective hearing aid use	− Perceived advantages of hearing aids: audibility, social, and technological. − Consistent use promoting acclimatization. − Motivation and psychological readiness.
Support with hearing aids	− Preferred support by patients − Resistance to support with hearing aids

Experiencing hearing loss

Accepting hearing loss

The onset of hearing loss varied among participants, but many attributed it to ageing and accepted it as a natural progression. For many participants, religious beliefs influenced how they accepted and managed hearing loss as part of the ageing process. This acceptance of hearing loss as being “from God” points to an external health locus of control. Which can shape both acceptance and help‑seeking behavior.

“I am adapting, and I am truly grateful to Allah. I thank Allah for blessing me and for making me better off than many others. Praise Allah, who has spared us from what has afflicted many people.” (64-year-old, male, using a BTE HA)

Despite being diagnosed with hearing loss, some participants reported not experiencing significant difficulties. Some participants described employing coping strategies, such as lip-reading, positioning themselves closer to the speakers, requesting repetition, and increasing the volume on their electronic devices. When discussing their hearing loss, many participants attributed it to familial predisposition, otitis media, noise exposure, and ototoxic medications for treating other medical conditions. However, they all demonstrated acceptance of their difficulties.

“When you’re watching TV alone, you can control it and adjust the volume as you wish.” (75-year-old, male, using bilateral RIC HAs)

”Sometimes I ask him to repeat. But sometimes, thank God, like when I’m talking to you, I don’t miss any words.” (70-year-old, male, using bilateral RIC HAs)

Hearing loss is a burden in itself

Participants reported that their hearing loss significantly affected their emotional state and social interactions, with adverse effects extending to their immediate family members. They emphasized the considerable embarrassment experienced when missing parts of conversations or requesting repetition in social settings. Consistently, participants identified speech comprehension and discrimination as the primary challenges associated with hearing impairment. Additionally, some participants reported social withdrawal and avoidance of conversations in social contexts because of their condition.

“When I felt that I could not hear well during meetings, I said to myself, ‘I need hearing aids.’ I am an active member in family gatherings, I conduct interviews, and I need to ensure my hearing is good because it causes me embarrassment.” (62-year-old, male, using bilateral RIC HAs)

Accessibility of hearing healthcare services

A recurring theme of delayed help-seeking behavior and access to care emerged from the participants’ accounts. While some participants described acquiring hearing aids as challenging, others did not report such difficulties. The delay in seeking diagnosis and treatment was attributed to participants’ acceptance of hearing loss as an age-related phenomenon and their reluctance to acknowledge its impact. Physicians, serving as the initial point of contact for participants seeking hearing loss management, played a crucial role in patients’ decisions to pursue hearing aid fitting.

“I consulted a doctor, specifically an ear, nose, and throat specialist. He told me that I might have nerve weakness, and nerves may not have a cure except for hearing aids. I ignored the matter then, as I wasn’t ready to accept the idea of wearing a hearing aid due to the negative things I had heard about them.” (70-year-old, male, using a bilateral RIC HAs)

Many participants expressed dissatisfaction with the quality of care received and the complex process of obtaining a diagnosis and subsequently managing it with hearing aids.

“Honestly, it took a long time to get the hearing aids—it wasn’t easy at all. First, I was referred to the labor and social services office, where they gave me instructions. I couldn’t manage to navigate through the instructions. Finally, after much difficulty, I was able to get the hearing aids from you.” (74-year-old, male, using bilateral RIC HAs)

Barriers to effective hearing aid use

Using hearing aids is a burden

The participant identified various burdens and challenges associated with hearing aid use. These barriers were categorized as physical, psychological, financial, and poor sound quality, among others. This highlights the complexity of adapting to hearing aids and the associated difficulties with this management option.

Physical burden

Participants expressed significant physical burdens associated with wearing the hearing aids and their physical form. These issues include discomfort from the devices’ size and fit in the ear. Other causes of discomfort were attributed to itchiness and occlusion effects from the hearing aid. It was also noted that larger behind-the-ear aids caused physical discomfort and were more difficult to fit in the ear than smaller in-the-ear styles. Religious practices further complicate hearing-aid use: although faith can facilitate acceptance of hearing loss, ritual requirements, such as repeated washing before daily prayers, pose practical barriers to consistent device use.

Some participants preferred smaller, more discreet in-the-ear models, which they perceived as less noticeable, easier to wear, and more comfortable. Furthermore, cleaning and maintaining the hearing aids was an additional burden added to the difficulty of adjusting the volume and the frequent need to replace the batteries.

“Sometimes the hearing aid causes me ear pain.” (70-year-old, male, using bilateral RIC HAs)

”I had to remove the hearing aid multiple times due to discomfort.” (66-year-old, female, using bilateral BTE HAs)

Psychological burden

The psychological burden of hearing-aid use emerged as a key theme. Several participants reported a lack of readiness or reluctance to use hearing aids consistently, citing personal vanity or social self-consciousness. The stigma associated with wearing hearing aids, perceived as a sign of ageing and handicap, was a barrier to their consistent use in some cases.

“First, the psychological barrier is very significant—it’s a major obstacle. I must overcome it and encourage myself to say, ‘Let’s do it again.’ Because I’ve had a previous experience that I wasn’t satisfied with, I feel like I have to motivate myself and say, ‘Give it a chance; give yourself a second opportunity to try. Maybe I was wrong.‘” (73-year-old, female, using bilateral RIC HAs)

Situational use of hearing aids

In many instances, participants reported that the different forms of burden associated with hearing aid use led to situational use. Participants stated that they were motivated to wear hearing aids only at social gatherings, as they perceived them as necessary only in those situations. Some participants justified their limited use by perceiving a lack of need for the devices or emphasizing that their hearing loss was not severe enough to warrant constant use.

“No, no, I don’t wear them at home. I only wear them when I am out. If I am in a small group, I hear well and respond. However, I need it when I am at a party or a wedding with competing noise. It becomes necessary, so I must use it.‘” (70-year-old, female, using a monaural CIC HA)

Financial burden

Some participants reported the economic burden of hearing aid use, particularly the high costs of devices, batteries, and ongoing maintenance. They expressed dissatisfaction with the recurring cost of batteries, which required frequent replacement. Additionally, maintenance costs for repairs added to the financial strain.

“If you go to the vendor, the repair costs are expensive, and the expenses for these batteries are significant—they consume a lot, typically lasting only about two to three days.” (63-year-old, male, using a bilateral CIC hearing aid)

It should be noted that this burden could be amplified in groups where the cost of hearing aids falls entirely on the patient and would be less significant in groups where the cost is covered by the healthcare system.

Ease of hearing aid

In contrast to the burdens experienced by some participants, others reported a relatively positive experience with hearing aids, often minimizing or negating significant challenges. For instance, several participants reported that hearing-aid batteries were easy to manage and that care and maintenance were straightforward. They also emphasized the physical ease of use, noting that the devices were comfortable to wear and easy to handle.

“There’s no difficulty at all—I simply remove the hearing aid, place it in its case, put it back on when needed, and at night, I disconnect the battery, praise be to God, changing the hearing aid’s battery is simple; when I hear the sound indicating that the battery needs replacement, I just go ahead and replace it. " (74-year-old, male, using bilateral RIC HAs)

Perceived limitations of hearing aids

Sound quality

The limitations of hearing aids, as experienced and reported by participants, contributed to their frustration and increased their perceived treatment burden. Poor sound quality of hearing aids was a frequently reported issue. Participants expressed dissatisfaction with speech clarity and discrimination, with some perceiving that the hearing aid did not provide adequate benefit given the burden it posed. These frustrations were exacerbated in challenging listening environments. Their inability to fully engage in social interactions due to difficulties hearing or following conversations with multiple speakers often led to frustration and a sense of social isolation. Dissatisfaction with the clarity or amplification provided by the devices led participants to choose not to wear them regularly, instead relying on lip-reading, residual hearing, or simply avoiding situations where hearing aids would be necessary.

“If you increase the volume, it becomes noisy, and if you lower it, I do not benefit from it at all. That is the problem. You have made it too loud now, and I can feel it. My voice is becoming annoying—annoying, annoying, annoying.” (64-year-old, male, using a BTE HA)

“The hearing aid sometimes buzzes a lot, and I leave it. It’s very annoying, so I remove it.” (74-year-old, male, using a bilateral RIC HA)

Additionally, participants reported that the poor sound quality of hearing aids in places of worship intensified their challenges, reducing functional benefit in social and spiritual contexts.

“If I receive a phone call while at the mosque, I am unable to answer. As a result, I usually have to leave the mosque before responding. I then explain to the caller that I am at the mosque and ask them to contact me later, or I tell them that I will return the call once I am home.” (64-year-old, male, using a BTE HA)

Telephone use

For telephone conversations, participants reported difficulty hearing clearly, as devices often fail to provide adequate amplification or speech clarity over the phone. Due to perceived limitations of hearing aids, participants often relied on family support to understand speech during phone calls. Family members frequently played an integral role in facilitating communication, particularly when hearing aids struggle to provide clear amplification of telephone conversations. Similarly, while watching television, participants found that sound quality did not sufficiently enhance their viewing experience.

“Now, if I receive a call, I can’t answer it like that (i.e. on speaker)—it would be embarrassing. If I answer, everyone hears, whether it is a family call, a friend’s call, or any other type. At home, I do not answer unless someone is nearby to listen and let me know what the person is saying. They will say, ‘So-and-so is telling you this or that.’ From this, I catch about 40% of the words, piecing them together like a crossword puzzle until they form a meaningful sentence.” (64-year-old, male, using a BTE HA in one ear, the other CI)

Technology

Participants frequently expressed a desire for improved hearing aid technology, particularly enhancements in connectivity with other devices. The unreliability of the phone’s wireless connection and limited control over sound quality were identified as areas requiring attention. Furthermore, there is a common desire for devices that can more effectively address challenges such as speech comprehension and reliance on disposable batteries.

“Science is indeed advancing, because I see that the design of hearing aids, especially the way they’re placed behind the ear, still feels quite primitive. Science has progressed significantly—just look at glasses, for instance; they’ve developed contact lenses, whether implanted or temporary, as an alternative.” (70-year-old, male, using a bilateral RIC HA)

It is worth noting that all participants in this study were receiving their hearing services and devices through a public healthcare system, a model intended to minimize direct financial burden. However, this system introduced subtler forms of burden that negatively affected both their capacity and workload. Participants consistently described poor access to services, long delays in securing follow‑up appointments, and restricted availability of devices as significant challenges. These systemic limitations were frequently cited as negative aspects of their care experience, contributing to an overall sense of strain despite the reduced financial cost.

“You see, the appointments, it takes a year to be seen. And if your hearing aid breaks, well, it takes another year to be able to come.” (75-year-old, male, using a bilateral RIC HA)

Facilitators to effective hearing aid use

Perceived advantages of hearing aids

Audibility

During the interviews, many participants expressed satisfaction with the hearing aids despite the burden they posed. Overall, they highlighted that it improved their ability to participate in daily activities, allowing for a more active lifestyle and greater independence. The enhanced audibility and improved speech clarity significantly reduced the frustration often associated with hearing loss. Furthermore, some participants noted decreased mental load when using hearing aids. They described how reduced effort in understanding speech allowed them to engage more comfortably in social interactions. One participant linked the use of hearing aids to improved quality of life and emotional well-being. For some participants, hearing and understanding the religious text “the Quran” was of profound importance, as it enhanced their spiritual experience.

“To be with people and hear everything being said, there are times I find myself forced to stay silent because I have not heard something I should have responded to. With a hearing aid, however, I can hear much better, and it’s definitely an improvement over not being able to hear at all.” (70-year-old, female, using a CIC HA)

Social

The social benefits of hearing aids were a recurring theme. Participants reported feeling more included in social settings. They appreciated being able to follow conversations more easily, which reduced their feelings of isolation. The perceived benefits of using hearing aids were a significant motivator for consistent use, and many reported wishing they had used them sooner, given their advantages.

“The benefits of it are that it brings you closer to the community, allowing you to interact and engage in discussions and conversations with them. Previously, a person might feel somewhat isolated—hearing one word while missing the others—but now, by hearing everything immediately as it’s being said, you can fully follow the conversation.” (69-year-old, male, using a monaural CIC HA)

“I feel relieved; praise be to God. I now live among people as they do, listening to their conversations, sitting with others, talking to individuals, understanding their words, and truly hearing them. I am filled with gratitude toward those in charge here for their care, prompt service, and kind treatment. I pray that God rewards them. They helped me with this matter, making me feel comfortable, able to hear, and live as part of the community.” (68-year-old, male, using bilateral CIC HAs)

Technological

The participants appreciated technological advancements and acknowledged that modern hearing aids offer innovations that have made wearing them more convenient. Many noted that Bluetooth connectivity enabled them to pair their hearing aids with smartphones and other devices, facilitating seamless communication and enhancing their overall auditory experience.

“I remember having a phone prior to this one, which was wirelessly paired to my hearing aid, similar to my current device, allowing me to hear the sound clearly whenever someone called. Now, it’s especially useful for me—I can enjoy programs or follow the Quran comfortably on my phone, without disturbing those around me, as I hear the sound privately and clearly.” (74-year-old, male, using bilateral RIC HAs)

Consistent use promotes acclimatization

Through personal experiences, the participants provided insights into the importance of consistent hearing aid use and its positive effect on adaptation, both of which were crucial in their journey. The more they wore their devices, the better they adapted to them, the care they required, and their sound quality. Additionally, some reported personal strategies they used to ensure proper placement of hearing aids. Overall, participants found that habituation to hearing aids was initially complicated, especially after the fitting.

“Honestly, I didn’t face any difficulties except on the first day when I wore it; it felt like it was doing something to my head. After two, three, four days, I got used to it.” (68-year-old, male, using a bilateral CIC HA)

Motivation and psychological readiness

The participants’ reports highlighted the critical role of motivation and psychological readiness in successfully using hearing aids. Their decision to pursue hearing aids was influenced by an internal motivation to improve their communication and social interactions. This intrinsic motivation often stemmed from recognizing the negative impact of hearing loss on their daily functioning. Some even stated that self-motivation was key in effectively using hearing aids and overcoming their burden. Participants also noted that readiness to wear hearing aids before fitting contributed to their successful use. Factors such as acceptance of hearing loss, encouragement from family, and personal readiness significantly influenced their decision to use hearing aids.

“I’m truly willing to do whatever it takes as long as it helps me adapt to people and prevents them from feeling annoyed by me repeating myself.” (69-year-old, male, using a CIC HA)

Physician counseling played a crucial role in shaping participants’ perceptions of hearing aids. Effective counseling provided by healthcare professionals facilitated the decision-making process, as participants who felt well-informed and supported by their physicians were motivated and psychologically ready to pursue hearing aids. On the other hand, some participants were driven by misinformation from family members or their community to use hearing aids to “improve hearing” or “preserve hearing from further loss.”

“The doctor told me, ‘We never force patients to use it; it depends entirely on their need.’ He was excellent and explained things clearly to me.” (73-year-old, female, using bilateral RIC HAs)

The contrasting perspectives on the perceived burden and advantages of hearing aid use illustrate the cyclical nature of burden. When participants were satisfied with their hearing aids or services, this satisfaction appeared to interrupt the cycle by enhancing motivation, strengthening adherence, and increasing perceived benefit, ultimately reducing the workload associated with managing hearing loss. In contrast, when workload increased—whether through effortful communication, device management, or system‑level barriers—it undermined adherence, satisfaction, quality of life, and outcomes. These poorer outcomes then fed back into the cycle, adding to perceived workload and diminishing capacity, as the limited benefit reduced motivation to continue engaging with support (Fig. 1).

Fig. 1.

Burden of treatment model

Support with hearing aids

Preferred support by patients

The participants emphasized a multifaceted approach to support, encompassing professional guidance, family involvement, and the importance of accessible communication channels. They preferred to receive support from a professional rather than from their family to overcome their burden. They stated that professional support was superior, especially regarding perceived technical burden, given that they were “the expert”. They highlighted the importance of hands-on assistance from professionals in navigating the complexities of hearing aids. Direct support during initial fittings and ongoing adjustments was frequently cited as crucial to fostering user confidence and alleviating the burden of hearing aids. They stated that their support needs from professionals ranged from emotional to technical.

“I feel comfortable coming here to this clinic, where I can meet with specialists, assistants, nurses, or audiologists, as they understand my needs. Their explanations are clear and comprehensive, and they can also assist me with programming.” (64-year-old, male, using BTE HAs).

Family involvement emerged as a vital component of the support framework. Their support began by encouraging participants to seek help in the first place, and then it encouraged them to use their hearing aids more consistently. Participants reported various forms of family support, categorizing these into emotional, technical, and motivational. Emotional support from family members, especially one’s children, was identified as a key motivator that enhanced patients’ willingness to engage with their hearing aids.

“One of my sons, in particular, is the only one who consistently follows up with me. He was with me during my audiology appointments and has always been by my side, accompanying me and ensuring that I use my hearing aids diligently.” (74-year-old, male, using a bilateral RIC).

The participants noted a strong desire for greater, more direct access to audiologists. Delays in professional support often led to frustration and disengagement. The value of using multimodal education for patients was reported. Videos and other printed materials would enhance the patient’s experience and mitigate the burden on participants when using the hearing aids.

“The audiologist, may God reward both her and you, gave me a future perspective during our first meeting. She painted a picture for me, emphasizing that everything is challenging at the beginning.” (70-year-old, male, using bilateral RIC HAs)

Participants sought to expand their capacity by drawing on support from various members of their social network, selecting each source based on its perceived competence. Professionals were viewed as the primary providers of both technical and emotional support, largely because of their expertise and their ability to understand and address the burden associated with hearing aid use. In contrast, family members played a more limited but still meaningful role, offering help with daily tasks and providing motivation.

Resistance to support with hearing aids

Some participants expressed a sense of personal resilience and emphasized their desire for independence. The desire to maintain agency and self-sufficiency often led to resistance to support from family members. Their resistance to their family’s support stemmed from the belief that their family’s support was not appropriate, as they were not “experts.” One participant stated that needing assistance and support with hearing aids was a burden.

“I try to manage everything on my own, including my treatment. My family lacks experience, so I have to teach them, as they don’t use a hearing aid.” (70-year-old, male, using BTE HAs)

Across the sample, all participants reported a notable burden associated with hearing aid use, regardless of their audiometric profile or hearing‑aid–related factors, including daily hours of device use or the specific type of hearing aid worn. Similarly, gender did not differentiate participants’ experiences; men and women alike articulated comparable challenges in navigating the functional and psychosocial demands imposed by their hearing loss. Collectively, these findings indicate that the perceived burden was a shared experience across all participants.

Discussion

This study aimed to examine how the Theory of Treatment Burden applies to hearing aid use, with particular attention to the interaction between workload and user capacity in older adults. The interviews were designed to capture the perceived workload of handling hearing aids and to explore how users leverage their social networks to enhance their capacity to cope with these demands. The burden of treatment associated with hearing aid use is inherently multi-dimensional, encompassing both objective factors—such as device style and hours of daily use—and subjective experiences, including stigma and adaptation difficulties.

Participants in this study expressed their views on hearing loss, its burden, and the reality of hearing health services. They identified many barriers to effective use of hearing aids, including their overwhelming burden and perceived limitations. A key barrier to hearing aid use is the combination of physical and psychological burden. Discomfort related to device size, fit, itchiness, and the sensation of occlusion frequently discouraged consistent use. Evidence from multiple studies shows that difficulties with the physical fit of hearing aids are common, with users often reporting discomfort, irritation, or even pain during use [22]. This suggests that such challenges are widespread and not limited to the participants in the current study.

Some participants were reluctant to wear hearing aids because of vanity, self-consciousness, and the stigma associated with ageing and disability. Stigma related to hearing loss and hearing-aid use remains a significant psychosocial barrier, driven largely by stereotypes linking hearing loss with ageing and disability [27]. Such stigma can diminish an individual’s psychological resources. When stigma undermines these internal resources, individuals may have reduced capacity to engage in self-management, seek support, or adopt hearing technologies, thereby increasing their overall perceived burden [28].

Public healthcare provision reduced the financial cost of obtaining hearing aids but did not eliminate the broader workload associated with their use. Limiting follow-up services to the dispensing facility effectively shifts responsibility for travel, maintenance, and logistical demands onto patients, thereby undermining the equity such programs aim to achieve [29]. Moreover, limited technology options within public healthcare systems exacerbate perceptions of burden, as certain features that could reduce workload, such as accessible devices, were not offered. It is also important to consider that participants in this study were treated in a tertiary care setting and commonly presented with multiple comorbidities, making a heightened burden an expected outcome [30].

Participants sought a balance between drawing on familial and professional support and maintaining autonomy and independence in managing their hearing aids [4]. Consistent with this preference, they expressed a strong desire for direct and timely access to audiologists, noting that delays in professional support contributed to frustration and disengagement. On the other hand, family members often played an important role by encouraging participants to seek help and by motivating them to use their hearing aids more consistently, offering emotional, technical, and motivational support. Existing evidence aligns with these findings, showing that support from significant others can facilitate early hearing aid uptake [20, 27] and that positive family involvement is associated with better hearing aid outcomes [28]. Both users and audiologists often aim to foster independence by gradually reducing reliance on external assistance and promoting internally driven strategies for management [31]. These findings underscore the need for support models that respect older adults’ desire for autonomy while ensuring that both professional and familial assistance remain accessible when needed.

The mention of “God’s will” in participants’ accounts of accepting their hearing loss suggests an external health locus of control. Recent evidence shows that individuals with an external locus of control are more likely to rely on external agents or circumstances when managing their condition and when deciding whether to accept or resist support [32, 33]. This pattern was also evident in our findings, where participants framed their acceptance through external forces and disclosed resistance to support from family members, suggesting that externalized control may shape both acceptance and help-seeking behavior. However, external control was not the only explanation for resisting family involvement. Some participants avoided seeking help from relatives to prevent burdening them, a pattern commonly observed among individuals managing long‑term conditions [34]. Others perceived family or social network support as insufficient or less helpful than professional guidance, reinforcing their preference for clinician‑led assistance [35]. These findings highlight that resistance to family involvement may stem from multiple motivations—maintaining autonomy, protecting loved ones from additional workload, or valuing professional expertise.

The findings of this study highlight that the burden associated with hearing aid use is strongly influenced by the interplay between patient capacity and workload, as evidenced by participants’ statements. While social networks are essential for increasing patient capacity and reducing burden, participants preferred professional support from healthcare providers over support from their families. When this expectation was unmet—due to poor access, delayed follow-ups, or restricted availability—patients perceived an increased burden, as their capacity was diminished and their workload expanded. Capacity is not determined solely by individual ability but is shaped by the opportunities and resources made available through the healthcare system. Limited access to professional support was reported to increase workload by adding travel, time, coordination, and administrative demands [11]. Furthermore, building trust with healthcare professionals is crucial, as hearing aid users who do not trust their providers are more likely to disengage [36]. Simultaneously, participants acknowledged the value of family support in encouraging consistent device use, assisting with interpreting speech and environmental cues, and mitigating isolation and stigma. Audiologists can strengthen these networks by involving family members in counseling and training, thereby expanding patient capacity and reducing workload.

When significant treatment burden emerged —particularly among older adults with multiple comorbidities— it manifests as non-adherence, reduced engagement, and poorer quality of life [37]. Beyond these immediate effects, untreated or poorly managed hearing loss has been consistently linked to accelerated cognitive decline in older adults, a population already at elevated risk. These findings highlight the need for interventions that address both the practical and psychosocial dimensions of hearing aid use, as failure to do so risks reinforcing a cycle of burden with long‑term consequences for health, well-being, and cognitive function [38].

These findings align with Theory of Burden of Treatment, which posits that burden arises when workload surpasses capacity, and underscore that capacity must be understood as both individual and collective, encompassing family, social networks, healthcare providers, and the broader health system [11, 39]. This burden is cyclical: the consequences of non-adherence, such as reduced communication ability or device rejection, can themselves become antecedents that perpetuate further non-adherence, thereby compounding the overall strain. Such cycles have significant clinical implications, contributing to poorer outcomes, diminished treatment satisfaction, and reduced quality of life [7] (Fig. 1).

Clinical care implications and future research

Applying the Theory of Burden of Treatment reframes hearing aid management from a focus on device fitting to a broader process of balancing workload and capacity. The theory emphasizes that successful management depends not only on the technology itself but on how well the demands of hearing aid use align with an individual’s available resources. Identifying areas of difficulty and understanding the specific challenges experienced by hearing aid users can help tailor rehabilitation strategies that reduce workload and enhance capacity, including by strengthening supportive social networks. Our findings show that while some individuals experience family involvement as beneficial, others perceive it as a threat to their personal agency. Similar patterns are described in the chronic illness literature, where autonomy‑protective behaviors emerge when individuals feel that support compromises their sense of control [40]. For these individuals, clinicians must adopt approaches that respect personal autonomy while still promoting effective and sustained hearing aid use.

Future research should examine the experiences of caregivers supporting older adults with limited self‑management abilities, as their perspectives are essential for identifying strategies to improve hearing aid use and the overall user experience. It is also important to explore the views of clinicians to determine what types and levels of support can be feasibly provided, and which factors influence the availability of services. Establishing clear protocols to ensure that first‑time users and their caregivers have access to appropriate resources would help facilitate timely and effective support. Technological solutions, such as mobile applications or virtual communication platforms, may also reduce the burden on healthcare providers while maintaining high‑quality care for hearing aid users. Ultimately, future work must account for the diverse needs and capacities of older adults to ensure that support models are both equitable and responsive.

Strengths and limitations

To our knowledge, this is the first study to use qualitative interviews to examine the treatment burden associated with hearing aids among older adults in Saudi Arabia. We included participants with different characteristics to explore different experiences. A second, independent researcher checked the study codes. They reached an agreement by consensus, enhancing the transparency and credibility of the study’s interpretation [25].

A key limitation is that clinicians conducting interviews worked at the same clinic where patients received care. This could cause conflicts between the clinician and researcher roles [41]. This is challenging for both the interviewees and the interviewers, as the patient might view these interviews as a means of receiving care or as a way to influence their willingness to disclose negative experiences or criticisms, given the perceived authority of clinicians and their dependence on the healthcare system. To minimize this bias, interviews were consistently conducted by clinicians who were not directly involved in the participants’ care, thereby reducing the likelihood of social desirability bias. Furthermore, the consent process explicitly emphasized that responses would not affect the care patients receive, reinforcing the voluntary nature of participation and encouraging openness. While these measures strengthen the credibility of the findings, it remains important to acknowledge that the clinical environment itself may still shape patient narratives, underscoring the need for methodological reflexivity in qualitative research conducted within healthcare settings.

Another concern is the risk to participants’ autonomy due to their vulnerability as patients receiving care from interviewers [41]. Patients may feel pressured to participate or provide socially desirable responses. We aimed to reduce social desirability bias by carefully wording questions and avoiding leading questions and judgmental phrasing. Guaranteeing privacy and confidentiality encourages honest, private accounts. Researchers ensured their role and participant relationships were acknowledged by enhancing rigor through reflexive diaries, documenting procedures, providing evidence for interpretations, analyzing the complete data set, considering deviant cases and disconfirming data, comparing data within and between cases, and contrasting findings with other studies. Finally, the study was conducted in Riyadh, the capital of Saudi Arabia. Residents of the capital city may have more advanced services than those in other regions. The hospital was chosen for its unique tertiary healthcare services, providing access to a diverse population. Results reflect participants willing to discuss their experiences, possibly underrepresenting older, more conservative adults or those with severe hearing loss, who are less inclined to share their hearing aid experiences.

Conclusion

This study examined hearing aid burdens among older adults, highlighting barriers such as feeling overwhelmed and experiencing limitations, as well as positive technological experiences. Participants reported preferring professional support over any other type of support. The findings indicate that hearing aids impose significant burdens; future research should explore caregivers’ and clinicians’ perspectives on the levels of support to be provided. Future healthcare programs must ensure access to resources for users and carers, incorporating technological solutions, such as applications, to ease healthcare providers’ workload and provide a consistent channel of communication between patients and their healthcare providers. Furthermore, the use of rechargeable hearing aids can alleviate some of the burden associated with hearing aid care and maintenance. Support should cater to the diverse needs of hearing aid users.

Authors’ contributions

Sarah Alageel (Conceptualization; Writing- Original Draft; Data Collection & Curation; Formal Analysis); Hawazen Alhamdan (Writing - Review & Editing; Formal Analysis); Azizah Bedaiwi (Writing- Original Draft; Data Collection & Curation); Hajar Alaqil (Writing - Review; Data Collection & Curation); Samah Alageel. (Conceptualization; Methodology; Writing - Review & Editing; Formal Analysis).

Funding

No funding was received to complete this study.

Data availability

The datasets generated and analyzed during the current study are not publically available due to lack of consent to share raw material, but parts of the material can be available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Research Advisory Council at KFSH&RC (RAC#2241084) as a non-interventional study on 17th March 2024. Participants gave informed consent for review, and consent was documented in the patient’s medical charts. All study procedures were conducted in accordance with the ethical standards of the Committee on Human Experimentation of the institution where the study was conducted, in accordance with the Declaration of Helsinki, 1975.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.