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. 2021 Jul 27;30(3):709–716. doi: 10.1044/2021_AJA-21-00043

Self-Reported Reasons for the Non-Use of Hearing Aids Among Hispanic Adults With Hearing Loss

Jamie L Desjardins a,✉, Loren R Sotelo b
PMCID: PMC8642098  PMID: 34314258

Abstract

Purpose

To examine the self-reported reasons for the non-use of hearing aids among Mexican–American Hispanic adults who have hearing loss.

Method

A total of 122 Hispanic adults with hearing loss, who did not currently or previously use a hearing aid, participated in this study. Participants completed a comprehensive hearing health questionnaire and the Hearing Handicap Inventory Screening Questionnaire to examine the possible reasons for the non-use of hearing aids.

Results

Self-reported hearing loss, hearing handicap score, and health insurance status were the best predictors of an individual's willingness to use hearing aids to treat their hearing loss. The primary reasons cited for the non-use of hearing aids among Hispanics with hearing loss was the belief that their hearing impairment was not severe enough to warrant using a hearing aid and that hearing aids were unaffordable.

Conclusions

Greater public health education regarding the deleterious effects of untreated hearing loss and the positive impact of amplification on cognitive, social, and psychological health may be warranted to improve the usage rates of hearing aids in Hispanic adults.

Persons of Hispanic/Latinx ethnicity represent 17% of the entire population, and are the fastest growing minority group in the United States. The rapid growth in the U.S. Hispanic/Latinx population since 1990, combined with higher life expectancies for Hispanic/Latinx at all ages, will almost triple the proportion of the elderly in the United States who are Hispanic/Latinx by 2050, from 7% in 2009 to 20% in 2050 (United States Census Bureau, 2020). In addition, nearly one in seven Hispanic/Latinx has hearing loss, which is close to the overall national average (Argawal et al., 2008). However, despite this large aging demographic with hearing loss, few studies have examined the use of hearing aids in the Hispanic/Latinx population in the United States.

Age-related hearing loss is associated with serious adverse effects on an individual's health including the increased risk of cognitive decline (Amieva et al., 2015), falls (Jiam et al., 2016), hospitalizations (Genther et al., 2013), anxiety, social isolation, and depression (Ciorba et al., 2012; Dalton et al., 2003; Gates & Mills, 2005; Heine & Browning, 2002). Hearing aids are the most common and effective treatment for age-related hearing loss (Ferguson et al., 2017; Sprinzl & Riechelmann, 2010). Treating age-related hearing loss with the use of hearing aids has been shown to improve an individual's quality of life (Cohen et al., 2004; Desjardins & Doherty, 2017), psychosocial function (Acar et al., 2011; Choi & Chung, 2011), cognitive function (Amieva et al., 2015; Desjardins, 2016; Doherty & Desjardins, 2015), and general overall health (Arlinger, 2003; Crandell, 1998; McPherson & Wong, 2005). However, despite the fact that hearing aids are an effective therapy option for individuals with hearing loss, they are often underutilized. It has been estimated that 30% of older adults with hearing loss use hearing aids (Bainbridge & Ramachandran, 2014; Gopinath et al., 2011).

Numerous factors have been shown to influence the use of hearing aids among adults with hearing loss. Namely, age, self-reported hearing handicap, and self-reported hearing loss were the most significant predictors of hearing aid use among adults with hearing loss (Gopinath et al., 2011; Kochkin, 2012). That is, individuals with hearing loss, who use hearing aids, have been shown to have significantly greater degrees of hearing loss, and are older in age compared to non-users of hearing aids (Kochkin, 2012). In addition, individuals who self-report greater hearing handicap are more likely to use hearing aids compared to individuals who perceive less need and experience less difficulties resulting from their hearing loss (Gopinath et al., 2011). When surveyed, the most common reasons reported by adults with hearing loss for not using hearing aids included the high cost of the devices, lack of perceived need for them (i.e., minimization of hearing loss), embarrassment associated with wearing hearing aids, and the perception that hearing aids do not work (Kochkin, 2007; Mahmoudi et al., 2018; Wong & McPherson, 2010).

While many studies have examined factors associated with hearing aid use, the majority of studies have included primarily non-Hispanic White population samples. Thus, currently, there is limited understanding of hearing aid use among Hispanic/Latinx in the United States. This is problematic as Hispanic/Latinx often lack access to health care and are less likely to have access to high-quality care compared to non-Hispanics due to a variety of financial and nonfinancial barriers to obtaining health care including degree of acculturation, language differences, and immigration status (Gresenz et al., 2009). In addition to health disparities and access to care, differences in how illness and health is interpreted in Hispanic cultures may also influence compliance with health treatment options, including the use of hearing aids (Salas-Provance et al., 2002). In particular, the desire to portray one's self as masculine among Hispanic male adults has been shown to lead to the denial of the presence of a disability, and the perception that accepting rehabilitation services is a sign of weakness or embarrassment (Salas-Provance et al., 2002). Hispanic women have also been shown to fail to acknowledge the presence of a disability or minimize the effects of disability to meet the social standards of “endurance of the aversive effects of one's illness” (Belgrave, 1994; Salas-Provance et al., 2002).

Data collected in the early 1980s from the Hispanic Health and Nutrition Examination Survey revealed 6% to 14% of Hispanic adults with hearing loss used hearing aids (Lee et al., 1991). A more recent study, which examined hearing aid use among Hispanic/Latinx in the United States, estimated usage rates to be closer to 5% (Arnold et al., 2019). Thus, hearing aid usage rates among Hispanic/Latinx adults with hearing loss are far lower than has been reported in non-Hispanic populations. Generally, the Hispanic/Latinx adults with hearing loss, who use hearing aids, have been shown to have poorer hearing thresholds and higher hearing handicap scores than those who do not use hearing aids (Arnold et al., 2019; Gopinath et al., 2011; Lee et al., 1996). In addition, Hispanic/Latinx individuals with hearing loss living below the poverty line are more likely to use hearing aids than those with higher incomes. This is thought to be attributed to the fact that individuals with lower incomes have access to the Medicaid health insurance program, which in some states provides a hearing aid(s) at no cost to the insured (Arnold et al., 2019; Lee et al., 1996).

The self-reported reasons for the non-use of hearing aids among Hispanic/Latinx with hearing loss, to our knowledge, has not been examined. In order to improve access to hearing health care services and increase hearing aid use in this large aging population, it is necessary to gain further insight as to why Hispanic/Latinx adults with hearing loss do not use hearing aids. Thus, in the current study, we examined the self-reported reasons for the non-use of hearing aids among Mexican–American Hispanic adults with hearing loss who have never used or tried a hearing aid. We hypothesized that negative stigma concerning the acceptance of rehabilitation services, minimization of hearing loss, and limited access to hearing health care would be the primary reasons reported for the non-use of hearing aids among Hispanics with hearing loss.

Method

Participants

Participants in this study were recruited from five senior centers and three community health fairs located across El Paso, Texas. Approval from the institutional review board (IRB) was obtained before initiating this study in accordance with The University of Texas at El Paso IRB committee. Of the 225 participants initially screened, 122 individuals met the inclusion criteria for participation in this study. To be eligible to participate, individuals must have had no current or previous personal experience wearing hearing aids, failed a hearing screening at 1000, 2000, and 4000 Hz at 40 dB HL, bilaterally, and identified as Hispanic.

Materials

Hearing Handicap Inventory–Screening Version

The English and Spanish language versions of the Hearing Handicap Inventory–Screening Version (HHI-S; Ventry & Weinstein, 1983) were used to assess participants' perceived hearing handicap. The HHI-S is composed of 10 questions that measure perceived hearing difficulties in specific situational contexts. Scores can range from 0–40 with higher scores indicating greater self-perceived hearing handicap. The Spanish language version of the HHI-S was previously adapted and validated specifically for use with Mexican–Americans who speak Spanish, and has demonstrated high correlation and test equivalence with the English-language version (Lichtenstein & Hazuda, 1998).

Hearing History Questionnaire

A hearing history questionnaire was used to assess general participant demographic characteristics (i.e., age, gender, country of birth, ethnicity, employment status, years of education, health insurance status, and language use), self-reported hearing loss, hearing aid use, willingness to use a hearing aid, and reasons for the non-use of hearing aids. The non-use of hearing aids was examined on the questionnaire using a closed set of five response choices. Participants were instructed to check all of the reasons for why they did not use hearing aids. There was also a space where participants could write in their own reason(s), if their reason was not listed or if they had additional reasons that they wished to report. The questionnaire was developed with reference to similar questionnaires (Desjardins & Doherty, 2009; Wong & McPherson, 2010), literature review, clinical experience of the first author, and pilot data obtained from adults in the El Paso community.

To accommodate the needs of the largely Spanish-speaking community in El Paso, the questionnaire was translated into Spanish by a native, local Spanish speaker. The questionnaire was then back-translated into English by four Spanish–English bilinguals: two Spanish–English bilingual graduate students in the speech-language pathology program at the University of Texas at El Paso, a professor from the Spanish Language Department at The University of Texas at El Paso, and a Spanish–English bilingual older adult from the El Paso, Texas community. The questionnaire was then piloted on 100 Spanish-speaking older adults at a community health fair. Based on the pilot data, minor changes were made to the wording of two questions to improve the clarity of the questionnaire in Spanish.

Procedure

Participants were presented with a research study information sheet, the hearing history questionnaire, and the HHI-S in paper and pencil format. After completing the questionnaires, participants' hearing thresholds were screened at 1000, 2000, and 4000 Hz at 40 dB HL, bilaterally. Individuals who failed the hearing screening were given a sheet with the contact information for local audiology practices to obtain a diagnostic hearing evaluation.

Statistical Analysis

All data were analyzed using SPSS v 25 software (IBM Corporation). Descriptive data analysis was conducted for participants' responses on the questionnaires. Logistic regression was used to determine the factors that were most predicative of willingness to use a hearing aid among the study participants. A .05 significance level was used for all analyses.

Results

Table 1 displays the demographic characteristics of the 122 participants who met the inclusion criteria for this study. Participants ranged in age from 43 to 93 years old (M = 66.6 years, SD = 10.5 years) and 76 (62%) were female. All participants in this study identified as Hispanic. The overwhelming majority of participants (81%) were first-generation U.S. residents from a Mexican background, and 75% of participants spoke mostly Spanish at home and in social contexts. On average, participants reported less than a high school education (mean years of education = 7.8, SD = 4.6). The majority of participants (54%) were currently retired from employment and 60% reported having some form of health insurance. Of the individuals with health insurance, more than half reported to have a form of government insurance (i.e., Medicare or Medicaid).

Table 1.

Demographic characteristics of study participants.

Demographic characteristic No. (%)
Total number in the study sample 122 (100)
Age in years, M (SD) 66.6 (10.5)
Sex, female 76 (62)
Country of birth
 Mexico 97 (81)
 United States 25 (19)
Ethnicity, Hispanic 122 (100)
Language(s) spoken at home
 Mostly Spanish 91 (75)
 Mostly English 4 (3)
 Equal amounts of Spanish and English 27 (22)
Education in years, M (SD) 7.8 (4.6)
Current employment status
 Full-time 17 (14)
 Part-time 21 (17)
 Unemployed 16 (13)
 Looking for work 2 (1.5)
 Work in the home 2 (1.5)
 Retired 66 (54)
Heath insurance status, insured 74 (60)
Self-reported as having a hearing loss (suspected or confirmed) 68 (56)
HHI-S score, M (SD) 12.6 (11.4)
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Note. HHI-S = Hearing Handicap Inventory–Screening Version.

Fifty-six percent of the participants self-reported that they had a hearing loss. Participants, mean self-reported hearing handicap on the HHI-S was 12.6 (SD = 11.4), consistent with a mild to moderate hearing handicap across participants. Specifically, 42% of participants reported no hearing handicap, 36% reported a mild to moderate hearing handicap, and 22% perceived that they had a severe hearing handicap.

Factors Related to the Willingness to use Hearing Aids

On the hearing history questionnaire, participants responded “yes” or “no” to the question, “Would you use hearing aid(s) to treat your hearing loss?” Results showed that 54% of participants responded that they would be willing to use hearing aids to treat their hearing loss. A forward step-wise binary logistic regression was performed to determine factors related to the willingness to use hearing aids to treat hearing loss among Hispanic adults. The dependent variable was the participants' response (yes or no) to the question, “Would you use hearing aid(s) to treat your hearing loss?” The independent variables were age of the participant (years), sex (male or female), years of formal education (number of years), health insurance status (insured or not insured), hearing handicap score on the HHI-S (0–40), and self-reported hearing loss (yes or no).

The variable enter criteria was p = .05 and remove criteria was p = .1 using forward stepwise variable selection. Significance of the independent variables was measured with the Wald test, which indicates the strength of the predictive variable (Harrell, 2001). The goodness-of-fit of the models was determined with the Hosmer & Lemeshow test (Hosmer et al., 2000). Odds ratios (ORs) and corresponding 95% confidence intervals (CI) were estimated by exponentiating the unstandardized pooled beta coefficients and lower and upper confidence limits. An OR of greater than 1.0 indicated a greater likelihood that the participant would be willing to use a hearing aid to treat their hearing loss, and an OR of below 1.0 indicated that it was less likely that the participant would be willing to use a hearing aid to treat their hearing loss.

Table 2 shows the best model for predicting willingness to use hearing aids among Hispanics with hearing loss. Increased odds of reported willingness to use a hearing aid was significantly (p < .05) associated with higher hearing handicap scores, affirmative self-report of hearing loss, and having health insurance. The likelihood of using hearing aids was 10% higher in participants with greater hearing handicap (OR = 1.1; 95% CI [1.05, 1.17]). Participants' who affirmatively self-reported their hearing loss were 3.1 times more likely to use a hearing aid than participants who did not self-report having a hearing loss (OR = 95% CI [1.2, 7.7]). Lastly, participants with health insurance were 3.5 times more likely to report that they were willing to use a hearing aid to treat their hearing loss than those without health insurance (OR = 3.5; 95% CI [1.2, 9.6]).

Table 2.

Statistics for independent variables in the logistic regression model.

Variables in the equation Statistics
Beta Standard error Wald statistic Degree of freedom Sig. Exp(B) 95% CI for Exp(B)
Lower Upper
Health insurance status 1.246 .522 5.696 1 .017 3.475 1.249 9.665
Self-reported hearing loss 1.118 .472 5.617 1 .018 3.058 1.213 7.709
HHI-S 0.101 .028 13.086 1 .000 1.106 1.047 1.168
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Note. HHI-S = Hearing Handicap Inventory–Screening Version; Exp(B) = exponentiated beta; CI = confidence interval; Sig = significance level.

Reasons Reported for the Non-Use of Hearing Aids

All of the participants in the current study had a hearing loss, yet none of them had ever used hearing aids. Table 3 displays the reasons reported by the study participants for their non-use of hearing aids. Participants were asked to report all of the reasons why they were not using hearing aids to treat their hearing loss. The most commonly cited reasons for the non-use of hearing aids among all the participants in this study was the perception that their hearing loss was not bad enough to require treatment with a hearing aid (minimization of hearing loss; 37%), followed by their inability to afford to purchase hearing aids (35%). Only 2% of the participants in this study wrote in the open-ended response section of the questionnaire. Additional reasons reported by participants for not using hearing aids included difficulty with obtaining transportation to medical appointments, and that their hearing loss was a low health priority compared to their other health concerns.

Table 3.

Self-reported reasons for the non-use of hearing aids.

Reported reason for non-use Participants (%)
All participants
(n = 122)		 Participants not willing to use a hearing aid
(n = 56)		 Participants willing to use a hearing aid
(n = 66)
I do not know where to obtain hearing aids. 11 15 2
I cannot afford to purchase hearing aids. 35 27 75
My hearing loss is not bad enough for me to need to use hearing aids. 37 47 8
It would embarrass me to have to wear a hearing aid. 9 12 2
Hearing aids do not work well/help a great deal. 13 12 17
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While none of the participants in the current study used hearing aids, 54% of the participants reported that they were willing to use hearing aids to treat their hearing loss. We were interested in examining the reasons given for the non-use of hearing aids by the participants who reported that they would be willing to use a hearing aid to treat their hearing loss compared to those participants who reported that they would not be willing to use a hearing aid to treat their hearing loss. Participants who reported that they would be willing to use a hearing aid, but have not adopted hearing aids, overwhelmingly (75%) cited cost as the primary reason for why they do not use hearing aids. The primary reason cited by 47% of participants who said they would not use a hearing aid to treat their hearing loss was that they did not perceive that their hearing loss was bad enough to warrant the use of hearing aids (see Table 3).

Discussion

The current study examined the self-reported reasons for the non-use of hearing aids among Hispanic adults who have hearing loss, but had never used hearing aids to treat their hearing loss. The participants in this study were Mexican–American Hispanic adults living in El Paso, TX, a minority–majority city located on the United States–Mexico border. Interestingly, more than half of the participants in the current study reported that they would be willing to use a hearing aid to treat their hearing loss. The most significant factors predictive of an individual's willingness to use a hearing aid were self-reported hearing handicap scores on the HHI-S, self-reported hearing loss, and health insurance status. Higher scores on the HHI-S and the self-report of a hearing loss were associated with willingness to use hearing aids among the participants in this study. This result is consistent with previous studies that have shown that one's motivation to utilize hearing aids may be related to the extent of the listener's hearing handicap, “personal distress,” and “minimization of hearing loss” (Alicea & Doherty, 2017).

In addition, individuals in this study who reported that they had health insurance were more willing to use hearing aids to treat their hearing loss compared to those who did not have health insurance. This was likely because many of the participants in this study with health insurance had Medicaid, which covers partial or total costs for hearing aids for older adults in Texas (Cohen-Mansfield & Infeld, 2006). In addition, individuals with health insurance coverage, in general, have better access to health care than people who are uninsured. Studies repeatedly demonstrate that uninsured people are less likely than individuals with insurance to receive preventive care and other services for health conditions and chronic diseases (Lewin-Epstein, 1991).

While this study showed that the intentions of the aging Hispanic population to use hearing aids to treat hearing loss was largely present, as 54% of the participants reported that they would be willing to use hearing aids, none of the participants in the current study had ever used or tried hearing aids. The most commonly cited reason for the non-use of hearing aids among participants was the perception that their hearing loss was not bad enough to require treatment with a hearing aid. In the current study, 42% of the participants reported that they had no hearing handicap, as indicated by their score on the HHI-S, and 44% of the participants reported that they did not have a hearing loss, when one was present. In addition, 9% of the participants reported that they would be embarrassed to wear hearing aids. The denial, minimization, and negative stigma of hearing disability among the participants in the current study is consistent with cultural Hispanic beliefs on masculinity and endurance (Salas-Provance et al., 2002). However, minimization of hearing loss is not unique to Hispanics, and is widely reported across the literature as one of the primary reasons for the non-use of hearing aids (Alicea & Doherty, 2017).

Increased patient education concerning the deleterious effects of untreated hearing loss may help to lessen minimization of hearing loss and stigma of wearing hearing aids among older Hispanic adults. However, in the medically underserved area of El Paso, TX, there are only two audiologists for every 100,000 individuals living in the county (Texas Department of Health, 2019). Thus, it would be difficult to rely solely on licensed hearing health care professionals to promote public awareness of the detrimental effects of untreated hearing loss. A more effective strategy to promote and educate Hispanic adults in medically underserved areas about hearing health care may be through information campaigns conducted by local public health agencies (Shaw, 2015; Suen et al., 2019).

Local public health agencies are considered essential community providers that help meet the health care needs of historically underserved areas and populations. They are also adept in educating residents on the benefits of preventive care and healthy behaviors to facilitate healthy lifestyles (Beitsch et al., 2006). However, despite hearing loss being the third most common chronic physical condition in the United States, and more prevalent than diabetes or cancer, it is still not a current focus of most local health departments. Hearing health care providers, in conjunction, with our professional organizations, must advocate and facilitate for hearing health care to become a priority public health concern for local public health agencies, especially among underserved older adult populations.

The second most cited reason for the non-use of hearing aids by participants in this study was the inability to afford to purchase them. Thus, financial strain may also be deterring individuals from seeking out hearing health care services. Over-the-counter (OTC) hearing aids have been touted as the best solution for expanding access to hearing technologies for the millions of Americans with hearing loss, due to increased access to the devices and the lower cost (Warren & Grassley, 2017). While these devices are significantly less expensive than conventional hearing aids, they cost on average $250 to $350 per ear (Bleiberg, 2019), which may still be financially burdensome or unaffordable to many lower income older Hispanic adults (Macartney et al., 2013). In addition, OTCs are sold predominately online via websites that include written information presented in English only. This is highly problematic for many older Hispanic adults who have Spanish as their first language and limited proficiency in reading English (Ruiz et al., 1992). Thus, older Hispanics, a historically medically underserved group, may be excluded from taking advantage of OTCs, which are supposed to be universally accessible hearing health care for all Americans with hearing loss.

A more comprehensive solution for access to hearing health care is necessary to meet the needs of older adult Hispanic populations who have been shown to have low health literacy and limited proficiency in English. Low health literacy is a significant barrier to health care access and service utilization, and language proficiency has been shown to significantly limit an individual's health literacy (Becerra et al., 2017). Affordable, accessible, and linguistically congruent services may be provided to older Hispanics through local public health departments in conjunction with teleaudiology services. That is, local public health campaigns presented in Spanish and English can be used to engage the community and promote self-care through means of education, evaluation, and prevention (Dillon & Sternas, 1997; Reavis et al., 2016). This can serve to motivate the Hispanic community to take charge of their hearing health, better understand the consequences if left untreated, and improve their overall health literacy pertaining to hearing loss and hearing aids. Additionally, public health initiatives may include free hearing screenings and appropriate referrals to local and teleaudiological services (Dillon & Sternas, 1997).

The use of teleaudiology in the last decade has been shown to be effective in increasing connections between patients in rural and underresourced areas to hearing health care providers (Swanepoel & Hall, 2010; for a comprehensive review, see Tao et al., 2018). Telemedicine, as a whole, has consistently been shown to speed up access to medical professionals, increase the convenience and money savings for patients, improve quality of patient care, and provide increased access to care within regions that were previously lacking access to health care resources (Hjelm, 2005). Thus, increased development and expansion of teleaudiology services to include additional underserved areas along the United States–Mexico border may be effective in increasing Hispanic adults' awareness of the deleterious effects of untreated hearing loss, providing comprehensive audiological services to medically underserved communities, and increasing hearing aid usage rates in this population.

All of the participants in the current study were Mexican–American Hispanic adults who resided in the El Paso, Texas region of the United States. Thus, the results from the current study may not generalize to all Hispanic/Latinx adults with hearing loss across the country. To obtain a more comprehensive profile of the reasons for the non-use of hearing aids among Hispanic/Latinx adults, future studies should investigate hearing aid use in Hispanic/Latinx populations residing in different areas of the country and with different cultural backgrounds. Future studies are also needed to further develop and implement policies and programs for hearing health care and hearing aid use in medically underserved areas of the United States.

Conclusions

The primary reasons cited for the non-use of hearing aids among Hispanic adults with hearing loss was that individuals considered their hearing impairment to not be severe enough to warrant using hearing aids, and that hearing aids were unaffordable. Targeted hearing health care education programs for Hispanic adults with hearing loss may be warranted to improve the usage rates of hearing aids among Hispanic adults.

Acknowledgments

This research was supported in part by the University of Texas at El Paso BUILDing SCHOLARS National Institutes of Health Grant 1RL5MD009592.

Funding Statement

This research was supported in part by the University of Texas at El Paso BUILDing SCHOLARS National Institutes of Health Grant 1RL5MD009592.

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