Next we asked potential hearing aid users to indicate whether or not each of eight features of hearing aids would increase their likelihood of purchasing hearing aids in the future. We did not repeat all the variables previously presented under obstacles to hearing aid adoption on the assumption that enhancement of these features (e.g., improved benefit, performance in noise) would eventually lead to improved attitudes in the marketplace followed by positive word of mouth. The results for the total population are documented by hearing loss decile in Table 6. With the exception of the lowest hearing loss decile, these enhancements would positively impact each hearing loss decile in roughly the same proportion. Thus, we have shown the total impact (all decile groups) in Figure 8.
Four out of ten non-adopters indicated a $500 tax credit would increase their likelihood of purchasing a hearing aid in the future, while about one in four (27%) indicated the ability to buy software upgrades would be appealing. Two out of ten said they would be interested in hearing aids built into fashionable eyeglasses, headset functionality with phones, or the ability to self-fit or adjust their hearing aids. One in ten would be motivated by MP3 connectivity to their hearing aids, an FM radio in their hearing aid, or a language translator (e.g., French voice-recognition software converted to English in the ear of the consumer).
Focusing on people with a 6-month purchase intent, we presented 22 aided awareness reasons why people purchase hearing aids. They were asked to indicate if one or more of these reasons influenced their intent to purchase in the near future. As seen in Figure 9, the top reasons were “hearing loss got worse” (67%) and “family recommendation or pressure” (62%). About one in five was influenced by an audiologist, safety concerns, or another hearing aid owner. One in six plans to purchase on the recommendation of an ENT or based on public relations and marketing material (e.g., TV, radio, newspaper, direct mail, Internet). Finally, about 10% are going to purchase because of a favorable price for a hearing aid, a hearing instrument specialist's recommendation, receipt of a free hearing aid, improved finances, family doctor recommendation, or recommendations from their place of employment.
There is a wide continuum in the degree of hearing loss among adults who acknowledge having a hearing loss. In estimating obstacles to hearing aid adoption it is useful to derive a method that allows us to directly compare hearing aid users and non-adopters with a comparable degree of hearing loss. A significant co-variate making it difficult to quantify “true” obstacles to hearing aid adoption in the past has been degree of hearing loss. Quite simply, people who purchase hearing aids have more severe hearing losses than non-adopters.
However, using hearing loss segmentation strategies we have derived a subjective method for directly comparing the relevant non-adopting hearing loss population with current users of hearing aids. Adults with hearing loss in deciles 6–10 equate most closely to current hearing aid users. Within this more serious hearing loss segment reside 83% of hearing aid users, but only 39% of non-adopters. While we have documented in detail each of 10 hearing loss segments for interested researchers, publicists, and strategists, we shall focus here on the obstacles to hearing aid adoption by those with the greatest degree of hearing loss (unless stated otherwise).
In our opinion, a clear understanding of obstacles among adults with the most serious hearing losses could be fruitful in devising strategies to change attitudes or behaviors that block them from an earlier search for a life-changing hearing solution. With opportunities for promoting better hearing in mind, here are our key observations:
The key reason that new users and potential new users (adults in this study with a 6-month purchase intent) buy hearing aids is the recognition that they have a problem; often motivation comes from the influence of family and friends. This is the same reason that people seek a solution for other problems, such as psychological problems, alcoholism, or drug addiction; namely, personal need recognition, whether internally or externally determined.
Any intervention designed to get people with hearing loss to comprehend their problem will perhaps be the most powerful motivator. This intervention could take many forms, including: greater involvement on the part of the physician in problem recognition, continued education on the signs of hearing loss, or quality-of-life public relations campaigns, such as the impact of untreated hearing loss on income and employability.
Only half the population has received an objective hearing test. Given the importance of problem recognition, the simple act of providing non-adopters with some form of hearing loss measure, whether objective or subjective, could have a powerful impact on their decision to seek a solution, especially if they have been simultaneously educated on the impact of untreated hearing loss on quality of life. Without personal knowledge of hearing loss it is unlikely that other interventions would be effective. You cannot search for a solution until you know you have a problem.
Recommendations from physicians, ENTs, and audiologists regarding hearing aids have become significantly more positive over the last 20 years. Continued efforts to educate physicians and ENTs on the efficacy of hearing aids (e.g., evidence-based research) and the impact on their patients' quality of life could significantly reduce negative word of mouth among professionals and encourage more people to seek a solution for their hearing loss.
Surgery and HA trial
Nearly 12% of the unamplified population reported that they had either undergone surgery and were not hearing aid candidates, were candidates for surgery in the future, or had tried hearing aids with little or no success. The key reasons for returning hearing aids were poor benefit, background noise, whistling and feedback, and poor value (performance relative to price). On the assumption that these are not future hearing aid candidates, the available possible amplification population should be reduced by 2.75 million.
Attitudes toward hearing loss
By focusing on non-adopters in hearing loss deciles 6–10, which is the level of loss equal to or greater than that of the typical hearing aid user, we can rule out people who do not need hearing aids. A great proportion of those in deciles 6–10 must be experiencing communication difficulty, whether they recognize it or not.
From this survey it is difficult to determine the origins of their belief that their “hearing loss is too mild” or “not severe enough” for amplification. Certainly some of this is minimization of hearing loss or a level of denial. At least one in four consumers surveyed reported a “mild” hearing loss as a definite reason for nonadoption, and half of them reported either that they don't need to hear well, they get by in most situations, they do not socialize enough, or they don't need fine hearing for their job, etc.
Focus groups with non-adapters have shown that people with hearing loss tend to underestimate the severity of their loss.9 To counter this misperception, educational efforts could be targeted at significant others, including medical pro-fessionals to assist them in communicating more accurate perceptions of the degree of hearing loss to the person with the loss.
Misinformation about candidacy
Some people do not try hearing aids because they have been given false information related to hearing aid candidacy. Specifically, people with high-frequency or low-frequency hearing loss, nerve damage (i.e., sensorineural hearing loss), or unilateral hearing loss were often told they were not candidates for hearing aids. Public awareness efforts to counter these myths could move more people toward considering hearing aids.
About four people in ten who have a hearing loss indicated that their tinnitus was either “definitely” or “somewhat” a reason for non-adoption of hearing aids. While the efficacy of hearing aids in treating hearing loss is well established, the impact of amplification on people with concurrent tinnitus and hearing loss needs to be investigated further and reported to the public and the medical community. If there is concurrent tinnitus relief in addition to meaningful benefit for hearing loss, this could have a substantial impact on hearing aid adoption rates. If tinnitus is contraindicative of hearing aid usage then the viable amplification population could be substantially reduced.
Attitudes toward hearing aids
Half of those in the most serious hearing loss segment hold at least one negative attitude toward hearing aids. In rank order the most commonly cited negative beliefs are: They are unable to perform in noise, they cannot restore hearing to normal (like glasses), they whistle and feedback, they do not work in crowds, they amplify unwanted background noise (e.g., the refrigerator), and they are a hassle.
A useful exercise is to determine which of the 18 hearing aid attitudinal items in Table 4 are valid, invalid, and perhaps which ones are improving. Once a person has accepted his or her hearing loss, has overcome stigma, and can afford hearing aids, the person must also have a positive view of the product's ability to provide substantial benefit in typical listening situations. Myths about hearing aid technology can be overcome with educational efforts to both the potential end-user and the medical community.
Undoubtedly, negative attitudes toward hearing aids emanate from the consumer journey of friends and relatives, not to mention what is seen and heard in the press. Among this sample of non-adopters, 19% indicated that the experiences of other hearing aid owners influenced their decision not to get hearing aids; that's 4.4 million people affected by negative word-of-mouth reports.
In the most recent MarkeTrak customer satisfaction study,10 one out of six people indicated that their hearing aids were in the drawer and half of these hearing aids were less than 5 years of age. Among hearing aid owners, only three out of four people said they wore their hearing aids more than 4 hours a day. In addition, it should be recognized that the key driver to positive attitudes toward hearing aids is a substantial customer base deriving benefit at a perceived high value.
Two large-scale studies11-12 have demonstrated that the absolute benefit (unaided score – aided score) to consumers is approximately 28%, which equates to a median problem resolution of about 44% (i.e., benefit/unaided). Since benefit is so highly correlated with overall satisfaction with hearing aids, it is logical to ask if a median benefit of 44% is sufficient to dramatically increase the number of people with untreated hearing loss turning to hearing aids as a solution.
While tremendous advances have been made in hearing aid technology in the past decade, realistically, attitudes cannot change dramatically without a corresponding improvement in the current consumer's journey. We think that the Hearing Industries Association's current research on improving the consumer's journey should lead to meaningful improvements.
Referring back to Table 4, about one-half of people with hearing loss (in deciles 6–10) choose not to try hearing aids due to stigma. The stronger issues are “hearing aids are a public admission of hearing loss,” “noticeable,” “embarrassment,” and perceived societal connotation of “disability” and “aging.”
In our opinion, the effects of stigma are stronger than admitted in this study when one takes into account hearing aid adoption rates controlling for age and degree of hearing loss as shown in Figure 1c. Given the same audiogram and speech discrimination we estimate that a 75-year-old is three to four times more likely to embrace hearing aids than a younger person, because hearing aids are still positioned in society as a product that only old people use. Yet MarkeTrak research demonstrates that 65% of people with hearing loss are below retirement age.1
The war on stigma should continue to be waged, but at a much more extensive level than in the past. Stigma can be alleviated by less conspicuous products such as open-fit BTES. While this may partially solve external stigma (what other people see), it does not solve the individual's internal stigma (what people with hearing loss feel about themselves).
Ultimately, massive public relations campaigns using famous or powerful celebrities and successful peers must be employed to break down the stigma barriers. The MarkeTrak population data can be used to refute the myth that only old people have hearing loss. Until younger people (versus the average age of 70 for first-time users) begin using hearing aids, the stigma of hearing aid use will remain; in short, the average age of first-time users must be reduced in the next generation.
Of those most in need of hearing aids, a significant number (64%) reported that the price was an obstacle to adoption. More than half were concerned about the ongoing expense and close to half questioned their value. In further investigation of people reporting that they could not afford hearing aids we found substantial income differentials—up to $40,000—controlling for age between the “can afford” and “cannot afford” hearing aid groups.
In addition, people in all age groups who reported that they could not afford hearing aids were below the national household income level. When asked to indicate if a $500 tax credit would increase their likelihood of purchase, four out of ten gave a resounding “yes.” Clearly, initiatives such as tax credits, insurance, and Medicare coverage for hearing aids are needed to help them become affordable to all. Greater public education on available financial help through charities, the Veterans Administration, unions, and employers (e.g., flex dollar spending programs, Americans with Disabilities Act) may also help remove personal finances as an obstacle to hearing aid adoption.
The process of hearing aid adoption is complex, as Figure 3 demonstrates. For a person to seek out a hearing solution a number of concurrent events, both perceptually and in reality, must occur:
* First, the individual must recognize his or her hearing loss.
* Second, the individual must recognize that the hearing loss causes them problems. Without problem recognition there cannot be problem resolution.
* Third, assuming that the problem is sufficiently disruptive to the quality of a person's life or that of their family and that the disruption is comprehended, the person's search for a solution must result in the formation of a reasonable probability that the problem will be sufficiently solved and that the solution will be a good value (e.g., I will get a better job, I will be safer, my relationships will improve, I will do better in school, my emotional life will improve). In other words, the cost of the problem must exceed the cost of the solution for there to be any expectation of movement toward a solution.
* Fourth, it should be recognized that there are many issues obstructing an individual's movement toward a hearing solution—some perceptual, some real.
If significantly more people are to discover the joys of better hearing the hearing healthcare industry will need to simultaneously improve perceptions as well as the reality of the consumer's journey.
This study was made possible by a special grant from Knowles Electronics, LLC, Itasca, IL.
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6. Adopted from Calder BJ, Garstecki DC, Iacabucci DM: Project Pygmalion Final Report
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7. U.S. Bureau of Census: The average household income for 2003–2004 was $45,893.
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9. Hearing Industries Association: 1989 focus groups with non-adopters.
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© 2007 Lippincott Williams & Wilkins, Inc.
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