Nearly all hearing aid users in America wear digital hearing aids. In 1990, when we first started reporting on the hearing health industry (MarkeTrak I),1 100% of hearing aids were analog. It is our contention that customer satisfaction with hearing aids is critical to increasing hearing aid adoption or usage; thus in 1991, we first started measuring customer satisfaction with hearing aids.2
In the first installment in the MarkeTrak VIII series,3 we demonstrated that the hearing loss population is now 34.25 million and hearing aid adoption rates are approximately one in four. We also showed that binaural rates are continuing to increase and the average age of hearing aids has dropped.
Unfortunately, new user demography remains the same with the product appealing primarily to the elderly segment, which means that the hearing aid industry has not substantially tapped into any new populations of users. With 18 years of hearing aid satisfaction trending behind us and in view of the introduction of new products such as open-fit mini-BTE hearing aids, it is useful to review any gains we have made in satisfying the users of hearing aids.
This article is the second installment of a multi-part publication that will cover significant issues and trends in the hearing aid market. The purpose is to explore customer satisfaction ratings of hearing aids with an emphasis on 18-year overall trends and to provide detailed ratings comparing 2004 and 2008 hearing aid populations (Note: We changed from a 5-point to a 7-point Likert customer satisfaction scale in 2004).
Because of the complexity and size of the MarkeTrak VIII database we will present the satisfaction findings in a number of papers. This paper will focus on the consumer's experience with hearing aids while the next installment will focus on the hearing healthcare provider's role in customer satisfaction. Future publications will explore how open-fit hearing aids compare with traditional style hearing aids, the sources of noise that bother consumers the most, why hearing aids are returned by non-users, and perceptions of benefit and quality-of-life changes due to hearing aids.
Detailed methodology for the MarkeTrak VIII survey is documented in the first publication in this series,3 so it will not be repeated here. In evaluating customer satisfaction with hearing aids, this paper will focus on hearing aids 4 years of age or less unless otherwise stated. In January 2009, we sent an extensive, seven-page, legal-size survey to the total universe of hearing aid owners identified (n=3789) during the screening phase. A total of 3174 surveys were returned, representing an 84% response rate.
The consumers were asked to rate their hearing aid experience on 44 items using a 7-point Likert scale: “Very dissatisfied,” “Dissatisfied,” “Somewhat dissatisfied,” “Neutral” (equally satisfied and dissatisfied), “Somewhat satisfied,” “Satisfied,” and “Very satisfied.” The attitude items covered overall satisfaction, product features, product performance, and satisfaction in 19 listening situations. In addition, consumers were asked if they would recommend hearing aids to their friends, how many hours a day they wear their hearing aids, and whether or not they would repurchase their current brand of hearing aid.
Hearing aid sample
In Table 1 we document the hearing loss characteristics of the hearing aid owner population (where hearing aids are </=4 years of age) responding to the customer satisfaction survey as well as information concerning their hearing aids. The average age of the hearing aid owners surveyed is 71, unchanged since 2004; six out of ten are male, though females with hearing loss have increased by 3% points; household incomes have increased by $6000 to $58,400; the percentage who are married is unchanged (64%); employment rates are virtually unchanged, with 66% being retirees; and the hearing loss population is slightly more educated, with 42% having either some college experience or a college degree.
Regarding the consumers' hearing loss, bilateral loss increased 4% points to 89%; reported subjective evaluations of hearing loss remain virtually unchanged, with a modal response of “moderate” hearing loss (54%); 47% report their best level of hearing is the ability to “hear a shout across a room” (Gallaudet scale) and 16% cannot hear shouts across a room; and 66% report hearing in the presence of background noise as “quite difficult” or “extremely difficult.”
With respect to product features, binaural fittings increased 3% points to 78%. The modal style is “BTE” (47%) and more than half (25% of all fittings) of these are open-fit or receiver-in-the-canal mini-BTEs. Despite the fact that close to 100% of hearing aids fitted during this period were programmable and digital, only 52% of this sample reported their hearing aids were digital and only 64% knew they were programmable. Awareness of directional microphones increased to 32% from 26%; telecoils increased to 34% from 26%; and the presence of an on-off switch decreased by 10% from 2004 to 43%. Only a small minority (8%) have a remote control, fewer than 1% indicate they have an FM feature on their hearing aids, and only 3% report musical connectivity such as Bluetooth on their hearing aids.
RESULTS AND DISCUSSION
Before we examine the detailed findings, it will be useful to consider the top 10 factors related to overall customer satisfaction with hearing aids in this sample. In rank order the factors that are most correlated with overall hearing aid satisfaction (correlation in parentheses) are:
- Overall benefit (.71)
- Clarity of sound (.70)
- Value (performance of the hearing aid relative to price) (.68)
- Natural sounding (.66)
- Reliability of the hearing aid (.65)
- Richness or fidelity of sound (.65)
- Use in noisy situations (.63)
- Ability to hear in small groups (.63)
- Comfort with loud sounds (.60)
- Sound of voice (occlusion) (.60)
These are the factors that tend to co-vary the most with overall satisfaction. The implication is that incremental improvements in these areas will drive improvements in overall satisfaction.
Overall satisfaction and hearing aids in the drawer
In Table 2, we have referenced the overall hearing aid satisfaction rating and hearing aids in the drawer over the past generation. Customer satisfaction with hearing aids for the total hearing aid owner population increased by 6% points to 74% over 2004. Hearing aids in the drawer dropped from 16.7% (1.23 million people) in 2004 to 12.4% (1.04 million people) in 2008. Satisfaction with new hearing aids (</=1 year old) increased 3% points to 80.6%, but new hearing aids in the drawer increased to 5.2%, the highest since we began measuring this. For hearing aids </=4 years old, customer satisfaction increased 5.5% points to 78.6% while hearing aids in the drawer decreased to 7.5% from 10% in-2004.
Focusing on hearing aids </=4 years of age, Figure 1 plots overall hearing aid satisfaction from 1991 to 2008. While it is difficult to compare satisfaction ratings in 2008 with those prior to 2004 due to a shift from a 5-point to a 7-point Likert scale, it is useful to compare the total consumers who are “satisfied” or “very satisfied” with their hearing aids.
In this author's opinion the intensity of satisfaction is important; the more passionate consumers are about their experience with hearing aids the more likely they are to wear them, recommend them to friends, and develop brand loyalty. Between 1991 and 2000 about 6 out of 10 consumers reported being “satisfied” or “very satisfied” with their hearing aids. Now, with nearly 100% digital penetration, 55% of respondents say they are “satisfied” or “very satisfied” and another 23% report being “somewhat satisfied.” Certainly the portion of satisfied consumers has increased due to the inclusion of the “somewhat satisfied” scale point, but these are primarily individuals who are on the outskirts of a “neutral” rating, hardly a strong endorsement for hearing aids.
Did the inclusion of a “somewhat dissatisfied” scale point cause overall dissatisfaction to increase due to siphoning downward from the “neutral” scale point? Figure 2 offers strong evidence that total dissatisfaction is improving; at-14% it is at its lowest point since we began measuring customer satisfaction. As for hearing aids in the drawer, that Figure has varied between 7% and 10% of newer hearing aids (</=4 years of age). So no discernible improvements are seen here.
Figure 3 shows the age distribution of hearing aids in the drawer for the periods 2000-2008. One would expect most of the hearing aids in the drawer to be at least 5 years of age and, in fact, 56% are older instruments. But the 44% of hearing aids in the drawer that are 5 years old or less should be in working order. The 28% of hearing aids in the drawer that are 2 years old or less is nearly unchanged from 2004, but a big improvement over the 38% in 2000. Still, newer hearing aids in the drawer continue to be a perplexing phenomenon given the cost of hearing aids.
Value (performance relative to cost) and benefit continue to be a large component of overall satisfaction with hearing aids. Referring to the top portion of Table 3 and to Figure 4, customer satisfaction with benefit is at 86% and 67% of consumers are either “satisfied” or “very satisfied” with the benefit they receive from their hearing aids. Consumer satisfaction with value is 66%; 50% are “satisfied” or “very satisfied” with value. Both benefit and value ratings are statistically unchanged from 2004. Later on we will show how multiple environmental listening utility (MELU) is related to perceptions of benefit, and a future paper will look at more detailed consumer perceptions of real-world benefit.
Behavioral indications of satisfaction
We think another clear indication of user satisfaction with hearing aids is whether or not they would recommend hearing aids to their friends and whether they would repurchase their current brand of hearing aid. As shown in Figure 4, currently 824, currently 82% of consumers would recommend hearing aids to their friends while 48% would repurchase their current brand of hearing aid.
As seen in Figure 5, the likelihood of recommending hearing aids between 1991-2008 is virtually unchanged at 8 in 10 consumers. Brand loyalty increased by 4% to 48%, which still indicates that when it is time for wearers to replace their current brand of hearing aids, they are very likely to shop for something better than what they have.
Figure 6 shows the average hours per day that owners wear their hearing aids. One would think that due to digital clarity and improvements in sound quality, and therefore a possible reduction in listening fatigue, current consumers would wear their hearing aids more. However, the survey found no changes in either the modal (most frequent) or median (50th percentile) hours worn, though there is perhaps evidence of a slight increase in average (mean) wearing time.
Consumer satisfaction with product features
The second section of Table 3 and Figure 7 include consumer ratings of 11 product features. New items in the MarkeTrak VIII survey are “ease of insertion or removal of the hearing aid” and “length of trial period.” Hearing aid reliability (80%) is the most important item in this category since it is in our “top ten list.”
Nearly 9 in 10 consumers are satisfied with ease of changing the battery (88%), fit and comfort of their hearing aids (87%), and ease of insertion or removal of their hearing aid (85%). More than three out of four are satisfied with the visibility of their hearing aids (78%), length of trial period (77%), and frequency of hearing aid cleaning (76%). Consumer satisfaction with battery life was 73%, but it garnered the highest negative ratings (18%). About two out of three consumers are satisfied with their hearing aid warranty (68%) and the maintenance expense associated with their hearing aid (66%).
The lowest rating in this category is ease of volume adjustment (60%), which is 6% lower than in 2004, a statistically significant difference (p<0.003). When consumers whose hearing aids don't have a volume control or remote to adjust volume were asked if they wanted one, their responses were Yes (44%), No (29%), and not sure (27%).
Consumer satisfaction with signal processing and-sound quality
The final section of Table 3 and Figure 8 show consumer ratings on 11 items related to hearing aid signal processing and sound quality. This is clearly the most important category to the consumer, since six of the top ten correlates of overall customer satisfaction are in this section. No factor in this category received a satisfaction rating above 80%.
Approximately three out of four consumers are satisfied with the clearness of tone and the sound of their hearing aids (77%) and the sound of their voice (73%). Seven out of ten are satisfied with directionality (71%), the naturalness of the sound (71%), whistling and feedback (69%), ability to hear soft sounds (69%), and sound fidelity (68%). Two out of three are satisfied with their comfort with loud sounds (67%) and the sound of chewing and swallowing (64%). About six in ten consumers are satisfied with use of their hearing aid in noisy situations (61%) and wind noise (58%).
Areas with the highest negative ratings in rank order are: Use in noisy situations (25%), wind noise (22%), comfort with loud sounds (19%), ability to hear soft sounds (19%), and feedback (18%). Factors with the lowest combined “satisfied” and “very satisfied” ratings are use in noisy situations (37%) and wind noise (37%).
There have been practical (at least 5% point increase) and statistically significant improvements in consumer ratings since 2004 in the following areas:
- Whistling and feedback (12% points, p<0.0001)
- Sound of chewing and swallowing (9% points, p<0.0001)
- Wind noise (7% points, p<0.0004)
- Use in noisy situations (7% points, p<0.0001)
- Comfort with loud sounds (5% points, p<0.001)
Consumer satisfaction in selected listening situations
In Table 4 and Figure 9 we show satisfaction ratings in 19 listening situations. For MarkeTrak VIII we added four new listening situations: while shopping, during recreation and exercise, at sports events, and while in bed. In addition to detailed satisfaction ratings we have also added consumer need to hear in those situations. The consumer need column labeled “Important” shows the percentage of consumers who assigned scores of 3 or 4 on a four-point scale ranging from “Very important” to “Not at all important” to each of the 19 listening situations listed. The consumer need column labeled “Critical” shows the percentage of consumers who assigned a 4 for “Very important” to a listening situation.
In terms of consumer need (critical rating column), the highest rated listening situations are one-on-one (75%), small groups (65%), and telephone (64%). The least important ones are in bed (13%), during recreation and exercise (22%), and at sports events (23%).
Ninety-one percent of consumers are satisfied with the ability of their hearing aids to improve communication in one-on-one situations. More than three in four are satisfied in small groups (85%), while watching television (80%), outdoors (78%), during leisure activities (78%), while shopping (77%), and while riding in a car (77%). About three out of four consumers are satisfied with their hearing aids in a place of worship (75%), restaurant (75%), and on the telephone (73%). Seven in ten report satisfaction at concerts and movies (72%), on a cell phone (69%), during recreation and exercise (68%), and in large groups (68%). The lowest ratings are achieved at sporting events (66%), in the workplace (65%), in school or a classroom (59%), and in bed (53%). However, the reader should be reminded that in terms of need (importance column) fewer than half of consumers rated hearing aid usage in bed and in a school or classroom as important or very important.
There have been practical (at least 5% point increase) and statistically significant improvements in consumer ratings since 2004 in only one listening situation: use on cell phone (8% points, p<0.0003).
INCREASING MELU IS CRITICAL
In a previous publication,4 we have demonstrated that increasing Multiple Environmental Listening Utility (MELU) with hearing aids is critical to consumer willingness to adopt and wear them. The goal of treating hearing loss with hearing aid technology is to optimally amplify users' residual auditory area and thereby help them reclaim listening situations that are personally important to them. So, in this final section, we are going to further demonstrate how the increased utility of hearing aids leads to happier consumers who are loyal to their brand and become advocates for hearing aids to their social network.
In calculating MELU for each consumer we divided the number of listening situations in which they were satisfied by the total number of listening situations, considering only those situations that were important to them. MELU scores ranged from 0% to 100% listening situations in which the consumer was satisfied; the consumer could, of course, have been neutral in all listening situations.
Figure 10 shows the distribution of MELU at three levels of satisfaction. The majority of consumers (55%) report that they are not “very satisfied” in any listening situation, while 11% report being very satisfied in 80% or more of the listening situations in their lives. When we include consumers who are satisfied or higher, 17% report they are not satisfied in any of the listening situations measured while 38% report satisfaction in 80% or more of the listening situations in their lives. Finally, when we include consumers who are “somewhat satisfied” or higher, only 6% of consumers report no satisfaction in any listening situation, while 59% report satisfaction in 80% or more listening situations. But, does intensity of satisfaction matter?
Figure 11 shows the average percent of listening situations by level of satisfaction with hearing aid benefit. Dissatisfied consumers derive benefit from amplification in only about 6% of listening situations, neutral consumers in 23% of situations, somewhat satisfied in 31% of situations, satisfied in 64% of situations, and very satisfied in 80% of situations. The point to be made here is that to reach a respectable level of satisfaction with benefit the consumer must experience a 60% or more environmental listening utility with hearing aids.
Finally, in Figure 12 we plot willingness to recommend hearing aids and hearing aid brand loyalty as a function of the utility of their hearing aids. Consumers reporting satisfaction (satisfied + very satisfied) in no listening situation would recommend hearing aids 42% of the time while 9 out of 10 consumers would recommend hearing aids when the utility of their hearing aids is 80% or higher. When consumers derive no utility from their hearing aids only 11% would repurchase their current brand. However, when they can hear in all listening situations of importance to them 66% would repurchase their brand of hearing aid.
A question that begs to be answered is why is there such great variability in the utility of hearing aids among consumers? Certainly we know that degree of hearing loss is related to hearing aid utility: The more severe the hearing loss the greater the difficulty of achieving utility in many listening situations.5 Hopefully, further research either in this series of MarkeTrak publications or by other researchers will shed light on factors associated with a successful hearing aid experience in the real world.
- For hearing aids 4 years of age or less, customer satisfaction (defined as “somewhat satisfied” or higher) increased 5.5% points to 78.6% while hearing aids in the drawer decreased to 7.5% from 10% in 2004. However, the number of “satisfied” or “very satisfied” customers has not improved.
- Over the last generation, consumer willingness to recommend hearing aids, brand loyalty, usage patterns, and user demography have remained virtually unchanged.
- Benefit, sound quality, and value remain the top correlates of overall satisfaction.
- With respect to product features on hearing aids satisfaction has remained the same except that satisfaction with ease of volume change has dropped as VCs continue to be removed from modern digital hearing aids. Among customers without a VC, 44% state they want one.
- Over 2004 ratings, consumers report improved signal processing in the following areas: whistling and feedback, sound of chewing and swallowing, wind noise, use in noisy situations, and comfort with loud sounds.
- Of all listening situations measured only satisfaction with cell phones has improved since 2004.
- The utility of hearing aids is highly related to perceptions of benefit, willingness to recommend hearing aids, and brand loyalty.
This study was made possible by a special grant from Knowles Electronics, LLC, Itasca, IL.