Cost and inaccessibility are often thought to be the primary factors why people with hearing loss are not getting over-the-counter hearing aids. But according to Brent Edwards, PhD, Director at the National Acoustic Laboratories in Australia, it may not be enough to only think about accessibility and affordability.
"[If] you Google affordable hearing aids or you go to Amazon and search for hearing aids, you'll find all kinds of hearing aids that are fairly affordable that can be delivered to you tomorrow," Edwards noted. There are many other factors that may explain why OTC or direct-to-consumer hearing aids are not fully adopted, he said.
Edwards proposed a different perspective during his featured presentation at AuDacity 2020, a conference organized by the Academy of Doctors of Audiology, together with the Independent Audiologists Australia (IAA) and Independent Audiologists New Zealand (IANZ). His presentation focused on using the COM-B model to identify reasons for the behavior of non-adopters of hearing aids.
COM-B model on hearing aid adoption
The COM-B model is a framework that helps health care professionals understand why people do what they do. It examines people's Capability, Opportunity, and Motivation, all of which shape their Behavior. Edwards used this tool to illustrate that OTC hearing aid adoption is not just a matter of cost and accessibility.
First, he zoomed in on a population segment that is relevant to the issue. Collectively labeled the HD-HL segment, this is composed of people who have audiometric hearing loss (as measured by an audiogram) and at the same time affirm that they experience hearing difficulty. Edwards said that about half of this segment do not own hearing aids, and this half was the focus of his COM-B analysis.
According to Edwards, the rejection of hearing aids involves "Capability" factors, such as a person's agility limitations and lack of skills to use OTC hearing aids. This tied with recent MarkeTrak data showing that half of the people with hearing loss were uncomfortable with tasks associated with OTC devices, like assessing their own hearing loss, selecting their device solution, fitting it, and maintaining it.
Meanwhile, "Opportunity" factors include social stigma, lack of support, high cost, and inaccessibility. Finally, "Motivation" factors may include stigma, the perception that one's hearing loss is not bad enough, and the perception that getting hearing aids is not worth the effort.
"So accessibility and affordability are just two of many, many factors that are necessary to get people in this segment to choose hearing aids," Edwards emphasized.
Improving hearing aid adoption requires changes that address these COM factors. For instance, to address Capability barriers, Edwards suggested that OTC devices should be popularized in a way that people can select and fit the device themselves, and manage it easily with an accompanying app.
Opportunity barriers can be overcome not only by making hearing aids accessible and affordable, but also by making them socially acceptable, with available support from others. And to steer people's Motivation, hearing aid stigma has to be minimized, potential users have to believe in self-treatment, and they have to be surrounded by a supportive environment.
Hearing aids for a focused population segment
Early in his presentation, Edwards explained that not all people who have auditory dysfunction may be considered for OTC hearing aid use, so some statistics on hearing aid adoption may have been overstated. He cited various industry reports stating that majority of people with hearing loss in the US are not getting the hearing aids that could help them.
"[I]f these are true, we're probably doing not the best job that we could be in treating the public with hearing loss. But I think we are," said Edwards. "And I think by the end of this talk, you'll kind of see how this can be reframed, more recently with respect to over-the-counter or direct-to-consumer hearing aids."
He segmented the hearing dysfunction market in two steps: First, the population was categorized based on whether or not they have a measurable hearing loss based on an audiogram. Then, those two groups were further classified into whether or not they say that they have difficulty hearing.
People in the HD-HL segment – those with measured hearing loss and who affirm that they experience hearing difficulty – are the ones "that really need to be considered as the viable market for hearing aids," said Edwards.
He further noted that within this segment, 50 percent already have a hearing aid, as opposed to other estimates that put that figure at only about 23 percent.
"So the number of people who need hearing aids but aren't getting them is actually a lot smaller than people think, which I think is going to be a little bit of a surprise for some of the new companies coming into the market waiting for OTC."
Edwards also addressed concerns that OTC hearing aids could replace audiologist-fitted devices, and that audiologists could eventually become obsolete.
"Pretty powerful questions. So what I want to convince you is that these are actually the wrong questions. These questions are actually based on a false premise, so in a sense, these are false questions."
For him, the right questions that audiologists should be asking are: "What are the unmet hearing needs of the different segments of the population?" and "Who has unmet needs that OTC hearing aids can address?"
The most viable market for OTC devices is only one fraction of Edwards's population model. The other population segments, even those that are already using hearing aids, will still need hearing care professionals.
Edwards cited surveys in the US, Sweden, and Australia which showed a strong correlation between patients' good experience with their hearing aids, and the amount of care they received from audiology practitioners.
"So, the greater care that they got from their audiologist, the better they believe that they're doing with their hearing aid," stressed Edwards. "This is a pretty strong case for the fact that the audiologists are a critical component for success with this population."