Factors Influencing Individuals’ Decisions to Access Hearing Care Services

A survey on the motivations and obstacles in obtaining appropriate hearing care

It has been estimated that 10% of the population has some degree of hearing loss significant enough to impact communication,¹ although others have suggested that this may actually be an underestimate, with the true percentage being significantly higher.² Epidemiological studies indicate that the numbers are increasing due to the aging of the general population and that by 2030 the total number of individuals exhibiting some degree of hearing loss will likely increase by 33%, from an estimated 33.4 million in 2010 to 43.7 million in 2030.¹ The prevalence of hearing loss varies greatly by age, the greatest prevalence being among seniors, with approximately 33% of those over age 65 and approximately 50% of those older than age 75 having some degree of hearing loss.³

Hearing loss is frequently regarded as a normal part of aging without many serious consequences, and often a disability that most individuals can do little about. However, a number of recent studies have shown hearing loss to significantly impact on one’s quality of life.^4-7 Because hearing loss affects communication, it often leads to increased frustration, fatigue, and social withdrawal.⁸ Hearing loss can also place a strain on interpersonal and intimate relationships, not only affecting the hard-of-hearing individuals, but their significant others. In turn, the psychosocial/mental health consequences can lead to physiological consequences, such as depression and increased hypertension. Hearing loss has also been shown to impact significantly on earning power.⁹

A significant percentage of individuals are unaware that they have a hearing loss or how they are being impacted. Even when they become aware of the hearing loss, the average time taken to address the hearing loss (if addressed at all) is approximately 7 years. Of those individuals with a hearing loss severe enough to impact communication, only 20% choose to obtain some form of hearing amplification.¹⁰ Numerous factors appear to serve as barriers to hearing-related health care.^10,11 Many of these factors are internal to the individual (eg, hearing loss is not bad enough, other health concerns are present, personality traits, self-esteem, cost of hearing aids, etc), but some are externally related (eg, a lack of knowledge about hearing loss by doctors, psychologists, etc, serving these individuals).

There often is a lack of congruence between the degree of hearing loss and resulting perceived hearing handicap, as well as the benefits from audiological intervention. Consequently, even when individuals with hearing loss have sought treatment, a significant proportion have reported dissatisfaction with their hearing aids and a relatively large number (approximately 9%) return their hearing aids for refund.¹²

To better understand factors serving as barriers to, or facilitators for, successful treatment, the authors pursued two basic questions or initiatives:

• Initiative #1: Why do people who fail a hearing screening at a health fair or open house choose to (or choose not to) go on for a comprehensive hearing assessment when one is recommended?
• Initiative #2: Why do people who fail a comprehensive hearing assessment choose to (or choose not to) follow recommendations for improving their ability to hear?

Initiative #1. Hearing Screenings at Health Fairs and Open Houses

As mentioned earlier, the average time between an individual becoming aware of his or her hearing loss and addressing it is approximately 7 years. Therefore, there is an important need to reach these individuals and help break down barriers earlier in the process. One way to do so is through consumer education, such as through presentations and hearing screenings.

However, little is known regarding the degree to which these events are successful. The authors are unaware of any research concerning the percentage of individuals identified with a hearing loss via a hearing screening who then proceed to undergo a comprehensive hearing evaluation.

Another important goal for the hearing care field is to understand the underlying factors influencing possible procrastination. Although a number of excellent studies have examined factors impacting consumers’ decision-making process, these have generally been done through surveys without knowledge of the respondents’ degree of hearing loss and corresponding perceived handicap. Thus, the goals of Initiative #1 were to:

1. Examine the percentage of individuals identified with a hearing loss via a hearing screening who, in turn, proceed with a comprehensive hearing assessment and
2. Better understand the factors influencing an individual’s decision to take action.

Over the course of 3 years, Rochester Hearing and Speech Center (RHSC), a large speech and hearing clinic in Rochester, NY, conducted 54 presentations/hearing screenings at various health fairs, open houses, and senior living centers. Prior to each hearing screening, hearing checks were conducted by the screener to ensure that the listening environment did not result in spurious findings that would indicate a hearing loss due to the presence of background noise; for the results reported, there were no instances where this was the case. A total of 2,049 individuals were screened in both ears at frequencies of 500, 1000, 2000, 3000, and 4,000 Hz. If an individual failed the hearing screening at any of these frequencies (ie, did not respond at the 25 dBHL screening level), then air conduction thresholds were obtained for these frequencies.

Findings. A hearing loss was considered to be present if the individual exhibited a threshold of at least 30 dBHL at any of the screened frequencies. Of these individuals, 1,337 (65.3%) failed the hearing screening (ie, at least at one frequency in one ear).

Screening participants had to fail at least two frequencies in one or both ears to be considered for a possible subsequent referral. Utilizing not only the results of the hearing screening, but also responses to RHSC’s customized hearing handicap screening questionnaire , RHSC clinicians recommended a follow-up comprehensive hearing assessment for 886 of these individuals (ie, 43.2% of the individuals who were screened received a recommendation for a hearing test).

To ascertain the percentage who proceeded with a hearing assessment, the authors initially examined the data for those who scheduled an appointment at RHSC. Recognizing that a number of individuals would schedule elsewhere, our staff attempted to contact all those who failed a hearing screening and did not schedule an appointment at RHSC to determine if these individuals indeed had scheduled an appointment elsewhere. Because of the difficulty in contacting all those who did not schedule an appointment at RHSC, the data for the latter group (based on written responses and phone calls) was extrapolated and combined with RHSC data to derive the total percentage.

Of the 886 individuals who were recommended a hearing assessment, 278 (31.4%) scheduled an appointment at RHSC. Of the 343 individuals who did not schedule an appointment at RHSC but did reply by either mail or phone, 51 (14.8%) of these individuals scheduled elsewhere. Extrapolating the percentage from this latter population sample and generalizing it to a population of 608 individuals (ie, the total population who did not schedule an appointment at RHSC) resulted in a total of 91 individuals who scheduled elsewhere. The combination of those who scheduled at RHSC and the extrapolated number of individuals scheduling elsewhere results in a total population of 369 individuals, or an overall percentage of 41.6% of individuals who proceeded to schedule an appointment following a failed hearing screening.

Location of the screenings. The next question examines the percentage of individuals who proceeded to take action as a function of the location of the presentation/hearing screening.

For dedicated hearing-related events on RHSC premises:

• 708 individuals were screened, of which 421 (59.5%) were recommended a hearing assessment.
• Of these 421 individuals, 237 scheduled a hearing assessment (209 scheduled an appointment at RHSC and 28 scheduled elsewhere, using the extrapolated percentages from the survey sample). That is, 56.3% scheduled a hearing assessment.

For events held off-site (either a dedicated event but requiring no travel, such as at a senior living center, or hearing screenings as part of a generalized health fair):

• 1,341 individuals were screened of which 465 (34.7%) were recommended a hearing assessment.
• Of these 465 individuals, 131 scheduled a hearing assessment (69 scheduled at RHSC and an extrapolated number of 62 scheduled elsewhere). That is, 28.2% scheduled a hearing assessment.

The data clearly reveal that a greater percentage of individuals who attended an event at RHSC required further comprehensive testing (59.5%) than those who attended an event off-site (34.7%). In addition, the percentage of individuals who actually proceeded to schedule an appointment was significantly greater for RHSC events (56.3%) versus off-site events (28.2%). Finally, for entities whose goal of conducting a hearing screening is to have individuals ultimately schedule an appointment at their location, the findings revealed:

• For dedicated events scheduled at RHSC premises, 88.1% of the individuals scheduled their appointment at RHSC (11.9% elsewhere), and
• For events held off-site, 52.6% of the individuals scheduled their appointment at RHSC (47.9% elsewhere).

Reasons for ignoring/heeding a recommendation for full evaluation. For those individuals who failed a hearing screening and received a recommendation for further hearing testing, the authors sought to examine the factors influencing an individual’s decision to choose/choose not to take further action. In analyzing the results, it was determined that:

• The mean threshold average (collapsed over the screened frequencies of 500, 1000, 2000, 3000, and 4000 Hz for the better ear) for the individuals who proceeded to a hearing assessment (Go Group) was 41.2 dBHL, while the mean threshold average for the No-Go Group was 37.2 dBHL. An analysis of variance of the difference in threshold means revealed that the threshold average for the Go Group was significantly poorer (F = 13.31; p < .01)
• A t-test of the difference in the means between the composite RHSC Screening Questionnaire handicap score for the Go Group/No-Go Group revealed the Go Group to have a significantly poorer composite handicap score (t = 4.75; p < .01). That is, on average, the perceived handicapping effects of the hearing loss was greater in those who proceeded to take action.

The threshold averages and composite scores were then each correlated with the dependent variable of going on for a hearing assessment/not going on for a hearing assessment. The results showed that:

• Threshold average was not significantly correlated to subsequent action/inaction (r = -.037; p > .05);
• Composite handicap score was not significantly correlated with taking action/inaction (r = -.083; p > .05).

Although thresholds and composite handicap scores were significantly poorer in the group who proceeded to get a hearing test, they were not significantly correlated with subsequent action/inaction. Therefore, it appears that other variables besides hearing thresholds and perceived handicap influenced individuals’ decisions to schedule an appointment for a hearing test.

For those individuals who chose not to take further action, we examined the underlying factors that influenced their decision. A total of 343 of these individuals were able to be reached by mail or phone. They were asked to indicate all of the factors that determined their lack of course of action. Listed below are the most common reasons why individuals chose not to proceed to schedule a hearing assessment. Note that the numerator indicates the number of yes responses, while the denominator indicates the number of total responses to that question:

1. I think my hearing is good enough (144/301 responses = 47.8%);
2. I have other health or family issues that are of a higher priority (73/264 = 27.7%);
3. I’m still undecided (59/264 = 22.3%);
4. I’m not convinced that a hearing aid would help me (48/264 = 18.2%);
5. I still intend to schedule the follow-up evaluation appointment (47/264 = 17.8%);
6. It’s too expensive (45/309 = 14.6%);
7. I’ve been too busy (36/265 = 13.6%).

It’s clear that the number-one reason why individuals who failed the hearing screening did not proceed with a hearing assessment is that they felt their hearing was still “good enough” (48.7% of respondents). Without knowing their lifestyles, it may be that these individuals could still function adequately in their listening environments.

On the other hand, it is possible that even with the knowledge gained from the hearing screening, they remained in denial and did not feel their hearing was bad enough to take action. It is also clear that, for more than 25% of these individuals, hearing loss was not a major life issue or valued as greatly as other issues confronting them in everyday life. A significant percentage also indicated they were not sure if hearing aids would be of benefit to them or that the cost/benefit ratio was sufficient to proceed with the next step; these findings are similar to those listed by Kochkin¹ in MarkeTrak VII.

Finally, a significant proportion of individuals indicated they still intended to schedule an appointment or were undecided. It is this group for whom dispensing professionals need to develop strategies to help them “get over the hump” and realize that it is in their best self-interests to address their hearing loss.

Discussion of Initiative #1

So, why don’t people who are screened and recommended for evaluation follow through? The results indicate that hearing screenings are a somewhat effective tool in educating consumers to the need for further hearing-related services. Approximately 42% of individuals who failed a hearing screening and received a recommendation for a comprehensive hearing assessment subsequently scheduled a hearing evaluation at either RHSC or elsewhere.

However, the site at which the hearing screening took place appears to be an important variable as to whether individuals as a whole subsequently scheduled a hearing assessment. Individuals who attended an event specifically dedicated to hearing-related issues (versus a general health fair) and required effort to attend the event (such as traveling to the event location) were more likely to fail the hearing screening; in addition, among those who failed the hearing screening, those who attended the hearing screenings at RHSC were more likely to schedule a hearing assessment.

It is likely that individuals who attend a general health fair are there to explore many health-related issues, of which hearing may be only one. The availability of a free hearing screening is likely to attract a number of individuals who may not have any real concern about a hearing loss. Because they are already there, it may provide an impetus to “just check” on their hearing (the latter also appears to apply to hearing screenings conducted at senior living facilities where no effort/travel is required to attend the hearing screening). This may help to explain the lower prevalence of hearing screening failures at these events.

Some clinicians may view the screening of these individuals as nonproductive; however, participation at a health fair can still be viewed as a good marketing opportunity:

1. If, and when, these individuals develop hearing difficulties at some future point, they are likely to recall you as a provider of hearing services, and
2. They may encourage family members and friends who they suspect of having loss to contact you, thus adding another word-of-mouth referral base.

The results also indicate that, when participating in a general health fair (or an off-site hearing screening), individuals are not as likely to schedule their subsequent hearing evaluation with the screening provider as they might be when the event is provided on-site. This suggests that marketing efforts would need to be intensified at this type of events to increase the percentage of individuals actually scheduling their subsequent appointment with that particular provider.

It was also determined that hearing threshold levels and composite handicap scores were not significantly correlated to an individual’s subsequent course of action. The variable that might best account for these findings is an individual’s awareness and readiness to address their hearing-related issues. For example, for those who failed the hearing screening, the number-one reason why an individual chose not to proceed with a hearing assessment was that they felt their hearing was still good enough; in addition, for many of these individuals, hearing loss was not a priority for them. Because the measures utilized were not predictive of an individual’s subsequent course of action, it appears that an instrument that addresses an individual’s need/readiness to address their problems would be useful.

In summary, the findings suggest that the most cost-effective approach in reaching out to the public is to hold dedicated screenings/presentations on the provider’s premises, rather than to do so as part of a generalized health fair or on-site at senior living facilities. Holding such an event on premises will likely not only attract the greatest percentage of individuals seeking hearing-related help but will allow them to see first-hand what is available to help individuals with hearing loss.

Initiative #2: Reasons for Patient Inaction Once Hearing Loss Is Identified by a Full Examination

The second initiative focused on examining why consumers with a confirmed hearing loss following a comprehensive hearing assessment choose to, or choose not to, go on and purchase hearing amplification. Factors assessed included: 1) degree of hearing loss; 2) level of perceived handicap; 3) demographic factors; and 4) internally derived factors (eg, health issues and perceptions of hearing loss and hearing aids).

In order to assess these factors, a survey form was mailed to all individuals who had failed a hearing assessment at RHSC encompassing a 2-year period. These individuals had no prior history of owning hearing aids and had been determined to have at least a mild hearing loss in the high frequency range (average of 2, 4, and 8 kHz). Approximately 1,400 forms were mailed out, of which 566 returned the survey form. Of these 566 individuals, 483 individuals had also completed RHSC’s customized handicap pre-questionnaire.

Findings. The first variables examine the impact that hearing loss and perceived handicap had in influencing an individual’s decision-making. Results are discussed as they pertain to the group who received hearing aids versus those who did not. Hearing loss for the low (250 Hz, 500 Hz, and 1 kHz) and high frequency (2, 4, and 8 kHz) puretone averages (PTA) for the better ear, as well as mean composite handicap scores, were obtained for each subject. The analyses revealed:

• As expected, the high frequency PTA for both groups were significantly poorer than the low frequency PTA (aided group: t = 2.51, p < .001; non-aided group: t = 2.37, p < .001);
• Low frequency and high frequency PTA were significantly poorer in those who proceeded to obtain hearing aids versus those who chose not to get hearing aids (low frequency PTA: t = 2.91, p < .01; high frequency PTA: t = 2.98, p < .01);
• The correlation of threshold PTA and purchase of hearing aids revealed:

   

  a) Low frequency PTA (r = -.324; p < .01),

   

  b) High frequency PTA (r = -.204; p < .01), and

   

  c) Low + high frequency PTA (r = -.315; p < .01);

• A significant correlation between composite handicap score and purchase of hearing aids (r = -.51; p < .001);
• The composite handicap score was significantly poorer in the group that proceeded to get hearing aids (t = 3.774; p < .001).

These results reveal that PTA and composite handicap scores were both significant predictors in the subsequent purchase of hearing aids. Even more importantly, the findings show composite handicap was a much better predictor in discriminating those who proceeded to a hearing aid.

Adopters. In addition to the degree of hearing loss and composite handicap scores, the authors also examined the personal, social-emotional, and environmental factors that impacted on decision-making. For those who proceeded to get hearing aids (273 respondents), the most common responses (ie, >70% of respondents indicated one of the following factors) were:

• I want to have an easier time understanding what people say to me (94.1%);
• I want to be able to participate more fully in social activities (82.8%);
• I felt the hearing aids would enhance my feeling of well-being and enjoyment of life (79.9%);
• I found it so hard to listen to conversations that I wanted to see if hearing aids could make it easier (78.8%);
• I was having a lot of trouble hearing (72.5% );
• I felt the benefits of hearing aids would far outweigh the costs (72.2%).

Less frequently reported reasons were:

• You are the experts and you told me I needed them (58.9%);
• My hearing loss was making me nervous because I was missing too much (53.5%);
• My hearing loss was causing a lot of stress with family members and friends (49.5%);
• I did it to satisfy my family (34.8%).

In general, the most common reasons listed by these respondents related to how the listening difficulties impacted on their ability to participate socially; in addition, they felt the derived benefits would far outweigh the costs of hearing aids. Although other factors such as family-related issues or professional recommendation may have been a factor influencing their decision, these factors were not reported by as many respondents.

Non-adopters. For the group who chose not to proceed with hearing aids (297 respondents), the most important factors are listed below (ie, >25% of respondents indicated one of the following factors):

• I get along okay with my hearing the way it is now (58%);
• I am not convinced the benefits of hearing aids are worth the expense (34.3%);
• I am still undecided (31.3%);
• I am not convinced a hearing aid would help me (30.3%);
• I still intend to proceed with getting a hearing aid (29%);
• I would have liked to get them but could not afford it (26%);
• I have health, family, and other issues that are a higher priority (26.3%).

The following were not as common as the factors listed above:

• Wearing them is too much fuss and bother (14.1%);
• The idea of getting hearing aids and getting used to them is too overwhelming (13.8%);
• I have been too busy (7.4%);
• Transportation to your center is a problem (2.7%).

In most cases, the responses for this group were similar to those reported by those who failed the hearing screening and chose not to proceed with a hearing evaluation. By far, the number-one reason why individuals chose not to get a hearing aid was that they felt their hearing was good enough and they could get by without them at the present time.

A significant percentage were not convinced that hearing aids were worth the expense, which may be because they felt they were doing okay and thus the costs would not bring them much additional benefits. On the other hand, many of them may have felt that, based on reports by family members, friends, etc, hearing aids would not provide sufficient benefits relative to their cost.

The cost factor is an important issue: 26% of the respondents indicated they would have liked to purchase hearing aids but felt they could not afford it.

One hopeful note for the No-Go group (if we assume they responded honestly) is that many of them indicated they were still undecided or still intended to proceed. This is the group for which hearing care professionals need to devise strategies. The goal would be to inspire increased hope and confidence in these consumers, such that they would feel it is in their best self-interests to go forward.

Discussion of Initiative #2

So, why do some people who fail the comprehensive hearing assessment choose not to follow a recommendation for amplification? Unlike the findings relative to subsequent action following a failed hearing screening, for those who revealed a hearing loss, hearing threshold levels and composite handicap scores were significantly correlated with subsequent action (in this case, the purchase of hearing aids). For those who revealed a hearing loss at the hearing assessment, the worse the hearing threshold levels and/or the poorer the composite pre-handicap score, the more likely the individual was to subsequently purchase a hearing aid.

Low frequency PTA was a better predictor than high frequency PTA. This is likely due to the fact that the high frequencies tend to deteriorate first, and thus are generally poorer than the low frequencies. For example, an individual may have a high frequency loss but still have normal low frequency hearing and choose not to go on for a hearing aid. However, the presence of a low frequency hearing loss tends to be in addition to an already existing high frequency loss, and as a result would add significantly to the perceived handicap.

Perhaps the most important finding was that the composite handicap score revealed a correlation that was almost twice as great as that revealed by the correlation between degree of hearing loss and subsequent purchase of hearing aids. That is, the perceived handicapping effects of the hearing loss was a greater predictor of hearing aid purchase than the actual degree of hearing loss.

The relevance of this finding is that most hearing care providers do not use handicap questionnaires as part of their practice, but rather rely on the audiogram to predict the need for hearing aids.¹³ Therefore, it would behoove practitioners to incorporate a handicap questionnaire into their practice.¹⁴

For those who proceeded to obtain hearing aids, the most common reasons revolved around how the listening difficulties were impacting their ability to participate socially. Additionally, these respondents felt that the benefits would far outweigh the costs of hearing aids.

On the other hand, the number-one reason why individuals chose not to get a hearing aid was that they felt their hearing was good enough and they could get by without them at the present time. In examining their hearing thresholds, on average, their PTAs were not as poor as those in individuals who proceeded to get hearing aids; thus, their hearing loss may not have been impacting them as much.

A significant number of individuals who chose not to purchase hearing aids were also not convinced that hearing aids were worth the expense. Many of these people may not have recognized the deleterious effects that hearing loss was having on their quality of life. In addition, many of them may have had preconceived ideas regarding the benefits (or pitfalls) of hearing aids due to “horror stories” from family members or friends fit with hearing aids in the past. If these assumptions are correct, then a major focus with these individuals should be specifically geared to how amplification would enhance their quality of life and is worth the expense. Even if these efforts did not result in immediate action, it would serve to move these individuals along the readiness scale for ultimate purchase.

Expense was a major issue for many; they would purchase hearing aids if they were more affordable. When this issue arises, efforts should be placed on the value that hearing aids would likely provide in enhancing their quality of life and the significant benefits they will glean from their usage (ie, attempting to enhance the perceived cost-benefits ratio in the client’s mind). Offering a reasonable finance payment plan is an effective tool, as well.

Future Research Needs

As is common in most areas of research, new questions arise. The findings suggest a number of prospective approaches that could shed further light on breaking down psycho-emotional barriers for those in need of hearing care:

1. Examining the relationship between the degree of hearing loss and lifestyle (including whether the individual is still active in the workplace, socially active, etc) and the likelihood that an individual perceives the need for amplification. This would subsume examining the responses for those individuals who receive a recommendation for hearing aids but do not do so because “they feel their hearing is good enough.”

1. Development of a simple instrument that could be used within the time constraints of most clinical practices to assess the key internal/external factors impacting the client’s life. This would include examining the individual’s readiness to address hearing-related problems. The responses would be used to guide recommendation and management strategies.

Acknowledgements

This work was supported by a grant to the Rochester Hearing and Speech Center from the Atlantic Philanthropic Organization. The authors also would like to acknowledge Robert D. Frisina, PhD, director of the International Center for Hearing and Speech Research, as well as John Scherer, for their contributions on this research project.¹⁵

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Correspondence can be addressed to HR or Larry Medwetsky, PhD, ator Marcia Scherer, PhD, at.