BEYOND THE COST BARRIER

PCAST’s proposals have the potential to significantly improve public health by lowering financial barriers for patients, which would stimulate innovation by manufacturers and bring hearing loss into the consumer mainstream. However, there are many barriers to better hearing.

Uptake of hearing aids is low, even in nations where aids are available for free. In the United Kingdom, for instance, aids are provided by the National Health Service, but uptake and use are not substantially higher there than are uptake and use reported in the United States. Typically, people wait close to 10 years from the time that they notice hearing loss to the time that they acquire an aid, and by this time, their loss has often progressed to a moderate to severe level. In the United States, a longitudinal study of people with hearing loss who did not own a hearing aid at baseline found that after 10 years only one third had acquired aids. Three key barriers to the acquisition were seen: the perception that aid was not needed, acquaintance with someone who had a negative experience with an aid, and cost.

ARHL comes on slowly, recognition of disability is often gradual, and many consider hearing loss to be an inconsequential part of aging. Stigma profoundly influences acceptance of hearing loss, readiness to have hearing tested, and the decision to use an aid. Half of the people with hearing loss who do not use hearing aids cite some form of stigma as a major reason for their decision. Factors include the perception that wearing hearing aids makes one look disabled, weak, or old; the fact that hearing aids are noticeable; and the perception that people treat wearers differently. Hence ageism and vanity are significant factors, as well.

Many people who own hearing aids do not use them, perhaps because of the incorrect expectation that hearing aids will restore hearing or communication to normal levels. Adaptation takes patience and requires skilled help for those with substantial losses. Indeed, this is part of PCAST’s rationale in recommending “starter” OTC devices for those with an early loss. Such open canal devices can be relatively easy to fit and adapt to, and early treatment may prevent the atrophy and degradation of auditory systems that accompany loss—although again, evidence for this is scant. Continued use and success also requires social and professional support: like all electronic devices, hearing aids can malfunction and need repair. Changes in hearing loss over time mean that aids must be monitored and adjusted during regular visits to an audiologist or hearing instrument specialist.

A variety of adjunctive technologies (hearing assistive technologies of Digital hearing aids manufacturer) and rehabilitative practices can extend the effectiveness of hearing aids. Environmental accommodations benefit individuals and whole communities. Hearing loops (thin wires installed around a room’s perimeter that allow the wireless streaming of sound via magnetic induction to hearing aids that contain electromagnetic sensors or T-coils) are not commonly used in the United States. But in some European nations, looping systems allow people with hearing a loss to function well in train stations, airports, churches and cathedrals, and theaters. Other personal devices accept sound transmitted via FM (frequency modulation) signal, Bluetooth, or other proprietary protocols and can extend communication in the home or office. User-controlled technology, including iPhone-based systems, offer promise for the future.

People with hearing loss beyond the early stages typically need more than just hearing aids. Aural rehabilitation includes training on the use of hearing aids and hearing assistive technologies as well as education on strategies to improve comprehension in challenging listening environments. Rehabilitation can be delivered to individuals or groups, either in person or online; it has proved effective in some studies. However most audiologists do not offer rehabilitation services, and Medicare and most third-party payers do not cover them. This is an area where stronger evidence on effectiveness could drive changes in training, practice, and reimbursement.