Hearables as a Gateway to Hearing Health Care

Eyes Open, Ears On: Supporting Hearing Technology Use in Children with Hearing Loss

Considerations on Health Literacy and Hearing Aid Use

Approximately 15 percent of U.S. adults report some degree of hearing loss. Untreated hearing loss is a huge issue for health.1,2 It may lead to isolation, and has been associated with serious conditions such as depression,3 anxiety, low self-esteem, dementia,4 reduced mobility, and falls.5 Hearing aids and other assistive devices can significantly improve the quality of life of many people, but only about one in four adults who could benefit from hearing aids has ever used these devices, citing roadblocks such as cost, stigma, perception that they are not effective, and limited access to hearing health care.1 As the lead federal agency supporting research and initiatives to prevent, detect, and treat hearing loss, the National Institute on Deafness and Other Communication Disorders (NIDCD), part of the National Institutes of Health, has made research on improving access to and affordability of hearing health care a priority over the past decade. In 2009, the NIDCD started a coordinated effort to tackle accessible and affordable hearing health care by forming a working group.6 The working group created a blueprint for research priorities to enhance the affordability and accessibility of hearing health care for adults with mild-to-moderate hearing loss. This launched a focused effort by the institute that has, to date, inspired a dozen funding opportunities leading to NIDCD's support of 40 research projects on the topic. In 2016, the National Academies of Sciences, Engineering, and Medicine (NASEM) published a consensus report, “Hearing Health Care for Adults: Priorities for Improving Access and Affordability.”1 The NIDCD co-sponsored this effort with other federal agencies and the Hearing Loss Association of America. The independent expert panel that conducted the study made recommendations for hearing health care reform, prioritizing the needs of adults with hearing loss. The panelists encouraged agencies, organizations, and professionals to improve access and affordability of services, develop innovative technologies, and better inform consumers about their choices for managing hearing loss. One of the panel's recommendations was for the U.S. Food and Drug Administration (FDA) to create and regulate a new category of over-the-counter (OTC) hearing devices, which could improve access to affordable hearing loss interventions for adults with mild-to-moderate hearing loss. In 2017, the president signed a law that directed the FDA to establish guidelines and quality standards for this new category of OTC hearing aids. A draft of these regulations is underway and expected to be released by August 2020.7 NIDCD-funded research informed the expert panel's recommendations, as well as the policy changes around improving adult hearing health care. For example, preliminary research showed that people with hearing loss are able to independently adjust the settings on their hearing devices in response to changing acoustic environments,8 and when given the ability to control their own hearing aid settings, they are generally more satisfied with the sound of the devices than with the audiologist's fit.9 In 2016, the first randomized, double-blind, placebo-controlled clinical trial comparing an OTC delivery model of hearing aids with traditional fitting by an audiologist found that hearing aid users in both groups reported similar benefits, supporting the viability of a direct-to-consumer service delivery model.10,11 The NIDCD also supports research that improves hearing aid technology for consumers. A small business research grant funded by the NIDCD led to the first self-fitted hearing aid approved by the FDA.12,13 As hearing researchers and clinicians, we are excited to witness the transformation of hearing health care for adults in the United States with mild-to-moderate hearing loss. We applaud the scientists who provided critical evidence leading to positive changes in public policy and in the marketplace. The NIDCD remains committed to improving the landscape of adult hearing health care, and we encourage continued research in this area to fill remaining gaps.

Programmatic Approach to Hearing Health in Low- and Middle-Income Countries

Significant Hearing Loss Found in Ukrainian Refugees

Using Patient Newsletters in an Audiology Practice

Lessons from LOCHI.

Survey of AuD students confirms need for counseling as part of audiologistʼs training

Universal Hearing Health Care: Brazil

Patient education materials (PEM) that highlight the risk factors, signs, symptoms, and treatment options for age-related hearing loss (ARHL) are critical given that the number of people with hearing loss is rapidly increasing due to population aging. When designing PEMs, it is important to consider the health literacy skills of the intended audience to ensure that the materials can be read, used, and understood by consumers. Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”1 If health care providers share educational materials that are not matched to the health literacy skills of their patients, these materials will be ineffective at encouraging individuals to seek hearing health care and will not support the development of self-efficacy and self-management skills. In the United States, the average adult reads at the eight- or ninth-grade level,2 and only an estimated 12 percent of adults can effectively read and understand health information.3 Readability and suitability are common measures used to assess the health literacy of written PEMs. Readability is an objective measure of how easy or difficult a text is to read, while suitability measures design appropriateness and evaluates the adequacy of material content and design, cultural and linguistic appropriateness, and ability to motivate individuals to take action.4iStock/SDI Productions, hearing loss, hearing aids, healthcare.Previous investigations into the readability and suitability of PEMs on hearing health have revealed that the majority of materials are not written at an appropriate level for the intended audience.5-8 These studies have focused on the readability and suitability of PEMs on general hearing health topics; however, the issue of health literacy is particularly relevant to older adults who demonstrate lower levels of health literacy compared with their younger counterparts. RESEARCH PREVIEW We recently explored the readability and suitability of PEMs on topics specifically related to ARHL.9 PEMs were sampled from electronic health record (EHR) systems based on the rationale that these resources are likely to be dispensed by trusted health care providers. While the inclusion of PEMs in EHR databases allows for quick dispensation of PEMs at point of care, practitioners may share these resources without carefully considering whether the health literacy demands are appropriate for their patients. PEMs were also obtained from communication sciences and disorders (CSD) organizations based on the rationale that these materials are likely to emerge in search results when people go online to learn more about hearing health care. The sample included 27 PEMs from select sources and focused exclusively on ARHL diagnosis, management, and treatment, hearing loss prevention, and communication strategies for affected individuals and their families. Readability was assessed using three formulas (i.e., Flesch-Kincaid Index10,11 and Simple Measure of Gobbledygook [SMOG,]12 and suitability was assessed using the Suitability Assessment of Materials [SAM]4). The SAM is used to score PEMs on 22 factors categorized into the following six domains: content, literacy demand, graphics, layout and typography, learning stimulation and motivation, and cultural appropriateness. SAM scores from the 22 factors were combined to generate an overall percentage score, which was then used to classify PEMs as not suitable, adequate, or superior based on the number of features that support usability. The SAM can help determine which area(s) of PEMs would benefit from modification to improve design appropriateness, comprehensibility, and usability. KEY ISSUES & SOLUTIONS Our study revealed that 66.7 percent of PEMs were written above target readability (i.e., above eighth-grade level), which was based on the average reading level of U.S. adults. The average readability of all PEMs in the study was grade level 9.73, indicating that an individual would need an education level higher than ninth grade to be able to read the material. An analysis of suitability using the SAM revealed that the average PEM was classified as adequate. In total, 85.2 percent (23/27) of PEMs were classified as adequate, and 14.8 percent (4/27) were classified as not suitable. No PEMs were identified as having superior suitability. The areas of strength among the selected PEMs included having an explicit statement of purpose, maintaining a scope that was limited to essential information, and using advanced organizers. In contrast, the areas of weakness included a lack of summary of key information, high reading grade level, failure to use reader-friendly vocabulary, and limited subdivision of complex topics. We found that the majority of PEMs failed to summarize key information, which is an important component that helps readers identify and review the most important information. The literacy demands of the majority of PEMs exceeded the reading abilities of the average U.S. adult, and most of them used field-specific jargon and vocabulary terms that would likely be unfamiliar to readers without prior knowledge of hearing health. The majority of PEMs on ARHL provided a great deal of complex information under a single heading, which is problematic because this may overwhelm readers and reduce their self-efficacy beliefs about their ability to obtain hearing health care and manage life with hearing loss. It would be beneficial to subdivide complex topics into smaller subcomponents to facilitate user motivation. Use a multidisciplinary team to design appropriate and effective patient education materials that emphasize motivation and encourage individuals to seek and obtain hearing health care. Professionals in the fields of education, gerontology, nursing, health psychology, and communication sciences and disorders could work collaboratively to design materials that address the complex health literacy needs of older adults because each profession has a unique perspective on the issues underlying the low use of hearing health care and strategies that can be used to motivate individuals to engage in healthy behaviors. Educational materials that are interactive, require users to make decisions and solve problems, model specific behaviors, and divide complex topics into smaller sub-topics enhance learning and motivation. Finally, there was a notable absence of graphics among PEMs. This is also related to user motivation because relevant graphics can attract attention, help model specific behaviors that are difficult to describe in writing, and support memory and comprehension of materials. Including relevant graphics within PEMs on ARHL may help enhance the usability and comprehensibility of these materials. Having effective educational materials on hearing loss is one of the key approaches to improving access to affordable hearing health care. However, our study found that publicly available and widely used PEMs on ARHL are not suitable for the intended audience. This is problematic considering the serious negative consequences associated with undiagnosed and unmanaged hearing loss, which include reduced physical, psychosocial, and cognitive outcomes. The lack of suitable educational resources on ARHL serves as a barrier to accessing hearing health care. Efforts should be made to modify existing PEMs on ARHL, with careful consideration of the characteristics of the target audience, because factors, such as age, can impact a person's ability to obtain, appraise, understand, and use health information. The findings of this study suggest that modifications should focus on reducing literacy demands, summarizing and highlighting key information, and subdividing topics into small, comprehensive units of information. Older adults, in particular, would benefit from typographic features such as increased font size and high contrast between font and paper as well as a writing style that uses the active voice and simple syntax. Existing PEMs on ARHL must be redesigned to account for the health literacy needs of older adults, who may have reduced visual and auditory acuity, as well as reduced working memory and processing speed.

The addition of over-the-counter hearing aid (HA) options has transformed the way individuals can access hearing health care (HHC). However, although critical to their adoption and use, consumer attitudes and opinions about direct-to-consumer (DTC) models of health care are often understudied. To assess how recent DTC market changes in HHC delivery may be associated with consumer choice and attitudes towards specific HHC models. A mixed-methods survey, distributed online between March 22 and 25, 2022, using Qualtrics Survey Panels. Participants were US residents older than 50 years with no previous hearing aid experience, enrolled using consecutive sampling. A minimum of 1000 completed responses was set; once the 70% threshold was met, any future respondent who identified as White would not be given the survey. Respondents were asked to report their level of comfort with using different variations of DTC-HHC and asked about their previous experience with other DTC health care models. Respondents then reported which model (in-person vs online) of HHC they would most likely pursue. Of 1377 respondents, 1037 were included in the survey study (mean [SD] age, 61.4 [7.84] years; 714 [69.0%] were female; 674 [65.0%] were White). Most respondents reported discomfort with pursuing hearing aids via DTC pathways, with 84% (874 of 1037) indicating they would pursue HHC via an in-person model. Individuals who were older (odds ratio [OR], 0.95; 95% CI, 0.92-0.98), reported an income greater than $150 000 (OR, 0.29; 95% CI, 0.08-0.91), and were not interested in HA (OR, 0.42; 95% CI, 0.23-0.79) were less likely to pursue HHC online. Those who had previous experience with DTC health care (OR, 1.97; 95% CI, 1.27-3.02), and did not have (OR, 2.61; 95% CI, 1.59-4.31) or were uncertain (OR, 2.05; 95% CI, 1.13-3.70) about their insurance coverage for HA were more likely to pursue HHC online. Current consumer attitudes and opinions found in this survey study suggest that DTC-HHC may not find immediate acceptance by most potential HA seekers in the US.

Background: Patients often need multiple fine-tuning appointments with their hearing health care provider to achieve satisfactory hearing aid outcomes. A smartphone app that enables patients to remotely request and receive new hearing aid settings could improve hearing health care access and efficiency.Introduction: We assessed the usability of ReSound Assist™, (ReSound America, Bloomington, MN) the remote communication feature of a hearing aid app, and investigated whether hearing aid outcomes are influenced by app-based versus in-person patient-provider communication.Materials and Methods: Thirty adults were fit bilaterally with hearing aids and randomized to intervention and control groups. During a 6-week field trial, participants reported hearing aid problems via ReSound Assist (intervention) or at a scheduled face-to-face follow-up appointment (control). Usability of ReSound Assist was assessed with a questionnaire and interview. Hearing aid performance, benefit, satisfaction, and daily usage were compared for both groups.Results: ReSound Assist was rated as highly usable. Participants identified specific aspects of effectiveness and efficiency that could be improved. Similar problems were reported by intervention and control participants regardless of communication mode (app-based vs. in-person). However, almost half the requests received via ReSound Assist were for problems that required advice from the provider or physical modifications to the hearing aids rather than fine-tuning, highlighting the continued importance of in-person hearing health care. There was no significant difference in hearing aid outcomes between intervention and control participants.Conclusions: Apps enabling remote patient-provider communication are a viable method for hearing aid users to seek and receive help with hearing aid problems that can be addressed through fine-tuning.

Hearing health care has been described as predominantly biomedical in its approach, with an emphasis on technological interventions for hearing loss and a clinician-led style of practice. Emerging evidence suggests that these characteristics – all of which are hallmarks of a health care system designed to address acute, rather than chronic, conditions – may contribute to low rates of hearing help-seeking and hearing rehabilitation uptake and use among older adults. The overall aim of this research was therefore to investigate the applicability of a chronic care model of service delivery to hearing health care, with a focus on the complementary roles of self-management (individuals managing their hearing loss) and self-management support (audiologists supporting individuals to manage their hearing loss).The research utilised a mixed methods approach within the theoretical frameworks of the Chronic Care Model and the World Health Organization’s International Classification of Functioning, Disability and Health. The first three studies focused on self-management from the perspective of older adults with hearing loss. A total of 91 adults between the ages of 51 and 85 were assessed with the Partners in Health scale and the Cue and Response interview, two validated tools for measuring chronic condition self-management from the Flinders Chronic Condition Management Program™. The first study aimed to determine whether the assessment tools could be successfully adapted for audiological use and whether they yielded clinical information that was not currently being gathered with existing tools in the standard audiological test battery. Seven pilot participants provided iterative feedback on the wording of the tools in the initial modification process. An analysis of data from 30 further participants, all of whom were current recipients of hearing health care, revealed that the modified tools provided novel clinical information and enabled the identification of clients who were self-managing well in one area but not in another (e.g. wearing hearing aids consistently, but not coping emotionally with the hearing loss).The capability of the Partners in Health scale and the Cue and Response interview to selectively identify areas of self-management strengths and weaknesses led to the second study. The chronic condition literature conceptualises self-management as a multidimensional construct; the second study aimed to determine to what extent this holds true in the context of hearing rehabilitation. Exploratory factor analysis conducted on the self-management data from 62 participants revealed three domains of hearing loss self-management: (1) Knowledge (knowing about hearing loss and one’s rehabilitation options); (2) Actions (adhering to treatment, participating in shared decision-making, accessing services and resources, attending appointments, and monitoring for and responding to changes in hearing and functional status); and (3) Psychosocial Behaviours (managing the effects of hearing loss on one’s social life and emotional wellbeing). Multiple linear regression analyses revealed that each self-management domain was predicted by a different set of personal factors, further strengthening the view of hearing loss self-management as a multidimensional construct.The third study was designed to determine the potential clinical utility of the Partners in Health scale and the Cue and Response interview by investigating the relationship between hearing loss self-management and hearing aid benefit and satisfaction in a sample of 37 participants, all of whom had worn bilateral hearing aids for 18 months or longer. Significant positive correlations were found between hearing loss self-management in the Psychosocial Behaviours and Actions domains and specific elements of hearing aid benefit and satisfaction, suggesting that assessment of a client’s hearing loss self-management could play an important role in clinical decision-making and management planning.The fourth and final study focused on self-management support from an audiologist’s perspective. Since the nature of the self-management support provided by the clinician has been identified in the chronic condition literature as a key influencer of a client’s self-management behaviours, the aim of this study was to probe audiologists’ perceptions of self-management among older adults with hearing loss. Data were collected from 11 clinical audiologists across two focus groups and analysed using thematic analysis. The focus group participants described both self-management and self-management support as ongoing, dynamic, multidimensional, and individualised processes in which management strategies are continuously monitored and modified to suit evolving client needs. Hearing loss self-management was also conceptualised as a staged process, with early management strategies serving as precursors or prerequisites to strategies that emerge or are introduced later in the rehabilitation journey. The latter theme is considered a novel contribution to the concept of self-management since it has not been reported previously in the chronic condition literature.This body of research has deepened our understanding of hearing loss self-management and self-management support and shown that both concepts are relevant to, and important for, the rehabilitation of older adults living with permanent hearing loss. Future research should focus on bridging the gap between research findings and clinical practice in order to improve hearing health care for older adults.

Hearing Aid User Perspectives: Reasons and Recommendations for Prescription and Over-The-Counter Device Uptake

Figure: Nepal, Hearing Health, Audiology. iStockphoto/rmnunesAmidst its famed snow-capped peaks and valleys, Nepal has been battling with hearing impairment as a significant public health issue. Hearing loss, for example, affects over eight percent of adolescents, while otitis media effusion has been reported in 24.5 percent of school-age children in Nepal (Int J Pediatr Otorhinolaryngol. 2011;75[12]:1589 http://bit.ly/2kzFpT4). At the forefront of this battle is the National Association of the Hard of Hearing and Deafened Nepal (SHRUTI), a non-profit organization created and managed by people with hearing disabilities to promote the welfare of the country's hard of hearing and deaf populations.Figure: Neeta Keshary BhattaraiSince its founding in 2012, SHRUTI has been advocating for the rights of people with hearing disabilities in Nepal, from their inclusion in national health care policies to their protection against discrimination. It has built its strength through fruitful partnerships with the Asia-Pacific Federation of the Hard of Hearing and Deafened (APFHD) and the International Federation of the Hard of Hearing (IFHoH), among many others. Guided by a vision of an inclusive society, SHRUTI has carefully designed its goals and programs to foster not only the immediate care of those with hearing problems, but ultimately, the long-term empowerment and integaration of hearing-impaired people into society. ACCESS TO HEARING HEALTH CAREFigure: Toni Marie BacalaDespite the backdrop of poverty in Nepal, SHRUTI is dedicated to overcoming the barriers to hearing health care access, starting with early identification and treatment of children with hearing problems. One of SHRUTI's established programs is the free ear camp, in collaboration with local hospitals and schools, to provide various communities with hearing tests and treatment options. The free ear camps have opened doors for other intervention opportunities, such as counseling for teachers and families of children with hearing impairment, to orient them to the distinct needs of students with hearing disabilities, and encourage supportive and functional environments at home and in school. Part of SHRUTI's long-term goals is to bring in psychological treatment and rehabilitative services for people suffering from the emotional and mental impact of hearing loss. A SUCCESS STORYFigure 1: SHRUTI conducted a seminar on the benefits of live captioning for people with hearing impairment.In 2014, SHRUTI organized an ear camp in two schools at the Kathmandu Valley, as well as an awareness program for teachers in 13 schools in the region. Called the “Early Intervention and Support for Hearing-Impaired Children in Nepal” project, the ear camp had a total of 478 primary school-level children who received ear examinations and hearing assessments. Of these children, 4.38 percent were found to have hearing loss. Most of the children were given medical interventions, but some had hearing conditions that required the use of hearing aids. One of the children assessed in the ear camp was a deaf-blind (low-vision) female student, Swastika, who was diagnosed with profound hearing loss. Her teachers shared that they've been having difficulties in trying to make her understand the lessons in class. She was 12 years old but was still in the first grade. She already had hearing aids, but those were an old model and not powerful enough to meet her needs. She was noticeably isolated from her peers, and exhibited psychosocial problems as well. Since the teachers were not successful in communicating with her, the school administration had planned to transfer her to a special education institution. After examining Swastika's hearing assessment results and her teachers’ input, SHRUTI made a careful observation: Swastika's main concern was her hearing loss. The group counseled Swastika's teachers and parents on the appropriate interventions, and provided her with new hearing aids. She also started getting speech therapy. It was not long before she began to show positive signs of adjustments in the classroom—she even began singing and seemed happier than ever! In 2016, SHRUTI had a follow-up meeting with Swastika's parents who noted her progress; she has been significantly more interactive. Her mother shared that Swastika has gained a lot of confidence, shows serious dedication to her studies, and even plans on pursuing a career in radio broadcasting. Before SHRUTI's intervention, Swastika rarely interacted with her brother, but their relationship has greatly improved in recent years. Unfortunately, her brother has been exhibiting signs of similar hearing problems, but Swastika has been showing great interest in her brother's treatment. This case shows the importance of early intervention and collaboration between hearing professionals, educators, and parents. While hearing tests are vital to identifying possible hearing problems in children, it is equally important to keep teachers and parents informed about hearing health care and intervention strategies for children with hearing disabilities. AWARENESS AGAINST DISCRIMINATION Promoting public awareness about hearing disabilities is one of SHRUTI's main goals. From art exhibits to local radio shows, SHRUTI has shared valuable information about the numerous challenges that hearing-impaired people face, including discrimination in the workplace. The organization maintains an active role in fostering inclusive education, and equal social and economic opportunities for hard of hearing and deaf people. In 2015, SHRUTI collaborated with U.K.-based Disability Development Partner (DDP) in a hearing disability awareness program for teachers in Kathmandu. At present, SHRUTI and DDP are working on a demonstration model for the inclusion of students with hearing disabilities in the district of Dhading in central Nepal. Self-efficacy is at the heart of SHRUTI's mission to help hearing-impaired and deaf people find suitable employment. Recognizing the importance of developing the physical, intellectual, and cultural capacities of this disabled population, SHRUTI organized the workshop, “Economic Empowerment of Persons with Disabilities and Post-Disaster in Nepal,” in June 2016. This community-based skills development training was supported by the local government and several international partners. While issues such as discrimination are not solved overnight, SHRUTI's job placement program, launched in 2014, has notably paved the way for engaging employers and local business owners to accommodate employees with hearing disabilities. NATION BUILDING To ensure the long-term impact of its health care and awareness campaigns, SHRUTI aims to ultimately integrate these in larger nation-building projects in Nepal. In an effort to bridge the policy gaps in hearing health care, SHRUTI was able to attain a seat in the National Federation of the Disabled Nepal to represent the hard of hearing population. The group was also involved in relief efforts following the devastating earthquake in April 2015, and distributed hearing aid batteries and relief goods to affected communities in Nuwakot, Sindhupalchowk, Dhading, Kathmandu, and Lalitpur. Today, SHRUTI continues to push for better access to support services such as captioning and other assistive devices. There's still much to do to achieve its goals at the national level, but inspired by success stories, such that of Swastika, SHRUTI is determined to make Nepal a better place for the hearing impaired.