Bridging the Gap in Hearing Care Accessibility: Technology, Perception, and Adoption

global hearing care accessibility
November 28, 2023

Despite increased availability of hearing devices, their adoption remains disappointingly low globally. This week, joined by Dr. Sophie Brice and Dr. Brent Edwards, Andrew Bellavia leads a discussion on global accessibility in hearing care, shedding light on the reasons behind the gap, focusing not only on those diagnosed with hearing loss but also individuals encountering situational struggles.

Tailored approaches catering to diverse needs and perceptions are crucial for boosting adoption rates. The discussion emphasizes leveraging tele-audiology, AI-driven recommendations, and innovative support strategies to bridge this gap effectively.

Dr. Edwards, Director of the National Acoustic Laboratories, sheds light on the complexities of user satisfaction, highlighting the substantial time audiologists invest in counseling. Professional shortages pose a barrier, prompting a reevaluation of access policies. Dr. Brice, digital health scientist and teleaudiologist, underscores the significance of offering supportive options instead of disregarding reports of hearing difficulties outright. Valuable insights emerge from understanding why some decline hearing devices.

Their advocacy focuses on disseminating adaptable, high-quality care through varied channels. While the road to widespread accessibility might be long, the positive impact on millions with hearing needs justifies the efforts undertaken. Join us as we unravel the potential of accessible hearing care and its transformative impact on individuals worldwide.

Full Episode Transcript

Hello, everyone, and welcome to This Week in Hearing. Lately, there have been a lot of articles and discussions assessing OTC hearing aid’s impact in the first year of the FDA rule taking effect. I myself plead guilty with both an editorial and Audio Express and the This Week in Hearing podcast with ASHA’s Janice Trent. Many of those suggested that rates of OTC adoption are lower than anticipated. What’s perhaps more interesting are the conversations attempting to discern the reasons why, focusing not only on the devices themselves, but also on the selling channels and service delivery. These can equally be applied to prescription hearing aids as well as OTC, since it is clear that the way most hearing aids are prescribed is only reaching a small fraction of those in need, especially in global contexts. My two guests, Sophie Brice and Brent Edwards, have spent a good deal of time considering how applying innovations in the three domains of device, channel and service can lead to a more inclusive model of hearing care. I welcome them today to share what they’ve learned and how that might be applied to deliver effective care to more people around the world. Let’s begin with introductions. Sophie, anyone who’s worked in tele-audiology prior to the pandemic has an interesting story to tell. Please tell everyone a little bit about yourself and your background. Thanks, Andy. So, yeah, thanks for having me. And as you say, I have been delivering tele audiology, or TA, as I like to say, just a bit more easily, for almost ten years now, coming up to the 10th year soon. So, yes, for all of that chunk before the pandemic and before it became everyone’s hot topic, things were very different and there was lots of learning on the go and very much consumer facing in my particular role. But it was certainly a fantastic place to learn the things that there was no rhyme or rule to learn how to make things work. And what were the observations that really actually do come to make a difference? So now that ta has become a lot more important, it’s become a much bigger focus of what I try to work on as a researcher and as a service delivery person, and hence where we are today. Well, you’re certainly in the right place at the right time. And if there’s anything positive that comes out of the pandemic, that work that you did earlier now has global application. If you even think about places where there aren’t even audiologists in a particular region, all of that work which was then amplified by the pandemic should have lasting impact. So that’s wonderful. And Brent, you’ve had a varied career on the way to your present position at the National Acoustic Labs. Please share a bit about your background and what you were responsible for at NAL today. Yeah, sure. So I’ve been in the hearing aid industry my whole career before joining NAL, head of Technology and Innovation at GN Resound and at Starkey, then also Head of Technology and Innovation at two Silicon Valley hearing device startups, Sound ID. and Earlens so I should also say that before I came to Australia, I was quite involved in the OTC discussions in the US. I spoke at the FDA workshop that was sort of assessing the need, and also an FTC workshop as well. So I have quite a few opinions on what I was anticipating in OTC that I expressed there. And it’s interesting to finally see it play out. Yeah, such an experience base you’ve ultimately brought to the National Acoustics Lab. So terrific. So I appreciate you both being on today. And Sophie, I want to ask you, you were the lead author on a recent paper with Brent and also Elaine Saunders, which was a scoping review for Global Hearing Care Framework. What were your goals in undertaking that research that led to the paper? Well, one thought people might have, when they look at my name, Elaine’s name and Brent’s name, is that’s three very different people, very different insights, know what are they doing in the same conversation? And that was exactly where we began. Because from all three of our positions, our careers and our insights, we’re three people who are very aware of tele- audiology and technology and innovations that were already here and happening and that they are very relevant and they’re only going to go forward and there’s so much to learn and take in and potential. And yet the current conversations at the time bear in mind we began this conversation in 2019, so really just before things really started picking up, is that there’s so much more to learn if we can include all the relevant parts into the conversation, because the whole industry has a lot to learn from each other. And so that was where we began in our conversation. In my specific role in delivering TA, one thing I would see was I would find it difficult to find good or enough information and literature to guide how things should be done, because that’s also the challenge of doing something new. You’re breaking new ground. So there aren’t very many rules written by everybody else. If you’re kind of first in that space, by now things will be a bit different. But there’s so much that’s been growing and changing in the various factors. We talk about how services are delivered, the products that are now changing, and how people can acquire devices. So. That was exactly what we wanted to look into what is there in the literature and information and guidance at this point, now that it’s starting to become very imperative. And so we investigated and that led us to creating this framework that allows everybody and everything to be included, to have a much more productive conversation and hopefully learn a lot more together going forward. I’m just going to say, for me, the need for this work. And I think what got me excited about joining Sophie and Elaine was I speak to a lot of audiology groups about the future of our field, and I would get questions that, to me, weren’t making sense, where people were confounding audiological services from the technology, from how it gets delivered. Questions like, are hearables going to eliminate the audiologist? Or is TA going to mean all the hearing clinics are going to disappear? And people were confusing these different dimensions of innovation in our field. So for me, that was the need for us to create this framework, I think, to help with the conversation. Well, in fact, I thought the paper did a really nice job breaking apart those things and showing how in different settings, different combinations could be most effective. And it was interesting because the paper stated that market surveys in the last few years do not show a significant increase in population uptake of hearing devices, despite greater accessibility. Now, that was based on sources of a few years ago, as you mentioned. Sophie and I’ll ask both of you in turn, have you seen anything more recently that would lead to a different conclusion in the scholarly literature? The first thing that I suppose comes to my mind is in your recent talk, actually, with the ASHA survey, with the 2% and the numbers are still it’s not the huge tidal wave. The people may have been nervous. About, which in itself, I think is extremely interesting because to me, it leads very much to the point that you can create all the tools, but you need to use things which then questions, what are we missing? There’s still more things to learn. There’s still more things to add to the equation. We’re widening our understanding of who is to be served with hearing devices much more than years gone by. We’re recognizing earlier in the hearing loss journey people will benefit from wearing devices. But one thing that goes with that is that for the person we’re trying to reach out, things aren’t the same as we assume. For that person, there’s insights and behaviors and consumer behavior to be able to learn from and understand the. Option rates are still a lot lower than we’d all like, what are we missing? What don’t we yet know? And these kind of tools, how can we get closer to that? Yeah, and what I’ll say is 2%, I think that’s smaller than a lot of people are anticipating, but it’s still tens of thousands of people in the US. And sort of my common theme since before the OTC legislation was this idea that access and affordability is keeping people from getting hearing health care is a false premise. Anyone in the US can get hearing aids delivered to their door the next day from Amazon. Accessibility is there, affordability is there. There are other reasons people don’t get hearing aids. Stigma. They don’t believe they work, their need isn’t big enough, they just don’t want them. And I’ve been on my hobby horse for 15 years that just because you have a hearing loss doesn’t mean you need a hearing aid. So even though we know there’s 36 million people with a hearing loss in the US. Not all of them want or need a hearing aid, because not all of them have changes in their lives that are caused by their hearing difficulty. So if you look at the numbers, they’re actually quite smaller. Which is why I think we’re not seeing this explosion of uptake with OTC. It’s proving that the premise was in fact invalid. Well, and another data point would be you look at countries where there’s a much heavier subsidy for hearing care and hearing devices and the uptake isn’t a whole lot larger than it is. And when I asked the question before, I was wondering if even though you haven’t seen an actual uptake yet, has there been recent work which has at least gone partway to identifying the different reasons which could generate some future actions that would help increase the uptake of hearing care? You’ve seen that sort of work taking place now where we may get some answers, or are we still as in the dark as we were a few years ago? There are a couple of things that I’m really excited to keep seeing that we learn more from. Earlier this year, I consulted with an evidence based medicine group, special interest group of health psychologists on this specific topic because exactly as Brent touched on the person who has a hearing loss for them, that does not equate. I need a hearing aid, though. That’s two very different facts. One of those facts is relevant to us as the hearing care professional. The other fact is the person who we’re trying to reach out to and they’re very different perspectives. And I think that as we’re targeting or aiming for people with earlier and earlier positions in their hearing loss journey, I think that’s going to become even more relevant because think there’s a lot that we’re missing in that space. So things that I’m looking forward to seeing more. Of is being able to learn more about consumer behavior in who actually approaches these devices and then do they actually wear them? Does it allow them to get closer to then go on to a hearing aid if they’re successful? Satisfaction rates and adherence. So in a paper that I published before, I kind of broke down some theories and some behavioral aspects and some data, I propose that and like the Consumer Technology Association standards for digital therapeutics, who recommended that the two things that are the two types of data that are collected are satisfaction and adherence. And that is what I think would be really important. And I’d be really excited to see more of that come forward across all types of hearing devices as our industry gets a bit more wide eyed. And if I consider your question, Andy, within the framework know Sophie Elaine and I published, why aren’t we seeing an uptake in devices from a technology perspective? OTC hasn’t produced any innovation in technology, which is surprising because the Consumer Electronics Association was clamoring that the hearing aid industry has produced no innovation in the past two decades and all they need is OTC to see this explosion of innovation, which isn’t happening yet. So we’re not seeing innovation, we’re not seeing new unmet needs being addressed through technology. And that’s how I think about it. There are segments out there who can use help, but they have different needs than the people who are currently getting hearing aids. So technology is not addressing those needs. Service I don’t see any innovation in hearing health services so far. I don’t consider teleaudiology to be new. It’s been around for a long time and the whole concept of self fitting and everything around self rehab and so on haven’t seen much innovation there. The only real innovation has been in the channel dimension. So getting devices in different channels, figuring out how to make the delivery successful over the Internet and stores and so on. So innovation in channel, not so much in the other two dimensions. So I think we need to see more creative solutions for the different segments with different unmet needs. Okay, well, given even that, you would consider Tele- audiology not an innovation because it’s been done even if in limited ways and limited regions, where do you see the innovation coming from? I would vote that, and this is a question I like about innovation in that if the parts are not particularly new, if people are using them more effectively or in a slightly different combo, is that still worth calling it innovation, whether that someone thinks it is or isn’t? If people do take up parts. Use them more effectively, that’s still worth celebrating and encouraging to happen. So myself, I’m obviously passionate about ta being used with any type of model, any type of product. For me, it’s the path that helps, that is the best chance of helping someone be successful with whatever they’ve chosen to do. So in the service I was delivering, the products I was working with to begin with were self fit product. Now, a clinician is not prevented from using a self fit product themselves, so it’s not about the product in what the client chose and might become happy with. But there is a lot around the path of how they come to meet, access the device that they’ve chosen and how they’re helped to use it and continue to use it. So the traditional clinic model is the best practices of everything, and yet there’s still a high rate of rejection. So there’s more opportunity, there’s more room we can experiment with. How can a different small clinic, big clinic, just the product provider everywhere’s, got a bit of room to try and innovate and tweak and adapt what they might be doing, all with the aim of helping that anyone who does choose to take on a particular product can hopefully become more successful. And that’s when that product is going to be useful, and that’s when that person is hopefully going to be happy and willing and wanting to use their product and become a successful hearing device. I mean, I think Sophie’s right. Tele audiology has been around a long time, but if you can creatively improve its use and uptake, there’s opportunity for innovation there. Necessity is a mother of invention, and COVID caused people to embrace teleaudiology, and unfortunately, they then let it go once COVID went away, and it’s not being used very, you know. Amin Amlani and Victor Bray have talked a lot about this looming crisis of the growing population, aging population who are going to need hearing, health care, the fact that the number of audiologists is a flatline. So there’s going to be this pressure, this big wave coming in and without the people who can service them. So I think the necessity that’s coming is how do you improve delivery of hearing health care with a limited number of hearing care professionals? And I do think that’s going to cause people to embrace different approaches like tele audiology, because I do think that can be more efficient way of delivering hearing services for some people. So I think it’s going to come just because it has to. Well, and what and I almost rebut you originally by saying there’s a lot of work going. On even within the space. People who are building the complete user experience first qualifying a person to make sure they’re going to get the right technology, the onboarding process and continuing support by remote means more so than just a teleaudiology version of a few visits to an audiologist. And I agree with you 100% those things can also make an audiologist with a brick and mortar clinic more efficient. In other words, so much of what can be done to take a new user through the process can be done remotely reserving the clinic space for the things that are really necessary to do in the clinic. And to me that struck me as innovation. I’ve even seen a company who’s starting to build AI models for the routine things so that you can ask questions and they’ll give you guidance and advice. To me, that’s innovation and also necessary both in developed countries where there’s a shortage of audiologists and also in economically developed countries where there hardly are any audiologists, there’s no way you can bring the traditional model there. So I think that the work that you’re doing and the work that other people are doing in this area are ultimately going to be key or we’re going to have a billion people not getting hearing care and being debilitated by it and all the subsidiary problems that come with that. One thing that you make me think of while you were saying that is I explored this in a chapter in the book that was on the podcast last week. So Vinay Manchaiah, and De Wet Swanopeol their tele audiology book. Again, another step in trying to help encourage and share the learnings and increase the practice. I contributed a chapter basically the collection of my particular learnings and insights and tricks and habits and things that I’ve learned, help and things and so forth. And in another aspect that is often misunderstood in conversations that I talk about, in that the use of TA at its simplest may simply be repeating the same task. You’ll just happen to be doing it online. And I think this is where the more consumer focused space has possibly got a bit more room to show us things. Of interest is that the way my personal style of using TA is much less about a checklist of tasks to complete. But insights from telepsychiatry where therapeutic alliance, the way people behave, can also be quite different. And that’s just being a human being. Any person getting aiming to adopt a device and be comfortable with it. Personal aspect of how they are positioned and how they relate to the device, whether it’s someone with a severe loss or someone who’s coming in quite early with a mild loss which closer to the OTC type person. There’s a lot of aspects there where things that have been touched on by Elizabeth Convery’s paper on the use of chronic care model which I love, and self management and self efficacy. There’s lots of aspects there which ta and versatile products and service delivery can utilize. I like to think retail theory and consumer behavior from those fields sometimes have an advantage in understanding how much room there is to move in the relationship that you’re having with someone. And online you’ve actually in some aspects got a lot more to gain and work with and explore because for the person this is a long term relationship you’re trying to help them achieve, not just a transactional experience. So I see it very much that way around. But I definitely do see that in exploring more OTC devices, however they’re delivered but whatever service or support you might attach around that or a flexibility that then someone can then go independently to touch base with an audiologist, separately to wherever they got a device that kind of flexibility all with the aim of creating a long term relationship. There’s so much room in an open and inclusive way to have hearing care available. No. Andy, you mentioned AI and I think that’s one area that’s just going to explode in our field. And as with other fields, it’s really hard to predict where, but we’re seeing companies apply AI to technology in many ways. We at the National Acoustic Laboratories are applying AI on so and if again, you think of our framework hearing services through both the consumer channel and the professional channel. So with the professional channel, AI is more as an assistant. So it’s like augmented audiology where the AI is almost this expert who’s looking at the data and making recommendations and we’re developing tools based on large databases of over a million patients that we have access to and making recommendations for strategies to the audiologist. On the other side, on the consumer side, as I think you mentioned, AI can provide help to the person. So provide that professional advice that if in the absence of an audiologist or hearing care professional being available, that knowledge can at least. In some way, certainly with natural language, large language models that now exist, and we’re developing those as well. Okay. And it’s interesting because the Scoping review really focused on finding scholarly papers addressing this topic and there didn’t seem to be very many, at least at the time you did it. But there’s a tremendous amount of work being done on ground. And how do you actually incorporate all the diversity of things happening today and use that to try and create a framework? That’s a really good question in that. Yeah, so much has changed from when we began to now that a lot of things have come out. So one of the really exciting things that is now out is so Brent and I are both in Australia and Australia has since updated their competency standards and also added teleology guidelines, which is very exciting because A, it’s taking a very practical and forward thinking approach to actually incorporating and OK, let’s how can we make best use of TA in our practices? And there are obviously other papers as well, so that is a great step forward that hopefully will happen elsewhere in other regions. But it also brings to light exactly. Your peer reviewed papers are absolutely valuable, but there are other types of documents and information that have actually got a lot to share and add to the conversation. And so, going forward, with the growth of more providers, more forms of data that can be there, that are going to be able to help us learn more and update our ideas and revise, and that is something that’s going to be quite important to think how to be more inclusive of a wider range of sources while supporting the need to have high quality data. But it would be a shame not to include things just because they’re not traditional sources of information we’re used to looking at. And that in itself is part of the innovation question in balancing high quality data versus nontraditional sources. Yeah, looking at what’s going on outside of the academic papers, so much innovation, so much activity, the framework helps me understand what’s going on. So I think to myself, is that technology clinical, more clinical, or is it more consumer? Is the service component more clinical, more consumer? Is the channel more clinical, more consumer? So all this work that’s going on, I apply the framework to what I would say there’s probably some missing components to the framework. So for example, if we were to write the paper today, we might add a consumer. Um, dimension where is it more of a clinical consumer or is it more of a commercial consumer, the person, or let’s say perhaps the hearing? Because we’re seeing that nontraditional consumers, not maybe consumer is the wrong word, nontraditional hearing function is being treated by know, we’ve talked a lot at NAL about people with normal audiograms, but who have hearing needs and hearing device needs. So that’s that’s another dimension to think about. What are they? Are they the classic person with a moderate hearing loss? Or are they this sort of emerging group that has normal audiograms but abnormal difficulty with speech in noise? And so, as I see all this other activity happening, I kind of think, is there another dimension that needs to be added to our framework in order to understand the complexity of what’s going on in hearing healthcare? And that group of consumers I’m quite interested in as well, because that person’s experience and perspective as to what they need is, again, it’s not going to be the way we’re used to receiving a person with a moderate to severe hearing loss. Their perspective and their concept of what do I need to do for myself, for my ears, for my ability to go to work, is completely different. And so we have an opportunity to learn more and expand our idea of what the person’s need is. In the special edition that the framework was in, all of the papers were invited to take a different angle. And one of the papers with Barbara Timmer and Caitlin Barr is one where there we revised, know, reconsidered our idea of what a need is and what an outcome could. So, you know, there’s lots of different aspects that we’ve got an opportunity to update our thoughts and learn a lot more from the consumer’s perspective because until we get better at that, we may remain limited at changing the adoption and rejection rates. So, Sophie, I’m curious. NAL is a part of a larger hearing services organization with a couple hundred clinics. We see a lot of people coming in who want hearing help but don’t have any measurable hearing loss. And so we actually say, congratulations, you’re fine. Come back in five years and we’ll test you again. Have you ever had any experience with that population? And what are your thoughts on what should be done, particularly within our framework that we’ve developed? Good question, because in initial years was only dealing with people online who were inquiring about. Up hearing services, hearing products, and then would then go through the full journey again with myself. So I’d speak to people in a very much an inquiry stage as well as a post fitting stage and especially those who did everything purely online. And so it’s almost quite a privilege to have had the insight as to what kind of things are on people’s mind and what their questions were when they were first curious. So we had a speech based test that people could do from home. There’s a lot more of self testing available today. At the time, there wasn’t that many, possibly the only one right at the beginning and the conversations would begin with that. The hearing need was on the person’s mind, pretty much. They don’t get to that phone call without it being on their mind. The self testing was a great tool in people gaining confidence of being able to validate the things that they’re observing in terms in a proof of yes, okay, this is a real issue. This is definitely a factor rather than something I can brush away because it hasn’t improved in any way. And the people who really felt comfortable to go ahead I give people a lot more credit in knowing that people have a lot more confidence and willing and wanting to serve themselves in a way that is for some people, that feels less intimidating. For some people, being able to do something on their own is a huge confidence boost. There are individuals I’ve spoken to who are over 100 years old or people who are using an app on their phone for the first time and we still were able to do something successfully. So it very much changed my ideas about who is and isn’t willing to engage. And so the 2% rates that you saw, Andy in the data and that’s where I see the gap between the fact that people are capable, that people will be willing, but the first part is being able to understand how they see the situation they’re in because that’s the diffraction. It’s not necessarily that people will purely reject everything. There’s something in between. And I guess that’s why I always kind of so far come towards if it’s our job to understand what their perception of their need is because it’s not the one we’re saying. And until we’re on the same page, that’s not really going to change very quickly. Well, and that also speaks to the high return rate because people who order an OTC device or might otherwise approach a hearing care professional do it because they perceive they have hearing difficulty. But especially in the. OTC case, if that hearing difficulty isn’t related to audiometric hearing loss, it’s clear that you’re going to get a high dissatisfaction rate for all those people who need something else. And so how do you bridge that gap, actually? How do you bridge the gap between a person who perceives they have hearing difficulty and identifying the right course of treatment, whether it’s aural rehab, whether it’s voice or something else? How do you actually bridge that gap in a way that can be propagated globally? We’ve done research at NAL into this, and again, I think about different segments of different groups of people who have different needs. So there’s a segment out there who have hearing needs, but their needs aren’t audibility. In other words, they don’t need gain and amplification from a hearing aid. Their needs are speech and noise improvement. Now, the funny thing is, hearing aids do a pretty good job of speech in noise improvement. And we’ve demonstrated that people with no hearing loss, but hearing and noise difficulty can benefit from traditional hearing aids because of noise reduction, directional microphones and beam forming. So that group can benefit from those technologies, but no one thinks that they have a need for it. AirPods pro can improve speech, understanding and noise. Most people have no idea that those devices can do that. There’s lots of solutions. You mentioned aural rehab, but I think that group, they want help in the moment. As professionals, we tell people of hearing loss where your hearing needs all day long because your brain needs to adapt and it needs to accommodate, so on and so forth. I think this unique group of people, they only want help maybe an hour or two a day, maybe just a few days a week. They don’t need to wear something all day long. They need a different solution. No one right now is really focused on what is right for them. Because we’re so focused on the traditional hearing aid user, we’re kind of ignoring the fact that there’s this whole other group out there who are waiting for something, but they have different needs and they need different technology, they need different services and they need a different channel. Yeah. And actually, in your paper of a few years ago, where you dissected MarkeTrak 10, that was the largest group of people. Of the people, far and away the largest group of people are people who complained of hearing difficulty but didn’t have audiometric hearing loss. And so, yes, when I myself have said there’s no innovation in hearing devices, it’s for exactly that reason. Because to fit a hearing aid, a higher end hearing aid in a person who does doesn’t actually need the amplification, really just needs good directional microphones and some noise filtering. That’s really where I think there’s a lot of space for innovation. This part I quite like because it’s funny because the people who on the fence of rejecting their hearing aids or who don’t settle into regular hearing aid use that you start off with either very poor use one or 2 hours a day or only when you need, which is on a Saturday afternoon. But these are people with moderate to severe hearing loss who really should be wearing them all day long. But the further down the hearing loss scale you see this behavior. But exactly, as Brent explained, people much higher up, that usage pattern is appropriate because it’s much more in line with the person. But the parts from that is that this person who successfully adopts something and that it’s still going to produce a benefit both in their lifestyle but also such that they will be much more hopefully likely to adopt appropriate hearing care as their hearing progresses over the years to come. It’s an entry point, which I think is itself exciting. But also there’s the scientific knowledge now that the impact of hearing hidden hearing loss or whichever terms are used, the beginnings of deficit that are happening even to a subclinical level is still quite interesting because it means that we should be encouraged that whatever that person in the very early point who has situational need or situational want of help, it should absolutely be supported and taken seriously in whatever terms will suit that person to adopt something successfully. And so it’s been more of a call to action to say okay, the further down the scale we want to encourage, someone becomes an all day wearer. Absolutely. But if we’re going to be very serious about helping people enter hearing care from a very early point, we do need to, exactly, as Bret was explaining, think a lot more from their perspective of, okay, this is the experience they have and this is what is going to allow them to do what they want and what their version of need is. Because if we can successfully support them then then that’s going to be hopefully a much more successful journey from that point on rather than the drop off of people who struggle to become successful and committed hearing aid users later when it’s a bigger problem. And what’s really interesting that no one is talking about, at least as far as I’ve seen, is the indications for use for OTC hearing AIDS are perceived mild to moderate hearing loss, not actual hearing loss. It’s for people who think they have a hearing loss. So that includes a lot of people who don’t have a hearing loss, but they think they do. And what does this mean in terms of know delivery and how they should function? Everyone’s assuming that it’s only people with hearing loss that are getting these. You know, Andy, to your point, that might be why there’s such a high return rate, because people think they have a hearing loss or buying an OTC. They don’t need the amplification and they’re returning it. I actually am very surprised because it’s been a year now and there’s no other industry that would be satisfied with those kind of return rates. If you were an automobile manufacturer and you had a 35% return rate, I mean, heads would be rolling. And so I’m actually very surprised, and I see third party companies doing it. I’ve got to believe that at some point we’re going to get earlier into the user experience so that OTC companies, either directly or through third parties, are properly pre qualifying people to make sure when they think this device is going to work for them, that it actually will. And of course, a subsidiary question we could have another whole podcast on this one is what happens then when a person comes into your company online and they do whatever tests you do in pre qualification and you find out that their device is not appropriate for them, what happens next? In other words, regardless of how a person enters the channel, the channel meaning a person declares their desire to have help with their hearing, regardless of how they enter, depending on their situation, how do they get routed to the appropriate care? That seems like we’re a long way off from being able to sort that out and get people to where they need to be. What do you both of you think about that? Sophie, I’ll start with you. I think that’s a call to action because something I get quite passionate about is leaving someone potentially with no options. As a scientist and health passionate person, I think that’s the last thing you want to find yourself doing, saying there’s nothing to offer, there’s nothing to give for someone who is telling you, I have a difficulty, or in their terms. So we as an industry, we have a responsibility to answer that space for people. And so in exactly that point where clinically recognized loss before that point, but they experience something and they want and need something to be able to do what’s needed. We need clarity on what is our responsibility to offer. Where should lines be drawn? Whose responsibility? Is this or that. Those are conversations we absolutely should be welcoming and saying, okay, we want to offer them something. What should it be? Where should we draw the line? How should we welcome them? What is the thing that’s going to matter to them? Hearing aids. And there was conversation about different OTC products that are very smart, very clever. They do great things as I don’t particularly feel concerned about the products. Of course they’re fantastic. There’s brilliant engineers behind them. The part is about matching it with the person. And the last thing I want is to be able to say to someone, I’ve got nothing for you. That’s the last thing I would ever want to say to someone. And I agree with what you said. I think also hearing care professionals spend a lot of time with their patients setting expectations appropriately and providing motivations to wear the device. Because people expect if they’re naive towards hearing devices, they expect them to be like glasses. Put them on and suddenly everything’s clear again. And so there’s an initial rejection when that doesn’t happen. And the hearing care professional spends a lot of time making sure those expectations are correct and for example, creating COSI goals. Goals so people can recognize that their devices are helping them. You’re on your own with OTC. I bet you the expectations are completely different. I haven’t seen data yet on whether they’re being met or not. My guess is they’re not. And people are dissatisfied because they don’t know what to expect. There’s no one there telling know here’s what’s going to happen with this device. People are on their own. So it’s probably an opportunity for OTC manufacturers to figure out how can they be more successful by not just delivering good technology, but making sure that people understand what the device can and can’t do for them and making sure that they’re grounded in reality. One idea I’d probably propose is learning from the failures, as in learning from the people who have rejected or who have not succeeded in committing to their hearing aids. Those are my favorite portion of people to learn from. What reasons did they say? What were their experiences as far as they’re concerned? And that has helped me revise and update my ideas and how I practice and what I do. And just a couple of weeks ago I saw one paper published, which is the best one I’ve seen so far, in cataloging the reasons that the people who did reject, what did they actually say in their terms? And then it won’t matter what clinically was the case, what the benefit recorded was as far as that person was concerned. What did they conclude was the reason they didn’t continue? Because tell us the first, most important thing as to what to address. In engaging that point of why did they feel it was not successful? And exactly as Brent said, the expectation someone approaches a product is absolutely shapes what happens as soon as they put it on and go, well, that wasn’t what I was expecting. And so most of my approach to TA, and especially in the post fitting space, I have lot more iterative and adaptive and loose contact with people rather than a couple of set appointments. And a lot of that period is renegotiating unpacking what the expectations were, rebuilding them in line with what they were experiencing. And as far as my successes in regaining someone back towards what they actually were aiming for is often about unpacking what they actually experienced versus what did they think was going to happen and how do we come back to the middle again? And we may be limited in shaping how a product is perceived in a sales phase, in a presales phase. There’ll be lots of factors that go into that. But then with that, there is certainly a responsibility to look at how to capture what happens from the point of purchase in that initial period for the fallout between the mismatched expectations and the experience that actually happens. Now, that makes a lot of sense. And ultimately I can see my perception of where you see this going. The end result of the framework is that with all the different channels available for accessing, hearing, care, you’ve somehow created a standard of care that takes all of these things into account. The person’s own perception, experience, expectations, appropriate treatment, all of those. And you’re able to propagate those throughout the different channels so that people are guided towards a high standard of care regardless of their entry point. And I think that’s an exciting vision of the future to think about. So as we wrap this up, Brent, let me ask you, how do you see that actually happening? Like, what period of time and what are the major mechanisms to actually get that in place? Boy, that’s the billion dollar question, isn’t it? Look, it’s going to require innovation, which means it’s something no one’s done yet, and it’s going to require some trying and failing. It’s going to require some creativity, but it’s going to take time. I think we knew the first couple of years with OTC was going to really be a shambles. People were going to try to figure out what was going on. It was going to be a mess. And we’re kind of seeing that if we haven’t figured. Out in three or four years exactly what you are suggesting. Maybe it’s not possible. Maybe there’s a way that our field has evolved to require hearing care professional for the majority of people out there for a reason. If it were so easy to make someone successful with a device, audiologist would only spend 30 minutes with them. Instead, they spend hours and hours and hours trying to help them and make them successful. So maybe we’ve been too optimistic about so far with the current state of technology, how easy it is to get someone satisfied with hearing help. I mean, that’s ultimately a version of the future I don’t hope come to pass, because on a global basis, it means you would never service people in regions where there are not enough audiologists to go around. So I would say this is a problem that has to be solved. And so I want to turn it to you, Sophie. How do you see it playing out and the chances that this is a solvable? I’d see it would take time, for sure, and exactly like I started in TA, trying and failing and adapting and listening and working with. But I’d certainly see the technology is happening. It’s brilliant. It does its job how the technology is actually delivered and supported. So capitalizing on, say, AI aspects to just all of these tools are there to help bridge every way that a client will need help, because you’ve got your stream of people and there will be different drop offs at different points. And all of the tools and ability to add technology to this bit, to that bit, to that bit, it’s not ignoring the person. It’s not pacifying them with removal of human touch. It’s different ways of listening and adapting to what the individual needs. And so smarter, more creative, more adaptive concept of how care is delivered. So adaptive and personalized is absolutely the way forward, even with the inclusion of different brilliant bits of tech that get brought in to help us achieve that. Okay, great. Well, thank you both for that answer. It’s clear that this is very difficult territory to cover and that a lot of innovative thinking and work is going to have to take place before we can reach everybody worldwide. So it’s been a great conversation. I appreciate you both being on. Brent, if people want to engage with you after listening to this, how do they best reach you? Well, my email Brent Edwards at nal gov. And go to our website and check out what we’re doing. We’ve got so much interesting research going on related to what we’re talking about right here. And Sophie. How about you? I can be reached on Sophie Brice at UTAS. And yeah, very much open to any ideas, questions, research, different bits of innovative ideas would be welcome to. Happy to chat. Okay, great. Well, thanks again to you both and thanks to everyone for watching or listening to this edition of this week in Hearing.

  1. Editorial in AudioXpress breaking down OTC hearing aid adoption in the first year
  2. TWiH interview with Dr. Janice Trent of ASHA discussing their recent OTC survey.
  3. TWiH episode on telehealth with De Wet Swanepoel and Vinaya Manchaiah
  4. Paper: Emerging Technologies, Market Segments, and MarkeTrak 10 Insights in Hearing Health Technology
  5. Paper: Reasons for the non-use of hearing aids: perspectives of non-users, past users, and family members 6)
  6. Paper: Behavior Change in Chronic Health: Reviewing What We Know, What Is Happening, and What Is Next for Hearing Loss
  7. TWiH episode with Dr. Victor Bray discussing shortage of audiologists 

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About the Panel

Andrew Bellavia is the Founder of AuraFuturity. He has experience in international sales, marketing, product management, and general management. Audio has been both of abiding interest and a market he served professionally in these roles. Andrew has been deeply embedded in the hearables space since the beginning and is recognized as a thought leader in the convergence of hearables and hearing health. He has been a strong advocate for hearing care innovation and accessibility, work made more personal when he faced his own hearing loss and sought treatment All these skills and experiences are brought to bear at AuraFuturity, providing go-to-market, branding, and content services to the dynamic and growing hearables and hearing health spaces.

Brent Edwards, Ph.D., is the Director of the National Acoustic Laboratories (NAL), where he is currently leading new innovation initiatives that focus on transforming hearing healthcare. For over 22 years he headed research at major hearing aid companies and at Silicon Valley startups that have developed innovative technologies and clinical tools used worldwide. Dr. Edwards founded and ran the Starkey Hearing Research Center in Berkeley, California that was a leading site for research in hearing impairment and cognition. Dr. Edwards is a Fellow of the Acoustical Society of America and an Adjunct Professor at Macquarie University.

Sophie Brice, PhD is a Digital Health Lead at Swinburne University of Technology. She is involved in curriculum development, education, research, and writing within the field of Teleaudiology and associated practices designed for hearing and healthcare professionals.

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