Is the problem of limited hearing aid usage that of the consumer or the system?

Last week’s post reported on the death of the hearing aid as we have known the device from the past. The hearing aid obituary post suggested that, in spite of its passing, its legacy could be expected to live and actually expand via a series of transformational devices – under the general communication heading of “Listening Systems,” or “Hearables.”

Many hearing aid providers comment that what dispensers really need to expand current hearing aid use is to provide more education/information to consumers to impress upon them the importance of hearing. History shows that this theme has been in play since the day hearing aids were invented. There have been many attempts to “educate” not only the public, but other health professionals as well about the importance of good hearing: free hearing tests, hearing screening, May is Better Hearing Month, family physician initiatives, advertising, and even celebrity endorsements. (With the exception of President Reagan, I can’t recall any celebrity endorsement having a significant effect on overall hearing aid sales. Who can recall anyone coming to their office demanding a hearing aid like Art Carney wears? Please understand, this is NOT a reflection on Art Carney, one of my favorite actors!

Figure 1. Prevalence of hearing aid use in the United States, where hearing aids are mostly purchased with private funds, compared with that of England/Wales, where the National Health Service provides hearing aids free. The 1975 figure of 27% refers to the hearing aid industry estimates of 1975, based on the author’s notes from that period. The 2009 estimate of 25% is taken from MarkeTrak VIII{{1}}[[1]]Kochkin S. (2009) MarkeTrak VIII: 25 Year Trends in the Hearing Health Market. Hearing Review 16(11)[[1]]. The 20% estimate in 2010 is from Amlani{{2}}[[2]]Amlani AM. (2010) Will Federal Subsidies Increase the U.S. Hearing Aid Market Penetration Rate. Audiology Today 22(3):40-46[[2]], and the 2012 estimate of 14.2% is from Lin{{3}}[[3]]Lin, F. Hearing loss in older adults: a public health perspective, Presentation given at the ADA Meeting, 2014, Las Vegas, NV, 2014, referenced to Arch Int Med. 2012[[3]]. The 2000 estimates for England and Wales were from Lin’s Las Vegas, NV 2014 presentation given at the ADA Meeting, 2014, references a NICE Report of 2000[[3]].

Despite all the good and honorable attempts to educate the public about hearing loss and hearing aids, if the numbers reflect reality, it appears that the hearing aid market penetration has changed little in the past several years (Figure 1). This trend could hardly be called a success, regardless of how one chooses to spin the numbers. Is it possible that eventually hearing health care professionals will recognize that engaging in the same failed attempts (even though modified) and expecting different results may not be the path to follow?  The statistics from Lin (2012) should be viewed in that they represent the prevelance of hearing aid use in individuals 50 years and older with hearing impairment, whereas the other numbers were attempts to estimate the prevalence of hearing aid use in entire markets.  It is doubtful that accurate statistics have been gathered that reflect actual numbers.  All are based on estimates.

The Greatest Issue in Play?

Perhaps there are other, more important, issues at play. A recent report concluded that the “hearing aid effect” (individuals responding negatively to those wearing hearing aids) has diminished, if not completely disappeared, in the 21^st century{{4}}[[4]]Rauterkus, E., and Palmer, C. 2014 October issue of the Journal of the American Academy of Audiology[[4]]. If that is the case, this should make accepting hearing aids as a form of treatment a much easier task, with improved unit sales.

But, color me a skeptic. If the “hearing aid effect” has been eliminated, it certainly did not occur overnight – meaning that it would have been in progress for a number of years, during which time hearing aid sales and use might logically have been expected to increase. Instead, we seem to be experiencing a decline in market penetration, as evidenced by the percent of hearing aid use, even in the face of slight unit and sales dollar growth.

Let’s consider instead that the greatest obstacle and detriment to acceptance and use is the word “hearing aid,” and its related and implied negative implications! The industry has attempted to use the word “hearing instrument” as a replacement, but the public still knows this item as a hearing aid, and “hearing aid” is a limiting term. It has negative implications denoting advancing age, deteriorated health, required assistance – all great incentives if one is purchasing a coffin.

Some have suggested that educating potential consumers about the importance of hearing, and having consumers consult with those professionals who have the greatest knowledge and experience is the best approach to follow. However, getting consumers to shift their way of thinking may be as difficult as getting them to change religions.

We know that consumers do not see, or want to accept their hearing changes the same as hearing professionals, or even their family, perceive them. For many, not hearing well under some conditions is not a serious problem. Is scaring them into action by insisting that their problem is serious enough that it must be managed professionally a good marketing approach? Would such an approach justify potentially spending millions of dollars to convince consumers about the concern professionals may have for the hearing-impaired, but which they have no, little, or suppressed concern about? Even if educated to the point of acceptance, the call to action is weak – seldom anything that would be elevated to an emergency room concern.

Solution?

Get the public to minimize this as a hearing issue, especially one that requires a hearing aid! Forget the term hearing aid completely (with certain exceptions as mentioned earlier). If consumers use the word, that’s fine, but there is no reason for professionals to “force” acceptance of this and other terms or hearing treatment that have negative connotations (hearing impairment, defective hearing, hearing aid, hearing instrument, poor hearing, hearing loss, etc.). But, isn’t this the reality of having a hearing loss? Perhaps not for hearing professionals, but consumers obviously have not bought into the story of how terrible hearing loss is, as low market penetration shows.

Perhaps we should not care if people hear, as long as they listen. How far removed is this from saying  “I can hear, I just don’t understand”? For a potential consumer searching for something to improve his/her listening, rather than a way to correct their defective hearing, this distinction may involve a completely different way of viewing and accepting a product.

Reality Check

Is the hearing aid actually a medical device? Many doubt this, even though it was so designated in 1977 by the FDA (U.S. Food and Drug Administration) to satisfy control of hearing loss and treatment by selected professionals, generally done as a method of turf protection, even if not so expressed or admitted.

There is no problem with turf protection as long as the real issues are understood and managed under justifiable terms. However, there is also a recognition that this single control designation may have done more to hinder hearing aid use than any other event.

What it did was to put obstacles in the way to hearing help – guaranteeing limited involvement in an issue that most individuals were not interested in accepting. Regardless of the intent (direct or otherwise), the medical model of hearing aid dispensing did not bring more hearing impaired into the fold. Instead, the system, and amplification products, continue to be designed for limited consumer involvement and relegated to those who are most likely to need serious hearing assistance, who are prepared to jump through the obstacle hoops, who finally accept that they have a hearing problem that requires treatment, and who are best able to afford the product. But, what about those who just want to listen better in some environments?  Could they potentially be the real target market?

The Hearing Aid as a Consumer Product

The hearing aid is actually a consumer product, not a medical product. When this is eventually considered, and understood, and the product is marketed appropriately to facilitate “listening” rather than to treat “hearing loss,” the use of listening systems is likely to expand. We can quit wasting money on teaching people about the importance of good hearing and how to treat it – something doomed to fail, just as history and millions of dollars have proven in the past.

An expensive new campaign to make people aware of their hearing condition will most likely be pouring good money after bad. People already know what their communication problems are, and many already employ alternate approaches to managing them – including many who have acceptable hearing but still desire the assistance of a consumer product to use as they choose. Most already use the volume control on their personal electronics, or other basic amplification devices   And, most do not want a hearing aid! That is an option they are reluctant to try, no matter how much we try to convince them it’s what they need. Many people just want to be able to communicate and listen better in certain conditions and environments they feel are appropriate for them, not something based on what someone else thinks is best for them, and certainly not under the banner “hearing aid.”

A difficult “sell” continues in the process of testing a person’s hearing, then telling them what they already know, and trying to sell them a product called a hearing aid, that they don’t necessarily want. Is this really the best that can be offered? My 50+ years’ experience in the hearing aid field has shown me that when a person comes to the realization that they really need some help with their hearing, they are hoping for some option other than a hearing aid.

A Couple of Analogies (perhaps poor, but analogies nevertheless)

Transportation to and from a job is a necessity for most individuals. The solution could involve a variety of options from purchasing a Ferrari to using public transportation, or even walking. Either extreme could satisfy the need. But, if this were a person with hearing impairment, the current model seems based on convincing people that they need to buy a Bugatti Veyron, the “gold standard,” from a person with a vested interest in selling it to them. Greater attention would naturally be given to the “gold standard” purchaser, but was that person’s need for transportation greater than the bus rider?

People tend to equate “high quality” with “high price.” But, sometimes all they want is a Snoopy fishing rod and reel. They may not feel the need for a professional fishing guide, detailed instructions on how to land a fish or bait the hook, or even where to go for best results. Might they end up with no fish on the table? Quite likely, but they may not care! Besides, they can always try another day – perhaps with upgraded equipment and expectations, but only if, and when, they choose to take that route. A visit to a grocery store could result in a purchased fish at a dollar savings (just ask my wife). Or, they just might not like fishing at all, and just continue to eat steak.

Some might argue that these examples do not equate with the importance of hearing loss treatment.  They may be correct, but regardless, it is the consumer who will make that distinction.

A consumer generally purchases a product that enhances their self-image, unless some other consequence requires them to make an adjustment (i.e., serious medical or financial consequence, etc.). A device that allows a person to listen better can enhance one’s self image, but, does it have to be something called a hearing aid to help their hearing loss – a statement that uses two generally negative terms (hearing aid and hearing loss).

Consumer products for those who have different communication and listening interests extend far beyond the limited “hearing aid market.” The terms that are currently used to describe the consumer’s situation and potential solutions limit market penetration without the “help” of convincing people that they are in some way “defective.”

Next Week’s Post will discuss “listening products” as a way to expand and improve upon the poor market penetration and use of current hearing aids.