HEARING LOSS

Introduction

A good number of people are aware their hearing has deteriorated over the years but are hesitant to seek help. Maybe they're somewhat in denial over their hearing loss, maybe they're a little embarrassed over acknowledging a shortcoming or weakness, or maybe they believe they can "get by" without the assistance of a hearing aid. And, unfortunately, too many people wait too many years before getting treatment.

But time and again, research demonstrates the considerable negative social, psychological, cognitive and health effects of untreated hearing loss. There are far-reaching implications that go well beyond hearing alone. In fact, many people who have difficulty hearing can experience such distorted and incomplete communication that it seriously impacts their professional and personal lives, at times leading to isolation and withdrawal.

• Reduced job performance and earning power
• Impaired memory and ability to learn new tasks
• Irritability, frustration, negativism and anger
• Fatigue, tension, stress and depression
• Social rejection and loneliness
• Diminished psychological and overall health

Hearing loss is just not a part of growing old. It can strike at any time and at any age, including childhood. For the young, even mild or moderate hearing loss can bring difficulty to the learning process, speech development and building the important interpersonal skills necessary to foster self-esteem and success in life.

If you or a loved one suffers from hearing loss, please give us a call. The SHEA HEARING AID CENTER's professional staff of hearing specialists stands ready and able to assist with the first steps to a world of better hearing.

How We Hear

To understand how we hear, it is important to understand the anatomy of the hearing system. The hearing system can be divided into four different components with each component having a different function.

1. Outer Ear
2. Middle Ear
3. Inner Ear
4. Central auditory pathways

The outer ear is made up of the pinna or auricle and the external auditory canal. The pinna collects and funnels sound down the ear canal. The ear canal is curved, "S" shaped, and about 1 inch long in adults. It has hairs and glands that produce wax called cerumen. Cerumen helps to lubricate the skin and keep it moist.

The eardrum (tympanic membrane) is a membrane at the inner end of the ear canal. On that inner side of the tympanic membrane is an air-filled space called the middle ear cavity. The vibrations of the tympanic membrane are transmitted through the malleus (hammer) incus (anvil) and stapes (stirrup), also called the ossicles. The stapes footplate transmits the vibrations into the inner ear.

The inner ear has two divisions: one for hearing, the other for balance. The hearing division consists of the cochlea and the nerve of hearing. The cochlea is a snail-shaped, bony structure that contains the sensory organ for hearing called the organ of Corti. The organ of Corti releases chemical messengers when the vibrations from the stapes activate its tiny hair cells. These then excite the nerves of hearing which carry sound to the brain.

The central auditory system is a complex network of neural pathways in the brain that is responsible for sound localization, speech understanding in noisy listening situations and other complex sounds, including music perception.

The process of "hearing" is quite complex. Sound is transformed into mechanical energy by the tympanic membrane. It is then transmitted through the ossicles to the inner ear where it is changed again into hydraulic energy for transmission through the fluid-filled cochlea. The cochlea's hair cells are stimulated by the fluid waves and a neurochemical event takes place that excites the nerves of hearing. The physical characteristics of the original sound are preserved at every energy change along the way until this code becomes one which our brain can recognize and process.

Hearing loss misleads our brain with a loss of audibility and introduces distortion into the message that reaches the brain. Changes in the effectiveness of the brain to process stimuli, from head trauma, disease, or from aging, can result in symptoms that mimic hearing loss. The ears and the brain combine in a remarkable way to process neural events into the sense of hearing. Perhaps it's fair to say that we actually "hear" with our brain, not with our ears!

Signs of Hearing Loss

The signs of hearing loss might be gradual and emerge slowly, or they might be significant and come about suddenly. Either way, there are common indications. You might have a hearing loss if you:

• Socially
  • Answer or respond inappropriately in conversations.
  • Think other people's speech is muffled or it appears they're mumbling.
  • Have difficulty following conversations involving more than 2 people.
  • Require frequent repetition.
  • Have trouble hearing and understanding women and children.
  • Find yourself reading people's lips or watching their faces when they speak.
  • Have difficulty hearing in noisy surroundings such as restaurants.
  • Require your TV or radio turned up to high volume.
• Emotionally
  • Feel stressed out from straining to hear what others are saying.
  • Feel annoyed with others because you can't hear or understand them.
  • Feel embarrassed from not being able to understand others.
  • Feel nervous about trying to hear and understand others.
  • Withdraw from social functions you once enjoyed because of difficulty hearing.
• Medically
  • Have a history of hearing loss in your family.
  • Take medications that can harm your hearing system.
  • Have diabetes, heart, circulation or thyroid problems.
  • Have been exposed to loud noise over a long period of time.
  • Have been exposed to a single, explosive noise.

Types of Hearing Loss

Generally, there are two specific types of hearing loss:

• Conductive hearing loss is caused by a mechanical problem in the ear canal or middle ear that blocks the conduction of sound.
• Sensorineural hearing loss or nerve hearing loss, is caused by damage to the inner ear, auditory nerve, or auditory nerve pathways to the brain

A mixed loss is a combination of a conductive and a sensorineural hearing loss. Hearing aids can be beneficial for persons with a mixed hearing loss, but caution should be exercised. Conductive hearing loss is often reversible; sensorineural hearing loss is not.

Causes of Hearing Loss

During normal hearing, sound waves travel through the ear canal and strike the eardrum causing it to vibrate. The eardrum is attached to three tiny bones in the middle ear. The last bone, the stapes, pushes on a fluid-filled chamber in the inner ear, called the cochlea. The fluid movement causes sensitive hair cells within the cochlea to bend. When the hair cells bend, they generate an electrical signal that is sent to the brain. Age, disease, injury, or repeated exposure to loud noise can damage the various structures of the ear and interfere with one's ability to hear.

Factors Influencing Individuals' Decisions to Access Hearing Care Services

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


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

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

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

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

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

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

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

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

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

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

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

Findings. 

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

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

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

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

Location of the screenings. 

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

For dedicated hearing-related events on RHSC premises:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Discussion of Initiative #1

So, why don't people who are screened and recommended for evaluation follow through? 

The results indicate that hearing screenings are a somewhat effective tool in educating consumers to the need for further hearing-related services. Approximately 42% of individuals who failed a hearing screening and received a recommendation for a comprehensive hearing assessment subsequently scheduled a hearing evaluation at either RHSC or elsewhere.

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

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

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

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

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

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

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

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

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

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

Findings. 

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

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

   

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

   

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

   

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



• A significant correlation between composite handicap score and purchase of hearing aids (r = -.51; p < .001);


• The composite handicap score was significantly poorer in the group that proceeded to get hearing aids (t = 3.774; p < .001).

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

Adopters. 

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

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

Less frequently reported reasons were:

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

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

Non-adopters. 

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

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

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

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

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

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

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

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

Discussion of Initiative #2

So, why do some people who fail the comprehensive hearing assessment choose not to follow a recommendation for amplification?

Unlike the findings relative to subsequent action following a failed hearing screening, for those who revealed a hearing loss, hearing threshold levels and composite handicap scores were significantly correlated with subsequent action (in this case, the purchase of hearing aids). For those who revealed a hearing loss at the hearing assessment, the worse the hearing threshold levels and/or the poorer the composite pre-handicap score, the more likely the individual was to subsequently purchase a hearing aid.

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

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

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

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

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

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

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

Future Research Needs

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

1. Examining the relationship between the degree of hearing loss and lifestyle (including whether the individual is still active in the workplace, socially active, etc) and the likelihood that an individual perceives the need for amplification. This would subsume examining the responses for those individuals who receive a recommendation for hearing aids but do not do so because "they feel their hearing is good enough."
2. Development of a simple instrument that could be used within the time constraints of most clinical practices to assess the key internal/external factors impacting the client's life. This would include examining the individual's readiness to address hearing-related problems. The responses would be used to guide recommendation and management strategies.

Acknowledgements

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

Hearing Aid Features and Capabilities

Hearing aids ( hearingaids ) can be defined by:

• Hearing aid form factor
  i.e. what they look like and their size and where they are placed in/ on the ear (BTE, ITE, ITC, and CIC): these terms are explained later in this article. The styles are designed for specific types of hearing loss as well as lifestyle and cosmetic considerations.
   
• Technology used in a hearing aid: 
  
  All hearing aids are built from either analog or digital circuitry. Digital hearing aids are the more technologically sophisticated type of hearing aids and the most expensive. As opposed to analog hearing aids, digital hearing aids are programmable and provide advantages of greater adjustment precision and more complex sound processing. With most digital hearing aids, volume adjustments are automatic.  Many of these newer hearing aids have multiple microphones for better directional hearing and sound processing for background noise reduction. For an explanation of the technical differences between analog and digital hearing aids, click here.

These two hearing aid definitions are not mutually exclusive when it comes to the outer part of the hearing aid (form factor) as both analog and digital technology have been available for most of the hearing aid styles, although most analog production has been phased out by most hearing aid manufacturers.

(BTE) Behind the ear hearing aids

All BTE hearing aids are comprised of basic parts as shown in the following diagram:

The locations of the microphones, speakers, amplifiers and batteries will differ between manufacturers. The newer and smaller open fit hearing aids replace the ear-mold with a a small "bud" or "dome" that has holes in it.
Also there is confusing terminology. For example, the hearing aid part that pushes the sounds to the  ear canal through the tube is called a "receiver" by manufacturers.  Most consumers call this component a speaker rather than a receiver.
The BTE model hearing aids come in a number of variations:

1. Analog (BTE) Behind the ear hearing aids (hearingaids)

BTE Analog Hearing Aids consist of three basic parts: the hearing aid case that fits behind the ear, a tube that connects to an an ear mold which sits inside the ear, and an ear mold. The hearing aid rests behind the ear and a plastic tube connects it to the ear mold. This was the most common type of hearing aid and at one time was the only type you could buy.

	Note the large ear-mold which is custom-made and completely fills in the ear canal and ear entrance
Behind The Ear Hearing Aid - Older Analog Version	Hearing Loss addressed- Mild to moderate hearing loss

Note the large hearing aid case behind the ear that can easily be seen from the side and the thick tube connecting the case to the mold in the ear canal.
Most European and North American companies no longer make these analog hearing aids and they now make the smaller Behind The Ear hearing aid (BTE hearing aid) with digital electronics. An example of this type of BTE hearing aid follows.

---

2. Digital Behind the ear (BTE) hearing aids ( hearingaids )

BTE Digital hearing aids are much like their analog cousins on the outside: Digital BTE hearing aids are made up of the hearing aid case, a "ear hook" extension, and a tube that connects to a mold in the ear. They are similar in size to the analog hearing aids, some perhaps a little smaller. These digital BTE hearing aids also fit behind and over the ear; the ear hook part fits over the front of the ear and points down towards the ear canal. One end of a tube is connected to the opening in the ear hook end the other end connects through a tube to a mold in the ear canal.

However, as opposed to the BTE analog hearing aids, digital BTE hearing aids have a DSP (Digital Signal Processing) chip that is the "brains" of the hearing aid. These DSP chips consist of micro-circuitry much like a CPU on a computer and they also have software programs that are "burned" into the chip.

Each hearing aid manufacturer has DSP chips that they purchase from specialized chip fabrication manufactures. They then program the chips to offer their unique features amplification and filtering features.

It is the DSP on a digital hearing aid that provides some of the following capabilities:

• Multiple frequency response bands like an equalizer on a stereo
• Multiple channels that the user can switch between for different listening environments (normal conversation, Telephone, TV listening, restaurants, theater etc.)
• Noise reduction filters - minimizes noisy environmental sounds when you are talking and listening to someone
• Dynamic contrast detection - able to pick up the different verbal conversational sounds from the environment
• Multiple microphones

Because these hearing aids also require a custom mold to fit inside the ear canal, either a licensed audiologist or a licensed audiologic dispenser is required to make the mold.

Digital Behind the Ear with ear hook extension	Hearing Loss addressed: Severe to profound hearing loss

---

 

3. Digital Behind the ear (BTE) Open Fit hearing aids

The digital open fit hearing aids or open ear hearing aids are all digital hearing aids and have a Digital Signal Processing chip like their BTE cousins. What makes these hearing aids different from the BTE hearing aids with the ear hook design?

• Some models are 1/2 - 1/3 the size of the fish hook BTE hearing aids. They still fit behind the ear but they are only about 1" long and about 1/4" wide which means they are very hard to see unless someone is looking intently.
• They are very light weight, some weighing in at just 1 -2 ozs.
• They do not have an ear hook extension.
• The sound tube that connects to the ear canal is very thin and opaque in color making it almost invisible.
• What really differentiates the BTE open fit hearing aids from the ear hook BTE models is that a custom ear canal mold is not required. Instead of an ear mold, a small bud is that looks like a mushroom cap is attached to one end of the sound tube and fits into the ear canal. Instead of occluding (plugging up) the ear canal, each ear bud has holes in it that allows some sounds from the environment to enter the ear canal at the same time the hearing aid is amplifying. This setup provides a much richer listening experience and allows the hearing aid wearer to better orient themselves to whoever is talking to them.

	Hearing Loss addressed: severe to profound hearing loss
Note that there is no ear mold. The small bud on the end of the tube fits into the ear canal so only the narrow, opaque tube can be seen from the side. Note also that the hearing aid case is invisible.
Digital Open Fit Hearing Aid

Interested in purchasing a digital open fit hearing aid?

  

---

Digital In-the-ear (ITE) and Canal (ITC) hearing aids (hearingaids)

Digital In-the-Ear (ITE) and In-the-canal (ITC) hearing aids come in two form factors: those with a custom mold, and those with a generic tip.  Both of these types of hearing aids occlude (plug up) the ear canal so all sounds that enter the ear canal, do so through the amplification of the hearing aid.

Both models have DSP chips that provides the wide range of features:

• Multiple frequency response bands like an equalizer on a stereo
• Noise reduction - minimizes noisy environmental sounds when you are talking and listening to someone
• Dynamic contrast detection - able to pick up the different verbal conversational sounds from the environment

What is the difference between an ITE hearing aid and an ITC hearing aid? The difference is size i.e. how much of the hearing aid case can be seen outside the ear.
In-the-Ear (ITE) hearing aids fit completely in the outer ear and are used for mild to severe hearing loss. The hearing aid case, which holds the components, is made of hard plastic. Older ITE and ITC aids could also accommodate added technical mechanisms such as a telecoil, a small magnetic induction coil contained in the hearing aid that minimizes feedback (the high pitched whistling sound) during telephone calls. Newer ITC hearing aids usually do not have a telecoil because of the size requirements for the coil and the fact that the DSP chips features obviate the need for a telecoil.

In-The-Ear	In-The-Canal	Hearing Loss addressed: moderate to severe hearing loss

The ITE and ITC hearing aid models with molds are usually sold by audiologists as they require a custom mold to be made; the ITE and ITC hearing aids that have generic tips are mostly sold by mail order houses and Internet retailers.
Interested in purchasing an In The Canal hearing aid?

---

Completely In The Canal (CIC) hearing aids ( hearingaids )
A Completely-in-Canal (CIC) hearing aid is largely concealed in the ear canal and is used for mild to moderately severe hearing loss. One of the great advantages of the CIC hearing aid is that it cannot be seen by someone else.  However, because of their small size, CIC hearing aids may be difficult for the user to adjust and remove. Trying to poke a finger into the ear canal to adjust a CIC hearing aid can be very frustrating.   Because of their proximity to the wax glands, Completely In the Canal hearing aids can also be easily damaged by earwax and ear drainage. They are not typically recommended for children.

CIC models have DSP chips that provides a wide range of features:

• Multiple frequency response bands like an equalizer on a stereo
• Noise reduction - minimizes noisy environmental sounds when you are talking and listening to someone
• Dynamic contrast detection - able to pick up the different veral conversational sounds from the environment

Completely in-The Canal

Although the advantage of the CIC aid style is the small size, the disadvantages of higher cost, and the extreme difficulty in adjusting are often not worth the effort or cost.
So, what IS the best hearing aid to buy?
If you have a moderate to severe hearing loss (up to 60 dB loss at any frequency):

• If you are vain and don't want people knowing you have a hearing aid, then purchase a CIC model hearing aid. But be aware they will easily get clogged with ear wax, and the volume adjustment is impossible without taking the hearing aid out of the ear. CIC hearing aids are not practical for remediation of hearing losses above 60dB as they are too small for the necessary amplification technology to fit into such a small size. Also the fact they are deep in the ear canal means that many frequencies will not reach the hearing aid to be amplified.
• If you want a discrete yet slightly visible hearing aid, and want an in the ear model, then choose and ITC or an ITE hearing aid. (Note: some of these hearing aid models can also  remediate severe hearing loss (60 - 80 dB))

If you have a severe to profound hearing loss in the higher frequencies (up to 110dB in the 2K+ hertz rate):

• Choose an Open Fit BTE hearing aid model. Why? They are much lighter than the regular digital BTE hearing aids and are more comfortable, and can easily be worn with eyeglasses. BTE Open Fit hearing aid models also easy to take off, clean, and switch between the various listening modes (normal, telephone, TV, restaurant etc.)

If you have severe -to profound hearing loss especially in the lower frequencies (up to 80 dB below 2K Hertz)

• Choose either a regular BTE hearing aid or a modified Open Fit BTE hearing aid model that has the  speaker in the ear (SIE) configuration. Why? The speaker in the ear configuration takes all available external frequencies and amplifies them to the ear drum. These models will not have any holes in them for external sounds to bypass the hearing aid; all sounds come through the hearing aid itself. The downside is that these SIE hearing aid models have the speaker in the ear often have potential problems with whistling feedback unless the mold or bud that goes in the ear canal fits snugly.

High-frequency hearing loss: Can hearing aids help?

Yes. In recent years, hearing aid manufacturers have made great strides in developing hearing aids that are more effective for all types of hearing loss — including high-frequency hearing loss.

For example, the advent of digital technology has resulted in significant hearing aid improvements. Digital hearing aids can be specifically adjusted to match an individual's unique hearing loss. With digital hearing aids, a computer chip converts incoming sounds into digital code and then analyzes and adjusts the signal based on your specific needs as revealed by your audiogram. The signals are then converted back into sound waves and delivered to your ears. The result is sound that's more finely tuned to your hearing loss.

Additionally, open-fit hearing aids — which leave your ear canal at least partially open — have become popular for high-frequency hearing loss. Open-fit hearing aids allow low- and mid-frequency sounds into the ear normally, so that only high-frequency sounds are amplified.

To find the best hearing aid for your situation, make an appointment with an audiologist to have your hearing tested and to discuss your communication needs. Together, you can decide which features will be most helpful for your hearing loss. Because it may take some time to get used to a hearing aid, most manufacturers allow at least a 30-day trial period during which you can "try out" the hearing aid and return it for a refund if you're not satisfied.

How to choose the right hearing aids?

Many types of hearing aids exist. So which is best for you? Find out what to consider when choosing a hearing aid.

Perhaps you've thought about getting a hearing aid, but you're worried about how it will look and wonder whether it will really help. Knowing more about the hearing aid options available to you, what to look for when buying a hearing aid and how to break it in may help alleviate some of your concerns.

Hearing aid styles

ll hearing aids contain the same parts to carry sound from the environment into your ear. However, hearing aids do come in a number of styles, which differ in size and the way they're placed in your ear. Some are small enough to fit inside your ear canal, making them almost invisible. Others fit partially in your ear canal. Generally, the smaller a hearing aid is, the less powerful it is, the shorter its battery life and the more it'll cost.

The following are common hearing aid styles.

Completely in the canal
Completely-in-the-canal hearing aids are molded to fit inside your ear canal and can improve mild to moderate hearing loss in adults.

A completely-in-the-canal hearing aid:

• Is the least noticeable in the ear
• Is less likely to pick up wind noise because the ear protects the instrument
• Is easy to use with the telephone in most cases
• Uses smaller batteries, which typically don't last as long as larger batteries
• Doesn't contain extra features, such as volume control or directional microphones

In the canal
An in-the-canal hearing aid is custom molded and fits partly in the ear canal, but not as deeply as the completely-in-the-canal aid. This hearing aid can improve mild to moderate hearing loss in adults.

An in-the-canal hearing aid:

• Is less visible in the ear
• Is easy to use with the telephone
• Includes features that won't fit on completely-in-the-canal aids, but the small size can make the features difficult to adjust
• May not fit well in smaller ears

Half-shell
A smaller version of the in-the-canal hearing aid, the half-shell is custom molded and fills the lower portion of the bowl-shaped area of your outer ear. This style is appropriate for mild to moderately severe hearing loss.

A half-shell hearing aid:

• Is bigger than an in-the-canal hearing aid
• Is a little easier to handle than are the smaller hearing aids
• Includes additional features, such as directional microphones and volume control
• Fits most ears

In the ear (full-shell)
An in-the-ear (full-shell) hearing aid is custom made and fills most of the bowl-shaped area of your outer ear. This style is helpful for people with mild to severe hearing loss.

An in-the-ear (full-shell) hearing aid:

• Is more visible to others
• May pick up wind noise
• Contains helpful features, such as volume control, that are easier to adjust
• Is generally easier to insert into the ear
• Uses larger batteries, which typically last longer and are easier to handle

Behind the ear
Behind-the-ear hearing aids hook over the top of your ear and rest behind the ear. The hearing aid picks up sound, amplifies it and carries the amplified sound to an ear mold that fits inside your ear canal. This type of aid is appropriate for almost all types of hearing loss and for people of all ages.

A behind-the-ear hearing aid:

• Is the largest, most visible type of hearing aid, though some new versions are smaller, streamlined and barely visible
• Is capable of more amplification than are other hearing aid styles

Open fit
These are usually very small behind-the-ear-style devices, although larger behind-the-ear devices can be modified for a more "open" fit. Sound travels from the instrument through a small tube or wire to a tiny dome or speaker in the ear canal. These aids leave the ear canal open, so they're best for mild to moderate high-frequency losses where low-frequency hearing is still normal or near normal.

An open-fit hearing aid:

• Is less visible
• Doesn't plug the ear like the small in-the-canal hearing aids do
• May use very small batteries
• Often lacks manual adjustments due to the small size

Hearing aid electronics

Hearing aid electronics control how sound is transferred from the environment to your inner ear. All hearing aids amplify sounds, making them louder so that you can hear them better. Most hearing aid manufacturers now only produce digital hearing aids — analog hearing aids are being phased out.

With digital technology, a computer chip converts the incoming sound into digital code, then analyzes and adjusts the sound based on your hearing loss, listening needs and the level of the sounds around you. The signals are then converted back into sound waves and delivered to your ears. The result is sound that's more finely tuned to your hearing loss. Digital hearing aids are available in all styles and price ranges.

Hearing aid options

Some hearing aid options improve your ability to hear in specific situations:

• Directional microphones. These microphones are aligned on the hearing aid to provide for improved pick up of sounds coming from in front of you with some reduction of sounds coming from behind or beside you. This technology improves your ability to hear when you're in an environment with a lot of background noise.
• Telephone adapters. This technology, also referred to as telecoil, makes it easier to hear when talking on the telephone. The telecoil eliminates the sounds from your environment and only picks up the sounds from the telephone. Some hearing aids switch automatically when the phone is held up to the hearing aid, while others require flipping a switch. Keep in mind that this technology works only with telephones that are compatible with hearing aids — most cell phones aren't.
• Bluetooth technology. New hearing aids can transmit sound from Bluetooth devices, such as Bluetooth cell phones. These hearing aids require an interface that wirelessly picks up the Bluetooth signal from Bluetooth-compatible devices and transmits the signal to the hearing aid. You don't have to hold the phone to your ear or hearing aid to hear the sounds.
• Remote controls. Some hearing aids use a remote control that makes volume control adjustments or other changes without touching the hearing aid. The remote may also make other adjustments, such as activating the directional microphone or increasing the noise reduction.

Before the purchase: Steps to take

When looking for a hearing aid, explore your options to understand what type of hearing aid will work best for you. Also:

• Get a checkup. See your doctor to rule out correctable causes of hearing loss, such as earwax, an infection or a tumor, and have your hearing tested by a hearing specialist (audiologist).
• Seek a referral to a reputable audiologist. If you don't know one, ask your doctor for a referral. A good audiologist works with you to find a hearing aid that best fits your needs and desires. This person takes an impression of your ear canal, chooses the most appropriate aid and adjusts the device to fit well. Be cautious of free consultations and people who sell only one brand of hearing aid.
• Ask about a trial period. A hearing aid should come with an adaptation period. It may take you a while to get used to the device and decide if it's useful. Have the seller put in writing the cost of a trial and whether this amount is credited toward the final cost of the hearing aid.
• Think about future needs. Ask whether the hearing aid you've chosen has residual amplification so it will still be useful if your hearing loss gets worse.
• Check for a warranty. Make sure the hearing aid includes a warranty that covers both parts and labor for a specified amount of time.
• Beware of misleading claims. Hearing aids can't restore normal hearing or eliminate all background noise. Beware of advertisements or salespeople who claim otherwise.
• Plan for the expense. The cost of hearing aids varies widely — from several hundred dollars to several thousand dollars. Professional fees, remote controls and other hearing aid options may cost extra. Talk to your audiologist about your needs and expectations. If cost is an issue, good instruments are still available at reasonable prices. If you're a veteran, you may be able to get your hearing aid at no cost. Some private insurance policies cover part or all of the cost of hearing aids, but you need to check your policy to be sure. Medicare doesn't cover the cost of hearing aids.

After the purchase: Breaking in your hearing aid

Getting used to a hearing aid takes time. Your listening skills should improve gradually as you become accustomed to amplification. The sound you hear is different because it's amplified. Even your own voice sounds different when you wear a hearing aid.

When first using a hearing aid, keep these points in mind:

• Hearing aids won't return your hearing to normal. Unlike corrective eyewear that restores your vision to normal, hearing aids can't restore normal hearing. They can improve your hearing, however, by amplifying soft sounds and reducing loud background noises.
• Allow time to get used to the hearing aid. It may take several weeks or months before you're used to the hearing aid. But the more you use it, the more quickly you'll adjust to amplified sounds.
• Practice using the hearing aid in different environments. Your amplified hearing will sound different in different places, so it's a good idea to practice using your hearing aid in various environments. You may also consider joining a support group for people new to hearing aids.
• Go back for a follow-up. Most providers include the cost of one follow-up visit in their fee. It's a good idea to take advantage of this for any necessary adjustments and to ensure your new hearing aid is working for you as well as it can.

Though it may be awkward at first, over time you'll likely adjust to the device and enjoy your enhanced ability to hear and communicate in a variety of situations. By wearing your hearing aid regularly and taking good care of it, you'll likely notice significant improvements in your quality of life.