Hearing Aid Satisfaction among Adults with Hearing Impairment in Lebanon

Hearing Aids satisfaction as an outcome measure

According to Wong et al. (2003), the concept of hearing aid satisfaction pertains to the emotional experience of pleasure that arises from an evaluation of performance, whereby the consumer perceives that their specific listening needs, communication requirements, or hearing-related goals have been adequately fulfilled. In other words, it can be seen as a process of assessing service, by collecting client feedback and observations regarding their altogether hearing journey. Numerous studies have included satisfaction as a measure of outcome, indicating that it is critical to the HA fitting process and is extremely important in audiology. Hearing aid satisfaction can be viewed as the culmination of the amplification journey. The first step is to seek help, the second is to decide to acquire a HA (uptake), the third is to decide to use an acquired HA, and the final goal is to be satisfied with the HA (Knudsen et al., 2010).  Such topic comes really handy in the context of hearing aids sales and development of a successful hearing professional image. In effect, multiple studies discovered that consumers who were “extremely satisfied” with their devices were three times more likely than consumers who were “very dissatisfied” to promote HAs to their friends. As a result, happy HA users make outstanding advocates for the adoption of HA. (Kochkin, 2000). As Michael LeBoeuf, American business author and former management professor at the University of New Orleans used to say: “A satisfied customer is the best business strategy of all” (LeBoeuf, 2007, p.96).

Factors Related to HA Satisfaction

1- Social environment & Motivation

In a study conducted by Ridgway et al. (2005), a substantial correlation was found between rising hearing thresholds in pure-tone audiometry and elevated depressive symptoms (p = 0.001). Aural therapy including hearing aid fitting and intervention had a significant positive impact on depression symptoms in the intervention group (p = 0.000) and between groups (p = 0.003) in P1. This might be explained by the fact that presbycusis, an age-related hearing loss, negatively affects the mental health of senior citizens. Using hearing aids can reduce depression and perhaps improve a person’s quality of life by enhancing their social environment.

The severity of a hearing impairment frequently impacts the motivational variables that are taken into account when determining hearing aids candidacy and assessing overall satisfaction. In effect, hearing impairment is harder to quantify than hearing loss, which can actually be quantified using audiometric data. In contrast, hearing impairment relates to how a hearing loss affects a person’s capacity for communication and overall quality of life.

In a study done by Öberg et al. (2011), 346 senior citizens participated in a survey that included questionnaires and home visits. Among those, 55% acknowledged having a degree of hearing impairment and 59% of these used hearing aids. The subjects’ most common excuse for not purchasing hearing aids was that they believed their hearing issue was not considered to be serious enough. The physical and emotional wellbeing of participants with hearing impairment who did not own hearing aids was worse (Öberg, 2011). Hickson et al., (2014),  also examined the different links in 160 older adults (older than 60 years old), between effective hearing aid use and satisfaction level. Results showed that participants were more likely to succeed and be satisfied as hearing aid owners if they had more support from close friends and family members, more positive attitudes toward them, as well as higher perceptions of their own ability to handle hearing aids more adeptly. In addition, Wiesner et al., (1996), similarly investigated the possible correlation between intention and behavior in hearing aids usage and satisfaction. The analyses showed that the person’s normative views, desire, and mindset toward using hearing aids, have a tremendous impact on overall hearing aid’s usage and satisfaction.

Therefore, it is important for the audiologist to be aware of the individual’s perceived need for amplification when considering them as a candidate for hearing aids. Individuals who are willing to acknowledge their hearing loss, committed to using hearing aids, and have positive expectations about their benefits, are more likely to experience success and satisfaction with their use. On the other hand, it is equally probable that people who are unmotivated to use amplification and who do not believe they have a hearing impairment will not use hearing aids effectively which will lead to lower satisfaction level. Therefore, the severity of the hearing impairment and motivation are important variables in deciding hearing device eligibility and future satisfaction.

2- Age

Kaplan-Neeman et al. (2012) discovered that age had unfavorable relationship on SADL ratings among 109 HA users (with an average age of 65.2). There was a link between age and the SADL’s Positive Effects subscale, but the relevance of the results was not published. The authors hypothesized that as subjects aged, they became less pleased with changes in acoustic information given by their HAs and did not believe their devices helped them comprehend speech sufficiently. Similar analyses were found in another study (n=1148) conducted in South Korea by Kim et al. (2022). The results indicate that there is a negative correlation between age and satisfaction with hearing aids. To be more precise, for every one-year increase in age, there was a decrease of 0.03 in satisfaction with hearing aids. This relationship was found to be statistically significant (β=-0.03, p<0.01).

On the other hand, age was found to have a favorable association with the Service and Cost subscale (r = 0.01, p =.001). As a result, as individuals mature and grow older, they become more pleased with the HA fitting quality, reliability, and cost/value of the devices. In effect, older people may be more likely to use hearing rehabilitation services such as troubleshooting and counselling sessions fitting, reliability, and cost/value of the devices during the trial period (Kaplan-Neeman et al., 2012).

Numerous older studies did not identify a significant connection between age and satisfaction; however, these studies used generic satisfaction measures rather than validated questionnaires (Kochkin, 1992; Bentler et al., 1993).

Knudsen et al. (2010) and Wong et al. (2003) concur that the literature shows no or little association between age and HA overall satisfaction. There are a few findings that stand out. It should be mentioned that a significant proportion of age-related research include participants over the age of 60 (Knudsen et al., 2010).

3- Gender

Cox et al. (2003) investigated the connection between diverse factors and satisfaction among 154 subjects in order to create baseline statistics for the International Outcome Inventory for Hearing Aids (IOI-HA; Cox & Alexander, 2002). MANOVA analyses showed that there was no substantial variation in mean satisfaction ratings between male and female subjects.

 Williams et al. (2009) used the IOI-HA to examine satisfaction among 160 individuals with multichannel digital hearing aids; however, no significant relationship between gender and satisfaction was identified. Additionally, when an independent group’s t-test was used, Uriarte et al. (2005) discovered no statistically significant variance between SADL Global ratings for male and female subjects. Similar results were observed in Purdy’s research, no substantial relationship between gender and satisfaction were found (Purdy, 2001).

4- Cost

Cost can prevent someone from getting hearing devices and may have an impact on satisfaction level. Surprisingly, the relationship between overall cost and satisfaction has rarely been researched, though comparisons of self-paying and non-paying customers’ satisfaction have been analyzed. According to Hosford-Dunn and Halpern (2000), clients from private clinics who self-purchased their aids reported being slightly more pleased when facing issues compared to typical hearing aid users. Thus, cost had a direct impact on the Positive image scale of the SADL questionnaire. Put into context, in a study conducted by Cox and Alexander (2001), higher satisfaction levels were obtained when third parties purchased their hearing aids compared to complimentary hearing aids provided free of charge to veterans. These studies appear to show that self-paying customers are more content in some ways, but the impact is minimal. The results might be explained by the fact that clients purchasing their own hearing devices are more aware and will take greater responsibility in using them effectively in order to tackle their hearing impairment. As the saying goes, you only know the value and worth of something when you pay for it from your own pocket.

Kochkin’s (2007) survey examined the barriers to acquiring a hearing aid and identified the top five attributes that could potentially encourage an unassisted individual to pursue obtaining a hearing aid. Among the five identified characteristics, two were found to be cost-effectiveness and the capacity for self-fitting or self-adjustment of a hearing aid. According to the survey results, 40% of the participants expressed that a reduction of US$500 in the price of hearing aids would motivate them to buy (Kochkin, 2007). However, lower cost also means lower technological level. In a study conducted by Newman and Sandridge (1998), a majority of over 75% of the participants expressed a preference for the instruments categorized as “higher end.” However, it was observed that 33% of the participants altered their inclination towards the “higher-end” hearing aids subsequent to being apprised of the associated expenses.

5- Binaural vs Monoaural

The advantages of utilizing two hearing aids as opposed to one have been a topic of intense discussion for a considerable period of time. However, it is widely accepted that binaural amplification is the preferred option unless there are notable contraindications. In her article, Holmes (2003) suggests that bilateral amplification is a recommended course of action for elderly patients exhibiting symmetrical hearing loss, unless there is reason to suspect any contraindications. Similar results were also found in Kim’s research, in which individuals fitted bilaterally were 1.23 times more likely to get satisfied during their amplification journey (Kim et al., 2022).

The most apparent benefits associated with binaural fitting were found to be an enhanced feeling of spatial localization and an improved speech recognition amidst noisy environments. The literature has repeatedly demonstrated the advantages of binaural hearing when the tasks assigned to the subjects have been adequately challenging (Ross, 1980).

Despite its potential benefits, there is a challenge in demonstrating the clinical efficacy of binaural amplification (Wernick, 1985). Furthermore, certain individuals with hearing impairment may necessitate a period of adaptation prior to exhibiting a binaural advantage and feel more comfortable when sound was presented monaurally. However, this only accounts for a small percentage of the observed individuals, more investigation was found to be necessary before reaching firm findings (Nabalek & Pickett, 1974).

6- HA experience

The MarkeTrak IV survey revealed that novice and inexperienced users (n=800) exhibited a notably reduced mean level of general satisfaction (54% rating) in comparison to users with previous experience (n=913, rating of 63%, p < .001). Furthermore, several other studies have extensively examined the correlation between experience and satisfaction and have arrived at a similar finding that individuals with previous experience tend to exhibit higher levels of satisfaction compared to newly fitted individuals (Cox & Alexander, 2000; Kochkin, 2000; Hosford-Dunn & Halpern, 2001). The authors assume that individuals that are already accommodated to the new hearing experience that a hearing aid provides will face less difficulty and be less annoyed in opposition to new users, leading to a higher satisfaction. The brain’s ability to adapt, also known as the phenomenon of plasticity, plays a big role in such situations.

7- HI severity

Uriarte et al. (2005) analyzed HA users with more severe hearing impairment (based on superior ear three frequency PTA) and found that the latter were to be considerably happier with their HAs in comparison to individuals with less acute hearing (based on SADL Global scores). However, it is important to mention that since only 1% of the variation in SADL Global scores is explained by degree of HI, this association may be concluded as comparatively insignificant (r = -0.100, p .01). Similar results were deducted in a recent study conducted by Khiavi et al. (2015); adults suffering from severe hearing loss reported significantly higher levels of satisfaction compared to those who had moderate or moderate to severe hearing loss (p=0.01).

In contrast, Hosford-Dunn & Halpern (2001) discovered a mixed association between SADL ratings and HI severity. In effect, greater hearing impairment severity was associated with lower satisfaction on the Negative Feature subscale (rs = -.29, p .001) as feedback and background noise issues were more prevalent. However, taking into consideration the advancement of technology improving feedback management and background noise cancellation, this may no longer be a problem nowadays.

Furthermore, it was discovered that HI intensity influenced SADL subscales by interacting with elements like experience and everyday use (Hosford-Dunn & Halpern, 2001). The Hearing Aid Users Questionnaire (HAUQ) was used by Dillon et al. (1999) to assess the correlation between satisfaction and multiple degree of HI. A moderately negative association was hence discovered by the research and calculation of the effect size reveals that HI intensity was responsible for a significant part (around 20%) of the variation in HA satisfaction. Nonetheless, it is important to mention that this association was found by four hearing centers in a state with lower-than-average outcomes and higher HI; as a result, the link might not hold true for the general population (Dillon et al., 1999).

8- Hearing ability & Handicap

Before delving into hearing ability, it is important to discern the concept of hearing disability and impairment (or handicap).

The World Health Organization (1980) distinguishes between the two terms: impairment and disability. Disability is the limitation or inability to execute a function in a way that is typical for a human being. The latter contrasts with a handicap, which is an impediment or condition that makes it difficult or impossible for a person to perform a function that is natural for that person.

Cheesman et al. (2013) looked into the connection between hearing ability utilizing the Self-efficacy for Situational Communication Management Questionnaire (SESMQ; Jennings, 2005) as well as handicap employing the Hearing Handicap Questionnaire (HHQ; Gatehouse & Noble, 2004). Results show that individuals expressing higher level of handicap did not indicate greater hearing difficulty. Thus, demonstrating that these are somewhat two distinct entities. Sadly, prior studies frequently treated these two factors as a single unit, making it challenging to infer specific connections between each of these factors and HA satisfaction.

Rather than using the word disability, studies frequently assess a person’s ability or trouble hearing in specific listening situations. According to Uriarte et al. (2005), the SADL Global, Positive Effect, Service, and Cost ratings have a substantial relationship with unassisted hearing impairment (p < .001). As a matter of fact, higher post-fitting satisfaction was correlated with higher issues and difficulties pre HA fitting. Similarly, Hosford-Dunn and Halpern (2001) noted that perceived hearing difficulties raised the SADL Positive Effect score (rs =.25, p<.005). According to Cox et al. (2003) findings, individuals with more subjective hearing issues expressed higher levels of satisfaction on the IOI-HA (p =.001).

Nonetheless, Kochkin (1997) discovered that individuals with milder disabilities were more likely to experience HA satisfaction. The authors explain that in some specific circumstances (such as when in big gatherings), their better hearing and sound directionality may have contributed to their increased satisfaction (Kochkin, 1997).

Numerous investigations revealed no connection between happiness and self-reported disability (Gatehouse, 1994; Norman et al., 1994; Dillon et al., 1997; Spitzer, 1998; Baumfield and Dillon, 2001; Humes et al., 2001). The use of various auditory ability and satisfaction measurements may account for discrepancies in findings. Even though impairment and handicap have very different meanings, much research does not distinguish between the two, as Gatehouse (1994) has urged. There is a need for more research in this field because the connection between disability and satisfaction is ambiguous, especially noting that disability hasn’t been examined as a standalone component.   

As for hearing handicap, Hickson et al. (2014) examined the Hearing Handicap Questionnaire (twelve five-point questionnaire which evaluates the adverse emotional effects of hearing impairment, such as emotional distress and discomfort, as well as the adverse societal effects, such as involvement limitations) ratings among 160 people aged 60 or later who had received HAs for the first time in the preceding two years in regressive research. Prior to receiving HAs, a customized variation of the HHQ was used to ascertain their handicap. It was discovered that individuals with higher HHQ difficulty scores were more likely to be successful and satisfied with their HA (defined as using a HA for more than an hour per day and experiencing at least modest benefits) (p < .05). However, many authors still believe that hearing handicap is still considered a subject worthy of further examination.

9- HA utilization hours per day

The study conducted by Kim et al. (2022) revealed a noteworthy association between the number of hours of hearing aid (HA) usage per day and satisfaction. Specifically, for every one-hour increase in wearing time, there was a corresponding increase in satisfaction with the hearing aid by 0.28 units. Similarly, in another recent study conducted in 2020, the level of satisfaction was found to be positively correlated with self-reported daily usage of hearing aids with a mean daily usage of 12 hours (Jilla et al., 2020).  In the same context, overall “non-regular” use of aids was significantly associated with lower degrees of satisfaction, with overall ratings increasing from 1.92  for low usage to 5.42 for moderate to high usage (Bertoli et al., 2009). In general, it can be observed that increased usage of hearing aids is positively correlated with increased levels of satisfaction.

Prevalence of HA satisfaction in different geographical locations

After conducting an extensive review of the relevant literature pertaining to the various factors that impact hearing aid satisfaction (found on the graph below), it would be worthwhile to investigate the overall prevalence of hearing aid satisfaction on a national scale.

Figure 1. Number of articles explored in the literature in function of each individual factor

However, it should be emphasized that satisfaction rates and satisfaction ratings are two distinct concepts. The former refers to the percentage of study participants who were satisfied with their hearing aids. The latter refers to the average satisfaction rating of all research participants, which may then be converted to a percentage value. Studying satisfaction rates in diverse geographical locations could give audiologists and hearing care professionals a general idea of success in their hearing aid fitting.

A recent study conducted in Israel, which is geographically situated adjacent to Lebanon, utilized the Satisfaction with Amplification in Daily Life (SADL) questionnaire developed by Cox and Alexander (1999). The study found that out of 109 individuals who use hearing aids, 92% reported varying degrees of satisfaction with their hearing aids. (i.e. had a global SADL score of 4 or more on a scale of seven). Another research conducted by the Otolaryngology Sakarya University Medical Faculty, also pertaining to the Middle East region, revealed that a subset of 14.28% (out of the initial 180 patients) did not opt to continue their amplification journey, and thus denied the use of  hearing aid despite being good amplification candidate, achieving  a satisfaction rate of 85.72% (Kayabaşoğlu et al., 2015). In line with Bertoli et al.’s (2009) findings from a cross-sectional survey conducted in Switzerland, the satisfaction rate of hearing aid users was 80%, as measured by a single 4-point item. All 3 studies seem to report a high satisfaction rate around 80%, meaning that on average 1 person in 5 hearing aid candidate could eventually be unsatisfied.