Why hearing aids end up in a drawer: what the evidence shows about use and adherence

Many people benefit from hearing aids, which can improve communication and quality of life for adults with acquired hearing loss [1]. We have previously explored what the evidence shows about hearing aid outcomes. However, getting a hearing aid is only the first step. A common challenge is that some people who are fitted with hearing aids do not use them consistently, or they may not get the full benefit from them [1]. Research suggests that up to 40% of people fitted with a hearing aid may not use it or may not gain optimal benefit [1].

This article looks at why hearing aids might not be used, and what research says about interventions designed to encourage their use.

Understanding Hearing Aid Use: More Than Just Fitting

Hearing loss is a common long-term condition for adults [1]. While hearing aids are the most common intervention, their effectiveness depends on consistent use [1]. Understanding the factors that influence whether someone uses their hearing aids, and what support might help, is an important area of study.

What Interventions Help People Use Hearing Aids?

A comprehensive review by Barker and colleagues in 2016 looked at studies on interventions designed to improve hearing aid use in adults [1]. This review, part of the Cochrane Database of Systematic Reviews, systematically gathers and analyzes evidence from randomized controlled trials (RCTs) to provide reliable information [1]. RCTs are studies where participants are randomly assigned to different groups, often one receiving an intervention and another receiving usual care, to compare outcomes.

The review included 37 studies with a total of 4129 participants [1]. Most participants were over 65 years old and had mild to moderate adult-onset hearing loss [1]. The studies included both new and experienced hearing aid users [1]. The researchers noted that the quality of evidence for the primary outcomes was generally very low or low across the included studies [1].

The interventions tested in these studies were categorized using the 'chronic care model' (CCM), which helps classify different types of support for long-term health conditions [1]. The main types of interventions studied were:

• Self-management support: These interventions aim to help individuals manage their hearing loss and hearing aids better [1]. This can involve providing information, offering practice and experience in listening and communicating, or asking people to practice tasks at home [1].
• Delivery system design interventions: These interventions involve changes to how the hearing aid service is delivered [1].
• Combined interventions: Some studies tested interventions that included both self-management support and changes to the delivery system [1].

The review also noted that no studies assessed other types of CCM interventions, such as decision support, clinical information systems, community resources, or broader health system changes [1].

Findings on Self-Management Support Interventions

The review found no studies that specifically investigated how self-management support interventions affected hearing aid adherence (consistent use), adverse effects, or the perceived benefit from hearing aids [1].

Two studies looked at the daily hours of hearing aid use, but their data could not be combined for a meta-analysis, which is a statistical method to combine results from multiple studies [1]. There was no evidence that these interventions had a statistically significant effect on quality of life over the medium term (more than 12 weeks but less than 52 weeks) [1].

However, self-management support did show some effects: * Reduced hearing handicap: Two studies with 87 participants found that self-management support reduced hearing handicap in the short to medium term [1]. Hearing handicap was measured on a 0 to 100 scale, and the mean difference was -12.80 [1]. The researchers noted that while this was a statistically significant finding, its clinical significance (how much it matters to a person's daily life) was uncertain [1]. They suggested it was likely clinically significant for some, but not all, participants [1]. * Increased use of verbal communication strategies: One study with 52 participants found that these interventions increased the use of verbal communication strategies in the short to medium term [1]. This was measured on a 0 to 5 scale, with a mean difference of 0.72 [1]. Again, the clinical significance of this statistical finding was uncertain [1].

The confidence in the quality of this evidence was rated as very low [1]. No self-management support studies reported long-term outcomes (one year or more) [1].

Findings on Delivery System Design Interventions

Interventions focused on changing how services were delivered did not significantly affect adherence or the daily hours of hearing aid use in the short to medium term [1]. They also did not significantly affect adverse effects in the long term [1].

The review found no studies that investigated the effect of these interventions on quality of life [1]. There was also no evidence of a statistically or clinically significant effect on hearing handicap, hearing aid benefit, or the use of verbal communication strategies in the short to medium term [1].

Confidence in the quality of this evidence was rated as low or very low [1]. Long-term outcome measurement for these types of interventions was rare [1].

Findings on Combined Self-Management Support and Delivery System Design Interventions

Interventions that combined self-management support with changes to service delivery showed some varied results: * Adherence: One study with 167 participants found a statistically significant effect on adherence in the short term [1]. The risk ratio was 1.06, with a 95% confidence interval of 1.00 to 1.12 [1]. This suggests a small increase in adherence. * Daily hours of use: However, there was no evidence of a statistically or clinically significant effect on daily hours of hearing aid use over the long term, or in the short to medium term [1]. * Adverse effects: No studies of this type investigated adverse effects [1]. * Quality of life: There was no evidence of an effect on quality of life over the long term, or in the short to medium term [1]. * Reduced hearing handicap: These combined interventions reduced hearing handicap in the short to medium term [1]. This finding came from 15 studies involving 728 participants, with a standardized mean difference (SMD) of -0.26 [1]. This represents a small to moderate effect size, but there was no evidence of a statistically significant effect over the long term [1]. * Hearing aid benefit: There was evidence of a statistically significant, but not clinically significant, effect on long-term hearing aid benefit [1]. This was based on two studies with 69 participants, showing a mean difference of 0.30 on a 1 to 5 scale [1]. There was no evidence of an effect in the short to medium term [1]. * Verbal communication strategies: There was evidence of a statistically significant, but not clinically significant, effect on the use of verbal communication strategies in the short term [1]. This was from four studies with 223 participants, showing a mean difference of 0.45 on a 0 to 5 scale [1]. There was no such effect in the long term [1].

Confidence in the quality of this evidence was rated as low or very low [1].

Conclusions from the Cochrane Review

The authors of the Cochrane review concluded that there is some low to very low quality evidence supporting the use of self-management support and complex interventions that combine self-management support and delivery system design in adult auditory rehabilitation [1]. However, they noted that the effect sizes observed were small [1]. The range of interventions tested was also relatively limited [1].

The review highlighted the need for future research to prioritize long-term outcome assessment, develop a core set of outcomes for adult auditory rehabilitation, and use study designs and outcome measures that are powerful enough to detect smaller, incremental effects of changes in rehabilitative healthcare systems [1].

Factors Influencing Hearing Aid Decisions and Use

Beyond specific interventions, many other factors can influence a person's journey with hearing aids, from first seeking help to consistent use and satisfaction. A 2010 review by Knudsen and colleagues explored these factors by summarizing literature published between 1980 and 2009 [2].

This review looked at studies related to four key stages: * Help-seeking behaviour: The decision to seek professional help for hearing loss [2]. * Hearing aid uptake: The decision to acquire a hearing aid after assessment [2]. * Hearing aid use: How consistently and for how long a person wears their hearing aids [2]. * Satisfaction with hearing aids: A person's overall contentment with their devices [2].

The researchers identified 39 papers that examined 31 different factors [2]. These factors were categorized into personal factors (such as motivation, expectations, and attitude), demographic factors (like age and gender), and external factors (such as cost and counseling) [2].

Key Findings on Influencing Factors

One significant finding was that self-reported hearing disability was the only factor that positively affected all four outcome variables: help-seeking, uptake, use, and satisfaction [2]. This suggests that a person's own perception of their hearing difficulties plays a central role in their entire experience with hearing aids [2].

Interestingly, the vast majority of studies reviewed showed no relationship between age and gender and any of the outcome domains (help-seeking, uptake, use, or satisfaction) [2]. This challenges common assumptions that these demographic factors are major determinants of hearing aid success.

The review also noted that only two studies covered the actual hearing aid fitting process itself [2]. This highlights a gap in research regarding the immediate experience of receiving and adjusting to hearing aids [2].

In their discussion, the authors concluded that while 28 years of research provided valuable information about relevant and irrelevant factors in hearing aid healthcare, many important issues had not yet been investigated in controlled studies [2].

How Hearing Aid Usage Is Measured

Understanding how often people use their hearing aids is crucial for research and for assessing the real-world impact of these devices. However, measuring hearing aid usage is more complex than it might seem. A 2012 systematic review by Perez and Edmonds highlighted the challenges in accurately assessing and reporting hearing aid usage in older adults [3].

The review aimed to identify and quality-assess how studies published since 1999 measured and reported hearing aid usage [3]. After an initial search yielding 1933 papers, 64 were found to be eligible for detailed review [3]. These papers were assessed on six dimensions, including study design, choice of outcome instruments, level of reporting (usage, age, and audiometry data), and cross-validation of usage measures [3].

The quality assessment revealed that only 5 papers were rated as high quality, 35 as moderate, 22 as low, and 2 as very low quality [3]. This indicates a general challenge in the robustness of research in this area.

The Measurement Gap

A key finding of the review was the lack of consistency in how hearing aid usage was measured [3]. The researchers identified 15 different methods for assessing hearing aid usage [3]. These methods can broadly be divided into: * Self-report: Asking individuals how often they wear their hearing aids. This relies on memory and perception, which can be subjective. * Data logging: Modern hearing aids often have internal data logging capabilities that record the actual hours of use. This provides a more objective measure.

The wide variety of measurement methods, combined with varying levels of reporting quality, means that claims like "X% of people wear their hearing aids" can be unreliable [3]. When different studies use different methods, or when the methods themselves are not robust, it becomes difficult to compare findings or draw firm conclusions about actual usage rates [3].

The authors concluded that usage data reviewed was generally not well specified, and there was a lack of consistency and robustness in how usage was assessed and categorized [3]. They emphasized the need for a more standardized level of reporting of hearing aid usage data to better understand the relationship between usage and overall hearing aid outcomes [3].

What this means for you

If you have hearing aids but find yourself not using them as much as you or your provider expected, you are not alone. Research shows this is a common challenge, and many factors, not just your hearing loss, can play a role [1, 2].

It can be helpful to discuss any difficulties you are experiencing with your hearing aid provider. Here are some questions you might consider raising:

• What kind of support is available after the initial fitting? Ask about ongoing support, counseling, or practice sessions that might help you manage your hearing aids and improve communication in different situations [1].
• Are there ways I can practice using my hearing aids more effectively? Some interventions focus on self-management support, which might include specific exercises or strategies to help you get used to your devices and improve your listening skills [1].
• What factors beyond my hearing loss might be affecting my use or satisfaction? Your provider might be able to discuss personal factors, expectations, or external circumstances that could be influencing your experience [2].
• How is my hearing aid usage being tracked, and what does that data tell us? If your hearing aids have data logging, discussing this objective information with your provider can offer insights into your actual usage patterns and help identify any specific challenges [3].

A licensed audiologist or hearing aid practitioner can assess your individual situation and help you explore options to improve your hearing aid use and satisfaction. You can verify the registration of an audiologist through the Alberta College of Speech-Language Pathologists and Audiologists (ACSLPA) [4], or a hearing aid practitioner through the College of Hearing Aid Practitioners of Alberta (CHAPA) [5]. You can also find audiologists in Edmonton through Clinic Directory.