A serious public health problem

Hearing loss, difficulties, deafness: whatever you call it, it is a serious public health problem.

In the coming years, more people will be affected by hearing loss as the population ages. Untreated hearing loss has been reported to negatively impact quality of life and has been associated with decreased independence, increased social isolation, increased risk of falls, accelerated cognitive decline, and other adverse health conditions.

Untreated hearing loss presents a substantial economic burden to both the individual and society. It has been estimated that people who have untreated hearing challenges tend to have much higher general healthcare costs than those without hearing loss – as much as 50-% more.

Despite the high prevalence of hearing loss and its associated negative effects, disparities exist in treatment. Few people who could benefit from treatment seek it – for example, only 30% of adults over 70 years old who would benefit from a hearing aid report using one, and the average delay from being aware of a need to address hearing loss to the time that treatment is started is 8 years. Socioeconomic, racial/cultural, and geographical barriers mean that these disparities disproportionately impact marginalised groups. Outside the capital cities and regional centres, access to hearing health care is limited by the travel distance to the nearest provider. Interestingly, both individuals and healthcare providers living in areas with low healthcare access tend to have poorer awareness of the benefits associated with the diagnosis and treatment of hearing loss.

There is a long history of research exploring reasons behind the non-use of hearing aids. The reasons include the degree of hearing loss, personal feelings about hearing aid use, ability to pay the cost of devices and associated treatment, comfort with wearing and using devices, expectations about outcomes, and social support. More recent work has focused on characterising the psychosocial and cognitive factors that impact hearing aid uptake. Adults with better psychomotor function and poorer self-reported health status are more likely to adopt and use their hearing aids. The subjective experience of hearing also influences help-seeking behaviour: older adults who do not seek treatment for hearing loss tend to perceive less difficulty with communication and are generally less accepting of their condition compared with their treatment-seeking peers. Recent high-profile critiques exploring underutilisation of hearing healthcare services cite access to a hearing healthcare professional and cost of devices as the largest barriers to treatment.

Source: Core Values in the Traditional Provision of Hearing Health Care, https://doi.org/10.1044/2022_JSLHR-22-00540

Disabling effects

Data from the World Health Organization (WHO) Model Disability Survey reveal that environmental factors such as inaccessible physical environments and transportation, lack of social support and assistive devices, and negative attitudes and barriers for accessing health care, increase limitations in functioning for persons with disabilities to a higher extent than people without disabilities.[1][2]

Providing cross-sectoral public health interventions that address the social determinants and risk factors to inclusive and equitable health, accelerates the achievement of the health sector in improving the health and well-being of its populations. Furthermore, advancing health equity for persons with disabilities is central to all efforts in protecting populations in health emergencies.

Health equity contributes to a meaningful participation in society

Advancing health equity is a prerequisite for the wider participation into society of persons with disability. Good health and well-being are essential to living a decent and meaningful life. Not benefiting from necessary health care hinders the realization of other fundamental rights, such as the right to education or employment. By not receiving the required health services, such as rehabilitation and assistive technology, persons with disability may not be able to go to work, attend school, access livelihood opportunities, or participate in community life and society.

[1] Loidl, V., Oberhauser, C., Ballert, C., Coenen, M., Cieza, A., & Sabariego, C. (2016). Which environmental factors have the highest impact on the performance of people experiencing difficulties in capacity?. International journal of environmental research and public health, 13(4), 416.

[2] Lee, L., Mou, F., Um Boock, A., Fellinghauer, C., Kohls, M., Cieza, A., & Sabariego, C. (2021). Identifying key environmental barriers experienced by persons with mild, moderate, or severe disability in Bankim Health District, Cameroon: a policy-targeted secondary analysis of data obtained with the World Bank and WHO model disability survey. Archives of Public Health, 79(1), 1-11.

Key policy and program interventions by governments will gain a return on investment of $15 for every $1 invested.

Hearing loss, which currently affects 20% of the global population, has risen from the 11th leading cause of years lived with disability in 2010 to the third in 2019.

A complex web of determining factors impacts hearing at different stages of life, including genetic characteristics, health conditions, living and working environment, and age-related degeneration. Many causes of hearing loss are preventable through public health measures. But it can become a chronic condition and worsen over time if not managed.

Many people with hearing loss do not actively seek hearing care for various reasons including limited awareness, high cost, and stigma. People with uncorrected hearing loss can experience difficulties with communication, mental health problems, social isolation, and a high unemployment rate.

In the World Report on Hearing published in 2021, WHO recommended a comprehensive set of interventions (H.E.A.R.I.N.G.) covering prevention, management, rehabilitation, and environmental factors. A modelling study published earlier this year in The Lancet Global Health used data from 172 countries to examine the cost-effectiveness of the interventions recommended by WHO. It estimates that 90% implementation of the core interventions will avert 130 million DALYs – ie, a monetary gain of $1·3 trillion – in 10 years, corresponding to a return of $15 for every $1 invested. Hearing aids are one major component of this set of cost-effective interventions, serving as first-line clinical management.

Nonetheless, for hearing aids to truly aid, some challenges must be tackled. First and foremost, cost. The global supply of hearing aids is mainly controlled by manufacturers headquartered in high-income countries, whose current pricing strategies seem to overlook affordability in low-income and middle-income countries (LMICs). Therefore, to bring down the price of hearing aids, investments and infrastructural support should be directed to new manufacturers located in LMICs to develop safe and low-cost hearing aids with features that satisfy local needs. In addition, national universal health coverage plans should consider including hearing aids and other hearing care to reduce out-of-pocket payment.

Affordable devices remove the financial barrier, yet other factors influencing people’s willingness to use hearing aids still stand in the way. A second challenge would be to mobilise people. Raising awareness of hearing loss and the harm of untreated hearing impairment is a key first step. Providing clear labelling, trial use, and easy-return policies can further remove hesitation to use hearing aids. More importantly, we should strive to de-stigmatise hearing loss. Unless we change how societies view people wearing hearing aids and actively engage the community to support people with hearing loss, we can hardly improve the health inequities experienced by this population.

A final challenge lies in the shortage of qualified workforce in LMICs (and rural and remote parts of countries such as Australia) to deliver prevention, treatment, and rehabilitation for people with hearing loss. The long-term solution would be through health system strengthened with a focus on primary care. Primary care workers can play an important role in expanding access to hearing care by participating in screening, raising awareness, and delivering treatment such as fitting hearing aids. And their work is likely to be cost-effective.

Hearing loss, a pressing yet often invisible problem, requires more attention from global health researchers and a systematic effort that considers various needs of diverse groups with vulnerabilities across the life course. Access to hearing aids is one crucial link in this effort, together with public awareness, a supportive community, a competent workforce, and a hearing-safe living and working environment.

Article info: DOI: https://doi.org/10.1016/S2214-109X(22)00390-4

From The Lancet Global Health