Systematic review of barriers and facilitators to hearing aid uptake
in older adults

L. Jenstad, J. Moon

The University of British Columbia, School of Audiology and Speech Sciences,Vancouver, Canada

Correspondence: Lorienne Jenstad, The University of British Columbia, School of Audiology and Speech Sciences, 2177 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada. E-mail:

Key words: hearing aids, utilization, barriers elderly, systematyc review.

Acknowledgements: the authors wish to thank Charlotte Beck for assistance with planning the literature searches and the University of British Columbia Care for Elders committee for providing funding.

©Copyright L. Jenstad and J. Moon, 2011
Licensee PAGEPress, Italy
Audiology Research 2011; 1:e25

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (by-nc 3.0) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Parts of this work were presented at the “AHS 2010 - International Conference on Adult Hearing Screening”, Cernobbio (Italy), June 10-12, 2010.


A key element to success in the implementation of any screening for a health condition is that an effective treatment is available, accessible, and complied with. As the main treatment for adult-onset hearing loss is hearing aids, but only about 25% of those who could benefit from hearing aids actually use them (e.g., Kochkin, 2000; Meister, et al., 2008), it is necessary to identify the factors that affect compliance with this treatment recommendation.
Several investigators have explored the barriers that may prevent those with hearing loss from choosing to purchase and use hearing aids to assist with their communication needs (e.g., Meister, et al., 2008). Among some of the barriers to hearing aid use are stigmatization, underestimation of hearing loss by the individual, coping strategies, personality factors, low trust in hearing aid benefit, cognitive and functional restrictions, cost, false expectations (Meister, et al., 2008), and communication styles (Helvik, et al., 2008).
The goal of this study was to conduct a systematic review of the literature to identify the main barriers and facilitators to hearing aid (HA) uptake in healthy elderly (age 65+) non-users of hearing aids who have hearing loss (i.e., have been diagnosed as having hearing loss and had hearing aids recommended, but did not purchase aids).


After an initial scoping of the literature, the specific search was planned, looking for research articles with the following characteristics. The research could focus on any potential barrier or facilitator, with a broad definition of these terms. Studies were not limited by type of data collection: for example, both self-report and objective data were considered. Only studies whose sample size exceeded 50 were included. Study sample characteristics were mainly adults over the age of 65 who had never used hearing aids, with participants having at least a mild to moderate sensorineural hearing loss but otherwise being relatively healthy.

Search and retrieval process

The databases searched were CINAHL, PubMed, PsycINFO, Medline – OVID, and Google Scholar using the following keywords in many possible combinations: hearing aids, rejection, personality, cost, financial, barriers, expectation, reasons, reluctance, accessibility, amplification, older adults, elderly, utilization, willingness, hearing impairment. The publication date range was limited to January 1990 to May 2010. Reference lists of all relevant articles identified were checked for other possible studies.


The search process identified 388 abstracts. After reviewing all of the studies, 374 articles either did not meet the inclusion criterion or they were not relevant to this systematic review. Step 1 of culling articles involved removing duplicates (i.e., the same article identified from multiple databases). In Step 2, based on title alone, we removed articles that were primarily about children, cochlear implants, or medical aspects of hearing loss. Next, again from title, we removed articles about hearing aid processing or about auditory processing. In Step 4, we used the abstract to remove any articles that were primarily about hearing aid outcomes. This left 50 full articles to be reviewed in entirety to determine whether each one met the specific inclusion criteria for this review, out of which 14 articles were retained. The main characteristics of the studies are given in Table 1.
From the table, it can be seen that all studies had older adults for participants; some of the studies focused solely on older adults, while others included a broad age range. Degree of hearing loss was defined differently in each of the studies, with details not provided in two articles. Across studies, the sampled degree of hearing loss ranged from mild to severe.

Table 1. Key characteristics of included articles.

Outcome measures

The definition of hearing aid outcome was generally whether or not a hearing aid was purchased, but sometimes measured as the participant’s willingness to purchase. The other relevant measures generally depended upon the specific research question, and included measures such as self-reported hearing loss, personality, general health and well-being, use of communication strategies, dexterity, hearing aid expectations, or interviews. These, along with the definition of HA outcome, are all provided in the table. The final column of Table 1 lists the significant predictors of HA outcome for each study, along with any statistical results.

Results and Discussion

Level of evidence

The level of evidence of each study can be rated based on the Scottish Intercollegiate Guideline Network (SIGN) system (2007), which categorizes the highest to lowest level of evidence on a scale from 1 to 4 respectively. A study with a rating of 1 includes high quality meta-analysis or systematic review, or randomized control trials; 2 is quasi-experimental controlled trials that use nonrandomized, parallel group, or crossover designs; 3 is for well-designed non-experimental studies that may use pre-post test designs with adequate description; and 4 is patient testimonials or expert opinions (Chisolm, et al., 2007). All of the relevant studies included in this review, except one, were non-experimental and based on self-report questionnaires, therefore the SIGN level of evidence is considered to be a 3 for all included studies except Yueh et al (2010) which is a randomized control trial (SIGN level 1).

Predictors of HA uptake

Self-reported hearing loss, as reflected in hearing-related quality of life, activity limitation, and participation restriction factors, was significant in six studies (Chang, et al., 2009; Garstecki & Erler, 1998; Helvik, et al., 2008; Humes, et al., 2003; Meister, et al., 2008; Palmer, et al., 2009). In general, as self-reported hearing loss increased, participants were more likely to obtain or be willing to obtain hearing aids.
Stigma was predictive of HA uptake in five studies (Franks & Beckmann, 1985; Garstecki & Erler, 1998; Kochkin, 2007; Meister, et al., 2008; Wallhagen, 2010). However, stigma appears to be inconsistent in terms of its predictability power. For example, Franks and Beckmann (1985) reported stigma as the highest concern among those surveyed, but Meister and colleagues (2008) found that stigma only accounted for 8% of the variability. Garstecki and Erler (1998) showed that the stigma effect may be gender-dependent: it was of greatest concern to male nonadherents.
Degree of hearing loss was significant in five studies (Chang, et al., 2009; Chao & Chen, 2008; Garstecki & Erler, 1998; Helvik, et al., 2008; Humes, et al., 2003). As degree of loss increased, participants were more likely to adhere to HA treatment. This effect may be modified by gender differences, as Garstecki and Erler (1998) found that better-ear four-frequency average threshold contributed most to accounting for the variability in adherence in the female group, but was not significant in the male group.
Personality or psychological factors were contributing factors in HA uptake in three studies (Cox, et al., 2005; Garstecki & Erler, 1998; Helvik, et al., 2008). According to Cox and colleagues (2005), individuals who seek hearing aids differ systematically in some personality characteristics when compared to the general population.
Other psychological variables that are predictive of HA uptake are locus of control (LOC) and coping strategies (Cox, et al., 2005; Garstecki & Erler, 1998; Helvik, et al., 2008). Cox and colleagues (2005) found that HA seekers have relatively strong internal control, but locus of control may be gender-specific, as found in Garstecki and Erler’s study (1998): only females who accepted hearing aids had greater internal control than all other participants. Maladaptive coping strategies, such as dominating conversations or avoiding social interactions, interfere with effective communication. Helvik et al (2008) found that individuals who report using fewer maladaptive behaviours were more likely to reject hearing aids, which may be due to an underlying denial of both hearing loss and the use of poor communication strategies.
Cost of hearing aids was reported as a barrier to use of amplification in two studies but it was not found to be a significant predictor in another study in which it was considered (Meister, et al., 2008). One should take careful consideration when interpreting cost results. For example, Kochkin’s survey (2007) showed that 64% of respondents reported they could not afford hearing aids, but 45% of respondents also indicated that they are not worth the expense.
Age was found to be a contradictory predictor of HA uptake in 3 studies: Helvik et al (2008) showed a slight increase in HA uptake with increasing age, Hidalgo et al (2009) showed a stronger increase in HA uptake with increasing age, but Uchida et al (2008) found that HA uptake decreased with age.
Gender was reported to be a modifying variable for several of the above factors: stigma, degree of loss, and locus of control. In addition, Hidalgo et al (2009) reported that the males in their study were more likely to report needing a HA than were the females.


There are some emerging consistencies in the factors associated with HA uptake for older adults. Those that may be modifiable, possibly self-perceived loss and stigma, should be explored further to determine whether there are ways to work with these factors in individual clients to increase HA uptake. Other interesting areas for further studies are the possibility of using the hearing screening process to alter HA uptake (e.g.. Yueh, et al., 2010).


1. Chang, H.P., Ho, C.Y., Chou, P., 2009. The factors associated with a self-perceived hearing handicap in elderly people with hearing impairment-results from a community-based study. Ear Hear, 30(5), 576-583.[CrossRef][PubMed]
2. Chao, T.K., Chen, T.H.H., 2008. Cost-Effectiveness of Hearing Aids in the Hearing-Impaired Elderly: A Probabilistic Approach. Otol Neurotol, 29 , 776-783.[CrossRef][PubMed]
3. Chisolm, T.H., Johnson, C.E., Danhauer, J.L., Portz, L.J., Abrams, H.A., Lesner, S., McCarthy, P.A., Newman, C.W., 2007. A Systematic Review of Health-related Quality of Life and Hearing Aids: Final Report of the American Academy of Audiology Task Force on the Health-Related Quality of Life Benefits of Amplification in Adults. J Am Acad Audiol, 18 , 151-183.[CrossRef][PubMed]
4. Cox, R.M., Alexander, G.C., Gray, G.A., 2005. Who wants a Hearing Aid? Personality Profiles of Hearing Aid Seekers. Ear Hear, 26(1) , 12-26.[CrossRef][PubMed]
5. Franks, J.R., Beckmann, N.J., 1985. Rejection of Hearing Aids: Attitudes of a Geriatric Sample. Ear Hear, 6(3) , 161-166.[CrossRef][PubMed]
6. Garstecki, D.C., Erler, S.F., 1998. Hearing Loss, Control, and Demographic Factors Influencing Hearing Aid Use Among Older Adults. J Speech Lang Hear Res, 41(3), 527-537.[PubMed]
7. Helvik, A.S., Wennberg, S., Jacobsen, G., Hallberg, L.R., 2008. Why do some individuals with objectively verified hearing loss reject hearing aids? Audiol Med, 6 (2), 141-148.[CrossRef]
8. Hidalgo, J.L., Gras, C.B., Lapeira, J.T., Verdejo, M.Á., del Campo, d.C., Rabadán, F.E., 2009. Functional status of elderly people with hearing loss. Arch Gerontol Geriatr, 49(1), 88-92.[CrossRef][PubMed]
9. Humes, L.E., Wilson, D.L., Humes, A.C., 2003. Examination of differences between successful and unsuccessful elderly hearing aid candidates matchd for age, hearing loss and gender. Int J Audiol, 42, 432-441.[CrossRef][PubMed]
10. Kochkin, S., 2000. MarkeTrak V: "Why my hearing aids are in the drawer": The consumer's perspective. Hear J, 53(2), 34-41.
11. Kochkin, S., 2007. MarkeTrak VII: Obstacles to adult non-user adoption of hearing aids. Hear J, 60(4), 24-51.[Full-Text]
12. Meister, H., Walger, M., Brehmer, D., von Wedel, U., von Wedel, H.. 2008. The relationship between pre-fitting expectations and willingness to use hearing aids. Int J Audiol, 47(4), 153-159.[CrossRef][PubMed]
13. Palmer, C.V., Solodar, H.S., Hurley, W.R., Byrne, D.C., Williams, K.O., 2009. Self-perception of hearing ability as a strong predictor of hearing aid purchase. J Am Acad Audiol, 20(6), 341-347.[CrossRef][PubMed]
14. Uchida, Y., Sugiura, S., Ando, F., Shimokata, H., Yoshioka, M., Nakashima, T., 2008. Analyses of factors contributing to hearing aids use and both subjective and objective estimates of hearing. Nippon Jibiinkoka Gakkai Kaiho, 111(5), 405-411.[PubMed]
15. Wallhagen, M.I., 2010. The stigma of hearing loss. Gerontologist, 50(1), 66-75.[CrossRef][PubMed]
16. Yueh, B., Collins, M.P., Souza, P.E., Boyko, E.J., Loovis, C.F., Heagerty, P.J., Lui, C.F., Hedrick, S.C., 2010. Long-term effectiveness of screening for hearing loss: The screening for auditory impairment--which hearing assessment test (SAI-WHAT) randomized trial. J Am Geriatr Soc, 58(3), 427-434.[CrossRef][PubMed]