Hearing Aids and Quality of Life

1
Hearing Aids and Quality of Life

• Sergei Kochkin, Ph.D.
• Knowles Electronics, Inc.

2
Sad Truth

• The industry (HIA) spent 100,000 on the NCOA
  Quality of Life Study a landmark study. The
  study demonstrated the real value of hearing
  aids.
• No major marketing interventions instituted to
  leverage these findings by any of the key
  associations.
• Business as usual
• Sluggish growth with naturally growing customer
  base.
• Marketing to an aging customer base our newest
  technology.
• Complacently living off the increased margins
  from advanced technology versus bringing in new
  and younger customers.

3
Agenda

• Present executive summary of NCOA Quality of Life
  study (Ref. 1/2000 Hearing Review)
• Some ideas for leveraging the quality of life
  findings in your practice.
• Optimizing the consumers experience with hearing
  aids.

4
The NCOA Quality of Life Study

• From Executive Summary
• Quantifying the Obvious The Impact of Hearing
  Aids on Quality of Life. Kochkin Rogin, The
  Hearing Review, January 2000.

5
Introduction

• The incidence of hearing loss in the U.S. is
  approximately 10 - 28.6 million
• Market growth in U.S. is flat despite positive
  demographics and improved technology.
• Hearing aids still positioned in market place as
  for old people.

6
Introduction

• Majority of hearing impaired non-owners and their
  physicians have negative view of hearing aids
• Low value
• Poor benefit
• Do not perform in noisy situations
• Even a few years ago FDA did not permit
  quality of life claims in U.S. advertising and
  marketing.

7
Research Objectives

• Assess the impact of aided hearing loss on
  multiple dimensions of quality of life.
• Psychological
• Emotional
• Social
• General health
• Family interaction
• Life satisfaction

8
Market Development Objectives

• Use the quality of life study to demonstrate
  value of hearing aids to the consumer and
  medical segments.
• Use an independent third party to carry this
  message to the press
• National Council on Aging (NCOA)

9
Market Development Objectives

• Overall Goals
• increase awareness of importance of hearing
• show that hearing aids are the treatment of
  choice
• stimulate sales of hearing aids

10
Methodology
11
Method - Knowles MarkeTrak V

• National family opinion panel
• Hearing loss screening 80,000 households
• Balanced to 9 key U.S. census variables
• 13,492 hearing-impaired households identified.
• Detailed questionnaire 2,720 hearing aid owners
  (MarkeTrak).
• Response rate 83

12
Method

• HIA commissioned National Council on Aging to
  conduct quality of life study using MarkeTrak V
  hearing loss panel.
• Seniors Research Group (Michigan) - detail
• Knowles Electronics - Executive summary
• Large nationally representative sample
• Individuals with hearing loss
• Aided and unaided - 1,500 surveyed each
• And their significant other (spouse)
• Ages 50 and above

13
Method

• Hearing-impaired - 8 page survey
• Family member - 4 page survey
• Response rate of 79 to mail survey
• Match aided and unaided respondents based on a
  simple screening test.
• Frequency distribution of hearing test into
  quintiles (five groups 20 - 100).
• Cohort analysis within the five hearing loss
  groups.

14
Method Screening Instrument

• American Academy of Otolaryngology 5 minute
  hearing test (Revised)
• 15 question unidimensional hearing test
  (principle components factor analysis with
  eigenvalues set to one)
• 5 point Likert scale (Strongly agree to Strongly
  disagree)

15
Method Screening Instrument Items

• Telephone
• Multiple speakers
• Television
• Background noise
• Missed calls/doorbell
• Directionality
• Ask people to repeat
• High frequency sounds
• People mumble

• Large reverberant rooms
• People annoyed by misunderstandings
• Avoid social situations
• Inappropriate response
• Family and friend perceptions
• Strain to hear

16
Method Screening Instrument

• Significantly correlated (Koike, Hurst Wetmore
  11/94) with objective hearing loss data
• Pure tone (highest)
• Air conduction thresholds
• Speech discrimination scores (SDS)
• Speech reception thresholds (SRT)

17
Method Screening Instrument

• Modal respondent subjective evaluation of their
  hearing loss in quintiles based on the five
  minute test
• Quintile 1 (20) - Mild/Moderate ()
• Quintile 2 (40) - Moderate/mild
• Quintile 3 (60) - Moderate/severe
• Quintile 4 (80) - Severe/Moderate ()
• Quintile 5 (100) - Severe/profound

18
Analysis

• Goal is to discern trends across the five hearing
  loss groups aided vs unaided.
• Calculate composite scores (e.g. emotional
  instability) in Z scores with a mean of 5 and
  standard deviation of 2 (Stanine normal curve
  method).
• e.g. 5average, 316, 784
• Or scores (e.g. depressed)

19
Analysis

• Compare for significant differences
• 95 or 99 or better confidence level
• 85 or 90 level (trends only especially at Q1
  and Q5 where sample sizes are smaller)
• Test of significance
• Attitudinal indices T-test
• Percents () Z test for differences in
  proportions

20
Demographics
21
Final sample sizes
Respondents 1,037 Users 1,032
Non-users Family members 873 Users 837
Non-users
22
Demographics Age of respondents
23
Demographics Household Income
24
Demographics Discretionary Income (plenty)
25
Demographics Gender ( Male)
26
Demographics Employment ( retired)
27
Demographics Marital Status ( married)
28
Demographics

• Groups reasonably matched
• Age (slightly older in two milder hearing loss
  user groups)
• Marital status
• Gender
• Income (favors 2 user groups)
• Employed status (favors 2 non-user groups)
• Segmented based on hearing loss as measured by
  five minute test (quintiles).
• No major systemic differences between user
  non-user groups.

29
Results

• Health Status

30
Health Status Overall self-assessment of health
and absence of pain
31
Health Status Percent Very Good or Excellent
32
Health Status

• Did not find significant differences on specific
  disease states
• Arthritis
• High blood pressure
• Heart problems

33
Results

• Social Solitary Activities

34
Activities

• Self-measure of monthly incidence
• Solitary (e.g. reading, TV, hobby) - 6 items
• Social (e.g. attend church, organized social
  events) - 7 items
• No significant differences on solitary activities
• But, significant differences on social activities.

35
Activities Organized social events
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Activities

• 3/5 groups attend senior center more.
• Might be related to small age differences between
  groups.
• No systematic significant differences
• attendance at church (2/5 user groups)
• Sport events (1)
• Theatre,movie (0)
• Volunteering/civic groups (2)
• Shop with family (1)

37
Results

• Relationship with Family Friends

38
Relationship with Family Friends

• 12 items on interpersonal relationship
• How much can you relax and be yourself around
  them (A lot - Not at all)
• 12 items on negativity in relationship
• How often do they argue with you (Often -
  never)
• 5 items on monthly incidence of contact (phone
  and in person)

39
Lack of Interpersonal Warmth in
Relationships(high scores are worse)
40
Low negativity in family relationships(e.g.
arguments, tenseness, criticism)(High scores are
better)
41
Contacts with friends and family

• Found no systematic significant differences on
  incidence of
• Phone contacts
• Meeting in person
• Total contacts

42
Results

• Social Effects

43
Social Effects

• Stigma (2 items)
• Difficulty in Communication (4 items)
• Discrimination (4 items)
• Rejection (2 items)
• Overcompensation for hearing loss (5
  items)
• Withdrawal (2 items) - family (6 items)
• Negative impact on family (6 items)
• Family accommodation (3 items)

44
Social Effects Stigmae.g. embarrassment
wearing hearing aids
45
Social Effects Overcompensation for hearing
losse.g. Pretend I understand what people say
46
Social Effects DiscriminationAccused of
hearing only what they want to hear
47
Social Effects Difficulty in Communicatione.g.
Trying to hear in some situations takes more
effort than its worth.
48
Social Effects Safety Concerns from Family
Memberse.g. Have made mistakes because of
hearing loss
49
Social Effects Non-significant variables

• Negative effects of hearing loss on family
  members.
• e.g. I find it exhausting to cope with their
  needs
• Family accommodation of hearing loss.
• e.g. I have to use signs and gestures a lot of
  the time
• Withdrawal
• e.g. They tend to withdraw from social activities
  where communication is difficult

50
Social Effects Non-significant variables

• Rejection
• e.g. They tend to get left out of social
  activities because of their hearing loss.
• All non-significant variables however,
  significantly related to degree of hearing loss.

51
Results

• Emotional Effects

52
Emotional Effects

• Emotional instability (12 items)
• Denial (2 items)
• Anger frustration (6 items)
• Paranoia (3 items)
• Sense of Confidence (2 items)
• Sense of independence (4 items)
• Depression (9 items)
• Anxiety (8 items)
• Phobias or unusual fears (6 items)

53
Emotional Effects Emotional Instability e.g.
Described as fearful, tense, insecure, unstable,
nervous, etc)
54
Emotional Effects Depressed Last 12 months
55
Emotional Effects Depression Symptomse.g.
Tired, lose 10 pounds, insomniac, think of death
56
Emotional Effects Anger/frustration e.g. I
get annoyed and irritated more easily than I used
to
57
Emotional Effects Anger/frustration (Family
assessment) e.g. They get annoyed and
irritated more easily than they used to
58
Emotional Effects Paranoiae.g. I am often
blamed for things which are not my fault
59
Emotional Effects Deniale.g. My hearing loss
is not as bad as other people say it is.
60
Emotional Effects Phobiase.g. Speaking in
public, going to social outing
61
Emotional EffectsNon-significant Factors

• Sense of Confidence
• Sense of independence
• Incidence of Anxiety
• Some indication of higher anxiety symptoms for
  non-users in 3 groups.

62
Results

• Cognitive Effects

63
Cognitive Effects

• Assessed by family member.
• Cognitive/personality changes (4 items) e.g.
  they often appear confused and disoriented

64
Cognitive Effects(Family member perception)
65
Results

• Personality Differences

66
Personality

• Locus of control (internal/external - 8 items)
• Powerful others (2 items)
• Emotional reliance/dependency (5 items)
• Assertion of autonomy ( 2 items)
• Interpersonal conformity (2 items)
• Sense of self control (6 items)
• Self criticism (2 items)
• Self Esteem (5 items)

67
Personality

• Active coping style (7 items)
• Fatalism (3 items)
• Justice (2 items)
• Introversion/extroversion (10 items)
• intellectual openness (9 items)

68
Personality Assessment Introverted(Family
member assessment)e.g. Private, passive, shy,
quiet, easily embarrassed.
69

Personality Assessment External Locus of
ControlBelieve they have little control over
the events in their lives.
70
Personality Self-criticale.g.I dwell on my
mistakes more than I should.
71
Respondent Family Assessment of Benefit of
Hearing Aids
72
Respondent Family Assessment

• Hearing aid owner respondent and family asked to
  rate the changes you have experienced in the
  following areas, that you believe are due to
  using your hearing aids.
• 5 point Scale A lot better to A lot worse
• 16 areas assessed.
• Analysis somewhat better or higher.
• Quintiles 1 5 presented

73
Perceptions of Hearing Aid Benefit Respondent
Family(Quintile 1 5)
74
Perceptions of Hearing Aid Benefit Respondent
Family(Quintile 1 5)
75
Perceptions of Hearing Aid Benefit Respondent
Family(Quintile 1 5)
76
Perceptions of Hearing Aid Benefit Respondent
Family(Quintile 1 5)
77
Conclusions
78
Conclusions Treatment with hearing aids is
related to

• Improved interpersonal relationships with family.
• Reduction in hearing loss compensation behaviors.
• Reduction in discriminatory behaviors toward the
  person with hearing loss.
• Reduction in anger frustration.
• Reduction in depression depressive symptoms.
• Improved earning power.
• Improved emotional stability.

79
ConclusionsTreatment with hearing aids is
related to

• Reduction in introverted behavior.
• Belief that subject is in control of their lives
  (locus of control).
• Reduced paranoid feelings.
• Reduced self-criticism.
• Enhanced group social activity.
• Improved overall-health pain reduction

80
Conclusions

• Strong evidence for the value of hearing aids
  in improving the quality of life from mild to
  severe hearing loss levels.
• Design of study was correlational. Findings are
  compelling suggestive of causation

81
Conclusions

• Findings suggestive of causation
• some consistent findings across cohorts.
• supportive of smaller experimental studies.
• large nationally representative study.
• corroboration within study (self family).
• positive halo or acquiescence not present.
• consistent with theoretical literature.
• findings hold up under multivariate analysis
  controlling for minor demographic differences.

82
Conclusions

• Hearing Health Industry needs to reach younger
  more active customers with hearing loss.
• Effective public relations on quality of life
  findings key to
• improved image of hearing aid value
• reinventing or repositioning the hearing aid
  industry.
• developing the market for hearing aids.

83
Conclusions

• Best time ever for collaborative market
  development
• BHI is being rebuilt - new director.
• Industry has superb technology.
• FDA battles behind us.
• Powerful new findings on hearing aid benefit
  which need to be leveraged.
• Integrated HIA and BHI market development
  thrust - 1 per hearing aid.
• Positive demographics.

84
Conclusions

• Time for a new message about our product and
  industry.
• Time to reinvent our industry to the public and
  medical communities.
• Need effective communication to three key
  segments
• Dispensers
• Physicians
• Potential consumers

85
Leveraging the Quality of Life Study Findings
86
Leveraging the Findings

• Must change our selling consciousness.
• We are not in the business of selling hearing
  aids.
• We are in the business of meeting deep seated
  human needs.
• Reposition the entire hearing aid industry.
• Necessitates
• Greater counseling focus
• More benefit selling versus feature selling
• Communicating our role to society

87
Fundamental Consumer Needs Met with Our Product
Service

• To improve speech intelligibility
• To improve hearing in all listening situations
• To improve communication
• To enhance belongingness
• To facilitate acceptance
• To reduce free-state anxiety
• To increase comprehension
• To enhance enjoyment of life
• To enhance psychological well-being
• sometimes even SAVE LIVES

88
Quality of Life Benefits Associated with Hearing
Aids

• gtInterpersonal relationships
• ltHearing loss compensation
• ltAnger frustration
• ltDepression
• gtEarning power
• gtEmotional stability
• ltIntroversion
• gtControl of life

• ltSelf-criticism
• ltParanoia
• gtOverall health
• gtCognitive functioning
• ltDiscrimination
• ltAnxiety
• ltSocial phobias
• gtSocial activity

89
Proposed Actions

• Develop a Mission Statement for Your practice
• Involve all staff make sure they understand and
  buy into the mission.
• Make it idealistic.
• Talk from your heart.
• Display it prominently.
• Give to each customer as if a contract.

90
Sample Simple Mission Statement

• Our mission is to improve the quality of your
  life, to improve the relationship between you and
  your family, to enhance your ability to belong
  and contribute to your community. We will do
  everything possible to assure your satisfaction
  with our service and benefit from our product.
  If you are not completely satisfied we are not
  satisfied.
• The staff of XYZ Audiovestibular Services

91
Proposed Actions

• Become very familiar with the executive summary
  of the NCOA study
• Kochkin Rogin. Quantifying the Obvious The
  impact of hearing aids on quality of life
  (Hearing Review, Jan. 2000)
• Counsel your potential clients on the benefits of
  hearing aids.
• Talk about the powerful human benefits.
• Spend less time selling technology or size
• Develop a presentation of the key results (e.g.
  Powerpoint). Use parts of my Powerpoint
  presentation if you want

92
Proposed Actions

• Spend more time exploring quality of life changes
  desired by the customer in the pre-fitting stage
• COSI
• Pre-fitting questionnaires
• Structured interviews
• Potential consumer may not know impact hearing
  loss has on their health
• Important to share research based impact in
  counseling sessions.

93
Proposed Actions

• Develop a small quality brochure on the key
  benefits of hearing aids
• Your business
• Local Association (Hearing HealthCare Alliance
  of..)
• National Association (AAA, IHS, ADA, BHI)
• Begin collecting powerful human interest stories
  from your practice which are related to quality
  of life changes and use them to "sell"
• Part of your counseling protocol
• Radio/public appearances
• Quotes in direct mail pieces or videos

94
Proposed Actions

• Develop 10-15 minute professional video on "real"
  quality of life changes using your State and
  National Organizations.
• CNN type human interest vignettes
• Key findings of NCOA study
• Multi-function video
• Physician education
• Consumer outreach
• Local media outreach

95
Proposed Action

• Especially share the information with physicians
  and managed care facilities who refer to you.
• In person
• Direct Mail
• Business newsletter
• Use the information in your community speeches.
• Ask your National and state organizations (ASHA,
  IHS, AAA) to develop market development programs
  on the Quality of Life theme.