Dr. Ross on Hearing Loss
Hearing Aid Services and Satisfaction: The Consumer Viewpoint
by Carren J. Stika*, Ph.D. & Mark Ross**, Ph.D.
In the U.S. today, a person can purchase hearing aids from two types of dispensers: Audiologists and Hearing Instrument Specialists (formally known as hearing aid dealers). Both groups are licensed to dispense hearing aids, but come to this activity based on significantly different paths of formal education and training. There is no information that indicates that consumers as a whole favor either group of dispensers. Such decisions are uniquely personal and appear to have less to do with the dispenser’s professional association (i.e., audiologist vs. hearing instrument specialist) than the consumer’s past experiences with a particular dispenser or facility, the recommendation of a referring source, the influence of advertising, as well as such factors as convenience, cost, etc. Once involved with someone, consumers are likely to continue to patronize the same person or facility in the future, if they are satisfied with the quality of services previously obtained.
There are significant differences in the nature and scope of training between audiologists and hearing instrument specialists. Audiologists receive their specialized training in colleges and universities and currently require a minimum of a master’s degree in order to be eligible for professional certification (CCC-A) and to meet state licensing requirements. Before being certified, audiologists must also pass a standardized, national competency examination. In 2007, a clinical doctorate (the Au.D.) will be required of all audiologists entering the profession. This will add, at a minimum, a full year to their academic training. Audiologists work in a variety of medical, educational, industrial, clinical and private practice settings with all ages and types of populations. Much of their training and activities, however, is concerned with the medical and diagnostic aspects of hearing loss and not with hearing aids directly.
State licensure practices for hearing instrument specialists, on the other hand, are less standardized across the country. The general requirement typically specifies a high-school diploma or two-year degree as well as the passage of a written and practical examination. In addition, approximately 15 states require a training program or apprenticeship ranging from 6 to 12 months before a hearing aid dispensing license can be obtained. In order to become a board certified hearing instrument specialist, two years of additional experience as a hearing instrument specialist, and the passage of a national competency examination, is required. Rather than working in a variety of settings, as do audiologists, hearing instrument dispensers are primarily engaged in private practice. It is when hearing aids are dispensed to adults that roles of the hearing instrument specialists and the audiologists overlap (audiologists are the group that usually selects and fits children under the age of 18 with hearing aids).
These differences in training and background between the two groups beg the question whether such differences are relevant insofar as consumer perceptions of satisfaction are concerned. In other words, is there indeed a difference in satisfaction between those who purchased their hearing aids from audiologists or hearing instrument specialists? In order to answer this question, we constructed a questionnaire in which we sought to determine, if on average, consumers were generally more satisfied with the services they received from a member of one or the other group. While there have been studies that have compared audiologists and hearing aid dispensers in regards to their relative demographic make-up, referral sources, financial factors, number of client visits, binaural/monaural recommendation, etc. (Skafte, 2000; Strom 2001), none have, to our knowledge explicitly reported the relative satisfaction of consumers to the services provided by these two groups.
In addition to this basic objective, we also included other questions related to the hearing aid selection process. These includes such factors as the cost of the hearing aids, number of visits and hours spent, the nature of the services received, and the work location of the audiologists (private practice, ENT office, hospital, University or Speech and Hearing Center). In total, the two-page questionnaire consisted of 13 questions. In the analyses below, respondent ratings for all types of audiologists were averaged when compared to hearing instrument specialists.
A total of 942 hearing aid users completed the questionnaire. Respondents were drawn from a number of sources, including people who attended the Self Help for Hard of Hearing People, Inc. (SHHH) national convention in St. Paul, MN, in 2000, members of several local SHHH chapters, members of the “SayWhatClub,” plus a large number of hearing aid users who received the Massachusetts Commission on the Deaf and Hard of Hearing newsletter. Respondents were mostly older folks (about 76% were age 60 years or older), with a wide range of educational levels (although half had either a bachelors or graduate degree). For the most part, these were experienced hearing aid users (about half had worn aids for 10 years or more).
Satisfaction with Services Received
It is important to emphasize that we did not ask whether people were satisfied with their hearing aids, but rather whether they were satisfied with the servicesthey received from the person who dispensed the aids to them. We view this as much broader question than focusing just on the hearing aids themselves, encompassing as it does the totality of interactions consumers have with the person who sold them the hearing aids.
The results indicated that most consumers (76.6%), regardless from which type of dispenser they purchased their aids (i.e., audiologist or hearing instrument specialist), indicated that they were “definitely satisfied” or “satisfied” with the services they received. However, with regards to the key question comparing satisfaction between the two groups of hearing aid dispensers, we found that a significantly greater percentage of people who received hearing aids from audiologists reported higher levels of satisfaction compared to those who received their aids from hearing instrument dispensers (81.4% versus 66.8%).
On the flip side of this question, we wondered whether there would be a difference in the percentage of consumers who expressed dissatisfaction with the services they received from audiologists versus hearing instrument specialists. The results of this survey did show such a difference: more folks who purchased their aids from hearing instrument specialists expressed dissatisfaction than those people who obtained hearing aids from audiologists (21.5% versus 9.6%). In a related question, people were asked if they would recommend their hearing aid dispenser to friends or relatives. In response, more people who saw audiologists said, “yes” (8l.3%) compared to those who saw hearing instrument specialists (62.7%). According to our findings, therefore, while people are generally satisfied with the services they receive when purchasing hearing aids, they are generally more satisfied, and less dissatisfied, with the services provided by audiologists than by hearing instrument specialists. For both groups, the longer a person wore a hearing aid and the higher the education level, the more satisfied they tended to be with their hearing aids.
Referral Patterns to Hearing Aid Dispenser
We were interested in knowing more about how people are referred to a particular hearing aid dispenser and whether there are differences in referral patterns for people who purchase their hearing aids from audiologists compared to those who purchase their aids from hearing instrument specialists. The results of this survey indicated clear differences in referral patterns. We found physicians referring a much higher percentage of consumers to audiologists (32.5%) than to hearing instrument specialists (7.8%). On the other hand, survey results indicated that fewer people who saw audiologists (2.3%) were influenced by advertisements in the public media compared to those individuals who purchased their hearing aids from hearing instrument specialists (21.2%). This is the same pattern found in other studies (Skafte 2000; Strom, 2001). Apparently, hearing instrument specialists depend more upon advertising than do audiologists to acquire new clients, while audiologists benefit more than do hearing instrument specialists from professional networking. For other sources of potential referral (e.g., family or friends), the percentages were similar for audiologists and hearing instrument specialists.
Number of Visits and Hours Spent with the Hearing Aid Dispenser
We wanted to know whether audiologists spend more or less time with their clients than hearing instrument specialists. Based on the results of this study, no significant difference emerged between audiologists and hearing instrument specialists with respect to number of visits and hours spent with the consumer. When obtaining a hearing aid, consumers tended to make slightly more visits to the hearing instrument specialist (4.3 visits) than to audiologists (4.1 visits), but actually spent a bit more time with the audiologists (3.2 hours) than with hearing instrument specialists (2.6 hours). Evidently, people saw their audiologists for a longer period with each visit.
Cost of Hearing Aid
There were no significant differences between the groups in respect to the prices they charged for hearing aids. We asked respondents to indicate cost category (e.g. $501-1000, $1001-1500, $1501-2000) rather than the specific price. While both groups charged people a wide range of prices for hearing aids, neither group favored either the higher or lower category price hearing aids. For both groups, however, cost was significantly related to the number of visits and hours devoted to the selection process, as well as to the age of the hearing aid. The more a hearing aid costs, the more visits and hours spent on the selection process and the more recently it had been purchased. Nothing surprising about this. Probably, these relationships reflect the fact that the more expensive hearing aids were purchased more recently, that they contain more programming options to work through, and that they may require more remakes (in the case in completely-in-the canal hearing aids).
Interestingly, while for the hearing instrument specialists there was no significant relationship between the cost of the hearing aids and subsequent satisfaction, there was such a positive relationship for the audiologists. In other words, those people who purchased expensive hearing aids from audiologists tended to be more satisfied than those who purchased similar hearing aids from hearing instrument specialists. We hasten to point out that this does not imply that people who purchased expensive aids from hearing instrument specialists are dissatisfied, only that no significant statistical relationship existed between satisfaction and cost. At this point in time, the reason for such an asymmetrical relationship can only be speculative; possibly, it reflects the generally higher satisfaction ratings received by audiologists.
Services and Information Received
During the hearing aid dispensing process, prospective users must receive certain kinds of information and services if they are to be successful hearing aid users. Certainly information about the care and maintenance of the hearing aids is essential; however, people with hearing loss can also benefit from other types of information and services, such as group hearing aid orientation programs, information about various assistive listening technologies other than hearing aids, coping strategies for both the hearing aid wearer and hearing family members, and community and national resources. Indeed, several SHHH position papers are explicit on this point, emphasizing the benefits of consumer education and support services at the time of the hearing aid purchase. Because we too recognize the value of providing this type of information and services to hearing aid consumers, we asked people to indicate whether or not they received various services and information at the time of purchasing their hearing aid(s). The results are shown in Table 1.
Table 1: Percentage of Respondents Indicating Information or Services were Provided by Hearing Aid Dispenser
As can be seen in Table 1, several patterns emerge with respect to services and information provided to hearing aid consumers. First, there is a slight, although not significant, greater frequency of services and information provided to consumers by audiologists than by hearing instrument specialists. Second, and certainly more striking, is the finding that services and information that directly impact upon the hearing aids themselves are provided more frequently by both groups than any which may appear to be secondary or ancillary to the hearing aid device itself. In other words, although the vast majority of respondents reported receiving information about the care of their new hearing aids, batteries, and earmold hygiene, fewer than fifty percent of the respondents noted that they received information about the use of the “T-switch” (telecoil), directional microphones, or other hearing assistive technology from either audiologists or hearing instrument specialists. Moreover, the number of respondents who reported receiving information about coping and communication strategies, support groups (e.g., SHHH, ALDA), or invitations to participate in group hearing aid orientation meetings drops precipitously to less than 20%.
A few points must be made clear when interpreting the results regarding services and information received. Respondents had three choices: “no,” “yes,” and “not needed.” This latter category was mostly appropriate for long-time hearing aid users, those who the dispenser “knew for certain” that the specified service or information was not needed. It is probable, therefore, that more hearing aid users actually received these services than these figures indicate.
It should also be noted that we were asking what people remembered, not what they actually received. It is probable that some people simply forgot that the information or services were provided. None of us can claim an infallible memory. Still, what people rated is what they recalled. If they did not remember receiving some service/information then it suggests a need for more extensive follow-up procedures for review and reinforcement.
While the results indicate that, on the average, consumers expressed a significant preference for the services provided by audiologists, it is important to note that there was a large overlap in the ratings between the two groups. These results represent average data and should not be applied to any individual. We do not recommend that consumers abandon any hearing instrument specialist whose services they were content with, just on the basis of the results of this study. On the other hand, however, it is apparent that consumers as a whole are generally more satisfied with the services they receive from audiologists than from hearing instrument specialists. This should hardly be a surprising observation. It conforms to every other professional activity that we are aware of. Given a condition of varying complexity, such as is presented by hearing loss, and “solutions” which likewise embody a range of possibilities, naturally that group with the most comprehensive training will, on the average, provide the more appropriate treatment. This is why schools were invented.
When we began this study, we were not certain how many people with hearing loss understood the background and training differences between audiologists and hearing instrument specialists, or understood that there were indeed two separate groups legally dispensing hearing aids. We are still not certain. We did try to get at this in several of our questions. In the very first question in the questionnaire, we specifically asked people to indicate the source from whom they purchased their last hearing aid. Choices included audiologists working in various settings, hearing instrument specialists and an “I don’t know” category. Only 2% of the respondents checked this latter option, which suggests that people did understand the differences between the two groups.
Still, when we tried to word several question to specifically make this determination, the responses we received are difficult to interpret. It was a challenging question to formulate without suggesting a preferred answer. We asked people to comment if they distinguished between the two groups when seeking professional help for their hearing loss needs. The majority of respondents (71%) reported distinguishing a hearing instrument specialist and an audiologist when purchasing hearing aids. But this doesn’t inform us whether a greater percentage actually knew the difference between the groups, but simply did not take that into consideration when they purchased hearing aids.
Written responses to this question suggested that people did sense that there was a “professional” difference, although they couldn’t specify exactly what that was. There were frequent comments that audiologists were trained in the medical aspects of hearing loss while hearing instrument specialists focused on the hearing aids themselves.
In our judgment, perhaps the most relevant information we obtained in this study is contained in Table 1. Frankly, from either group, the percentage of respondents who reported that they received some particular service or information was appallingly low. Perhaps, as we noted above, these items were actually conveyed to the hearing users; no matter, what they recall is the only information that can possibly be of assistance to them. Neither audiologists nor hearing instrument specialists did a very good job in conveying information about T-coils, directional microphones, and other types of hearing assistive devices. Very few conveyed information about coping and communication strategies generally, or on the job. Few also administered some sort of standardized self-report scale, either before or after the hearing aid was dispensed. Without this kind of information, it is not possible to develop quantitative accountability information or the content necessary for individualized counseling of the client and family. In a way, it matters little how many degrees a hearing aid dispenser has; if he/she does not incorporate the additional information obtained in routine clinical practice, it might as well be non-existent.
It is likely that people would express more satisfaction with the services they received from any hearing aid dispenser had more extensive and intensive services aural rehabilitation been provided them. For the most part, and for most people, we believe that this can be provided within a routine group hearing aid orientation program, as recommended by an SHHH position paper. There is no magic to this; we know that hearing aid users can benefit from additional counseling and a group A/R program (Kochkin, 1999; reviewed in Ross, 1999). Current marketing and clinical trends, however, suggest a future where even less follow-up services and information will be provided rather than more. Hearing aids purchased via the internet is one example of how the product and aural rehabilitation services can be disconnected (as reviewed in another SHHH position paper). Clearly, consumers will have to be both more knowledgeable and more assertive if they are to ensure that they receive the kinds of information and services necessary to help them reduce the total impact of a hearing loss on their lives.
This project was a collaborative effort of the Rehabilitation Research and Training Center RRTC) for Persons who are Hard of Hearing or Late Deafened, located in San Diego, and the Rehabilitation Engineering Research Center Center (RERC), located at the Lexington School for the Deaf in NYC. The RRTC and RERC are funded by the US Department of Education, National Institute on Disability and Rehabilitation Research, to learn more about how individuals adjust to their hearing loss, including their use of assistive listening technology.
* Director of Research, Rehabilitation Research Training Center, San Diego
** Rehabilitation Engineering Research Center, Lexington School for the Deaf