1. MarkeTrak VII: New Opportunities for Promoting Hearing Solutions Sergei Kochkin, Ph.D.

2. Introduction Altruistic goal of the BHI is to Bring the gift of better hearing to millions of Americans.Altruistic goal of the BHI is to Bring the gift of better hearing to millions of Americans. To do this we need to:To do this we need to: –Elevate the importance of hearing health in America (general public, medical profession, media). –Increase the number of people seeking a hearing solution EARLIER in their life. –Partner with the hearing health industry to translate National initiatives into local initiatives.

3. Overall Agenda Part I : Review MarkeTrak VII findings in detail:Part I : Review MarkeTrak VII findings in detail: –Impact of hearing loss on income –21 year trends –Customer satisfaction with hearing aids in the digital age –Why adults with hearing loss choose not to adopt hearing aids –Including why adults return hearing aids –Why children with hearing loss choose not to use hearing aids As we review this data: ask how can I turn this problem, obstacle, misinformation, consumer disappointment, etc into an opportunity?As we review this data: ask how can I turn this problem, obstacle, misinformation, consumer disappointment, etc into an opportunity?

4. Overall Agenda Part II – Integrating national and local promotion of hearing solutions.Part II – Integrating national and local promotion of hearing solutions. Review the current BHI : mission, strategies, tactics for promoting hearing solutionsReview the current BHI : mission, strategies, tactics for promoting hearing solutions Explore ways of promoting hearing solutions based on:Explore ways of promoting hearing solutions based on: –MarkeTrak research –Knowledge of impact of hearing loss on quality of life –Integrate National with local initiatives

5. www.betterhearing.org

6. Redesigned HHP website www.betterhearing.org/professionals

7. Redesigned HHP website

8. MarkeTrak Methodology

9. Method National family opinion panelNational family opinion panel –80,000 households –Balanced to 9 key census variables –Used since 1984 starting with HIA survey. –MarkeTrak I – Knowles 1988-2003 –MarkeTrak VII - Sponsored by Knowles Electronics at BHI 2004. –Does not include institutional settings. Screening Question – Phase I (11/2004)Screening Question – Phase I (11/2004) –Does anyone in your household have a hearing difficulty in one or both ears without the use of a hearing aid?

10. Method Screening QuestionsScreening Questions –Physician screening for hearing loss during last physical within last six months. –Self, Spouse, Other, Child (Under age 18), Dependent 18-22. Hearing aid ownerHearing aid owner Non-ownerNon-owner –15,947 hearing-impaired individuals –66% response rate

11. Method Detailed Survey - Phase II (1/2005)Detailed Survey - Phase II (1/2005) –3,000 hearing aid owners –3,000 adult non-owners –Response rate 75% & 77% Detailed Survey – Phase III (5/2005)Detailed Survey – Phase III (5/2005) –475 parents of children/dependents with untreated hearing loss –Included essays from parents

12. Impact of Untreated Hearing Loss on Household Income (Oct 2005 HR)

13. Objective Research has established link between hearing loss and:Research has established link between hearing loss and: Unemployment Unemployment Underemployment (salary & position) Underemployment (salary & position) Educational achievement Educational achievement Primarily profound hearing loss population.Primarily profound hearing loss population.

14. Objective Need for understanding impact of untreated hearing loss in employment and scholastic situations for typical hearing loss profile since majority of people with hearing loss are not deaf.Need for understanding impact of untreated hearing loss in employment and scholastic situations for typical hearing loss profile since majority of people with hearing loss are not deaf. Support consumer educational objectives Support consumer educational objectives Secure needed support services for children Secure needed support services for children Support tax-credit initiative Support tax-credit initiative To get media attention To get media attention

15. Method MarkeTrak VII database from National Family Opinion Panel:MarkeTrak VII database from National Family Opinion Panel: 1,891 households – aided (head of household or spouse) 1,891 households – aided (head of household or spouse) 1,954 households – unaided (head of household or spouse) 1,954 households – unaided (head of household or spouse) 39,420 households – no hearing loss (head of household and spouse) 39,420 households – no hearing loss (head of household and spouse)

16. Method Household income predicted with following variables (which were related to hearing aid ownership):Household income predicted with following variables (which were related to hearing aid ownership): Hearing loss - factor analysis score Hearing loss - factor analysis score Gallaudet Scale, Gallaudet Scale, Number of ears impaired, Number of ears impaired, Subjective hearing loss, Subjective hearing loss, Unaided abbreviated profile of hearing aid benefit). Unaided abbreviated profile of hearing aid benefit). Hearing loss measure expressed as deciles taking the value 10% (mild) to 100% (profound). Normal hearing coded as none. Hearing loss measure expressed as deciles taking the value 10% (mild) to 100% (profound). Normal hearing coded as none.

17. Method Household income predicted with following variables (Continued):Household income predicted with following variables (Continued): Household designation (7 point classification of household composition) Household designation (7 point classification of household composition) Marital status (2 point classification) Marital status (2 point classification) Age (12 brackets) Age (12 brackets) Geography ( 9 regions) Geography ( 9 regions) Market size (range from 2 million) Market size (range from 2 million) Group (aided, unaided, normal) Group (aided, unaided, normal)

18. Method Analysis of variance:Analysis of variance: All variables significant at p<.0001 level All variables significant at p<.0001 level Hearing loss by group interaction significant at p<.0001 level indicative of different income slopes as a function of hearing loss. Hearing loss by group interaction significant at p<.0001 level indicative of different income slopes as a function of hearing loss. Least square household income means calculated (see next chart) Least square household income means calculated (see next chart)

19. Hearing Less Means Earning Less Mild Moderate Severe Unaided $23,000

20. But, Use of Hearing Aids Cuts Income Loss in Half Mild Moderate Severe Unaided Aided $12,000

21. Linear (smoothed) relationship between household income and hearing loss Unaided household income = :Unaided household income = : $53.5k - $2.25k (for every decile of hearing loss). $53.5k - $2.25k (for every decile of hearing loss). Aided household income = ;Aided household income = ; $54.1k - $1.13k (for every decile of hearing loss). $54.1k - $1.13k (for every decile of hearing loss). While both treated and untreated hearing loss groups show deterioration of income as their hearing loss worsens the income decline is cut in half for hearing aid owners. For example, the difference between decile 1 (mild) and decile 10 (profound) incomes is as follows:While both treated and untreated hearing loss groups show deterioration of income as their hearing loss worsens the income decline is cut in half for hearing aid owners. For example, the difference between decile 1 (mild) and decile 10 (profound) incomes is as follows: Unaided income differential - $20,200 Unaided income differential - $20,200 Aided income differential - $10,200 Aided income differential - $10,200

22. Use of Hearing aids Increases Income Depending on Severity of Hearing Loss

23. Simulation of income loss Currently 24 million people with admitted hearing loss, who do not use hearing aids in the U.S.Currently 24 million people with admitted hearing loss, who do not use hearing aids in the U.S. Non-owner population segmented into hearing loss decile group:Non-owner population segmented into hearing loss decile group: Non-owner hearing loss significantly lower than hearing aid owner population hearing loss. Non-owner hearing loss significantly lower than hearing aid owner population hearing loss. Cross multiplying population size by income differential:Cross multiplying population size by income differential: Estimated loss in income due to untreated hearing loss. Estimated loss in income due to untreated hearing loss. Estimated Federal taxes not realized due to untreated hearing loss assuming 15% tax bracket (simplified). Estimated Federal taxes not realized due to untreated hearing loss assuming 15% tax bracket (simplified).

24. Simulated household income loss and unrealized Federal Taxes from non-aided households Hearing Loss (Decile) Current HL DistributionPopulation Size (Millions) Annual Lost Income ($Billions) Annual unrealized Federal Taxes ($Billions) 10%18.1%4.36$7.36$1.10 20%17.0%4.09$11.46$1.72 30%14.6%3.53$13.81$2.07 40%12.0%3.90$15.92$2.19 50%10.8%2.59$15.92$2.39 60%08.1%1.95$14.16$2.12 70%06.8%1.63$13.64$2.05 80%05.7%1.38$13.11$1.97 90%04.2%1.00$10.61$1.59 100%02.8%0.67$7.80$1.17 Total100%24.08$122.4$18.4

25. Conclusions & Commentary The greater the hearing loss the greater the decline in household income.The greater the hearing loss the greater the decline in household income. On average, the use of hearing aids would appear to mitigate income loss by 50%.On average, the use of hearing aids would appear to mitigate income loss by 50%. For sensitivity analysis one can assume no impact on bottom 30% of population with hearing loss. No matter what cut-off is accepted the impact on household income and unrealized Federal taxes will be significant.For sensitivity analysis one can assume no impact on bottom 30% of population with hearing loss. No matter what cut-off is accepted the impact on household income and unrealized Federal taxes will be significant. The diverging income profiles (e.g. interactive slopes) of aided and unaided households leads one to conclude that there is a probable positive causal relationship between hearing loss treatment and household income.The diverging income profiles (e.g. interactive slopes) of aided and unaided households leads one to conclude that there is a probable positive causal relationship between hearing loss treatment and household income.

26. 21 Year Trends July 2005 Hearing Review

27. Hearing Loss Population has doubled since 1984 and will reach 41 million by 2025

28. Hearing instrument adoption rates are improving

29. Hearing loss population 1989-2004. Active* hearing instrument users and non-owners. * Note: Active user is defined as a hearing instrument owner who uses their hearing instruments even if only once a year.

30. Binaural penetration has nearly peaked 30

31. Physician screening for hearing loss is still declining

32. Third-party payment trend is flat but VA is growing

33. Average out-of-pocket retail price paid by consumer (includes free, direct mail hearing aids, & all third-party discounts but excludes VA fittings) --- close to inflation.

34. Some evidence that HIS fittings are increasing (as perceived by the consumer)

35. Hearing instrument fittings by source of distribution as perceived by the consumer ranked in order of 2004 fittings * Note: In the 2004 MarkeTrak hearing Aid store was changed to hearing aid specialist office.

36. U.S. overall customer satisfaction trends for hearing instruments 1-4 years old. Note: In 2004 the MarkeTrak scale was changed to include somewhat satisfied and somewhat dissatisfied.

37. U.S. overall customer satisfaction trends for new hearing instruments (< 1 year)

38. Average age of hearing instruments is increasing Mean age of instruments: 1991 = 3.1 yrs 1994 = 3.7 yrs 1997 = 3.8 yrs 2000 = 3.8 yrs 2004 = 4.5 yrs

39. First -time user rate is improving

40. Average age of new hearing instrument users is increasing

41. And so is household income as digital sales penetration passes 90%

42. The opportunity is still below retirement age

43. Hearing instrument adoption rates highly related to age This would make sense if hearing loss was perfectly correlated with age. Subject of special Childrens MarkeTrak

44. Trend Summary Population admitting HL grew to 31.5 million.Population admitting HL grew to 31.5 million. Hearing aid adoption rate – a stubborn 23%Hearing aid adoption rate – a stubborn 23% Major increases in baby boomer and 75+ populations.Major increases in baby boomer and 75+ populations. Official Press Indices:Official Press Indices: –Generation Y & Children (0-28) – 2% –Children (<18 ) - (1.4 million) –Generation Xers (ages 29-40) – 7.4% –Baby Boomer (ages 41-59) – 14.6% –Silent Generation (60+) – 29%

45. Trend Summary Physician screening 12.9% (declining).Physician screening 12.9% (declining). New User ProfileNew User Profile –New user rate still low (39% trending upward) –Average age 70 years of age (trend toward older). –Average income ($56,000 trending upward) 6/10 people with HL are male – though female population increased (15%).6/10 people with HL are male – though female population increased (15%).

46. Trend Summary Binaural growth maxed out at 74% (86% for bilateral loss patients).Binaural growth maxed out at 74% (86% for bilateral loss patients). 10% perceived reduction in use of audiologist for HA fitting.10% perceived reduction in use of audiologist for HA fitting. Highest growth segments:Highest growth segments: –Veterans Administration –Internet and mail sales Out-of-pocket costs of HA to consumer at about the rate of inflation.Out-of-pocket costs of HA to consumer at about the rate of inflation. Average age of instrument 4.5 years (trending upward) – could reduce sales w/o new user rate improvement. Average age of instrument 4.5 years (trending upward) – could reduce sales w/o new user rate improvement.

47. Trend Summary 1.23 million people with hearing aids in drawer.1.23 million people with hearing aids in drawer. Customer satisfaction improving:Customer satisfaction improving: 73% for HI <4 years 73% for HI <4 years 78% for HI <1 year 78% for HI <1 year Due to 2 factors: Due to 2 factors: 50% digital penetration last 5 years 50% digital penetration last 5 years Change in satisfaction scale (somewhat) Change in satisfaction scale (somewhat)

48. Customer Satisfaction with Hearing Instruments in the Digital Age September 2005 Hearing Journal

49. Overall indices of customer satisfaction with hearing instruments (H.I. < 6 years of age).

50. Customer Satisfaction is Highly Related to $$$ Spent per 1% Improvement in Hearing Disability Where % change = (benefit/unaided APHAB)

51. Overall Customer Satisfaction as a Function of Price and Hearing Disability Improvement (Statistical Model) Price Hearing disability improvement (%) Overall Customer Satisfaction (%) R 2 =.86

52. Key customer satisfaction ratings by age of hearing instrument.

53. Percent of current hearing instrument users reporting improved quality of life due to hearing instruments (H.I. < 6 years)

54. Customer satisfaction with hearing instrument product features (H.I. < 6 years of age).

55. Customer satisfaction with signal processing and sound quality (H.I. < 6 years of age).

56. Customer satisfaction with hearing instruments in selected listening situations (H.I. < 6 years of age).

57. Impact of improving multiple environmental listening utility (MELU) on overall satisfaction; Hearing instruments < 6 years (n=1,368)

58. Customer satisfaction with hearing instrument hearing healthcare provider (H.I. < 6 years of age)

59. Satisfaction Summary Customer satisfaction improving:Customer satisfaction improving: 73% for HI <4 years 73% for HI <4 years 78% for HI <1 year 78% for HI <1 year Due to 2 factors: Due to 2 factors: 50% digital penetration last 5 years 50% digital penetration last 5 years Change in satisfaction scale (somewhat) Change in satisfaction scale (somewhat) Only 44% of consumers will repurchase their current brand of hearing aids when it is time to replace.Only 44% of consumers will repurchase their current brand of hearing aids when it is time to replace. Satisfaction with HHP is 92%. When something goes wrong it is not their fault it is the product.Satisfaction with HHP is 92%. When something goes wrong it is not their fault it is the product.

60. 1.23 million people with hearing aids in drawer; thats 1/6 owners. Defined as 0 hours per year usage.Defined as 0 hours per year usage. Huge unused hearing aid population.Huge unused hearing aid population. –1.23 million people –1 in 6 users Half of them are new hearing aids (<1-5 years old)Half of them are new hearing aids (<1-5 years old) And consider of all HA:And consider of all HA: –61% use them more than 4 hours per day. –26% < 1 hour per day. 60

61. HA in The Drawer Half of hearing aids in the drawer represent a possible opportunity for upgrade (>5 years).Half of hearing aids in the drawer represent a possible opportunity for upgrade (>5 years). Half of hearing aids in the drawer are < 5 years old:Half of hearing aids in the drawer are < 5 years old: –An Albatross around our neck according to U.S. World and News Report –Most likely due to top 5 reasons measured in MarkeTrak V (2000): Poor benefit or utilityPoor benefit or utility Poor performance in noisy situationsPoor performance in noisy situations Poor fit and comfortPoor fit and comfort Negative side effectsNegative side effects Cost of repairsCost of repairs

62. Reasons for Non-Use #1. Poor benefit (30%) - 268,507#1. Poor benefit (30%) - 268,507 When ______sold me the H.A., I was confident it would help me hear better. When I received it and wore it every day, it did not make my hearing any better. So, I dont wear the HA and feel like I wasted my money. I tried to return it and the person did not seem to want to help me. I am quite dissatisfied with the whole experience.

63. Reasons for Non-Use #2. Background noise (25%) - 229,383#2. Background noise (25%) - 229,383 I dont wear my H.A. because I need it at a dance, restaurants, and large groups. All the H.A. does is increase all sound including background sounds. No help.

64. Reasons for Non-Use #3. Fit & Comfort (19%) - 169,431#3. Fit & Comfort (19%) - 169,431 Its hard to keep it in my ear. I travel for business a lot and cant risk it falling out of my ear.

65. Satisfaction Rankings 45 subjective evaluations ranked by average mean score.45 subjective evaluations ranked by average mean score. Satisfaction segments color coded.Satisfaction segments color coded. Is somewhat satisfied really acceptable?Is somewhat satisfied really acceptable? Satisfaction ratings actually lower when you add Very satisfied and Satisfied and then compare to previous MarkeTrak surveys.Satisfaction ratings actually lower when you add Very satisfied and Satisfied and then compare to previous MarkeTrak surveys.

66. Detailed Positive Satisfaction in Ascending Order (#1-9)

67. Detailed Positive Satisfaction in A Ascending Order (#10-18)

68. Detailed Positive Satisfaction in Ascending Order (#19-27)

69. Detailed Positive Satisfaction in A Ascending Order (#28-36)

70. Detailed Positive Satisfaction in Ascending Order (#37-45)

71. Factors Correlated with Digital HIA statistics demonstrate 50% digital penetration previous 5 years.HIA statistics demonstrate 50% digital penetration previous 5 years. MarkeTrak survey presents consumer with a number of product features for which consumer responds:MarkeTrak survey presents consumer with a number of product features for which consumer responds: –Yes, No, Not sure –HA purchased last 5 years –MarkeTrak consumer indicates – 47% digital. Compare Yes with No.Compare Yes with No.

72. Factors Correlated with Digital One negativeOne negative –Ease of volume adjustment (-11%) 20% + difference:20% + difference: –Comfort with loud sounds 15-19% + difference15-19% + difference –Sound quality (fidelity) –Whistling/feedback –Workplace –Use in noisy situations –Wind noise

73. Factors Correlated with Digital 11-14% + difference11-14% + difference –Soft sounds audible –Telephone and cellphone –Clarity of sound –Sound of voice –Natural sounding –Chewing/swallowing –Overall satisfaction –Localization of sound –Leisure activities

74. Satisfaction & HL Severity User population divided into Quintiles based on factor scores of:User population divided into Quintiles based on factor scores of: –# ears impaired –Perception of HL –Unaided APHAB (with exception of AV) –Gallaudet Scale Difference scoresDifference scores –Quintile 1 (bottom 20% on subjective hearing loss) –Quintile 5 (Top 20% on subjective hearing loss)

75. Largest Differences 25% + difference25% + difference –Cell phone 15-19% difference15-19% difference –Comfort with loud sounds –Able to hear soft sounds –School/classroom usage –Wind noise –Large Group –Telephone –Concert/movie –Directionality –Listening to Music 11-14% difference11-14% difference –TV –Place of worship –Leisure activities –Whistling/feedback –Workplace –Use in noisy situations –Richness sound –Restaurant –Car –Outdoors –Natural sounding

76. Hearing Instrument Improvements Sought by Consumers MarkeTrak VI 2002

77. Hearing Aid Improvements Sought by Current Hearing Aid Owners (n=2,428) (Highly desirable scores =4-5 on 5 point scale)

78. Hearing Aid Improvements Sought by Current Hearing Aid Owners (n=2,428) (Desirable scores =4-5 on 5 point scale)

79. MarkeTrak VII: Obstacles to Hearing Aid Adoption Among Adult Non-users in the U.S. April 2007 Hearing Journal

80. Introduction Hearing aid adoption rate stubborn at about 20%.Hearing aid adoption rate stubborn at about 20%. Growth to 23% penetration due to Internet and VA.Growth to 23% penetration due to Internet and VA. Known serious consequences of untreated hearing loss.Known serious consequences of untreated hearing loss. Why do so many people delay or avoid amplification?Why do so many people delay or avoid amplification? –23 million adults –1.5 million children/dependents <age 23

81. Method 3,000 adult non-adopters from MarkeTrak VII database3,000 adult non-adopters from MarkeTrak VII database 2,300 responded to 7 page survey2,300 responded to 7 page survey 64 reasons why they dont use hearing aids.64 reasons why they dont use hearing aids. Reasons for return if tried HAReasons for return if tried HA Factors that might entice themFactors that might entice them Focus on top 50% of people with hearing loss.Focus on top 50% of people with hearing loss.

82. HA owners versus non-owners Not terribly dissimilar.Not terribly dissimilar. Hearing aid owners greater hearing loss and younger.Hearing aid owners greater hearing loss and younger. –Bilateral loss (61% versus 83%) –Perceived mild hearing loss (39% versus 7%) –Ability to hear whisper across a room without visual cues (16% versus 5%) –Modal unaided APHAB (40-49% versus 50-59%)

83. Aided versus unaided populations by hearing loss decile.

84. Hearing aid adoption rates by hearing loss decile. 83% hearing aid owners 39% non-adopters

85. Non-adopters New hearing aid user is age 70.New hearing aid user is age 70. Non-adopter ages vary from a low of age 56 (decile 1) to 61 (deciles 6+).Non-adopter ages vary from a low of age 56 (decile 1) to 61 (deciles 6+). Why such a large age difference?Why such a large age difference? Lets control for hearing loss & then look at adoption rates.Lets control for hearing loss & then look at adoption rates.

86. Hearing aid adoption by HL decile controlling for age; evidence for the effects of age stigma.

87. Percent of hearing-impaired evaluated for hearing loss and recommendations received.

88. Number of positive recommendations for hearing aids compared to negative recommendations by professional (1984-2004).

89. Hearing Screening Problem resolution begins with problem identification.Problem resolution begins with problem identification. 50% of 23 million adult non-adopters never had their hearing professionally tested.50% of 23 million adult non-adopters never had their hearing professionally tested. Huge progress when comparing positive to negative recommendations from professionals.Huge progress when comparing positive to negative recommendations from professionals.

90. Hearing solution adoption model BHI Mission Specific drivers: Internal stigma External stigma Influencers Product perception Service perception Physicians attitude Fear Physical impairment Stages of denial Perceived loss of communication performance & need Attitude toward getting hearing solutions Behavior intent/ Hearing health solutions Predisposition Price & hearing health solution delivery model Drivers: Perceived age Communication situations Change & emotional reaction Social comparison Alternative solutions General moderators: Socio economic status Health Personality Lifestyle Social network Emotional state Medical care Surgery Aural rehab Cochlear Impl. Hearing Aids ALDs Behavior Modif. 90

91. Reasons for non-adoption of hearing aids: Top 5 deciles of hearing loss

92. Reasons for not-adoption of hearing aids Factor = Hearing Loss

93. Reasons for not-adoption of hearing aids Factor = financial

94. Median income comparing people who state they can and cannot afford hearing aids controlling for age.

95. Reasons for not-adoption of hearing aids Factor = Minimization or lack of need

96. Reasons for not-adoption of hearing aids Factor = Attitudes towards hearing aids

97. Reasons for not-adoption of hearing aids Factor = Attitudes towards hearing aids (Cont.)

98. Reasons for not-adoption of hearing aids Factor= Knowledge & experience

99. Reasons for hearing aid return (n=237)

100. Reasons for not-adoption of hearing aids Factor = Stigma

101. Reasons for not-adoption of hearing aids Factor = Professional recommendations

102. Reasons for not-adoption of hearing aids Factor= Social network recommendations

103. The Cost of Negative Word-of-Mouth One out of four people with serious hearing loss dont purchase hearing aids due to bad experiences of their friends with hearing aids.One out of four people with serious hearing loss dont purchase hearing aids due to bad experiences of their friends with hearing aids. 19% of total 23 million adults dont purchase because of other hearing aid owners.19% of total 23 million adults dont purchase because of other hearing aid owners. Thats 4.4 million peopleThats 4.4 million people Assuming 1.75 hearing aids each over 5 purchase cycles of 5 years (their average age is now 60)Assuming 1.75 hearing aids each over 5 purchase cycles of 5 years (their average age is now 60) Thats potentially 38,200,000 hearing aids not purchased over their lifetime….if we cannot overcome these negative perceptions based on REAL experiences (@$1,800 retail price)Thats potentially 38,200,000 hearing aids not purchased over their lifetime….if we cannot overcome these negative perceptions based on REAL experiences (@$1,800 retail price) Thats 19 years of lost sales for the whole US!Thats 19 years of lost sales for the whole US! Thats $69 billion in lost revenue!Thats $69 billion in lost revenue!

104. Reasons for not-adoption of hearing aids Factor = Trust

105. Hearing aid adoption intent by hearing loss decile.

106. Positive impact of hearing aid enhancements on the total hearing loss population currently not using hearing aids.

107. Reasons for intent to purchase hearing aids

108. Unamplified Children & Dependents Are a million dependents in America being left behind due to hearing loss? 9/2007 HR

109. Introduction Only 12% of children (ages 0-17) with admitted hearing loss use hearing aids.Only 12% of children (ages 0-17) with admitted hearing loss use hearing aids. –Equates to 1.2 million children –And another.3 million dependents ages 18-21 –JAMA (1998) quantified that 15% of children 6-19 had at least a low or high frequency hearing loss of 16 dB or more. Do they all have transitory hearing loss due to ear infections?Do they all have transitory hearing loss due to ear infections? If not why dont they use hearing aids especially given the importance of hearing in speech development?If not why dont they use hearing aids especially given the importance of hearing in speech development?

110. Method Queried MarkeTrak VII database:Queried MarkeTrak VII database: –Children under age 18 –Dependents up to age 21 –Sample 475 –52% response rate to survey SurveySurvey –Subjective survey questions with emphasis on reasons why hearing aids not used. –Essay questions from parents Nature of hearing lossNature of hearing loss Quality of life impactQuality of life impact Interventions for childs hearing lossInterventions for childs hearing loss

111. Method ExclusionsExclusions –Children/dependents with transitory ear infections (4%) –And with Tinnitus but NO hearing loss (5%) Thus 91% of unamplified dependents have a hearing loss according to their parents.Thus 91% of unamplified dependents have a hearing loss according to their parents.

112. Some Comparisons Factors HA Owners Non-owners Median age 1312 Bilateral % 7844 Subjective HL – Moderate > 79%50% Gallaudetwhisper73%83% HH income $31.3$$43.8

113. Hearing loss testing & diagnosis First hearing test (Mode 4-6 years old)First hearing test (Mode 4-6 years old) HL first identifiedHL first identified –ENT office (21%) –Pediatricians office (19%) –Audiologist office (17%) –School 18% Age of first diagnosis (Mode 4-6 years old)Age of first diagnosis (Mode 4-6 years old) Main prompting for hearing test (Parental concern – 37%; family doctor – 25%)Main prompting for hearing test (Parental concern – 37%; family doctor – 25%)

114. Follow-up by Parents (Multiple response)

115. Impact of hearing loss on quality of life

116. Quality of Life Impact Quotes She gets very frustrated and wants to give up because she isnt like other people. (#2494762, parent of a 17- year old girl with perforated ear drum that required surgery and resulted in subsequent scarring and moderate hearing loss).She gets very frustrated and wants to give up because she isnt like other people. (#2494762, parent of a 17- year old girl with perforated ear drum that required surgery and resulted in subsequent scarring and moderate hearing loss).

117. Quality of Life Impact Quotes Hearing loss had dramatic negative effects on my daughters social development, making and keeping friends and generally feeling good about herself. Professional at the time said there did not appear to be any reason for the hearing loss and that she just could not hear and that a hearing aid would not help. Her hearing loss isolated her almost completely. She received classroom adjustment but in the end she dropped out of school then dropped out of job corps. (#1772639, parent of a dependent age unknown, with profound hearing loss in one ear according to parent).Hearing loss had dramatic negative effects on my daughters social development, making and keeping friends and generally feeling good about herself. Professional at the time said there did not appear to be any reason for the hearing loss and that she just could not hear and that a hearing aid would not help. Her hearing loss isolated her almost completely. She received classroom adjustment but in the end she dropped out of school then dropped out of job corps. (#1772639, parent of a dependent age unknown, with profound hearing loss in one ear according to parent).

118. Quality of Life Impact Quotes I noticed I had to yell really loud for him to hear me if I were to ask him a question. A lot of time nobody wants to talk to him cause if they dont talk loud then when they ask him a question and he cant hear so he doesnt answer them and they think he is ignoring them. Have not sought any solution for childs hearing. Doctor said he could adjust. Maybe a wax build up. He would check it at a later date. I dont think my child would be comfortable with a hearing aid in his ear. He might lose it. (#2136004, parent of a 4 year old boy who the parent describes with moderate hearing loss; child cannot hear normal speech across a room).I noticed I had to yell really loud for him to hear me if I were to ask him a question. A lot of time nobody wants to talk to him cause if they dont talk loud then when they ask him a question and he cant hear so he doesnt answer them and they think he is ignoring them. Have not sought any solution for childs hearing. Doctor said he could adjust. Maybe a wax build up. He would check it at a later date. I dont think my child would be comfortable with a hearing aid in his ear. He might lose it. (#2136004, parent of a 4 year old boy who the parent describes with moderate hearing loss; child cannot hear normal speech across a room).

119. Reasons why children with hearing loss do not use hearing aids

120. Minimization of HL Many parent essays did not agree with the subjective evaluations of their childs HL.Many parent essays did not agree with the subjective evaluations of their childs HL. The hearing loss was discovered from my daughters speech. She doesnt talk as well as she should. The family doctor has her going to Easter Seals for speech. Hearing testing was mild but not real bad hearing loss (#1557570, parent of 4 year old female) The hearing loss was discovered from my daughters speech. She doesnt talk as well as she should. The family doctor has her going to Easter Seals for speech. Hearing testing was mild but not real bad hearing loss (#1557570, parent of 4 year old female) 120

121. Minimization When you talked to him, he wouldnt answer you or he would say huh? You have to repeat what you say to him. The teacher sets him closer up front of the class. He does not have hearing aids because his hearing isnt that bad yet. (#1595791, parent of dependent age 8 years, with hearing loss described as moderate and inability to hear normal speech across a room w/o visual cues).When you talked to him, he wouldnt answer you or he would say huh? You have to repeat what you say to him. The teacher sets him closer up front of the class. He does not have hearing aids because his hearing isnt that bad yet. (#1595791, parent of dependent age 8 years, with hearing loss described as moderate and inability to hear normal speech across a room w/o visual cues).

122. Minimization Had some difficulty with phonetic based hearing program when in kindergarten and first grade. This hindered confidence in performance in language arts and is still 3 years behind peers. The reason for not using hearing aids is hearing loss is very mild at this time but will be monitored by physicians. (#2339100, parent of 14 year old boy with mild hearing loss)Had some difficulty with phonetic based hearing program when in kindergarten and first grade. This hindered confidence in performance in language arts and is still 3 years behind peers. The reason for not using hearing aids is hearing loss is very mild at this time but will be monitored by physicians. (#2339100, parent of 14 year old boy with mild hearing loss)

123. Professional Recommendations Some parents received conflicting information from two or more professionalsSome parents received conflicting information from two or more professionals Some of the advice would appear to be misinformation. Some professional reasons for NOT getting hearing aids are that hearing aids would not help dependentSome of the advice would appear to be misinformation. Some professional reasons for NOT getting hearing aids are that hearing aids would not help dependent –with high frequency hearing loss (21%), –low frequency hearing loss (22%), or –unilateral loss (42%).

124. Professional Recommendations At approximately 18 months of age I noticed my daughter walked like a drunken sailor. She did not respond if I stood behind her and talked to her. I took her to our pediatricians office. At first he brushed me off. I persisted until he did a basic audio test. She was flat line – the test would have had a bell curve if she could hear. He referred me to an ENT doctor. (#1246561, parent of 9 year old female with mild hearing loss requiring speech therapy).At approximately 18 months of age I noticed my daughter walked like a drunken sailor. She did not respond if I stood behind her and talked to her. I took her to our pediatricians office. At first he brushed me off. I persisted until he did a basic audio test. She was flat line – the test would have had a bell curve if she could hear. He referred me to an ENT doctor. (#1246561, parent of 9 year old female with mild hearing loss requiring speech therapy).

125. Professional Recommendations I was concerned because Steven wouldnt turn to look when a loud noise was made. The pediatrician referred us to have his hearing tested and they say he is hearing within normal ranges. He still does not seem to hear well. For awhile he had fluid in his ears, but now it is gone. He still has a speech delay. (#2220301, parent of 11 year old male with mild hearing loss now home schooled by parents and described as introverted).I was concerned because Steven wouldnt turn to look when a loud noise was made. The pediatrician referred us to have his hearing tested and they say he is hearing within normal ranges. He still does not seem to hear well. For awhile he had fluid in his ears, but now it is gone. He still has a speech delay. (#2220301, parent of 11 year old male with mild hearing loss now home schooled by parents and described as introverted).

126. Stigma One in three indicated that the stigma associated with hearing aids impacted their decision not to pursue hearing aids.One in three indicated that the stigma associated with hearing aids impacted their decision not to pursue hearing aids. Some physicians concurred that the stigma of hearing aids out-weighed the benefit.Some physicians concurred that the stigma of hearing aids out-weighed the benefit. Obstacles to hearing aids:Obstacles to hearing aids: –make dependent or parent embarrassed (22%), –aversion with wearing the devices in front of friends (20%), –peers make fun of the dependent with hearing aids (19%), –discriminatory treatment (19%), –too noticeable (18%), –make the dependent look disabled (17%) or mentally slow (14%).

127. Stigma As a high school student she doesnt want that stigma of wearing a hearing aid. Her hearing loss has not affected her schooling, friendships, etc. that greatly. (#1073992, parent of 16 year old female with ear infections as child, adenoid removal, PE tubes, ear drum perforations requiring surgery that did not heal properly, described as moderate hearing loss by parent).As a high school student she doesnt want that stigma of wearing a hearing aid. Her hearing loss has not affected her schooling, friendships, etc. that greatly. (#1073992, parent of 16 year old female with ear infections as child, adenoid removal, PE tubes, ear drum perforations requiring surgery that did not heal properly, described as moderate hearing loss by parent).

128. Stigma His hearing loss is not too severe. He has special seating in school which helps him pay attention more. Its difficult with new relationships. We must tell people to speak to him face-to-face or on left side. Family was saddened by many surgeries but we speak slow and clear, and louder than normal. He gets very frustrated often. He doesnt want hassle at this time with hearing aids. Maybe when young adult he may change mind. (#1888350, parent of 8 year -old described as moderate hearing loss in one ear by parent).His hearing loss is not too severe. He has special seating in school which helps him pay attention more. Its difficult with new relationships. We must tell people to speak to him face-to-face or on left side. Family was saddened by many surgeries but we speak slow and clear, and louder than normal. He gets very frustrated often. He doesnt want hassle at this time with hearing aids. Maybe when young adult he may change mind. (#1888350, parent of 8 year -old described as moderate hearing loss in one ear by parent).

129. Financial 28% indicated financial barriers28% indicated financial barriers Do not buy hearing aids mostly due to the high cost and we cant afford them. I hate to deny his need of them if we cant afford them. We have a hard time paying bills, but yet we never seem to qualify for financial assistance because we make too much money. (#2320407, parent of 8 year- old male with moderate hearing loss according to parent)Do not buy hearing aids mostly due to the high cost and we cant afford them. I hate to deny his need of them if we cant afford them. We have a hard time paying bills, but yet we never seem to qualify for financial assistance because we make too much money. (#2320407, parent of 8 year- old male with moderate hearing loss according to parent)

130. Conclusions Optimum communication access by dependent, not just in the classroom, is critical for language competence, cognitive development, social and emotional well- being, academic competence and ultimately their development as productive citizens.Optimum communication access by dependent, not just in the classroom, is critical for language competence, cognitive development, social and emotional well- being, academic competence and ultimately their development as productive citizens. When communication access is denied through misinformation, minimization, neglect, stigma or where there are financial barriers to communication access, then it is likely that the dependent with untreated HL will eventually join the ranks of adults with untreated hearing loss leading to a life of underperformance.When communication access is denied through misinformation, minimization, neglect, stigma or where there are financial barriers to communication access, then it is likely that the dependent with untreated HL will eventually join the ranks of adults with untreated hearing loss leading to a life of underperformance.

131. Concluding Questions This study raises more questions then it answers:This study raises more questions then it answers: –While newborn screening tests are successful is there adequate follow-up when the infant fails the test and the parent does not return with the child for detailed testing in a timely fashion? (historically 50% did not follow-up) –Are pediatricians adequately trained to identify childhood hearing loss? –Are too many children with mild or moderate hearing loss falling through the cracks? e.g. they dont fit existing paradigms of hearing-impairment. –Are parents receiving misinformation regarding their childs hearing loss? –Is there too much HL minimization and denial on the parts of parents? –In such a rich nation how can financial need be a barrier to care for children?

132. Opportunities

133. Motivation Key reason for purchasing is recognition that hearing loss has gotten worse.Key reason for purchasing is recognition that hearing loss has gotten worse. 50% need testing50% need testing Concerted effort to test either objectively or subjectively (e.g. BHI Quick Hearing Check).Concerted effort to test either objectively or subjectively (e.g. BHI Quick Hearing Check). –Physician offices –Free hearing checks by HHP in and outside of office. Problem recognition is a critical precursor to problem resolution.Problem recognition is a critical precursor to problem resolution.

134. Professional Recommendations Significant improvement over last 20 years.Significant improvement over last 20 years. Continued physician education needed:Continued physician education needed: –Efficacy of hearing aids –Improved customer satisfaction –Evidence based critical –Need hearing testing as part of best practice protocol for family doctor.

135. Surgery and HA Trial 12% of population may not be candidates for hearing aids.12% of population may not be candidates for hearing aids. Thats 2.75 million peopleThats 2.75 million people Close to 1 out of 10 tried and rejected hearing aids and found:Close to 1 out of 10 tried and rejected hearing aids and found: –Insufficient benefit –Problems in noise 40% of most serious hearing loss group (decile 10) found that HA did not help their hearing loss.40% of most serious hearing loss group (decile 10) found that HA did not help their hearing loss.

136. Attitudes towards hearing loss People with serious hearing loss still believe:People with serious hearing loss still believe: –Hearing loss too mild for HA –Many believe their life style precludes need for better hearing. Continued PR on impact of untreated hearing loss especially for younger segments critical to move them toward a solution.Continued PR on impact of untreated hearing loss especially for younger segments critical to move them toward a solution.

137. Misinformation about candidacy Opportunity to correct misinformation on who can be helped with hearing aids.Opportunity to correct misinformation on who can be helped with hearing aids. –High frequency hearing loss –Low frequency hearing loss –Nerve damage – probably sensorineural –Unilateral hearing loss

138. Tinnitus 4 out of 10 also have tinnitus4 out of 10 also have tinnitus May be contraindicative of candidacy or may be an opportunity.May be contraindicative of candidacy or may be an opportunity. For PR purposes need greater understanding of impact of hearing aid usage when a person has tinnitus.For PR purposes need greater understanding of impact of hearing aid usage when a person has tinnitus.

139. Attitudes towards hearing aids Need to demonstrate to this population:Need to demonstrate to this population: –Improved ability to communicate in noise –Reduction in aversiveness of sounds when using hearing aids –Reduction in hassle factor (maybe now with open fit HA) –4.4 million potential users were influenced by other hearing aid owner experiences. –17% have hearing aids in drawer – needs to be reduced because of impact on negative word of mouth advertising. –Benefit has to be increased. 28% absolute benefit28% absolute benefit Translates into 44% problem resolutionTranslates into 44% problem resolution –Need greater utility in various listening situations especially phone, cellphone, and group situations.

140. Finances Significant barrier to two out of three (64%)Significant barrier to two out of three (64%) Evidence that finances NOT a convenient excuse.Evidence that finances NOT a convenient excuse. Initiatives to mitigate this problem critical:Initiatives to mitigate this problem critical: –Tax credit bill –Insurance –Education on available help (e.g. charities, VA, union, flex dollar programs in corporations, etc) 40% indicate greater likelihood of HA trial with tax credit of $500.40% indicate greater likelihood of HA trial with tax credit of $500.

141. Conclusions Model of hearing aid adoption is complex.Model of hearing aid adoption is complex. No one initiative will be enough.No one initiative will be enough. First – person must recognize their loss.First – person must recognize their loss. Second – must recognize loss causes them problems.Second – must recognize loss causes them problems. Third – must believe there is a reasonable probability that visiting a HHP will sufficiently solve their problem.Third – must believe there is a reasonable probability that visiting a HHP will sufficiently solve their problem. Some obstacles are perceptual and some are real.Some obstacles are perceptual and some are real. HIA research on improving consumers journey is a critical step in introducing more people to the world of better hearing.HIA research on improving consumers journey is a critical step in introducing more people to the world of better hearing.

142. Opportunities Demography – demonstrates extent of problem.Demography – demonstrates extent of problem. Challenging common myths about hearing loss (e.g. only an issue of aging).Challenging common myths about hearing loss (e.g. only an issue of aging). Positive customer satisfaction ratings can elevate image of hearing aids and HHP.Positive customer satisfaction ratings can elevate image of hearing aids and HHP. Impact of untreated hearing loss on quality of life (e.g. Income) can motivate younger hearing-impaired.Impact of untreated hearing loss on quality of life (e.g. Income) can motivate younger hearing-impaired. Greater awareness of impact of untreated hearing loss on children.Greater awareness of impact of untreated hearing loss on children. Lack of involvement of MDs – still an important gatekeeper.Lack of involvement of MDs – still an important gatekeeper.

143. Acknowledgment: All MarkeTrak research made possible through a special grant from Knowles Electronics