1. Hearing Aids and Quality of Life Sergei Kochkin, Ph.D. Better Hearing Institute

2. Sad Truth n 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. n No major marketing interventions instituted to leverage these findings by any of the key associations. n 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 n Present executive summary of NCOA Quality of Life study (Ref. 1/2000 Hearing Review) n Some ideas for leveraging the quality of life findings in your practice. n 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 n The incidence of hearing loss in the U.S. is approximately 10% - 31.5 million n Market growth in U.S. low despite positive demographics and improved technology. n Hearing aids still positioned in market place as for old people.

6. Introduction n 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 n Even a few years ago : FDA did not permit quality of life claims in U.S. advertising and marketing.

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

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

12. Method n 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 n Large nationally representative sample: –Individuals with hearing loss n Aided and unaided - 1,500 surveyed each n And their significant other (spouse) n Ages 50 and above

13. Method n Hearing-impaired - 8 page survey n Family member - 4 page survey n Response rate of 79% to mail survey n 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 n 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 n Telephone n Multiple speakers n Television n Background noise n Missed calls/doorbell n Directionality n Ask people to repeat n High frequency sounds n People mumble n Large reverberant rooms n People annoyed by misunderstandings n Avoid social situations n Inappropriate response n Family and friend perceptions n Strain to hear

16. Method Screening Instrument n Significantly correlated (Koike, Hurst & Wetmore 11/94) with objective hearing loss data: n Pure tone (highest) n Air conduction thresholds n Speech discrimination scores (SDS) n Speech reception thresholds (SRT)

17. Method Screening Instrument n 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 n Goal is to discern trends across the five hearing loss groups: aided vs unaided. n 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. 5=average, 3=16%, 7=84% n Or % scores (e.g. % depressed )

19. Analysis n 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) n 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 Is Related to Severity Hearing Loss

24. Demographics: Household Income

25. Demographics: Discretionary Income (%plenty)

26. Demographics: Gender (% Male)

27. Demographics: Employment (% retired)

28. Demographics: Marital Status (% married)

29. Demographics n 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). n No major systemic differences between user & non-user groups.

30. Results Health Status

31. Health Status: Overall self-assessment of health and absence of pain

32. Health Status: Percent Very Good or Excellent

33. Health Status n Did not find significant differences on specific disease states: –Arthritis –High blood pressure –Heart problems

34. Results Social & Solitary Activities

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

36. Activities: Organized social events

37. Activities n 3/5 groups attend senior center more. –Might be related to small age differences between groups. n 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)

38. Results Relationship with Family & Friends

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

40. Lack of Interpersonal Warmth in Relationships (high scores are worse)

41. Low negativity in family relationships (e.g. arguments, tenseness, criticism) (High scores are better)

42. Contacts with friends and family n Found no systematic significant differences on incidence of: –Phone contacts –Meeting in person –Total contacts

43. Results Social Effects

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

45. Social Effects: Stigma e.g. embarrassment wearing hearing aids

46. Social Effects: Overcompensation for hearing loss e.g. Pretend I understand what people say

47. Social Effects: Discrimination Accused of hearing only what they want to hear

48. Social Effects: Difficulty in Communication e.g. Trying to hear in some situations takes more effort than its worth.

49. Social Effects: Safety Concerns from Family Members e.g. Have made mistakes because of hearing loss

50. Social Effects: Non-significant variables n Negative effects of hearing loss on family members. –e.g. I find it exhausting to cope with their needs n Family accommodation of hearing loss. –e.g. I have to use signs and gestures a lot of the time n Withdrawal –e.g. They tend to withdraw from social activities where communication is difficult

51. Social Effects: Non-significant variables n Rejection –e.g. They tend to get left out of social activities because of their hearing loss. n All non-significant variables however, significantly related to degree of hearing loss.

52. Results Emotional Effects

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

54. Emotional Effects: Emotional Instability e.g. Described as: fearful, tense, insecure, unstable, nervous, etc)

55. Emotional Effects: % Depressed Last 12 months

56. Emotional Effects: Depression Symptoms e.g. Tired, lose 10 pounds, insomniac, think of death

57. Emotional Effects: Anger/frustration e.g. I get annoyed and irritated more easily than I used to

58. Emotional Effects: Anger/frustration (Family assessment) e.g. They get annoyed and irritated more easily than they used to

59. Emotional Effects: Paranoia e.g. I am often blamed for things which are not my fault

60. Emotional Effects: Denial e.g. My hearing loss is not as bad as other people say it is.

61. Emotional Effects: Phobias e.g. Speaking in public, going to social outing

62. Emotional Effects: Non-significant Factors n Sense of Confidence n Sense of independence n Incidence of Anxiety –Some indication of higher anxiety symptoms for non-users in 3 groups.

63. Results Cognitive Effects

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

65. Cognitive Effects (Family member perception)

66. Results Personality Differences

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

68. Personality n Active coping style (7 items) n Fatalism (3 items) n Justice (2 items) n Introversion/extroversion (10 items) n intellectual openness (9 items)

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

70. Personality Assessment: External Locus of Control Personality Assessment: External Locus of Control Believe they have little control over the events in their lives.

71. Personality: Self-critical e.g.I dwell on my mistakes more than I should.

72. Respondent & Family Assessment of Benefit of Hearing Aids

73. Respondent & Family Assessment n 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. n 5 point Scale : A lot better to A lot worse n 16 areas assessed. n Analysis : % somewhat better or higher. n Quintiles 1 & 5 presented

74. Perceptions of Hearing Aid Benefit: Respondent & Family (Quintile 1 & 5)

78. Conclusions

79. Conclusions Treatment with hearing aids is related to: n Improved interpersonal relationships with family. n Reduction in hearing loss compensation behaviors. n Reduction in discriminatory behaviors toward the person with hearing loss. n Reduction in anger & frustration. n Reduction in depression & depressive symptoms. n Improved $$ earning power. n Improved emotional stability.

80. Conclusions Treatment with hearing aids is related to: n Reduction in introverted behavior. n Belief that subject is in control of their lives (locus of control). n Reduced paranoid feelings. n Reduced self-criticism. n Enhanced group social activity. n Improved overall-health & pain reduction

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

82. Conclusions n 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.

83. Conclusions n Hearing Health Industry needs to reach younger more active customers with hearing loss. n 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.

84. Conclusions n Best time ever for collaborative market development: –BHI is being rebuilt –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 –Positive demographics.

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

86. Leveraging the Quality of Life Study Findings

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

88. Fundamental Consumer Needs Met with Our Product & Service n To improve speech intelligibility n To improve hearing in all listening situations n To improve communication n To enhance belongingness n To facilitate acceptance n To reduce free-state anxiety n To increase comprehension n To enhance enjoyment of life n To enhance psychological well-being n sometimes even SAVE LIVES

89. Quality of Life Benefits Associated with Hearing Aids n >Interpersonal relationships n <Hearing loss compensation n <Anger & frustration n <Depression n >Earning power n >Emotional stability n <Introversion n >Control of life n <Self-criticism n <Paranoia n >Overall health n >Cognitive functioning n <Discrimination n <Anxiety n <Social phobias n >Social activity

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

91. 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

92. Proposed Actions Become very familiar with the executive summary of the NCOA study 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. Counsel your potential clients on the benefits of hearing aids. Talk about the powerful human benefits. Talk about the powerful human benefits. Spend less time selling technology or size 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 Develop a presentation of the key results (e.g. Powerpoint). Use parts of my Powerpoint presentation if you want

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

94. Proposed Actions n Develop a small quality brochure on the key benefits of hearing aids: Your business Your business Local Association (Hearing HealthCare Alliance of..) Local Association (Hearing HealthCare Alliance of..) National Association (AAA, IHS, ADA, BHI) National Association (AAA, IHS, ADA, BHI) n 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 Part of your counseling protocol Radio/public appearances Radio/public appearances Quotes in direct mail pieces or videos Quotes in direct mail pieces or videos

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

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