>>Ron: Welcome, folks. I'm Ron Leavitt. I want to tell you about a group that we formed 13 years ago called the Oregon Association for Better Hearing (OABH). I was an Oregon State University faculty member and an audiologist at the Corvallis Good Samaritan Hospital. The hearing aid performance information appearing in the newspapers was supplied primarily by hearing aid manufacturers. It is natural to expect that hearing aid manufacturers and sales persons have a built-in bias toward their products. If people are to really learn about what hearing aids can and cannot do, they should have a source of information based upon the real life experiences of people who have actually used the hearing aids. OABH has since become the largest consumer product test group for hearing aids in the Western United States.
Hearing aids selected for testing are limited to those that are purported to incorporate new signal processing technology or useful new features. A given hearing instrument is evaluated by several product testers. Test periods are usually about two weeks in length. Product testers are permitted unlimited office visits for fine tuning of the hearing aids. Product testers report their findings at regular meetings of the Oregon Association for Better Hearing.
To date, some 20 experienced hearing aid users, all of whom are unpaid volunteers, have participated in the product testing. Their ages range from the 20s to the 80s. They have varying degrees of hearing loss ranging from mild to profound. Their backgrounds are varied. They are students, housewives, professionals, and retirees. None of them sell or service hearing aids or have an affiliation with a hearing aid manufacturer. Thus, there is no financial incentive to promote one brand or one model of hearing instrument over another. Our goal is to provide our members with the most unbiased hearing aid performance information possible.
Considering the diversity of our product testers, it is rather amazing that we were able to get 20 people to agree on 15 items associated with hearing aid user satisfaction. These items are documented in a publication entitled, Fifteen Rules for Satisfied Hearing Aid Users.
As mentioned, I am an audiologist and have a private hearing and speech center in Corvallis. I am also a member of the faculty of the Oregon State University Speech Communications Department. With me today is one of the OABH product testers who will be presenting several of the "Fifteen Rules." He is a retired faculty member of the Oregon State University Agricultural Engineering Department and has personal use experience with 27 different hearing aids. I would like to introduce to you at this time, Dean Booster.
>>Dean: Good morning ladies and gentlemen. According to the1993 edition of the New Oxford Dictionary, to "satisfy" means, among other things, (1) fulfilling a person's desires, hopes, and demands, or (2) putting an end to a person's wants or needs. In the case of hearing aid performance, achieving complete user satisfaction is a pretty tall order. Not only do hearing aid users have different hearing losses, they function in different listening environments, and, to further complicate matters, they have different personal likes and dislikes. The Fifteen Rules, by themselves, cannot unconditionally guarantee user satisfaction, but persons following these rules will certainly achieve a greater degree of satisfaction than those who do not.
It is my pleasure to discuss with you six of the Fifteen Rules from the perspective of a hearing aid user. Ron will cover the remaining nine rules from the perspective of an audiologist. The comments that I will share with you today are based on approximately 11 years' experience as a hearing aid user and nearly 10 years as an OABH product tester. During that time, three fundamental truths related to hearing aids and hearing aid users have become evident.
1. The goal of any hearing aid user should be to get the simplest and least expensive hearing instrument that does what the user wants it to do.
2. A particular hearing aid may meet the needs of someone, but no single hearing aid will meet the needs of everyone.
3. User satisfaction is a personal thing. It all depends upon what the user is willing to accept.
There are more than 60 hearing aid manufacturers of consequence in the world market. Collectively, they produce literally hundreds of hearing instrument models from which to choose. Why is it, then, that only about five million individuals in this country have taken advantage of the technology available that could potentially improve their quality of life?
There are numerous reasons, but one that
is oftentimes the most difficult to deal with is denial. Acknowledging
that you have a hearing loss is not easy or pleasant. But, it is the necessary
first step in the long road to better hearing. Unless the individual is
willing to accept the responsibility for dealing constructively with his/her
hearing loss, rehabilitation is not likely to occur.
Some of the potential benefits from using two hearing aids versus one hearing aid are shown below:
• Generally speaking, speech understanding ability deteriorates with the passage of time. Research shows that for persons wearing only one hearing aid, the deterioration rate of the unaided ear is likely to be greater than that of the aided ear over a given period of time.Please keep in mind that an ear with either normal hearing or no hearing at all is not considered aidable.
• Improved speech understanding in noisy environments.
• Improved ability to hear soft sounds and distant speech.
• Improved ability to locate the source or direction from which sounds originate.
Identifying the type and magnitude of a person's hearing loss is of utmost importance in achieving even minimal user satisfaction. The starting point is a medical examination. No matter how sophisticated they may be, hearing aids are not remedies for medically treatable hearing impairments.
A comprehensive audiological evaluation
involves more than just a pure tone air conduction test where you raise
your hand or press a button each time you hear a tone. It involves a battery
of tests. In addition to the pure tone air conduction test, the following
tests are recommended for adults:
The importance of having qualified personnel conduct these tests cannot be over emphasized. The hearing aid dispenser is at least as important as the brand and model of hearing aid in achieving user satisfaction. This must have the appropriate equipment at his/her disposal and possess the knowledge, training, and experience to properly conduct the tests and accurately interpret the test results. As you might expect, the training and skill levels of hearing aid dispensers vary widely.
The minimum education and training requirements for hearing aid dispensers in Oregon are as follows:
For Hearing Instrument Specialists (HIS)
>>Ron: Up to this point, you may be thinking this has been a fairly noncontroversial presentation. But, you can't imagine the amount of trouble these first three rules have given us. For example, the actual amount of amplification being provided by the hearing aid can be determined using the real-ear aided test talked about in Rule Three. We were very surprised last year when the results of a national survey of showed that only 15 percent of the people dispensing hearing aids in this country routinely make use of real-ear aided testing equipment.
Some manufacturers have told us that today's sophisticated hearing aids are far too complex to be performance-tested in the provider's office. They have suggested that all we have to do is follow their fitting instructions and everything will be fine. Our experience has been that following the manufacturer's fitting instructions to the letter more often than not results in hearing aid performance unacceptable to experienced hearing aid users. At a recent OABH meeting, we asked one of our product testers to evaluate the performance of one of the most highly rated, and coincidentally one of the most expensive fully digital hearing aids, in the meeting room environment. The hearing aid had been programmed according to the manufacturer's recommendations and using product tester's audiological evaluation data. When asked how it performed, she said she could not tell if the hearing aid was turned on or not. Numerous programming adjustments were required to raise the performance to an acceptable level to meet the product tester's listening needs and preferences.
Do not let people tell you these sophisticated
hearing aids cannot be tested with conventional testing equipment. They
can, and they must be if your goal is to have the user achieve maximum
satisfaction from their use.
Vanity often plays a large role when the user selects a hearing aid style. Manufacturers would like you to believe that "smaller is better" and place added emphasis on completely-in-the-canal (CIC) style instruments. This tends to promote the idea that "People will not know I am hearing impaired if they cannot see my hearing aids." Our experience, from the standpoint of trouble-free hearing aid operation, is that smaller is not always better.
As the style name suggests, completely-in-the-canal aids are positioned deep in the ear canal. One of the most prevalent problems with CIC hearing aids is that they get fouled with ear wax. It takes only a minute amount of ear wax to render them inoperative. Even the best wax-guard systems available today, cannot guarantee freedom from wax plugging. You may say, "I know a lot of people who wear hearing aids in their ear canal, and they don't seem to have that much trouble with them." I do, too. But I also know people who come in every month, and sometimes more often, with a dead hearing aid because of the ear wax in it.
I don't mean to imply that all of our product
testers are behind-the-ear hearing aid users. Far from it. We are not trying
to change people's mind. We only want them to be able to make a style choice
base upon facts rather than hype. We want them to know that behind-the-ear
hearing aids provide the best protection against ear wax plugging because
the electronic circuit components of the hearing aid are far removed from
the source of the ear wax.
Individual companies change personnel and
corporate philosophies frequently. Sometimes, these changes are not user
friendly changes. For example, some companies have recently decided that
they will not service their hearing aids if they are more than five years
old. This amounts to forced obsolescence. We believe that if a given hearing
aid meets the user's needs, and the user is willing to pay for any needed
repairs, the user should not be forced into buying new hearing aids every
five years. We are reluctant to do business with companies that have such
policies. We recommend that you choose an audiologist who offers multiple
brands of hearing aids.
On a national average, programmability adds about $500 to the cost of a hearing aid. We believe the added cost is a good investment. Using a personal computer or a manufacturer's proprietary programming device, the audiologist is able to send operating instructions directly to the computer chip inside the hearing aid. Because this can be done in the audiologist's office and with the hearing aid in the user's ear, the changes in operating characteristics can be immediately evaluated. If you don't have programmable hearing aids, the same changes can be made only by opening the case and rebuilding the instrument circuitry.
Secondly, we find that new hearing aid wearers cannot initially tolerate as much amplification as experienced users. However, in a very short time, the new users are back in the office requesting more power. The audiologist cannot easily respond to these types of requests if the hearing aid is non-programmable.
Although programmable hearing aids have a higher first cost, we believe they are cost effective in the long run. I can dramatically improve the fitting if I have more control of it. That control can come only when the programming capability is used in conjunction with real-ear aided testing. There have been a series of studies over the last 20 years that show manufacturers' fitting recommendations are oftentimes inappropriate for meeting the user's needs. The manufacturers are handicapped because they do not have access to the user when making their fittings.
>>Question from the audience: Are Behind-the-Ear hearing aids easier to program than other hearing aid styles?
>>Ron: Fortunately, for a given manufacturer, the same programming software is used for all hearing aid styles. The second bit of good news is that most all of the sophisticated hearing aid features available can be incorporated in any of the instrument styles. Once you have that manufacturer's software in your computer, it does not matter whether it is a behind-the-ear or a completely-in-the-canal hearing aid.
>>Question from the audience: You talked about users having to return to the office three or four times for hearing aid adjustment. What length of time period are you talking about–a week or a month, and do you charge a new hearing aid user for each office visit?
>>Ron: The length of time required for
users to get their new hearing aids adjusted to their liking varies from
person to person. In our clinic, we let people have as many no-charge follow-up
visits as they want during the first two months. After that, depending
upon circumstances, there is usually a charge. Our typical charge is $35.
It takes about half an hour of time to make the changes and to give the
user a chance to evaluate the changes before leaving the office. This question
leads into Rule 7 very nicely.
The two-month recommendation is merely a starting point. Some may require more time, other less time. In any event, the new user needs to be prepared for the fact that it takes time and effort to learn how to live with and appreciate his/her new hearing aids.
What are some of the challenges a new hearing aid user may encounter?
• Your ears may feel plugged up.Keep in mind that the mere act of inserting a pair of hearing aids into your ears does not guarantee user satisfaction. Be prepared for several follow up visits to your audiologist to fine tune the operating characteristics of your hearing aids. The results of a survey of more than 20,000 hearing aid users, conducted by Sergi Kochkin, a Chicago researcher working for Knowles Electronics, indicated that a greater degree of user satisfaction was achieved by those persons who spent 90 minutes or more with their audiologist in the fitting and fine tuning processes than those who spent 30 minutes or less regardless of hearing aid brand or degree of hearing loss.
• Your voice may sound different to you.
• You have to learn how to change batteries and properly care for your new hearing aids.
• You are likely to hear more and different sounds than you did without hearing aids.
• Things do not always sound the same in your normal living and working environments as they do in the audiologist's office.
Achieving a high degree of user satisfaction requires a team effort. The team players are the user and the hearing aid dispenser. Each has certain responsibilities. Certainly, the education and experience levels of the hearing aid dispenser are of major importance in successful hearing instrument selection and fitting. But, in addition, the hearing aid dispenser is also responsible for providing adequate and appropriate counseling so the user does not develop unrealistic expectations.
User attitude is definitely a key factor. Without a proper user attitude, the competency of the hearing aid dispenser and the degree of sophistication of the hearing aid are of little consequence. The user must have a positive attitude toward hearing aids and really want them to work. What does that mean? It means the user must have patience, persistence, and a willingness to try new ways of doing things. If a hearing aid has a telecoil, for example, how the telephone hand set is oriented with respect to the hearing aid makes a big difference in what the user will be able to hear. But, if the user is not willing to try different handset positions, he or she may never find the one that maximizes the telecoil benefits.
Recently, an article entitled, "What Should Users of New Hearing Aids Realistically Expect?" appeared on the web site of the American Academy of Audiology. Some of the expectations include:
• Your hearing in quiet environments should be improved.
• Your hearing in moderate background noise should be improved.
• Your hearing in background noise is NOT going to be as good as your hearing in quiet.
• Your hearing in loud background noise should be NO WORSE than without hearing aids.
• Soft speech should be audible; loud speech should be loud, but not uncomfortably loud.
• Your own voice should be "acceptable" to you.
• There should be no feedback when the hearing aids are properly seated in your ears.
Properly fitted earmolds should not hurt your ears. If you experience even the slightest pain, contact your audiologist immediately and have the problem remedied.
>>Question from audience: How long does it take for a new hearing aid wearer to become really comfortable having a foreign object like a hearing aid in his/her ear?
>>Ron: The majority of our product testers,
all long-time hearing aid users, will tell you that they are almost always
aware that there is a foreign object in their ear. But, that awareness
is not one that is incapacitating if the earmold is properly fitted. There
are some, however, that make the transition in a relatively few days. For
these individuals, they say they have to continually remind themselves
that they are wearing hearing aids in order to avoid taking a shower with
them still in their ears.
AT&T Bell Laboratories introduced a hearing aid 10 years ago that would give proportionally less power as the input level of the sounds increased, i.e., non-linear amplification. With this technology, the audiologist is able to program the hearing aid so that its amplification characteristics stay within the barely audible and uncomfortably loud levels. Many OABH members have changed from their old linear hearing aids, which give equal amplification regardless of the input sound level, to the newer non-linear hearing aids with automatic volume control.
Nationally, the switch from linear hearing aids to non-linear hearing aids has been slow. As I mentioned earlier, non-linear hearing aid sales did not surpass linear hearing aid sales until last year. While this is progress, it still means that more than 40 percent of the people buying hearing aids last year are still using 30- or 40-year old amplification technology.
>>Question from the audience: Are you talking about programmable non-linear hearing aids or non-programmable linear hearing aids?
I am talking about programmable non-linear hearing aids. The good news is that once you get to the programmable level, there is usually some type of automatic volume control included.
>>Comment from the audience: I have been wearing digital hearing aids for about two years. In some situations, I need more volume for soft sounds than the hearing aid provides.
>>Ron: There are times when you want dramatically more power or less power depending upon the source of the sound. And, it is not just a function of gain per frequency. It has to do with sound quality and the user's personal likes and dislikes. A number of manufacturers of both analog and fully-digital, programmable, non-linear hearing aids now offer instrument models that have a manual volume control override.
>>Question from the audience: Are you going to explain the difference between linear and non-linear amplification?
>>Ron: Linear hearing aids, as their name implies, give the same amount of volume increase to every sound that comes through the hearing aid. For example, let's say you have a sound of 30 dB coming through the hearing aid and the hearing aid gives 40 dB of additional gain. That will put a 70 dB sound against your eardrum. By contrast, if a 70 dB sound comes into the hearing aid, and the hearing aid gives it 40 dB additional gain as before, you will have a 110 dB sound hitting your eardrum. That is loud!
A non-linear hearing aid, on the other hand, provides progressively less volume as the input level increases. The maximum gain provided by the hearing aid is determined by the user's uncomfortable loudness level. You will recall that in Rule 3 one of the tests recommended for inclusion in a complete audiological evaluation was determination of the user's most comfortable and uncomfortably loudness levels.
>>Question from the audience: Does the non-linear and linear discussion apply only to fully-digital hearing aids?
>>Ron: Definitely not. Non-linear hearing
aids utilizing analog technology have been available for 10 years. It just
hasn't been widely used, and we are concerned about that.
Completely-in-the-canal style hearing aids generally cannot be effectively vented because of their small size. The hearing industry would like you to believe that if the hearing aid is placed deep enough in the ear canal, the user will not experience the plugged up feeling. Our long time hearing aid users who have tried CIC instruments do not agree. The plugged up feeling still exists. Moreover, they frequently have a finger in their ear as they try to break the air seal between the earmold and the ear canal. As the user of an unvented hearing aid which is deeply seated in the ear canal talks or chews, the earmold moves and creates a suction against the eardrum. In some instances, the pressure differential may cause ear discomfort. An appropriately sized air vent on a hearing aid can make a big difference in raising the user's comfort level.
>>Question from the audience: Is the lack of venting and the unbroken air seal the cause of the loud hearing aid squeaking or whistling?
>>Ron: No, the whistling or feedback comes
from a variety of potential sources including over-amplification, poor
physical fit, or poor insertion to name a few.
>>Question from the audience: Is the T-Switch the same as a telecoil?
>>Ron: Yes, T-Switch and telecoil are two words for the same thing. One of the problems associated with telecoils is the loss of fidelity. It is like making a photocopy of a photocopy. The image is degraded each time you make a copy of a copy. Using a good amplified telephone, such as the State of Oregon provides for persons with severe hearing loss, or a telephone amplifier will get better fidelity.
>>Comment and question from the audience: Telecoils can be used with many assistive devices. Don't telecoils get rid of background noise?
>>Ron: Yes, it is true that telecoils can
be used in conjunction with other assistive listening devices, such as
loop systems. FM systems, or infrared systems. Telecoil usage may also
present new problems. For example, telecoils react to fluorescent lights
and computer monitors.
I would like to mention some of the things that did not appear in our book. These are items in which there is not a consensus among our product testers.
• Fully-digital hearing aids. We do not suggest that everyone should immediately switch to fully-digital hearing aids. Those that are well-designed do have certain advantages over the traditional analog instruments in terms of sound quality and programming flexibility. However, the cost-benefit ratio may not be attractive to all users.
• Directional microphones. A number of manufacturers now offer hearing aids with directional microphones which potentially can improve the user's speech understanding capability by reducing the adverse effects on background noise. The majority of these hearing aids have two microphones–one facing forward and one facing backward. When operating in the background noise reduction mode, the hearing aid becomes "front" sensitive. This is achieved by subtracting portions of the signal received by the backward facing microphone, primarily background noise, from the signal received by the front facing microphone. To date, we have tested 11 instruments from eight different manufacturers having background noise reduction benefit claims. Only four of them, all of which were behind-the-ear style instruments, received a " Good" rating from our product testers.
• Assistive listening devices or systems for use with the telephone. Alternatives include telecoils, infrared, loop, and FM systems, amplified telephones and telephone amplifiers. Even though all of these devices have certain advantages, they also each have certain shortcomings or limitations. No single approach to enhance telephone usage is widely used by hearing impaired persons.
• Disposable hearing aids. A recent entry in the hearing industry is a disposable hearing aid. It is a non-programmable, one size fits all instrument. Our product testers encountered several problems with this disposable hearing aids. All of the testers reported some degree of ear discomfort ranging from mild to painful. Half of them could not use the hearing aids because of uncontrollable feedback.
Hearing aid user satisfaction is an evolutionary quality. As the user gains experience with hearing aids and knowledge of what hearing aids can and cannot do, their level of acceptability changes. As mentioned earlier, the Fifteen Rules do not unconditionally guarantee user satisfaction, but following them will help the user minimize the frustration associated with being a hearing aid user.
To order "Fifteen Rules for Satisfied Hearing Aid Users," send $10/copy to Hearing Assistance Technology, 301 SW 4th Street, Suite 180, Corvallis OR 97333, or to use Visa/Mastercard, call (503) 754-1377.
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Last modified on 15JUN01