Elderly who refuse to use hearing aids: an analysis of the causes

ABSTRACT

Purpose

The present research sought to describe the elements that interfere with the use of hearing aids in the elderly beneficiaries of a hearing aid delivery from Chile in a Family Health Center.

Methods

A descriptive, cross-sectional study was conducted with 24 beneficiary users, with application of a closed-question questionnaire prepared by the researchers.

Results

A 75% adherence to the use of hearing aids is reported. There was a difference of 3.8 h in the use between adherents and non-adherents and in the frequency of use. The main reasons for not using the hearing aids are discomfort due to mold and noise.

Conclusion

It is necessary to provide quality education during the implementation process, as well as to address the technical difficulties related to atrial adjustment and calibration of the hearing aid in order to increase adherence.

Keywords
Hearing; Hearing Loss; Hearing Aids; Aged; Medication Adherence

RESUMEN

Objetivo

Describir los elementos que interfieren en el uso de audífonos en adultos mayores beneficiarios del operativo de entrega de audífonos de un Centro de Salud en Chile.

Método

Estudio descriptivo con diseño de corte transversal en 24 usuarios beneficiarios, con un cuestionario de preguntas cerradas de elaboración propia.

Resultados

Se reporta un 75% de adherencia al uso de audífonos. Hubo una diferencia de 3.8 horas en el uso entre adherentes y no adherentes y en la frecuencia de utilización. Los principales motivos de no uso corresponden con incomodidad por molde y ruidos del audífono.

Conclusión

Es necesario entregar educación de calidad durante el proceso de implementación, así como también abordar dificultades técnicas relacionadas al ajuste auricular y calibración del audífono, ya que esto podría aumentar la adherencia a su uso.

Descriptores
Audición; Hipoacusia; Audífonos; Adulto Mayor; Adherencia al Tratamiento

INTRODUCTION

According to several studies, nowadays Chile would be classified as an aging country thanks to the increase in the population of older adults, and it is estimated this way that by the year 2020, 20% of the national population will be over 60 years old⁽¹⁾. This brings with it the appearance of concomitant diseases associated with age, among them auditory difficulties, that influence notoriously in the quality of life⁽²⁾. As previously, it is added that people older than 65 years, develop in a stage characterized by constant functional deficiencies of all kinds, due to biological, psychological and social changes, which are related to intrinsic and extrinsic aspects of each individual⁽³⁾.

The hearing, unlike other sensory modalities, turns out to be an essential element for communication, so the quality of life of those who present difficulties of this type is directly impaired ⁽⁴⁾. On the other hand, hearing loss alters mental processes, emotional, educational and occupational risks, which in the elderly can lead to isolation, depression, decreased social participation, lack of interest in daily activities and frustration with family members and friends, harming their interaction and their integration in society⁽⁵⁾.

Hearing impairment related to aging is known as presbycusis, and has no known apparent cause. It is characterized by a progressive loss of ganglion neurons and cochlear hair cells related to aging^(6,7). This type of sensorineural hearing loss leads to problems in understanding speech at comfortable levels, especially in unfavorable situations, as well as in the presence of ambient noise and increased speech speed, seriously compromising the verbal communication process ⁽⁸⁾. The equivocal answers of the elderly during the dialogue, create in the interlocutor an image of senility, which may not correspond with the reality of the individual⁽⁹⁾. A way to solve this problem, in a partial or complete way, and to increase the quality of life of older adults is the use of hearing aids. Hearing aids are electronic sound amplification systems, compact, high technology, covered by a plastic housing. Its function is to amplify the sounds it receives. In the case of people with severe hearing loss, the hearing aids allow them to hear sirens, traffic and other sounds of the environment, thus increasing their safety ⁽¹⁰⁾.

The National Health Fund (FONASA) of Chile has sought to improve the functionalities of the elderly, delivering free hearing aids to those over 65 years of age, according to the prescription of the otolaryngologist. From July 1, 2007, this benefit was incorporated into the Explicit Health Guarantees, a right granted by law to all members of FONASA (National Health Fund) and Preventive Health Institutions (ISAPRES) (private), in order to improve the quality of life and reduce morbidity and, indirectly, the mortality of these users, decreasing the risk of accidents ⁽¹¹⁾. It has been proven that the use of hearing aids improves their social integration and autonomy, and decreases the impact of hearing loss on their mental health⁽¹²⁾.

One of the reasons that supports the need for the use of hearing aids is the need to integrate socially ⁽¹³⁾, what justifies the form, the moment and the reason why the Health Sector has prioritized bilateral hearing loss as a priority problem. According to the Clinical Guide of bilateral hearing loss in people of 65 years and more that require the use of hearing aids, from the Ministry of Health, it is recommended to implement hearing aids in users with moderate and severe hearing loss. The implementation of monaural headphones is also recommended in those users who present moderate or severe bilateral hearing loss with a pure tonal average (PTP) equal to or greater than 40 dB and in users with hearing loss between 35 to 40 dB in the best ear and having a social impact with a score equal to or greater than 10 in the HHIE-S test (Hearing Handicap Inventory for the Elderly) ⁽¹⁴⁾. It is defined as adherence to the hearing aid when the user uses it at least four hours per day and attends rehabilitation sessions. When the user does not follow the instructions given by the speech-language therapist or otorhinolaryngologist regarding the use of the hearing aid and does not use it for different reasons, it is considered as a non-adherence to the therapy or use of the hearing aid. Adherence to the use of hearing aids can change over time depending on the perception of the user regarding the effectiveness of treatment, economic, sociocultural, environmental factors, among others⁽¹⁵⁾. In Chile, it is reported that the adherence to the use of hearing aids reaches 53% according to the National Health Survey⁽¹⁵⁾.

The non-adherence to the hearing aids can be explained by a bad technique of use of the hearing aid (inadequate insertion in the auricle, poor care of the hearing aid, poor handling of batteries and volume), problems inherent to the maintenance of the hearing aid (inadequate mold or lack of calibration, that is recommended to do every 6 or 12 months), rejection associated with non-compliance of expectations or annoying phenomena (noise by coupling), poor hearing performance with the hearing aid and also non-auditory factors such as visual, cognitive and motor impairments that must be considered at the time of beginning auditory rehabilitation in the elderly⁽¹⁶⁾.

In a study conducted in Germany, users pointed out reasons for not using their hearing aids. At first place, the lack of auditory comfort, followed by the comfort in the use and appearance of the devices. In the United States, however, the reasons were: the cost, in 50%; the appearance, in 20%; and the fact that these devices did not solve their problem, in 30%⁽¹⁷⁾. On the other hand, a study conducted in Chile, with 179 older adults, reported that 80% of these participants used your hearing aids on a regular basis, while some of them, in a smaller percentage, assure you do not use them due to a personal decision, while there are those who point out that they did not perceive a significant change when using them or they abandoned the device due to various technical difficulties with which they had to face; in short, these are some of the reasons that explain why they stop using them⁽¹³⁾.

It is important to look for possible ways to enhance the quality of life of older adults with presbycusis ⁽¹⁸⁾ for the reasons stated above; this is why this research is aimed at analyzing the causes that interfere in the use of hearing aids in older adults in a population sample from southern Chile.

This information is essential to help increase the efficiency of the implementation of public policies in the delivery of hearing aids to the elderly and the consequent increase is their quality of life.

METHODS

A descriptive study was carried out, with a cross-sectional design⁽¹⁹⁾, in which data was collected at a specific time, with the objective of characterizing the personal elements and context that interfere in the adherence to the use of hearing aids. We interviewed older adults participants of the program of implementation of hearing aids of the Family Health Center (CESFAM) in the city of Villarrica, Chile, during the year 2016. A description of the sociodemographic characteristics of the sample was made and the identification of personal and contextual elements that hinder the adherence to the use of hearing aids.

The inclusion criteria were: (1) to belong as a registered user to CESFAM (Family Health Center) Villarrica and (2) for having been a beneficiary of the operation of delivery of hearing aids of the same premises during the 2014-2015 period. As exclusion criteria: (1) Neurodegenerative pathology that implies cognitive commitment, declared by relatives or caregivers; (2) Theft or early loss of equipment (less than one month of use).

The instrument consisted of a survey prepared by the research team, consisting of 12 closed questions, so that the respondent could answer briefly and accurately, that collected basic personal information, as well as investigating personal elements and contextual aspects that could influence the adherence to the use of hearing aids, according to information investigated in previous similar studies ^(10-11).

The sample was non-probabilistic, selected by means of convenience sampling⁽¹⁹⁾ according to the accessibility of the users to participate in the workshop that was created. Initially, 30 individuals of both genders participated: 15 men and 15 women, between 68 and 98 years of age (average of 78.9) beneficiaries between 2015 and 2016 for the delivery of this device through of an operation of the same establishment. Six people were excluded from the study, 5 due to theft or early loss of equipment and 1 for neurodegenerative pathology; the final sample was composed of 24 participants.

The study was approved by the Ethics Committee, Resolution Number: 97/2016. Participants were informed about the purpose of the research and invited to participate in it through assistance to a hearing aid general care workshop and guidance regarding communication skills. All the participants included in the study signed an informed consent. Both the conduct of this study and the application of the instrument was carried out in accordance with the ethical regulations in the declaration of Helsinki for research with human beings⁽²⁰⁾.

For the analysis of the results of this study, descriptive and inferential statistics measures were used, using chi2 tests (comparison of study variables according to adherence), student's t test (comparison of the differences in the average hours of use of the hearing aid) and Mann-Whitney test (comparison of differences in terms of days of use). The variables considered for the analysis of results are presented in Table 1 .

Table 1
Analysis of the use of hearing aids in older adults of the Villarrica Health Center. Survey conducted in 2016

Variables in Study	Adherence				p-valor
	YES (≥4h)		No (<4h)
	n	%	n	%
Gender
Female	9	50.0	2	33.3	p>0.05
Male	9	50.0	4	66.7
Origin
Rural	4	22.2	1	16.7	p>0.05
Urban	14	77.8	5	83.3
Year of implementation
2015	4	22.2	3	50.0	p>0.05
2016	14	77.8	3	50.0
Frequency of use in days *
0-2d	0	0.0	3	50.0	p=0.001 *
3-5d	6	33.3	3	50.0
6-7d	12	66.70	0.0
The person needs help with the use
Sí	12	66.7	4	66.7	p>0.05
No	6	33.3	2	33.3
Relationship with the person who supports its use (n=8)
Family member or relative	4	66.7	2	100.0	p>0.05
Nonfamily member or relative	2	33.3	0	0.0
Origin of the aid
The person lives with the user	4	66.7	2	100.0	p>0.05
The person does not live with the user	2	33.3	0	0.0
Reasons for not using (n=24)
The mold is uncomfortable for the user	7	38.9	1	16.1	p=0.037 **
The person does not have spare batteries	1	5.6	0	0.0
It does not fit the user	0	0.0	2	33.3
It bothers due to the noise that produces	4	22.2	3	50.0
He/She uses it daily	6	33.3	0	0.0

• ^*
  Statistical significance in the U-Mann-Whitney test;
• ^**
  Statistical significance for x² test

RESULTS

Regarding the sociodemographic characterization, it is highlighted that, of the total population under study (n=24), 75% (n=18, 9 men and 9 women) presented adherence to the use of hearing aid at the time of being surveyed; the remaining 25% (n=6, 4 men, 2 women) was categorized as non-adherent. These prevalence values differ from that established in Chile (test of x2, p = 0.06). The average age of the adherents was 79 ± 8.4 years (95% CI 62.5, 95.5), compared to 80.2 ± 9.9 years (95% CI 60.8, 99.6) of non-adherents, this difference is not significant (t-student test, p = 0.78).

As for the averages of daily hours of use of the hearing aid, they differ between adherents and non-adherents, evidencing that in the first group this is 7.83 ± 3.3 hours (95% CI 1.4; 14.3) and 1.33 ± 1.03 hours in the second group (95% CI -0.69; 3.3), there was a difference of 6.5 hours in its use (95% CI 3.6; 9.4), which was significant (t-student test, p <0.01).

On the other hand, the same tendency occurs with the days of use, where non-adherents did not register frequency in the category "6-7 days", distributing in the categories "0-2 days" and "3-5 days", unlike the adherents, where 66.7% of these were in the category "6-7 days". These differences were found to be significant, according to the hypothesis (U-Mann-Whitney, p <0.001).

There were no significant differences in the study variables related to the need for support in the use of the hearing aid according to the adherence, but for the report of the causes that lead the participants not to use hearing aids, observing those with greater numerical frequency among the non-adherents were the annoyance due to noise and the feeling of uselessness. In the case of adherents, the motive that registers the highest numerical frequency corresponds to "the mold bothers me". These differences were found to be significant (test x2, p = 0.026). In addition, when performing the comparison according to the gender variation, there are differences that allow associating the female category with a greater frequency in the report of the motive "discomfort of the mold" (test x2, p = 0.042). In the male gender, the highest frequency was reported in the motive "discomfort due to the noise it produces" (test x2, p = 0.015).

DISCUSSION

Despite the fact that adhesion values differ from those obtained at the national level (53%) ⁽¹⁵⁾, the international literature establishes that non-adherence to the use of hearing aids must reach a maximum of 30%⁽²¹⁾, which is related to the findings reported in this particular population. In turn, the results of this study are similar to those obtained in another study conducted in a health care complex in Santiago de Chile⁽¹⁷⁾ and slightly higher in a private health complex in the same city (16). The variability could be hypothesized in the different contexts and modalities of attention, despite the fact that the national (GES) plan would protect access and would supply equal attention for the population ⁽¹⁴⁾.

In this investigation, significant differences were found for both study groups, according to the hours of use, with a difference of daily use of -3.8 hours in non-adherents, representing 37.8% of the total participants. However, there is a discrepancy regarding the adherence according to seniority, since in the present study, such discrepancy was not evident.

From another point, although the use of hearing aids has increased in past decades, the levels of use still remain insufficient⁽²²⁾. Therefore, the objective of health policies must be to continue with the increase of this use.

Regarding social support (considering it as support for the use of the hearing aid)⁽²³⁾, no significant differences were observed in this aspect. Nor in demographic terms, which could be explained due to the context where the research was developed, in which the results show that a small number of participants requires this support. However, it is necessary to take these aspects into consideration for future research, given their relevance as part of this construction⁽²³⁾.

In the data presented, the most frequent reasons for non-adherence (problems with the mold and noises emitted by the hearing aid) agree with another Chilean study. There too the problems associated with the use of hearing aids tend to be more related to the adaptation of people to technology, for coupling problems that require special devices to solve them or for difficulties in the design, mold and atrial adjustment⁽²⁴⁾. However, the literature expresses that the evidence, regarding differences in the reasons for non-use of hearing aids, is weak⁽²⁵⁾.

There is no clear trend regarding this relationship; however, the present study found differences in the reasons for non-use, which may be useful or interesting to deepen further studies, with the aim of improving clinical practice, addressing the main reasons for non-use with greater precision.

Considering the results obtained, the international and national evidence and the recommendations of the aforementioned clinical guide, education on the use of the hearing aid and follow-up would improve patient adherence and quality of life ⁽¹²⁾.

As limitations of this study, although the small sample size does not allow to generalize the results, because of the feasibility of the study, it constitutes a clinical finding for future research in the area, considering larger sample sizes, ideally conceptualized as a multicenter study and with probabilistic sampling. It is also suggested to deepen with qualitative methodology regarding dimensions not addressed in similar studies.

CONCLUSION

Given the characteristics of the study, the main objective was to provide background information that favor the identification of factors that can be identified by the clinician, in order to modify the clinical practice, with the aim of improving the adherence in the use of the hearing aid in this age group. For this case, it is suggested to continue implementing education and teaching measures for its use and to monitor as far as possible fluctuations in long-term adherence, as this would strengthen the assessment of the device, by making users aware of the importance of the hearing aid in their daily living and socialization.

ACKNOWLEDGEMENTS

We thank all those who made it possible to carry out this study, especially to the families for the support provided, and to staff of the Villarrica Family Health Center for the help in the sampling process, especially to Mrs. Nayadeth Leigthon, director of center.

• Study conducted at Centro de Salud Familiar de Villarrica, Temuco, Región de la Araucanía, Chile.
• Financial support: nothing to declare.

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Publication Dates

• Publication in this collection
  04 Oct 2018
• Date of issue
  2018

History

• Received
  18 Oct 2017
• Accepted
  11 Mar 2018