Consumer and audiologist perspectives on hearables: a qualitative study

Abstract

Objective

We aimed to explore (i) what adults with hearing difficulties want and need from hearables, which we defined as any non-medical personal sound amplification product, and (ii) what hearing care professionals think about hearables.

Design

This was an exploratory, qualitative study conducted using separate focus groups with adults with hearing difficulties and audiologists. Data were analysed inductively using reflexive thematic analysis.

Study sample

Participants were 12 adults with hearing difficulties and 6 audiologists.

Results

Adults with hearing difficulties expressed desire for trustworthy information and support, described evaluating hearables and other devices according to diverse personal criteria, and expressed willingness to vary their budget according to product quality. Audiologists expressed views that hearables are an inferior product but useful tool, that it is not necessarily their role to assist with hearables, that hearables are a source of uncertainty, and that the provision of hearables by audiologists is not currently practical.

Conclusion

Adults with hearing difficulties may have complex reasons for considering hearables and may desire a high level of clinical support in this area. Ongoing research into the efficacy and effectiveness of hearables is needed together with research into effective strategies to incorporate hearables into clinical practice.

Keywords:

• Hearables
• personal sound amplification products
• direct-to-consumer
• over-the-counter
• adult rehabilitation
• consumer perspectives

Introduction

Hearing loss is a leading cause of disability, with an estimated global prevalence of 20%, and the vast majority of cases falling within the mild-to-moderate range (94%, Haile et al., 2021). Untreated hearing loss has significant negative impacts, being associated with higher rates of depression (Lawrence et al., 2020), loneliness (Shukla et al., 2020), and economic hardship (Emmett & Francis, 2015). In addition to these individual costs to health and quality of life, untreated hearing loss represents a significant economic burden, with a global annual cost estimated at US$980 billion (WHO, 2017). Therefore, continuing improvement of hearing services is a priority in improving health and well-being worldwide (WHO, 2021).

The first-line intervention for hearing loss is the provision of hearing aids. Hearing aids are clinically effective, improving listening ability and both hearing-specific and health-specific quality of life (Ferguson et al., 2017). However, the majority of people who are likely to benefit from hearing aids do not own them (e.g. Bisgaard & Ruf, 2017; Dawes et al., 2014). For those who do access hearing aids, there is an average delay of 8.9 years between becoming aware of a hearing loss and obtaining hearing aids (Simpson et al., 2019). Therefore, the opportunity to reduce the disease burden of hearing loss via the provision of hearing aids is not fully realised.

The source of this limited uptake of hearing aids appears to be multifaceted (Knoetze et al., 2023). However, importantly, problems with the accessibility and affordability of hearing devices have been identified as key contributors to the limited uptake (Lin et al., 2016). One option to improve the accessibility and affordability of hearing devices is the provision of direct-to-consumer (DTC) devices. Recently, there has been a steep increase in the availability of DTC devices (Seol & Moon, 2022). Direct-to-consumer hearing devices can be broadly divided into two categories. The first category is over-the-counter (OTC) hearing aids, which are regulated medical devices marketed towards people with a subjective impression of hearing loss (e.g. in the US, these are designated a specific category by the FDA under the legislation “Medical Devices; Ear, Nose, and Throat Devices; Establishing Over-the-Counter Hearing Aids,” 2022). The focus of the present study is a second category of non-medical DTC devices, commonly called hearables or personal sound amplification products (PSAPs), depending on their specific features. For the purposes of this article, we use the term hearables as an umbrella term to capture all of these non-medical DTC devices. Hearables are advertised as a potential amplification solution to situational listening difficulties, for example, listening to someone in a noisy restaurant, and marketing is aimed at people with normal hearing (FDA, 2022).

While hearables are not advertised as a management option for hearing loss, they do, in principle, have the potential to be taken up as an alternative solution for people who experience listening difficulties but are unwilling or unable to access hearing aids. Emerging evidence suggests that hearables could be comparable to hearing aids in their effect on outcomes in a range of key areas. A recent meta-analysis of a small number of available studies (K(number of studies) = 5, total N participants = 124) found no evidence of significant differences in speech intelligibility, sound quality, and listening effort between PSAPs and hearing aids (Chen et al., 2022). A more recent systematic review and meta-analysis (K = 8, total N participants = 225) concluded that premium PSAPs were associated with improved speech intelligibility performance compared to unaided performance and basic hearing aids when measured in a laboratory. Premium hearing aids were associated with the best speech intelligibility performance compared to all other tested devices (Maidment et al., 2024).

Hearables might also improve outcomes via indirect routes, for example, improved attitudes towards amplification in people with hearing difficulties, who may then be more likely to proceed to conventional hearing aids in future (Amlani et al., 2019; Olson et al., 2022). Furthermore, qualitative analysis of product reviews suggests that consumers have predominantly positive experiences with hearables, particularly those that are higher cost (Lakshmi et al., 2019). Therefore, hearables may have a place in hearing services as a precursor to, rather than replacement of, conventional hearing aids.

While the extent of the clinical effectiveness of hearables remains somewhat uncertain, consumer interest in them is high (Edwards, 2020). Furthermore, hearables are offered by major public funding bodies such as the Australian Hearing Services Program and the UK National Health Service. Hearing care professionals are, therefore, likely to encounter clients interested in hearables in their clinical practice. The purpose of this study is not to comment on the clinical effectiveness of hearables, but to investigate an important but relatively under-studied subject in this area: consumers’ and hearing care professionals’ perspectives about hearables and their place in the practice of clinical audiology. It is important to understand what adults with hearing difficulties desire from hearables and what adults with hearing difficulties and audiologists consider the role of hearing care professionals to be in the provision of hearables. Knowledge in this area will help inform the development of clinical pathways for hearables. For example, the extent to which clinics choose to dedicate resources to the provision of hearables might depend on the demand from clients for clinical support and on the extent that clinical staff are willing and confident to provide this support.

In this exploratory, qualitative study, we aimed to conduct an initial investigation into (i) what adults with hearing difficulties want and need from hearables, and (ii) what audiologists’ impressions of hearables are. The purpose of this study was to identify issues that i) audiologists and other hearing care professionals should be mindful of encountering in their clinical practice and ii) should be investigated in future qualitative studies with other client and hearing care professional groups and measured systematically in future quantitative studies.

Materials and methods

Here, we present a summary of the methods used in the current study. Further detail, including complete reporting of methods according to the Standards of Reporting for Qualitative Research (O’Brien et al., 2014) is included in the supplementary materials.

Study design

This was a qualitative study using focus groups with two participant groups (i) adult clients of audiology clinics and (ii) audiologists. This study was approved by the Curtin University Human Ethics Committee (HRE2022-0253). All participants gave informed, written consent.

Participants

Recruitment

Participants were recruited from a commission-free hearing services provider that is part of a not-for-profit medical research institute in Perth, Western Australia. Clients were invited via email to participate if they had consented to being contacted for research purposes, had attended a clinic in the previous two years, and had not been fit with hearing aids. This group was targeted to capture perspectives of those who might consider hearables (i.e. experiencing hearing difficulties and either ineligible, unwilling, or unable to use hearing aids). We did not screen participants based on their audiogram. Audiologist participants were practicing audiologists registered with Audiology Australia and were recruited from the same hearing services provider. The resulting sample contained 12 adults with hearing difficulties and 6 audiologists.

Participant characteristics

Participant characteristics are reported in Table 1. Air-conduction hearing thresholds across octave frequencies 0.5–4 kHz in the better-hearing ear were accessed from clinical records with participants’ consent. Hearing thresholds ranged from normal to mild hearing loss, according to classification by the WHO (2021). One participant had experienced hearing difficulties since childhood; all others had begun experiencing hearing difficulties within the past decade.

Table 1. Participant characteristics.

Adults with hearing difficulty		Audiologists
N	12	N	6
Age (years)	M = 71	Age (years)	M = 32
	SD = 4.80		SD = 6.80
	Range = 58–79		Range = 23–42
Gender	n male = 6	Gender	n male = 2
	n female = 6		n female = 4
Self-reported years of hearing difficulty	Mdn = 6.25	Years of clinical experience	M = 8
	IQR = 4.25-9.50		SD = 7.78
	Range = 1–72		Range = 0.5–12
BEA0.5-4kHz (dB HL)	M = 24.7
	SD = 4.80
	Range =17.5–32

Note. BEA_0.5–4kHz = Better-ear pure-tone average for octave frequencies 0.5–4 kHz. One adult with hearing difficulty chose not to report their age; pure-tone audiometry was not available for two participants.

Procedure

Three focus groups of 3, 4, and 5 adults with hearing difficulty were conducted, lasting approximately 1.5 hours each. To accommodate participant preferences, one was conducted online via Microsoft Teams and the other two were conducted in-person. Evidence suggests that results generated from online and in-person focus groups do not differ substantially, with both formats having similar potential to generate high-quality data (Woodyatt et al., 2016; Guest et al., 2020). One 1-hr focus group was conducted with all 6 audiologists online via Teams. Each participant attended only one session. The focus groups were facilitated by MF. Participants in the in-person groups were offered the opportunity to look at and touch a pair of hearables (Nuheara IQbuds² MAX, which appear visually similar to modern earphones) during the session. Online participants were shown the hearables via video. Focus groups were run in accordance with the topic guide (see supplementary materials) with questions such as, “What might influence your choice to try a hearable compared to a hearing aid?” (adults with hearing difficulty) and “What might the role of audiologists be in supporting clients interested in hearables?” (audiologists). Probe questions were included as required. The focus groups were audio-recorded using Microsoft Teams and transcribed verbatim by an external service.

Data analysis

The focus group data were analysed using reflexive thematic analysis in accordance with the six steps outlined in Braun and Clarke (2006). This is a qualitative research method that seeks to identify patterns of meaning in a dataset, organise these patterns, and describe them as a set of themes (Braun & Clarke, 2019). Given the exploratory nature of this study, we took an inductive approach to this analysis, meaning that we did not seek to analyse the data according to a particular theoretical framework, but rather we generated themes according to the content of the transcripts. The analysis was conducted using NVivo (QSR International Pty Ltd. Version 12), by the first author (EB) with support from the second author (RJB). Throughout the process, all of the authors met regularly for discussion (see Table S1 of the supplementary materials for further detail).

Results

Themes for adults with hearing difficulties and audiologists are presented separately. Themes are numbered for structure but are presented in no particular order. Comparison and contrast of themes across participant groups is included in the discussion. Contextual information discussed during the focus groups not directly relevant to the research questions is included in the supplementary materials.

What do adults with hearing difficulties want and need from hearables?

Themes

We identified four themes, shown in Figure 1.

Figure 1. Themes identified for the research question: What do adults with hearing difficulties want and need from hearables? from the perspective of adults with hearing difficulties.

Adults with hearing difficulties desire trustworthy sources of advice and information about hearables

Consistent with other reports of trust being an important factor in engagement with hearing care (Poost-Foroosh et al., 2011), participants expressed a strong desire for access to trustworthy information about hearables. An essential requirement was that sources of information were reliable and free from conflicts of interest.

“They’re trying to milk our bank accounts all the time. And how do we mitigate that? Well, we can mitigate that through proper advice, through government sources, academic sources, a range of other sources we can go to…”

The key concern in this area was the potential for organisations and individuals to have financial motivations to sell hearables.

“And I would feel that if I paid for an audiologist and they were linked to that device or that device then by definition they would advise that. And I would suspect that they were trying to sell me something that I didn’t really need, but that they were trying to get the money out of my pocket.”

One participant expressed that their trust in their audiologist was strengthened by their advising them that their hearing loss was not severe enough to warrant hearing aids:

“…I’m very happy that they said no, you don’t need it now… Because [the audiologist] did that my trust in them was enhanced…”

In the context of this wariness of financial motivations, participants identified a number of sources that they would consider to be trustworthy. These included independent reviews, not-for-profit hearing clinics, hearing care professionals whose pay was not commission-based, universities and other research institutes, and peer-reviewed publications. Participants who had sought information online noted that a large amount of information was available, though some was not in a format accessible to the public (e.g. scientific publications).

Adults with hearing difficulties desire help and support when considering and using hearables

A desire for help and support was articulated during the focus groups. While some participants felt confident to independently select and self-fit hearables, it was acknowledged that many people would not be comfortable with this approach. This desire for support was largely focused on the early stages of the hearing journey. Participants, including some who were comfortable with the DTC model, emphasised the importance of seeking an up-to-date hearing test prior to any further decision-making.

“Myself, I’ve been tested, I know where I’m at. It’s my choice to try a hearable or a hearing aid, and I can make that decision based on cost and other factors.”

Several participants expressed a general preference to receive in-person support rather than shop online, without necessarily requiring that this support be given by anyone in particular.

“I would just prefer to buy from somebody, rather than go online.”

Motivations for this desire included a desire for social interaction, to physically handle products before purchase, to avoid potential shipping delays, to observe the seller’s non-verbal communication, and to ensure advice and future support were available. In addition, many participants felt that support should come specifically from an audiologist or other hearing care professional, both during the decision-making process and the fitting process.

“Yes, I would just want a really clear discussion about the trajectory of it, so I could make an informed decision”

“I think it’s really setting up the device so it suits you.”

This desire was linked to concerns that inappropriate devices could damage hearing and to beliefs that hearing care professionals would be knowledgeable about hearables through experience.

“I would not go to anybody else other than the professionals because I would be afraid…. that [non-professionals] would, possibly, make my ears worse than they are now.”

“Audiologists would have a lot more people coming through and hear a lot more about the real ins and the outs.”

It was felt that difficulties with device set-up would have consequences in terms of whether hearables were used or not.

“You can go off to [an electronics store] and pay $400, take them home, and you can’t get them to work. They go in the bedside table like a lot of the $7,000 and $8,000 hearing aids do.”

One participant who generally described feeling comfortable with the self-fitting model nonetheless described valuing professional consultation on specific issues:

“Because when I go to see an audiologist or a professional in any sort of thing, I’ll often have a very specific question, and that’s what I want attended to. And that’s gold to me, in that consultation. And it saves me time and effort, but thing is, I like to feel like I can problem solve things myself.”

Overall, the general sentiment was that many people will desire support across one or more stages of the hearables journey, with the extent and nature of desired support varying individually.

Adults with hearing difficulties balance cost and performance when considering hearables

Lower cost was identified as an important motivator both in considering whether to purchase hearables in the first instance and choosing between different brands of hearables.

“Well, I’d say can I start on the hearables because that’s not a big cost if you find you can’t handle it.”

One participant observed that individuals’ budgets would be expected to vary based on their unique circumstances. Importantly, however, a central consideration was value for money. That is, the amount that participants were willing to pay increased as a function of confidence in product quality.

“…I know what I want, I know the performance and specs that I would be looking for and I also know the manufacturing techniques and the cost that would be needed to make that device at that level.”

Some participants expressed that they would be more likely to initially select products at a lower price point in order to mitigate risks.

“…I’m just going to go with something pretty low price point and if it doesn’t work [or I misplace it] I’m not going to be hugely disappointed…”

“I think I’d probably need a little more experience before I went up to the $1,000 sort of range, really.”

In keeping with this desire for confidence in value, participants expressed a desire for a trial period prior to making a purchase, an option that is not routinely available for hearables but is often offered for hearing aids.

“I think for me the important thing is it works, first. And then so I need a trial period, especially for more expensive items it’s essential because if you can’t try them seriously it’s not worth it, it’s not worth it.”

Adults with hearing difficulties evaluate hearables based on their compatibility with their individual lifestyle, needs, and perception of brand morals

Finally, participants described being motivated to select hearables (and hearing devices more generally) based on a number of individual needs and preferences. A key consideration was sound quality, with participants looking for products that would meet expectations of natural sound and control of background noise. Improved speech discrimination was identified as particularly important. Furthermore, some participants who had experienced occlusion with hearing devices described it as undesirable. This issue may be problematic for people considering hearables, given that many work by creating a seal in the ear canal, generating an occlusion effect. Participants identified a number of other factors they would take into account when considering hearables. One was battery life, both in terms of time between charges and the lifespan of the battery itself. The look of the device was important for some people. Some participants preferred a discrete device in terms of colour and size.

“I’d like them maybe to be smaller and maybe flesh coloured.”

In contrast, others were happy for a device to be noticeable, provided it did not look like a conventional hearing aid, which they associated with stigma (including self-stigma) associated with ageing and disability. This is a common finding in existing literature on hearing aids (David & Werner, 2016)

“If I had something that I could wear that I used, that [made me] look as cool as the average 20-year-old that’s listening to music through their iPhone, I’d feel absolutely normal in the community.”

Participants further identified factors such as ease of connectivity with other devices such as smartphones, physical features improving ease of handling, ease of control, and other features unrelated to sound amplification such as monitoring of health metrics. Organisational integrity, demonstrated, for example, via philanthropic and recycling programs, was also considered by select participants.

“I’m really troubled by the idea that we buy things, and we just throw them out. One of the things I like about the optometrist that I go to see, is that they will take back the glasses and the frames and repurpose them. And they encourage you to not discard your old glasses that no longer fit for your purpose.”

There was no obvious consensus among participants that any one of these features was more important than others.

What are audiologists’ impressions of hearables?

Themes

We identified six themes, shown in Figure 2.

Figure 2. Themes identified for the research question: What do audiologists think about hearables? From the perspective of audiologists.

Hearables are an inferior product to conventional hearing aids

A general impression of hearables as an inferior product to hearing aids was apparent, reflecting a number of factors. One was direct experience, with one participant having tried hearables and found their sound quality to be suboptimal.

“…just acoustically or sonically just sounds like a low-end hearing aid from maybe four or five years ago.”

Less directly, other impressions were shaped by a higher level of returns for hearables than for hearing aids—the hearing services provider by which these participants were employed sold Nuheara IQbuds² MAX, which are supported by the Australian Hearing Services program, with troubleshooting as necessary. Some participants had also been told by clients that they were dissatisfied with hearables, and they therefore highlighted the importance of managing expectations. It was felt that clients who expected hearables to perform at the same level as hearing aids would experience disappointment.

“… for him it was a price deal. And he wanted hearing aid performance out of a [hearable]. So, he was never going to be happy.”

“I'd almost make the assumption they’ll be disappointed in what the hearable’s doing.”

Participants described various features of hearables that they felt would have a negative impact on users’ experiences. Occlusion was raised as a key issue, with one audiologist considering it excessive for people with mild hearing loss, who represent the target demographic for hearables.

“But my first thought is always occlusion because the people that you’re recommending them for do normally have that more normal to mild hearing loss. And so that is often the report that I've gotten is that it was too much.”

Occlusion was further described as likely to be particularly unpleasant in those situations where clients would most want to use hearables, for example, social situations involving eating. Other features perceived as undesirable were the large size and noticeable colour of some hearables. One participant explained that if a client was not suitable for hearing aids, they would be more likely to recommend delaying the provision of devices than to recommend hearables.

“I'm more inclined to say okay, you’re not quite there yet. Come back in 12 months and let’s try you with a hearing aid…”

One participant felt that cost is the only deciding factor in choosing between hearing aids and hearables.

“So, size wise a hearing aid’s more discreet. Sound quality, I would argue is better with a hearing aid. So, it’s down to cost. It’s just a cost benefit thing.”

Hearables are a useful tool

Balanced with less positive impressions of hearables was an overall sentiment that they nonetheless represent a useful tool. A key point raised by many participants was that stigma, particularly relating to ageing, is an important barrier in the uptake of hearing aids.

“There’s definitely a big stigma with hearing aids. People worry it makes them look old.”

In contrast, hearables were described as being associated with substantially less stigma, particularly in younger people for whom wearing ear buds is normalised.

“And I think they’re more accepted in a younger age group as well because they’re closer to the headphones. And that it’s so normalised to have headphones in now.”

More generally, audiologists described the availability of an alternative device as beneficial, both for clients who were unwilling to use hearing aids and those for whom hearing aids were not yet indicated.

“And if they are not accepting of hearing aids then we can offer them something else like a hearable.”

While hearing aids were felt to be superior, it was acknowledged that using a potentially inferior product was preferable to the alternative of taking no action.

“Obviously, in my opinion, doing something is better than nothing.”

Other benefits of hearables included enjoyment and benefit from features such as streaming, the ability to easily set them up for older family members, and a potential support for tinnitus. An important idea discussed was that of hearables as a gateway to hearing aids, by allowing people with hearing difficulty to experience the benefits of amplification and allowing them to become accustomed to device usage.

“…it’s almost like okay, they perceive some benefit through amplification. But then there’s also limitations and those limitations being the occlusion effect, the size and how cumbersome they are, etc. So, it’s like, okay, now that you’ve actually perceived benefit, it’s almost like a trial hearing aid. That’s not quite right for you but hearing aids can minimise a lot of those effects. And we can fit a more open fitting, it’s more natural sound quality.”

Hearables fit into a specific niche

There was a general consensus that hearables are not universally suitable for people with hearing difficulties but rather, are appropriate for clients with a number of specific characteristics. While hearables were not described as being more suitable for younger people per se, it was felt that younger people would usually be more likely to possess these characteristics.

“I automatically assume, though, that the demographic that would be suitable candidate for the hearable would be that younger generation.”

Consistent with their intended use, hearables were described as more suitable for people who experienced milder losses. It was felt that clients purchasing independently would need to feel confident in making online purchases and willing to forgo any money back guarantees that might be available with in-person purchases.

“Whereas I've had clients that have purchased them online that it may have been cheaper, but now they just can’t get their money back for them.”

It was felt that older generations would be more comfortable handing their money over to a real person. Similarly, older generations were described as being more likely to prefer to attend a brick-and-mortar shop on a personal recommendation.

“Where they go, okay, well, maybe I'll go to the audiologist for this because Joe at the Men’s Shed tells me that I've got to go see that person.”

Participants also considered that young people would be more comfortable with the self-fitting process, though it was noted that comfort with technology varies on an individual level and many older clients would be very capable of completing the self-fitting process.

A hearing care professional's role in hearables is not to fit hearables in the same way as hearing aids but to educate clients on their options

Participants generally did not see themselves as having a direct role in the provision of hearables. There was a sentiment that if an individual required the support of a hearing care professional in setting up and managing their hearables, then it is likely that DTC products would not be the best fit for them.

“Yes. It’s for us to educate. I think if we have to hold their hand in setting up the device, [it is] probably not going to work out for them.”

Similarly, it was felt that a desire for DTC products would go hand in hand with a tendency to research and purchase products independently, and those without this tendency would be less likely to consider hearables.

“I really believe that the people that want or know about that device are seeking it out themselves.”

“They’d probably research it themselves and purchase it themselves rather than coming in for the prescription of them. That’s really the market that is going to proceed with hearables.”

Further, factors that might predispose people to consider hearables, such as younger age and concern about stigma, were considered to make it less likely that they would come into contact with a hearing care professional.

“I think those people are the people who would not set foot in an audiological clinic. They just feel hearing loss maybe is just for older people. And so, the people who I think are successful with this particular product may be a lot younger clients. Just do their own research. Don’t want to set foot in an audiology clinic.”

In practice, one participant described that they would advise a client seeking hearables to go through the process independently and return to the clinic in the event that they would like to discuss hearing aids.

“You deal with them yourself with the postage back and forward, 30-day return, all this stuff.”

“You go manage that yourself. Then come to me when you want to talk hearing aids.”

Some audiologists explained that they responded to questions regarding hearables with curiosity.

“My first question would be, ‘what’s your thought process behind wanting it?’”

Overall, most expressed a desire to become or remain competent in discussing hearables with clients, both because clients would expect it and because it would assist clients in finding the best device for them.

“It’s not a good look for us to not have an answer when someone comes in asking about it.”

“I would want them to know all the options. I would want to have that available in a range of devices. And I’d want to talk to them about the pros and the cons of each option.”

Uncertainty about hearables is a barrier to their effective use

Several participants explained that they currently feel a degree of uncertainty towards hearables that is detrimental to their ability to incorporate hearables, or education about them, into their practice. This uncertainty was attributed both to limited education about hearables and an actual or perceived lack of evidence for their effectiveness, despite their appeal.

“It’s different. And that’s the thing. I love the idea of, there’s a tool, there’s something available for auditory processing disorder. But I don’t know if that’s actually, I've never seen the evidence, is that actually improving that client’s experience?”

Doubt about the effectiveness of hearables for certain individuals and situations, such as people with higher-frequency losses and in noisy environments, was also described. Evidence that would increase confidence in hearables as a product was described as a combination of anecdotal reports from clients, formal analysis of self-reported benefits and speech-in-noise testing, and a pattern of hearables not being returned. This uncertainty was described as having a negative impact on discussions with clients. They recalled instances where reservations about hearables seemed to come across to the client, presumably influencing the client’s expectations of the product.

“And so, it’s almost like I don’t trust myself enough to fit them to then relay that confidence onto the client.”

“…my own sort of bias against it comes out a little bit. I say, give it a shot. I can’t promise you anything.”

Current clinic processes would need to be adjusted to accommodate hearables

In terms of the possibility of providing hearables through the clinic, some participants explained that they did offer support for hearables and feel comfortable doing so. However, they reflected that their clinics were currently set up in such a way that offering this support was impractical.

“We can show you how to like, oh, this is how you do your audiogram on your app but in terms of long-term service we don’t really have the capabilities to provide that.”

Participants described that while some clinics sold and offered trials of hearables, simple processes that exist for hearing aids, such as holding spare parts in stock and having appropriate appointment codes, were not in place for hearables. The impracticality of offering support for hearables was not considered insurmountable. Rather, several possible methods to incorporate hearables into current processes were described, including selling hearables in the same way as consumables, offering supported set-up sessions, holding demonstration stock for trials, and offering short appointments for hearables in the same manner as for assistive listening devices.

Discussion

We now consider each of the themes for adults with hearing difficulty in turn, contrast them with views of the audiologists and review implications for research and practice. When considering these findings, it is important to hold in mind the exploratory and qualitative nature of this study. We do not suggest that current findings would necessarily generalise to most or all adults with hearing difficulties or hearing care professionals. Rather, our results serve to highlight potential issues that hearing care professionals should be aware of in their clinical practice as it relates to hearables.

The first theme, adults with hearing difficulties desire trustworthy sources of advice and information about hearables, highlighted the need for unbiased and accessible information about hearables and hearing healthcare more generally from a trustworthy source. Most audiologist participants in the current study felt it was their role to provide good-quality information about hearables to clients. However, other research demonstrates that limitations in accessible information represent a barrier to the uptake of hearing healthcare and may be a barrier to people with hearing difficulties consulting with a hearing care professional in the first instance (Barker et al., 2016; Ferguson & Bothe, 2023). Indeed, improving access to unbiased information was highlighted as a priority in both the Australian Roadmap for Hearing Health (2019) and the Report of the Independent Review of the Hearing Services Program (Woods & Burgess, 2021). Our group is currently co-developing with key stakeholders an online decision-support intervention (HearChoice) that aims to provide high-quality and unbiased information to facilitate informed decision-making across all hearing healthcare options in Australia. This includes hearables and non-device options, such as communication and wellbeing education, and auditory-cognitive training. This desire from participants to receive trustworthy sources of advice was in contrast with findings from audiologist participants that many felt less able to advise clients on hearables relative to conventional hearing aids. An important message from current findings, therefore, is that hearing care professionals are likely to benefit from ongoing education about hearables regardless of whether they intend to incorporate them into their practice, because at least some clients are likely to seek clinical advice about them.

The second theme, adults with hearing difficulties desire help and support when considering and using hearables, represented an interesting contrast with the views of many of the audiologists. Many adults with hearing difficulty described a desire for help and support at one or more stages of their hearing journey, preferably from a hearing care professional, even if they were to consider proceeding with DTC devices. While this idea appears to be inconsistent with the DTC model, it likely reflects that many people with hearing difficulties consider hearables as an alternative to conventional hearing aids for reasons other than the fact that they can be purchased directly, discussed further in relation to other themes. Current findings indicate that hearing care providers should not assume that clients considering hearables do not desire audiological support. A challenge for researchers and clinicians going forward will be to find ways to reconcile growing interest in hearables with other clinical and business factors.

In relation to this theme, an important finding was that many audiologists did not feel it was their role to provide support for hearables at the level desired by clients, did not feel that their current workplace was conducive to offering it, or simply did not believe that many clients would desire this level of support. These findings indicate that there may be a mismatch between the support that some adults with hearing difficulties who are considering hearables desire and the support that many hearing care professionals are able or willing to provide. This reluctance on the part of some audiologists was explained as reflecting multiple factors, including limited training in hearables relative to extensive expertise in hearing aids gained through both university training and continuing professional development, a belief that hearing aids are more likely to be beneficial given both anecdotal experience and limited evidence, and organisational procedures geared towards conventional hearing aids. Some of these factors may be specific to Australian audiologists, where premium hearables and basic hearing aids are relatively close in terms of cost, and therefore, audiologists may see limited advantage to suggesting them. Overall, as noted above, high-quality training for audiologists should be a priority to address many of these factors and increase their capacity to provide clinical guidance in this area.

The third theme, adults with hearing difficulties balance cost and performance when considering hearables, described a simple but important finding that adults with hearing difficulties were largely willing to vary their budget according to quality. Taken together with the expressed desire for support with hearables, this finding suggests that clients considering hearables may be open to guidance from a hearing care professional towards a more suitable hearable, or conventional hearing device, for them. As discussed, different hearables differ in their effect on important outcomes such as speech discrimination, where premium PSAPs performed better than basic PSAPs and basic hearing aids (Maidment et al., 2024). Providing this guidance to the clients is important, therefore, to improve the client’s experience in the immediate term, and to reduce the likelihood that an unpleasant experience with hearables could put them off future hearing care (see Olson et al., 2022).

The fourth and final theme, adults with hearing difficulties evaluate hearing devices, including hearables, based on their compatibility with their individual lifestyle, needs, and perception of brand morals, described that adults with hearing difficulties may consider hearables or other devices based on a range of factors. To hearing care professionals, the most salient attributes of hearables are likely to be their cost, their sound quality, and their status as non-medical, DTC devices. However, while some participants highlighted cost as an important factor for them, our focus groups discussed a range of other features, such as appearance, that might make hearables appear more appealing than conventional hearing aids. Similarly, sound quality may be one factor that is weighed among many by consumers. These findings also highlight that consumers may desire hearables for reasons unrelated to the fact they can be purchased independently without clinical input. The sample as a whole indicated a desire for some degree of professional support when using hearables. Based on these findings, client interest in hearables could represent a useful opportunity to discuss goals and desires for these devices and provide education. Hearing care professionals should therefore approach discussions about hearables with an open mind as to the client’s intentions for hearing devices. For example, a client who has developed an interest in hearables based on their less medicalised appearance and smartphone connectivity might be interested to learn about conventional hearing aids that offer similar features while providing more natural sound quality.

Finally, we highlight two other findings from discussions with audiologist participants, namely, that they generally viewed hearables as an inferior product to conventional hearing aids and that many described feeling uncertain about the effectiveness of hearables. These findings are consistent with the presently limited evidence base as to the clinical effectiveness of hearables. However, as discussed, currently available evidence suggests that hearables may not, in fact, be universally inferior to conventional hearing aids. Rather, the relative efficacy of different products may vary based on individual models, with premium hearables yielding superior results to basic hearing aids in terms of speech intelligibility in noise (Maidment et al., 2024). Further, it is possible that some consumers would be more likely to consistently use, and therefore benefit from, a hearable than a conventional hearing aid. Current findings suggest that adults with hearing difficulties may consider hearables to be a less stigmatising alternative to hearing aids. Given that embarrassment is a reported barrier to use of hearing aids in people who own them (e.g., Linssen et al., 2013), people embarrassed by hearing aids may be more likely to wear hearables. Overall, therefore, whether hearables are indeed an inferior product to conventional hearing aids may depend on circumstances of specific clients and specific makes of hearables. Current findings emphasise the need for ongoing high-quality investigation of the efficacy of hearables and for evidence-based clinical guidelines for hearing care professionals considering incorporating hearables into their practice. We recently reported an early exploration into potential service delivery models for hearables (Bennett et al., 2023)

Limitations and future directions

The primary limitation of the current study is that all participants, including audiologists, were recruited from the same hearing services provider, with clinics in the vicinity of a single metropolitan area. Additionally, while the adults with hearing difficulty taking part were considered potentially suitable candidates for hearables (i.e. attended clinic but did not proceed with device), they had not necessarily considered using hearables prior to participation in our study, and the Nuheara IQbuds² MAX, which are more similar in appearance to earphones than hearing aids, may have been the only hearables they had seen. Further, reasons for not proceeding with hearing aids recorded in clinical records were not available for analysis. Opinions could differ based on factors specific to this location, service, and client group. For example, it is plausible that adults with hearing difficulty who have previously had a positive experience with hearing services would be more likely to desire involvement from that service when considering hearables. Similarly, the funding landscape of different locations is likely to considerably influence desire for hearables and for clinical support. Further, our audiologist participants were all practising audiologists. It is possible that different hearing care professionals (such as audiometrists) would have different insights. Future research should aim to explore perspectives of clients and hearing care professionals from a range of backgrounds. Well-powered quantitative studies would be useful to measure statistically how perspectives differ between different groups of adults with hearing difficulties and hearing care professionals. Finally, updated research will be needed in this area as the OTC and DTC landscapes evolve. It is possible that consumer demand for hearables will drop as the availability of OTC hearing aids increases.

As discussed, emerging evidence suggests that some hearables are efficacious in improving speech discrimination (for review see Chen et al., 2022; Maidment et al., 2024). Crucially, future research in this area should consider both efficacy, a measure of outcomes in a controlled experimental environment, and effectiveness, a measure of real-world outcomes. That is, research should consider how well hearables support speech discrimination in a controlled setting and how well they support outcomes such as self-reported listening ability and quality of life, as well as measures of cognition and listening effort. It is possible that findings in these areas could differ. For example, the creation of occlusion, often a feature of hearables, was raised by both adults with hearing difficulties and audiologists as undesirable. Therefore, even if hearables have the potential for speech discrimination support comparable with conventional aids, the real-world benefit experienced by users may be impeded by a tendency to remove them due to uncomfortable occlusion.

Conclusions

Current findings indicate that adults with hearing difficulties may have multiple and complex reasons for considering hearables and may desire a high level of clinical support when doing so. Taken together, these findings indicate that there may be an opportunity afforded by hearables to improve outcomes for people with hearing difficulties. Individuals who might previously have avoided engaging with hearing clinics due to a desire to avoid hearing aids might now do so in order to discuss hearables. These clients may, therefore, benefit from assessment and education that they would not otherwise have received. Many of these individuals could be open to gentle encouragement to consider conventional hearing aids. To our knowledge, evidence does not exist as to whether adults with hearing difficulties generally understand the boundaries between hearables and conventional hearing aids, and many issues such as trust and stigma appear to be consistent themes across those considering hearing aids and hearables. Therefore, a client claiming to desire a hearable over a hearing aid might simply be attracted to certain salient features of hearables. A number of concerns have been raised that hearables may cause harm in people with hearing difficulty (Olson et al., 2022). We consider that support from hearing care professionals is likely to be a protective factor against many of these potential harms. With this in mind, an ongoing priority should be determining how hearables will fit within audiology practice long-term.

Acknowledgements

We thank each of the participants for their time.

Disclosure statement

No potential conflict of interest was reported by the author(s).