Barriers to hearing aid adoption among older adults in mainland China

Figures & data

Table 1. Participants’ demographic information.

Participant	Sex	Age	Pure-tone average in the better ear (HL)	Pure-tone average in the worse ear (HL)	Years of education	Marital status	Living situation	Place of residence (City, Province)	Occupation before retirement	Self-perceived health status
1	F	64	50.00	60.00	11	Divorced	Alone	Beijing, Suburb	Farmer	Bad
2	F	53	48.75	55.00	15	Married	With spouse	Loudi, Hunan	Officer	Bad
5	F	76	52.50	56.25	3.5	Widowed	Alone	---Shanxi*	Country doctor	Good
8	M	74	58.75	60.00	11	Married	With spouse, children and grandchildren	Chifeng, Neimenggu	Businessman	Very good
15	F	78	37.50	45.00	12	Married	With spouse	Beijing	Technician	Good
16	M	76	40.00	56.25	12	Married	With spouse	Beijing	Engineer	Good
18	F	78	51.25	51.25	11	Widowed	Alone	Beijing	Engineer	Good
20	M	80	43.75	43.75	16.5	Married	With spouse	Beijing	Technician	Good
21	M	75	58.75	62.50	20	Married	With spouse	Beijing	Teacher	Good
23	F	56	62.50	63.75	8	Married	With spouse, children and grandchildren	Hengshui, Hebei	Farmer	Good
26	M	72	47.50	67.50	0	Married	With spouse, children and grandchildren	Eerduosi, Neimenggu	Farmer	Neutral
28	M	60	42.50	48.75	9	Divorced	With spouse, children and grandchildren	Lvliang, Shanxi	Driver	Bad

*Participant No. 5 did not disclose the name of the city.

Table 2. Overview of subthemes, codes, and example quotes for theme one “Desire a cure for hearing loss”.

Subtheme	Example codes	Example participant quotes
Passively accepting insufficient information about diagnosis and treatments of hearing loss from ENT specialists	ENT specialists did not explain the diagnosis	I don’t know. He gave me this conclusion. That’s it. There was no medication anyway.
	Participants did not ask for an explanation of the diagnosis	Interviewer: Did you ask the doctor some questions? Participant: No.
	Participants did not understand why their hearing loss could not be cured	Interviewer: Do you know why your hearing loss cannot be cured? Participant: (Because) the age is old. Interviewer: Did doctors tell you anything else? Participant: Nothing else.
	ENT specialists did not explain why their hearing loss could not be cured	The doctor didn’t tell me why. I have a sensorineural (hearing loss), that cannot be cured. I think this is what they meant.
	The consultation was short	And then I came here, and other people consulted for a long time, my consultation ended quickly, in a minute or two.
	Participants thought the ENT specialists would not answer them if they asked questions	Interviewer: Did you ask the doctor why your hearing loss cannot be cured? Participant: He would not answer.
Receiving information of treatments	Read information about Chinese medicine on WeChat	But I saw information, on WeChat search, I searched, echo (重音) is related to tympanic membrane invagination. You can take Chuanxiong(川芎), salvia miltiorrhiza (丹參), and vitamin B1. Giving nutrition to the nerve could restore hearing. The hearing could still be cured and treated.
	The newspaper says XXX* is the best hospital to treat hearing loss	I read in the newspaper that XXX hospital is the best hospital for treating tinnitus and hearing loss.
	Heard other people had medication	He said he registered here. Someone consulted him, and he went to somewhere to get a few pills and someone asked him to drink some kind of liquid. Someone said please swallow. He told me that he swallowed, he didn’t tell me in detail I didn’t ask in detail…
	Other people said hearing loss is curable	Someone says hearing loss is curable, now that technology is improving.
	Was prescribed vitamin C	Then he (the ENT specialists) asked me if I wanted some medicine. This is the tone he used. In the end (he) prescribed vitamin C and that was it.
	Was suggested to have acupuncture by Chinese medicine doctor	Traditional Chinese medicine doctor said (it) I needed acupuncture, insert (needles) at these four points, but I did not go for acupuncture, I was afraid hearing may be worse after getting acupuncture.
Trying various treatments	Read information about massage on WeChat and had it	I saw on WeChat that we can massage here on the ear (demonstrating while he explained). Massage here. So every day when I have time, say in a car, I press here and, then rub my ear.
	Had traditional Chinese medicine	I also saw some traditional Chinese medicine doctors and took some traditional Chinese medicine, for three months, but it didn’t work.
	Had acupuncture	XXX hospital said this is age-related hearing loss, I had acupuncture that didn’t work.
	Had intravenous injection and ginkgo leaf	At XXX hospital, I had intravenous injection of ginkgo leaf for 9 days, he (the doctor) said there was no change and (he suggested) oral ginkgo leaf medication. I said I took ginkgo leaf medicine every day.
	Had intravenous injections of Cobamamide	I think I also had about 20 intravenous injections of Cobamamide (腺苷钴胺), but I didn’t feel better…
Give priority to medical treatments	Feeling unsettled when doctors said there was no cure	After doing tests in the city hospital, I felt unsettled.
	Insisted on medicine when doctors said it would not work	I said can you give me some medicine, or acupuncture or something like that, and then the doctor said maybe yes but it wouldn’t have any effect. Then I said I will try (even you said so), the doctor gave me acupuncture and prescribed with oryzanol.
	Various doctors should be sought for illnesses (得病多求医)	But I want to go (to another hospital), I want to consult again, multiple doctors should be sought for illnesses.
	Went to better hospital to seek a cure	I feel that hospitals in the capital city are the best. I searched online, to confirm …and reconfirm the diagnosis… Because technology is developing, maybe there are new technologies, (But) the outcomes (in Beijing) are similar.
	Consulted better doctors (the experts) to seek a cure	Because at the beginning I looked for an ordinary doctor, (the doctor) consulted me and I took the tests. Later I did not check out anything, and I specifically found a doctor whose registration fee is more expensive, is equivalent to a chief physician qualification in the system.
	Would like to consult other doctors in the future	And (I) also made another appointment in a different hospital, tomorrow morning I will go to XXX, XXX what hospital.
	Would accept any medical intervention and would actively cooperate with doctors to be cured	I can accept taking medication or acupuncture, but that is, whether it can control (hearing loss), not sure. As long as it can control (hearing loss), and I’m willing to devote myself to it.
	Ideal solution was to maintain the hearing or to alleviate hearing loss	I think my point is, at least, to restore parts of the hearing, or at the very least, it’s not getting worse. That’s my requirement.
	Ideal solution was to cure hearing loss or to maintain hearing	The ideal solutions are, one is to stop getting worse, and the other one is to cure it.
	Assuming medication is the best treatment for hearing loss	I come here to ask if I can’t take medication, it is the best if I can take medicine.
	Feeling confident that hearing can be improved	I think it is becoming true, I am still quite confident, I still quite believe in you, I guess someone like you still see it as important, you see it as important. I reckon there’s still possibility for improvement.
	Thinking hearing aids cannot cure hearing loss	(Hearing aids) are not the cure. It mainly brings people a kind of hearing. It does not seem to cure disease.
	Preferred medical treatments over hearing aids	Is there a way to treat my ear? Is there a treatment? Must I be fitted with hearing aids? It seems like if I need to wear hearing aids now… If there is a cure, my priority is to have a cure for sure. If there is no cure, then I will have a hearing aid fitted… I just want to go back…go back and then try to get some treatment. If it really does not work, then hearing aids will be considered.

*The names of hospitals are being withheld to protect privacy.

Table 3. Overview of subthemes, codes, and example quotes for theme two “Lack of a perceived need for hearing aids”.

Subtheme	Example codes	Example participant quotes
My level of hearing loss is not bad enough for hearing aids	Differentiating hearing less well from not hearing at all	I cannot hear clearly, not that I cannot hear.
	I’m hard of hearing therefore I don’t need hearing aids	I say I’m still fine now. I just can’t hear clearly, not totally deaf and can’t hear, that’s it.
	Some people are deaf therefore they need hearing aids	(Deafness) means they can’t hear people talking, when it’s normal speaking… If someone is so deaf, and they can hear with it (hearing aids) on, then they should wear it.
	Able to hear the interviewer	I’m feeling that, when we two talk like this, I’m able to hear clearly.
	Would adopt hearing aids when I cannot hear people talking loudly	Participant: So I want to maintain the status quo, extending it for a few years., I will get a hearing aid when there is no choice. Interviewer: What do you mean when there is no choice? Participant: (It means) I can’t hear people even when they talk loudly. For now, I can hear when people talk loudly.
	Would adopt hearing aids when I cannot hear at all	For hearing aids, (I) want to wear, I want to wear after another two years, when I cannot hear anymore. For now, it’s not like I cannot hear. When I get to that stage, I will wear (hearing aids). I don’t want to wear (hearing aids) now, I can still cope. This is what I mean.
Strategies used by themselves or others to hear and communicate	Turning up the volume of the TV	And for television, you turn the volume up a little bit, (I) can hear clearly if (I) turn the volume up a little bit. That’s it.
	Reading subtitles on the TV	I read subtitles, I read subtitles if the volume is not high enough.
	Watching TV in a separate room	I usually watch TV on the first floor. My wife stays on the second floor, my children stay on the third floor.
	Turning the better ear towards the speaker	Sometimes (I) use (the better ear) a bit more, that is, when I talk to (people) such as now, I will consciously turn slightly, so that my ear can hear clearly.
	Moving closer to the speaker	If I want to talk about something at home, I tell him (the husband) you said once but you are so far away from me, I can’t hear clearly. I go over to him to listen.
	Requesting their communication partners to move closer	(I tell my wife) When I’m talking to you, if you want me to hear you, you should speak a little louder, or you can come up to me and say it, you are so far away (from me), I can’t hear you in your normal voice.
	Requesting their communication partners to speak louder	I would introduce myself (to other people), I’m old, my hearing is bad, (you) need to talk louder to me.
	Requesting their communication partners to repeat	Sometimes I can’t hear clearly, I would ask what they said, then they would speak louder.
	Continuing the conversation regardless of whether I can understand	When I talk with them (family members), sometimes they think I didn’t hear clearly or give inappropriate responses. That is actually I mishear it, mishear it. (Thus, my response is wrong)
	Responding to other people with smiles and nods	Other people say something to me, I just smile and nod and I don’t answer them.
	Other people would speak louder because they knew my situation	They (my children) talk to me louder now, (they) talk to me louder than they used to, the voice is raised, the kids know (my hearing is not good).
	Relying on spouse to listen for them	When I run errands, such as coming to the hospital, I have to ask my spouse to come, in case I can’t hear clearly, lest I mess up.
Little perceived impact from hearing loss	Tolerate/accept hearing loss as normal ageing	Because (I) am old, (I’m) a person who is almost 80, it’s ok if my hearing is slightly worse.
	Had few social interactions	There are no other impacts, anyway now that I don’t contact with others much, anyway there is not a lot of communication.
	It was not a big deal if they cannot hear	I go out and talk to people, if I hear I hear, if I don’t I don’t.
	Observed hearing loss did not affect other people	My mother was deaf at her 50 s, and both ears were deaf. She was deafer than I am. After she was deaf, she was 50 years old. Even after becoming deaf, after both ears were deaf, she still lived to 87. She was all fine and that’s it.

Table 4. Overview of subthemes, codes, and example quotes for theme three “Negative impressions of, and misconceptions about, hearing aids”.

Subtheme	Example codes	Example participant quotes
Little perceived benefits of hearing aids	Other people reported hearing aids were not good	I know other people say that all people who wear hearing aids say it is not good.
	Other people reported wearing hearing aids is slightly better than not wearing them	They said wearing hearing aids is slightly better than not wearing them.
	Observing that others abandon using hearing aids	There were a lot of people who wore hearing aids in my place of work. They tried to wear again and again then they all thrown hearing aids aside. They abandoned wearing them.
	Friends reported they only wear hearing aids occasionally	Two friends say they don't wear it these days. Sometimes they don't need to wear it. When they have special occasion and when going out, (they)put it on.
	Can’t hear language clearly with hearing aids	Hearing aids are…, for example, I listen to the words, I can’t hear what it is. The sound is clear, (but) sometimes I can’t hear language clearly.
	Lost confidence in hearing aids after obtaining user experiences	As for hearing aids or cochlear, (I) have considered them, but according to my family’s feedback, the outcomes are not good, the sensitivity is improved, the noise is also amplified. For example, traffic noise outdoor, (make) your ears feel uncomfortable. Thus, (I) feel that (I am) not that confident to have hearing aids fitted.
Concerns about hearing aids	Hearing aids are not good for self-image	Wearing hearing aids on the ear is not very good for self-image.
	Hearing aids are ugly	And yesterday when I was asked to wear a hearing aid, my first reaction was that it is ugly, that’s it.
	Using hearing aids is inconvenient	I saw they take off and put on hearing aids, I think that is troublesome
	Wearing hearing aids is uncomfortable	Hearing aids don’t seem very comfortable to wear because there’s something inside your ears.
	Hearing aids amplify noise	My family bought her (my mother-in-law) a hearing aid. (We) put it on but she refused to wear it because she hated the buzzing sounds.
	Hearing aids distort sound	(I hope) hearing aids can restore the sound that people speak. I guess most hearing aids can do that.
	The cost of hearing aids is high	And the price of hearing aids is too high. I had asked about that. Some of them are more than tens of thousands (RMB) and some of them are thousands (RMB). My friend firstly bought a ten thousand (RMB) hearing aid, and then bought an eight thousand (RMB) one. Others are five or six thousand (RMB). They say the more expensive the better…How many months would it take to skip meals to save that money.
Misconceptions about hearing aids	Observed other people in their 60 s don’t wear hearing aids	Let’s say it (hearing aids) when I’m older. Now I’m only in my 60 s. Wear it when 70 years old. Now not many people in their 60 s wear hearing aids.
	Planned to wear hearing aids at their 70 s	Let’s say it when I’m old. Now I’m only in my 60 s. I wear it when I’m 70 years old.
	Rejected hearing aids because they were still young	…He (the ENT specialists) asked me to be fitted with hearing aids, I said I was still young after all, and I didn't want to be fitted with hearing aids.
	Heard from other people that hearing aids should not be adopted too early	I heard from the older generation that hearing aids should not be adopted too early, you should wait a few years.
	Thought hearing aids cannot be adjusted	Because it (hearing loss) is worsening, and what you are fitted today may not be suitable anymore tomorrow. It's like a disease, right? If you are fitted with a hearing aid now when the disease is still mild, when the disease becomes severe, the one fitted when the disease was mild will not work anymore, you have to get a new one fitted.
	Thought hearing aids cannot amplify high frequency	I have some frequencies that I can't hear at all. I guess hearing aids amplify sounds. All frequencies are amplified somewhat, and high frequencies cannot be amplified, correct? The amplifier amplifies. My frequencies are different. My frequency is at the high frequency and other people’s frequency is probably at the low frequency, right? If your hearing aids gear towards high-frequency, I may give it a try.
	Thought dependency on hearing aids would make their hearing worse	It (hearing aid) is a bit scary. I’m afraid that after using hearing aids, my ears can’t function well again. They will rely on the hearing aid, and will get worse. I’m worried…worried that my hearing will deteriorate faster. That’s all.
	Was frightened by the outcomes of hearing aids	Then there is a friend, he (or she) did get hearing aids fitted according to standards. He (or she) got a bargain, his (or her) brain “exploded”, not “explosion”. I mean, all sounds are extremely noisy, and the brain had trouble, that frightened me. Then I didn’t get a hearing aid.