Barriers to hearing aid adoption among older adults in mainland China

Abstract

Objective

This study aimed to explore barriers to hearing aid adoption amongst older adults in mainland China.

Design

Semi-structured interviews were audio-recorded and analysed using qualitative thematic analysis.

Study sample

The study included 12 older adults who had seen ENTs and had not adopted hearing aids.

Results

Three overarching themes and ten subthemes were generated to explain why older adults in mainland China do not adopt hearing aids: (1) Desire a cure for hearing loss, (2) Lack of a perceived need for hearing aids, and (3) Negative impressions of, and misconceptions about, hearing aids.

Conclusion

Although barriers are similar to those reported in Western societies, the under-developed hearing healthcare infrastructure, Chinese health beliefs, Chinese culture, and low health literacy play important roles in preventing older adults to adopt hearing aids in mainland China. To identify barriers to hearing aid adoption and address them, hearing health practitioners should learn what older adults know about their hearing loss, how they perceive the effects of hearing loss, and how they feel about hearing aids.

Keywords:

• Hearing loss
• older adults
• hearing aid adoption
• barriers

Introduction

In the journey to adopt hearing aids, an individual with hearing loss first notices hearing problems, seeks information about hearing loss, seeks help from hearing health practitioners, gets diagnostic testing, and evaluates hearing aids after fitting (Manchaiah, Stephens, and Meredith 2011). Despite the benefits of hearing aid usage, the hearing aid adoption rate among older adults is very low and individuals usually postpone taking up hearing aids for many years (Simpson et al. 2019; Wong et al. 2014), or do not continue to use hearing aids after obtaining them (Gianopoulos and Stephens 2005; Knudsen et al. 2010). Individuals in different stages of the patient journey may face different barriers to hearing aid adoption (Knudsen et al. 2010; Meyer and Hickson 2012), therefore understanding where and why challenges occur is vital for promoting hearing aid usage.

Low rates of hearing aid adoption in the older population have been reported all over the world. The use of hearing aids in older adults with hearing loss is less than 25% in developed countries such as the United Kingdom (UK) and the United States of America (USA) (Bisgaard and Ruf 2017; Chien and Lin 2012; Kochkin 2001; Zhao et al. 2015). The adoption rate in mainland China is even lower. Several studies have indicated that fewer than 10% of older adults with hearing loss use hearing aids in mainland China (Huang et al. 2003; Lian, Wang, and Shan 2005; Zhao et al. 2015). He et al. (2018) found that among the 1503 older adults (>65 years old) who should wear hearing aids as assessed by otologists, only 6.5% had acquired them.

Delaying hearing aid adoption has also been reported widely (Brooks 1979; Simpson et al. 2019; Wong et al. 2014). Studies revealed that individuals often wait about 10 years between first noticing hearing loss and the initial fitting of hearing aids (Brooks 1979; Davis et al. 2007). Similarly, Wong et al. (2014) found a group of older adult hearing aid users in Hong Kong had waited 11 years from noticing hearing difficulties to hearing aid adoption. Simpson et al. (2019) also reported that it took 8.9 years, on average, for 857 adults aged over 18 years in Australia to move from hearing aid candidacy to hearing aid adoption. Thus, despite advances in hearing device technologies, the time it takes to adopt hearing aids does not appear to have shortened.

Several major barriers to hearing aid adoption have been reported. Older adults who report less severe hearing difficulties and perceive fewer activity limitations and participation restrictions are less likely to adopt hearing aids (Helvik et al. 2008; Humes, Wilson, and Humes 2003; Laplante-Lévesque, Hickson, and Worrall 2010a; Meister et al. 2008; Winsor 2011). Negative attitudes towards hearing aids (Meister et al. 2008; Meyer and Hickson 2012; Van den Brink et al. 1996) and lack of information and knowledge about hearing loss and hearing aids (Carlson et al. 2019; Knudsen et al. 2010; Knudsen et al. 2013; Pryce et al. 2016) also contribute to reduced likelihood of hearing aid adoption. Individuals who are less confident about their ability to manage and use hearing aids and those who perceive stigma are also less likely to adopt hearing aids (Kochkin 2007; Saunders et al. 2013; Smith and West 2006; Van den Brink et al. 1996; Wallhagen 2010).

It is important to note that the vast majority of studies examining barriers to hearing aid adoption have been conducted in Western societies and such findings may not be reflected in mainland China for a range of reasons. For example, differences in hearing healthcare infrastructure and culture may impact hearing aid adoption. In mainland China, hearing health in public health infrastructure is mostly managed by Ear, Nose, and Throat specialists (ENTs). Although Zhao et al. (2015) reported that there were approximately 1200 graduates who had obtained either undergraduate or postgraduate audiology degrees, audiologist (听力学家) is not a recognised profession. Most of the graduates work as audiology technicians and a few dispense hearing aids. As referrals are not needed, those who perceive hearing issues can directly consult ENTs in a hospital who will then have an audiology technician at the hospital assess the hearing status. The ENTs may recommend medical interventions or hearing devices and these devices can be obtained from hearing aid dispensers stationed at or near the hospital. Hearing aid dispensers do not have tertiary qualifications and are trained on the job.

Cultural differences may also influence hearing aid adoption. In mainland China where collectivism influences individual beliefs, values, and preferences, the journey to hearing aid adoption is expected to differ from societies where individualism is more prominent (Hofstede 2010; Knafo, Roccas, and Sagiv 2011; Zhao et al. 2015). Research on other disorders (rheumatoid arthritis and mental health problems) suggests that populations characterised by collectivism are less likely to seek help and are less able to deal with disease conditions than those from individualistic societies (Chen and Mak 2008; Devins et al. 2009). Perceptions of ageing and attitudes towards hearing loss and hearing aids also vary from culture to culture (Knudsen et al. 2010; Manchaiah et al. 2015; Wong and McPherson 2008; Zhao et al. 2015). While hearing loss is seen as a part of normal ageing, Chinese older adults tend to expect others to adapt to their needs and this may reduce their desire to take action and adopt hearing aids (Wong and McPherson 2008; Zhao et al. 2015). In other words, the abovementioned factors may mean there are more barriers for older adults in mainland China to adopt hearing aids compared to older adults in Western societies.

The aim of the present study was thus to explore barriers to hearing aid adoption amongst older adults in mainland China. A qualitative approach using semi-structured interviews was chosen so that participants could express their perspectives freely and important information about barriers to hearing aid adoption could be generated (Carson 2005; Laplante-Lévesque, Hickson, and Worrall 2010a; Winsor 2011).

Methods

Study design

Data were extracted from a larger study that included interview transcripts of 29 Chinese older adults who had consulted ENTs for hearing problems. The original study was conducted in 2019 in Beijing and received ethical approval (No. EA1905011) from the Faculty Research Ethics Committee, the University of Hong Kong. The original study was conducted to examine (1) the daily routines of Chinese older adults, their communication needs, and their relationships with others; (2) their perceptions of hearing impairment, the impact of the hearing impairment on their activities and quality of life, their listening experiences and the help-seeking process; and (3) their experience with, and attitudes towards, hearing aids and other interventions, and their future plans for hearing problems. The first author reviewed the transcripts and identified 12 participants who had not adopted hearing aids. In the present study, we defined hearing aid non-adoption as (1) participants who consulted ENTs and decided not to adopt hearing aids; or (2) participants who had consulted ENTs and subsequently purchased hearing aids but did not continue using them. Data from these participants were examined to identify barriers that contributed to hearing aid non-adoption.

Participants

Potential participants were aged 50 years or older and had visited ENTs for hearing problems. Eligibility was confirmed by the first author according to the following selection criteria: (1) physically mobile; (2) presence of bilateral sensorineural hearing impairment (greater than 25 dB HL pure-tone average obtained at 0.5, 1, 2, and 4 kHz in the better hearing ear); (3) able to communicate in Mandarin; (4) have consulted ENTs regarding hearing problems, (5) were not diagnosed with or reported dementia or cognitive decline and (6) were not using hearing aids. Potential participants were screened using the Mini-Mental State Examination (MMSE) Chinese version and those whose scaled scores were less than 23 were excluded (Folstein, Folstein, and McHugh 1975; Li, Shen, and Chen 1989). A total of 29 participants were referred by hospital staff and 17 were excluded from the study, including two participants whose speech recognition was too poor to finish the interview, two had otitis media, one did not realise he had hearing loss, one had very mild hearing loss of 30 dB HL, eight had already adopted hearing aids or decided to adopt hearing aids before undertaking the interview; and three were in the middle of decision-making for hearing aids and did not have a final decision. The remaining 12 participants (6 males and 6 females) decided not to use hearing aids and were included in the current research to investigate the barriers to hearing aid adoption (Table 1). The average age was 70.17 ± 9.37 years and the better ear pure-tone average hearing was 49.48 ± 7.82 dB (HL).

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.

The experiences of the 12 participants were as follows: six had seen ENTs on the same day as the interview and had no hearing aid experience; two were the husband and the friend of a participant who attended the interview, and they had visited ENTs in another hospital previously and had no hearing aid experience; two had seen ENTs and had consultations with hearing aids dispenser on the same day as the interview but did not purchase hearing aids, although one of them did try hearing aids on the day; and two had previously purchased hearing aids but did not use them, and on the interview day they had regular medical consultations with ENTs and then consultations with hearing aid dispensers. Among the two who previously owned hearing aids, on the day of the interview, one tried hearing aids but did not purchase them and the other one did not try hearing aids after consulting with hearing aid dispensers. In summary, two participants had purchased hearing aids but had given them up; one participant tried hearing aids at the hospital on the day of the interview but decided not to purchase them; and nine participants had never tried hearing aids.

Procedures

Interviews were conducted in a quiet room used for hearing aid fitting at a Grade A Class III general hospital in Beijing (The Classification of Chinese hospitals is a 3-tier system according to the Ministry of Health of the People’s Republic of China. Grade A Class III hospital is the highest level in the “Grade III and Grade VI” classification of hospitals in mainland China). Details of the study were explained to the patients in both oral and written format and those who agreed to participate signed a written consent form. Participants then answered a questionnaire, collecting information about personal characteristics, family relationships, and health conditions; and completed the Chinese version of the MMSE. After that, semi-structured interviews were conducted with each individual and audio-recorded. Participants were interviewed without the presence of family members.

The interview outline was developed as part of the larger study as stated above (see supplemental materials online). The open-ended questions allowed the participants to express themselves freely on their own terms and raise issues that were important to them (Cohen, Manion, and Morrison 2013). The first author (who is from mainland China and has Mandarin as her first language) interviewed participants, without prompting or suggestions on what was expected, and participants were encouraged to talk about their experiences freely. The scripted questions served as probes, and follow-up questions were conversational, contextual, and responsive to the participants’ accounts. Field notes on the impressions of the participants and the contexts in which the interview was conducted were also taken by the first author immediately after the interview. These were then used to support the interpretations of the data during analysis. The data collection took an average of about 30 to 69 minutes.

Data analysis

Interviews were transcribed verbatim in Chinese by the first author. NVivo 12 (www.qsrinternational.com) was used as a platform for qualitative data analysis. To ensure anonymity and confidentiality, identifying data were removed, and each participant was assigned a serial number.

Thematic analysis, which involves identifying, analysing, and reporting patterns within data, was carried out by the first author to perform inductive coding and generate themes (Braun and Clarke 2006; Braun and Clarke 2019). Six phases of the thematic analysis process suggested by Braun and Clarke (2006) were followed. First, the first author familiarised herself with the data and the coding. Active notetaking was used to record the author’s thoughts to allow examination of the assumptions made during interpretation and to promote reflectivity (Patton 2015). A total of 454 meaningful units related to the research aim were identified and coded. Second, the second author (who speaks Mandarin) cross-checked the transcripts and discussed them with the first author. This step served as an opportunity to reflect on the coding process and the underlying assumptions (Braun and Clarke 2019). Third, the first author generated initial themes in Chinese and discussed them with the second author to reach a consensus. Fourth, the first author reviewed the themes and narrowed 357 codes down to three themes and ten subthemes. Then the first and second authors defined and named the themes in both Chinese and English. Fifth, the first author wrote up the analysis. The first and second authors translated chosen excerpts from simplified Chinese into English to illustrate the results. These were discussed with the third author. During translation, every attempt was made to reflect the participants’ intents. However, the authors acknowledge that certain cultural and linguistic aspects were inevitably lost when translating Chinese to English (Ten Have 1999). Thus, the original Chinese excerpts are provided in supplemental materials online following the suggestion by Nikander (2008). Only the translated English excerpts are provided in the results section of this paper.

Results

Three overarching themes explained why participants were not adopting hearing aids: (1) they desired a cure for hearing loss; (2) there was a lack of perceived need for hearing aids; and (3) they had formed negative impressions of, and misconceptions about, hearing aids. Each theme and associated subthemes, codes, and example quotes are included in Tables 2–4.

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.

Theme one: Desire a cure for hearing loss

Participants seemed to have a strong desire for a cure (Table 2); they talked about consulting multiple ENTs and trying multiple treatments. This is summarised in the statement from participant 2:“If there was a cure, I am definitely still willing to try”.

Participants consulted multiple ENTs but still did not appear to have understood what sensorineural hearing loss is and why it cannot be cured. Participants were asked to recount the consultation with the ENTs on the day of the interview and to recall previous experiences with ENTs; the diagnosis they received included “sensorineural” (感音神经性), “sensory” (感音性), “neural” (神经性), “age-related” (老年性), and “mechanical” (机械性) hearing loss. They were able to recount the diagnoses but did not understand what they meant. When asked if they knew why their hearing loss could not be cured, none had any idea. Follow-up explanations from ENTs were not apparent and participants did not ask for further explanation when they felt confused after seeing ENTs. Participants mentioned time constraints and one participant explained that she believed ENTs would not have answered the question if she had asked.

Participants sought further information about their hearing loss from acquaintances and from a wide range of sources such as newspapers, television, and web-based mass media. They searched for information on the treatment of hearing loss and the experiences of those who received treatments. Medical or alternative treatments were reported, including traditional Chinese medicine, acupuncture, massage, and vitamins. Some participants went further and tried various treatments for hearing loss themselves: massage, traditional Chinese medicine, acupuncture, injections, and ginkgo leaf.

Participants saw medical treatments as a priority. Although they generally reported that doctors gave consistent diagnoses and concluded that there was no cure for age-related hearing loss, they did not accept this information and felt unsettled. Sometimes their doctors did not prescribe medications, however, participants still insisted on asking for medicines. Participants mentioned that multiple doctors should be sought for illnesses. In the present study, most participants (9 of 12) had consulted two or three doctors prior to the interview day; non-Beijing residents (6 of 12) came to Beijing after visits to a few local ENTs, believing they were not as good as those in the capital city. When participants were asked what the ideal solution might be for their hearing, they talked about wanting a cure for the hearing loss, a means to alleviate hearing loss or maintain their hearing. To achieve this goal, they would accept any medical intervention (medication or surgery) and cooperate with doctors. Participants mentioned that hearing aids could not cure hearing loss and they would prefer medical intervention to hearing aids.

Theme two: Lack of a perceived need for hearing aids

Participants in the current study said they did not need hearing aids, at least for now because they felt that their hearing loss was not severe enough, they managed well with the help of strategies, and their hearing loss did not impact them greatly (Table 3).

Results show a dichotomous conceptualisation of hearing loss referred to here as “hard of hearing”(耳背) versus “deafness”(耳聋). Hard of hearing was seen as having occasional hearing difficulties and as a normal ageing process. Participants also described it as they can hear but lack clarity. The majority of participants believed they were hard of hearing and still able to compensate for their hearing loss; thus, there was no need to adopt hearing aids. In contrast, participants defined deafness as a hearing loss that is so severe that normal conversation could not be understood, and thus hearing aids are needed. Participants planned to adopt hearing aids when they could not hear people talking loudly or when they could not hear at all.

When participants were asked how they dealt with their hearing loss, various strategies were reported, including turning up the volume and/or reading subtitles for television, having the better ear towards the speaker, moving closer to the speakers, and asking others to speak louder or to repeat. Sometimes participants said they continued the conversation regardless of whether they understood or not. Participants also used smiles and nods in response to missed information. They also reported that their communication partners, especially their adult children, helped by speaking louder to them.

Finally, participants did not perceive that hearing loss had an impact on them. They believed that it was quite normal for older adults to have hearing loss and having a hearing loss did not influence what they did in daily life.

Theme three: Negative impressions of, and misconceptions about, hearing aids

Although all participants saw hearing aids as a potential intervention for hearing problems, they were reluctant to adopt hearing aids. Negative impressions and misconceptions were formed based on their own experiences or on information gathered from others (Table 4).

Participants observed and heard from hearing aid users about a lack of benefit from devices and how people used them inconsistently. This influenced them to feel uncertain about the benefits of hearing aids. Participants who had purchased hearing aids in the past thought hearing aids did not provide enough benefit to understand conversations.

In addition, participants described many concerns about hearing aids, including self-image, appearance, inconvenience, discomfort, amplified noise, and high cost. Some said hearing aids were very ugly and not good for self-image. They also learned from their friends and relatives that hearing aids would amplify both speech and noise. One participant and his relative felt it was earsplitting when hearing a car horn. Some participants stated that the price of hearing aids was quite high. One participant from the countryside said she could not afford a hearing aid priced at RMB 7000–8000 (about USD 1,100–1250). Others did not mention whether they could afford hearing aids, but nevertheless commented that hearing aids were quite expensive.

Finally, participants described a number of misconceptions about hearing aids. For example, they ascribed an age threshold for the use of hearing aids based on their observations. Their consensus was that only those who were at least in their 70s or 80s were candidates for hearing aids. Participants compared their age with acquaintances who wore hearing aids and thought they had not reached the “appropriate” age for using hearing aids. Other misconceptions included that hearing aids cannot be adjusted, cannot amplify certain frequencies, make hearing worse, and might cause “brain problems”.

Discussion

This study explored, for the first time, the perspectives of older adults in mainland China about barriers to the adoption of hearing aids after ENT consultation. The semi-structured interviews provided detailed descriptions and uncovered novel information regarding how participants view hearing loss and hearing aids. Three themes emerged: desire a cure for hearing loss, lack of a perceived need for hearing aids, and negative impressions of, and misconceptions about, hearing aids. Participants who sought help from ENTs perceived some degree of need to address hearing problems but perceived little need for hearing aids. Participants were well aware of medical treatments and hearing aids as two possible solutions; they sought information about both and some tried both. They expressed a clear preference for a medical cure for hearing loss. As the benefits of hearing aids were perceived as limited and there were many negative impressions of them, participants would rather not adopt hearing aids to treat their hearing loss.

A number of findings of the current study support results from previous studies conducted in Western societies about factors associated with hearing aid non-adoption. First, insufficient information and knowledge have been identified as barriers to hearing aid adoption previously (Carlson et al. 2019; Knudsen et al. 2010; Knudsen et al. 2013; Pryce et al. 2016). Participants in the current study passively accepted limited information about diagnosis and treatments of hearing loss from ENTs. Thus it was unlikely they were able to make an informed decision about hearing aid adoption as an option.

Second, it is known that hearing aids may not be adopted when hearing loss is not perceived as bad enough (Davis et al. 2007; Helvik et al. 2008; Humes, Wilson, and Humes 2003; Knudsen et al. 2010; Meister et al. 2008; Van den Brink et al. 1996), and the impact of hearing loss on activity limitations and participation restrictions is low (Helvik et al. 2008; Jenstad and Moon 2011; Laplante-Lévesque, Hickson, and Worrall 2010a; World Health Organisation 2001). Participants in this study also reported that their hearing loss was not a big deal; they emphasised that they were hard of hearing (耳背) not deaf (耳聋). We suggest that, although self-perceived need is a barrier to hearing aid adoption in both Western societies and in mainland China, it may be that this is an even greater barrier to hearing aid adoption in China. Previous studies have reported that compared with their counterparts with similar hearing loss in Western societies, Chinese older adults reported fewer hearing difficulties (Doyle and Wong 1996; Wong and McPherson 2010). This may be related to the concept of filial piety and veneration for the old in Chinese culture (Fan 2000) and the high prevalence of co-dependent living. Qu and Wu (2013) reported that 47.9% of older adults were living with their children and/or grandchildren, and similar living arrangements are reported in 33.3% (4 of 12) of participants in this study. These living arrangements may mean that help with communication, alleviating the effects of hearing loss, is readily available.

Third, previous studies showed that patients who did not adopt hearing aids often held negative attitudes and beliefs about hearing aids compared to those who adopted hearing aids (Claesen and Pryce 2012; Meister et al. 2008; Meyer and Hickson 2012; Van den Brink et al. 1996). Inadequate benefit from hearing aids has been reported as the main reason for hearing aid owners discontinuing usage (Gallagher and Woodside 2018; McCormack and Fortnum 2013). Similarly, theme three in this study suggested a number of reasons for negative attitudes to hearing aids, including lack of benefit, discomfort, and high cost. Many of these views were based on word of mouth and the influence of others’ experiences has also been highlighted as a barrier to hearing aid adoption by Laplante-Lévesque, Hickson, and Worrall (2010a) and Winsor (2011). Participants in the current study also expressed misconceptions about hearing aids (e.g., hearing aids make my hearing worse, hearing aids are only for people of a certain age) and concerns associated with hearing aids including self-image, appearance, inconvenience, discomfort, amplified noise, and high cost. These have been reported as barriers to hearing aid adoption in Western societies also (Grenness et al. 2014; Guerra-Zúñiga et al. 2014; Kochkin 2000, 2007; Laplante-Lévesque, Hickson, and Worrall 2010a, 2010b; McCormack and Fortnum 2013; Preminger and Laplante-Lévesque, 2014; Saunders et al. 2013; Smith and West 2006; Tomita, Mann, and Welch 2001; Van den Brink et al. 1996; Wallhagen 2010).

Although barriers to hearing aid adoption among older adults in mainland China and Western societies share similarities, there were evident differences between cultures. In particular, this study found one theme that is barely reported in Western society as a barrier to hearing aid adoption: desire a cure for hearing loss. Essentially, participants believed that it was possible to cure hearing loss and they preferred a cure over hearing aid adoption; they had received information on and tried alternative treatments. In the current study, ten of 12 participants wanted to have hearing loss treated and five of 12 participants had seen Chinese medical doctors, tried Chinese medicine, and/or acupuncture. Five of 12 participants explicitly stated that ENTs recommended hearing aids, although all participants had hearing loss that would benefit from hearing aids. This novel finding may be attributed to the under-developed hearing healthcare infrastructure in mainland China, Chinese health beliefs, Chinese culture, and lower health literacy.

Under-developed hearing healthcare infrastructure

Hearing healthcare infrastructure in mainland China is still under-developed compared to many Western societies and this means that the system is not conducive for older adults to adopt hearing aids compared to Western societies or they can access audiology consultations directly. Patients are typically referred by medical practitioners to audiologists for consultation in Western societies. There are two advantages to consulting an audiologist. First, the average hearing consultation length with audiologists could be as long as 57.4 minutes (Grenness et al., 2015), which means more information and explanation can be provided. Second, patients are more likely to receive hearing aid recommendations from audiologists than medical practitioners (Jorgensen and Novak 2020). As mentioned in the Introduction, the profession of audiologists has yet to be recognised in mainland China; hearing consultation in the public hospital system often ceases after the patient has seen an ENT. Usually, three brief conclusions are provided: “you have age-related sensorineural hearing loss”, “there is no treatment”, and “I suggest adopting hearing aids”. It is not unusual for ENTs at a busy hospital to handle about 80–120 cases per day, limiting consultation time to a few minutes.

Chinese health beliefs

Health beliefs importantly determine the way our participants responded to hearing loss. Traditional Chinese medicine, which is deep-rooted in Chinese culture (Lai and Surood 2009), has been an integral self-help process (Xu et al. 2006). Some diseases, including hearing loss, are believed to have been caused by poor circulation and can be treated by herbal medicines and other types of alternative care that deliver nutrition and encourage blood circulation. Herbal remedies have also been used to treat hearing and tinnitus in Asian countries, such as China, Japan, and South Korea, where traditional oriental medicine is popular (Castañeda et al. 2019). A recent review suggests potential benefits of sensorineural hearing loss treatments although the evidence is very limited preclinically and clinically (Castañeda et al. 2019). However, success stories in using alternative medicine for other diseases offer hope for hearing restoration. In fact, four of the eight older Chinese-Canadians in Hsu’s study (2006) indicated they would like to give alternative therapies a try before trying hearing aids, and another one would try both. One Chinese participant in that study believed acupuncture could be effective because there are a lot of “pressure points” on the body to cure hearing loss. In contrast, five of the seven Euro-Canadians in that study would never try alternative therapeutic methods.

One common health belief in mainland China is that “a cure for the root of the disease is better than symptomatic treatment (治标不如治本)”. Chinese older adults believed and hoped a cure would allow them to use their natural hearing (Hsu 2006). If so, they would not have to adopt hearing aids, which are considered to be merely palliative and an artificial prosthesis that cannot restore hearing (Hsu 2006).

Another behaviour reported in the present study that is related to a health belief was participants consulting with multiple doctors about their hearing loss (得病多求医). They believed that a cure must exist and only needed to be found either from a better hospital or a better doctor. A better hospital usually means hospitals located in major cities and a better doctor could be a reputable “expert” (专家) with more experience diagnosing and treating hearing problems. As older Chinese prefer a cure for hearing loss and consider hearing aids as a backup alternative (theme one), it is not surprising that participants reported medication as the first intervention they received from ENTs. Future studies are needed to understand how ENTs decide whether medication or hearing aids should be trialled.

Chinese culture and low health literacy

Theme one shows that although participants expected a cure, they did not ask the ENTs for an explanation when being informed that the hearing loss could not be cured. Cultural differences can affect beliefs, preferences, and choices in health help-seeking, including hearing aid adoption (Hofstede 2010; Knafo, Roccas, and Sagiv 2011; Zhao et al. 2015). Institutional power and hierarchical patient-doctor relationships are ingrained in the Chinese culture (Fan 2000). One participant mentioned that her questions would be ignored by the ENTs, suggesting a belief that a hierarchical relationship exists between patients and doctors.

Low health literacy also affects older adults’ ability to understand and request further information in consultations. Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (US Department Health and Human Services, 2000). Health literacy is reduced among those who attained a lower level of education (Kutner et al. 2006; Paasche‐Orlow et al., 2005; Wang et al. 2010). A survey showed that 3.81% of adults between 65 and 69 years of age and 5.37% of adults with secondary or higher education in mainland China exhibit adequate health literacy (Wang et al. 2010). In the current study, participants’ average age was 70.17 ± 9.37 years and the average education year was 10.76 ± 5.38 years. They might have difficulties formulating questions when they did not understand the information presented.

Low health literacy also affects patients’ ability to evaluate online health information (Diviani et al., 2015). When seeking information outside of consultations, participants in the current study relied on web-based mass media and social media, such as Baidu (a search engine like Google), WeChat searching (a Chinese version of WhatsApp with a built-in search engine), WeChat articles, and Toutiao (a newspaper App) for health information, which varies in quality and could be misinformed (Cline and Haynes 2001).

Limitations

This study has two major limitations. First, China is a vast country with variations in demographics across geographic regions and the findings of this study may not be applicable to all older populations in mainland China. Further research including participants from second or third-tier cities and from rural China is necessary as they may face more barriers than the participants in the present study due to a lower education level. Second, this study did not examine the role of family members. Previous studies have suggested that family members can be facilitators of or barriers to hearing aid adoption (Duijvestijn et al. 2003; Hickson et al. 2014; Meyer et al. 2014; Singh and Launer 2016). Future studies should thus examine hearing aid adoption from the perspectives of family members in mainland China in order to provide a better understanding of their role.

Conclusions and clinical implications

This exploratory study, which includes semi-structured interviews with 12 older adults, uncovered barriers to hearing aid adoption among older adults in mainland China for the first time. The results indicate that like their counterparts in Western societies, older adults who do not adopt hearing aids in mainland China do not readily perceive hearing needs and hold negative impressions of, and misconceptions about, hearing aids. This study also uncovered some barriers that may be unique in the Chinese population, such as desiring a cure for hearing loss.

In terms of clinical implications, the findings indicate the need for those hearing health professionals who work with older adults in mainland China (ENTs, audiology technicians, hearing aid dispensers) to identify and address barriers to hearing aid adoption. This could be facilitated by asking the following questions:

1. What do you understand about your hearing loss? (Theme one)

2. What treatments have you heard or tried for hearing loss? (Theme one)

3. How does your hearing loss affect you? (Theme two)

4. How do you feel about hearing aids? (Theme three)

Considering the limited time that ENTs have for hearing consultations it is likely to be other hearing health professionals who will ask these questions and provide the ongoing education and support those older adults who need to make decisions about hearing aid adoption.

Author contribution

Huili Zheng, Lena L. N. Wong, and Louise Hickson conceived the presented idea. Huili Zheng designed the research materials. Lena L. N. Wong and Louise Hickson provided critical feedback on the proposal and helped finalise interview questions. Huili Zheng conducted the interviews. Huili Zheng transcribed the interviews and analysed the data. Louise provided guidance on analysis. Lena L. N. Wong cross-checked the transcripts and discussed them with the first author. Huili Zheng generated the original themes and subthemes. Lena L. N. Wong and Louise Hickson provided comments and finalised themes and subthemes. Huili Zheng and Lena L. N. Wong translated all the codes and quotes from Chinese to English. Huili Zheng and Lena L. N. Wong wrote the manuscript. Louise Hickson provided advice and revised the manuscript.

Acknowledgments

We would like to acknowledge all the doctors who helped us recruit participants. We are grateful to all the participants for their time and collaboration.

Disclosure statement

The authors report no conflicts of interest.

Additional information

Funding

This project was supported by a donation from Sonova AG.