Removing the Stigma from Hearing Aids

With the meteoric rise in the sale of earbuds, there’s an increasing amount of speculation about what this means for the hearing aid market. Most miss the fundamental difference, which is that earbuds are selling in the hundreds of millions because consumers like them, whereas hearing aids are still seen by many as a product of last resort, because there is a stigma attached to them.  That means that most people with hearing loss don’t go for a hearing test until around ten years after they should.  If we could get rid of that stigma, and make hearing aids as popular as earbuds, life would be very much better for hundreds of millions of people. 

Hearing aids are not the first products to have a stigma.  I’m old enough to remember a similar situation with glasses.  A child with a sight impairment would do everything they could not to admit it, lest they were labelled “four-eyes” or “speccy” by their classmates.  Most children’s books up to the 1960s had a glasses-wearing child as the scapegoat of the story.  Then John Lennon came along and all of a sudden, glasses were cool.  Nobody could quite explain why, but glasses changed from being something you tried not to wear to being a multi-billion dollar fashion industry, which conveniently managed to restore your sight at the same time.  Whilst the arrival of contact lenses threated their existence, glasses resisted the competition and remain immensely popular.  You no longer make a spectacle of yourself by wearing them, and nobody would consider them as a “seeing-aid”.  So how is that changing for hearing aids?

It’s not that the hearing aid industry hasn’t tried, but it must often feel that the world doesn’t want to change their image.  If you look at the way they are promoted, it’s still predominantly aimed at the elderly; they’re something you expect your parents to wear, even if you’re in your sixties yourself.  There have been a few notable exceptions.  I particularly like a campaign that Widex ran in New Zealand which really broke the model with the billboard ad below:

Sadly, it was withdrawn after complaints, so we never found out whether it might have made a difference. 

A more down-to-earth TV campaign in Australia suffered a similar fate.  It depicted a wife, at the end of her tether with her husband who couldn’t hear her, about to throw a jar of food at him, with the strapline of “Get your Mum what she really wants this Mother’s Day – a hearing test for your Dad”.

In this case the advertising regulator banned it after receiving complaints that it condoned domestic violence.  You can still see it here.  If you’ve experienced a parent having hearing loss, you’ll probably recognise the conversation and sympathise with the mother in the advert.

Both campaigns had their heart in the right place.  The Widex ads (you can see the others in the campaign here) were unusual in reflecting the fact that hearing loss is increasingly becoming a disease of the young.  Health and Safety initiatives have done a lot to reduce noise-induced hearing loss in the workplace, but being perverse creatures, we’ve replaced that with recreational hearing loss from loud music.  The WHO have warned that over a billion people below the age of 35 are at serious risk of hearing loss.

The TV campaign is a good example of the daily frustration that comes with hearing loss.  We usually choose to make a life-long commitment to a partner because of shared interests.  When conversation starts to die out, which is an early effect of hearing loss, it can have a devastating impact on relationships.  It may be apocryphal, but many audiologists feel that patients only come to see them because of a threatened divorce from their partner if they don’t get a hearing aid.

Sadly, the Antipodean regulators chose to side with the politically correct views of pressure groups, rather than those with the disability of hearing loss.  With this rebuff, the industry reverted back to the safe ground of advertising hearing aids to the elderly, with beaming octogenarians on cruise ships and golf courses, reinforcing the message that hearing aids are for the elderly. 

Their acceptance of the stigma of wearing a hearing aid has had an interesting effect on their design.  It’s promoted a strategy of trying to hide them; making them ever smaller and equating invisibility with acceptability, presumably on the basis that if you can’t see it, it can’t stigmatise.  That has some interesting unintended consequences.

The first of these is that most hearing aids fit behind the ear, which is not a great place to put a set of microphones when you want to listen to the person in front of you.  Then, making them tiny restricts the battery options.  The little zinc-air batteries which most use have an impressive power capacity, but they’re not rechargeable.  They’re chosen because they let you make a smaller hearing aid which runs for days on each battery, but they’re fiddly to replace, which puts off older, less dextrous users.  Running audio into the ear through a tiny, transparent tube has an effect on audio quality, requiring more expensive transducers.  The list continues; whilst the industry fixates on making hearing aids smaller and smaller, it introduces largely unnoticed compromises, which make them more expensive, as they are pushing technology and manufacturing to its limit.  You have to admire the technical wizardry and skill which goes into making them.    They nestle behind the ear, are almost invisible, contain more sophisticated audio processing than consumer hearables, yet can run for days on a tiny zinc-air battery.  But that introduces compromises and doesn’t really address the stigma – it just hides it.  However tiny and invisible modern hearing aids are, people still wait ten years before getting one.  And about of third of owners don’t wear them after the first month.

Almost any other item you wear that costs over $1000 would have a fashion label that you would want others to be aware off, but with hearing aids, invisibility takes over again.  The hearing aid industry has tried – you can get hearing aids in some very funky colours.  Despite that choice, I’ve yet to see an adult wearing a hearing aid in any of the nice, metallic colours which are available.  Almost all of the time I see a neutral pink or skin tone.

This brings audiologists and procurement managers into the stigma equation.  Particularly where hearing aids are sourced by large organisations, it feels that they are treated as a commodity, medical product, where function is orthogonal to fashion, perpetuating the stigma.  We’ll see further consequences of that later.  Whereas fashion is aspirational, with everyone aware of its companies – Hermes, Louboutin, Gucci, Prada et al, the hearing aid manufacturers are as invisible as their products; you only hear of Oticon, GN, Widex, Starkey, Phonak and Sonova at the point you visit your audiologist.  The result is that there are plenty of users who have posted articles about how to make their hearing aids more exciting, presumably because their audiologists never mentioned the fact that they can look good in the first place.

The current apotheosis of this trend to conceal hearing aids is probably Phonak’s Virto M, which is almost invisible, fitting inside the ear.  Although advertised as being “stylish black”, it also comes in regulation pink.  Inside, it is a technical marvel, which their YouTube video describes as blurring the line between hearing aid and hearable.

That makes an interesting contrast to Nuheara’s approach.  Nuheara were one of the first startups to target consumers with hearing loss, as their founder, David Cannington describes in an interview with Wearable World, back in 2015.  Yet their current advertising describes their earbuds as “NOT being a hearing aid”, immediately followed by a list of customer endorsements from:

• Grazi S.  Age 55-64, Tinnitus, Moderate Hearing Loss.
• Brendan K.  Age 65+, Moderate Hearing Loss.
• Jeff M.  Age 65+, Moderate Hearing Loss, Tinnitus.
• Michael G.  Age 65+, Moderate Hearing Loss.

There’s obviously something going on here, as companies grapple for the growing number of consumers whose hearing is not as good as it used to be.

The elephant, if not the argentinosaurus in the room is obviously Apple.  Apple’s first foray into hearing aids was back in 2012, when iOS6 introduced their Made for iPhone protocol.  This was licensed to hearing aid manufacturers and used a proprietary version of Bluetooth low energy to connect them to their phones.  Although targeting high end consumers, both from a phone and hearing aid point of view, it started to make hearing aids cool.  Conceived primarily as a tool for Apple to lobby for regulatory change, rather than any altruistic motive, it nevertheless started a much wider industry initiative which is culminating in the new Bluetooth low energy audio standard.

Of more immediate significance, was the launch of AirPods in December 2016.  Initially derided by media commentators, they have become the faster growing consumer product ever.  Covid and Zoom have only served to push the sales up.  Whatever concerns may have been voiced about their appearance, users have pushed that aside and taken to them likes ducks to water, voting with their Apple Wallets.  The original AirPods eschewed the techy features that other hearables manufacturers were pursuing, like biosensors, MP3 players and translation and concentrated on two things – making them sound as good as wired earbuds and making them simple to use.  Equally interesting are the hearing enhancements which have been quietly rolling out with subsequent iOS releases.  The first was Listen Live, which allowed you to use your iPhone as a remote microphone.  That’s particularly useful for situations such as the family around the dinner table, to help pick up conversations.  More recently, we’ve seen the Transparency mode that came with the Airpod Pro.  This allows you to mix external sound with what you’re listening to.  What is interesting with Transparency is that I’m discovering a growing number of people who continue to use this mode when they’re not listening to anything over the Bluetooth link – they’re keeping their AirPods in and using them as a simple form of hearing aid.  The most recent addition to their hearing tools is Headphone Accommodation, which appeared in iOS14.  This allows users to customise the frequency response of what they hear.  You can choose from preset options, or import an audiogram produced by an app such as Mimi’s Hearing Test. 

Whilst none of these are medical grade hearing aids, they mimic the steps an audiologist would take.  This means that users will start to familiarise themselves with the steps of testing their hearing and appreciating the benefits, seamlessly starting them down the path of audiology.  That should make the transition to a hearing aid much smoother once they reach the limit of what their earbud can do.

That obviously raises the question of where an earbud stops and a hearing aid starts.  If we look at purchase decisions, there’s an evident gap as people slow down their purchase of the latest consumer earbuds or headphones and start buying hearing aids.

That dip in the middle correlates with the time at which hearing loss starts to appear.  The problem is that if it is left untreated, we start to see the secondary effects, as personal behaviour moves from social to isolation.

The gap, during which those effects occur, largely delineates the marketing and approach of the two industries – consumer hearables and hearing aids.   Both are very likely to remain successful in their own domains, but there is a battleground in the middle to address moderate hearing loss, which is starting to attract attention.

Companies are beginning to enter this space.  The effect of Covid and lockdown on the traditional audiology chain has highlighted the opportunity for more remote prescribing and customer self-testing. We’re also seeing great steps in technology.  The latest Bluetooth chips from Qualcomm are lower powered and more capable than any previous generation.  They’ve just announced a partnership with Jacoti – a European supplier of hearing software whose mission is “hearing without barriers”, which makes it possible for new entrants to develop earbuds which sit in this gap.  We’ll probably see the first fruits of that collaboration by the end of 2021.  Meanwhile, startups like Nuheara and Olive are already on their second generation of these types of device.

It looks as if the stigma is finally disappearing, but we might need to fight a new one which is replacing it.  The next generation of hearing aids, which will be using Bluetooth LE audio, will have the ability to do everything that consumer earbuds do (as well as their existing, advanced hearing aid functionality).  That raises an interesting dilemma for the people who procure them in volume, such as the NHS and VHA, as for a medical procurement manager, this next generation of hearing aids will look remarkably like consumer devices.  There is a real risk that they don’t understand the benefit of these new features, in the same way they’ve not seen the benefit of fashionable colours.  If they try to insist purely on the medical correction features, it will perpetuate the reluctance of people to wear them.  This is probably a bigger threat to the hearing aid industry than the introduction of Over the Counter (OTC) or Direct to Consumer (DTC) sales.  The industry will need to forget about the restrictions that consumer stigmatisation has imposed on their designs for the last twenty years, design products that all ages want to wear and concentrate on making sure that insurers and health services don’t deny those users access to the same facilities that those without hearing loss currently enjoy as part of their everyday life.

Read more of my articles on hearing and hearables.