Download The Latest Hearing Technologies: Uptake and Evaluation

The Ear Foundation
Hearing and Communicating in a Technological Era
The Latest Hearing
Technologies:
Uptake and Evaluation
[Confidential Report for NHS Innovations]
The Ear Foundation
[2011]
The Ear Foundation, 2011
Contents
Contents ..................................................................................................................... 2
Executive Summary ................................................................................................... 3
1. Introduction ............................................................................................................ 6
2. Hearing Aids in the UK ........................................................................................... 9
2.1. Hearing aid provision ....................................................................................... 9
2.2. Hearing aid market ......................................................................................... 10
2.2.1. Public vs. Private ..................................................................................... 10
2.2.2. Retail vs. Wholesale ................................................................................ 12
3. Perspectives of individuals with hearing loss ....................................................... 16
3.1. Background .................................................................................................... 16
3.2. Patient journey ............................................................................................... 16
3.3. Hearing aid owners and non-owners ............................................................. 17
3.4. Buying/obtaining intentions ............................................................................ 18
4. Other Hearing Technologies ................................................................................ 20
4.1. Cochlear Implants .......................................................................................... 20
4.2. Electric Acoustic Stimulation .......................................................................... 23
4.3. Bone Conduction Hearing Aids ...................................................................... 23
4.3. Middle ear implants ........................................................................................ 26
4.4. Brainstem implants ........................................................................................ 27
5. Assistive Technologies ......................................................................................... 28
5.1. FM amplification technology ........................................................................... 28
5.2. Telecoil........................................................................................................... 29
5.3. Speech to text ................................................................................................ 30
5.4. Subtitle Spectacles ........................................................................................ 31
6. Conclusions .......................................................................................................... 32
7. References ........................................................................................................... 33
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Executive Summary
“You lose total self esteem, you don’t want to mix, anything like that because
that’s what deafness does to you”. (Individual with hearing loss, The Ear
Foundation, 2011)
Advances in hearing technology have given access to speech to many individuals
with hearing loss where previously there was little to help them. The current report
provides detailed information on the most recent available data on
the prevalence of hearing loss,
the uptake of hearing aid technology and the public, private, retail and
wholesale hearing aid market,
the perspectives of individuals with hearing loss,
the range of currently available hearing technologies
and a range of assistive technologies available for individuals with hearing
loss.
The findings from the report reveal that:
Deafness has a significant functional impact for individuals in their daily
routines, living at home, at work and in social and formal situations.
Early onset hearing loss (in childhood) impacts on the development of spoken
language, reading ability, educational attainment and future employability.
Late onset hearing loss impacts individuals‟ communication abilities leading to
feelings of isolation, low self esteem and reduced independence.
Advancements in hearing technologies provide individuals with hearing loss
with the opportunity to overcome many of the challenges they face with
routine auditory tasks.
Deaf children fitted early in life with hearing technology can (if other things are
equal) be expected to acquire spoken language and age appropriate
educational attainment.
Hearing technologies can significantly improve the quality of life and meet the
communication needs for adults with hearing loss.
Although hearing technologies do provide considerable benefit, challenges
associated with background noise, distance and room acoustics can have a
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significant impact on the potential benefits of these hearing technologies.
Assistive technologies such as FM systems, telecoil and speech to text
facilities can help overcome many of these challenges.
The most current figures from Action on Hearing Loss (AoHL) show 10.1
million people in the UK suffer from some form of hearing loss.
The most recent iData Research (2011) figures show 3.2 million people
suffering with hearing loss are hearing aid users. With the figure expected to
rise up to 4.2 million by 2017.
In 2010 the UK had the second largest hearing aid penetration rate in Europe
at 35.3% and this is expected to rise by 2017 to 40%.
Just over 80% of the hearing aids provided in the UK are done so by the
public sector (NHS) and approximately less than 20% are provided through
the private sector.
Although the NHS provide 80% of the hearing aids, because of their
purchasing power and the lower prices on hearing aids they can command,
they hold 55.6% of the total market share.
The private retail companies own approximately 45% of the total market share
of the UK.
Two of the five largest companies in the private sector are owned by optical
store groups, with Specsavers holding 7.6% of the total market share and The
Hearing Company (owned by Scrivens Optical Group) holding 2.8% of the
total market share in 2010.
In 2010, the total retail market share for hearing aids in the UK was worth
€617.6 million and the total wholesale market was worth €121.8 million
The findings from the most recent European Hearing Instrument
Manufacturers Association (EHIMA; 2009) commissioned research identified
the more severe the perceived hearing loss the higher the hearing aid
adoption rate.
The stage of the patient journey at which the highest percentage of dropout
rates for individuals with hearing loss who seek advice was after discussing
their hearing loss with their GP or ENT doctor. 39% of individuals decided not
to have a hearing aid after this stage. When considering individuals with lower
degrees of hearing loss the dropout rate at the GP/ENT stage increased to
64%.
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Individuals who had purchased their hearing aid from the private sector were
slightly more satisfied than those who had received it through the NHS.
Similarly those who had the more recent technology were more satisfied than
those with the older technology.
The most important influencing factor for non owners of hearing aids to
purchase/obtain hearing aids was if their GP/family doctor would recommend
it.
The findings highlight the importance of GPs in the decision making process
for individuals with hearing loss. This has serious implications for future
uptake of hearing aids and amplification technology bearing in mind the recent
government initiatives of GP consortia and any qualified provider (AQP).
A range of hearing technology is currently available for individuals who cannot
benefit from standard hearing aids including cochlear implants, electroacoustic implants, bone conduction hearing aids, middle ear implants and
brainstem implants. These technologies are rapidly developing with outcomes
improving.
Assistive technologies available to people using amplification technology
include the use of FM technology and telecoil/induction loops.
The use of speech to text technology as subtitles, in meetings or conferences
through palantypists and through captioning at theatres and performance
venues by companies like STAGETEXT, also help provide all individuals with
hearing loss access to speech.
Text removed
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1. Introduction
“They forget because it’s not a visual illness so people forget and because
you catch the odd word... You’ve lost half of the conversation so you felt as if
you’ve been left out” (Individual with hearing loss, The Ear Foundation, 2011).
The functional impact of a hearing loss is significant. For children with early onset
hearing loss, their development of spoken language, reading ability, educational
attainment and future job prospects are all impacted. For adults with later onset
hearing loss deafness has a functional impact in their daily routines, at home and
work and in social and formal situations. The impact of hearing loss on
communication abilities results in feelings of isolation, low self esteem and reduced
independence.
Hearing loss can be of three types, conductive, sensorineural or a combination of the
two (mixed). Conductive hearing loss results from middle ear and ear canal
problems. The middle ear consists of the eardrum, the middle ear cavity and the
ossicles (three tiny bones). Hearing loss of this nature is typically a result of ear
infections (otitis media), wax impaction, problems with the ossicles or
underdeveloped or absent outer ear. Sensorineural hearing loss results from
damage to the cochlea or cochlear nerve. This can be from birth or can be a result of
illness, noise exposure or aging.
The advancements in hearing technologies including digital hearing aids, bone
conduction hearing aids and cochlear implants provide individuals with hearing loss
with the opportunity to overcome many of the challenges they face with routine
auditory tasks. Similarly, the implementation of the newborn hearing screening
program (NHSP; see www.hearing.screening.nhs.uk) has resulted in children being
identified with hearing loss and fitted with hearing technology very early in life.
Children with hearing loss fitted early in life with hearing technology have improved
opportunities to acquire spoken language and age appropriate educational
attainment, other things being equal (Davis et al. 1997; Harrison et al., 2005;
Yoshinaga-Itano et al, 1998). As a result they can be expected to have improved
employment and future prospects. Although the challenges faced by adults with late
onset hearing loss are not the same as those faced by children with early onset
hearing loss the impact is still significant. The fitting of hearing technologies has
significantly improved the quality of life for adults with hearing loss. Furthermore,
those with profound hearing loss that previously could not benefit from conventional
hearing aids can now benefit from cochlear implants.
Although hearing technologies do provide considerable benefit many challenges still
exist. A multitude of situational factors such as background noise, competing noise,
room acoustics and familiarity with a situation can impact individuals with normal
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hearing; the impact for individuals with hearing loss in these situations is magnified.
Assistive technologies such as FM systems and telecoil can help overcome many of
the challenges associated with background noise, distance and room acoustics.
Similarly, subtitles can help individuals with hearing loss to understand speech in
difficult listening situations, for example, when watching television at a volume set for
individuals with normal hearing levels, or when unfamiliar accents or unfamiliar
dramatic contexts are in use.
The most recent research conducted by Action on Hearing Loss (AoHL) formerly
known as the Royal National Institute for the Deaf (RNID) reports more than 10
million people in the UK are with some form of hearing loss (AoHL, 2011). They
further estimate that, due to the ageing population of the UK, by 2031 14.5 million
people will be with a hearing loss in the UK. According to the World Health
Organisation by 2030 adult onset hearing loss will be in the top ten disease burdens
in the UK.
A breakdown of the total number of individuals with hearing loss in the UK shows
around 6.4 million are of “retirement” age (65+) and around 3.7 million are of
“working” age (16-64). From the total number with hearing loss approximately
800,000 people have a severe to profound hearing loss. The following tables show
estimated figures for the amount of people with hearing loss in the UK.
Table 1.1. Most recent figures for the number of people with hearing loss in the UK (AoHL, 2011)
UK
All hearing loss
Severe/ profound
Working age
3,721,000
135,500
Retirement age
6,390,500
685,000
Total
10,111,500
820,500
From the above total, there are an estimated 356,000 people with combined visual
and hearing loss in the UK. Of the estimated 365, 000, approximately two thirds
(62%) are aged 70 or over. The predicted number of these individuals is expected to
increase to 569,000 by 2030.
The current number of children (0-16) with permanent hearing loss in the UK is
estimated to be more than 45,000.
The current report has been set out in five subsequent sections. Chapter 2 will focus
on the provision of hearing aids in the UK. This section will cover the uptake of
hearing aids by individuals with hearing loss and will also consider the major
wholesale and retail market for hearing aids in the UK. The latter will help readers to
appreciate the possible routes for the introduction and retail of new technology to
help individuals with hearing loss. Chapter 3 will describe the findings from the latest
research on the hearing aid adoption rates by individuals with hearing loss. This
research was a large comprehensive study and the first of its kind completed in the
UK and was conducted by an independent company on behalf of the European
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Hearing Instrument Manufacturers Association. Chapter 4 will provide an overview of
existing amplification technologies currently available to individuals with hearing loss.
Chapter 5 will describe some of the assistive technologies used by individuals with
hearing loss. The report will conclude with Chapter 6 providing a summary of the
report and recommendations for the introduction of new technology to assist
individuals with hearing loss.
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2. Hearing Aids in the UK
2.1. Hearing aid provision
Hearing aids in the UK are provided through the National Health Service (NHS) and
can also be purchased privately through retail shops. The provision of hearing aids
through the NHS is free at the point of delivery and this has contributed significantly
to the UK having one of the highest hearing aid penetration rates in all of Europe.
However, no reimbursement policies exist in the UK for individuals who purchase
their hearing aids from the retail sector.
The route to acquire a hearing aid through the NHS for adult users varies, however
the most common pathway is through the GP who depending on the diagnosis will
either refer the patient to the Audiology department or the Ear Nose and Throat
(ENT) department at the nearest NHS hospital. Any patient who may have a clinical
contra-indication would be referred onto the ENT department and on the consultant‟s
approval would be given a hearing aid. Patients have a very minimal choice of
hearing aids they receive from the NHS as these are generally pre-selected by
audiologists from a limited choice of options. The route to acquiring hearing aids
through private retail is much more open in that individuals can directly book their
appointment with a private hearing aid dispenser. However, if the dispenser finds
any medical contra indications present they must refer the individual to an ENT
department and can only fit a hearing aid once the ENT consultant has approved it.
Individuals have a much greater selection of hearing aids when purchasing through
private retail, however the full cost is paid for by the individual without any
reimbursement from the government.
The latest figures from iDATA (2010) indicate a total of 9.1 million people in the UK
suffered from hearing loss in 2010. Although this figure is lower than the 2011 figures
obtained from AoHL (10.1 million), the difference can be attributed to the more
inclusive terminology of deafness used by AoHL. This more inclusive terminology is
consistent with their role as a campaigning charity. As the iData report provides an
overview of the market for hearing aid and audiology devices the more conservative
figures provide a more realistic appreciation of the potential for new assistive
technologies in this market.
In 2010 the number of hearing aid users in the UK was approximately 3.2 million
(iData, 2011). The main driver for hearing aid adoption in the UK is the aging
population which will see a compounded annual growth rate (CAGR) of 2% over the
forecast period till 2017. Currently the UK has the second highest penetration rate in
Europe (35.3% in 2010) and this is expected to increase to over 40% by 2017 (4.2
million; iData, 2011). As a result of the increase in the number of hearing aid users
the opportunities and need for assistive technologies would be expected to increase
as well.
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2.2. Hearing aid market
To establish the potential for any new assistive technological device for individuals
with hearing loss, a better understanding of the hearing aid market is required. The
following section will initially provide an insight into the hearing aid market and will
differentiate between the public and private sectors in the UK. Thereafter the
subsequent section will detail the current distribution of the retail and wholesale
market.
2.2.1. Public vs. Private
The total hearing aid market in the UK in 2010 was valued at £531 million, a 1.8%
increase over the previous year (iData, 2011). The total number of units sold in 2010
was over 1 million making the UK the country with the highest unit sales in Europe.
This is primarily a result of the large purchasing order by the NHS. For the year
2010, the percentage of hearing aids sold to the NHS was 81%, and 19% was sold
to private retailers. As a result of the large purchasing power of the NHS the average
selling price (ASP) of hearing aid units in the UK was one of the lowest in Europe.
This does nevertheless result in the government incurring a large expense in the
provision of hearing aids through the NHS. Currently the government is introducing
new measures to change the way hearing aids are provided in the UK with their “any
qualified provider” scheme (AQP). It is expected that this may lead to a gradual shift
of patients moving towards the private sector while continuing to receive their
hearing aids through NHS funding.
In the UK, then, a clear distinction between public and private retail markets exists
which is why it would be difficult to fully appreciate the hearing aid market simply
using the figures from the total retail hearing aid market. In 2010 the public retail
market (that is, the cost of hearing aids purchased by the NHS) was valued at £295
million, with an increase of 3.6% from the previous year. The public retail market
value is expected to increase to £320 million by 2017. The last few years has seen
an increase in the number of units provided and a corresponding increase in the
market value of the public retail hearing aid market. This is in large part because of
the “18 week initiative” embarked on by the Government in 2008, where patients‟
waiting times for receiving a hearing aid were reduced to 18 weeks. This prompted
an increase in the number of hearing aid units issued.
Another potential factor to be considered is the improvements in the hearing aid
technology available through the NHS. Hearing aids available through the NHS are
purchased through public tender systems every four years. As the NHS is the largest
purchasing organisation of hearing aids in the world, it is able to pressure
manufacturers to abide by the criteria set out in NHS tender documentation; indeed,
in order to win a four year contract manufacturers will often redesign their equipment
specifically to comply with the criteria.
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The NHS introduced improved criteria for their last tender period. Using their large
purchasing power the NHS were able to secure mid-level technology where
previously only economy-level or a mix of economy and some features of mid-level
hearing aid technology were available. For premium-level technology individuals
would still need to go through the private sector.
The value of the private retail market in the UK was £235 million in 2010. Although
the market value for the private sector was not considerably lower than the public
sector, the number of units sold and the current installed base were much lower than
in the public sector and the average selling price (ASP) correspondingly a great deal
higher. In 2010, the number of units sold in the private sector was 192,632 resulting
in an installed base of approximately 1 million. In comparison the NHS had sold
close to 1 million hearing aids in 2010 and had an installed base of approximately 4
million. Similarly, the ASP for hearing aids in the private sector in 2010 was £1,224
compared to £320 in the public sector.
Year
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
Units Sold
Public
Private
835,400 198,532
870,487 189,400
901,824 190,536
923,468 192,632
942,861 196,099
960,775 201,002
977,108 207,635
992,742 215,525
1,007,633 224,577
1,021,740 234,908
1,034,001 246,183
Installed Base
Public
Private
3,501,929 774,291
3,676,026 831,111
3,856,391 888,272
4,041,085 946,062
4,229,657 1,004,891
4,421,812 1,065,192
4,617,233 1,127,482
4,815,782 1,192,140
5,017,309 1,259,513
5,221,657 1,329,985
5,428,457 1,403,840
Average Selling Price
Public
Private
£304
£1,303
£311
£1,272
£316
£1,247
£320
£1,224
£322
£1,205
£323
£1,187
£322
£1,171
£320
£1,158
£317
£1,148
£314
£1,140
£310
£1,133
Market Value
Public
Private
£253.7m £258.8m
£271.0m £240.9m
£285.2m £237.5m
£295.6m £235.8m
£303.6m £236.2m
£310.0m £238.5m
£314.6m £243.2m
£317.7m £249.6m
£319.6m £257.8m
£320.5m £267.8m
£320.1m £278.9m
Table 2.1 the number of units sold, installed base, average selling price and market value for the public
and private sector in the UK 2007-2017 (iData, 2011).
Although, because of the improvements in the NHS the demand for hearing aids in
the private sector has slowed down, a steady increase in the number of units sold
privately is expected over the forecast period. This has been attributed to the
mounting budgetary constraints on NHS spending which would be expected to affect
the current provision of hearing aids through the NHS. As a result more individuals
may look to the private sector resulting in the private sector having a larger share of
the compounded annual growth rate (CAGR) compared to the public market. By
2017 the expected market value for the private sector is £278 million with an
installed base of over 1.4 million (iData, 2011).
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2.2.2. Retail vs. Wholesale
The major portion of the retail hearing aid market in the UK comprises of the NHS
healthcare system (55.6%). Although, the NHS dispenses just over 80% of the
hearing aids the average cost per hearing aid is far less than the private sector.
Approximately 200 audiology departments and standalone clinics provide hearing
aids through the NHS in the UK.
The rest of the 45.4% of the retail hearing aid market is shared out by private
companies. The largest single retailer from the private sector is Specsavers who
have 7.6% of the total market share. Thereafter the next four companies that have
the largest share of the market are Amplifon (7.1%), Hidden Hearing (6.5%), The
Hearing Company (2.8%) and David Ormerods/Boots (2.6%). The remaining 17.9%
of the retail hearing aid market is held by independent retailers or smaller
companies. Figure 2.1 illustrates the retail hearing aid market share in the UK.
Figure 2. the total retail hearing aid market share in the UK.
Specsavers are also the leading supplier of prescription eyewear in the UK.
The majority of their hearing aid departments are based within their optical
stores with approximately 110 stores dispensing hearing aids. They also have
approximately 15 independent standalone hearing aid stores. They use high
retail price discounting with aggressive pricing promotions and are the leaders
in unit sales in the private sector. Specsavers has recently initiated a five year
partnership with Action on Hearing loss (AoHL) to improve hearing aid uptake
in the hearing loss population and increase awareness of issues related to
hearing loss. The partnership aims to launch a nationwide advertising
campaign to provide free hearing screening to potentially more than one
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million individuals with hearing loss who could benefit from a hearing aid. It
has been made clear that individuals identified as potentially benefiting from a
hearing aid will be encouraged to go to their GP if appropriate, and will not be
pressured to purchase an aid from Specsavers.
Amplifon had the second highest share of the private sector at 7.1%.
Hidden Hearing is a company owned by William Demant which is the market
leader in the wholesale hearing aid market (see below) and also owns Oticon
the hearing aid company.
The Hearing Company is a subsidiary company of the Scrivens Optical
Group.
David Ormerods group is a hearing aid company that has merged with Boots
pharmacies. More recently, the Sonova Group, which owns Phonak has
gained a minority ownership in Ormerods/Boots
The wholesale hearing aid market distributes to both the public and private sector. In
2010 approximately 90% of the total wholesale market was held by four companies,
William Demant, Siemens, Sonova and GN Resound. The remaining 10% of the
market was shared out by companies including Widex, Starkey, Puretone, Hansaton,
etc. William Demant Company (who own Oticon, Bernafon and Sonic Solutions)
were the market leader in 2010 comprising of 31.7% share by value. The company
held the leading share in the public market (36.6%) and also held the second highest
position in the private retail market (22.4%). Siemens held the second highest
position in the total wholesale market. Similar to William Demant, this is because of
the large share the company held in the public hearing aid market (33.2%). In the
private market Siemens held a market share of 13.8%. Sonova owns Phonak, their
main hearing aid company, Unitron and has also recently acquired the second
biggest cochlear implant company Advanced Bionics. Sonova held the largest
market share in the private market at 34.3%. However their success in the private
market was not mirrored in the public market; as a result the company held third
position in the overall total market share (18%). GN Resound accounted for 14.7%
share of the total wholesale hearing aid market in the UK. Although the company has
seen a reduction in market share over the last few years it still held 15.6% of the
public market and 12.9% of the private market. GN Resound continues to be
regarded as an innovative manufacturer and as a result of newer technology is
expected to gain market share in the coming years. Figures 2.2 to 2.4 illustrate the
public, private and overall wholesale market in the UK.
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Figure 2.2 the public wholesale market share in the UK.
Figure 2.3 the private wholesale market share in the UK
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Figure 2.4 the overall wholesale market share in the UK.
The current chapter provided an overview of the hearing aid market in the UK. The
following chapter will focus more on the perspectives of the end user.
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3. Perspectives of individuals with hearing loss
3.1. Background
In 2009 Avonum, a research company based in Zurich, Switzerland, were
commissioned by the European Hearing Instrument Manufacturers Association
(EHIMA) to conduct an in depth study on hearing aid adoption rates in Germany,
France and the UK. The current chapter will provide an overview of the UK findings
from this study. The study was the first of its kind conducted in Europe and provides
a comprehensive insight on the perspectives of hearing impaired individuals with and
without a hearing aid.
The total representative sample included for screening was 14,980 of which 1,335
self reported to having a hearing loss. Of these 513 were using hearing aids and 822
were not. As part of the study the sample was segmented into 6 groups based on
each individual‟s „degree of hearing loss‟ which was determined by the following
factors:
Number of ears impaired (one or two)
Stated hearing loss (Mild to Profound)
Scores on 6 APHAB (Abbreviated Profile of Hearing Aid Benefit) like
questions (Scaled 1-7)
When NOT using a hearing aid, how difficult respondents reported it was for
them to follow conversations in the presence of noise.
The answers to the above factors were provided by the users and as a result were
subjective, most especially in the case of the non hearing aid users who may not
have had a hearing test. Based on the 6 hearing loss segments the findings
illustrated the more severe the perceived hearing loss the higher the hearing aid
adoption rate (EuroTrak, 2009).
3.2. Patient journey
The individuals from the UK sample were asked to provide feedback on their patient
journey based on five distinct stages:
Discuss hearing loss with GP or ENT doctor
GP or ENT doctor recommend hearing aid
Discuss hearing loss with Audiologist or HA dispenser
Audiologist or HA dispenser recommends hearing aid
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HA purchased or provided (NHS)
Although the individuals included in this sample all accepted that they were having
troubles with hearing a large percentage (33%; EuroTrak, 2009) did not do anything
about it. However once individuals with hearing loss did seek medical advice the
largest dropout rate occurred at the GP/ENT doctor stage (39%; EuroTrak, 2009).
These figures were lower than the AoHL (2011b) which suggests 45% of people who
report hearing problems to their GP are not referred for a hearing test or hearing
aids. Once patients had discussed their hearing loss with an audiologist or hearing
aid dispenser the dropout rate was minimal at 6% (EuroTrak, 2009). This highlights
the significant position GPs are in when considering the provision of hearing aids for
this population.
The rates for not seeking hearing aids increased for individuals in the lower „degree
of hearing loss‟ segments both in terms of seeking advice from a GP/ENT doctor and
also for being recommended for a hearing aid by the GP/ENT doctor. 45% of
individuals in the lower „degree of hearing loss‟ group did not seek advice from a
GP/ENT doctor. From the 55% of individuals who did seek advice from their GP/ENT
64% were not recommended for a hearing aid. As expected the dropout rates for
individuals in the higher degree of hearing loss groups were lower. 20% of the
individuals in the higher „degree of hearing loss‟ groups (segments 4-6) did not seek
GP/ENT advice. From the 80% of individuals who did seek advice from their GP/ENT
doctor, just over a quarter dropped out after the advice given. These findings again
highlight the important position held by GP‟s and ENT doctors in the decision making
process and is especially worrying as GP‟s do little or no hearing testing.
Furthermore, for those in the „lower „degree of hearing loss‟ groups the current
advancements in hearing technologies do provide advanced amplification options.
3.3. Hearing aid owners and non-owners
The „degree of hearing loss‟ for hearing aid users included in the study sample were
subjectively captured. The majority of the hearing aid owners had a mild to moderate
hearing loss with severe to profound hearing loss accounting for only 32% of the
total hearing aid owners. Although the hearing loss levels were subjective, for the
hearing aid owners it would be expected that their subjective levels of hearing loss
would be reliable.
The majority of the hearing aid owners (74%) had received their hearing aid through
the NHS with approximately a quarter of the sample (24%) purchasing their hearing
aids privately. 2% noted down that they did not know where they had received their
hearing aid from. Of those who had purchased their hearing aid 74% had been
purchased in 2007 or later.
The satisfaction levels for individuals with hearing aids was assessed using a 7 point
Likert scale where 1 = very dissatisfied and 7= very satisfied. The results comparing
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satisfaction levels for individuals with hearing aids showed 83% of individuals with
private hearing aids were „somewhat satisfied‟ to „very satisfied‟. In comparison 76%
of individuals who had received their hearing aid through the NHS were somewhat to
very satisfied with their hearing aids. The biggest difference for satisfaction levels
was for the „very satisfied‟ category where 30% of private hearing aid owners were
very satisfied compared to 18% of NHS hearing aid owners.
A further comparison was done for satisfaction levels with hearing aids purchased
within two years of the study (2007-2009) compared to hearing aids purchased
before 2006 (Figure 3.8). The findings highlighted the newer the hearing aid the
higher the satisfaction with 82% who had received or purchased their hearing aids
within two years being „somewhat satisfied‟ to „very satisfied‟. In comparison 67% of
individuals who had received or purchased their hearing aids two or more years
previous were „somewhat satisfied‟ to „very satisfied‟
The subjective „degree of hearing loss‟ for non hearing aid owners revealed only 7%
of the hearing impaired non owners felt that they had a severe to profound loss. The
sample of hearing impaired non owners in the higher „degree of hearing loss‟ groups
(4-6) were questioned on reasons for not owning hearing aids. Their responses
suggested various reasons for non use of hearing aids with the major reasons cited
as: hear well enough in most situations, hearing aids uncomfortable and
embarrassed to wear hearing aids. 40% of the individuals cited one of the reasons
for non use of hearing aids was because their family doctor recommended them not
to.
3.4. Buying/obtaining intentions
Both groups of individuals were questioned on what had influenced them or would
influence them to obtain/purchase a hearing aid. The question for the two groups
was phrased differently:
Owner: Thinking back to when you obtained your first hearing aid(s), what
influenced you to obtain /purchase the hearing aid(s)?
Non-owner: Think about the option to obtain / purchase a hearing aid. What do you
think would influence you to obtain / purchase a hearing aid?
The results for both groups highlighted differences in what non-owners say would
influence them to buy a hearing aid in the future compared to what owners said
would influence them to buy. The most important influencing factors for non owners
were if their GP/family doctor recommended it (58%), if their hearing loss got worse
(57%) and if their ENT doctor recommended it (42%). In comparison those who had
purchased their hearing aid cited their hearing loss got worse (48%), their hearing
aid dispenser recommending it (41%) and their NHS audiologist recommending it
(39%) as their main reasons for purchasing/obtaining another hearing aid. The
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findings highlight how non hearing aid owners often rely greatly on GP‟s and ENT
doctors for advice and how they are often a barrier to hearing aid use.
Both groups were also asked about their buying intentions in the future. The group
who already owned hearing aids were more likely to repurchase a new hearing aid.
The results indicated 13% of non owners intend to purchase hearing aids within the
next two years compared to 20% of existing owners of hearing aids.
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4. Other Hearing Technologies
4.1. Cochlear Implants
Cochlear implants are surgically implanted electronic amplification devices. Overall
they consist of two components, the implant and the external sound processor. The
implant includes a receiver coil and associated electronics, which sits under the skin
around the mastoid area, and an electrode array that is inserted directly into the
cochlea. The external sound processor is housed in a device shaped similar to a
hearing aid and has an external transmitter coil that attaches magnetically to the
implanted receiver coil. The external processor picks up the sound via a microphone,
converts the digitally coded sound into electrical impulses, and transmits these
impulses through the two coils to the implant. The implant then sends these impulses
to the appropriate electrodes in the array placed in the cochlea and these provide
direct electrical stimulation of the aural (hearing) nerve (Figure 4.1). This provides
the sensation of sound to the wearer.
Cochlear implants provide a treatment option for individuals who do not receive
sufficient benefit from a standard hearing aid. Individuals with hearing loss levels
ranging from moderate to profound can be considered for cochlear implantation,
provided the auditory nerve still has function. With the implementation of newborn
hearing screening and the guidelines set out by the National Institute for Health and
Clinical Excellence (NICE), cochlear implantation has become routine in the
paediatric population. The improved listening abilities offered by cochlear implants
have been shown to result in improved speech, language, educational and social
outcomes for children with hearing loss (Archbold et al., 2008). Cochlear implants
provide the ability to hear spoken language for profoundly deaf children and adults
for the first time. They provide access to the high frequency speech sounds at the
quiet levels enabling deaf children implanted early (and with no other difficulties) to
acquire age appropriate spoken language equivalent to their normally hearing peers
(Dettman et al., 2007). Similarly, adults fitted with cochlear implants have
significantly benefited with the technology in understanding conversations and using
the telephone (Clinkard et al., 2011). A number of studies have determined the cost
effectiveness of cochlear implants and have highlighted the significantly improved
quality of life and speech perception they provide for both the adult and paediatric
populations (Stacey et al., 2006; Summerfield et al., 2002).
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Figure 4.1 external and internal components of cochlear implant (www.isvr.soton.ac.uk)
In the UK cochlear implants are provided through the NHS through specifically
dedicated cochlear implant programme centres. There are currently approximately
25 centres across the UK dealing in both adult and paediatric fittings
(www.bcig.org.uk). Each centre has a dedicated team of professionals including
specialist ENT surgeons, audiologists, speech and language therapists and teachers
of the deaf. For patients to receive a cochlear implant they would be referred to a
cochlear implant centre by their local audiology department. The centre conducts a
detailed assessment of their suitability to receive the device. If a patient is suitable
for the device they are referred to the ENT specialist to undergo the surgical
procedure. The surgical procedure can be performed on children in the first year of
life. After the surgical implantation of the internal components the external
components are fitted by the audiologist. Thereafter an intensive rehabilitation
process with teachers of the deaf and speech and language therapists occurs.
Regular appointments at the centre are required and the external processor is
usually upgraded every five years.
Traditionally cochlear implants have been fitted to one ear only but latest UK
National Institute for Clinical Excellence (NICE) guidelines have recommended
bilateral fittings for children and for adults with additional disabilities (NICE, 2009). As
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a result the number of binaural cochlear implant fittings has risen and the overall
number of cochlear implant units sold will expectedly rise.
There is a very small “private” market for cochlear implants. In contrast to hearing
aids, cochlear implants funded by the NHS are the latest available and it is not
generally possible to purchase a superior implant or processor even if one had the
resources to do so.
In children the penetration rate of cochlear implantation is proportionately high in the
UK compared to adults. Although many adult patients are suitable candidates for
receiving a cochlear implant, the penetration rates are low. In 2010 there were
91,483 cochlear implant users in the whole of Europe (including the UK), with a total
of 106,508 cochlear implant devices in use (a small proportion of users are already
fitted with two implants) (iData, 2011). According to iData (2011) figures, in the UK
1,670 cochlear implants were fitted in 2010 resulting in an installed base of 17,026. A
compound annual growth rate (CAGR) of 8.3% for units sold in the UK is expected,
resulting in the number of units sold per year increasing to 2,913 by 2017 (iData,
2011). The installed base for cochlear implants is expected to have a CAGR of
10.2% resulting in an installed base of 33,515 by 2017 in the UK. The UK average
selling price (ASP) for cochlear implants in 2010 was €20,032 and it is expected that
the price will remain stable with a 1.4% CAGR resulting in an ASP of €22,112 in
2017. The UK market for cochlear implants in 2010 was €33.5 million and with a
9.8% CAGR forecast the expected market in 2017 is €64.4 million.
There are four cochlear implant manufacturers, Cochlear, Advanced Bionics, MEDEL and Neuralec. In 2010, Cochlear Europe was the clear market leader in the UK
with a 68.3% share of the market. Advanced Bionics was the second leading
competitor and had a 16.2% share of the UK market. MED-EL was the third leading
competitor with a market share of 14.3% in the UK. Neuralec had the lowest market
share in the UK with a 1.2% share of the market. Although Cochlear Europe is the
clear market leader and is expected to remain so for the forecast period until 2017,
Sonova's acquisition of Advanced Bionics has put the company in a position to
challenge for a greater share of the market by using both companies‟ resources.
Advanced Bionics did suffer a temporary decline in their market share in 2010 after a
precautionary product recall of the HiRes 90K however the company is expected to
regain momentum with the support from Sonova as well as the launch of their new
cochlear implant product the Neptune. Recently, in 2011 Cochlear have recalled
their latest product the Nucleus 5 from the market and the product is expected to
remain off the market for approximately 6 months. MED-EL is a well established
cochlear implant company based in Austria. Neuralec is a relatively new company
based in France and hold the second highest market share in France. The company
has however found it difficult to challenge the wide distribution channels of the other
three manufacturers in other markets.
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4.2. Electric Acoustic Stimulation
More recently the use of both a hearing aid and a cochlear implant together in the
same ear has become an option (Figure 4.2). The cochlear implant is used to
provide the mid to high frequencies and the hearing aid amplifies low frequencies.
The inner ear then processes the acoustic and electric stimuli simultaneously. This
hybrid hearing system has been specifically developed for individuals with severe to
profound high frequency hearing loss. Results have shown good outcomes for
patients using electro-acoustic stimulation technology (Gstoettner et al., 2006;
Skarzynski et al., 2006). The technology has only recently been introduced in the UK
and as such the numbers using it are still low. However, the positive outcomes from
current users should increase the numbers receiving this hybrid technology.
Figure 4.2 electro-acoustic stimulation, cochlear implant and hearing aid used simultaneously in same
ear.
4.3. Bone Conduction Hearing Aids
Bone Conduction Hearing Aids (BCHA) are the only amplification technology that
provides hearing treatment through direct bone conduction. The sound travels
directly through the bone, by-passing the ear canal and middle ear. The bone
conduction hearing aid is used in situations where an individual cannot use standard
hearing aids because of infections in the ear or if a part of or all the outer ear or ear
canal is missing. It has been well recognised as a hearing treatment for conductive
and mixed hearing loss since 1977. Research on the benefits of bone conduction
hearing aids has highlighted significantly improved quality of life, speech perception
and overall satisfaction with bone conduction hearing aids for individuals using the
technology (Dutt et al., 2002; Newman et al., 2008)
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The implanted bone conduction hearing aid consists of three components. The first
component is the titanium implant that is surgically fitted into the skull around the
mastoid area. The second component is the abutment that attaches to the titanium
implant. The third component is the hearing aid processor which snaps onto the
abutment (Figure 4.3).
Figure 4.3 the components of a bone conduction hearing aid (www.earfoundation.org.uk)
Once the processor is attached to the abutment, sound travels through the skull by
vibrations and directly stimulates the inner ear (Figure 4.4).
Figure 4.4 sound travels through to the cochlea via vibrations in the skull (www.earfoundation.org.uk)
In the case of single sided deafness, the sound is picked up by the bone conduction
hearing aid implanted on the side of the deaf ear and the sound travels to the better
ear (Figure 4.5).
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Figure 4.5 how sound vibrations travel to the opposite ear for individuals with single sided deafness
(www.earfoundation.org.uk).
Another type of bone conduction hearing aid consists of an internal implanted
magnet, an external magnetic spacer and a sound processor (Figure 4.6). This setup
avoids the need for an abutment.
Figure 4.6 the components for a bone conduction hearing aid using magnets instead of an abutment
(www.earfoundation.org.uk).
Bone conduction hearing aids can also be worn on a softband. This allows for young
children to get the benefit of the aid, without having the surgery (Figure 4.7). The
softband can also be used to test the sound of a bone conduction hearing aid with
adults before proceeding with the surgery.
Figure 4.7 bone conduction hearing aids with softband (www.earfoundation.org.uk).
There are two main suppliers for the traditional bone conduction hearing aid using
the abutment, Cochlear and Oticon Medical. Cochlear is the market leader for
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cochlear implants and Oticon is the flagship hearing aid company for William Demant
(the leading wholesale hearing aid company in the UK, as already noted). The other
company supplying bone conduction hearing aids in the UK is Sophono, however
they specialise in the magnetic implant style of bone conduction hearing aids.
Currently the data on the number of units sold and the number of individuals using
the bone conduction hearing aid is not available. However, the Ear Foundation has
just started a bone conduction database registry for the UK. The national registry
should be beneficial in obtaining information on the number of individuals using the
technology, the success rates of the technology and the different types of deafness
the technology is fitted to. The Ear Foundation is also conducting qualitative
research exploring the views and perspectives of families of children who have
received the technology and a separate study on the views and experiences of
individuals with SSD using bone conduction hearing aids.
4.3. Middle ear implants
Middle ear implants use mechanical energy to stimulate the structure of the inner
ear. Middle ear implants are suitable for individuals with moderate to severe hearing
loss who are unable to gain benefit from standard hearing aids because of infections
or if the outer ear and ear canal are missing. The technology is made up of two
components, an internal implanted component and an external processor. The
internal component of the middle era implant consists of a receiver (vibrating
ossicular prosthesis) and a floating mass transducer attached to the small bones in
the middle ear. The external component is an audio processor worn behind the ear
(Figure 4.8).
Figure 4.8 diagram of middle ear implant, floating transducer magnified (www.audio-infos.org).
More recent advances in middle ear implant technology have resulted in a totally
implantable device with no external components for the user. The device consists of
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The Ear Foundation, 2011
a rechargeable battery, a signal processor and a microphone, all implanted under
the skin. These are connected to an electromagnetic vibrator positioned inside the
mastoid bone and attached directly to the middle ear bones. The first fully
implantable middle ear device was fitted in the UK in 2011.
4.4. Brainstem implants
The auditory brainstem implant (ABI) is an implant that directly stimulates the brain
stem. It is clinically suitable for an individual who has a damaged or no cochlear or
auditory nerve. This may be due to a tumour or surgery. The technology is the same
as a cochlear implant except that the electrical stimulation is used to stimulate the
brainstem instead of the cochlea. Currently there are very few recipients of ABI‟s in
the UK because of the nature of the surgery and the limited reported benefits
associated with its use. Individuals expect to only have an awareness of sound.
However more recent research is highlighting outcomes are dependent on the cause
of the hearing loss and some level of success has been seen in younger children
and adults who did not have a tumour (Coletti et al. 2010).
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5. Assistive Technologies
The recent developments in hearing technologies such as digital hearing aids,
cochlear implants and bone conduction hearing aids have provided access to
spoken language that previously have never been experienced. However, there still
remain challenges for users of the technology in difficult listening situations.
Background noise, distance and reverberation have a significant impact on the ability
to listen in educational, work and social settings. Assistive devices overcome many
of the challenges present in difficult listening situations and help provide individuals
with hearing loss access to speech in these difficult settings.
5.1. FM amplification technology
FM amplification technology consists of two components, a transmitter and a
receiver. The FM receiver can be attached to standard hearing aids, cochlear
implants and bone conduction hearing aids. The FM transmitter is worn by a primary
speaker for example a teacher or a lecturer and the microphone of the transmitter
picks up the speaker‟s voice. The sound is converted into an electrical signal and
transmitted via FM radio waves to the receiver attached to an individual‟s hearing
aid/cochlear implant/bone conduction hearing aid (Figure 4.9). Some general
purpose receivers attach by electrical lead connection rather than directly to the
device as shown.
The signal is then amplified/processed by the hearing aid/cochlear implant/bone
conduction hearing aid and delivered to the user. The transmission occurs on
reserved radio frequency bands.
Figure 5.1 FM transmitter and receiver attached to hearing aid.
The improved signal to noise ratio provided by FM technology to individuals using
hearing devices has been widely accepted in the literature to improve speech
comprehension in challenging listening situations. The effects of room reverberation
times on adult hearing aid users have long been shown to have a far greater impact
on individuals with a hearing loss using a hearing aid compared to normal hearing
adults (Finitzo-Hieber and Tillman 1978; Hawkins and Yacullo, 1984). Similarly,
these studies have also shown how reduced signal to noise ratios have
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The Ear Foundation, 2011
disproportionately greater effect on hearing aid users compared to normal hearing
adults. Furthermore, the optimal distance for speech discrimination is within a metre
from the listener (Ross, 1992). In most rooms, at distances of two metres or less the
inverse square law of acoustic signals applies. This law dictates for every halving or
doubling of distance, the intensity of the acoustic signal would increase or decrease
by 6 dB respectively (Ross, 1992). It would be expected that the optimal distance
would not be maintained during routine daily activities and that the distance between
the user of hearing technology and the speaker would regularly increase.
FM technology is widely used in educational settings with school aged children
where the teacher would wear the transmitter and children would be loaned a
receiver during the course of the school day (of course one transmitter can be used
with a number of receivers). The use of FM with pre-school children and adults is
starting to pick up, however the numbers are still very low. Although no data is
currently available for the number of adult users of FM amplification technology the
expected number of adult users, estimated by the leading manufacturer of FM
technology (Phonak), is close to 1 in 500 adults with hearing aids. This remarkably
low figure – given the potential advantages that FM technology offers – suggests
there is considerable room for expansion in this market.
5.2. Telecoil
The telecoil („T‟)/loop function is routinely available with the majority of standard
hearing aids (including implants and BCHAs). Once placed on the „T‟ setting the
hearing aid can pick up sound coming through a loop system directly into their
hearing aids. The hearing aid can only pick up sound in rooms where a floor
induction loop has been fitted. The induction loop is a cable that encloses a
particular area and transmits sounds in the form of a magnetic field that can be
picked up within the coverage area when hearing aids are switched to the „T‟ setting:
often the loop is connected to an existing microphone and amplifier/public address
system. The coverage area can be as small as an individual‟s front room but can
also cover areas as large as conference halls. The induction loop can be found in
many public buildings like banks, churches and shopping centres and have been
shown to provide great benefit to users of hearing technology (Ross, 2002). Portable
induction loops as well as neck loops can also be used. The neck loop is a
lightweight cable worn around the neck and can be used with mobile phones and
blue tooth enabled devices. Similarly, much smaller „ear hook‟ loop systems have
been designed that can be used in place of ear phones by transmitting sound directly
to the hearing aid via the „telecoil‟.
Although the majority of hearing aids have the loop function or can have them
activated the uptake of the technology is not widespread. Findings from the EHIMA
study (2010) reported that the majority (62%) of hearing aid owners were not aware
of what the telecoil was and only 15% were aware they had a telecoil on their
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The Ear Foundation, 2011
hearing aid and 8% were not sure. The 15% who did have a telecoil setting on their
aids made most use of the setting when using the telephone (68%) and watching
television (59%). Other situations where the telecoil was used were at a house of
worship/church (43%) and listening to lectures (47%).
5.3. Speech to text
Speech to text conversion is widely used to help individuals with hearing loss
understand what is being said at public events (more rarely in private meetings or
interactions)
Speech to text is widely used as “subtitles”, particularly with television programmes,
movies, and stage plays (where the subtitles are projected on a special screen
above the stage). In these situations the subtitles can clearly be prepared well in
advance, and be shown in perfect synchronisation with the speech itself – though
this takes some operator skill in a stage play. Companies like STAGETEXT
specialise in this.
Recent research conducted by the Ear Foundation looking at the long term use and
outcomes for cochlear implant users found over 95% of respondents made use of
subtitles with televisions and found them beneficial.
In situations where the exact text spoken has not been agreed in advance –
meetings, conferences, legislative debates – speech must be rendered into text in
real time with as little delay as possible. Speech to text reporters, also referred to as
palantypists or stenographers (the two systems are slightly different but work in the
same way as far as the user is concerned) use a special keyboard to phonetically
type every word that is spoken in the meeting or conference. This is then converted
into English via special software and displayed on a screen (AoHL, 2011c).
Individuals with hearing loss find this useful when trying to follow a lecture or
conference presentation.
Palantypists and stenographers are skilled and efficient at transcribing speech, but
the operators need to be highly trained and this increases the cost of the service.
The concentration level required of the operator is also very high and in formal
events two palantypists are often used in alternating “shifts” of around thirty minutes
each. Providing a palantype service for (e.g.) an eight hour “day conference” may
therefore currently cost around £750. For some years efforts have been made to
devise computer (hardware and software) solutions that would render speech to text
efficiently without human intervention, and at proportionately lower cost.
Although many speech to text software packages are available now, the main
limitations to the computer based technology is the level of accuracy (word error
rate) achieved by such technology. There is a far higher word error rate with the
existing packages than with a good palantypist or stenographer (especially when he
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The Ear Foundation, 2011
or she has been briefed in outline on the subject under discussion). Software
packages can be “trained” to respond to an individual‟s voice – for example by
asking the individual concerned to read out a number of sentences displayed on the
screen by the computer - and this increases their accuracy. This may be practicable
when a hearing person wishes to use them for “dictation” but is hardly helpful when
an individual with a hearing loss wishes to use the package for general
communication. In the absence of this “training”, and when exposed to many new
voices and users, the level of accuracy for standalone software packages is
questionable.
5.4. Subtitle Spectacles
Recently (BBC, 2011), Sony UK has developed „subtitle glasses‟ aimed at movie
goers with hearing loss. Currently the movie industry only screen subtitle movies on
certain days a week and at odd times. This makes it difficult for individuals with
hearing loss to arrange their schedule around these special screenings. Sony UK‟s
new visual device places timed “closed captions” on the screen of the glasses so
that they are super imposed on the cinema screen. The captions have been
prepared in advance and are not generated by speech-to-text conversion. For the
user the glasses give the impression that the subtitles are on the cinema screen. The
BBC (2011) interviewed an individual with hearing loss on his experience of using
the device. He mentions:
“The good thing about them is that you're not refocusing. It doesn't feel like
the words are really near and the screen is far away. It feels like they're
together”
The introduction of such a device would give cinema goers with hearing loss the
freedom of choice to attend at times that suited them. The current device developed
by Sony UK is limited to cinemas for the viewing of movies.
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6. Conclusions
In summary the above report has highlighted the impact of the advances in hearing
technologies and reviewed the current hearing aid market in the UK. Thereafter the
perspective of individuals with hearing loss was considered. Subsequently other
amplification technologies and assistive devices were described. The report has
highlighted the dramatic change in the technological options available to individuals
with hearing loss. The range of technologies available for individuals with hearing
loss and the quality of the signal processing strategies have seen rapid
advancement in recent years. The outcomes for individuals with hearing loss using
these technologies, including hearing aids, cochlear implants and bone conduction
hearing aids, have been significantly improved. The social, educational, employment
and health benefits achieved by the use of these technologies have been
considerably positive. However, even with these excellent outcomes there are still
many challenges users of hearing technologies face in difficult listening situations.
Even individuals with normal levels of hearing can find difficult listening situations
challenging, however these challenges are magnified for individuals using hearing
technologies. The use of assistive technologies such as FM systems, telecoils and
subtitles allows users of hearing technologies to overcome many of the challenges
associated with distance, reverberation, background noise and poor acoustic
conditions.
Text removed.
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