Hearing Aid Use and Audiology Services in Times of Prolonged Crisis

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Asher Efrati This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7383438/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Individuals with hearing impairments face significant challenges during crises, particularly in accessing emergency alerts and maintaining communication, but little is known about the impact of prolonged crises on hearing aid usage. Objectives The aim of the study was to examine changes in hearing aid usage and concerns related to hearing emergency alerts among adults with hearing impairment during the October 7 war in Israel. Methods 847 hearing aid users (85.4% aged ≥ 60 years), 80% with at least moderate hearing difficulty participated in a survey. Results Changes in hearing aid use during the war were characterized with increased hearing aid usage and changes in usage patterns such as more frequent sleeping or showering with the devices. Fear of missing missile sirens was prevalent, with over 25% expressing concerns and 10% frequently failing to hear alarms. Despite regional differences in attack frequency, changes in hearing aid use were not correlated with place of residence, suggesting that psychological stress, rather than direct exposure, influenced behaviour. Notably, 75% of participants recognized remote hearing aid tuning as essential. Conclusions The study highlights the role of hearing aids in crisis situations, emphasizing the need for preparedness and integrating audiological support into emergency plans. In response, the HIMIC (Hearing Instruments Management in Crisis) guidelines for individual (HIMIC-I) and for public health (HIMIC-P) preparedness and hearing care, were developed to ensure device functionality, user preparedness and public services during major crisis, such as war times, pandemic, and environmental disasters. These recommendations address device selection, emergency planning, and usage in extreme conditions as well as preparedness of hearing clinics, human resources considerations, training, emergency inventory and establishing responsibilities. Ensuring access to remote audiological services and promoting proactive hearing aid preparedness can enhance safety and well-being for individuals with hearing impairment during prolonged crises. Introduction Individuals with disabilities constitute a particularly vulnerable group, often encountering substantial barriers to effective communication and access to healthcare services, particularly in times of crisis. In these challenging times, the barriers they encounter are often intensified, exacerbating their struggles and emphasizing the critical need for inclusive support and accessible resources [ 1 ]. Local or global emergencies can disrupt standard communication channels, necessitating unique access to critical alerts and essential information. Periods of major crisis and significant global, environmental or national stress introduce unique challenges for individuals relying on hearing aids. Such circumstances may necessitate changes in hearing aid usage, especially when access to professional audiological services may be altered or limited. As a result, individuals with hearing loss become a vulnerable group requiring targeted interventions to ensure their safety and well-being [ 2 ]. Studies on individuals with hearing impairment during emergencies or disasters mainly focused on communication barriers and access to critical alerts to ensure the safety of individuals with hearing impairments during emergencies. For example, Tannenbaum-Baruchi et al. [ 2 ] studied deficiencies in access to critical information regarding hazards, assistance and evacuation during major wildfires, along with challenges in communication with significant others and with professional firefighters. Similarly, Engelman et al. [ 3 ] reported challenges in reaching deaf and hard of hearing people due to communication barriers during hurricanes, and Wood and Weisman [ 4 ] inspected the ability of individuals with hearing impairments to receive life-saving alerts in advance of severe weather events. While these events may be relatively short in duration, requiring limited periods of alert reception and evacuation, longer emergencies or prolonged stressful periods, with repeated alerts or significant ongoing lifestyle changes, may introduce additional challenges for individuals with hearing impairment. These challenges may include repeated events requiring communication, such as access to life-saving alerts, significant social changes that can disrupt supportive networks, and reduced availability of professional assistance for individuals who use hearing aids [ 2 ]. As a result, individuals may need to alter their daily use of hearing aids and may require audiological and technical support in new formats, such as remote services or tele-audiology, to accommodate changes in accessibility and the availability of in-person care. In recent years individuals with (and without) hearing loss were influenced by major prolonged events: first, the Covid-19 pandemic, which had a global and enduring effect on lifestyle and access to hearing rehabilitation services; and second, long-lasting wars, such as in Ukraine and in Israel. The aim of this study was to investigate the effects of national emergency situation caused by the war on adults who use hearing aids, focusing on the case of the October 7 war in Israel. The October 7 War has impacted various aspects of daily life in Israel [ 5 ]. Among these effects, numerous people on the home front were repeatedly exposed to sirens and missile fire, altering their news consumption, leisure activities, and healthcare services utilization. By early December 2023, two months after the beginning of the war, over 115,000 individuals had been evacuated from their homes, forced apart from their supportive communities, and had become refugees [ 6 ]. In total, nearly 250,000 people from the northern and southern areas of Israel were eventually displaced from their homes for more than a year due to the events of the war [ 7 ]. For individuals with hearing impairment, the need to stay "connected", to hear sirens, stay updated on the news, and engage in communication, may take on unique forms during wartime, potentially affecting hearing aid usage and the consumption of audiology services related to hearing rehabilitation and hearing aid use. Moreover, the availability of healthcare services was limited due to mobilization of healthcare professionals or their spouses for reserve duty, further complicating access to hearing rehabilitation services. Indeed, according to a large-scale study from the Taub Center for Social Policy Studies in Israel [ 5 ], public systems such as the welfare, education and health systems have been seriously affected by the war. However, to the best of our knowledge, patterns of hearing aid usage, as well as hearing rehabilitation and the provision of audiology services during times of public crisis or national stress, have been scarcely researched. The impact of wartime periods with significant involvement of the home front on hearing aid usage and the use of hearing rehabilitation services has never been studied. Furthermore, apart from studies conducted during the COVID-19 pandemic, the impact of prolonged extreme events on a social or national level on hearing aid usage patterns was not studied. During the COVID-19 pandemic, significant lifestyle changes were associated with changes in hearing aid usage patterns [ 8 ] and audiology service utilization [ 9 , 10 ]. Factors such as mask-wearing, which impaired speech intelligibility and lip-reading, along with social distancing and lockdowns, impacted both hearing-aid usage patterns and the contact with audiologists and hearing clinics. Hearing aid users reported that they reduced the use of their hearing aids [ 8 ] and avoided appointments with audiologists [ 9 ], while audiologists reported fewer visits to their clinics [ 10 ] and changes in the way services were provided to patients [ 11 – 13 ]. During wartime, decreased availability of medical and rehabilitation personnel, fear of leaving home and being at a distance from a bomb shelter or a protected space, exposure to life-saving alerts and feelings of stress and anxiety, can affect the willingness to use hearing aids and the patterns of their use. Therefore, it is crucial to identify these effects among patients and develop tailored care frameworks that can improve support for hearing aid users during complex periods and national emergencies. Since a major portion of hearing aid users are older adults [ 14 ], identifying the needs of this population is also important in terms of maintaining communicative, wellbeing and social functioning [ 15 – 21 ] and caring for older individuals during times of crisis. Research Objectives The current study aimed to examine the effects of the October 7 war on hearing aid usage in Israel, and to identify factors and processes that may influence how adults cope with hearing loss during prolonged wartime. Method The study was conducted during the initial months of the war, from mid-January to mid-March 2024. A multiple-choice questionnaire was developed and distributed to hearing aid users. Participants We targeted adults aged 18 years and older who use hearing aids and resided in Israel during the October 7 war. Convenience sample was collected through direct outreach and online community engagement to ensure a diverse participant population. Study design A structured questionnaire was developed using Qualtrics software. The questionnaire consisted of 39 multiple-choice questions and 3 open-ended questions designed to capture detailed information about hearing aid usage and related experiences before and during the war. The multiple-choice questionnaire, included inquiries regarding the respondents' hearing difficulties, with and without hearing aids, patterns of hearing aid usage before and after the onset of the war (on October 7, 2023) utilization of audiology services at hearing clinics, device usage time, and attitudes towards remote device adjustment. Additional topics addressed changes in methods of information consumption, ways of receiving alerts about sirens (if present near residence), and more. The three open-ended questions sought specific information regarding the respondents’ place of residence, aiming to assess exposure to missile attacks, as well as their total years of hearing aid use and the duration of use of their current devices. Procedure A pilot study was conducted with a small sample of potential participants, to evaluate the response rate, assess the effectiveness of the questionnaire distribution method, and determine the relevance and clarity of the questions for the target population. An initial invitation to participate was sent to 721 individuals, yielding a response rate of 4.9% (N = 36). Following the pilot study, an initial message was distributed via WhatsApp Messenger to a convenience sample of 31,000 potential participants, identified from the databases of hearing rehabilitation clinics. The message provided information about the research and invited recipients to participate. 1850 individuals (5.9%) who gave their consent to participate were sent a follow-up message containing a detailed explanation of the study and a link to the questionnaire. Participants were asked to reconfirm their consent prior to proceeding to fill out the questionnaire. To further enhance participant diversity, a research invitation containing a link to the questionnaire was also shared in five Facebook groups dedicated to senior citizens. This strategy aimed to broaden the demographic representation and include a wider range of hearing aid users in the study. The initial list of potential participants that was obtained from the hearing rehabilitation clinics database was kept separate from the data collected via questionnaire responses. The questionnaire was administered anonymously, and individual responses could not be traced back to specific participants. Participation was voluntary, and respondents were free skip questions and/or withdraw from the study at any point without repercussions. Recognizing the need to collect this data during the ongoing conflict, emergency ethical approval was obtained from the Ethics Committee of the Faculty of Social Welfare and Health Sciences at the University of Haifa (permit no. 005/24). Statistical analysis Data collected from the questionnaires were analyzed using SAS software, version 9.4. The statistical analysis encompassed various methods to evaluate changes in hearing aid use and related behaviors before and during the war, assess the impact of the war on hearing aid use, and explore associations with demographic and clinical variables. Descriptive statistics were used to summarize participant characteristics, including age distribution and hearing difficulties. Chi-square (χ²) tests were employed to assess associations between categorical variables, such as the relationship between self-reported hearing difficulties and concerns about hearing sirens. Wilcoxon signed-rank tests were applied to compare changes in hearing aid usage over time, specifically examining differences in the number of days per week and hours per day that participants used their devices before and during the war. Inter-rater reliability was assessed using the Simple Kappa statistic to determine agreement in categorical responses regarding changes in hearing aid usage habits. Additionally, logistic regression modeling was conducted to identify significant predictors of hearing aid use such as age and gender. Results Responses were received from 847 hearing aid users (51% males). The majority of the respondents (85.4%) were adults aged ≥ 60 years (Table 1 ). Dwelling place was classified according with the Home Front Command’s alert areas. The responses came from participants residing in various locations across the country, from north to south, including northern and southern conflict areas. Table 1 Age distribution of the participants. Age (years) Number Percent Cumulative Frequency Cumulative Percent 18–29 2 0.30 2 0.30 30–39 12 1.77 14 2.07 40–49 28 4.14 42 6.20 50–59 57 8.42 99 14.62 60–69 129 19.05 228 33.68 70–79 281 41.51 509 75.18 80–89 150 22.16 659 97.34 > 90 18 2.66 677 100.00 Frequency Missing = 170 Hearing and hearing aids More than 80% of the participants reported at least moderate difficulty hearing without the hearing aids: 19% reported mild difficulty, 46% moderate difficulty, 28% great difficulty, and 7% reported that they can’t hear without the hearing aids. 92% use bilateral hearing aids, and 67% of the participants use rechargeable hearing aids. Nevertheless, the majority of respondents reported a moderate to substantial benefit from using hearing aids (Table 2 ), underscoring the importance of properly functioning devices. Table 2 Hearing aid benefit (% of the participants) One on one conversation Multi talker conversation Talking on the phone Watching TV Listening to the news Substantial benefit 35.05 27.29 26.67 26.18 25.59 Significant benefit 35.32 26.32 26.23 30.47 30.15 Moderate benefit 20.84 31.16 22.32 23.18 25.59 Minimal benefit 6.77 11.63 11.45 13.02 11.76 No benefit 2.03 3.60 13.33 7.15 6.91 Use of hearing clinics services A series of questions were designed to assess the frequency and purpose of visits to hearing clinics. Nearly 50% of hearing aid owners who participated in the study reported attending the hearing clinics from once every one or two months to once every six months, and 19% reported visiting the clinic once a year. Approximately 40% of the respondents visited the hearing centers after October 7, 2023, with 20% of them seeking new hearing aids. Participants who required service for their existing hearing aids attended for fine tuning or routine maintenance (52%), troubleshooting (22%), receiving instructions in using the hearing aids (5%), replacement of earmolds or ear tips (9%) and/or purchasing batteries (8%) or assistive listening devices (ALDs) (2.5%). 5.5% requested maintenance or inspection for backup or long-unused devices. The effect of the war The primary objective of the questionnaire was to evaluate lifestyle changes following the outbreak of the war on October 7 and to analyze hearing aid usage patterns before and during the war. Emphasis was placed on concerns related to hearing, including the ability to hear sirens warning of missile attacks and the frequency of alarm occurrences. Lifestyle changes During the initial months of the war, 44% of the participants reported a significant increase in watching TV and 56% indicated an increase in listening to the news. Additionally, 31% experienced a notable decline in social interactions, whereas 16% engaged in more frequent phone conversations. 6% of respondents were displaced and relocated due to the war. Alert to sirens When a siren indicating a missile attack or the invasion of an unmanned aerial vehicle (explosive drone) is activated, multiple alert modes are available, including auditory, tactile and visual signals. We asked how the participants are alerted to sirens. 57% reported hearing the sirens, and 44% received alerts through a designated app, either via auditory notifications (32%) or through vibration (12%). 25% relied on visual alerts on TV, and 14% reported that others alerted them to the sirens. Over a quarter of the study participants expressed concern about not hearing the sirens, and approximately 10% reported that they often didn’t hear them. More severe self-reported hearing difficulties were significantly associated with an increased likelihood of fearing they would not hear the sirens (χ 2 (4) = 58.99, p˂0.0001), and a higher probability of failing to hear them (χ 2 (8) = 81.20, p˂0.0001) Hearing aid use before and after the war Usage time We compared reported hearing aid usage (measured in days per week and hours per day) before October 7, 2023, and during the war. The majority of participants (80%) reported no change in their hearing aid usage time. Among the 20% who did alter their usage patterns, most reported an increase in usage duration. A Wilcoxon signed ranks test indicated a significant increase in days per week of hearing aid use (Z=-2.399, p = 0.016) and the number of usage hours per day (Z=-3.347, p = 0.001). However, despite great regional differences in the frequency of missile attacks across Israel, hearing aid usage time was not correlated with region of residence (days per week: χ 2 (4) = 5.321, p = 0.256; hours per day: χ 2 (4) = 3.819, p = 0.431). In addition, 8% of the participants significantly increased hearing aid use during weekends (Shabbat) and holidays. The inter-rater reliability was assessed using the Simple Kappa statistic (Kappa value 0.734, SE = 0.034, 95% confidence interval 0.668–0.801), indicating substantial agreement. There was also a significant increase in fear of being left without hearing aids during the war (Z=-6.607, p˂0.001), underscoring the heightened reliance on hearing devices in times of crisis. Usage modes Hearing aid users are generally instructed to remove their devices while sleeping and during bathing or showering. We examined whether users altered their usage habits in these conditions during the war. The majority of participants did not modify their hearing aid usage patterns. However, among those who did, the changes primarily reflected an increase in using the hearing aids in situations where they were previously not used. 2.6% of the participants changed their nighttime sleeping habits, such that a total of 3.14% of the participants (1.2% of the men, 5.3% of the women) reported they sleep with their hearing aids since October 7, compared to 0.85% before the war (Kappa value 0.483, SE = 0.007, 95% confidence interval 0.346–0.621). A regression model for predicting nighttime use of hearing aids identified age and gender as significant predictors of nighttime use. Specifically, each additional year of age was associated with a decrease in the likelihood of sleeping with hearing aids by a factor of 0.56. Women were four times more likely than men to sleep with their hearing aids. Regarding daytime napping, the results were similar. 3.7% of participants changed their sleeping habits, leading to 14% of participants napping with their hearing aids since October 7 compared to 11.9% before the war (Kappa value 0.775, SE = 0.029, 95% confidence interval 0.717–0.833). In addition, a total of 1.8% of the participants – 0.6% of the men and 3.1% of the women reported taking showers while wearing their hearing aids. Remote care In recent years, there has been increasing interest in remote care. We examined how the war affected participants’ perceptions of the necessity of remote tuning of hearing aids. Overall, 35% of the respondents changed their perspectives, with a significant increase in recognizing remote tuning of the hearing aids as an essential service. Notably, 58% of those who had previously considered remote tuning unnecessary now perceived it as essential. As a result, after October 7 approximately 75% of respondents regarded the ability to adjust hearing aids remotely as crucial. Discussion The results of the current study indicate significant changes in hearing aid use among adults during the October 7 war. These changes reflect lifestyle changes and concerns related to the war, highlighting the unique challenges faced by adults with hearing impairment during times of crisis. One of the most critical concerns identified in this study was the ability to hear sirens warning of missile attacks and drone invasions. Participants were alerted to sirens through various modalities including auditory, tactile, and visual cues. Over a quarter of the study participants expressed concerns about not hearing the alarms, and as much as 10% frequently failed to hear them. This finding likely contributed to the observed changes in the duration and patterns of hearing aid use. Interestingly, while exposure to missile and drone attacks varied significantly based on participants' place of residence and has changed throughout the war, changes in hearing aid usage patterns were not correlated with participants' place of residence or the actual frequency of sirens. These findings are in line with previous studies indicating that uncertainty, unpredictability and anticipation of a negative event can increase stress and induce greater anxiety than the event itself [ 22 ]. Neuroscientific research further supports this, showing that brain areas associated with anxiety, such as the prefrontal cortex and amygdala, show heightened activation in response to the anticipation of a potential threat compared to the actual occurrence of the threat [ 23 ]. Nevertheless, it is plausible that fear of potential malfunction or damage might have discouraged others from adopting usage patterns such as sleeping or showering with their hearing aids, as audiologists generally advise against these practices. The fear of being left without functioning hearing aids during wartime likely contributed to more cautious behavior among many participants. During times of national crisis, particularly in wartime involving the home front, individuals with hearing impairment face unique challenges, because essential auditory information, such as sirens alerting to seek shelter, may be difficult to perceive. This information is often life-saving, underscoring the importance of functioning hearing aids. Indeed, the results of our study indicated a significant increase in fear of being left without working hearing aids, further reinforcing the dependence on these devices for safety and communication. Given the potential barriers to accessing hearing rehabilitation clinics during times of crisis, including safety concerns and reduced access to services due to reduced availability of professional staff, remote care emerged as an essential option. Remote services must include not only fine tuning of the hearing aids, but also a comprehensive support, including instructions in use, maintenance and troubleshooting. Indeed, participants significantly increased their recognition of the essentiality of remote care options. This shift in attitude, mirrors findings from studies conducted during the COVID-19 pandemic, where the necessity of remote audiological care was similarly acknowledged due to restrictions in physical access to healthcare services [ 24 ]. Crisis situations, whether caused by natural disasters, human-made events, or national conflicts, pose significant challenges for individuals with disabilities. To effectively support these individuals during such transformative experiences, it is essential to develop specialized preparedness and response protocols. These protocols and guidelines should address both personal and collective needs and be integrated into community, municipal, and national response systems. By implementing these measures, we can enhance the capabilities of individuals with disabilities to navigate crises successfully, and ensure their rights and well-being are protected [ 25 , 26 ]. The results of the current study highlight the need for quality solutions for individuals with hearing impairments during wartime, particularly as their needs may change while access to healthcare services remains limited. Despite the clear importance of addressing these needs, no specific protocols, intervention programs or best practices have been formulated to guide audiological care under such conditions. The findings of the current study underscore the necessity of developing strategic guidelines to ensure that individuals with hearing impairment receive adequate support during emergencies. HIMIC - Hearing Instruments Management in Crisis Guideline for preparedness and hearing care during prolonged crises Global events highlight the need for proactive strategies to ensure the functionality and utility of hearing aids during emergencies. In the UN Global Survey on Disaster Preparedness (27) high percentage of survey respondents reported a degree of difficulty hearing (39%). One of the report’s conclusions is that disaster preparation should specifically address the needs of individuals with hearing or communication impairments (28). Wars, political conflicts, pandemics, natural disasters, or human-made catastrophes can arise unexpectedly, disrupting daily life and access to essential healthcare services. Given the increasing frequency of global crises, preparedness for hearing aid use in emergencies has become critically important. In response, we have developed the HIMIC (Hearing Instruments Management in Crisis) Guidelines for preparedness and hearing care during prolonged crises to raise awareness among hearing aid users, professionals and institutional actors including ministries of health, civil protection authorities, health insurers, public health systems, professional associations about essential preparedness actions and considerations in prolonged disruptions and emergency scenarios, such as war times, pandemic, environmental disasters (e.g. hurricanes, tsunamis, earthquakes or wild fires) and mass evacuations. Hearing aids play a critical role in maintaining awareness during emergencies, enabling users to hear important announcements, sirens, and other alerts, thereby enhancing their sense of control and safety. Additionally, hearing aids facilitate communication with care and rescue teams, emergency services and significant others, which is vital during times of stress and disasters. The HIMIC guidelines consist of two parts: HIMIC-I (Individual) and HIMIC-P (Public Policy). The subsequent sections will outline these guidelines. The HIMIC-I (Individual) guidelines (Table 3 ) offer short three-dimensional practical guidelines aiming to safeguard users’ access to critical auditory information and support their ability to maintain social connections. Note that individualized advice from certified audiologists, hearing aid specialists or otolaryngologists is strongly recommended to tailor HIMIC-I guidelines to specific needs. Table 3 HIMIC-I (Hearing Instruments Management in Crisis) Guidelines for preparedness and hearing care during prolonged crises – Individual Guidelines* Dimension Focal point Recommendation Initial considerations When selecting and purchasing hearing aids, the following considerations are recommended: Device Features: • Choose hearing aids with a high Ingress Protection Rating (e.g., IP68) for enhanced durability. • Opt for hearing aids that support professional remote services, enabling remote troubleshooting and full adjustments Spare Devices and Supplies: • It is recommended to have an alternative amplification device in case of a malfunction in hearing aids. These may include a spare pair of hearing aids or ALDs such as a personal amplified system • Ensure that spare amplification devices are functional and maintained Preparations for Emergency Evacuation In preparation for potential evacuations, hearing aid users should include the following in their emergency go-bag: • Spare hearing aids or ALDs • Spare domes/tips or spare earmold, if relevant • A cleaning and maintenance kit • For rechargeable hearing aids: • A charger • Appropriate cables • A fully charged power bank • For non-rechargeable hearing aids: • At least two packages of suitable batteries for each hearing aid Using Hearing Aids During Crisis Situations Hearing aids with an IP68 rating are designed to withstand water exposure and can be worn while showering; however, users should: • Refrain from using shampoo or conditioner while wearing hearing aids • After showering, gently dry the hearing aids with soft, dry cloth During Sleep: • If necessary, hearing aids may be worn while sleeping • Users with bilateral devices may consider wearing one device at a time alternating between devices to reduce wear and ensure functionality * Individualized advice from qualified audiologists or otolaryngologists is strongly recommended to tailor these guidelines to specific needs. The HIMIC-P (Public Policy) guidelines (Table 4 ) are aimed for policy makers and other organizational actors to help plan, budget for and integrate services for hearing impaired adults into emergency preparedness and health systems. This comprehensive approach not only enhances emergency response capacity but also fosters a resilient and cohesive community, capable of responding effectively in times of crisis. Effective national disaster preparedness is essential and hinges on several key factors: the nature of the disaster, the existence of well-structured emergency plans, robust coordination among organizations at both national and local levels, and the vital public trust in health systems and the authorities responsible for emergency and disaster management (29, 30). Integrating the HIMIC-P recommendations into national and local emergency plans will not only improve preparedness but also ensure that vulnerable populations receive communication support during emergencies. The HIMIC-P follows the four phases of the traditional disaster management cycle: mitigation, preparedness, response, and recovery (29). Table 4 HIMIC-P (Hearing Instruments Management in Crisis) Guidelines for preparedness and hearing care during prolonged crises – Public Policy Guidelines* Dimension Focal point Responsible Entities Infrastructure and Strategic Planning Mitigation Assessment of the potential impact of emergencies and prolonged crises on support services for adults with hearing impairment Identifying risks and disruptions to hearing support services • Health authorities • Disability services departments • Emergency preparedness agencies • Needs assessments and risk mapping for adults with hearing impairment • Address potential disruptions to hearing services and include strategies for remote communication • Allocate budget for hearing rehabilitation and remote care Operational guidelines for providing hearing care Teleaudiology for remote support • Ministry of Health • National Emergency Authority • Develop guidelines for remote hearing care and hearing management in evacuee reception centers • Include regulations for backup and secure access to patients’ data • Plan and budget an inventory of hearing aids and amplification devices • Form an on-call system for audiologists and hearing aid technicians Public information Dedicated information websites • Ministry of Health • National Emergency Authority • Information websites and portals to emergency preparedness resources (HIMIC-I) Preparedness Personnel Training Training audiologists • Ministry of Health • Training audiologists to provide teleaudiology and remote hearing services and instructions Training emergency teams and support staff • National Emergency Authority • Provide targeted communication training for hotline and support staff for communication with individuals with hearing loss and assisting with hearing aids and personal amplifiers Hearing amplification equipment Hearing instruments and ALDs maintenance • National Emergency Authority • Inclusion of ALDs, hearing aid batteries, power banks and hearing aids in emergency stockpiles, health, and welfare services Teleaudiology Equipment Equipment for teleaudiology and remote support • National Emergency Authority • Equip clinics with computers and telehealth infrastructure Professional resources Audiologists in emergency and rescue organizations • National Emergency Authority • Include audiologists in emergency services or maintain on-call contact information for audiological consultation Response Teleaudiology and hearing rehabilitation services • National Emergency Authority • Remote care to ensure provision of hearing rehabilitation services Recovery Integration of information and lessons learned • National Emergency Authority • Compilation of information regarding hearing management services provided • Examination of teams’ activities and collaborations • Examination of the equipment and infrastructures * For Rationale and Comments on HIMIC-P, please refer to Appendix A Limitations This study was conducted under emergency conditions. Owing to the constraints imposed by the wartime context, the design and distribution of the questionnaire had to be expedited and abbreviated. Consequently, the findings reflect the responses of individuals who chose to participate, and it is possible that others may have provided different perspectives. Despite these limitations, the study offers valuable insights into behavioral changes and concerns among hearing aid users during a national crisis. These findings contributed to the development of the HIMIC (Hearing Instruments Management in Crisis) Guidelines, which aims to support hearing aid use during prolonged emergencies. Complementary research examining the perspectives, experiences, and recommendations of audiologists during such events could further inform and enhance the development of guidelines for hearing rehabilitation in crisis settings, providing valuable insights for clinicians, policymakers, and other relevant stakeholders. Conclusions The findings of this study highlight the significant impact of prolonged major crisis on hearing aid usage patterns among adults with hearing impairment, reflecting both lifestyle adjustments and heightened concerns about accessibility to critical auditory information. The war underscored the critical role of hearing aids in crisis situations, emphasizing the need for preparedness and accessibility of audiological care, including remote services. Given the challenges faced by individuals with hearing impairment during emergencies, proactive strategies such as the HIMIC Guidelines are essential to ensure uninterrupted access to auditory information and communication and enhance awareness and preparedness among hearing aid users in the face of future global crises. Future efforts should focus on integrating hearing accessibility considerations into national emergency response plans to ensure the safety and well-being of individuals with hearing impairments in times of crisis. Abbreviations ALDs Assistive Listening Devices HIMIC Hearing Instruments Management in Crisis HIMIC I–Hearing Instruments Management in Crisis–Individual Guidelines HIMIC P–Hearing Instruments Management in Crisis–Public Policy Guidelines Declarations Ethics approval All aspects of the study were approved by the Ethics Committee of the Faculty of Social Welfare and Health Sciences at the University of Haifa (permit no. 005/24). Consent to participate Participants gave their consent to take part in the study by checking a response box in an online form. Participants were asked to reconfirm their consent prior to proceeding to fill out the questionnaire. Consent for publication Not applicable Funding This research was partially supported by the Faculty of Social Welfare and Health Sciences at the University of Haifa. The research was also supported by Amplifon Medtechnica Orthophone Hearing Technologies. The funding sources did not influence the study design, collection, analysis, or interpretation of the data, nor the content of the paper, or the decision to submit the article for publication. Declaration of interests All authors are senior audiologists in managerial positions and employees in Amplifon Medtechnica Orthophone Hearing Technologies. Authors contribution Limor Lavie and Tali Bar-Moshe developed the initial study outline. Limor Lavie, Tali Bar-Moshe, and Asher Efrati collaboratively designed the study and contributed to the development of the questionnaire. Limor Lavie authored the first draft of the manuscript, and Tali Bar-Moshe wrote the second draft and the first version of the HIMIC-I Guidelines. Limor Lavie, Tali Bar-Moshe, and Asher Efrati revised and edited the manuscript and approved the final version. Declaration of Generative AI and AI-assisted technologies in the writing process AI was only used to improve the readability and language of the work. During the preparation of this work the authors used ChatGPT and Grammarly in order to improve the readability and language of the work. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. Availability of data and materials The questionnaire is available upon request Acknowledgements We would like to express our gratitude to Avigail Rubinger RIP and Amit Topus for their help during the early stages of this research, to Sapir Yunger for her assistance in data organization and to the study participants who made the study possible. References Annaswamy TM, Verduzco-Gutierrez M, Frieden L. 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Taub Center Researchers. The October War and Its Impact on Israel’s Society and Economy. In Weiss, A. (2018). The Singer Series: State of the Nation Report 2023. Jerusalem: Taub Center for Social Policy Studies in Israel. Retrieved February 5, 2025, from https://www.taubcenter.org.il/wp-content/uploads/2023/12/War-ENG-2023-3.pdf Lerer M, December 19. (, 2023). Information on evacuees and those evacuated from the northern border during the Iron Sword War – Background to the discussion. Knesset – Research and Information Centre. Retrieved November 21, 2024, from https://fs.knesset.gov.il/globaldocs/MMM/b2d7a9d4-899d-ee11-815f-005056aac6c3/2_b2d7a9d4-899d-ee11-815f-005056aac6c3_11_20329.pdf Information. and Knowledge Center, to Support the Home Front in the Special Emergency, with Technological Assistance from the National Digital System. (2024, October 6). Summary of a year of the Iron Swords War. Retrieved February 19, 2025, from https://ffi.org.il/wp-content/uploads/2024/01/241006 Alqudah S, Zaitoun M, Alqudah O, Alqudah S, Alqudah Z. Challenges facing users of hearing aids during the COVID-19 pandemic. Int J Audiol. 2021;60(10):747–53. https://doi.org/10.1080/14992027.2021.1872806 . Gaeta L. Survey of Hearing Health During the COVID-19 Pandemic: Implications for Service Delivery. Am J Audiol. 2020;29(4):944–7. https://doi.org/10.1044/2020_AJA-20-00037 . Manchaiah V, Eikelboom RH, Bennett RJ, Swanepoel W. International survey of audiologists during the COVID-19 pandemic: Effects on the workplace. Int J Audiol. 2022;61(4):265–72. https://doi.org/10.1080/14992027.2021.1937348 . Aggarwal K, Gunjawate DR, Yerraguntla K, Ravi R. Impact of COVID-19 pandemic on audiology practice: A scoping review. Clin Epidemiol Global Health. 2022;13:100939. https://doi.org/10.1016/j.cegh.2021.100939 . Ehlert K. Impact of the COVID-19 pandemic on audiology services in South Africa: A preliminary study. Health SA = SA Gesondheid. 2023;28:2318. https://doi.org/10.4102/hsag.v28i0.2318 . Parmar B, Beukes E, Rajasingam S. The impact of COVID-19 on the provision of UK audiology services & on attitudes towards delivery of telehealth services. Int J Audiol. 2022;61(3):228–38. https://doi.org/10.1080/14992027.2021.1921292 . Reed, N. S., Garcia-Morales, E. E., Myers, C., Huang, A. R., Ehrlich, J. R., Killeen,O. J., … Deal, J. A. (2023). Prevalence of Hearing Loss and Hearing Aid Use Among US Medicare Beneficiaries Aged 71 Years and Older. JAMA Network Open, 6(7), e2326320. https://doi.org/10.1001/jamanetworkopen.2023.26320. Davis AC, Hoffman HJ. Hearing loss: Rising prevalence and impact. Bull World Health Organ. 2019;97(10):646–A646. https://doi.org/10.2471/BLT.19.224683 . Mulrow CD, Aguilar C, Endicott JE, Velez R, Tuley MR, Charlip WS, Hill JA. Association between hearing impairment and the quality of life of elderly individuals. J Am Geriatr Soc. 1990;38(1):45–50. https://doi.org/10.1111/j.1532-5415.1990.tb01595.x . Lin FR. Hearing loss and cognition among older adults in the United States. Journals Gerontol Ser A: Biol Sci Med Sci. 2011;66(10):1131–6. https://doi.org/10.1093/gerona/glr115 . Lin, F. R., Yaffe, K., Xia, J., Xue, Q. L., Harris, T. B., Purchase-Helzner, E., …Health ABC Study Group. (2013). Hearing loss and cognitive decline in older adults.JAMA Internal Medicine, 173(4), 293–299. https://doi.org/10.1001/jamainternmed.2013.1868. Huang AR, Lin FR. Hearing loss and dementia in older adults: A narrative review. J Chin Med Association. 2024;87(3):252–8. https://doi.org/10.1097/JCMA.0000000000001042 . Weinstein BE, Ventry IM. Hearing impairment and social isolation in the elderly. J Speech Hear Res. 1982;25(4):593–9. https://doi.org/10.1044/jshr.2504.593 . Mick P, Kawachi I, Lin FR. The association between hearing loss and social isolation in older adults. Otolaryngology–Head Neck Surg. 2014;150(3):378–84. https://doi.org/10.1177/0194599813518021 . Grillon C, Baas JMP, Cornwell B, Johnson L. Context conditioning and behavioral avoidance in a virtual reality environment: Effect of predictability. Biol Psychiatry. 2006;60(7):752–9. https://doi.org/10.1016/j.biopsych.2006.03.072 . Yoshimura S, Okamoto Y, Yoshino A, Kobayakawa M, Machino A, Yamawaki S. Neural basis of anticipatory anxiety reappraisals. PLoS ONE. 2014;9(7):e102836. https://doi.org/10.1371/journal.pone.0102836 . Blyth M, Saunders GH. Remote hearing-aid delivery and support: Perspectives of patients and their hearing care providers. Int J Audiol. 2024;1–9. https://doi.org/10.1080/14992027.2024.2304585 . Kruger J, Hinton CF, Sinclair LB, Silverman B. Enhancing individual and community disaster preparedness: Individuals with disabilities and others with access and functional needs. Disabil Health J. 2018;11(2):170–3. https://doi.org/10.1016/j.dhjo.2017.12.005 . Morales DX. Natural disaster vulnerability among people with disabilities: Insights from the 2024 Household Pulse Survey. Disabil Health J. 2024;101763. https://doi.org/10.1016/j.dhjo.2024.101763 . United Nations Office for Disaster Risk Reduction. (2014). UNISDR annual report 2013. https://www.undrr.org/publication/unisdr-annual-report-2013 Battle DE. Persons with Communication Disabilities in Natural Disasters, War, and/or Conflict. Communication Disorders Q. 2014;36(4):231–40. https://doi.org/10.1177/1525740114545980 . Herstein JJ, Schwedhelm MM, Vasa A, Biddinger PD, Hewlett AL. Emergency preparedness: What is the future? Antimicrob stewardship Healthc Epidemiol ASHE. 2021;1(1):e29. https://doi.org/10.1017/ash.2021.190 . Sopory P, Novak JM, Day AM, Eckert S, Wilkins L, Padgett DR, Noyes JP, Allen T, Alexander N, Vanderford ML, Gamhewage GM. Trust and Public Health Emergency Events: A Mixed-Methods Systematic Review. Disaster Med Pub Health Prep. 2022;16(4):1653–73. https://doi.org/10.1017/dmp.2021.105 . Additional Declarations Competing interest reported. All authors are senior audiologists in managerial positions and employees in Amplifon Medtechnica Orthophone Hearing Technologies. Supplementary Files AppendixA.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7383438","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":503891342,"identity":"5aa8b3bc-1880-4a9b-9567-982b1285bf29","order_by":0,"name":"Limor Lavie","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIie2OMUvDQBiG3/DBZQnNeln0L0QKYqHkt+QIuEUQlwwBLxSSra666F+Iv8BIIFOwq9Ilk3OhIHUJPZoOIklwdLhnuHvgvufjAI3mHzIx1eFjDphGg4NTJ2Bmf8LoMHYJELnHpJPuaSgByh8JjgkGE/rkTbQSd0TGNopwZWdkbBB7mAwm7Jz79Vo8LIicusYNL4k4qmDsY1NXpOswL+3CSVIIqYSDFSOJuXVF+xa+qOXfSQvxpGSHdiyxzhohizAnYk4iIfKSGDfS0eS68avg9l5NzmTFxbOSC7EMrKHENrP8dRd7Uztb0IeM5+JxVdL75ss7Oc1kf/ML3l0+YP1pXqPRaDS97AGWqE2E/MaYdgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Haifa","correspondingAuthor":true,"prefix":"","firstName":"Limor","middleName":"","lastName":"Lavie","suffix":""},{"id":503891343,"identity":"6a26f2eb-e322-47f5-a020-3a637d4a6ae4","order_by":1,"name":"Tali Bar Moshe","email":"","orcid":"","institution":"Ben-Gurion University of the Negev","correspondingAuthor":false,"prefix":"","firstName":"Tali","middleName":"Bar","lastName":"Moshe","suffix":""},{"id":503891344,"identity":"9aad8fd7-40d2-4723-a3b1-e2b2f62877f9","order_by":2,"name":"H. Asher Efrati","email":"","orcid":"","institution":"Amplifon-Medtechnica Orthophon","correspondingAuthor":false,"prefix":"","firstName":"H.","middleName":"Asher","lastName":"Efrati","suffix":""}],"badges":[],"createdAt":"2025-08-15 18:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7383438/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7383438/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92804731,"identity":"6ba2c769-841e-4188-8b6b-bafa72b9568a","added_by":"auto","created_at":"2025-10-05 12:46:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1111460,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7383438/v1/23743b9d-1a60-4464-a324-db6c1e43e3da.pdf"},{"id":89795296,"identity":"289895b4-412c-438f-a38d-71d9f643c45a","added_by":"auto","created_at":"2025-08-25 06:59:50","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18824,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-7383438/v1/f1340ff78f1c9073f0e5dfb1.docx"}],"financialInterests":"Competing interest reported. All authors are senior audiologists in managerial positions and employees in Amplifon Medtechnica Orthophone Hearing Technologies.","formattedTitle":"Hearing Aid Use and Audiology Services in Times of Prolonged Crisis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIndividuals with disabilities constitute a particularly vulnerable group, often encountering substantial barriers to effective communication and access to healthcare services, particularly in times of crisis. In these challenging times, the barriers they encounter are often intensified, exacerbating their struggles and emphasizing the critical need for inclusive support and accessible resources [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Local or global emergencies can disrupt standard communication channels, necessitating unique access to critical alerts and essential information. Periods of major crisis and significant global, environmental or national stress introduce unique challenges for individuals relying on hearing aids. Such circumstances may necessitate changes in hearing aid usage, especially when access to professional audiological services may be altered or limited. As a result, individuals with hearing loss become a vulnerable group requiring targeted interventions to ensure their safety and well-being [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Studies on individuals with hearing impairment during emergencies or disasters mainly focused on communication barriers and access to critical alerts to ensure the safety of individuals with hearing impairments during emergencies. For example, Tannenbaum-Baruchi et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] studied deficiencies in access to critical information regarding hazards, assistance and evacuation during major wildfires, along with challenges in communication with significant others and with professional firefighters. Similarly, Engelman et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] reported challenges in reaching deaf and hard of hearing people due to communication barriers during hurricanes, and Wood and Weisman [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] inspected the ability of individuals with hearing impairments to receive life-saving alerts in advance of severe weather events.\u003c/p\u003e\u003cp\u003eWhile these events may be relatively short in duration, requiring limited periods of alert reception and evacuation, longer emergencies or prolonged stressful periods, with repeated alerts or significant ongoing lifestyle changes, may introduce additional challenges for individuals with hearing impairment. These challenges may include repeated events requiring communication, such as access to life-saving alerts, significant social changes that can disrupt supportive networks, and reduced availability of professional assistance for individuals who use hearing aids [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. As a result, individuals may need to alter their daily use of hearing aids and may require audiological and technical support in new formats, such as remote services or tele-audiology, to accommodate changes in accessibility and the availability of in-person care. In recent years individuals with (and without) hearing loss were influenced by major prolonged events: first, the Covid-19 pandemic, which had a global and enduring effect on lifestyle and access to hearing rehabilitation services; and second, long-lasting wars, such as in Ukraine and in Israel. The aim of this study was to investigate the effects of national emergency situation caused by the war on adults who use hearing aids, focusing on the case of the October 7 war in Israel.\u003c/p\u003e\u003cp\u003eThe October 7 War has impacted various aspects of daily life in Israel [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Among these effects, numerous people on the home front were repeatedly exposed to sirens and missile fire, altering their news consumption, leisure activities, and healthcare services utilization. By early December 2023, two months after the beginning of the war, over 115,000 individuals had been evacuated from their homes, forced apart from their supportive communities, and had become refugees [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In total, nearly 250,000 people from the northern and southern areas of Israel were eventually displaced from their homes for more than a year due to the events of the war [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFor individuals with hearing impairment, the need to stay \"connected\", to hear sirens, stay updated on the news, and engage in communication, may take on unique forms during wartime, potentially affecting hearing aid usage and the consumption of audiology services related to hearing rehabilitation and hearing aid use. Moreover, the availability of healthcare services was limited due to mobilization of healthcare professionals or their spouses for reserve duty, further complicating access to hearing rehabilitation services. Indeed, according to a large-scale study from the Taub Center for Social Policy Studies in Israel [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], public systems such as the welfare, education and health systems have been seriously affected by the war.\u003c/p\u003e\u003cp\u003eHowever, to the best of our knowledge, patterns of hearing aid usage, as well as hearing rehabilitation and the provision of audiology services during times of public crisis or national stress, have been scarcely researched. The impact of wartime periods with significant involvement of the home front on hearing aid usage and the use of hearing rehabilitation services has never been studied. Furthermore, apart from studies conducted during the COVID-19 pandemic, the impact of prolonged extreme events on a social or national level on hearing aid usage patterns was not studied. During the COVID-19 pandemic, significant lifestyle changes were associated with changes in hearing aid usage patterns [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and audiology service utilization [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Factors such as mask-wearing, which impaired speech intelligibility and lip-reading, along with social distancing and lockdowns, impacted both hearing-aid usage patterns and the contact with audiologists and hearing clinics. Hearing aid users reported that they reduced the use of their hearing aids [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and avoided appointments with audiologists [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], while audiologists reported fewer visits to their clinics [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and changes in the way services were provided to patients [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDuring wartime, decreased availability of medical and rehabilitation personnel, fear of leaving home and being at a distance from a bomb shelter or a protected space, exposure to life-saving alerts and feelings of stress and anxiety, can affect the willingness to use hearing aids and the patterns of their use. Therefore, it is crucial to identify these effects among patients and develop tailored care frameworks that can improve support for hearing aid users during complex periods and national emergencies. Since a major portion of hearing aid users are older adults [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], identifying the needs of this population is also important in terms of maintaining communicative, wellbeing and social functioning [\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and caring for older individuals during times of crisis.\u003c/p\u003e\n\u003ch3\u003eResearch Objectives\u003c/h3\u003e\n\u003cp\u003eThe current study aimed to examine the effects of the October 7 war on hearing aid usage in Israel, and to identify factors and processes that may influence how adults cope with hearing loss during prolonged wartime.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThe study was conducted during the initial months of the war, from mid-January to mid-March 2024. A multiple-choice questionnaire was developed and distributed to hearing aid users.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eWe targeted adults aged 18 years and older who use hearing aids and resided in Israel during the October 7 war. Convenience sample was collected through direct outreach and online community engagement to ensure a diverse participant population.\u003c/p\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eA structured questionnaire was developed using Qualtrics software. The questionnaire consisted of 39 multiple-choice questions and 3 open-ended questions designed to capture detailed information about hearing aid usage and related experiences before and during the war. The multiple-choice questionnaire, included inquiries regarding the respondents' hearing difficulties, with and without hearing aids, patterns of hearing aid usage before and after the onset of the war (on October 7, 2023) utilization of audiology services at hearing clinics, device usage time, and attitudes towards remote device adjustment. Additional topics addressed changes in methods of information consumption, ways of receiving alerts about sirens (if present near residence), and more. The three open-ended questions sought specific information regarding the respondents\u0026rsquo; place of residence, aiming to assess exposure to missile attacks, as well as their total years of hearing aid use and the duration of use of their current devices.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eA pilot study was conducted with a small sample of potential participants, to evaluate the response rate, assess the effectiveness of the questionnaire distribution method, and determine the relevance and clarity of the questions for the target population. An initial invitation to participate was sent to 721 individuals, yielding a response rate of 4.9% (N\u0026thinsp;=\u0026thinsp;36). Following the pilot study, an initial message was distributed via WhatsApp Messenger to a convenience sample of 31,000 potential participants, identified from the databases of hearing rehabilitation clinics. The message provided information about the research and invited recipients to participate. 1850 individuals (5.9%) who gave their consent to participate were sent a follow-up message containing a detailed explanation of the study and a link to the questionnaire. Participants were asked to reconfirm their consent prior to proceeding to fill out the questionnaire. To further enhance participant diversity, a research invitation containing a link to the questionnaire was also shared in five Facebook groups dedicated to senior citizens. This strategy aimed to broaden the demographic representation and include a wider range of hearing aid users in the study. The initial list of potential participants that was obtained from the hearing rehabilitation clinics database was kept separate from the data collected via questionnaire responses. The questionnaire was administered anonymously, and individual responses could not be traced back to specific participants. Participation was voluntary, and respondents were free skip questions and/or withdraw from the study at any point without repercussions.\u003c/p\u003e\u003cp\u003eRecognizing the need to collect this data during the ongoing conflict, emergency ethical approval was obtained from the Ethics Committee of the Faculty of Social Welfare and Health Sciences at the University of Haifa (permit no. 005/24).\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eData collected from the questionnaires were analyzed using SAS software, version 9.4. The statistical analysis encompassed various methods to evaluate changes in hearing aid use and related behaviors before and during the war, assess the impact of the war on hearing aid use, and explore associations with demographic and clinical variables. Descriptive statistics were used to summarize participant characteristics, including age distribution and hearing difficulties. Chi-square (χ\u0026sup2;) tests were employed to assess associations between categorical variables, such as the relationship between self-reported hearing difficulties and concerns about hearing sirens. Wilcoxon signed-rank tests were applied to compare changes in hearing aid usage over time, specifically examining differences in the number of days per week and hours per day that participants used their devices before and during the war. Inter-rater reliability was assessed using the Simple Kappa statistic to determine agreement in categorical responses regarding changes in hearing aid usage habits. Additionally, logistic regression modeling was conducted to identify significant predictors of hearing aid use such as age and gender.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eResponses were received from 847 hearing aid users (51% males). The majority of the respondents (85.4%) were adults aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Dwelling place was classified according with the Home Front Command\u0026rsquo;s alert areas. The responses came from participants residing in various locations across the country, from north to south, including northern and southern conflict areas.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAge distribution of the participants.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercent\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCumulative\u003c/p\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCumulative\u003c/p\u003e\u003cp\u003ePercent\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u0026ndash;29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026ndash;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60\u0026ndash;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e228\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e70\u0026ndash;79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e281\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e509\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e80\u0026ndash;89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e659\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e97.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e677\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e100.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eFrequency Missing\u0026thinsp;=\u0026thinsp;170\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eHearing and hearing aids\u003c/h3\u003e\n\u003cp\u003e More than 80% of the participants reported at least moderate difficulty hearing without the hearing aids: 19% reported mild difficulty, 46% moderate difficulty, 28% great difficulty, and 7% reported that they can\u0026rsquo;t hear without the hearing aids. 92% use bilateral hearing aids, and 67% of the participants use rechargeable hearing aids. Nevertheless, the majority of respondents reported a moderate to substantial benefit from using hearing aids (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), underscoring the importance of properly functioning devices.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHearing aid benefit (% of the participants)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOne on one conversation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMulti talker conversation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTalking on the phone\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWatching TV\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eListening to the news\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubstantial benefit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSignificant benefit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate benefit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMinimal benefit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo benefit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6.91\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eUse of hearing clinics services\u003c/h3\u003e\n\u003cp\u003eA series of questions were designed to assess the frequency and purpose of visits to hearing clinics. Nearly 50% of hearing aid owners who participated in the study reported attending the hearing clinics from once every one or two months to once every six months, and 19% reported visiting the clinic once a year. Approximately 40% of the respondents visited the hearing centers after October 7, 2023, with 20% of them seeking new hearing aids. Participants who required service for their existing hearing aids attended for fine tuning or routine maintenance (52%), troubleshooting (22%), receiving instructions in using the hearing aids (5%), replacement of earmolds or ear tips (9%) and/or purchasing batteries (8%) or assistive listening devices (ALDs) (2.5%). 5.5% requested maintenance or inspection for backup or long-unused devices.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eThe effect of the war\u003c/h2\u003e\u003cp\u003eThe primary objective of the questionnaire was to evaluate lifestyle changes following the outbreak of the war on October 7 and to analyze hearing aid usage patterns before and during the war. Emphasis was placed on concerns related to hearing, including the ability to hear sirens warning of missile attacks and the frequency of alarm occurrences.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLifestyle changes\u003c/h2\u003e\u003cp\u003eDuring the initial months of the war, 44% of the participants reported a significant increase in watching TV and 56% indicated an increase in listening to the news. Additionally, 31% experienced a notable decline in social interactions, whereas 16% engaged in more frequent phone conversations. 6% of respondents were displaced and relocated due to the war.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eAlert to sirens\u003c/h2\u003e\u003cp\u003eWhen a siren indicating a missile attack or the invasion of an unmanned aerial vehicle (explosive drone) is activated, multiple alert modes are available, including auditory, tactile and visual signals. We asked how the participants are alerted to sirens. 57% reported hearing the sirens, and 44% received alerts through a designated app, either via auditory notifications (32%) or through vibration (12%). 25% relied on visual alerts on TV, and 14% reported that others alerted them to the sirens. Over a quarter of the study participants expressed concern about not hearing the sirens, and approximately 10% reported that they often didn\u0026rsquo;t hear them. More severe self-reported hearing difficulties were significantly associated with an increased likelihood of fearing they would not hear the sirens (χ\u003csup\u003e2\u003c/sup\u003e (4)\u0026thinsp;=\u0026thinsp;58.99, p˂0.0001), and a higher probability of failing to hear them (χ\u003csup\u003e2\u003c/sup\u003e (8)\u0026thinsp;=\u0026thinsp;81.20, p˂0.0001)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eHearing aid use before and after the war\u003c/h2\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003eUsage time\u003c/h2\u003e\u003cp\u003eWe compared reported hearing aid usage (measured in days per week and hours per day) before October 7, 2023, and during the war. The majority of participants (80%) reported no change in their hearing aid usage time. Among the 20% who did alter their usage patterns, most reported an increase in usage duration. A Wilcoxon signed ranks test indicated a significant increase in days per week of hearing aid use (Z=-2.399, p\u0026thinsp;=\u0026thinsp;0.016) and the number of usage hours per day (Z=-3.347, p\u0026thinsp;=\u0026thinsp;0.001). However, despite great regional differences in the frequency of missile attacks across Israel, hearing aid usage time was not correlated with region of residence (days per week: χ\u003csup\u003e2\u003c/sup\u003e (4)\u0026thinsp;=\u0026thinsp;5.321, p\u0026thinsp;=\u0026thinsp;0.256; hours per day: χ\u003csup\u003e2\u003c/sup\u003e (4)\u0026thinsp;=\u0026thinsp;3.819, p\u0026thinsp;=\u0026thinsp;0.431). In addition, 8% of the participants significantly increased hearing aid use during weekends (Shabbat) and holidays. The inter-rater reliability was assessed using the Simple Kappa statistic (Kappa value 0.734, SE\u0026thinsp;=\u0026thinsp;0.034, 95% confidence interval 0.668\u0026ndash;0.801), indicating substantial agreement. There was also a significant increase in fear of being left without hearing aids during the war (Z=-6.607, p˂0.001), underscoring the heightened reliance on hearing devices in times of crisis.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eUsage modes\u003c/h2\u003e\u003cp\u003eHearing aid users are generally instructed to remove their devices while sleeping and during bathing or showering. We examined whether users altered their usage habits in these conditions during the war. The majority of participants did not modify their hearing aid usage patterns. However, among those who did, the changes primarily reflected an increase in using the hearing aids in situations where they were previously not used. 2.6% of the participants changed their nighttime sleeping habits, such that a total of 3.14% of the participants (1.2% of the men, 5.3% of the women) reported they sleep with their hearing aids since October 7, compared to 0.85% before the war (Kappa value 0.483, SE\u0026thinsp;=\u0026thinsp;0.007, 95% confidence interval 0.346\u0026ndash;0.621). A regression model for predicting nighttime use of hearing aids identified age and gender as significant predictors of nighttime use. Specifically, each additional year of age was associated with a decrease in the likelihood of sleeping with hearing aids by a factor of 0.56. Women were four times more likely than men to sleep with their hearing aids. Regarding daytime napping, the results were similar. 3.7% of participants changed their sleeping habits, leading to 14% of participants napping with their hearing aids since October 7 compared to 11.9% before the war (Kappa value 0.775, SE\u0026thinsp;=\u0026thinsp;0.029, 95% confidence interval 0.717\u0026ndash;0.833). In addition, a total of 1.8% of the participants \u0026ndash; 0.6% of the men and 3.1% of the women reported taking showers while wearing their hearing aids.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eRemote care\u003c/h2\u003e\u003cp\u003eIn recent years, there has been increasing interest in remote care. We examined how the war affected participants\u0026rsquo; perceptions of the necessity of remote tuning of hearing aids. Overall, 35% of the respondents changed their perspectives, with a significant increase in recognizing remote tuning of the hearing aids as an essential service. Notably, 58% of those who had previously considered remote tuning unnecessary now perceived it as essential. As a result, after October 7 approximately 75% of respondents regarded the ability to adjust hearing aids remotely as crucial.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of the current study indicate significant changes in hearing aid use among adults during the October 7 war. These changes reflect lifestyle changes and concerns related to the war, highlighting the unique challenges faced by adults with hearing impairment during times of crisis.\u003c/p\u003e\n\u003cp\u003eOne of the most critical concerns identified in this study was the ability to hear sirens warning of missile attacks and drone invasions. Participants were alerted to sirens through various modalities including auditory, tactile, and visual cues. Over a quarter of the study participants expressed concerns about not hearing the alarms, and as much as 10% frequently failed to hear them. This finding likely contributed to the observed changes in the duration and patterns of hearing aid use. Interestingly, while exposure to missile and drone attacks varied significantly based on participants\u0026apos; place of residence and has changed throughout the war, changes in hearing aid usage patterns were not correlated with participants\u0026apos; place of residence or the actual frequency of sirens. These findings are in line with previous studies indicating that uncertainty, unpredictability and anticipation of a negative event can increase stress and induce greater anxiety than the event itself [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Neuroscientific research further supports this, showing that brain areas associated with anxiety, such as the prefrontal cortex and amygdala, show heightened activation in response to the anticipation of a potential threat compared to the actual occurrence of the threat [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. Nevertheless, it is plausible that fear of potential malfunction or damage might have discouraged others from adopting usage patterns such as sleeping or showering with their hearing aids, as audiologists generally advise against these practices. The fear of being left without functioning hearing aids during wartime likely contributed to more cautious behavior among many participants.\u003c/p\u003e\n\u003cp\u003eDuring times of national crisis, particularly in wartime involving the home front, individuals with hearing impairment face unique challenges, because essential auditory information, such as sirens alerting to seek shelter, may be difficult to perceive. This information is often life-saving, underscoring the importance of functioning hearing aids. Indeed, the results of our study indicated a significant increase in fear of being left without working hearing aids, further reinforcing the dependence on these devices for safety and communication.\u003c/p\u003e\n\u003cp\u003eGiven the potential barriers to accessing hearing rehabilitation clinics during times of crisis, including safety concerns and reduced access to services due to reduced availability of professional staff, remote care emerged as an essential option. Remote services must include not only fine tuning of the hearing aids, but also a comprehensive support, including instructions in use, maintenance and troubleshooting. Indeed, participants significantly increased their recognition of the essentiality of remote care options. This shift in attitude, mirrors findings from studies conducted during the COVID-19 pandemic, where the necessity of remote audiological care was similarly acknowledged due to restrictions in physical access to healthcare services [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eCrisis situations, whether caused by natural disasters, human-made events, or national conflicts, pose significant challenges for individuals with disabilities. To effectively support these individuals during such transformative experiences, it is essential to develop specialized preparedness and response protocols. These protocols and guidelines should address both personal and collective needs and be integrated into community, municipal, and national response systems. By implementing these measures, we can enhance the capabilities of individuals with disabilities to navigate crises successfully, and ensure their rights and well-being are protected [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. The results of the current study highlight the need for quality solutions for individuals with hearing impairments during wartime, particularly as their needs may change while access to healthcare services remains limited. Despite the clear importance of addressing these needs, no specific protocols, intervention programs or best practices have been formulated to guide audiological care under such conditions. The findings of the current study underscore the necessity of developing strategic guidelines to ensure that individuals with hearing impairment receive adequate support during emergencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHIMIC\u003c/strong\u003e - \u003cstrong\u003eHearing Instruments Management in Crisis Guideline for preparedness and hearing care during prolonged crises\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGlobal events highlight the need for proactive strategies to ensure the functionality and utility of hearing aids during emergencies. In the UN Global Survey on Disaster Preparedness (27) high percentage of survey respondents reported a degree of difficulty hearing (39%). One of the report\u0026rsquo;s conclusions is that disaster preparation should specifically address the needs of individuals with hearing or communication impairments (28). Wars, political conflicts, pandemics, natural disasters, or human-made catastrophes can arise unexpectedly, disrupting daily life and access to essential healthcare services. Given the increasing frequency of global crises, preparedness for hearing aid use in emergencies has become critically important. In response, we have developed the \u003cstrong\u003eHIMIC (Hearing Instruments Management in Crisis) Guidelines for preparedness and hearing care during prolonged crises\u003c/strong\u003e to raise awareness among hearing aid users, professionals and institutional actors including ministries of health, civil protection authorities, health insurers, public health systems, professional associations about essential preparedness actions and considerations in prolonged disruptions and emergency scenarios, such as war times, pandemic, environmental disasters (e.g. hurricanes, tsunamis, earthquakes or wild fires) and mass evacuations. Hearing aids play a critical role in maintaining awareness during emergencies, enabling users to hear important announcements, sirens, and other alerts, thereby enhancing their sense of control and safety. Additionally, hearing aids facilitate communication with care and rescue teams, emergency services and significant others, which is vital during times of stress and disasters.\u003c/p\u003e\n\u003cp\u003eThe HIMIC guidelines consist of two parts: HIMIC-I (Individual) and HIMIC-P (Public Policy). The subsequent sections will outline these guidelines.\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003eHIMIC-I\u003c/strong\u003e (Individual) guidelines (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) offer short three-dimensional practical guidelines aiming to safeguard users\u0026rsquo; access to critical auditory information and support their ability to maintain social connections. Note that individualized advice from certified audiologists, hearing aid specialists or otolaryngologists is strongly recommended to tailor HIMIC-I guidelines to specific needs.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIMIC-I (Hearing Instruments Management in Crisis) Guidelines for preparedness and hearing care during prolonged crises \u0026ndash; Individual Guidelines*\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDimension\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFocal point\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRecommendation\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eInitial considerations\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhen selecting and purchasing hearing aids, the following considerations are recommended:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDevice Features:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Choose hearing aids with a high Ingress Protection Rating (e.g., IP68) for enhanced durability.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Opt for hearing aids that support professional remote services, enabling remote troubleshooting and full adjustments\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpare Devices and Supplies:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; It is recommended to have an alternative amplification device in case of a malfunction in hearing aids. These may include a spare pair of hearing aids or ALDs such as a personal amplified system\u003c/p\u003e\n \u003cp\u003e\u0026bull; Ensure that spare amplification devices are functional and maintained\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePreparations for Emergency Evacuation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn preparation for potential evacuations, hearing aid users should include the following in their emergency go-bag:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Spare hearing aids or ALDs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Spare domes/tips or spare earmold, if relevant\u003c/p\u003e\n \u003cp\u003e\u0026bull; A cleaning and maintenance kit\u003c/p\u003e\n \u003cp\u003e\u0026bull; For rechargeable hearing aids:\u003c/p\u003e\n \u003cp\u003e\u0026bull; A charger\u003c/p\u003e\n \u003cp\u003e\u0026bull; Appropriate cables\u003c/p\u003e\n \u003cp\u003e\u0026bull; A fully charged power bank\u003c/p\u003e\n \u003cp\u003e\u0026bull; For non-rechargeable hearing aids:\u003c/p\u003e\n \u003cp\u003e\u0026bull; At least two packages of suitable batteries for each hearing aid\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eUsing Hearing Aids During Crisis Situations\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHearing aids with an IP68 rating are designed to withstand water exposure and can be worn while showering; however, users should:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Refrain from using shampoo or conditioner while wearing hearing aids\u003c/p\u003e\n \u003cp\u003e\u0026bull; After showering, gently dry the hearing aids with soft, dry cloth\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDuring Sleep:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; If necessary, hearing aids may be worn while sleeping\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Users with bilateral devices may consider wearing one device at a time alternating between devices to reduce wear and ensure functionality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e* Individualized advice from qualified audiologists or otolaryngologists is strongly recommended to tailor these guidelines to specific needs.\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003eHIMIC-P\u003c/strong\u003e (Public Policy) guidelines (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) are aimed for policy makers and other organizational actors to help plan, budget for and integrate services for hearing impaired adults into emergency preparedness and health systems. This comprehensive approach not only enhances emergency response capacity but also fosters a resilient and cohesive community, capable of responding effectively in times of crisis. Effective national disaster preparedness is essential and hinges on several key factors: the nature of the disaster, the existence of well-structured emergency plans, robust coordination among organizations at both national and local levels, and the vital public trust in health systems and the authorities responsible for emergency and disaster management (29, 30). Integrating the HIMIC-P recommendations into national and local emergency plans will not only improve preparedness but also ensure that vulnerable populations receive communication support during emergencies. The HIMIC-P follows the four phases of the traditional disaster management cycle: mitigation, preparedness, response, and recovery (29).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIMIC-P (Hearing Instruments Management in Crisis) Guidelines for preparedness and hearing care during prolonged crises \u0026ndash; Public Policy Guidelines*\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDimension\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFocal point\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eResponsible Entities\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInfrastructure and Strategic Planning\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cem\u003eMitigation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAssessment of the potential impact of emergencies and prolonged crises on support services for adults with hearing impairment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIdentifying risks and disruptions to hearing support services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Health authorities\u003c/p\u003e\n \u003cp\u003e\u0026bull; Disability services departments\u003c/p\u003e\n \u003cp\u003e\u0026bull; Emergency preparedness agencies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Needs assessments and risk mapping for adults with hearing impairment\u003c/p\u003e\n \u003cp\u003e\u0026bull; Address potential disruptions to hearing services and include strategies for remote communication\u003c/p\u003e\n \u003cp\u003e\u0026bull; Allocate budget for hearing rehabilitation and remote care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eOperational guidelines for providing hearing care\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTeleaudiology for remote support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Ministry of Health\u003c/p\u003e\n \u003cp\u003e\u0026bull; National Emergency Authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Develop guidelines for remote hearing care and hearing management in evacuee reception centers\u003c/p\u003e\n \u003cp\u003e\u0026bull; Include regulations for backup and secure access to patients\u0026rsquo; data\u003c/p\u003e\n \u003cp\u003e\u0026bull; Plan and budget an inventory of hearing aids and amplification devices\u003c/p\u003e\n \u003cp\u003e\u0026bull; Form an on-call system for audiologists and hearing aid technicians\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePublic information\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDedicated information websites\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Ministry of Health\u003c/p\u003e\n \u003cp\u003e\u0026bull; National Emergency Authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Information websites and portals to emergency preparedness resources (HIMIC-I)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cem\u003ePreparedness\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePersonnel Training\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraining audiologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Ministry of Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Training audiologists to provide teleaudiology and remote hearing services and instructions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraining emergency teams and support staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; National Emergency Authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Provide targeted communication training for hotline and support staff for communication with individuals with hearing loss and assisting with hearing aids and personal amplifiers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eHearing amplification equipment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHearing instruments and ALDs maintenance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; National Emergency Authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Inclusion of ALDs, hearing aid batteries, power banks and hearing aids in emergency stockpiles, health, and welfare services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eTeleaudiology Equipment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEquipment for teleaudiology and remote support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; National Emergency Authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Equip clinics with computers and telehealth infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eProfessional resources\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAudiologists in emergency and rescue organizations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; National Emergency Authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Include audiologists in emergency services or maintain on-call contact information for audiological consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cem\u003eResponse\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eTeleaudiology and hearing rehabilitation services\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; National Emergency Authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Remote care to ensure provision of hearing rehabilitation services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cem\u003eRecovery\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIntegration of information and lessons learned\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; National Emergency Authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Compilation of information regarding hearing management services provided\u003c/p\u003e\n \u003cp\u003e\u0026bull; Examination of teams\u0026rsquo; activities and collaborations\u003c/p\u003e\n \u003cp\u003e\u0026bull; Examination of the equipment and infrastructures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003eFor Rationale and Comments on HIMIC-P, please refer to Appendix A\u003c/p\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eLimitations\u003c/h2\u003e\n \u003cp\u003eThis study was conducted under emergency conditions. Owing to the constraints imposed by the wartime context, the design and distribution of the questionnaire had to be expedited and abbreviated. Consequently, the findings reflect the responses of individuals who chose to participate, and it is possible that others may have provided different perspectives. Despite these limitations, the study offers valuable insights into behavioral changes and concerns among hearing aid users during a national crisis. These findings contributed to the development of the HIMIC (Hearing Instruments Management in Crisis) Guidelines, which aims to support hearing aid use during prolonged emergencies. Complementary research examining the perspectives, experiences, and recommendations of audiologists during such events could further inform and enhance the development of guidelines for hearing rehabilitation in crisis settings, providing valuable insights for clinicians, policymakers, and other relevant stakeholders.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe findings of this study highlight the significant impact of prolonged major crisis on hearing aid usage patterns among adults with hearing impairment, reflecting both lifestyle adjustments and heightened concerns about accessibility to critical auditory information. The war underscored the critical role of hearing aids in crisis situations, emphasizing the need for preparedness and accessibility of audiological care, including remote services. Given the challenges faced by individuals with hearing impairment during emergencies, proactive strategies such as the HIMIC Guidelines are essential to ensure uninterrupted access to auditory information and communication and enhance awareness and preparedness among hearing aid users in the face of future global crises. Future efforts should focus on integrating hearing accessibility considerations into national emergency response plans to ensure the safety and well-being of individuals with hearing impairments in times of crisis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eALDs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAssistive Listening Devices\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHIMIC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHearing Instruments Management in Crisis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHIMIC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e I\u0026ndash;Hearing Instruments Management in Crisis\u0026ndash;Individual Guidelines\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHIMIC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e P\u0026ndash;Hearing Instruments Management in Crisis\u0026ndash;Public Policy Guidelines\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll aspects of the study were approved by the Ethics Committee of the Faculty of Social Welfare and Health Sciences at the University of Haifa (permit no. 005/24).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants gave their consent to take part in the study by checking a response box in an online form. Participants were asked to reconfirm their consent prior to proceeding to fill out the questionnaire.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was partially supported by the Faculty of Social Welfare and Health Sciences at the University of Haifa. The research was also supported by Amplifon Medtechnica Orthophone Hearing Technologies. The funding sources did not influence the study design, collection, analysis, or interpretation of the data, nor the content of the paper, or the decision to submit the article for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors are senior audiologists in managerial positions and employees in Amplifon Medtechnica Orthophone Hearing Technologies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLimor Lavie and Tali Bar-Moshe developed the initial study outline. Limor Lavie, Tali Bar-Moshe, and Asher Efrati collaboratively designed the study and contributed to the development of the questionnaire. Limor Lavie authored the first draft of the manuscript, and Tali Bar-Moshe wrote the second draft and the first version of the HIMIC-I Guidelines. Limor Lavie, Tali Bar-Moshe, and Asher Efrati revised and edited the manuscript and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Generative AI and AI-assisted technologies in the writing process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAI was only used to improve the readability and language of the work. During the preparation of this work the authors used ChatGPT and Grammarly in order to improve the readability and language of the work. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe questionnaire is available upon request\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to Avigail Rubinger RIP and Amit Topus for their help during the early stages of this research, to Sapir Yunger for her assistance in data organization and to the study participants who made the study possible.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAnnaswamy TM, Verduzco-Gutierrez M, Frieden L. Telemedicine barriers and challenges for persons with disabilities: COVID-19 and beyond. 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Trust and Public Health Emergency Events: A Mixed-Methods Systematic Review. Disaster Med Pub Health Prep. 2022;16(4):1653\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/dmp.2021.105\u003c/span\u003e\u003cspan address=\"10.1017/dmp.2021.105\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7383438/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7383438/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIndividuals with hearing impairments face significant challenges during crises, particularly in accessing emergency alerts and maintaining communication, but little is known about the impact of prolonged crises on hearing aid usage.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eThe aim of the study was to examine changes in hearing aid usage and concerns related to hearing emergency alerts among adults with hearing impairment during the October 7 war in Israel.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e847 hearing aid users (85.4% aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years), 80% with at least moderate hearing difficulty participated in a survey.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eChanges in hearing aid use during the war were characterized with increased hearing aid usage and changes in usage patterns such as more frequent sleeping or showering with the devices. Fear of missing missile sirens was prevalent, with over 25% expressing concerns and 10% frequently failing to hear alarms. Despite regional differences in attack frequency, changes in hearing aid use were not correlated with place of residence, suggesting that psychological stress, rather than direct exposure, influenced behaviour. Notably, 75% of participants recognized remote hearing aid tuning as essential.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe study highlights the role of hearing aids in crisis situations, emphasizing the need for preparedness and integrating audiological support into emergency plans. In response, the HIMIC (Hearing Instruments Management in Crisis) guidelines for individual (HIMIC-I) and for public health (HIMIC-P) preparedness and hearing care, were developed to ensure device functionality, user preparedness and public services during major crisis, such as war times, pandemic, and environmental disasters. These recommendations address device selection, emergency planning, and usage in extreme conditions as well as preparedness of hearing clinics, human resources considerations, training, emergency inventory and establishing responsibilities. Ensuring access to remote audiological services and promoting proactive hearing aid preparedness can enhance safety and well-being for individuals with hearing impairment during prolonged crises.\u003c/p\u003e","manuscriptTitle":"Hearing Aid Use and Audiology Services in Times of Prolonged Crisis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-25 06:59:45","doi":"10.21203/rs.3.rs-7383438/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"44faad1d-4d28-4804-8aaa-a441aef74ce7","owner":[],"postedDate":"August 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-05T12:38:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-25 06:59:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7383438","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7383438","identity":"rs-7383438","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}