Burden of treatment associated with hearing aid use among older adults with hearing loss: a qualitative study

Burden of treatment associated with hearing aid use among older adults with hearing loss: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Burden of treatment associated with hearing aid use among older adults with hearing loss: a qualitative study Sarah Alageel, Hawazen Alhamdan, Azizah Bedaiwi, Hajar Alaqil, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8773833/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Background Treatment burden can affect patients’ ability to carry out tasks or follow recommendations from healthcare providers. Evaluating the burden associated with using and maintaining hearing aids can help identify factors affecting patient compliance. This study also examined the support that older adults receive and prefer to overcome this burden. This enables healthcare providers to understand the burden better and promote improved adherence to hearing aid use among older adults. Methods We conducted a qualitative study using semi-structured interviews with older adults recruited from the Audiology Clinic at King Faisal Specialist Hospital and Research Center (KFSH&RC). Participants were diagnosed with hearing loss and were using hearing aids. Data collection was continued until thematic saturation was reached. The data was analyzed using a thematic analysis method. Results This study included 17 participants aged 62–80 years. Four main themes were identified from the interviews: experiencing hearing loss, barriers to hearing aid use, facilitators to hearing aid use, and support needs. The subtheme highlighted the burden associated with hearing loss and hearing aid use; physical, psychological and financial burdens were cited in addition to the perceived limitation of hearing aid use. On the other hand, the perceived benefit of hearing aids in terms of audibility and promoting social engagement was identified as a facilitator to effective use of hearing aids as they act as motivators. Consistent use of hearing aids was found to help in acclimatization. Support from professionals for hearing aid use is preferred over family to promote autonomy. Findings highlight the need for individualized support, improved device features, and accessible hearing healthcare to enhance hearing aid adoption and user satisfaction in older adults. Conclusion Our research has identified several factors that affect adherence to hearing aid use in older adults. The identified barriers included physical, psychological and financial burden. Difficulty of hearing aid use and care was cited as a burden that can limit the hearing aid use. The study highlighted the need for improved support and counseling in hearing healthcare. Furthermore, the study showed the need for improved hearing aid technology and for providing accessible and direct communication channels with their healthcare providers. The hearing aid users in our study preferred support from their healthcare providers over their family. Hearing loss hearing aid burden of treatment support. Introduction Individuals who have long-term health conditions such as diabetes, hypertension, heart disease, stroke, or cancer face not only the challenges of their illness but also the increasing responsibilities associated with managing their healthcare. Those responsibilities can include adhering to medication schedules, attending medical appointments, monitoring their health, laboratory tests, lifestyle changes, use of new devices and other actions in addition to their typical daily responsibilities 1 – 3 . The burden of managing treatments can negatively affect patients' quality of life, as they dedicate significant time, effort, and financial resources to maintain their well-being 1 . The term "burden of treatment" refers to the overall demand that medical care places on individuals and how it affects their function and well-being 1 , 3 , 4 . This concept is significant in clinical practice because it can reduce adherence to recommended treatments and self-management 5 . Studies have shown that non-adherence is associated with adverse outcomes, such as increased hospitalizations, higher mortality rates, and lower quality of life 4 . Patients with a high burden of treatment struggle to adhere to their therapeutic care, regardless of their specific illness 6 , 7 . Factors such as education, culture, beliefs, family and social support, financial resources, available support systems, and the healthcare environment all contribute to the variation in treatment burden 2 . By evaluating the burden of treatment in clinical practice, healthcare professionals can become aware of the distress experienced by patients and caregivers. This awareness can help in building a collaborative relationship with the patient, working together to develop treatment strategies that are effective and acceptable for both the patient and caregiver 8 . Additionally, research in this area showed that decreasing the treatment burden could promote the patient’s well-being and improve the patient's quality of life 9 . The reduction in treatment burden can be achieved by using simplified devices or home services 10 . Research shows that the burden of treatment transcends the burden of adhering to a specific treatment to all the changes a patient must make in order to comply with the treatment recommendations 8 . Additionally, it can add to the difficulties experienced by the patient caused by their primary condition 11 . For example, a patient who is newly identified with hearing loss has to make lifestyle changes and employ communication strategies in addition to using hearing aids for optimal communication. This, in addition to the repeated clinic visits for the adjustment of the hearing aids 12 . Introducing this concept in clinical settings can empower the patients to acknowledge the burden and advocate for their needs, which in turn will reduce the burden and help adherence. Hearing loss is a chronic health condition that affects approximately 430 million individuals worldwide 13 . Hearing loss prevalence in Saudi Arabia is reported to be between 1.7% and 16.8% 14 . Those experiencing hearing loss often feel embarrassed or frustrated by their communication difficulties, leading them to limit their social interactions 15 . This isolation can result in feelings of loneliness, anxiety, and even depression, as well as fewer opportunities for effective communication 16 . Research has shown that the use of hearing aids can improve hearing function and positively affect overall quality of life by enhancing communication 17 . Despite these advantages, hearing aid usage remains low 18 , 19 . The social stigma attached to hearing aids and the physical discomfort they may cause can result in a tendency to avoid wearing them or reject using them altogether. There is an increased likelihood of experiencing negative emotions right after receiving hearing aids because of the complex process of adapting to them, which involves dealing with practical obstacles and emotional challenges 20 . Enhancing our comprehension of the precise factors that lead to positive and negative emotional responses in situations related to hearing and hearing aids would help in the improving the clinical evaluation and counseling skills of health care providers. It would also help in refining the focus of interventions and managing expectations more effectively 21 , 22 . There is a need for qualitative evidence to examine the treatment burden associated with prescribing hearing aids for older adults with hearing loss. The findings from this research will inform the development of clinical practice guidelines that incorporate the perceived burden into the management and counselling of patients eligible for hearing aid fitting. Without evidence in this area, patient-centred care may be compromised, leading to decreased compliance. Methods The study explored the perceived burden of treatment experienced by older adults diagnosed with hearing loss while using hearing aids following a qualitative research design. Data was collected using semi-structured interviews with older adult patients using hearing aids in King Faisal Specialists Hospital and Research Center (KFSH&RC). Qualitative methodology enables the exploration of patients’ perspectives and experiences, providing a deeper understanding of the factors that may exacerbate their treatment burden 23 . The research proposal was approved by the Research Advisory Council at KFSH&RC (RAC#2241084) as a non-interventional study. Study setting and sample The data collection took place at the Audiology clinic in KFSH&RC using convenience sampling. The recruitment targeted older adults aged 60 and above, diagnosed with hearing loss while using hearing aids. Interested participants were given an information sheet explaining the study and their role in it and any expected benefits and harms from participating. An informed consent was obtained and documented in the patient’s medical records. Eligible participants who met the criteria were invited to participate in the face-to-face interviews by research coordinators after their management has completed. The research coordinators were junior Audiologists who were trained on conducting the interviews by the principal investigator. We continued interviewing until we reached inductive thematic saturation. Thematic saturation was determined when no new codes or themes emerged 23 . Topic guide A topic guide was developed based on the literature examining patient experiences with hearing aids 1 , 21 , 24 . The topic guide was influenced by the Burden of Treatment Theory, which examines the demands placed on individuals in terms of their healthcare management, especially those with chronic conditions, such as hearing loss 24 . The theory emphases the demand becomes too heavy, it can impact the quality of life and individual’s ability to adhere to treatment. The topic guide was developed for this study and it included questions about participants’ overall experience with hearing loss and hearing aid and factors associated with facilitating or hindering the use of hearing aids. The guide also included questions on participants’ suggestions on how to improve healthcare delivery to improve their experiences and reduce any unnecessary burden associated with hearing aid use. Participants had the freedom to discuss any relevant areas that was not covered by the guide. The topic guide is available in Supplementary material 1. Data analysis The interviews were audio recorded, following the participants’ consent, and transcribed verbatim. Thematic analysis was used to identify and describe patterns derived from qualitative data 25 . After the transcription and familiarization with all interviews, all transcripts were coded using ATLAS.ti software by the lead author (SA 1 ). SA is a senior Audiologist with 15-year experience working with older adults using amplification. She is trained in qualitative research methodology. A sample of the data was double coded by another researcher (SA 2 ), who is a public health researcher with expertise in qualitative research. Meetings were conducted to discuss and amend the codes as needed. Categories were developed by grouping codes into an analytical framework, which was continuously refined through discussions with the research team. All themes and sub-themes emerged from these collaborative discussions, enhancing both rigor and reliability. The quotes presented in the findings were translated from Arabic to English by two authors, who then jointly agreed on the final translations. Results Seventeen participants, both male and female, aged 62–80 (mean age of 69.4 years), participated in this study. The characteristics of the participants are presented in Table 1 . Four major themes were identified from the data (Table 2 ). Table 1 Study participants’ characteristics. Age 60–65 4 66–70 8 71–75 3 76–80 2 Gender Male 11 Female 6 Pure Tone Average of the better ear 25–40 4 41–50 9 51–70 3 71 – >90 1 Years of hearing loss 10 6 Hearing aid type Behind The Ear 5 Receiver in The Canal 7 Custom made 5 Monaural vs binaural Monaural 4 Binaural 13 Table 2 Themes and subthemes identified from the data. Themes Sub-themes Experiencing hearing loss − Accepting hearing loss. − Hearing loss is a burden in itself. − Accessibility of Hearing Healthcare Services. Barriers to effective hearing aid use − Hearing aid is a burden: physical, psychological and financial − Ease of hearing aid − Perceived limitation of hearing aids: sound quality, telephone use, technology. Facilitators to effective hearing aid use − Perceived advantages of hearing aids: audibility, social, and technological. − Consistent use promoting acclimatization. − Motivation and psychological readiness. Support with hearing aids − Preferred support by patients − Resistance to support with hearing aids 1- Experiencing hearing loss Accepting hearing loss: The onset of hearing loss varied among participants, but many attributed it to ageing and accepted it as a natural progression. The impact of religious beliefs was apparent in their general acceptance of hearing loss and how they coped with it as an aspect of the ageing process. “ I am adapting, and I am truly grateful to Allah. I thank Allah for blessing me and for making me better off than many others. Praise Allah, who has spared us from what has afflicted many people.” (64 year-old, male, using a BTE HA) Despite being diagnosed with hearing loss, some participants reported not experiencing significant difficulties. Some participants described employing coping strategies, such as lip-reading, positioning themselves closer to the speakers, requesting repetition, and increasing the volume on their electronic devices. When discussing their hearing loss, many participants attributed it to familial predisposition, otitis media, noise exposure, and ototoxic medications for treating other medical conditions. However, they all demonstrated acceptance of their difficulties. " When you're watching TV alone, you can control it and adjust the volume as you wish." (75-year-old, male, using a bilateral RIC HA) " Sometimes I ask him to repeat. But sometimes, thank God, like when I'm talking to you, I don't miss any words." (70-year-old, male, using a bilateral RIC HA) Hearing loss is a burden in itself: Participants reported that their hearing loss significantly affected their emotional state and social interactions, with adverse effects extending to their immediate family members. They emphasized the considerable embarrassment experienced when missing parts of conversations or requesting repetition in social settings. Consistently, participants identified speech comprehension and discrimination as the primary challenges associated with hearing impairment. Additionally, some participants reported social withdrawal and avoidance of conversations in social contexts because of their condition. “ When I felt that I could not hear well during meetings, I said to myself, ‘I need hearing aids.’ I am an active member in family gatherings, I conduct interviews, and I need to ensure my hearing is good because it causes me embarrassment.” (62-year-old, male, using a RIC HA) Accessibility of Hearing Healthcare Services A recurring theme of delayed help-seeking behavior and access to care emerged from the participants' accounts. While some participants described acquiring hearing aids as challenging, others did not report such difficulties. The delay in seeking diagnosis and treatment was attributed to participants' acceptance of hearing loss as an age-related phenomenon and their reluctance to acknowledge its impact. Physicians, serving as the initial point of contact for participants seeking hearing loss management, played a crucial role in patients' decisions to pursue hearing aid fitting. " I consulted a doctor, specifically an ear, nose, and throat specialist. He told me that I might have nerve weakness, and nerves may not have a cure except for hearing aids. I ignored the matter then, as I wasn't ready to accept the idea of wearing a hearing aid due to the negative things I had heard about them." (70-year-old, male, using a bilateral RIC HAs) Many participants expressed dissatisfaction with the quality of care received and the complex process of obtaining a diagnosis and subsequently managing it with hearing aids. " Honestly, it took a long time to get the hearing aids—it wasn’t easy at all. First, I was referred to the labor and social services office, where they gave me instructions. I couldn’t manage to navigate through the instructions. Finally, after much difficulty, I was able to get the hearing aids from you." (74-year-old, male, using a bilateral RIC HAs done twice) Barriers to effective hearing aid use Using hearing aids is a burden The participant interviews identified various burdens and challenges associated with hearing aid use. These barriers were categorized as physical, psychological, financial, and poor sound quality, among others. This highlights the complexity of adapting to hearing aid devices and the associated difficulties with such a management option. Physical burden Participants expressed significant physical burdens associated with wearing the hearing aids and their physical form. These issues include the discomfort caused by the size and fit of the devices in the ear. Other causes of discomfort were attributed to the itchiness and occlusion effects caused by the hearing aid. It was also noted that larger behind-the-ear aids caused physical discomfort and were more challenging to fit into the ear than the smaller in-the-ear styles. This was particularly problematic due to the frequent need to remove and fit the device during the day, especially when required after each Wudu in preparation for prayer, approximately five times daily. Some participants preferred smaller, more discreet in-the-ear models, which they perceived as less noticeable, easier to wear, and more comfortable. Furthermore, cleaning and maintaining the hearing aids was an additional burden added to the difficulty of adjusting the volume and the frequent need to replace the batteries. " Sometimes the hearing aid causes me ear pain ." (70-year-old, male, using a bilateral RIC HA) " I had to remove the hearing aid multiple times due to discomfort ." (66-year-old, female, using a bilateral BTE HA) Psychological burden The psychological burden associated with hearing-aid use emerged as a key theme. Several participants expressed a lack of readiness or reluctance to use hearing aids consistently due to personal vanity or social self-consciousness. The stigma associated with wearing hearing aids, which was viewed as a sign of ageing and handicap, was a barrier to their consistent use in some cases. " First, the psychological barrier is very significant—it's a major obstacle. I must overcome it and encourage myself to say, 'Let’s do it again.' Because I’ve had a previous experience that I wasn’t satisfied with, I feel like I have to motivate myself and say, 'Give it a chance; give yourself a second opportunity to try. Maybe I was wrong.' " (73-year-old, female, using a bilateral RIC HA) Situational use of hearing aid In many instances, participants reported that the different forms of burden associated with hearing aid use resulted in situational use of hearing aids. Participants stated being motivated to wear hearing aids only in social gatherings, as they perceived them as necessary only in those circumstances. Some participants justified their limited use by perceiving a lack of need for the devices or emphasizing that their hearing loss was not severe enough to warrant constant use. " No, no, I don’t wear them at home. I only wear them when I am out. If I am in a small group, I hear well and respond. However, I need it when I am at a party or a wedding with competing noise. It becomes necessary, so I must use it. '" (70-year-old, female, using a monaural CIC HA) Financial burden Some participants reported the economic burden related to hearing aid use, particularly concerning the high cost of devices, batteries, and ongoing maintenance. They expressed dissatisfaction regarding the recurring cost of batteries, which required frequent replacement. Additionally, maintenance costs for repairs contributed to the financial strain. It should be noted that this burden could be amplified in groups where the cost of hearing aids falls entirely on the patient, and would be less significant in groups where the hearing aid cost is covered by the healthcare system. " If you go to the vendor, the repair costs are expensive, and the expenses for these batteries are significant—they consume a lot, typically lasting only about two to three days." (63-year-old, male, using a bilateral CIC hearing aid) Ease of hearing aid In contrast to the burdens experienced by some participants, others reported a relatively positive experience with hearing aids, often minimizing or negating significant challenges. For instance, several participants indicated that hearing aid batteries were easily manageable and that care and maintenance were uncomplicated. These participants also emphasized the physical ease of using hearing aids, noting that the devices were comfortable to wear and manipulate. This contrasting perspective illustrates how individual experiences with hearing aid use can vary considerably, with some perceiving minimal burden and others experiencing substantial challenges associated with their use. " There’s no difficulty at all—I simply remove the hearing aid, place it in its case, put it back on when needed, and at night, I disconnect the battery, praise be to God, changing the hearing aid’s battery is simple; when I hear the sound indicating that the battery needs replacement, I just go ahead and replace it. " (74-year-old, male, using a bilateral RIC HA, done twice) Perceived limitations of hearing aids Sound quality The limitations of hearing aids, as experienced and reported by the participants, contributed to their frustration and increased their perceived burden of treatment. Poor sound quality of hearing aids was a frequently reported issue. Participants expressed dissatisfaction with the clarity of speech and discrimination, with some participants perceiving that the hearing aid did not provide adequate benefits, given the burden it posed. These frustrations were exacerbated in challenging listening environments. Their inability to engage fully in social interactions due to difficulties in hearing or following conversations with multiple speakers often resulted in frustration and a sense of social isolation. Dissatisfaction with the clarity or amplification provided by the devices led to participants choosing not to wear them regularly, instead relying on lip-reading, residual hearing, or simply avoiding situations where hearing aids would be necessary. “ If you increase the volume, it becomes noisy, and if you lower it, I do not benefit from it at all. That is the problem. You have made it too loud now, and I can feel it. My voice is becoming annoying—annoying, annoying, annoying.” (64-year-old, male, using a BTE HA) " The hearing aid sometimes buzzes a lot, and I leave it. It’s very annoying, so I remove it." (74-year-old, male, using a bilateral RIC HA) Telephone use For telephone conversations, participants reported difficulties in hearing clearly, as the devices often fail to provide adequate amplification or clarity of speech over the phone. Due to the perceived limitations of hearing aids, participants often relied on family support to assist them in understanding speech during phone calls. Family members frequently played an integral role in facilitating communication, particularly when hearing aids struggle to provide clear amplification of telephone conversations. Similarly, while watching television, participants found that sound quality did not sufficiently enhance their viewing experience. " Now, if I receive a call, I can’t answer it like that (i.e. on speaker)—it would be embarrassing. If I answer, everyone hears, whether it is a family call, a friend’s call, or any other type. At home, I do not answer unless someone is nearby to listen and let me know what the person is saying. They will say, 'So-and-so is telling you this or that.' From this, I catch about 40% of the words, piecing them together like a crossword puzzle until they form a meaningful sentence ." (64-year-old, male, using a BTE HA in one ear, the other CI) Technology Participants frequently expressed a desire for improved hearing aid technologies, particularly regarding enhancements in their connectivity to other devices. The unreliability of the wireless connection to the phone and limited control over sound quality were mentioned as areas that require attention. Furthermore, there is a common desire for devices that can more effectively address challenges such as speech comprehension and the use of disposable batteries. " Science is indeed advancing, because I see that the design of hearing aids, especially the way they're placed behind the ear, still feels quite primitive. Science has progressed significantly—just look at glasses, for instance; they’ve developed contact lenses, whether implanted or temporary, as an alternative." (70-year-old, male, using a bilateral RIC HA) Facilitators to effective hearing aid use Perceived advantages of hearing aids Audibility During the interviews, many participants expressed satisfaction with the hearing aids despite the burden they posed. Overall, they highlighted that it improved their ability to participate in daily activities, allowing for a more active lifestyle and greater independence. The enhanced audibility and improved speech clarity significantly reduced the frustration often associated with hearing loss. Furthermore, some participants noted decreased mental load when using hearing aids. They described how reduced effort in understanding speech allowed them to engage more comfortably in social interactions. One participant linked using hearing aids to an improved quality of life and emotional well-being. For some participants, hearing and understanding religious texts, “the Quran”, was of profound importance as it enhanced their spiritual experience. “ To be with people and hear everything being said, there are times I find myself forced to stay silent because I have not heard something I should have responded to. With a hearing aid, however, I can hear much better, and it’s definitely an improvement over not being able to hear at all .” (70-year-old, female, using a CIC HA) Social The social benefits of hearing aids were a recurring theme. The participants reported feeling more included in social settings. They appreciated being able to follow conversations easily, reducing their feelings of isolation. The perceived benefits of using hearing aids served as a significant motivator for consistent use, and many reported that they wished they had used the hearing aids sooner, given their advantages. " The benefits of it are that it brings you closer to the community, allowing you to interact and engage in discussions and conversations with them. Previously, a person might feel somewhat isolated—hearing one word while missing the others—but now, by hearing everything immediately as it’s being said, you can fully follow the conversation ." (69-year-old, male, using a monaural CIC HA). " I feel relieved, praise be to God. I now live among people as they do, listening to their conversations, sitting with others, talking to individuals, understanding their words, and truly hearing them. I am filled with gratitude toward those in charge here for their care, prompt service, and kind treatment. I pray that God rewards them. They helped me with this matter, making me feel comfortable, able to hear, and live as part of the community." (68-year-old, male, using a bilateral CIC HA). Technological The participants appreciated the technological advancement and acknowledged that modern hearing aids offer technological innovations that have made wearing hearing aids more convenient. Many noted that Bluetooth connectivity allowed them to connect their hearing aids to smartphones and other devices, facilitating seamless communication and enhancing their overall auditory experience. " I remember having a phone prior to this one, which was wirelessly paired to my hearing aid, similar to my current device, allowing me to hear the sound clearly whenever someone called. Now, it’s especially useful for me—I can enjoy programs or follow the Quran comfortably on my phone, without disturbing those around me, as I hear the sound privately and clearly." (74-year-old, male, using a bilateral RIC HAs done twice) Consistent use promotes acclimatization Through personal experiences, the participants provided insights into the importance of persistent hearing aid use and its positive effect on adaptation, which was crucial in their journey. The more they wore their devices, the better they adapted to them, the care they required, and their sound quality. Additionally, some reported on personal strategies they used to promote the correct placement of hearing aids. Overall, participants found that habituation to hearing aids was initially complicated, especially after the fitting. " Honestly, I didn't face any difficulties except on the first day when I wore it; it felt like it was doing something to my head. After two, three, four days, I got used to it." (68-year-old, male, using a bilateral CIC HA) Motivation and psychological readiness The participants’ reports highlighted the critical role of motivation and psychological readiness in successfully using hearing aids. Their decision to pursue hearing aids was influenced by internal motivation to improve their communication and social interactions. This intrinsic motivation often stemmed from recognizing the negative impact of hearing loss on their daily functioning. Some even stated that self-motivation was key in effectively using hearing aids and overcoming their burden. Participants also noted that readiness to wear hearing aids before fitting contributed to their successful use. Factors such as acceptance of hearing loss, encouragement from family, and personal readiness significantly influenced their decision to use hearing aids. “ I’m truly willing to do whatever it takes as long as it helps me adapt to people and prevents them from feeling annoyed by me repeating myself.” (69-year-old, male, using a CIC HA) Physician counseling played a crucial role in shaping participants' perceptions of hearing aids. Effective counseling provided by healthcare professionals facilitated the decision-making process, as participants who felt well-informed and supported by their physicians were motivated and psychologically ready to pursue hearing aids. On the other hand, some participants were driven by misinformation from family members or their community to use hearing aids to “improve hearing” or “preserve hearing from further loss.” "The doctor told me, 'We never force patients to use it; it depends entirely on their need.' He was excellent and explained things clearly to me.” (73-year-old, female, using a bilateral RIC HA) Support with hearing aids Preferred support by patients The participants emphasized a multifaceted approach to support, encompassing professional guidance, family involvement, and the importance of accessible communication channels. They preferred receiving support from a professional rather than their family to overcome their burden. They stated that professional support was superior, especially regarding perceived technical burden, given that they were “the expert”. They highlighted the importance of hands-on assistance from professionals in navigating the complexities of hearing aids. Direct support during initial fittings and ongoing adjustments was frequently cited as crucial in fostering user confidence and overcoming the hearing aids’ burden. They stated that their needs in terms of support from professionals varied between emotional and technical. “ I feel comfortable coming here to this clinic, where I can meet with specialists, assistants, nurses, or audiologists, as they understand my needs. Their explanations are clear and comprehensive, and they can also assist me with programming.” (64-year-old, male, using BTE HAs) Family involvement emerged as a vital component of the support framework. Their support started by pushing the participants to seek help in the first place, and then it encouraged them to use the hearing aids more consistently. Participants reported various forms of family support, categorizing these into emotional, technical, and motivational. Emotional support from family members, especially one’s children, was identified as a key motivator, enhancing patients’ willingness to engage with their hearing aids. " One of my sons, in particular, is the only one who consistently follows up with me. He was with me during my audiology appointments and has always been by my side, accompanying me and ensuring that I use my hearing aids diligently." (74-year-old, male, using a bilateral RIC) The participants noted a strong desire for increased and direct accessibility to audiologists. Delays in professional support often led to frustration and disengagement. The value of using multimodality in educating the patient was reported. Videos and other printed materials would enhance the patient’s experience and mitigate the burden experienced by the participants while using the hearing aids. " The audiologist, may God reward both her and you, gave me a future perspective during our first meeting. She painted a picture for me, emphasizing that everything is challenging at the beginning." (70-year-old, male, using a bilateral RIC HAs) Resistance to support with hearing aids Some participants expressed a sense of personal resilience and emphasized their desire for independence. The desire to maintain agency and self-sufficiency frequently resulted in resisting support from family members. Their resistance to their family’s support stemmed from believing they were not the appropriate support as they were not “experts.” One participant stated that needing assistance and support with hearing aids was a burden. “ I try to manage everything on my own, including my treatment. My family lacks experience, so I have to teach them, as they don’t use a hearing aid.” (70-year-old, male, using BTE HAs) Discussion This study aimed to explore the burden of treatment associated with hearing aid use among older adults with hearing loss and their experience with receiving support. Participants expressed their views on hearing loss, its burden, and the reality of hearing health services. They identified many barriers to effective use of hearing aids, including their overwhelming burden and perceived limitations. On the other hand, many subjects had a positive experience with hearing aids regarding their advantages and technology. Finally, older adults generally preferred professional support when overcoming any burdens associated with hearing loss. Findings from this study suggested that hearing aids as a treatment for hearing loss pose a significant burden on their users. A key barrier to hearing aid use is the physical and psychological burden. Discomfort from device size and its fit, in addition to the perception of itchiness and occlusion caused by it, acted as a barrier. Some participants were reluctant to wear hearing aids because of vanity, self-consciousness, and the stigma associated with ageing and disability. It has been suggested that hearing aid visibility embarrasses users 21 . Another reason for not using hearing aids was based on the belief that they are burdensome 26 . Evidence from several studies indicated that hearing aid users experienced difficulty with the physical fit of the hearing device 20 . They also reported discomfort, irritation, or even physical pain when wearing the aid 20 , suggesting it is a common experience beyond the current study participants. Therefore, hearing aid users tend to weigh the costs and benefits of wearing the aid, and positive experiences occur when the benefits outweigh the negatives. At the same time, they may wear it reluctantly when associating the aid with negative experiences 21 . There is a need to support first-time hearing aid users by emphasising the benefits of using hearing aids while recognising the challenges to ensure a positive, long-term experience. Providing peer support could help normalize the appearance of hearing aids and share difficulties and potential solutions to everyday challenges. Participants in the current study highlighted the need for a multifaceted support approach, including professional guidance, family involvement, and accessible communication. They preferred professional help over family, citing its superiority and its effectiveness in reducing the burden. On the other hand, family support included emotional, technical, and motivational support that facilitated hearing aid use. There is a balance sought when using hearing aids between having familial and professional support while also ensuring preserved autonomy and independence. Several studies suggested that receiving care from a significant other or other family members facilitated the initial experience with hearing aids 20 . While some described it as primarily limited to hearing aid uptake 27 , others reported that users had better hearing aid outcomes when they perceived positive support from their significant others 28 . Evidence also suggested that hearing aid users and audiologists aim to reach independence by depending less on external sources of support and to value internally-based approaches 29 . Some hearing aid users resisted external support to maintain their autonomy and saw it as their own responsibility to look after their health 4 . Participants in the current study expressed a strong desire for direct access to audiologists, noting that delays caused frustration and disengagement. A direct connection with healthcare professionals using different technological tools, such as online portals, was reported as a facilitator to successful hearing aid use 4 . However, building trust with healthcare professionals is crucial, as hearing aid users who do not trust their providers are more likely to disengage 26 . Therefore, balancing support from external sources with fostering hearing aid user independence within their capabilities is crucial. Healthcare professionals should develop a strong relationship with hearing aid users and offer a reliable tool to address their needs, especially during the initial phase of use. Clinical care implications and future research Future research should examine the experiences of carers of older adults with limited self-support abilities to find ways to improve their use and experience with hearing aids. It is also essential to explore the views of clinicians and policymakers on the kind and level of support that could be provided to hearing aid users and the factors influencing the level of services offered. Protocols should be established to ensure resources are available for first-time users and their caregivers, facilitating access to different types of support. Technological solutions could reduce the burden on healthcare providers without compromising the care and support provided to hearing aid users. This might include applications or virtual communication methods. The diverse needs of hearing aid users must be taken into account. Strengths and limitations To our knowledge, this is the first study to use qualitative interviews to examine the burden of treatment associated with hearing aids among older adults in Saudi Arabia. We included participants with different characteristics to explore different experiences. A second, independent researcher checked the study codes. They reached an agreement through consensus, enhancing the transparency and credibility of the study interpretation 23 . A key limitation is that clinicians conducting interviews worked at the same clinic where patients received care. This could cause conflicts between the clinician and researcher roles 30 . This is challenging for both the interviewees and the interviewers, as the patient might see these interviews as a way to receive care, or the clinician might feel responsible for addressing the patient's needs. Another concern is risking participants’ autonomy because of their vulnerability as patients receiving care from interviewers 30 . Patients may feel pressured to participate or provide socially desirable responses. We aimed to reduce social desirability bias by carefully wording questions, avoiding leading questions and judgment, and ensuring participants' autonomy by explaining participation was voluntary and wouldn't affect care. Guaranteeing privacy and confidentiality encourages honest, private accounts. Researchers ensured their role and participant relationships were acknowledged by enhancing rigor through reflexive diaries, documenting procedures, providing evidence for interpretations, analyzing the complete data set, considering deviant cases and disconfirming data, comparing data within and between cases, and contrasting findings with other studies. Finally, the study was conducted in Riyadh, Saudi Arabia's capital. Residents of the capital city may have more advanced services than those in other regions. The hospital was chosen for its unique tertiary healthcare services, providing access to a diverse population. Results reflect participants willing to discuss their experiences, possibly underrepresenting older, more conservative adults or those with severe hearing loss, who are less inclined to share their hearing aid experiences. Conclusion This study examined hearing aid burdens among older adults, highlighting barriers such as being overwhelmed and facing limitations, but also positive technological experiences. Participants reported preferring professional support over any other type of support. The findings indicate that hearing aids impose significant burdens; future research should explore the caregivers’ and clinicians' perspectives on potential support levels to be provided. Future healthcare programs must ensure facilitating access to resources for users and carers, incorporating technological solutions, such as applications, to help ease healthcare providers' workload and provide a consistent channel of communication between the patients and their healthcare providers. Furthermore, the use of rechargeable hearing aids can alleviate some of the burden associated with hearing aid care and maintenance. Support should cater to the diverse needs of hearing aid users. Declarations Human Ethics and Consent to Participate declarations This study was approved by the Research Advisory Council at KFSH&RC (RAC#2241084) as a non-interventional study on 17th of March, 2024. Participants gave informed consent for review and consent was documented in the patient’s medical charts. All study procedures were conducted in accord with the ethical standards of the Committee on Human Experimentation of the institution in which the study was done in accord with the Helsinki Declaration of 1975. Consent for Publication: Not applicable. Competing Interests : The authors declare that they have no competing interests. Declaration of interest statement : The Authors declare that they have no competing interests. Clinical trial number Not applicable Funding: No funding was received in order to complete this study. Author Contribution Sarah Alageel (Conceptualization; Writing- Original Draft; Data Collection & Curation; Formal Analysis); Hawazen Alhamdan (Writing - Review & Editing; Formal Analysis); Azizah Bedaiwi (Writing- Original Draft; Data Collection & Curation); Hajar Alaqil (Writing - Review; Data Collection & Curation); Samah Alageel. (Conceptualization; Methodology; Writing - Review & Editing; Formal Analysis). Acknowledgement The authors express their gratitude to all the participants for their involvement and taking the time to partake in the interviews. Data Availability The datasets generated and analyzed during the current study are not publically available due to lack of consent to share raw material, but parts of the material can be available from the corresponding author upon reasonable request. References Eton DT, Ramalho de Oliveira D, Egginton JS et al. Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Relat outcome measures. 2012:39–49. Tran V-T, Barnes C, Montori VM, Falissard B, Ravaud P. Taxonomy of the burden of treatment: a multi-country web-based qualitative study of patients with chronic conditions. BMC Med. 2015;13(1):115. Selvakumar D, Sivanandy P, Ingle PV, Theivasigamani K. Relationship between treatment burden, health literacy, and medication adherence in older adults coping with multiple chronic conditions. Medicina. 2023;59(8):1401. Ridgeway JL, Egginton JS, Tiedje K et al. Factors that lessen the burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Prefer Adherence. 2014:339–51. Schreiner N, DiGennaro S, Harwell C, Burant C, Daly B, Douglas S. Treatment burden as a predictor of self-management adherence within the primary care population. Appl Nurs Res Aug. 2020;54:151301. 10.1016/j.apnr.2020.151301 . Khojah YY, Bashawri MA, Khojah NY, Hassanien NSM. Prevalence of and Factors Associated with Treatment Burden and Medication Adherence Among Primary Care Patients with Multimorbidity in Jeddah, Saudi Arabia: A Cross-Sectional Study. Cureus Aug. 2024;16(8):e67514. 10.7759/cureus.67514 . Sav A, King MA, Whitty JA, et al. Burden of treatment for chronic illness: a concept analysis and review of the literature. Health Expect Jun. 2015;18(3):312–24. 10.1111/hex.12046 . Sheehan OC, Leff B, Ritchie CS, et al. A systematic literature review of the assessment of treatment burden experienced by patients and their caregivers. BMC Geriatr. 2019;19(1):262. Gebreyohannes EA, Gebresillassie BM, Mulugeta F, Dessu E, Abebe TB. Treatment burden and health-related quality of life of patients with multimorbidity: a cross-sectional study. Qual Life Res Nov. 2023;32(11):3269–77. 10.1007/s11136-023-03473-3 . Lesage A, Leclère B, Moret L, Le Glatin C. Decreasing patient-reported burden of treatment: a systematic review of quantitative interventional studies. PLoS ONE. 2021;16(1):e0245112. Gallacher KI, Batty GD, McLean G, et al. Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1,424,378 patients in Scotland: implications for treatment burden. BMC Med. 2014;12(1):151. Smith SK, Pryce H, O'Connell GB, Hussain S, Shaw R, Straus J. The burden is very much on yourself': A qualitative study to understand the illness and treatment burden of hearing loss across the life course. Health Expect Jun. 2024;27(3):e14067. 10.1111/hex.14067 . Organisation WH. World report on hearing. https://www.who.int/publications/i/item/9789240020481 Sidenna M, Fadl T, Zayed H. Genetic epidemiology of hearing loss in the 22 Arab countries: a systematic review. Otology Neurotology. 2020;41(2):e152–62. Podury A, Jiam NT, Kim M, Donnenfield JI, Dhand A. Hearing and sociality: the implications of hearing loss on social life. Front Neurosci. 2023;17:1245434. 10.3389/fnins.2023.1245434 . Heffernan E, Withanachchi CM, Ferguson MA. The worse my hearing got, the less sociable I got’: a qualitative study of patient and professional views of the management of social isolation and hearing loss. Age Ageing. 2022;51(2). 10.1093/ageing/afac019 . Ellis S, Sheik Ali S, Ahmed W. A review of the impact of hearing interventions on social isolation and loneliness in older people with hearing loss. Eur Arch Otorhinolaryngol Dec. 2021;278(12):4653–61. 10.1007/s00405-021-06847-w . Peñaranda D, Pérez-Herrera LC, Moreno-López S, et al. Audiological benefit, quality of life, and factors associated with functional gain in elderly hearing aid users in a developing country between 2017 and 2020: a pre-post-study. BMC Geriatr Jun. 2023;19(1):376. 10.1186/s12877-023-04051-5 . Ferguson MA, Kitterick PT, Chong LY, Edmondson-Jones M, Barker F, Hoare DJ. Hearing aids for mild to moderate hearing loss in adults. Cochrane Database Syst Rev Sep. 2017;25(9):Cd012023. 10.1002/14651858.CD012023.pub2 . Oosthuizen I, Manchaiah V, Launer S, Swanepoel DW. Hearing aid experiences of adult hearing aid owners during and after fitting: a systematic review of qualitative studies. Trends Hear. 2022;26:23312165221130584. Holman JA, Ali YH, Naylor G. A qualitative investigation of the hearing and hearing-aid related emotional states experienced by adults with hearing loss. Int J Audiol. 2023;62(10):973–82. Pryce H, Smith SK, Burns-O'Connell G, et al. Protocol for the development and validation of a patient-reported experience measure (PREM) for people with hearing loss: the PREM-HeLP. BMJ open. 2023;13(11):e075229. Green J, Thorogood N. Qualitative Methods for Health Research. Sage Publications Ltd. Lodon; 2018. May CR, Eton DT, Boehmer K, et al. Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness. BMC Health Serv Res. 2014;14(1):281. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Res sport Exerc health. 2019;11(4):589–97. Ritter CR, Barker BA, Scharp KM. Using attribution theory to explore the reasons adults with hearing loss do not use their hearing aids. PLoS ONE. 2020;15(9):e0238468. Laplante-Lévesque A, Jensen LD, Dawes P, Nielsen C. Optimal hearing aid use: Focus groups with hearing aid clients and audiologists. Ear Hear. 2013;34(2):193–202. Hickson L, Meyer C, Lovelock K, Lampert M, Khan A. Factors associated with success with hearing aids in older adults. Int J Audiol. 2014;53(sup1):S18–27. Bennett RJ, Barr C, Cortis A, et al. Audiological approaches to address the psychosocial needs of adults with hearing loss: perceived benefit and likelihood of use. Int J Audiol. 2021;60(sup2):12–9. Taquette SR, Borges da Matta Souza LM. Ethical dilemmas in qualitative research: A critical literature review. Int J Qualitative Methods. 2022;21:16094069221078731. Additional Declarations No competing interests reported. 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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-8773833","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":606240044,"identity":"bdfda188-e048-4b7c-b900-bf44e48b577d","order_by":0,"name":"Sarah Alageel","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIiWNgGAWjYFAC5gYQKcMv//gwQwVEyICAFkawFh7JhrRkhjMkaTE4kGNMnBb59oONH79U2AC1nPlscODPPXkG9uZtEgx/7HBqMTiT2CwtcyaNR/Jg7+aEg23Fhg08x8okGNuScWthSGyQlmw7zMN3mHfz4Y8NCQkMEjlmEowNzLgd1v+w+bfkv/88DMd4Hh848AeoRf6NGdBh9bg9cyOxTfJjwwEegTM8zAkH2EC28AC1sB3G7bAbD9usGY4l80jOYDM2ONiWYNjGk1Zskdh2HI/Dkg/f/FFjJ8cvwfxYAugweX72wxtvfPhTjdthQMDMg8xjAxEJeDUAI/MHAQWjYBSMglEwwgEAO3JWGi5M/4UAAAAASUVORK5CYII=","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center","correspondingAuthor":true,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Alageel","suffix":""},{"id":606240045,"identity":"40a3c8d4-7abc-4f9f-a68e-8484c9d11c21","order_by":1,"name":"Hawazen Alhamdan","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center","correspondingAuthor":false,"prefix":"","firstName":"Hawazen","middleName":"","lastName":"Alhamdan","suffix":""},{"id":606240046,"identity":"c2fd72cc-86b2-4e24-9a52-3caedcdf4e49","order_by":2,"name":"Azizah Bedaiwi","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center","correspondingAuthor":false,"prefix":"","firstName":"Azizah","middleName":"","lastName":"Bedaiwi","suffix":""},{"id":606240047,"identity":"9354e809-4bef-46f1-a783-16c7846dcdb6","order_by":3,"name":"Hajar Alaqil","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center","correspondingAuthor":false,"prefix":"","firstName":"Hajar","middleName":"","lastName":"Alaqil","suffix":""},{"id":606240048,"identity":"91dfbbb3-b197-411a-a1c8-fbfb6f8b4bba","order_by":4,"name":"Samah Alageel","email":"","orcid":"","institution":"King Saud University","correspondingAuthor":false,"prefix":"","firstName":"Samah","middleName":"","lastName":"Alageel","suffix":""}],"badges":[],"createdAt":"2026-02-03 09:41:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8773833/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8773833/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104750983,"identity":"1fe0b30f-2774-4927-b1d3-a3dc02373b9c","added_by":"auto","created_at":"2026-03-16 19:51:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":874596,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8773833/v1/5842f3b2-fc70-40c8-9234-fa49576a9b46.pdf"},{"id":104750982,"identity":"ae327b7c-d3fc-4bb7-b1d3-ac4e87ea37ec","added_by":"auto","created_at":"2026-03-16 19:51:18","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":13313,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial1Topicguide.docx","url":"https://assets-eu.researchsquare.com/files/rs-8773833/v1/c90e881fd1e63f801f68d5b9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Burden of treatment associated with hearing aid use among older adults with hearing loss: a qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIndividuals who have long-term health conditions such as diabetes, hypertension, heart disease, stroke, or cancer face not only the challenges of their illness but also the increasing responsibilities associated with managing their healthcare. Those responsibilities can include adhering to medication schedules, attending medical appointments, monitoring their health, laboratory tests, lifestyle changes, use of new devices and other actions in addition to their typical daily responsibilities \u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The burden of managing treatments can negatively affect patients' quality of life, as they dedicate significant time, effort, and financial resources to maintain their well-being\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The term \"burden of treatment\" refers to the overall demand that medical care places on individuals and how it affects their function and well-being\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. This concept is significant in clinical practice because it can reduce adherence to recommended treatments and self-management \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Studies have shown that non-adherence is associated with adverse outcomes, such as increased hospitalizations, higher mortality rates, and lower quality of life \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Patients with a high burden of treatment struggle to adhere to their therapeutic care, regardless of their specific illness \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Factors such as education, culture, beliefs, family and social support, financial resources, available support systems, and the healthcare environment all contribute to the variation in treatment burden \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. By evaluating the burden of treatment in clinical practice, healthcare professionals can become aware of the distress experienced by patients and caregivers. This awareness can help in building a collaborative relationship with the patient, working together to develop treatment strategies that are effective and acceptable for both the patient and caregiver \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Additionally, research in this area showed that decreasing the treatment burden could promote the patient\u0026rsquo;s well-being and improve the patient's quality of life \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. The reduction in treatment burden can be achieved by using simplified devices or home services \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eResearch shows that the burden of treatment transcends the burden of adhering to a specific treatment to all the changes a patient must make in order to comply with the treatment recommendations \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Additionally, it can add to the difficulties experienced by the patient caused by their primary condition \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. For example, a patient who is newly identified with hearing loss has to make lifestyle changes and employ communication strategies in addition to using hearing aids for optimal communication. This, in addition to the repeated clinic visits for the adjustment of the hearing aids\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Introducing this concept in clinical settings can empower the patients to acknowledge the burden and advocate for their needs, which in turn will reduce the burden and help adherence.\u003c/p\u003e \u003cp\u003eHearing loss is a chronic health condition that affects approximately 430\u0026nbsp;million individuals worldwide\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Hearing loss prevalence in Saudi Arabia is reported to be between 1.7% and 16.8% \u003csup\u003e14\u003c/sup\u003e. Those experiencing hearing loss often feel embarrassed or frustrated by their communication difficulties, leading them to limit their social interactions \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. This isolation can result in feelings of loneliness, anxiety, and even depression, as well as fewer opportunities for effective communication\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Research has shown that the use of hearing aids can improve hearing function and positively affect overall quality of life by enhancing communication\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Despite these advantages, hearing aid usage remains low \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. The social stigma attached to hearing aids and the physical discomfort they may cause can result in a tendency to avoid wearing them or reject using them altogether. There is an increased likelihood of experiencing negative emotions right after receiving hearing aids because of the complex process of adapting to them, which involves dealing with practical obstacles and emotional challenges \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Enhancing our comprehension of the precise factors that lead to positive and negative emotional responses in situations related to hearing and hearing aids would help in the improving the clinical evaluation and counseling skills of health care providers. It would also help in refining the focus of interventions and managing expectations more effectively \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere is a need for qualitative evidence to examine the treatment burden associated with prescribing hearing aids for older adults with hearing loss. The findings from this research will inform the development of clinical practice guidelines that incorporate the perceived burden into the management and counselling of patients eligible for hearing aid fitting. Without evidence in this area, patient-centred care may be compromised, leading to decreased compliance.\u003c/p\u003e"},{"header":"Methods","content":" \u003cp\u003eThe study explored the perceived burden of treatment experienced by older adults diagnosed with hearing loss while using hearing aids following a qualitative research design. Data was collected using semi-structured interviews with older adult patients using hearing aids in King Faisal Specialists Hospital and Research Center (KFSH\u0026amp;RC). Qualitative methodology enables the exploration of patients\u0026rsquo; perspectives and experiences, providing a deeper understanding of the factors that may exacerbate their treatment burden \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The research proposal was approved by the Research Advisory Council at KFSH\u0026amp;RC (RAC#2241084) as a non-interventional study.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eStudy setting and sample\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe data collection took place at the Audiology clinic in KFSH\u0026amp;RC using convenience sampling. The recruitment targeted older adults aged 60 and above, diagnosed with hearing loss while using hearing aids. Interested participants were given an information sheet explaining the study and their role in it and any expected benefits and harms from participating. An informed consent was obtained and documented in the patient\u0026rsquo;s medical records.\u003c/p\u003e\n \u003cp\u003eEligible participants who met the criteria were invited to participate in the face-to-face interviews by research coordinators after their management has completed. The research coordinators were junior Audiologists who were trained on conducting the interviews by the principal investigator. We continued interviewing until we reached inductive thematic saturation. Thematic saturation was determined when no new codes or themes emerged\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTopic guide\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eA topic guide was developed based on the literature examining patient experiences with hearing aids \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. The topic guide was influenced by the Burden of Treatment Theory, which examines the demands placed on individuals in terms of their healthcare management, especially those with chronic conditions, such as hearing loss \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. The theory emphases the demand becomes too heavy, it can impact the quality of life and individual\u0026rsquo;s ability to adhere to treatment.\u003c/p\u003e\n \u003cp\u003eThe topic guide was developed for this study and it included questions about participants\u0026rsquo; overall experience with hearing loss and hearing aid and factors associated with facilitating or hindering the use of hearing aids. The guide also included questions on participants\u0026rsquo; suggestions on how to improve healthcare delivery to improve their experiences and reduce any unnecessary burden associated with hearing aid use. Participants had the freedom to discuss any relevant areas that was not covered by the guide. The topic guide is available in Supplementary material 1.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe interviews were audio recorded, following the participants\u0026rsquo; consent, and transcribed verbatim. Thematic analysis was used to identify and describe patterns derived from qualitative data \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. After the transcription and familiarization with all interviews, all transcripts were coded using ATLAS.ti software by the lead author (SA\u003csup\u003e1\u003c/sup\u003e). SA is a senior Audiologist with 15-year experience working with older adults using amplification. She is trained in qualitative research methodology. A sample of the data was double coded by another researcher (SA\u003csup\u003e2\u003c/sup\u003e), who is a public health researcher with expertise in qualitative research. Meetings were conducted to discuss and amend the codes as needed.\u003c/p\u003e\n \u003cp\u003eCategories were developed by grouping codes into an analytical framework, which was continuously refined through discussions with the research team. All themes and sub-themes emerged from these collaborative discussions, enhancing both rigor and reliability. The quotes presented in the findings were translated from Arabic to English by two authors, who then jointly agreed on the final translations.\u003c/p\u003e\n"},{"header":"Results","content":"\u003cp\u003eSeventeen participants, both male and female, aged 62\u0026ndash;80 (mean age of 69.4 years), participated in this study. The characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Four major themes were identified from the data (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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\u003eStudy participants\u0026rsquo; characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u0026ndash;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u0026ndash;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePure Tone Average of the better ear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 \u0026ndash; \u0026gt;90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eYears of hearing loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1\u0026ndash;4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHearing aid type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBehind The Ear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReceiver in The Canal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCustom made\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMonaural vs binaural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMonaural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBinaural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \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\u003eThemes and subthemes identified from the data.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-themes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperiencing hearing loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus; Accepting hearing loss.\u003c/p\u003e \u003cp\u003e\u0026minus; Hearing loss is a burden in itself.\u003c/p\u003e \u003cp\u003e\u0026minus; Accessibility of Hearing Healthcare Services.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarriers to effective hearing aid use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus; Hearing aid is a burden: physical, psychological and financial\u003c/p\u003e \u003cp\u003e\u0026minus; Ease of hearing aid\u003c/p\u003e \u003cp\u003e\u0026minus; Perceived limitation of hearing aids: sound quality, telephone use, technology.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitators to effective hearing aid use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus; Perceived advantages of hearing aids: audibility, social, and technological.\u003c/p\u003e \u003cp\u003e\u0026minus; Consistent use promoting acclimatization.\u003c/p\u003e \u003cp\u003e\u0026minus; Motivation and psychological readiness.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupport with hearing aids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus; Preferred support by patients\u003c/p\u003e \u003cp\u003e\u0026minus; Resistance to support with hearing aids\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003e1- \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eExperiencing hearing loss\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAccepting hearing loss:\u003c/h2\u003e \u003cp\u003e The onset of hearing loss varied among participants, but many attributed it to ageing and accepted it as a natural progression. The impact of religious beliefs was apparent in their general acceptance of hearing loss and how they coped with it as an aspect of the ageing process.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI am adapting, and I am truly grateful to Allah. I thank Allah for blessing me and for making me better off than many others. Praise Allah, who has spared us from what has afflicted many people.\u0026rdquo;\u003c/em\u003e (64 year-old, male, using a BTE HA)\u003c/p\u003e \u003cp\u003eDespite being diagnosed with hearing loss, some participants reported not experiencing significant difficulties. Some participants described employing coping strategies, such as lip-reading, positioning themselves closer to the speakers, requesting repetition, and increasing the volume on their electronic devices. When discussing their hearing loss, many participants attributed it to familial predisposition, otitis media, noise exposure, and ototoxic medications for treating other medical conditions. However, they all demonstrated acceptance of their difficulties.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eWhen you're watching TV alone, you can control it and adjust the volume as you wish.\"\u003c/em\u003e (75-year-old, male, using a bilateral RIC HA)\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eSometimes I ask him to repeat. But sometimes, thank God, like when I'm talking to you, I don't miss any words.\"\u003c/em\u003e (70-year-old, male, using a bilateral RIC HA)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eHearing loss is a burden in itself:\u003c/h3\u003e\n\u003cp\u003e Participants reported that their hearing loss significantly affected their emotional state and social interactions, with adverse effects extending to their immediate family members. They emphasized the considerable embarrassment experienced when missing parts of conversations or requesting repetition in social settings. Consistently, participants identified speech comprehension and discrimination as the primary challenges associated with hearing impairment. Additionally, some participants reported social withdrawal and avoidance of conversations in social contexts because of their condition.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWhen I felt that I could not hear well during meetings, I said to myself, \u0026lsquo;I need hearing aids.\u0026rsquo; I am an active member in family gatherings, I conduct interviews, and I need to ensure my hearing is good because it causes me embarrassment.\u0026rdquo;\u003c/em\u003e (62-year-old, male, using a RIC HA)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eAccessibility of Hearing Healthcare Services\u003c/h3\u003e\n\u003cp\u003eA recurring theme of delayed help-seeking behavior and access to care emerged from the participants' accounts. While some participants described acquiring hearing aids as challenging, others did not report such difficulties. The delay in seeking diagnosis and treatment was attributed to participants' acceptance of hearing loss as an age-related phenomenon and their reluctance to acknowledge its impact. Physicians, serving as the initial point of contact for participants seeking hearing loss management, played a crucial role in patients' decisions to pursue hearing aid fitting.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eI consulted a doctor, specifically an ear, nose, and throat specialist. He told me that I might have nerve weakness, and nerves may not have a cure except for hearing aids. I ignored the matter then, as I wasn't ready to accept the idea of wearing a hearing aid due to the negative things I had heard about them.\"\u003c/em\u003e (70-year-old, male, using a bilateral RIC HAs)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany participants expressed dissatisfaction with the quality of care received and the complex process of obtaining a diagnosis and subsequently managing it with hearing aids.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eHonestly, it took a long time to get the hearing aids\u0026mdash;it wasn\u0026rsquo;t easy at all. First, I was referred to the labor and social services office, where they gave me instructions. I couldn\u0026rsquo;t manage to navigate through the instructions. Finally, after much difficulty, I was able to get the hearing aids from you.\"\u003c/em\u003e (74-year-old, male, using a bilateral RIC HAs done twice)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eBarriers to effective hearing aid use\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eUsing hearing aids is a burden\u003c/h3\u003e\n\u003cp\u003e The participant interviews identified various burdens and challenges associated with hearing aid use. These barriers were categorized as physical, psychological, financial, and poor sound quality, among others. This highlights the complexity of adapting to hearing aid devices and the associated difficulties with such a management option.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePhysical burden\u003c/strong\u003e \u003cp\u003e Participants expressed significant physical burdens associated with wearing the hearing aids and their physical form. These issues include the discomfort caused by the size and fit of the devices in the ear. Other causes of discomfort were attributed to the itchiness and occlusion effects caused by the hearing aid. It was also noted that larger behind-the-ear aids caused physical discomfort and were more challenging to fit into the ear than the smaller in-the-ear styles. This was particularly problematic due to the frequent need to remove and fit the device during the day, especially when required after each Wudu in preparation for prayer, approximately five times daily. Some participants preferred smaller, more discreet in-the-ear models, which they perceived as less noticeable, easier to wear, and more comfortable. Furthermore, cleaning and maintaining the hearing aids was an additional burden added to the difficulty of adjusting the volume and the frequent need to replace the batteries.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\"\u003cem\u003eSometimes the hearing aid causes me ear pain\u003c/em\u003e.\" (70-year-old, male, using a bilateral RIC HA)\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eI had to remove the hearing aid multiple times due to discomfort\u003c/em\u003e.\" (66-year-old, female, using a bilateral BTE HA)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePsychological burden\u003c/strong\u003e \u003cp\u003eThe psychological burden associated with hearing-aid use emerged as a key theme. Several participants expressed a lack of readiness or reluctance to use hearing aids consistently due to personal vanity or social self-consciousness. The stigma associated with wearing hearing aids, which was viewed as a sign of ageing and handicap, was a barrier to their consistent use in some cases.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\"\u003cem\u003eFirst, the psychological barrier is very significant\u0026mdash;it's a major obstacle. I must overcome it and encourage myself to say, 'Let\u0026rsquo;s do it again.' Because I\u0026rsquo;ve had a previous experience that I wasn\u0026rsquo;t satisfied with, I feel like I have to motivate myself and say, 'Give it a chance; give yourself a second opportunity to try. Maybe I was wrong.'\u003c/em\u003e\" (73-year-old, female, using a bilateral RIC HA)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSituational use of hearing aid\u003c/strong\u003e \u003cp\u003e In many instances, participants reported that the different forms of burden associated with hearing aid use resulted in situational use of hearing aids. Participants stated being motivated to wear hearing aids only in social gatherings, as they perceived them as necessary only in those circumstances. Some participants justified their limited use by perceiving a lack of need for the devices or emphasizing that their hearing loss was not severe enough to warrant constant use.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\"\u003cem\u003eNo, no, I don\u0026rsquo;t wear them at home. I only wear them when I am out. If I am in a small group, I hear well and respond. However, I need it when I am at a party or a wedding with competing noise. It becomes necessary, so I must use it.\u003c/em\u003e'\" (70-year-old, female, using a monaural CIC HA)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFinancial burden\u003c/strong\u003e \u003cp\u003eSome participants reported the economic burden related to hearing aid use, particularly concerning the high cost of devices, batteries, and ongoing maintenance. They expressed dissatisfaction regarding the recurring cost of batteries, which required frequent replacement. Additionally, maintenance costs for repairs contributed to the financial strain. It should be noted that this burden could be amplified in groups where the cost of hearing aids falls entirely on the patient, and would be less significant in groups where the hearing aid cost is covered by the healthcare system.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\"\u003cem\u003eIf you go to the vendor, the repair costs are expensive, and the expenses for these batteries are significant\u0026mdash;they consume a lot, typically lasting only about two to three days.\"\u003c/em\u003e (63-year-old, male, using a bilateral CIC hearing aid)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eEase of hearing aid\u003c/h3\u003e\n\u003cp\u003e In contrast to the burdens experienced by some participants, others reported a relatively positive experience with hearing aids, often minimizing or negating significant challenges. For instance, several participants indicated that hearing aid batteries were easily manageable and that care and maintenance were uncomplicated. These participants also emphasized the physical ease of using hearing aids, noting that the devices were comfortable to wear and manipulate. This contrasting perspective illustrates how individual experiences with hearing aid use can vary considerably, with some perceiving minimal burden and others experiencing substantial challenges associated with their use.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eThere\u0026rsquo;s no difficulty at all\u0026mdash;I simply remove the hearing aid, place it in its case, put it back on when needed, and at night, I disconnect the battery, praise be to God, changing the hearing aid\u0026rsquo;s battery is simple; when I hear the sound indicating that the battery needs replacement, I just go ahead and replace it.\u003c/em\u003e \" (74-year-old, male, using a bilateral RIC HA, done twice)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePerceived limitations of hearing aids\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eSound quality\u003c/strong\u003e \u003cp\u003e The limitations of hearing aids, as experienced and reported by the participants, contributed to their frustration and increased their perceived burden of treatment. Poor sound quality of hearing aids was a frequently reported issue. Participants expressed dissatisfaction with the clarity of speech and discrimination, with some participants perceiving that the hearing aid did not provide adequate benefits, given the burden it posed. These frustrations were exacerbated in challenging listening environments. Their inability to engage fully in social interactions due to difficulties in hearing or following conversations with multiple speakers often resulted in frustration and a sense of social isolation. Dissatisfaction with the clarity or amplification provided by the devices led to participants choosing not to wear them regularly, instead relying on lip-reading, residual hearing, or simply avoiding situations where hearing aids would be necessary.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIf you increase the volume, it becomes noisy, and if you lower it, I do not benefit from it at all. That is the problem. You have made it too loud now, and I can feel it. My voice is becoming annoying\u0026mdash;annoying, annoying, annoying.\u0026rdquo;\u003c/em\u003e (64-year-old, male, using a BTE HA)\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eThe hearing aid sometimes buzzes a lot, and I leave it. It\u0026rsquo;s very annoying, so I remove it.\"\u003c/em\u003e (74-year-old, male, using a bilateral RIC HA)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTelephone use\u003c/strong\u003e \u003cp\u003e For telephone conversations, participants reported difficulties in hearing clearly, as the devices often fail to provide adequate amplification or clarity of speech over the phone. Due to the perceived limitations of hearing aids, participants often relied on family support to assist them in understanding speech during phone calls. Family members frequently played an integral role in facilitating communication, particularly when hearing aids struggle to provide clear amplification of telephone conversations. Similarly, while watching television, participants found that sound quality did not sufficiently enhance their viewing experience.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\"\u003cem\u003eNow, if I receive a call, I can\u0026rsquo;t answer it like that (i.e. on speaker)\u0026mdash;it would be embarrassing. If I answer, everyone hears, whether it is a family call, a friend\u0026rsquo;s call, or any other type. At home, I do not answer unless someone is nearby to listen and let me know what the person is saying. They will say, 'So-and-so is telling you this or that.' From this, I catch about 40% of the words, piecing them together like a crossword puzzle until they form a meaningful sentence\u003c/em\u003e.\" (64-year-old, male, using a BTE HA in one ear, the other CI)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTechnology\u003c/strong\u003e \u003cp\u003e Participants frequently expressed a desire for improved hearing aid technologies, particularly regarding enhancements in their connectivity to other devices. The unreliability of the wireless connection to the phone and limited control over sound quality were mentioned as areas that require attention. Furthermore, there is a common desire for devices that can more effectively address challenges such as speech comprehension and the use of disposable batteries.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\"\u003cem\u003eScience is indeed advancing, because I see that the design of hearing aids, especially the way they're placed behind the ear, still feels quite primitive. Science has progressed significantly\u0026mdash;just look at glasses, for instance; they\u0026rsquo;ve developed contact lenses, whether implanted or temporary, as an alternative.\"\u003c/em\u003e (70-year-old, male, using a bilateral RIC HA)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eFacilitators to effective hearing aid use\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePerceived advantages of hearing aids\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eAudibility\u003c/strong\u003e \u003cp\u003e During the interviews, many participants expressed satisfaction with the hearing aids despite the burden they posed. Overall, they highlighted that it improved their ability to participate in daily activities, allowing for a more active lifestyle and greater independence. The enhanced audibility and improved speech clarity significantly reduced the frustration often associated with hearing loss. Furthermore, some participants noted decreased mental load when using hearing aids. They described how reduced effort in understanding speech allowed them to engage more comfortably in social interactions. One participant linked using hearing aids to an improved quality of life and emotional well-being. For some participants, hearing and understanding religious texts, \u0026ldquo;the Quran\u0026rdquo;, was of profound importance as it enhanced their spiritual experience.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eTo be with people and hear everything being said, there are times I find myself forced to stay silent because I have not heard something I should have responded to. With a hearing aid, however, I can hear much better, and it\u0026rsquo;s definitely an improvement over not being able to hear at all\u003c/em\u003e.\u0026rdquo; (70-year-old, female, using a CIC HA)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSocial\u003c/strong\u003e \u003cp\u003eThe social benefits of hearing aids were a recurring theme. The participants reported feeling more included in social settings. They appreciated being able to follow conversations easily, reducing their feelings of isolation. The perceived benefits of using hearing aids served as a significant motivator for consistent use, and many reported that they wished they had used the hearing aids sooner, given their advantages.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\"\u003cem\u003eThe benefits of it are that it brings you closer to the community, allowing you to interact and engage in discussions and conversations with them. Previously, a person might feel somewhat isolated\u0026mdash;hearing one word while missing the others\u0026mdash;but now, by hearing everything immediately as it\u0026rsquo;s being said, you can fully follow the conversation\u003c/em\u003e.\" (69-year-old, male, using a monaural CIC HA).\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eI feel relieved, praise be to God. I now live among people as they do, listening to their conversations, sitting with others, talking to individuals, understanding their words, and truly hearing them. I am filled with gratitude toward those in charge here for their care, prompt service, and kind treatment. I pray that God rewards them. They helped me with this matter, making me feel comfortable, able to hear, and live as part of the community.\"\u003c/em\u003e (68-year-old, male, using a bilateral CIC HA).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTechnological\u003c/strong\u003e \u003cp\u003e The participants appreciated the technological advancement and acknowledged that modern hearing aids offer technological innovations that have made wearing hearing aids more convenient. Many noted that Bluetooth connectivity allowed them to connect their hearing aids to smartphones and other devices, facilitating seamless communication and enhancing their overall auditory experience.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\"\u003cem\u003eI remember having a phone prior to this one, which was wirelessly paired to my hearing aid, similar to my current device, allowing me to hear the sound clearly whenever someone called. Now, it\u0026rsquo;s especially useful for me\u0026mdash;I can enjoy programs or follow the Quran comfortably on my phone, without disturbing those around me, as I hear the sound privately and clearly.\"\u003c/em\u003e (74-year-old, male, using a bilateral RIC HAs done twice)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eConsistent use promotes acclimatization\u003c/h3\u003e\n\u003cp\u003e Through personal experiences, the participants provided insights into the importance of persistent hearing aid use and its positive effect on adaptation, which was crucial in their journey. The more they wore their devices, the better they adapted to them, the care they required, and their sound quality. Additionally, some reported on personal strategies they used to promote the correct placement of hearing aids. Overall, participants found that habituation to hearing aids was initially complicated, especially after the fitting.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eHonestly, I didn't face any difficulties except on the first day when I wore it; it felt like it was doing something to my head. After two, three, four days, I got used to it.\"\u003c/em\u003e (68-year-old, male, using a bilateral CIC HA)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMotivation and psychological readiness\u003c/h2\u003e \u003cp\u003e The participants\u0026rsquo; reports highlighted the critical role of motivation and psychological readiness in successfully using hearing aids. Their decision to pursue hearing aids was influenced by internal motivation to improve their communication and social interactions. This intrinsic motivation often stemmed from recognizing the negative impact of hearing loss on their daily functioning. Some even stated that self-motivation was key in effectively using hearing aids and overcoming their burden. Participants also noted that readiness to wear hearing aids before fitting contributed to their successful use. Factors such as acceptance of hearing loss, encouragement from family, and personal readiness significantly influenced their decision to use hearing aids.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI\u0026rsquo;m truly willing to do whatever it takes as long as it helps me adapt to people and prevents them from feeling annoyed by me repeating myself.\u0026rdquo;\u003c/em\u003e (69-year-old, male, using a CIC HA)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Physician counseling played a crucial role in shaping participants' perceptions of hearing aids. Effective counseling provided by healthcare professionals facilitated the decision-making process, as participants who felt well-informed and supported by their physicians were motivated and psychologically ready to pursue hearing aids. On the other hand, some participants were driven by misinformation from family members or their community to use hearing aids to \u0026ldquo;improve hearing\u0026rdquo; or \u0026ldquo;preserve hearing from further loss.\u0026rdquo;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"The doctor told me, 'We never force patients to use it; it depends entirely on their need.' He was excellent and explained things clearly to me.\u0026rdquo; (73-year-old, female, using a bilateral RIC HA)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSupport with hearing aids\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePreferred support by patients\u003c/h2\u003e \u003cp\u003e The participants emphasized a multifaceted approach to support, encompassing professional guidance, family involvement, and the importance of accessible communication channels. They preferred receiving support from a professional rather than their family to overcome their burden. They stated that professional support was superior, especially regarding perceived technical burden, given that they were \u0026ldquo;the expert\u0026rdquo;. They highlighted the importance of hands-on assistance from professionals in navigating the complexities of hearing aids. Direct support during initial fittings and ongoing adjustments was frequently cited as crucial in fostering user confidence and overcoming the hearing aids\u0026rsquo; burden. They stated that their needs in terms of support from professionals varied between emotional and technical.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI feel comfortable coming here to this clinic, where I can meet with specialists, assistants, nurses, or audiologists, as they understand my needs. Their explanations are clear and comprehensive, and they can also assist me with programming.\u0026rdquo;\u003c/em\u003e (64-year-old, male, using BTE HAs)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFamily involvement emerged as a vital component of the support framework. Their support started by pushing the participants to seek help in the first place, and then it encouraged them to use the hearing aids more consistently. Participants reported various forms of family support, categorizing these into emotional, technical, and motivational. Emotional support from family members, especially one\u0026rsquo;s children, was identified as a key motivator, enhancing patients\u0026rsquo; willingness to engage with their hearing aids.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eOne of my sons, in particular, is the only one who consistently follows up with me. He was with me during my audiology appointments and has always been by my side, accompanying me and ensuring that I use my hearing aids diligently.\"\u003c/em\u003e (74-year-old, male, using a bilateral RIC)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe participants noted a strong desire for increased and direct accessibility to audiologists. Delays in professional support often led to frustration and disengagement. The value of using multimodality in educating the patient was reported. Videos and other printed materials would enhance the patient\u0026rsquo;s experience and mitigate the burden experienced by the participants while using the hearing aids.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eThe audiologist, may God reward both her and you, gave me a future perspective during our first meeting. She painted a picture for me, emphasizing that everything is challenging at the beginning.\"\u003c/em\u003e (70-year-old, male, using a bilateral RIC HAs)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eResistance to support with hearing aids\u003c/h2\u003e \u003cp\u003eSome participants expressed a sense of personal resilience and emphasized their desire for independence. The desire to maintain agency and self-sufficiency frequently resulted in resisting support from family members. Their resistance to their family\u0026rsquo;s support stemmed from believing they were not the appropriate support as they were not \u0026ldquo;experts.\u0026rdquo; One participant stated that needing assistance and support with hearing aids was a burden.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI try to manage everything on my own, including my treatment. My family lacks experience, so I have to teach them, as they don\u0026rsquo;t use a hearing aid.\u0026rdquo;\u003c/em\u003e (70-year-old, male, using BTE HAs)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore the burden of treatment associated with hearing aid use among older adults with hearing loss and their experience with receiving support. Participants expressed their views on hearing loss, its burden, and the reality of hearing health services. They identified many barriers to effective use of hearing aids, including their overwhelming burden and perceived limitations. On the other hand, many subjects had a positive experience with hearing aids regarding their advantages and technology. Finally, older adults generally preferred professional support when overcoming any burdens associated with hearing loss. Findings from this study suggested that hearing aids as a treatment for hearing loss pose a significant burden on their users.\u003c/p\u003e \u003cp\u003eA key barrier to hearing aid use is the physical and psychological burden. Discomfort from device size and its fit, in addition to the perception of itchiness and occlusion caused by it, acted as a barrier. Some participants were reluctant to wear hearing aids because of vanity, self-consciousness, and the stigma associated with ageing and disability. It has been suggested that hearing aid visibility embarrasses users\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Another reason for not using hearing aids was based on the belief that they are burdensome \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Evidence from several studies indicated that hearing aid users experienced difficulty with the physical fit of the hearing device \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. They also reported discomfort, irritation, or even physical pain when wearing the aid \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, suggesting it is a common experience beyond the current study participants. Therefore, hearing aid users tend to weigh the costs and benefits of wearing the aid, and positive experiences occur when the benefits outweigh the negatives. At the same time, they may wear it reluctantly when associating the aid with negative experiences\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. There is a need to support first-time hearing aid users by emphasising the benefits of using hearing aids while recognising the challenges to ensure a positive, long-term experience. Providing peer support could help normalize the appearance of hearing aids and share difficulties and potential solutions to everyday challenges.\u003c/p\u003e \u003cp\u003eParticipants in the current study highlighted the need for a multifaceted support approach, including professional guidance, family involvement, and accessible communication. They preferred professional help over family, citing its superiority and its effectiveness in reducing the burden. On the other hand, family support included emotional, technical, and motivational support that facilitated hearing aid use. There is a balance sought when using hearing aids between having familial and professional support while also ensuring preserved autonomy and independence. Several studies suggested that receiving care from a significant other or other family members facilitated the initial experience with hearing aids \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. While some described it as primarily limited to hearing aid uptake \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e, others reported that users had better hearing aid outcomes when they perceived positive support from their significant others \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Evidence also suggested that hearing aid users and audiologists aim to reach independence by depending less on external sources of support and to value internally-based approaches \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Some hearing aid users resisted external support to maintain their autonomy and saw it as their own responsibility to look after their health \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Participants in the current study expressed a strong desire for direct access to audiologists, noting that delays caused frustration and disengagement. A direct connection with healthcare professionals using different technological tools, such as online portals, was reported as a facilitator to successful hearing aid use \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. However, building trust with healthcare professionals is crucial, as hearing aid users who do not trust their providers are more likely to disengage \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Therefore, balancing support from external sources with fostering hearing aid user independence within their capabilities is crucial. Healthcare professionals should develop a strong relationship with hearing aid users and offer a reliable tool to address their needs, especially during the initial phase of use.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eClinical care implications and future research\u003c/h2\u003e \u003cp\u003eFuture research should examine the experiences of carers of older adults with limited self-support abilities to find ways to improve their use and experience with hearing aids. It is also essential to explore the views of clinicians and policymakers on the kind and level of support that could be provided to hearing aid users and the factors influencing the level of services offered. Protocols should be established to ensure resources are available for first-time users and their caregivers, facilitating access to different types of support. Technological solutions could reduce the burden on healthcare providers without compromising the care and support provided to hearing aid users. This might include applications or virtual communication methods. The diverse needs of hearing aid users must be taken into account.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eTo our knowledge, this is the first study to use qualitative interviews to examine the burden of treatment associated with hearing aids among older adults in Saudi Arabia. We included participants with different characteristics to explore different experiences. A second, independent researcher checked the study codes. They reached an agreement through consensus, enhancing the transparency and credibility of the study interpretation \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA key limitation is that clinicians conducting interviews worked at the same clinic where patients received care. This could cause conflicts between the clinician and researcher roles \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. This is challenging for both the interviewees and the interviewers, as the patient might see these interviews as a way to receive care, or the clinician might feel responsible for addressing the patient's needs. Another concern is risking participants\u0026rsquo; autonomy because of their vulnerability as patients receiving care from interviewers \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Patients may feel pressured to participate or provide socially desirable responses. We aimed to reduce social desirability bias by carefully wording questions, avoiding leading questions and judgment, and ensuring participants' autonomy by explaining participation was voluntary and wouldn't affect care. Guaranteeing privacy and confidentiality encourages honest, private accounts. Researchers ensured their role and participant relationships were acknowledged by enhancing rigor through reflexive diaries, documenting procedures, providing evidence for interpretations, analyzing the complete data set, considering deviant cases and disconfirming data, comparing data within and between cases, and contrasting findings with other studies. Finally, the study was conducted in Riyadh, Saudi Arabia's capital. Residents of the capital city may have more advanced services than those in other regions. The hospital was chosen for its unique tertiary healthcare services, providing access to a diverse population. Results reflect participants willing to discuss their experiences, possibly underrepresenting older, more conservative adults or those with severe hearing loss, who are less inclined to share their hearing aid experiences.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study examined hearing aid burdens among older adults, highlighting barriers such as being overwhelmed and facing limitations, but also positive technological experiences. Participants reported preferring professional support over any other type of support. The findings indicate that hearing aids impose significant burdens; future research should explore the caregivers\u0026rsquo; and clinicians' perspectives on potential support levels to be provided. Future healthcare programs must ensure facilitating access to resources for users and carers, incorporating technological solutions, such as applications, to help ease healthcare providers' workload and provide a consistent channel of communication between the patients and their healthcare providers. Furthermore, the use of rechargeable hearing aids can alleviate some of the burden associated with hearing aid care and maintenance. Support should cater to the diverse needs of hearing aid users.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Research Advisory Council at KFSH\u0026amp;RC (RAC#2241084) as a non-interventional study on 17th of March, 2024. Participants gave informed consent for review and consent was documented in the patient\u0026rsquo;s medical charts. All study procedures were conducted in accord with the ethical standards of the Committee on Human Experimentation of the institution in which the study was done in accord with the Helsinki Declaration of 1975.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e:\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eDeclaration of interest \u003cstrong\u003estatement\u003c/strong\u003e:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe Authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eNo funding was received in order to complete this study.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eSarah Alageel (Conceptualization; Writing- Original Draft; Data Collection \u0026amp;amp; Curation; Formal Analysis); Hawazen Alhamdan (Writing - Review \u0026amp;amp; Editing; Formal Analysis); Azizah Bedaiwi (Writing- Original Draft; Data Collection \u0026amp;amp; Curation); Hajar Alaqil (Writing - Review; Data Collection \u0026amp;amp; Curation); Samah Alageel. (Conceptualization; Methodology; Writing - Review \u0026amp;amp; Editing; Formal Analysis).\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors express their gratitude to all the participants for their involvement and taking the time to partake in the interviews.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publically available due to lack of consent to share raw material, but parts of the material can be available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEton DT, Ramalho de Oliveira D, Egginton JS et al. Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study. 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Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness. BMC Health Serv Res. 2014;14(1):281.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Res sport Exerc health. 2019;11(4):589\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRitter CR, Barker BA, Scharp KM. Using attribution theory to explore the reasons adults with hearing loss do not use their hearing aids. PLoS ONE. 2020;15(9):e0238468.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaplante-L\u0026eacute;vesque A, Jensen LD, Dawes P, Nielsen C. Optimal hearing aid use: Focus groups with hearing aid clients and audiologists. Ear Hear. 2013;34(2):193\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHickson L, Meyer C, Lovelock K, Lampert M, Khan A. Factors associated with success with hearing aids in older adults. Int J Audiol. 2014;53(sup1):S18\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBennett RJ, Barr C, Cortis A, et al. Audiological approaches to address the psychosocial needs of adults with hearing loss: perceived benefit and likelihood of use. Int J Audiol. 2021;60(sup2):12\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaquette SR, Borges da Matta Souza LM. Ethical dilemmas in qualitative research: A critical literature review. Int J Qualitative Methods. 2022;21:16094069221078731.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hearing loss, hearing aid, burden of treatment, support.","lastPublishedDoi":"10.21203/rs.3.rs-8773833/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8773833/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTreatment burden can affect patients\u0026rsquo; ability to carry out tasks or follow recommendations from healthcare providers. Evaluating the burden associated with using and maintaining hearing aids can help identify factors affecting patient compliance. This study also examined the support that older adults receive and prefer to overcome this burden. This enables healthcare providers to understand the burden better and promote improved adherence to hearing aid use among older adults.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative study using semi-structured interviews with older adults recruited from the Audiology Clinic at King Faisal Specialist Hospital and Research Center (KFSH\u0026amp;RC). Participants were diagnosed with hearing loss and were using hearing aids. Data collection was continued until thematic saturation was reached. The data was analyzed using a thematic analysis method.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThis study included 17 participants aged 62\u0026ndash;80 years. Four main themes were identified from the interviews: experiencing hearing loss, barriers to hearing aid use, facilitators to hearing aid use, and support needs. The subtheme highlighted the burden associated with hearing loss and hearing aid use; physical, psychological and financial burdens were cited in addition to the perceived limitation of hearing aid use. On the other hand, the perceived benefit of hearing aids in terms of audibility and promoting social engagement was identified as a facilitator to effective use of hearing aids as they act as motivators. Consistent use of hearing aids was found to help in acclimatization. Support from professionals for hearing aid use is preferred over family to promote autonomy. Findings highlight the need for individualized support, improved device features, and accessible hearing healthcare to enhance hearing aid adoption and user satisfaction in older adults.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur research has identified several factors that affect adherence to hearing aid use in older adults. The identified barriers included physical, psychological and financial burden. Difficulty of hearing aid use and care was cited as a burden that can limit the hearing aid use. The study highlighted the need for improved support and counseling in hearing healthcare. Furthermore, the study showed the need for improved hearing aid technology and for providing accessible and direct communication channels with their healthcare providers. The hearing aid users in our study preferred support from their healthcare providers over their family.\u003c/p\u003e","manuscriptTitle":"Burden of treatment associated with hearing aid use among older adults with hearing loss: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-16 19:51:00","doi":"10.21203/rs.3.rs-8773833/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-15T15:45:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T22:09:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T04:19:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35477785238845195652099166797249267788","date":"2026-03-26T04:05:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66047659617051276985491559527270490696","date":"2026-03-23T18:46:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-12T07:15:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-09T07:51:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-16T13:14:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-15T09:20:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2026-02-15T09:16:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f479c7fe-9f04-46f5-9bc2-97aa517d4bc1","owner":[],"postedDate":"March 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T15:55:08+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-16 19:51:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8773833","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8773833","identity":"rs-8773833","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}