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UNSAF
Personal, social and
economic consequences
of hearing loss
Kim Ruberg
Secretary General
Hear-It AISBL
Aims of project
 To carry out wide review of literature on effects of hearing
impairment including
prevalence of hearing impairment in Europe
psychosocial effects of hearing impairment
use of hearing aids
costs of hearing impairment
 To estimate current costs to Europe of untreated hearing
impairment
Scope of project
 Hearing impaired adults only
 Hearing impairment that would benefit from hearing aids
eg not tinnitus
 Definitions of Europe
European Union (25 member states)
Continent of Europe (not Russia, Turkey, includes Ukraine)
The Bridget Shield report at a glance
 Hearing loss is much more prevalent and damaging
to individuals and society and the benefits from
proper treatment are much greater than previously
believed.
 The cost to society of untreated hearing loss is a
staggering 215 billion euro a year for all of Europe
and 170 billion euro a year for the countries of the
European Union.
 The most comprehensive scientific empirical study
ever performed of the consequences of hearing loss.
Prevalence of HL in Europe
Data from studies of the prevalence of HL in several
European countries have been reanalysed to
estimate the current prevalence of different grades of
HL in Europe
BEHL
% pop
Mild
21-39
16.9
Moderate
40-69
4.6
Severe
70-94
0.7
Profound
>94
0.2
May be underestimates owing to upper age limits of
75 and 80 in studies considered
Psychosocial effects of hearing loss
Hearing loss causes
loneliness/social isolation
psychiatric
disturbance/depression
low self esteem
employment difficulties
memory loss
prejudice/abuse
Hearing loss affects
overall quality of life
family relationships
education
general health
visiting doctor
social life
going to restaurants, theatres,
church etc
Hearing loss reduces overall quality of life
Difference hearing impaired or not
60
With > 70dB HI
50
40
% 30
20
10
0
Psychiatric
disturbance
Health problems
Significant differences between
hearing impaired and control groups
(Thomas and Herbst, 1980)
Loneliness
Social isolation Difficulty making
friends
Hearing Impaired
Control Group
Lack of
emotional
support
Left out of family
life
Satisfaction with life
40
35
30
25
% 20
15
10
5
0
Life as a whole
Health/physical
condition
Financial situation
With hearing loss
Friendships
Without hearing loss
Family life
Handling of problems
Retirement
70
60
50
40
%
30
20
10
0
Completely retired
Table 5.3 Percentages of adults
aged 51 to 61 concerned w ith
various aspects of retirement
Poor health a factor in deciding to
retire
With hearing loss
Wanted to retire
Without hearing loss
Satisfaction with retirement
Labour Market
80
70
60
50
% 40
30
20
10
0
18-44
Table 5.1 Comparison of labour participation
rate in severe to profoundly hearing
impaired
and non-hearing impaired [11]
45-64
Severe to profound HL
65 and over
Non-hearing impaired
Impact of hearing aids on quality of life
Results of many studies over past 25 years










Greater self confidence and higher self-esteem
Reduced deterioration in psychological functioning
Reduction in physical health difficulties
Psychosocial improvements
Greater satisfaction with life and less depression
Benefits in social life, group activities,family relationships
Satisfaction higher with greater hearing loss/does not depend on age
Better emotional life
Better cognitive functioning
Greater overall health status
Improvements occur in first few weeks after fitting
Milder Loss
50
45
40
35
30
% 25
20
15
10
5
0
Sad or
depressed
Worried or Participation Participation
anxious
in social
in senior
activities
centre
activities
Users
Non-users
Paranoia
Insecure
More Severe Loss
45
40
35
30
25
%
20
15
10
5
0
Sad or
depressed
Worried or Participation Participation
anxious
in social
in senior
activities
centre
activities
Users
Non-users
Paranoia
Insecure
Improvement from HA - Milder
60
50
40
% 30
20
10
0
Re
la
tio
ns
Fe
eli
ng
hip
s
at
Lif
sa
ho
me
bo
ut
eo
ve
se
lf
Se
lf
r al
l
-co
nfi
d
Re
la
en
ce
tio
ns
Wi
ll in
wi
th
ch
gt
op
ild
re
Ab
ili ty
art
ic
ipa
na
Users
to
nd
te
gra
n
So
c
pla
in
dc
Family
ial
yc
gr o
hil
dr
ar d
up
a
en
life
/bo
ar d
cti
vit
ies
De
p
ga
en
de
me
s
Re
la
nc
tio
eo
no
ns
th e
rs
at
wo
rk
Improvement from HA - More Severe Loss
70
60
50
40
%
30
20
10
0
Re
lat
Fe
ion
sh
eli
ips
at
Lif
ng
sa
bo
ho
me
Se
lf
eo
ut
ve
ra
ll
se
lf
Re
-co
nfi
W
lat
de
nc
e
illin
ion
gt
sw
ith
Ab
ility
op
art
ch
ild
re
na
icip
nd
to
ate
gra
pla
in
nd
So
cia
l
yc
ard
gro
up
ch
ild
re
Family
pe
life
nd
ard
ac
Re
lat
en
ce
o
ion
sa
tw
ork
no
the
/bo
n
Users
De
tiv
ga
me
itie
s
s
rs
Evaluation of costs of hearing loss
Method
 Review of previous studies
 Selection of method
 Determination of values of required data
 Calculations
Cost effectiveness of cochlear implants
 Uses ‘cost utility analysis’
method of evaluating cost effectiveness of medical
interventions
 Based upon ‘health utility index’ and ‘quality
adjusted life year’ (QALY)
 Health utility index: number between 0 and 1
1 corresponds to full health, 0 to death
 Average value of HUI for adult in Europe is 0.85
(Sorri et al, 2001)
Cost effectiveness of cochlear implants
Meta analysis of nine previous studies
(Cheng and Niparko, 1999)
 All studies assigned health utility values to
profoundly deaf adults with and without cochlear
implants
 Results of all studies very consistent
Profound deafness (no CI)
With cochlear implant
Mean HUI
0.54
0.8
Evaluation of hearing loss in Europe
Quality of life approach
Data required
Numbers of hearing impaired people in Europe
Numbers of people who would benefit from hearing aids
but do not have them
Quality of life value for each degree of hearing loss
Monetary value associated with full quality of life year
Prevalence of HL in Europe
Assumed prevalence in Europe
BEHL
% pop
Mild
21-39
16.9
Moderate
40-69
4.6
Severe
70-94
0.7
Profound
>94
0.2
Population of Europe (millions)
European Union
Rest of Europe
Whole of Europe
Total
457
122
579
Adult
355
95
450
Prevalence of HL in Europe
Estimates of numbers of HI adults in Europe who would
benefit from hearing aids (ie BEHL >= 25 dB) (millions)
European Union
Rest of Europe
Whole of Europe
Mild
37
10
47
Moderate Severe
16.3
2.5
4.4
0.7
20.7
3.2
Profound
0.7
0.2
0.9
Evaluation using QoL approach
 Need to assign HUI to degrees of HL
Profound deafness (no CI)
With cochlear implant
Average adult
0.54
0.8
0.85
Following values have been assumed:
Health Utility Index
Mild
0.8
Moderate Severe
0.7
0.6
Profound
0.55
Loss in HUI due to HL
Mild
0.05
Moderate Severe
0.15
0.25
Profound
0.3
Evaluation using QoL approach
 Need to assign value to full quality life year
European Commission value (2003)
44,000 euros
•Annual cost of hearing impairment per person:
Loss in HUI due to HL
Cost in euros
Mild
0.05
2,200
Moderate
0.15
6,600
Severe
0.25
11,000
Profound
0.3
13,200
Evaluation using QoL approach
Total costs
(Millions of euros)
European Union
Rest of Europe
Whole of Europe
Mild Moderate Severe Profound
81,000
108,000 27,000
9,000
22,000
29,000
7,000
3,000
103,000 137,000 35,000
12,000
Overall costs (billions of euros)
European Union
Rest of Europe
Whole of Europe
226
60
286
Evaluation using QoL approach
Costs of unaided hearing impairment
(billions of euros)
Assuming 1 in 4 hearing impaired people use aid
European Union
Rest of Europe
Whole of Europe
170
45
215
NB - underestimate as even if 1 in 4 own an aid, fewer will use one
Conclusion
Using this method
Cost to European Union of hearing loss is
between 170 and 226 billion euros annually
Cost to whole of Europe of hearing loss is
between 215 and 286 billion euros annually
Annual cost € pr. person
400
Australia
2006
Hear-It
2006
350
300
250
Euro 200
150
100
50
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Societal costs of severe to profound hearing loss
600.000
500.000
400.000
1998
300.000
US $
200.000
100.000
0
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MS
Untreated Hearing Loss Costs
France 19-25 Billion Euro per Year
 Untreated hearing loss costs France 19-25 billion euros per
year, according to a new, previously undisclosed multinational
scientific report, ”Evaluation of the Social and Economic Costs
of Hearing Impairment”. This equals 350-400 euros per year for
each person in France.
 16% of all adult French, more than 7,5 million people, suffer
from a hearing loss of more than 25 dB, the definition of hearing
loss recognised by the World Health Organisation, WHO.
People with a hearing loss of more than 25 dB generally have
daily problems caused by their hearing loss. Yet, fewer than one
in six of those who could benefit from using hearing aids are
being treated adequately
New international scientific report shows:
More than 7.5 Million Hearing Impaired
in France
 Just a small minority of those in need use hearing aids
even though hearing aids can ensure employment and
improve quality of life.
 16% of all adult French citizens, more than 7.5 million people,
suffer from a hearing loss of more than 25 dB, the definition of
hearing impairment recognised by the World Health
Organisation, WHO. People with a hearing loss of more than 25
dB generally have daily problems caused by their hearing loss.
At work conversations with colleagues, and the concentration
needed for communication during the day demand much energy,
potentially affecting both mood and work efficiency. Untreated
hearing loss may also affect your social and family life, lower
your quality of life and cause mental anguish.
What to do about it
 We try to document and persuade
 Document – that life quality is reduced drastically if
you have a hearing loss
 Document – that treating your hearing loss drastically
increases your quality of life
 Document – that a hearing loss decreases your
productivity and your income
 Document – that this loss in productivity and income
is reduced by treating your hearing loss.
 Document – that proper intervention against hearing
loss is one of the best investments for any society.
UNSAF
Personal, social and
economic consequences
of hearing loss
Kim Ruberg
Secretary General
Hear-It AISBL
Help us (and yourself):
State the facts loudly
 - The costs of untreated hearing are so high economically to
society and in terms of personal consequences for so many
individuals that we must take this problem seriously, on the
individual level and as a society.
 - With 16 % of all adults suffering from hearing loss, we all have
to be more aware of the problem and talk about it without
prejudices. In particular, I find it extremely important that family
doctors generally must be more focused on potential hearing
loss in individual patients.
 - Typically, the closest family members are most deeply affected
when a person has a hearing loss. Conversations become
shorter, less frequent, less spontaneous and less personal. They
sense a loss of intimacy, withdrawal and changed personality.
Help us (and yourself):
State the facts loudly
 - As a family member of a hearing impaired individual you can
do a lot to help. Most often relatives are the ones to first
discover when someone may have a hearing loss. Family
members must be supportive, understanding and helpful and
approach the situation in a gentle way. The hearing impaired
individual may be unaware of the problem and sensitive to the
idea of having a hearing loss.
 - Family members are those most affected by someone’s
hearing loss, with the exception of the hearing impaired person.
Conversely, family members enjoy the greatest benefits when
the hearing loss is treated.
 - Hearing tests should be a natural and integrated part of getting
a health check at the family doctor for anyone aged 40 years or
older.
Help us (and yourself):
State the facts loudly
 - About half of all hearing impaired people are of working age or
younger. The major reason for this is that hearing impairment
occurs earlier and earlier in life, most likely because of our
increased exposure to loud music noise.
 - We all loose our hearing sooner or later. Hearing loss is a
natural consequence of getting older. But more and more loose
their hearing early in life because of exposure to loud music or
other excessive noise.
 - Today’s digital hearing aids are placed either inside or
discreetly behind the ear. Digital hearing aids make all the
difference in the quality of life for many hearing impaired people.
 - Hearing aids take time getting used to, like bifocal glasses.
The longer you use your hearing aids the better you’ll like them.
BSHAA
Personal, social and
economic consequences
of hearing loss
Kim Ruberg
Secretary General
Hear-It AISBL
BSHAA
Kim Ruberg
Secretary General
Hear-It AISBL
Evaluation of costs of hearing loss
Review
 Very few relevant previous studies
 None directly applicable
 Many studies on cost effectiveness of
cochlear implants
Previous studies
Societal costs of moderate hearing impairment
‘The Maastricht study’ (Joore et al, 2003)
 Netherlands
 80 subjects, 10 in paid employment
 Considered factors which have economic impact
health related quality of life
social functioning
productivity in paid and unpaid labour
use of medical services
 Concluded hearing aids are highly cost effective
Quality of life increases significantly with hearing aids
Previous studies
The costs of communication disorders
(USA, Ruben, 2001)
 Considered losses to economy of unemployment and
underemployment of people with communication disorders
hearing
voice
speech and language
 Results translated into monetary values
 Annual costs to US economy: $154 to $186 billion
Previous studies
Societal costs of severe to profound hearing loss
(USA, Mohr et al, 2003)
 Very comprehensive study
 Calculate lifetime costs of an individual
medical costs associated with hearing loss
special education and rehabilitation
productivity costs (reduced earnings over lifetime)
 Largest component is reduced productivity
 Average cost to society over lifetime of individual is
$297,000
 But no account taken of psychosocial effects
Previous studies
Societal costs of severe to
profound hearing loss
(Mohr et al, 2003)
Condition
1998 US$
Accidents with fireams
89,100
Near drowning
98,500
Strokes
129,200
Rheumatoid arthritis (25 yrs)
130,500
Epilepsy (frequent seizures)
172,900
Schizophrenia
295,000
Severe to profound hearing loss
297,000
Family with member with MS
593,000
Previous studies
Societal costs of severe to
profound hearing loss
(Mohr et al, 2003)
Condition
1998 US$
Accidents with fireams
89,100
Near drowning
98,500
Strokes
129,200
Rheumatoid arthritis (25 yrs)
130,500
Epilepsy (frequent seizures)
172,900
Schizophrenia
295,000
Severe to profound hearing loss
297,000
Family with member with MS
593,000
Previous studies
Costs to UK of new EC Noise at Work
Regulations (Health and Safety Executive, 2003)
(UK Government body responsible for health and safety at
work, in transport etc)
 Used ‘quality of life’ approach in evaluating NIHL
 Quantified reduction in quality of life (QoL) associated with
degree of hearing loss
 Converted reduction in QoL to monetary value assuming
one full quality life year has value of £42,000 (standard UK
value)
 Calculated value of hearing loss over remaining working
life
Challenge to old beliefs
 Many more people than previously believed are hearing
impaired.
 Hearing impairment generally affects people at a
younger age than previously assumed.
 Hearing loss reduces the quality of life much more than
previously assumed.
 Hearing loss has a much stronger negative impact on
family life than previously assumed.
 Hearing loss makes many more people than previously
assumed retire early from the workforce.
 Hearing loss costs society much more than previously
assumed.
Challenge to old beliefs
 Proper intervention against hearing loss benefits hearing
impaired people much more than previously believed.
 Proper intervention against hearing loss benefits families
of hearing impaired people much more than previously
assumed.
 Proper intervention against hearing loss keeps hearing
impaired people on the workforce much longer than
previously assumed.
 Proper intervention against hearing loss benefits society
much more than previously assumed, economically as
well as socially
Satisfaction with life
Table 5.2 Percentages of adults aged 51 to 61 dissatisfied with various aspects of life
With hearing loss
Without hearing loss
Life as a whole
9
4
Health/physical condition
28
12
Financial situation
37
22
Friendships
6
3
Family life
7
3
Handling of problems
9
4
Difference hearing impaired or not
Table 3.1 Significant differences between hearing impaired and control groups
(Thomas and Herbst, 1980)
Category of effect
Hearing
impaired %
Control
group %
Psychiatric disturbance
19
57*
5**
Health problems
28
13
Loneliness
24
14
Social isolation
40
25
Difficulty making friends
40
15
Lack of emotional support
45
26
Left out of family life
27
12
** Figure for the general population, not the control group
* Refers to those with >70 dB HL and speech discrimination < 70%
Labour market
Table 5.1 Comparison of labour participation rate in severe to profoundly
hearing impaired and non-hearing impaired [11]
Age
Severe to profoundly hearing
impaired
Non-hearing impaired
Number
Percentage
Number
Percentage
18-44
149
59
97737
77
45-64
273
49
45299
68
65 and over
851
7
28443
13
Retirement
Table 5.3 Percentages of adults aged 51 to 61 concerned with various aspects of retirement
With hearing loss
Without hearing loss
Completely retired
18
12
Poor health a factor in
deciding to retire
70
44
Wanted to retire
23
42
Satisfaction with retirement
29
42
Users – non users
Table 5.4 Percentages of respondents involved in social activities or
experiencing negative emotions [15]
Milder loss
More severe loss
Users
Non-users Users
Nonusers
Sad or depressed
14
23
22
30
Worried or anxious
7
12
12
17
Participation in social
activities
47
37
42
32
Participation in senior
centre activities
24
15
21
16
Paranoia
13
24
14
36
Insecure
8
10
11
17
Effects of HL and use of HA
Table 5.4 Percentages of respondents involved in social activities or experiencing negative emotions [15]
Sad or depressed
Milder loss
More severe loss
Users
Users
Nonusers
Nonusers
14
23
22
30
7
12
12
17
Participation in social
activities
47
37
42
32
Participation in senior
centre activities
24
15
21
16
Paranoia
13
24
14
36
Insecure
8
10
11
17
Worried or anxious
Table 6.2. Percentages of users and family members reporting improvements from using hearing aids
Percentages reporting improvement
All
Milder loss
More severe loss
Users
Family
Users
Family
Users
Family
Relationships at home
56
66
44
59
60
68
Feelings about self
50
60
40
54
53
61
Life overall
48
62
33
53
53
64
Mental health
36
39
29
37
38
35
Self-confidence
39
46
28
35
42
48
Relations with children and
grandchildren
40
52
28
44
43
53
Willing to participate in
group activities
34
44
23
33
37
47
Sense of independence
34
39
27
30
36
41
Sense of safety
34
37
25
32
37
38
Ability to play card/board
games
31
47
25
39
33
49
Social life
34
41
27
28
36
45
Physical health
21
24
21
21
21
25
Dependence on others
22
31
17
26
24
32
Relations at work
26
43
19
37
28
45
Ability to play sports
7
10
8
11
7
9
Sex life
8
N/A
4
N/A
9
N/A
Previous studies
Costs to UK of new EC Noise at Work Regulations
(Health and Safety Executive, 2003)
Value of hearing loss based upon value of
£42,000 for full quality life year
Hearing loss (dB)
50
30
20 to 30
15 to 20
10 to 15
<10
Reduction in QoL
10%
5%
2.50%
1%
0.25%
0%
Value (£)
4,200
2,100
1,050
420
105
0
Previous studies
Costs to UK of new EC Noise at Work Regulations
(Health and Safety Executive, 2003)
Value of hearing loss over remaining working life
Hearing loss (dB)
50
30
20 to 30
15 to 20
10 to 15
<10
Value (£)
96,000
48,000
24,000
9,600
2,400
0
Definitions of grades of deafness
WHO
EC
ANSI
RNID
BSA
None
< = 25
< = 20
< = 26
Mild
26 - 40
21 - 39
27 - 40
25 - 39
20 - 40
Moderate Mod-sev
41 - 60
40 - 69
41 - 55
56 - 70
40 - 69
41 - 70
Severe
61 - 80
70 - 94
71 - 90
70 - 94
71 - 95
Profound
Above 80
95 & above
Above 90
95 & above
Above 95
• Note differences between organisations
• ‘normal’ hearing: BEHL of up to 20 dB or up to 26 dB
• Differences of up to 14 dB HL in definition of severe/profound HL
• In evaluating costs, only those with BEHL >= 25 dB considered
Users - non users Milder Loss
50
45
40
35
30
% 25
20
15
10
5
0
Sad or depressed
Worried or anxious
Table 5.4 Percentages of respondents involved in
social activities or experiencing negative emotions [15]
Participation in social Participation in senior
activities
centre activities
Users
Non-users
Paranoia
Insecure
Users - non-users More Severe Loss
45
40
35
30
%
25
20
15
10
5
0
Sad or depressed
Worried or anxious
Table 5.4 Percentages of respondents involved in
social activities or experiencing negative emotions [15 ]
Participation in social
activities
Users
Participation in senior
centre activities
Non-users
Paranoia
Insecure
Evaluation of costs of hearing loss
Different approaches
 Direct calculation of costs
 ‘Quality of Life’ approach
uses ‘health utility index’
standard method used for evaluating cost effectiveness
of various medical interventions
 Combination of above methods
Prevalence of HL in Europe
Estimates of numbers of hearing impaired
adults in Europe (millions)
European Union
Rest of Europe
Whole of Europe
Mild
60
16
76
Moderate Severe
16.3
2.5
4.4
0.7
20.7
3.2
Profound
0.7
0.2
0.9
Evaluation of costs of hearing loss
Health utility index
 Health utility index: number between 0 and 1
1 corresponds to full health
0 corresponds to death
subjective evaluation of quality of life
 A ‘quality adjusted life year’ (QALY) is the
‘value’ of a year of full health adjusted by the
health utility index
Why people don’t say YES
TABLE 6.1. PERCENTAGES OF NON-USERS OF HEARING AIDS CITING VARIOUS REASONS FOR NON-USE [1]
Type of loss
Type of
reason
Denial
Consumer
concerns
Stigma/
vanity
All
More severe
Milder
Hearing not bad enough
69
64
73
Can manage without
68
55
78
Too expensive
55
64
48
Won’t help my problem
33
36
31
They don’t work well
28
31
26
Mistrust hearing specialists
25
29
22
Tried, didn’t work
17
20
15
Make me feel old
20
22
18
Don’t like way they look
19
21
18
Embarrassment
18
21
16
Don’t like what others think
16
19
15
Ownership of hearing aids
Percentages of population wearing hearing aids in Northern
Europe (Sorri et al, 2001)
Denmark
Finland
Norway
Sweden
UK
3.4
1
2.4
2.3
3.5
Ownership of hearing aids
Percentages of population wearing hearing aids in Northern
Europe (Sorri, 2001)
Denmark
Finland
Norway
Sweden
UK
Average
3.4
1
2.4
2.3
3.5
2.5
In Europe only about 1 in 4 of people who could
benefit from using a hearing aid have one
Improvement from HA - All
70
60
50
40
%
30
20
10
0
Re
lat
ion
sh
Fe
ips
eli
at
Lif
ng
ho
sa
me
bo
ut
Se
lf
eo
ve
ra
ll
se
lf
-co
Re
nfi
W
l at
de
nc
e
ion
sw
ith
illin
gt
op
ch
ild
re
Ab
ility
art
na
icip
nd
to
ate
gra
pla
in
nd
So
cia
l
yc
ard
gr o
up
ch
ild
re
n
Users
Family
De
pe
life
/bo
ac
nd
en
Re
lat
ion
ce
o
sa
tw
ork
no
ard
tiv
it
the
ga
m
i es
es
rs
- and then what
 Hear-It makes our data available to ALL
interested parties sharing our objectives
 Hear-It assists in building national or regional
campaigns
 - let’s look at some possibilities
3 reasons why people don’t say YES
Hearing not bad enough
Too expensive/
won’t help
Make me feel/look old
Evaluation of the social and
economic costs of hearing
loss in Europe
Bridget Shield
Professor of Acoustics
London South Bank University