Discussion
Results from the current study highlight the heterogeneity of HL and HA use prevalence by age and gender among a diverse group of countries. Though results are wide-ranging, several patterns emerge. The four countries with the highest reported levels of HL (China, South Korea, Mexico and Brazil) are also those with the lowest reported HA use. While men are more likely to report HL in nearly all countries, China and South Korea stand out for their lack of gender differences. In contrast, men in the USA, Northern Europe and Western Europe are most likely to report HL relative to women. In most regions, gender differences in HL decrease with age, as HL increases. Similar to HL, HA use increases with age in most countries (with the notable exception of South Africa, where use decreases with age). Together, our results underscore the wide-ranging contribution of country and gender contexts in producing self-reports of HL and HA use. Large international variation in prevalence, and gender differences therein, suggests complex processes at play.
Prevalence
The wide range in self-reported HL, from 17% in South Africa to 65% in China, suggests complex interactions between a country’s structural factors, like medical and educational systems, and a host of socio-cultural elements, such as beliefs around stigma, disability and gender norms. The role of structural systems may be especially pertinent for LMICs, whose health systems are still developing and where specialty services, such as audiology, have only been recently established (audiology is still not a recognised profession in China).56 For example, in South Africa, the public health system is underfunded and overburdened, so individuals have difficulty accessing affordable services and may delay seeking help or turn to expensive private care as a last resort.57
To understand the high prevalence of self-reported HL in China and South Korea (consistent with previous research16 58), it may be useful to consider a cultural perspective. For example, research has shown that HL can be viewed as a sign of divine punishment59 60 or a penalty for past sins.61 In China’s Confucian tradition, disability is viewed as disorderly, irregular and improper, while the Buddhist doctrine of karma can lead disability to be viewed as a punishment for past sins.62 While we might expect that this stigma associated with HL would lead individuals to self-report better hearing, it may be that people underreport their condition to healthcare professionals but are more willing to acknowledge it on anonymous surveys.
Another possible explanation is that cultural differences in the role of the family may influence older adults’ willingness to acknowledge their HL. For example, prior research has shown that Hispanic individuals reap health benefits from their family-centred culture, which can buffer older adults against loneliness and stress.63 64 Strong family bonds and an emphasis on mutual care might make older adults more open about their health conditions.65
The countries examined in the current study represent a mix of healthcare systems. Although differing financial barriers appear to explain some disparities in HL use within countries, pinpointing the correlation between access and uptake at the international level is complicated. We find that even in countries with complete or near-complete insurance coverage (eg, Western Europe, Northern Europe), HA uptake remains well below 100%, suggesting that financial access can only tell some of the story. For example, in Iceland, HAs are fully covered by the national insurance programme, yet only 23% of eligible Icelandic men and 16% of eligible Icelandic women use HAs.66 Brazil also offers full coverage of basic HAs,67 yet we find extremely low usage. China covers the cost of older adults’ access,68 yet we find no increasing use with age. Covered devices may not be of good enough quality,68 or reasons for non-use may be unrelated. In South Korea, where we also found low usage, the number one reason for non-use among hard-of-hearing adults was the feeling that hearing levels are adequate, followed distantly by the inability to afford an HA and the perception that HAs are uncomfortable.69
In addition to reflecting variation in access to HAs, the low prevalence of HA use in many countries (particularly in China and South Korea) may reflect cultural differences in the perception of ageing. For example, in Chinese culture, the values of filial piety and veneration for the old may lead older Chinese adults to believe that since HL is a natural part of the ageing process, those around them should adapt rather than expect the older adult to change or seek help for their HL.56 Moreover, older adults who rely on traditional medicine have noted a preference for a cure for HL over HA adoption and therefore tend to opt for alternative treatments, including Chinese medicine or acupuncture, instead of seeking HAs.56
Of course, we cannot ignore the possibility that linguistic differences across surveys may lead to data artefacts. Online supplemental appendix VIII shows the detailed distribution of hearing-status responses across surveys. Of note, nearly half of respondents in China’s CHARLS survey reported ‘fair’ hearing, more than in any other survey. Because our study, consistent with previous research on self-reported hearing in China,58 classifies both fair and poor hearing as hearing loss, China’s high levels of self-reported hearing loss may be due to translation issues between English and Chinese, such as for the Chinese character used for ‘fair’. The possibility of China’s high prevalence actually being a data artefact (and how to best address that in international comparisons) is an important question for future research.
Gender differences
Our findings are broadly consistent with prior research showing that men have a greater prevalence of HL compared with women in the USA,19 20 Europe,21 Mexico,16 Brazil70 and Costa Rica.71 Gender differences in HL tend to diminish with age, possibly reflecting earlier onset of HL for men.72 In contrast, we find little to no gender differences in HL in South Africa, China and South Korea. Data on HL prevalence is particularly limited in South Africa, but prior evidence suggests a lack of gender differences.73
Our results conflict with studies using objective measures of HL that have shown a greater prevalence of HL in men compared with women in China74 75 and South Korea.76 However, a study using self-reported HL data also found no significant gender difference in HL in South Korea,16 and another using objective measures found that while being a man was associated with the incidence of HL, it was not associated with deterioration of hearing over time.77
Our finding that women in high HA-use countries (like the USA and parts of Europe) tend to be heavier HA-users than men at younger ages highlights the importance of conducting research at the intersection of age, gender and hearing status. Research on the role of age for ‘the hearing aid effect’, or associating negative attributes to people who wear HAs,78 has yielded inconsistent results. One study using picture rating tasks to measure how participants perceive individuals who wear HAs found that both children and adults perceived children wearing HAs to be less athletic, confident or healthy,79 while another study did not find significant HA effects for perceived attractiveness, intelligence or age by participant age group (older adult mean age 70 years, younger adult mean age 23 years).80
Moreover, a research study on women in three age groups (34–45; 55–65; 75–85) with age-normal hearing found that younger women held more negative perceptions (greater stigma) toward HA use than older women.81 Other research has shown that women in the USA tend to seek help earlier after perceiving a hearing problem,82 are more likely to disclose a diagnosed HL to peers83 and adopt HAs sooner after candidacy than men,84 consistent with our finding that younger US women are more likely HA-users.
While we find that women in countries with relatively high HA use tend to adopt HAs earlier than men, men in low HA use regions such as China, South Korea and South Africa tend to be the predominant HA users at all ages. It is possible that this pattern of results reflects known gender disparities in access to information and technology.85 This disparity is particularly evident in healthcare, where men are more likely to benefit from advanced medical treatments and technologies sooner than women. For example, women in China receive advanced cardiac treatments and interventions less frequently than men,86 and men are often prioritised for newer and more effective diagnostic tools.87 In South Korea, older men tend to have higher digital literacy compared with older women, which makes men more adept at adopting new technologies.88 In South Africa, the fragmented and uncoordinated science and technology system, inherited from the apartheid era, has had an impact on the equitable distribution of technological advancement, with women being underrepresented in science and technology fields and having less access to new technologies.89 South Africa also stands out as the only country in which younger adults are more likely than their older counterparts to report using HAs, possibly suggesting disuse among older adults previously fitted with an HA.90
Strengths and limitations
This study has several strengths, including its wide coverage of countries from different regions and income levels, allowing us to identify patterns both within and between many different contexts. Additionally, focusing on cross-national gender differences adds a novel perspective to existing literature on HL and HA use and highlights the importance of considering cultural and structural factors in hearing health.
However, findings from the current study should be considered in light of several limitations. First, hearing function and HA use were self-reported measures. While pure-tone audiometry is considered the gold standard for clinically assessing hearing sensitivity,91 research also indicates that it may not fully capture the real-world experience of hearing disability.92 This is particularly evident in situations involving an individual’s reported listening comprehension during group conversations93 or in noisy environments.94 Moreover, self-reported data on hearing have been identified as one means for assessing disease burden in regions with insufficient access to audiometric technologies and audiologists.14 15 Finally, a meta-analysis suggests that though findings using self-reported data were more heterogenous than audiometric studies, effect sizes between the groups were similar.95
Second, while our study encompasses a diverse array of countries, it is limited to those classified as upper middle-income to high-income. Consequently, we are unable to extrapolate our findings to low or lower-middle income countries, leaving a gap in understanding the patterns that may emerge in these contexts. The current study thus highlights the need for better data collection on HL and HA use in order to inform future research in these settings.
Third, as the current study was intended to be descriptive in nature rather than explanatory, we cannot make claims about the mediating factors that may produce international differences.
Fourth, the surveys used in our analyses varied in terms of time periods covered (eg, ELSI-Brazil, 2016–2020 vs CRELES, 2005–2009). However, we found no evidence of time trends (online supplemental appendix IX).
Finally, we cannot rule out bias introduced by international reporting differences due to survey differences (in number of hearing loss categories, for example) or in linguistic/cultural interpretation of the categories. While any such bias may influence international differences in prevalences, they likely have minimal influence on international differences in gender ratios as both men and women complete the same survey within a country.
Future directions
The findings of the current study highlight myriad avenues for future research, including an accounting of the elements that produce international differences. Another promising area for future research is a deeper exploration of countries with high levels of self-reported HL and low HA use, like China, South Korea and South Africa. If HA use in these countries is low for structural reasons, and not because adults with HL do not wish to use HAs, these areas may be fruitful for improving HA uptake. However, any processes looking to increase HA use should be mindful of the emerging pattern of gender inequality in HA use in low-use areas.
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