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Curti SA, Taylor EN, Su D, Spankovich C. Prevalence of and Characteristics Associated With Self-reported Good Hearing in a Population With Elevated Audiometric Thresholds. JAMA Otolaryngol Head Neck Surg. 2019;145(7):626–633. doi:10.1001/jamaoto.2019.1020
What percentage of persons with elevated audiometric thresholds self-report good hearing, and what factors are associated?
This population-based survey study of 1373 participants showed that nearly two-thirds of people who have audiometric evidence of hearing loss report good hearing. Younger age, nonwhite race, and women, as well as those who reported overall good health, were more likely to report good hearing.
A considerable number of people who have audiometric evidence of hearing loss self-perceive good hearing.
Audiometric evidence of hearing loss does not always relate to self-reported hearing loss.
To determine the prevalence of self-reported good hearing in a population with audiometrically defined hearing loss and identify associated factors.
Design, Setting, and Participants
We analyzed audiometric data from adults aged 20 to 69 years from the 1999 to 2002 cycles of the US National Health and Nutrition Examination Survey, a cross-sectional, nationally representative interview and examination survey of the civilian, noninstitutionalized population. Logistic regression was used to examine unadjusted and multivariable-adjusted relationships between demographic, hearing health, and general health factors related to self-perceived hearing status. Analysis was conducted between September 4, 2018, and November 30, 2018.
Audiometry and questionnaires.
Main Outcomes and Measure
The prevalence of persons reporting good hearing among those with audiometrically defined hearing loss and the variables associated with this population.
The mean (SD) age was 47.0 (0.4) years for hearing loss defined by any frequency >25 dB HL and 52.5 (1.1) years for hearing loss defined by PTA >25 dB HL. For the sample with hearing loss defined by any frequency >25 dB HL, 744 (56.1%) were men and 629 (43.9%) were women. For the sample with hearing loss defined by PTA >25 dB HL 251 (68.5%) were men and 114 (31.5%) were women. Of the 1373 participants who were found to have hearing loss (at least 1 individual frequency >25 dB HL in either ear) 993 (68.5%) reported good hearing. Younger age, nonwhite race, and women were all more likely to report good hearing. When the definition of hearing loss was made more stringent (pure-tone average >25 dB HL), 365 participants had audiometric hearing loss, but 174 (43%) continued to report good hearing. We observed that better self-perceived general health status (OR, 1.90; 95% CI, 1.25-2.90) and higher dietary quality (OR, 1.01; 95% CI, 1.00-1.02) were significantly associated with increased self-report of good hearing, whereas tinnitus (OR, 0.25; 95% CI, 0.14-0.44), noise exposure (OR, 0.39; 95% CI, 0.26-0.58), and several comorbid conditions were associated with decreased self-report of good hearing.
Conclusions and Relevance
A significant proportion of the study population reported good hearing despite having audiometric evidence of hearing loss; the prevalence was related to how hearing loss was defined. The report of good hearing was significantly associated with demographics and general health status. The high prevalence of mild hearing loss and self-reported good hearing was associated with the low reported use of hearing aids.
Self-reported hearing loss has poor concordance with hearing loss defined by pure-tone audiometry. Recent studies have shown only a 43% to 71% correlation between self-reported hearing loss and measured pure-tone audiometric thresholds.1-3 Sex, age, race/ethnicity, and education have all been shown to have an impact on a person’s ability to “accurately” self-report hearing status. One study4 found that older women, blacks, and Hispanics were less accurate in self-reporting than their respective younger age groups. Keiley et al1 found that age was associated with levels of accuracy of self-reported hearing loss, with adults younger than 70 years overestimating hearing loss and those older than 75 years underestimating hearing loss. Others have reported personality, importantly how a person handles stress, may also play a role in self report of hearing status.5
The lack of a strong correlation between perceived hearing loss and hearing loss defined by pure-tone audiometry is not only dependent on population characteristics, but also how hearing loss is defined. Common clinical definitions of hearing loss based on pure-tone audiometry often use a 15 to 25 dB HL cutoff at frequencies from 250 to 8000 Hz,6,7 whereas epidemiological definitions often use a pure-tone average (PTA) of 500, 1000, 2000, and 4000 Hz with comparable cutoff.8-10 We recently examined the prevalence of self-reported hearing difficulty despite “normal” audiometric results .3 Our findings showed that 10% to 15% of the US population reported hearing difficulty despite having normal audiometric thresholds, however the estimated prevalence was dependent on how normal audiometric threshold was defined. More stringent criteria for normal audiometric thresholds revealed lower prevalence estimates of reported hearing difficulty. Factors related to report of hearing difficulty despite normal audiometric thresholds included tinnitus, noise exposure, cardiometabolic health, mental/cognitive health, use of medications, and peripheral neuropathy symptoms.
Reciprocal to this relationship, it is also plausible that persons with milder hearing loss may not self-perceive hearing difficulty. Hearing ability of patients with mild hearing loss in quiet conditions is typically within the normative range11 and deficits are often not demonstrated until patients are presented with a competing or compromised signal, eg, speech-in-noise perception.11,12 It is also plausible that patients may attribute their hearing difficulties to external factors, such as people not speaking clearly or mumbling.13 Patients who do not perceive hearing loss may be at risk for delay in diagnosis and delay in proper treatment, training, or rehabilitation.
According to data from Goman et al,14 26.8% of those aged 60 to 69 years have some level of hearing loss based on pure-tone audiometry. Yet, 19.9% of the 26.8% with hearing loss based on pure-tone audiometry from the population in their study (nearly 75%) had hearing loss consistent with a mild severity (mild hearing loss was defined as PTA of 0.5, 1.0, 2.0, 4.0 kHz >25 dB HL through 40 dB HL). The high prevalence of mild hearing loss and potential lack of perceived hearing difficulty may contribute to the low utilization of hearing aids consistently reported across populations, including in health care systems with minimal to no cost for devices.15
In the present study we examined the prevalence of patients who had evidence of hearing loss and those in this population who self-reported good hearing using the National Health and Nutrition Examination Survey (NHANES). We aimed to define the demographic characteristics as well as other determinants that were associated with this relationship. Finally, we considered perceived hearing loss as a factor in utilization of hearing aids.
The National Health and Nutrition Examination Survey (NHANES) is an ongoing “rolling” cross-sectional survey of the civilian noninstitutionalized population of the United States. The NHANES protocol was reviewed and approved by the National Center for Health Statistics institutional review board and informed written consent was obtained from all participants. For detailed discussion see Johnson et al16 and Curtin et al.17 Between 1999 and 2002, NHANES collected data on 21 004 individuals of all ages (9965 in 1999-2000 and 11 039 in 2001-2002). From the total pool of 21 004 NHANES participants from the 1999 to 2000 and 2000 to 2002 cycles, there were 8143 participants ages 20 to 69 years. Audiometric data were collected in a subsample of 3853 participants from the 2 NHANES cycles (1999-2000: 1807 participants; 2000-2002: 2046 participants). We excluded 1172 participants. The primary exclusion criteria included incomplete auditory data and/or other missing data (n = 537 excluded) and evidence of conductive pathology as measured by presence of ear tubes, abnormal otoscopy, impacted cerumen, or abnormal tympanometry (peak pressure ≤−150 daPa; compliance ≤0.3 mL) (n = 635 excluded) for a sample size of 2681 participants. Finally, the sample was delimited to participants with hearing loss defined as thresholds greater than 25 dB HL at any frequency tested (0.5, 1.0, 2.0, 4.0, 6.0, and 8.0 kHz) in either ear (n = 1373) or as a 4-frequency PTA (PTA4; 0.5, 1.0, 2.0, and 4.0 kHz) greater than 25 dB HL for the worse ear (n = 365). We also examined the sample limited to PTA4 greater than 40 dB HL (n = 94). The selected definitions of hearing loss are based on common clinical and epidemiological cutoffs for hearing loss.3 Individuals with evidence of conductive pathology were excluded owing to the often-transient nature of the deficit.
Self-reported hearing status was based on a question of general condition of hearing, which read, “Which statement best describes your hearing (without a hearing aid)? Would you say your hearing is good, that you have a little trouble, a lot of trouble, or are you deaf?” A response of “good” was defined as good hearing and “little trouble,” “lot of trouble,” and “deaf” as hearing difficulty. Any tinnitus in the past year was defined as answering, “yes” to the question, “In the past 12 months, have you ever had ringing, roaring, or buzzing in your ears?” This was followed by the question “How often did this happen?” Persistent tinnitus was defined as answering “almost always,” “at least once per day,” “at least once per week,” or “at least once per month;” less frequent tinnitus was defined as nonpersistent/no tinnitus.
The audiologic examination was performed in a mobile examination center equipped with sound-isolated rooms by trained health technicians. The examination consisted of an audiometric questionnaire, an otoscopic examination, tympanometry, and pure-tone air-conduction threshold measures at 0.5, 1.0, 2.0, 3.0, 4.0, 6.0, and 8.0 kHz (National Health Examination Survey 2001). Detailed descriptions of the audiometric testing procedures are available online (http://www.cdc.gov/nchs/nhanes/au.pdf). In addition to PTA4 (0.5, 1.0, 2.0, 4.0 kHz), low- and high-frequency PTAs were calculated (0.5, 1.0, 2.0 kHz; and 3.0, 4.0, 6.0, 8.0 kHz, respectively).
The Healthy Eating Index (HEI) provides an overall assessment of type, quantity, and variety of foods, as well as compliance with US dietary recommendations. For additional detail, see United States Department of Agriculture (1995). As per previous report,18 the overall HEI score is the sum of 10 equally weighted components with a maximum HEI score of 100.
Covariates included in our analyses were based on the previous literature, preliminary Spearman ρ correlation analyses, and preliminary logistic regression models. Covariates considered included age, sex, race/ethnicity, marital status, education level, PTAs, noise exposure, balance issues, veteran/military status, diabetes, hypertension, stroke, cancer, arthritis, vision difficulties, neuropathy symptoms, alcohol use, smoking status, confusion/memory issues, physical/mental/emotional issues, and medication use.
Race/ethnicity was grouped as non-Hispanic white (hereafter, white), non-Hispanic black (hereafter, black), Mexican American, or other. Education was coded as less than high school, high school diploma (including general equivalency diploma), or more than high school. Marital status was coded as married or unmarried (including divorced, single, widowed, never married, living with partner, and separated). Participants were asked if they were “Ever told by a doctor that you have diabetes?”, “Ever told by a doctor that they have high blood pressure?”, “Ever told by a doctor you have cancer?”, “Ever told by a doctor you have arthritis?”, “Ever told by a doctor you are overweight?”, “Ever told by a doctor that you had a stroke”, “Do you have trouble seeing, even when wearing glasses or contact lenses?”, “During the past 3 months, have you had numbness or loss of feeling in your hands or feet, other than from hands or feet falling asleep?”, “During the past 3 months, have you had a painful sensation or tingling in your hands or feet? Do not include normal foot aches from standing or walking for long periods.”, “Was there a time or times in your life when you drank 5 or more drinks of any kind of alcoholic beverages almost every day?”, “Are you limited in any way in activity because of a physical, mental, or emotional problem?”, “Are you limited in any way because of difficulty remembering or because you experience periods of confusion?”, “Have you ever taken any prescription or over-the-counter pain relievers nearly every day for as long as a month (aspirin, acetaminophen, ibuprofen, etc?)”, “In the past month have you used or taken a medication for which a prescription is needed, do not include vitamins or minerals?”, “During the past 12 months have you had dizziness, difficulty with balance or difficulty with falling?” and smoking history was self-reported as having smoked at least 100 cigarettes in entire life or current smoker. All answers were reported as “yes or no”.
There were several topics about noise exposure sources included in the NHANES from 1999 to 2002, with loud noise defined in the NHANES as “so loud that you had to speak in a raised voice to be heard.” The areas included work-related noise, military service, recreational firearm use, and other nonoccupational exposure.
Data were entered into the complex samples analysis incorporating 4-year sample weights according to National Center for Health Statistics (NCHS) guidelines, which allows for data to be generalized to the US population. Descriptive data for self-perceived hearing status (good hearing vs hearing difficulty) are presented and significance were tested using logistic regression; odds ratios and corresponding 95% confidence intervals (CIs) are reported. Based on unadjusted logistic regression, multivariable logistic regressions were performed to estimate odds ratios to identify potential variables that were related to good hearing, adjusted for age, sex, race/ethnicity, and hearing thresholds (high- and low-frequency PTA); odds ratios and corresponding 95% CIs are reported. The variables included in adjusted models were based on analyses of unadjusted relationships. The PTA4 for high and low frequencies were adjusted to account for severity of hearing loss in models. Multicollinearity analysis was completed to determine if predictors were highly correlated. No collinearity issues were indicated (variance inflation factor <3). All analyses were performed in SPSS statistical software (version 24; SPSS, Inc).
Overall, 1373 participants met the criteria for hearing loss (defined by at least 1 individual frequency >25 dB HL in either ear), of those and applying sample weights 993 (68.5%; standard error of mean [SEM], 1.8%; 95% CI, 64.7%-72.1%) self-reported good hearing and 380 (31.5%; SEM, 1.8%; 95% CI, 27.9%-35.3%) reported hearing difficulty. Table 1 shows the descriptive data and unadjusted associations. Age, sex, race/ethnicity, as well as high- and low-frequency hearing PTAs were significantly different based on self-reported hearing status. Men and white participants were less likely to report good hearing, whereas minority participants were more likely to report good hearing. The greater the severity of hearing loss the less likely the report of good hearing. We also observed that persons with better diet and self-reported general health were more likely to report good hearing. On the contrary, presence of comorbid conditions decreased report of good hearing. In addition, report of current marriage was significantly associated with decreased report of good hearing.
Table 2 provides the multivariable adjusted logistic regression findings for predictors of good hearing despite audiometric hearing loss. We observed that diet quality (HEI) and better self-reported general health significantly increased the odds of self-reported good hearing, whereas several variables including tinnitus, noise history, neuropathic symptoms, vision difficulty, arthritis, being overweight, use of analgesics, and use of prescription drugs decreased the odds of good hearing. Stroke, diabetes, marriage, and reported use of hearing aid no longer remained significant.
Next, we examined the prevalence of self-reported good hearing despite audiometric evidence of at least mild hearing loss affecting speech frequencies (PTA4 >25 dB HL). Of the sample with hearing loss defined by PTA4 greater than 25 dB HL (n = 365) and applying sample weights, 174 (43%; SEM, 3.0%; 95% CI, 37.1%-49.2%) reported good hearing and 191 (57%; SEM, 3.0%; 95% CI, 50.8%-62.9%) reported hearing difficulty. Table 3 reports the descriptive data for the sample (PTA4 >25 dB HL) and unadjusted relationships. With the more stringent definition of hearing loss, sex and age were no longer significant factors, but race/ethnicity and low- and high-frequency PTA remained significant. The multivariable adjusted relationships are presented in Table 4. We observed that tinnitus, noise exposure, being overweight, neuropathic symptoms, prescription drug use, confusion/memory issues, physical/mental/emotional limitations, and balance issues were significantly related to reduced odds of reporting good hearing.
We also considered report of good hearing and hearing loss defined as PTA4 greater than 40 dB HL, a hearing loss defined by the World Health Organization9,10 as a “disabling” hearing loss (n = 94). Owing to the small sample size, we did not incorporate sample weights to examine relationships and do not report on multivariable models, rather reporting only descriptive statistics, odds ratios, and independent group t test findings. Of the 94 individuals with PTA4 greater than 40 dB HL, only 21 (22%) reported good hearing; however, most participants reporting hearing difficulty (73 [78%]), reported “little trouble” (44 [46.8%]), whereas only 29 (31.2%) reported “greater than a little trouble.” Despite the higher prevalence of reported hearing difficulty, only 25 (26.6%) of the participants reported use of a hearing aid. Low- and high-frequency PTA and age were not significantly different between those that reported good hearing and hearing difficulty. Sex, race/ethnicity, education, marital status, noise exposure history, hypertension, stroke, neuropathic symptoms, arthritis, and dietary quality were not significant factors. Any tinnitus (odds ratio [OR], 0.24; 95% CI, 0.07-0.78), persistent tinnitus (OR, 0.28; 95% CI, 0.08-0.93), and use of a hearing aid (OR, 0.10; 95% CI, 0.01-0.81) were related to decreased odds of reported good hearing.
Finally, we examined the odds of reported use of hearing aids among participants with hearing loss defined by any frequency or PTA4 greater than 25 dB HL. For the “any frequency” definition of hearing loss, only 34 (2.5%; SEM, 0.4%; 95% CI, 1.7%-3.5%) participants reported use of hearing aids. When limited to participants based on hearing loss defined by PTA4, 33 (9.3%; SEM, 1.5%; 95% CI, 6.7%-12.7%) reported use of hearing aids. Using PTA4 as definition of hearing loss, the variables age (OR, 1.10; 95% CI, 1.05-1.14), arthritis (OR, 5.25; 95% CI, 1.81-15.22), loud noise outside work (OR, 2.46; 95% CI, 1.15-5.29), prescription drug use (OR, 4.16; 95% CI, 1.79-9.64), physical/mental/emotional issues (OR, 6.42; 95% CI, 2.86-14.38), persistent tinnitus (OR, 3.10; 95% CI, 1.52-6.30), and perceived hearing difficulty (OR, 14.52; 95% CI, 2.70-76.65) were significantly related to use of hearing aids; education, sex, marital status, race/ethnicity, veteran/military status, vision trouble, confusion/memory issues, being overweight, stroke, cancer, diabetes, neuropathic symptoms, work-related noise, firearm noise outside work, balance issues, alcohol intake, smoking history, and analgesic drug use were not related in unadjusted models. Table 5 shows the factors significantly associated with use of hearing aids adjusting for age (other variables such as sex, race/ethnicity, and PTA were not significantly related in unadjusted analysis and not included in the multivariable model). Noise exposure outside of work, arthritis, prescription drug use, physical/mental/emotional issues, perceived hearing difficulty, and persistent tinnitus remained statistically significant factors.
Audiometric evidence of hearing loss does not necessarily indicate perceived hearing difficulty. In the present analysis we identified 1373 people who had hearing loss as defined as at least 1 frequency higher than 25 dB HL in at least 1 ear. Of this population, 993 (68.5%) reported good hearing. Younger age, nonwhite race, and women were all more likely to report good hearing. In addition, perceived good hearing was related to report of fewer comorbidities, report of better general health and diet, and absence of hearing loss related symptoms such as tinnitus.
How hearing loss is defined influences the prevalence of perceived good hearing, ie, persons with more severe hearing loss were less likely to report good hearing. Clinically, hearing loss is often defined as a single frequency above 25 dB HL. Using this definition in our analysis does not imply that just 1 frequency was abnormal, indeed most participants had more than 1 frequency with abnormal thresholds. It could be argued that a single elevated threshold above 25 dB HL may be of limited clinical correlation to hearing loss complaints. However, the average normal hearing for frequencies from 250 to 8000 Hz is 0 dB HL.18 Applying a normal range of −10 to 25 dB HL does not rule out the possibility of large threshold shifts even within a range considered normal. When a stricter definition of hearing loss was applied, pure-tone average of 4 frequencies (500, 1000, 2000, and 4000 Hz) higher than 25 dB HL, the numbers of persons with hearing loss dropped (n = 365). Of this population, 174 (43%) reported good hearing. There was still a significant correlation between race/ethnicity and perceived hearing status, but sex and age were no longer significant. Consistent with the findings of Goman et al,14 approximately 271 (75%) of the 365 participants with hearing loss defined by PTA4 had what is commonly defined as a mild hearing loss (PTA4 range of 25 through 40 dB HL). Low-frequency and high-frequency PTA4 were associated with perceived hearing status for cutoff at any frequency and PTA4 greater than 25 dB HL, but not PTA4 greater than 40 dB HL. In other words, severity of hearing loss contributed to the variance of reported hearing status for more mild forms of hearing loss, but not moderate or greater. In our multivariable models we adjusted for low- and high-frequency PTA4 to limit influence of severity of loss.
The use of hearing aids was also related to severity of hearing loss and self-perceived hearing status; participants with perceived hearing difficulty were more than 16 times as likely to report use of a hearing aid. The question in the NHANES about subjective hearing status asks participants to report the status of their hearing without a hearing aid. Of the participant’s that reported use of hearing aids, 31 (91.2%) reported at least a “little trouble” or more. Including all participants, only 3 (0.14%) participant’s with good hearing reported use of a hearing aid, 15 (3.2%) reporting “little trouble” reported use of hearing aids, whereas 16 (33%) of persons with “a lot of trouble” or more reported use of hearing aids. It is evident that use of hearing aids is highly related to perceived hearing status and severity of hearing loss. It is possible that participants that reported good hearing may have done so owing to the benefit from reported hearing aid use (note the NHANES question on self-perceived hearing status specifically asks about hearing without use of hearing aids) creating a potential confound. However, only 3 participants with hearing loss who reported use of hearing aids, reported good hearing.
Importantly, although a small sample size, 21 (22%) persons with a PTA over 40 dB reported good hearing. We suggest several reasons as to why adults with audiometric evidence of hearing loss would perceive good hearing. Hearing loss is often gradual and partial (high frequency only), which may limit perception of change in volume and instead present with more subtle changes in clarity that are easier to externalize.19,20 If a person is able to communicate effectively and does not suffer significant setbacks or have other related comorbidities (eg, tinnitus, hyperacusis), they may not recognize their own deficits. In addition, hearing loss is painless and invisible, therefore it is not always recognized by primary care physicians and, if not brought into the patient-physician dialogue, may further reinforce lack of awareness and delay referral for an audiological evaluation. It is also clear that pure-tone audiometry has limitations in regard to determination of hearing difficulty21 and other outcomes of subjective hearing status are important to determining influence on communication and quality of life.22,23 Finally, there is also a negative social connotation associated with hearing loss that may lead some to disregard or continue to believe their hearing is good.20,21
The NHANES data are comprehensive and represent the national population well, which is a major strength for an epidemiological study design; however, this study does have inherent limitations. Owing to the nature of the epidemiologic design, cause and effect relationships cannot be made. We are unable to say with absolute certainty that this data set is absolutely complete and therefore cannot exclude bias. It is also possible that additional confounding variables exist. Pure-tone audiometry was the primary measure of hearing status. Although pure-tone audiometry is frequently used in the clinical setting, hearing difficulty has many factors that extend beyond pure-tone audiometric thresholds.21 The NHANES does not include bone conduction audiometry and therefore we were unable to include it in our analysis. It should be noted that no hearing handicap or effect on quality of life data are available in the NHANES data set. Finally, this analysis was completed based on an earlier version of NHANES (1999-2002).
There is a considerable proportion of the population that will report good hearing despite having audiometric evidence of hearing loss. This holds true even as the definition of hearing loss is made stricter and is likely related to the high prevalence of mild hearing loss; nearly half of people with hearing loss defined by PTA4 greater than 25 dB HL report good hearing. Women, nonwhite minorities, and younger people were more likely to report good hearing despite elevated thresholds and those with better overall health were more likely to report good hearing. Use of hearing aids was also significantly associated with perceived hearing difficulty. Further studies are needed to confirm these associations and help determine the significance of these findings.
Corresponding Author: Christopher Spankovich, AuD, PhD, MPH, University of Mississippi Medical Center, Department of Otolaryngology and Communicative Sciences, 2500 N State St, Jackson, MS 39216 (email@example.com).
Accepted for Publication: April 2, 2019.
Published Online: June 6, 2019. doi:10.1001/jamaoto.2019.1020
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Spankovich.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Curti, Spankovich.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: All authors.
Administrative, technical, or material support: Taylor.
Conflict of Interest Disclosures: None reported.
Acknowledgement: The research for this manuscript was conducted at the Department of Otolaryngology and Communicative Sciences, the University of Mississippi Medical Center in Jackson, Mississippi.