Predictors of Hearing Help-Seeking among Older Adults in England and Implications for Health Policy Strategies in Primary Care

Background 
Hearing loss is a major public health issue that affects over 9 million people in England. Traditionally, people with hearing difficulties will present to their GP to seek advice and investigation. Many of these people will be referred to Secondary Care Audiology or ENT for assessment and management. However, as hearing loss almost always develops gradually, people do not see it as a dramatic health problem requiring urgent intervention. In the absence of a HL screening program in England, It is therefore important to examine whether the self-identification of hearing problems is accurate, as it affects the initiation of hearing help-seeking.
Method 
Cross-sectional analysis of participants aged 50-89 years old from a representative sample of adults aged 50 years and over living in England (the English Longitudinal Study of Ageing, Wave 7). Our cohort was composed of 8,529 individuals that had assessment in their hearing by both self-reported measures and consented for assessment by a qualified nurse via a hearing screening device (HearCheck™ Screener). Hearing loss was defined as >35dB HL at 3.0 kHz, in the better-hearing ear. Multiple logistic regression models examined whether the self-reported measures of hearing -including hearing in background noise- are valid in comparison to objective measures of hearing and which the predictors of the potential inaccuracies are across different population subgroups of a representative population sample. 
Results 
30.2% of individuals with HL went undetected by the self-report measure in ELSA. Statistically significant predictors of misreporting hearing difficulties (while they had objectively measured HL >35dBHL at 3.0kHz, in the better-hearing ear) were: female gender (OR 1.97, 95%CI 1.18-3.28), no educational qualifications (OR 1.37, 95%CI 1.26-2.55), routine/manual occupation (OR 1.43, 95%CI 1.28-2.61), tobacco consumption (OR 1.14, 95%CI 1.08-1.90), alcohol intake above the low risk level guidelines (OR 1.13, 95%CI 1.11-2.34), and lack of moderate physical activity (OR 1.25, 95%CI 1.03-1.42). Age was largely associated with misreporting of moderately severe to severe HL; the odds were 5.75 (95%CI 1.17-8.13) higher on those aged 65-74 and 7.08 (95%CI 1.41-9.30) on those aged 75-89 to not report their hearing difficulties compared to those 50-64 years old. Also, socioeconomic indicators such as education (OR 1.95, 95%CI 1.63-6.01) and occupation (OR 2.07, 95%CI 1.78-5.40) along with lifestyle factors such as smoking (OR 1.46, 95%CI 1.25-2.48) and alcohol intake above the low risk level guidelines (OR 1.86, 95%CI 1.67-5.12) were predictors of misreporting moderately severe or severe HL.
Implications 
The self-identification of hearing difficulties is a major barrier for the initiation of help-seeking, which can affect the referral to ear specialists and the consequent hearing aid uptake. Our study showed that the self-report measurement of HL had limited accuracy and was not sufficiently sensitive to detect HL. In England, up to one third of adults with HL may remain undiagnosed and therefore not referred to ear specialists or given access to hearing aids. Importantly, people belonging in high-risk groups for HL, such as older and less educated people that face socioeconomic inequalities and adopt an unhealthy lifestyle, are the least likely to be accurately identified using self-report measures. These findings provide novel insights into clinical practice and reinforce the importance of an effective and sustainable hearing loss screening strategy in primary care, for the early detection and intervention for HL in older adults.