I was first drawn to write this article on the very first day I started my placement in the audiological field. As a black woman, I constantly navigate life trying to find myself in others – I look out for people who look like me. The people who came in for hearing appointments and who were fitted with hearing devices certainly did not look like me. I initially put this down to the fact I was working in the North, perhaps a less diverse area from my London home. I thought surely the situation will differ when I returned to London, the most diverse city in the UK.

When I first started my working career, I was first placed in what would be considered diverse areas in London – Lewisham and Croydon. Yet again, I was surprised at the lack of diversity of those people attending hearing appointments. Nonetheless, there was an increase in the diversity of the patients I saw. I quickly noticed that there was a significantly higher reluctance of the uptake of hearing devices from those of ethnic minority backgrounds. I would always probe what was the reasoning of this reluctance. The reasons differed but the overriding responses were, “It’s just something that is not done”, “I don’t want to wear that in my ear”, “What will my family think of this?”. I looked down at the “pink” custom hearing device I was automatically provided as demonstration against my dark skin; and I looked at my reflection with the “clear” receiver that is obtrusive down the side of my face and I found understanding.

What catapulted me into writing this article was a recent appointment I had with a black woman. She was a professional woman in her early 50s whose main issues were hearing conversations in work meetings. She wanted to tackle the issue with her hearing early, breaking the trend that was present in previous generations in her family. I was delighted at the opportunity to provide intervention for someone from my ethnic background – something I hadn’t had the opportunity to do for a notably long time. As standard, I provided a comprehensive test and she accepted hearing devices were the solution. She was thoroughly impressed by the sound quality of the RIC demonstration devices and wanted the exact same solution. It came to the time of display of style, and I advised her to look in the mirror to gain an understanding of the aesthetics of the RIC product. I held my breath as I awaited her response.

Her response was one that I rarely see from a white patient. As she looked in the mirror and viewed the “clear” receiver against her dark skin, disappointment spread across her face. She was instantly disappointed by the visibility of the device. This particular patient who initially came in motivated to gain help with her hearing left without a solution; she left without a solution as she felt there wasn’t one aesthetically catered to her. Many will have the thought, “Well why not use the receiver dyeing system?”. But the frustration comes when, for some, these receivers have the cosmetic appeal straight out the box and for others a greater level modification is required for the ultimate cosmetic appeal. It provoked me to think: what role do manufacturers play in making the market more appealing to ethnic minorities?

Wallhagen (2010) conducted a study in the US surrounding the effects of stigma on the use of hearing devices. Wallhagen expressed that stigma was related to three interrelated experiences: alterations in self-perception, ageism, and vanity. Vanity as a contributing factor to the deterrence of the use of hearing devices was through the perception that hearing aids would make participants appear unattractive. 

Participants emphasised that there is an importance of hiding the hearing aid and not drawing attention to one’s ears for there to be a consideration of hearing devices. Wallhagen admittedly noted that research is also needed on cultural aspects contributing to the experience of hearing loss and usage. The recruitment for the study involved a range of hearing centres, but few people from ethnic minorities were in the final sample for the study. Do we draw the conclusion that from this study there is a lower prevalence of hearing loss among African Americans, or does it provoke a greater need for understanding of the differing cultural views on hearing loss and hearing aid uptake?

Hearing impairment causes substantial challenges in the lives of those affected; if untreated, hearing impairment can have negative social and health impacts in both adults and children. In the UK, hearing loss is thought to impact the lives of one in six of the population. Estimates show that 14.5 million people in the UK, approximately 20% of the population, will have a hearing loss by 2031. In 2010, the number of hearing aid users in the UK was approximately 3.2 million (iData, 2011). Although the number of those affected by hearing impairment is steadily rising, the uptake of hearing aids is relatively low. There are various factors other than stigma that deter people from the use of hearing devices. Reasons include a lack of public awareness and education about the effects of a hearing impairment and how to cope with the effects of this (Knudsen et al., 2010), and the insufficient and restricted management of hearing impairment as part of general healthcare provision (Meyer & Hickson, 2012; Schneider et al., 2010). General hearing health research is largely centred around a white demographic. There is little to no research about understanding the uptake of hearing devices among ethnic minorities (Cruickshanks et al., 1998; Gates et al., 1990; Nash et al., 2013).

The discussion of health inequalities in the UK is largely conceptualised into focusing on socioeconomic factors. Although there are various types of inequality that can represent a fundamental cause, the greatest research focus has been on inequalities based on socioeconomic status. Certainly, low economic status is regarded as the central cause of introducing health inequalities but it is worth exploring other factors that can cause this issue. Nazroo (2003) found that when the health status of ethnic minority communities and white communities in the same socioeconomic position are compared, individuals from minority ethnic groups still display poorer health. Nazroo argued there is an additional factor of ethnicity that surges the exposure of ethnic minorities to poor health, stating this additional component is a complex one. One factor is explored by Annandale (2014) – racial prejudice. I want to discuss how race can be a tumultuous factor in contributing to health inequalities in the UK. This aspect has been studied in the US and therefore I will make reference to studies and findings that have been concluded from this lens. Research exposes that race and ethnicity remain powerful predictors of variations in health status (Braithwaite & Taylor, 1992; Furino 1992; Livingston, 1994; Zane et al, 1994).

A study from Kung et al. (2008) concluded that for most of the 15 leading causes of death – including heart disease, cancer, stroke, diabetes, kidney disease and hypertension – African Americans have higher death rates than whites. Research on health inequalities pertaining to race have been conducted and it is worth focusing our attention on how this can be translated in the audiological field.

A study from Nieman et al (2015) concluded that amongst older Americans with hearing loss, black older adults were 58% and Mexican American older adults were 78% less likely than white older adults to report regular hearing aid use. These findings were after controlling for age and degree of hearing impairment. Other studies also confirm that minority older adults were less likely to use hearing aids (Bainbridge & Ramachandran, 2014; Tomita et al., 2001). The results from Bainbridge & Ramachandran, which studied hearing aid use among older United States adults, found the quantity of hearing aid use among white people was over twice that of black, Hispanic or other (including multiracial) people (35.4% vs. 17.1%, (p<0.05). There is a duty to investigate why this is the case and if clinicians – but also if manufacturers and hearing aid dispensing companies – have a role of responsibility towards these disparities.

Clinician bias manifests in preconceived notions about the probability of an existing disorder or illness due to socioeconomic background or racial or cultural conditions. When a clinician is biased, this can be in an unconscious way, but it could result in misdiagnosis and inaccurate treatment recommendations. However, when an individual is judged according to their race, which results in bias, it is quite plainly considered discrimination. I urge clinicians to be introspective and challenge the current thoughts they may have when a patient who is from a minority background enters the consultation room. Have we noticed that there is this disparity present about the uptake of hearing intervention of those from ethnic minority backgrounds? Does this alter the level of care and attentiveness towards minorities because of these preconceived ideas we have about whether they would be a variable dispense? A study from O’Sullivan and Schofield (2018) surrounding the cognitive bias in clinical medicine provided various suggestions on how we can “unbias” ourselves – one simple but effective strategy is “slowing down.” They noted an improvement in diagnostic accuracy when clinicians adapted slowing down and consciously deliberating on problems, regardless if there was any specific underlying bias present.

Is it time to also question if the industry – through advertising, website pages and marketing materials – are marketing to all ethnic groups or is there a focus on one ethnic group? Do these subtle but powerful choices manufacturers and hearing dispensing companies make have an effect on the uptake of hearing devices for minorities, and what responsibility do these companies have in changing the statistics we currently have around the uptake of hearing devices in minority communities? We are inundated with messages everywhere we look, from TV commercials, magazine articles or billboards on the street. These advertisements tell us what we should do, how we should think, but these advertisements also tell us who they are marketing to. Companies establish who their target market is and then focus their marketing material towards their audience.

The purpose of this observation is not to accuse those working in the industry of being racially prejudiced, but to suggest that the operation of services may discriminate against ethnic minority groups due to embedded social norms, values and practices which can then have an impact on the journey of individuals from ethnic minorities’ hearing health.

We as hearing healthcare professionals living in a multicultural world, who want to provide greater personalised care for all our patients, should call for more research and interest in the profession to make sure we are catering to the diverse group of patients we see.