Abstract
Introduction:
Age related hearing loss is in the top ten contributors to the global burden of disease and one of the largest modifiable risk factors for age-related dementia. However, awareness of the consequences of untreated hearing loss is poor and many adults do not seek hearing assessment. Despite World Health Organisation recommendations, no EU country currently has a national adult screening programme.
Method:
The aim of this trial was to raise awareness of hearing loss by providing screening audiograms in a range of community settings. Results were explained to every participant and professional advice given. Seven hundred participants came forward for testing with a mean age of 60 to 70 years old.
Results:
Data was recorded from 597 individuals (51% female and 49% male), 44% had a disabling hearing loss (≥35 dB HL in the better ear) and 15% of individuals had a moderately severe loss or greater. No participants currently wore or had been fitted with a hearing aid. Both the proportion of those with hearing loss and the severity of the hearing loss increased with age. Tinnitus was present in 38% of the sample and wax occlusion in 24%.
Conclusion:
Many individuals came forward who had not accessed the audiological services currently provided. This indicates a need for more awareness of hearing care in the population and an unmet need for audiological services.
Keywords
Introduction
The World Health Organization (WHO) World Report on Hearing highlights the need for better adult hearing care. 1 Europe and the Americas have a prevalence of moderate or higher level of hearing loss of 6.2%, this is even higher for older adults. 1 Unaddressed hearing loss potentially effects not just communication but cognition, employment, mental health and social integration. 1 The latest study puts age related hearing loss in the top ten contributors to the global burden of disease. 2 Hearing loss is also one of the largest modifiable risk factors for age-related dementia. 3
Providing a suitable hearing device can mitigate some of the negative effects of hearing loss on quality of life, especially with early intervention. 4 But many adults do not actively seek hearing assessment and often wait 9 to 10 years before doing somanonyng about their hearing loss. 5 This may be because the loss progresses slowly and is not recognised as a significant impairment or that it is considered a normal part of the ageing process. 6 General knowledge about the long-term consequences of hearing loss is poor and one study reported that respondents were twice as likely to take their pet to the veterinarian than have their hearing checked.7,8 The costs of getting a hearing test are also a significant barrier in some regions, especially for those who are older and may be retired. Individuals will not seek treatment if the barriers to getting treatment exceed the risks of living with hearing loss. 8 To address this inertia, the WHO report recommends adult hearing screening to encourage the earlier fitting of hearing aids and improved hearing outcomes. 9 It is also cost effective due to the benefits that early identification of hearing loss can bring.9 -11 However, the global screening guidelines for hearing loss in adults lack clear consensus. For example, the US Preventative Service Task Force determined that evidence concerning hearing loss screening in adults is inconclusive, with no clear indication that screening leads to improved health outcomes. 12 In contrast the American Academy of Otolaryngology recommend hearing screening for adults aged 50 and over. 13 No EU country currently has a national adult screening programme.
In Malta there is a small population of 520,000 individuals. Of these 19% are aged 65 years or more, the age at which the WHO recommends hearing screening every 1 to 3 years.9,14 A newborn hearing screening programme and diagnostic hearing tests for adults and children are currently available free of charge from the National Health Service. Adult services require a referral from a General Practitioner, Ear Nose and Throat specialist or Audiology Services. However, the number of adults actively seeking hearing assessment remains lower than expected. An ongoing public health campaign to promote hearing care for all in Malta was launched in 2021. The first phase of this campaign was to raise awareness of hearing loss and encourage individuals to get their hearing tested via an advertising campaign offering free Audiograms in community settings. The key difference compared to existing hearing services was the use of a community setting and the ability to get a free hearing test without a referral or any commercial pressure to purchase a hearing aid. This Government funded programme was seen as an initial step towards the implementation of an adult hearing screening service.
The primary objective of this Government initiative was to raise hearing loss awareness and improve access to hearing care to people from all walks of life. The main outcome measured was the number of individuals coming forward for testing. A secondary analysis of the hearing data collected was conducted to identify the number and severity of undiagnosed hearing loss cases.
Materials and Methods
This was a descriptive observational study with a secondary analysis of collected data. Results are described using descriptive statistics and thus no sample size calculation was required.
Procedures
The testing sessions were advertised via TV, social media and press conference and individuals were invited to phone and book a slot to have their hearing tested.
The sessions were held over 8 weekends between June 2021 and October 2022 A pure tone audiogram, the gold standard for the detection of hearing loss, was performed by licensed local Audiologists or Audiology Master’s Students supervised by a licensed Audiologists. 15 Five staff members were always needed and did this on a voluntary basis. Testing was carried out in six different locations including a water sports club, community hall, local council building, and day care centre.
The tests were performed in large rooms, that were identified beforehand in each location and checked for low ambient noise. Four test stations were set up in each room with the option of a fifth station to take a patient history and otoscope ear examination. COVID-19 prevention measures were strictly observed. All participants had their ears examined with an otoscope. The external auditory canal and ear drum was checked for wax, abnormalities or infections. If wax was completely occluding the ear canal participants were not tested but given advice on wax softening and removal.
On arrival at the centre participants were registered and a verbal consent given for anonymised information to be collected and stored in a data base. Data was collected on age bracket, locality, history of noise exposure and history of tinnitus. All participants were asked if they hear sounds like ringing, waves crashing, crickets or any other sound. These particular risk factors were highlighted as a high incidence of noise induced hearing loss was expected given Malta’s past economic dependency on ship building, farming and manufacturing and also traditional hobbies such as hunting and firework making and displays.
There were no age restrictions, although results are only reported for those aged 18 years and over.
The study followed the relevant EQUATOR guidelines. 16
Audiometry
Audiometers were set up in 4 screening stations, allowing 4 participants to be tested at a time. Standard audiograms were conducted at 500, 1000, 2000, 3000, 4000 and 6000 Hz using Inventis clinical calibrated Audiometers and were performed using recommended procedures for Puretone Audiometry and tdh-39 headphones. 17 The threshold for normal hearing was set to 30 dBHL at each frequency as per the recommendations to account for background noise levels of 45–50 dBA, measured using a calibrated sound level meter. 17 The maximum intensity was capped at 100 dBHL.
Results were explained to every participant and whenever there were issues with hearing loss or tinnitus, they were given professional advice and recommendations for follow up. Each person was given the Audiogram, and a qualified audiologist explained the results and gave recommendations on how to proceed. For example, those that had wax were told to seek medical attention and those with a hearing loss were told how to get a hearing aid from a public healthcare hospital or private clinic. No direct referral to the National Health Audiology Service could be made without going through the right referral pathway and therefore participants were responsible for making their own follow up arrangements.
Informed Consent
Ethics approval was obtained for the secondary analysis of the data from this study. Subjects were informed of the details of the Government project via the advertising campaign material. Verbal consent to the hearing test was given when they attended the screening centre. It was explained to them at the beginning of the session that anonymised hearing data would be collected in a database and may be used for future analysis. No personal data or identifying information was stored. Participants were asked to verbally confirm that they understood that the data would be anonymously recorded and may be used for future research purposes. If consent was not given, the data from this subject was not recorded or stored. Written consent for data collection was considered but due to the number of people attending each session and the limitations of the literacy abilities of some of the older participants, verbal consent was considered the best option to make sure that all the information has been understood. This approach was approved by the ethics committee. Due to the large attendance expected and literacy limitations among older participants, verbal consent was chosen over written consent to ensure all the information was understood and the screening ran efficiently.
Data Collection
A google form was created to record and store the data obtained. Personal details such as name, ID number, date of birth, address or contact details were not recorded so that no individual could be identified. Each participant’s hearing history data and test results were recorded on an Audiogram form and given to the person to take home or to use in case they need further medical or audiological management.
Funding and Costs
The Ministry for Inclusion and the Voluntary Sector funded 3000 euros to cover the cost of consumables and renting audiometers and otoscopes. Items included disposable specula, alcohol wipes, headphone covers, stationery, audiogram forms, hand sanitiser, gloves, masks, and visors due to COVID-19. Audiology staff were recruited voluntarily via the Association of Audiologists. Costs for staff to provide security and manage the queues, and marketing were undisclosed and covered by the Ministry. The average cost of screening was 4 euros per participant.
Without the government funding and voluntary work, the estimated costs of providing a similar service in the future would be approximately 27 euros per participant for the same 700 participants tested in this study, covering expenses like equipment, paid staff and marketing, as shown in the in the projected costs in Table 1.
Projected Costs for Providing a Similar screening Service Outside of the Government Initiative.
Results
Subjects
In all, 700 participants were tested and 597 responses were successfully recorded on the google form. Issues with internet connectivity resulted in the data from some participants not being saved.
None of the participants coming forward had previously been fitted for hearing aids or currently wore them.
The mean age of participants was between 60 and 70 and 51% were female and 49% male. The age ranges of participants are shown in Figure 1.
Total number of participants in each age bracket.
Exposure to noise was reported by 47% (282) participants.
Ear Examination
There were 24% (144) of individuals who had wax partially blocking either 1 ear or both ears and 4% (27) had other medical conditions such as fungal infections, perforations, dry skin or trauma caused by excessive cleaning. All other examinations were normal.
Tinnitus
Tinnitus was reported by 38% (227) of individuals. No information was collected on the type or severity of the tinnitus. Those reporting tinnitus were given tips on how to manage their tinnitus or how to seek further help or rehabilitation.
Hearing Test Thresholds
Average hearing thresholds were calculated across 500, 1000, 2000, 3000, 4000 Hz for each ear and participants categorised according to the new grades of hearing impairment recommended by the Global Burden of Disease (GBD) Expert Group on Hearing Loss.18,19 Under this classification any individual with a hearing loss of ≥ 35 dBHL in the better ear has a disabling hearing loss. Values exceeding 100 dB (the audiometer limit) were entered as 110 dB. Table 2 gives the different grade boundaries and illustrates the effects of that loss in quiet and noise at each level. The threshold for mild hearing loss was set at 30 to 34.9 dBHL due to the background noise levels. Whilst background noise may mask the quietest of sounds, it does not elevate the detection levels for supra threshold pure tones, thus all other boundaries remained the same. A hearing aid is recommended for individuals with a moderate hearing loss or worse.
Hearing Boundaries for the Better Ear set by the Global Burden of Disease Expert Group on Hearing Loss.
Under this classification, any individual with a hearing loss in the better ear of ≥ 35 dBHL (moderate or worse) has a disabling hearing loss. PTA- pure tone average of 500 Hz, 1, 2, and 4 KHz. Reproduced with permission from Olusanya et al. 18
Out of the 597 responses recorded, 264 had a disabling hearing loss as per the GBD definition. This represents 44% of the study group. The highest number of participants were in the 60 to 70 age bracket, and almost half (46%) of these had a disabling loss (Figure 2). As age increased the proportion of people with hearing loss and the severity of the loss increased.
Number of participants in each age bracket with either normal hearing or a mild loss which is not disabling (<35 dB) and a disabling loss (split into moderate, moderately/severe or severe to profound or worse).
Follow Up Advice
Results were explained to every participant and were given professional advice on how to proceed if a hearing problem was identified. Those who had an average hearing loss across both ears exceeding the 30 dBHL threshold for normal set for the study, were advised to seek further assessment at an audiology practice. Those with tinnitus were counselled on how to reduce or cope with the perception of this phantom sound. Participants with wax were advised not to use cotton buds but to seek professional medical advice, especially if there was any outer ear condition that needed medical attention.
Discussion
A high percentage of the participants (44%) had a disabling hearing loss which points towards a large unmet need for hearing care in the population coming forward. The ease of obtaining a hearing test, in a community setting and with no referral, and the absence of any commercial pressure to purchase a hearing aid after diagnosis, may have removed some of the barriers to seeking a hearing assessment. However, the outcomes from this study represent data from a group who chose to come forward for hearing screening which would suggest that they already had some concerns about their hearing levels. Thus, the numbers could not be used to extrapolate to the overall need for the wider population. The proportion of those with hearing loss and its severity increased with age. This was expected from the literature as by 70 years old or over 80% of individuals can expect to have significant hearing loss in need of treatment. 20 This demographic group is particularly challenging to engage, yet they are the most in need of support, especially given the increased risk of cognitive decline associated with hearing loss. 3 The use of easy to access community-based settings improves access for these older individuals. However, the inability to directly refer to audiological services should be addressed, as older patients may not initiate follow-up care themselves.
Malta’s past ship building history, ongoing manufacturing industry and also traditional hobbies such as shooting and firework manufacturing and displays likely contributed to the high incidence noise exposure reported, correlating with elevated rates of hearing loss and tinnitus.21,22 Those still working in noise were advised to wear ear protection to prevent further hearing damage and greater employer and public education about noise induced hearing loss is warranted. Employer based hearing screening for at risk groups should be encouraged, explored and adopted. There were also high rates of otoscopic abnormalities, wax occlusion accounting for most of these. Although this is a common finding in studies of this type, reported rates are generally lower at 10% to 12% .23,24
Despite the availability of free audiological services, participants had not previously accessed hearing care. Long public sector waiting times and private sector costs may contribute to low service uptake, highlighting the need for improved intervention. Evidence suggests that early hearing testing increases hearing aid adoption and self- awareness. 25 Implementing hearing screening or a direct self-referral care pathway could enhance hearing loss awareness and be a better use of health care resources. 26 Allowing adults over 60 to self-refer to public audiology services for hearing tests is potentially more cost-effective than the current GP referral system. 26 The study’s results aim to encourage policy makers to develop frameworks for universal adult screening and enhanced hearing health services, possibly within the community. However, Malta lacks plans for a national adult hearing screening programme. Innovative service models should be considered such as using mobile audiometry for rural areas or alternative tests methods such as speech in noise tests or questionnaires.27,28 Any policy change needs to be supported by enhanced public awareness campaigns to normalise hearing health, encourage early detection and ensure that adults receive timely, high-quality care, ultimately improving quality of life and reducing the societal and economic burden of untreated hearing loss. 1 The investment needed for this will yield significant public health benefits and reduce long term cognitive and social costs. 10 Future research should prioritise long-term impact evaluation, cost-effectiveness, and improved screening logistics. The study is a strong indicator that a formally funded trial of adult hearing screening is required.
Limitations
Testing was carried out in rooms with higher ambient noise than recommended, which may have limited our ability to detect mild hearing loss. Other hearing loss risk factors were not recorded, limiting understanding of participants’ overall hearing health. The costs and model of providing the hearing screening are not generalisable and may vary in different countries and health care systems. It was not possible to collect follow up data on audiologist visits or hearing aid uptake so the project’s long-term impact could not be assessed. Participant feedback on the screening experience was also not recorded, which would be a valuable addition for future research.
Conclusions
This pilot project demonstrates a high rate of undiagnosed hearing loss among older adults and a compelling case for Malta to establish a formal policy introducing a national adult hearing screening programme. The results show that despite the provision of free audiograms on the National Health Service and also advertised in private hearing aid shops, many individuals with hearing problems still had not sought professional hearing evaluation or been fitted with a hearing aid. The benefits of a direct self-referral system within the National Health Service are clear and this demands urgent attention. Questions remain regarding the systematic delivery of hearing screening to large populations. Future research should evaluate the cost-effectiveness and logistics of providing an adult hearing screening service, its impact on hearing aid adoption and its short and long term impact on hearing loss awareness. However, there can be little doubt that a change is required with a substantial unmet need, especially in the older population.
Footnotes
Acknowledgements
The authors would like to thank Alex Aguis Saliba MEP, Hon Julia Farrugia Portelli, Minister responsible for the Ministry for Inclusion and Voluntary Sector and the Malta Association of Audiologists for their invaluable help and support.
Ethical Considerations
Ethics approval was retrospectively obtained from the University of Malta Research Ethics Committee for the secondary analysis and publication of the data on the 02/07/2025, reference number FHS-2025-00252.
Consent to Participate
Verbal informed consent for participation in the study was given when participants came to their screening appointment. Ethics approval was given for the waiving of the requirement to get written consent.
Author Contributions
Conceptualization, PH AS; methodology, AS.; formal analysis, AS; investigation, AS.; resources, PH, AS.; data curation, AS and PG.; writing—original draft preparation, PG.; writing—review and editing, AS, PH, PG.; visualization, AS, PG, PH; supervision, AS; project administration, AS; funding acquisition, PH, AS. All authors have read and agreed to the published version of the manuscript
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for the screening was provided by the Minister for Inclusion, Voluntary Organisations and Consumer Rights as part of a public health ‘Hearing Care For All’ campaign. Funding for the preparation and publication costs of the manuscript was provided by MED-EL GmbH.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Andrew Sciberras is an employee of Loud & Clear Professional Audiology Services and could potentially benefit from increased referral to audiology services for hearing aid fitting. Patrick D’Haese is an employee of MED-EL- GmbH, Innsbruck, Austria and a visiting professor at the Vrije Universiteit Brussel. Paula Greenham acts as a paid consultant for various hearing device providers.
Data Availability Statement
The raw data supporting the conclusions of this article will be made available by the authors on request.