Research | Direct-Mail Hearing Aids | January 2014 HR

A Comparison of Consumer Satisfaction, Subjective Benefit, and Quality of Life Changes Associated with Traditional and Direct-mail Hearing Aid Use

By Sergei Kochkin, PhD

A survey involving customers of one of the largest and longest-established US direct-mail hearing aid companies reveals surprising data on benefit, satisfaction, and value. Overall, it shows that consumers are willing to make trade-offs in benefit for substantial reductions in price. The direct-mail hearing aids in this survey delivered “about average” real-world benefit, but significantly less real-world benefit than hearing aids dispensed by those professionals who adhere to the highest levels of best practices.

In the last national consumer study of the United States hearing aid market (MarkeTrak VIII database),1 3.28% (280,000 people) of hearing aid owners indicated they received their hearing aids through the mail. In the 2004-2008 surveys, 5.1% of first-time users of hearing aids were by direct-mail.2 Within the last few years, one would expect that direct-to-consumer hearing aids (direct-mail and over the counter or OTC) have grown even more, given the number of products offered in big-box stores (eg, Walmart, Sam’s Club) as well as the Internet sites devoted to this product segment. These products vary from one-size-fits-all (analog and digital) to fully programmable digital when the consumer supplies their audiogram. Some companies even provide the consumer with an earmold impression kit through the mail, allowing the consumer to customize their hearing aid shell.

Little is known about the consumer of direct-mail hearing aids. MarkeTrak VIII1 contained a small sample of 187 direct-mail consumers. The results suggested that direct-mail hearing aid purchasers: were more likely to be male, had significantly lower household income, were less likely to be a college graduate, had hearing loss profiles similar to the traditional hearing aid user, were less likely to purchase binaural, on average paid out-of-pocket costs that were about 17% of traditional hearing aids, and wore their hearing aids less.

From a consumer experience perspective, we know virtually nothing about their satisfaction with the product, their behaviors (ie, Do they use them and would they recommend them to their friends?), their perceived benefit (ie, Do they experience reduced hearing handicap in the environments important to them?), and quality of life changes associated with their usage of this product (ie, Do they improve their lives socially, mentally, emotionally, or physically?). One 2009 clinical study3 on two consumers comparing hearing aids fitted through the mail (and tested over the Internet) versus professionally fitted in a clinic concluded that the clinic provided a superior ear-impression and prescriptive fitting. Another case study on one consumer raised concerns about the safety of direct-mail hearing aids following the discovery of a “sleeve” found in a consumer’s ear, who also had a history of otitis media; yet the authors failed to determine that this individual was a direct-mail hearing aid consumer or quantify their safety concerns.4

In a recent study5 conducted at the Michigan Ear Institute on 9 consumers and presented at the 2012 American Academy of Otolaryngology-Head & Neck Surgery Foundation (AAO-HNSF), it was demonstrated that a behind-the-ear (BTE) hearing aid sold by direct mail offered a reasonable low-cost hearing solution to those who are not using hearing aids or other amplification devices because of cost concerns. The researchers found that the hearing aid met the acoustic targets. In addition, all participants demonstrated user satisfaction scores that were within the standard range for consumers with mild to moderately-severe hearing loss.

In one of the few clinical studies6 on 15 consumers, the researchers compared the real-ear response provided by traditional hearing aids to the closest matching fixed-format disposable hearing aids in consumers with precipitous high-frequency hearing loss. The results revealed that relatively close approximations to the real-ear aided responses of the traditional hearing aids were possible for most participants. No significant differences in mean performance for aided speech recognition or field ratings of aided performance were found. Patient satisfaction was lower for disposable hearing aids probably due to fit and comfort and deep insertion of the hearing aid.

As indicated, our clinical knowledge of direct-mail or OTC hearing aids is based on fewer than 30 consumers and our consumer knowledge is based on fewer than 200 subjects (with only demographic information on the subjects for the latter).


The purpose of this study is to expand our knowledge of the hard-of-hearing population who are the users of direct-mail hearing aids. Specifically, it explores the nine issues comparing a large sample of direct-mail consumers versus a nationally representative sample of traditional hearing aid consumers who had owned their hearing aids from 6 months to 3 years:

1) Demography;

2) Hearing loss characteristics;

3) Factors influencing first-time purchase;

4) Behavioral outcomes including hearing aid usage patterns, whether they would recommend hearing aids and repurchase their hearing aid;

5) Detailed consumer satisfaction ratings on benefit, value, product features, sound quality, and the hearing health professional or direct-mail firm staff;

6) Multiple environmental listening utility (MELU);

7) Estimates of the ability of the hearing aid to reduce their hearing handicap;

8) Quality of life changes that the consumer attributes to their use of a hearing aid; and

9) Positioning of direct-mail hearing aids within the traditional market based on degree of best practices used in fitting the hearing aid.

In this paper, the term traditional hearing aid fittings specifically refers to the fact that the hearing aids were prescriptively fitted in-person in an office or clinic by an audiologist or hearing instrument specialist to compensate for a consumer’s hearing loss. The author is not referring to the earmold, since the hearing industry in recent years has moved away from custom earmolds in favor of small thin-tube open-fit or receiver in the canal (RIC) BTE hearing aids,8 and about one-quarter (26%) of hearing aids in the direct-mail sample used what would be viewed by professionals as “custom earmolds.”


The author developed a tracking survey of the hard-of-hearing population and hearing aid market in 1988 titled MarkeTrak. The MarkeTrak survey was administered periodically, with six extremely detailed surveys being conducted in 1991, 1994, 1997, 2000, 2004, and 2008. The latter two surveys were conducted while at the Better Hearing Institute, Washington, DC. The methodology has never varied from the 2008 survey method described below.

Over the 20-year period of this tracking survey, various items were included in each survey to research specific issues about  hard-of-hearing persons or hearing aids. The full body of research emanating from this longitudinal survey currently resides on the Better Hearing Institute website (

The present study compares data from  MarkeTrak surveys (normative sample) and from a recent survey of direct-mail hearing aid users. 


Figure 1. Direct-mail survey respondents: hearing aid purchase experience.


Normative sample (MarkeTrak). In November and December 2008, a short screening survey was mailed to 80,000 members of the National Family Opinion (NFO) panel.  The NFO panel consists of households that are balanced to the latest US Census information with respect to market size, age of household, size of household, and income within each of the 9 census regions, as well as by family versus non-family households, state (with the exception of Hawaii and Alaska), and the nation’s top 25 metropolitan statistical areas. The screening survey, which was completed by close to 47,000 households, helped identify consumers who were hearing aid owners. In January 2009, an extensive 7-page survey was sent to the total universe of hearing aid owners in the panel database; 3,174 completed surveys were returned representing an 84% response rate. It should be noted that this unusually high response rate to such a lengthy survey is partly due to the fact that the panel was recruited to specifically participate in surveys for incentives and the topic, hearing loss and hearing aids, was specifically targeted to people who had previously admitted to their hearing loss.

The data presented in this normative sample refer only to households as defined by the US Bureau of Census; that is, people living in a single-family home, duplex, apartment, condominium, mobile home, etc.  Institutionalized people living in institutions are not included in this sample. The full MarkeTrak survey can be found on the BHI website.7

Including hearing aids prescriptively fitted only through traditional channels (direct mail were excluded) within the time frame of 6 months to 3 years, the resulting sample size was 1,721. During this time frame, approximately 94% of the hearing aids sold were digital and 6% analog.8

Direct-mail sample. A nationally representative sample of all direct-mail consumers is not available and would be extremely difficult to obtain. Thus, the direct-mail consumers  studied were the customers of Hearing Help Express, DeKalb, Ill, which claims to be the largest US direct-mail hearing aid firm, with close to 30 years of experience. The firm provided the author with the complete population of customers (anonymous ID# in an Excel file) who purchased hearing aids in the previous 6 months to 3 years as of July 2013. In turn, a random sample of consumers was selected and the customer IDs were supplied to Hearing Help Express, which then mailed out a 6-page MarkeTrak-type survey to these randomly selected customers. To motivate participation, the envelope was clearly labeled as a hearing aid satisfaction survey (versus a direct-mail catalog), and the letter from the Chairman of the Board of Hearing Help Express did not solicit favorable responses. He also assured consumers that their surveys were completely anonymous and would be processed and analyzed by completely independent sources. A free package of batteries was offered as an incentive to participate in the survey.

The surveys were returned to Hearing Help Express and then delivered unopened to a data entry firm in the Chicago area. Under no circumstance were the surveys viewed by Hearing Help Express, and at no time did Hearing Help Express participate in the processing, data entry, or analysis of the data. All surveys were confidential. The battery incentive card included in the returned envelopes was delivered by the data processing firm to Hearing Help Express for redemption. A notarized letter confirming the anonymity and integrity of the data entry process is on record with the author and with Hearing Help Express.

Considering usable surveys, the sample size achieved was 2,332, representing a 16% return rate. It should be noted in 15 years of household political polling, mail surveys with a 20% response were shown to be more accurate than telephone surveys with a 60% response rate. In addition, extraordinary efforts (follow-up, pre-notification, incentives) to increase response rates in a telephone survey from 36% to 61% yielded virtually identical results in one study in 1997. A replication of this study in 2003 yielded the same results. A meta-analysis of previous survey research has shown that higher response rates do not necessarily reduce bias in the survey, and that response rates have at most a modest effect on survey accuracy. 9-11

Hearing Help Express offers a full line of hearing aids: ITC, ITE, power BTE, and thin-tube BTE with a range of full-on gain of 17-66 dB and maximum SSPL90 range of 103-131 dB. During this time frame, approximately 95% of the hearing aids sold were analog and 5% digital. In addition, 26% of the hearing aids had custom earmold impressions provided by the consumer through the mail. All products had a volume control and frequency response consistent with the most common hearing aid fittings. Some had high- and low-cut tone controls, MPO adjustments, a telecoil, directional microphones, and pre-programmed acoustic settings that the consumer could switch manually, depending on the listening situation. Consumers received a catalog with information to help them self-assess the amount of amplification they needed together with suggested hearing aids corresponding to needed amplification. Customers self-selected their preferred hearing aid style, features, and price. Each customer received instruction manuals for their hearing aid that included directions for adapting to the hearing aid. All customers had essentially unlimited access to licensed hearing aid dispensers for recommendations, and all received a “free home trial” and 100% money-back guarantee.


  Kochkin tble_1

Table 1. Demography of owners of direct-mail and traditional hearing aids. Difference in practical significant (>10 percentage points) noted by colored cells. Green = in favor of direct-mail; blue = in favor of traditional. *Includes free custom hearing aids from VA.


Table 1 documents the demography of the direct-mail and traditional hearing aid consumer samples. The direct-mail consumer is more likely to be male (73.6% versus 59.2%), is older on average by 5.5 years, and more likely to be 75 years or older (68.6% versus 50.7%). The direct-mail consumer is also more likely to be retired (81.6% versus 70.7%), to have a household income less than $26,000 (38.1% versus 23.9%), and more likely to have an education of high school graduate or less (50.1% versus 31.7%).

A total of 43.4% of direct-mail hearing aid users are first-time users, compared to slightly more than 47% for traditional hearing aid users. Nearly half of direct-mail customers were previous traditional hearing aid users (45.3%), 5.6% had previously tried over-the-counter hearing aids, and about one-fifth (18.8%) were previous customers of other direct-mail firms (Figure 1). The direct-mail consumer has been a hearing aid user significantly longer than the traditional hearing aid user (14.2 versus 9.6 years).

The main style of hearing aid used by direct-mail customers is the larger BTE hearing aid with an earmold or eartip (37.8% versus 21.2%). Considering slim-tube BTEs, nearly 6 out of 10 direct-mail consumers use BTE hearing aids compared to nearly 45% for the traditional users; however, since this 2008 MarkeTrak data was published, traditional hearing aid dispensers now fit far more BTEs, including slim-tube and receiver-in-the-canal, than any other style (73.5% in Q3 2013). The direct-mail consumer is more likely to purchase one hearing aid (45%) than the traditional hearing aid consumer (22%). The median out-of-pocket cost per hearing aid for the direct-mail customer is $299 compared to $1,500 for the traditional user; the latter price includes discounts due to third-party pay and free hearing aids from the Veterans Administration.

Hearing Loss Demography

Kochkin tble_1

Table 2. Hearing loss characteristics of owners of direct-mail and traditional hearing aids. Difference in practical significant (>10 percentage points) noted by colored cells. Green = in favor of direct-mail; blue = in favor of traditional.


Table 2 compares the subjective degree of hearing loss of direct-mail and traditional hearing aid users. Subjective measures of hearing loss captured in the MarkeTrak survey are described in the last MarkeTrak survey2 and rely on: the number of ears impaired (1 or 2), score on the 8-point Gallaudet Scale,12 subjective hearing loss score (mild to profound), difficulty hearing in noise (a 5-point scale based on the work of Plomp13), and the BHI Quick Hearing Check based on the revised American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) 5-minute hearing test.14,15

Direct-mail hearing aid owners are less likely to report having a bilateral loss (82.9% versus 88.5%), are more likely to have a perceived loss of severe to profound (45.6% versus 38.2%), have more difficulty hearing normal speech across a room without visual cues (71% versus 62%), have equal difficulty hearing in noise (“quite difficult” to “extremely difficult”), and are more likely to score in the top quartile (75th percentile) of the BHI Quick Check (58.8% versus 44.4%). Their estimated pure-tone average (predicted from the BHI Quick Check hearing check15) is 54.6 dB compared to 52.5 dB for the traditional consumer. They are also roughly equivalent in terms of the years they waited to get hearing aids once they learned of their hearing loss (median years = 4 and 3, respectively).

Kochkin table_3

Table 3. Factors influencing first-time hearing aid users to purchase hearing aids. Difference in practical significant (>10 percentage points) noted by colored cells. Green = in favor of direct-mail; blue = in favor of traditional.


In Table 3, the direct-mail and traditional first-time users are compared on 22 factors that influenced their hearing aid purchase. Focusing only on the most important differences (10 percentage point differences or more), the direct-mail consumer is more likely to be influenced by the price of the hearing aid (61% versus 5%), magazine advertisements (26% versus .3%), direct-mail pieces (25% versus 3%), hearing loss literature (23% versus 3%), and the opinions of other hearing aid owners (22% versus 8%).   


Kochkin Table_4

Table 4. Behavioral outcomes: owners of direct-mail and traditional hearing aids. Difference in practical significant (>10 percentage points) noted by colored cells. Green = in favor of direct-mail; blue = in favor of traditional.


Behavioral outcomes. Four behavioral variables were surveyed and are documented in Table 4: How often the person wears their hearing aid in a typical day and whether they recommend hearing aids, the person who fitted their hearing aid, and whether they would repurchase their current brand of hearing aid.

Direct-mail and traditional hearing aid owners both wear their hearing aids on average more than 9 hours per day. Although none of the factors rise above our 10 percentage point criterion, the data suggest that the direct-mail owner is slightly less likely to place their hearing aid in the drawer (3% versus 8.2%), and more likely to recommend hearing aids to others (91% versus 82%), recommend the professionals at the direct-mail firm over a licensed dispenser (84% versus 75%), and have greater brand loyalty for their hearing aid than traditional consumers (55% versus 47%).

Consumer Satisfaction. Consumers were asked to rate their experience with their hearing aid on a 7-point Likert scale with scale points ranging from very satisfied (7) to very dissatisfied (1). Ratings were captured in 5 key areas: overall experience (3 factors), product features (11), sound quality and signal processing (11 factors), hearing health professional or DM staff (8), and multiple environmental listening utility or MELU (19 listening situations).

Kochkin table_5

Table 5. Consumer satisfaction with direct-mail and traditional hearing aids. Difference in practical significant (>10 percentage points) or 1/2 of a Likert scale point noted by colored cells. Green = in favor of direct-mail; blue = in favor of traditional.


Figure 2. Consumer satisfaction on overall satisfaction, benefit, value, and fit & comfort comparing traditional and direct-mail hearing aids.


In Table 5 and Figure 2, direct-mail and traditional hearing aids are nearly equivalent on overall satisfaction and perceived benefit by the consumer. However, the direct-mail consumer rates their hearing aid significantly higher on value (79% versus 65%). Toward the end of this report, the author will demonstrate the value proposition as the amount of dollars the consumer paid for every percentage-point reduction in their hearing handicap.

With respect to product features, direct-mail and traditional hearing aids are statistically equivalent on ease of battery change, reliability, frequency of cleaning, warranty, and ongoing expense. Again focusing on practical significance (10+ percentage points or at least a 1/2 Likert scale point), traditional hearing aids receive higher ratings on fit & comfort (87% versus 83%, see Figure 2) while direct-mail hearing aids are rated higher on battery life (82% versus 72%) and ease of volume adjustment (76% versus 60%).

With respect to the all-important sound quality ratings, direct-mail and traditional hearing aids are statistically equivalent on clarity of tone/sound, sound of voice, natural sounding, directionality (ability to localize sound), and sound of chewing/swallowing. While the traditional hearing aids are rated statistically higher on 6 factors, none of these differences is practically significant at the cut-off of 10 percentage points or more. The highest difference is seen on ability to hear soft sounds (+8%), comfort with loud sounds (+7%), and performance in noisy situations (+6%). The latter is graphed in Figure 3, where it can be seen nearly 30% of hearing aid users are dissatisfied with their direct-mail and traditional hearing aids in noisy situations. A factor analysis of the 11 sound quality variables revealed one underlying factor; thus, the average of these ratings is plotted in Figure 3 as “overall sound quality.” Traditional hearing aids are rated better overall on sound quality (70% versus 64%), but only by a margin of 6 percentage points, which is quite remarkable considering this is a digital-to-analog comparison.


Figure 3. Consumer satisfaction on overall sound quality, performance in noise, and one-on-one situations comparing traditional and direct-mail hearing aids.



Figure 4. Distribution of MELU scores comparing direct-mail and traditional hearing aids. MELU is defined as the percent of situations where the consumer indicated they were satisfied or very satisfied in up to 19 situations important to them.

The hearing care professional was rated statistically higher on all measures if the hearing aid was traditional versus direct-mail, with quality of service during the fitting process being most significant (93% versus 76%).

Multiple Environmental Listening Utility (MELU). People with hearing loss purchase hearing aids to enhance their ability to communicate in or enjoy many listening situations varying from one-on-one in quiet to noisy situations with many people (such as a family celebration) to musical appreciation. The utility of a hearing aid is its ability to help a hard-of-hearing person reclaim their ability to hear in as many listening situations as possible.

MarkeTrak measures satisfaction in 19 listening situations, only if the situation is important to the consumer. Table 5 documents consumer satisfaction in these 19 listening situations. Traditional hearing aids are rated statistically higher in all 19 listening situations and achieve practical significant ratings in five listening situations: large group (+19%), leisure activities, telephone, concert/movie, and cell phone (all +10%). 


Figure 5. Hearing handicap improvement in percent comparing traditional and direct-mail hearing aid owners.



At the bottom of Table 5 are their respective MELU median percentages, with the sample distributions plotted in Figure 4. This measure indicates the percent of consumer-relevant situations in which the individual was “very satisfied” or “satisfied.” In the author’s opinion, a MELU figure quantifying situations where the consumer was satisfied or higher is most important, since “somewhat satisfied” has been shown earlier to be nearly equivalent to a “neutral” rating and  contributes nothing to consumer loyalty.16 Traditional fittings are shown to be notably superior to direct-mail hearing aids on multiple environmental listening utility (63% versus 41%).

It should be noted, as shown in Figure 4, that for both direct-mail and traditional consumers the two biggest segments of consumers are those who report satisfaction in all listening situations and in no situations. In fact, more than 1 in 5 direct-mail consumers report little utility of the hearing aid in no situation using this rigorous metric (satisfied or very satisfied). A sizable portion (17%) of the traditional consumer segment reports poor utility using this metric.

Kochkin table_6

Table 6. Perceptions of percent hearing handicap reduction due to direct-mail and traditional hearing aids.


Hearing handicap reduction. The consumer was presented with the 10 listening situations detailed in Table 6 and was asked to rate them on a scale of 0% to 100% the “percent of time your hearing problem has been resolved due to the use of your hearing aids.” Participants were instructed not to respond if they did not participate in the particular listening situation.

A comparison of average handicap reduction in these 10 listening situations for direct-mail and traditional hearing aid consumers is documented in Table 6. A factor analysis of consumer perceptions of hearing handicap improvement in these listening situations determined that there was only one factor in the ratings. Thus, the average benefit score is also documented. Direct-mail hearing aids and traditional fittings provide equivalent benefit according to the consumer in business meetings, while watching TV, in places of worship, while talking on the telephone, in small gatherings, and while engaging in conversations in quiet. Traditional fittings are statistically superior in restaurants, at large public lectures, and in conversations on the street. Direct-mail hearing aid owners report higher ratings while listening to music. But none of these differences exceeds a 7 percentage point differential. On average, consumers report that traditional fittings and direct-mail hearing aids reduce their hearing handicap slightly more than 50%, and only conversation in quiet approaches a 70% hearing handicap reduction. 

Figure 5 shows the distribution of hearing handicap improvement for the traditional and direct-mail samples. It should be acknowledged that 17.4% of traditional consumers report trivial hearing handicap reduction (<20%) compared to 11.9% of direct-mail consumers. In contrast, 25.1% of traditional consumers experience spectacular hearing handicap reduction (>80%) compared to 17% of direct-mail consumers.

Quality of Life changes associated with hearing aid usage.With respect to quality of life (QOL), the consumer was asked to “rate the changes you have experienced in the following areas, that you believe are due to your hearing aids.” The 14 quality of life areas assessed were based on a 5-point scale from “a lot better” to “a lot worse”:

1) Emotional health

2) Mental ability-memory

3) Physical health

4) Relationships at home

5) Relationships at work

6) Social life

7) Feelings about yourself

8) Ability to participate in group activities

9) Sense of independence

10) Sense of safety

11) Confidence in yourself

12) Sense of humor

13) Romance in my life

14) Overall ability to communicate more effectively in most situations

In addition, the consumer was asked to rate how satisfied (7-point Likert scale) they were with the changes they have experienced in their life specifically due to hearing aid use. A factor analysis of the 14 quality of life factors yielded one factor. The range of QOL changes for the direct-mail sample ranged from a high of 66% for effectiveness of communication to a low of 22% for changes in physical health. The range of QOL changes for the traditional sample ranged from a high of 65% for effectiveness of communication to a low of 21% for changes in physical health. Both samples are basically equivalent in their reporting of quality of life changes due to amplification.

Summary of Findings

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Table 7. Outcome summary:  differences between direct-mail and traditional hearing aids


In Table 7, the differences between direct-mail and traditional hearing aids are summarized showing differences that were equivalent, statistically significant, and practically significant (ie, differences were at least 10 percentage points or 1/2 Likert scale point). Of the 82 factors presented earlier, direct-mail and traditional hearing aids are equivalent on 32 factors, direct-mail hearing aids were rated significantly higher on 9 factors, and traditional hearing aids were rated higher on 41 factors. However, when considering practical significance (10 percentage points or 1/2 Likert scale point), direct-mail and traditional hearing aids were shown to be nearly equivalent on 72 factors; direct-mail customers had superior ratings on 2 factors and traditional hearing aids had superior ratings on 8 factors. 


Figure 6. Quality of life changes attributed to hearing aids by hearing aid owners comparing direct-mail (DM) and traditional hearing aid fittings ranked by best practices (BP1-BP10). Ten levels of best practices are expressed in deciles, where BP1=minimal hearing aid fitting protocol, BP5=average protocol (50%), and BP10=comprehensive protocol compared to direct-mail.



Figure 7. Overall success with hearing aids comparing direct-mail (DM) and traditional fittings ranked by best practices (BP1-BP10). Success = linear composite of benefit, usage, utility, positive attitudes toward hearing aids and quality of life changes with mean=5 and std=2. Ten levels of best practices are expressed in deciles, where BP1=minimal hearing aid fitting protocol, BP5=average protocol (50%), and BP10=comprehensive protocol compared to direct-mail. 


Positioning Direct-mail Hearing Aids in Hearing Healthcare

Earlier MarkeTrak studies demonstrated that there is an intimate relationship between perceived benefit and consumer perceptions of changes in quality of life,17 and indicated that best practices employed by the hearing healthcare professional are key drivers of real-world consumer success with hearing aids.18 A study of more than 16,000 Abbreviated Profile of Hearing Aid Benefit (APHAB) profiles—the absolute benefit divided by the unaided hearing handicap, and not including the aversiveness of noise (AV) scale—across 36 studies conducted between 1989 and 2000 by the author estimated that consumers experienced a 44% reduction in their hearing handicap when using analog hearing aids.19 As noted earlier, hearing handicap reduction has improved in a generation perhaps by only 10%, despite the fact that hearing aids in the traditional hearing aid market are nearly all digital. The following was learned from earlier studies:

  • Price is not related to consumer success or happiness. But value—where value is expressed as how much the consumer paid for every percentage-point reduction in  hearing handicap—is a key driver of consumer satisfaction. This means consumers are rationally willing to trade-off incremental changes in benefit for substantial reductions in price.
  • Higher levels of benefit are associated with higher levels of QOL changes.
  • Higher levels of consumer success with amplification are related to comprehensive best practices protocols.

There is evidence that there are diminishing returns in the form of hearing handicap reduction even when we employ the very best comprehensive hearing aid fitting protocol. In all likelihood, this is due to the consumer’s residual hearing and the fact that hearing aids per se do not offer the consumer a complete solution for many difficult listening situations due to poor signal to noise.

To understand how direct-mail hearing aids are positioned in the marketplace, note a few key issues:


Figure 8. “Value” expressed as median dollars spent for each percentage-point reduction in hearing handicap. Ten levels of best practices are expressed in deciles, where BP1=minimal hearing aid fitting protocol, BP5=average protocol (50%), and BP10=comprehensive protocol compared to direct-mail.



Best Practices (BP) Index. In an earlier study on the impact of the hearing healthcare provider on hearing aid user success,17,18 aspects of the hearing aid fitting protocol were weighted based on their relationship to real-world success. An overall index of best practices was standardized to a z-score with a mean of 5 and standard deviation of 2 (stanine scores). In this study, the stanine scores were converted to percentile rankings and then grouped into 10 levels of best practices in deciles, where BP1 = a minimal hearing aid fitting protocol (10%), BP5 = an average  protocol (50%), and BP10 = a comprehensive protocol (100%), compared to direct-mail (DM). Hearing healthcare providers with minimal hearing aid fitting protocols were shown earlier to be less likely to use a sound booth, use real-ear measurement to verify the hearing aid fitting, use validation techniques, or provide aural rehabilitation services. The reader is referred to previous studies documenting hearing healthcare professional fitting behaviors for each of the best practices deciles.17,18

Direct-mail hearing aids are devoid of most aspects of a hearing-aid fitting protocol, including verification and validation, loudness discomfort measures, use of a sound booth to measure hearing loss, face-to-face counseling/orientation, and aural rehabilitation. However, consumers do self-verify their hearing aid selection by their action of keeping, exchanging, or returning the hearing product they ordered. Direct-mail customers are empowered to judge for themselves the quality of the device they are trying, and many are counseled by mail and/or by telephone about how to adjust switches and controls, and encouraged to try alternative products if the first selection does not seem appropriate.

Most direct-mail hearing aids are basic amplifiers with high-frequency emphasis and some modest consumer customization through selection of hearing aid style and the availability of basic controls, such as a volume control, trimmers, and directional microphones—but they are not prescriptively fitted to compensate for a person’s unique hearing loss. So it is of interest to understand how this segment of the marketplace, designated as DM in graphs to follow, performs compared to the 10 best practices groups (BP1-BP10).

Overall Quality of Life (QOL). The reader will recall that direct-mail and traditional fittings are basically equivalent considering consumer ratings of their hearing handicap improvement and quality of life changes associated with amplification. Figure 6 plots quality of life changes attributed to hearing aids by hearing aid owners segmented by best practices ranking scored in percentiles (eg, BP1 = lower 10%, BP10 = top 10%) compared to direct-mail (DM) hearing aids. Three out of four consumers experiencing the highest level of best practices (BP10) report their life is “better” or “a lot better” due to their amplification, while only 14% of consumers in BP1 (the lowest best practice group) report positive life changes. In comparison, 46% of the direct-mail consumers report positive changes in their lives, higher than QOL changes reported in the bottom 50% of best practices groups (BP1-BP5).

Overall success index. A composite measure of hearing aid user success was derived using principle components factor analysis of the following 9 outcome variables; only the first factor was chosen. (For the technically inclined, this represents 3.83 Eigenvalues, which is 43% of the common variance.) The correlation with the underlying factor (hearing aid user success) is shown in parentheses, with higher values signifying greater correlation to overall success:

1) Satisfaction with improvements in quality of life (.85);

2) Satisfaction with achieved benefit (.80);

3) MELU in 19 listening situations in which the consumer was satisfied or higher (.71);

4) Average quality of life change score (.64);

5) Average hearing handicap improvement (.61);

6) Would repurchase their hearing aid brand (brand loyalty) (.60);

7) Would recommend hearing aids to others (positive-word-of mouth) (.59);

8) Would recommend the hearing health professional or DM staff (.59), and

9) Hours hearing aid worn per day and hearing aids in the drawer (.34)

The output factor score (overall success score) was standardized to a z-score with a mean of 5 and standard deviation of 2 (stanine scores). Mean total success scores are shown in Figure 7. As documented in previous publications,17,18 there is a strong relationship between best practices and overall real-world success. Consumers experiencing minimal best practices (BP1) report a success score of 1.74, which is more than one standard deviation below the mean, while consumers who experience the absolute best protocols (BP10) report a success score of 6.91, which is one standard deviation above the mean. Direct-mail consumers report an overall real-world success score of 4.97, equal to the average best practice segment (BP5) and superior to the lower best practices segments (BP1-BP4).

Value index. Consumers are rational. They look for the greatest value. For the hard-of-hearing person, the key question is “How much of my hearing problem is solved relative to how much money I have spent?” A three-dimensional model based on 16,000 consumers  previously showed the following19:

  • Price divided by hearing handicap reduction (value) is strongly related to consumer satisfaction.
  • Consumers are willing to pay high prices for hearing aids if they get substantial benefit.
  • You cannot generate happy consumers even with free hearing aids if they get no benefit.
  • The most coveted hearing aid product sought by the consumer is a free hearing aid that completely restores their hearing to normal.

Using the same methodology, the out-of-pocket cost for the hearing aid system, taking into account whether the consumer was binaurally or monaurally fitted, was calculated. Next, the total price was divided by the consumer’s estimated hearing handicap reduction scores, yielding the dollars paid for each percentage point change in hearing handicap reduction. The value scores for the 10 best practice segments and the direct-mail segment are plotted in Figure 8. Value is highly related to best practices. The lowest best practices segments (BP1-BP2) cost the consumer $66 for every percentage-point reduction in hearing handicap, while the best practices groups (BP8, BP10) are half this cost. The highest value is the direct-mail segment at about $11 for every percentage point reduction in hearing handicap.

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Figure 9. Overall consumer success with hearing aids by value, where value is expressed as the median dollars spent for each percentage-point reduction in hearing handicap. Ten levels of best practices are expressed in deciles, where BP1=minimal hearing aid fitting protocol, BP5=average protocol (50%), and BP10=comprehensive protocol compared to direct-mail.


Finally, a plot of value and overall real-world success with hearing aids is shown in Figure 9. Direct-mail hearing aids are positioned as high-value products delivering “about average” real-world success compared to the traditional hearing aid market.


This study set out to determine if non-prescriptive basic hearing aid amplification through the mail has the ability to satisfy consumers, reduce their hearing handicap by providing them with benefit, and therefore positively impact their quality of life. Given the substantial sample sizes in this study, it is easy to achieve statistically significant differences when comparing traditional and direct-mail consumers. Thus, the author focused on practical differences between the groups. The key findings with relevant commentary are as follows:

1) Nearly half (45.3%) of direct-mail consumers have previously tried or owned traditional hearing aids.

2) The direct-mail consumer has a hearing loss profile not dissimilar from the typical traditional hearing aid consumer.

3) The direct-mail user is older, is more likely to be retired, has a lower income, is a more experienced hearing aid user, and is more likely to wear only one hearing aid.

4) The direct-mail consumer wears their hearing aid more than 9 hours a day, the same as the traditional hearing aid consumer, although direct-mail consumers are slightly less likely to place their hearing aid in the drawer (3.0% versus 8.2%).

5) The out-of-pocket price per hearing aid to the direct-mail consumer is only 20% of the price in the traditional market. Not surprisingly, the #1 motivator to purchase direct-mail hearing aids by first-time users is price (56% of direct-mail first-time users). In a previous study by this author, hearing aid insurance coverage was rated as the #1 influence of future purchase intent among hard-of-hearing people who had not purchased hearing aids. In fact, nearly half of hard-of-hearing non-adopters with serious hearing loss indicated they would purchase a hearing aid within the next 2 years if the hearing aids were priced under $500.20 In the MarkeTrak VII series, it was shown that price was a significant barrier of accessibility to hearing healthcare. Half of non-adopters with the most severe hearing loss indicated they could not afford hearing aids. An analysis of  household income confirmed that their  income was lower by up to $40,000 compared to people who indicated affordability was not a barrier to hearing aid adoption.21 

6) From the consumer’s perspective, direct-mail and traditional hearing aids provide equivalent benefit and quality of life changes from the use of amplification. This is in agreement with the results of a clinical study6 comparing disposable and traditional hearing aids (although in this clinical study the disposable product offered greater flexibility with 7 fixed electroacoustic configurations).

7) Direct-mail consumers are more likely to have positive attitudes toward their hearing aids than traditional consumers, as evidenced by their brand loyalty and willingness to recommend hearing aids to others. However, traditional hearing aids provide superior multiple environmental listening utility (MELU), but not enough to impact overall satisfaction ratings, which are highly driven by perceptions of value.

8) Given the equivalence of perceived benefit, direct-mail hearing aids provide the consumer with high value compared to traditional fittings—especially for those consumers who had their hearing aids fitted in settings utilizing below-average best practices. However, for traditional hearing aid fittings, the value proposition to the consumer doubles when their hearing aids are fitted in practices utilizing comprehensive hearing aid fitting protocols.

In general, it appears that most hard-of-hearing consumers can be satisfied with a hearing aid, but significantly more satisfied if all best practices are employed by the hearing professional in the clinic or office. Satisfaction from direct-mail purchases exceeds that from offices where best practices are not followed. The key factor in success appears to be improved audibility—a conclusion that has been reached repeatedly over the last 50 years by respected thought leaders in the field of hearing. ?


This publication was made possible by a grant from Hearing Help Express, DeKalb, Ill, which in advance stated that all analysis of its customer satisfaction, benefit, and quality-of-life data could be published without exception or interference. The author thanks Mead Killion, PhD, and Gail Gudmundsen, AuD, of Etymotic Research, Elk Grove Village, Ill, for reviewing and making valuable suggestions to the manuscript.


1. Kochkin S. MarkeTrak VIII: Utilization of PSAPs and direct-mail hearing aids by people with hearing impairment. Hearing Review. 2010;17(6):12-16.

2. Kochkin S. MarkeTrak VIII: 25 year trends in the hearing health market. Hearing Review. 2009;16(11):12-31.

3. Kimball SH, Yopchick S. Study compares hearing aids fitted online with clinical fittings on the same subjects. Hearing Journal. 2009;62(3):44-46.

4. Kasper CA, Spitzer JB, Rodriguez H. Mail-order hearing aids and patient safety: a case study. Hearing Journal. 1999;52(7):41-44.

5. Hearing Review. Small Study Presented at AAO-HNSF Positively Evaluates OTC Device. October 2, 2012. /all-news/20680-clarification-small-study-presented-at-aao-hnsf-positively-evaluates-otc-device.

6. Walden TC, Walden BE, Cord MT. Performance of traditional versus fixed-format hearing aids for precipitously sloping high-frequency hearing loss. J Am Acad Audiol. 2002;13:356-366.


8. Hearing Industries Association, Washington, DC.

9. Groves RM. Nonresponse rates and nonresponse bias in household surveys. Public Opinion Quarterly, 2006;70(5):646–675. Special issue.

10. Groves RM, Peytcheva E. The impact of nonresponse rates on nonresponse bias: a meta-analysis. Public Opinion Quarterly. 2008;72(2):167-189.

11. Radwin D. High response rates don’t ensure survey accuracy. The Chronicle Review, October 5, 2009. Washington, DC: The Chronicle of Higher Education.

12. Schein JD, Gentile A, Haase KW. Development and evaluation of an expanded hearing loss scale questionnaire. National Center for Health Statistics. Vital Health Statistics. 1970;2(37).

13. Plomp R. Auditory handicap of hearing impairment and the limited benefit of hearing aids. J Acoust Soc Am. 1978;63:533-549.

14. Koike J, Hurst MK, Wetmore SJ. Correlation between the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) five minute hearing test and standard audiologic data. Otolaryngol Head Neck Surg. 1994;111(5):625-632.

15. Kochkin S. Bentler R. The validity and reliability of the BHI Quick Hearing Check. Hearing Review. 2010;17(12):12-28.

16. Kochkin S. MarkeTrak VIII: Customer satisfaction with hearing aids is slowly increasing. Hearing Journal. 2010;63(1):11-19.

17. Kochkin S. MarkeTrak VIII: Consumers report improved quality of life with hearing aid usage. Hearing Journal. 2011;64(6):25-32

18. Kochkin S, Beck D, Christensen L, Compton-Conley C, Fligor B, Kricos P, McSpaden J, Mueller G, Nilsson M, Northern J, Powers T, Sweetow R, Taylor B, Turner R. MarkeTrak VIII: The impact of the hearing healthcare professional on hearing aid user success. Hearing Review. 2010;17(4):12-34.

19. Kochkin S. MarkeTrak VI: On the issue of value: hearing aid benefit, price, satisfaction and brand repurchase rates. Hearing Review. 2003;10(2):12-25.

20. Kochkin S. MarkeTrak VIII: The key influencing factors in hearing aid purchase intent. Hearing Review. 2012;19(3):12-25.

21. Kochkin S. MarkeTrak VII: Obstacles to adult non-user adoption of hearing aids. Hearing Journal. 2007;60(4):27-43.

About the author

Dr. Sergei Kochkin has 25 years experience in the hearing healthcare industry as past Executive Director of the Better Hearing Institute in Washington DC and Director of Market Development & Market Research at Knowles Electronics, a supplier of components to the hearing aid industry. The author can be reached at [email protected].

Original citation for this article: Kochkin, S. A comparison of consumer satisfaction, subjective benefit, and quality of life changes associated with traditional and direct-mail hearing aid use. Hearing Review. 2014;21(1):16-26.