Research and Technology

Paper

The Hearing Aid Effect 2005: A Rigorous

Test of the Visibility of New Hearing Aid Styles
Carole E. Johnson
Auburn University, Auburn, AL

Jeffrey L. Danhauer
University of California, Santa Barbara

Reid B. Gavin
Summer Raye Karns
Amber C. Reith
Auburn University, Auburn, AL

Ilian Priscilla Lopez

University of California, Santa Barbara

Purpose: The visibility of open ear (OE) styles of

hearing instruments was rigorously investigated
for their potential to reduce the stigma of
wearing hearing aids.
Method: Three groups of 50 young adults
(150 total) rated the visibility of 6 hearing
aid stylesOE, invisible completely-in-thecanal (CIC), mini in-the-canal (m-ITC), halfand full-shell in-the-ear (ITE), and behind-theear (BTE)worn by a peer model with
revealing hairstyle, photographed from

he stigma of wearing hearing aids continues to

be a major reason why people with hearing loss
do not pursue amplification. Several studies have
demonstrated the hearing aid effect (Blood, Blood, &
Danhauer, 1977) or stigma that various groups of observers
have attributed to persons shown wearing hearing instruments. These investigations have involved photographs of
preschool children with normal hearing and speaking
abilities who were rated by audiologists and speechlanguage pathologists (Danhauer, Blood, Blood, & Gomez,
1980); school-age hearing aid wearers rated by their peers
(Dengerink & Porter, 1984); school-age hearing aid
wearers who were normal hearing, hard of hearing, and
deaf rated by college students (Blood, Blood, & Danhauer,
1978); and elderly persons rated by college students
and their peers (Johnson & Danhauer, 1982; Johnson,
Danhauer, & Edwards, 1982; Mulac, Danhauer, & Johnson,
1983). Ratings in those studies were based solely on the
American Journal of Audiology

Vol. 14

2 ft and at 3 different angles (458, 908, and

1358).
Results: CIC was rated significantly most
invisible at 458 and 908, OE and m-ITC were
next at those angles, and OE and BTE were
least invisible at 1358.
Conclusions: The findings have implications
for counseling potential users who are reluctant
to try hearing aids for cosmetic reasons.
Key Words: stigma, open ear hearing aids

visual presence and size of hearing aids because

observers had no prior interaction with or knowledge of
the participants depicted in the photographs.
In addition to their acoustic benefits for certain hearing
losses, completely-in-the-canal (CIC) hearing aids were
introduced by the hearing aid industry, in part, as a solution for the hearing aid effect. As one of several studies
completed to assess the market impact of CIC hearing
aids, Kochkin (1994) disseminated a survey specifically
designed for the CIC market to 2,900 hearing instrument
owners and 3,600 nonowners who were identified as having a
hearing impairment from a screening survey administered
in a previous study. The response rate for both owners and
nonowners was 82%. Respondents were randomly shown
1 of 13 colored photographs of the same male model
wearing different styles of hearing aids, including behindthe-ear (BTE; large and mini), in-the-ear (ITE; full-shell and
half-shell), in-the-canal (ITC; regular and mini), and CIC

169175  December 2005  A American Speech-Language-Hearing Association

1059-0889/05/1402-0169

169

(flesh- and brown-colored at four insertion depths: at the

entrance of the canal, below the entrance, at the first bend,
and deep). The deep-fitting CIC was actually illustrated
by an empty ear, making it truly invisible. A professional
photographer took the photographs from two different
angles: looking directly into the models ear from the side
(908) and from behind (about 1358).
An average of 399 completed forms was received for each
hearing aid condition. Participants provided information
about their hearing loss (i.e., ears affected, self-perception
of loss, and responses to the Hearing Handicap Inventory
for the ElderlyScreening Form; Ventry & Weinstein,
1982) and rated their general intent to purchase hearing aids
within the next 5 years using a 10-point scale ranging from
definitely will purchase to definitely will not purchase. The
participants also indicated their purchase intent and their
impressions of the hearing instrument depicted in the
photographs using 19 seven-point semantic differential
scales (e.g., low technology to high technology).
The results of that study showed that hearing instrument
owners had the highest purchase intent for ITCs (37%) and
next highest for invisible CICs and ITEs (both styles at
33%), while the nonowners had the greatest purchase intent
for the invisible CIC (25.9%) and the brown CIC positioned
around the first bend (27.4%) of the models ear canal.
Apparently, nonowners focused on the visibility of the
devices, whereas owners, perhaps at peace with the hearing
aid effect, based their ratings on their knowledge and
experience with hearing aids. Regarding the overall image
of hearing instruments for both groups of respondents, the
factors most associated with hearing aid size were cosmetics/
stigma (e.g., attractiveness, embarrassment, age image,
and visibility), comfort, nuisance factor, and perceptions
of technology. Thus, Kochkin (1994) concluded that the
20 million individuals with hearing loss who did not own
hearing aids represented a huge market potential for CICs.
A decade has passed since Kochkins study, but CIC
hearing aids have not reached their full market potential.
There are several possible reasons. First, CICs are typically
appropriate for a restricted range of hearing losses in patients
with thresholds better than about 60 dB HL in the lowfrequency regions and better than about 80 dB HL in the high
frequencies (Mueller & Ebinger, 1996; Vol & Jones, 1998).
Second, CICs seem to fit best in ear canals that are round and
of medium-to-firm outer ear texture, and that have
discernible first and second bends and minimal jaw movement in the cartilaginous portion (Vol & Jones, 1998).
Third, a considerable amount of skill and experience is
needed in obtaining deep canal impressions that result in
successful CIC fittings (Johnson & Danhauer, 1997a,
1997b). Further, in order to obtain a successful fit, some
CICs can require remakes and considerable time and
patience from both the patient and the dispenser, which
either or both parties may be unwilling to commit.
In the past few years, several hearing aid manufacturers
have developed new open ear (OE) styles of hearing aids that
use a mini BTE which directs sound through a generic tube
and earpiece situated in an open ear canal. One manufacturers device directs the sound from a mini BTE through a
wire to a generic receiver and/or ear tip positioned in an

unoccluded ear canal. Many of these devices provide all the

advantages of digital circuitry and directional microphones
along with reduction in the occlusion effect and feedback,
and they have promise of wide patient applicability, easy
fit, and cosmetic appeal. Most manufacturers now offer
some variation of the OE styles.
Cosmetic appeal is one of the major benefits of the
OE styles. Thus, prior to widespread acceptance of these
newer OE styles by both professionals and patients, it would
be helpful to know how observers rate the visibility of these
devices compared with other more traditional hearing aid
styles. These ratings should be based on rigorous tests of
visibility using critical and informed raters of a hearing
aid wearer for whom hearing aid use would not usually be
expected. For example, young adults who are typically
sensitive about personal appearance would be ideal to judge
the visibility of various styles of hearing aids worn by a
peer. Further, a rigorous test of visibility should involve
hairstyles, typical ears, and viewing angles that do not
purposely try to conceal the hearing aids. The purpose of this
study was to assess young adult observers impressions of
the visibility of six different hearing aid styles: an OE
representative of the new OE styles mentioned above, an
invisible deep-fitting CIC (df-CIC), a mini ITC (m-ITC), a
half-shell ITE (hs-ITE), a full-shell ITE (fs-ITE), and a
BTE with a skeleton earmold, all representative of more
traditional styles. Each of these hearing aid styles would be
worn by the same peer model with her hair pulled back
and digitally photographed from a close distance (2 ft) and
at 458, 908, and 1358 viewing angles (with 08 being at the
wearers nose). The results of this study have implications
for professionals counseling patients considering various
styles of hearing aids and provide indications of the market
potential for these products.

Method
Observers
Observers were 122 women and 28 men (150 total)
between 18 and 27 years old (M = 21). They were students
recruited from undergraduate classes in the Communication
Sciences and Disorders and Education Departments at
Auburn University and the Department of Speech and
Hearing Sciences at the University of California, Santa
Barbara who volunteered to participate in a study asking
them to rate the visibility of hearing aids in photographs.
The observers were not expected to have any more than
casual training or experience with hearing aids. This
investigation posed minimal risk to participants, and the
Institutional Review Boards at both the University of
California, Santa Barbara and Auburn University approved
the experimental protocol as exempt.

Hearing Aids
A 23-year-old adult female served as the model for the six
styles of hearing aids investigated in the study. Six earmold
impressions taken in the same session were made on the
models right ear and used to order the shells of five styles
of hearing aids and one skeleton earmold for the BTE.

170 American Journal of Audiology  Vol. 14  169175  December 2005

Figure 1. Stimuli used for rating from upper-left to bottom-right: (a) invisible deep-fitting completelyin-the-canal (df-CIC), (b) mini in-the-canal (m-ITC), (c) half-shell in-the-ear (hs-ITE),
(d) full-shell in-the-ear (fs-ITE), (e) open ear (OE), and (f) behind-the-ear (BTE) with a skeleton
earmold, at the 458 angle.

The impressions were all taken as similarly as possible by

the same audiologist, who was an experienced, licensed
hearing aid dispenser, and they were randomly assigned to
the various hearing aid styles to avoid any biases across
aids. Otoscopy was performed before and after each ear
impression. All of the silicon ear impressions were sent to
the same hearing aid manufacturer requesting the following:
(a) a df-CIC, (b) an m-ITC, (c) an hs-ITE, (d) an fs-ITE, and
(e) a skeleton earmold for coupling to a BTE. Although a
df-CIC was made for the model, we adopted Kochkins
(1994) use of an empty ear to represent a truly invisible
df-CIC condition in order to make this evaluation as rigorous
as possible. The manufacturer of the OE device provided
us with complimentary fitting guides, sound processors, and
an array of different sizes of speaker links and ultrasoft tips
for use in this study. The OE device was fitted according
to the manufacturers recommendations, with the sound
processor placed over the models pinna and into the natural
pocket behind her ear, and the speaker module with an
appropriate size tip inserted into her ear canal while pulling
posteriorly and superiorly on the pinna to ensure a proper fit.

(e) OE, and (f) BTE with a skeleton earmold; all photos were
taken from 458, 908, and 1358 viewing angles (08 being at the
wearers nose).
The models hair was pulled back in a ponytail revealing
her entire pinna. A professional media specialist took all
of the pictures with the same digital camera at a distance of
2 ft from the model and at the three viewing angles. Two
pictures were taken of each hearing aid style at each viewing angle, and a panel of three audiologists selected the
picture that most typically represented each hearing aid style
for use as stimuli in the study. Careful consideration was
taken to ensure that the pictures selected were virtually
identical to each other in each viewing angle and that they
differed only by hearing aid style.
Fifty wallet-size pictures of each hearing aid style at each
viewing angle were produced digitally at a local processing
laboratory for a total of 900 pictures (i.e., six styles of hearing
aids  three viewing angles  50 pictures = 900 pictures).
Fifty test booklets were assembled for each viewing angle for
the observers to use in assessing the visibility of the six styles
of hearing aids. Figures 1, 2, and 3 show the six styles of
hearing aids at the 458, 908, and 1358 angles, respectively.

Stimuli
The stimuli were wallet-size portrait photographs of
the same model wearing the following hearing aid styles:
(a) invisible df-CIC, (b) m-ITC, (c) hs-ITE, (d) fs-ITE,

Rating Scale
Observers used a 7-point, equal-interval semantic
differential scale (with 1 = obvious on the left end of the
Johnson et al.: New Styles of Hearing Aids

171

Figure 2. Stimuli used for rating from upper-left to bottom-right: (a) invisible df-CIC, (b) m-ITC,
(c) hs-ITE, (d) fs-ITE, (e) OE, and (f) BTE with a skeleton earmold, at the 908 angle.

scale and 7 = invisible on the right end of the scale) to rate

the visibility of the six styles of hearing aids.

Procedures
Observers were tested individually or in groups (the
experimenters were always present to prevent any discussion among participants) and were given a test booklet
consisting of an instruction set, six rating forms, and a
demographic information sheet. They were told that they
would be looking at some portrait shots of a person
wearing a hearing aid. The instruction sheet described how
to use the 7-point semantic differential scale (i.e., obvious
to invisible) to rate the visibility of the hearing aids.
Three examples of ratings were provided. The first showed
an X placed in the space closest to obvious to indicate
that a hearing aid was rated as obvious. The second showed
an X in the space closest to invisible to indicate that
a hearing aid was rated as invisible. A third showed that
an X in the fourth or middle space, equidistant from
obvious and invisible, would indicate a hearing aid
rating of visible but not obvious. Observers were informed
that they were free to use any of the spaces on the scale
to represent their ratings of the photos on the semantic
differential scale. The demographic information sheet
elicited responses about the observers gender and age.
Each observer then rated the visibility of the six hearing
aid styles from only one viewing angle. Hearing aid styles
were randomized and counterbalanced across observers.

The entire rating process required only about 5 min for

each observer (group). The data collection procedure
resulted in three groups of 50 response booklets, each
group containing ratings of hearing aid visibility from only
one viewing angle.

Data Management and Analysis

Observers responses were assigned numeric values
ranging from 1 (most obvious) to 7 (most invisible) for
each of the spaces on the semantic differential scale.
Data were transferred to Microsoft Excel spreadsheets
and transported into data files for use with SPSS Version
11.5 statistical software. Responses gleaned from each
of the three groups of observers were submitted to a
treatments-by-participants analysis of variance for repeated
measures to assess significant differences among mean
ratings of visibility for the six styles of hearing aids at
each of the three viewing angles. Significant differences
among mean ratings were assessed using Bonferroni
contrast testing.

Results
Tables 1, 2, and 3 show the means and standard
deviations of the observers ratings of the six hearing
aid styles at the 458, 908, and 1358 viewing angles,
respectively. Observer gender was not treated as a

172 American Journal of Audiology  Vol. 14  169175  December 2005

Figure 3. Stimuli used for rating from upper-left to bottom right: (a) invisible df-CIC, (b) m-ITC,
(c) hs-ITE, (d) fs-ITE, (e) OE, and (f) BTE with a skeleton earmold, at the 1358 angle.

variable here, and inspection of the data revealed no

noticeable differences between the male and female
observers ratings.

908 Viewing Angle

458 Viewing Angle

A significant difference was found among observers
mean ratings of the visibility of the six styles of hearing
aids at the 458 viewing angle, F(5, 245) = 231.8, p < .0001.
Bonferroni contrast testing revealed that the invisible
df-CIC was rated significantly more invisible than all other
styles of hearing aids. The m-ITC and OE were rated
significantly more invisible than the hs-ITE, fs-ITE, and
BTE hearing aids but were not rated significantly different
from each other. Similarly, the hs-ITE, fs-ITE, and BTE
were not rated significantly different from each other.

A significant difference was also found among

observers mean ratings of the visibility of the six styles of
hearing aids at the 908 viewing angle, F(5, 245) = 131.20,
p < .0001. As was seen for the 458 angle, Bonferroni
contrast testing revealed that the invisible df-CIC was
again judged to be significantly more invisible than all
other styles of hearing aids from the 908 viewing angle.
Likewise, the m-ITC and OE were not significantly
different from each other but were rated significantly more
invisible than the hs-ITE, fs-ITE, and BTE hearing aids.
The hs-ITE and fs-ITE were rated significantly less
obvious than the BTE but were not significantly different
from each other.

1358 Viewing Angle

Table 1. Means and standard deviations of the observers
ratings of the visibility of the six styles of hearing aids at
the 458 angle.

M
SD

df-CIC

m-ITC

hs-ITE

fs-ITE

OE

BTE

6.94
0.31

6.08
0.96

2.52
1.30

2.08
1.50

6.02
1.00

2.86
1.54

Note. df-CIC = invisible deep-fitting completely-in-the-canal;

m-ITC = mini in-the-canal, hs-ITE = half-shell in-the-ear; fs-ITE =
full-shell in-the-ear; OE = open ear; BTE = behind-the-ear.

A significant difference was also found among observers

mean ratings of the visibility of the six styles of hearing
Table 2. Means and standard deviations of the observers
ratings of the visibility of the six styles of hearing aids at
the 908 angle.

M
SD

df-CIC

m-ITC

hs-ITE

fs-ITE

OE

BTE

6.68
1.20

5.50
1.37

3.28
1.35

3.60
1.62

5.32
1.24

1.48
0.91

Johnson et al.: New Styles of Hearing Aids

173

Table 3. Means and standard deviations of the observers

ratings of the visibility of the six styles of hearing aids
at the 1358 angle.

M
SD

df-CIC

m-ITC

hs-ITE

fs-ITE

OE

BTE

6.96
0.20

6.94
0.24

6.96
0.20

6.88
0.38

2.12
1.22

2.02
1.36

aids at the 1358 viewing angle, F(5, 245) = 586.3, p < .0001.
Bonferroni contrast testing revealed that the OE and the BTE
were judged to be significantly more obvious than all the
other styles of hearing aids from the 1358 viewing angle, but
they were not significantly different from each other, nor
were the other styles different from each other.

Discussion
This study assessed young adult observers impressions
of the visibility of six different hearing aid styles all
worn by the same model and photographed from a close
distance at three different viewing angles.
The invisible df-CIC was judged to be significantly
more invisible than all the other styles at the 458 and 908
viewing angles. This finding is not surprising, because
the empty ear (Kochkin, 1994) for this condition made it
virtually impossible to see a hearing aid from any of
the viewing angles. The OE and the m-ITC were judged
to be next most invisible compared with the remaining
styles at these angles. Although the invisible df-CIC was
statistically more invisible than the OE and the m-ITC,
the means of the ratings for these two styles were similar
at these two angles, indicating that the newer OE style
was judged to be similarly invisible to some of the most
inconspicuous styles of hearing aids on the market,
especially at the 458 viewing angle. This certainly
agrees with our clinical experience and with patients
acceptance of these devices. However, the OE and the BTE
were rated as being similarly least invisible at the 1358
viewing angle.
Therefore, audiologists may counsel patients that newer
OE hearing aid styles like the one used here should be about
as invisible as most CICs and m-ITCs to observers at the 458
viewing angle, which is common in communication interactions. At a 908 viewing angle, df-CICs should be more
invisible than all the other styles, probably because from this
angle, the users tragus no longer conceals the other aids. The
mini BTE component of the OE, like the BTE, was visible
when viewed from behind the pinna (e.g., at 1358). We
assume that this would also be true for any of the other OE
styles currently available, but the mini BTE component of
these devices would likely be concealed by most hairstyles
and should not be a major concern to typical hearing aid
users. These findings represent a worst case situation for
all the styles sampled here. That is, this study was a rigorous
test of hearing aid visibility because the model had a
hairstyle that revealed a full view of her ear and she was
photographed from a close distance and at angles that did
not purposely try to conceal the hearing aids. Further,
the observers were all specifically instructed to rate the

hearing aid worn by the model. In reality, people usually

would not notice any of these styles of hearing aids
this easily, because typical wearers often attempt to
conceal them.
The findings of this study have implications for
counseling potential hearing aid wearers. After more than
25 years of research documenting the hearing aid effect,
stigma remains a major reason why people with hearing
loss do not pursue amplification, and these findings from
these young observers and model suggest that how a device
looks will continue to be an issue for hearing aid wearers
in the future as well. More than 25 years ago, our first
studies of the hearing aid effect involved body-style
hearing aids and BTEs. The development of less conspicuous styles and the surge in hearing aid sales resulting
from President Reagans experience with amplification
signified a possible end to the stigma in the mid-1980s.
In 1985, we made what we thought were some final
recommendations regarding the hearing aid effect and
concluded that the stigma found in our earlier investigations was based on the visual presence of hearing instruments worn by inanimate participants in photographic
slides (Danhauer, Johnson, Kasten, & Brimacombe, 1985)
and that although the hearing aid effect may be present
in initial interactions, long-lasting impressions would be
based on other more important factors such as the acoustic
benefits of the devices, enhanced communication ability,
and self-esteem of the hearing aid wearer.
Our optimism may have been premature, because
cosmetics and stigma still seem to be factors in more recent
studies. For example, middle-aged women were rated more
negatively when wearing hearing aids than when not, even
by peers who were unaware of the wearers hearing loss
status or use of amplification (Doggett, Stein, & Gans,
1998). These results continue to suggest that stigma may be
a self-fulfilling prophecy based partly on some patients
low sense of self-esteem when wearing hearing aids.
Therefore, in counseling prospective hearing aid users,
dispensers may need to entertain their patients desires for
selecting the most cosmetically appropriate hearing aid
style in order to help reduce any hearing aid effect resulting
from a poor self-image.
The counseling process after the initial diagnosis of
hearing loss is critical regarding patients decisions to
pursue amplification. Kochkin (1994) found that people
with hearing loss who have elected not to purchase and
use hearing aids are more focused on cosmetics than on
performance when indicating purchase intent. Moreover,
Abrams, Hnath-Chisolm, and Block (2004) found that
willingness-to-purchase values became increasingly higher
as hearing aid size decreased for patients having no prior
hearing aid experience, which reflected the high value they
placed on cosmetics. In fact, that group was willing to pay a
higher price for CICs than for other styles, suggesting that
inexperienced hearing aid users may be unduly biased by
hearing aid cosmetics in their initial decisions regarding
choice of hearing aid style.
Our results suggest that for the 458 and 908 viewing
angles, newer OE hearing aid styles may be comparable
to CICs in discreetness, particularly in face-to-face

174 American Journal of Audiology  Vol. 14  169175  December 2005

interactions. However, in a side-by-side comparison of

devices, some patients initially may react negatively to these
OE styles because of their BTE and deep canal components,
which may appear overly complicated compared with the
simplicity of CICs. To avoid negative first impressions,
audiologists might candidly wear models of these OE styles
during the first part of the counseling session and later alert
patients to the discreetness of the device(s). This may help
establish an initial positive cosmetic impression of the
hearing aids and may prepare reticent patients for considering the potential acoustic benefits of particular styles.
Clinically, we have found that these new OE styles
possess some advantages over more traditional styles for
both dispensers and patients that can facilitate the hearing
aid acquisition process. The OE styles allow us to provide
instant, in-the-office demonstrations of current hearing aid
technology for reluctant patients, particularly those having
cosmetic concerns. We often let our patients experience
these devices during initial counseling sessions, immediately after the audiologic diagnostic and hearing aid
evaluations.
Because many of these newer OE devices use a generic
fit, employ easy and fast programming capabilities, and
offer the latest digital features along with directional
microphones, patients are often delighted to be able to
leave the office wearing hearing aids after the first visit and
frequently return for the next appointment satisfied and
ready to purchase them. This can be beneficial to the
rehabilitation process by speeding up some patients
willingness to wear hearing aids. Fitting hearing aids
immediately after the diagnostic evaluation may reduce
the likelihood of patients nonadherence to audiologists
rehabilitative recommendations and may help introduce
amplification to that portion of the potential market that
should but does not yet own hearing aids.
The ratings from the observers in this study, coupled
with our clinical experiences with these devices, suggest
that new OE hearing aid styles may be beneficial for a
segment of the potential hearing aid market that may have
otherwise deferred doing something about rehabilitating
their hearing losses, often for several years. OE devices
may have a niche, particularly for patients having cosmetic/
stigma issues about being seen wearing hearing aids or for
those having occlusion and/or acoustic feedback issues
with other more traditional styles. These results should
encourage manufacturers to pursue the development and
marketing of the OE hearing aid styles as possible solutions
for patients feeling stigmatized and for prospective hearing
aid users who have been reluctant to try amplification.

Acknowledgments
The authors wish to acknowledge and thank a major hearing
aid manufacturer for an equipment loan for part of this study.

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Received May 10, 2005
Accepted September 17, 2005
DOI: 10.1044/1059-0889(2005/019)
Contact author: Carole E. Johnson, Department of Communication Disorders, 1199 Haley Center, Auburn University,
Auburn, AL 36849-5232. E-mail: johns19@auburn.edu

Johnson et al.: New Styles of Hearing Aids

175

The "Hearing Aid Effect" 2005: A Rigorous Test of the Visibility of New Hearing
Aid Styles
Carole E. Johnson, Jeffrey L. Danhauer, Reid B. Gavin, Summer Raye Karns, Amber
C. Reith, and Ilian Priscilla Lopez
Am J Audiol 2005;14;169-175
DOI: 10.1044/1059-0889(2005/019)

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