By Khwaja Moinudeen

Socio-economics status (SES) is a means to understand many of the underlying inequity in a given society. Although not accurate, the measures that are currently available provide a subjective means to approximate an individual's SES. The mere act of shopping for clothes or dining in a restaurant can depict a person’s SES. For example, buying clothes to cover oneself or buying designer outfits. However, SES cannot be decided based on what one wears or what one eats, rather it is often measured as a combination of education, income and occupation of a person. 

Most commonly, SES is categorized as lower, working, lower middle, upper middle, or upper class, and depicted in the form of a pyramid, with lower class at the bottom and upper class at the top. There are numerous studies that discuss the influence of SES and all reveal inequities in HealthCare. SES also influences the accessibility, affordability and acceptability of health care services. My discussions in this article will focus on the role of SES on hearing loss and hearing aids, derived from my experiences working with clients from India. Specifically, I draw from my interactions with clients that belong to various SES. The scenarios discussed below belong to clients from different SES. These contexts inform how SES influences clients’ needs, the functional effect of hearing loss on their lives, and the information they seek from an audiologist. For providing equitable care, we as audiologists are required to understand their struggle and develop appropriate courses of care.

Client 1: Mrs. Amala was a single mother aged 55 years, who stays with her married daughter. Her son-in-law was the only breadwinner in their family of 5. Due to her lower income status, her medical needs are being taken care of through government schemes. She developed hearing loss ten years ago and audiological tests revealed bilateral severe sensorineural hearing loss. As I mentioned earlier, SES influences accessibility, affordability, and acceptability of health care. In Mrs. Amala’s case she has difficulty accessing hearing care for herself, specifically purchasing hearing aids as she cannot afford to buy even the most basic ones. Given her SES, she sought the help of a government scheme and was fitted with a monaural hearing aid. She complains of poor sound quality and excessive noise due to basic noise reduction. While this was not an ideal situation, Mrs. Amala has accepted the situation as that's what she can afford. 

Client 2: Mr. Nandu, aged 40 years, is a father of two, who does overtime to make extra income for the family. As the sole breadwinner of the family, he tries his best to save money by minimizing his expenses. Over the years, he has experienced gradual hearing loss. With the worsening of his hearing loss, he approached me for hearing care. His hearing assessment revealed a moderate high frequency sloping sensorineural hearing loss. Although the hearing care was accessible to him in terms of physical distance to the hearing center, affordability and acceptability wasn't. In terms of accessibility, he was more concerned about visibility as he felt that hearing aids could affect his job security. During a trial with several models of hearing aids, he found 12-channel comfortable but could only afford 8-channel. The 8-channel aid was noisy compared to 12 channel aid but he accommodated the issues because of his financial constraints. 

Client 3: Mr. Balan, aged 60 years, worked as a factory worker for 40 years before retiring at the age of 55 years. He suffers from tinnitus that affects his sleep. Tinnitus has changed his sleeping pattern, which further affects his daily activities and mental health. Audiological assessment showed moderate sensorineural hearing loss with dip at 4 kHz. The hearing aid trial indicated an 8-channel hearing aid along with a tinnitus program as a satisfactory option for his needs. Fortunately, hearing health was much more accessible to him as compared to the previous clients as his son worked in IT and could afford to purchase the required hearing aid. In this scenario both affordability and acceptability were not a major concern.

Client 4: Mr. Prasad, a businessman who had a moderately severe sensorineural hearing loss has 4 pairs of hearing aids, which he purchased within a span of 15 years. He had no difficulty in accessing hearing healthcare. Prior to getting hearing testing and hearing aids, he had access to the internet, found a potential hearing technology, discussed with his friends with similar hearing conditions, approached me for more information, and purchased a suitable hearing aid for his exact needs. In this context, Mr. Shankar had the ability to afford hearing aids that were comfortable and satisfactory for his needs, including purchase of hearing aids that met his acceptability requirements.

From these vignettes shared above, I highlight the differences in the clients’ needs and requirements based on their SES. Mrs. Amala, who is from a lower SES, does not want to know about hearing aid features, details about her hearing loss, or how the hearing aids function, while Mr. Prasad wants to know all the details. The latter is willing and able to spend financially to ensure access to specialized hearing aid features that will make his life easier, whereas the former client was more interested in purchasing a bare minimum to address her hearing needs. Similarly, Mr. Nandu, who belonged to lower SES, chose to go with battery operated hearing aids to cut costs, while Mr. Prasad wanted only rechargeable hearing aids to reduce the hassle of changing batteries. Mr. Balan, whose son was able to fund his hearing aid purchase, wanted to address his tinnitus through a cost-effective hearing aid with minimal features. His son was interested in knowing the causes of tinnitus and was eager to know scientific details of how the ear functions, along with details on how hearing aids can reduce tinnitus. I hope by sharing my experiences, I have provided a glimpse into the effects of SES on hearing care and encouraged alteration of treatment and counseling methods to accommodate the needs of the clients from diverse SES.