Audiology across the border podcast - AEA and more

Since a podcast in Dutch is not very accessible to people speaking other languages and since we talk about hearing care and work closely with associations for Hard of Hearing People, having a text available is also much more inclusive for the users.

With Hertz and Soul interview/podcast June 2023.

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- Throughout Europe and beyond, what audiology story has always stuck with you?

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In a previous life, I worked for the audiology research department of a Danish hearing aid manufacturer, and I was always a strong advocate of "hearing is believing", so we liked to make things clear with sound demos.?We then had a new digital hearing aid with multiband adaptive directionality, and we worked out a setup where we could send the sound coming out of the hearing aid's speaker wirelessly to a whole range of headphones.?Then I spoke at the front of the hearing aid and switched on a speaker with noise, which we moved around the hearing aid.?The response from listeners was super enthusiastic, we heard lots of "wows" and they literally couldn't believe their ears, that hearing aids were able to suppress unwanted noise so efficiently while you could continue to understand speech perfectly.

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But years later, we were working on a research project, with KU-Leuven for the same manufacturer, to find out what the impact was of different directional systems, including multiband adaptive directionality, on localisation ability. And then we saw that this was an unmitigated disaster for natural localisation of sounds around. Fortunately, there were also directional systems that approximated the pinna effect of the human ear, and did much better, so it certainly wasn't all doom and gloom.

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It then made me take both feet off the ground, and realise, that the strongest signal processor we have is between our ears, namely central auditory processing, and that the Wow effects of aggressive signal processing in hearing aids, often come at the expense of natural hearing and the power of human auditory processing.

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We as audiologists, must have an eye and ear for the human being, expectations, abilities, needs and so much more.?That is why we have two ears and one mouth, so we will listen at least twice as much as speak.?That end-user is the core, the hearing aids a tool, which we have to personalise and adjust in close consultation with that user, to maximise their potential and improve their quality of life as much as possible.?That should be our ambition.

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- What is the AEA?

The idea for the AEA (ASSOCIATION EUROPEENNE DES AUDIOPROTHESISTES) / (European Association of Hearing Aid Professionals) was born in 1967 (when I was 7 years old), and the AEA was officially established in 1970, by the professional organisations from Belgium, Germany, France, Italy, Luxembourg and the Netherlands, with the aim, at the European level, of having the profession of audiologist (they still used the terrible term "hearing protesist or audioprothésist" at the time) recognised as a paramedical profession, to develop a code of ethics and to establish quality criteria for training.

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In 2008, the AEA got its headquarters in Brussels, closer to the European Institutions. Meanwhile, the AEA has been in existence for 53 years, has 14 member countries and represents the interests of more than 40,000 audiologists active in hearing aid fitting, as well as cochlear implants and tinnitus management.

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The AEA works very closely with the EFHOH, the European Federation of Associations for People with Hearing Loss, and with EURO-CIU, for cochlear implant users, and we have regular consultations with EHIMA, the association of hearing aid and cochlear implant manufacturers.

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What has been the role of the AEA over the years?

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The members of the AEA mainly expect us to represent them in international organisations and bodies, such as the European Commission, the European Parliament, the World Health Organisation and the various standards bodies such as ISO, IEC, CENELEC, ITU etc ...

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Already in 1971, the AEA delivered a memorandum to the Commission of the European Communities, a forerunner of the European Commission, with the objective we just described.

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In 1996, the AEA secured a European Project "Leonardo Da Vince" to map out training, which resulted in 2010 in the first European Standard EN 15927:2010 - Services offered by "hearing aid professionals". This standard describes all acts performed, and also includes an annex with all the theoretical courses, practical experience and the needed competences essential for the educational programs. This standard is also the basis for the royal decree recognising the professions of hearing aid professional and audiologist in Belgium.

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It did not stop there, because in 2020, the ISO standard 21388, was published, in which the AEA and its members played a very active role, and it was also converted as a European Standard (EN ISO 21388:2021) in 2021.

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Since 2014, the AEA has already been one of the interest groups invited by the World Health Organisation's Ear and Hearing Department to participate in consultations. We were at the forefront of the WHO Make Listening Safe initiative in 2015, and we have been organising an annual lunchtime debate in the European Parliament (every 3rd March) together with EFHOH and EHIMA since the launch of WHO World Hearing Day in 2016, in close cooperation with WHO.?Due to COVID, it has now gone on virtually a number of times, but we are making every effort to organise a live version (perhaps hybrid) back in 2024, and herewith all listeners of this podcast are welcome to participate.

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In 2015, EFHOH informed us, that their members were concerned and confused about the promotion of personal amplifiers (PSPSs) in Europe and they asked us to investigate these products and share the results with them. Our members collected 27 PSAPs (hearing aid-like products, which you can often see in late-night television spots), and after the analysis, we were really shocked by the results.?Although these are personally amplifiers intended for people with normal hearing, the maximum output was higher than 120 dBSPL in all PSAPS, higher than 125 dBSPL in 24 of the 27, and even higher than 130 dBSPL in 8 (i.e. 30%). This analysis led to the development and publication of the ITU standard H.871 for Personal Sound Amplifier Systems published in 2019, which is part of a series of WHO/ITU standards around safe listening.

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In 2019, WHO established the World Hearing Forum, with the objective of promoting WHO communication around ear and hearing care, and as a representative of AEA, we were appointed as co-chair of the "Make Listening Safe working group" and as a member of the WHF steering committee. ?About "Make Listening Safe", we can hopefully record another with Hertz and Soul podcast on occasion, because I am so excited about this project, I could easily fill hours ?? ... but now back to the AEA.

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What is the main focus of the AEA at the moment?

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We just had our AEA general meeting on 5 June, with elections, and one of the main topics there was determining the AEA main focus for the next few years.

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Focus 1: All people who are hearing-impaired have the right to access, in-person quality hearing care. Therefore, we are now working on different standards and guidelines on tele-audiology, and "remote fitting", which are good complements to the services provided by audiologists, but which must meet the existing quality criteria for hearing care, where the user must always have the choice in the type of care (person-centered care) and where safety must always come first.?

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Focus 2: Hearing care should, in all European countries, be provided by recognized specialized and regulated healthcare professionals (audicien/audiologists/akustiker/audioprothésistes/etc ...). Do you know that in the Netherlands and Switzerland, a hearing aid professional (audicien/audioprothésiste) is not a protected profession, and anyone can put up a sign audicien/audioprothésiste without any recognition or training?

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Focus 3: In the local implementation of the European MDR (Medical Device Regulation), the Audiologist/Audiologist should be seen as the professional recognized by local law to select, fit, adjust and customize hearing aids for use by people with hearing loss. We have consulted with the European Commission on this topic and they share this view.

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Focus 4: Hearing care cannot be part of a tender, as this results in a reduction in the quality of care, while every person with hearing loss is entitled to professional quality care. In Germany, there have already been several higher court rulings on tenders in health care that support this view.

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Besides these 4 focus points, we follow everything closely on the following issues:

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- Tinnitus management

- Fitting cochlear implants

- All standards related to acoustics, audiology, safe listening and hearing care

- Digital medical data exchange and regulations

- Continuing education for audiologists/audiologists

- Tele-audiology training package

- PSAPs (personal sound amplifiers and hearables) and OTC hearing aids.

- Regulations for prescription, fitting and reimbursement for hearing aids, CIs and Tinnitus management.

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What is the referral process and reimbursement like for hearing aid fitting in other countries? Where are the biggest differences?

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There are a lot of differences in that area in our most recent survey of our AEA members in 14 countries.

- The prescription by an ENT doctor is only required in Belgium, Luxembourg and Switzerland for all fittings. In Italy it can also be a prescription by the GP, but in all other countries, it is certainly not necessary for a second fitting or for elderly clients.

- In most European countries, the minimum hearing loss to be entitled to reimbursement is 30 dBHL average hearing loss and an improvement in functionality after fitting must be demonstrated. Belgium is an exception there with the need for 40dBHL average hearing loss, and this can also be seen in the EuroTrak results:

o In Belgium, an ENT doctor advises only 46% of people who self-report having hearing problems to use hearing aids, and this may be due to that famous 40dBHL average loss. We score second worst in Europe there.

o Belgium does very badly in terms of the use of hearing aids by people who self-report having hearing problems.?Belgium also ranks second worst in Europe, with 32%, while the average is 42%, and countries like France, Switzerland, Norway, Denmark and England are well above that, ranging from 46% to 53%.

- In terms of the level of reimbursement, Belgium is around the European average, but the shame is that Belgians who self-report hearing problems are very poorly informed about the fact that there is a refund for hearing aids. 57% do not know if there is a refund and 4% think there is no refund, so 61% are misinformed, and with that we score the worst of all European countries, so there is definitely a lot of work to be done here.

- But before we all get depressed, we do score very well on the following points:

o In terms of user satisfaction with hearing care, we are in the top 3, with a satisfaction score of 80%

o In terms of hours of hearing aid use per day, we are also in the top 3, with 8.9 hours of use per day

o And with 82% stereo fittings, we rank second.

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What learnings from other countries would you definitely like to share with us?

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In terms of access to hearing care, France is a very good example. Based on WHO reports and a socioeconomic study in France, on the impact of untreated hearing loss on general health, depression, mental health, quality of life and employment and loss of productivity, the Macron government, launched the “100% santé” (100% health) project to boost access to dental, eye and hearing care. Reimbursement has increased to €950 per ear, for class 1 hearing aids including fitting and aftercare. The criteria are, either a hearing loss of 30 dBHL on average, or signal noise loss for speech audiometry in noise of 3 dB (which in Belgium is only the case for people under 65) or an SRT for speech audiometry in silence higher than 30 dBHL (they calibrate their audiometers differently there).

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As a result, the number of people getting access to hearing aids doubled in 2021 and 2022 compared to the years before. France is now the country where most hearing aids are fitted across the EU.

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The beauty of these regulations, is that the free choice of the end user, is guaranteed, and the emphasis is on the quality of care and follow-up after fitting.

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To what extent is there a difference in education?

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This was also just surveyed among our members, and the differences are smaller than you might expect.

In most countries, the training is equivalent to a bachelor degree (at a college or university) of 3 to 4 years. In France, it is a Diplome D'état and the name is Audioprotésist, as in Italy, Spain and French-speaking Switzerland. Germany, Austria and German-speaking Switzerland have a craftmenship training system, a dual learning system, where you work for a H?rakustiker and train part-time.?After three years, you have the certificate of "Gezel", which allows you to work only under the supervision of the Meister, and after training as a Meister, while continuing to work and passing "Meister exam", you are allowed to work independently.?The Meister normally has a level of education equivalent to our Bachelor courses.

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In Portugal, Malta, England and Belgium, these are Audiology courses (Bachelor and Master), leading to both a diploma and recognition to fit hearing aids, as well as to work as a clinical audiologist. The acts that can be performed by a Bachelor and Master are identical, but the latter are better prepared to teach, do research, etc ...

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What do you think audiology will look like within Europe in 2050?

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We have the positive problem in Europe, as in the whole world, that people are living longer and longer. This is good, of course, but because the prevalence of hearing loss, is higher in the older age groups, this means that more and more people will have recourse to hearing care.

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In most Western countries, however, we see a shortage of audiologists who can provide this care. We will therefore have to find solutions, such as training audiology assistants, the use of more and more self-testing procedures, which can be used both in hearing centres and online.

Furthermore, we also see that Hearables, such as Apple, Samsung, Sony and other earbuds, are getting smarter and smarter, and through their transparency mode, can improve communication in a safe way ... and the transition of these hearables to smart hearing aids, can be very beneficial to both lower the stigma, and organise effectiveness and access to quality care in a different way. Consider also the new Auracast already under development that will allow audio messages, picked up by both hearables and hearing aids, and will make communication easier for everyone.

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Furthermore, we believe that hearables, will increasingly be able to use bio-feedback, to control signal processing, and use of other smart devices, such as smartphone, smartwatch, smart ... who knows what else, can provide a total audio-eco-system, serving people with hearing impairments.?We need to make sure, though, that our audiologists of the future, are with the boat, picking up these new evolutions in education and continuing education.?The potential is huge, let's surf all these favourable waves ??

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Remember that audiology is the most beautiful profession in the world, we see people blossom in just a few weeks, we can really make a difference to drastically improve their quality of life.