Report on the Lunch Debate from the European Parliament for World Hearing Day 2023

Since 2013, the joined associations AEA (European Association of Hearing Aid Professionals), EFHOH (European Federation of Hard of Hearing People) and EHIMA (European Hearing Instruments Association) organise a yearly Lunch Debate from the European Parliament for World Hearing Day, in strong cooperation with the World Health Organisation and hosted by a Member of the European Parliament. And the last 3 years, Euro-CIU (the European Association of Cochlear Implant users) also joined us.

This year the lunch debate was organised on the 1^st of March from 12.30 till 14.30h CET, the theme was “Ear and Hearing Care for All – Let’s make it a reality”, and we had 279 registered participants from in total 49 countries. The majority of the participants were from Europe, but we also had a strong participation from Brazil, The United States, Australia and India. For more details, see the graph in the annex of this report.

This year, our host was MEP David Lega (EPP) from Sweden. In his welcome and introduction, he praised the fact that all the presentation during the conference were subtitled, and the debate was supported by speech to text to ensure it was accessible for all people with hearing loss, and the subtitles were available in eight languages: French, German, Spanish, Polish, Italian, Slovenian, Danish and Dutch. And the fact that it’s great to see that hearing care professionals, hearing aid users and manufacturers are all joining forces with the World Health Organization to inform policymakers, including governments and EU institutions, users, but also the wider public about the importance of awareness and intervention regarding hearing loss,
He introduced himself as an MEP who serves on the Committee on Foreign Affairs and the Subcommittee on Human Rights. He was born with a severe disability and before being a politician he had a Paralympian swimming career and managed to win several World Championship Gold medals.
He also mentioned that research shows that people with an untreated disabling hearing loss are at greater risk of social isolation, depression, cognitive decline and dementia, while people who treat their hearing loss do not experience higher risks than people without hearing loss.
His closing remarks were that if persons who are hard of hearing would enjoy hearing aids suiting their individual needs, the quality of life would most certainly increase. So, let's strive for a future where we don't have to think about our disabilities any longer, where we can, like everyone else, focus on families, on friends, on our careers, but also to have fun.

Shelly Chadha (WHO Geneva) introduced “Ear and Hearing Care for All – Let’s make it a reality”, the theme for World Hearing Day 2023.
She starts with a view into the future, imagining we were in 2050, when there will be nearly 10 billion people living on Earth and that over 7% of them, that is, about 700 million, would need Ear and Hearing Care. The field of hearing care would also have made great advances by this time. There would be even better types of implants, and maybe these implants and aids would even be redundant, with neuro regeneration, regeneration of cochlear hair cells being a reality at that time. But all these technological advances would have no impact on health, unless they are accompanied by public health action, and in this case, public health action to integrate ear and hearing care as part of national health plans for universal health coverage.
Currently, most of the ear and hearing care, services are focused on the tertiary and at times at secondary level of care. What we now understand is that integrating and providing these services at the primary level, at the community level, can actually address 60% of the need for these services. The World Report on Hearing, which WHO launched in 2021, actually outlines how this is possible through training of non specialist health workforce in ear and hearing care. Also, through building capacity at the primary level, through provision of tools and resources, through application of telemedicine and use of digital technology.
She compares the provision of ear and hearing care, with an iceberg, where only about 17% of the need for ear and hearing care, is above the water level, and is accessed, while 83% of those in need of care, remains hidden from us, symbolised by the part of the iceberg in the water level, because they do not often reach the secondary and tertiary level of care. Therefore, WHO calls upon governments, upon policy makers and civil society to improve access to ear and hearing care to do this through integrating ear and hearing care.

Patrick D’Haese (EHIMA) presented “Adult hearing screening in Europe: a key prerequisite towards a hearing health strategy.”
The recommendations of the World Health Organization for adult hearing screening, are that adults from the age of 50 should be screened regularly for hearing loss. Initially it might be conducted at a five yearly interval until the age of 64. But from the age of 65 onwards, the frequency of screening should be increased to every one to three years.
What are the steps in there towards the screening?
• The first step is using simple question, like “Do you have a hearing problem”, or you can also use of adult hearing screening questionnaires such as the Hearing Handicap Inventory for the Elderly (HHIE-S).
• The second step might be the use of more semi objective tests, like the detection of pure tones in both ears at a fixed decibel level might be used. A test which is very often used also in the hearWHO app for example on screening is a digit triple-in-noise test (identifying numbers in babble noise).
In which European member states are national adult hearing screening programs currently in place? Unfortunately, the answer is very easy and very straightforward, it’s nowhere. In not a single country within the EU 27 countries do we have adult hearing screening programs in place.
Adult hearing screening, as recommended by the WHO, should be implemented in all member states in line with other health screening programs which are already existing.

Lidia Best (EFHOH) presented the EFHOH reimbursement report, with details on how “Hearing Care and Hearing Aids are Accessible in Europe.”
EFHOH has sent out the Hearing Aid Reimbursement Survey to all their members and used comparable questions as in the 2018 survey. They focussed on national health hearing aids reimbursement for adults, specifically as part of hearing care provisions in policies. Responses were received were from 18 countries based in European Union and three countries outside of the European Union. The results were analysed, grouped and peer reviewed during 2022. The good news is that four extra countries provided data, and further a notable positive change in France with a significant increase of the reimbursement for class one hearing aids, meaning that nearly everybody in France can now get hearing aids for free. Unfortunately, in some countries, hard of hearing people have no choice in deciding which device suits them best.
In the report EFHOH urges member states to develop action plans and strategies on ear and hearing care, specifically based on hearing interventions as outlined in the World Health Organization World Report on Hearing: focusing on equality, prevention, and rehabilitation to enable people who are hard of hearing equal opportunities. The strategy should include universal reimbursement provision of hearing aids as well as rehabilitation, which does not put a new burden on hard of hearing citizens. The strategy should be led by the experts who are working in the field of hearing care and who are in direct consultation with hard to hearing people organizations and should also define the threshold for reimbursement of hearing aids corresponding with the World Health Organization mild to moderate hearing loss at 20 to 35 decibels at the minimum level of functional speech understanding in noise.

Teresa Amat (Euro-CIU), presented “Hearing Care Access in Europe with the focus on Cochlear Implants.”
She proposes that the first priority should be prevention, caring in a holistic and global way and accompaniment. We should accompany people from all communities by teaching them strategies and giving them tools to be healthiest as possible.
The paradox is that on many occasions hearing health is seen and experienced as something secondary, as a stigma attached to old age, since it does not affect vital, organs, (of the life or die type).
Indeed, it is a real problem which has both a personal and a socio-economic side. In the first case, the individual stops communicating with his environment and might be isolated and on many occasions without fully developing, affecting all areas of their work, family and relational life. Regarding the social economic negative aspects, which occur as the consequence of untreated hearing loss, they account for the highest cost to society, which can be prevented by timely and appropriate interventions. Therefore, hearing health access campaigns for all should be a priority for any government.
Her presentation was interweaved with the personal stories, presented by cochlear implant users, which was very refreshing and made the message very concrete.

Mark Laureyns (AEA) presented “Why and how to avoid the consequences of untreated hearing loss.”
The consequences of untreated hearing loss are clearly described in the WHO World Report on Hearing.
Communication problems: In a recent article in Ear and Hearing (Huang et al, 2022), the association between hearing loss and surgical complications in older adults is discussed. The conclusions are that that for every 10 dB increase in hearing loss, you get a 14% increase in the odds of developing a post operative complication. You can imagine that communication before surgery is essential.
Employment and burn-out: In as systematic review in the Journal of Laryngology and Otology (Shan et al, 2020) it is concluded that the highest quality studies currently available indicate that adult-onset hearing loss is associated with unemployment. And other study on stress and prevalence of hearing problems in the Swedish working population (Hasson et al, 2011), concludes that there is a statistically significant difference in the prevalence of hearing problems between those with higher burnout scores compared to those with lower scores.
Social isolation and loneliness: A systematic review in the journal of Otolaryngology Head and Neck Surgery (Shukla et al, 2020), reports that hearing loss is associated with loneliness and social isolation, and this of course can have significant implications for other aspects of cognitive and psychosocial health.
Dementia: In the “Dementia Prevention, Intervention and Care 2020 Report” of the Lancet Commission (Livingston et al, 2020), we find the conclusion, which is also mentioned in the WHO World Report on Hearing, that hearing loss is the largest potentially modifiable risk factor for age-related hearing loss.
And further Depression and reduced Quality of Life, are other consequences of untreated hearing loss.
The WHO action plan consists of Prevention (#safelistening), Screening (awareness) and Timely and appropriate Hearing Care Intervention, which is very cost-effective (return on investment of more than 30 to 1) and should not be seen as a cost, but as an investment.
At the end, a Belgian Case Story is presented on a Campaign called “Hearing Loss is Never Normal” towards General Practitioners, organised by the Belgian National Institute for Health and Disability Insurance (NIHDI), which is based on the WHO World Report on Hearing and aims to avoid the consequences of untreated hearing loss by early identification, referral and intervention.

Ariane Laplante-Lévesque (WHO Europe) concludes the presentations with “The importance of Quality Hearing Care and Rehabilitation in Europe.”. She presents the perspectives of the World Health Organization's Regional Office for Europe on quality hearing care and rehabilitation.
It's estimated that about 20% of the population live with some degree of hearing loss, and it's expected that unless action is taken, this will rise to 25% by 2050. In children, over half, nearly 60% of hearing loss is due to avoidable causes that could be prevented should we have public health measures implemented and some of those public health measures could be, for example, immunization in girls and women and good neonatal care. Likewise, in adults, most common causes of hearing loss, such as exposure to loud noises or to chemicals that could damage the hearing system, which we call auto toxic, they're preventable.
Ear and hearing problems are amongst one of some of the most common health problems encountered in the community. But that doesn't mean that they're benign or that they're harmless.
Investing in ear and hearing care, it's important for two reasons.
• Firstly, it's essential for good functioning for those living with ear and hearing problems, and also for those that are at risk of developing those problems. Prevention and addressing the problems.
• The second reason is that it is cost effective at a societal level. At a societal level, lack of ear and hearing care services comes at a very high cost due to the reduced educational and work opportunities that unfortunately often come with untreated hearing loss and the resulting social isolation that we see too often.
When we address hearing loss, we make one step towards making sure that all people realize the full potential, that all people contribute to the best that they can to society.
Addressing hearing loss doesn't have to be expensive. In the WHO European region, it would cost less than 1.15 Euro annually per capita to provide ear and hearing care services. Based on economical analysis, we think that every euro invested would result in a return on investment of over 30 Euro over a ten-year period.
She concludes her presentation, by giving the voice to Paulina as someone who has lived experience of hearing loss and as someone who represents the future of Europe.

Debate and Conclusions – By the full panel.

The first question during the debate raised a very interesting discussion. Are primary care physicians quick to refer adults for hearing care and what to do about it?
Shelly: What we do know from inputs from experts who are developing guidance for all the adults. This is an area which is commonly neglected. Often not tested. Hearing testing is specialized and not easily available, not accessible for everybody. Whereas the fact that it can be done even as by people themselves. They can screen their own hearing. It can be done in primary care clinics. So, it is really not an excuse that this is something super sophisticated. Screening can be done. We do have that information from expert sources. With hearing loss adults are often not directed in the right pathway. For 2 reasons mainly. One, because hearing is not often screened. And even when people do complain of some hearing difficulty, often it is indicated that this is, you know, it is age. Just accept it. That is also awareness raising that needs to be done amongst health professionals.
Mark: When we investigate the people who self report to have hearing problems, how many times they are advised or get referral, when they go to the ENT and GP. The lowest number of referrals is Holland and Belgium with 36%. The average in Europe is around 55%. And the highest numbers are France and Norway with respectively 64% and 67% referred. These data are based in the latest EuroTrak surveys.
Ariane: We have to think of accessibility of services overall and to have a broad lens. To think that we need to have a healthcare workforce that is a facilitator rather than a barrier. We saw examples in the chat. Perhaps it has been a barrier. That's one thing. We also have to think of other types of barriers for accessibility. It can be cost sharing. For the fact there is cost associated to the services. The services are not close to the person where they live or work. Services that are not person centred as we were talking earlier. The person is feeling the needs are not being addressed or a number as part of the chain. The interventions go with the need. I think for sure the healthcare workforce must be looked at to make sure they are facilitators. And to break down the barriers.
Lidia: Across Europe, especially in the UK. My experience as the chair of the national association. Actually, a lot of times our concerns are being dismissed as adults. And often, it is hearing loss seen as an ageing process. Because there is no need really. I think that is a problem. I think we need to address that. We are going to look at this as well. At the European federation. To see how our members and population at large is listened to, from the adult’s perspective.
Teresa: In a lot of countries, they give even, people go to early retirement because of untreated hearing loss. So, if you really think about this. The person stops paying taxes. And starts to receive taxes. So, if we invest in them, probably these persons can keep working for a while. Politicians sometimes need exactly to talk in their terms. To talk in economical way. So, they really understand that this is a really investment. Not just for quality of life. But an economical one as well.
The conclusions by Shelly Chadha:
The topic of World Hearing Day this year is the access to ear and hearing care. Not just hearing screening. Because hearing screening of course is the first step. A very important first step as we have determined for various reasons. In adults and in children. And here the important thing is that we can't just screen. We have to make sure that people then have access to the care. To the rehabilitation that has to be provided. And it is with this idea that WHO highlighting that over 60% of the needs for hearing care can be met at the primary level, has developed this training material. Accompanying resources that are available to anybody who wishes to use them. The idea being that of course, there is a gradation of what can be done at the primary level. By doctors, and healthcare workers. Who are trained to provide that care. And then what can be done by specialists, also specialists available at the secondary and tertiary level of care. This categorisation is important. The understanding what can be done at that level. A realistic expectation. And then, how it can be done.
This is what the WHO efforts are about. It is about strengthening this service across the continuum of care at the primary level. And for this, the training resource we are launching is one effort. And another effort we are undertaking is developing service delivery models which are fit for purpose for being implemented in primary care settings. Hearing aid services and so on. So, that is really the focus of our work right now is that services should trickle down to people where they need them. When they need them. And in a way that it doesn't impose unfit hardships for them. That is the universal coverage. All countries are working to achieve this goal. For that to happen we need to make sure that hearing care is integrated. Not just we as stakeholders and professionals working in this field, but countries, governments need to make sure that they make the commitment to facilitate and foster this integration across the continuum of care and course of life.

All the videos of the presentations and the full debate can be found at: https://www.aea-audio.org/portal/index.php/world-hearing-day

Annex:
The number of registered participants at the lunch debate, per country.