Hearing aid (HA) amplification is a crucial rehabilitation technique when hearing loss cannot be treated medically or surgically. The HA’s function is to amplify sounds and maximize their audibility for the hearing impaired (HI) user [1]. Owing to the inherent nature of electronic circuits used in HA, these devices generally require good maintenance and care for their smooth and trouble-free functioning [2]. The output from the HA gets adversely affected if due care and maintenance are not provided.

HAs are prone to physical and electroacoustic breakdown. Variations of the HA electroacoustic characteristics can be seen with the use of HA over some time. The other environmental causes, such as humidity and temperature, also affect the proper functioning of HAs [3]. Debris found naturally within the ear, such as cerumen, may block earmolds or In-the-ear/In-the-canal (ITE/ITC) HAs [4]. Sweat, certain sprays, and gels used outside the ear canal may also unintentionally contact the HA [5]. The effect of relative humidity (RH) on the proper functioning of receivers or ITC HAs has also been reported [6]. The temperature between 80°F (26.67°C) and 99°F (37.22°C) in 77% of the shells of ITC and ITE HAs is reported [7]. All these conditions affect the functioning of the, leading to repair and affecting listening.

Whenever HAs become defective, they have significant negative effects on communication. Greater the defect, higher is the reported hearing handicap and communication difficulties [8]. Communication breakdowns impact cognitive, speech, language, emotional, academic, and psychosocial development and functioning [9]. One important reason for the repeated high incidence of communication breakdown is the generalized lack of knowledge and HA troubleshooting. Whether the reported problem is minor or significant, the consumer would render HA ‘useless’ or ‘unsatisfactory’ until it is repaired. Satisfaction with the HA depends on many factors like cost, appearance, acoustic benefit, comfort, and service. Satisfaction with the HA is the measurement of the auditory rehabilitation effect that represents a combination of factors which are not only related to the performance of HA [10], but also on the perceptions and attitudes of the customers [11].

Depending upon the consumer’s complaint, type of HA, and problem, the repair duration will vary from weeks to months. Most of the HA dispensers send their products to authorized dealers/manufacturers for repair and services. Reviewing the repair of HA, Gupta [12] found that 50% of the problems were minor/peripheral and did not require the opening of the HA, 30% mechanical, 10% required replacement of defective parts, 5–8% electronic (mostly dry soldering, loose contact, or shorting) and 2% needed advice by experts. Many HA had more than one defect, with 60% of the defective HAs being of a specific model having defective switches [13]. Despite its crucial role in preventing averting communication breakdowns and enhancing customer satisfaction, there is scanty literature on the factors affecting HA repair and servicing.

A total of sixty-seven participants aged 0–87 years (49 males, 18 females) participated in the present study. These participants were HA users who reported to the organization during the lockdown due to the COVID-19 pandemic. The survey questions include the demographic data and the complaints from the HAs provided through the Assistance to Disabled Persons for Purchase/Fitting of Aids and Appliances (ADIP) scheme and Hearing aid dispensing (HAD) scheme. The developed questionnaire had 44 questions, and 10 audiologists rated the questionnaire for content validation. The experts were asked to check if the questionnaire’s sentences met the criteria regarding familiarity, and absence of emotional, cultural, and religious overlay. They were asked to mark it as highly relevant or not relevant. The items were revised based on the suggestion and comments provided by the expert for rephrasing and relevancy. The content validity index (CVI) value of 0.8 was obtained [16]. Written consent was taken for their willingness to participate in the study.

The developed questionnaire has 38 questions divided into four subsections (Appendix-I). Section I (9), questions 1–4: patient’s demographic details, questions 5–9: onset of hearing loss, duration of HA use, and style of HA (intrinsic factors of the study). Section II (18) questions were related to the complaints, questions 1–3 of section II are multiple-choice, and the remaining 15 questions have ‘yes,’ ‘no’ as choices for responses. Section III (4) questions were related to the patient’s problems with HA servicing during the pandemic with the multiple-choice answer. Section IV (7) questions were about the repair section regarding components repaired/replaced, cost, duration of the repair, the reason for the delay in repair, and their remarks/satisfaction of repair (extrinsic factors) under the subheadings of general problems with the HA, physical issues related to HAs, sound quality/output related issues of HAs during analysis. The participants filled the developed questionnaire, and in the case of children, the responses were obtained from the parents or the caregivers, and the data was documented. However, for further analysis of the data, these questions were categorized into six intrinsic (age, gender, duration of the hearing problem, ear in which HA was used, HA experience, and hearing instrument) and three groups of extrinsic factors (general problems, physical issues, and sound quality/output related issues to HAs) according to Wong et al. [2] as in Table 1. The influence of these factors on HA service, repair, and satisfaction was analyzed in Table 2.

The demographic data (count and number of participants) for intrinsic factors (age, gender, duration of hearing problem, ear in which HA is used, HA experience, and HA) and extrinsic factors (general features, physical issues of the HAs, the sound quality/output of the HAs) of the cohort considered in the study are detailed in Table 1.

The distribution of the number of participants for each question under the categories of service, repair, and satisfaction issues is given in Table 2.

The association (if any) between the intrinsic and HA service, repair, and satisfaction examined using the chi-square test are shown in Tables 3 and 4 respectively.

Chi-square analyses showed eight significant associations of intrinsic factors with the repair and satisfaction-related domains enlisted in the study. On the observed eight significant associations, four questions were service-related, while the two questions in the repair and satisfaction-related domains constituted the other significant associations. The association related to service of the HAs was reported for the duration of the hearing loss and the number of years of HA experience with that of the number of times the HA was serviced. The longer the years of experience with the HA, the number of times the servicing required for the HA was also more. There was a significant association of warranty period with the duration of hearing problems and HA experience. The difficulty getting the HA serviced was more during the pandemic, though the HAs were within warranty period. Also, the more the years the HA was used by the participant, the time taken to repair the HA was also longer by 3 weeks to 2 months as in Figure 1.

As in Figure 2 the duration of the hearing loss had significant associations with the problems with the servicing of the HA during the pandemic, with more the years of use with the HA reporting better listening satisfaction with HA.

Among the satisfactory measures depicted in Figure 3, the type of HA use had a significant association with the cost involved for the repair of the HA. The behind-the-ear (BTE) HA involved more cost for repair; however it was dependent on the problem with the HA.

As shown in Figure 4, the general extrinsic factors which had a significant association with the duration from when the HA was not working are the number of times for services of HA (service related factor) and reason for the delay in repair (repair related factor). Significantly higher number of participants who had their HA not working for 3–6 months reported that they had given their HA for repair for atleast 2 times. While the same group reported the reason for the delay of their HA repair was the unavailability of the spare parts for repair of the HA during the pandemic situation. From Table 2, it is evident that there were sigfnificant associations of physical extrinsic factors with service-related issues, were physical damage to the HA, hardening and breaking of the tube of the ear mould, and accumulation of the sweat in the HA.

From Figure 5, significant association of the sound quality-related extrinsic factors with repair related issues were delay in transport, duration of HA repair, and not availing the HA for repair to the service centers. The above factors significantly had associations with sound clarity. Those participants who complained of poor sound clarity from HA for 3 weeks to 2 months had the major reason of non-availability of the service center and lack of transport during pandemic to avail the service facility for their HAs. Out of those who availed facility for complaint of sound clarity had non-availability as spare parts as the major reason for the delay in HA repair. Similarly, when the complaint was distorted sounds from their HA, unavailability of spare parts and delay in payment of the amount for repair were the major reasons for service delay of the HAs.

The question evaluating the problems related to servicing HA in COVID-19 lockdown encountered larger and more significant associations (p<0.05 and p<0.001) with physical issues in the service-related category. Among the general problems with the HA, the number of times the HA user had visited the institute had an association with the duration of the HA repair also there was significant association between the duration of the HA repair and the various reasons for the delay in repairing back the HA to provide it to the users. The reasons majorly include the delay in transport, the delay in payment for the repair, and the unavailability of the spares for repairing the HA. However, no significant associations were seen in the consumer satisfaction-related category.

The significant associations of service-related (continuous black lined frames), repair-related (black dotted frames), and satisfaction related (grey dotted frames) issues considered in the study with intrinsic factors in descending order are HA experience (3 associations, Figure 1), duration of hearing loss (1 association, Figure 2), and HA (1 associations, Figure 3).

The significant associations of service-related (continuous black lined frames), repair-related (black dotted frames), and satisfaction related (grey dotted frames) issues were considered in the study with questions corresponding to extrinsic factors categorized under general issues, HA’s physical issues, and sound quality-related issues are shown in Figures 4 and 5 respectively. The three most extrinsic factors which showed significant associations with measures used in the study were sound quality (4 associations, Figure 5), broken tube (2 associations, Figure 5), and duration from which HA is not working (2 associations, Figure 4).

The COVID-19 pandemic is an prodigious, fortuitous situation which made the worldwide changes. The challenges posed by COVID-19 on healthcare sector was huge and first of its magnitude. Audiologists and speech-language pathologists, as healthcare professionals, directly interact with patients during service delivery. Due to safety and precautionary measures during COVID, only limited services were provided. One such service which was limited during the pandemic was the servicing of the HA after being subjected to physical or programming realated damages. During pandemic, HA users encountered challenges in obtaining new ear molds, replacing earmold tubing, purchasing new batteries, and repairing their HAs. The reasons for these challenges included lack of transport facility, closure of the HA servicing and repair center, self-illness, and limited availability of professionals. Hence the HAs remained unrepaired, affecting optimal listening and communication. So, HI users faced many difficulties due to the suboptimal performance of HAs and ill-fitting ear molds. The present study aimed to survey the HA-related repairs and the servicing issues during the COVID 19 pandemic. The data collected through the questionnaire were divided into intrinsic factors and extrinsic factors and were associated with HA servicing, repair, and satisfaction-related corners. The results of the analysis are also discussed accordingly. The service-related domain analysis with intrinsic variables revealed that the number of services sort for HA complaints increased with the HA user’s experience and duration of the hearing loss. Jones [18] reported that despite HAs design and durability materials used in its construction, some structural degradation occured over time, leading to internal distortion and non-functionality. This explanation is also supported by the study’s findings, where 85.1% of the HA users reported distortion, and 59.7% reported intermittent sound output. The general issues of HA output stemming from wear and tear are usually sorted out by servicing, especially when in warranty period. Despite being under warranty, HA users encountered significant challenges getting their devices repaired during the pandemic.

Related to the HA repair aspects, there was significant association between the HA experience and the HA repair duration. It suggests that more problems are reported with various HA components with he time of usage and hence takes a longer duration to replace and repair the components. Also, the unavailability of the spares parts was due to obsolete status. However, this increase in the waiting period for the repair of the HA was more notable due to the lockdown in pandemic.

The HA type and usage duration also had a significantly strong association with repair cost. The repair for the digital BTE HAs was expensive compared to the digital receiver-in-the-canal (RIC) HAs. However, in the present study, the number of users of RIC HAs were lesser compared to the BTE HAs. The increase in cost for repair could be dependent on the cause for the damage of the HA. The HAs are liable to get damaged due to damp environments. Though the HAs are nano-coated, the moisture, dust, ear wax, sweat, and extreme temperatures add to HA’s working life span [18] leading to increase in cost of repair. According to Kochkin at al. [19], around 10.3% of the individuals reported dissatisfaction with their HAs due to the repair cost. The number of HA repairs negatively influences satisfaction and the use of the individual’s HA [20].

Under satisfaction measure, the type of HA had a more significant association with satisfaction measures. Since the HAs provided are digital, the noise reduction would be more with better speech clarity. Hence the satisfaction with these HA after the repair is also higher. The longer the hearing loss, the more frequent the HA repair issues reported by the user. However, the more the duration of the hearing loss, the use of their HA will also be for longer duration, hence the repair issues were reported more. Still, there was a good association with their satisfactory measure, which means that the experienced users had a higher acceptance of the HA and were satisfied. Greater satistsfaction rates in experience users is in contrast to Kochkin et al. [21] who reported that the new HA users had less satisfaction with the HA.

On analyzing the association of other variables, it was found that physical damage has a significant association with the frequency of the HA servicing. 11.9% reported physical damage to the HA. 6% reported problems due to wax accumulation 6% to earmold tubing breakage, and 9% to tubing hardening. During the COVID pandemic lockdown, the HA services were suspended, preventing individuals from utilizing them. The issues causing the most trouble were a faulty receiver (29.9%) and a malfunctioning internal board (22.4%). The other problems were the microphone (11.9%) and switches (11.9%). The repair durationfor the HA depends on the HA company and the parts that require the replacement. During the lockdown, the HA technician’s absence prevented the availability of spare parts at several company service centers. Without transport services, acquiring spares and accessories on time proved challenging. 28.4% of HAs took between 3 weeks and 2 months for repair. However, 100% satisfied post-repair with their HA. The other HA factors that had a good correlation include loose-fitted tubing of the earmold, tubing becoming harder, broken tubing, and non-availability of the batteries with the time required to get the batteries HA serviced. The inadequate HA repair and services during lockdown disrupted individuals’ communication requirements. The interlinking of intrinsic and extrinsic factors demands users to exercise caution concerning HA satisfaction in general, and during pandemic situation in particular.

The lockdown during the COVID-19 pandemic has an adverse effect on the services provided for the repair of the HA users. The unavailability of spares for repair, and the lack of transport facility had an adverse effect. There was overlap of intrinsic variables and extrinsic variables considered in the study that affected the overall servicing and repair of the HA users during the pandemic. Being informed of the relationships among HA repair, service, and satisfaction is essential. This would enhance a professional’s ability to deliver effective HA repair services, especially during pandemics.