We All Need a HearO Fighting Hearing Aid Stigma Lukas Riedel Thure Waller Master of Science Thesis, Industrial Design Engineering CHALMERS UNIVERSITY OF TECHNOLOGY Gothenburg, Sweden 2018 Department of Industrial and Materials Science Division of Design & Human Factors Master of Science Thesis, Industrial Design Engineering Authors Lukas Riedel Thure Waller Supervisor Fredrick Ekman Examiner Oskar Rexfelt CHALMERS UNIVERSITY OF TECHNOLOGY Gothenburg, Sweden 2018 Department of Industrial and Materials Science Division of Design & Human Factors We All Need a HearO Fighting Hearing Aid Stigma Master of Science Thesis IMSX30 We All Need a HearO Fighting Hearing Aid Stigma Master of Science Thesis in the Master Degree Program Industrial Design Engineering © Riedel Lukas, Waller Thure Chalmers University of Technology SE-412 96 Göteborg, Sweden Tel. +46(0) 31-772 1000 Cover photo: Riedel Lukas, Waller Thure Print: Repro Service Chalmers Preface This master thesis project was made by us, Thure Waller and Lukas Riedel. We are both tall, skinny and from the countryside. When we started our collaboration before this project, we launched a company called najs design. This was a way for us to showcase who we are for interesting companies. Our homepage looked like this: We got tired of people not hearing what is said. The endless repeating of “what” that followed us in the everyday. Not because we always have interesting things to say, but because we want people to be able to listen. A lecture on the theme design for all showed what journey eyeglasses had made, which inspired us to try the same with hearing aids. With five years at Chalmers and in total almost 17 years at school, we felt an urge to spend some time in other premises. We got warmly welcomed at yovinn, a company with one of the finest offices in Gothenburg. Sorry for booking the meeting rooms almost every day. We also got in contact with Widex, a hearing aid company in Denmark. Many interesting people spent time with us. Thanks a lot for that! Also thank you to Widex for always replying so quickly to our emails. Thank you to our supervisor Fredrick for your support and extraordinary moustache. Thank you to our examiner Oskar Rexfelt for teaching us the fine art of writing a thesis. Thank you family and friends for your sup- port and belief in us. Thank you Johanna and Camilla for being the best a man can get. Abstract Hearing loss is a major health concern. In Sweden, 18.9% of the popula- tion above 16 experience it and only half of them take action to treat it. Hearing is vital for us to stay healthy and social, so why are we not fixing our hearing losses? We wanted to investigate what hinders people from wearing products that help them hear better. The aim was to create moti- vation for people to solve their hearing loss. According to the public opinion, hearing aids make you look old, stu- pid and handicapped. These strong attributions play a significant role in why people are not wearing them. Nowadays, people want to hide their hearing aids as much as possible, why the design efforts on the mono- tone hearing aid market are pushed towards smaller and more invisible products. When people take the big step to acknowledge their need for the product, they often get disappointed in the performance. To acquire hearing aids today you are in the hands of your audiologist, with little power to choose which product you will get. Eyewear was once a stigmatized product. A product that made you get attributions similar to those when wearing hearing aids today. Now how- ever, they are a strong product to express your personal style with. How can the same revolution happen in the hearing aid business? A radical change is needed on the market. We created a vision for what hearing aids should be in the future. With this we added five focus areas that pinpoint how the stigmatization could be solved. One of the most effective ways to diminish stigma was found to be by making a product used by all, even people without hearing loss. That would extinguish the special treatment hearing aid wearers get. A key to reach this was to find a function desired by everyone. After numerous surveys and a co-creation session, it was found that most people have sit- uations when they can not hear conversations and would like to control their sound environment. Therefore this would become the main func- tion in the final concept. The final concept further builds on the speech enhancement and sound control function by extending it to include wellbeing in general. The ear is a perfect placement for biosensors. This gives the opportunity to capture data on stress levels and a new way of keeping track of your training efforts. This product called the HearO is for everyone. With an easy solution to change the style entirely, no one is left out. This will create proud users that want to show the product. The most important interaction is done in an innovative way that is intuitive to use, just like a volume knob. Contents 1. Introduction 1 1.1 Background 2 1.2 Aim 3 1.3 Demarcations 3 1.4 Target Group 3 1.5 Objective 3 2. Approach 5 3. Applied Methods 8 3.1 Data Collection 10 3.2 Analysis 12 3.3 Concept Development 14 4. Background Study 17 4.1 Hearing 18 4.2 Hearing Loss 19 4.3 Hearing Aids 20 4.4 Stakeholders 26 4.5 Laws and Regulations 28 4.6 Benchmark 29 4.7 Analysing the Widex Brand 33 4.8 Interviewing Users and Audiologists 38 4.9 Studying Attributes and Emotions 51 4.10 Wearing Hearing Aids Ourselves 55 4.11 Observations at the Audiologists 56 4.12 Creating a Storyboard 59 4.13 Listing Requirements 62 4.14 Visiting Companies 63 5. Strategies for Enhancements 70 5.1 Creating Focus Areas 72 5.2 Creating a Vision 75 5.3 Finding Strategies 76 5.4 Innovating Together With Users 79 5.5 User Thoughts on Functionality 90 5.6 Morphological Matrix 92 5.7 Creating Conceptual Strategies 93 5.8 Evaluation 97 6. Manifesting a Strategy 103 6.1 Elaborating on Extra Functions 104 6.2 Probing Extra Functions 105 6.3 Packaging the Extra Functions 109 6.4 Creating a New Customer Journey 111 6.5 Creating Boards 114 6.6 Finding the Key Functions 116 6.7 Exploring the Form 117 6.8 Conclusion 121 7. Developing the HearO 122 7.1 Developing the Physical Shape 124 7.2 Defining the Interaction 132 7.3 Building the Brand 133 7.4 Selling the HearO 135 8. Discussion 139 9. Conclusions 142 10. References 147 10.1 Literature and Digital Sources 148 10.2 Expert Interviews 151 10.3 Images 152 Appendix 154 1. Introduction In this chapter, the project is introduced. 1 2 1.1 Background Hearing loss is a major public health concern, with almost one fifth (18.9%) of the Swedish population over 16 having a hearing loss (Statis- tiska Centralbyrån, 2017). The most common type of hearing loss is age related (presbycusis). Among adults aged 65-74 one third has a hearing loss and among people over 85 this increases to more than half having a hearing loss (Statistiska Centralbyrån, 2017). Presbycusis affects both ears to the same degree and impacts high frequencies first. Another factor affecting hearing loss is noise exposure. Both these types of hear- ing loss makes it hard to follow conversational speech in noisy situations (David, D. and Werner, P., 2016). A person with hearing loss needs to concentrate harder to follow conver- sations and can have difficulties to understand what is said. This can lead to people with hearing loss avoiding social situations (Socialstyrelsen, 2009). Research shows that untreated hearing loss has a negative impact on life quality and physical and mental health (David, D. and Werner, P., 2016). It is especially difficult for people working, for whom it is hard to live up to the demands at work (Socialstyrelsen, 2009). Hearing aids can help a lot of people with hearing loss to hear better, thus giving them better life quality and health. Despite this, a small portion of all who could benefit from hearing aids are using them. In Sweden there are around 360 000 people using hearing aids but research shows that twice as many are in need of hearing aids (Hörselskadades Riksförbund, 2008). This means a large potential market for the hearing aid companies. Widex, one of the world’s leading hearing aid manufacturers are interest- ed in reaching this market. With their global strength and knowledge as well as their reputation of being one of the most innovative in the indus- try, this makes for a good collaboration. Designing for disability is an interesting area where it traditionally has been about enabling and attracting as little attention as possible. The approach has not been to project a positive image, rather trying to hide the products with glossy skin coloured plastics. However, when seen, these products may send out a signal that disability is something to be ashamed of. Fashion is rather the opposite, where it is much about creat- ing a product seen by others. Eyewear is a fairly rare market where fash- ion and disability meet. Eyewear has a positive image without the effort of hiding the product (Pullin, 2011). It is interesting to see if hearing aids can make the same transformation. 3 1.2 Aim Create more motivation for people to solve their hearing loss. 1.3 Demarcations • Solution should not be an information campaign • Complete technical documentation with correct drawings of a concept will not be included 1.4 Target Group The main target group for this product development is set to people not using hearing aids with mild hearing loss of age 45-60. This is be- cause we wanted to target those that are not using hearing aids today. By early research we found that people with severe hearing loss treat it, as they can not live a normal life without hearing aids. The ones not treating it are people that have a mild hearing loss where the motiva- tion of solving it is weaker than the barriers of acquiring a hearing aid. The age span is defined by when people start suffering from hearing loss to a great degree. 1.5 Objective The objective is to develop a concept that invites more users to treat their hearing loss. This will be performed by conceptualizing a new experience of acquiring a product that treats hearing loss. It must include aspects from the full experience. The result should be a product concept shown in its full context with a time to market of around five years. Research Questions: • Why are people refusing from solving their hearing loss? • How can you make more users affected by hearing loss, be unob- structed by it? 4 5 2. Approach In this chapter the overall process is introduced. A figure over the report layout is also presented. 6 A hypothesis when this project started was that an incremental change to the products on the market today will not battle the underlying barriers of hearing aid usage. This hypothesis was soon confirmed in the first research phase of the project. In this development process, where ground-breaking new innovations and radical solutions are searched for, information needs to be processed on a high abstraction level. The project started by researching the current products, abstracting it into basic needs of users before developing a new solution. This ensured that the current solutions did not influence the final design, rather solving the basic needs that people experience having a hearing loss. An abstraction model used in the project in three steps was created, see figure 2.1, where all the chapters describing the design process are in- cluded. The basic level is product, where it is all about the key functions and physical construction of a product. The interaction level is where the user and the product meet. How the interface should be and what the product should do for the user. The top level are the basic needs that the user wants to accomplish by using the product. 7 Basic need Interaction Product 5. Strategies for Enhancement Abstracting user information to �nd motivations for use. Developing concept strategies. Key Methodologies Co-creation sessions, ideation sessions and information analysis. 4. Understanding the Context Discovering what hearing aids are today and the user’s relations to them. Key Methodologies Interviews, literature research, company visits and observa- tions. 6. Manifesting the Strategy Develops on embodying the strategy. Determine user goals and functionality. Key Methodologies Ideation, prototyping, user research and expert interviews. 7. Detailed Design Developing the product idea and re�ning it into a concept to be communicated. Key Methodologies Computer aided design, prototyping and visualizations. Figure 2.1 The abstraction model. 8 3. Applied Methods This chapter is a database to use as reference for the methodology used throughout the project. 9 10 3.1 Data Collection 3.1.1 Interview Interviewing is a research method for direct contact with participants, used to collect first hand personal accounts of experiences, opinions, attitudes and perceptions. Interviews are best conducted face-to-face so that nuances of personal expressions and body language are recogniza- ble. However, they can be conducted remotely over the phone or social media (Martin and Hanington, 2012). An interview can be structured and follow a template with questions or unstructured with a more conversational format, allowing for flexible detours. Interviews can also be semi-structured following a template but allowing for improvisation and tweaking of the questions depending on the answers and the given situation (Martin and Hanington, 2012). The form of the interview vary depending on the aim of the interview. When collecting quantitative data a structured interview is preferred. A structured interview gives data with less bias which is easier to com- pare between interview persons. For explorative research with quali- tative data an unstructured interview might be preferable (Martin and Hanington, 2012). 3.1.2 Observation The visual studies of people, artefacts, environments, events, behaviours and interactions are called observations. The purpose of observations in a design process is often to understand how the user acts in a certain situa- tion. What the user says in an interview and what the user actually does in a real life situation can often differ (Martin and Hanington, 2012). There are several types of observations. In a direct observation the event of interest is studied directly without alteration of the environ- ment. In a participatory observation the observer is taking part in the event studied. There is also what is called self-observations, when the participants observe themselves, for example by writing a diary (Martin and Hanington, 2012). Direct and participatory observations can be open or hidden. Open ob- servations mean that the subject studied is aware of the observers, while the subject is not aware that they are being studied during a hidden observation. Open observations allow the observer to ask questions to 11 the participants and have them think aloud. This can give useful insights that are difficult to find in interviews (Boeijen et al., 2013). 3.1.3 Online Questionnaire Online questionnaires are a type of survey used to collect information from people, typically from a large sample of respondents. The surveys are made using online survey platforms and distributed to participants using social media or emails. The method is an efficient way to collect a large number of quantitative data in a short period of time. With a large sample it is possible to analyse the data statistically. The validity of the survey is heavily dependent on the design of the survey. It is important that the participants can understand the questionnaire and answer in a correct way as they can not ask complementary questions if they do not understand (Martin and Hanington, 2012). 3.1.4 PrEmo PrEmo is a specific type of online questionnaire which measures emo- tions towards a product. The tool is built on stimuli in the form of pic- tures of a product and an emotional rating of it by the participant. The participant rates 14 emotions, 7 pleasant and 7 unpleasant, by seeing an animated character with dynamic facial, bodily, and vocal expressions. This is to ensure a validity of the ratings and the sensed emotions and builds on how we communicate emotions to other people. The scale goes from 0 to 4. The pleasant emotions are: desire, pleasant surprise, inspira- tion, amusement, admiration, satisfaction and fascination. The unpleas- ant emotions are: indignation, contempt, disgust, unpleasant surprise, dissatisfaction, disappointment and boredom (Desmet, 2003). 3.1.5 Literature Review A literature review is a method to collect and synthesize research on a given topic. The literature review is intended to distil information from published sources, capturing the essence of previous research that can be of use in the current project (Martin and Hanington, 2012). Internet has made the search for information a lot faster, giving researchers access to libraries from around the world using online tools, digital jour- nals and books. However, it is still important to consider the credibility of the sources. It is especially important for websites and blog post which have not been peer reviewed for credibility (Martin and Hanington, 2012). 12 3.2 Analysis 3.2.1 Affinity Diagram As long as the knowledge is in people’s minds or buried in interview transcripts it is difficult for designers to synthesize what has been learned. An affinity diagram is a method used to externalize the overall picture from a huge amount of data. When doing affinity diagramming all data is written on sticky notes, with each sticky note containing one unit of data. The sticky notes are then clustered based on affinity into a number of research-based themes. The result is an affinity diagram tell- ing a story of the people interviewed, their tasks and the nature of their problems (Martin and Hanington, 2012). 3.2.2 Stakeholder Map In the beginning of the design process it is important to define all the key constituents that might have a part in the outcome of the final design. One way to do this is through a stakeholder map. The stakeholder map aims to visualize all the key players affected by the design project. The stakeholder map also serves as a guide for the design team during the process, creating a good setting for a user-centered research (Martin and Hanington, 2012). Stakeholder maps are often created speculative with the design team brainstorming all the people who may have an interest in the design. Stakeholders can be identified by general roles (students, nurses), spe- cific roles (CEO, chief of surgery) or actual people (Robert, Linda). The different stakeholders are then sketched out on a paper or whiteboard. The sketch then evolves into a more structured net with connections and hierarchies between the stakeholders (Martin and Hanington, 2012). 3.2.3 Customer Journey Map A customer journey map is used to understand all the steps a customer goes through while experiencing the use of a product or service. The cus- tomer journey map covers the emotions, goals, interactions and barriers the user experiences during the different steps. The customer journey map is often presented in a graphical way on a timeline with the different stages in the journey (Boeijen et al., 2013). A problem faced by many designers is that they design touch points or features that work well in themselves but do not fit in to the whole 13 experience. The customer journey map is a tool to understand the whole process and experience, thus reducing the risk of designing isolated touch points. The customer journey can be created by the researchers in the project but the customers themselves can also be asked to draw their experience of a product or service (Boeijen et al., 2013). 3.2.4 Storyboard Storyboards tell a narrative in a visual way meant to create empathy for the user and explain the context in which a product or service will take place. With the use of storyboards the context of how, where and why people en- gage with products can be communicated (Martin and Hanington, 2012). Storyboards use a number of panels similar to those used in comics. How many panels that are used depend on the narrative. Usually there are three to six panels, but can be more if the narrative is complex. The panels con- tain illustrations which do not have to be photo realistic, often times sim- ple stick figures will do just fine. The illustrations are then complemented with text-based narration or explanations (Martin and Hanington, 2012). 3.2.5 List of Requirements A list of requirements states the important factors that a design needs to meet in order to be successful. The requirements are based on findings from the research study in the project and more requirements are added throughout the project. The list can also be useful in the evaluations of concepts during the design process (Boeijen et al., 2013). The requirements in the list should be substantial. One way to make the requirements more substantial is to define them numerically. For exam- ple instead of saying that the product should be portable, say the product should weigh less than 5 kg (Boeijen et al., 2013). 14 3.3 Concept Development 3.3.1 Brainstorming Brainstorming is an idea generation method based on the idea that quantity leads to quality. No premature criticism is allowed during the brainstorming process and the list of requirements can therefore be ignored during the process. Another way to do the brainstorm is to focus on a specific requirement at a time, and brainstorm ideas around that specific requirement (Boeijen et al., 2013). The brainstorm is usually done in a group of people. It is important to create an environment where everyone feels safe and secure so that they dare to say even their most crazy ideas. Improvements and combinations of ideas are wanted so the participants should be encouraged to build on each others ideas (Boeijen et al., 2013). 3.3.2 Co-Creation Session A co-creation session is a way to involve the users into the design pro- cess. The users often have a lot of knowledge and insights into the con- text and use of a product. Therefore the users can give good feedback on what works and what can be improved in a design (Designkit.org, 2017). The first step when creating a co-creation session is to decide on which participants are wanted. It may be people that have been interviewed previously in the project or a specific demographic group like teens or people without jobs. The next step is to arrange a space, get necessary supplies and invite the participants to join. It is useful to have tasks or some kind of triggers to get the participants engaged in the problems to be solved. The feedback that the participants are giving during the ses- sion should be captured for use at a later stage. It is important to treat the participants as designers and not interview subjects during the co-crea- tion session (Designkit.org, 2017). 3.3.3 Prototyping Prototypes play a crucial role in the design process. It is the prototypes that make ideas and visions tangible, allowing them to be tested by de- signers, clients and potential users. Prototypes are defined by their level of fidelity. Low-fidelity prototypes are used in the early stages of ideation to quickly test ideas. This kind of prototypes can be created fast with the things at hand (Martin and Hanington, 2012). 15 High-fidelity prototypes are more refined and often represent the appear- ance of the final design in look and feel. These type of prototypes are used in the later stages of the product development to get feedback on aesthet- ics, interaction and usability from users and clients. In between low-fidel- ity and high-fidelity prototypes there often are a wide range of prototypes as prototyping is an iterative process (Martin and Hanington, 2012). 3.3.4 Image Board Image boards or mood boards have been used for a long time in different design professions. Image boards can be used to visually communicate the targeted aesthetics, audience, context or other aspects of design intent. Image boards are made up of a number of images depicting the wanted expression (Martin and Hanington, 2012). Image boards can be used in- ternally to make sure that everyone in a team are on the same track, func- tioning as a visual reminder of the targeted style. Image boards can also be used to communicate design intent to a client, clarifying on aesthetics or a specific target group (Martin and Hanington, 2012). 16 17 4. Background Study In this chapter, the context of the project is explored. Technological research is performed and users are involved. 18 4.1 Hearing This chapter summarizes the findings from a literature review on the ba- sics of hearing and sound. This understanding is basic knowledge need- ed for the development of a product in this area. The aim was to clarify the physics behind sound and to investigate the hearing organ. 4.1.1 Sound Sound is made up of pressure waves, which means that the molecules in the transmitting matter are densified and attenuated. The speed of sound differs depending on which material it is transmitted through. As sound is made up of pressure waves, it spreads out just as rings on water. Sound can be reflected or absorbed in different physical materials standing in the way of the waves. Sound level, how loud we perceive the sound, is often measured in deci- bel (dB). The frequency of sound, or how high or low a tone is perceived, is measured in hertz (Hz). As we have different sensitivity for sound depending on the frequency, a normalized dB-scale has been developed known as dB HL (Hearing Level), where 0 dB HL in all frequencies describe normal hearing. Normal hearing frequencies lie between 20 Hz and 20 000 Hz, where the upper limit decreases with age (Andersson and Arlinger, 2007). 4.1.2 Anatomy of the Ear The human hearing system consists of two main parts, the brain and the ear which together create perceived sound. The ear itself consists of three main parts, the outer, the middle and the inner ear, see figure 4.1. Figure 4.1 The parts of the ear (OpenStax, 2016). 19 The outer ear transfers the sound and the shape of it helps to perceive direction as frequency changes depending on where the sound source is. The ear canal then leads the sound further into the eardrum and slightly amplifies it. The area between the eardrum and the cochlea is called the middle ear and is an air-filled cavity. In this cavity three ossicles, or au- ditory bones, transmit the sound from the eardrum to the oval window of the cochlea. The inner ear consists of both the balance organ and the cochlea, which we use for hearing. The cochlea is liquid filled, and the vibrations caused by the ossicles on the oval window is perceived by hair cells, which transmit electrical signals to the auditory nerve which in turn leads the signals to the brain (Andersson and Arlinger, 2007). 4.2 Hearing Loss In the following chapter hearing loss, its causes and how it appears is described. Data was gathered through literature reviews and interviews with audiologists. This is fundamental knowledge for developing a prod- uct aiming at solving issues related to hearing loss. 4.2.1 Diagnosing Hearing Loss To diagnose the specific hearing loss someone experiences, numerous tests are performed at an audiologist. A general health check is done to see if any other disease could cause the hearing loss. It could be as simple as a plug of wax blocking the ear canal. When that is done, a hearing test is performed in an anechoic chamber. Both air conduction and bone conduction tests are performed, and signals are sent through the speak- ers to the patient who has to push a button when a sound is heard. Air conduction tests use headphones similar to consumer headphones, and bone conduction tests use a headphone vibrating on the bone in front of the ear. If there is a difference in hearing level between the two methods, it indicates a problem in the middle ear. If there is no difference, that means there is a problem in the inner ear. Speech recognition tests are also performed where the patient has to listen to words masked in noise and repeat the words (Grunditz, Gunnelid and Thelin, 2017). 4.2.2 Types of Hearing Loss There are three main types of hearing loss, conductive hearing loss, sen- sorineural hearing loss and mixed hearing loss. Conductive hearing loss means that there is failure in transmitting the sound from the outer ear into the inner ear, typically middle ear issues such as hole in the eardrum 20 or stiffness in the ossicles. Sensorineural means that there are issues either in the cochlea or on the auditory nerve. Hearing impairment because of age, presbycusis, is sensorineural and is a degeneration of the cochlea. It is the most common hearing loss. Noise induced hearing loss is also sensorineural, and these two conditions can worsen each other. A mixed hearing loss means that you have both sensorineural and conduc- tive issues (Grunditz, Gunnelid and Thelin, 2017). 4.2.3 Untreated Hearing Loss There are numerous drawbacks with not treating a hearing loss. The brain deteriorates and socially a person with hearing loss will become more disconnected. A person with hearing loss is more likely to experi- ence depression, social isolation and even dementia. Also physical risks have been found related to hearing loss, such as increased risks of falling (Bouton, n.d.). Neuroplasticity is the ability our brain has to reorganize itself by mak- ing new neural connections. This is what happens to visually impaired persons who experience increased hearing and haptical precision. The same process happens when not treating your hearing loss, as the brain does not get the auditory stimuli it is used to (MedicineNet, n.d.). This means that speech recognition and voice perception in noisy envi- ronments will gradually worsen. Therefore an early treatment of the hearing loss to limit the neuroplasticity is important (Anderson and Kraus, 2013). 4.3 Hearing Aids A market analysis of existing hearing aids together with literature review and expert interviews with people working with hearing aids gave an un- derstanding of the components and the different types used today. This information was useful to understand the possibilities of development with the state of the art today. 4.3.1 What They Are and How They Work Hearing aids are sound-amplifying devices made to help people with hearing impairments. There are quite a few different types of hearing aids on the market, but most of them share a similar set of components. Today most hearing aids are digital and have at least one microphone to pick up sound, a sound processor, a small speaker sending the sound 21 into the ear and a battery for power (Fda.gov, 2016). These components are the core of almost every hearing aid but can be made in different siz- es and shapes. Hearing aids can be categorized into two main categories. The ones sitting behind the ear and the ones that are placed in the ear (Plotnick, 2017). Within these categories there are several sub categories. 4.3.2 Behind the Ear Behind the Ear (BTE) Behind the ear hearing aids have the components placed in a plastic case resting behind the ear, see figure 4.2. The case is connected to an ear mold by a clear plastic tube in which the sound travels into the ear. This type of hearing aid is easier to clean and handle because of its bigger size (Fda.gov, 2016). Receiver in the Ear (RITE) RITE hearing aids are similar to BTE in that they have most of the com- ponents in a plastic case resting behind the ear. The difference is that the speaker (receiver) lies in the ear canal instead of in the plastic case of the hearing aid, see figure 4.3. Therefore the receiver gets further into the ear canal and closer to the eardrum. The other components such as micro- phones and the processor are still placed in the plastic case. The wire between the plastic case and the receiver is much thinner than that used in regular BTE hearing aids (Aids and Plotnick, 2017). 4.3.3 In the Ear In the Ear (ITE) These hearing aids sit inside the outer ear instead of behind the ear. ITE are the largest hearing aids sitting in the ear. Because of the larger size they can accommodate more advanced technology, have longer-lasting batteries compared to other hearing aids sitting in the ear. They can also be easier to handle than other smaller hearing aids (Oticon.global, 2016). In the Canal (ITC) In the canal hearing aids fit partly inside the ear canal but are not com- pletely inside the ear canal (figure 4.4). Because they are larger than hearing aids that fit completely inside the canal they have longer battery life and more advanced technology. They are also easier to handle than the smallest hearing aids and can handle a wider range of hearing disa- bilities (Oticon.global, 2017). Figure 4.2 BTE hearing aid. Figure 4.3 RITE hearing aid. Figure 4.4 ITC hearing aid. 22 Completely in the Canal (CIC) CIC aids are smaller than ITCs and sit completely inside the ear canal and are therefore hard to see, but not entirely hidden. They are often made in a skin coloured plastic to make them less visible. They usually have less functions but are good for people wanting discreet hearing aids. This kind of hearing aid requires you to have large enough ear canals and are suitable for people with mild to moderate hearing loss (Oticon.global, 2017). Invisible in the Canal (IIC) These hearing aids sit so far inside the ear canal so that other people are not able to see them. The only thing sticking out of the ear canal is a small plastic pin with which you can pull them out. Because they are so small, they lack many of the functions of the larger ones. As with CIC, you need a large enough ear canal and a mild to moderate hearing loss (Oticon.global, 2017). 4.3.4 Components This chapter gives a more detailed description of the components of a hearing aid. A hearing aid is composed of the following main compo- nents: one or two microphones, an amplifier/signal processor, a receiver (loudspeaker) and a battery. The hearing aids also contain other elec- tronics such as chips, coils, capacitors and resistors. Microphones The microphone in hearing aids is a diaphragm that converts acoustic energy into electrical signals. The diaphragm vibrates in response to the condensation and rarefaction of air molecules from incoming sounds. The vibrations of the diaphragm are then transferred to electrical signals corresponding to the amplitude, frequency and phase of the acoustic sig- nal. The microphone is not only sensitive to acoustic vibrations, but also mechanical vibrations. Mechanical vibrations can therefore lead to feed- back problems, when the signal output is registered by the microphone, and it is therefore important to reduce the risk of mechanical vibrations in the design of the hearing aids. Microphones used in hearing aids can be either omnidirectional or di- rectional. Omnidirectional are similarly sensitive to sounds from all di- rections while the directional microphones are more sensitive to sounds coming from a specific direction. The directional microphones are used to enhance speech intelligibility in noisy environments. The directional microphones are optimized to pick up sounds coming from a specific direction and sounds from other directions are attenuated. 23 The hearing aid industry are mostly using what is called electrostatic ca- pacitor mics (ECM) in their products. There is another microphone tech- nology called MEMS (micro electromechanical systems) with some advan- tages. The main advantages with MEMS compared to ECM are that they have the same performance with less volume, less variation of sensitivity with temperature and less variation between different microphones of the same type. They are more expensive though (Sound & hearing, 2007). A/D Converter Most hearing aids today are digital which means that the analogue signal from the microphones must be converted to digital signals. This is done with analogue to digital converters (A/D converters). The advantages of digital is that complex analogue circuits requiring many components can be transformed into a number of computations. Another big advantage is higher precision, as digital is not as sensitive to changes in temperature and voltage (Sound & hearing, 2007). Digital Signal Processor The digitised signal is processed in the signal processor and amplified ac- cording to the needs of the user. As the signal is digital there is no need for external components, all is done by the signal processor, see figure 4.5. One of the main challenges for the hearing aid manufacturers is to make the signal processor perform optimally while using little power. Another is the physical size of the signal processor, in order to make the hearing aids as small as possible. There are three ways to go when developing a signal processor for a hearing aid. First is to use a generic digital signal processor (DSP) and implement the right functionality in a programmable software. The second way is to use a specialised off-the shelf DSP and the third is to develop a dedicated DSP. The open-platform generic DSP is software-controlled which gives add- ed flexibility. The development of a generic DSP often requires a shorter time frame than a dedicated DSP. The disadvantages are larger size and higher power consumption. The specialised off-the-shelf DSP is similar to the generic but developed for a more specific use, in hearing aids for example. Similar to the gener- ic DSP it requires less time than a custom DSP, and what takes most time is to program the software. The size is fixed and the only way to reduce the power consumption is by lowering performance. Figure 4.5 A DSP chip. 24 A dedicated custom DSP is adapted for a very specific purpose, and optimized for size and power consumption. Most of the functionalities are hard-wired, which permits quicker processing than in software based processors. There is little flexibility in dedicated DSP but the power consumption is lower. This is the type of DSP used in Widex hearing aids (Sound & hearing, 2007). Electronic Filters Hearing aids use filters to modify the characteristics of the sound spec- trum. The filters are electronic circuits that amplify or attenuate specific frequencies. The number of filters used differ between hearing aids, some have 15 filters whereas other have two or three. One of the most common types of hearing loss is presbycusis, which af- fects only the high frequencies. The low frequencies are not affected. Re- duced capability to hear high frequency sounds makes it hard to under- stand speech in noisy environments. A low-cut filter is used to attenuate the low frequencies that are fully audible for a person with presbycusis. Only the high frequencies are amplified to make it easier to understand speech in noisy environments. Apart from low-cut filters there are high-cut filters. The high-cut filters are used to reduce the gain for high frequencies, above 1000 Hz. This is to give an appropriate amount of high frequency gain for a given hearing loss. On more powerful hearing aids it can also be used to reduce the risk of feedback. Before the digital signal enters the signal processor it is divided into a number of frequency bands. The more advanced hearing aids usually have more frequency bands. The division of the signal into multiple bands makes it possible to manipulate different parts of the signal in different ways. This means that the output sound can be manipulated to match the user’s hearing loss. Unwanted sounds can be identified and a particular frequency band can be attenuated (Sound & hearing, 2007). D/A Converter After the digital signal has been processed by the signal processor it needs to be converted back to an analogue signal that can be reproduced as a sound by the receiver. This is done by a digital-to-analogue converter (Sound & hearing, 2007). Receiver The receiver or loudspeaker converts the amplified electric signal into sound waves. A receiver works like a reversed microphone. The electrical Figure 4.6 A balanced armature receiver. 25 675 13 312 10 signal from the amplifier sets the diaphragm of the receiver into motion, generating vibrations that are picked up by the ear and heard as sounds. The type of receiver used by Widex is called balanced armature, see figure 4.6. The output level that a receiver can generate is dependent on the phys- ical size of the receiver. This means that a larger receiver can generate a higher output level. The smallest receivers are used in CIC hearing aids, where space is limited. This means that CIC hearing aids are only recommended to be used by people with mild to moderate hearing loss. The larger hearing aids like BTE and RITE can have larger receivers with output levels around 140 dB (Sound & hearing, 2007). Batteries The most common type of batteries used in hearing aids are disposable zinc air batteries. These come with different capacities and dimensions, see figure 4.7. Modern hearing aids operate at a voltage of 1.1 volts. Zinc air batteries have a nominal voltage of 1.4 volts but this is only the case when the batteries are not in use. When the hearing aid is in use the effective voltage is between 1.15 and 1.35 volts. High and stable voltage ensures that the hearing aids are functioning optimally. Too low voltage increases the risk of hearing aid malfunction. If the operating voltage is below 1.1 volts the gain and output of the hear- ing aid might be reduced. The only drawback of a high operating voltage is high power consumption (Sound & hearing, 2007). In an interview with Kim Hjortgaard Nielsen (2017), who has been part of developing electronics for hearing aids at Widex, he explained how much energy the components in the current hearing aids consume. The consumption is shown in figure 4.8. Figure 4.7 Zinc air batteries used in hearing aids. Figure 4.8 Power consumption for different components. Tabell 2 Loudspeaker DSP Microphones Bluetooth Other Microamps 100 1000 50 1500 200 0 400 800 1200 1600 Loudspeaker DSP Microphones Bluetooth Other Microamps Other 7 % Bluetooth 53 % Microphones 2 % DSP 35 % Loudspeaker 4 % Tabell 1 Sonova William demant Sivantos GN Resound Widex Starkey Other 24 23 17 16 9 9 2 Other 2 %Starkey 9 % Widex 9 % GN Resound 16 % Sivantos 17 % William demant 23 % Sonova 24 % �1 26 In the recent year, hearing aid manufacturers have introduced hearing aids with rechargeable batteries. There are two technologies of recharge- able batteries being used, lithium-ion or silver-zinc. Both technologies give a full day of battery life before they need to be charged. One re- chargeable silver-zinc battery provider is a company called Z-power. They provide retrofit batteries that will fit into existing hearing aid mod- els and use the same form factor as traditional zinc air batteries (ZPower Hearing, 2017). These are now implemented in Widex’ hearing aids. The most common battery size in RITE hearing aids is 312 which has a capacity of 210 mWh (Sound & hearing, 2007). To receive similar kinds of energy levels in a silver-zinc battery from Z-Power, you need a size 675 which has 211 mWh (ZPower Hearing, 2017). Telecoil A tele coil is a receiver in some types of hearing aids. It uses a loop system that can be installed in specific rooms. This loop system creates an electromagnetic field sensed by the tele coil in the hearing aids. The hearing aids convert the electromagnetic variations into sound. A switch on the hearing aid lets users decide if they want to hear what is sent out on the tele coil or use the built-in microphones. The loop systems are of- ten installed in theatres, cinemas and churches (Sound & hearing, 2007). 4.4 Stakeholders The stakeholders are important to investigate in order to create a prod- uct that is feasible to put to market. It is also important to see what the different stakeholders can contribute with and what their different needs are. The stakeholder map was created by brainstorming and by inter- views with Widex representatives, see figure 4.9. The most important stakeholders are: the end users, audiologists, hear- ing aid clinics and hearing aid manufacturers. Other stakeholders to take into consideration are the suppliers of parts for the hearing aids and the legislation controlled by the government. The way the hearing aid industry looks today, the hearing aid manufac- turers are dependent on the audiologists. The hearing aid companies do not sell hearing aids directly to the end consumer. All sales are done through audiologists. Because of this, the hearing aid manufacturers are keen on keeping a good relationship with the audiologists. 27 Figure 4.9 Stakeholder map. Audiologist End User Subcontractor Hearing Aid Clinic Hearing Aid Manufacturer Level of Innovation Consumption Power Ownership Development In�uence Product O�er Preferred Brands Little or No In�uence Diagnosis and Product Proposal 28 The audiologists diagnose hearing losses and adjust the hearing aids cor- respondingly. Apart from diagnosing, they present the different hearing aid products that the end user can choose from. In Sweden there are two options when getting hearing aids: either via the public healthcare or via private clinics. In both cases the end user is in the hands of the audiolo- gist when it comes to which products are being presented. The audiolo- gists often have a preferred hearing aid brand. Either because they have the best knowledge of how to adjust these hearing aids or because the clinic they work for are owned by this brand. Many private hearing aid clinics in Sweden are owned by hearing aid manufacturers and the audiologists working there are not only med- ically responsible, they are also sellers. The clinics carry other brands than their own but might be biased on the preferred brand based on the shop’s ownership. Hearing aids are classified as medical devices and the manufacturers are therefore bound to follow certain regulations. The legislation varies between countries and concerns both the technical details of the hearing aids as well how they are to be sold. Hearing aids use a type of loudspeakers called balanced armatures. Ac- cording to Joe Jensen (2017), Electroacoustic Engineer at Widex, there are two large manufacturers of balanced armatures in the world, Know- les and Sonion. The hearing aid companies are dependent on what kind of balanced armatures the two manufacturers are developing. 4.5 Laws and Regulations In order to design a product that is possible to sell, a research on mar- ket regulations is needed. This was performed by literature review and expert interviews with an employee at Widex working with regulations. 4.5.1 General Regulations In an interview with the Senior Innovation Architect at Widex, Svend Vitting (2017), it was explained how they handle regulations at Widex. In general there are strict regulations. The regulations in the USA pro- nounced by the FDA (Food and Drug Administration) are the toughest and the ones they look the closest to when designing new products. In the EU, the European Commission makes the rules for hearing aids. To- day, hearing aids can only be sold through audiologists. In the USA there 29 is a category called PSAP (personal sound amplification product) which is similar to hearing aids, but can not be marketed as solving hearing loss. These products can however be sold by anyone. 4.5.2 Over the Counter Hearing Aid Act On August 18 2017 a new law was signed in the USA called the Over the Counter Hearing Aid Act (OTC). This law includes that hearing aids di- rected towards people suffering from mild to moderate hearing loss should not need to be sold only by specialists. This means that there is no need for prescriptions. There will still be sharp regulations on the devices though. The FDA is required to establish regulations for this new category of hear- ing aids within the coming three year period. (Hearing Review, 2017) 4.6 Benchmark A benchmark was performed to investigate the state of the art on the hear- ing aid market. It starts by finding the major players on the market, and continues to investigate new alternative technologies and innovations. This gave input on how far the development in the industry has come and gave a good starting point on technology insights for the product development. 4.6.1 The Hearing Aid Market The hearing aid market is controlled to a large extent by six manufacturers, see figure 4.10. The company with the largest market share (24%) is the Swiss Sonova. They have two large sub brands making hearing aids, Phonak and Unitron. The second largest manufacturer is Danish William Demant (23%) with the sub brand Oticion. There are two more Danish companies among the six, GN Resound (16%) and Widex (9%). Apart from the Danish companies there is the German manufacturer Sivantos (17%) and the American Starkey (9%) (Hearing Loss Journal, 2016). Together these six manufacturers control 98% of the global market. All manufacturers provide a similar range of products, each with their own strengths and weaknesses (Hearing Loss Journal, 2016) Figure 4.10 Market shares. Tabell 2 Loudspeaker DSP Microphones Bluetooth Other Microamps 100 1000 50 1500 200 0 400 800 1200 1600 Loudspeaker DSP Microphones Bluetooth Other Microamps Other 7 % Bluetooth 53 % Microphones 2 % DSP 35 % Loudspeaker 4 % Tabell 1 Sonova William demant Sivantos GN Resound Widex Starkey Other 24 23 17 16 9 9 2 Other 2 %Starkey 9 % Widex 9 % GN Resound 16 % Sivantos 17 % William demant 23 % Sonova 24 % �1 30 4.6.2 Wireless Earbuds With the evolution of wireless technologies it is now possible to connect headphones wirelessly to other devices. This has led to manufacturers releas- ing wireless earbuds, some with similar functions to hearing aids, see one example in figure 4.11. Some of the wireless earbuds can amplify sounds and filter out unwanted noise. Three companies which were early with releasing this kind of products are Bragi, Doppler Labs and Nuheara. As the hearing aid companies are trying to make their products as discreet as possible, these earbuds are larger and more visible. They sit in the ear as traditional in-ear head- phones, but are larger and without wires. Many wireless earbuds have rechargeable batteries with a battery life of two to four hours per charge. Most of them come with a portable charg- ing case giving around three extra charges. The wireless earbud is a product relatively close to hearing aids and some hearing aid companies have made collaborations with earbud com- panies. The American hearing aid company Starkey for example have a collaboration with Bragi. Together they make a version of the Bragi earbuds, custom made for your ear canals for a better fit. 4.6.3 Alternative Technologies Phonak Lyric Phonak Lyric is marketed as the contact lens for your ears. It is a really small hearing aid that sits even further into the ear canal than the invisi- ble in canal (IIC) hearing aids. The Phonak Lyric is placed approximately four millimetres from the eardrum by an audiologist. Because of the Figure 4.11 Bragi the Dash (Chris F, 2014). 31 placement close to the eardrum less electronic gain is needed. This in combination with an analogue sound processing means that the battery can last up to 120 days (Hearing Review, 2009). Another benefit of having the hearing aid far into the ear canal is a more natural sound. The microphone picks up the sound inside the ear thus letting the outer ear transform the sound as it does naturally (Hearing Review, 2009). Except that it sits deeper inside the ear canal, Phonak Lyric differs from regular hearing aids in that it uses a subscription model. Patients pay a subscription fee and get a new Phonak Lyric inserted by an audiologist when the battery runs out (Hearing Review, 2009). EarLens EarLens is a new type of hearing aid that uses light to transmit sound. The Earlens system includes a custom lens placed on the eardrum by an Ear, Nose and Throat physician. It also has a behind the ear proces- sor picking up sound and delivering it to an in-ear light emitter. The sound is then converted into light delivered to the lens attached to the eardrum. The lens then activates the natural hearing system (Hearing Review, 2015). The advantage with this technology is that it prevents the feedback loop troubling traditional amplification, with the microphone and speaker close together. With no risk of feedback loops the EarLens can achieve high gain values across a broad bandwidth (125-10.000 Hz) (Hearing Review, 2015). Bone Conduction Headphones Sound is vibrations. Traditional hearing aids and headphones send vibra- tions through the air into our ears where they are transformed into elec- tric impulses. With bone conduction headphones this is done by sending the vibrations directly through the bone into the inner ear. Most of the bone conduction headphones on the market today sends the vibrations through the top of the jaw (Everyday Hearing, 2017). The sound quality with bone conduction headphones are is not as good as with air conduction headphones. This is in part due to the transmis- sion not being direct to the bone because of the skin in between. What might be an advantage though with bone conduction headphones is that they do not cover the ears making it possible to hear ambient noise (Everyday Hearing, 2017). 32 Adhear Adhear is a new type of hearing aid using bone conduction developed by Otorix, see figure 4.12. The main difference between Adhear and other bone conduction hearing aids is that Adhear does not require surgery. This eliminates costs and complications related to surgery. Their solu- tion is based on an audio processor that snaps onto an adhesive adapter placed on the skin behind the ear. The disposable adapter sticks to the skin of the user like an adhesive plaster that can be worn 3-7 days before changing to a new plaster (Otorix.com, n.d.). SoundBite The first patent for a bone conduction listening device was registered in 1924 by Hugo Gernsback. This device used the teeth as the conduction medium (The Verge, 2016). In the late 2000’s a company called SoundBite introduced a hearing aid using similar technology. This hearing aid has two units. One behind the ear with a microphone picking up the sound from the environment and one device placed inside the mouth (ITM). The part in the mouth sits around the inner teeth. The BTE wirelessly sends information about the surrounding sounds to the device in the mouth. The ITM then sends out sound vibrations to the teeth which through the bones lead the vibrations to the inner ear (Everyday Hearing, n.d.). Personal Sound Amplification Products (PSAPs) The hearing aids today are very expensive and in countries where they are not subsidized by the government the high cost is a large reason why people are not using hearing aids. In the USA there is a category of Figure 4.12 Adhear in use. 33 devices supposed to combat the affordability problem of hearing aids. The product category is called personal sound amplification products (PSAPs). The PSAPs are retailed at much lower prices than traditional hearing aids and can be sold directly to consumers without going via an audiologist (Hearing Review, 2016). For a regular consumer the traditional hearing aids and the PSAPs prob- ably appear to be identical. They both amplify sound, but there are reg- ulations saying that a PSAP is intended to amplify environmental sound for non-hearing impaired consumers. The PSAPs cannot be marketed as hearing aid replacements and should not be seen as hearing aids sold over the counter (Hearing Review, 2016). 4.7 Analysing the Widex Brand A brand is more than a logo. A brand is how consumers perceive a company. To analyse the Widex brand we have therefore searched in numerous channels to see how they portray themselves and how they communicate with the customers. The aim with this was to see how a fu- ture product could fit into the current portfolio or how the brand could be developed. The hearing aid business is different from other consumer electronics brands in that the brands are not as strong. This might be due to that the hearing aid companies are selling to audiologists and not directly to the end consumers. This means that the branding has been focused towards audiologists. The brand elements can be seen in figure 4.13. 4.7.1 Widex Branding Guidelines The Logo The logo originates from the start of Widex in 1956. It has been updated a couple of times during the years but stays true to the original. The most recognisable part of the logo is the shield with the negative space form- ing a “w”. This shield is used on its own when space is limited and on the products. Most of the time though it is accompanied with a custom typeface writing out the rest of the letters in Widex. The logotype is always presented in a monochrome way in either white, black, grey or silver. With the silver having a brushed metal effect. Some- times the logo is accompanied by the corporate slogan “high definition hearing” (Branding.widex.com, 2017). 34 Logotype Imagery Shield Colours Typeface 35 Colours The colour scheme of Widex is minimal using black and white as a base. This is to make the content stand out and make the products seem less complicated. To complement the black and white colours they use sup- porting blue colours (Branding.widex.com, 2017). Typeface Widex uses the geometric sans-serif Gotham typeface in their printed materials. It has simple undecorated letter forms making it good at deliver- ing messages in a clear way. To make the message even clearer Widex uses two different weights, Gotham Light and Gotham Bold. The bold weight is used to highlight words or parts of sentences (Branding.widex.com, 2017). Slogans Apart from the main slogan “high definition hearing” sometimes seen with the logo, they use slogans for the different product series. The Beyond range has the slogan “Life without limits” and the Unique range uses “Live life large”. Both clearly meant to express that you can have an active life even with a hearing loss using Widex products (Branding.widex.com, 2017). Images Most of the images used to communicate the Widex brand focus on peo- ple and activities. It is about telling a story of the user and the benefits of using hearing aids. The images are made to look authentic and as they are captured in the moment (Branding.widex.com, 2017). 4.7.2 Communications on the Website The website follows a similar style as the graphical profile. Focus is on storytelling using videos and images. The videos and images show people in active situations. There is little information about the products on the website and it is hard to find images showing the hearing aids. Apart from the storytelling focus is on technology and functions. This is done by using clear copy writing with the text set in a mix of light and bold weights. This highlights the key functions of the products. The technology and functions are communicated in a non-technical, easy to understand tone. Compared to some of the competitors, Widex has a website focused much more on lifestyle and storytelling. They also have less information and statistics about hearing loss presented on the website. The lifestyle focus is probably a strategy to tackle the stigma surrounding hearing aids.Figure 4.13 Elements from Widex’s visual identity (Widex, 2016). 36 4.7.3 Communications on Social Media YouTube Widex has a YouTube channel with over 100 videos uploaded. The content of the videos vary between user testimonials, instruction videos, product videos and more lifestyle focused content. In general the videos have a couple of thousand views. The first video was uploaded 2007. In 2015, with the promotion of Widex Unique, the videos started to get more professional with higher quality filming and editing. This was con- tinued with the Beyond series. For the Beyond series five fictive personas were introduced in short YouTube videos. The videos tell the stories of these personas and how the hearing aids help them in their active everyday lives. The personas are in their late sixties and are portrayed as active and healthy. Of the personas two are female and three are men. They all have fancy jobs and hobbies. The five personas can be seen in figure 4.14. Figure 4.14 The five personas used to promote Widex Beyond (Widex, 2016). James, 67 Design CEO and Surfer Haru, 67 Novelist and Jogger Selene, 67 Restauranteur and Photographer Dana, 67 Fashion Consultant and Yogini Lawrence, 70 Trumpet Player and Grandfather 37 Figure 4.15 Widex Beyond with blue- tooth connectivity. Facebook, Instagram and Twitter Widex has almost 200 000 followers worldwide on Facebook. There are new posts one or two times a week and the content ranges from product information and information about hearing loss to other news related to hearing aids. The interaction from the followers is low with few likes and comments on each post. Widex does not have an official global Instagram account but there are national accounts. The content of these national accounts differ but most of it is promotional materials with images of the Beyond personas and the hearing aids. The accounts have few followers with little interaction. Widex is active on Twitter and has 4500 followers. The content is similar to that on facebook but with more focus on their products. During the hurricanes Harvey and Irma, Widex searched for goodwill when they announced that all customers would get free replacements of hearing aids lost or damaged during the catastrophes. 4.7.4 Product Portfolio Widex has two main product series, Beyond and Unique. Beyond is the newest of the two and has bluetooth connection making it possible to stream sound from a smartphone directly to the hearing aids (figure 4.15). Both series comes in a large number of models and form factors. The look of the products do not differ much between Beyond and Unique. If you are not into hearing aids you probably would not notice the difference. The shells have a simple design with slightly sharper edges compared to some of the competitors. The larger models have the Widex logo on a button. Other than that there is not much distinguishing a Wi- dex hearing aid from the competitors. Worn behind the ear they all look more or less the same. 38 The products do not match the other communication from Widex. Widex is portraying themselves as a lifestyle brand with cool people in active situations but their products do not express this lifestyle. Hearing aids have had the same form factor since at least the 60’s (Hearing aid museum, 2017) which can be a reason why they feel outdated. They also carry a stigma built up during a long time. 4.8 Interviewing Users and Audiologists All information in this chapter is derived from interviews. Six interviews were held with users and potential users. The interview sample was select- ed by their usage of hearing aids and their age. Key were interviews with people with presbycusis that do not use hearing aids, as they are the main target group for this project. Two interviewees fit this description, both around 55. Important were also interviews of other ages and users of the current products, as the stigma is hypothesized to be general in society and users can highlight how usage of the product is. Two other interviewees were younger, 18 and 29, one with hearing aids and one without. One of the last two interviewees was a hearing aid user of 80 years of age and one non-user of 54 years age. Three of the interviewees were women and three were men. To supplement these interviewees, a discussion session was held at “Hörselskadades Riksförbund” in Gothenburg Sweden. 20 participants elaborated on the barriers of acquiring hearing aids. To get the professional point of view, audiologists were interviewed. One audiologist working in a private clinic in Gothenburg was inter- viewed. Three more working at the hospital Sahlgrenska in Gothenburg were interviewed. All interviews had the focus of finding barriers when acquiring hearing aids and how the usage of them is. The interviews were planned before- hand, and the semi-structured interview guidance documents used can be found in appendix 1. 4.8.1 The Public Opinion All interviews were transcribed and categorized by doing an affinity diagram, see figure 4.17. This analysis formed different subjects that were named. Below all subjects are presented with what the interviewed subjects told. 39 Batteries Regarding battery lifetime, the wearers of hearing aids said they last between 3 to 14 days. A preference from all subjects showed an expected battery life of one day if they were rechargeable or one week for single use batteries. Charging was said to be easier than changing batteries. Rechargeable batteries were preferred due to environmental and price reasons. The hearing aids today do not signal in an acceptable manner when they run out of power. Battery handling was believed to be hard for elderly by the non-users that were interviewed. However, the users that were interviewed told handling was not an issue. Distinguishing between new and old batter- ies and that batteries fall out of the hearing aid when stored were ex- perienced problems for users. The batteries were sometimes lost when they were dropped because of their size. As the only way to turn off the hearing aid is by opening the battery lid, the batteries were prone to fall out during storage. Hearing aid users said they kept batteries everywhere in case they needed them. Handling When speaking about putting on and taking off hearing aids, non-us- ers imagined it as hard, especially for elderly (figure 4.16). This was confirmed by some of the elderly interviewed but not one said it was a problem. However, the audiologist told that many elderly do come back for help and had problems with their hearing aids. Figure 4.16 Person handling a pair of hearing aids. 40 41 Figure 4.17 The affinity diagram from the interviews. 42 Cleaning the hearing aid is the most important maintenance the user needs to do. Insufficient cleaning is the biggest reason for broken hearing aids according to the audiologists. Sometimes users are unable to do it themselves which leads to visits at the audiologist for that single reason. All users that were interviewed were ashamed about the cleaning and said they do it to seldom. Cleaning was said to be unsatisfying, as there was never a true feeling of complete cleanliness, even after thorough cleaning. Changing volume is a much used feature of the hearing aid, and is expe- rienced as very important by hearing aid users. It is a desired function by all the interviewees, but not all hearing aids have it. Some hearing aids have different programs for different soundscapes, to help the user get the best sound. An audiologist told that the programs were hard to change and that only experienced hearing aid wearers used them. The interviewees at “Hörselskadades Riksförbund” told that the telecoil mode was an important function. Comparing to Other Disabilities Many interviewees envy the success story of the eyeglasses and want the hearing aid industry to follow a similar transformation. They think that glasses can be worn only to be cool without any impairment, but hearing aids are still connected to stigma. One reason for this was told to be that glasses are always visible, you can not hide them. However, age related stigma still exists with glasses, as one interviewee refuses to wear reading glasses despite the experienced vision impairment. The impairment of vision is seen as much less of a handicap than impairment of hearing. Pricing The interviewees were all ready to pay themselves for hearing aids, except the audiologists interviewed. The amount varied between 4 000 and 20 000 SEK. There are also differences in what should be paid for. One argues that the care should be for free, but that the product can cost money. Conditions that the interviewees had on paying for a hearing aid were set higher than the existing hearing aid on the market. They wanted to have them smaller and more invisible, and better technological features. The interviewees compared paying for glasses and paying for hearing aids. Many agreed on that paying for a pair of glasses was nothing strange, but somehow it felt a bit more strange paying for hearing aids. However, if given the same care and the same feeling in the shops, the interviewees said they were ready to pay for hearing aids as well. One 43 thinks that the branding is important in glasses but not hearing aids, which might be a reason for the willingness to pay yourself. The prices at a private audiologist clinic are between 10 000 and 27 000. The price range has less to do with the physical type of hearing aid and more to do with how advanced the sound processing is. This means that the more expensive hearing aids handle hard listening situations better than the cheaper ones. The pricing does not depend much on the degree of hearing loss either. Usage of Hearing Aids A majority of the interviewees including the audiologists agree on that you need to wear hearing aids constantly in order to get accustomed to them. However, one interviewee who had hearing aids had never worn them for a long time and thought their sound was too bad. One hear- ing aid wearer said that the hearing aids were worn during occasions when better hearing was needed, such as lectures at school. Another wearer said that the aids were taken on in the morning and then worn for the full day. The users agree on that it is more comfortable not wearing them, but one has to use them at home since the partner is not speaking clearly enough to not wear the hearing aids. One user says that they can be tickling, and sometimes she gets a strong need of taking them off. The users tell stories both about when they were close to forget or for- got to take them off for swimming, as they are not waterproof. A wish from a user is that they should be possible to use for activity sports, hence they should be possible to wear in more extreme conditions. Listening Situations All interviewees confirm that the hearing aids handle situations with background noises, such as restaurants, badly. However, one user says that they help in those situations too, even if they are not perfect. One user refuses to wear hearing aids because of the belief that they are not helping in such situations. Other Problems That Users Experience Some of the issues that users experience that did not fit in the other categories are explained in this paragraph. Streaming music to the hearing aids provides bad sound quality, so two of the users inter- viewed told that they rather use their headphones for that purpose. The hearing aid does not show that it is functioning properly, and one wearer was stressed putting them on in order to hear the startup sound to know that they were on. Feedback is seen as a big problem for 44 one user, as when it happens it clearly tells everyone around that one is wearing a hearing aid. It happens when hugging other people, and restricts from wearing a cap. Acquiring Your Hearing Aids How people realize their hearing loss differs from user to user. One user realized it when someone surprisingly came up behind her and she did not hear the person coming. Another user tells about a Christ- mas tie that all friends thought was funny, but for the user only ap- peared as blinking even though it played a funny melody. One inter- viewee tells about a gradual loss and that the loss was realized only by comparing the current state to when the interviewee was younger. Some users tell about other people in their vicinity telling about the problem before they realized it themselves. One user only went to the audiologist to take out a plug of wax, but was told that the problem was a hearing loss. When trying to solve the problem, some users speak about a surprise when the doctor said the solution would be to use hearing aids. An un- derlying hope for another way to fix the problem such as by surgery was present. The interviewees without hearing loss told that they would get hearing aids if they needed them. One user did a hearing test seven years ago which showed hearing loss and got hearing aids, they have not been used since then. The audiologists at Sahlgrenska spoke about a fairly long and tiresome process of getting hearing aids. The audiologists at Sahlgrenska say that it takes at least six months be- fore you are a user. The audiologist from the private clinic says that the patients can do a hearing test and get hearing aids the same day. The interviewees without hearing loss thinks it takes around one year. The motivation for solving a hearing loss differs between patients ac- cording to the audiologists. Many patients have motivation to come to Sahlgrenska as they like the social connection they get. Others are only motivated as their families say they have to address the hearing loss. If someone else is the driving force for the patient to visit, they are usual- ly more negative. The audiologists say that it is most often men that are motivated to go there by their wives. View on Hearing Impaired The view on oneself wearing hearing aids tends to be negative for both users and non-users. The general view shows attributes such as old, handicapped and stupid. When telling this view, interviewees say they are embarrassed having it. One user tells that as the hearing aids are not 45 giving back hearing to 100%, it is the function rather than the size and shape of the product that gives away that someone has a hearing loss. When speaking to people with hearing loss, even if it is treated with hearing aids, interviewees tell that you have to speak in a different way, slower and more accentuated. One audiologist also says that younger people tend to not speak to hearing aid wearers, as they do not know how to handle it. Self-Image When Wearing Hearing Aids Four interviewees agree on that the self-image is distinguishably worse when wearing hearing aids than without. One user says it is a difference of telling someone about your hearing loss and telling someone about the need for hearing aids, where the latter is worse. Another interviewee agrees on the difference of hearing loss and hearing aids, but goes further and says that everyone thinks you are older and more stupid when wear- ing them. The same interviewee has no problem telling about the self-ex- perienced hearing loss. The audiologists interviewed said that the self-im- age still is bad, but has become much better lately. They think it is thanks to new technology. The result of the bad self-image makes people wait 7-8 years before they solve their hearing loss, according to the audiologists. The interviewees think that their self-image has a connection to the pub- lic opinion, but they think that their view is worse. They think that the stigmas of being handicapped and old are not only self-experienced, but do exist in public. For the interviewees to feel less stigma, they think that the hearing aids need to become smaller, so they are not seen. Also, a change in how the products make you feel would make a change, making you feel cool instead of handicapped. When it comes to romance, hearing aids tend to make moments disap- pear. One user says that when the partner whispered something to be sexy, the partner needs to be told to speak up. Another story is when a partner first said that “I love you”, and needed to repeat the phrase because it was whispered. Telling someone that you need hearing aids is not something one interviewee would do on the first date. Handling a Hearing Loss Without Hearing Aids There are ways to improve understanding of voices except amplifying the sound as a hearing aid does. One interviewee says that you can use lip reading to understand others. Another interviewee says that one way to understand others is to look at their expressions. This is needed for 46 that user, as it is one way to assure that something is not happening that is unnoticed. By moving the sound source closer to you, you can avoid having loud sounds. One user does that by connecting a portable speak- er to the TV to not disturb the neighbours with a loud TV. The Sound Quality in Hearing Aids Most of the interviewees, both users and non-users think hearing aids have bad sound quality. Users tell that the soundscape is different wear- ing the hearing aids than when not wearing them. Background noises are amplified too much according to the users which makes hearing harder in situations with much background noise. To tell the direction of sounds is also harder with hearing aids, especially to distinguish be- tween front and back. The audiologists tell that hearing aids amplify soft sounds more than loud, and that the sound is strange with a sharp tone with noises from the letters f and s. Sound quality is a restricting property of usage in hearing aids today. Some users say that they take them off when they are at home to limit hearing scratching noises from paper and such. That they do not help that much in noisy situations is also a limiting factor. According to the audiologists, sound quality differs between different types of hearing aids. ITCs are so far into the ear, so they can use the frequency response of the outer ear which gives them a more natural sound. However, one user says that ITCs have worse sound quality compared to RITEs. Aesthetics of Hearing Aids In general, the interviewees had many opinions on the appearance of hearing aids. A big majority wanted small and discreet hearing aids. One comment was that if hearing aids were more connected to fashion, they would probably be worn more. To handle stigma, three interviewees think that the hearing aids should express coolness and a wow-factor. To be able to express your personal style through hearing aids is also wanted. The users want to be able to change the appearance themselves. A big majority also concludes that it is OK if the hearing aids express that they are hearing aids. One said they should not be compared to something else, for example headphones, to avoid uncertainty of the function of the product. Audiologists have a clear picture of what hearing aid wearers want in terms of aesthetics. Most of the users want a neutral coloured hearing aid that is matched to the colour of their hair. Men tend to be more sensitive in their colour and type choice, according to the audiologists. They want to hide their hearing loss more and often prefer a hearing aid type that 47 sits in the canal, ITCs. The audiologists also agree on that there is little difference in aesthetics between brands. Different hearing aid types have different aesthetics. Many interviewees agree on that ITCs are most visible, even though they are the smallest. An attribute the ITCs get is that they with their skin colouring resemble an aid for a handicapped person more. The RITEs are preferred by many, as they are the least visible ones. BTEs are similarly experienced as RITEs, but have plastic tubing and a transparent mold that can look scary. When looking at development in hearing aids, most interviewees are hap- py that they are getting smaller. They like that the hearing aids now have a small wire instead of a tube. One interviewee says that they are still uncool. Some interviewees speak about camouflaging the hearing aids to resem- ble something else. One user has tried to use a smartphone with head- phones because it looks better than hearing aids. There are counter-ar- guments, as the interviewees tell that if they look like something else, people might think that you are not listening. Alternative Ways of Testing Hearing Loss Many of the interviewees want the ability to test their hearing loss at home. Arguments are that it is much easier and less embarrassing. One hearing aid user said that the tests can be embarrassing, as when you do not react for a long time in the tests, you know you have missed silent noises. How- ever, trust is an important factor, and the user must be assured that there is no better treatment than that proposed by the test at home. During the interviews with the audiologists about self-testing, they did not seem to be as optimistic. The hearing tests they do are performed in an anechoic chamber and the headphones must be calibrated, this preci- sion would be hard to achieve in home tests. Medically there is another problem, and that is that the audiologists always perform a check of the ear canal to look for other reasons for deteriorated hearing. The audiol- ogists also mean that if a user has full control over the adjustments for their hearing aid, they might adjust it to be as comfortable as possible, which is not always optimal for hearing. Private Clinics Versus Public Clinics There are both benefits and drawbacks of a private health care. The most profound drawbacks are that you need to pay for your care and your hearing aids. One audiologist compared a specific hearing aid for 15 000 SEK at a private clinic to a public clinic, who buys the same for 1 500 SEK. You also do not have the same assurance that the audiologists have 48 the right education. Another problem is that the audiologists at private clinics benefit from someone’s hearing loss, which could lead to more care than needed. A benefit is that private clinics often have much short- er waiting times. Audiologists from both private and public clinics were interviewed, and there were of course differences in their opinions about the two sys- tems. From the private clinics perspective, they say that they have more modern technology and faster handling times. So people who have the money can get a better service than at the public clinics. The audiolo- gists from the public health care however say that they all have the same hearing aids. The audiologists also tell that there is a difference in the healthcare system throughout Sweden, and in some countys there are only private clinics. The Experience From Wearing a Hearing Aid For the First Time It is a rather special moment when you first put on your hearing aids. One user says that the clock on the wall was ticking, which was never ex- perienced before. Another user said it was tiresome to wear them in the beginning, and they could only be worn for around one hour at a time. Another user said it was only a pleasurable experience, as the hearing came back. A non-user believed that the first experience might be tough. Meeting With an Audiologist How users got their first contact with the audiologist differs. One user got a letter of referral from the public clinics homepage, and got diag- nosed during the first meeting. After that some more meetings were necessary to try out and calibrate the hearing aids. The same user thinks it is tiresome to visit the audiologists for simple calibrations. One inter- viewee who has hearing aids but does not use them said that there was no problem in going to the audiologists, but also remembers that the last visit was cancelled and a new one was not booked. One user says it is not nice to need to go to a hospital for treating your hearing loss, as the environment is special at hospitals and not nice. Interviewees have different estimations on how long time it takes to get hearing aids. Users say it takes around three months. Non-users believe it takes weeks before your first appointment and then one or two months to get them. Users tell that the diagnosis and prescribed hearing aid came as a sur- prise for them. One user absolutely wanted ITCs, but was prescribed RITEs, which was tough. Another user is lyrical about the ones that were received the latest. One user was unaware of the need for a hearing aid 49 throughout the diagnosis process, and the need for hearing aids came as a big shock as it was believed that the problem could be surgically solved. 4.8.2 Procedures at the Audiologist According to the audiologists at Sahlgrenska hospital, the process of acquiring your hearing aids is not quick. First you need to get a letter of referral from a physician at your health centre, and to book a scheduled meeting there you often need at least one month. When this letter is received, another due time of around two months is normal. At the au- diologist, they do hearing tests, both through bone conduction and air conduction with tones and speech understanding (figure 4.18). If a serious medical issue with the hearing organs is found, the patient will be sent to another doctor. When the first tests are performed, the patient will revisit the audiologist to try out hearing aids. This is also the time they receive their hearing aids, unless they have a need for custom fit hearing aids. Diagnostics The diagnostics are performed in two major steps: first a medical screen- ing to see if the ear is healthy, then a hearing test. The first screening is performed mostly by general health questions and through inspection of the ear canal and ear. After that the patient sits in an anechoic chamber and wears carefully positioned headphones. The audiologist plays tones and checks the hearing level for every tone between 250 and 8000 Hz. After that, the same test is performed with bone conducting headphones and if the results differ more than 10 dB HL, there is an issue with the middle ear. Hearing the tones between 0 and 20 dB HL means that you have normal hearing. Some audiologists also perform speech tests, where speech is heard in noise, and the patient has to repeat the same words. Figure 4.18 Images taken during a hearing test. 50 Regarding how the audiologists decide which hearing aids to prescribe, there are many parameters. However, for the audiologists at Sahlgrenska, price is not one of them. First of all, the greater the hearing loss, the big- ger the hearing aid. This is because smaller hearing aids are more sensi- tive to feedback with strong amplifications. It is also important to make an evaluation if the patient can handle small things, as some hearing aids are very small. They also check if the patients are sensitive to if the hearing aid is visible. Most prescribed hearing aids are of the RITE type. It is often not good to use hearing aids that plug the ear canal completely, as you can get infections in the ear canal from them. It is also very im- portant not to mix two patients, as that can be dangerous for the patient with less hearing loss. Different Types of Hearing Losses When speaking to the audiologists, they mainly tell about presbycusis. This together with noise induced hearing loss stand for around 95% of all hearing loss diagnoses they experience at the clinic. These both diagno- ses affect the hearing organs in the same way, the hair cells in the cochlea are degenerated. That people come for hearing loss treatments but only have a plug of wax is very unusual, it is often combined with another hearing loss as well. The audiologists at Sahlgrenska say that the average age of their patients is around 75. Own Experiences of Hearing Aids The audiologists agree that you can not wear hearing aids if you do not experience a hearing loss yourself. Despite that, many of them have tried using hearing aids to get a personal experience. Those that have tried say that the sound quality is not that good and that the soundscape is hard to get accustomed to, as soft sounds are amplified more than loud sounds. The audiologists also agree that you need a certain degree of hearing loss before it gets useful with hearing aids, as the artificial sound they create not is as good as the natural sound. Performance of Hearing Aids Many patients believe that they will be fully treated when they get hear- ing aids. When comparing to eyeglasses, which gives back the visual sense to almost 100%, the hearing aids are not as good. Therefore it is important for the audiologists to inform the patients that they will be helped by the product, but the experience might not be great at the be- ginning. 51 4.9 Studying Attributes and Emotions This chapter shows and explains the results of two surveys, one on prod- uct emotions and one on product attributes. They were made to lay a benchmark for further development, to know how the current products are experienced. An online survey was used for the product attributes, and a tool called PrEmo, see figure 4.19, was used to measure product emotions. 4.9.1 Implementation of Methods The selection for this study was open, as it was shared on social media. The 90 participants were between 19 and 74, with an average of 35. 73% were women. In total 45% told they experienced some kind of hearing loss or were unsure. 11% used a hearing aid. The participants were then asked to rate their experience on likert scales on three pictures of different products to wear in the ear, see figure 4.20. One was a RITE hearing aid, one was an ITC hearing aid and one was the HereOne wireless earphone from Doppler Labs. The last was included to see which attributes that differed between hearing aids and earphones. Figure 4.19 PrEmo tool in use. 52 The attribution adjectives were chosen based on how hearing aids and earphones are marketed today. The selection is also based on attributes that were thought to be important in a new product category. The pairs of adjectives shown on the following page were used, the first three are about experience of wearing the product, the latter are how the product is experienced. There are many tools to measure product emotions. A tool called PrEmo was seen as robust and to give good results for this measurement. The stimuli used were the same used in the product attribute survey. Due to technical instability with the tool, only eleven participants were able to finish the questionnaire. Therefore the reliability of the results are not as high as could be wished for. 4.9.2 Results on Product Attributes The RITE hearing aids and the ITC hearing aids receive similar ratings in the different product attributes. This could be explained by the prod- ucts being rated more on their product categories than on their physical appearance, meaning they are both hearing aids. The RITE hearing aids are the ones that express the most hearing aid of all products tested. They are rated the least robust and the least on shame. We think that the RITEs have the closest relationship to the semantics of traditional hearing aids, they both sit behind the ear with a cable or tube into the ear canal. This explains that they are rated highest on hearing aid. The low rating on robustness is analysed to that these hearables have a thin wire and sit loosely behind the ear. The least shame might have a connec- tion to that the interviewees expressed a clear longing for discreet hearing aids and that the RITEs were seen as the most invisible. Figure 4.20 Stimuli used in the product attribute survey and PrEmo shown in the order RITE, HereOne and ITC. 53 The HereOne is rated the least comfortable and by far the least discreet. They are rated the ugliest and the lowest on status, hearing aid and smartness. They receive the highest rating on robust and shame. We think that as they are rated the least discreet, the ratings on ugly, low status, shame and smart are closely connected, as said in the user inter- views. The least comfortable could be explained by their size and place- ment in the ear. Their appearance is also not seen in hearing aids today, why their rating on hearing aid could be explained by that. 4.9.3 Results on Product Emotions All hearables that were tested score low on shame and desire, and high on fascination and boredom. We think that desire and boredom are closely connected, why the connection between them in this result is not surprising. The high boredom might have to do with that there is only one product that actually has a newer appearance, the other two have an appearance well known for a long time. The high fascination is a bit surprising, but could be connected to that hearing aids and hearables are not familiar groups of products to many. The RITE hearing aids score the highest on hope, satisfaction and boredom. They score the lowest on disgust and dissatisfaction. In total they score higher on pleasant feelings than on unpleasant feelings. We analyse this re- sult to that there is a lot of familiarization with traditional hearing aids. The boredom could be explained by the fact that hearing aids have had a similar appearance for a long time. The lowest disgust rating could be explained by that the product sits less in the ear canal than the other two. The ITC hearing aids score the least on joy and pride and the highest on disgust. We think that these are connected, as a high disgust makes it hard to be proud. The ITC hearing aids were spoken about in the inter- views as disgusting and as they were more looking like a prosthesis than a high-tech product. This is reflected in this result as well. The HereOne score the least on satisfaction and the highest on fear. We think that the high score on fear has a close relationship to that the interviewees said that it might be hard to wear a product that does not yet belong to a product category. The low score on satisfaction might be connected to that the interviewees told that they would rather wear a discrete hearing aid than a visible one. The HereOne is clearly the most visible of the three products in this survey. Adjective Pairs Used in the Product Attribute Survey Shame - Pride Low status - High status Dumb - Smart Something else - Hearing aid Not personal - Personal Uncomfortable - Comfortable Outdated - Modern Ugly - Beautiful Weak - Powerful Cheap - Expensive Conventional - Advanced Discrete - Visible Fragile - Robust 54 Figure 4.21 Lukas wearing hearing aids. 55 4.10 Wearing Hearing Aids Ourselves Hearing aids were tested by us in a participatory observation in order to create empathy for the users, see figure 4.21. We received RITE hearing aids from the hearing aid clinic at Sahlgrenska university hospital, one pair of Phonak hearing aids and one pair of Signia. The hearing aids were borrowed for three months and were worn for longer periods of time. A diary of experiences was made. 4.10.1 Results from the Experience Diary When first receiving the hearing aids, we realized that they need to go very far into the ear canal. This feels uncomfortable the first time, and wax got stuck on the hearing aid as well. It comes with different inserts that either block the ear canal from outside sounds well or almost not at all. This meant that you could sometimes hear what was said with the aid turned off. The hearing aid is very small, and inserting batteries was a bit hard the first time. Adjusting the volume was hard when wearing them, and it was easy to touch the microphone and create unpleasant sounds and feedback when doing it. Otherwise the size made them sit behind the ear without you noticing it. One of us felt a strong sensation of tickling in the ear canal when wear- ing the hearing aids. This sensation was so strong that they were taken of. Another drawback of wearing hearing aids is that you cannot listen to music via your headphones while wearing them. The sound in the hearing aids was experienced as fairly bad. Sounds that came from a longer distance than two meters were harder to hear. Wind noises were attenuated well. The validity of our sound experience is how- ever low, as hearing aids do not function well for people without hearing loss. There was a tendency of feedback throughout our tests though, when wearing hats or when changing the volume. 56 4.11 Observations at the Audiologists In order to get a good understanding for what a person acquiring a hear- ing aid goes through during a visit at an audiologist, we paid multiple visits to clinics and did a participatory observation. Both private and public clinics were visited. Information was gathered and impressions of our own ears were taken to be used later in the product development process. 4.11.1 General Impressions The audiologist clinics visited were hidden away and nothing you would ever visit if you were not in need of hearing aids. The public clinic was placed in a hospital area, one private clinic was placed on the second floor with an anonymous entry and the second private clinic had a sign but no display windows. The clinics felt old and disorganized with things everywhere and they all had a feeling of hospital environment. The staff were always welcoming and raised the experience of the clinics. 4.11.2 Making Ear Impressions The ear impressions were primarily made in order to get a 3D-file of our own ears. This was to be used when 3D-printing the product in develop- ment to ensure a good fit. It was however also a good moment for a par- ticipatory observation on how impressions are taken and what it feels like, see figure 4.22. The process starts by the audiologist checking the ear canal. The first visit we paid to an audiologist was not successful, as we both had too much wax in the ear canal to make impressions, and both felt embarrassed. This was not at all foreseen. The second visit was successful, and all impressions were taken. The audiologist puts a foam stopper in the ear canal in order to protect the eardrum. This hurts a lot. After that a fluid silicone is pressed into the ear canal, which feels a bit odd but not un- comfortable. The silicone sets in about two minutes and the audiologist wiggles the impression out, see figure 4.23. The audiologist then checks the ear canal for wounds and if there is silicone left. It often starts bleed- ing from the foam stopper, and it hurts some time after the visit. Figure 4.22 Steps when making impres- sions at the audiologist. 57 Step 1 The audiologist checks the ear canal to see that everything looks good and there is not too much wax. Step 2 The audiologist puts in the foam stopper to protect the eardrum from the silicone. S