I used my first pair of programmable hearing aids in 1998. These allowed audiologists to use computer software to tailor programs to meet patients' specific needs. Using a remote control, users could select the program best-suited to their current environment, adjust the volume, turn the built-in t-coil on or off, and mute the hearing aids. Today's hearing aids are adjusted using buttons on the hearing aids themselves, which isn't the most discrete method, or by using a mobile application, if available. In the 1990s, the slightest of adjustments to a program required a trip to the audiologist. There was no way to hear audio from external devices directly through your hearing aids, individually control settings such as whether the t-coil and microphone were active at the same time, or adjust the volume of active components. The only way to connect to external devices like telephones and radios was by using an FM system, placing the telephone up to your ear when connected to the t-coil, or putting headphones over your hearing aids. With an FM system, all sound was mono and fidelity was quite poor. A t-coil had limited range, and the sound quality wasn't good for anything other than an audiobook or phone call. Headphones produced a lot of feedback when placed over hearing aids.
In 2012, hearing aid manufacturers began using proprietary technology to achieve a more direct connection to external devices. One such option, reviewed in AccessWorld, was the ComPilot, which allowed Phonak hearing aid users to receive a direct signal to their hearing aids from various devices. It provided excellent fidelity and offered stereo sound, making listening to music a pleasure. Just as when using a Bluetooth headset to listen to a screen reader, keeping an active Bluetooth connection with one of these devices is challenging, as the connection drops after just seconds of inactivity. If you are using the ComPilot or devices like it to listen to your screen reader over Bluetooth, this means missing words until the connection is reestablished. A Bluetooth connection is very sluggish, and there are often delays of up to one second between the signal leaving the iOS device and reaching your hearing aids. Connecting a 3.5 MM cable meant almost no latency, and made for a much smoother experience. The disadvantage, of course, is that a wire is required for a signal to travel from an external device to your hearing aids. You also have to wear this type of device around your neck.
Audiologists now have the ability to do the things mentioned above, filter out certain sounds, and amplify certain frequencies more within the audiological spectrum to offset a loss. Hearing aids connect to external devices more directly than ever before, providing a much clearer sound. Premium hearing aids from some manufacturers offer audiologists the ability to make adjustments remotely, as long as the hearing aids have an active connection to your iOS device. Hearing aid manufacturers can also push software updates to your hearing aids, eliminating the need to visit an audiologist. A user can adjust many levels and settings with the use of MFi support and applications developed by the manufacturer. A mobile application is always required for an audiologist to make adjustments remotely. All of the applications I have tried present various accessibility issues to users of VoiceOver and braille. However, many options can be configured by using Apple's built-in accessibility settings.
Are My Hearing Aids Supported?
Many manufacturers have models that are MFi-compatible. Check Apple's official support page to see if your hearing aids are MFi-compatible. This support article was last updated in October 2018, so it might not list all supported models. You must have an iPhone 5S or later to use supported hearing aids. If in doubt, consult your audiologist, or complete the steps in the article to learn if your hearing aids are compatible.
MFi hearing aids are paired using the MFi Hearing Devices option within Accessibility settings. Before pairing your hearing aids, turn them off and back on again. After doing this, double tap on the hearing aids you wish to pair, and then confirm the pairing request. A second pairing request will come through your hearing aids if you have VoiceOver running. After confirming this request, your hearing aids will be paired, and VoiceOver audio will come through them, softening all other sound. When VoiceOver finishes speaking, your hearing aids will be return you to your normal sound settings. Until speech is muted, the screen is locked, or audio routing is changed in Control Center, you will remain cut off from everything around you whenever VoiceOver is speaking. To continue hearing speech through your iOS device, bring up the Control Center, select Routes Available, and choose the iOS device.
After pairing your hearing aids, the Accessibility Shortcut will include the option of MFi Hearing Devices. If VoiceOver is set as your Accessibility Shortcut, you will be presented with multiple options when triple clicking the Side or Home button. If you want to quickly launch the MFi Hearing Devices menu, and want VoiceOver to be your only Accessibility Shortcut, you can go to Settings > General > Accessibility > Accessibility Shortcut, and choose your preference accordingly. If you still want a quick way to access hearing devices, you can do so by adding it to the Control Center. To add items to the Control Center, go to Settings > Control Center > Customize Controls. Under the More heading, select Hearing to add this menu to the Control Center.
After pairing your hearing aids, there are numerous user-customizable options. Many of these are independent of hearing aid manufacturer or model, though some options are dependent on how the manufacturer has configured the hearing aids to work with MFi support. After connecting my ReSound hearing aids, I have the ability to specify whether I wish to stream to one or both hearing aids, as well as whether I would like to control them through my iOS device independently. I can also adjust the volume of the hearing aids’ internal microphone along with the level of any connected devices. I'm shown the programs my audiologist set up, and can select one by double tapping it. To adjust the audio levels, flick up or down with one finger on the touchscreen. Some hearing aid manufacturers have chosen to put an equalizer in this group of settings, so you can control the bass and treble of your hearing experience.
Near the bottom of the screen Live Listen is found. This turns your iOS device's microphone into an assistive listening device (ALD). With Live Listen, someone speaks into your iPhone, and the audio is sent to your hearing aids. Some who have used this feature report a delay of up to three seconds between when the person speaks and the audio reaches your hearing aids. I experienced little delay using ReSound hearing aids unless multiple Bluetooth devices were in range, which resulted in a choppy connection, though the person using my iPhone was three feet away.
After activating the Back button, you are shown options that are not specific to the manufacturer. The first option, enabled by default, is to play ringtones through your hearing aids when a call comes in. The next option is Audio Routing. This allows you to specify what type of audio is sent to your hearing aids. The first setting controls call audio routing. Selecting this allows you to choose whether call audio goes to your hearing aids Always, Never, or Automatically. Choosing Automatically means that if a call is answered with the phone to your ear, audio comes through the earpiece instead of your hearing aids.
The other option in this menu is Streaming Media. The settings are the same as those found under the Call Audio Routing submenu. This controls where VoiceOver will be heard. There is no way to configure VoiceOver and other media separately.
The next two options are works in progress. If all devices are signed into the same iCloud account and on the same WiFi network, supposedly it is possible to control your hearing aids on iOS devices not paired to them. Sadly, no one I have spoken with has gotten this to work successfully. Handoff does not function reliably either. In theory, you should be able to start audio playback on an iOS device not paired to your hearing aids, and receive that audio through your hearing aids, as long as both devices are signed into the same account on the same network.
Though Apple says pairing your hearing aids with multiple iOS devices is a seamless process, I did not find this to be so. In an ideal situation, my hearing aids played the audio from one device in my left ear, and the other in the right.
Some hearing aid manufacturers allow control of your hearing aids from the Lock screen. The only thing displayed on my Lock screen is the battery status of my ReSound hearing aids. Unfortunately, the reading is inaccurate. My hearing aids always show 100% until they beep, and suddenly drop to 10%. This problem is not specific to VoiceOver users, but seems to only affect those with hearing aids from certain manufacturers.
The Menu Accessed Through the Control Center or Accessibility Shortcut
After activating the Hearing Devices menu, you can adjust the volume level of any of the active audio devices, or adjust the bass and treble on hearing aids that support this feature. In this menu, you can also switch programs, and turn Live Listen on or off. Any adjustments made are immediate. This can come in handy if you are listening to something using an assistive listening device and do not want to hear anything going on around you. Setting the internal microphone’s volume to 0% will allow you to hear only audio sent through the ALD. You can listen simultaneously to your environment and audio from a connected device, or turn the volume of the connected device down all the way. You can adjust the level of the internal microphone using your iOS device, but will need to adjust the iOS device’s level using its volume buttons.
There is one option within VoiceOver settings that some may find helpful. Navigate to Settings > General > Accessibility > VoiceOver > Audio, and scroll down to the bottom. You will find the option to control whether VoiceOver comes through the right, left, or both hearing aids.
How Well Do They Function?
One of the challenges I mentioned in my introduction was latency. With my ReSound hearing aids, and many newer models, this latency is down to less than a quarter of a second. Typing on a touchscreen with VoiceOver has become a more pleasant experience than when I last tried it using a ComPilot in 2015. One of the challenges I faced, though, was having several Bluetooth devices connected to my iOS device at once. If my hearing aids are connected, my braille display will not auto-connect as quickly. Some Bluetooth keyboards struggle more than others to keep up with typing when the hearing aids are paired. When setting up a new iPhone and using Bluetooth to transfer settings from an older device, the transfer failed repeatedly until I unpaired my hearing aids.
If you are composing a document on a Bluetooth keyboard or the touchscreen and pause for more than a second, the Bluetooth connection stops to conserve battery. This can be very disruptive to a VoiceOver user's productivity, especially with hearing aids that do not preserve the second or so of audio between when the connection resumes and audio is once again being transmitted to your hearing aids. One way to prevent the connection from dropping is to start audio and leave it playing quietly in the background. Another option is to record silence and play it as long as you need the constant connection.
When I first paired my hearing aids, music sounded horrible through them because the MFi support respects the currently active hearing aid program when the connection is established. My audiologist worked with me to customize a hearing aid program specifically for music, which I switch to before listening to an audiobook or music to ensure the best sound.
The Bottom Line
Hearing aid technology has evolved in the last two decades. The ability to have control over one’s sound environment on demand is a very liberating thing. In many instances, the more simple adjustments that a user may want to make no longer require a trip to an audiologist and can be done on the fly. It would be helpful if Apple offered the option to have VoiceOver stream independently of other media.
The biggest concern for a blind hearing aid user is the inaccessibility of applications provided by hearing aid manufacturers that offer access to even more features for sighted users. I have tested applications from Oticon, Widex, and Phonak in demo mode and found several accessibility issues that others have confirmed exist when using hearing aids from these companies. One feature that is consistently inaccessible irrespective of manufacturer is the equalizer. It is my hope that hearing aid manufacturers will begin taking this feedback from blind users more seriously. I further hope these manufacturers will begin to utilize tools in the way Apple suggests, so that blind users can have equal access to all of the great options our sighted counterparts do. We are also paying customers and deserve nothing less than everyone else. Alternatively, hearing aid manufacturers can offer a discount to those who are prevented from taking full advantage of their products. As the prices for these hearing aids can be over $3,500 per ear, a discount wouldn’t be unappreciated.
This article is made possible in part by generous funding from the James H. and Alice Teubert Charitable Trust, Huntington, West Virginia.
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