It is important to know that regardless of whether consumers prefer to listen and speak for themselves or prefer to use sign language, consumers generally rely on both visual and auditory information to varying degrees to maximize communication. For example, someone with hearing loss may need to see a speaker's face and utilize speechreading to better understand what they are hearing. Another consumer who uses sign language may also want to hear the speaker and meeting participants, and other non-speech information (e.g., the sound of a door opening) that might occur during the meeting.

Providing an accommodation without checking in with the consumer risks losing everyone’s time and money and most importantly, the goodwill and trust of the consumer. If the wrong accommodation is chosen, it can be completely useless to the consumer. For example, someone might have significant hearing loss, but no understanding of sign language. Provision of a sign language interpreter, in that case, would not help communication at all. Likewise, for someone who uses American Sign Language, the use of captioning as a substitute for sign communication can impact understanding of what others are saying and reduce or eliminate the person’s ability to provide input to spoken conversation.  

The best way to meet the needs expressed by the consumer is to have knowledge of the various communication access options and the best practices for implementing them. Communication access usually involves the provision of one or a combination of the following technologies and services: real-time captioning, assistive listening systems, or sign language interpretation. Equally important is setting communication ground rules for all participants about what is expected of them to support effective communication.

Real-Time Captioning

Captioning is a process by which speech is transcribed into text. Not only should live meetings and events be made accessible by providing real-time captioning of all participants' speech, but any media played during these occasions should be closed captioned as well. For media, there are many captioning vendors that can prepare high-quality closed captions; make sure they follow guidelines for best practices. 

For real-time captioning, there are two ways this service is provided.

Communication Access Realtime Translation (CART):

CART services are performed by a trained human transcriptionist called a CART writer. The CART writer uses a stenography machine with a phonetic keyboard and special computer software that translates the phonetic symbols into captions. CART can be provided on-site, in-person. It can also be provided remotely using an audio connection for the CART writer to receive the speech and an Internet connection to transmit the text to the consumer.

CART writers who provide onsite or remote captioning can be found in many communities. The National Court Reporters Association (NCRA) certifies court reporters who demonstrate their proficiency in the skills needed to provide CART or captioning services. Look for a CART writer who is a Certified Realtime Reporter (CRR). You can find certified CART providers in your area by searching the NCRA professional directory or contacting a local court reporting firm to get a referral.

Best Practices:

• Book a CART writer as soon as possible; it can be difficult to find CART writers on very short notice.
• Provide the CART writer with as much information about your meeting or event in advance as possible, for example, the names of those participating and any presentation material that will be used; CART writers follow a code of ethics that requires all information provided in advance of and shared during a meeting or event be kept confidential.
• Pay attention to the audio conditions; good microphone pick of everyone’s speech and quiet conditions with minimal extraneous sounds are key to achieving high-quality captioning.
• Schedule breaks in your program at intervals recommended by the CART writer; CART provision is both physically and mentally demanding work, and breaks are required.
• Consider the location of any screen dedicated to the display of captions relative to the primary speaker and any other screens used to display presentation materials for in-person meetings or events.
• Know how to enable caption viewing through the video conferencing software being used for consumers participating remotely; inform participants about how to see the captions and any useful captioning features (e.g., being able to adjust caption location or size) available to them for adjustment.

Automatic Speech Recognition (ASR) Captioning:

Real-time captioning can also be performed by a machine using automatic speech recognition (ASR) software and a computer interface; no human intervention is involved. Captions provided using ASR are generally not as well accepted nor are they considered to be equivalent to CART for communication access.

ASR captioning can differ in important ways from CART captioning. For example, some ASR captions may not include punctuation, speaker identification, or non-speech information (e.g., a barking dog or phone ringing). Some software may struggle with background music or non-English accents. If you decide to use an ASR platform to provide access, be sure to know what the weak points are for that program, and account for them. Let consumers know that you will be using ASR captioning.

ASR captioning is available through mobile apps, internet browsers for smartphone, tablet, or computer use, videoconferencing software, and presentation software. Some applications are free; others have fees. Live Transcribe by Google, Live Captions by Microsoft, Otter, and AVA are a few examples of ASR captioning that can be downloaded or used via the web. Examples of videoconferencing software with ASR captioning include Zoom automated transcription, Google Meet live captions, and Skype live captions. Presentation software such as Microsoft Powerpoint and Google Slides have ASR captioning capabilities. An Internet search will provide the latest entries into this marketplace.

Best Practices:

• Pay attention to the audio conditions; good microphone pick of everyone’s speech and quiet conditions with minimal extraneous sounds are key in achieving high-quality captioning.
• Know how to enable caption viewing for whatever captioning application, presentation software, or video conferencing software is being used.
• Instruct participants about what, if anything, they need to do to see the captions.
• Inform participants at the beginning of the meeting or event about any useful captioning features (e.g., being able to adjust caption location or size) available to them for adjustment.
• Have someone who is hearing monitor the captions and be willing to make corrections as they are needed.

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Assistive Listening Systems

Even among individuals who benefit from and choose to use personal hearing devices, these devices may not be enough to provide full communication access, especially in certain circumstances and under certain conditions. Distance from the desired sound source can reduce the level of the signal of interest; noise in the environment can make speech harder to understand. In combination, these two factors can further reduce the communication experience of personal hearing device users. Other aspects of the acoustic space, such as reverberation, can reduce sound clarity. One way these issues can be addressed is with an assistive listening system.

All assistive listening systems contain the same basic components. A direct electrical connection to or microphone near the sound source is critical. The sound is then transmitted wirelessly using one of several methods to a receiver worn by the listener. The receiver is connected to the individual’s ear or their personal hearing device’s microphone using a headset. If the personal hearing device is equipped with a telecoil, a neckloop can be used for inductive coupling to the telecoil. And in the case of an induction hearing loop system, the device’s telecoil acts as the receiver and will be able to connect to a hearing loop directly and wirelessly.

Assistive listening systems are effective. They provide better objective measures of speech understanding in noise than with personal hearing devices alone. Individuals using these systems report improvement in perceived communication performance, improved listening satisfaction in specific situations, and reduced listening effort.

Currently, there are several main types of assistive listening systems used by people with hearing loss during in-person meetings and events. These systems are not for use during remote meetings and events.

Hearing Induction Loop Systems

Hearing Induction Loop Systems consist of a copper wire placed within a room that is connected via a special loop “driver” to a public address or sound system and a microphone. An electromagnetic field is created that can be picked up directly by a telecoil in hearing aids or cochlear implants. People who do not have hearing devices or who do not have access to telecoils in their hearing devices or a streamer need to use a hearing loop receiver and wired headset to connect to the system.

Infrared (IR) Systems

IR Systems transmit sound wirelessly using invisible infrared light waves. Infrared light cannot penetrate walls or ceilings. As a result, this system is often used in situations where a secure signal is required. However, it cannot be effectively used outdoors during the daytime due to the IR signal being affected by sunlight. In settings where there are poor sightlines, users might experience interference or receive no sound at all. Anyone using the system needs a receiver and either a wired headset or neckloop.

Frequency Modulation (FM) Systems

FM Systems transmit sound wirelessly using low-power FM radio transmission. FM systems can transmit several hundred feet within and outside the room with the transmitter. Anyone using the system needs a receiver and either a wired headset or neckloop.

WiFi Systems

WiFi systems stream sound wirelessly over a WiFi network. The receiver, typically a smartphone, must be WiFi capable. A compatible application, usually available for both iOS and Android smartphones, must be downloaded to select and utilize the appropriate WiFi network transmitting the audio stream. This allows individuals to use their own smartphones as receivers. A wired headset or neckloop is required to transmit the audio from the phone to the person's hearing device or ear. While a Bluetooth connection between the smartphone and hearing device may work, it can introduce delays in the audio signal received by the listener or increase power requirements of the phone and hearing device; either or both may be unacceptable.

A note about Bluetooth:

We also expect increased use of Bluetooth wireless connectivity for assistive listening. Currently, many hearing aids and some cochlear implants can connect via Bluetooth to another device, like a cell phone or personal listening accessory, mostly using proprietary extensions. However, it is not possible to use Bluetooth to broadcast audio from one source, like a presenter at a meeting, directly to anyone attending the meeting and listening through a personal hearing device. When a new version of Bluetooth LE, called Bluetooth LE-Audio, becomes integrated into personal hearing devices, it should provide for more seamless access to audio on any device or in any space that implements it.

The availability and use of Bluetooth LE-Audio in public spaces, in personal consumer devices like computers and cell phones, and in hearing aids and cochlear implants will happen gradually over the next several years. The eventual goal is for Bluetooth LE-Audio and its broadcast capability, branded as Auracast, to be used everywhere and support full interoperability among devices. Bluetooth LE-Audio and Auracast will coexist with traditional assistive listening technology for the foreseeable future.

There are several assistive listening system vendors:

https://www.diglo.com/

https://teltex.com/

https://en-us.sennheiser.com/

https://williamsav.com/

Best Practices:

• Ensure good audio conditions, particularly good microphone pick of everyone’s speech, and a quiet location.
• Practice setting up the assistive listening system in advance, so you are familiar with its operation.
• Verify the system is fully charged or has new batteries, with extra batteries and equipment available if they become needed.
• Ask the participants how they prefer to connect to the system being used; assistive listening systems should provide a means to connect the system to consumers' personal hearing devices or directly to their ears.
• Consider the time it will take for participants to receive and/or set up any assistive listening equipment in your calculations for the overall meeting time.

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Sign Language Interpretation

Some individuals rely on or prefer to use sign language for communication. The use of real-time captioning should not be considered an adequate substitute for communication access for these individuals unless they indicate otherwise. While there are several types of interpreting, American Sign Language (ASL) interpreting is the most typical form of interpreting requested today. Interpreters must be fluent in both languages, ASL and English, to be effective. Interpreting can be provided on-site, in-person. It can also be provided remotely using an audiovisual connection.

The Registry of Interpreters for the Deaf (RID) and the National Association for the Deaf (NAD) certify interpreters who demonstrate their proficiency in the skills needed to provide ASL interpreting. Look for an interpreter who is RID or NAD certified. Interpreters may be hired directly or through an interpreter agency or service. The Registry of Interpreters for the Deaf (RID) provides searchable databases for individual interpreters and interpreter agencies and referral services by city, state, and/or zip code. Not all interpreters, agencies, or services are RID members and, as a result, may not be listed.

Best Practices:

• Book ASL interpreters as soon as possible; it can be difficult to find interpreters on very short notice, and more than one may be required depending on the number of participants and duration of your program.
• Provide the interpreters with as much information about your meeting or event in advance as possible, for example, the names of those participating and any presentation material that will be used; Interpreters follow a code of ethics that requires all information provided in advance of and shared during a meeting or event be kept confidential.
• Schedule breaks in your program at intervals recommended by the interpreter; Interpreting is both physically and mentally demanding work, and breaks are required.
• Pay attention to the audio conditions; the ability to hear everyone’s speech clearly and quiet conditions with minimal extraneous sounds are key to achieving high-quality interpretation.
• Ask the advice of the consumers and interpreters as to the best location for the interpreters when having in-person meetings.
• Know how to pin the interpreter’s video within the video conferencing software being used for consumers participating remotely so the interpreter can always be viewed regardless of who is speaking.

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Communication Ground Rules

Communication access is not only about providing a technology or service solution, managing communication behavior by establishing communication ground rules is also very important to ensure clear communication and full participation for individuals with hearing loss and Deaf consumers. For example, managing turn-taking in a group by establishing some simple rules upfront, like - one person speaks at a time, raise your hand to speak, and identify yourself before you speak - can have a dramatic impact on the ease and effectiveness of communication for everyone and the usefulness of any technologies or other means of communication access being employed. Setting up an environment conducive to effective communication can significantly enhance the results of your session and the quality of information you receive.

Best Practices:

• Request that only one person speaks at a time.
• Ask people to raise their hands to speak and identify themselves before speaking; this aids not only the consumer but any CART writer or interpreter providing communication access services.
• Get listeners' attention before starting to speak.
• Face listeners directly.
• Pause to let everyone read and look at your slides or other presentation material before you speak to it; take this into account when deciding the length of any session you are running.
• Rephrase if you are not understood.
• Give clues when changing the subject.
• Provide written instructions in advance of and at the time of the meeting or event.
• Ensure the room is well-lit and eliminate backlighting so all speakers' faces can be easily seen to facilitate speech reading; cues on the face during communication are important whether you are communicating by voice or by sign.

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Although underused, the most common technology utilized by people with hearing loss for communication access is a personal hearing device that has been programmed for their specific hearing characteristics and needs. These devices include over-the-counter hearing aids, prescription hearing aids, and cochlear implants. Less often, personal sound amplification products may be used by people with hearing loss.

Deaf individuals may find that personal hearing devices provide very limited access to sound. Because of this minimal benefit and in some cases, cultural preferences, some people who are deaf choose not to wear a personal hearing device. These individuals use technologies that afford visual communication access, such as video calling apps, visual home alerting devices, and television captioning.

Personal Hearing Devices

Hearing aids

The Food and Drug Administration (FDA), which regulates hearing aids as medical devices, defines a hearing aid as a “sound-amplifying device designed to aid people who have impaired hearing.” This simple definition obscures the very sophisticated devices that modern hearing aids have become. Hearing Tracker provides a guide to hearing aid manufacturers, brands, and features. The FDA has defined two regulatory categories of hearing aids: Over-the-Counter Hearing Aids and Prescription Hearing Aids. Both are electronic medical devices. They differ in terms of their intended users and conditions for sale.

Over-the-Counter Hearing Aids: The FDA defines over-the-counter (OTC) hearing aids as hearing aids for adults with perceived mild-to-moderate hearing loss that may be purchased directly by consumers without the involvement of a licensed professional. OTC hearing aids are regulated by the FDA with clear labeling as to use, safety and efficacy. This option allows for affordable and easily accessible hearing aids.

Prescription Hearing Aids: The FDA defines prescription hearing aids as hearing aids for people of any age and any degree of hearing loss. A prescription is needed to purchase these devices, and in some states, they must be purchased from a licensed professional.

Cochlear implants

The FDA also regulates cochlear implants, which it defines as “electronic hearing devices.” These devices are very complex, consisting of an external microphone and sound processor that typically sits behind the ear and a surgically implanted electrode array placed in the cochlea of the inner ear. Sound picked up by the microphone is processed and transmitted to the electrode array, where electrical impulses are delivered as a representation of sound.

Personal Sound Amplification Products

Personal sound amplification products (PSAP) are considered consumer electronics products rather than medical devices. They are intended to enhance typical hearing, not address hearing loss. Nevertheless, individuals with hearing loss may choose to purchase and use a PSAP to accommodate their personal hearing needs. PSAPs are not regulated by the FDA. However, the FDA does have non-binding guidance on PSAPs that includes recommendations and their current thinking on this type of device.

Furthermore, companies that participate in ICAAT and recruit consumer stakeholders through ICAAT for their design and development work must agree that they will not solicit testimonials, positive stories, or any other kind of endorsement via any media, including written testimonies, social media, in photos or videos from those ICAAT consumers that use the names, logos or images of ICAAT or its partner organizations (HLAA, Gallaudet University or AIR).

Hearing Loss Association of America (HLAA) is a consumer organization and partner in ICAAT. HLAA provides information and education about technology that can benefit people with hearing loss. HLAA also does not endorse or promote any product or service.

Companies that work with ICAAT will not receive an endorsement from either ICAAT or its partner organizations (HLAA, Gallaudet University, and AIR).

Additionally, companies cannot use ICAAT for promotion or advertising purposes. However, companies can advertise with HLAA, which has print and digital opportunities through their website, publications, e-News, webinars, social media, and annual convention.

Co-Design Essentials provides practical information for industry participants when working with consumers with hearing loss or those who are deaf or hard of hearing through ICAAT. Our practical information touches on various topics, including the size and makeup of the community, identity terms and communication preferences, types of hearing technology utilized, communication accessibility and best practices, and expectations around compensation and marketing.

• By the Numbers
• Identity and Communication
• Hearing Technology Use
• Communication Access
• Compensation
• Marketing Policy

Benefits of Consumer-Centric, Cooperative Design and Development

• Creates a clear market focus on the consumer
• Facilitates design and development that is consumer-driven and better suited to addressing consumer need
• Forms a partnership that builds trust and strengthens relationships
• Communicates that consumer opinion matters
• Improves the knowledge of industry professionals and creates a better understanding of the end user
• Generates valuable, relevant, and new ideas and competitive insights based on unique, real-world perspectives

These benefits are far greater than the risk of competitors learning something about a company's plans indirectly, which can be reduced through nondisclosure and confidentiality agreements

What ICAAT provides:

• Opportunities for consumers and industry to engage with one another
• Insights for consumers into new and existing technology products and services
• Insights for industry into the unique needs of people with hearing loss and Deaf individuals
• Cost-effective, efficient ways for industry to recruit for and consumers to participate in research and testing activities
• Different levels and types of collaboration at various stages of design and development
• Sustained engagement between consumers and industry