Results from this cross-sectional study, conducted in a community-based sample of the general population, suggest more recent generations were less likely to have audiometric hearing loss, and relatedly, they had better hearing, defined by PTA and SPIN. These trends were observed across age strata. Associations between generation and the prevalence of audiometric hearing loss were present for males, but not females. Results suggest a lack of generational differences in the prevalence of self-reported hearing difficulties or hearing aid use.

The finding that more recent generations had better hearing could be explained by improved population health. For example, more recent generations experienced fewer industrial workplaces and better occupational noise regulations, and military service is less common [37].

Research shows more recent generations experience better outcomes in other age-related conditions, including vision, cardiovascular disease, and cognitive function [15, 38,39,40,41]. Shared risk factors between hearing and other age-related conditions, such as improved nutrition, increased availability of vaccinations and medications to reduce infection, and reduced rates of smoking among more recent generations, may improve overall healthy aging [41]. Taken together, generational shifts in health and their association with hearing reiterate that age-related hearing loss may be at least partially modifiable [8, 42].

Most, but not all, previous generation/birth cohort or across-cohort studies reported more recent generations/birth cohorts or cohorts show lower prevalence or incidence of hearing loss [8,9,10, 12,13,14, 43]. The study that did not report an association between birth cohort and generation was conducted among 75-year-old people born in 1901, 1915, and 1930 in Sweden [10]. In the present study, those birth years correspond to the Greatest Generation (1901–1924) and beginning of the Silent Generation (1925–1945). Therefore, it is possible that there was not enough variability in birth year to detect an association with hearing loss. In this, and other studies, hearing loss prevalence or incidence is defined by PTA, because it provides a single metric to quantify hearing. Our definition of PTA was comprised of thresholds at frequencies most important for speech understanding. However, this definition does not capture the thresholds at frequencies higher than 4.0 kHz, which is often where damage to the auditory system first occurs [44]. We presented associations of generation with audiometry, SPIN, and self-reported hearing to enhance understanding of generational differences across several hearing-related outcomes.

The finding that generation was associated with the prevalence of audiometric hearing loss in males, but not females, is consistent with previous cross-sectional studies evaluating generational/birth cohort or across-cohort impacts on hearing loss [8, 13, 14, 43]. Associations of generation with audiometric hearing loss were present for males and not females, but associations of generation with speech perception in noise were observed in both sexes. These differences are likely because audiometric hearing loss was modeled as a binary variable, which is meaningful for communicating the burden of hearing loss. However, speech perception in noise does not have a standardized cut-point value to define prevalence and so was modeled as a continuous variable, which could increase statistical power. There are several possible explanations for the sex differences reported in this study. Despite more women entering the workforce in recent generations, men remain more likely to have jobs in noisy environments [45, 46]. Therefore, these sex differences could be explained by policy changes to reduce occupational noise exposure in jobs more likely filled by men. Importantly, among females, the OR for the Silent, Baby Boom, and Gen X Generations, compared to the Greatest Generation, suggested a non-significant trend that more recent generations of females are less likely to experience hearing loss.

To the authors’ knowledge, this is the first study to evaluate generational differences in self-reported hearing difficulty. Previous studies in this cohort showed older individuals, who have a higher prevalence of audiometric hearing loss, are less likely to report hearing difficulties [19, 25]. In this study, generation was not associated with self-reported hearing difficulty. Taken together, results suggest age, rather than the secular constructs captured by generation, is a better predictor of self-reported hearing difficulty.

Results from this study suggested no generational differences in hearing aid use, among Greatest, Silent, and Baby Boom generations. We did not report associations for Gen X and Millennial/Gen Z groups given limited sample sizes of hearing aid users in those groups. While it has been hypothesized that more recent generations, including Baby Boom [47], may be more willing to adopt technology (vs older generations), results suggest that negative perceptions of hearing aids likely persist. Contrary to our findings, a few studies have reported more recent (birth) cohorts may be more likely to use hearing aids [14, 20]. A study conducted in the Norwegian HUNT cohort showed the prevalence of hearing aid use increased from 1996–1998 to 2017–2019 [14]. However, that study evaluated prevalence of hearing aid use in the entire sample, rather than only among those with hearing loss [14]. Another across-cohort study, conducted in NHANES, suggested that among adults aged 50 to 69 years, the prevalence of hearing aid use was higher in 2011–2016 than in 1999–2004 [20]. An association between cohort and hearing aid use was reported only among participants with any hearing loss, but not after stratification to hearing loss severity [20]. These estimates were generated from a limited sample size of 26 and 56 hearing aid users across both cohorts, which was smaller for analyses stratified to hearing loss severity [20]. That limitation, along with the limited research focused on generational/birth cohort effects on hearing aid use, highlights the need for future research on this topic. Understanding generational/birth cohort differences in hearing aid use could inform tailored messaging to reduce stigma and policy that aims to promote treatment for hearing loss across the adult lifespan.

Findings from this study and others [8, 9, 12,13,14, 43] suggest the caseload of hearing loss may be lower than projected [8]. Research in other areas of aging indicates some generational improvements to health could plateau or reverse due to lack of or negative changes to population health [36]. Examples of factors associated with hearing loss include unmet needs in reducing occupational noise exposure in certain sectors [48], recent declines in nutrition (e.g., consuming more processed foods), increased rates of obesity and sedentary lifestyles [49, 50], and high prevalence of recreational sound exposure [51]. Continued longitudinal epidemiological studies of hearing loss are needed to inform caseload projections and to determine generational trends as more recent generations (e.g., Gen X, Millennials) age. Existing or future systems and policy-level changes, such as availability of over-the-counter hearing aids, improved access to hearing health care, and systematic screening for hearing loss could change generational differences in hearing-related outcomes.

This community-based cohort study has several strengths, including its large and diverse sample of the general population and comprehensive measures of hearing. This cohort study is similar to other epidemiological studies of age-related hearing loss in terms of age and audiometric hearing thresholds, which improves generalizability of study findings [4, 21, 52]. However, some limitations exist. First, although this community-based sample is comprised of individuals from the general population, results may not be generalizable to the entire population, as study participants reside in a relatively small geographic area. Moreover, it is possible there are regional differences in exposure to risk factors for hearing loss, and secular trends in these exposures. Second, despite the relatively large sample size, there were few participants in the Gen X and Millennial/Gen Z Generations with audiometric hearing loss. Similarly, although the proportion of study participants who were Black was consistent with the region's Census data, there were few participants who reported Black race across each generation group. Therefore, we were limited in our ability to draw conclusions related to hearing-related outcomes among Millennial/Gen Z Generations, and we could not report whether generational trends in hearing differed among White and Black, or other, races. Third, cross-sectional observational studies, such as this one, cannot determine temporality, including generational differences in the progression or incidence of hearing loss [9].