What Ecological Momentary Assessment Taught Us About Real-World Hearing Outcomes

By Megan Quilter, Au.D., and Nikki Mutter, Au.D.

For decades, clinical research has relied on standardized assessments conducted within the walls of a clinic. These measures remain essential for understanding efficacy and safety, but they represent only a snapshot of a patient's experience. The reality is that life does not happen in a sound booth. Hearing challenges rarely occur under controlled laboratory conditions or on demand. They happen at the dinner table, in a busy restaurant, during a conversation with a partner, while walking through a noisy environment, or in the countless other moments that make up everyday life.

That realization led us to incorporate ecological momentary assessment (EMA) into our hearing research. Rather than asking participants to remember how they felt days or weeks earlier (recall), EMA allowed us to capture their experiences as they were happening, in the environments that mattered most to them. For us, this changed the way we thought about hearing outcomes. We were no longer looking only at how someone performed during a scheduled assessment in clinic; we were beginning to see what hearing was actually like for that person throughout their day

One of the greatest advantages of EMA is its ability to reduce recall bias. Instead of relying on memory, participants respond in real time, providing a more immediate picture of their communication experiences. Through EMA, we began to understand each participant's audiological landscape — not simply whether they could hear, but how, when, and where communication unfolded across the situations that shaped their daily lives. We could see the moments when listening became challenging, the environments where hearing technology provided the greatest or least benefit, and how participants perceived their ability to remain engaged in everyday conversations. These were the moments we could not always see when appointments were confined to the clinic. And, in many ways, they were the moments that mattered most.

What we learned from these real-world experiences also began to influence how we thought about hearing-aid development. EMA helped us identify the situations and listening challenges that matter most in people's daily lives, giving us another layer of information to consider alongside traditional laboratory and clinical measures. In that sense, EMA has helped us work toward hearing aids that are not only effective under controlled conditions but can also be designed with the complexity and variability of everyday listening in mind.

Designing An EMA Study Begins Before the First Survey

One of our biggest lessons was that an effective EMA project starts long before the first participant is enrolled. We learned quickly that the best place to begin was not with the survey or the technology but with the question we were trying to answer. Before designing surveys or selecting a technology platform, we first defined the research questions and the outcomes we wanted to understand. Working backward from those desired outcomes helped determine exactly what information needed to be collected, when it needed to be collected, and how each question would contribute to the overall study objectives.

What sounds straightforward became one of the most important disciplines in our study design. It can be surprisingly tempting to ask one more question, collect one more data point, or capture one more measure simply because the technology makes it possible and because, as researchers, we can quickly become intrigued by everything it can tell us. We had to continually remind ourselves that more data does not necessarily mean better data. Our goal was never to collect more data; our goal was to collect the right data.

That philosophy shaped the surveys themselves. We intentionally kept questions brief, relevant, and easy to answer in the moment. Participants needed to be able to complete a survey quickly and effortlessly, regardless of where they were or what they were doing. That is a unique challenge of EMA: You are not designing a questionnaire for someone sitting quietly at a desk. You are asking someone to tell you about their experience(s) while they are actually living it.

There were numerous iterations before we finalized our questionnaires. We refined the wording, reconsidered the number of questions, and continually asked ourselves whether each item was truly necessary. That process was not always quick, but it was valuable. It forced us to think carefully about what we really wanted to learn and what we were asking participants to give us in return.

The technology platform required the same intentionality. In our work, we have continued to successfully use a platform that provided flexibility in survey design while maintaining a straightforward participant experience. More broadly, we learned that platform selection should be driven by the requirements of the study rather than convenience, as tempting as that may be. Ease of survey creation and management, the participant experience, and the specific types of data that can be captured all matters and are platform dependent. For hearing research, some capabilities can be particularly valuable. For example, the ability to capture smartphone-derived environmental sound levels alongside participant responses can provide important context for understanding a reported communication experience. Not every EMA platform offers the same capabilities, making this an important consideration early in study design.

One of the most exciting possibilities of EMA is its ability to bring together subjective and objective information. Participant-reported outcomes can be paired with sensor- or device-generated data to provide additional context about what was happening around them. For example, environmental sound levels, acoustic characteristics of the listening environment, or device-generated information about hearing-aid use and processing. Together, these data streams can begin to tell a much richer story: not only what happened, but how the participant experienced what happened. A participant's perception provides something that an objective measurement cannot, while objective data can provide context that memory and perception alone cannot. The combination brings us closer to understanding the participant's experience.

Of course, integrating these data streams introduces additional considerations around data quality, privacy, technical limitations, and the management of large volumes of data. One of our lessons was that the richness of real-world data is both its greatest strength and one of its greatest challenges. The more we capture the moment, the more carefully we have to consider what is meaningful, what is reliable, and what ultimately helps answer the research questions we set out to answer.

Success Depends on Simplicity

If there is one lesson we would emphasize for anyone considering EMA, it is this: Make it simple. EMA provides valuable real-world insights, but collecting those insights introduces its own operational complexity. Successful implementation requires careful participant onboarding, clear training, ongoing participant engagement, and careful management of the enormous amount of data generated throughout the study. The challenge is to make the experience feel simple for the participant, even when the study itself is anything but simple behind the scenes.

Participant burden became one of the most important considerations in our study designs. We learned that keeping surveys short, intuitive, and meaningful was not simply a matter of convenience; it was essential to maintaining engagement and reducing survey fatigue. Participants complete surveys in the middle of their everyday lives. They might be at home, driving in a car, in the middle of a meeting, or simply busy with something else. Real life does not stop because a survey prompt appears. We learned that missed prompts are inevitable, and participants may intend to return to a survey only to become distracted or forget.

That experience reinforced something important for us: The easier we made participation, the better chance we had of capturing the experience we were trying to understand. Clear instructions, simple workflows, and few, if any, technical barriers all helped improve the participant’s experience and, ultimately, the quality of the data. We also learned that restraint matters. It can be tempting to capture everything a participant might possibly report, but every additional question comes with a cost. The goal is not to ask everything. It is to ask what matters. That principle ultimately benefits everyone — from the participant who is trying to answer one more survey to the study team who will eventually need to make sense of thousands of responses.

Capturing The Right Moment

Another important consideration is deciding when participants should be asked to report an experience. The sampling strategy should be driven by the research question. Time-based sampling can help reveal patterns across the day, while event-based sampling can be more useful when the goal is to understand a specific experience as it occurs. In practice, we found that the most meaningful approach depends on what we are trying to understand exactly. Sometimes the question is about the broader rhythm of someone's day; other times, it is about what happened in a particular listening situation in a specific environment.

The key is to capture the experience close enough to the moment that it remains meaningful, without making the participant feel as though the study is following them around all day. EMA is particularly valuable when outcomes depend heavily on experiences that vary across people, environments, or moments in time. In hearing research, this includes communication experiences that change throughout the day or listening situations that cannot easily be replicated during a traditional clinic visit. The closer the sampling strategy reflects the experience being studied, the more meaningful the resulting data can become.

Looking Ahead

EMA has fundamentally changed how we think about measuring hearing outcomes. Of course, traditional clinical assessments remain essential, but they tell only part of the story. A score collected in a clinic can tell us how someone performed at that time in the sound booth. EMA helps us understand what that performance means when that person goes back to living their daily life.

For us, that has been one of the most exciting aspects of incorporating EMA into hearing research. We began by looking for a better way to capture real-world outcomes, but we gained something broader: a different perspective on what a hearing outcome represents. Hearing is not experienced only as a score. It is experienced in conversations, relationships, environments, moments of connection, and moments when communication becomes difficult. Those moments are easy to miss when we only measure what happens in the clinic. That is the greatest lesson EMA gave us; that the most meaningful hearing outcomes may not happen during the assessment at all. They can happen afterward when the participant leaves the clinic and returns to the life that we were ultimately trying to understand.

For anyone considering EMA, start with the research question. Define what success looks like, work backward from the desired outcomes, and design every survey, every data element, and every operational decision with that goal in mind. Then ask a second question just as carefully: Can the participant do this easily in the middle of real life? When thoughtfully designed, EMA does more than move research beyond the clinic. It brings us closer to the person behind the outcome and to the moments that matter most to them.

About The Authors:

Megan Quilter, Au.D., is a lead audiologist with GN Hearing Global Audiology team and primarily focuses on research, adult and pediatric amplification, and cochlear implants. Her background includes clinical adult and pediatrics, neuro-vestibular audiology, and tinnitus. Dr. Quilter currently holds a Doctorate of Audiology and resides with her family in Chicago.

Nikki Mutter, Au.D., is the director, clinical and academic alliances at ReSound US, serving as business lead for ReSound in the Smart Hearing Alliance and ReSound University. With over 15 years of clinical experience with pediatrics and adults in diagnostics, hearing aids, and cochlear implants, Nikki joined ReSound in 2016 and has served in various roles focused on pediatrics and bimodal. She provides training and support for internal teams on bimodal, pediatrics, and specialized clinical content, as well as working with KOL accounts in medical and academic settings. Dr. Mutter holds a Doctorate of Audiology from the University of Tennessee and resides in Knoxville, TN, with her family.