eHealth Library Login

Has the COVID-19 pandemic created greater communication barriers between healthcare personnel and hearing- impaired individuals?

Download Full Summary of Evidence (PDF)

Main Points

  1. The necessity for many HCP to wear face-masks during the pandemic has exacerbated communication difficulties — especially in busy clinical settings — among deaf or hard-of-hearing (DHH) patients who may lip-read to assist with communication, or among individuals (eg older people) with diminished hearing capacity who may use hearing assistive technology.
  2. Major challenges encountered by DHH during the COVID-19 pandemic include: difficulties around accessing information; difficulties around sign language and the availability of sign language interpreters; face-masks inhibiting effective communication; social distancing affecting physical and mental health; stigma and discrimination; and systemic problems due to COVID-19-related restrictions.
  3. Strategies to confront these challenges include: potential use of transparent face-masks; potential use of technology; help from sign language instructors; and preparedness of health-care settings for DHH patients. System strengthening, telemedicine and policy amendments may be required to build up a support system for the hearing impaired during the COVID-19 pandemic.

Summary of Evidence

The Health Service Executive (HSE)1 has issued advice for healthcare personnel (HCP) on communicating with deaf or hard-of-hearing patients (DHH) in healthcare settings during the COVID-19 pandemic. The necessity for many HCP to wear face-masks during the pandemic has exacerbated communication difficulties — especially in busy clinical settings — among DHH patients who may lip-read to assist with communication, or among individuals (eg older people) with diminished hearing capacity who may use hearing assistive technology. Strategies to improve communication with DHH patients in such circumstances include: removal of face-masks, or use of transparent face-masks; minimising noise interference; speaking clearly and at a slightly slower pace, without over-enunciating; provision of Irish Sign Language (ISL) interpretive services; and facilitating lip-reading and non-verbal communication.

Major challenges encountered by DHH during the COVID-19 pandemic include: difficulties around accessing information; difficulties around sign language and the availability of sign language interpreters; face-masks inhibiting effective communication; social distancing affecting physical and mental health; stigma and discrimination; and systemic problems due to COVID-19-related restrictions23. Strategies to confront these challenges include: potential use of transparent face-masks; potential use of technology; help from sign language instructors; and preparedness of health-care settings for the hearing disabled. System strengthening, telemedicine and policy amendments may be used to build up a support system for the hearing impaired during the COVID-19 pandemic23, 24.

ref1Face-coverings negatively impact hearing, understanding, engagement, and feelings of connection with the speaker10, 20. Wearing face PPE impairs transmission of middle-to-high voice frequencies and affects speech intelligibility21, 26. Surgical masks are responsible for up to 23.3% loss of speech intelligibility in noisy environments21. Saunders et al10 report that impacts are greatest when communicating in medical situations; and that people with hearing loss are significantly more impacted than those without hearing loss. The type and combination of protective face-coverings used have differential effects on attenuation of speech information, influencing speech recognition of patients with hearing loss15. Face-coverings impact communication content, interpersonal connectedness, and willingness to engage in conversation; increase anxiety and stress; and result in fatiguing and frustrating verbal communication encounters10, 11. Barriers to communication for DHH individuals are associated with reduced access to essential healthcare services, health information, and poorer health outcomes including higher rates of readmission, preventable adverse medical events, reduced adherence, longer hospitalisation, and poor functional recovery following ICU admission5, 27, 32.

In a cross-sectional survey of 1000 participants from the general population, HCP, and HCP who are deaf or hard of hearing in the United States, Chu et al2 report that transparent masks may help to improve communication during the COVID-19 pandemic, particularly for DHH individuals. In the general population, 45% felt positively about interacting with HCP wearing a transparent mask; 61.8% of general HCP and 82.2% of DHH HCP felt positively about wearing a transparent mask to communicate with a patient. Thibodeau et al14 affirm that use of transparent masks can significantly facilitate speech recognition. Transparent mask benefits were not attributable to an acoustic advantage — in fact, transparent masks have greater sound attenuation and resonance, and deflect sounds in ways that non-transparent masks do not — but rather to the addition of the visual cues of the speaker’s face14, 22.

In an account of the deaf community’s experiences navigating COVID-19 pandemic information, Panko et al13 report that individuals who are deaf had 4.6 times higher odds of experiencing difficulty in accessing COVID-19–related information than participants who are hearing (p = .013). Participants who are deaf were more likely to report trouble accessing information compared to participants who are hearing (26% vs. 2.7%; p < .001), to find the information frightening (76.9% vs. 27.0%; p < .001), and to mistrust the information (61.5% vs. 41.9%; p = .010).

Specific challenges to hearing aid users during the COVID-19 pandemic include limited supplies of batteries for hearing devices, limited access to repair or programming services for devices and accessories, termination of speech therapy sessions, and obstacles to employment and education6. Compared with hearing aid users, cochlear implant (CI) users experience more difficulty communicating with family and friends (53% vs. 41%, p = 0.017), obtaining pandemic information (10% vs. 3%, p = 0.002), and understanding live broadcasts (47% vs. 17%, p = 0.001) during the pandemic8. CI users are less likely than hearing aid users to seek general (52% vs. 69%, p = 0.001) and hearing healthcare services (20% vs. 34%, p = 0.002)8. Homans and Vroegop9 report that face-masks caused considerable problems in daily life communication among 80% of CI users. CI users described feelings of loneliness and isolation, and all subdomains of the Nijmegen Cochlear Implant Questionnaire worsened due to the use of face-masks9. Gordon et al17 report an association between COVID-19 lockdowns and a reduction in child CI users’ access to spoken communication.

Deardorff et al12 report that although HCP have implemented some methods to facilitate communication — reducing background noise, raising voice, or using written communication — the likelihood of using advanced communication technologies such as sound amplifiers, live captioning or real-time speech-to-text applications was low. In respect of deaf or hard-of-hearing HCP, Grote et al7 report that 78% felt that the communication needs of D/deaf HCP had not been met during the pandemic; and that HCP felt isolated and frustrated by a lack of transparent masks and reasonable adjustments to meet their communication needs.

Irish and/or International Guidance

    N/A

Health Service Executive (2021) Communicating with deaf or hard-of-hearing patients in healthcare settings during COVID-19[1]

The Health Service Executive (HSE) has produced advice for healthcare personnel (HCP) on communicating with deaf or hard-of-hearing patients in healthcare settings during the COVID-19 pandemic. The necessity for many HCP to wear face-masks during the pandemic has exacerbated communication difficulties, especially in busy clinical settings, among deaf or hard-of-hearing patients who may lip-read to assist with communication, or among individuals (eg older people) with diminished hearing capacity who may use hearing assistive technology. Strategies to improve communication with deaf or hard-of-hearing patients in such circumstances include:

  • Ask patients how they wish to communicate in advance of an appointment
  • Provide an Irish Sign Language (ISL) interpreter for members of the deaf. community for whom ISL is a first language and who may require communication via ISL to process complex information.
  • Face-masks reduce speech clarity and, combined with loss of lip-reading and other visual facial cues, can make communication very difficult. If possible, do not use a face-mask, or use a transparent visor. Face the individual, and establish eye contact before initiating communication.
  • Maintain eye contact while speaking.
  • Do not speak while moving.
  • Minimise background noise, or move to a quiet location.
  • For patients who use hearing assistive technology, ensure that devices are available and in good working order.
  • The patient may want to lip-read, or observe facial expressions. Light on the speaker’s face is important. Do not stand in front of a bright light or window.
  • Speak clearly and at a slightly slower pace.
  • Do not shout or over-enunciate. Exaggerated mouth movements will distort natural lip patterns and inhibit lip-reading.
  • The patient may wish to communicate with written notes. Take the time necessary to exchange notes.
  • Be responsive in the conversation. Use gestures, body language and facial expressions to help communicate information.
  • Nod instead of saying ‘Hmm.’
  • Be prepared to repeat or re-phrase information if necessary.

Irish and/or International Literature

    Level 2

Chu JN, Collins JE, Chen TT, Chai PR, Dadabhoy F, Byrne JD, Wentworth A, DeAndrea-Lazarus IA, Moreland CJ, Wilson JAB, Booth A, Ghenand O, Hur C, Traverso G. Patient and Healthcare Worker Perceptions of Communication and Ability to Identify Emotion When Wearing Standard and Transparent Masks. JAMA Netw Open. 2021 Nov 1;4(11):e2135386. doi: 10.1001/jamanetworkopen.2021.35386. PMID: 34807257; PMCID: PMC8609412.[2]

This pilot cross-sectional survey included the general population, healthcare personnel (HCP), and HCP who are deaf or hard of hearing in the United States. Respondents viewed 2 short videos of a study author wearing both a standard and transparent N95 mask and answered questions regarding mask use, communication, preference, and fit. Participants’ perceptions were assessed surrounding the use of both mask types related to communication and the ability to express emotions.

The national survey consisted of 1000 participants (mean [SD] age, 48.7 [18.5] years; 496 [49.6%] women) with a response rate of 92.25%. The survey of general HCP consisted of 123 participants (mean [SD] age, 49.5 [9.0] years; 84 [68.3%] women), with a response rate of 11.14%. The survey of HCP who are deaf or hard of hearing consisted of 45 participants (mean [SD] age, 54.5 [9.0] years; 30 [66.7%] women) with a response rate of 23.95%. After viewing a video demonstrating a study author wearing a transparent N95 mask, 781 (78.1%) in the general population, 109 general HCP (88.6%), and 38 HCP who are deaf or hard of hearing (84.4%) were able to identify the emotion being expressed, in contrast with 201 (20.1%), 25 (20.5%), and 11 (24.4%) for the standard opaque N95 mask. In the general population, 450 (45.0%) felt positively about interacting with a HCP wearing a transparent mask; 76 general HCP (61.8%) and 37 HCP who are deaf or hard of hearing (82.2%) felt positively about wearing a transparent mask to communicate with patients.

The findings of this study suggest that transparent masks could help to improve communication during the COVID-19 pandemic, particularly for individuals who are deaf and hard of hearing.

    Level 2

Bubbico L, Bellizzi S, Ferlito S, Maniaci A, Leone Guglielmotti R, Antonelli G, Mastrangelo G, Cegolon L. The Impact of COVID-19 on Individuals with Hearing and Visual Disabilities during the First Pandemic Wave in Italy. Int J Environ Res Public Health. 2021 Sep 28;18(19):10208. doi: 10.3390/ijerph181910208. PMID: 34639515; PMCID: PMC8508015.[3]

A 39-item online national survey was disseminated from 1 April 2020 to 31 June 2020 via social media throughout Italy to communities of individuals with proven severe sensory-neural disabilities. The survey collected extensive information on the socio-demographic profile, health, everyday activities, and lifestyle of individuals with hearing and visual disabilities.

One hundred and sixty-three respondents with hearing (66.9%) and visual (33.1%) disabilities returned a usable questionnaire. The mean age of interviewees was 38.4 ± 20.2 years and 56.3% of them were females. Among the various risk mitigation measures, face-masks caused the greatest discomfort due to communication barriers, particularly among interviewees affected by hearing disabilities (92.2% vs. 45.7%). The most common request (46.5%) of respondents to reduce the inconveniences of the COVID-19 emergency was improving the access to and delivery of health and social services for individuals with sensory-neural disabilities (19.3%), followed by the use of transparent masks (17.5%).

Although health protection measures such as face-masks and social distancing play a key role in preventing and controlling the spread of SARS-CoV-2, the unmet needs of disabled individuals should be carefully considered, especially those affected by sensory-neural disabilities.

    Level 2

Bernard A, Weiss S, Rahman M, Ulin SS, D’Souza C, Salgat A, Panzer K, Stein JD, Meade MA, McKee MM, Ehrlich JR. The Impact of COVID-19 and Pandemic Mitigation Measures on Persons With Sensory Impairment. Am J Ophthalmol. 2021 Jun 29;234:49-58. doi: 10.1016/j.ajo.2021.06.019. Epub ahead of print. PMID: 34197781; PMCID: PMC8238639.[4]

This cross-sectional survey assessed the impact of the COVID-19 pandemic and associated mitigation measures on persons with sensory impairments (SI), including visual impairments (VI) and hearing impairments (HI).

Adults with VI (best-corrected visual acuity <20/60 in the better-seeing eye), HI (International Classification of Diseases, Tenth Revision, codes), and age- and sex-matched controls (n = 375) were recruited from the University of Michigan. The 34-item Coronavirus Disability Survey was administered. Both χ2 tests and logistic regression were used to compare survey responses between groups.

All groups reported high levels of disruption of daily life, with 80% reporting “a fair amount” or “a lot” of disruption (VI: 76%, HI: 83%, CT: 82%, P = .33). Overall, 30% reported difficulty obtaining trusted information about the pandemic.

    Level 2

Almusawi H, Alasim K, BinAli S, Alherz M. Disparities in health literacy during the COVID-19 pandemic between the hearing and deaf communities. Res Dev Disabil. 2021 Dec;119:104089. doi: 10.1016/j.ridd.2021.104089. Epub 2021 Sep 29. PMID: 34624721; PMCID: PMC8488063.[5]

Barriers to communication for those with hearing loss are not only associated with social, emotional, educational and occupational difficulties, but also with reduced access to essential healthcare services, health information, and poorer health outcomes (Emond et al 2015). These concerns are amplified with mandates such as physical distancing and the use of masks, which although needed to prevent respiratory transmission of SARS-Cov-2, obscure access to facial features needed for lip-reading and sign language.

The objective of this cross-sectional survey was to compare the disparities of health knowledge and practice surrounding COVID-19 among hearing and Deaf or Hard of Hearing (DHH) individuals. A total of 110 (70 hearing and 40 DHH) participants were recruited. Participants were differentiated according to status of hearing loss, communication mode, as well as country, age, sex, occupation, education level and satisfaction with available information. Various aspects of knowledge relating to COVID-19 and associated public health measures were tested by means of a questionnaire.

A multivariate regression analysis showed that both the degree of hearing loss and use of sign language as a primary means of communication were associated with lower scores. In addition, disparities exist in the use of health information sources: DHH participants relied mostly on social media; the hearing group relied predominantly on official government sources. In addition to the general obstacles faced by DHH individuals in everyday life, specific to the pandemic are the issues of attenuated acoustic transmission and the inability to lip-read due to the use of face-masks by healthcare personnel (Trecca et al 2020). Reliance on visual mechanisms for information access (McKee et al. 2015), when obstructed by face-masks, results in reduced understanding and discomfort in listening when wearing hearing aids and devices (Brooks 2020; Trecca et al 2020). Although those with mild hearing loss were not found to be at a disadvantage according to this study, a moderate, severe or profound hearing impairment was associated with reduced knowledge scores, supporting the degree of impairment as a discriminatory factor. Data showing that sign language users had poorer knowledge about COVID-19 and associated public health measures are further indication of the importance of providing information in sign language. The use of written communication in the majority language does not reliably compensate as it is invariably considered the second language of deaf individuals (Castro et al 2020).

    Level 2

Alqudah S, Zaitoun M, Alqudah O, Alqudah S, Alqudah Z. Challenges facing users of hearing aids during the COVID-19 pandemic. Int J Audiol. 2021 Oct;60(10):747-753. doi: 10.1080/14992027.2021.1872806. Epub 2021 Feb 16. PMID: 33590784.[6]

In this cross-sectional study, individuals with permanent hearing loss (n=278) answered a questionnaire designed to identify potential obstacles caused by using hearing aids during the COVID-19 pandemic. The duration of daily device usage before the imposed lockdown was significantly higher than that during (Z=-2.01, p<0.05), potentially attributable to pandemic-induced difficulties faced by hearing-technology users. Such challenges include the shortage of batteries for hearing devices, limited access to repair or programming services for devices and accessories, termination of speech therapy sessions, and obstacles to employment and education.

    Level 2

Grote H, Izagaren F, Jackson E. The experience of D/deaf healthcare professionals during the coronavirus pandemic. Occup Med (Lond). 2021 Aug 20;71(4-5):196-203. doi: 10.1093/occmed/kqab048. PMID: 33903904; PMCID: PMC8135376.[7]

The coronavirus pandemic and in particular the introduction of face-masks presented a huge challenge for the D/deaf community, many of whom rely on visual cues in lip-reading and sign language. This particularly affected D/deaf healthcare personnel (HCP) who endured significant communication challenges at work due to the lack of transparent masks or other reasonable adjustments. Grote et al aimed to determine the impact of a lack of transparent masks on communication, confidence at work and well-being among D/deaf HCP during the coronavirus pandemic.

A survey was sent to all members of the UK Deaf Healthcare Professionals Group and Healthcare Professionals with Hearing Loss. Eighty-three responses were received. Nine (11%) individuals had access to transparent masks. Over three-quarters of respondents reported feeling anxious and fearful of making a mistake due to communication difficulties. Fourteen (17%) were removed from clinical roles due to a lack of reasonable adjustments. One-third felt that they would need to consider an alternative career if improvements were not made. 78% felt that the communication needs of D/deaf HCP had not been met during the pandemic. 

D/deaf HCP felt isolated and frustrated by a lack of transparent masks and reasonable adjustments to meet their communication needs.

    Level 2

Wilson HL, Crouch J, Schuh M, Shinn J, Bush ML. Impacts of the COVID-19 Pandemic on Communication and Healthcare Access for Adults With Hearing Loss. Otol Neurotol. 2021 Sep 1;42(8):1156-1164. doi: 10.1097/MAO.0000000000003203. PMID: 34049333; PMCID: PMC8373686.[8]

This prospective cross-sectional questionnaire study in a tertiary referral centre collected data from adults with hearing loss which included socio-demographic data, communication challenges, pandemic preparedness, access to healthcare, and mental and emotional health. A total of 614 patients responded (27.8% response rate). Compared with hearing aid users, cochlear implant (CI) users reported more difficulty communicating with family/friends (53% vs. 41%, p = 0.017), obtaining pandemic information (10% vs. 3%, p = 0.002), and understanding live broadcasts (47% vs. 17%, p = 0.001) during the pandemic. CI users were less likely than hearing aid users to seek general (52% vs. 69%, p = 0.001) and hearing healthcare services (20% vs. 34%, p = 0.002). Rural residents reported greater difficulty than urban residents communicating with friends/family (53% vs. 39%, p = 0.001), obtaining food/supplies (41% vs. 20%, p = 0.004), and understanding live broadcasts (31% vs. 20%, p = 0.001) during the pandemic. Compared with urban residents, rural residents reported greater difficulty accessing general (57% vs. 42%, p = 0.004) and hearing healthcare (49% vs. 34%, p = 0.043). Rural residents reported poorer mental/emotional health than urban residents. Among adults with hearing loss, CI users and rural residents experienced greater challenges in communication, pandemic preparedness and access to healthcare during the COVID-19 pandemic.

    Level 2

Homans NC, Vroegop JL. Impact of face masks in public spaces during COVID-19 pandemic on daily life communication of cochlear implant users. Laryngoscope Investig Otolaryngol. 2021 May 6;6(3):531-539. doi: 10.1002/lio2.578. PMID: 34195375; PMCID: PMC8223455.[9]

This prospective cross-sectional study used an online questionnaire about the effects of face-masks on daily life communication of adult cochlear implant (CI) users. Two hundred and twenty one adult CI users (54% female, mean age 62 years) participated in the study.

Face-masks caused considerable problems in daily life communication among 80% of study participants. CI users described feelings of loneliness and isolation, and all subdomains of the Nijmegen Cochlear Implant Questionnaire [a self-assessment health-related QoL instrument for CI users] worsened due to the use of face-masks. 

    Level 2

Saunders GH, Jackson IR, Visram AS. Impacts of face-coverings on communication: an indirect impact of COVID-19. Int J Audiol. 2021 Jul;60(7):495-506. doi: 10.1080/14992027.2020.1851401. Epub 2020 Nov 27. PMID: 33246380.[10]

An online survey consisting of closed-set and open-ended questions was distributed in order to gain insights into experiences of interactions involving face-coverings, and of the impact of face-coverings on communication. Four hundred and sixty members of the general public were recruited via sampling. People with hearing loss were intentionally over-sampled to more thoroughly assess the effect of face-coverings in this group.

Participants reported that face-coverings negatively impacted hearing, understanding, engagement, and feelings of connection with the speaker. Impacts were greatest when communicating in medical situations. People with hearing loss were significantly more impacted than those without hearing loss. Face-coverings impacted communication content, interpersonal connectedness, and willingness to engage in conversation; increased anxiety and stress; and made communication fatiguing, frustrating and embarrassing.

    Level 2

Naylor G, Burke LA, Holman JA. Covid-19 Lockdown Affects Hearing Disability and Handicap in Diverse Ways: A Rapid Online Survey Study. Ear Hear. 2020 Nov/Dec;41(6):1442-1449. doi: 10.1097/AUD.0000000000000948. PMID: 33136621.[11]

The aim of this study was to explore the perceived effects of Covid-19 social distancing restrictions and safety measures on people with hearing loss. A rapidly deployed 24-item online questionnaire asked about the effects of certain aspects of lockdown including face-masks, social distancing and video-calling on participants’ behaviour, emotions, hearing performance, practical issues, and tinnitus. On behaviour, Naylor et al report that video calls were used more frequently than pre-lockdown. The better-hearing group used their hearing aids less. On emotions: there were increased feelings of anxiety (especially among the worse hearing group) concerning verbal communication situations and access to audiology services, and greater rumination about hearing loss. The worse hearing group showed substantial relief at not being obliged to attend challenging social gatherings. Across both groups, a majority expressed a preference to see all key workers equipped with transparent face-masks. On hearing performance: a large majority found it hard to converse with people in face-masks due to muffled sound and lack of speech-reading cues. In the worse hearing group, performance in video calls was considered generally inferior to face-to-face, but similar to phone calls. Those who use live subtitling in video calls appreciated their value. Television and radio updates about Covid-19 were easy to follow for most respondents. There was only weak evidence of face-mask fixtures interfering with hearing aids on the ear, and of tinnitus having worsened during lockdown.

    Level 2

Deardorff WJ, Binford SS, Cole I, James T, Rathfon M, Rennke S, Wallhagen M. COVID-19, masks, and hearing difficulty: Perspectives of healthcare providers. J Am Geriatr Soc. 2021 Oct;69(10):2783-2785. doi: 10.1111/jgs.17349. Epub 2021 Jul 6. PMID: 34228350; PMCID: PMC8447172.[12]

In a survey of healthcare personnel (HCP) which focused on changes in hearing loss awareness during the COVID-19 pandemic, communication challenges in the context of increased use of face-masks, and methods used by HCP to improve communication, Deardorff et al received a total of 257 responses. Of those who reported demographic data, the largest group of respondents were physicians (57.8%, n = 90/156), followed by nurse practitioners (19.9%, n = 31/156). Before the pandemic, most respondents (59.7%, n = 114/ 191) felt that hearing difficulty either had no impact or only slightly impacted the quality of care provided to patients. These results changed dramatically during the COVID-19 pandemic, with 85.4% of respondents (n = 164/192) reporting that hearing difficulty either moderately or extremely impacted the quality of care provided to patients. Since the start of the pandemic, 37.9% of respondents (n = 58/153) reported that awareness of communication issues related to hearing difficulties significantly increased. However, most respondents (67.1%, n = 102/152) reported that screening for hearing impairment has either not increased or only increased a little since the start of the pandemic. Similarly, 53.6% of respondents (n = 81/151) reported that the use of aids in patient encounters has either not increased or only increased a little since the start of the pandemic. Common changes experienced in clinical encounters due to HCP mask-wearing included more difficulty being understood due to muffled speech (37.1%), and longer encounters with patients (20.6%).

Results suggest that the implementation of safety measures such as PPE and physical distancing has altered awareness of hearing difficulties and practice patterns among HCP. Specifically, HCP were more inclined to recognize that hearing difficulties adversely impacted the quality of care received, and to experience obstacles to providing care based on mask-wearing. Although HCP reported implementing some methods to facilitate communication — reducing background noise, raising voice, or using written communication — the likelihood of using advanced communication technologies such as sound amplifiers, live captioning or real-time speech-to-text applications was low.

    Level 2

Panko TL, Contreras J, Postl D, Mussallem A, Champlin S, Paasche-Orlow MK, Hill J, Plegue MA, Hauser PC, McKee M. The Deaf Community’s Experiences Navigating COVID-19 Pandemic Information. Health Lit Res Pract. 2021 Apr;5(2):e162-e170. doi: 10.3928/24748307-20210503-01. Epub 2021 Jun 22. PMID: 34213997; PMCID: PMC8241230.[13]

In surveys of 104 deaf and 74 hearing adults who had participated in a prior health literacy study, Panko et report that participants who are deaf were more likely to be older (p = .005) when compared to participants who are hearing. The deaf and hearing groups did not differ based on gender (p = .651), income (p = .188), or education (p = .556). Participants who are deaf were more likely than participants who are hearing to have risk factors for inadequate health literacy (61% vs. 23.0%, p < .001).

20% of participants who are deaf reported having difficulty accessing information regarding COVID-19, which was significantly higher than participants who are hearing (5.5%; p = .005). When controlling for race, age, and health literacy, participants who are deaf had 4.6 times higher odds of reporting difficulty in accessing COVID-19–related information than participants who are hearing (p = .013). When asked about specific challenges in getting information about COVID-19, participants who are deaf were more likely to report trouble accessing information compared to participants who are hearing (26% vs. 2.7%; p < .001), to find the information frightening (76.9% vs. 27.0%; p < .001), and to mistrust the information (61.5% vs. 41.9%; p = .010). However, both groups of participants found COVID-19 information equally difficult to understand (26% vs. 19%; p = .27). Overall, respondents who are deaf reported more COVID-19 information challenges than respondents who are hearing (mean [SD] = 2.5 (1.5) vs. 1.2 (1.1); p < .001). Regarding information source, participants who are deaf were more likely to report getting their information from television (86% vs. 54%; p < .001) or social media (90% vs. 57%; p < .001) than their hearing counterparts.

Respondents were able to correctly identify, on average, 3.3 (SD = 1.2) COVID-19 symptoms, which was not different between people who are deaf and people who are hearing (p = .76). Respondents who are deaf mentioned using more preventive strategies (mean = 3.3, SD = 1.1) than respondents who are hearing (mean = 2.9, SD = 1.2) (p = .008). Specifically, respondents who are deaf were more likely to report hand hygiene (71% vs. 50%; p = .005) and cleaning and disinfecting (37% vs. 18%; p = .006).

    Level 3

Thibodeau LM, Thibodeau-Nielsen RB, Tran CMQ, Jacob RTS. Communicating During COVID-19: The Effect of Transparent Masks for Speech Recognition in Noise. Ear Hear. 2021 Jul-Aug 01;42(4):772-781. doi: 10.1097/AUD.0000000000001065. PMID: 33813522.[14]

The purpose of this study was to assess the speech recognition in noise when using a transparent mask that allows greater visibility of the speaker’s face compared to an opaque mask in persons with normal and impaired hearing. A repeated-measures design was used to evaluate the auditory-visual recognition of sentences recorded in background noise with transparent and opaque face-masks, and without a mask (N = 154). In a smaller follow-up study (N = 29), the same files were presented via auditory-only presentation to determine if differences observed in the transparent and opaque mask conditions were attributable to additional visual cues or to acoustic differences between the recordings of the two mask types.

Auditory-visual recognition of sentences recorded with the transparent mask was significantly better (M = 68.9%) than for sentences recorded with the opaque mask (M = 58.9%) for all participants. There was a trend for those who used hearing assistive technology to score lower than the other two groups who had similar performance across all conditions regardless of the mask type. Subjective ratings of confidence and concentration followed the expected pattern based on objective scores. Results of the auditory-only presentation of the sentences to listeners with normal hearing suggested that the transparent mask benefits were not attributable to an acoustic advantage but rather to the addition of the visual cues of the speaker’s face available through the transparent mask. In fact, performance in the auditory-only presentation was significantly lower with the transparent mask (M = 40.7%) compared to the opaque mask (M = 58.2%).

Use of transparent masks can significantly facilitate speech recognition in noise even for persons with normal hearing and thus may reduce stressful communication challenges experienced in medical, employment and educational settings during the global pandemic. To mitigate the spread of COVID-19 and facilitate communication, safety-approved transparent masks are strongly encouraged over opaque masks.

   Level 4

Vos TG, Dillon MT, Buss E, Rooth MA, Bucker AL, Dillon S, Pearson A, Quinones K, Richter ME, Roth N, Young A, Dedmon MM. Influence of Protective Face-coverings on the Speech Recognition of Cochlear Implant Patients. Laryngoscope. 2021 Jun;131(6):E2038-E2043. doi: 10.1002/lary.29447. Epub 2021 Feb 16. PMID: 33590898; PMCID: PMC8014501.[15]

The objective of this prospective cohort study was to characterize the effects of wearing face-coverings on acoustic speech cues and speech recognition of patients with hearing loss who listen with a cochlear implant (CI).

Spectral analysis demonstrated preferential attenuation of high-frequency speech information with the N95 mask plus face-shield condition compared to the other conditions. Speech recognition did not differ significantly between the uncovered (median 90% [IQR 89%-94%]) and N95 mask conditions (91% [IQR 86%-94%]; P =.253); however, speech recognition was significantly worse in the N95 mask plus face shield condition (64% [IQR 48%-75%]) compared to the uncovered (P <.001) or N95 mask (P <.001) conditions. The type and combination of protective face-coverings used have differential effects on attenuation of speech information, influencing speech recognition of patients with hearing loss. In the face of the COVID-19 pandemic, there is a need to protect patients and clinicians from spread of disease while maximizing patient speech recognition. The disruptive effect of wearing a face-shield in conjunction with a mask may prompt clinicians to consider alternative eye protection, such as goggles, in appropriate clinical situations.

    Level 4

Wu YH et al. Impact of the COVID-19 pandemic on social isolation in older adults with sensory loss. Investigative Ophthalmology and Visual Science. 2021; 62 (8).[16]

This study was designed to understand the impact of the COVID-19 pandemic on the social interactions and emotional wellbeing in adults with sensory loss. Three groups of older adults – vision loss (N = 13, legally blind), hearing loss (N = 24, hearing aid or cochlear-implant users), and controls (N = 18) – were recruited from the Twin Cities Minnesota community (mean age = 68.18, range = 57 to 80). Participants were interviewed every 4 to 6 weeks from the end of April to the end of October using the same set of questions. The initial interview at the end of April included retrospective responses to the questions regarding participants’ status at the beginning of March, prior to pandemic restrictions, and the beginning of April, after the onset of pandemic restrictions. The survey questions addressed demographic and health information, average number of in-person and electronic social interactions per week, sense of loneliness, accessibility of daily services such as grocery shopping, mental health, worry levels about COVID infection, and impact on daily activities.

There was a significant decline of in-person social interactions in all three groups after the pandemic started, accompanied by a significant increase of electronic social interaction. From late April to October, the number of in-person interactions increased in the control and hearing-loss groups but remained depressed in the vision-loss group. The number of electronic social interactions did not change significantly during this time period. All three groups had worse scores on the patient health questionnaire (PHQ-9) after the start of the pandemic. Participants with hearing loss worried more about understanding speech from people wearing face-masks.

    Level 4

Gordon KA, Daien MF, Negandhi J, Blakeman A, Ganek H, Papsin B, Cushing SL. Exposure to Spoken Communication in Children With Cochlear Implants During the COVID-19 Lockdown. JAMA Otolaryngol Head Neck Surg. 2021 Apr 1;147(4):368-376. doi: 10.1001/jamaoto.2020.5496. PMID: 33599710; PMCID: PMC7893549.[17]

Children were recruited from the Cochlear Implant Program at a tertiary paediatric hospital in Ontario, Canada.

A total of 45 children (mean (SD) age, 7.7 (5.0) years; 23 girls (51.1%)) participated in the study. Results showed similar daily use of cochlear implants during the pre- and peri-COVID-19 periods (9.80 mean hours pre-COVID-19 and 9.34 mean hours peri-COVID-19). Despite consistent device use, children experienced significant quieting of input sound levels peri-COVID-19 by 0.49 hour (95% CI, 0.21-0.80 hour) at 60 to 69 dBA and 1.70 hours (95% CI, 1.42-1.99 hours) at 70 to 79 dBA with clear reductions in speech exposure by 0.98 hour (95% CI, 0.49-1.47 hours). This outcome translated into a reduction of speech:quiet from 1.6:1.0 pre-COVID-19 to 0.9:1.0 during lockdowns. The greatest reductions in percentage of daily speech occurred in school-aged children (elementary, 12.32% (95% CI, 7.15%-17.49%); middle school, 11.76% (95% CI, 5.00%-18.52%); and high school, 9.60% (95% CI, 3.27%-15.93%)). Increased daily percentage of quiet (7.00% (95% CI, 4.27%-9.74%)) was most prevalent for children who had fewer numbers of people in their household (estimate (SE) = -1.12% (0.50%) per person; Cohen f = 0.31).

The findings of this cohort study indicate a clear association between COVID-19 lockdowns and a reduction in children’s access to spoken communication.

    Level 6

Xu D, Yan C, Zhao Z, Weng J, Ma S. External Communication Barriers among Elderly Deaf and Hard of Hearing People in China during the COVID-19 Pandemic Emergency Isolation: A Qualitative Study. Int J Environ Res Public Health. 2021 Nov 2;18(21):11519. doi: 10.3390/ijerph182111519. PMID: 34770033; PMCID: PMC8583539.[18]

The COVID-19 pandemic poses a great risk to older people with hearing impairment who face a higher threshold of external communication after the implementation of emergency isolation policies. As part of a study on the optimization of external communication among the deaf and hard of hearing (DHH) population in central China, Xu et al employed a qualitative research method based on in-depth interviews to explore the needs and difficulties faced by older DHH in external communication during public health emergencies in Wuhan, China, in the context of the COVID-19 pandemic.

Results showed that older DHH had weak reception of critical information about the epidemic and had suboptimal access to medical care during emergency quarantine, which increased interpersonal communication barriers. Because of the limitation of social distance, the original social support network maintained by interpersonal communication was cut off, and older DHH who were accustomed to offline small-circle communication were suddenly plunged into social isolation. Older DHH were less proficient in social media than younger people, leading to an increased sense of psychological isolation and social alienation. The digital divide and technophobia are particularly pronounced among older DHH because of the strong relationships and circle-group interpersonal communication styles that have solidified over many years, and accompanying deterioration in reading levels and word processing skills. Even when there were brief opportunities for face-to-face communication, masks and various facial PPE blocked recognizable communication with lips and facial expressions.

Many of the older DHH were suffering from multiple chronic illnesses at the same time, and more than half of the respondents reported that they faced doctor-patient communication problems. Due to isolation policies, family members and sign language interpreters were not allowed to accompany patients in order to minimize infection, which directly contributed to increased communication barriers between DHH and their physicians. In addition to the prevalence of chronic diseases, aging also leads to cognitive decline, and even for general consultations, older DHH face more communication difficulties than younger people and take longer to comprehend the medical assistance provided by their doctors.

    Level 6

Smith E, Hill M, Anderson C, Sim M, Miles A, Reid D, Mills B. Lived Experience of Emergency Healthcare Utilization during the COVID-19 Pandemic: A Qualitative Study. Prehosp Disaster Med. 2021 Dec;36(6):691-696. doi: 10.1017/S1049023X21001126. Epub 2021 Oct 8. PMID: 34622748; PMCID: PMC8523975.[19]

Qualitative data were collected from 67 participants aged from 32 to 78-years-of age (average age, 52). Just over one-half of the research participants were male (54%) and three-quarters lived in metropolitan regions (75%). Participants caring for people with sensory and developmental disabilities identified unique communication needs during interactions with emergency health services during the COVID-19 pandemic; communicating with emergency healthcare personnel wearing PPE was identified as a key challenge, with face-masks reported as especially problematic for people who are deaf or hard-of-hearing (DHH).

    Level 6

Ritter E, Miller C, Morse J, Onuorah P, Zeaton A, Zanation A, Ebert CS, Thorp BD, Senior B, Kimple A. Impact of Masks on Speech Recognition in Adult Patients with and without Hearing Loss. ORL J Otorhinolaryngol Relat Spec. 2021 Sep 28:1-7. doi: 10.1159/000518944. Epub ahead of print. PMID: 34583365.[20]

Ritter et al investigated the effect of surgical masks and face-shields on speech intelligibility of adults with moderate to severe hearing loss.

The study measured speech tracking scores in quiet for life speech in three different conditions: without a mask, with a surgical mask and with a face-shield. Acoustic effects of the masks and face-shields on the speech signal were also investigated. The study sample consists of 42 patients with moderate to severe hearing loss, 23 cochlear implant users and 19 hearing aid users.

A significant average difference in speech perception scores was found for the use of a surgical mask compared to the listening situation without a mask. Sound distortion for the face-shield was greater than for a surgical mask. Surgical face masks have a negative speech perception effect for patients with moderate to severe hearing loss.

    Level 6

Muzzi E, Chermaz C, Castro V, Zaninoni M, Saksida A, Orzan E. Short report on the effects of SARS-CoV-2 face protective equipment on verbal communication. Eur Arch Otorhinolaryngol. 2021 Sep;278(9):3565-3570. doi: 10.1007/s00405-020-06535-1. Epub 2021 Jan 3. PMID: 33389012; PMCID: PMC7778571.[21]

Muzzi et al assessed the effect of common types and combinations of face personal protective equipment on speech intelligibility in quiet and in a simulated noisy environment.

Wearing face PPE impairs transmission of middle-to-high voice frequencies and affects speech intelligibility. Surgical masks are responsible for up to 23.3% loss of speech intelligibility in noisy environments. The effects are larger in the condition of advanced face PPE, accounting for up to 69.0% reduction of speech intelligibility. The use of face PPE causes significant verbal communication issues. Healthcare workers, school-aged children, and people affected by voice and hearing disorders may represent specific at-risk groups for impaired speech intelligibility.

    Level 6

Atcherson SR, McDowell BR, Howard MP. Acoustic effects of non-transparent and transparent face-coverings. J Acoust Soc Am. 2021 Apr;149(4):2249. doi: 10.1121/10.0003962. PMID: 33940920; PMCID: PMC8110248.[22]

The widespread use of face-coverings during the COVID-19 pandemic has created communication challenges for many individuals, particularly for those who are deaf or hard of hearing and for those who must speak through masks in suboptimal conditions. This study includes some newer mask options as well as transparent masks to help those who depend on lip-reading and other facial cues.

Results corroborate earlier published results for non-transparent masks, but transparent options have greater attenuation, resonant peaks, and deflect sounds in ways that non-transparent masks do not. Although transparent face-coverings have poorer acoustic performance, the presence of visual cues remains important for both verbal and non-verbal communication.

    Level 6

Garg S, Deshmukh CP, Singh MM, Borle A, Wilson BS. Challenges of the Deaf and Hearing Impaired in the Masked World of COVID-19. Indian J Community Med. 2021 Jan-Mar;46(1):11-14. doi: 10.4103/ijcm.IJCM_581_20. Epub 2021 Mar 1. PMID: 34035568; PMCID: PMC8117910.[23]

Garg et al conducted a narrative literature review to assess the challenges faced by deaf and hearing-impaired individuals during the COVID-19 pandemic. Major challenges include: difficulties around accessing information; difficulties around sign language and the availability of sign language interpreters; face-masks inhibiting effective communication; social distancing affecting physical and mental health; stigma and discrimination; and systemic problems due to COVID-19-related restrictions. Strategies to confront these challenges include: use of technology; help from sign language instructors; and preparedness of health-care settings for the hearing disabled. System strengthening, telemedicine and policy amendments may be used to build up the support system for the hearing impaired during the COVID-19 pandemic.

    Level 6

Tavanai E, Rouhbakhsh N, Roghani Z. A review of the challenges facing people with hearing loss during the COVID-19 outbreak: toward the understanding the helpful solutions. Auditory and Vestibular Research. 2021, 30 (2).[24]

People with hearing loss may experience problems during COVID-19 pandemic. There are some strategies that can be implemented to partially solve some communicative and social problems in this group. The use of transparent face-masks, compensatory strategies, as well as optimization of virtual, and telehealth, telerehabilitation and tele-education services may be helpful for hearing-impaired people during the COVID-19 pandemic.

    Level 7

Vellozzi-Averhoff C et al. Masks and the hearing impaired: An ethical quagmire. Journal of General Internal Medicine. Jan 2021; 36 (Supp 1).[25]

Despite their public health benefits, masks may impact communication and generate ethically complex situations when caring for partially deaf patients. The tension between the necessity to decrease risk of infection and the obligation to sufficiently communicate with patients who rely on lip-reading has potential to create moral injury among healthcare personnel (HCP). In the United States, 15% of adults report hearing difficulty and greater than 50% of adults older than 75 suffer from hearing loss. Many hearing-impaired individuals rely on lip-reading to communicate. The American Speech-Language and Hearing Association (ASHA) and the National Institute on Deafness and Other Communication Disorders (NIDCD) acknowledge that masks exacerbate communication difficulties in this population. When comprehension is impaired, patients are at increased risk of isolation and misinterpretation of medical information. The American College of Physicians’ Charter on Medical Professionalism underscores the primacy of patient welfare and patient autonomy, which rests upon adequate communication. When caring for hearing impaired patients, mask use illustrates a tension between the ethical principles of beneficence and non-maleficence. HCP must choose between wearing a mask to protect their patients from COVID-19 (non-maleficence) or forgoing a mask to communicate medical information (beneficence). Moral injury, defined as psychological stress that arises when forced to contradict deeply held moral principles, may result from these encounters; HCP are compelled to violate one ethical principle in order to uphold another. Mask use will remain ubiquitous in healthcare settings and public spaces for the foreseeable future. If healthcare is to remain patient-centred and clinicians are to uphold ethical principles, effective communication tools and interventions are needed to provide comprehensive care to all patients regardless of disability. 

    Level 7

Brotto D, Sorrentino F, Agostinelli A, Lovo E, Montino S, Trevisi P, Favaretto N, Bovo R, Martini A. How great is the negative impact of masking and social distancing and how can we enhance communication skills in the elderly people? Aging Clin Exp Res. 2021 May;33(5):1157-1161. doi: 10.1007/s40520-021-01830-1. Epub 2021 Mar 16. PMID: 33725340; PMCID: PMC7962629.[26]

Facial masks attenuate the medium–high frequencies of the speaker’s voice with a reduction from 3 to nearly 12 dB depending on the mask type. More importantly, speech discrimination is deteriorated causing listening difficulties. The COVID-19 pandemic has negatively affected older adults, especially those with hearing impairment, impeding communication, exacerbating social isolation, and compromising mental health.

In most situations, it is not possible to avoid the use of face-masks; consequently, it may be useful to improve the way we interact especially with the elderly people to avoid some of the limitations imposed by face-coverings. Specifically, it is important to use a more sustained tone and a lower pitch of voice because face-masks damage high-frequency transmission in speech.

Another coping strategy is to simplify as much as possible the message to reduce the required cognitive effort. In addition, slowing down the rhythm of the eloquium without “chanting” syllables and repeating the information several times should be considered useful strategies especially with older people. It is important to have a more accurate communication awareness when addressing older people, especially those with hearing loss. The use of gestures and written language provides visual information that can be a helpful source of guidance to enhance auditory comprehension. Modern retro-auricular hearing aids, in-the-ear hearing aids, and single-unit processors for cochlear implant (CI) users are also put forward by Brotto et al as helpful assistive technologies.

    Level 7

Moreland CJ, Ruffin CV, Morris MA, McKee M. Unmasked: How the COVID-19 Pandemic Exacerbates Disparities for People With Communication-Based Disabilities. J Hosp Med. 2021 Mar;16(3):185-188. doi: 10.12788/jhm.3562. PMID: 33617440.[27]

Adults with communication-based disabilities struggle with healthcare inequities, largely secondary to poor healthcare provider-patient communication. The prevalence of communication-based disabilities — which include speech, language, voice and/or hearing disabilities — is relatively high yet difficult to ascertain. 10% of adults in the United States report having had a speech, language, or voice disability within the past year, and hearing loss also affects 17% of the US population. These individuals’ collective communication difficulties have been exacerbated by the COVID-19 pandemic, with healthcare systems mandating PPE including face-masks to ensure the safety of workers and patients.

Hospitals pose challenging communicative environments due to multiple factors: eg noisy equipment alarms, harried healthcare teams spending less time with patients, PPE use obstructing faces and muffling sounds. Adverse communication among those with communication-based disabilities results in poorer healthcare outcomes, including higher rates of readmission and preventable adverse medical events, as well as lower healthcare satisfaction. Ineffective communication leads to reduced adherence, longer hospitalizations, and worse health outcomes in general. This is problematic because those with communication-based disabilities are more likely to require hospitalization due to higher rates of associated comorbidities, including frailty, cardiovascular disease, cognitive decline, and falls.

Moreland et al state that potential solutions include: identification and assessment of communication breakdown risks; assistive communication; training in patient-centred communication; clear face-masks; tools for communicating within the patients’ rooms (eg whiteboards or personalized sound amplification apps); tools for isolation-limited communication (eg phone-based videoconferencing); interpreter accessibility; signage; systematic noise reduction; and communication concordance or developing effective inpatient communication policies and processes.

    Level 7

Crume B. The Silence Behind the Mask: My Journey as a Deaf Pediatric Resident Amid a Pandemic. Acad Pediatr. 2021 Jan-Feb;21(1):1-2. doi: 10.1016/j.acap.2020.10.002. Epub 2020 Oct 10. PMID: 33045413; PMCID: PMC7546964.[28]

A doctor describes how he  coped during COVID -9 wearing PPE along with all his colleagues and caring for patients without completely knowing what was happening regarding patient care. He describes that COVID-19 exposes multiple disparities, especially related to hearing loss  and contributes to significant isolation for individuals like him, and not only from the lack of social interaction to keep the virus at bay, but also from the rising barriers in daily communication. Another obstacle in this pandemic is the shift away from in-person congregation to the virtual world—meetings, conferences, clinics, even interviews for next steps in training. I struggle to articulate how lip-reading on a screen is more difficult. 

There is a wealth of technological tools and smartphone applications to assist in communication when interpreters and lip-reading visuals are not available.  For virtual conferences, lectures, and meetings that do not require Health Insurance Portability and Accountability Act protection, Google Meet and Microsoft Teams have a live captioning feature to aid in ensuring the content is understood by all parties involved. Ultimately, the most powerful tool is the recognition of these barriers, and collaborative advocacy to overcome them.

    Level 7

Ten Hulzen RD, Fabry DA. Impact of Hearing Loss and Universal Face Masking in the COVID-19 Era. Mayo Clin Proc. 2020 Oct;95(10):2069-2072. doi: 10.1016/j.mayocp.2020.07.027. Epub 2020 Aug 3. PMID: 33012338; PMCID: PMC7396946.[29]

Ten Hulzen and Fabry call attention to the negative impacts of universal masking and social distancing in both healthcare and community settings for individuals with hearing loss. Approximately 14.1% of American adults (27.7 million) aged 18 years and older report some difficulty hearing. Hearing loss impacts all age groups; however, is more prevalent among unscreened older adults who are also more likely to be without hearing assistance. For 60- to 69-year-old individuals, the prevalence of hearing loss affecting speech intelligibility was 39.3%. In addition, COVID-19 fatality rates are higher in older adults who are frail with other comorbidities. Current policies often require patients to be unaccompanied by supporting family members. This can be detrimental to effective communication, patient safety, and quality healthcare with individuals with hearing loss who cannot understand attenuated and distorted speech nor gain clues from lip-reading and facial expressions due to universal masking. A recent study showed each type of mask wearing causes a low-pass filter effect attenuating the higher frequencies (2000-7000 Hz) of the speaker’s voice with decibel reduction ranging from 3 to 4 dB (medical mask) to nearly 12 dB for the N95 mask (respirator/FFP). The addition of a noisy background setting such as ED or ICU further confounds the problem and makes communication extremely difficult, if not impossible.

Social distancing also has an impact on speech audibility. Sounds rapidly become quieter as they travel away from their sources. Whereas conversational distances between two talkers in the United States typically ranges from 1.5 to 3 feet, the currently recommended social distancing of at least 6 feet means the sound pressure level decreases by 6 to 12 dB. Social distancing further compounds the negative effect of universal masking on audibility for individuals with hearing loss. Universal masking degrades speech quality and denies visual clues such as lip-reading or facial expressions. Individuals with hearing loss using American Sign Language convey grammar and tone by body language/facial expression. Similarly, individuals with hearing loss rely on adequate lighting, face-to-face positioning, and lip-reading to provide contextual clues and augment speech comprehension during normal encounters. A noisy environment, the reverberation of sounds off of smooth clinical surfaces, and those individuals who do not intentionally speak louder than ambient sound pressure levels for well-intentioned reasons (eg patient confidentiality) all compound the situation further. Universal masking blocks the important facial expressions used by both healthcare professionals and patients to augment dialogue and to build trust, clarity and rapport during encounters. Universal masking impedes the healthcare professional’s ability to monitor patients’ facial expressions and nonverbal cues during encounters; consequently, nonverbal cues of misunderstanding, which normally would have prompted the provider to employ various communication strategies to repair the communication breakdown, may be missed. Moreover, a randomized clinical trial has shown mask wearing by healthcare professionals to have a significant and negative impact on patients’ perceived empathy and diminished the positive effects of relational continuity.

    Level 7

Sher T, Stamper GC, Lundy LB. COVID-19 and Vulnerable Population With Communication Disorders. Mayo Clin Proc. 2020 Sep;95(9):1845-1847. doi: 10.1016/j.mayocp.2020.06.034. Epub 2020 Jun 29. PMID: 32861328; PMCID: PMC7323656.[30]

In collaboration with hospital and practice information and audio-visual technology experts, audiologists and otolaryngologists can play a critical role in advocating for and helping address the challenges faced by people with hearing loss (HL) and other communication disorders. Measures such as video remote interpreting, captioning, and speech-to-text applications can go a long way to help individuals with HL deal with this challenging time. Educating family members and loved ones on the enhanced need to stay in touch with their relatives with HL is critical to ensure emotional, social, and psychological well-being.

    Level 7

McKee M, Moran C, Zazove P. Overcoming Additional Barriers to Care for Deaf and Hard of Hearing Patients During COVID-19. JAMA Otolaryngol Head Neck Surg. 2020 Sep 1;146(9):781-782. doi: 10.1001/jamaoto.2020.1705. PMID: 32692807.[31]

McKee et al put forward certain mitigation strategies against barriers to healthcare for DHH including: transparent face-masks; interpreters; captioning apps; virtual visits; signage; and communication boards.

    Level 7

Reed NS, Ferrante LE, Oh ES. Addressing Hearing Loss to Improve Communication During the COVID-19 Pandemic. J Am Geriatr Soc. 2020 Sep;68(9):1924-1926. doi: 10.1111/jgs.16674. Epub 2020 Jul 2. PMID: 32548882; PMCID: PMC7323388.[32]

Reed et al state that poor communication may mediate the association between hearing loss and health outcomes. Adults with hearing loss have increased risk of 30-day readmission, experience longer length of stay, and are less satisfied with care. Moreover, hearing loss is associated with poor functional recovery following intensive care unit admissions. Sensory deprivation may increase risk to experience delirium as older adults are cut off from communication and their environment.

The current extended use of PPE during the COVID-19 pandemic limits visualization of the mouth, preventing lip-reading, and acts as a general sound barrier. Even when using videoconferencing equipment, lag and poor image quality may cause significant visual barriers. Coupled with noisy hospital environment, these visual barriers render the natural sensory substitution compensation methods used by adults with hearing loss futile. Additionally, distancing may limit access to caregivers or interpreters to facilitate conversations during visits.

Thoughtful consideration of addressing barriers is needed. In the outpatient and telehealth setting, clear surgical masks allow visualization of the mouth. In hospitals, N95 masks that prevent visualizing the mouth are required in the patient’s room. However, utilization of clear surgical masks outside of the room could improve communication between patients and providers over videoconferencing. Notably, utilization of clear surgical masks outside of the patient’s room could also improve communication among providers, most of whom have been required to wear surgical masks throughout the day during the COVID-19 pandemic.

Technology offers additional solutions. Handheld amplifiers can increase signal volume but require sterilization considerations and are not compatible with videoconferencing technology. More advanced solutions through smartphones such as speech to text and amplifier applications with customization for user preferences should be considered. Using smartphone applications eliminates the need for sharing products in some cases and may be integrated into videoconferencing technology. Moreover, simple methods such as preparing common questions and statements on placards with large text and using whiteboards for written statements can help facilitate communication.

    Level 7

Chen CH, Pan MY, Liu HY. Nursing Experience Caring for a COVID-19 Patient With Hearing Loss. Hu Li Za Zhi. 2020 Dec;67(6):97-103. Chinese. doi: 10.6224/JN.202012_67(6).13. PMID: 33274431.[32]

During the period of hospitalization (March 14 to April 13, 2020), Chen et al used Roy’s adaptation model to perform a nursing assessment, which confirmed that the patient faced the following problems: ineffective breathing pattern related to COVID-19; impaired verbal communication related to hearing impairment; and social isolation related to communication barriers with healthcare personnel.

Other Sources of Information

    N/A

Rochester Regional Health (New York, United States) (2021) [Webpage] How COVID-19 impacts the deaf and hard-of-hearing community[33]

Rochester Regional Health points out that both face-masks and hearing aids are worn around the ear, hearing impaired individuals may experience increased discomfort and/or increased risk of losing their hearing aids. RRH also recommend reducing background noise when communicating with a patient; and re-phrasing as opposed to repeating a phrase or sentence that is not grasped by the patient.

    N/A

Haile (2021) Hearing loss, social isolation, and the COVID-19 pandemic[34]

Haile (2021) asserts that prior to the COVID-19 pandemic, hearing loss was already associated with social isolation; however, the pandemic has increased and highlighted existing inequities for the hard-of-hearing in built and social environments. Face-masks may decrease speech recognition or obstruct facial expressions and lip movements, which are critical non-verbal information cues. Access to healthcare has also become more difficult for hard-of-hearing individuals during the pandemic. Telemedicine services and hospitals with strict visitor restrictions do not always provide translator services for individuals with hearing loss. Hard-of-hearing individuals hospitalised with COVID-19 may experience distinct challenges such as difficulty adjusting hearing equipment or utilising interpretive devices. More than 60% of hearing-impaired individuals are older than 50 years, and age-group that requires hospital admission at a greater rate and is at greater risk of complications arising from COVID-19. Among hearing-impaired children, many have experienced inaccessible remote schooling environments, limited interpretive services, and increased vulnerability to stress during the pandemic. Haile insists that the pandemic represents an opportunity to develop infrastructure (eg closed captioning in telecommunications or speech-to-text applications) that is more inclusive of deaf and hard-of-hearing populations.

References

[1] Health Service Executive (2021) Communicating with deaf or hard-of-hearing patients in healthcare settings during COVID-19. Accessed 8 December 2021.

[2] Chu JN, Collins JE, Chen TT, Chai PR, Dadabhoy F, Byrne JD, Wentworth A, DeAndrea-Lazarus IA, Moreland CJ, Wilson JAB, Booth A, Ghenand O, Hur C, Traverso G. Patient and Healthcare Worker Perceptions of Communication and Ability to Identify Emotion When Wearing Standard and Transparent Masks. JAMA Netw Open. 2021 Nov 1;4(11):e2135386. doi: 10.1001/jamanetworkopen.2021.35386. PMID: 34807257; PMCID: PMC8609412.

[3] Bubbico L, Bellizzi S, Ferlito S, Maniaci A, Leone Guglielmotti R, Antonelli G, Mastrangelo G, Cegolon L. The Impact of COVID-19 on Individuals with Hearing and Visual Disabilities during the First Pandemic Wave in Italy. Int J Environ Res Public Health. 2021 Sep 28;18(19):10208. doi: 10.3390/ijerph181910208. PMID: 34639515; PMCID: PMC8508015.

[4] Bernard A, Weiss S, Rahman M, Ulin SS, D’Souza C, Salgat A, Panzer K, Stein JD, Meade MA, McKee MM, Ehrlich JR. The Impact of COVID-19 and Pandemic Mitigation Measures on Persons With Sensory Impairment. Am J Ophthalmol. 2021 Jun 29;234:49-58. doi: 10.1016/j.ajo.2021.06.019. Epub ahead of print. PMID: 34197781; PMCID: PMC8238639.

[5] Almusawi H, Alasim K, BinAli S, Alherz M. Disparities in health literacy during the COVID-19 pandemic between the hearing and deaf communities. Res Dev Disabil. 2021 Dec;119:104089. doi: 10.1016/j.ridd.2021.104089. Epub 2021 Sep 29. PMID: 34624721; PMCID: PMC8488063.

[6] Alqudah S, Zaitoun M, Alqudah O, Alqudah S, Alqudah Z. Challenges facing users of hearing aids during the COVID-19 pandemic. Int J Audiol. 2021 Oct;60(10):747-753. doi: 10.1080/14992027.2021.1872806. Epub 2021 Feb 16. PMID: 33590784.

[7] Grote H, Izagaren F, Jackson E. The experience of D/deaf healthcare professionals during the coronavirus pandemic. Occup Med (Lond). 2021 Aug 20;71(4-5):196-203. doi: 10.1093/occmed/kqab048. PMID: 33903904; PMCID: PMC8135376.

[8] Wilson HL, Crouch J, Schuh M, Shinn J, Bush ML. Impacts of the COVID-19 Pandemic on Communication and Healthcare Access for Adults With Hearing Loss. Otol Neurotol. 2021 Sep 1;42(8):1156-1164. doi: 10.1097/MAO.0000000000003203. PMID: 34049333; PMCID: PMC8373686.

[9] Homans NC, Vroegop JL. Impact of face masks in public spaces during COVID-19 pandemic on daily life communication of cochlear implant users. Laryngoscope Investig Otolaryngol. 2021 May 6;6(3):531-539. doi: 10.1002/lio2.578. PMID: 34195375; PMCID: PMC8223455.

[10] Saunders GH, Jackson IR, Visram AS. Impacts of face-coverings on communication: an indirect impact of COVID-19. Int J Audiol. 2021 Jul;60(7):495-506. doi: 10.1080/14992027.2020.1851401. Epub 2020 Nov 27. PMID: 33246380.

[11] Naylor G, Burke LA, Holman JA. Covid-19 Lockdown Affects Hearing Disability and Handicap in Diverse Ways: A Rapid Online Survey Study. Ear Hear. 2020 Nov/Dec;41(6):1442-1449. doi: 10.1097/AUD.0000000000000948. PMID: 33136621.

[12] Deardorff WJ, Binford SS, Cole I, James T, Rathfon M, Rennke S, Wallhagen M. COVID-19, masks, and hearing difficulty: Perspectives of healthcare providers. J Am Geriatr Soc. 2021 Oct;69(10):2783-2785. doi: 10.1111/jgs.17349. Epub 2021 Jul 6. PMID: 34228350; PMCID: PMC8447172.

[13] Panko TL, Contreras J, Postl D, Mussallem A, Champlin S, Paasche-Orlow MK, Hill J, Plegue MA, Hauser PC, McKee M. The Deaf Community’s Experiences Navigating COVID-19 Pandemic Information. Health Lit Res Pract. 2021 Apr;5(2):e162-e170. doi: 10.3928/24748307-20210503-01. Epub 2021 Jun 22. PMID: 34213997; PMCID: PMC8241230.

[14] Thibodeau LM, Thibodeau-Nielsen RB, Tran CMQ, Jacob RTS. Communicating During COVID-19: The Effect of Transparent Masks for Speech Recognition in Noise. Ear Hear. 2021 Jul-Aug 01;42(4):772-781. doi: 10.1097/AUD.0000000000001065. PMID: 33813522.

[15] Vos TG, Dillon MT, Buss E, Rooth MA, Bucker AL, Dillon S, Pearson A, Quinones K, Richter ME, Roth N, Young A, Dedmon MM. Influence of Protective Face-coverings on the Speech Recognition of Cochlear Implant Patients. Laryngoscope. 2021 Jun;131(6):E2038-E2043. doi: 10.1002/lary.29447. Epub 2021 Feb 16. PMID: 33590898; PMCID: PMC8014501.

[16] Wu YH et al. Impact of the COVID-19 pandemic on social isolation in older adults with sensory loss. Investigative Ophthalmology and Visual Science. 2021; 62 (8).

[17] Gordon KA, Daien MF, Negandhi J, Blakeman A, Ganek H, Papsin B, Cushing SL. Exposure to Spoken Communication in Children With Cochlear Implants During the COVID-19 Lockdown. JAMA Otolaryngol Head Neck Surg. 2021 Apr 1;147(4):368-376. doi: 10.1001/jamaoto.2020.5496. PMID: 33599710; PMCID: PMC7893549.

[18] Xu D, Yan C, Zhao Z, Weng J, Ma S. External Communication Barriers among Elderly Deaf and Hard of Hearing People in China during the COVID-19 Pandemic Emergency Isolation: A Qualitative Study. Int J Environ Res Public Health. 2021 Nov 2;18(21):11519. doi: 10.3390/ijerph182111519. PMID: 34770033; PMCID: PMC8583539.

[19] Smith E, Hill M, Anderson C, Sim M, Miles A, Reid D, Mills B. Lived Experience of Emergency Healthcare Utilization during the COVID-19 Pandemic: A Qualitative Study. Prehosp Disaster Med. 2021 Dec;36(6):691-696. doi: 10.1017/S1049023X21001126. Epub 2021 Oct 8. PMID: 34622748; PMCID: PMC8523975.

[20] Ritter E, Miller C, Morse J, Onuorah P, Zeaton A, Zanation A, Ebert CS, Thorp BD, Senior B, Kimple A. Impact of Masks on Speech Recognition in Adult Patients with and without Hearing Loss. ORL J Otorhinolaryngol Relat Spec. 2021 Sep 28:1-7. doi: 10.1159/000518944. Epub ahead of print. PMID: 34583365.

[21] Muzzi E, Chermaz C, Castro V, Zaninoni M, Saksida A, Orzan E. Short report on the effects of SARS-CoV-2 face protective equipment on verbal communication. Eur Arch Otorhinolaryngol. 2021 Sep;278(9):3565-3570. doi: 10.1007/s00405-020-06535-1. Epub 2021 Jan 3. PMID: 33389012; PMCID: PMC7778571.

[22] Atcherson SR, McDowell BR, Howard MP. Acoustic effects of non-transparent and transparent face-coverings. J Acoust Soc Am. 2021 Apr;149(4):2249. doi: 10.1121/10.0003962. PMID: 33940920; PMCID: PMC8110248.

[23] Garg S, Deshmukh CP, Singh MM, Borle A, Wilson BS. Challenges of the Deaf and Hearing Impaired in the Masked World of COVID-19. Indian J Community Med. 2021 Jan-Mar;46(1):11-14. doi: 10.4103/ijcm.IJCM_581_20. Epub 2021 Mar 1. PMID: 34035568; PMCID: PMC8117910.

[24] Tavanai E, Rouhbakhsh N, Roghani Z. A review of the challenges facing people with hearing loss during the COVID-19 outbreak: toward the understanding the helpful solutions. Auditory and Vestibular Research. 2021, 30 (2).

[25] Vellozzi-Averhoff C et al. Masks and the hearing impaired: An ethical quagmire. Journal of General Internal Medicine. Jan 2021; 36 (Supp 1).

[26] Brotto D, Sorrentino F, Agostinelli A, Lovo E, Montino S, Trevisi P, Favaretto N, Bovo R, Martini A. How great is the negative impact of masking and social distancing and how can we enhance communication skills in the elderly people? Aging Clin Exp Res. 2021 May;33(5):1157-1161. doi: 10.1007/s40520-021-01830-1. Epub 2021 Mar 16. PMID: 33725340; PMCID: PMC7962629.

[27] Moreland CJ, Ruffin CV, Morris MA, McKee M. Unmasked: How the COVID-19 Pandemic Exacerbates Disparities for People With Communication-Based Disabilities. J Hosp Med. 2021 Mar;16(3):185-188. doi: 10.12788/jhm.3562. PMID: 33617440.

[28] Crume B. The Silence Behind the Mask: My Journey as a Deaf Pediatric Resident Amid a Pandemic. Acad Pediatr. 2021 Jan-Feb;21(1):1-2. doi: 10.1016/j.acap.2020.10.002. Epub 2020 Oct 10. PMID: 33045413; PMCID: PMC7546964.

[29] Ten Hulzen RD, Fabry DA. Impact of Hearing Loss and Universal Face Masking in the COVID-19 Era. Mayo Clin Proc. 2020 Oct;95(10):2069-2072. doi: 10.1016/j.mayocp.2020.07.027. Epub 2020 Aug 3. PMID: 33012338; PMCID: PMC7396946.

[30] Sher T, Stamper GC, Lundy LB. COVID-19 and Vulnerable Population With Communication Disorders. Mayo Clin Proc. 2020 Sep;95(9):1845-1847. doi: 10.1016/j.mayocp.2020.06.034. Epub 2020 Jun 29. PMID: 32861328; PMCID: PMC7323656.

[31] McKee M, Moran C, Zazove P. Overcoming Additional Barriers to Care for Deaf and Hard of Hearing Patients During COVID-19. JAMA Otolaryngol Head Neck Surg. 2020 Sep 1;146(9):781-782. doi: 10.1001/jamaoto.2020.1705. PMID: 32692807.

[32] Reed NS, Ferrante LE, Oh ES. Addressing Hearing Loss to Improve Communication During the COVID-19 Pandemic. J Am Geriatr Soc. 2020 Sep;68(9):1924-1926. doi: 10.1111/jgs.16674. Epub 2020 Jul 2. PMID: 32548882; PMCID: PMC7323388.

[33] Chen CH, Pan MY, Liu HY. Nursing Experience Caring for a COVID-19 Patient With Hearing Loss. Hu Li Za Zhi. 2020 Dec;67(6):97-103. Chinese. doi: 10.6224/JN.202012_67(6).13. PMID: 33274431.

[34] Rochester Regional Health (2021) [Webpage] How COVID-19 impacts the deaf and hard-of-hearing community. Accessed 8 December 2021.

[35] Haile, L (2021) Hearing Loss, Social Isolation, and the COVID-19 Pandemic. Accessed 8 December 2021.

Produced by the members of the Health Library Ireland | Evidence service. Current as at 06 December 2021. This evidence summary collates the best available evidence at the time of writing and does not replace clinical judgement or guidance. Emerging literature or subsequent developments in respect of COVID-19 may require amendment to the information or sources listed in the document.  Although all reasonable care has been taken in the compilation of content, the Health Library Ireland | Evidence service makes no representations or warranties expressed or implied as to the accuracy or suitability of the information or sources listed in the document.  This evidence summary is the property of Health Library Ireland and subsequent re-use or distribution in whole or in part should include acknowledgement of the service.

Helen Clark, Librarian, Sligo University Hospital [Author]; Margaret Morgan, Librarian, Midland Regional Hospital Mullingar [Author]; Brendan Leen, Area Library Manager, HSE South [Author, Editor]

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License