social relationship. This observation further suggests that hearing can be considered a “social sense.” Given the critical role of social relationships for mortality, morbidity, and quality of life (García, Banegas, Pérez-Regadera, Cabrera, & Rodríguez-Artalejo, 2005), this chapter is designed to provide a high-level overview of research on hearing loss and hearing rehabilitation through the lens of social relationships. Specifically, we set out to:
1. Define terms and describe concepts commonly used in hearing research to investigate social relationships;
2. review measures commonly used in hearing research that assess social relationships, as well as provide a framework to assist readers to select measures for either clinical or research purposes;
3. review research investigating the effect of hearing loss on social relationships, with a particular emphasis on specific domains of social relationships;
4. review research investigating the effects of hearing rehabilitation on social relationships;
5. provide descriptions of concepts relevant to social influence, as well as an overview of how the behaviors of others may influence the thoughts, attitudes, and behaviors of a person with hearing loss;
6. review research investigating how social relationships influence help seeking and hearing rehabilitation uptake; and
7. provide several recommendations for improving clinical practice.
Part I: Definition of Terms
Over the past four decades, there have been important developments in our understanding of the role of social relationships in audiology. However, a review of the literature observes that the use of terminology is not used consistently within hearing research. How one researcher defines and operationalizes social isolation is often different than when investigated by others. For example, social isolation has been measured by the use of composite measures (i.e., the combination of questions inquiring about marital status, size of friendship networks, etc.), by the use of formal questionnaires coupled with measures of social belonging (Ramage-Morin, 2016), availability of social support (Mick, Kawachi, & Lin, 2014), and by the use of a single question (i.e., “Do you often feel lonely?”; Dawes et al., 2015). While such approaches may be appropriate given a particular research goal, a consequence is that comparisons between studies become more challenging. Hence, in Part I of this chapter, we set out to provide clarification by first defining commonly used terms.
Social Isolation, Social Integration, and Social Ties
Researchers have used a number of terms to describe effects on interpersonal or social well-being, including social isolation, social ties, and social integration. These terms are loosely defined, used interchangeably, and depending on the study, operationalized differently (Valtorta, Kanaan, Gilbody, & Hanratty, 2016). Of the terms just described, social isolation is likely most commonly used in the audiology literature. Cacioppo and Cacioppo (2014) distinguish between objective social isolation, or the extent to which an individual is socially isolated, and subjective social isolation, or the extent to which a person feels socially isolated. In scientific communication, it is often necessary to make use of umbrella terms such as social isolation that encompass subdomains of the phenomena. For the remainder of the chapter, we use the term social relationships as an umbrella term that encompasses domains of interpersonal well-being (described below). It should also be mentioned that there can be conceptual overlap between/among various terms.
Loneliness
Throughout the academic literature, researchers conflate the terms social isolation and loneliness (Valtorta et al., 2016). Whereas social isolation tends to be used as a “catch-all” term, and whereas objective social isolation can be empirically quantified using markers such as living alone, having few social network ties, and/or having infrequent social contact, loneliness is the perception of social isolation or the subjective experience of being lonely. Loneliness can stem from a mismatch between desired and actual social network size, depth, or frequency of contact.
Loneliness is a complex emotion, but critically it is dependent on cognitive appraisals of experience. Theoretical descriptions of loneliness suggest an affective component as well as a social-cognitive component (Weiss, 1973). Affective loneliness represents the emotional response arising from a lack of social bonding especially with specific others, and results in felt emotions such as sadness, fear, and emptiness. Social-cognitive loneliness stems from evaluations of the self, such as when an individual perceives a relationship as unsatisfactory or a social network as unavailable, as well as from social comparisons such as that which occurs when individuals recognize a lack of bonding as compared to others with well-formed social bonds. Experiences of social-cognitive loneliness result in feelings such as exclusion, marginality, and boredom (Peplau & Perlman, 1982; Weiss, 1973).
Social Support
In contrast to measures of relationship quality that focus on the number of significant others within a social network, social support refers to the availability of members within one’s social network that can provide supportive behaviors in times of need (Cohen 2004; House, 1981). Social support describes the functional content of relationships, and can be categorized into four types of supportive behaviors:
1. Emotional support involves the provision of empathy, love, trust, and caring.
2. Instrumental support involves the provision of tangible aid and services that directly assists a person in need.
3. Informational support involves the provision of advice, suggestions, and information to address issues and problems.
4. Appraisal support involves the provision of feedback and affirmation that is useful for evaluative purposes.
Notably, there is limited research investigating social support per se, because of the methodological challenges associated with measuring supportive behaviors within a social network. Instead, researchers use measures, typically questionnaires, that assess perceived social support; that is, the belief that social support is available. Interestingly, there is evidence to support the idea that perceived social support is a better predictor of health outcomes than actual levels of social support (McDowell & Serovich, 2007).
Social Network
A social network refers to the interpersonal linkages that surround an individual—people who may provide care, social support, companionship, and influence, and who act as points of social comparison. Social network analysis (Scott, 1991) is a method of investigating social structures through consideration of both nodes (e.g., individuals, groups, etc.) and the ties (i.e., relationships or interactions) that bind them. In contrast to other measures of social relationships, analyses of social networks focus on objective characteristics of ties (e.g., relationship roles, frequency of contact, etc.) rather than appraisals of relationship quality, such as perceived availability of others and social support provided by one’s network. Social networks can be assessed along multiple dimensions including size (the number of people in the network), density and complexity (the extent to which network members know and interact with each other), reciprocity (the extent to which supports and obligations are equal within a network or between members), homogeneity (the extent to which network members are similar along factors of interest such as age, ethnicity, social class, etc), proximity (a measure of geographic distance between a person of interest and their network), durability (a measure of the duration of relationships within a social network), and accessibility (the ease with which one can access their social network) (Wellman, 1981).
Part II: Measures of Social Relationships
Given the importance of social relationships to the human experience, hearing health care practitioners and researchers are often interested in better understanding how hearing loss and hearing rehabilitation affects social relationships. This can be accomplished using various methods, ranging from discussions with patients and their families to the use of standardized measurement tools. In audiology, there are a number of questionnaires designed to assess aspects of social relationships, and a recent systematic review identified 54 such instruments available in epidemiology research (Valtorta et al., 2016). Further complicating matters, clinicians and researchers are at times interested in understanding social relationships in their totality, and at other times interested in specific domains of social relationships, such as whether an individual is experiencing loneliness or reduced social activity. Accordingly, one challenge facing clinicians and researchers alike concerns how one might select a specific measurement tool to assess a social phenomenon of interest. Part II of this chapter attempts to serve as a guide for clinicians and researchers to assist in the selection of measurement tools when assessing social relationships.
Provided in Table 10–1 is a categorization scheme of measures commonly used to assess social relationships in audiology practice and research. Notably absent are measures assessing handicap experienced by the significant others of persons with hearing loss, as these are covered in greater detail in Chapter 6 (Scarinci, 2019). The classification scheme presented here is based on Valtorta et al. (2016) but modified to be better suited for audiology. In this classification scheme, the measures reviewed are assessed along the following four dimensions of social relationships:
1. Social Activity: Assesses participation in activities that involve interaction with others or membership in various relational roles (e.g., spouse, parent, friend, etc.). These items are designed to gauge degree of involvement for a specified list of activities, size, and range of social relationships;
2. Availability of Social Support: Assesses the extent to which social relationships are perceived to be available to an individual;
3. Adequacy of Social Support: Assesses the extent to which social relationships satisfy interpersonal needs, either in quality or quantity;
4. Feelings Related to Social Relationships: Assesses affective experiences arising from interpersonal relationships or interactions.
The assessment tools are categorized along two additional dimensions. First, we report whether the tool is “hearing specific” or not. This column denotes whether the self-reported measure was explicitly developed for the purpose of assessing experiences of hearing or was designed to provide a more global assessment of experience. Second, we examine whether the tool is a “unidimensional measure” or not. This column denotes whether the tool or subscales of the tool provides a score quantifying a particular domain or domains of social relationships (i.e., domain-specific) or not (i.e., domain-general). For example, the de Jong Gierveld Loneliness Scale is considered a unidimensional measure of social relationships because it contains a subscale assessing adequacy of social support as well as a subscale assessing feelings related to social relationships. In contrast, the HHIE is not considered a unidimensional measure of social relationships because its subscales reflect both interpersonal and noninterpersonal aspects of communication. (For additional information on the use of self-reported inventories, the reader is referred to Chapter 6 of this text.)
Table 10–1. Categorization of Measures Commonly Used in Hearing Research to Assess Social Relationships
Note. HHIE: Hearing Handicap Inventory for the Elderly; CPHI: Communication Profile for the Hearing-Impaired; SPaRQ: Social Participation Restrictions Questionnaire; EMO-CHeQ: The Emotional Communication in Hearing Questionnaire; SF-36: Short-Form 36 Health Survey Questionnaire; SF-6D: Short-Form 6 Dimensions; SELF: Self-Evaluation of Life Function Scale; SNI: Social Network Index; FSSQ: Duke-UNC Functional Social Support Questionnaire; MOS: Medical Outcomes Study Social Support Survey.
Hearing Handicap Inventory for the Elderly (HHIE)
The HHIE (Ventry & Weinstein, 1982) is a 25-item self-reported measure of situational and emotional effects of hearing loss, with higher scores indicating more hearing handicap. Respondents are asked whether they experience hearing or hearing-related difficulties and respond with a “yes,” “sometimes,” or “no.” The 12-item situational subscale asks participants to rate both hearing difficulty in different listening situations (e.g., when listening to TV or radio, shopping, etc.) as well as limits imposed on interpersonal activities (e.g., attending religious services, visiting family, etc.). The emotional consequences subscale assesses feelings and experiences in a variety of nonsocial and social situations. Three caveats regarding the measure are worth noting. First, about half of the items on the situational subscale inquire about hearing in difficult listening situations, and the other half of the items on the situational subscale inquire about limits on social activities. Second, slightly less than half of the items on the emotional subscale assess emotions experienced in social situations. Hence, the subscales in and of themselves, while excellent in many respects, are not ideal if the goal of the clinicians or researchers is to use a measure whose subscales solely assess impact of hearing loss and rehabilitation on social relationships. Third, it is worth mentioning that since about half of the items from the HHIE assess social consequences associated with hearing loss, item-by-item analysis could enable one to understand effects of hearing loss on activities and emotions related to social relationships from effects of hearing loss on emotion that are not related to social relationships.
Communication Profile for the Hearing-Impaired (CPHI)
The CPHI (Demorest & Erdman, 1987) is a 145-item self-reported questionnaire designed to assess experiences of communication across 25 subscales. Of most relevance for this chapter are the subscales assessing: “Attitudes of others,” which measures the respondent’s views of communication partner’s attitudes (e.g., “People treat me as if I’m stupid because I can’t understand what they say”); “behaviors of others,” which measures the respondent’s views of communication partner’s behaviors (e.g., “Members of my family leave me out of conversations or discussions”); “verbal strategies,” which measures the respondent’s use of verbal behaviors with others that compensate for hearing loss (e.g., “When I don’t understand what someone has said, I explain that I have a hearing loss”); “maladaptive behaviors,” which measures the respondent’s use of undesirable interpersonal coping behaviors (e.g., “I tend to avoid social situations where I think I’ll have problems hearing”); and a subscale assessing “withdrawal,” which measures feelings of withdrawal and isolation (e.g., “Because of my hearing loss, I keep to myself”). The CPHI is a communication-focused questionnaire that includes components assessing social activity participation and perceived availability of, perceived adequacy of, feelings related to, and avoidance behaviors designed to discourage social relationships.
Social Participation Restrictions Questionnaire (SPaRQ)
The SPaRQ (Heffernan, Coulson, & Ferguson, 2018; Heffernan, Maidment, Barry, & Ferguson, 2019) is a 19-item hearing-specific, patient-reported outcome measure that could be used in research or clinical practice to assess efficacy of auditory rehabilitation interventions on participation restrictions in adults with hearing loss. The SPaRQ contains two subscales: a nine-item social behaviors subscale that measures difficulties in performing behaviors in a social context due to a hearing loss, and a 10-item social perceptions subscale that measures thoughts and feelings experienced in social contexts due to hearing loss. Thus, the SPaRQ assesses perceived involvement in and feelings related to social relationships.
The Emotional Communication in Hearing Questionnaire (EMO-CHeQ)
The EMO-CHeQ (Singh, Liskovoi, Launer, & Russo, 2018) is a 16-item questionnaire assessing hearing difficulties when listening to voices which contain emotion information. Difficulties are assessed across four subdomains: (a) characteristics of encountered talkers (e.g., voices on television), (b) communication in challenging listening situations (e.g., noisy environments), (c) speech production (e.g., the ability to convey emotion in a subtle manner using one’s own voice), and (d) the associated impact of such deficits on socioemotional well-being (e.g., Item 16: My difficulty identifying emotions expressed in speech negatively affects my relationships with friends and family). Thus, subdomain (d) is seemingly most relevant when assessing the social impact of vocal emotion hearing difficulties.
Short-Form 36 Health Survey Questionnaire (SF-36)
The SF-36 (Brazier et al., 1992; Brazier, 1993) is a 36-item patient-reported survey of general health covering eight dimensions of health (vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, mental health, and social role functioning). The social role functioning subscale contains two items. The first social item asks if “Emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?” with five response options response ranging from “not at all to very severe. The second social item asks “During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?” with five response options ranging from all of the time to “none of the time. Thus, the social functioning questions of the SF-36 assess social activity participation.
Short-Form 6 Dimensions (SF-6D)
The SF-6D (Brazier, Roberts, & Deverill, 2002) is a 6-item patient-reported survey of general health derived from the SF-36. The SF-6D assesses physical functioning, role limitations, pain perception, vitality, mental health, and social functioning. All dimensions are assessed with a single item, with social functioning assessed by the item “Your health limits your social activities _____.” The blank is completed with one of five possible response options ranging from none of the time to all of the time. Thus, the social functioning question of the SF-6D assesses social activity participation.
Self-Evaluation of Life Function (SELF) Scale
The SELF Scale (Linn & Linn, 1984) is a 54-item comprehensive self-reported measure of health for older adults that assesses six areas of functioning: physical disability, symptoms of aging, depression, self-esteem, personal control, and social satisfaction. A total of four items assess social satisfaction. (These items are: Item 18: “How often do you see your friends and relatives?”; Item 19: “How often have you made telephone calls over the past month?”; Item 20: “How often have you worked on a hobby or some activity of interest over the past month?”; Item 21: “How often have you attended meetings at associations, church, organizations, get-togethers, or clubs over the past month?”) For items 18 to 21, there are four response options that range from often/several times a day to rarely or never/not at all. Two of the items from the social satisfaction subscale of the SELF do not ask questions regarding interpersonal relationships. Thus, the social satisfaction subscale of the SELF mostly assesses social activity participation.
Social Network Index (SNI)
The SNI (Cohen, 1991) is a 12-item measure of social network diversity whereby respondents report membership in various social roles (e.g., marital status, parent, employee, student, etc.) and degree of interpersonal contact every 2 weeks. One point is assigned for each type of relationship for which respondents indicate that they speak (in person or on the phone) to someone in that relationship at least once every 2 weeks. Thus, the SNI assesses social network breadth and social activity participation.
UCLA Loneliness Scale
The UCLA Loneliness Scale (Russell, Peplau, & Ferguson, 1978) is a 20-item self-reported questionnaire designed to measure subjective feelings of loneliness. Respondents read statements (e.g., “I have nobody to talk to”) and report their experience with one of four response options (“often,” “sometimes,” “rarely,” or “never”). The UCLA Loneliness Scale assesses both perceived adequacy of social relationships and feelings relating to social relationships.
de Jong Gierveld Loneliness Scale
The de Jong Gierveld Loneliness Scale (de Jong & Tilburg, 2006) is an 11-item scale whereby respondents read statements (e.g., Item 7: “There are many people that I can count on completely” and Item 10: “Often I feel rejected”) and report experiences with one of three response options (“yes,” “more or less,” or “no”). The scale assesses both perceived adequacy of social relationships and feelings related to social relationships.
Duke-UNC Functional Social Support Questionnaire (FSSQ)
The FSSQ (Broadhead et al., 1988) is an eight-item self-reported questionnaire that is commonly used in research investigating the effects of perceived social support (e.g., Item 1: “I have people who care what happens to me”; Item 2: “I get love and affection”; Item 7: “I get useful advice about important things in life”). Responses are made on a 5-point Likert scale with higher values corresponding to greater perceived social support (i.e., 1 = Much less than I would like to 5 = as much as I would like). The FSSQ can be analyzed to yield scores on two subscales, confidant support and affective support. Confidant support refers to having someone with whom to discuss important and personal matters, whereas affective support refers to being cared for emotionally. Thus, the FSSQ assesses perceived adequacy of social relationships.
Medical Outcomes Study (MOS) Social Support Survey
The MOS Social Support Survey (Sherbourne & Stewart, 1991) is a 19-item self-reported questionnaire that investigates four dimensions of perceived availability of social support: (1) emotional/informational support (availability of expressions of positive affect, empathetic understanding, encouragement of expressions of feelings, offering of advice, feedback, or guidance); (2) tangible support (availability of material aid or behavioral assistance); (3) affectionate support (availability of expressions of love and affection); and (4) positive social interactions (availability of others to do fun things with). Responses are made on a 5-point Likert scale with higher values corresponding to greater perceived social support (i.e., 1 = none of the time to 5 = all of the time). Thus, the MOS Social Support survey assesses perceived availability of social relationships.
Part III: Social Relationships
One of the long-standing beliefs in audiology, held by many researchers, clinicians, patients, and significant others, concerns the relationship between hearing loss and effects on social relationships, whereby poorer hearing abilities leads afflicted individuals, and often their significant others, to withdraw from others and social situations, and to experience social disconnectedness. Indeed, there is considerable evidence that severity of hearing loss and associated communication difficulties can negatively affect our social world (Barker, Leighton, & Ferguson, 2017; Dalton et al., 2003; Hétu, Jones, & Getty, 1993; Pronk et al., 2011; Kramer, Kapteyn, Kuik, & Deeg, 2002; Vas, Akeroyd, & Hall, 2017; Wallhagen, Strawbridge, Shema, & Kaplan, 2004; Weinstein & Ventry, 1982). As discussed previously in the chapter, there are different domains of social relationships that can be affected. Next, we discuss the findings from various approaches adopted by researchers to understand the social consequences associated with hearing loss and hearing rehabilitation.
Before moving on to this review, we draw attention to an important caveat. Numerous studies describe social effects of hearing loss and rehabilitation, but in many cases, it is unclear whether the measure or item used in a study reflects interpersonal or noninterpersonal aspects of experience. This is understandable because items or questionnaires are often designed to understand experiences of hearing that are both social and nonsocial. For example, consider Item 14 from the social/vocational subscale of the modified Denver Scale of Communication Function: “I do not enjoy my job as much as I did before I began to lose my hearing” (Schow & Nerbonne, 1980). This item could be construed to reflect difficulties with interpersonal communication at work, difficulties with interpersonal bonding and connectedness, auditory challenges that do not involve others such as the ability to localize sounds, or some other difficulty that is not social. Hence, in this chapter, we attempt to limit our discussion and review of the literature by focusing on research studies that use measures that more concretely assess social relationships.
A number of qualitative studies have examined the impact of hearing loss on everyday social relationships. It is often observed that individuals with hearing impairment report engaging in various interpersonal coping behaviors such as the avoidance of social activities (Hallberg & Carlsson, 1991; Heffernan, Coulson, Henshaw, Barry, & Ferguson, 2016; Lockey, Jennings, & Shaw, 2010), less active participation while attending social activities (Hétu, Riverin, Lalande, Getty, & St-Cyr, 1988), or active communication management during social interactions (i.e., controlling conversational topics, altering communication patterns, explicit requests for repetition, optimizing body position relative to others) (Hallberg & Carlsson, 1991; Heffernan et al., 2016; Hétu et al., 1988; Lind, Hickson, & Erber, 2006).
Hearing Loss and Involvement in Social Activities
In the quantitative literature investigating the effects of hearing loss on social relationships, researchers have used a myriad of research designs and questionnaires. Overall, there appears to be good evidence that there are significant effects of hearing loss on social activity (Andrade, Pereira, & Silva, 2017; Dalton et al., 2003; Hallam & Brooks, 1996; Helvik, Jacobsen, & Hallberg, 2006).
In classic work first describing the HHIE, perhaps the most popular measure of handicap in audiology, Ventry and Weinstein (1982) assessed 100 adults aged 65 years or older with varying degrees of audiometric hearing loss from normal to severe. On the situational subscale (of which about half the items assess social activity limitations imposed by hearing loss), it was observed that greater handicap is systematically observed with poorer hearing, thus suggesting that activity limitations are associated with hearing loss. Complementing this work, a related finding was observed by the National Council on the Aging (1999) who obtained responses from 2,304 individuals with varying degrees of hearing loss. When asked whether respondents participate regularly in social activities, 37% of those with milder hearing losses reported regular activity, whereas this number drops to 32% for those with more severe hearing losses.
Longitudinal evidence has also observed that hearing-impaired respondents report poorer social activity (indexed by the HHIE-S, a shorter version of the HHIE; Ventry & Weinstein, 1983) compared with normal hearing peers (Andrade, Pereira, & Silva, 2017). Using data from the Epidemiology of Hearing Loss Study in Beaver Dam, WI (Dalton et al., 2003), it was found that relative to individuals with normal audiometric thresholds, hearing loss severity was associated with poorer scores on the HHIE-S. Importantly, the study included a measure of social activity other than the HHIE-S, and the authors also observed poorer social relationships on this measure of involvement in social relationships (SF-36).
Notably, there are important limitations regarding the effect of hearing loss on social activity participation. To date, there is a dearth of evidence demonstrating the effect of hearing loss on actual involvement in social relationships. Instead, the literature relies on proxy measures of social activity, namely self-reported questionnaires. Moving forward, it is anticipated that novel research methodologies using smartphones (e.g., ecological momentary assessment; Kimball, Singh, John, & Jenstad, 2018; Stone & Shiffman, 1994; Timmer, Hickson, & Launer, 2018) will address methodological limitations imposed by self-reported paper and pencil questionnaires, and will be better able to track individuals close in time to events to study social interactions.
Hearing Loss and Loneliness
Recall that loneliness represents a negative affective state resulting from an unfulfilled desire to have friends, deprivation of affective bonding, and a perception of the gap between actual and desired levels of bonding. Both cross-sectional and longitudinal research methodologies, and multiple measures of loneliness have been used to investigate whether hearing loss is associated with loneliness.
Data from several cross-sectional datasets all suggest an association between loneliness and hearing loss. Using data from the first wave of the Canadian Longitudinal Study of Aging, Mick, Parfyonov, Wittich, Phillips, and Pichora-Fuller (2018) investigated whether self-reported hearing loss was associated with experiences of loneliness in 21,241 adults aged 45 to 59 years. They measured loneliness with the following single item: “In the past week, how often did you feel lonely?” and found that self-reported hearing loss was significantly associated with loneliness. Similarly, Dawes et al. (2015) assessed loneliness (labelled as “social isolation” in their paper) using the single item “Do you often feel lonely” (yes/no) using data from 164,770 individuals aged 50 to 69 years of age from the U.K. BioBank dataset. It was observed that social isolation was associated with poorer hearing. Finally, Sung, Li, Blake, Betz, and Lin (2016) assessed experiences of loneliness in 145 hearing-impaired adults aged 50 to 94 years using the UCLA Loneliness Scale and found that greater hearing loss was associated with higher levels of loneliness.
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