Effect of face mask use on hearing impaired adult patients

INTRODUCTION

In many countries, the increased use of face masks and other face coverings has been adopted as a response to the COVID-19 pandemic. The world health organization has released guidance that encourages the use of face masks in public settings as well as in settings where it is not possible to observe physical distancing.¹ According to Asadi et al the use of face masks has been instrumental in reducing particle spread, thereby reducing viral transmission from one person to another.² However, it has not yet been established, or well understood, the impact of face masks on communication and hearing, especially for patients with hearing impairment. A better understanding of the impact of face masks on communication and hearing will enable the improvement of face mask design, communication awareness (especially when dealing with hearing-impaired patients), and the provision of more informed advice to health care service providers and the general public. Having the lower part of the face covered can impact communication in a number of ways. Facial visibility is limited, thus removing visible cues that might be used for reading the lips and mouth. Facial expression is suppressed and wearing a mask can affect sound transmission, muffling the user's voice.

It is estimated that almost 35% of all adults aged above 65 years require treatment that is related to some form of hearing loss, with a significant proportion of them requiring acute care admissions.³ Various reports have indicated that both visual and auditory stimulation help in appreciating and understanding vocal stimuli.⁴ The mandatory use of face masks in acute care settings during the COVID-19 pandemic has had a potentially negative effect on history taking and educating or counselling patients. Although this shift has been necessary, it has made communication with patients, particularly the hearing impaired, and their relatives, more problematic.

A significant number of the hearing impaired, from mild to severe, rely heavily on lip reading in addition to other facial expressions.^5,6 Following the mandatory use of face masks, these patients have been finding it far more difficult to lip read or recognize facial cues.^7,8 This is more pronounced in situations where a hearing impaired patient is required to communicate concerns, to respond to health care questions, or to understand their management or diagnosis, especially during encounters in a high volume facility where rapid service delivery is commonplace. Compounding the problem, a significant number of these patients do not wear identifiable hearing disability signs or “hearing-impaired” badges, which might alert health care workers and others to their communication difficulties.⁹

According to the world health organization masks are key in reducing the spread of COVID-19, although there are some negative aspects to health care delivery, especially for patients with hearing impairment.⁹ Newton and Shah reported that masks tend to muffle portions of high-frequency sound that are important to speech.¹⁰ In addition, masks have made communication increasingly challenging in areas commonly known for loud background noise, including acute care wards and emergency departments. Lack of consideration or recognition of hearing impairment is among the leading barriers in health care service delivery to patients with hearing impairment.¹¹ Health care service providers who fail to address the needs of hearing-impaired patients breach professional and ethical duties, especially during a pandemic, and may face malpractice suits.¹² Also, deaf patients who could have relied upon members of their family or friends in translating consultations for them are increasingly being advised to access health care services by themselves without companion support. Another barrier to access quality health care services is the admission of hearing-impaired patients to wards in which the nursing and medical staff wear masks. This makes awareness and recognition of this potentially “invisible” disability important for health care service providers. According to Crume et al it is highly likely for poor communication to result in poor health care outcomes, including patient dissatisfaction, unnecessary investigation, and discontinuity of care, among others.¹³ In order to address this, clinicians must be mindful of patients with hearing impairment. For a health care service provider to recognize that a patient is hearing impaired, the provider has to observe the body language of the patient, read the patient’s general practitioner notes prior to interacting with the patient, or ask the patient directly. Although half the visible face may be covered when one wears masks, it is still important for a health care provider to face patients when communicating to enable the interpretation of facial expressions through other facial muscles and the eyes.

Study objective

The objective of the study was to investigate the effect of face mask use on hearing impaired adult patients.

METHODS

Study design

The study design was of cross-sectional study

Participants and procedure

The study was performed from August 2021 to October 2021 in the ENT Department of Sligo University Hospital. The 100 patients with reduced hearing were randomly sampled from those attending the ENT clinic. The respondents comprised 55 females and 45 males. Any patient with normal hearing was excluded from the study.

Ethical requirements

The respondents who participated in the survey gave their oral consent before the study was conducted. The ethical requirements for the collection of personal data were strictly followed.

Questionnaire design

Respondents were asked to indicate their agreement level for each item on a seven-point Likert-type scale, from ‘strongly disagree (=1)’ to ‘strongly agree (=7)’. Options included; strongly disagree (=1), disagree (=2), somewhat disagree (=3), either agree or disagree (=4), somewhat agree (=5), agree (=6), and strongly agree (=7). Mean near close to (7) is strong agreement and mean near close to (1) is strong disagreement.

Data cleaning and analysis

The collected data was pre-coded for entry in SPSS, the statistical software package. Data entry error was minimized by the incorporation of a check code in addition to cleaning the data by frequency run and reverse coding to ensure consistency.

RESULTS

The results of the analysis are summarized below. Figure 1 demonstrates the respondents’ level of agreement on whether the use of face masks has a negative impact on communication and hearing, especially for patients with hearing impairment. It was evident that 35% of the respondents strongly agreed, 23% of them agreed, 22% of them somewhat agreed, 10% were neutral (neither agreed nor disagreed), 5% somewhat disagreed, 3% disagreed, and only 2% strongly disagreed. Therefore, the majority (80%) of the respondents generally agreed that the use of face masks has a negative impact on communication and hearing, especially for patients with hearing impairment.

69% of respondents strongly agree that face masks limit facial visibility and, not surprisingly, 69% of respondents agree they find it far more difficult to lip read or recognize facial cues following their mandatory use. 68% of respondents agree that covering the lower part of the face using a face mask changes sound transmission. 60% of respondents agree that the use of clear masks may provide the option to lip-read. 80% of respondents agree that the use of face masks has a negative impact on communication and 50% of respondents agree that poor communication is likely to result in patient dissatisfaction. 53% of respondents somewhat agree that poor communication is likely to result in unnecessary investigation. Understandably therefore, 68% of respondents agree that poor communication is likely to result in poor health care outcomes.

Despite the majority of respondents being aware of the negative impact of face mask use on communication and health outcomes and strong support for the notion that clinicians be mindful of patients with hearing impairment (mean 6.47), there was less support for the use of badges or signs to indicate that the wearer has a hearing impairment. This suggests that a perceived stigma may surround the advertisement of one’s hearing disability. Similarly, there was little support for the statement, ‘hearing-impaired patients should be accompanied by their family members or friends to translate consultations for them when seeking health care services’ (mean 4.35), inferring that hearing impaired patients might prefer an independent, unbiased assistant (or technological solution) to aid communication in much the same way as a translator would be used for non-English speaking patients.

DISCUSSION

According to results of this study 69% of respondents strongly agree that face masks limit facial visibility and, not surprisingly, 69% of respondents agree they find it far more difficult to lip read or recognize facial cues following their mandatory use. Which is supported by previous study participants with severe-to-profound hearing loss benefited from the presence of visual cues as evidenced by better performance in audiovisual conditions than any other condition, more over study findings confirm improved speech perception performance in noise for listeners with hearing impairment when visual input is provided using a transparent surgical mask. Most importantly, the use of the transparent mask did not negatively affect speech perception performance in noise.¹⁴

68% of respondents agree that covering the lower part of the face using a face mask changes sound transmission. The 60% of respondents agree that the use of clear masks may provide the option to lip-read, which is supported by previous study showing that a transparent face mask, such as the one used here, does not decrease the acoustic integrity of the speech signal and offers speechreading advantages for listeners with severe-to-profound hearing losses over auditory-only conditions. It is anticipated that listeners with NH may show benefit with the transparent mask in more challenging listening environments where more noise exists. Mask wearing causes a low-pass filter effect attenuating the higher frequencies (2000-7000 Hz) of the speaker’s voice with decibel (dB) reduction ranging from 3 to 4 dB (medical mask) to nearly 12 dB for the N95 mask (respirator /FFP).¹⁵

80% of respondents agree that the use of face masks has a negative impact on communication and 50% of respondents agree that poor communication is likely to result in patient dissatisfaction. 53% of respondents somewhat agree that poor communication is likely to result in unnecessary investigation. Study supports our study with conclusion that universal masking degrades speech quality and denies visual clues (e.g., lip reading, 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.¹⁶

Study was conducted on a smaller sample size and study more settings could have been used for better generalizability. Patient from different age could have been incorporated in study. Study was conducted for limited time period.

CONCLUSION

It is evident that most hearing-impaired patients are aware of the need to visualize facial expression to aid communication. Most hearing-impaired patients rely heavily on lip reading in addition to other facial expressions. Whilst the use of face masks is important in reducing the spread of COVID-19, this study found that their use has a negative impact on communication and hearing, especially for patients with hearing impairment. Covering the lower part of the face limits visibility of the face, removes visible cues that are used for speech reading the lips and mouth, and changes sound transmission. KN95 respirators and single-use surgical masks are recommended for use as they both dampen sound minimally (approximately 5 dB) and filter out small particles effectively. Health care service providers who attend to hearing-impaired patients should consider using an assistive listening system or sound reinforcement system to reduce vocal fatigue and improve audibility. Transparent or clear masks are also recommended as they may be helpful in lip-reading and conveying emotions.

ACKNOWLEDGMENTS

Author would like to thanks Marie Shannon whose assistance in data collection was instrumental and much appreciated.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. World Health Organisation. 2020. Advice on the Use of Masks in the Context of COVID-19. Interim guidance 5. WHO Reference Number: WHO/2019-nCov/IPC_Masks/2020.4. Available at: https://www.who.int/publications/i/item/advice-on-the-use-of-masks-in-the-community-during-home-careand-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak. Accessed on 20 January 2021.
2. 2. Asadi SCD, Barreda CS, Wexler AS, Bouvier NM, Ristenpart WD. Efficacy of Masks and Face Coverings in Controlling Outward Aerosol Particle Emission from Expiratory activities. Sci Rep. 2020;10(1):15665.
3. 3. Lohler J, Walther LE, Hansen F. The prevalence of hearing loss and use of hearing aids among adults in Germany: a systematic review. Eur Arch Otorhinolaryngol. 2019;276(4):945-56.
4. 4. Picou EM, Ricketts TA, Hornsby BW. How hearing aids, background noise, and visual cues influence objective listening effort. Ear Hear. 2013;34(5):e52-64.
5. 5. Manchaiah VK, Stephens D, Meredith R. The patient journey of adults with hearing impairment: the patients’ views. Clin Otolaryngol. 2011;36(3):227-34.
6. 6. 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;146(9):781-2.
7. 7. Ebert DA, Heckerling PS. Communication with deaf patients. Knowledge, beliefs, and practices of physicians. JAMA. 1995;273(3):227-9.
8. 8. Dickson M, Magowan R, Magowan R. Meeting deaf patients’ communication needs. Nurs Times. 2014;110(49):12-5.
9. 9. Corey RM, Jones U, Singer AC. Acoustic effects of medical, cloth, and transparent face masks on speech signals. J Acoust Soc Am. 2020;148(4):2371.
10. 10. Newton VE, Shah SR. Improving communication with patients with a hearing impairment. Community Eye Health. 2013;26(81):6-7.
11. 11. Laur A. Healthcare access for deaf patients-the legal and ethical perspectives. Med-Leg J. 2018;86(1):36-41.
12. 12. Vermeir P, Vandijck D, Degroote S. Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract. 2015;69(11):1257-67.
13. 13. Crume B. The silence behind the mask: my journey as a deaf paediatric resident amid a pandemic. Acad Pediatr. 2021;21(1):1-2.
14. 14. Atcherson SR, Mendel LL, Baltimore WJ, Patro C, Lee S, Pousson M, Spann MJ. The effect of conventional and transparent surgical masks on speech understanding in individuals with and without hearing loss. J Am Academy Audiol. 2017;28(01):058-67.
15. 15. Ten Hulzen RD, Fabry DA. Impact of hearing loss and universal face masking in the COVID-19 era. In Mayo Clin Proceedings. 2020;95(10):2069-72.
16. 16. Goldin A, Weinstein B, Shiman N. Speech blocked by surgical masks becomes a more important issue in the era of COVID-19. Hearing Review. 2020;27(5):8-9.

APPENDIX

The tables displayed below reveal the responses based on the questionnaire questions developed to investigate the effect of face mask use on hearing impaired patients and were collected from one hundred (100) patients in ENT Sligo university hospital Having reduced hearing. The data was collected by means of questionnaire which was given to the target groups. The respondents’ responses are presented in systematic order. The numbers of respondents who participated in this research were displayed on the tables below depending on the level of their agreement or disagreement with respect to the question asked: