AU communication discussion

In 2020, people around the world began wearing face coverings in order to prevent the spread of COVID-19. While evidence shows that face coverings can reduce particle spread and limit virus transmission (Asadi et al. 2020), there is little research on how face coverings affect communication, especially for individuals with hearing loss. Saunders, Jackson and Visram (2021) assess the impact of face coverings on hearing and communication, which in turn can be used to improve the design of face coverings to make them more communication-friendly, and to educate the public on better communication tactics while wearing face coverings.

Study authors recruited 460 adults in the United Kingdom using snowball sampling, primarily through social media channels such as Twitter and Facebook, or through emails. They targeted Facebook groups for hearing loss support in order to oversample adults with hearing loss. Each participant completed a survey about communicating with someone wearing a face covering, or communicating while the participant is wearing a face covering. Participants were asked about a variety of settings and their experiences – how connected they felt to the other person in the conversation, how well they can hear and understand the other person, and how engaged they felt.

The results of the study showed that 60 percent of participants who had worn a face covering when communicating said it caused them to “communicate differently” than if they were not wearing a covering. The study confirmed that face coverings have a bigger impact on communication amongst individuals with hearing loss than those without. Communication issues may cause individuals with hearing loss to experience a myriad of negative emotions, such as “anxiety, isolation, feeling stupid, and losing confidence (Saunders, Jackson and Visram, 2021). Saunders, Jackson and Visram call on “acousticians and industrial designers” to create improved face coverings, and healthcare providers and the general public to utilize important communication strategies when wearing a face covering.

Questions:

The study surveyed 460 members of the general public in the United Kingdom using snowball sampling. The researchers note that “people with hearing loss were intentionally oversampled.” Is including a larger proportion of individuals with hearing loss in this study beneficial to the accuracy of the results, or detrimental?

Of the 460 people surveyed, almost 80 percent were female and more than 93 percent were white. How do you think this affected the findings of the study? What are some other limitations you notice?

Authors of the study note that one of the most difficult settings for individuals with hearing loss to communicate through face coverings is a medical situation. How can medical professionals wearing face coverings use findings from the study to address communication gaps when working with people with hearing loss?

International Journal of Audiology
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/iija20
Impacts of face coverings on communication: an
indirect impact of COVID-19
Gabrielle H. Saunders, Iain R. Jackson & Anisa S. Visram
To cite this article: Gabrielle H. Saunders, Iain R. Jackson & Anisa S. Visram (2021) Impacts
of face coverings on communication: an indirect impact of COVID-19, International Journal of
Audiology, 60:7, 495-506, DOI: 10.1080/14992027.2020.1851401
To link to this article: https://doi.org/10.1080/14992027.2020.1851401
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Published online: 27 Nov 2020.
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INTERNATIONAL JOURNAL OF AUDIOLOGY
2021, VOL. 60, NO. 7, 495–506
https://doi.org/10.1080/14992027.2020.1851401
ORIGINAL ARTICLE
Impacts of face coverings on communication: an indirect impact of COVID-19
Gabrielle H. Saunders
, Iain R. Jackson and Anisa S. Visram
Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester, UK
ABSTRACT
ARTICLE HISTORY
Objective: To understand the impact of face coverings on hearing and communication.
Design: An online survey consisting of closed-set and open-ended questions distributed within the UK
to gain insights into experiences of interactions involving face coverings, and of the impact of face coverings on communication.
Sample: Four hundred and sixty members of the general public were recruited via snowball sampling.
People with hearing loss were intentionally oversampled to more thoroughly assess the effect of face
coverings in this group.
Results: With few exceptions, 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; they increased anxiety and stress, and made communication fatiguing, frustrating and embarrassing – both as a speaker wearing a face covering, and when
listening to someone else who is wearing one.
Conclusions: Face coverings have far-reaching impacts on communication for everyone, but especially
for people with hearing loss. These findings illustrate the need for communication-friendly face-coverings,
and emphasise the need to be communication-aware when wearing a face covering.
Received 8 October 2020
Revised 7 November 2020
Accepted 10 November 2020
Introduction
A common response to the COVID-19 pandemic has been the
increased use of face coverings, including mandatory use in many
countries. Guidance from the World Health Organization (2020)
encourages their use of face coverings in public settings and in
settings when physical distancing is not possible. The benefit of
face coverings in reducing particle spread and thus virus transmission has been established (Asadi et al. 2020). Less well understood
is the impact of face coverings on hearing and communication. A
better understanding of these factors will inform improvements to
face covering designs, communication awareness, and provision of
better advice to the general public and healthcare workers alike.
By covering up the lower part of the face, face coverings
potentially impact communication by changing sound transmission, removing visible cues from the mouth and lips used for
speechreading, and limiting visibility of facial expressions and
the face in general. While there has been much writing about the
potential impacts of these on communication during healthcare
provision (Baltimore and Atcherson 2020; Chodosh et al. 2020;
Mehta, Venkatasubramanian, and Chandra 2020; Schl€
ogl & Jones
2020; Vaidhyanathan et al. 2020), and education (Nobrega et al.
2020; Spitzer 2020), little empirical data is available on the direct
impact of face coverings on communication more broadly.
A few studies have examined the acoustic impacts of face coverings by measuring sound transmission through various types
of mask, including surgical masks, respirators, masks with a
CONTACT Gabrielle H. Saunders
Gabrielle.saunders@manchester.ac.uk
of Manchester, Manchester, UK
Supplemental data for this article is available online here.
KEYWORDS
COVID-19; face coverings;
masks; hearing; hearing
loss; communication;
lipreading; visual cues;
facial expressions
transparent panel, and splash visors (Corey, Jones, and Singer
2020; Goldin, Weinstein, and Shiman 2020; Saeidi, Huhtakallio,
and Alku 2016; Stone and Munro 2020). These studies have consistently illustrated that masks act as low-pass filters, attenuating
output above 2 kHz. The extent of this attenuation is maskdependent with surgical masks being least attenuating (decreasing sound by 2–4 dB), and transparent masks and splash visors
being the most attenuating (up to 20 dB attenuation). Palmiero
et al. (2016) examined this attenuation in terms of impact on the
speech transmission index (STI) and determined that surgical
face masks had relatively little impact it. This perhaps explains
the findings of Mendel, Gardino, and Atcherson (2008) who
found that, despite spectral differences between speech recorded
with and without a surgical mask, the mask had very little
impact on listeners’ understanding of speech. This was the case
regardless of the presence of background noise and whether or
not the listener had hearing loss. In a more recent study,
Atcherson et al. (2017) assessed the role of visual cues by examining the impact of a standard versus a transparent face mask on
speech understanding in noise among people with and without
hearing loss. People with normal hearing performed well with
both types of mask, while those with hearing loss performed best
in the transparent mask condition. Likewise, Radonovich et al.
(2010) examined a variety of types of face mask for their impact
on speech intelligibility and determined that the impact was
dependent on type. Some, including surgical masks, had little or
Manchester Centre for Audiology and Deafness, School of Health Sciences, University
ß 2020 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society
496
G. H. SAUNDERS ET AL.
no effect on intelligibility, while others, such as the half-face
elastomeric respirator, decreased performance substantially.
In addition to altering acoustics, covering the mouth limits
access to speechreading cues. Such cues are used by everyone to
supplement incoming speech information (Grant and Seitz 2000;
Sumby and Pollack 1954), although the benefit gained is highly
variable across individuals (MacLeod and Summerfield 1990).
Nonetheless, it is generally accepted that people with hearing
loss rely on visual cues to a greater extent than do people with
normal hearing (Moberly et al. 2020). Thus it is reasonable to
expect that face coverings will impact those with hearing loss to
a greater extent than those with normal hearing. Indeed patients
with hearing loss seen in an Italian hospital during the COVID19 pandemic reported significant communication difficulties,
which were more often attributed to inability to lipread (56%)
than to speech being muffled (44%) (Trecca, Gelardi, and
Cassano 2020). Worries about face coverings were also reflected
in a recent survey by Naylor, Burke, and Holman (2020). They
asked their participants, all of whom had hearing loss, about
concerns they would have if the wearing of face coverings was to
become more common. They learned that participants were concerned about this, and that more severe hearing loss was associated with greater levels of concern. The difference, however, was
not statistically significant. Henn et al. (2017) conducted interviews with students with hearing loss to find out whether and
how their hearing loss impacted medical consultations. About
60% reported that they had misheard or misinterpreted information during a medical appointment because of their hearing loss.
About 20% attributed their difficulties to the physician’s or
nurse’s way of communicating, which included mention that
wearing of masks by staff was problematic.
Covering the mouth also limits perception of facial expressions indicating happiness and disgust. It has less impact for recognition of anger, fear, and surprise. This has been illustrated in
studies of women wearing various types of Islamic face covering
(e.g. niqab, hijab; Fischer et al. 2012; Kret and de Gelder 2012)
and by studies in which different areas of the face were systematically covered (Wegrzyn et al. 2017). The real-world impact on
emotion perception from covering the mouth region was illustrated by Wong et al. (2013), who showed that although satisfaction with a medical appointment was not affected when the
physician was wearing a face covering, the physician was perceived as being less empathic when a face covering was worn.
Based on this literature review, we expect that face coverings will
be detrimental to communication on many levels. We also expect
that people with hearing loss will be affected to a greater degree by
face coverings than people without hearing loss. To examine this,
we conducted a survey of members of the general public in the UK
around the time face coverings were becoming common, but before
their use was mandatory. The survey contained both closed-set and
open-ended questions to gain insights into experiences of interactions involving face coverings, and of the impact of face coverings
on communication. Questions were designed to cover a wide range
of listening situations and social interactions, and examined experiences of communicating when wearing a face covering and when
interacting with someone else wearing a face covering.
Methods
Participants
Participants were members of the general public who resided in
the UK and were aged 18 years. or over. They were recruited via
snowball sampling through social media (Twitter, Facebook) and
emails sent to professional and personal networks. People with
hearing loss were intentionally oversampled to more thoroughly
assess the effect of face coverings in this group by targeting
Facebook groups for people with hearing loss. Due to the form
of recruitment, it is not possible to calculate a survey response
rate. Data collection took place between 8 June 2020 and 5
August 2020. Participants did not receive payment for completing the survey. This study was approved by the University of
Manchester Research Ethics Committee (Ref: 2020-9954-15640).
Informed consent was obtained online as a condition for beginning the survey.
Survey
The survey examined the impacts of face coverings on communication from the perspective of (a) communicating with someone
who is wearing a face covering and (b) communicating when
wearing a face covering. Some survey items required selection of
options from a 5-point Likert scale, while others requested openended input. See Appendix 1 for a full list of the survey items.
The survey consisted of four sections:
1. Demographic and hearing-related items. These items
queried age, gender, ethnicity, location (UK or not), selfreported hearing ability, and use of hearing assistive technology (hearing aids and cochlear implants).
2. Items about communicating with someone who is wearing
a face covering. The impact on the ability to hear what was
said, understand what was said, how engaged in the conversation the listener felt, and how connected they felt to the
person speaking, were rated for communicating in a variety
of situations: talking with family/friends, communicating
during a doctor’s appointment, during an outpatient hospital appointment, with hospital staff as an in-patient, and
with a pharmacist, a shop assistant, and a bus/train conductor. The option to add an “other” situation was also provided. Additional items assessed whether participants
thought face coverings impacted communication, and an
open-ended question asked for general thoughts about talking with someone who was wearing a face covering, how it
impacted communication, and how they felt about it.
3. Items about communicating when wearing a face covering. This was evaluated with items asking whether the participants felt they communicated differently when they
personally were wearing a face covering. If so, they were
asked in what way they communicated differently, and how
the nature of conversations differed.
4. Perceptions of face coverings from a public health perspective. Four multiple choice items queried participants’
general attitudes about face coverings and transmission of
COVID-19.
Study data were collected and managed using REDCap electronic data capture tools hosted at the University of Manchester.
REDCap (Research Electronic Data Capture) is a secure, webbased software platform designed to support data capture for
research studies (Harris et al. 2009). Questionnaire items were
presented using branching logic tailored to each participant’s
individual responses. For instance, participants were asked to
specify the types of communication situations in which they had
encountered someone wearing a face covering. Follow-up questions were then only presented for those particular situations.
INTERNATIONAL JOURNAL OF AUDIOLOGY
Procedure
An email was sent to potential participants and information was
posted on social media inviting members of the general public to
complete the survey by following the in-message or posted link.
The link led to a participant information sheet and consent form
that had to be signed electronically before the survey items
became accessible. In order to ensure inclusion criteria around
age (aged 18 or over) and location (reside in the UK) were met,
the survey automatically ended if the participants said they
resided in a country outside of the UK or that they were younger
than 18 years old.
Analyses
Survey data were exported from REDCap into IBM SPSS
Statistics 25 (IBM Corp. 2017) and R (R Core team 2013) for
analysis. Descriptive analyses and Kruskall–Wallis tests were
used to examine responses to the closed-set questions answered
on a Likert scale. Inductive content analysis was used to analyse
the open-ended responses by identifying themes in the data. This
approach is useful when analyses are exploratory and there is
limited research or theory about a phenomenon (Hsieh and
Shannon 2005). Author G.S. generated the initial themes,
Figure 1. Self-reported hearing by age group. Number of particpants in each
age group is shown at the top of each bar.
497
categories and codes using the guidelines provided by Elo and
Kyng€as (2008). Authors A.V and I.J. then reviewed the content
and provided input.
Results
Demographic and hearing-related information
Complete surveys were obtained from 460 individuals. The vast
majority were female (79.5%, n ¼ 365), and white (93.3%,
n ¼ 429). Figure 1 shows the ages of participants as a function of
their self-reported hearing. While the overall proportion of individuals rating their hearing from “very good” to “very poor” was
equally distributed across rating categories, the distribution of
rating categories within age groups follows the expected profile –
namely, that hearing declines with age. Figure 2 shows participants’ use of assistive technology. Fifty percent of participants
used some form of assistive technology, which is considerably
higher than would be found in a random sample of the general
population in the UK, thus confirming that people with hearing
loss were oversampled as intended. In addition to showing the
proportion of participants who use no technology, cochlear
implants and hearing aids, Figure 2 also provides a breakdown
of hearing aid use. It is seen that the vast majority of people
with hearing aids used them “usually” or “almost always”.
Communicating with someone who is wearing a face covering
Table 1 shows the number and percentage of participants who
had encountered each communication situation in which the
speaker was wearing a face covering. Ninety-six of the 137
“other” responses described communicating at work, so a “work”
category was created.
For each communication situation encountered by more than
50 participants, Figure 3 shows how hearing, understanding, feelings of being engaged and connected were affected when listening to someone wearing a face covering. Note that questions
about engagement and connectedness were not asked of conversations with shop assistants since it was assumed that these interactions
would
have
been
short
and
limited
to
information exchange.
Figure 2. Use of hearing assistive technology. The number of paricipants is shown on top of each bar. Reported frequency of hearing aid use is shown for people
who own hearing aids with the percentage in each use category shown to the right of the bar.
498
G. H. SAUNDERS ET AL.
With very few exceptions, participants reported that face coverings negatively impacted hearing, understanding, engagement,
and feelings of connection with the speaker. A comparison of
the red bars across listening situations suggests that the negative
impacts of face coverings are greater when communicating in
medical situations (doctor, pharmacist, hospital visits) than when
communicating with family/friends, shop assistants and at work.
Interaction with hearing loss. Figure 4 illustrates the differential
effects of hearing loss on the impacts of face coverings using
communicating with family/friends and the doctor as examples.
The upper graphs shows how face coverings impacted the ability
to hear; the lower graphs show their impact on feeling engaged
in the conversation. Each is plotted as a function of self-reported
hearing ability (left hand graphs) and use of hearing aids (right
hand graphs). Degree of hearing loss, both reported and as
reflected by hearing aid use, significantly impact the difficulty
people have hearing and feeling engaged in a conversation with
someone who is wearing a face covering. This is reflected in the
results of Kruskall–Wallis tests showing significant differences
(p < 0.001) for comparisons of responses by self-reported hearing and use of hearing aids for communicating with both family/ friends and the doctor. Thoughts about communicating with someone who is wearing a face covering. Table 2 shows the themes, categories, and codes that emerged along with example statements from content Table 1. Number and percentage of participants who had encountered each communication situation in which the speaker was wearing a face covering. Situation N % Shop assistant Family/friends Pharmacist At work Doctor appointment Hospital out-patient appointment Other Bus/train conductor Other medical-related appointment As a hospital in-patient 247 108 98 96 84 75 23 21 18 13 53.7 23.5 21.3 20.9 18.3 16.3 5.0 4.6 3.9 2.8 analysis of the open-ended responses obtained to the question “In general, what are your thoughts about talking with someone who is wearing a face covering? Do you think it changes the way you communicate? If so, how do you feel about this?” Seven themes emerged, each of which is described below. Theme 1: Hearing. This theme was associated with ways in which face coverings affected the ability to hear sound – noting that sound is muffled and quieter, but being aware that the impact was dependent on individual differences, such as how loudly or clearly the person speaks and the familiarity of their accent. Theme 2: Visual cues. This theme was about the impacts of face coverings on visual cues. Many people noted their reliance on the lips and face for communication, that in the absence of visual cues it is more difficult to interpret the meaning of an interaction, and that social distancing exacerbates these problems. A number of individuals noted being unaware of the extent to which they relied on the lips and facial expressions until face coverings had become ubiquitous, as illustrated by comments such as “I had no idea how much I relied on lip reading and facial gestures to piece together conversations until the current pandemic”. Theme 3: Impact on the interaction. This theme addressed the way in which face coverings changed the content of and perceptions about an interaction. It was noted that communication becomes about information sharing with little or no informal chat, that conversations are shorter and flow less well, are less personal and engaging, and that emotions and reactions are hard to read. Theme 4: Impact on the individual. The theme was associated with the impact of face coverings on the individual. Face coverings elicited many emotional reactions, made it harder cognitively, and raised unpleasant reminders. The emotions reported were consistently negative. They included feelings of anxiety, stress, isolation, stupidity, vulnerability, distress embarrassment, loss of confidence and frustration associated with difficulties communicating with someone wearing a face covering. An example of such a comment is “It will change the way we communicate because some of us will not understand what is being said. I feel overwhelmed and quite upset”. At a cognitive level, Figure 3. Reported impact of face coverings by listening situation showing impact on ability to hear (upper left), ability to understand (upper right), how engaged the listener feels in the conversation (lower left) and how connected the listener feels with the talker (lower right). INTERNATIONAL JOURNAL OF AUDIOLOGY 499 Figure 4. Reported impact of face coverings by self-reported hearing (left hand graphs) and use of assistive technology (right hand graphs) for hearing the conversation (upper graphs) and feeling engaged in the conversation (lower graphs), using conversations with family/friends (F/F) and the doctor (Doc) as examples. participants reported the need to use extra concentration and effort to communicate, and that they were more fatigued following communication with someone wearing a face covering, as illustrated by the statement “My listening fatigue has gone up to a whole other level and I constantly feel exhausted”. Further, face coverings were a constant reminder of the pandemic and, among people with hearing loss, were a reminder of the time before they had obtained hearing assistive technology. Theme 5: Impact on behaviour. This theme reflected coping mechanisms – some were solution-focused approaches, while others were about avoidance. Solutions included the technological approach of using a transcription app, non-technological solutions such as using a transparent face covering or having a card to alert others to hearing loss, and using communication strategies to manage the situation. The negative approaches involved avoiding communication situations entirely, not communicating when in a problematic situation, or relying on others to communicate for them. For example “It has stopped me from leaving the house to go to shops as I fear not being able to hear at all”. Theme 6: Social impacts. This theme was about the social impacts of face coverings. It revealed both interpersonal changes and communication changes during interactions when a face covering was being worn. Interpersonal changes noted were difficulties recognising someone wearing a face covering, the effect of not seeing smiles, and empathy for those with hearing loss. One person shared her concern as “I am currently a mum of a NICU baby. He has never seen my face. I worry he will not be able to connect with me as a result”. Communication-wise people mentioned that face coverings caused communication barriers and that they used their eyes and words as a substitute for facial expressions. Theme 7: Big picture. The final theme addressed the big picture and was about accepting or tolerating face coverings for the public good. There was also mention of worries about the future if face coverings were to become the norm, and reference to feeling that communication changes had some positive outcome regarding the need to engage more and take notice of smiles in the eyes. Communicating when wearing a face covering At the time the survey was completed, 62% of participants had encountered a situation in which they had worn a face covering while communicating. Sixty percent of these individuals said they communicated differently as a result of wearing a face covering, and 46% said the nature of the conversation had differed, with a further 17% and 25% respectively saying “maybe”. Open-ended responses to the questions “In what way do you communicate differently when you are wearing a face covering?” and “In what way are the nature of your conversations different when you are wearing a face covering?” were analysed using content analysis. The resultant themes and categories are shown in Tables 3 and 4 and are discussed below. Four themes associated with communicating differently emerged: Theme 1: Delivery. This theme reflected reports of changes in manner of speaking (louder, slower, clearer), linguistic content (minimised), and an awareness of overcompensation for the situation. Theme 2: Body language. This theme reflected changes in use of body language. Gestures and facial expressions are used more often and purposefully, as is use of a more expressive tone of voice, conscious attempts to use the eyes to communicate, and a focus on gaining and maintaining eye contact during communication. Theme 3: Awareness of others’ needs. This theme is associated with adapting to the needs of others when communicating, and included using cues from others to guide communication, feeling the need to help others, and removing a face covering if others are struggling. Theme 4: Inward changes. This theme reflects changes within the person communicating and includes actions taken to limit communication, and changes in self-image. There were two themes associated with changes in the nature of communication, as follows: Theme 1: Impact on content. This theme revealed that the content of communication is quite different when face coverings are present: interactions are shorter, more direct and less complex, informal chat is omitted, and that content is less humorous, less deep, and lacking. 500 G. H. SAUNDERS ET AL. Table 2. Themes, categories, codes and example statements in response to the question “In general, what are your thoughts about talking with someone who is wearing a face covering? Do you think it changes the way you communicate? If so, how? How do you feel about this?”. Themes Hearing Categories Sound Codes Muffled Volume Individual differences Visual cues lips/ expressions Needed for communication Non-verbal cues New awareness Social distancing Impact on the interaction Content Focus Duration Perceptions Flow Interpersonal Non-verbal content Impact on the Individual Emotions Anxiety/stress Isolation/ disconnection/ disengagement stupid/ inadequate vulnerability/ fear Sadness/ distress/upset/ suicidal Examples Even though I’m always wearing hearing aids, masks muffle the sound Muffles the sound so can be difficult to hear words properly Moreover, the volume of the sound is a bit lower which also affects my ability to understand speech I have been having some difficulty hearing people. I feel that they are muted slightly I know this happens when a mask is not being used because people don’t speak clearly but masks have aggravated the problem Some people are not very good communicators without a mask. Adding a mask on, soft spoken people and people who don’t speak clearly, makes it harder for everyone to understand, regardless of their hearing status I find understanding those with unfamiliar accents (second language English) embarrassingly hard I use lip reading and not being able to see people’s faces affects this It’s already extremely challenging to hear as a hearing impaired person but the mask tasks away any facial expressions, ques, emotion For someone with normal hearing, it mainly effects the interpretation of facial expression You do not get access to other facial cues that help you understand the feeling of the conversation A persons facial expression is as important if not more important than the spoken word I feel I rely a lot on lip reading – but hadn’t realised this until people’s mouths were hidden I have become more aware of how much I value seeing somebody’s face when communicating … and also difficulty if social distancing is maintained as the effect of combining being further away from the speaker plus muffling from the face mask impairs hearing the conversation I rely heavily on facial clues expressions and lip reading. The face masks mean I can’t hold a conversation or hear what they say with the social distance makes it harder Definitely, not knowing the emotion someone has behind a mask completely changes the dialogue and it becomes information giving rather than a conversation Where I might make small talk or banter with colleagues or customers normally, I tend not to if they are in masks or face coverings Less likely to make small talk as not as easy Conversations are shorter as people get fed up of trying to repeat themselves to me I’m tending to try and cut social conversations shorter It makes communication slightly less smooth If I can’t hear properly end up always saying “excuse me” or “can you repeat that”. Hugely affects the flow of conversation As you can’t see the facial expressions it takes away part of the way we communicate Less personal engagement I feel my connection with some speakers is not as strong Reassurance from the person is lost and also the person does not seem approachable Unable to gauge person’s reactions And feel I have to confirm my feeling when i speak, as emotions cannot be read as easily It is more stressful to talk with a person with a face covering, in case I don’t hear them, especially if it is an opaque one Yes induces anxiety in us hearing aid users. We struggle at the best of times but face masks are my worst nightmare! I started a new job a month ago and the first time I met the lady I’m working with. I felt really quite anxious because although I could see her eyes were smiling, I couldn’t see her facial expressions And it adds to a sense of isolation I feel disconnected from the conversation It makes it difficult for me to feel engaged with the person I am talking to Sometimes I just smile I have no idea what they have said. Makes me feel stupid I feel thick as I have to get people to repeat what they say I am now scared to go out, because I feel I have been totally disabled and stopped from being able to communicate Makes me feel anxious and vulnerable to a certain degree Very sad, my son relies on lip reading so it’s totally impossible if someone wearing a face mask I cannot easily communicate with people wearing facemasks. I have to guess what they are saying. It makes me feel inferior, inadequate, unimportant, disconnected. Hopeless about the future. I have experienced suicidal thoughts (continued) INTERNATIONAL JOURNAL OF AUDIOLOGY 501 Table 2. Continued. Themes Categories Codes Embarrassment Loss of confidence/ intimidated Frustration/ anger Cognitive factors Concentration Fatigue Effort Associations COVID Past problems Impact on behaviour Solution-focused Technological Non-technological Communication strategies Avoidance Participation Communication Reliance on others Social impacts Interpersonal Recognition Smiles Empathy Communicative Barriers Non-verbal cues Big picture Acceptance Concern for others Tolerance Future Positives Concerns Examples I feel very embarrassed at having to ask what is being said repeated constantly It is embarrassing to talk to someone with a face covering as I don’t want to misunderstand them Makes you feel more insecure about how the other person has responded to what you said Feels a bit intimidating as can’t read people as well My confidence at work has been significantly affected due to the increased difficulties in understanding and getting the information I require to do my job either from patients or colleagues I feel it is frustrating It makes it next to impossible for me as I have a profound hearing loss this can make me feel very anxious frustrated isolated and sometimes felt anger It requires great concentration and in the end I lose the will to continue … Have to concentrate on the conversation more I feel very drained by it all At work it is exhausting and I have to keep asking for clarity It takes more listening effort especially when at a distance and/or when you’re doing something else at the same time I think it required slightly more effort to communicate – especially as I was not familiar with the person I was communicating with I feel grateful that they are being considerate enough to wear one, but I simultaneously feel on edge because it is a visible reminder that we do not feel entirely safe Makes me feel like I did before had a hearing aid where I couldn’t interact fully with people and star avoiding certain situations I really struggle, it’s very isolating – just like it was before I got my hearing aid I am currently experimenting use of phone app Live Transcribe (live captions using voice recognition) in readiness for when I might need to use it in wider public I would prefer a clear mask (apparently there’s a life hack to stop the mask from steaming) Thankfully I applied for a card from a Hearing Loss organisation that I could show to show that I was deaf and couldn’t understand them due to not being able to lip read Explain my hearing loss asked the pharmacist to speak slowly which she did It sometimes is necessary for people to change the sentence to make the meaning clearer Most people have moved their masks for me, and we have been stood further apart I also talk quite direct/simple in order to get a clear and direct response I try not to go out unless I have to and try, where I can to avoid or reduce communication It makes me not want to communicate with them, I avoid communication if possible I now go out of my way to avoid communicating with someone wearing a mask I now go out with my partner at all times, who doesn’t wear a face mask and translates or communicates for me I disengage and let my husband respond They also cause difficulty in recognising a person in the first place Seeing smiles would be much better It makes you feel a bit down as seeing people’s smiles makes your day better and we cannot have this at the minute I can imagine this can be an awful experience to someone with a hearing loss For me it’s a minor inconvenience, but for those who are hard of hearing it must be extremely off-putting and isolating When my work colleagues make jokes I don’t understand as I can’t see the facial expressions Talking to someone with a face covering means there is a barrier in communication I am very aware and try to express more using my eyes when possible I am telling people when I am smiling at them You rely much more on the eyes While communication is important, so is health and life so we all need to do our part to not inadvertently transmit the virus to someone who will be severely affected or even killed by it My right to communicate does not override anyone’s right to live It’s annoying but i can deal with it if it’ll help things go back to normal quicker I accept it as means to an end and a solution that is not permanent. I do not like the fact that we are in the pandemic but what to do! I’m concerned because I’m a deaf nurse and feel I won’t be able to do my job It will be very hard to communicate in noisy situations i.e. shops etc. I haven’t had problems with people wearing masks, you can see a smile in the eyes But you do have to engage more fully to hear what’s being said, so i do think that is a positive 502 G. H. SAUNDERS ET AL. Table 3. Themes, categories, codes and example statements in response to the question “How do you communicate differently when you are wearing a face covering?”. Themes Delivery Categories Manner Linguistic Compensatory Body language Gestures/facial expressions Voice Eyes Eye contact Awareness of others needs Cues from others Social pressure Face covering specific Inward changes Actions Self-image Theme 2: Social impacts. The second theme is about the social impacts of speaking while wearing a face covering. These were reflected in reports that conversations are less personal and engaging, that the nature of the communication means it is harder to make relationships, that conversations are less spontaneous, and that it elicits a variety of emotions – some are positive (e.g. people are being nicer), while others are negative (e.g. interactions are forced or unnatural). These wide-ranging responses to the open-ended questions reflect high levels of concern about communication associated with face coverings among the general public. In fact, we received open-ended content from 83% of participants, provision of which was independent of self-reported hearing (v2 ¼ 3.21, p ¼ 0.523). Perceptions of face coverings from a public health perspective Responses to the items querying participants’ general attitudes about face coverings and transmission of COVID-19 are shown in Figure 5 as a function of self-reported hearing. In general, participants agreed that face coverings were beneficial for protecting themselves and others from COVID-19. In conflict with this however, is the finding that fewer participants agreed that they wanted more people wear face coverings. It is notable that these opinions are independent of reported hearing loss (Kruskall–Wallis tests p > 0.6 for all questions).
Examples
Had to talk slightly louder, slightly more slowly and with bigger spaces in case
person didn’t understand what I was saying
I speak slowly and slightly raise my voice
I keep it as brief as possible
Keep words to a minimum
Speak more carefully and as little as possible
Probably shouted/spoke louder than I needed
My voice was raised to what would be described as being at a “shouting” level
I think I use my hands more to gesture and emphasise what I mean
More expressive hands/body language
Bigger facial expressions, hand gestures
Much more physical movement e.g. head nodding instead of just saying yes
I am purposefully more expressive with my voice and gesture knowing that my
face is hidden
Yes, have to talk louder and ensure clear in voice expression
Try to smile with my eyes
I make sure I’m really smiling, so people can see my eyes are welcoming
Ensuring I’m facing the person I’m communicating with
Focus more on eye contact
Perhaps more eye contact – I need to know that the other person knows I am
talking to them and is listening
I watch for people’s eyes/eyebrows and can see if they are having to focus on
what is being said
Look people directly in the eye to check they are listening and understanding
I am more attentive to the quality of the interaction and Whether the other
person is understanding me
Feel like I have to make more effort to pronounce my words clearly
I make an effort to compensate for not being able to see my facial expression
I am aware of the difference and need to get it right
I pull the face mask down as I don’t expect people to wear one when talking to
me
Sometimes I just have to remove the mask to make people understand me
I hide behind my mask when I want to in the hospital as mum of a NICU baby
I am more reserved and tend not to speak as much
Communicate less, do not interact if possible
I am less confident
I feel more self-conscious of how I am communicating
Discussion
The arrival and rapid spread of the COVID-19 pandemic triggered a global increase in the use of face coverings in an attempt
to reduce transmission of the virus. One unintended consequence of face coverings, however, is their impact on communication. The results of this survey illustrate that the impacts of
face coverings on communication are far-reaching, going well
beyond their impact on the acoustics of speech transmission.
The members of the general public who responded to this survey
reported that face coverings impacted the content of communication, feelings of interpersonal connection and willingness to
engage in conversation, and that they had strong negative
impacts on anxiety levels, stress, and self-confidence. They also
reported that face coverings make communication fatiguing,
frustrating, and embarrassing. Many of these impacts applied
both as a speaker wearing a face covering, and when listening to
someone else who is wearing one.
These reported impacts are unsurprising based on literature
showing the importance of the mouth and lips in communication (Grant and Seitz 2000; Wegrzyn et al. 2017), combined with
acoustic changes associated with face coverings (Goldin,
Weinstein, and Shiman 2020). However, the depth of feeling and
willingness to provide input was unanticipated. It illustrates that
communication problems associated with face coverings are not
limited to people with hearing loss. Considering these data were
collected prior to 24 July 2020, the date on which the UK government made it mandatory to wear a face covering in shops
(Department of Health and Social Care, UK 2020), one can only
INTERNATIONAL JOURNAL OF AUDIOLOGY
503
Table 4. Themes, categories, codes and example statements in response to the question “How does the nature of the communication differ when you are wearing
a face covering?”.
Themes
Categories
Impact on content
Duration
Content
Depth
Humour
Complexity
Expression
Completeness
Social impacts
Content
Connection
Relationships
Spontaneity
Emotions
Examples
I’m shorter with my conversations and far more direct now
Shorter conversations and more to the point, as it’s harder to communicate
The minimum of information is shared to take myself out of the situation as quickly as possible
Keep to essentials, few pleasantries
Less social but to the point, what I necessarily need to discuss
More instructive, less chatty
I don’t want to talk loudly so I chat less
I avoid asking questions in case I am misheard
Less in depth
I tend to just say Yes or No to questions instead of going into details
Cannot joke or be sarcastic, as people cannot see facial expression wearing mask
More difficult to joke
My humour through conversation is lost so I cut conversations short
I used simpler and more direct phrases
More straight forward, simpler sentences
Conversations with a face covering have now been shortened to small sentences
Feel the need to put more emphasis on tone, due to not being able to see the whole face/facial expressions
Try to use more expressive language to display my emotions
They were shorter, missing information
Shorter / more limited because it’s harder work
Less personal conversation
Less subjective/ emotional matters
Conversation is less engaging
Less “chat”, more likely to just speak when necessary, therefore less human connection
More time is needed to build up rapport
Has affected usual social interactions (jokes, long conversations etc.), hence relationships
Less spontaneous conversation with strangers
They are less spontaneous
People are trying harder to be nicer – it’s one of the only positives!
It feels more forced – less natural as you can’t see smiles/facial expressions
They feel a bit more comical or aggressive in the way I and others exaggerate gestures to be understood or heard
Figure 5. Participants’ opinions about use of face coverings to reduce COVID-19 transmission by selfreported hearing. Responses to these items were received from
458, 457, 456 and 458 participants respectively.
assume that more people are now encountering communication problems.
It is important to remember however, that while communication problems were broadly reported, impacts were significantly
greater for people who reported hearing loss, and/or for those
who used hearing assistive technology. One reason for this is
because people with hearing loss rely on cues from the mouth
and lips for communicating to a greater extent than people with
normal hearing (Moberly et al. 2020). It is also possible that the
use of face coverings will raise awareness of hitherto untreated
hearing loss and prompt a proportion of those people to
seek help.
A potential solution to this face covering problem is the use
of transparent face coverings (Atcherson et al. 2017). Trecca,
Gelardi, and Cassano (2020) reported that more patients with
hearing loss attributed problems with surgical masks to the
inability to lip read than to muffled speech. This indicates that
increasing visibility of the face to allow for speechreading and
504
G. H. SAUNDERS ET AL.
interpreting of facial expressions, at the expense of increased
sound attenuation by transparent materials, might be an acceptable trade-off for many people with hearing loss. In response to
public concerns, the UK National Health Service has recently
purchased clear face masks with the goal of enabling better care
for people who use lip-reading and facial expressions to communicate (UK Government 2020). However, transparent masks are
not without their problems. In addition to being acoustically
more problematic than non-transparent ones (Corey, Jones, and
Singer 2020; Stone and Munro 2020), they steam up, and reusability is an issue since they cannot go into a washing machine
like their cloth counterparts. For hearing aid users at least, mask
adjustments (for an unspecified type of mask) have been developed for the National Acoustic Laboratories (NAL) fitting algorithm (National Acoustic Laboratories 2020) but this does not
address acoustic problems for the rest of the population.
It is noteworthy that the reported impacts of face coverings
vary by listening situation, with impacts on communicating in a
healthcare setting (doctor, pharmacist, hospital) being greater
than on communication with a shop assistant, family/friends,
and at work. This could be interpreted as suggesting that the
perceived impact of the face covering is associated with some
combination of the importance of information being discussed,
the familiarity of the person/people speaking, and the predictability of the content of the discussion, rather than solely the
acoustic environment in which communication is taking place. It
is not surprising then, that healthcare situations in which
important information is often shared by a relatively unfamiliar
individual in an already stressful situation, are particularly anxiety provoking. The cumulative effect of this was reflected in one
participant’s distress “It was incredibly difficult in hospital to
understand a really important diagnosis, it left me in tears”.
The communication issues associated with face coverings elicited a diverse array of negative emotions, including anxiety, isolation, feeling stupid, and losing confidence. These same
emotions are also associated with untreated hearing loss
(Preminger and Laplante-Levesque 2014; Seniors Research Group
1999), suggesting that face coverings result in the same problems,
and thus the same resultant feelings, as hearing loss. High rates
of mental health symptoms have been reported in the general
population since the onset of COVID-19 (see Xiong et al. 2020
for a systematic review). While some of these symptoms overlap
with those reported in this study (e.g. anxiety, stress), others do
not (e.g. depression, post-traumatic stress disorder). Thus the
data here appear to be specific to face coverings and communication, rather than being a general impact of COVID-19,
although there is likely overlap between the two. Data specific to
COVID-related mental health of people with hearing loss have
not yet been published but preliminary data indicate that people
with listening difficulties are particularly vulnerable to the effects
of the pandemic, with increased risk of elevated anxiety, depression, and cognitive dysfunction (Littlejohn, personal
communication).
Many individuals said they used gestures, facial expressions
and their eyes to enhance communication when they were wearing a face covering. Studies do indeed show that these forms of
communication can enhance speech understanding (Drijvers &
€ urek 2017; Jordan and Thomas 2011; Munhall et al. 2004;
Ozy€
Wagner, Malisz, and Kopp 2014). This perhaps suggests that,
with guidance and instruction, communication problems resulting from face coverings could be eased through greater use of
non-verbal cues. Conversely, using a raised voice, another strategy reported by participants here, can have negative effects for
both the talker (vocal fatigue) and the listener (decreased speech
intelligibility resulting from the secondary effects of increased
vocal effort; Abou-Rafee et al. 2019). Indeed, a recent survey
found that users of face coverings reported increased perception
of vocal effort, difficulty in speech intelligibility, and difficulty in
coordinating speech and breathing (Ribeiro et al. 2020).
There were some, albeit small, positive findings from the survey. Participants were highly sensitive to the communication
needs of others and did their best to adapt communication
accordingly, they perceived that others are coming together to
cope with a difficult situation and they were accepting of the
need to wear face coverings for the greater good – as illustrated
by both the open-ended responses and agreement that face coverings are effective at preventing spread of the virus. Public attitudes towards face coverings varies greatly by country, with their
use being almost universally accepted in China (Sun et al. 2020),
but often rejected in the US (Kantor and Kantor 2020). A UK
poll of 2000 people conducted around the time data here were
collected, showed high approval for use of face coverings
(Redfield & Wilton Strategies 2020).
The wearing of face coverings became mandatory in shops in
the UK on the 24 July 2020 (Department of Health and Social
Care and UK 2020), shortly before data collection for this survey
was completed. Inevitably, attitudes, behaviour, and social norms
will adapt and evolve as the use of face coverings becomes an
accepted part of everyday life. A fruitful area for future research
will be to examine whether widespread use of face coverings
leads to a corresponding increase in communication problems,
or conversely, whether feelings of anxiety, stress, and embarrassment decrease as face coverings become part of the wider culture. The emergence of new strategies for improved
communication while wearing face coverings should be monitored and encouraged, with the hope that use of avoidance as a
coping strategy, noted here and by others (Hallam and Corney
2014), becomes less common.
We acknowledge that because the survey was only available
online, and because we used social media (Twitter, Facebook) to
recruit participants, those without the ability or inclination to
access the internet, and/or those who do not use social media
platforms, will have been excluded from participation. This is
likely to include some of those most vulnerable to communication problems arising from the use of face coverings. Additional
research should explore whether this group has needs that have
not been elucidated here.
Finally, our survey did not ask participants to distinguish
between different types of face covering when reporting their
experiences. As the use of face coverings becomes more widespread across society it seems likely that different designs will
emerge for different purposes and situations. Further work will
be necessary to examine the impact of different types of face
covering on communication, and to inform future face covering designs.
Summary and conclusion
This study has revealed that face coverings have far-reaching
impacts on communication for all individuals and, as expected,
they impact people with hearing loss significantly more than
those with normal hearing. These findings represent a call to
action to acousticians and industrial designers to develop communication-friendly face coverings, to healthcare providers to
ensure they address the communication needs of their patients,
and to the general public to use good communication tactics
INTERNATIONAL JOURNAL OF AUDIOLOGY
such as those described in Eby et al. (2020) when wearing a
face covering.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This research was supported by the NIHR Manchester Biomedical
Research Centre. The views expressed are those of the author(s) and
not necessarily those of the NHS, the NIHR or the Department
of Health.
ORCID
Gabrielle H. Saunders
http://orcid.org/0000-0002-9997-0845
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