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A scoping review of studies investigating hearing

loss, social isolation and/or loneliness in adults

Anthea Bott & Gabrielle Saunders

To cite this article: Anthea Bott & Gabrielle Saunders (2021) A scoping review of studies
investigating hearing loss, social isolation and/or loneliness in adults, International Journal of
Audiology, 60:sup2, 30-46, DOI: 10.1080/14992027.2021.1915506

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INTERNATIONAL JOURNAL OF AUDIOLOGY
2021, VOL. 60, NO. S2, S30–S46
https://doi.org/10.1080/14992027.2021.1915506

REVIEW ARTICLE

A scoping review of studies investigating hearing loss, social isolation and/or

loneliness in adults
Anthea Botta and Gabrielle Saundersb
a
GN Hearing A/S, Ballerup, DK; bManchester Centre for Audiology and Deafness (ManCAD), University of Manchester, Manchester, UK

ABSTRACT ARTICLE HISTORY

Objectives: Social isolation and loneliness are interrelated but independent constructs that threaten Received 17 July 2020
healthy aging and well-being and are thought to be associated with hearing loss. Our aim was to review Revised 2 April 2021
the empirical studies that have examined the association between hearing loss and social isolation and/ Accepted 6 April 2021
or loneliness to highlight future research needs.
KEYWORDS
Design: Scoping review. Hearing loss; social
Study sample: Three electronic databases were searched combining key terms of “hearing loss”, “hearing isolation; loneliness;
impairment” and “deaf
” with “social isolation” or “loneliness”, yielding an initial result of 939 articles. After scoping review
removing duplicate articles, abstract screening and full-text review, 57 original articles met our inclusion criteria.
Results: Studies were diverse in terms of methodology with the most common type of study being stud-
ies that have explored the relationship between hearing loss and social isolation/loneliness from large
population-based datasets. Only eight studies were intervention studies and of these, only one specifically
explored the outcomes of hearing aids (HAs) on social isolation/loneliness.
Conclusions: Further research is warranted to examine the influence that hearing interventions, in par-
ticular HAs, have on social isolation and/or loneliness, with a specific need to include people who identify
as being socially isolated and/or lonely at baseline.

Introduction
Social isolation and loneliness are independent yet interrelated
concepts. Both are highly prevalent and adversely affect health
and well-being (Steptoe et al. 2013; Valtorta and Hanratty 2012)
and are associated with increased risk of mortality (National
Academies of Sciences, Engineering and Medicine (NASEM),
2020). Approximately 50% of adults over 60 years are at risk of
social isolation and about one-third will experience loneliness
(Landeiro et al. 2017). Social isolation is defined as an objective
and quantifiable reflection of reduced social network size and
lack of social contact (Steptoe et al. 2013), with limited participa-
tion in activities and lack of social participation being risk factors
for social isolation (Lubben 1988). Loneliness, however, is a sub-
jective negative feeling associated with a perceived paucity of a
wider social network (social loneliness) or absence of a specified
desired companion (emotional loneliness; Valtorta and Hanratty
2012; Weiss 1973). In other words, loneliness is a subjective mis-
match between one’s actual level of social connection and desired
level of connection (Valtorta and Hanratty 2012). It should be
noted that although social isolation can theoretically be measured
objectively, it is defined less consistently than loneliness (Fakoya,
Mccorry, and Donnelly 2020) because a variety of constructs can
be used to measure it including network size, social support and
social participation (Newall and Menec 2019). Importantly,
although people can be both socially isolated and lonely, people
can also be socially isolated but not lonely and vice versa, thus it
is important to examine these constructs separately.
Hearing loss is a risk factor for social isolation and loneliness
and remediation of hearing loss can contribute to a reduction in
social functioning (see NASEM 2020 for review). However, there
is a need to further examine this association to help guide clin-
ical practices and awareness outside of audiology. Of four sys-
tematic or scoping reviews that have explored intervention
outcomes for improving social isolation and loneliness in adults
(Cattan et al. 2005; Fakoya, Mccorry, and Donnelly 2020;
Gardiner, Geldenhuys, and Gott 2018; Jarvis et al. 2020), few
studies were found to have employed high quality, randomised
controlled trial methods, and of those that had, treatment effect
sizes were small (Jarvis et al. 2020). Moreover, none considered
the sequelae of hearing loss or hearing interventions. Indeed,
Fakoya, Mccorry, and Donnelly (2020) highlighted that it was
essential to consider less well-researched groups, including adults
with hearing loss, in the context of understanding and managing
social isolation and loneliness in older adults. A systematic litera-
ture review that examined the association between hearing loss,
social isolation and loneliness (Shukla et al. 2020) identified that
despite heterogeneity in terms of how social isolation and loneli-
ness were measured, most studies have found an association
between hearing loss and social isolation and/or loneliness.
The review of Shukla et al. (2020) was limited to studies in
which participants were older than 60 years, social isolation and/

CONTACT Anthea Bott abott@gnhearing.com GN Hearing A/S, Lautrupbjerg 7, 2750 Ballerup, DK.
Supplemental data for this article can be accessed online at https://doi.org/10.1080/14992027.2021.1915506
See supplementary material for references of the 57 studies included in the scoping review.
ß 2021 The Authors. Published by Informa UK Limited, trading as Taylor & Francis Group on behalf of British Society of Audiology, International Society of Audiology, and Nordic
Audiological Society.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

or loneliness were assessed using a validated measure and had a
design that used a formal control group. All qualitative studies
were excluded, as were studies investigating younger populations
and intervention outcomes. By omitting studies of individuals
younger than 60 years of age we lose insights into the experien-
ces of young people; by omitting studies that used qualitative
methodology we lose insights into lived experiences, and by
excluding examination of intervention studies we limit insights
into potential solutions for loneliness and/or social isolation
among people with hearing loss. Thus, we consider there is the
need for a broader review to identify the extent, range and
nature of research concerning hearing loss, social isolation and
loneliness across the life span, that includes qualitative as well as
quantitative findings, and the outcomes of hearing-related inter-
ventions. We chose to conduct a scoping review rather than a
systematic review. This is because scoping reviews are used to
identify and map the available evidence (Arksey and O’Malley
2005; Anderson et al. 2008), as in the work here, while system-
atic reviews are used to identify and retrieve international evi-
dence that is relevant to a particular question or questions and
to appraise and synthesise the results (Munn et al. 2018).
Specifically then, we conducted a scoping review of studies that
examined the relationship between hearing loss, social isolation
and/or loneliness to broadly understand the current state of the
literature with a view to identify research gaps and characterise
findings for clinical practice.
Methods
This scoping review was conducted using guidelines from Arksey
and O’Malley (2005), Peters et al. (2015) and Fraser et al. (2015).
See Supplementary data file 1 for PRISMA-Scoping Review
checklist. The review consisted of:
1. Determining the purpose of the study
2. Identifying potential studies to include
3. Screening and selecting studies for inclusion
4. Extracting data
5. Collating and summarising the results
6. Synthesising review findings
Determining the purpose of the study
The purpose of this scoping review was to examine the extent,
range and nature of research concerning hearing loss and social
isolation and/or loneliness in post-lingually deafened adults.
Empirical studies were included if the study also examined social
isolation and/or loneliness. No limitation on study design, year
of publication or social context was applied. Any method used to
assess social isolation/loneliness was acceptable and included
studies that used validated questionnaires, study-specific single
item questions or questionnaires, open-ended questionnaires,
and open-ended interviews in which social isolation and/or lone-
liness were thematically extracted.
Identifying potential studies
After conducting preliminary scoping searches to gain familiarity
with the literature and key terms, three databases (EMBASE,
pubmed and CINAHL) were searched for relevant literature
from their inception until the date the search was conducted
(29th November 2019). Key search terms used were “hearing
loss”, “hearing impairment” and “deaf
” combined with “social
INTERNATIONAL JOURNAL OF AUDIOLOGY S31
isolation” or “loneliness”. Electronic search results were exported
to an Endnote library and duplicates deleted. The initial search
yielded 939 articles, of which 282 were duplicates, leaving 657
unique references. See Supplementary Data File 2 for search
strategy output.
Screening and selecting studies for inclusion
The 657 unique references were then screened using Covidence
(https://www.covidence.org/home). The inclusion criteria from
title/abstract screening to full-text review were: (a) a primary
research study; (b) participants were adults with an acquired
hearing loss—subjectively reported, objective measured or
assumed. By “assumed” we mean that there were some studies
that did not specify participants’ hearing ability, but in which
participants used hearing aids (HAs) or cochlear implants (CIs),
self-identified as hearing impaired, or used an alternative form
of communication, such as sign language. Thus, we considered it
acceptable to assume these individuals had hearing loss; (c) social
isolation and/or loneliness were assessed in some manner or
revealed through qualitative methodology and (d) the full text
article was available in English. Our exclusion criteria were stud-
ies in which (a) hearing loss could not be differentiated from
other conditions; (b) data were duplicated in another publication
and (c) the statistical analyses precluded an examination of the
association between hearing loss and social isolation/loneliness.
The two authors screened the titles/abstracts and completed
the full-text review independently. Discrepancies were discussed,
and criteria were updated as necessary to clarify resolutions. A
total of 57 studies were included for data extraction (see
Figure 1).
Extracting data
Guidelines for data extraction were developed jointly by the
authors. The authors then reviewed a sample of three articles
together to assess and refine the guidelines. Once completed,
both authors reviewed the articles independently and entered
information extracted into tables in Microsoft Excel. Data extrac-
tion included: first author name, author affiliations, country of
first author, year of publication, aims, concept (association, inter-
vention, both), study type (quantitative, qualitative, mixed-meth-
ods), design, sample size, age of participants, other pertinent
participant characteristics (gender, living circumstances etc.),
hearing status, device use, how hearing was measured, how social
isolation was measured, how loneliness was measured, descrip-
tion of intervention, analysis and overview of key findings rele-
vant to social isolation and/or loneliness and hearing loss.
It should be noted that when extracting the information and
interpreting the findings, we used the author-given labels of
social isolation and loneliness; we did not relabel and re-categor-
ize studies using our interpretation of what was measured. We
did this because, as noted by the National Academies of Sciences
Engineering and Medicine report (2020) “The concepts of social
isolation and loneliness have been defined in different ways
which has led to some variability in how these concepts are
measured”. The report goes on to say that “a number of tools
capture elements of both social isolation and loneliness, which
may obscure differences between these two concepts”. (NASEM
2020, Chapter 6 pp107). In other words, our relabelling and re-
categorizing studies would not have yielded a clear set of
interpretations.
S32 A. BOTT AND G. SAUNDERS

Figure 1. Flow chart of studies included in scoping review.

Collating and summarising the results
Both authors reviewed the extracted data and worked together to
determine the most appropriate way to summarise the findings.
The final summary included categorisation of studies into one of
five groups based on study design as follows:
a. Quantitative comparison studies: studies that compared the
degree or presence of social isolation and/or loneliness
among two or more groups of participants, at least one of
which included adults with hearing loss.
b. Quantitative experiential studies: studies that examined the
association between hearing loss and social isolation and/or
loneliness among individuals selected for study participation
based on their hearing status.
c. Quantitative population-based studies: studies in which data
were extracted from large datasets often designed for longi-
tudinal epidemiological studies. Participants were not
included in these studies based on their hearing status, i.e.
the presence of hearing loss was incidental to their study
participation but was used as a variable in the analysis.
d. Quantitative interventional studies: Studies that examined
the effect of a hearing intervention, such as HAs, CIs or an
auditory rehabilitation program, on social isolation and/
or loneliness.
e. Qualitative studies: studies that used qualitative methods,
irrespective of whether it explored an association or the
effect of an intervention.
Two studies used mixed-methods. The authors came to agree-
ment as to which category these studies best fitted with. One
study was placed in the qualitative category (Smith 2012) and
one in quantitative experiential category (Canton and
Williams 2012).
Synthesising review findings
Finally, the findings were jointly synthesised by the authors
focussing on identifying the relationships between hearing and
social isolation/loneliness and their implications.
Results
Tables 1–5 provide key information about each study, separated
by study type (quantitative comparison studies, quantitative
experiential studies, etc.) to explore the association between hear-
ing loss and social isolation and/or loneliness. Each is discussed
Table 1. Summary of key findings of comparison studies (n ¼ 9).
Aims associated with Measures Relationship between hearing loss and:
hearing loss/hearing
interventions, loneliness
ID Authors and isolation Social isolation Loneliness Comparison groups Outcomes Social isolation Loneliness
1 Bosdriesz To examine psychosocial Not measured Loneliness 37 CI users CI users and NH were less NA Mixed
et al. (2017) health of people with Scalea 418 HA users emotionally lonely than
and without HL who 247 with untreated HL HA users and people
use or do not use 553 with NH with untreated HL.
interventions Age range 18–70 years (CI CI users and NH did not
users 5 years older than differ in emotional
other groups) loneliness.
Social loneliness did not
differ across HL groups
2 Hay-McCutcheon To examine the impact Positive Social Not measured 13 rural-dwelling NH Urban dwellers with HL Yes NA
et al. (2019) of HL on social Interaction Scale, 18 rural-dwelling HL were less socially isolated
interactions using MOS Social 24 urban-dwelling NH than rural dwellers with
MOS data Support surveyb 25 urban-dwelling HL Mean HL.
age: 60þ years HL was a predictor of
(NH individuals 4 years social isolation
younger than those
with HL)
3 King and To examine factors Not measured R-UCLA 20 NH with report HL Participants reporting NA Yes
Stephens (1992) associated with Loneliness 20 NH with no reported HL hearing problems were
auditory disability scalec Age matched groups. Mean significantly more lonely
with normal hearing age 30 years than those not reporting
hearing problems
4 Knutson and To examine the MMPI Social Revised UCLA 27 CI candidates Sample was more socially Yes Yes
Lansing (1990) relationship between introversion Loneliness Mean age ¼ 49.1 year isolated than norms.
reported scale 0d Scalee Revised UCLA Most participants would
communication published norms be described as being
function from CPHI “somewhat” to
and general measures “extremely” lonely
of loneliness, social
isolation and
other outcomes
5 Murphy and To investigate loneliness Not measured Revised UCLA 94 mainstreamed college Mainstreamed students NA Mixed
Newlon (1987) in mainstreamed Loneliness students identifying as were lonelier than NH
hearing impaired Scalee “deaf”, 76 mainstreamed students. Association
college students Self-report: college students between loneliness and
loneliness in identifying as “hearing adjustment to HL and
prior week impaired”, NH students, comfort using speech/
Norms from Russell, Peplau, sign. No difference in
and Cutrona (1980) UCLA loneliness of self-defined
scale, and NH students deaf and self-defined
hearing-impaired
students. No differences
in loneliness by college
year or gender
6 Øhre et al. (2017) To investigate whether Not reported Not measured 40 users of Norwegian sign No difference in social No NA
communication mode language (NSL) isolation between NSL
(sign vs. spoken 36 hearing impaired users and users of
language) impact of spoken language spoken language
mental health Mean age 36.7 years
(continued)
Table 1. Continued.
Aims associated with Measures Relationship between hearing loss and:
hearing loss/hearing
interventions, loneliness
ID Authors and isolation Social isolation Loneliness Comparison groups Outcomes Social isolation Loneliness
7 Ringdhal and To describe hearing and Swedish version of Not measured 311 HA users with profound HA users more socially Mixed NA
Grimby (2000) other factors in the Nottingham deafness isolated than age
relation to subjective Health Profilef Mean age ¼ 66.0 years matched norms. Working
health and compare 2356 age-matched norms people with HL had
them with age- lower isolation scores
matched than non-working
community sample individuals. Degree of HL
did not predict social
isolation within the
HL group
8 Stevens (1982) To examine the main Scale developed Not measured 50 HA users HA users were less socially Yes – benefit of NA
problems of people for study 49 people with untreated isolated than people with HA reported
who are deaf HL untreated HL
Age range 45–82 years
9 Thomas and To examine social and Questions developed Questions 211 HA users fitted between HA users were more lonely Yes Mixed
Herbst (1989) psychological effects for study developed 1970 and 1976, and more socially and
of acquired deafness for study 418 matched non-HA user emotionally isolated than
in working age adults controls the control group. No
provided with Age range 16–64 relationship between
NHS HAs degree of HL
and loneliness
CI: cochlear implant; CPHI: Communication Profile for Hearing Impaired; HA: hearing aid; HL: hearing loss; MMPI: The Minnesota Multiphasic Personality Inventory; MOS: Medical Outcomes Study; NA: not applicable; NH: normal
hearing; NHS: National Health Service (UK); NSL: Norwegian Sign Language; UCLA: University of California Los Angeles.
a
De Jong-Gierveld and Kamphuls (1985).
b
Sherbourne and Stewart (1991).
c
Hays and Dimatteo (1987).
d
Hathaway and McKinley (1943).
e
Russell, Peplau, and Cutrona (1980).
f
Wiklund (1992).
Table 2. Summary of key findings of experiential studies (n ¼ 5).
Aims associated with Measures Relationship between hearing loss and:
hearing loss, social Sample
ID Authors isolation and/or loneliness Social isolation Loneliness Hearing n ¼ age other Results Social isolation Loneliness
1 Canton and To examine social, Open-ended questionnaire Self-report or 74 HL resulted in social Yes Not reported
Williams psychological and ‘confirmed’ HL Range: 16–30 isolation in general
(2012) economic impacts of 31 reported HL (22%) and at
NIHL among dairy work (39%)
farmers in NZ
2 Chen (1994) To examine relations Not measured UCLA Self-report 88 HHIE correlated with NA Mixed
between hearing Loneliness Range: 65–90 loneliness in whole
handicap, loneliness Scale (mean ¼ 74.9) population and in
and low self-esteem in women, but not in
an elderly population men. HHIE-
emotional scale
showed stronger
associations with
loneliness than did
the HHIE-social scale
3 Christian To explore hearing loss Not measured UCLA Four-frequency 63 Loneliness scores did NA No
et al. (1989) and loneliness among Loneliness screening 65–74 years: n ¼ 30 not differ between
an older population Scalea 75–94 years: n ¼ 33 normal/mild HL
versus serious/
severe HL
4 Picou and To evaluate the Social Disconnectedness and Perceived Audiometry 83 Degree HL not No No
Buono (2018) relationship between Isolation scalesb Range: 22–80 associated with
emotional responses, 23 HA users degree of social
isolation and hearing isolation
or loneliness
5 Simpson To examine whether Not measured UCLA Loneliness Self-report: Do you 65 Higher internet use NA Yes
et al. (2018) internet usage by adult Scale V3c own HAs? Range: 65-81þ was associated with
HA users lowers All HA users lower loneliness
perceptions scores among
of loneliness HA users
6 Sung To investigate factors Not measured Revised UCLA Audiometry 145 Degree of HL was NA Yes
et al. (2016) associated with Loneliness Range: 50-80þ yr. associated with
loneliness among older Scalea 81 HA candidates, degree of loneliness.
individuals presenting 64 CI candidates People with severe/
to clinic for profound HL were
hearing assessment lonelier than those
with NH
7 Weinstein and To determine the Comprehensive Not measured Audiometry Hearing 80 Isolation scores were Yes NA
Ventry (1982) relationship between Assessment Measurement Range: 65-88 (mean ¼ 74) similar to norms.
social isolation and and Referral Scalee All with reported HL Degree of isolation
auditory performance Evaluationd was associated with
degree of HL.
Reported HL was a
predictor of
social isolation
CI: cochlear implant; HA: hearing aid; HL: hearing loss; NA: not applicable; NIHL: noise-induced hearing loss; NH: normal hearing; NZ: New Zealand; UCLA: University of California Los Angeles.
a
Russell, Peplau, and Cutrona (1980).
b
Cornwell and Waite (2009).
c
Russell (1996).
d
Gurland et al. (1977–1978).
e
Noble and Atherley (1970).
Table 3. Summary of key findings of population-based studies (n ¼ 21).
Aims associated with Measures Relationship between hearing loss and:
hearing loss, social
isolation and/ Social
ID Authors or loneliness Dataset Social isolation Loneliness Hearing n ¼ Age Results isolation Loneliness
1 Cheung To investigate Individuals who None InterRAI Self-report: 51,239 Reported hearing NA Yes
et al. (2019) sociodemographic, completed InterRAI loneliness single item mean: 82.3 years difficulty was a
physical, functional from 2014 to 2016a itema predictor of loneliness
and psychological
predictors
of loneliness
2 Cimarolli To explore effects of Fordham Centenarian None UCLA Loneliness Self-report 119 Reported hearing NA Yes
et al. (2018) sensory impairment study data Scale V3b single item Range: 95–107 difficulty correlated
among the with loneliness
oldest old
3 Dawes To model statistical UK Biobank Single item: Do you None Digit Triplet testc 64,770 Poorer hearing and HA Yesd NA
et al. (2015) associations often feel lonely? Not reported use were associated
between hearing with social isolation.
and cognition Effect of HA use on
accounting for the cognition was partly
mediating role of mediated by
social isolation social isolation
and depression
4 Dugan and Examine impact of Longitudinal study of Quantified based on Single item: Do Self-report 119 Reported hearing Not analysed Yes
Kivett (1994) emotional and social rural persons in social interactions you find single item Mean: 83 years difficulty was a
isolation on North Carolina yourself predictor of loneliness
loneliness in very feeling lonely
old rural adults
5 Guthrie To understand how a Canadian Institute for None InterRAI Subjective 26,495 with HL, More people with HL NA Yes
et al. (2018) sensory impairment Health Information loneliness ratings by 59,360 with than with NH
adds to impact of for people with itema interviewere NH were lonely
cognitive interRAI data range: 65–85þ
impairment on
health-
related outcomes
6 Harithasan To determine whether Long Term Research None R-UCLAf Audiometry 137 No sensory No differences in NA No
et al. (2019) sensory impairment Grant Scheme study loss, 46 HL, 27 loneliness across the
is independently VL, 19 DSI four groups. HL was
associated with 60þ years not a predictor
loneliness and more of loneliness
7 Hawthorne To examine prevalence South Australian Health Friendship scaleg None Self-report: 3015 Reported hearing Yes NA
(2006) and correlates of Omnibus Survey single item Mean: 45.3 years difficulty was
perceived social associated with
isolation in social isolation
a community
8 Kramer To examine the Longitudinal Aging Not measured Loneliness Scaleh Self-report: 3017 People with HL were NA Yes
et al. (2002) association between Study Amsterdam three items Range: 55–85 more lonely than
HL, chronic people with NH. HL
conditions and was a predictor
psychosocial status of loneliness
9 Maharani To test the hypothesis English Longitudinal Index of R-UCLAf Self-report: 8199 Reported hearing Yes Yes
et al. (2019) that higher rate of Study of Ageing social isolationi single item Mean: 62.8 years difficulty was
cognitive decline associated with
with poor hearing is isolation and
mediated loneliness. HL and
by loneliness episodic memory
scores were mediated
(continued)
Table 3. Continued.
Aims associated with Measures Relationship between hearing loss and:
hearing loss, social
isolation and/ Social
ID Authors or loneliness Dataset Social isolation Loneliness Hearing n ¼ Age Results isolation Loneliness
by social isolation
and loneliness
10 Mick To examine the Canadian Longitudinal None Single item: In Self-report: 19,325 HL was associated NA Yes
et al. (2018) association between Study on Aging the past week single itemj Range: with loneliness
sensory impairment, how often did 45–89 years
social engagement you
and loneliness feel lonely?
11 Mick and To determine whether National Health and NHANES SSQk None Audiometry and Varied by HL was associated with Mixed NA
Pichora- HL is associated Nutrition self-report measure and social isolation in
Fuller (2016) with social isolation, Examination Survey single item cohort from people age
and more among 465 to 1845 60–69 years only
people that might Varied by
benefit from measure and
hearing screening cohort Range
40–70þ years
12 Mick To determine whether National Health and NHANES SSQk None Audiometry 1453 More HL associated with Mixed NA
et al. (2014) age-related HL is Nutrition Range: social isolation in
associated with Examination Survey 60–84 years women aged
social isolation, and 60–69 years only
how age, gender,
income, race and/or
HA use moderate it
13 Nachtegaal To examine Netherlands None Loneliness Scaleh National 1588 HL was associated with NA Yes for HL
et al. (2009) relationship Longitudinal Study Hearing Testl Mean: 46.3 years loneliness. Use of HAs No for HA use
between hearing on Hearing did not
and self-reported impact loneliness
psychosocial
functioning
14 Pronk To examine the Longitudinal Aging None Loneliness Scaleh National Varied by cohort Rate of change in NA Mixed
et al. (2014) relationship Study Amsterdam Hearing Testl and measure hearing was
between rate of Range across all associated with rate
hearing decline and cohorts: of change in
rate of decrease in 57–97 years loneliness for
psychosocial health subcategories of
participants
15 Pronk To examine Longitudinal Aging None Loneliness Scaleh National Hearing Varied by HL (reported and NA Mixed
et al. (2011) longitudinal Study Amsterdam Test and self- participant measured) was
relationships report: type associated with
between hearing three itemsl and measure loneliness in
status, loneliness subcategories of
and more participants
16 Ramage- To examine the Canadian Community Two items from R- None HUI Mark 3m,n 30,176 HL was associated with Mixed NA
Morin (2016) association between Health Survey— UCLA combined Mean: 60.4 years social isolation in
HL and Health Aging with single sense of women but not men.
social solation community Male HA users were
belonging itemf more socially isolated
than NH males
17 Ray et al. (2018) To determine whether English Longitudinal Index of social None Two-frequency 7385 HL was associated with Mixed NA
untreated HL and Study of Ageing isolationi hearing Mean: 67.4 years higher odds of social
social isolation screening isolation among non-
explain the link HA users but not
between age related among HA users.
Social isolation was a
(continued)
Table 3. Continued.
Aims associated with Measures Relationship between hearing loss and:
hearing loss, social
isolation and/ Social
ID Authors or loneliness Dataset Social isolation Loneliness Hearing n ¼ Age Results isolation Loneliness
HL and mediating factor
cognitive decline between cognition
and HL
18 Savikko To examine prevalence Community dwelling None Single item: Do Self-report: 3915 HL was not a predictor NA Mixed
et al. (2005) of loneliness in the sample recruited you suffer single item Mean: 81.1 years of loneliness. People
Finnish older from The Finnish from with good hearing
population and its National loneliness? were less lonely than
association with Population register those with poorer
health- hearing. HA use did
related factors not impact loneliness.
Loneliness was rarely
attributed to HL
19 Stam et al. To understand Netherlands None Loneliness Scaleh National 508 HL was associated NA Mixed
(2016) longitudinal Longitudinal Study Hearing Testk Range: 18–69 longitudinally with
relationship on Hearing (mean ¼ 47) loneliness. Changes in
between decline in loneliness and
hearing and hearing were
psychosocial health associated in some
subcategories of
participants
20 Strawbridge To examine Alameda County Study Self-report: two items Self-report: Do Self-report: 2461 Degree of HL was Yes Yes
et al. (2000) relationship you feel three items Range: 50–102 associated with
between degree of lonely loneliness
HL and functioning or remote? and isolation
over time
21 Tomioka To evaluate relation Community-dwelling None Revised UCLA Self-report: 731 Odds of loneliness NA Mixed
et al. (2013) between self- adults recruited Loneliness single item Males: mean ¼ increased with
reported hearing through Scaleo and Japanese 71.0 yr. increased HHIE-S
and quality of life neighbourhood HHIE-S Females: score, but not with
associations mean single item self-report
¼ 70.0 years
22 Van der Werf To examine the Maastricht Aging Study Quantified based on Loneliness Scaleh Thresholds at .5, 1823 HL was associated with Yes No
et al. (2010) association between single item 1, 2 and 4 kHz Range: 24–86 social isolation but
HL and psychosis not loneliness
DSI: Dual Sensory Impairment; HA: hearing aid; HHIE-S: Hearing Handicap Inventory for the Elderly – screening version; HL: hearing loss; NH: normal hearing; NA: not applicable; UCLA: University of California Los Angeles; SIS:
Social Isolation Score; VL: vision loss.
a
InterRAI: International Resident Assessment Instrument.
b
Russell (1996).
c
Hall (2006).
d
Association between loneliness and hearing aid use in unexpected direction.
e
Rated using RAI-HC and MDS 2.0 instruments (www.interrai.org).
f
Hughes et al. (2004).
g
Hawthorne (2006).
h
De Jong-Gierveld and Kamphuls (1985).
i
Steptoe et al (2013).
j
Answered for aided hearing if applicable.
k
Seeman and Berkman (1988).
l
Smits et al. (2004).
m
Feng et al. (2009).
n
Feeny et al. (2002).
o
Russell, Peplau, and Cutrona (1980).
Table 4. Summary of key findings of interventional studies (n ¼ 8).
Relationship between hearing
Aims associated with Measures loss and:
hearing loss, social Sample
isolation and/ n¼
ID Authors or loneliness Social Isolation Loneliness Hearing Design Age Results Social isolation Loneliness
1 Applebaum To examine impact of Not measured UCLA Loneliness Audiometry Intervention: HAs and CIs. 81 HAs did not change NA Mixed
et al. (2019) HAs and CIs Scale V3a Assessment: pre- Range loneliness. CIs decreased
on loneliness intervention, and 6 63.5  78.5 years loneliness initially, but
month, 12 and 60 loneliness returned to near
months post-intervention baseline by 5 years
2 Bai and To examine impact of CI Open-ended Self-report: Intervention: CIs. 47 CIs decreased social isolation. Yes, for Not revealed
Stephens on quality of life problems questionnaireb Single item Assessment: pre- Range: 21–78 years HL and social isolation intervention
(2005) using an open-ended implantation and at (mean ¼ 52.4) only associated at 12 and Mixed for HL
questionnaire approx. 6, 12, 24 and 36- 24-month post-
month post-implantation implantation
3 Cooper (1995) To examine how CIs Questions Not measured Not measured Intervention: CIs. 18 Pre-implantation participants Yes NA
change quality of life developed Assessment: 1-mth pre-CI Range: 55–64 years were more socially isolated
and whether it is for study switch on, 1 and 6- than norms.
maintained over time month post switch on CI decreased social isolation
to normative level by 1
month. No
change thereafter
4 Jones To examine feasibility Not measured Loneliness Self-report: Hearing Intervention: GAR vs. no 66 Emotional loneliness NA Mixed
et al. (2019) and impact of a Scalec Handicap GAR. Mean: 74.5 years decreased following GAR
group exercise/social Inventory for the Assessment: attendance. Social
program Elderly-25d Pre- and post- loneliness did not change
supplementing intervention period
GAR program
5 Knutson To assess the Minnesota Revised UCLA Audiometry Intervention: CIs. 37 Pre-implantation participants Yes Yes
et al. (1998) psychological state of Multiphasic Loneliness Assessment: pre- Range: 24–70 years were more socially isolated
experienced CI users Personality Scalef implantation and at 9, mean ¼51.8) than norms.
Inventory 18, 30, 42 and 54-month CI decreased social isolation
Scale 0e post-implantation and loneliness at each
time point.
Measured CI benefit
correlated with change
in loneliness
6 Sarant To investigate how CIs Lubben Social Loneliness Audiometry Intervention: CIs. 59 CI did not change loneliness No No
et al. (2019) impact quality of life Network Scaleg Scalec Assessment: pre- Range: 61–89 years, or social isolation
implantation and at 18 (mean ¼ 72.3)
months post-implant
switch on
7 Weinstein, To determine whether Not measured Loneliness Audiometry Intervention: HAs. 40 HAs decreased emotional NA Yes for HAs.
Sirow, and HAs impact Scalec Assessment: pre-fitting and Range: 62–92 years loneliness but not social No for degree
Moser (2016) loneliness 4–6 weeks post-fitting (mean ¼80.4) loneliness. Change of HL
greatest for people with
more HL. Degree of HL
was not associated with
degree of loneliness
8 Zhao To determine how CIs Open ended problems questionnaireb Not Audiometry Intervention: CIs. 24 CI decreased social isolation. Yes Not revealed
et al. (2008) change reported Assessment: pre- Range: 32–78 years Scores plateaued by
quality of life implantation and at 9, (mean 18–24 months
12, 18, 24, 36 and 48 ¼53.8 years)
weeks post-implantation
CI: cochlear implant; GAR: group audiological rehabilitation; HA: hearing aid; HL: hearing loss; NA: not applicable; UCLA: University of California Los Angeles.
a
Russell (1996).
b
Barcham and Stephens (1980).
c
De Jong-Gierveld and Kamphuls (1985).
e
Hathaway and McKinley (1943).
f
Russell, Peplau, and Cutrona (1980).
g
Lubben (1988).
Table 5. Summary of key findings of qualitative studies (n ¼ 11).
Aims associated with
hearing loss,
ID Authors social isolation and loneliness
Experiential studies
1 Aguayo and To examine psychological
Coady (2001) and sociological effects
resulting from deafness
2 Barlow et al. (2007) To examine the experience
of living with
acquired deafness
3 Bennion and To explore and understand
Forshaw (2013) experience of living
with HL
4 Heffernan To explore psychological
et al. (2016) experiences of adults
with HL
5 H
etu et al. (1988) To understand handicap
associated with
occupational
noise exposure
6 Hughes et al. (2018) To explore how listening
effort impacts
relationships and
shared activities
7 Ingram et al. (2016) To understand the
perspectives of people
with HL, their family
and their friends
towards hearing loss
Relationship between hearing loss and:
Qualitative method Study sample Results Social isolation Loneliness
Thematic analysis Eight deaf individuals Problems communicating with Yes Not reported
of interviews Age range: 31–68 years family lead to feelings of
(mean ¼ 49 years) being isolated within the
Users of HAs, CIs, and family, that family members
neither overlooked their needs and
minimised the situation. All
felt socially isolated in general,
and inadequate in social
situations. Withdrawal/
avoidance lead to
more isolation
Framework analysis Nine adults with acquired Deafness caused physical and Yes Yes
of interviews deafness emotional isolation
Age range: 33–60 years and loneliness
Descriptive thematic 9 HA users Inability to hear household Yes Not reported
analysis Age range: 61–93 years sounds (e.g. phone, doorbell)
of interviews resulted in missing visitors and
phone calls, and thus to
social isolation
Thematic analysis 15 HA users with mild to Communication difficulties and Yes Yes
of interviews moderate HL participation restrictions from
Age range: 20–91 years HL led to sensations of
(mean ¼ 68.8; loneliness and isolation
SD ¼16.5)
Combination of n ¼ 61 workers plus their In groups, persons with HL felt Yes Not reported
phenomenological spouses isolated, less communicative,
and content Age: mean ¼ 39.5 years and less participatory
analysis of Presence/absence and than others
interviews degree of HL varied
among workers
Grounded theory 11 CI users As HL progressed individuals Yes. CI Yes
methodology 4 HA users waiting for CI began to disconnect, which decreased
applied to focus 2 NH spouses resulted in increasing isolation. isolation
group data Age range 20–70þ HL threatened social
connectedness, leading to
feeling invisible, lonely, like an
outsider. Following
implantation, reconnection
was sought, resulting in
increased social connectedness
Content analysis 20 adults with HL Adults with HL reported HL Yes Yes
using socio- 27 family members/ friends negatively impacted social
ecological model Adults with HL engagement. Family said HL
of interviews with age> 50 years caused the person with HL to
adults with HL. feel isolated and lonely
Focus group data
from family
members/friends
(continued)
Table 5. Continued.
Aims associated with Relationship between hearing loss and:
hearing loss,
ID Authors social isolation and loneliness Qualitative method Study sample Results Social isolation Loneliness
8 Smith (2012) To explore the meaning of Interpretive 12 community-dwelling Participants attributed loneliness Yes Yes
loneliness in phenomenological adults reporting to declining health, including
community-dwelling analysis loneliness hearing—not being able to
older adults of interviews Age: 74–98 years engage meaningfully, lead to
feelings of isolation and being
left out
Interventional studies
9 Barlow et al. (2007)a To examine impact of LINK Framework analysis Nine adults with acquired LINK programb participants said Not reported Yes. LINK program
rehabilitation course of interviews deafness the program gave them a decreased
Age not reported sense of belonging, and made loneliness
them realise they were
not alone
10 Ross and To examine effects of HL Thematic analysis Six CI users and their Pre-implantation, participants Yes. CI Not reported
Lyon (2007) pre-and post-cochlear of interviews normal hearing partners reported a downward spiral of decreased
implantation Age range: 46–71 years withdrawal and reduced social isolation
(Mean ¼ 67 years) contact. Post-implantation
they engaged in wider social
interaction
11 Maki-torkko To examine pre-operative Inductive content 101 CI users; 87 family All described experiences of Yes. Family said CI Not reported
et al. (2015) expectations and post- analysis of open- members/friends: isolation prior to CI. Family decreased
operative impacts of CIs ended Age range: 27.1–91.7 years members considered CI isolation
on users and questionnaire (Mean ¼ 66.0 years) decreased isolation and
family/friends responses worried that if CI
malfunctioned the person with
HL would become isolated
12 Smith et al (2016) To evaluate the impact of Thematic analysis 12 adults with self- Individual attended WISC because Yes. WISC program Not reported
attending a sensory of interviews reported HL, 7 of whom HL had caused feelings of decreased
support centre had measured HL isolation. Individuals given HAs isolation
support (WISC) Age range: 61–85 said the HAs positively
impacted social interaction
CI: cochlear implant; HA: hearing aid; HL: hearing loss; NH: normal hearing; WISC: WESTERN Isles Sensory Centre.
a
Study included as both experiential and intervention.
b
An intensive two-week rehabilitation program for people with hearing loss.
S42 A. BOTT AND G. SAUNDERS
below. Supplementary Data File 3 shows the distribution of stud-
ies by country and year of publication.
Nine studies compared social isolation and/or loneliness
among two or more populations, at least one of which included
adults with hearing loss. Three studies examined loneliness only
(ID 1, 3, 5), four studies examined social isolation only (ID 2, 6,
7, 8) and the remaining two examined both social isolation and
loneliness (ID 4, 9). Of those that examined social isolation, four
showed social isolation was associated with hearing loss, in that
people with hearing loss had higher social isolation scores as
compared to people without hearing loss (ID 2, 4, 7, 9) and one
showed that HAs can improve social isolation relative to no
intervention (ID 8). Of the studies that examined loneliness, five
showed that relative to normative data and people with normal
hearing, people with hearing loss are more lonely (ID 1, 3, 4, 5,
9); and one showed that CIs can improve loneliness relative to
no intervention (ID 1).
Seven studies examined how hearing status related to social
isolation and/or loneliness among different groups of individuals.
Two studies examined both social isolation and loneliness (ID 1,
4), four studies examined loneliness only (ID 2, 3, 5, 6) and one
study examined social isolation only (ID 7). Of the three studies
that examined social isolation and hearing loss, two showed an
association (ID 1, 7). Of the studies that examined loneliness,
three showed no association (ID 3, 4,5), one showed an associ-
ation only for sub-groups of participants (ID 2) and one showed
that more hearing loss was associated with higher loneliness
scores (ID 6).
Twenty-two studies examined the association between hearing
loss and social isolation and/or loneliness using population-based
datasets. Of the studies that examined the relationship between
hearing loss and social isolation, four reported that hearing loss
was a predictor of social isolation, or that degree of hearing loss
correlated with degree of reported social isolation (ID 7, 9, 19,
21). The findings of four studies showed associations for subcate-
gories of participants only (ID 11, 12, 16, 17).
Of the studies that examined the association between hearing
loss and loneliness, ten reported a significant association across
the study population (ID 1, 2, 4, 5, 6, 8, 9, 10, 13, 20), five found
an association for subcategories of participants (ID 14, 15, 18,
19, 21), and two found no association between hearing loss and
loneliness (ID 6, 22).
Eight studies investigated the effect of hearing interventions
on social isolation and/or loneliness. Of these, all five studies
that examined the outcomes of a hearing intervention on social
isolation, did so for CIs (ID 2, 3, 5, 6, 8). Four of the five studies
showed that CIs decreased social isolation (ID 2, 3, 5, 8) and one
did not (ID6).
Seven studies examined the effect of hearing interventions on
loneliness (ID 1, 2, 4, 5, 6, 7, 8). Hearing interventions included
CIs and/or HAs, and the effect of Group Audiological
Rehabilitation (GAR) supplemented with an exercise program.
Only one of the five studies that examined the impact of CIs on
loneliness showed them to reduce loneliness (ID 5). Regarding
the impact of HAs on loneliness, one showed that HAs reduced
loneliness (ID 7) and one did not (ID 1). The GAR program had
positive effects on emotional loneliness, in that emotional loneli-
ness was lowered, but did not impact social loneliness (ID 4).
The most common methodological approach used by qualita-
tive studies was that of thematic analysis (n ¼ 5). Ten of the 11
qualitative studies explicitly asked adults with hearing loss to dis-
cuss their experiences of hearing loss and identified social isola-
tion and/or loneliness as a theme, while one (ID 8) focussed on
exploring loneliness in older adults more generally. In this latter
study, the participants spontaneously brought up the impact of
hearing loss describing how it contributed to both loneliness and
isolation. Of the ten other qualitative studies, six explored the
experience of living with hearing loss (ID 1, 3, 4, 5, 6, 7), three
examined perceptions related to an intervention for managing
hearing loss (ID 10, 11, 12, 13), and one related to both experi-
ences of living with hearing loss and perceptions of a hearing
loss intervention (ID 2, 9—note this is the same study, but find-
ings are reported relevant to experiences and interventions separ-
ately). Three studies revealed that people with hearing loss
experience social isolation rather than loneliness (ID1, 3, 5).
Three revealed that social isolation decreased after an interven-
tion (ID, 11, 12, 13) and one study identified that loneliness
decreased after a hearing intervention (specify hearing interven-
tion) (ID 9).
Discussion
This article reports the findings of a scoping review conducted
to review the research examining the association between hearing
loss, social isolation and loneliness, with a view to identifying
future research needs and guiding clinical practices. Fifty-seven
empirical studies were included, most of which have been pub-
lished since 2015 (see Supplementary File 3), indicating that the
topic is of current interest. The studies reviewed were highly het-
erogeneous in terms of methodology, participants and measures.
The key findings of the review are that hearing loss is associ-
ated with both social isolation and loneliness, that this applies
across the life span and that this association is somewhat inde-
pendent of degree of hearing loss. Further, when participants
qualitatively describe the impacts of their hearing, they more
often use vocabulary around social isolation than loneliness.
Finally, research examining the impact of hearing interventions
on social isolation and loneliness is relatively sparse, those stud-
ies that have been conducted indicates that hearing interventions
can be effective at decreasing social isolation and loneliness. We
discuss each of these points below.
Almost all studies that examined social isolation showed a
positive association between hearing loss and social isolation
while, for studies examining loneliness, just over half of all stud-
ies showed a positive association between hearing loss and loneli-
ness with a further third showed mixed outcomes such as the
finding only applying to a subset of participants. These findings
are unsurprising in light of the recent review of Shukla et al.
(2020), because our review included all but one of the papers
reviewed by Shukla et al. (2020). The one paper not included
here is Wells et al. (2020), in which 20,244 individuals aged
65 year and older were surveyed via an automated telephone
interview to explore whether a variety of physical and psycho-
social conditions, including loneliness, were associated with hear-
ing loss and HA use. This paper was omitted from our review
because it was published after the date of our original search.
They found no association between loneliness and HA use
regardless of degree of self-reported hearing loss (mild versus
severe), which is in line with the findings of Applebaum et al.
(2019) but not with those of Weinstein, Sirow, and
Moser (2016).
It was evident that loneliness and social isolation are both
associated with hearing loss in adults of all ages. This was con-
cluded from the findings of studies in which all participants
were younger than age 65 years and that reported associations
between hearing loss and social isolation (Canton and Williams

2012; Hawthorne 2006), or between hearing loss and loneliness
(King and Stephens 1992; Murphy and Newlon 1987; Nachtegaal
et al. 2009). Two qualitative studies also support this: Barlow
et al. (2007) noted reports of both loneliness and social isolation
among their deaf participants who were aged 33–60 years, and
H
etu et al. (1988) reported that workers with hearing loss (mean
age 39.5 years) felt socially isolated at work. There is evidence
that the implications of hearing loss for health and well-being
may differ with age and with age of onset of hearing loss. For
example, social isolation and loneliness in older adults (over the
age of 65 years) increases the risk of all-cause mortality (NASEM
2020), whereas in younger adults it increases the risk of depres-
sion (Loades et al. 2020). Thus, hearing interventions provided
to adults with hearing loss may have different mitigating health
effects, depending on the age of the individual.
Hearing interventions have the potential to mitigate the nega-
tive health impacts of social isolation and loneliness by ensuring
adequate audibility to facilitate social interaction and thus
encourage patients to connect socially. Our review showed that
CIs have been relatively more widely examined than HAs, per-
haps because it is thought that CIs have a greater potential to
impact social isolation and/or loneliness than do HAs. The data
do indeed bear this out, in that four of five studies showed CIs
to decrease social isolation, and one of five showed CIs to
decrease loneliness. Conversely, for HAs, none have examined
the impact of HAs on social isolation, and one of two studies
showed HAs decreased loneliness. Further, note that Wells et al.
(2020) also found that HAs did not impact loneliness. It should
be noted however, that in these studies (and in most of the
others reviewed here), participants had low loneliness scores i.e.,
were not particularly lonely, thus it the impacts of an interven-
tion would be difficult to measure. A further point to note is
that the participants in the intervention studies are unlikely to be
representative to the true population of people with hearing loss,
since the vast majority of people with hearing loss wait for
between 5 and 10 years before seeking help for their hearing after
becoming aware of hearing difficulties (Davis et al. 2007). The
lack of help seeking might be influenced by their being socially
isolated, and thus not seeing value in accessing hearing services.
As mentioned above, participants giving open-ended reports
about the impacts of HL, more often used vocabulary referring
to feelings of social isolation than to feelings of loneliness. It is
not possible to determine whether this is because hearing loss is
more strongly associated with social isolation, or whether it is
because reporting feelings of social isolation is less stigmatising
than reporting feelings of loneliness (Aguayo and Coady 2001;
Bennion and Forshaw 2013; H
etu et al. 1988; Ross and Lyon
2007; M€aki-Torkko et al. 2015; Smith et al. 2016). Indeed, admis-
sion of being lonely is often considered to be stigmatising
(Rokach and Brock 1997). Nonetheless, the observation might
indicate that providing interventions that facilitate connections
between individuals might be a way to ameliorate the situation.
Indeed, two of the reviewed studies used an intervention with a
social component. Jones et al. (2019) used an intervention that
involved a combination of GAR and an exercise program which
was found to decrease emotional loneliness among participants
relative to individuals who did not attend the program. Smith
et al. (2016) examined the impacts of attending a sensory sup-
port centre. Thematic analysis of interviews conducted with
attendees revealed that for some, attendance at the centre was
motivated by feelings of isolation, and that attendance had
decreased these feelings. Together, these studies suggest that pro-
viding hearing assistive technology in combination with
INTERNATIONAL JOURNAL OF AUDIOLOGY S43
providing a forum for interaction, whether for socialising, educa-
tion, or exercise, has the possibility of connecting people with
hearing loss who feel socially isolated with others.
Loneliness is considered to reflect subjective negative feelings
associated with perceived paucity of a wider social network or
absence of desired companionship while social isolation is
defined as an objective and quantifiable reflection of one’s social
network. It could thus be hypothesised that loneliness is more
strongly associated with perceived hearing than measured hear-
ing, while the converse is true for social isolation. To examine
this, we looked at the findings of studies in which hearing was
assessed using both self-rated and behavioural measures and
their associations with loneliness and/or social isolation were dir-
ectly compared. This applies for just two studies (Weinstein and
Ventry 1982; Pronk et al. 2011). Weinstein and Ventry (1982)
determined that social isolation was significantly associated with
both self-rated and behaviourally assessed hearing, but that self-
rated hearing was more strongly associated with subjective isola-
tion than measured hearing (r ¼ 0.52 versus r ¼ 0.39, respect-
ively) while here was little difference for objective isolation
(r ¼ 0.26 and 0.24, respectively). Social isolation reflected the
respondent’s reaction to constrictions in social networks, feelings
of loneliness and inferiority, reduced interest in leisure activities,
and desire to withdraw from others, while objective isolation
reflected the number of face-to-face contacts with friends and
relatives, contacts with distant significant others, and involve-
ment in a variety of leisure activities during the month prior to
the interview. This supports the hypothesis above. Conversely,
Pronk et al. (2011) examined the association of loneliness with
self-rated and behaviourally assessed hearing and reported that
both predicted adverse effects on social and emotional loneli-
ness—but only for specific subgroups of individuals. With such
limited data it is not possible to support or refute the hypothesis
but it is an avenue for future research.
It is worthy of mention that there was considerable overlap
across studies in the measures used to assess loneliness, but this
was not the case for measures of social isolation. Specifically, 10
studies used the de Jong Loneliness Scale (De Jong-Gierveld and
Kamphuls 1985) and 11 used a version of the UCLA loneliness
scale (Hays and DiMatteo 1987; Hughes et al. 2004; Russell 1996;
Russell, Peplau, and Cutrona 1980). On the other hand, no two
studies from different research groups used the same measure of
social isolation. Aspects such as social network size, frequency of
social interactions, and perceived social support were all assessed
under the umbrella term social isolation. However, in these stud-
ies these sub-constructs were considered to be umbrella measures
of social isolation. However, these sub-constructs differ from one
another as illustrated by studies showing that with age, social
network size decreases and yet social support increases (van
Tilburg 1998). It therefore would seem important that the associ-
ation between different sub-constructs of social isolation and
hearing loss are examined independently if a thorough under-
standing of the impacts of hearing loss on social isolation is to
be attained.
All but one of the reviewed studies assessed social isolation
and loneliness from the perspective of the individual with hear-
ing loss. It is important to recall however, that the communica-
tion partners of people with hearing loss are also affected, the
impacts of which can lead to withdrawal from social activities
and interactions (see meta-analysis by Barker, Leighton, and
Ferguson 2017). To gain a more complete picture of healthy
aging, studies examining social isolation and loneliness from the
S44 A. BOTT AND G. SAUNDERS
perspective of communication partners of people with hearing
loss should be conducted.
In sum, this review showed distinct associations between
hearing loss, loneliness and social isolation. These associations
likely arise because hearing loss leads to behavioural changes
resulting from having to cope with listening to a degraded audi-
tory signal, the consequences of which are difficulties under-
standing speech, and/or speech being more effortful to decode.
This can lead to increased fatigue (Holman et al. 2021) and a
decreased desire to participate in social situations (Pichora-
Fuller, Kramer, and Wingfield 2016). Thus, people with hearing
loss can become frustrated, withdrawn, socially isolated and/or
lonely (Shukla et al. 2020). This sequence of events likely
explains why interventions that improve the auditory signal (e.g.
HAs/CIs) tend to decrease social isolation and loneliness.
Clinical application
As discussed in Saunders, Vercammen, and Bott (2021), there is
debate as to the extent to which audiologists should screen for
non-audiological conditions such as social isolation and loneli-
ness and how these can be used as outcome measures.
Nonetheless, as noted by Clark, English, and Montano (2020), it
is important that hearing care professionals are aware that their
patients might be socially isolated and/or lonely and should be
equipped to address this in their practice—by for example, refer-
rals to social support services.
For clinicians who want to integrate screening of loneliness
and/or social isolation into their practice, they should be aware
that these are different constructs and that these can fluctuate
independently over time (NASEM 2020). There are a number of
validated tools available to measure one or both constructs.
NASEM (2020) recommends using the Berkman-Syme Social
Network Index (Berkman and Syme 1979) for measuring social
isolation and the three-item UCLA Loneliness scale (Hughes
et al. 2004) for measuring loneliness.
This review highlights the need for hearing care professionals
to work collaboratively with other care professionals (i.e. geriatri-
cians, general practitioners, allied health professionals), to
address loneliness and social isolation in people with hear-
ing loss.
Likewise, health professionals, and in particular geriatricians
need to aware that hearing loss contributes of social isolation
and loneliness. They should therefore consider encouraging their
patients to seek hearing health care if they encounter a person
with untreated hearing loss. The coronavirus pandemic has cer-
tainly raised awareness about social isolation and feelings of
loneliness and thus, there has never been a more opportune time
to implement strategies for managing social isolation and loneli-
ness and bringing to the forefront the recognition that hearing
loss is a factor associated in both.
Limitations
While this review was conducted following a search of three
databases, we did omit the grey literature and studies that were
not published in English, thus some relevant work is likely to
have been missed. Further, our review did not appraise the qual-
ity of the studies, and our search criteria did not include the
terms HAs or CIs, nor terms for sub-constructs of social isola-
tion and loneliness so again some relevant studies might have
been omitted. Secondly, as described in the methods, we decided
to use the author-given labels of social isolation and loneliness;
we did not relabel and re-categorize studies using our interpret-
ation of what was measured. As a result, some readers may dis-
agree with the categorisation of some of the studies included in
this review. However, we do not believe that relabelling and re-
categorizing the studies would necessarily have yielded greater
clarity in interpretations. The important message to take away is
that researchers must clearly differentiate between social isolation
and loneliness in terms of how they are referred to, measured,
and interpreted if the field is to gain a good understanding of
hearing as it relates to the distinct constructs of social isolation
and loneliness.
Conclusion
This scoping review identified that hearing loss is associated with
both social isolation and loneliness. Moreover, it has identified
that these associations occur for adults across their lifespan and
with varying degrees of hearing loss. Clinicians should be aware
that social isolation and loneliness are risk factors for patient
wellbeing and should refer patients at risk to appropriate support
services. Future research should consider social isolation and
loneliness as independent constructs, it should examine the rela-
tionship and influence of hearing interventions on these con-
structs and should focus on people who identify as being socially
isolated and/or lonely. Such research may provide insights into
ways social isolation and loneliness can be addressed among peo-
ple with hearing loss.
Disclosure statement
Dr Anthea Bott is employed as a research scientist with
GN Hearing.
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
Anthea Bott http://orcid.org/0000-0003-1824-388X
Gabrielle Saunders http://orcid.org/0000-0002-9997-0845
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