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International Journal of Audiology

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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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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 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 cover- ings 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 connected- ness, and willingness to engage in conversation; they increased anxiety and stress, and made communica- tion 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.

ARTICLE HISTORY Received 8 October 2020 Revised 7 November 2020 Accepted 10 November 2020

KEYWORDS COVID-19; face coverings; masks; hearing; hearing loss; communication; lipreading; visual cues; facial expressions

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 transmis- sion 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 transmis- sion, 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 cov- erings by measuring sound transmission through various types of mask, including surgical masks, respirators, masks with a

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 con- sistently illustrated that masks act as low-pass filters, attenuating output above 2 kHz. The extent of this attenuation is mask- dependent with surgical masks being least attenuating (decreas- ing 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 exam- ining 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

CONTACT Gabrielle H. Saunders [email protected] Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester, UK

Supplemental data for this article is available online here.

� 2020 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society

INTERNATIONAL JOURNAL OF AUDIOLOGY 2021, VOL. 60, NO. 7, 495–506 https://doi.org/10.1080/14992027.2020.1851401

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 COVID- 19 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 con- cerned about this, and that more severe hearing loss was associ- ated with greater levels of concern. The difference, however, was not statistically significant. Henn et al. (2017) conducted inter- views 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 informa- tion 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 expres- sions indicating happiness and disgust. It has less impact for rec- ognition 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 systemat- ically covered (Wegrzyn et al. 2017). The real-world impact on emotion perception from covering the mouth region was illus- trated by Wong et al. (2013), who showed that although satisfac- tion with a medical appointment was not affected when the physician was wearing a face covering, the physician was per- ceived 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 interac- tions 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 experi- ences 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 complet- ing 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 begin- ning the survey.

Survey

The survey examined the impacts of face coverings on communi- cation 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 open- ended 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), self- reported hearing ability, and use of hearing assistive tech- nology (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 conver- sation 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 hos- pital appointment, with hospital staff as an in-patient, and with a pharmacist, a shop assistant, and a bus/train con- ductor. The option to add an “other” situation was also pro- vided. Additional items assessed whether participants thought face coverings impacted communication, and an open-ended question asked for general thoughts about talk- ing 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 cover- ing. This was evaluated with items asking whether the par- ticipants 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 per- spective. Four multiple choice items queried participants’ general attitudes about face coverings and transmission of COVID-19.

Study data were collected and managed using REDCap elec- tronic data capture tools hosted at the University of Manchester. REDCap (Research Electronic Data Capture) is a secure, web- based 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 ques- tions were then only presented for those particular situations.

496 G. H. SAUNDERS ET AL.

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,

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%, n¼ 365), and white (93.3%, n¼ 429). Figure 1 shows the ages of participants as a function of their self-reported hearing. While the overall proportion of indi- viduals 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 partici- pants’ 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, feel- ings of being engaged and connected were affected when listen- ing to someone wearing a face covering. Note that questions about engagement and connectedness were not asked of conver- sations with shop assistants since it was assumed that these inter- actions would have been short and limited to information exchange.

Figure 1. Self-reported hearing by age group. Number of particpants in each age group is shown at the top of each bar.

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.

INTERNATIONAL JOURNAL OF AUDIOLOGY 497

With very few exceptions, participants reported that face cov- erings 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

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 vis- ual cues it is more difficult to interpret the meaning of an interaction, and that social distancing exacerbates these prob- lems. 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 per- ceptions 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 cover- ings elicited many emotional reactions, made it harder cogni- tively, 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 com- municate because some of us will not understand what is being said. I feel overwhelmed and quite upset”. At a cognitive level,

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 247 53.7 Family/friends 108 23.5 Pharmacist 98 21.3 At work 96 20.9 Doctor appointment 84 18.3 Hospital out-patient appointment 75 16.3 Other 23 5.0 Bus/train conductor 21 4.6 Other medical-related appointment 18 3.9 As a hospital in-patient 13 2.8

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).

498 G. H. SAUNDERS ET AL.

participants reported the need to use extra concentration and effort to communicate, and that they were more fatigued fol- lowing 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 pan- demic and, among people with hearing loss, were a reminder of the time before they had obtained hearing assist- ive technology.

Theme 5: Impact on behaviour. This theme reflected coping mechanisms – some were solution-focused approaches, while others were about avoidance. Solutions included the techno- logical 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 com- municating 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 refer- ence 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 cover- ing, 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 con- tent analysis. The resultant themes and categories are shown in Tables 3 and 4 and are discussed below.

Four themes associated with communicating differ- ently 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 communi- cate, and a focus on gaining and maintaining eye contact dur- ing 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, feel- ing 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 con- tent of communication is quite different when face coverings are present: interactions are shorter, more direct and less com- plex, informal chat is omitted, and that content is less humor- ous, less deep, and lacking.

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 conversa- tion (upper graphs) and feeling engaged in the conversation (lower graphs), using conversations with family/friends (F/F) and the doctor (Doc) as examples.

INTERNATIONAL JOURNAL OF AUDIOLOGY 499

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 Categories Codes Examples

Hearing Sound Muffled Even though I’m always wearing hearing aids, masks muffle the sound Muffles the sound so can be difficult to hear words properly

Volume 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

Individual differences 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

Visual cues lips/ expressions Needed for communication 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

Non-verbal cues 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

New awareness 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

Social distancing … 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

Impact on the interaction

Content Focus 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

Duration 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

Perceptions Flow 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

Interpersonal 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

Non-verbal content 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

Impact on the Individual

Emotions Anxiety/stress 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

Isolation/ disconnection/ disengagement

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

stupid/ inadequate 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

vulnerability/ fear 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

Sadness/ distress/upset/ suicidal

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)

500 G. H. SAUNDERS ET AL.

Table 2. Continued.

Themes Categories Codes Examples

Embarrassment 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

Loss of confidence/ intimidated 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

Frustration/ anger 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

Cognitive factors Concentration It requires great concentration and in the end I lose the will to continue… Have to concentrate on the conversation more

Fatigue I feel very drained by it all At work it is exhausting and I have to keep asking for clarity

Effort 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

Associations COVID 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

Past problems 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

Impact on behaviour Solution-focused Technological 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

Non-technological 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

Communication strategies 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

Avoidance Participation I try not to go out unless I have to and try, where I can to avoid or reduce communication

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

Reliance on others 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

Social impacts Interpersonal Recognition They also cause difficulty in recognising a person in the first place Smiles 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

Empathy 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

Communicative Barriers 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

Non-verbal cues 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

Big picture Acceptance Concern for others 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

Tolerance 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!

Future Concerns 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.

Positives 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

INTERNATIONAL JOURNAL OF AUDIOLOGY 501

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 spon- taneous, 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, p¼ 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 pro- tecting 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).

Discussion

The arrival and rapid spread of the COVID-19 pandemic trig- gered a global increase in the use of face coverings in an attempt to reduce transmission of the virus. One unintended conse- quence of face coverings, however, is their impact on communi- cation. 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 communi- cation, 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 communica- tion (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 gov- ernment made it mandatory to wear a face covering in shops (Department of Health and Social Care, UK 2020), one can only

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 Categories Examples

Delivery Manner 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

Linguistic I keep it as brief as possible Keep words to a minimum Speak more carefully and as little as possible

Compensatory Probably shouted/spoke louder than I needed My voice was raised to what would be described as being at a “shouting” level

Body language Gestures/facial expressions 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

Voice 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

Eyes Try to smile with my eyes I make sure I’m really smiling, so people can see my eyes are welcoming

Eye contact 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

Awareness of others needs Cues from others 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

Social pressure 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

Face covering specific 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

Inward changes Actions 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

Self-image I am less confident I feel more self-conscious of how I am communicating

502 G. H. SAUNDERS ET AL.

assume that more people are now encountering communica- tion problems.

It is important to remember however, that while communica- tion 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

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 Examples

Impact on content Duration 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

Content 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

Depth Less in depth I tend to just say Yes or No to questions instead of going into details

Humour 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

Complexity I used simpler and more direct phrases More straight forward, simpler sentences Conversations with a face covering have now been shortened to small sentences

Expression 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

Completeness They were shorter, missing information Shorter / more limited because it’s harder work

Social impacts Content Less personal conversation Less subjective/ emotional matters

Connection Conversation is less engaging Less “chat”, more likely to just speak when necessary, therefore less human connection

Relationships More time is needed to build up rapport Has affected usual social interactions (jokes, long conversations etc.), hence relationships

Spontaneity Less spontaneous conversation with strangers They are less spontaneous

Emotions 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.

INTERNATIONAL JOURNAL OF AUDIOLOGY 503

interpreting of facial expressions, at the expense of increased sound attenuation by transparent materials, might be an accept- able 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 commu- nicate (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 reus- ability 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 devel- oped for the National Acoustic Laboratories (NAL) fitting algo- rithm (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 predict- ability 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 anx- iety 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 eli- cited a diverse array of negative emotions, including anxiety, iso- lation, feeling stupid, and losing confidence. These same emotions are also associated with untreated hearing loss (Preminger and Laplante-L�evesque 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 communi- cation, 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, depres- sion, and cognitive dysfunction (Littlejohn, personal communication).

Many individuals said they used gestures, facial expressions and their eyes to enhance communication when they were wear- ing a face covering. Studies do indeed show that these forms of communication can enhance speech understanding (Drijvers & €Ozy€urek 2017; Jordan and Thomas 2011; Munhall et al. 2004; Wagner, Malisz, and Kopp 2014). This perhaps suggests that, with guidance and instruction, communication problems result- ing from face coverings could be eased through greater use of non-verbal cues. Conversely, using a raised voice, another strat- egy 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-Raf�ee 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 sur- vey. 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 cov- erings are effective at preventing spread of the virus. Public atti- tudes 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 embarrass- ment decrease as face coverings become part of the wider cul- ture. The emergence of new strategies for improved communication while wearing face coverings should be moni- tored 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 communica- tion 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 wide- spread 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 cover- ing 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 com- munication-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

504 G. H. SAUNDERS ET AL.

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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