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

Abstract

Objectives

Social isolation and loneliness are interrelated but independent constructs that threaten healthy aging and well-being and are thought to be associated with hearing loss. Our aim was to review the empirical studies that have examined the association between hearing loss and social isolation and/or loneliness to highlight future research needs.

Design

Scoping review.

Study sample

Three electronic databases were searched combining key terms of “hearing loss”, “hearing impairment” and “deaf*” with “social isolation” or “loneliness”, yielding an initial result of 939 articles. After 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 studies 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 particular 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.

Keywords:

• Hearing loss
• social isolation
• loneliness
• scoping review

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 participation in activities and lack of social participation being risk factors for social isolation (Lubben 1988). Loneliness, however, is a subjective 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 mismatch 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 clinical practices and awareness outside of audiology. Of four systematic 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 literature 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 loneliness 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/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 experiences 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 interventions. 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 systematic reviews are used to identify and retrieve international evidence 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 loneliness 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 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 studies 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).

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

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 extraction included: first author name, author affiliations, country of first author, year of publication, aims, concept (association, intervention, both), study type (quantitative, qualitative, mixed-methods), 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, description of intervention, analysis and overview of key findings relevant 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-categorize 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.

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:

1. 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.

2. 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.

3. Quantitative population-based studies: studies in which data were extracted from large datasets often designed for longitudinal 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.

4. 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.

5. 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 agreement 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 hearing loss and social isolation and/or loneliness. Each is discussed below. Supplementary Data File 3 shows the distribution of studies by country and year of publication.

Table 1. Summary of key findings of comparison studies (n = 9).

		Aims associated with hearing loss/hearing interventions, loneliness and isolation	Measures				Relationship between hearing loss and:
ID	Authors		Social isolation	Loneliness	Comparison groups	Outcomes	Social isolation	Loneliness
1	Bosdriesz et al. (2017)	To examine psychosocial health of people with and without HL who use or do not use interventions	Not measured	Loneliness Scale^a	37 CI users 418 HA users 247 with untreated HL 553 with NH Age range 18–70 years (CI users ∼5 years older than other groups)	CI users and NH were less emotionally lonely than HA users and people with untreated HL. CI users and NH did not differ in emotional loneliness. Social loneliness did not differ across HL groups	NA	Mixed
2	Hay-McCutcheon et al. (2019)	To examine the impact of HL on social interactions using MOS data	Positive Social Interaction Scale, MOS Social Support survey^b	Not measured	13 rural-dwelling NH 18 rural-dwelling HL 24 urban-dwelling NH 25 urban-dwelling HL Mean age: 60+ years (NH individuals ∼4 years younger than those with HL)	Urban dwellers with HL were less socially isolated than rural dwellers with HL. HL was a predictor of social isolation	Yes	NA
3	King and Stephens (1992)	To examine factors associated with auditory disability with normal hearing	Not measured	R-UCLA Loneliness scale^c	20 NH with report HL 20 NH with no reported HL Age matched groups. Mean age 30 years	Participants reporting hearing problems were significantly more lonely than those not reporting hearing problems	NA	Yes
4	Knutson and Lansing (1990)	To examine the relationship between reported communication function from CPHI and general measures of loneliness, social isolation and other outcomes	MMPI Social introversion scale 0^d	Revised UCLA Loneliness Scale^e	27 CI candidates Mean age = 49.1 year Revised UCLA published norms	Sample was more socially isolated than norms. Most participants would be described as being “somewhat” to “extremely” lonely	Yes	Yes
5	Murphy and Newlon (1987)	To investigate loneliness in mainstreamed hearing impaired college students	Not measured	Revised UCLA Loneliness Scale^e Self-report: loneliness in prior week	94 mainstreamed college students identifying as “deaf”, 76 mainstreamed college students identifying as “hearing impaired”, NH students, Norms from Russell, Peplau, and Cutrona (1980) UCLA scale, and NH students	Mainstreamed students were lonelier than NH students. Association between loneliness and adjustment to HL and comfort using speech/sign. No difference in loneliness of self-defined deaf and self-defined hearing-impaired students. No differences in loneliness by college year or gender	NA	Mixed
6	Øhre et al. (2017)	To investigate whether communication mode (sign vs. spoken language) impact mental health	Not reported	Not measured	40 users of Norwegian sign language (NSL) 36 hearing impaired users of spoken language Mean age 36.7 years	No difference in social isolation between NSL and users of spoken language	No	NA
7	Ringdhal and Grimby (2000)	To describe hearing and other factors in relation to subjective health and compare them with age-matched community sample	Swedish version of the Nottingham Health Profile^f	Not measured	311 HA users with profound deafness Mean age = 66.0 years 2356 age-matched norms	HA users more socially isolated than age matched norms. Working people with HL had lower isolation scores than non-working individuals. Degree of HL did not predict social isolation within the HL group	Mixed	NA
8	Stevens (1982)	To examine the main problems of people who are deaf	Scale developed for study	Not measured	50 HA users 49 people with untreated HL Age range 45–82 years	HA users were less socially isolated than people with untreated HL	Yes – benefit of HA reported	NA
9	Thomas and Herbst (1989)	To examine social and psychological effects of acquired deafness in working age adults provided with NHS HAs	Questions developed for study	Questions developed for study	211 HA users fitted between 1970 and 1976, 418 matched non-HA user controls Age range 16–64	HA users were more lonely and more socially and emotionally isolated than the control group. No relationship between degree of HL and loneliness	Yes	Mixed

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.

^aDe Jong-Gierveld and Kamphuls (1985).

^bSherbourne and Stewart (1991).

^cHays and Dimatteo (1987).

^dHathaway and McKinley (1943).

^eRussell, Peplau, and Cutrona (1980).

^fWiklund (1992).

Table 2. Summary of key findings of experiential studies (n = 5).

		Aims associated with hearing loss, social isolation and/or loneliness	Measures			Sample n = age other		Relationship between hearing loss and:
ID	Authors		Social isolation	Loneliness	Hearing		Results	Social isolation	Loneliness
1	Canton and Williams (2012)	To examine social, psychological and economic impacts of NIHL among dairy farmers in NZ	Open-ended questionnaire		Self-report or ‘confirmed’ HL	74 Range: 16–30 31 reported HL	HL resulted in social isolation in general (22%) and at work (39%)	Yes	Not reported
2	Chen (1994)	To examine relations between hearing handicap, loneliness and low self-esteem in an elderly population	Not measured	UCLA Loneliness Scale	Self-report	88 Range: 65–90 (mean = 74.9)	HHIE correlated with loneliness in whole population and in women, but not in men. HHIE-emotional scale showed stronger associations with loneliness than did the HHIE-social scale	NA	Mixed
3	Christian et al. (1989)	To explore hearing loss and loneliness among an older population	Not measured	UCLA Loneliness Scale^a	Four-frequency screening	63 65–74 years: n = 30 75–94 years: n = 33	Loneliness scores did not differ between normal/mild HL versus serious/severe HL	NA	No
4	Picou and Buono (2018)	To evaluate the relationship between emotional responses, isolation and hearing	Social Disconnectedness and Perceived Isolation scales^b		Audiometry	83 Range: 22–80 23 HA users	Degree HL not associated with degree of social isolation or loneliness	No	No
5	Simpson et al. (2018)	To examine whether internet usage by adult HA users lowers perceptions of loneliness	Not measured	UCLA Loneliness Scale V3^c	Self-report: Do you own HAs?	65 Range: 65-81+ All HA users	Higher internet use was associated with lower loneliness scores among HA users	NA	Yes
6	Sung et al. (2016)	To investigate factors associated with loneliness among older individuals presenting to clinic for hearing assessment	Not measured	Revised UCLA Loneliness Scale^a	Audiometry	145 Range: 50-80+ yr. 81 HA candidates, 64 CI candidates	Degree of HL was associated with degree of loneliness. People with severe/profound HL were lonelier than those with NH	NA	Yes
7	Weinstein and Ventry (1982)	To determine the relationship between social isolation and auditory performance	Comprehensive Assessment and Referral Evaluation^d	Not measured	Audiometry Hearing Measurement Scale^e	80 Range: 65-88 (mean = 74) All with reported HL	Isolation scores were similar to norms. Degree of isolation was associated with degree of HL. Reported HL was a predictor of social isolation	Yes	NA

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.

^aRussell, Peplau, and Cutrona (1980).

^bCornwell and Waite (2009).

^cRussell (1996).

^dGurland et al. (1977–1978).

^eNoble and Atherley (1970).

Table 3. Summary of key findings of population-based studies (n = 21).

		Aims associated with hearing loss, social isolation and/or loneliness		Measures					Relationship between hearing loss and:
ID	Authors		Dataset	Social isolation	Loneliness	Hearing	n = Age	Results	Social isolation	Loneliness
1	Cheung et al. (2019)	To investigate sociodemographic, physical, functional and psychological predictors of loneliness	Individuals who completed InterRAI from 2014 to 2016^a	None	InterRAI loneliness item^a	Self-report: single item	51,239 mean: 82.3 years	Reported hearing difficulty was a predictor of loneliness	NA	Yes
2	Cimarolli et al. (2018)	To explore effects of sensory impairment among the oldest old	Fordham Centenarian study data	None	UCLA Loneliness Scale V3^b	Self-report single item	119 Range: 95–107	Reported hearing difficulty correlated with loneliness	NA	Yes
3	Dawes et al. (2015)	To model statistical associations between hearing and cognition accounting for the mediating role of social isolation and depression	UK Biobank	Single item: Do you often feel lonely?	None	Digit Triplet test^c	64,770 Not reported	Poorer hearing and HA use were associated with social isolation. Effect of HA use on cognition was partly mediated by social isolation	Yes^d	NA
4	Dugan and Kivett (1994)	Examine impact of emotional and social isolation on loneliness in very old rural adults	Longitudinal study of rural persons in North Carolina	Quantified based on social interactions	Single item: Do you find yourself feeling lonely	Self-report single item	119 Mean: 83 years	Reported hearing difficulty was a predictor of loneliness	Not analysed	Yes
5	Guthrie et al. (2018)	To understand how a sensory impairment adds to impact of cognitive impairment on health-related outcomes	Canadian Institute for Health Information for people with interRAI data	None	InterRAI loneliness item^a	Subjective ratings by interviewer^e	26,495 with HL, 59,360 with NH range: 65–85+	More people with HL than with NH were lonely	NA	Yes
6	Harithasan et al. (2019)	To determine whether sensory impairment is independently associated with loneliness and more	Long Term Research Grant Scheme study	None	R-UCLA^f	Audiometry	137 No sensory loss, 46 HL, 27 VL, 19 DSI 60+ years	No differences in loneliness across the four groups. HL was not a predictor of loneliness	NA	No
7	Hawthorne (2006)	To examine prevalence and correlates of perceived social isolation in a community	South Australian Health Omnibus Survey	Friendship scale^g	None	Self-report: single item	3015 Mean: 45.3 years	Reported hearing difficulty was associated with social isolation	Yes	NA
8	Kramer et al. (2002)	To examine the association between HL, chronic conditions and psychosocial status	Longitudinal Aging Study Amsterdam	Not measured	Loneliness Scale^h	Self-report: three items	3017 Range: 55–85	People with HL were more lonely than people with NH. HL was a predictor of loneliness	NA	Yes
9	Maharani et al. (2019)	To test the hypothesis that higher rate of cognitive decline with poor hearing is mediated by loneliness	English Longitudinal Study of Ageing	Index of social isolation^i	R-UCLA^f	Self-report: single item	8199 Mean: 62.8 years	Reported hearing difficulty was associated with isolation and loneliness. HL and episodic memory scores were mediated by social isolation and loneliness	Yes	Yes
10	Mick et al. (2018)	To examine the association between sensory impairment, social engagement and loneliness	Canadian Longitudinal Study on Aging	None	Single item: In the past week how often did you feel lonely?	Self-report: single item^j	19,325 Range: 45–89 years	HL was associated with loneliness	NA	Yes
11	Mick and Pichora-Fuller (2016)	To determine whether HL is associated with social isolation, and more among people that might benefit from hearing screening	National Health and Nutrition Examination Survey	NHANES SSQ^k	None	Audiometry and self-report single item	Varied by measure and cohort from 465 to 1845 Varied by measure and cohort Range 40–70+ years	HL was associated with social isolation in people age 60–69 years only	Mixed	NA
12	Mick et al. (2014)	To determine whether age-related HL is associated with social isolation, and how age, gender, income, race and/or HA use moderate it	National Health and Nutrition Examination Survey	NHANES SSQ^k	None	Audiometry	1453 Range: 60–84 years	More HL associated with social isolation in women aged 60–69 years only	Mixed	NA
13	Nachtegaal et al. (2009)	To examine relationship between hearing and self-reported psychosocial functioning	Netherlands Longitudinal Study on Hearing	None	Loneliness Scale^h	National Hearing Test^l	1588 Mean: 46.3 years	HL was associated with loneliness. Use of HAs did not impact loneliness	NA	Yes for HL No for HA use
14	Pronk et al. (2014)	To examine the relationship between rate of hearing decline and rate of decrease in psychosocial health	Longitudinal Aging Study Amsterdam	None	Loneliness Scale^h	National Hearing Test^l	Varied by cohort and measure Range across all cohorts: 57–97 years	Rate of change in hearing was associated with rate of change in loneliness for subcategories of participants	NA	Mixed
15	Pronk et al. (2011)	To examine longitudinal relationships between hearing status, loneliness and more	Longitudinal Aging Study Amsterdam	None	Loneliness Scale^h	National Hearing Test and self-report: three items^l	Varied by participant type and measure	HL (reported and measured) was associated with loneliness in subcategories of participants	NA	Mixed
16	Ramage-Morin (2016)	To examine the association between HL and social solation	Canadian Community Health Survey—Health Aging	Two items from R-UCLA combined with single sense of community belonging item^f	None	HUI Mark 3^m^,n	30,176 Mean: 60.4 years	HL was associated with social isolation in women but not men. Male HA users were more socially isolated than NH males	Mixed	NA
17	Ray et al. (2018)	To determine whether untreated HL and social isolation explain the link between age related HL and cognitive decline	English Longitudinal Study of Ageing	Index of social isolation^i	None	Two-frequency hearing screening	7385 Mean: 67.4 years	HL was associated with higher odds of social isolation among non-HA users but not among HA users. Social isolation was a mediating factor between cognition and HL	Mixed	NA
18	Savikko et al. (2005)	To examine prevalence of loneliness in the Finnish older population and its association with health-related factors	Community dwelling sample recruited from The Finnish National Population register	None	Single item: Do you suffer from loneliness?	Self-report: single item	3915 Mean: 81.1 years	HL was not a predictor of loneliness. People with good hearing were less lonely than those with poorer hearing. HA use did not impact loneliness. Loneliness was rarely attributed to HL	NA	Mixed
19	Stam et al. (2016)	To understand longitudinal relationship between decline in hearing and psychosocial health	Netherlands Longitudinal Study on Hearing	None	Loneliness Scale^h	National Hearing Test^k	508 Range: 18–69 (mean = 47)	HL was associated longitudinally with loneliness. Changes in loneliness and hearing were associated in some subcategories of participants	NA	Mixed
20	Strawbridge et al. (2000)	To examine relationship between degree of HL and functioning over time	Alameda County Study	Self-report: two items	Self-report: Do you feel lonely or remote?	Self-report: three items	2461 Range: 50–102	Degree of HL was associated with loneliness and isolation	Yes	Yes
21	Tomioka et al. (2013)	To evaluate relation between self-reported hearing and quality of life	Community-dwelling adults recruited through neighbourhood associations	None	Revised UCLA Loneliness Scale^o	Self-report: single item and Japanese HHIE-S	731 Males: mean = 71.0 yr. Females: mean = 70.0 years	Odds of loneliness increased with increased HHIE-S score, but not with single item self-report	NA	Mixed
22	Van der Werf et al. (2010)	To examine the association between HL and psychosis	Maastricht Aging Study	Quantified based on single item	Loneliness Scale^h	Thresholds at .5, 1, 2 and 4 kHz	1823 Range: 24–86	HL was associated with social isolation but not loneliness	Yes	No

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.

^aInterRAI: International Resident Assessment Instrument.

^bRussell (1996).

^cHall (2006).

^dAssociation between loneliness and hearing aid use in unexpected direction.

^eRated using RAI-HC and MDS 2.0 instruments (www.interrai.org).

^fHughes et al. (2004).

^gHawthorne (2006).

^hDe Jong-Gierveld and Kamphuls (1985).

ⁱSteptoe et al (2013).

^jAnswered for aided hearing if applicable.

^kSeeman and Berkman (1988).

^lSmits et al. (2004).

^mFeng et al. (2009).

ⁿFeeny et al. (2002).

^oRussell, Peplau, and Cutrona (1980).

Table 4. Summary of key findings of interventional studies (n = 8).

		Aims associated with hearing loss, social isolation and/or loneliness	Measures				Sample		Relationship between hearing loss and:
ID	Authors		Social Isolation	Loneliness	Hearing	Design	n = Age	Results	Social isolation	Loneliness
1	Applebaum et al. (2019)	To examine impact of HAs and CIs on loneliness	Not measured	UCLA Loneliness Scale V3^a	Audiometry	Intervention: HAs and CIs. Assessment: pre-intervention, and 6 month, 12 and 60 months post-intervention	81 Range 63.5 − 78.5 years	HAs did not change loneliness. CIs decreased loneliness initially, but loneliness returned to near baseline by 5 years	NA	Mixed
2	Bai and Stephens (2005)	To examine impact of CI on quality of life using an open-ended questionnaire	Open-ended problems questionnaire^b		Self-report: Single item	Intervention: CIs. Assessment: pre-implantation and at approx. 6, 12, 24 and 36-month post-implantation	47 Range: 21–78 years (mean = 52.4)	CIs decreased social isolation. HL and social isolation only associated at 12 and 24-month post-implantation	Yes, for intervention Mixed for HL	Not revealed
3	Cooper (1995)	To examine how CIs change quality of life and whether it is maintained over time	Questions developed for study	Not measured	Not measured	Intervention: CIs. Assessment: 1-mth pre-CI switch on, 1 and 6-month post switch on	18 Range: 55–64 years	Pre-implantation participants were more socially isolated than norms. CI decreased social isolation to normative level by 1 month. No change thereafter	Yes	NA
4	Jones et al. (2019)	To examine feasibility and impact of a group exercise/social program supplementing GAR program	Not measured	Loneliness Scale^c	Self-report: Hearing Handicap Inventory for the Elderly-25^d	Intervention: GAR vs. no GAR. Assessment: Pre- and post-intervention period	66 Mean: 74.5 years	Emotional loneliness decreased following GAR attendance. Social loneliness did not change	NA	Mixed
5	Knutson et al. (1998)	To assess the psychological state of experienced CI users	Minnesota Multiphasic Personality Inventory Scale 0^e	Revised UCLA Loneliness Scale^f	Audiometry	Intervention: CIs. Assessment: pre-implantation and at 9, 18, 30, 42 and 54-month post-implantation	37 Range: 24–70 years mean =51.8)	Pre-implantation participants were more socially isolated than norms. CI decreased social isolation and loneliness at each time point. Measured CI benefit correlated with change in loneliness	Yes	Yes
6	Sarant et al. (2019)	To investigate how CIs impact quality of life	Lubben Social Network Scale^g	Loneliness Scale^c	Audiometry	Intervention: CIs. Assessment: pre-implantation and at 18 months post-implant switch on	59 Range: 61–89 years, (mean = 72.3)	CI did not change loneliness or social isolation	No	No
7	Weinstein, Sirow, and Moser (2016)	To determine whether HAs impact loneliness	Not measured	Loneliness Scale^c	Audiometry	Intervention: HAs. Assessment: pre-fitting and 4–6 weeks post-fitting	40 Range: 62–92 years (mean =80.4)	HAs decreased emotional loneliness but not social loneliness. Change greatest for people with more HL. Degree of HL was not associated with degree of loneliness	NA	Yes for HAs. No for degree of HL
8	Zhao et al. (2008)	To determine how CIs change reported quality of life	Open ended problems questionnaire^b		Not Audiometry	Intervention: CIs. Assessment: pre-implantation and at 9, 12, 18, 24, 36 and 48 weeks post-implantation	24 Range: 32–78 years (mean =53.8 years)	CI decreased social isolation. Scores plateaued by 18–24 months	Yes	Not revealed

CI: cochlear implant; GAR: group audiological rehabilitation; HA: hearing aid; HL: hearing loss; NA: not applicable; UCLA: University of California Los Angeles.

^aRussell (1996).

^bBarcham and Stephens (1980).

^cDe Jong-Gierveld and Kamphuls (1985).

^eHathaway and McKinley (1943).

^fRussell, Peplau, and Cutrona (1980).

^gLubben (1988).

Table 5. Summary of key findings of qualitative studies (n = 11).

		Aims associated with hearing loss, social isolation and loneliness				Relationship between hearing loss and:
ID	Authors		Qualitative method	Study sample	Results	Social isolation	Loneliness
	Experiential studies
1	Aguayo and Coady (2001)	To examine psychological and sociological effects resulting from deafness	Thematic analysis of interviews	Eight deaf individuals Age range: 31–68 years (mean = 49 years) Users of HAs, CIs, and neither	Problems communicating with family lead to feelings of being isolated within the family, that family members overlooked their needs and minimised the situation. All felt socially isolated in general, and inadequate in social situations. Withdrawal/avoidance lead to more isolation	Yes	Not reported
2	Barlow et al. (2007)	To examine the experience of living with acquired deafness	Framework analysis of interviews	Nine adults with acquired deafness Age range: 33–60 years	Deafness caused physical and emotional isolation and loneliness	Yes	Yes
3	Bennion and Forshaw (2013)	To explore and understand experience of living with HL	Descriptive thematic analysis of interviews	9 HA users Age range: 61–93 years	Inability to hear household sounds (e.g. phone, doorbell) resulted in missing visitors and phone calls, and thus to social isolation	Yes	Not reported
4	Heffernan et al. (2016)	To explore psychological experiences of adults with HL	Thematic analysis of interviews	15 HA users with mild to moderate HL Age range: 20–91 years (mean = 68.8; SD =16.5)	Communication difficulties and participation restrictions from HL led to sensations of loneliness and isolation	Yes	Yes
5	Hétu et al. (1988)	To understand handicap associated with occupational noise exposure	Combination of phenomenological and content analysis of interviews	n = 61 workers plus their spouses Age: mean = 39.5 years Presence/absence and degree of HL varied among workers	In groups, persons with HL felt isolated, less communicative, and less participatory than others	Yes	Not reported
6	Hughes et al. (2018)	To explore how listening effort impacts relationships and shared activities	Grounded theory methodology applied to focus group data	11 CI users 4 HA users waiting for CI 2 NH spouses Age range 20–70+	As HL progressed individuals began to disconnect, which resulted in increasing isolation. HL threatened social connectedness, leading to feeling invisible, lonely, like an outsider. Following implantation, reconnection was sought, resulting in increased social connectedness	Yes. CI decreased isolation	Yes
7	Ingram et al. (2016)	To understand the perspectives of people with HL, their family and their friends towards hearing loss	Content analysis using socio-ecological model of interviews with adults with HL. Focus group data from family members/friends	20 adults with HL 27 family members/ friends Adults with HL age> 50 years	Adults with HL reported HL negatively impacted social engagement. Family said HL caused the person with HL to feel isolated and lonely	Yes	Yes
8	Smith (2012)	To explore the meaning of loneliness in community-dwelling older adults	Interpretive phenomenological analysis of interviews	12 community-dwelling adults reporting loneliness Age: 74–98 years	Participants attributed loneliness to declining health, including hearing—not being able to engage meaningfully, lead to feelings of isolation and being left out	Yes	Yes
	Interventional studies
9	Barlow et al. (2007)^a	To examine impact of LINK rehabilitation course	Framework analysis of interviews	Nine adults with acquired deafness Age not reported	LINK program^b participants said the program gave them a sense of belonging, and made them realise they were not alone	Not reported	Yes. LINK program decreased loneliness
10	Ross and Lyon (2007)	To examine effects of HL pre-and post-cochlear implantation	Thematic analysis of interviews	Six CI users and their normal hearing partners Age range: 46–71 years (Mean = 67 years)	Pre-implantation, participants reported a downward spiral of withdrawal and reduced social contact. Post-implantation they engaged in wider social interaction	Yes. CI decreased isolation	Not reported
11	Maki-torkko et al. (2015)	To examine pre-operative expectations and post-operative impacts of CIs on users and family/friends	Inductive content analysis of open-ended questionnaire responses	101 CI users; 87 family members/friends: Age range: 27.1–91.7 years (Mean = 66.0 years)	All described experiences of isolation prior to CI. Family members considered CI decreased isolation and worried that if CI malfunctioned the person with HL would become isolated	Yes. Family said CI decreased isolation	Not reported
12	Smith et al (2016)	To evaluate the impact of attending a sensory support centre support (WISC)	Thematic analysis of interviews	12 adults with self-reported HL, 7 of whom had measured HL Age range: 61–85	Individual attended WISC because HL had caused feelings of isolation. Individuals given HAs said the HAs positively impacted social interaction	Yes. WISC program decreased isolation	Not reported

CI: cochlear implant; HA: hearing aid; HL: hearing loss; NH: normal hearing; WISC: WESTERN Isles Sensory Centre.

^aStudy included as both experiential and intervention.

^bAn intensive two-week rehabilitation program for people with hearing loss.

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 association 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 subcategories 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 loneliness was lowered, but did not impact social loneliness (ID 4).

The most common methodological approach used by qualitative studies was that of thematic analysis (n = 5). Ten of the 11 qualitative studies explicitly asked adults with hearing loss to discuss their experiences of hearing loss and identified social isolation 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 experiences of living with hearing loss and perceptions of a hearing loss intervention (ID 2, 9—note this is the same study, but findings are reported relevant to experiences and interventions separately). 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 intervention (ID, 11, 12, 13) and one study identified that loneliness decreased after a hearing intervention (specify hearing intervention) (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 published since 2015 (see Supplementary File 3), indicating that the topic is of current interest. The studies reviewed were highly heterogeneous in terms of methodology, participants and measures.

The key findings of the review are that hearing loss is associated with both social isolation and loneliness, that this applies across the life span and that this association is somewhat independent 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 studies 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 studies showed a positive association between hearing loss and loneliness 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 psychosocial conditions, including loneliness, were associated with hearing 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 concluded 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 Hétu 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 depression (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 negative 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, perhaps 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 intervention 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; Hétu et al. 1988; Ross and Lyon 2007; Mäki-Torkko et al. 2015; Smith et al. 2016). Indeed, admission 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 support 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 providing hearing assistive technology in combination with providing a forum for interaction, whether for socialising, education, 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 hearing, 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 directly 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 isolation than measured hearing (r = 0.52 versus r = 0.39, respectively) while here was little difference for objective isolation (r = 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 involvement 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 loneliness—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 studies 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 association between different sub-constructs of social isolation and hearing loss are examined independently if a thorough understanding 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 hearing loss. It is important to recall however, that the communication 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 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 auditory signal, the consequences of which are difficulties understanding 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 loneliness 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, referrals 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. geriatricians, general practitioners, allied health professionals), to address loneliness and social isolation in people with hearing 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 certainly 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 loneliness 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 quality of the studies, and our search criteria did not include the terms HAs or CIs, nor terms for sub-constructs of social isolation 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 interpretation of what was measured. As a result, some readers may disagree 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 relationship and influence of hearing interventions on these constructs 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 people with hearing loss.

Disclosure statement

Dr Anthea Bott is employed as a research scientist with GN Hearing.

Additional information

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.