Mask your word, mask my world: mask wearing behavior in Chinese deaf people during the COVID-19 pandemic

Abstract

Community mask wearing can effectively reduce the spread of the novel coronavirus disease (COVID-19). However, it may also hinder face-to-face interpersonal communication, particularly for deaf individuals who depend on non-manual articulations to convey and comprehend various types of meanings. The current research, for the first time in the literature, quantitatively assessed the hypothesis that deaf individuals are less likely to comply with mask policies during the pandemic than their hearing counterparts because face coverings negatively impact their everyday communication. Across two studies, Chinese people exhibited lower adherence to mask wearing in their self-report and actual behavior than typical-hearing individuals. It may be that taking off face masks can facilitate communication among people with hearing loss. These findings have important implications for both everyday communication and public health preventive measures for hearing-impaired populations.

Keywords:

• Deafness
• COVID-19
• masks
• preventive measures
• health inequity

Hearing loss and the COVID-19 pandemic

In 2023, many parts of the world, including Europe and North America, have moved to the endemic phase of the COVID-19 outbreak. When preparing to enter endemicity, health experts continue to emphasize the important role of preventive measures, such as regular handwashing, social distancing, and the wearing of face masks, in the fight against the disease. For example, the preponderance of evidence indicates that mask wearing can significantly reduce transmission of the new coronavirus in both laboratory and clinical settings (Howard et al. 2021).

Although face coverings have been key in containing the rapid spread of COVID-19, they have hindered interpersonal communication, particularly for hearing impaired people who rely on non-manual articulations (e.g. facial expressions, head shake, and mouthing) to facilitate face-to-face interactions (McKee, Moran, and Zazove 2020). Recently, an emerging line of research has began to investigate the communication challenges faced by deaf people due to the community-wide use of face masks during the pandemic (Poon & Jenstad, 2022). For example, in a cross-national survey involving 395 UK and Spanish deaf/hearing impaired residents, Gutierrez-Sigut et al. (2022) found that respondents experienced more difficulties in visual communication when masks were mandatory. However, the vast majority of deaf studies were conducted in western deaf communities, which casts doubt on the generalizability of previous investigations. To date, there is a paucity of information available about deaf people in other societies during the pandemic.

In addition, despite prior research providing important insights into the negative impact of face coverings on deaf/hearing impaired people, it is unclear whether the lack of visual cues in interpersonal communication would influence face mask wearing behavior in hearing-impaired populations. It is possible that deaf people show the same level of compliance with mask wearing policies as typical-hearing individuals despite greater communication difficulties. Another possibility is that deaf people are less likely to wear face masks than hearing people because wearing masks leads to the loss of information. To disentangle these possibilities, we compared self-report and actual mask use behavior between Chinese hearing and deaf people at a time (December, 2021) when masks were mandatory.

Self-reported and objective mask-wearing behavior in Chinese deaf people

We first explored whether there were differences in self-reported mask-wearing behavior and in other preventive measures between Chinese deaf and hearing people. In Study 1, 197 deaf people (104 females, Mean_age = 29.6, SD = 8.3) and 204 hearing people (119 females, Mean_age = 29.1, SD = 7.7) were asked to rate their level of compliance with six public health guidelines (i.e. keeping a safe distance, mask wearing, promoting cough etiquette, quarantine and self-monitoring, regular handwashing, and prohibiting spitting) on a 5-point Likert scale ranging from 1 = Not At All to 5 = Always. The results showed that Chinese deaf people showed the same level of compliance with most preventive measure (social distancing, cough etiquette, quarantine, hand hygiene, and anti-spitting) as their hearing counterparts, ps > .18. However, the former were less willing to wear masks (M = 3.09, SD = 0.88) than the latter (M = 3.36, SD = 0.74), t(399) = 3.28, p = .001, Cohen’d = 0.33, 95%CI = [–0.4259, −0.1070].

To substantiate these preliminary findings, Study 2 sought to demonstrate a behavioral confirmation in a real-life context. Specifically, we examined whether Chinese deaf people were less likely to comply with a compulsory mask-wearing rule before entering the laboratory as requested than hearing people. A total of 85 deaf people (40 females, Mean_age = 34.4, SD = 6.3) and of 88 hearing people (46 females, Mean_age = 33.7, SD = 6.7) participated in the study for a monetary reward. To take part in the study, participants were required to contact the experimenter in advance. They were told that the consent form did not include all of the information about the research question being tested. However, all procedures performed in the study involving human participants were approved by the institutional research ethic committee. The researchers will give them more information when the study is completed.

Participants were then allocated an appointment time so that they could be tested individually. Participants were told that they should arrive at the meeting point on time and wear face masks before entering the experimental room. Once they walked into the laboratory, the experimenter recorded whether they complied with the mask policy. During the debriefing session, participants were provided with a clear and informative explanation for the design of the study. All of them understood that the deception is necessary for the study and gave their permission that the data can be used for research purpose.

Debriefing responses indicated that all participants correctly recalled the lab mask policy. However, no participants guessed the the true purpose of the study. A vast majority of hearing people (71 of 88 or 80.7%) and more than a half of deaf people (53 of 85 or 61.1%) wore face masks as requested. The rates substantially differed from the chance level (50%), ps < .05. To ascertain whether there was a significant difference in compliance with mask wearing policies between Chinese hearing and deaf people, we performed a binary logistic regression (Logit) with mask wearing behaviors (wearing a mask = 1 vs. not wearing a mask = 0) as the dependent variable. Consistent with the findings of Study 1, Chinese deaf people were less likely to engage in mask wearing behavior than Chinese hearing people, Nagelkerke R² = .05, Wald (df = 1) = 6.29, p = .01, odds ratio = 0.42, 95% confidence interval [CI] = 0.213, 0.827.

Health inequities, what can we do for deaf people?

Across two studies, we provided consistent evidence that Chinese people exhibited lower adherence to mask wearing in their self-report and actual behavior than typical-hearing individuals. It may be that the rapid and drastic changes in health care norms related to COVID-19 put deaf people at a great disadvantage for being able to achieve accessible and effective communication. Key publications have highlighted significant communication challenges for hearing-impaired populations during COVID-19 (Garg et al. 2021). For example, Gutierrez-Sigut et al. (2022) found that deaf people missed varying amounts of information in daily communication and experienced greater feeling of social disconnection due to face coverings during the pandemic. By removing face masks, they are more likely to overcome this communication barrier and to facilitate language comprehension.

In addition to communication challenges, there are also other explanations that may account for the differences in mask-wearing behavior between Chinese deaf and hearing people. For example, deaf signers, through cultural and language barriers, may have inequitable access to medical and behavioral care information that is often considered as common knowledge among hearing people (Kuenburg et al. 2016). Although sign language interpreting on television has become one of the most prominent types of media interpreting in many countries, there are still several issues underlying health inequities experienced by deaf signers. To remove the communication barriers and address the public health inequities, several approaches can be taken by health ministers and deaf communities during the COVID-19 pandemic.

First, press conferences on major coronavirus updates should have qualified and certified sign language interpreters who communicate information to the hearing-impaired viewers. In press conferences on coronavirus developments, dialects of sign languages are preferred since they are better understood by local deaf signers. Since there might be no existing signs for many vocabulary items related to the COVID-19 crisis, sign language interpreters need to work with deaf communities, regional units of deaf associations, and sign language research groups, to brainstorm and coin new signs.

Second, governments and deaf associations should provide different kinds of resources for disseminating coronavirus information in sign languages. On the one hand, guideline documents for the prevention and control of COVID-19 should be translated into local sign languages as seamless sign language videos in real time. The smooth video stream could serve as a facilitator to access health information and health care service for deaf individuals. On the other hand, many coronavirus brochures and booklets must highlight the importance of visual information in communicating health knowledge to deaf communities in addition to straight language narrative. For instance, illustrating hygiene and health habits to prevent pneumonia from disease infection may provide deaf people with more accurate information about preventive measures.

Finally, deaf leaders, who are fluent in both sign language and the surrounding spoken language, are supposed to play a role in addressing inequalities in health information access with their effective communication skills and bicultural identities. Insufficient knowledge of health-related vocabulary is common among deaf communities, which may put them at a high risk of infection. For deaf individuals with low educational attainment especially those in rural areas, it is unrealistic for them to rely on internet or TV programs as primary sources to obtain health information. Under these circumstances, deaf leaders could act as major disseminators of health information and foster social cohesion among deaf communities.

Conclusion

Taking off masks may increase the risk of exposure to virus. To strike a balance between communication improvement and public health protection, our findings underscore the importance of creating and promoting a mask with a transparent window. These clear face masks can cover the nose but make the mouth visible, which allow hearing-impaired people to decode non-manual markers in sign language or to read the lips of someone speaking to them. Yet, there is no officially approved version of clear face masks for medical use in China. Before the products arrive to the market, a powered air-purifying respirator (PAPR) can be used to help deaf people see the speaker’s lips or the signer’s non-manuals in some contexts that require readily accessible and accurate information sharing (e.g. inpatient service and language education).

Additional information

Funding

This work was supported by Educational Science Foundation of Chongqing Municipality of China (2021-GX-103).