Self-esteem among Individuals with Hearing Loss: A Systematic Review

Abstract

Purpose

Self-esteem is important for decision making, emotional health, and overall well-being. In individuals with hearing loss (HL), self-esteem may vary due to degree of HL, hearing devices, academic set-ups and communication strategies used by family members. This study aimed to systematically review the impact of hearing loss on self-esteem.

Method

A systematic search was conducted to identify the studies focusing on self-esteem of the individuals with HL. Four electronic databases, PubMed, Scopus, Embase, and CINAHL, were used. Title screening and abstract reading were performed by two independent authors. Appropriate studies were considered for full-length reading. The references of the obtained articles were manually searched to identify eligible studies. A mixed-methods appraisal tool was used to critically appraise the included studies.

Results

Out of 1219, twelve studies met the inclusion criteria. Individuals with HL exposed to total communication had a positive impact on self-esteem. Interestingly, hearing competence of parents and siblings was linked with their self-esteem. Children with HL have higher self-esteem than normal-hearing children. Children with HL attending mainstream schooling and using cochlear implants had positive and higher self-esteem. Further, higher education level, employment, and marital status were effectively associated with self-esteem.

Conclusion

Positive self-esteem intensely improves mental and emotional well-being. Appropriate and timely provided rehabilitation accompanied by family support can induce healthier and more fulfilling social life. Additionally, healthy self-esteem can empower individuals with HL to engage in social activities diligently. To sum up, early intervention and family participation are required to improve overall quality of life.

Introduction

Self-esteem is a mindset about self and reflects the outlook and opinions of a person about his/herself. Rosenberg [1] defined self-esteem as one’s overall evaluation of one’s own thoughts and emotions about oneself as well as their positivity or negativity towards oneself. Self-esteem determines the perspective, capabilities, strengths, weaknesses, and accomplishments of an individual. Additionally, self-esteem has positive association with psychological health and quality of life as it is a crucial component for personal well-being [2]. Adequate interaction between parents and children, and experiences of early childhood influence self-esteem. Adolescent self-esteem is dependent on parents and peer interaction [3]. Hudd et al. [4] reported that stressed-out students possess low self-esteem and reduced sensitivity toward their health. Self-esteem rises from adolescent to middle life, peaks about the age of sixty years, and then declines as people get older [5]. Wagner et al. [6] suggested decline in self-esteem due to health constraints in old age.

Low self-esteem limits communication abilities and causes anxiety, and poor social functioning [7]. Moreover, individuals with low self-esteem suffer from depression, anxiety, and academic stress which may end up in a lower quality of life [8]. In contrast, individuals with higher self-esteem create a better impression and are more willing to share their thoughts in groups than reduced self-esteem individuals [9]. Also, children with low or poor self-esteem are at risk of psychological problems [10].

There are several influencing factors that mold self-esteem in positive and negative ways. Especially, parental and peer group support influence self-esteem [11]. Krauss and Orth [12] reported that factors like parental monitoring, involvement in education life, their relationship with each other, and financial security inculcate positive self-esteem in children. Teacher’s support, and achievements in education life helps in the development of positive self-esteem. Other factors, such as job satisfaction, performance at work, and interpersonal relations with colleagues are also linked to self-esteem [9]. Studies have shown self-esteem is related to, emotional well-being, life satisfaction, happiness, stress, and loneliness [13–15].

As the age increases, personal, professional, and social involvement tend to build up. Hearing loss (HL) diminishes the overall growth of individuals. Untreated HL affects language development, literacy, social skills, and self-esteem [16]. Schooling and educational achievements are significantly restricted due to HL [17, 18]. As a result, adults with HL frequently face unemployment or a less desirable job. When compared to normal-hearing people, the odds of being unemployed are 1.98 times greater for individuals with HL [19]. A review by Granberg and Gustafsson [20] suggested that individuals with HL face various complications like confusion, poor work performance, need for verbal repetition, and difficulty in using a telephone. Besides professional growth, quality of life is hindered by HL. Moreover, HL leads to loneliness, depression, frustration, and dependency in the elderly population [21]. Delayed diagnosis of HL in old age population can affect the physical, mental, and social well-being extensively [22].

Self-esteem has been investigated in various disorders such as specific language impairment [23], stuttering [24], down syndrome [25] as well as HL [26, 27]. Population with HL has confined communication skills, face emotional and social problems which may lead to reduced self-esteem and confidence.

To the date, numerous studies have conducted on self-esteem of individuals with HL across the lifespan. Research areas have included effect of communication mode on self-esteem, impact of type of schooling on self-esteem, personal and social factors affecting self-esteem. The aim of current review was to investigate the self-esteem among individuals with hearing loss.

Method

The systematic review was conducted according to the Preferred Reporting for Systematic Review and Meta-analysis statement (PRISMA statement).

Eligibility Criteria

The criteria for including the studies were specified in terms of participants, intervention, outcomes (PIO).

Population

Studies focusing on individuals with any severity of HL were included in the study.

Intervention

Hearing devices such as hearing aids and cochlear implants, school setting, communication mode and personal factors were referred as the intervention.

Observation

Studies exploring self-esteem included in the review.

Timeline

Studies published from 1994 till 2023 with all types of study designs were searched.

Exclusion Criteria

Studies focusing on the self-esteem of parents of child with HL, scales of self-esteem, editor notes, magazine articles were excluded.

Information Source and Search Strategy

The following databases were systematically searched PubMed, Scopus, Embase and CINAHL. In addition, a manual search was carried out for reference articles in retrieved articles. Two independent authors developed the search strategy. Keywords ‘self-esteem,’ ‘hearing loss’, ‘hearing impairment’, ‘hearing disorder’, ‘cochlear implant’, was used by applying Boolean operators ‘AND’ and ‘OR’.

Data Management and Study Selection

The obtained data were transferred to an excel spreadsheet for duplicate removal and title screening. After duplicate removal, two independent authors screened the titles and abstracts. The shortlisted articles were considered for full-length reading. References were checked of selected articles to find the eligible articles. Wherever, there was disagreement, it was resolved by discussion.

Appraisal of Individual Studies

All studies that fulfilled the inclusion criteria underwent a quality assessment process. The quality of each study was appraised by Mixed methods appraisal tool (MMAT) version 18 [28].

Results

Total 1219 publications were retrieved across all the databases including PubMed, Scopus, Embase and CINAHL. The included studies which met the inclusion criteria were published from 1994 to 2018. Figure 1 indicates PRISMA flow chart of the detailed procedure of study selection.

Fig. 1.

PRISMA flowchart explaining the steps followed in the review

A total of 12 studies were included in the present review. These studies focused on various factors related to self-esteem of individuals with HL. Communication mode used by parents, educational setup, degree of HL, hearing devices, hearing status of parents and siblings were such factors. The study design of included articles was cross-sectional. The characteristics of included articles were depicted in Table 1.

Table 1.

Characteristics of included studies

S No	Author	Country	Participants	Study Tool
1.	Desselle [29]	United States	90 participants Age range: 13 to 19 years.	Modified Self-Esteem Inventory (MSEI)
2.	Yee et al. [30]	Hong Kong	45 participants with moderately severe HL and 300 participants with normal hearing. Age range: 12 to 20 years.	Chinese version of the Self-Description Questionnaire SDQ-1
3.	Desselle and Pearlmutter [31]	United States	53 participants Age range: 13 to 19 years.	Modified Self-Esteem Inventory (MSEI) and Subject Communication Questionnaire (SCQ)
4.	Woolfe and Smith [32]	United Kingdom	45 participants Age range:10 to 14 years.	Battle ‘Self-esteem’ Inventory and Family systems test (FAST)
5.	Crowe [33]	United States	152 participants Age range:18 to 49 years.	Rosenberg Self-Esteem Scale (RSES)
6.	Jambor and Elliott [34]	United States	78 participants Age range: 19 to 48 years.	Self -Administered Questionnaire and Rosenberg self-esteem scale (RSES)
7.	Sahli and Belgin [35]	Turkey	30 participants with cochlear implant and 60 participants with normal hearing. Age Range: 12 to 19 years.	Rosenberg self-esteem scale (RSES)
8.	Hintermair [26]	Germany	618 participants Age range: 14 to73 years.	Generalized Self-Efficacy Scale
9.	Percy-Smith et al. [36]	Denmark	164 participants with cochlear implant and 2169 with normal hearing Age range: 2 to 17 years.	Parental questionnaire
10.	Lesar and Smrtnik Vitulić [37]	Slovenia	80 participants Age range: 11 to 24 years.	Self-Esteem Scale
11.	Warner-Czyz et al. [27]	United States	50 participants with cochlear implants and hearing aids. Age range: 8 to 18 years.	Rosenberg Self-Esteem Scale (RSES)
12.	Kobosko et al. [38]	Poland	120 participants with Cochlear implant Age range: 22 to 60 years.	Rosenberg Self-Esteem Scale (RSES)

Because of the heterogeneity of population, studies were grouped into two tables separating adolescents, adults, and elderly population as shown in Tables 2 and 3.

Table 2.

Represent findings of studies focusing on adolescent population

S No	Author	Aim	Participants	Study Tool	Results
1.	Desselle [29]	To investigate the effect that family communication mode on the self-esteem of deaf children.	90 participants Age range: 13 to 19 years.	Modified Self-Esteem Inventory (MSEI)	Children raised by parents who used total communication had higher self-esteem scores than children raised by parents who only used oral communication. Moreover, children whose parents used sign language with mastery had higher self-esteem than children whose parents were less skilled in sign language.
2.	Yee et al. [30]	To assess the self-esteem of hearing-impaired secondary school students with their normal hearing peers.	45 participants with moderately severe hearing loss and 300 participants with normal hearing. Age range: 12 to 20 years.	Chinese version of the Self-Description Questionnaire SDQ-1	The hearing-impaired male student group showed higher self-esteem in four different areas of self-esteem, i.e., physical appearance, parent relationships, physical ability, and mathematics.
3.	Desselle and Pearlmutter [31]	To define the effect of parents’ communication pattern on self-esteem of deaf children.	53 participants Age range: 13 to 19 years.	Modified Self-Esteem Inventory (MSEI) and Subject Communication Questionnaire (SCQ)	Adolescents exposed to total communication had higher esteem than parents using oral communication. Parents using a few signs or lip reading, their children showed lower self-esteem.
4.	Woolfe and Smith [32]	To explore impact of parents and sibling hearing status on self-esteem and family cohesion in deaf children.	45 participants Age range:10 to 14 years.	Battle ‘Self-esteem’ Inventory and Family systems test (FAST)	Children with deaf parents showed higher self-esteem than children with normal-hearing parents. The hearing status of siblings did not show any effect on the self-esteem of hearing-impaired children.
5.	Sahli and Belgin [35]	To compare the levels of self-esteem of adolescents with cochlear implants and normal hearing individuals.	30 participants with cochlear implant and 60 participants with normal hearing. Age Range: 12 to 19 years.	Rosenberg self-esteem scale (RSES)	Positive changes were noticed in self-esteem after cochlear implantation in both gender groups.
6.	Percy-Smith et al. [36]	To compare the parameters of self-esteem and social well-being between children with cochlear implants and normal-hearing children.	164 participants with cochlear implant and 2169 with normal hearing. Age range: 2 to 17 years.	Parental questionnaire	Children implanted with cochlear implants had higher self-esteem than normal-hearing children. Girls with CI had higher self-esteem than normal-hearing girls. The same findings were found for boys, too.
7.	Lesar and Smrtnik Vitulić [37]	To compare the self-esteem of deaf and hard of hearing students.	80 participants Age range: 11 to 24 years.	Self-Esteem Scale	Young children had higher self-esteem than the older group. Children with HL studying in regular school showed higher self-esteem in terms of emotional, physical self and confidence.
8.	Warner-Czyz et al. [27]	To observe the influence of generic factors (e.g., age, gender, temperament) and specific factors (e.g., age at identification, communication skills) on self-esteem of children with cochlear implants or hearing aids.	50 participants with cochlear implants and hearing aids. Age range: 8 to 18 years.	Rosenberg Self-Esteem Scale (RSES)	No association found between self-esteem and demographic factors (i.e., age, age of intervention, duration of device use), self-perceived communication (i.e., perception of quiet or noise), or social engagement (i.e., number of organized activities, presence of friendships). Children with higher attention had positive self-esteem, suggesting a greater capacity to focus and shift attention.

Table 3.

Represent findings of studies focusing on adult and elderly population

S No	Author	Aim	Participants	Study Tool	Results
1.	Hintermair [26]	To discover the significance of acculturation for self-esteem, satisfaction with life and well-being.	618 participants. Age range: 14 to73 years.	Generalized Self-Efficacy Scale	Deaf and hard-of-hearing people with adequate personal resources have higher self-esteem, life satisfaction, and overall well-being.
2.	Crowe [33]	To evaluate if self-esteem among deaf college students differed significantly depending on gender, parents’ hearing status, and signing skills.	152 participants. Age range: 18 to 49 years.	Rosenberg Self-Esteem Scale (RSES)	Children with parents who use sign language had higher self-esteem than those who could not use sign language. In addition, children whose parents were deaf and who used sign language showed more self-esteem than children whose parents had normal hearing.
3.	Jambor and Elliott [34]	To assess the effects of mode of communication at home, degree of hearing loss and adopted coping styles on self-esteem of deaf individuals.	78 participants Age range: 19 to 48 years.	Self -Administered Questionnaire and Rosenberg self-esteem scale (RSES)	Children with severe hearing loss had higher self-esteem. For deaf children, mainstream school settings and oral communication methods were found to be superior. Using oral communication at home reduced the self-esteem.
4.	Kobosko et al. [38]	To evaluate the global self-esteem of deaf and partially deaf individuals who used cochlear implant from adulthood.	120 participants with Cochlear implant. Age range: 22 to 60 years.	Rosenberg Self-Esteem Scale (RSES)	Individuals with higher education, a job, and married status had higher self-esteem. Females with cochlear implants had lower self-esteem than the general population.

Quality Appraisal of the Included Study

The quality assessment of included studies was performed by using the Mixed Methods appraisal tool (MMAT) version 2018. The appraised studies are presented in Table 4.

Table 4.

Quality appraisal of the included study

Study ID	Q1 Is the sampling strategy relevant to address the research question?	Q2 Is the sample representative of the target population?	Q3 Are the measurements appropriate?	Q4 Is the statistical analysis appropriate to answer the research question?
Desselle [29]	Y	Y	Y	Y
Yee et al. [30]	Y	Y	Y	Y
Desselle and Pearlmutter [31]	Y	Y	Y	Y
Woolfe and Smith [32]	Y	Y	Y	Y
Crowe [33]	Y	Y	Y	Y
Jambor and Elliott [34]	Y	Y	Y	Y
Sahli and Belgin [35]	Y	Y	Y	Y
Hintermair [26]	Y	Y	Y	Y
Percy-Smith et al. [36]	Y	Y	N	Y
Lesar and Smrtnik Vitulić [37]	Y	Y	Y	Y
Warner-Czyz et al. [27]	Y	Y	Y	Y
Kobosko et al. [38]	Y	Y	Y	Y

*Y-Yes, N-No

Discussion

This systematic review was undertaken to highlight the impact of HL on self-esteem and list out different variables influencing self-esteem. An electronic search was conducted using four databases: Scopus, PubMed, CINHAL, and Embase to eliminate publication bias. Articles were reviewed by two independent authors at each stage. Twelve studies were included in this review. Self-esteem is a subjective entity and is altered by several factors including communication mode at home, schooling, and severity of HL. Most of the studies investigated the effect of parents’ communication mode, hearing devices, and school setting on the self-esteem of individuals with HL.

Higher self-esteem brings a sense of being liked, accepted, and confidence in individuals. Parents, siblings, and family play a notable role in building the self-esteem of children. Pérez-Fuentes et al. [39] supported that parenting style affects self-esteem and life satisfaction among adolescents. Rezaei-Dehaghani et al. [40] stated that family functioning like socializing, cultural activities, expressiveness, idealization, and self-esteem of children is highly correlated. As reported by Desselle et al. [29], children exposed to total communication had higher self-esteem than those who were only exposed to oral communication from their parents. The same findings were reported by Desselle & Pearlmutter [31]. In addition, Jambor and Elliott [34] documented children exposed to oral communication had low self-esteem. In contrast, Crowe [33] supported that children whose parents communicate through sign language had higher self-esteem than parents who could not use sign language.

Parents and siblings are an incredible source of support, care, and help. Major findings were reported by Woolfe and Smith [41], children had higher self-esteem whose parents had HL whereas sibling’s hearing status did not affect the self-esteem of another sibling. Adolescent self-esteem and the quality of their sibling relationships are linked, which forecasts higher self-esteem and nurturing sibling relationships [42].

Family atmosphere, neighborhood, and school setup influence self-esteem. Schooling is one of the influencing factors. Zhao et al. [43] suggested that parents and teachers create a positive environment and encourage the child to improve academic performance. Furthermore, the mainstream schooling approach strengthened the self-esteem of children with HL [34]. Likewise, Lesar and Smrtnik Vitulić [37] reported children with HL attending regular schools had higher self-esteem in terms of their emotional, physical self, and confidence than those in special schools. A recent review by Baumeister et al. [9] concluded self-esteem and academic achievements have an influential association, students with high self-esteem perform better in school rather than students with low self-esteem.

Yee et al. [30] suggested male students with HL had higher self-esteem in four areas: physical appearance, parent-child connection, physical ability, and mathematics. Similarly, Burnett [44] mentioned that global self-esteem was linked to physical appearance, performance in class, and peer-group interaction among school-going children. A few studies suggested cochlear implant users had higher self-esteem [35, 36]. Though early identification and intervention, usage of hearing devices, communication skills, and peer group interaction influence the overall development of children with HL but there was no association between self-esteem and these factors [27].

The correlation between higher self-esteem and performance at work is highly variable. Baumeister et al. [9] described self-esteem improves job performance and individuals with higher self-esteem prefer to socialize with others. Besides, individuals with low self-esteem stay away from socialization. The self-esteem of individuals with HL can be influenced by their literacy level, employment status, and marital status [38].

To sum up, the mode of communication used by parents, their hearing status, mainstream schooling, and hearing devices are associated with self-esteem of individuals with HL. Higher self-esteem was found in individuals who were exposed to total communication, attended regular schooling, and used cochlear implants. Moreover, marital status and professional status influence the self-esteem of individuals with HL.

Clinical Implication

The findings of present review emphasized the impact of HL, type of hearing devices used by individuals with HL, school setting attended by them, and communication mode used by parents on self-esteem. Individuals with HL require family cooperation, educational support, resources, and opportunities to grow personally and interact socially to boost their self-esteem. It is also necessary to comprehend the emotional and social requirements of individuals with HL which can affect the self-esteem. Furthermore, exclusive behavioral training programs and support groups can be developed to maintain the positive and high self-esteem of individuals with HL.

Summary and Conclusion

This review highlighted the impact of HL on self-esteem. Major aspects such as the communication mode of parents with their children, the educational settings, and the type of hearing devices used by individuals with HL were also highlighted in the review. Communication and interaction of parents with their children were found to be highly associated with self-esteem. Children exposed to total communication had higher self-esteem. Also, children attending mainstream showed higher self-esteem than special school children. In addition, children who had a cochlear implant had higher self-esteem. Finally, socio-demographic characteristics such as education, employment, and marital status were linked to robust self-esteem. To conclude, parents, peer group interaction, and teaching style were crucial element in the enhancement and improvement of the self-esteem of individuals with HL.

Funding

None.

Declarations

Competing interests

None of authors have competing interest.

Ethics Approval

No procedures were involved on the participants; the study is a systematic review of existing published data.

Conflict of Interest

There is no conflict of interest to disclose.

Informed Consent

Not applicable.