International Journal of Audiology 2014; 53: 174–181

Original Article

Conversation tactics in persons with normal hearing and hearing-impairment Richard S. Hallam & Roslyn Corney Department of Psychology, University of Greenwich, London, UK

Abstract Objectives: To investigate the tactics people use when aural communication fails owing to environmental circumstances or impaired hearing. Design: Persons with different degrees of self-reported hearing impairment completed an online questionnaire constructed from items taken from the literature on communication strategies but reworded to be understood by people with normal hearing. Tactics were examined for frequency of use in two severities of impairment and between genders. All the data were then factor analysed and factor scores related to variables of relevance to communication. Study sample: A large convenience sample (n ⫽ 188) with a range of self-assessed hearing impairment from normal to profound. Results: Descriptive data revealed some differences in frequency of use in relation to severity and gender. Factor analysis yielded six clearly interpretable factors, the largest relating to disengagement (avoidance). Self-assessed impairment was chiefly associated with a speech reading tactic, negatively with environmental optimization strategies, and to a small extent with disengagement and conversation repair. Conclusions: Only the tactic of speech reading was closely associated with impaired hearing, with some evidence that females were more inclined to use it. Otherwise, all tactics were commonly employed, regardless of hearing status.

Key Words: Hearing impairment; audiological rehabilitation; conversation tactics; gender

The ability to communicate aurally is commonly affected by background noise and by the level and distinctness of a speaker’s voice. Even though difficulties of this nature are a daily occurrence, there has been little research into the tactics employed by persons with normal hearing when they encounter them. The situation is different in the case of persons with hearing impairment (PHI) who have been supplied with a prosthesis, where it has been important to investigate obstacles to good communication. Demorest & Erdman (1986) assessed ‘comunication strategies’ dividing them into maladaptive, verbal, and non-verbal. Tye-Murray et al, (1992) classified strategies as ‘repair’, ‘corrective’ and ‘anticipatory’. Stephens et al, (1999) used the term ‘communication tactics’ while Field & Haggard (1989) referred to ‘hearing tactics’. We prefer the term ‘conversation tactics’ for persons who have not been identified as needing a prosthesis or perhaps have not wanted one. This group is likely to include people who have mild or even moderate hearing impairment because acquired hearing loss is the second most common disability in the UK (Martin et al, 1998), and for a proportion of affected persons the hearing problem is not distressing or an aid is not wanted (Hallam & Brooks, 1998). The stigma of hearing loss or of wearing an aid may also reduce reporting of impairment (Hetu et al, 1990). The label ‘conversation tactics’ is taken to include gesture, speech reading, use of other visual and contextual cues, and various means through dialog or cognitive preparation to exploit the effectiveness of communication.

It is widely accepted that conversation and discourse (and, by implication, its impairment through sensory loss) should be conceptualized ecologically (Demorest & Erdman, 1989; Noble, 1983). This means that a variety of interacting factors - sensory conditions, social environment, familiarity of speakers, motivation to communicate, etc. should all be considered. Consequently, observational studies of social interaction in conditions approaching the natural state have proved very informative (e.g. Caissie et al, 1998, Lind et al, 2010). However, other research methods, such as qualitative interview, diary logs, and self-report, can also make a contribution (e.g. Hallberg & Carlson, 1991; Tye-Murray et al, 1993). To date, self-report methods have focused on PHIs in the context of rehabilitation. Our aim was to develop a short self-report questionnaire of conversation tactics that is not restricted in this way and enables research into conversation tactics as a normal phenomenon across the full spectrum of ability. We had already developed a measure (the conversation checklist, CCL) suitable for family members of a PHI, with encouraging results (Hallam et al, 2007). The items relate to any situation in which there is a failure to hear/comprehend what is being said for any reason apart from limitations of intellect or language. Even in the latter case, non-verbal tactics are commonly employed if an effort to communicate remains. In sum, given the dearth of research with non-clinical populations, we wished to develop a set of questions that made sense to persons with or without hearing impairment. This

Correspondence: R. S. Hallam, 56 Limes Grove, Lewisham, London, SE13 6DE, UK. E-mail: [email protected] (Received 10 March 2013; accepted 2 October 2013) ISSN 1499-2027 print/ISSN 1708-8186 online © 2014 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.3109/14992027.2013.852256

Conversation tactics

Abbreviations APHL CCL PHI

Acquired profound hearing loss Conversation checklist Persons with hearing impairment

would allow us to investigate use of tactics in relation to social, personal, and environmental factors, and also to ascertain whether the behavior of individuals with allegedly normal hearing and PHIs differs in important ways. The checklist may also prove useful in clinical situations where it is important to obtain a rapid assessment of the tactics used by communication partners of a PHI. For this type of research, a measure that is suited to the full range of hearing impairment is desirable. The structure and content of questions in existing self-report measures of communication strategies reflect situations that commonly arise for a PHI. To a person who does not acknowledge hearing impairment the questions may seem irrelevant but with a little rewording they can be made so. Accordingly, the target situation in our questionnaire was framed very broadly, the instructions asking how the person would respond when ‘you cannot hear or make out what is being said’ for any reason, including noisy surroundings, a quiet speaker, or a deficiency in one’s own hearing. A number of conversation tactics were then rated for frequency of use in situations of this type. Some questionnaires used in this area have assessed attitudes, knowledge, or skills rather than frequency of response. We felt that a frequency format would more likely mirror actual behavior and require less reflection on the part of the respondent. This is an assumption that needs to be substantiated. If so desired, the instructions can be modified to reflect more specific situations (e.g. difficulties in communication with family members or with strangers). The broad characterization of the situation causing difficulty means that our checklist is likely to emphasise cross-situational factors such as the social desirability of a response, gender differences, and personality traits. Previous research has already shown that psychosocial and personality factors are likely to be influential in audiological rehabilitation (Demorest & Erdman, 1989a; Gomez & Madey, 2001; Heydebrand et al, 2005; Knutson & Lancing, 1990). Gender differences have also been identified in speech processing (e.g. Daly et al, 1996; Strelnikov et al, 2009). Tye-Murray et al (1993) reported that women are more likely than men to use corrective and instructional strategies when they interact with familiar talkers. In view of these observations, our analyses included a focus on gender differences. The CCL that we employed in an earlier study (Hallam et al, 2007) was constructed by examining the literature on hearing tactics and audiological rehabilitation (e.g. Erber, 1996; Erber & Lind, 1994; Tye-Murray, 1994, 2008). The content of each item was selected on the basis that it had been considered important by an expert in the field, although we reworded items, as explained above, to be meaningful for someone who considers his/her hearing to be normal. The 54 items amounted to twice the number used in the communication subscales of the CPHI (Demorest & Erdman, 1986). In our first study, the items were grouped into eight a priori categories, but the present study employs factor analysis of data obtained from a large mixed sample to ascertain the grouping empirically. Factor analyses of the communication strategies scale of the CPHI have largely replicated the original division of tactics into

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maladaptive, verbal, and non-verbal (Demorest & Erdman, 1989b), even though different samples of PHIs and somewhat different factoring techniques have been employed (Helvik et al, 2007, Mokkink et al, 2009). It was of interest to know whether our analysis would yield similar results when the number of potentially relevant items was expanded, their wording was simplified, and the instructions changed. We also explored how factor scores were related to age, gender, degree of self-assessed hearing impairment, and to whether or not the respondent communicated regularly with a PHI. Following an analysis of the factorial structure of the checklist items, we investigated differences between the responses of persons with mild and severe hearing impairment. On the basis of previous literature reviewed by Hallam et al (2007) it appeared that the psychosocial consequences of acquired hearing impairment only become obvious with a severe/profound loss. At this level, persons cannot easily ‘pass as normal’ and they are forced to resort to tactics such as speech reading or signing. We therefore hypothesized that the most and least frequently employed tactics would differ between these groups.

Method Participants We wished to recruit a large sample for the purposes of factor analysis, and one that included a range of ages and degrees of hearing impairment from absent to severe. The research was advertised on the website of the Royal National Institute for the Deaf (now Action on Hearing Loss), a charity that serves those with an adventitious loss. Anyone interested was invited to participate, whether hearing impaired or not. To supplement the number of younger respondents with normal hearing, participants were also recruited from university, friends, and acquaintances. Although the sample is not representative of the general population, it is heterogeneous with respect to the variables of interest to us. The final sample size was 188 (71 male, 117 female). The age range was 18 to 94 (mean, 50.7; sd, 17.4). There were missing data on severity of self-reported hearing impairment for three respondents. Impairment was rated as none (n ⫽ 42), slight or mild (n ⫽ 17), moderate (n ⫽ 43), severe (n ⫽ 40), or profound (n ⫽ 46). Eighty participants said that they wore a hearing aid, and 17 that they wore one some of the time. Forty-nine were fitted with a cochlear implant.

Instruments The instructions for administering the CCL are given in full in the Appendix, which is available in the online version of the journal (please find this material with the direct link to the article at: http://www.informahealthcare.com/doi/abs/10.3109/14992027.2013. 852256). The checklist can be constructed from the items supplied in Table 1 but a formatted paper version is available in supplemental material. It was assumed that respondents would not always perceive items as relevant to them (e.g. ‘Turn your ear towards the talker’ for someone who is profoundly deaf, or ‘Use visual cues – watch the lips of the speaker’ for a hearing person who is unaware of making use of these cues). The instructions therefore included the statement: ‘All of these items refer to what you do about the situation. If you believe that the tactic doesn’t apply to you at all, just check off ‘never use’.’ The rationale here is that ‘non-applicable’ is functionally equivalent to ‘never use’, and our intention was to assess frequency of use, not attitude. If a respondent considers that a tactic does not apply to them, then they are extremely unlikely to

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use it. It is of course possible that respondents use tactics without being aware of doing so, and a self-report method cannot overcome this potential weakness. Before answering the questions, participants indicated their gender, age, geographical location, degree of self-assessed hearing impairment, and whether or not they wore a hearing aid and/or were fitted with a cochlear implant. We gave no specific instruction to respond in the aided condition, although we assumed that this would probably be the case. (We were not investigating whether wearing a prosthesis altered the use of tactics but, rather, asked this question for the sake of completeness of description of our sample). Respondents were also asked whether or not they interacted on a regular basis with someone with impaired hearing as this did seem to be a factor that might modify the frequency of using different tactics. The wording of the items used by Hallam et al (2007) was carefully examined and some small changes were made to a few items in order to improve clarity and singularity of meaning. The program that delivered the online questionnaire was accessed through home computers. For each item, the respondent had to choose between never use (scored 1), rarely use (2), sometimes use (3), and usually use (4). A four-point scale was chosen, firstly, because it was thought respondents would be unlikely to be capable of making finer distinctions, and, secondly, because it prevents a tendency to use the midpoint of an odd-numbered scale. The four response options were presented as each item appeared on the screen and respondents had the option of changing their choice. As already noted, the respondents were instructed at the beginning of the checklist to use the ‘never use’ option (scored 1) if they considered that an item did not apply to them, i.e. a ‘not-applicable’ choice was not offered. Some items apply to both partners in a conversation (e.g. ‘Try to move with the talker to a quieter place’), some refer to attempts to achieve successful communication (e.g. ‘Speak clearly’), and some to optimizing sensory conditions or initiating repair. Some forms of optimizing are self-managed (e.g. ‘Take note of facial expressions or gestures’) while others involve a request for behavior to change (e.g. ‘Ask the talker to show his or her face while speaking’). Examples of general strategies designed to change a speaker’s behavior are: ‘Act as though you have heard nothing so others have to repeat themselves’ and ‘Get irritated with the other person’. An example of a repair strategy is: ‘Ask the talker to repeat what they said’. A further tactic is to take a meta-perspective on communication, such as, ‘Organize what you want to say in your mind before saying it’. Some items refer to alternative channels of communication (i.e. signing, gesture, writing).

Results Factor analysis of whole sample (n ⫽ 188) Given the desirability in factor analysis of including only items that discriminate between respondents, frequencies across response categories for each item were first checked. Each response category was used by some respondents for all items and so no item was excluded on this basis. The most frequently chosen response was three (sometimes use). The ‘never use’ response was selected on 14.7% of occasions on average across all items. The size of the sample meant that there were approximately 3.5 respondents per item, which is at the lower limit of a desirable number (Henson & Roberts, 2006). Principal components analysis was conducted with varimax rotation (IBM SPSS V. 16, 2008). There were 16 principal components with an eigenvalue greater than one, with no obvious boundary in the scree test. The KMO value for sampling adequacy was .747, which

is considered satisfactory. Items with loadings above .40 were used to define a factor. A decision on the number of factors to extract followed a method adopted by Hiller & Goebel (1992) in which the interpretability of factors is taken into consideration. Successive analyses extracting eight, seven, and six varimax factors were carried out. The analyses that imposed eight and seven factor solutions produced some very small non-interpretable factors. The six-factor solution, accounting for 43% of the variance, produced clearly interpretable factors and was therefore the one selected. Although the two smallest factors each accounted for less than 5% of the variance, they were composed of six or more conceptually related items. The present study is one of the first exploratory factor analyses of conversation tactics and therefore it seems important to retain potentially important dimensions of responding. Further research may or may not confirm their significance. Moreover, replication analyses with a shorter CCL are likely to show that more of the total variance can be explained. Of the 54 CCL items, 45 loaded at a level of .40 or above on at least one of the six factors (see Table 1). Three of the items load more than one factor. A description of each factor follows. Factor 1 (‘disengage’, 12 items) appears to identify tactics of avoidance, disengagement, irritation, and diminished effort to overcome obstacles to communication. Examples are ‘Get up and leave if conversing is too difficult’ and ‘Pretend to understand what the talker is saying’. This factor is similar to the ‘maladaptive strategies’ that have been found to cluster in the CPHI. Factor 2 (‘optimize speech reading cues’, 9 items) seems to be defined by the tactic of speech reading. The items focus on the visibility of the talker’s face and a request for clear, measured speech. Factor 3 (‘optimize volume of speech’, 6 items) appears to be composed of tactics that optimize auditory discrimination through behavioral and environmental means. Examples include switching off or moving away from distracting noise, and requesting adequate loudness of speech. Factor 4 (‘anticipate and mitigate difficulty’, 7 items): The items share in common a deliberate attempt to prepare or anticipate difficulties by cognitively simplifying or organizing the message (meta-cognitive strategies). Examples include using fewer or simpler words and repeating what has been said. The use of gesture or signs also loads this factor. Factor 5 (‘read the context/attract attention’, 8 items): The items can be interpreted as tactics that endeavor to use behavioral observation, attention grabbing, and contextual means to improve the chances of successful communication. Examples include catching a person’s eye before speaking and taking note of facial expressions and what a person is doing. Factor 6 (‘confirm message’, 6 items) appears to be defined by tactics that confirm understanding of what has already been communicated. Examples are asking another person to repeat or to say something in a different way, and repeating the message back to confirm content.

Short CCL: Psychometric properties A shorter 45-item CCL can be constructed from the items in Table 1 that have a significant loading on one (or more) of the factors. The statistics for these six subscales are given in Table 2. Note that three items load more than one factor (there are two items in common between subscales 2 and 5 and one between 4 and 5). The sample is not representative of either a clinical or a non-clinical population; the statistics should therefore be taken as guides rather than norms. The first five subscale scores have satisfactory internal

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Conversation tactics Table 1. Item means (SDs) and loadings ⬎.40 for each of the factors. Mean (SD) Factor one: Disengage (14.9% of variance) Avoid having the conversation altogether if you think it will be difficult Give up and leave if conversing is too difficult Give up trying to understand and switch off End the conversation if the other person looks irritated Decide that what you are saying is not important enough to keep repeating it Get irritated with the other person Make the minimum amount of effort and withdraw into your own thoughts Keep quiet to avoid the effort of conversing Avoid talking about unimportant things Pretend to understand what the talker is saying Deliberately ignore the other person until he or she communicates more effectively Smile if your are following, frown or look puzzled if you are not Factor two: Optimize speech reading cues (9.2% of variance) Ask the talker to show his or her face when speaking Ask a talker to face you when talking Remind a talker that shouting does not help Ask a talker to catch your attention before speaking to you Ask the talker to speak more clearly Ask the talker to speak more slowly Make sure that you can see the talker’s face clearly Use visual cues - watch the lips of the speaker Ask the talker to tell what the subject of the conversation will be about Factor three: Optimize volume of speech (5.9% variance) Ask a quietly spoken talker to speak more loudly Turn off any external noise or shut window, etc. Move closer to the talker Turn your ear towards the talker Ask the talker to speak more loudly Try to move with the talker to a quieter place Factor four: Anticipate and mitigate difficulty (5.1% of variance) Use fewer words or simplify to get your message across Organize what you want to say in your mind before saying it Use gestures or sign language Repeat what you say word for word Write down what you want to say Phrase a question so that only a few answers are possible Speak clearly Factor five: Read the context/attract attention (4.1% of variance) Take note of facial expressions and gestures Take note of what the other person is doing or looking at Catch the other person’s eye before speaking Use visual cues - watch the lips of the speaker Mentally fill in the gaps or guess when you miss parts of the conversation Make sure you can see the talker’s face clearly Phrase a question so that only a few answers are possible Keep calm and unflustered when you miss one thing, so as not to miss the next Factor six: Confirm message (3.7% of variance) Ask the talker to say something in a different way Repeat back to the talker what you think you have just heard Ask the talker to write down important information or unusual words e.g. names of people Replay in your mind what you have just heard and try to piece together the sounds Ask the talker to repeat what they said Give more information to make sure the other person understands Items that failed to load on a factor (⬍ 0.40) Interrupt the speaker if you begin to lose track of what they are saying Ask a partner or friend who is with you in a group to summarize the conversation or tell you what people are talking about Try to look interested when you are not hearing clearly Act as though you have heard nothing so others have to repeat themselves Ask others not to shout to you from another room Mention to others your difficulty in hearing when you cannot understand what they are saying Just keep on talking so you don’t have to listen Ask a ‘reverse question’ to check that you have heard correctly Speak slowly

Item loading

2.70 (0.89) 2.26 (0.83) 2.45 (0.87) 2.90 (0.92) 2.51 (0.96) 2.29 (0.80) 2.23 (0.77) 2.44 (0.83) 2.42 (0.94) 2.85 (0.76) 1.63 (0.81) 3.02 (0.80)

.76 .69 .65 .64 .58 .57 .57 .54 .50 .50 .47 .43

3.01 (1.11) 3.16 (1.04) 2.48 (1.14) 2.47 (1.16) 2.84 (0.93) 2.63 (0.90) 3.60 (0.74) 3.45 (0.90) 2.18 (1.01)

.81 .81 .71 .66 .59 .57 .56 .49 .47

2.95 3.16 3.37 2.83 2.32 3.10

(0.94) (0.84) (0.72) (1.08) (0.89) (0.75)

.68 .65 .61 .61 .60 .53

2.78 (0.83) 2.65 (1.01) 2.38 (0.98) 2.39 (0.93) 1.76 (0.89) 2.66 (0.95) 3.40 (0.78)

.65 .64 .54 .50 .48 .47 .42

3.54 (0.76) 3.22 (0.84) 3.28 (0.82) 3.45 (0.90) 3.25 (0.75) 3.60 (0.74) 2.66 (0.95) 3.34 (0.70)

.60 .58 .57 .54 .50 .48 .46 .42

2.62 (0.89) 2.90 (0.68) 2.18 (1.03) 2.95 (1.00) 3.23 (0.63) 3.24 (0.72)

.56 .51 .45 .42 .41 .41

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Table 2. Factor sub-scale scores: Range, mean, sd, coefficient alpha (n ⫽ 185). Name Factor one: Disengage Factor two: Optimize speech reading cues Factor three: Optimize volume of speech Factor four: Anticipate and mitigate difficulty Factor five: Read the context/ attract attention Factor six: Confirm message

No. of items Range Mean

SD

Table 3. Correlations between factor scores and age, gender, and severity of impairment.

Cronbach’s alpha

12 9

14–44 29.68 6.13 10–36 25.86 6.11

.83 .85

6

6–24 17.69 3.46

.73

7

7–26 18.01 3.96

.73

8

14–32 26.38 3.94

.76

Age Factor one: Disengage Factor two: Optimize speech reading Factor three: Optimize volume of speech Factor four: Anticipate/mitigate difficulty Factor five: Read the context/attract attention Factor six: Confirm message

Gender

Severity of impairment ⫹.15* ⫹.51** ⫺.32*

⫹.15*

⫹.17*

*p⬍.05, **p⬍.01. 6

9–24 17.13 2.79

.55

reliabilities (Cronbach’s alpha) of between .73 and .85. The figure was lower at .55 for the sixth factor.

Correlation of factor regression scores with age, gender, and level of hearing impairment Factor regression scores for each participant were generated. These scores, providing a single measure for each factor, were correlated with the respondent’s level of self-assessed hearing impairment, age, and gender (see Table 3). When examining these correlations it should be noted that gender and degree of hearing impairment are negatively correlated ⫺.35, p⬍.01 (females were less impaired) and that females were younger than males (age and gender, r ⫽ ⫺.26, p ⬍.01). However, there were no other significant correlations with gender. As expected, age was associated with degree of self-assessed hearing impairment (r ⫽ .51, p ⬍.01). One conclusion that can be drawn from this pattern of correlations is that ‘optimize speech reading cues’ (Factor 2) tends to be associated, as expected, with greater impairment and age, and negatively with tactics that seek to optimize communication by changing the external environment or requesting that the speaker speak more loudly (Factor 3). These findings are in line with the expected usefulness of these tactics for a PHI as impairment becomes severe or profound. Severity of hearing impairment is slightly associated with ‘disengagement’ (Factor 1).

Frequency of use as a function of self-reported hearing impairment In view of the fact that the frequency with which some tactics are employed is related to severity of impairment (see above), the sample was divided into two groups on the basis of the respondent’s selfrating of impairment, i. e. none, mild, or moderate vs. severe or profound. Each respondent had indicated frequency of use on the 1 to 4 scale for each of the items and so an ‘average use’ measure across the ‘mild’ and ‘severe’ groups was derived for each item by summing across the individual scores and dividing by the number, N. The three least used and most used items for each group are compared in Table 4. (Three was an arbitrary choice, and only the 45 items defining the factors were included). Two of the three least employed tactics were identical for the two severity groups. The item ‘deliberately ignore the other person, etc.’ may have been deemed socially undesirable. The item ‘write down

what you want to say’ may have only rare occasions of use. The third item differs for mild and severe groups, perhaps reflecting the low value of the tactic bearing in mind hearing level. All three of the most employed tactics focus on physical closeness to the speaker and observation of a speaker’s face, expressions, gestures, or lips. However, there is greater emphasis on the lips in the severe group, consistent with the employment of speech reading by this group (Hallam et al, 2006).

Frequency of use according to gender in mild and severe groups Gender differences were explored separately in the mild and severe groups. Correlations between gender and factor scores across the whole sample had already been shown to be non-significant (see above). The comparison was first made in terms of mean factor regression scores. In the mild severity group, the ‘optimize speech reading cues’ factor showed a gender difference with males having lower scores (independent samples t test, t ⫽ 1.98, p ⬍.05). This result justified an examination of raw scores on all 45 CCL items, setting the significance level at ⬍.02 to avoid a Type II error. This revealed six items with a p value between .02 and .002, all of them consistently pointing to less frequent employment of full facial contact in the males, e.g. Make sure you can see the talker’s face clearly (2.92 vs. 3.56, t ⫽ 3.25, p ⬍.002, male n ⫽ 24, female n ⫽ 75), Ask the talker to show his or her face while speaking (2.00 vs. 2.78,

Table 4. Average frequency of use for least and most employed tactics in two impairment severity groups (frequency rated 1–4).

Three least employed tactics Deliberately ignore the other person until he or she communicates more effectively Write down what you want to say Ask the talker to tell you what the subject of the conversation will be about Ask the talker to speak more loudly Three most employed tactics Make sure you can see the talker’s face clearly Take note of facial expressions and gestures Move closer to the talker Use visual cues - watch the lips of the speaker

Mild (N ⫽ 99)

Severe (N ⫽ 86)

1.54

1.74

1.62 1.82

1.92

2.03 3.41 3.42 3.41

3.84 3.69 3.78

Conversation tactics t ⫽ 2.93, p ⬍.004), Use visual cues – watch the lips of the speaker (2.76 vs. 3.30, t ⫽ 2.35, p ⬍.02), Take note of facial expressions and gestures (3.08 vs. 3.53, t ⫽ 2.40, p ⬍.02), Catch the other person’s eye before speaking (2.80 vs. 3.23, t ⫽ ⬍ 2.26, p ⬍.02), and Ask a talker to face you when talking (2.33 vs. 2.96, t ⫽ 2.48, p ⬍.02). The consistency of direction of these differences and the similarity of their thematic content makes it hard to dismiss them as chance findings. They are of interest given evidence of gender differences in speech reading ability (see Discussion). In the severely hearing-impaired group, there was a significant gender difference on ‘anticipate/mitigate difficulty’ (t ⫽ 2.38, p ⬍.02, male n ⫽ 46, female n ⫽ 40). A follow-up analysis of all individual items revealed differences on four of them. The findings with the mild group were not replicated, perhaps because the need for speech reading overrides any pre-existing gender difference in the employment of facial cues. Males used one tactic with greater frequency than females which was ‘interrupt others if you begin to lose track of the conversation’ (3.41 vs. 3.03, t ⫽ 2.73, p ⬍.008). This may be a sign of male social assertion; the remaining differences are consistent with less assertion in females, namely, ‘Ask the talker to repeat what they said’ (3.07 vs. 3.43, t ⫽ 2.75, p ⬍.007), ‘Try to look interested when you are not hearing clearly’ (2.98 vs. 3.50, t ⫽ 2.55, p ⬍.02), and ‘Pretend to understand what the talker is saying’ (2.67 vs. 3.08, t ⫽ 2.33, p ⬍.02).

Factor scores for persons regularly interacting with a PHI Participants were asked to indicate whether they interacted on a regular basis with someone who has a moderate to severe impairment of hearing. A majority (n ⫽ 112) replied affirmatively. These respondents had lower regression scores on factor one, ‘disengagement’, indicating significantly less frequent employment of avoidance or similar tactics (independent t test, t ⫽ 3.64, p ⬍.0001). They were more likely to use the tactics that define factor four, ‘anticipate/ mitigate difficulty’, (t ⫽ 5.49, p ⬍.0001). These associations are consistent with a positive and helpful response to the PHI.

Factor scores for persons who were aided or non-aided Persons who either wore a hearing aid or were fitted with a cochlear implant (n ⫽ 138) were compared in terms of factor scores with the unaided group (n ⫽ 47). Only ‘optimize speech reading cues’ revealed a difference (independent samples t test, t ⫽ 3.98, p ⬍.0001), presumably reflecting the greater hearing impairment of the former.

Discussion Factor analysis of the 54-item CCL was undertaken on an exploratory basis in order to provide support for an earlier categorization of tactics into eight types based on the existing literature. The fact that all but nine items of 54 contributed to the definition of factors probably reflects the origin of the items in this literature. Although the results are consistent with expert description of communication tactics used by people with impaired hearing, further factorial analyses of the 45-item CCL would help to confirm the robustness of factors. This applies especially to the sixth sub-scale of the shortened CCL (‘confirm message’) which has an internal reliability of only .55. The results of the factor analysis are consistent with the significance of the ‘maladaptive strategies’ factor of the CPHI but has expanded the potential for a more refined dimensional classification. Avoidance and some other potentially maladaptive tactics (here

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renamed ‘disengagement’) seem to lie on a continuum and form one factor. The analysis has revealed an overlap, close to identity, between the types of tactic employed by persons with normal hearing and those with hearing impairment. The tactic of asking a talker to say something in a different way, to repeat what they have said, or to repeat back what the listener thinks was said, are common when spoken language communication becomes difficult for any reason. Only the tactic of visual speech reading seems to be highly associated with level of hearing impairment. Nevertheless, vision is heavily implicated in the tactics that persons with mild or no impairment commonly employ when they observe, for instance, a speaker’s expression or direction of gaze. The internal reliability of subscales of the CCL (derived from summing raw scores of items loading a factor) appears to be good for the first five factors. The construct validity of the CCL is supported by differential and meaningful associations between factor regression scores and variables such as level of self-rated impairment, age, regular interaction with a PHI, and aided versus non-aided respondents. Tactics of speech reading make up the second largest factor. Although there was no correlation across the whole sample between gender and rated frequency of using any kind of tactic, a breakdown into two severity of impairment groups (no/mild/moderate vs. severe/profound) revealed some interesting and consistent gender differences on a number of individual CCL items. For the mild severity group, females reported more frequent employment of visual facial cues. Research into gender differences in speech reading has produced a complex set of findings, in part dependent on factors such as type and complexity of task and experimental paradigm (see review by Strelnikov et al, 2009). Tye-Murray et al (2007) found no gender differences regardless of stimulus type (i.e. consonants, words, sentences). Irwin et al (2006) reported that a female advantage was only shown for very brief visual presentations. Strelnikov et al found that females performed better in a word recognition task but performed equally for isolated phonemes. This was true both of normal controls and persons with profound hearing loss. They also observed that males receiving cochlear implants improved their performance after two years of auditory recuperation whereas females showed no statistically significant improvement, leading to similar overall performance for males and females. It is possible that everyday performance will show up more gender effects than a laboratory task, given that the former is influenced by complex behavioral, emotional, and motivational factors. Strelnikov et al (2009) cite evidence that women are more ‘attentive gazers’ and ‘better at recognizing facial expressions’. These authors prefer an explanation of gender differences in terms of information processing strategies of a predictive and integrative type. They also speculate that there are wider differences in communication and interaction strategies. The present findings that males (in the mild severity group) are less likely to report a strategy of full facial contact to facilitate communication is consistent with this position. Viewed from a male standpoint, full attention to the face may be viewed as a threatening signal when communicating with either a male or a female. Moreover, when a male communicates with a female in a test situation (or merely expects to do so), their cognitive performance declines (Nauts et al, 2012). Males could avoid facial contact to minimize these effects. Other motivational differences between men and women could also influence their conversation tactics. For persons with severe hearing loss, who rely heavily on visual cues, it is necessary to encourage full facial contact through

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non-verbal signals or by requesting that a talker face you. The necessity to do so may override any predisposing gender differences. The fact that male performance improves after cochlear implantation (see above) supports this view. With regard to the results on individual items of the CCL in the severe group, a different pattern of gender differences emerged. These are most readily explained in terms of the assertion needed to signal a failure of communication. According to our results, males were more likely to step in earlier to signal a problem whereas females were more inclined to ask the talker to repeat or feigned understanding. The self-report method of the CCL checklist cannot reveal what must be considerable cross-situational variation in use of tactics, although the instructions could be varied to investigate situational effects. The self-report method may also be insensitive to tactics that have become so habitual as to be inaccessible to conscious reflection. These limitations are offset by the speed of administration and convenience of the CCL. We would recommend reducing the number of items to those that load the six factors and to conduct further psychometric studies. The CCL may prove useful in rehabilitation by identifying unhelpful tactics in the PHI or their partner (Preminger & Meeks, 2010). It could also assist in the process of educating couples about hearing tactics in conjunction with behavioral assessment methods (Caissie & Tranquilla, 2010, Lind et al, 2010, Manchaih et al, 2012, Preminger & Lind, 2012).

Acknowledgements The authors are very grateful to the Royal National Institute for the Deaf (now Action on Hearing Loss) for permission to place the online questionnaire on their website. And thanks, too, to the anonymous participants and for the suggestions of reviewers. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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Supplementary material available online Supplementary Appendix to be found online at http://www.informa healthcare.com/doi/abs/10.3109/14992027.2013.852256.

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Conversation tactics in persons with normal hearing and hearing-impairment.

To investigate the tactics people use when aural communication fails owing to environmental circumstances or impaired hearing...
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