Aging & Mental Health

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Sensory loss and its consequences for couples’ psychosocial and relational wellbeing: an integrative review Christine M. Lehane, Jesper Dammeyer & Peter Elsass To cite this article: Christine M. Lehane, Jesper Dammeyer & Peter Elsass (2016): Sensory loss and its consequences for couples’ psychosocial and relational wellbeing: an integrative review, Aging & Mental Health, DOI: 10.1080/13607863.2015.1132675 To link to this article: http://dx.doi.org/10.1080/13607863.2015.1132675

Published online: 07 Jan 2016.

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Date: 15 March 2016, At: 06:26

AGING & MENTAL HEALTH, 2016 http://dx.doi.org/10.1080/13607863.2015.1132675

Sensory loss and its consequences for couples’ psychosocial and relational wellbeing: an integrative review Christine M. Lehane, Jesper Dammeyer and Peter Elsass

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Department of Psychology, University of Copenhagen, Copenhagen, Denmark

ABSTRACT

ARTICLE HISTORY

Objectives: Previous research has shown that marital communication is key to couples’ successful illness adjustment. However, little is known about couples’ experiences of health conditions characterised by communication difficulties such as acquired hearing, vision, and dual-sensory loss. The aim of this review was to identify the effect of sensory loss, and associated communication difficulties, on couples’ relational and psychosocial adjustment. Method: A systematic search was conducted to identify studies investigating the social, psychological, and relational impact of sensory loss on couples. Results: Twenty-four articles met the criteria for inclusion in the review. Significant heterogeneity in the measurements and design of the quantitative studies prevented statistical data synthesis. All but two studies reported some effect of sensory loss on couples’ psychosocial or relational wellbeing. Higher levels of marital satisfaction were found to buffer against adverse psychological outcomes. Results of quantitative and qualitative studies were synthesised to form an integrative model illustrating the associations between sensory loss and couples’ relational and psychosocial wellbeing. Conclusions: Although this review reports an association between sensory loss and couples’ relational and psychosocial wellbeing, the results should be viewed with caution given that relatively few studies on couples’ experiences of acquired sensory loss exist, and many have methodological limitations.

Received 6 August 2015 Accepted 10 December 2015

Introduction Marriage has consistently shown to be associated with subjective wellbeing (Wadsworth, 2015), and the more satisfied partners are within their marriage, the stronger the association (Carr, Freedman, Cornman, & Schwarz, 2014). Research on marital satisfaction has long argued for the interdependent nature of communication (verbal and nonverbal) and relational development. More specifically, according to socialpenetration theory (Altman & Taylor, 1973), reciprocal disclosure of thoughts, feelings, and concerns between partners is essential for the maintenance of marital satisfaction (Ayres, 1979; Hendrick, 1981). While these findings have formed the basis of many couples’ therapy models (Dandeneau & Johnson, 1994), recent research has focused on the efficacy of general and illness-related reciprocal disclosure as an intervention prospect among couples living with chronic health conditions (Manne, Badr, Zaider, Nelson, & Kissane, 2010). Previous research has shown that illness or disability can either increase or decrease a couple’s risk for psychological and social distress (Beach, Schulz, Yee, & Jackson, 2000), depending upon their level of marital satisfaction (Ball et al., 2010; Davis, Gilliss, Deshefy-Longhi, Chestnutt, & Molloy, 2011; Kramer, 1993; Steadman, Tremont, & Davis, 2007); and irrespective of the type of illness or disability, maintaining a sense of marital satisfaction requires open marital communication, both about the illness or disability, and in general (Arden-Close, Moss-Morris, Dennison, Bayne, & Gidron, 2010; Chen & Habermann, 2013). Research findings on the therapeutic potential of reciprocal disclosure have proved valuable

CONTACT Christine M. Lehane © 2016 Taylor & Francis

[email protected]

KEYWORDS

Sensory loss; couples; wellbeing; relationship quality; review

for the design of communication-based interventions for couples living with serious health conditions such as cancer (Arden-Close, Gidron, Bayne, & Moss-Morris, 2013; Mowll et al., 2015). Nevertheless, the question remains - if open marital communication plays a role in couples’ illness-related adjustment, how do couples living with health conditions characterised by communication difficulties such as acquired hearing-, vision-, and dual-sensory loss adjust psychologically, socially, and maritally? Acquired single and dual-sensory impairments are amongst the most disabling chronic conditions in older adults, and first of all affect the ability to communicate (Crews & Campbell, 2004). Having lived most of their lives as fully sighted and hearing individuals, older adults in particular have difficulty adjusting their communication styles to other modalities (Heine & Browning, 2002). Previous reviews of the literature on sensory loss and intimate relationships have collectively argued for a negative effect of sensory loss on older couples’ psychosocial and marital wellbeing. More specifically, that the onset of sensory loss is associated with increases in communication related frustrations, activity limitations, stress, fatigue, mutual resentment, and guilt (Donaldson, Worrall, & Hickson, 2004; H
etu, Jones, & Getty, 1993). However, although these reviews are valuable, both articles have only considered couples living with hearing loss, reviewed literature no later than 2003, and failed to include a method section detailing how the articles were sourced and chosen. Further, both articles focused their review on the impact of hearing loss on couples’ wellbeing but neglected to discuss the factors

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related to couples’ adjustment. As a result, the currently available reviews can only give an indication of how difficulties in verbal communication may affect couples’ wellbeing, with no assessment of the literature on vision loss or dual-sensory loss which pertains to visual or both verbal and visual communication difficulties. Population-based surveys examining the prevalence of sensory impairments indicate that single and dual-sensory impairments increase dramatically with age (Agrawal, Platz, & Niparko, 2008; Laitinen et al., 2005; Schneider et al., 2012; van der Pols et al., 2000). More specifically, from the age of 65 onwards, up to 27% of individuals are diagnosed with a vision impairment, (Campbell, Crews, Moriarty, Zack, & Blackman, 1999; Horowitz, Brennan, & Reinhardt, 2005); approximately 33% are diagnosed with a hearing impairment, (Campbell et al., 1999); and as many as 21% are diagnosed with concurrent visual and hearing impairments, i.e. dual-sensory loss (Campbell et al., 1999; Saunders & Echt, 2007). Considering the world’s growing older population, prevalence rates of sensory impairments are projected to increase by as much as 70% by 2020 (Congdon et al., 2004). Therefore, it is expected that in the coming years more couples will be presented with the issue of adjusting to acquired sensory loss. In light of the limitations of previous reviews and the projected increase in the number of couples who will need to adjust to life with single and dual-sensory loss, there is a need for a more systematic, up-to-date review of the literature on sensory loss and its consequences for couples’ marital and psychosocial wellbeing. Thus, the aims of the current review are as follows: (1) to present an overview of prior research on couples’ psychosocial and marital experiences of acquired hearing-, vision-, and dual-sensory loss; and (2) to identify factors associated with couples’ adjustment.

the impact of sensory loss on the psychosocial or marital wellbeing of married or partnered individuals. Articles were excluded if (1) the participant sample was mixed and couple/partner experiences could not be distinguished separately in the results; (2) the sensory loss was congenital; (3) the sample did not include participants 50 years and older; and (4) if both partners in the study had a diagnosed sensory impairment. The final exclusion criteria was decided upon due to the expectation that wellbeing reports would differ between couples where both partners are diagnosed with a sensory impairment and couples where only one person has a sensory impairment(s).

Study selection process On the basis of the above criteria, titles and abstracts of the database-identified articles were screened for relevancy by two independent data extractors and two authors (CL and JD). If sufficient information was not available via the title or abstract to determine study inclusion eligibility, full texts were retrieved and screened for relevancy. All full texts were available via the university library. Following the initial title and abstract screening process, two authors (CL and JD) and two independent data extractors screened the full articles for eligibility. The initial percentage agreement was 92.5%. Disagreements were then discussed until a consensus was met. A flowchart illustrating the article selection process is provided in Figure 1. Our literature search of four databases produced 628 citations. Following the initial screening of titles and abstracts, 106 articles were found, of which 48 were duplicates. By reading all 58 articles entirely, a total of 17 articles were found to correspond to the inclusion criteria. An examination of the articles’ reference lists then produced a further 7 articles.

Method

Quality assessment

Literature search

Articles with a quantitative research design were quality assessed using a checklist developed by Fowkes and Fulton for the critical appraisal of published research (Fowkes & Fulton, 1991). According to this measure, articles are rated from 0 (no problem) to CC (major problem) on the following parameters: (1) appropriateness of study design, (2) sample representation, (3) acceptability of control group (if applicable), (4) measurement and outcome quality, (5) completeness of results, and 6) distorting influences. In order to be labelled good, adequate, or poor, three final guideline questions are provided. On the basis of the parameter ratings, i.e. whether each parameter had no, minor, or major methodological problems, the reviewers must decide whether or not the results are erroneously biased in a certain direction, whether there are any serious confounding or other distorting influences, and whether it is likely that the results occurred by chance. Answering ‘No’ to each of these three questions leads to a good quality rating, a ‘No’ to two forms an adequate quality rating, and ‘No’ to one or less forms a poor quality rating. Articles employing a qualitative design were quality assessed using the qualitative research checklist developed by the Critical Appraisal Skills Programme (CASP) (Milton Keynes Primary Care Trust, n.d.). The CASP requires reviewers to answer ‘Yes’, ‘No’, or ‘Can’t tell’ to 10 questions pertaining to: (1) Clarity of study aims, (2) methodological suitability, (3) choice of research design, (4) appropriateness of

We conducted a search in November 2014 using the databases PsycINFO, PubMed, Scopus, and Web of Science. No publication date restrictions were applied. The search term used involved a combination of the expressions (‘hearing’ OR ‘vision’ OR ‘hearing loss’ OR ‘vision loss’ OR ‘hearing impairment’ OR ‘vision impairment’ OR ‘visual impairment’ OR ‘dual-sensory loss’ OR ‘dual-sensory impairment’ OR ‘deafblind’ OR ‘combined sensory impairment’ OR ‘combined sensory loss’) AND (‘relationship’ OR ‘marital’) AND (‘spouse’ OR ‘partner’ OR ‘husband’ OR ‘wife’ OR ‘couple’ OR ‘marriage’). The search results were then screened for relevancy by article titles and abstracts. Duplicate articles were removed from the results and remaining articles were read thoroughly to assess inclusion eligibility. A number of additional articles were subsequently identified through the reference lists of the selected articles.

Inclusion and exclusion criteria Articles included in the review were as follows: (1) available in English; (2) published in a peer-reviewed journal; (3) qualitative or quantitative in design; (4) focused on acquired single or dual-sensory loss as the primary diagnosis or the main investigative focus; (5) focused on individuals with single or dual-sensory loss and/or their partners; and (6) reported on

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Data extraction For each article selected for inclusion in the review, data was extracted and summarised by the first author and checked by the second author. The data extracted included author, year of publication, study design, aims, sample size, recruitment strategy, study setting, measures, study findings and conclusions.

Results

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Study characteristics The search resulted in 24 articles for review. Sixteen articles focused on hearing loss only, seven articles focused on vision loss only, and one article included vision, hearing, and dualsensory loss. Eight articles employed a qualitative research design and 16 employed a quantitative research design. The articles included in the review are presented in two summary tables: one for hearing loss (Table 1) and one for vision loss (Table 2). The final paper included spouses of those with hearing, vision, and dual-sensory loss, and is therefore present in both summary tables. Quantitative studies were found to be heterogeneous in terms of design, sample size, aims, and methodology; thus it was decided not to statistically pool the data for meta-analysis. The quality of the articles selected for review also varied considerably; 10 articles were rated as good, five as adequate, and nine as poor (according to the two assessment measures used (Fowkes & Fulton, 1991; Milton Keynes Primary Care Trust, n.d.)). Furthermore, 16 of the 24 studies reached an evidence value of 2- or less (according to the SIGN rating system used (Harbour & Miller, 2001)). Despite such low ratings, it was decided to include all studies in the review in order to comprehensively cover the available literature. The main study limitations will be presented in the Discussion section. Finally, in consideration of the potential differential impact of each type of sensory loss on couple’s psychosocial and relational wellbeing, the findings in relation to hearing, vision, and dual-sensory loss are presented in three separate sections. Figure 1. Flowchart illustrating the article selection process.

Hearing loss recruitment strategy, (5) data collection method, (6) consideration of researcher bias, (7) ethical issues, (8) data analysis, (9) clarity of results presentation, and (10) overall value of research. In order to maintain consistency, following the 10 questions, the reviewers were asked to provide a general rating of the quality of the study as good, adequate, or poor. It was decided that a ‘Yes’ response to eight or more questions formed a ‘good’ quality rating, a ‘Yes’ to six or seven of the questions was labelled ‘adequate’, and studies with five or less ‘Yes’ responses were labelled as poor. Additionally, articles were ranked according to the value of their findings using the Scottish Intercollegiate Guidelines Network (SIGN) levels of evidence grading system (Harbour & Miller, 2001). Assessment of quantitative articles was independently conducted by the first author and one independent quantitative researcher. Qualitative articles were also independently assessed by the first author and one independent qualitative researcher. Assessment disagreements were discussed in a meeting until a consensus was met. Quality and level of evidence judgements are presented in Tables 1 and 2.

Psychosocial wellbeing At present, the literature is divided as to whether or not the onset of hearing loss in older adults is associated with negative psychosocial outcomes (Herbst & Humphrey, 1980; Tambs, 2004). Similarly, with regard to couples’ psychosocial experiences of hearing loss, the literature also appears conflicted. Two cohort studies reported an association between hearing loss and couples’ psychosocial wellbeing. Wallhagen, Strawbridge, Shema, and Kaplan (2004) examined data from 418 older couples to determine whether hearing loss had an impact on the wellbeing of unimpaired spouses five years post-onset. It was found that spouses of hearing impaired individuals were more likely to report lower psychological and social wellbeing compared to the general population. Likewise, through analyses of data including 178 cochlear implant patients, of which approximately 53% were married, Knutson, Johnson, and Murray (2006) determined that spouses, particularly wives, experienced increased psychological distress and social withdrawal compared to normal controls. Additionally, those with cochlear implants were characterised by an increased incidence of depression, social introversion, social anxiety, and loneliness (Knutson et al., 2006).

Cohort

Case-controlled

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-Sectional

Cross-sectional

Wallhagen et al. (2004)

Westaway et al. (2011)

Qualitative articles Armero (2001)

Hallam et al. (2008)

Hallberg and Barren€as (1993)

LaPierre et al. (2012)

Scarinci et al. (2008)

Stephens et al. (2004)

Yorgason et al. (2007)

LOE D Level of evidence.

Cross-sectional

Scarinci et al. (2012)

USA

UK

Australia

USA

Sweden

UK

USA

Canada

USA

Australia

USA

USA

Cohort

Randomised control trial

USA

UK

Cross-sectional

Cross-sectional

South Africa

Norway

Cross-sectional

Cross-sectional

Australia

Setting

Cross-sectional

Design

Preminger and Meeks (2010)

Kelly and Atcherson (2011) Knutson et al. (2006)

Govender et al. (2014) Hallam et al. (2007)

Quantitative articles Anderson and Noble (2005) Ask et al. (2010)

Authors

Table 1. Articles investigating couples’ experiences of hearing loss.

8 couples

102 participants (49 spouses)

10 partners

7 couples

10 partners

25 dyads (19 couples)

16 couples

25 spouses

418 couples

100 couples

36 couples

178 dyads

20 couples

22 dyads (13 couples)

35 partners

18,137 couples

66 couples

Participants

Semi-structured interviews

One open-ended question on positive experiences of hearing loss.

Relationship Assessment Scale; Structured interviews Semi-structured in-depth interviews

Thematised interviews

Grounded theory driven interviews

Not reported

SOS-HEAR; Significant Other Assessment of Communication; Self-Assessment of Communication; Relationship Assessment Scale 12-item diagnostic criteria for a major depressive episode DSM; Self-made items measuring happiness, social wellbeing and marital quality; 8-item Bradburn Affect Balance Scale. Caregiver Burden Scale; Geriatric Depression Scale

Hearing Handicap Inventory; Perceived Stress Scale; Primary Communication Inventory

10-item Hopkins Symptom Checklist; selfdesigned 3-item subjective wellbeing measure. Adapted Significant Other Scale for Hearing Disability Hospital Anxiety and Depression Scale; Selfdevised Conversation Checklist; Couple Behaviour Report Hearing Handicap Inventory for the Elderly; Short structured interview UCLA Loneliness scale; Social Avoidance and Distress Scale; Dyadic Adjustment Scale

Relationship Assessment Scale

Measures

Findings

Couples reported social, emotional, and communication issues as a result of hearing loss. Hearing loss strains personal relationships through communication difficulties, social withdrawal, relationship inequity, and burden. Spouses experienced problems with communication, relationship inequity, and conflict. Couples reported high marital satisfaction overall with some communication and equity-related issues. Spouses reported communication difficulties, emotional strain, dependency, conflict, social withdrawal, and relationship inequity. Most spouses reported no positive or only negative experiences, 42.5% reported some positive experience of partner’s hearing loss. Couples kept a positive focus overall, but reported difficulties regarding equity, communication, and socialising.

Spousal acquired hearing impairment predicts poorer psychological and social wellbeing, including marital quality. Negative impact on wellbeing was stronger for women. Burden was significantly related to depression. No differences were found between sensory loss groups and controls on depression scores.

Participants reported communication-related marital difficulties and frustration. Distressed married participants experienced a greater impact on marital behaviour in relation to exciting activities, small talk, and feedback. Quality of life scores were high overall. Couples reported issues with communication and socialising. Significant levels of psychological distress and social withdrawal were found in both partners compared to controls. At baseline couples reported communication and social participation related issues. Intervention significantly improved understanding of hearing loss among spouses but not quality of life. Most spouses reported a third-party disability. Lower relationship satisfaction related to severe or complete third party disability.

Couples showed high levels of relationship satisfaction. Women were less satisfied than men. No significant associations hearing impairment and spouse depression, anxiety or subjective wellbeing.

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Good Poor Adequate Poor

3 3 3 3

Adequate

Good

3 3

Poor

Poor

2¡

3

Good

2CC

Good

1C

Good

Good

2C

2C

Adequate

Poor

2¡ 2¡

Poor

Good

2CC 2¡

Poor

Quality rating

2¡

LOE

4 C. M. LEHANE ET AL.

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Table 2. Articles investigating couples’ experiences of vision loss. Authors

Design

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Quantitative articles Barron Cross-sectional et al. (1994)

Setting

Participants

Measures

USA

87 adults with vision loss

Revised UCLA Loneliness Scale; Social Support Questionnaire Rand Mental Health Index; Beck Depression Inventory; Rosenberg Self-Esteem Scale; Perceived Social Support Scale; Family Assessment Device NSHAP Marital quality assessment

Bernbaum et al. (1993)

Cross-sectional

USA

22 participants (9 married)

Bookwala (2011)

Cross-sectional

USA

738 adults with vision loss

Chac
on-L
opez et al. (2013)

Case-controlled

Spain

75 carers

State-Trait Anxiety Inventory; Beck Depression Inventory

Goodman and Shippy (2002) Strawbridge et al. (2007)

Cross-sectional

USA

123 couples

CES-D; The Quality of Marriage Index

Cohort

USA

418 couples

Westaway et al. (2011)

Case-controlled

Canada

25 partners

12-item diagnostic criteria for a major depressive episode DSM-IV; 8-item Bradburn Affect Balance Scale; Self-made marital quality and unhappiness items Caregiver Burden Scale; Geriatric Depression Scale

Australia

34 adults with vision loss

Qualitative articles McCloud et al. Cross-sectional (2014)

Focus groups and individual indepth interviews

Findings

LOE

Quality rating

Married participants reported higher social support and less loneliness. Vision loss is reported as a risk for separation, decrease in affection, and communication issues for couples.

2

Adequate

2

Poor

High marital satisfaction mitigated negative effects of poor vision on depression. Spouses of those with retinal degeneration reported highest depression scores. Vision loss predicted spouse depression. Poorer marital quality related to depression. Spouse vision impairment negatively affected partner depression, wellbeing, social participation, and marital quality.

2CC

Good

2C

Adequate

2

Adequate

2CC

Good

Burden was significantly related to depression. No differences were found between sensory loss groups and controls on depression scores.

2

Poor

Married participants felt a loss of relationship equity.

3

Good

LOE D Level of evidence.

In an attempt to increase couples’ awareness of the communicative and social impacts of hearing loss, Preminger and Meeks (2010) conducted a randomised control trial wherein 36 couples were randomly assigned to two intervention conditions. Condition one involved a standard audiological rehabilitation class for the hearing impaired spouse only and no rehabilitation was provided for the hearing spouse. Condition two involved the same standard audiological rehabilitation class for hearing impaired spouses, but with an added class for the hearing spouses including communication strategy training, clear speech training, and stress reduction training. All couples taking part in the study reported communication, activities of daily living, and social participation related difficulties as a result of one partner’s hearing loss. Both hearing and hearing impaired spouses reported significant improvements in hearing loss-related quality of life within the first two weeks following the intervention; however, these effects began to decline for the hearing spouses by 6 months post-intervention. In order to be included in Preminger and Meeks (2010) intervention study couples had to report hearing loss-related quality of life disruptions; however, in contrast to the above studies, it may not always be the case that couples experience difficulties adjusting to hearing loss. Westaway, Wittich, and Overbury (2011) conducted a case-controlled study comparing caregiver burden and depression scores among spouses to those with hearing loss, vision loss, dual-sensory loss, and no sensory loss. The hearing loss, vision loss, dual-sensory loss, and control samples consisted of eight, six, five, and six spouses, respectively. The researchers found no group differences in depression, yet, caregiver burden scores were highest among the spouses whose partners had no sensory

impairment. Furthermore, in a Norwegian population-based study of 18,137 couples, Ask, Krog, and Tambs (2010) found that those married to a person with hearing loss reported no more symptoms of anxiety or depression than those whose spouse did not have a hearing impairment. Note that genderspecific analyses indicated that women married to men with hearing impairments experienced more social and psychological distress than vice versa. This was also previously found by Wallhagen et al. (2004) and Knutson et al. (2006). Study findings were also conflicted amongst the qualitative literature. For instance, through interviewing hearing spouses and couples both Armero (2001) and Kelly and Atcherson (2011) identified an association between hearing loss and emotional, social, and communication issues for couples. Nonetheless, Stephens, Kerr, and Jones (2004) show that despite reporting mostly negative experiences, hearing spouses also report some positive experiences connected to their partner’s hearing loss. Notably, such positive experiences included improving patience, respect for own hearing, and improving communication skills.

Relationship satisfaction Survey-based studies examining hearing loss and relationship satisfaction have also found conflicting results. In addition to examining the association between hearing loss and spouse wellbeing, Wallhagen et al. (2004) investigated the impact of hearing loss on spouses’ relationship quality overtime. The results revealed that those who were married to an individual with hearing loss rated their relationship quality as significantly lower five years post-onset. Additionally, Anderson and Noble (2005) showed that when a discrepancy exists between a

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C. M. LEHANE ET AL.

couple’s ratings of the severity of hearing loss, i.e. if the hearing spouse rates the hearing impairment as worse than that of the hearing impaired spouse, then relationship satisfaction scores tend to be lower. Taking a closer look at the association between hearing loss and relationship satisfaction, Govender, Maistry, Soomar, and Paken (2014) showed that communication related frustrations and subsequent conversational withdrawal were most strongly associated with relationship dissatisfaction. Nevertheless, having followed 178 cochlear implant patients over a 3-year period, Knutson et al. (2006) found that couples were largely happy in their relationships despite the difficulties posed by one partner’s hearing loss. Another study conducted by LaPierre, Ferguson, and Jiregna, (2012) examined how the development of hearing loss impacts a couple’s relationship and how couples cope. The researchers interviewed seven couples using a combination of validated scales and a series of self-designed open-ended questions. Their results also revealed that couples were highly satisfied in their relationships and used coping strategies such as humour, positivity, normalising the experience, seeking advice from professionals, and developing specific communication techniques including the use of hearing aids and other assistive devices. The results of LaPierre and colleague’s study also re-establish the importance of research design. For instance, while the couple’s survey scores indicated high levels of relationship satisfaction, subsequent open-ended questions revealed that couples more frequently withdrew from conversation and felt a greater sense of disconnection since the onset of hearing loss. Gender imbalances in coping were also noted, with women taking more responsibility to adjust their communication style than men (LaPierre et al., 2012). Findings from qualitative studies are also inconclusive. For instance, while interviews with couples have shown that everyday occurrences such as reductions in conversation, misunderstandings, the need for interpretation and repetition, and an imbalance in the give and take in the relationship contribute towards marital conflict (Hallam, Ashton, Sherbourne, & Gailey, 2008; Hallberg & Barren€as, 1993; Scarinci, Worrall, & Hickson, 2008), Yorgason, Piercy, and Piercy (2007) found that couples adapt quite well to hearing loss-related communication difficulties and subsequently improve marital communication. Couples who were described as well adjusted employed similar coping mechanisms such as accepting the hearing loss, seeking more information, availing of family support, and using audiological and technological assistive hearing devices (Hallam et al., 2008; Yorgason et al., 2007).

Relationship satisfaction and psychosocial wellbeing Although it is difficult to discern whether living with hearing loss leads to psychosocial and relational difficulties for couples, the association between relationship satisfaction and couple’s psychosocial wellbeing seems to be more straightforward. Surveying 100 partners of hearing impaired persons, Scarinci, Worrall, and Hickson (2012) identified that partners who rated their relationship satisfaction as lower reported more severe effects of the impairment on their quality of life than partners who were more satisfied in their relationship. Similar findings have also been discovered among hearing impaired partners, whereby, those who were found to suffer higher levels of psychological distress also reported more of an impact of their hearing loss on marital behaviours such as participating in exciting activities together, small talk, and emotional exchange (Hallam, Ashton, Sherbourne, Gailey, & Corney, 2007).

Vision loss Psychosocial wellbeing Given the importance of vision in one’s daily life, relationship, and social interactions, it stands to reason that the loss of one’s vision may negatively affect the psychosocial wellbeing of both visually impaired persons and their partners. However, while studies have found an association between acquired vision loss and psychological wellbeing among visually impaired persons (Nyman, Dibb, Victor, & Gosney, 2012), few studies have focused on those within a relationship and their partners. Strawbridge, Wallhagen, and Shema (2007) analysed data from a US-based cohort study to determine whether vision loss affects the wellbeing of unimpaired spouses over time. Using data from 418 older couples, it was found that those married to an individual with visual impairments hold a risk for lower psychological and social wellbeing, and higher levels of depression. Cross-sectional studies have also suggested an association between one spouse’s vision loss and their partner’s quality of life and depressive symptomology
n-Lo
pez, Lo
pez-Justicia, Fern
andez-Jim

n(Chaco enez, Chaco Medina, & Polo-S
anchez, 2013). Additionally, Westaway et al. (2011) found an association between caregiver burden and depression; however, no group differences on depressive symptomology between spouses to those with a vision impairment and controls were identified. Goodman and Shippy (2002) investigated emotional contagion among 123 couples in the context of acquired vision loss. As has previously been demonstrated among non-distressed couples (Katz, Beach, & Joiner, 1999), experience of depression among visually impaired partners statistically predicted experiences of depression among unimpaired partners (Goodman & Shippy, 2002). This result highlights the importance of including both partners when conducting research related to psychological wellbeing. Despite the need to gain a better understanding of the associations found in the quantitative research, qualitative studies within the field of couples’ experiences of vision loss are few. Only one study on couples’ psychosocial experiences of vision loss used a qualitative design. Conducting interviews with 34 persons diagnosed with age-related macular degeneration, McCloud, Khadka, Gilhotra, and Pesudovs (2014) revealed that maintaining self-confidence was an issue among married participants, reportedly linked to their inability to contribute to shared, home-based daily tasks. Relationship satisfaction Although other research fields have shown that illness onset can significantly alter a couple’s relationship (Ablitt, Jones, & Muers, 2009), studies on relationship satisfaction and vision loss are scarce. Focusing on the spouse’s experience, Strawbridge et al. (2007) identified that the onset and development of vision loss negatively affected the spouse’s ratings of the quality of their relationship overtime. Furthermore, Bernbaum, Albert, Duckro, and Merkel (1993) identified vision loss as a risk for separation. Of 18 participants with diabetes-related vision loss who had been in a committed relationship, nine were separated. Risk for separation was higher when the degree of vision loss was more severe. Participants reported that the onset of vision loss led to a reduction in the expression of affection within their relationship and a reduction in their ability to participate in recreational social outings with their partner.

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Unlike research on hearing loss, McCloud et al. (2014) were the only researchers to investigate the impact of vision loss on marital relationships using a qualitative methodology. Although few differences between the married and unmarried participants’ reports were identified, married participants were mainly concerned about their inability to contribute to household tasks and maintain relationship equity.

Relationship satisfaction and psychosocial wellbeing The protective nature of marriage against the adverse psychosocial outcomes of vision loss has previously been highlighted amongst the literature (Reinhardt, 2001). However, few studies have attempted to explain this association further. A study on loneliness among 87 older adults with visual impairments showed that being married increased participants’ perceived level of social support and lessened the experience of loneliness (Barron, Foxall, Von Dollen, Jones, & Shull, 1994). And further, Bookwala (2011) analysed data from 738 married persons with a visual impairment and found that those who reported higher levels of marital satisfaction had a significantly lower risk for depression. Similar findings were also found among studies incorporating both partner’s perspectives, in that, couples who rated the quality of their relationship as lower had the highest risk for depression (Goodman & Shippy, 2002). Dual-sensory loss Psychosocial wellbeing Previous research in the field of dual-sensory loss has identified that there is a strong association between acquired dualsensory loss and depression (Capella McDonnall, 2009; Capella-McDonnall, 2005; Heine & Browning, 2002). Yet, very little is known about how the onset or development of acquired dual-sensory loss may impact couples. The only study to date that looks at dual-sensory loss in the context of marriage/a relationship was conducted by Westaway et al. (2011). Westaway et al.’s (2011) study recruited 25 participants, split across four groups, using a survey methodology. However, since data was only collected on five spouses to individuals with dual-sensory loss, the authors could not look specifically into their experiences, as subgroup correlations were too small. Overall, the researchers found no significant differences between spouses to a person with dual-sensory loss, single sensory loss, and controls on level of depression or caregiver burden.

Discussion Although it was expected that hearing, vision, and dual-sensory loss may differentially influence the psychosocial and

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relational wellbeing of couples, the results of our review indicate little difference between couples’ wellbeing as an effect of sensory modality. Additionally, given the heterogeneity of the articles’ quality and value assessments it was expected that those with higher ratings would produce qualitatively different results from those with lower ratings. This was not found to be the case. With the exception of two articles (Ask et al., 2010; Westaway et al., 2011), all other articles reported some consequence of sensory loss on couples, with most reports pertaining to communication difficulties, social withdrawal, increased dependency, relationship inequity, reduced marital satisfaction, or psychological distress. Nevertheless, with so few articles reporting no association between sensory loss and couples’ psychosocial and/or marital wellbeing, it should be kept in mind that a publication bias may exist within this field of research. Nonetheless, stemming from the findings of this review, a visual outline of the associations between sensory loss, relationship satisfaction, and psychological wellbeing has been composed (Figure 2). While there still remains little information on couples living with dual-sensory loss, our findings lead us to propose that associations between dual-sensory loss, relationship satisfaction, and psychological wellbeing may also be illustrated according to the framework in Figure 2. According to this framework, when one person in a relationship develops single or dual-sensory loss, the extent of their sensory loss will determine the extent of both their ability to communicate with their partner (Communication Level), and their functional ability (ADL/Functional Ability). The functional ability of the person with sensory loss determines the level of care required by the spouse (Caregiving Experience) which, in turn, may influence both partners’ perception of the balance of equity within their relationship (Relationship Equity). When the balance of give and take in the relationship becomes inequitable, added to a reduced ability to self-disclose, couples may be less likely to report high levels of satisfaction in their relationship (Relationship Satisfaction). However, the results of our review also revealed that while communication level may directly affect the partners’ marital satisfaction, this association may be subject to gender differences. More specifically, reduced communication between partners as a result of sensory loss showed to affect relationship satisfaction for wives more than for husbands. Wallhagen et al. (2004) propose two explanations for gender differences in psychosocial outcomes. Referring to a study by Acitelli (2002), it is explained that for wives but not husbands, the proportion of time that partners spend communicating is indicative of their level of marital satisfaction. This may indicate that the breakdown in communication associated with sensory loss disproportionately affects females. An alternative

Figure 2. An illustration of the associations between sensory loss, relationship satisfaction, and psychosocial wellbeing according to the findings of this review.

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hypothesis, supported by the findings of LaPierre et al. (2012), states that in the light of women’s greater emphasis on marital communication, wives may be more likely to acknowledge and take steps to adapt to their own sensory loss, which in turn minimises the effect of their sensory loss on their husbands and overall relationship. Keeping with the above explanations for the moderating role of gender, we add, on the basis of social-penetration theory, that Wallhagen et al.’s (2004) proposition that wives may be more likely to make the effort to adapt to sensory lossrelated communication difficulties could be a result of their greater perceived rewards from mutual self-disclosure. For instance, previous research has shown that wives tend to initiate the reciprocal disclosure of negative emotions such as fears and anxieties more so than husbands, and that the disclosure of fears and concerns between partners is related to positive psychological and marital wellbeing (Cozby, 1973; Sprecher & Hendrick, 2004). For wives in particular, marital communication (both verbal and nonverbal) is perceived as a main form of support (Cozby, 1973; Wright & Aquilino, 1998). Thus, in the context of single and dual-sensory loss, where verbal and/or nonverbal means of support are disrupted, wives who do not adjust to the reduction in marital communication risk becoming more dissatisfied in their relationship and suffering greater psychological costs than their husbands. Continuing with the link between marriage, support, and psychological wellbeing, in our review psychological distress was found to be associated with relationship satisfaction; in that, couples who reported lower levels of relationship satisfaction also scored worse on psychological wellbeing. The argument that relationship satisfaction includes elements of support was strengthened, given that the association between marriage and psychological wellbeing among persons with vision loss could be explained by level of perceived support (Barron et al., 1994). Communication level also showed to affect couple’s social participation and subsequent psychological wellbeing. Such that, increased problems with communication were reported as contributing to feelings of social embarrassment; as a result thereof, couples reported participating in fewer social events. Social participation is a strong predictor of psychological wellbeing in older populations (Chiao, Weng, & Botticello, 2011); therefore, it is not surprising that our reviewed studies found that less frequent social participation, as a result of one partner’s sensory loss, increases a couple’s risk for psychological distress. From a rehabilitation perspective, one intervention study was conducted to assess the value of educational training for couples’ hearing loss adjustment. While the intervention did not show significant, long-lasting effects on spouse’s quality of life ratings, the researchers concluded that educational interventions can help improve spouse’s perceptions of their hearing impaired partner’s disability (Preminger & Meeks, 2010). This type of intervention may be relevant for those similar to the participants included in Hallam et al. (2008), Hallberg and Barren€as (1993), and Scarinci et al.’s (2008) studies where misunderstandings were reported as a significant problem for the couples. However, articles specifically investigating couples’ coping mechanisms revealed that the use of assistive devices in particular proved valuable for couples’ sensory loss adjustment. Nevertheless, little information is available on how couples can overcome the negative consequences associated with a partner’s sensory loss, or why it is that some couples maintain a high level of marital satisfaction

following the onset of one partner’s sensory loss, while others do not. Given that the maintenance of marital satisfaction has shown to buffer the negative effects of sensory loss, future research examining couples’ adjustment strategies is needed.

Additional factors Although the results of this review have illustrated our current level of knowledge regarding the path of associations between sensory loss, relationship satisfaction, and psychological wellbeing, there are also many other factors which may influence this framework that have not been considered in the current literature. For instance, Rolland’s (1999) family system-illness model details the importance of considering the speed at which the sensory loss developed in order to gauge family illness adjustment. While this model is primarily developed for parent child adjustment, the importance of onset speed may still be an important factor for couples’ illness adjustment and overall psychological wellbeing. Comorbidity is another important factor. For example, Chou (2008) analysed data on 3782 older adults from waves 1 and 2 of the English Longitudinal Study of Ageing and identified that, after controlling for health indicators, the association between dual-sensory loss and depression disappeared. Therefore, it can be argued that it was not the participants’ sensory loss that contributed towards their psychological wellbeing, but their general health instead. From studies in the field of Alzheimer’s disease and dementia we have seen that measuring prior relationship satisfaction is also important (Steadman, Tremont, & Davis, 2007). It may be that the couples were dissatisfied in their relationship both before and after the onset of sensory loss, and that what is being measured is simply a reflection of longstanding marital difficulties. Alternatively, prior relationship satisfaction may act as an important indicator of a couple’s adjustment ability. There are many criticisms regarding the use of retrospective questioning, for instance, a participant’s mood may impact the way in which they recall the quality of their relationship prior to the onset of sensory loss (Quinn, Clare, & Woods, 2009). For this reason, future studies aiming to assess previous relationship satisfaction should ask for further details, such as relationship length and divorce or separation history (Kramer, 1993). Interestingly, despite the importance of non-verbal communication for couples’ support, relationship satisfaction, and adjustment, there was an apparent lack of emphasis on nonverbal communication disruption amongst the literature concerning vision loss. From the results of this review, it seems that the current literature is focused on establishing a link between sensory loss, relationship satisfaction, and psychological wellbeing, with little emphasis on the factors in between. While not specifically looking at relationship satisfaction, Barron et al. (1994) included a focus on support and the supportive role that a marriage plays; however, the manner in which couples living with vision loss communicate support to one another remains unclear.

Methodological considerations In the light of the finding that many of our reviewed studies did not receive high quality or evidence value ratings, it is important to consider some of the main methodological limitations. First, the majority of the studies used different

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measures of relationship satisfaction and psychological wellbeing. Therefore, many different dimensions of relationship satisfaction and psychological wellbeing were measured. For instance, of those assessing the relationship, dimensions included marital quality (Bookwala, 2011), relationship satisfaction (Anderson & Noble, 2005), marital behaviour (Hallam et al., 2007), and relationship adjustment (Knutson et al., 2006). In addition, there are limitations with examining the quality of the relationship measurements. For example, two studies used self-formulated items to measure the quality of the couple’s relationship of which both were single-item indicators (Strawbridge et al., 2007; Wallhagen et al., 2004); this makes it difficult to compare findings across studies. Similarly, the way in which sensory loss is measured showed to be an important factor. Ask et al. (2010) measured hearing loss by both asking for audiometric hearing loss and self-reported hearing loss. In their study, the researchers found that audiometrically measured hearing loss had no association with psychological wellbeing; however, selfreported hearing loss showed a small association in the direction of a link between one partner’s hearing loss and another’s psychological distress. This also further complicates our ability to compare studies, given that previous research is conflicted regarding what self-reported hearing loss actually measures. For instance, Kiely, Gopinath, Mitchell, Browning, and Anstey (2012) suggest that self-reported hearing loss measures are not reliable, are subject to age effects, and are more representative of an individual’s perceived hearing loss, while Gibson, Cronin, Kenny, and Setti, (2014) argue for the reliability of self-report measures, having compared them to the whispered voice test. Future studies should aim to include both audiometric and self-reported measurements of sensory loss in order to account for potential discrepancies between perceived and actual sensory loss. Finally, few studies included in this review consisted of 100 or more participants, took a longitudinal perspective, recruited control groups, or discussed the potential implications of sampling bias on their results. Small samples sizes meant insufficient power to conduct exploratory analyses, gender analyses, or to control for potential confounding variables. Future studies should try to overcome these methodological limitations.

Conclusions The review aimed to synthesise existing knowledge regarding the impact of single and dual-sensory loss on the lives of romantic partners, their psychological and social wellbeing, relationship satisfaction, and coping mechanisms. The results indicate that the onset of sensory loss, and associated communication difficulties, may have a psychological, social, and relational effect on couples. However, the number of published studies is still low, and many of these have methodological limitations. Further research is warranted, among others, to identify how practitioners can recognise and assist couples at risk of maladjustment.

Acknowledgements The authors would like to sincerely thank Flemming Ask Larsen for his valuable contributions to this article. This study was approved by the Institutional Ethical Review Board of the Department of Psychology, University of Copenhagen, Denmark.

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Disclosure statement No potential conflict of interest was reported by the authors.

Funding This work was supported by the VELUX Foundation [grant number VELUX33847].

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