Data selection

A search was conducted by the first author in May 2023 using Nexis, a database of news, business and legal sources, to find published UK newspaper articles that focused on HL. Eligibility criteria for the articles were: (1) written in the English language, (2) primary focus on HL and D/deafness, (3) news stories, not advertisements or letters, (4) about chronic, rather than acute, HL, which could range from mild to profound, (5) about HL and D/deafness in adults only, (6) published in national newspapers, and (7) published between 1^st May 2022 and 30^th April 2023 only. The timeline of a year was chosen to capture a spread of articles and reduce the impact of one prominent news story. This timeline was also selected because the study focused on recent, rather than historical, media representations.

Newspapers were selected as they are a major source of information about HL and D/deafness for the public and may influence help-seeking [30]. The PPI panel confirmed that they are an important source to examine. Six of the most widely read and circulated newspapers in the UK were searched (see Table 1). They included three tabloids and three broadsheet newspapers to examine a variety of HL portrayals. Generally, tabloids are image led, whereas broadsheets are text led [44].

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Table 1. Number of articles retrieved, screened and analysed for each newspaper.

https://doi.org/10.1371/journal.pone.0342462.t001

The Nexis database was searched using search terms (S2 File) that were developed by examining the HL and D/deafness literature, particularly systematic reviews [5,14,45]. The broadsheet search retrieved 2,377 articles, whilst the tabloid search retrieved 4,796 articles. In each search, the articles were ordered by relevance within Nexis. The top 100 broadsheet articles and the top 100 tabloid articles in terms of relevance were extracted for screening. Additional articles could be extracted if required.

Screening

Table 1 shows the total number of articles retrieved, screened, and analysed for each newspaper. To ensure a random selection of articles, every tenth article was examined for the tabloids and broadsheets to determine eligibility. The full text and images within each article were examined. All articles were screened by the first author, and a sample was independently screened by a second researcher. A third researcher was consulted to resolve any disagreements. As this was a qualitative study, there was no pre-determined sample size, although it is comparable to previous studies of dementia representations that analysed 11–31 articles [39,46]. Screening continued until saturation was reached, or the point at which little new information that was salient to the research aims could be identified from additional articles. Saturation was assessed via a preliminary data analysis and discussions at research team meetings. The main reasons that articles were excluded were as follows: main focus not on HL or D/deafness, wrong population (e.g., children), or wrong article type (e.g., advertisements).

Analytical method

This research used Multimodal Critical Discourse Analysis (MCDA) to examine both visual and written representations [47]. MCDA is concerned with the ideologies underlying the communicative choices made in texts and images, and how these may reflect or shape the wider social context, particularly power imbalances and the stigmatisation of a social group [41]. In this study, communicative choices refer to written representations (e.g., text) and visual representations (e.g., photographs) that are used within the newspaper articles, hence the ‘multimodal’ focus within CDA, which is also known as Critical Discourse Studies.

Analysis drew upon stigma theory, van Leeuwen’s work on the representation of social actors [48] and the Visual Discourses of Disability (ViDD) framework [49]. A summary of our analytical framework can be found in Table 2. Regarding stigma, the framework is particularly informed by Link and Phelan’s modified labelling theory for stigma [50], as indicated by the following interrelated focuses:

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Table 2. Summary of analytic framework.

https://doi.org/10.1371/journal.pone.0342462.t002

1. (1) How people with HL and D/deafness are labelled and (negatively) stereotyped. This focus underlies much of Table 2 due to our concern with positioning (e.g., what attributes and (in)actions are attributed to people with HL and D/deafness, visually and linguistically?). We were concerned with both identifying stereotypes that occurred across the dataset and in relating these, where possible, to the wider literature. Stereotypes could also be linked to negative attitudes towards HL, for instance, that HL should be hidden [21].
2. (2) Whether/how people are socially othered. This includes consideration of features of visual and textual proximity/distance (e.g., gaze, pronoun use) to help explore whether an ‘us’ vs ‘them’ is established.
3. (3) Any examples of status loss, discrimination and power imbalances. This includes a concern with who writes and is quoted in the articles, the visual exercise of power (e.g., regarding angle) and the roles and actions associated with people with HL and D/deafness. For example, do the articles cover being discriminated against or themselves discriminate against these groups?

For visual analysis, ViDD provided a critical discursive framework that applies van Leeuwen’s foundational work on representation and social actors to the context of visualisations of disability [48,49]. ViDD theorises that there are four types of visual representations that may be used to represent people with disabilities. These four types of visual representation align with the two clines (i.e., the continuums of perspectivising → personising and enabling → disabling) detailed in Table 2.

1. (1) Empowering (enabling and personising): focusing on the person as an active individual, undifferentiated from non-disabled people.
2. (2) Advocating (enabling, perspectivising): foregrounding the disability in an inclusive, enabling way.
3. (3) Handicapping (disabling, personising): person presented in a negative or non-participatory way.
4. (4) Othering (disabling, perspectivising): focusing on the disability in a disabling manner that socially ‘others’ the person.

We combined a consideration of the overarching ViDD categories with a focus on specific visual choices within the clines (e.g., gaze and action) and additional considerations (e.g., visual subjects that were not included in the ViDD framework). This provided the necessary flexibility to explore patterns across this specific dataset.

Overall, our analysis is guided by Fairclough’s [51] three-dimensional approach to CDA (of which MCDA is the multimodal branch), which considers the level of (1) the text, (2) discursive practice, and (3) social practice. Therefore, we sought to contextualise our descriptions of specific textual features (e.g., camera angle) in relation to social practice and discursive practice, which considers production, distribution and consumption, here, specifically focusing on article authors and readership. We considered the articles within the wider social context, namely how they might reflect and help shape current norms and social values surrounding HL and D/deafness in the UK.

The analysis was led by the first and second authors, which entailed developing themes in line with the MCDA approach. First, the authors immersed themselves in the data by reading and re-reading the selected newspaper articles. They made extensive notes about the main topics of the articles, points of discursive tension, and the people/perspectives that were foregrounded (and backgrounded or excluded) overall. They coded the text and images from the articles by applying the analytical framework (see Table 2). Rather than constraining visual analysis to the four pre-existing categories established by ViDD, the authors categorised images according to what visual features within the framework (which includes but is not limited to ViDD) were particularly salient across this dataset. For instance, direct gaze was a particularly popular visual strategy for the images in this dataset and within a focus on actions (see ‘role’ in Table 2), a specific subgroup emerged relating to communicating with HL using an interpreter and/or sign language. From this more inductive approach to categorising images, links could then be made to the four overarching ViDD categories when appropriate and helpful for the data. Throughout, attention was paid to the relationship between text and images, notably regarding how they might reinforce and/or contradict each other at the levels of image and caption, news article and across the articles. This approach enabled close analysis of examples from the data to ground the analysis in the visual and linguistic features identified. The first author developed initial themes by identifying patterns in the coded data. These themes were then reviewed and refined in collaboration with the second author.

Recognised strategies for enhancing the rigour of the qualitative analysis were used [52]. First, peer debriefing was used; where the analysis was reviewed by the research team to support or challenge the analysts’ interpretations. Disconfirming evidence analysis also took place, which entails searching for data that conflict with the main findings to ensure any such data are not overlooked [52]. Finally, the research team kept reflexive notes throughout (S3 File).

Patient and public involvement

A panel of seven PPI contributors with lived experience of HL and D/deafness were consulted throughout. Initial meetings were held with five PPI contributors to obtain feedback on the research objectives and scope. Additional meetings were conducted, where four PPI contributors gave their input on the analysis and made recommendations for future media representations of HL and D/deafness.

Theme 1: Representing social progress

The majority of articles report on some form of social progress as their main story. This includes technological advancements, such as a new subtitling app or a haptic suit for concert goers with HL or D/deafness (4,5,9). It also includes first-time events that signal greater inclusion and representation of people with HL or D/deaf people (1,2,7,13,14,16,18). Examples include the first Barbie doll with hearing aids, the first deaf contestant for a popular dating show, and a law change enabling jurors to have sign language interpreters in court. Perpetuating this sense of advancement are metaphors of journeying towards a more inclusive society (“really positive step towards inclusion”, 7) and of eliminating barriers while doing so (e.g., “Smashing through barriers”,3; “breaking boundaries”,7; “further break down barriers for our community”,1). As well as indicating a defiance of the restrictive status quo, the repeated use of destructive verbs (“breaking”, “smashing”) infers a sense of finality for the dismantling of such barriers, much as smashed objects cannot be re-pieced together. Contributing further to this sense of social progress, Deaf adults reflect on this newfound “mainstream visibility” (3) and contrast it to their past experiences. These reflections usually prompt the conclusion (implicit or explicit) that “my life would have been different if I’d experienced something similar [to the current improvements in representation and inclusion]” (11).

Visually, this social progress discourse is realised through the overwhelming use of images that portray people with HL or D/deaf people as individuals who are active members of society that viewers are encouraged to connect with through various framing choices. Notably, 28 of the total 53 images depict people with HL or D/deaf people looking directly at the camera, which invites viewers to form an imaginary social connection through mimicking real-life eye-contact [53]. Fig 1 offers one example of this visual trope. The friendly nature of this imagined relationship is signalled through recurring uses of a close-up shot. This mimics the closer proximity that tends to be associated with greater social intimacy (i.e., we tend to get physically closer to people we know and like). It is also signalled through the frontal and eye level angle, which is indicative of being part of the same social world, and of being social equals [53]. A further 13 images (Fig 3) show individuals with HL and D/deaf people being engaged, often alongside others, in an activity (e.g., dancing, celebrating, cooking, acting) or in the act of communicating through signing, having an interpreter, or interacting with hearing individuals. Thus, whether engaging with viewers through a direct gaze (e.g., Fig 1) or engaging with other people or in actions (e.g., Fig 2), individuals with HL are depicted as agentive and socially involved individuals. Furthermore, they are often smiling, which is a key signal of positive affect. These features are associated with personising (i.e., focusing on the individual) and enabling (rather than disabling) representations, and as thus being empowering visual tropes in a disability context [49].

Overall, the articles tend to visually and linguistically foreground individual people with HL and individual D/deaf people (exactly who these individuals are and are not will be returned to shortly). As such, photographs tend to be used of the person (or people) being featured (with even Beethoven having a painted portrait; see 4). While HL and D/deafness is the feature overwhelmingly incorporated into the descriptions of individuals, this can be alongside other identity features, as shown with “She looks amazing in a bikini, has a great bubbly personality and just happens to be deaf” (16). The articles in the present study regularly feature the voices and perspectives of individuals with HL and D/deaf people. This facilitates the inclusion of different viewpoints across the articles regarding what it means to experience HL or D/deafness, particularly the latter. Most frequently, HL and D/deafness is categorised as, or otherwise associated with, ‘disability’ (1,3,5,11,12,15). However, other views are also acknowledged, with one deaf celebrity representing being deaf as “not a disability” but “a superpower” (1). This is critiqued by an author from the Deaf community, who argues that most of this community, “want to be treated the same as everybody else, not to be put up on a pedestal as ‘superhuman’ or…‘inspiration porn’” (1). This critique aligns with criticisms of the ‘supercrip’ narrative, whereby people with disabilities can be overly glorified in media [34,35]. Simultaneously, someone can “love being deaf” but find it “exhausting sometimes”, in part through being a “lone voice” and thus being “forced to ‘be political without wanting to be political’” when making the workplace “accessible for deaf [people]” (15). The pathological model of deafness is also referenced as influencing individuals’ self-concept as having a “physical ‘deficit’” (8), or as its converse, of celebrating Deaf identity and culture (3) [31,54].

Specifically, four articles (20%) are authored by someone who explicitly identifies as D/deaf (1,3,5,8), while thirteen directly quote people with HL and D/deaf people, who are by far the most frequently used source (1,2,4,5,7,11,12,13,14,15,16,19,20). Overall, then, 75 per cent of articles directly feature the voice of someone with HL or D/deafness, although there is a large variation regarding exactly how much of the person’s perspective is featured. Media communication guidelines, produced by organisations such as the National Association of the Deaf [55], advise the media to consistently include the first-hand viewpoints of d/Deaf people regardless of the story’s angle (e.g., medical, legal, social, cultural, etc.). In addition, they advise carefully considering relevant sources to best reflect the diversity of this community. While a 75 per cent inclusion rate signals progress towards inclusion, then, it is also worth noting that this remains very similar to the 71 per cent inclusion rate of the voices of D/deaf people observed by Haller [56] in American news coverage between 1986–1990.

Theme 2: Missing people and perspectives

Whilst there are advantages to the above emphasis on the individual within a social progress discourse, it is also arguably problematic in two main ways. Firstly, certain types of people and experiences are foregrounded, while others are excluded. Secondly, such individualisation risks backgrounding issues of systemic change. First, the individuals featured tend to be celebrities, namely TV personalities and successful writers (for exceptions, see 5, 8, 14, 18). As social elites, celebrities are considered especially newsworthy [57], and in the articles, they are often positioned as “an inspirational figure” who can change “perceptions of what it means to be deaf” (12). Yet, an overemphasis on people with exceptional achievements or status is unattainable for most people, and risks backgrounding more everyday experiences and barriers associated with HL and D/deafness. Moreover, all featured individuals are of working age (approximately aged 20–45). Whilst this challenges the stereotype that people with HL are always older adults [58], it also perpetuates the widespread backgrounding, and even exclusion, of older people (including those with HL or D/deaf people) in popular media [29,31,59]. Relatedly, most articles appear to foreground white, cisgendered people, further perpetuating a lack of diversity in representations of people with HL or D/deaf people [29].

Furthermore, focusing on how individuals engage with and embody social progress risks backgrounding broader systemic change (for the exception, see article 14, which reports on a new law that gives D/deaf jurors access to interpreters). Notably, multiple moments of social progress (such as a televised sign language story for children) are tied to a particular campaign (11,12) or to Deaf Awareness Week (2,11,20). The temporary nature of these moments of progress leads to the question of whether they are worth reporting because they are and will continue to be rare. It appears that these moments do not reflect a comprehensive and sustainable inclusion of people with HL and D/deaf people within larger social structures, as the irrevocability of the metaphor of “smashing” or “breaking” barriers might suggest. Recognising this tension, one Deaf and disabled journalist notes that, as well as a TV dating show including their first deaf contestant, the TV itself must be accessible through subtitles, which the show’s broadcaster previously failed to do (1). Elsewhere, an app that converts speech into subtitles and translates different languages is presented as “truly life-changing”. However, it only offers a free user option for English, with non-English speakers needing to pay £19.99 per month, and the top-tier costing £49.99 a month, a disparity that remains unmentioned in the article (9).

Moreover, although multiple articles report on communication-oriented campaigns, there remain examples of outdated, inaccurate or ambiguous representations of HL in the dataset. This indicates a need for further education and guidance on HL and D/deafness for media institutions themselves. For instance, the term “hearing impaired” is occasionally used (7,17), which has been criticised as outdated and inaccurate for making assumptions about a person’s abilities, rather than just describing the person [55]. In terms of hearing technologies, despite its caption discussing “the latest hearing aids”, the image shown in Fig 2 depicts a somewhat outdated hearing aid model. Article 16 uses the terms hearing aids and cochlear implants interchangeably to describe an individual’s hearing device, conflating the two, despite the images clearly depicting a cochlear implant. Such examples are important to address, since media institutions contribute to the misconceptions of HL, D/deafness and hearing technology that have been identified amongst the public [60].

Theme 3: (In)visibility in a “hearing world”

Having considered who and what is (and is not) made visible in these articles, the very concept of (in)visibility will be examined further, specifically as it pertains to experiencing HL and D/deafness in a primarily “hearing world” (2,3). This world is shown to underrepresent, misrepresent, undermine and exclude people with HL or D/deaf people (3,8,11,12). Accompanying the discourse of social progress, then, is one of stigma and social barriers in a hearing-oriented society. A common thread throughout the accounts of people with HL or D/deaf people and articles more broadly is an anxiety about showing HL or D/deafness. This can be linked to “ableism, first systemic, then internalised” (3), and the resulting “stigma” surrounding “wearing a hearing aid” (6) and “intense shame about my deafness” (11). Internalised stigma, or shame, is a key psychosocial consequence of HL/deafness in these articles, alongside a sense of isolation (3,4,9,12,19), mental health difficulties, including psychosis, suicidal ideation, and depression (1,4,6,8,9,12,15). Indeed, while being associated with making social progress by “helping break down […] barriers” (12), that the articles report on multiple campaigns tackling the psychosocial impact of HL and D/deafness. This highlights the many social barriers that such individuals still face in a hearing-oriented world, which is further reinforced by campaign statistics, including that 50 per cent of D/deaf survey respondents feel isolated and frustrated (12).

Reflecting (and arguably reproducing) the stigma surrounding HL and D/deafness, multiple articles foreground the (in)visibility of hearing aids and cochlear implants. Assuming a preference to “hide” such signs of HL and deafness (8,11), one article claims that the “latest hearing aids are unobtrusive” (6). Only seven of the 41 images of people with HL and deafness clearly show a hearing aid or cochlear implant (e.g., Figs 1 and 3). This could be interpreted as a positive move away from defining people solely in relation to this identity feature, or as perpetuating the normalisation of hiding HL or deafness. The newsworthiness of making HL or deafness visible is exemplified by Fig 3, which foregrounds that a newsreader’s “white hearing aid implant [is] clearly visible” and is “in plain sight”. The newsreader is quoted explaining that “I wanted it to stand out, to make sure people with hearing aids know they’re not alone”. Here, visibility is associated with building a sense of community within an often-isolating hearing-oriented world. Elsewhere, a celebrity is “praised for her bravery in showing off her [cochlear implant]” in a modelling campaign. She positions herself as “inspirational because of my hearing and my cochlear implant. I inspire quite a lot of people because I’m really open about it” (16). To ‘show off’ a cochlear implant situates this choice as a piece of activism, and perhaps a fashion statement, rather than as a device that supports her communication and is a normal part of daily life. While not intending to diminish the difficulties that people with HL and D/deafness face, evaluating celebrities as being “brave” and “inspirational” for wearing a cochlear implant risks being interpreted as patronising [55] or as perpetuating the ‘supercrip’ narrative. Indeed, many members of the Deaf community would contest the notion that they have a deficit that needs to be ‘fixed’ or ‘cured’ [61]. Similarly, Fig 1 positions a celebrity’s involvement with the first Barbie doll with hearing aids as “an incredible achievement”. Alternative framings are ignored, including that this is a necessary and long overdue step towards better representation, and that companies should be held accountable to become more inclusive. Explicitly engaging with this issue, Article 6 claims that society should “normalise the wearing of a hearing aid and the stigma will then be reduced”.