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Body Image Perceptions and Influencing Factors in Adolescent Cochlear Implant Recipients
Abstract
Background Body image perception significantly impacts adolescent psychological well-being. For adolescents with sensorineural hearing loss, cochlear implantation may affect body image due to the visible nature of the device, influencing their self-esteem and social interactions. Understanding these factors is essential for targeted interventions.
Objective To investigate the current status of body image in adolescent patients following cochlear implantation and analyze the factors influencing it.
Methods A total of 104 adolescent patients with severe to profound sensorineural hearing loss who underwent unilateral cochlear implantation at our Cochlear Implantation Center from January 2020 to January 2024 were selected. Data were collected using a general information questionnaire, the Body Image Scale (BIS), the Rosenberg Self-Esteem Scale (SES), the Perceived Social Support Scale (PSSS), and the Positive and Negative Affect Schedule (PANAS). Multiple stepwise regression analysis was applied to identify factors affecting body image in adolescents post-cochlear implantation.
Results The mean body image score among adolescent patients was 8.43±3.65. Multiple linear regression analysis identified gender, primary caregiver’s education level, self-esteem, social support, and negative emotions as significant influencing factors of body image in adolescents, explaining 34.4% of the total variance.
Conclusion Body image disturbances are present in adolescent patients post-cochlear implantation. Clinical healthcare providers should be attentive to the body image concerns of these patients and implement targeted interventions based on influencing factors to enhance body image, thereby promoting physical and mental well-being.
Keywords cochlear implantation; adolescent; body image
Introduction
Body image, defined as an individual’s mental representation and attitudes toward their physical self, is a multifaceted concept involving cognitive, affective, and behavioral component.1 Extensive research highlights the impact of body image on various aspects of mental and physical health, with disturbances in body image linked to increased risks of depression, anxiety, low self-esteem, and reduced quality of life.2-4 During adolescence, a critical period for self-identity formation, body image concerns often intensify. Studies have found that negative body image is particularly prevalent in adolescents, leading to detrimental effects on self-worth, social relationships, and overall well-being.5
Cochlear implantation (CI) is a widely used intervention for individuals with severe to profound sensorineural hearing loss, with proven benefits in auditory and language development and significant improvements in quality of life.6, 7 Research demonstrates that CI recipients often experience enhanced communication abilities, social integration, and educational opportunities, thereby leading to improved life satisfaction.7-9 However, the procedure, which involves a visible implant, may introduce new psychosocial challenges, especially for adolescent patients who are in a sensitive phase regarding self-image and social acceptance.
Several studies have addressed the psychosocial implications of CI in adult populations, revealing that body image issues are a concern among CI users, often related to the visibility of the device and social stigma. For example, Ozturk et al.10 reported that adult CI users frequently experience body image concerns, which can affect their social confidence and self-perception. Similarly, Zara et al.11 found that while CI improves auditory abilities, it can also lead to heightened self-consciousness due to the device’s appearance, especially in younger adults. Nevertheless, research on the impact of CI on adolescents’ body image and psychosocial adjustment remains limited. Adolescents face unique challenges due to heightened social awareness and the development of self-identity, making the psychological impact of CI an essential area for further exploration.
Current studies on adolescents with CI primarily focus on auditory and language outcomes, with relatively few examining the broader psychosocial impacts, including body image and self-esteem. In a notable study, Boerrigter et al. 12 found that while adolescents with CI report improved auditory satisfaction, they also expressed concerns about social acceptance and self-confidence, particularly regarding the implant’s visibility. Additionally, studies highlighted that CI can introduce both benefits and challenges, with improved hearing often accompanied by concerns over appearance and self-image, especially among younger recipients.13, 14
Thus, understanding the influence of CI on body image in adolescents is crucial for developing holistic care approaches that not only address auditory outcomes but also consider the psychological well-being of these patients. This study aims to fill this gap by investigating the current status of body image in adolescent CI recipients and identifying the key factors influencing it. Insights gained from this research may inform targeted interventions that help adolescents develop a positive body image, enhancing their overall quality of life and supporting a well-rounded rehabilitative process.
Methods
Study Population
This study used cluster sampling to select participants. Adolescent patients with severe to profound sensorineural hearing loss who underwent unilateral cochlear implantation at the Zhejiang Cochlear Implant Center between January 2020 and January 2024 were included in this study. Inclusion criteria were as follows: (1) a diagnosis of severe sensorineural hearing loss; (2) age between 12 and 18 years; (3) successful intraoperative electrode implantation with no postoperative complications; and (4) absence of other diseases affecting intellectual development. Exclusion criteria included: (1) postoperative damage to the implant; (2) a history of mental disorders or cognitive impairment; and (3) the presence of other physical deformities prior to cochlear implantation.
Measurement Tools
General Information Questionnaire: Developed by the researchers to capture demographic and clinical characteristics, including age, gender, residence, school location, type of hearing impairment, body mass index (BMI), use of hearing aids prior to implantation, duration of cochlear implant usage, primary family caregiver, educational level of the primary caregiver, and monthly household income.
Body Image Scale (BIS) 15: Developed by Hopwood et al., the BIS assesses body image perceptions. It consists of 10 items rated on a 4-point Likert scale from “not at all” (0 points) to “very much” (3 points), with a total score range of 0–30. Higher scores indicate poorer body image and more severe body image disturbance. To enhance contextual relevance for adolescent cochlear implant users, we supplemented the instructions with references to implant-related features such as device visibility and surgical scars, without altering the original item content. The scale demonstrated good internal consistency (Cronbach’s α = 0.83). For the CI-specific items, inter-item correlations ranged from 0.42 to 0.67, indicating stable reliability and supporting the validity of the adapted instructions.
Rosenberg Self-Esteem Scale (SES)16: Originally developed by Rosenberg in 1965, this 10-item scale evaluates self-esteem, with responses ranging from “strongly agree” (4 points) to “strongly disagree” (1 point). Total scores range from 10 to 40, with higher scores indicating greater levels of self-esteem. The Cronbach’s α for the SES in this study was 0.86, indicating high reliability.
Perceived Social Support Scale (PSSS)17: Developed by Zimet et al. [12], the PSSS measures perceived social support from family, friends, and significant others. The 12 items are scored on a 7-point Likert scale. Higher total scores reflect greater perceived social support. In this study, the PSSS had a Cronbach’s α of 0.79, indicating satisfactory internal consistency.
Positive and Negative Affect Schedule (PANAS)18: Comprising 20 affective adjectives, the PANAS is divided into two subscales, Positive Affect (10 items) and Negative Affect (10 items). Responses range from “very slightly” (1 point) to “extremely” (5 points). Higher scores on the positive affect subscale indicate greater vitality and focus, while higher scores on the negative affect subscale reflect higher levels of distress and confusion. The PANAS demonstrated good reliability in this study, with a Cronbach’s α of 0.84.
Data Collection
During follow-up visits, researchers distributed questionnaires to participants. Prior to completing the questionnaires, each participant and their legal guardian (usually a parent) received a thorough explanation of the study’s objectives, procedures, potential risks, and benefits. Written informed consent was obtained from the adolescent participants as well as from their legal guardians to ensure full understanding and voluntary participation. Researchers emphasized confidentiality and explained that participation was entirely voluntary, with the option to withdraw from the study at any point without affecting their treatment. To ensure that participants fully understood the study and to address any queries, researchers provided standardized instructions and were available to assist as needed throughout the survey process. The completion time for each questionnaire was approximately 20-30 minutes. Upon completion, researchers reviewed each questionnaire on-site to verify completeness and accuracy before collecting it. In total, 104 questionnaires were distributed, and all were completed and returned, resulting in a 100% effective response rate.
Ethical Considerations
This study was conducted in accordance with the Declaration of Helsinki and received approval from the Ethics Committee (approval number: 2023-IRB-0218-P-01). The privacy of all participants was strictly protected; personal information was anonymized during data processing, and results were reported in aggregate form to prevent individual identification. All study procedures were designed to minimize potential risks and discomfort to participants, and participants and their guardians were provided with contact information for further questions or concerns regarding the study.
Statistical Analysis
Data were processed using SPSS version 26.0. Continuous variables were expressed as mean±standard deviation, and categorical variables were reported as frequencies and percentages. Independent samples t-tests and one-way ANOVA were used for between-group comparisons, while Pearson correlation analysis was applied for continuous variables. Multiple linear regression analysis was used for multivariate analysis. The significance level was set at α=0.05.
Results
Body Image Scores and Comparison Across Adolescent Subgroups
The overall BIS among adolescent patients following cochlear implantation was 8.43±3.65. The three items with the highest scores on the Body Image Scale, indicating greater concern, were scar appearance (1.58±0.63), overall appearance (0.97±0.35), and physical attractiveness (0.94±0.39). Significant differences in body image scores were observed across various subgroups. Specifically, body image scores varied significantly based on age, gender, preoperative use of hearing aids, duration of cochlear implant use, and educational level of the primary caregiver (P < 0.05) (Table 1).
Correlation Analysis of BIS with SES, PSSS, and PANAS
The SES among adolescent patients was 27.45±3.24, the PSSS score was 72.73±5.28, the positive affect score was 20.31±9.95, and the negative affect score was 35.32±9.21. Pearson correlation analysis revealed that BIS scores were negatively correlated with SES (r = -0.374, P < 0.001), PSSS (r = -0.318, P < 0.001), and positive affect (r = -0.283, P < 0.05). BIS scores were positively correlated with negative affect (r = 0.413, P < 0.001).
Multivariate Analysis of Factors Influencing Body Image in Adolescents
A multiple linear regression analysis was conducted to identify significant predictors of BIS in adolescents following cochlear implantation (Table 2). The model included both categorical variables (age, gender, preoperative use of hearing aids, duration of cochlear implant use, and caregiver educational level) and continuous variables (self-esteem, social support, positive affect, and negative affect). The results showed that gender and educational level of the primary caregiver were significant predictors of BIS, with females and those with lower caregiver education levels reporting worse body image. Additionally, higher self-esteem and greater social support were associated with more positive body image, while negative affect was a significant negative predictor. The model explained 37.5% of the variance in BIS (R² = 0.375), and after adjusting for the number of predictors, the adjusted R² value was 0.344.
Discussion
This study highlights the significant body image disturbances experienced by adolescents following cochlear implantation, with an average BIS of 8.43±3.65. This score, slightly lower than the 8.62 reported by Hopwood et al. for breast cancer patients, aligns closely with findings from other adolescent populations facing visible conditions. 15,19 The findings suggest that adolescents with cochlear implants face body image challenges comparable to, or even more pronounced than, those dealing with other visible conditions. Specifically, concerns related to scar appearance, overall appearance, and physical attractiveness were most prominent. These results highlight the substantial psychological impact that visible surgical scars and implants can have on adolescents’ self-perception and social confidence.
Factors Influencing Body Image Disturbances
The underlying reasons for these body image disturbances are likely multifactorial, with adolescence being a critical period for self-identity development. During this stage, physical appearance and peer acceptance significantly shape self-image. Visible surgical scars or implants may amplify negative self-assessments and social anxiety. As indicated in prior research, such as by Chen et al.,20 head and neck surgeries, which often result in visible scarring, are linked to substantial body image issues due to the disruption of skin integrity.
To better understand these disturbances, Social Comparison Theory (SCT)21 offers a robust framework for analysis. SCT posits that individuals, particularly adolescents, often evaluate themselves by comparing themselves to others22. Adolescents with CIs, especially those with visible implants and surgical scars, may compare themselves to their peers without such visible markers. These comparisons can lead to negative self-assessments, exacerbating body image concerns. Our study observed that the visible components of cochlear implants, such as external devices and surgical scars, can heighten self-consciousness and feelings of difference, contributing to the body image disturbances noted in the participants. These social comparisons can amplify the psychological impact of having a cochlear implant, particularly when adolescents feel they do not meet societal appearance standards. Choi et al.23 found that CI children, despite gains in hearing and language, still lagged in social cognition compared to their peers, which could increase self-doubt and body image concerns. Similarly, Dixon et al.24 found that children with disabilities, when comparing themselves to non-disabled peers, experience negative shifts in self-concept. This applies to CI populations, where visible differences intensify the psychological impact of social comparisons. Furthermore, Sears et al.25 highlighted how young patients with pacemaker implants struggle with social comparison due to the lack of similar peers, mirroring the challenges CI adolescents face. These findings emphasize that social comparisons among CI adolescents affect not only appearance but also social cognition and self-concept. Therefore, interventions focusing on reducing the negative impact of social comparisons and fostering positive self-concept development independent of peer judgments are crucial for improving body image and psychological well-being.
Key Determinants of Body Image Perception
Several factors were found to significantly influence body image in this population.
Gender differences
Female adolescents reported more severe body image concerns than male adolescents, aligning with previous studies.26 Females tend to place greater importance on appearance and may be more vulnerable to negative self-evaluations when their appearance deviates from societal standards.27 The visible aspects of cochlear implants, such as shaved scalp areas or surgical scars, may heighten self-consciousness in females, who are especially sensitive to physical changes. Early psychological support tailored to female patients could foster self-acceptance and resilience in adapting to post-surgical changes.
Caregiver education
A notable factor influencing body image was the educational level of the primary caregiver. Higher education levels were associated with more positive body image perceptions. Educated caregivers are more likely to provide emotional support, seek relevant information, and promote a positive self-concept in their children28-30. In Chinese society, where academic achievement is highly valued, caregivers with higher education may be better positioned to offer the support necessary to foster positive body image31. Conversely, caregivers with lower education levels may struggle to provide adequate support, potentially worsening the adolescent's body image. Future studies should explore how societal factors, particularly those related to education, influence adolescents' psychosocial experiences post-implantation.
Self-esteem
Higher self-esteem was another critical factor influencing body image. Adolescents with greater self-esteem showed more positive body image perceptions. This finding aligns with previous studies highlighting the importance of self-esteem in resilience to social pressures and acceptance of physical imperfections.32 Adolescents with congenital hearing loss may have lower resilience and heightened sensitivity to social feedback, which can further impact their self-esteem. Therefore, interventions aimed at boosting self-esteem and fostering self-acceptance could play a key role in supporting positive body image post-surgery.
Social support
Our study also identified social support as a crucial factor in body image perception. Adolescents who reported stronger social support had higher body image scores. This is consistent with previous findings that suggest social support can alleviate the psychological burden of visible physical changes.33 For adolescents, support from family and friends is particularly valuable, helping them feel more accepted and adapt to changes in appearance. Strengthening social support networks could therefore enhance body image and mental well-being in adolescent cochlear implant patients.
Negative affect
Lastly, negative affect was found to significantly influence body image. Adolescents with higher levels of negative affect reported poorer body image perceptions. This aligns with findings from Rhoten et al.,34 who noted that individuals experiencing negative emotions often exaggerate perceived physical flaws. Adolescents with negative affect may feel anxious and self-conscious about their visible surgical changes, which can exacerbate body image concerns. Conversely, adolescents with a more positive outlook are generally better able to accept physical changes and maintain a healthier self-image.35 Addressing emotional health, therefore, is crucial for promoting more adaptive body image perceptions.
Limitations
This study has several limitations. First, it was conducted at a single center, limiting the generalizability of the findings. Multi-center studies would enhance external validity. Second, the cross-sectional design restricts causal inferences, and longitudinal studies are needed to better understand the temporal relationships between body image and influencing factors. Although we considered participants' current age and years of cochlear implantation, we did not include key variables such as the duration of deafness and age at implantation, which are known to significantly impact psychosocial adaptation and body image perceptions. The exclusion of these factors is a limitation of the study. Future research should incorporate these variables to provide a more comprehensive understanding of their role in body image perceptions. Longitudinal tracking of these variables could offer valuable insights into the long-term effects of early versus late implantation on psychosocial outcomes. Finally, the unexplained variance in our model suggests that additional factors not captured in our analysis may play a significant role in shaping body image perceptions. Potential omitted variables include psychosocial factors such as peer bullying, media exposure, and social comparison, as well as environmental and genetic influences. Future studies should explore these factors to provide a more complete picture of body image in cochlear implant recipients.
Conclusion
This study highlights significant body image disturbances among adolescent patients following cochlear implantation, with notable influences from gender, primary caregiver’s educational level, self-esteem, social support, and negative affect. The findings emphasize that cochlear implantation, while beneficial for auditory rehabilitation, poses psychological challenges related to body image, particularly due to visible changes such as surgical scars and implant devices. Addressing these challenges requires a holistic approach in clinical practice, where healthcare providers prioritize both the physical and psychological well-being of adolescent patients. Early identification of at-risk individuals, especially female patients or those with lower social support and self-esteem, combined with tailored psychological support and enhanced social and family involvement, may help improve body image and promote overall mental health in this vulnerable population.
Authors' Contribution
Study design: N.L., C.J.
Data collection: N.L., C.Y., Y.Z., H.C.
Data analysis: N.L.
Study supervision: C.J.
Manuscript writing: N.L.
Critical revisions for important intellectual content: N.L., C.J.
Ethical Approval
The study was conducted in accordance with the ethical standards set forth by the Declaration of Helsinki and was approved by the hospital's ethics committee (2023-IRB-0218-P-01).
Funding/Support
This study was supported by the Medical and Health Research Project of Zhejiang Province (2024KY1165).
Data Availability
Data underlying the findings described in this manuscript are available from the corresponding authors upon request.
Conflict of Interests Statement
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Table 1 Comparison of Body Image Scores Across Adolescent Patient Subgroups (n=104)
Variable | n | BIS (Mean ± SD) | Test Statistic | P | Effect Size | |
Age (years) | 12~15 | 67 | 7.83±3.45 | -2.4451) | 0.016 | -0.2403) |
16~18 | 37 | 9.52±3.23 | | | | |
Gender | Male | 56 | 7.67±3.39 | -2.3951) | 0.018 | -0.2353) |
Female | 48 | 9.32±3.63 | | | | |
Residence | Urban | 41 | 7.68±4.72 | -1.5181) | 0.132 | -0.1493) |
| Rural | 63 | 8.92±3.59 | | | |
School Location | Urban | 53 | 7.84±3.91 | 1.2681) | 0.208 | 0.1243) |
| Rural | 51 | 9.04±4.13 | | | |
Type of Hearing Loss | Sensorineural | 78 | 8.30±3.58 | -0.6561) | 0.513 | -0.0643) |
| Mixed | 26 | 8.82±3.24 | | | |
BMI | ＜18.5 | 3 | 8.29±4.32 | 1.1192) | 0.345 | 0.1524) |
| 18.5～23.9 | 51 | 7.92±4.46 | | | |
| 24～27.9 | 29 | 8.26±3.95 | | | |
| ≧28 | 21 | 9.92±4.13 | | | |
Preoperative Use of Hearing Aids | Yes | 69 | 7.89±3.58 | -2.0171) | 0.046 | -0.1973) |
| No | 35 | 9.36±3.37 | | | |
Duration of Cochlear Implant Use (years) | ＜1 | 36 | 9.32±3.89 | 3.4372) | 0.036 | 0.2034) |
| 1～3 | 39 | 8.57±2.97 | | | |
| ＞3 | 29 | 7.14±3.13 | | | |
Primary Family Caregiver | Parents | 83 | 8.27±3.59 | -0.8681) | 0.387 | -0.0853) |
| Other Family Members | 21 | 9.06±4.23 | | | |
Primary Caregiver’s Educational Level | Junior High School or Below | 23 | 9.56±3.37 | 3.2542) | 0.025 | 0.2274) |
| High School | 37 | 9.15±2.96 | | | |
| Associate Degree | 35 | 7.24±3.82 | | | |
| Bachelor’s Degree or Above | 9 | 7.21±3.18 | | | |
Monthly Household Income (CNY) | ＜5000 | 23 | 8.15±3.28 | 0.2482) | 0.781 | 0.0274) |
| 5000~10000 | 61 | 8.37±3.82 | | | |
| ＞10000 | 20 | 8.94±4.35 | | | |
BIS Body Image Score，
¹ t-value; ² F-value；3Cohen's d；4 Cohen's f
Table 2 Multivariate Analysis of Factors Influencing Body Image in Adolescent Patients (n=104)
Variable | β | sb | β’ | t | P |
Constant | 21.354 | 3.135 | - | 6.615 | ＜0.001 |
Gender | 7.465 | 1.409 | 0.346 | 2.115 | 0.002 |
Primary Caregiver’s Education Level | -2.078 | 0.768 | -0.187 | -2.476 | 0.024 |
Self-Esteem | -7.266 | 1.034 | -0.354 | -1.937 | 0.007 |
Social Support | -5.178 | 1.031 | -0.283 | -2.783 | 0.004 |
Negative Affect | 6.264 | 1.074 | 0.248 | 4.851 | ＜0.001 |
Note: F = 29.196, P = 0.000, R² = 0.375, Adjusted R² = 0.344