Hearing Loss Is Associated With Reduced Social Participation for Older Adults in Communities and Nursing Homes in China: The Mediating Role of Falls Risk

Hearing Loss Is Associated With Reduced Social Participation for Older Adults in Communities and Nursing Homes in China: The Mediating Role of Falls Risk | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Hearing Loss Is Associated With Reduced Social Participation for Older Adults in Communities and Nursing Homes in China: The Mediating Role of Falls Risk Lulu Xiao, Xinyi Yao, Tiantian Zhang, Reyhangul·Aken, Shixing Song, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8393372/v2 This work is licensed under a CC BY 4.0 License Status: Posted Version 2 posted You are reading this latest preprint version Show more versions Abstract This cross-sectional study investigated the mediating role of falls risk between hearing loss and social participation decline among 468 older adults from Lianyungang, China. The association between hearing and social participation decline was analyzed via binary logistic regression, and mediating effects were assessed via mediation models. Hearing loss was significantly associated with reduced social participation (adjusted OR = 1.38; p = 0.026). Mediation analyses revealed that hearing loss had a significant direct effect on reduced social participation (β = 0.10, p < 0.001) and that falls risk partially mediated the indirect effect of hearing loss on social participation decline (β = 0.05, p < 0.001). The total effect of hearing loss on social participation decline was significant (β = 0.15; P < 0.001), and the mediating effect of falls risk accounted for 38.90% of the variance in the total effect. This study found that hearing loss is associated with reduced social participation, and this association may be partially explained by falls risk. Geriatrics & Gerontology hearing loss social participation falls risk older adults ICOPE Figures Figure 1 Figure 2 Figure 3 INTRODUCTION The rapid global increase in the aging population and the severe issues associated with aging societies have become matters of global concern. The Healthy Aging Initiative (HAI) of the World Health Organization (WHO) aims to address these challenges by emphasizing efforts to increase life expectancy while simultaneously improving the quality of life of older adults. Social participation is defined as engaging in activities that involve interaction with other individuals (Levasseur et al., 2022 ). This participation is not limited to specific social groups or activities but also includes interactions in community life and important shared spaces. Social participation has been recognized as an important indicator of successful aging; furthermore, it has been identified as a modifiable determinant of health that can improve the mental health and physical health of older adults by promoting physical activity, socialization, and recreational activities (Zhang et al., 2024 ). Moreover, social participation not only increases life satisfaction among older adults by improving their social networks and reducing their loneliness (Wu et al., 2024 ) but also significantly reduces the risk of mortality among this population (Sandoval et al., 2022 ). Hearing loss is a prevalent problem among older people, and it is likely the most common sensory impairment in this population (Cesari et al., 2019 ), affecting approximately half of all older adults (Britt et al., 2024 ). Hearing loss is not only an auditory problem but also involves cognitive and psychological aspects, which significantly affect individuals’ quality of life and health status (Cesari et al., 2019 ). Moreover, studies have reported that hearing loss can significantly affect social participation among older adults. For instance, hearing loss often leads to communication difficulties, mental health problems, and social isolation, thereby limiting an individual’s social participation (Podury et al., 2023 ). Falls are particularly common among older adults. The global prevalence of falls among older adults has been reported to be 26.5% (Salari et al., 2022 ). Falls represent major causes of functional impairment, disability and death among older adults; they can also have serious social and economic consequences (Vaishya & Vaish, 2020 ) and constitute important constraints on healthy aging (Li et al., 2021 ). Solares’s research demonstrates that perceiving the risk of falls can help prevent their occurrence (Solares et al., 2023 ). Therefore, identifying and reducing falls risk is crucial. Through previous research, we can preliminarily observe that hearing loss, falls risk, and social participation are not mutually exclusive phenomena; rather, they exhibit potential interconnections in the health maintenance process of older adults. Social participation is negatively influenced by hearing loss and falls risk: First, hearing loss impairs verbal communication and environmental perception, thereby reducing the willingness for social participation. Second, the risk of falls and associated fears limit outdoor activities, decreasing opportunities for social interaction. Existing research indicates that older adults with hearing loss often face challenges in maintaining social networks and sustained participation in social activities due to multiple factors, including auditory-verbal communication barriers and psychosocial functional decline (Prieur Chaintré et al., 2024 ). A longitudinal study showed that hearing loss negatively affects social participation, and this effect is independent of sociodemographic characteristics, behavioral habits, and medical conditions (Bernabé et al., 2023 ). Concurrently, falls risk incidents may limit social participation by reducing opportunities for outdoor socializing through acute or chronic injuries, activity restrictions, and falls-related fears. Dashner et al. found that among participants with a history of falls or falls concerns, both levels of social participation and satisfaction with participation experiences tended to decline, suggesting falls risk may adversely affect social functioning in older adults (Dashner et al., 2024 ). Akosile's research demonstrates that the falls risk in both indoor and outdoor social activities may limit people’s social engagement (Akosile et al., 2023 ). Furthermore, some studies have found that hearing loss may increase the risk of falls. Research by Wang et al. confirmed a significant positive correlation between hearing loss and falls risk. Among Chinese older adults, individuals with hearing impairment exhibited higher falls incidence compared to those with normal hearing ( J. Wang et al., 2022 ). A study based on the NHANES database demonstrated a significant association between self-reported hearing loss and the risk of falls (Riska et al., 2021 ). Although the above pairwise associations have been preliminarily explored, there remains a lack of research examining the overall pathway by placing all three variables within a unified framework and using falls risk as the mediating variable. However, focusing solely on hearing loss may underestimate the synergistic benefits of falls risk management in improving social participation. Therefore, this study attempts to construct the hypothesized pathway “hearing loss → falls risk → social participation decline” to provide theoretical insights for developing subsequent multidimensional intervention strategies. The following are the hypotheses for the research: H1: Hearing loss is positively correlated with social participation decline; H2: Hearing loss is positively correlated with the falls risk; H3: Falls risk is positively correlated with social participation decline; H4: The association between hearing loss and social participation decline is partially explained by falls risk. MATERIALS AND METHODS Study Population The participants in this study were older people living in communities and nursing homes in Lianyungang city, Jiangsu Province, which hosts an Integrated Care for Older People (ICOPE) China pilot project, between March and July 2024. The inclusion criteria used for the participants in this research were as follows: age ≥ 60 years, good consciousness, and voluntary signing of an informed consent form. The exclusion criteria were as follows: the presence of critical illness, inability to complete the assessment, and missing key variables. Initially, 507 people were screened, excluding 36 individuals under 60. Of the 471 remaining, 3 were excluded due to missing data, leaving 468 participants included (Fig. 1 ). Measures Measures of social participation Social participation was assessed based on the National Standard of the People’s Republic of China (GB/T 42195 − 2022),“Specification for ability assessment of older adults” ( State Administration for Market Regulation, 2022 ). The subjects were asked to assess themselves across five domains: “ability to actively participate in society and treat people appropriately; ability to adapt to simple environments, difficult to detect intellectual problems at the first meeting, and unable to understand metaphors; detachment from society, only passive contact with others, and easily fooled; reluctant to socialize, but poorly articulated, with inappropriate facial expressions; and difficult to contact people at all”. The items were scored on a scale ranging from 0 to 4, with 0 indicating perfect, 1 indicating mildly reduced social participation, 2 indicating moderately reduced social participation, and 3–4 indicating severely reduced social participation. For the purpose of binary logistic regression, a score of 0 was defined as “no decline”, and scores of 1–4 were combined and defined as “having social participation decline”. Measures of hearing loss Currently, most researchers employ participant self-reporting in hearing loss testing (Bernabé et al., 2023 ; Riska et al., 2021 ), and multiple studies have demonstrated that participant self-reporting is effective and convenient for hearing loss assessment (Bonetti et al., 2018 ; Torre et al., 2006 ). The hearing loss screening in this study also adopts this approach, which specifically includes two stages: initial screening and further screening. First, initial screening employs the ICOPE guidelines (Cesari et al., 2019 ): a tester whispers “basketball, red flag, apple” and “flower, door, rice” in the participant’s ear at arm’s length behind the subject’s left and right sides, respectively, and asks the participant to repeat the words. A wrong answer on either side is considered a positive initial screening. Second, further screening evaluates the issues arising from the long-term clinical use of the self-report scale at renowned medical institutions in China (e.g., Peking Union Medical College Hospital and Beijing Geriatric Hospital). Positive participants subsequently answer three questions:“Are you often accused of turning up the TV and radio too loudly?”, “Do you often need others to repeat what they say?”, and “Do you have difficulty in listening to the telephone?”. A score of 'no' for all three items equaled 0, indicating good hearing, while a ‘yes’ for 1–2 items resulted in 1 point, signifying poor hearing, and a ‘yes’ for all three items resulted in 2 points, indicating bad hearing. Measurement of falls risk The Morse Falls Risk Factor Assessment Scale (Morse et al., 1989 ) was used to assess the risk of falls on the basis of “falls in the last 3 months, multimorbidity of two or more illnesses, use of mobility aids, intravenous fluids, and gait and cognitive status”. The items were scored on a scale including response options of 0, 10, 15, 20 and 30. A total score of 0 was considered to indicate no risk, 1–24 was considered to indicate low risk, 25–45 was considered to indicate moderate risk, and > 45 was considered to indicate high risk. Measurement of multimorbidity The Charlson Comorbidity Index (CCI) and the Geriatric Cumulative Illness Rating Scale (CIRS-G), which are commonly used in clinical practice to assess multimorbidity, have been demonstrated to possess good reliability and validity (Baris et al., 2025 ; Castelli et al., 2014 ). This study integrated the disease framework of CCI (Charlson et al., 2022 ) and the CIRS-G scale (Jia et al., 2023 ), combined with clinical experience, to identify 19 diseases (Supplementary File 1). A score of 0 was assigned to indicate no multimorbidity, while scores ranging from 1 to 10 corresponded to the number of multimorbidities (the maximum number of multimorbidities in the study subjects was 10). Covariates The baseline covariates included demographic characteristics (age, gender), sociodemographic indicators (marital status, educational level, and living setting), and multimorbidity. Be aware that the sample size for some subgroups was too limited. To achieve sample balance and model robustness, we split age and marriage into two distinct categories. These variables were assigned specific values as follows: age (1 = < 80 years, 2 = ≥ 80 years); gender (1 = male, 2 = female); marital status: 1 = married, 2 = unmarried (unmarried, divorced, or widowed); educational level (1 = no education, 2 = primary school, 3 = middle school, 4 = high school or above); living setting (0 = community, 1 = nursing home); and multimorbidity (0 = No, 1 = Yes). Statistical Analysis Data organization and statistical analysis were performed with the assistance of Zstats ( http://www.zstats.net ), R version 4.3.3 (2024-02-29) software and SPSS 29.0 software (processv41 plugin model 4). Binary logistic regression models were constructed to analyze the associations between hearing loss and social participation decline, and odds ratio (OR) and 95% confidence interval (CI) were calculated. Categorical data are expressed as frequencies and percentages (n, %), and comparisons between groups were performed using the chi-square test. The threshold for statistical significance was P < 0.05. In the multivariate analysis, Model 1 was adjusted for age and marital status; Model 2 was further adjusted for living setting; and Model 3 was further adjusted for multimorbidity. Mediation analysis was conducted using Zstats and R version 4.3.3 software, with hearing loss as the independent variable, social participation decline as the dependent variable, and falls risk as the mediator. The 95% confidence interval was estimated using the bootstrap method (5,000 samples). If the interval did not include 0, the mediation effect was considered significant, and the proportion of the mediation effect to the total effect was calculated. RESULTS Baseline Characteristics of the Study Participants Among the 468 participants in this study, 59.62% were aged ≥ 80 years, 55.77% were female, 47.22% were married, 33.55% had received no education, 45.94% were living in nursing homes, and 38.68% had multimorbidity. In addition, age, marital status, living setting and multimorbidity were significantly associated with hearing loss (Table 1 ). Table 1 Baseline characteristics of the study participants. Variables Hearing Loss Total (n = 468) 0 (n = 309) 1 (n = 159) χ² P Age (in years), n(%) 29.30 < 0.001 < 80 189 (40.38) 152 (49.19) 37 (23.27) ≥ 80 279 (59.62) 157 (50.81) 122 (76.73) Gender, n(%) 2.90 0.088 Male 207 (44.23) 128 (41.42) 79 (49.69) Female 261 (55.77) 181 (58.58) 80 (50.31) Marital status, n(%) 15.42 < 0.001 Married 221 (47.22) 166(53.72) 55 (34.59) Unmarried 247 (52.78) 143 (46.28) 104(65.41) Educational level, n(%) 5.10 0.165 No education 157 (33.55) 95 (30.74) 62 (38.99) Primary school 142 (30.34) 92 (29.77) 50 (31.45) Middle school 80 (17.09) 58 (18.77) 22 (13.84) High school or above 89 (19.02) 64 (20.71) 25 (15.72) Living setting, n(%) 34.42 < 0.001 Community 253 (54.06) 197 (63.75) 56 (35.22) Nursing home 215 (45.94) 112 (36.25) 103 (64.78) Multimorbidity 10.94 < 0.001 No 287 (61.32) 206 (66.67) 81 (50.94) Yes 181 (38.68) 103 (33.33) 78 (49.06) Abbreviations: χ², chi-square test Multifactorial Regression Analysis Spearman’s correlation analysis revealed that social participation decline was positively correlated with hearing loss (r = 0.173, P < 0.001) and falls risk (r = 0.678, P < 0.001) and that hearing loss was also positively correlated with falls risk (r = 0.105, P < 0.05) (Table S1). The multicollinearity assessment indicated that all variables had a variance inflation factor (VIF) below 10 and a tolerance above 0.1, implying no significant collinearity and stable model performance (Miles, 2014 )(Table S2). Four logistic regression models were constructed to investigate the associations between hearing loss and social participation decline. The results revealed that hearing loss was significantly and positively associated with decreased social participation, and this association remained robust after adjusting for confounders. The specific results are as follows. Overall, in the non-adjusted model, hearing loss was significantly associated with reduced social participation (OR = 1.59, 95% CI: 1.22–2.07, P < 0.001). After stepwise adjustment for Model 1 (age and marital status), Model 2 (age, marital status and living setting), and Model 3 (age, marital status, living setting and multimorbidity), the association remained significant (Model 3: OR = 1.38, 95% CI: 1.04–1.83, P = 0.026). For hearing loss level 1 (poor hearing), the non-adjusted model showed an OR of 3.27 (95% CI: 1.68–6.37, P < 0.001) for social participation decline; after sequential adjustments across the three models, the OR were 2.88 (95% CI: 1.45–5.73, P = 0.003), 2.66 (95% CI: 1.32–5.35, P = 0.006), and 2.46 (95% CI: 1.22–4.96, P = 0.012), respectively. For hearing loss level 2 (bad hearing), the non-adjusted OR for social participation decline was 2.38 (95% CI: 1.38–4.11, P = 0.002); with the same sequential adjustments, the OR in Model 1, Model 2, and Model 3 were 2.22 (95% CI: 1.27–3.89, P = 0.005), 2.03 (95% CI: 1.14–3.60, P = 0.016), and 1.86 (95% CI: 1.04–3.32, P = 0.038) in that order (Table 2 ). Table 2 The association between hearing loss and social participation decline. Variables Non-adjusted model Model 1 * Model 2 † Model 3 ‡ OR (95% CI) P OR (95% CI) P OR (95% CI) P OR (95% CI) P Overall 1.59(1.22 ~ 2.07) < 0.001 1.52(1.16 ~ 1.99) 0.003 1.45(1.09 ~ 1.91) 0.010 1.38(1.04 ~ 1.83) 0.026 Hearing Loss 0 1.00(Reference) 1.00(Reference) 1.00 (Reference) 1.00 (Reference) 1 3.27(1.68 ~ 6.37) < 0.001 2.88(1.45 ~ 5.73) 0.003 2.66(1.32 ~ 5.35) 0.006 2.46(1.22 ~ 4.96) 0.012 2 2.38(1.38 ~ 4.11) 0.002 2.22(1.27 ~ 3.89) 0.005 2.03(1.14 ~ 3.60) 0.016 1.86(1.04 ~ 3.32) 0.038 Abbreviations: OR: odds ratio; CI: confidence interval Notes. *Model I, Adjusted for age and marital status. †Model II, Adjusted for Model 1 + living setting. ‡Model 3, Adjusted for Model 2 + multimorbidity. Abbreviations: OR: odds ratio; CI: confidence interval Subgroup Analyses Subgroup analyses revealed that hearing loss was positively associated with reduced social participation. These analyses also highlighted the presence of an interaction effect between hearing loss and gender in this context (Fig. 2 ). Mediation analysis Mediation analysis suggested that the direct effect of hearing loss on social participation decline was significant (β = 0.10, p < 0.001). Falls risk partially mediated the relationship between hearing loss and social participation decline, as indicated by a significant indirect effect (β = 0.05, p < 0.001). The total effect of hearing loss on social participation decline was significant (β = 0.15; P < 0.001), and falls risk accounted for 38.90% of the variance in the total effect (Fig. 3 ). More specifically, Hearing loss was associated with a higher risk of falls (β = 0.43), and falls risk itself showed a strong negative association with social participation (β = 4.68) (Table S3). DISCUSSION This study explored the association between hearing loss and social participation decline through the construction of four progressive models (non-adjusted model → Model 1 → Model 2 → Model 3), subgroup analyses and Mediation analysis. First, regression analysis implied that hearing loss was significantly and independently associated with reduced social participation in the older people. Without adjustment for confounding factors, hearing loss was associated with a 59% increased risk of decreased social participation (OR = 1.59). More importantly, this association remained stable after stepwise adjustment for a series of potential confounding factors, including age, marital status, living setting, and multimorbidity (fully adjusted OR = 1.38), indicating that the association between hearing loss and reduced social participation was independent of these common health and social factors and exhibited strong robustness. Further stratified analysis revealed that the risk increase (adjusted OR = 2.46) in individuals with hearing loss level 1 was even higher than that in those with hearing loss level 2 (adjusted OR = 1.86) compared to those without hearing loss. One possible explanation is that individuals with hearing loss level 1, due to the relatively mild nature of their impairment, may not have received sufficient attention from themselves, their families, or clinicians. This may have resulted in delayed hearing aid fitting or ineffective communication strategies, leading to persistent uncorrected communication difficulties. In contrast, those with hearing loss level 2, whose impairment is more pronounced, are more likely to have received strategies (such as hearing aids), which may be associated with a lesser degree of social participation reduction compared to those with mild hearing loss. Another possible reason is that individuals with mild hearing loss may still be striving to participate in routine social activities, but frequent misunderstandings and frustrations can impose significant psychological burdens. In contrast, those with more severe hearing loss may have adjusted their social expectations, forming more stable, limited but effective social circles or communication patterns, thereby reducing uncertainty and stress. Second, subgroup analysis revealed that the positive correlation between hearing loss and reduced social participation was consistent across all subgroups, but there was a significant gender interaction effect, with this association being significantly stronger in women (OR = 2.04) than in men (OR = 1.38). The reason for this gender difference may lie in the differences in social roles and communication patterns. Older women typically rely more on verbal communication to maintain their core social networks, making the impact of hearing loss on their social functioning more direct and severe. Additionally, women may be more sensitive to social embarrassment and anxiety caused by communication barriers, leading to a more proactive withdrawal from social interactions. Third, the results of the mediation analysis show that the direct effect accounts for 61.10% of the total effect, while the indirect effect accounts for 38.90% of the total effect. These findings suggest an association between hearing loss and reduced social participation, part of which might operate through an association with increased falls risk. The core findings of the present study on the relationship between hearing loss and social participation decline in older adults are consistent across populations and cultures, as several international and Chinese studies provide evidence supporting the negative impact of hearing loss on social participation in older populations. For example, Cheung (Cheung & Zhang, 2023 ) indicated that older adults with self-reported deafness or hearing loss in the United States were significantly less likely to participate in social activities. Similarly, Wang (Z. Wang et al., 2022 ) reported that Chinese older adults with hearing loss had significantly fewer types of activities and a lower frequency of participation than did normal-hearing older adults. Bernabé (Bernabé et al., 2023 ) collected data from Brazilian individuals and found that hearing loss reduced baseline social participation and accelerated its decline. Additionally a study by Prieur Chaintré (Prieur Chaintré et al., 2024 ) noted that older adults with hearing loss experience difficulties in maintaining interpersonal relationships and participating in social activities, and Kojima (Kojima et al., 2023 ) noted that hearing loss inhibits social activities that require high-frequency communication. However, the results of the present study are inconsistent with those of Yamada et al., who concluded that self-reported hearing loss is not associated with social participation (Yamada et al., 2012 ), which may stem from differences in the study population and assessment tools. On the one hand, the present study included older adults living in communities and nursing homes, more than half of whom were ≥ 80 years of age, nearly half of whom living in nursing home, a group that is older, has lower functional reserve, and relies on institutionalized socialization with a higher degree of hearing dependence; whereas, Yamada’s study included individuals aged 65 years and older in a rural community in Japan, with a mean age of 75.4 years and greater functional independence, socialization based on acquaintance networks, and nonauditory cues that can partially compensate for the effects of hearing loss. On the other hand, in terms of assessment tools, this study used the Chinese national standard GB/T 42195 − 2022, which focuses on social adaptation and cognitive dimensions, and hearing loss may directly affect higher-order social functioning; but Yamada’s study used the subscales of the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC), which assesses specific behaviors in familiar scenarios with lower auditory requirements. Overall, this is the first study to explore the potential mediating role of falls risk in the relationship between hearing loss and decreased social participation. This study found that falls risk mediate the relationship between hearing loss and social participation decline. The underlying mechanism of this mediation effect comprises three interrelated components. The first aspect is the association between hearing loss and decline in social participation: First, hearing loss makes it difficult for older people to communicate, which reduces their social participation (Shukla et al., 2019 ). Second, individuals with hearing loss may experience reduced social participation due to fear of interacting with unfamiliar people, maintaining frequent communication with friends, or participating in group activities (Prieur Chaintré et al., 2024 ). Finally, compared to individuals without hearing loss, those with hearing loss often require more demanding environmental conditions for communication. For instance, even moderately noisy backgrounds can hinder normal conversation, forcing them to reduce their social participation (Brewster et al., 2021 ). The second aspect is the association between hearing loss and a higher risk of falls in a variety of ways: First, hearing loss may impair vestibular system function, directly affecting balance and gait stability (Lubetzky et al., 2025 ). Second, the reduced perception of auditory cues lowers environmental vigilance, which impairs the ability to respond to changes in personal postural stability and the external environment (Campos et al., 2018 ), consequently raising falls risk. Third, lack of auditory input impacts visual processing in the dorsal visual pathway, leading to vision impairment (Mitchell & Maslin, 2007 ), and visual impairment itself is a risk factor for falls (Terheyden et al., 2023 ). Finally, hearing loss may impair cognitive function by consuming cognitive resources (Babajanian & Gurgel, 2022 ) and affecting the brain's perception and processing capabilities (Williams et al., 2020 ), thereby impairing balance control, gait adjustment, and environmental judgment (van Schooten et al., 2021 ). The third aspect is the association between falls risk and a lower level of social participation among older adults: Falls often result in serious physical injuries such as fractures and head trauma (Vaishya & Vaish, 2020 ) and may lead to loss of independence, thus increasing the risk of prolonged hospitalization or admission to a care facility (Aranda-Gallardo et al., 2018 ). More importantly, the experience of falling can easily trigger intense fear of falling again among older adults. This fear not only restricts their daily activities but is also often accompanied by depression and social isolation (Trevisan et al., 2019 ). The multifaceted consequences of falls encompass physical, functional, psychological, and social dimensions. These interact to create a vicious cycle that severely impedes social participation. Affected older adults often withdraw from community life, including volunteer work, group activities, and family events, which in turn results in the loss of social roles, decreased social capital, and exacerbated loneliness and isolation (Yue et al., 2022 ). In summary,hearing loss is associated with reduced social participation, and falls risk appears to be a factor that partly accounts for this association. Therefore, the implementation of comprehensive interventions is necessary. First, early screening and multidimensional assessment through audiometry and gait analysis are needed to identify hearing loss and falls risk. Second, technological interventions with the help of hearing aids, cochlear implants, walking aids and smart devices reduce the risk of falls. Behavioral and lifestyle interventions such as exercise, nutritional management, and psychotherapy are used to improve hearing health and prevent falls. Additionally, individuals with hearing loss and/or falls risk are actively rehabilitated to minimize the negative impact. Finally, medical and nursing training and health education should be strengthened, and the accessibility of assistive devices should be increased through policy support to improve quality of life and promote healthy aging among older individuals. Limitations This study has several limitations. First, a cross-sectional design can only reveal the static associations among hearing loss, falls risk, and social participation decline and cannot clarify the time series, causal direction, and reversibility. Second, the hearing and falls risk data were self-reported and thus may have been influenced by subjective bias, thereby reducing the accuracy of the variable effect estimates. Third, although multivariate regression was used to control for known covariates, unmeasured confounding variables may have led to residual confounding. Fourth, the sample was limited to older individuals in Lianyungang City, and the homogeneity of regional characteristics restricted the generalizability of the results. Finally, while dividing age and marital status into categories can enhance model stability, it might obscure differences between subgroups, such as the varying physiological reserves between individuals aged 60–69 and those aged 70–79, as well as differences in psychological support. To address these limitations, future studies could conduct multicenter, large-sample prospective cohort studies in combination with long-term follow-up to clarify the temporal relationships between variables to support causal inference. Additionally, objective hearing tests and digital falls monitoring could be introduced to increase data accuracy. Furthermore, multidimensional environmental and behavioral covariates could be included to further elucidate the relationships among the three variables. Finally, future research should also consider the bidirectional causal relationship between hearing loss, falls risk and reduced social participation. Conclusion Among older adults aged 60 and above in Chinese communities and nursing homes, hearing loss is associated with reduced social participation, and this association is partly explained by its correlation with increased falls risk. Therefore, policymakers, healthcare providers, communities, and families need to work together to promote dual interventions targeting hearing loss and falls risk to improve social participation among older adults. Abbreviations HAI Healthy Aging Initiative WHO World Health Organization ICOPE Integrated Care for Older People CCI The Charlson Comorbidity Index CIRS-G Geriatric Cumulative Illness Rating Scale OR Odds Ratio CI Confidence Interval VIF Variance Inflation Factor TMIG-IC Tokyo Metropolitan Institute of Gerontology Index of Competence Declarations Note In the variable hearing loss classification, 0 indicates no hearing loss, while 1 indicates hearing loss (including poor hearing and bad hearing). CONFLICT OF INTEREST STATEMENT The authors state that they have no conflicts of interest. ETHICS STATEMENT The study protocol was reviewed and approved by the Medical Ethics Committee at The First People's Hospital of Lianyungang (Implementation of Integrated Elderly Care in Geriatrics and Recommendations for Developing a Continuous Elderly Care Service System, Grant No. QT- 20221118001-02) on December 9, 2022. Written informed consent was obtained from all participants prior to their enrollment in this study. FUNDING INFORMATION This research received funding from the 2023 Lianyungang Health Science and Technology Project, which focuses on a prospective randomized controlled study aimed at enhancing the comprehensive evaluation of frail older individuals through a national multicenter integrated elderly care pilot. The Pilot Office of the WHO Integrated Care for Older People in China (National Multicenter Medical and Nursing Integrated Care Pilot) and Grant No. 202307. AUTHOR CONTRIBUTIONS The study’s conception and design were a collaborative effort by all the authors. Xinyi Yao, Tiantian Zhang, Shixing Song, Li Wang, Kuixu Qian and Jing Gao were responsible for data collection, whereas Lulu Xiao, Yan Dong, Yadong Shi, Xinyi Yao, and Tiantian Zhang were responsible for the data analysis and interpretation. Lulu Xiao and Reyhangul·Aken prepared the first draft of the manuscript. Finally, Yan Dong, Nicolás Martínez-Velilla and Yadong Shi organized the proofreading and formatting of the manuscript. The final version was approved by all the authors for submission. ACKNOWLEDGMENTS The authors express their gratitude to all the participants for their involvement in this study. DATA AVAILABILITY STATEMENT The datasets utilized and/or examined in this study can be obtained from the corresponding author upon reasonable request. References Akosile CO, Ngwu NP, Okonkwo UP, Onwuakagba IU, Okoye EC (2023) Neighborhood safety, fall indices, physical activity level and social participation restrictions from a population of community-dwelling older adults in Nsukka, Enugu State, Nigeria. 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Geriatr Nurs 47:145–150. https://doi.org/10.1016/j.gerinurse.2022.07.007 Wang Z, Chen D, Pan T, Chen C, Guan L (2022) Hearing loss, depression and social participation of older adults: Evidence from the China health and retirement longitudinal study. Geriatr Gerontol Int 22(7):529–535. https://doi.org/10.1111/ggi.14413 Williams N, Guthrie DM, Davidson JGS, Fisher K, Griffith LE (2020) A Deterioration in Hearing Is Associated With Functional and Cognitive Impairments, Difficulty With Communication, and Greater Health Instability. J Appl Gerontol 39(2):159–171. https://doi.org/10.1177/0733464818755312 Wu M, Yang D, Tian Y (2024) Enjoying the golden years: social participation and life satisfaction among Chinese older adults. Front Public Health 12:1377869. https://doi.org/10.3389/fpubh.2024.1377869 Yamada M, Nishiwaki Y, Michikawa T, Takebayashi T (2012) Self-reported hearing loss in older adults is associated with future decline in instrumental activities of daily living but not in social participation. J Am Geriatr Soc 60(7):1304–1309. https://doi.org/10.1111/j.1532-5415.2012.04039.x Yue Z, Liang H, Gao X, Qin X, Li H, Xiang N, Liu E (2022) The association between falls and anxiety among elderly Chinese individuals: The mediating roles of functional ability and social participation. J Affect Disord 301:300–306. https://doi.org/10.1016/j.jad.2022.01.070 Zhang Z, Jin L, Liu J, Liao D, Zhang X (2024) The impact of social participation on the health status of the older adult: An empirical study based on CGSS 2021 data. PLoS ONE 19(6):e0305820. https://doi.org/10.1371/journal.pone.0305820 Additional Declarations The authors declare no competing interests. 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2","display":"","copyAsset":false,"role":"figure","size":485422,"visible":true,"origin":"","legend":"\u003cp\u003eSubgroup analysis of the relationship between hearing loss and social participation decline.\u003c/p\u003e\n\u003cp\u003eAbbreviations: OR: odds ratio; CI: confidence interval\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8393372/v2/74d689ded8e598a17fbc25ab.png"},{"id":100732234,"identity":"38e63db2-4724-4761-bad5-592b44d2fde4","added_by":"auto","created_at":"2026-01-20 21:44:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":166860,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFig. 3.\u003c/strong\u003e\u0026nbsp;Analysis of the effect of falls risk on the association between hearing loss and social participation\u0026nbsp;decline.\u003c/p\u003e\n\u003cp\u003eNote: In the diagram, path c indicates the total effect, path c' 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21:44:43","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":72359,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-8393372/v2/ac3ed81b682925c5f3e0c9ef.docx"},{"id":100732071,"identity":"2694cb75-2855-4ecb-97ea-17bb9e69cf94","added_by":"auto","created_at":"2026-01-20 21:41:21","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":80859,"visible":true,"origin":"","legend":"","description":"","filename":"EditingCertificate.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8393372/v2/6c98824e240264f4164cda9b.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eHearing Loss Is Associated With Reduced Social Participation for Older Adults in Communities and Nursing Homes in China: The Mediating Role of Falls Risk\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe rapid global increase in the aging population and the severe issues associated with aging societies have become matters of global concern. The Healthy Aging Initiative (HAI) of the World Health Organization (WHO) aims to address these challenges by emphasizing efforts to increase life expectancy while simultaneously improving the quality of life of older adults.\u003c/p\u003e \u003cp\u003eSocial participation is defined as engaging in activities that involve interaction with other individuals (Levasseur et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This participation is not limited to specific social groups or activities but also includes interactions in community life and important shared spaces. Social participation has been recognized as an important indicator of successful aging; furthermore, it has been identified as a modifiable determinant of health that can improve the mental health and physical health of older adults by promoting physical activity, socialization, and recreational activities (Zhang et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Moreover, social participation not only increases life satisfaction among older adults by improving their social networks and reducing their loneliness (Wu et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) but also significantly reduces the risk of mortality among this population (Sandoval et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHearing loss is a prevalent problem among older people, and it is likely the most common sensory impairment in this population (Cesari et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), affecting approximately half of all older adults (Britt et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Hearing loss is not only an auditory problem but also involves cognitive and psychological aspects, which significantly affect individuals\u0026rsquo; quality of life and health status (Cesari et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Moreover, studies have reported that hearing loss can significantly affect social participation among older adults. For instance, hearing loss often leads to communication difficulties, mental health problems, and social isolation, thereby limiting an individual\u0026rsquo;s social participation (Podury et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFalls are particularly common among older adults. The global prevalence of falls among older adults has been reported to be 26.5% (Salari et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Falls represent major causes of functional impairment, disability and death among older adults; they can also have serious social and economic consequences (Vaishya \u0026amp; Vaish, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and constitute important constraints on healthy aging (Li et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Solares\u0026rsquo;s research demonstrates that perceiving the risk of falls can help prevent their occurrence (Solares et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Therefore, identifying and reducing falls risk is crucial.\u003c/p\u003e \u003cp\u003eThrough previous research, we can preliminarily observe that hearing loss, falls risk, and social participation are not mutually exclusive phenomena; rather, they exhibit potential interconnections in the health maintenance process of older adults. Social participation is negatively influenced by hearing loss and falls risk: First, hearing loss impairs verbal communication and environmental perception, thereby reducing the willingness for social participation. Second, the risk of falls and associated fears limit outdoor activities, decreasing opportunities for social interaction. Existing research indicates that older adults with hearing loss often face challenges in maintaining social networks and sustained participation in social activities due to multiple factors, including auditory-verbal communication barriers and psychosocial functional decline (Prieur Chaintr\u0026eacute; et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). A longitudinal study showed that hearing loss negatively affects social participation, and this effect is independent of sociodemographic characteristics, behavioral habits, and medical conditions (Bernab\u0026eacute; et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Concurrently, falls risk incidents may limit social participation by reducing opportunities for outdoor socializing through acute or chronic injuries, activity restrictions, and falls-related fears. Dashner et al. found that among participants with a history of falls or falls concerns, both levels of social participation and satisfaction with participation experiences tended to decline, suggesting falls risk may adversely affect social functioning in older adults (Dashner et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Akosile's research demonstrates that the falls risk in both indoor and outdoor social activities may limit people\u0026rsquo;s social engagement (Akosile et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Furthermore, some studies have found that hearing loss may increase the risk of falls. Research by Wang et al. confirmed a significant positive correlation between hearing loss and falls risk. Among Chinese older adults, individuals with hearing impairment exhibited higher falls incidence compared to those with normal hearing (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eJ.\u003c/span\u003e Wang et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). A study based on the NHANES database demonstrated a significant association between self-reported hearing loss and the risk of falls (Riska et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Although the above pairwise associations have been preliminarily explored, there remains a lack of research examining the overall pathway by placing all three variables within a unified framework and using falls risk as the mediating variable. However, focusing solely on hearing loss may underestimate the synergistic benefits of falls risk management in improving social participation. Therefore, this study attempts to construct the hypothesized pathway \u0026ldquo;hearing loss \u0026rarr; falls risk \u0026rarr; social participation decline\u0026rdquo; to provide theoretical insights for developing subsequent multidimensional intervention strategies. The following are the hypotheses for the research:\u003c/p\u003e \u003cp\u003eH1: Hearing loss is positively correlated with social participation decline;\u003c/p\u003e \u003cp\u003eH2: Hearing loss is positively correlated with the falls risk;\u003c/p\u003e \u003cp\u003eH3: Falls risk is positively correlated with social participation decline;\u003c/p\u003e \u003cp\u003eH4: The association between hearing loss and social participation decline is partially explained by falls risk.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eThe participants in this study were older people living in communities and nursing homes in Lianyungang city, Jiangsu Province, which hosts an Integrated Care for Older People (ICOPE) China pilot project, between March and July 2024. The inclusion criteria used for the participants in this research were as follows: age\u0026thinsp;\u0026ge;\u0026thinsp;60 years, good consciousness, and voluntary signing of an informed consent form. The exclusion criteria were as follows: the presence of critical illness, inability to complete the assessment, and missing key variables. Initially, 507 people were screened, excluding 36 individuals under 60. Of the 471 remaining, 3 were excluded due to missing data, leaving 468 participants included (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eMeasures of social participation\u003c/p\u003e \u003cp\u003eSocial participation was assessed based on the National Standard of the People\u0026rsquo;s Republic of China (GB/T 42195\u0026thinsp;\u0026minus;\u0026thinsp;2022),\u0026ldquo;Specification for ability assessment of older adults\u0026rdquo; (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eState Administration for Market\u003c/span\u003e Regulation, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The subjects were asked to assess themselves across five domains: \u0026ldquo;ability to actively participate in society and treat people appropriately; ability to adapt to simple environments, difficult to detect intellectual problems at the first meeting, and unable to understand metaphors; detachment from society, only passive contact with others, and easily fooled; reluctant to socialize, but poorly articulated, with inappropriate facial expressions; and difficult to contact people at all\u0026rdquo;. The items were scored on a scale ranging from 0 to 4, with 0 indicating perfect, 1 indicating mildly reduced social participation, 2 indicating moderately reduced social participation, and 3\u0026ndash;4 indicating severely reduced social participation. For the purpose of binary logistic regression, a score of 0 was defined as \u0026ldquo;no decline\u0026rdquo;, and scores of 1\u0026ndash;4 were combined and defined as \u0026ldquo;having social participation decline\u0026rdquo;.\u003c/p\u003e \u003cp\u003eMeasures of hearing loss\u003c/p\u003e \u003cp\u003eCurrently, most researchers employ participant self-reporting in hearing loss testing (Bernab\u0026eacute; et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Riska et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), and multiple studies have demonstrated that participant self-reporting is effective and convenient for hearing loss assessment (Bonetti et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Torre et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). The hearing loss screening in this study also adopts this approach, which specifically includes two stages: initial screening and further screening. First, initial screening employs the ICOPE guidelines (Cesari et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2019\u003c/span\u003e): a tester whispers \u0026ldquo;basketball, red flag, apple\u0026rdquo; and \u0026ldquo;flower, door, rice\u0026rdquo; in the participant\u0026rsquo;s ear at arm\u0026rsquo;s length behind the subject\u0026rsquo;s left and right sides, respectively, and asks the participant to repeat the words. A wrong answer on either side is considered a positive initial screening. Second, further screening evaluates the issues arising from the long-term clinical use of the self-report scale at renowned medical institutions in China (e.g., Peking Union Medical College Hospital and Beijing Geriatric Hospital). Positive participants subsequently answer three questions:\u0026ldquo;Are you often accused of turning up the TV and radio too loudly?\u0026rdquo;, \u0026ldquo;Do you often need others to repeat what they say?\u0026rdquo;, and \u0026ldquo;Do you have difficulty in listening to the telephone?\u0026rdquo;. A score of 'no' for all three items equaled 0, indicating good hearing, while a \u0026lsquo;yes\u0026rsquo; for 1\u0026ndash;2 items resulted in 1 point, signifying poor hearing, and a \u0026lsquo;yes\u0026rsquo; for all three items resulted in 2 points, indicating bad hearing.\u003c/p\u003e \u003cp\u003eMeasurement of falls risk\u003c/p\u003e \u003cp\u003eThe Morse Falls Risk Factor Assessment Scale (Morse et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e1989\u003c/span\u003e) was used to assess the risk of falls on the basis of \u0026ldquo;falls in the last 3 months, multimorbidity of two or more illnesses, use of mobility aids, intravenous fluids, and gait and cognitive status\u0026rdquo;. The items were scored on a scale including response options of 0, 10, 15, 20 and 30. A total score of 0 was considered to indicate no risk, 1\u0026ndash;24 was considered to indicate low risk, 25\u0026ndash;45 was considered to indicate moderate risk, and \u0026gt;\u0026thinsp;45 was considered to indicate high risk.\u003c/p\u003e \u003cp\u003eMeasurement of multimorbidity\u003c/p\u003e \u003cp\u003eThe Charlson Comorbidity Index (CCI) and the Geriatric Cumulative Illness Rating Scale (CIRS-G), which are commonly used in clinical practice to assess multimorbidity, have been demonstrated to possess good reliability and validity (Baris et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Castelli et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). This study integrated the disease framework of CCI (Charlson et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and the CIRS-G scale (Jia et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), combined with clinical experience, to identify 19 diseases (Supplementary File 1). A score of 0 was assigned to indicate no multimorbidity, while scores ranging from 1 to 10 corresponded to the number of multimorbidities (the maximum number of multimorbidities in the study subjects was 10).\u003c/p\u003e\n\u003ch3\u003eCovariates\u003c/h3\u003e\n\u003cp\u003eThe baseline covariates included demographic characteristics (age, gender), sociodemographic indicators (marital status, educational level, and living setting), and multimorbidity. Be aware that the sample size for some subgroups was too limited. To achieve sample balance and model robustness, we split age and marriage into two distinct categories. These variables were assigned specific values as follows: age (1\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;80 years, 2\u0026thinsp;=\u0026thinsp;\u0026ge;\u0026thinsp;80 years); gender (1\u0026thinsp;=\u0026thinsp;male, 2\u0026thinsp;=\u0026thinsp;female); marital status: 1\u0026thinsp;=\u0026thinsp;married, 2\u0026thinsp;=\u0026thinsp;unmarried (unmarried, divorced, or widowed); educational level (1\u0026thinsp;=\u0026thinsp;no education, 2\u0026thinsp;=\u0026thinsp;primary school, 3\u0026thinsp;=\u0026thinsp;middle school, 4\u0026thinsp;=\u0026thinsp;high school or above); living setting (0\u0026thinsp;=\u0026thinsp;community, 1\u0026thinsp;=\u0026thinsp;nursing home); and multimorbidity (0\u0026thinsp;=\u0026thinsp;No, 1\u0026thinsp;=\u0026thinsp;Yes).\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData organization and statistical analysis were performed with the assistance of Zstats (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.zstats.net\u003c/span\u003e\u003cspan address=\"http://www.zstats.net\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), R version 4.3.3 (2024-02-29) software and SPSS 29.0 software (processv41 plugin model 4). Binary logistic regression models were constructed to analyze the associations between hearing loss and social participation decline, and odds ratio (OR) and 95% confidence interval (CI) were calculated. Categorical data are expressed as frequencies and percentages (n, %), and comparisons between groups were performed using the chi-square test. The threshold for statistical significance was P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eIn the multivariate analysis, Model 1 was adjusted for age and marital status; Model 2 was further adjusted for living setting; and Model 3 was further adjusted for multimorbidity. Mediation analysis was conducted using Zstats and R version 4.3.3 software, with hearing loss as the independent variable, social participation decline as the dependent variable, and falls risk as the mediator. The 95% confidence interval was estimated using the bootstrap method (5,000 samples). If the interval did not include 0, the mediation effect was considered significant, and the proportion of the mediation effect to the total effect was calculated.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Characteristics of the Study Participants\u003c/h2\u003e \u003cp\u003eAmong the 468 participants in this study, 59.62% were aged\u0026thinsp;\u0026ge;\u0026thinsp;80 years, 55.77% were female, 47.22% were married, 33.55% had received no education, 45.94% were living in nursing homes, and 38.68% had multimorbidity. In addition, age, marital status, living setting and multimorbidity were significantly associated with hearing loss (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the study participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eHearing Loss\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;468)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (n\u0026thinsp;=\u0026thinsp;309)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (n\u0026thinsp;=\u0026thinsp;159)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eχ\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (in years), n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e189 (40.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e152 (49.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37 (23.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e279 (59.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e157 (50.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e122 (76.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e207 (44.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e128 (41.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e79 (49.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e261 (55.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e181 (58.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80 (50.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e221 (47.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e166(53.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55 (34.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e247 (52.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e143 (46.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e104(65.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational level, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e157 (33.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95 (30.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62 (38.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e142 (30.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92 (29.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50 (31.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80 (17.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (18.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22 (13.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89 (19.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64 (20.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 (15.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving setting, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e253 (54.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e197 (63.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56 (35.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursing home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e215 (45.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e112 (36.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e103 (64.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultimorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e287 (61.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e206 (66.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e81 (50.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e181 (38.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e103 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e78 (49.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eAbbreviations: χ\u0026sup2;, chi-square test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMultifactorial Regression Analysis\u003c/h3\u003e\n\u003cp\u003eSpearman\u0026rsquo;s correlation analysis revealed that social participation decline was positively correlated with hearing loss (r\u0026thinsp;=\u0026thinsp;0.173, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and falls risk (r\u0026thinsp;=\u0026thinsp;0.678, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and that hearing loss was also positively correlated with falls risk (r\u0026thinsp;=\u0026thinsp;0.105, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table S1). The multicollinearity assessment indicated that all variables had a variance inflation factor (VIF) below 10 and a tolerance above 0.1, implying no significant collinearity and stable model performance (Miles, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)(Table S2).\u003c/p\u003e \u003cp\u003eFour logistic regression models were constructed to investigate the associations between hearing loss and social participation decline. The results revealed that hearing loss was significantly and positively associated with decreased social participation, and this association remained robust after adjusting for confounders. The specific results are as follows.\u003c/p\u003e \u003cp\u003eOverall, in the non-adjusted model, hearing loss was significantly associated with reduced social participation (OR\u0026thinsp;=\u0026thinsp;1.59, 95% CI: 1.22\u0026ndash;2.07, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). After stepwise adjustment for Model 1 (age and marital status), Model 2 (age, marital status and living setting), and Model 3 (age, marital status, living setting and multimorbidity), the association remained significant (Model 3: OR\u0026thinsp;=\u0026thinsp;1.38, 95% CI: 1.04\u0026ndash;1.83, P\u0026thinsp;=\u0026thinsp;0.026).\u003c/p\u003e \u003cp\u003eFor hearing loss level 1 (poor hearing), the non-adjusted model showed an OR of 3.27 (95% CI: 1.68\u0026ndash;6.37, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) for social participation decline; after sequential adjustments across the three models, the OR were 2.88 (95% CI: 1.45\u0026ndash;5.73, P\u0026thinsp;=\u0026thinsp;0.003), 2.66 (95% CI: 1.32\u0026ndash;5.35, P\u0026thinsp;=\u0026thinsp;0.006), and 2.46 (95% CI: 1.22\u0026ndash;4.96, P\u0026thinsp;=\u0026thinsp;0.012), respectively.\u003c/p\u003e \u003cp\u003eFor hearing loss level 2 (bad hearing), the non-adjusted OR for social participation decline was 2.38 (95% CI: 1.38\u0026ndash;4.11, P\u0026thinsp;=\u0026thinsp;0.002); with the same sequential adjustments, the OR in Model 1, Model 2, and Model 3 were 2.22 (95% CI: 1.27\u0026ndash;3.89, P\u0026thinsp;=\u0026thinsp;0.005), 2.03 (95% CI: 1.14\u0026ndash;3.60, P\u0026thinsp;=\u0026thinsp;0.016), and 1.86 (95% CI: 1.04\u0026ndash;3.32, P\u0026thinsp;=\u0026thinsp;0.038) in that order (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe association between hearing loss and social participation decline.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNon-adjusted model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eModel 1\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eModel 2\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eModel 3\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.59(1.22\u0026thinsp;~\u0026thinsp;2.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.52(1.16\u0026thinsp;~\u0026thinsp;1.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.45(1.09\u0026thinsp;~\u0026thinsp;1.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.38(1.04\u0026thinsp;~\u0026thinsp;1.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHearing Loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00(Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00(Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.27(1.68\u0026thinsp;~\u0026thinsp;6.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.88(1.45\u0026thinsp;~\u0026thinsp;5.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.66(1.32\u0026thinsp;~\u0026thinsp;5.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.46(1.22\u0026thinsp;~\u0026thinsp;4.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.38(1.38\u0026thinsp;~\u0026thinsp;4.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.22(1.27\u0026thinsp;~\u0026thinsp;3.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.03(1.14\u0026thinsp;~\u0026thinsp;3.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.86(1.04\u0026thinsp;~\u0026thinsp;3.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eAbbreviations: OR: odds ratio; CI: confidence interval\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eNotes.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e*Model I, Adjusted for age and marital status.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u0026dagger;Model II, Adjusted for Model 1\u0026thinsp;+\u0026thinsp;living setting.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u0026Dagger;Model 3, Adjusted for Model 2\u0026thinsp;+\u0026thinsp;multimorbidity.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eAbbreviations: OR: odds ratio; CI: confidence interval\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eSubgroup Analyses\u003c/h3\u003e\n\u003cp\u003e Subgroup analyses revealed that hearing loss was positively associated with reduced social participation. These analyses also highlighted the presence of an interaction effect between hearing loss and gender in this context (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMediation analysis\u003c/h2\u003e \u003cp\u003eMediation analysis suggested that the direct effect of hearing loss on social participation decline was significant (β\u0026thinsp;=\u0026thinsp;0.10, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Falls risk partially mediated the relationship between hearing loss and social participation decline, as indicated by a significant indirect effect (β\u0026thinsp;=\u0026thinsp;0.05, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The total effect of hearing loss on social participation decline was significant (β\u0026thinsp;=\u0026thinsp;0.15; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and falls risk accounted for 38.90% of the variance in the total effect (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). More specifically, Hearing loss was associated with a higher risk of falls (β\u0026thinsp;=\u0026thinsp;0.43), and falls risk itself showed a strong negative association with social participation (β\u0026thinsp;=\u0026thinsp;4.68) (Table S3).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study explored the association between hearing loss and social participation decline through the construction of four progressive models (non-adjusted model \u0026rarr; Model 1 \u0026rarr; Model 2 \u0026rarr; Model 3), subgroup analyses and Mediation analysis. First, regression analysis implied that hearing loss was significantly and independently associated with reduced social participation in the older people. Without adjustment for confounding factors, hearing loss was associated with a 59% increased risk of decreased social participation (OR\u0026thinsp;=\u0026thinsp;1.59). More importantly, this association remained stable after stepwise adjustment for a series of potential confounding factors, including age, marital status, living setting, and multimorbidity (fully adjusted OR\u0026thinsp;=\u0026thinsp;1.38), indicating that the association between hearing loss and reduced social participation was independent of these common health and social factors and exhibited strong robustness. Further stratified analysis revealed that the risk increase (adjusted OR\u0026thinsp;=\u0026thinsp;2.46) in individuals with hearing loss level 1 was even higher than that in those with hearing loss level 2 (adjusted OR\u0026thinsp;=\u0026thinsp;1.86) compared to those without hearing loss. One possible explanation is that individuals with hearing loss level 1, due to the relatively mild nature of their impairment, may not have received sufficient attention from themselves, their families, or clinicians. This may have resulted in delayed hearing aid fitting or ineffective communication strategies, leading to persistent uncorrected communication difficulties. In contrast, those with hearing loss level 2, whose impairment is more pronounced, are more likely to have received strategies (such as hearing aids), which may be associated with a lesser degree of social participation reduction compared to those with mild hearing loss. Another possible reason is that individuals with mild hearing loss may still be striving to participate in routine social activities, but frequent misunderstandings and frustrations can impose significant psychological burdens. In contrast, those with more severe hearing loss may have adjusted their social expectations, forming more stable, limited but effective social circles or communication patterns, thereby reducing uncertainty and stress. Second, subgroup analysis revealed that the positive correlation between hearing loss and reduced social participation was consistent across all subgroups, but there was a significant gender interaction effect, with this association being significantly stronger in women (OR\u0026thinsp;=\u0026thinsp;2.04) than in men (OR\u0026thinsp;=\u0026thinsp;1.38). The reason for this gender difference may lie in the differences in social roles and communication patterns. Older women typically rely more on verbal communication to maintain their core social networks, making the impact of hearing loss on their social functioning more direct and severe. Additionally, women may be more sensitive to social embarrassment and anxiety caused by communication barriers, leading to a more proactive withdrawal from social interactions. Third, the results of the mediation analysis show that the direct effect accounts for 61.10% of the total effect, while the indirect effect accounts for 38.90% of the total effect. These findings suggest an association between hearing loss and reduced social participation, part of which might operate through an association with increased falls risk.\u003c/p\u003e \u003cp\u003eThe core findings of the present study on the relationship between hearing loss and social participation decline in older adults are consistent across populations and cultures, as several international and Chinese studies provide evidence supporting the negative impact of hearing loss on social participation in older populations. For example, Cheung (Cheung \u0026amp; Zhang, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) indicated that older adults with self-reported deafness or hearing loss in the United States were significantly less likely to participate in social activities. Similarly, Wang (Z. Wang et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reported that Chinese older adults with hearing loss had significantly fewer types of activities and a lower frequency of participation than did normal-hearing older adults. Bernab\u0026eacute; (Bernab\u0026eacute; et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) collected data from Brazilian individuals and found that hearing loss reduced baseline social participation and accelerated its decline. Additionally a study by Prieur Chaintr\u0026eacute; (Prieur Chaintr\u0026eacute; et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) noted that older adults with hearing loss experience difficulties in maintaining interpersonal relationships and participating in social activities, and Kojima (Kojima et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) noted that hearing loss inhibits social activities that require high-frequency communication.\u003c/p\u003e \u003cp\u003eHowever, the results of the present study are inconsistent with those of Yamada et al., who concluded that self-reported hearing loss is not associated with social participation (Yamada et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), which may stem from differences in the study population and assessment tools. On the one hand, the present study included older adults living in communities and nursing homes, more than half of whom were \u0026ge;\u0026thinsp;80 years of age, nearly half of whom living in nursing home, a group that is older, has lower functional reserve, and relies on institutionalized socialization with a higher degree of hearing dependence; whereas, Yamada\u0026rsquo;s study included individuals aged 65 years and older in a rural community in Japan, with a mean age of 75.4 years and greater functional independence, socialization based on acquaintance networks, and nonauditory cues that can partially compensate for the effects of hearing loss. On the other hand, in terms of assessment tools, this study used the Chinese national standard GB/T 42195\u0026thinsp;\u0026minus;\u0026thinsp;2022, which focuses on social adaptation and cognitive dimensions, and hearing loss may directly affect higher-order social functioning; but Yamada\u0026rsquo;s study used the subscales of the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC), which assesses specific behaviors in familiar scenarios with lower auditory requirements.\u003c/p\u003e \u003cp\u003eOverall, this is the first study to explore the potential mediating role of falls risk in the relationship between hearing loss and decreased social participation. This study found that falls risk mediate the relationship between hearing loss and social participation decline. The underlying mechanism of this mediation effect comprises three interrelated components.\u003c/p\u003e \u003cp\u003eThe first aspect is the association between hearing loss and decline in social participation: First, hearing loss makes it difficult for older people to communicate, which reduces their social participation (Shukla et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Second, individuals with hearing loss may experience reduced social participation due to fear of interacting with unfamiliar people, maintaining frequent communication with friends, or participating in group activities (Prieur Chaintr\u0026eacute; et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Finally, compared to individuals without hearing loss, those with hearing loss often require more demanding environmental conditions for communication. For instance, even moderately noisy backgrounds can hinder normal conversation, forcing them to reduce their social participation (Brewster et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe second aspect is the association between hearing loss and a higher risk of falls in a variety of ways: First, hearing loss may impair vestibular system function, directly affecting balance and gait stability (Lubetzky et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Second, the reduced perception of auditory cues lowers environmental vigilance, which impairs the ability to respond to changes in personal postural stability and the external environment (Campos et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), consequently raising falls risk. Third, lack of auditory input impacts visual processing in the dorsal visual pathway, leading to vision impairment (Mitchell \u0026amp; Maslin, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), and visual impairment itself is a risk factor for falls (Terheyden et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Finally, hearing loss may impair cognitive function by consuming cognitive resources (Babajanian \u0026amp; Gurgel, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and affecting the brain's perception and processing capabilities (Williams et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), thereby impairing balance control, gait adjustment, and environmental judgment (van Schooten et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe third aspect is the association between falls risk and a lower level of social participation among older adults: Falls often result in serious physical injuries such as fractures and head trauma (Vaishya \u0026amp; Vaish, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and may lead to loss of independence, thus increasing the risk of prolonged hospitalization or admission to a care facility (Aranda-Gallardo et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). More importantly, the experience of falling can easily trigger intense fear of falling again among older adults. This fear not only restricts their daily activities but is also often accompanied by depression and social isolation (Trevisan et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The multifaceted consequences of falls encompass physical, functional, psychological, and social dimensions. These interact to create a vicious cycle that severely impedes social participation. Affected older adults often withdraw from community life, including volunteer work, group activities, and family events, which in turn results in the loss of social roles, decreased social capital, and exacerbated loneliness and isolation (Yue et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In summary,hearing loss is associated with reduced social participation, and falls risk appears to be a factor that partly accounts for this association.\u003c/p\u003e \u003cp\u003eTherefore, the implementation of comprehensive interventions is necessary. First, early screening and multidimensional assessment through audiometry and gait analysis are needed to identify hearing loss and falls risk. Second, technological interventions with the help of hearing aids, cochlear implants, walking aids and smart devices reduce the risk of falls. Behavioral and lifestyle interventions such as exercise, nutritional management, and psychotherapy are used to improve hearing health and prevent falls. Additionally, individuals with hearing loss and/or falls risk are actively rehabilitated to minimize the negative impact. Finally, medical and nursing training and health education should be strengthened, and the accessibility of assistive devices should be increased through policy support to improve quality of life and promote healthy aging among older individuals.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, a cross-sectional design can only reveal the static associations among hearing loss, falls risk, and social participation decline and cannot clarify the time series, causal direction, and reversibility. Second, the hearing and falls risk data were self-reported and thus may have been influenced by subjective bias, thereby reducing the accuracy of the variable effect estimates. Third, although multivariate regression was used to control for known covariates, unmeasured confounding variables may have led to residual confounding. Fourth, the sample was limited to older individuals in Lianyungang City, and the homogeneity of regional characteristics restricted the generalizability of the results. Finally, while dividing age and marital status into categories can enhance model stability, it might obscure differences between subgroups, such as the varying physiological reserves between individuals aged 60\u0026ndash;69 and those aged 70\u0026ndash;79, as well as differences in psychological support.\u003c/p\u003e \u003cp\u003eTo address these limitations, future studies could conduct multicenter, large-sample prospective cohort studies in combination with long-term follow-up to clarify the temporal relationships between variables to support causal inference. Additionally, objective hearing tests and digital falls monitoring could be introduced to increase data accuracy. Furthermore, multidimensional environmental and behavioral covariates could be included to further elucidate the relationships among the three variables. Finally, future research should also consider the bidirectional causal relationship between hearing loss, falls risk and reduced social participation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAmong older adults aged 60 and above in Chinese communities and nursing homes, hearing loss is associated with reduced social participation, and this association is partly explained by its correlation with increased falls risk. Therefore, policymakers, healthcare providers, communities, and families need to work together to promote dual interventions targeting hearing loss and falls risk to improve social participation among older adults.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHAI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealthy Aging Initiative\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWHO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eICOPE\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntegrated Care for Older People\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCCI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Charlson Comorbidity Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCIRS-G\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeriatric Cumulative Illness Rating Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eOR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eVIF\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVariance Inflation Factor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eTMIG-IC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTokyo Metropolitan Institute of Gerontology Index of Competence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eNote\u003c/h2\u003e \u003cp\u003eIn the variable hearing loss classification, 0 indicates no hearing loss, while 1 indicates hearing loss (including poor hearing and bad hearing).\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCONFLICT OF INTEREST STATEMENT\u003c/h2\u003e \u003cp\u003eThe authors state that they have no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eETHICS STATEMENT\u003c/h2\u003e \u003cp\u003eThe study protocol was reviewed and approved by the Medical Ethics Committee at The First People's Hospital of Lianyungang (Implementation of Integrated Elderly Care in Geriatrics and Recommendations for Developing a Continuous Elderly Care Service System, Grant No. QT- 20221118001-02) on December 9, 2022. Written informed consent was obtained from all participants prior to their enrollment in this study.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFUNDING INFORMATION\u003c/h2\u003e \u003cp\u003e This research received funding from the 2023 Lianyungang Health Science and Technology Project, which focuses on a prospective randomized controlled study aimed at enhancing the comprehensive evaluation of frail older individuals through a national multicenter integrated elderly care pilot. The Pilot Office of the WHO Integrated Care for Older People in China (National Multicenter Medical and Nursing Integrated Care Pilot) and Grant No. 202307.\u003c/p\u003e\u003ch2\u003eAUTHOR CONTRIBUTIONS\u003c/h2\u003e \u003cp\u003eThe study\u0026rsquo;s conception and design were a collaborative effort by all the authors. Xinyi Yao, Tiantian Zhang, Shixing Song, Li Wang, Kuixu Qian and Jing Gao were responsible for data collection, whereas Lulu Xiao, Yan Dong, Yadong Shi, Xinyi Yao, and Tiantian Zhang were responsible for the data analysis and interpretation. Lulu Xiao and Reyhangul\u0026middot;Aken prepared the first draft of the manuscript. Finally, Yan Dong, Nicol\u0026aacute;s Mart\u0026iacute;nez-Velilla and Yadong Shi organized the proofreading and formatting of the manuscript. The final version was approved by all the authors for submission.\u003c/p\u003e\u003ch2\u003eACKNOWLEDGMENTS\u003c/h2\u003e \u003cp\u003eThe authors express their gratitude to all the participants for their involvement in this study.\u003c/p\u003e\u003ch2\u003eDATA AVAILABILITY STATEMENT\u003c/h2\u003e \u003cp\u003eThe datasets utilized and/or examined in this study can be obtained from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAkosile CO, Ngwu NP, Okonkwo UP, Onwuakagba IU, Okoye EC (2023) Neighborhood safety, fall indices, physical activity level and social participation restrictions from a population of community-dwelling older adults in Nsukka, Enugu State, Nigeria. 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PLoS ONE 19(6):e0305820. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0305820\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0305820\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Xuzhou Medical University Affiliated Hospital","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"hearing loss, social participation, falls risk, older adults, ICOPE","lastPublishedDoi":"10.21203/rs.3.rs-8393372/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8393372/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis cross-sectional study investigated the mediating role of falls risk between hearing loss and social participation decline among 468 older adults from Lianyungang, China. The association between hearing and social participation decline was analyzed via binary logistic regression, and mediating effects were assessed via mediation models. Hearing loss was significantly associated with reduced social participation (adjusted OR\u0026thinsp;=\u0026thinsp;1.38; p\u0026thinsp;=\u0026thinsp;0.026). Mediation analyses revealed that hearing loss had a significant direct effect on reduced social participation (β\u0026thinsp;=\u0026thinsp;0.10, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and that falls risk partially mediated the indirect effect of hearing loss on social participation decline (β\u0026thinsp;=\u0026thinsp;0.05, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The total effect of hearing loss on social participation decline was significant (β\u0026thinsp;=\u0026thinsp;0.15; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the mediating effect of falls risk accounted for 38.90% of the variance in the total effect. This study found that hearing loss is associated with reduced social participation, and this association may be partially explained by falls risk.\u003c/p\u003e","manuscriptTitle":"Hearing Loss Is Associated With Reduced Social Participation for Older Adults in Communities and Nursing Homes in China: The Mediating Role of Falls Risk","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2026-01-20 20:02:11","doi":"10.21203/rs.3.rs-8393372/v2","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2025-12-19 07:37:12","doi":"10.21203/rs.3.rs-8393372/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0f314c5e-406e-4c1c-82c3-2f104850e47a","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61228762,"name":"Geriatrics \u0026 Gerontology"}],"tags":[],"updatedAt":"2025-12-19T07:37:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-20 20:02:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v2","identity":"rs-8393372","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8393372","identity":"rs-8393372","version":["v2"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}