Barriers to Health Care for the Deaf
Health care is important to everyone and every one should have equal
access to quality health care. More than 20 million people in the
United States have a hearing loss (Harmer, 1999). Approximately 10%
of Americans have some level of hearing loss and this number is
expected to increase as Baby Boomers age (Scheier, 2009). The number
of people with hearing loss is also expected to increase due to
noise exposure and with an increase in the number of premature
babies surviving (Msall, 2008). There are several barriers to
quality health care for the Deaf, but there are also things that can
be done to help the problem.
A primary reason that the Deaf have difficulty accessing health care
is communication. American Sign Language (ASL) is the primary
language of the Deaf. Few health care providers are fluent in ASL.
The Americans with Disabilities Act (ADA) of 1990 mandates
communication services for the Deaf or hard of hearing when they
receive health care (Scheier, 2009). However, many people choose not
to use interpreters because of privacy concerns (Glickman, 2003).
Deaf communities can be very close knit and it is likely that a Deaf
patient knows or will eventually know the interpreter outside of the
medical appointment. Another problem that can lead to dangerous
miscommunications during medical appointments is that some
interpreters are not knowledgeable in medical terminology (Scheier,
Choosing to understand a health care provider through lip reading
instead of an interpreter can be very difficult. The best lip reader
can see only about 30% of English on the speaker's lips (Lieu,
2007). Many sounds look the same. For example, a 'P' and a 'B' look
identical on the lips. A mustache or accent complicates lip reading.
Other factors, also add to the difficulty the Deaf experience when
communicating through lip reading, including multiple speakers,
improper lighting, speakers placing their hands near their mouth or
not directly facing the Deaf listener. (Scheier, 2009).
Literacy is another factor adversely affecting health care for the
Deaf. Since English is a second language for many Deaf individuals
and since they are not able to hear the language, reading can be
difficult. A study of the literacy level of 17 -18 year old Deaf
students found that their median reading level corresponded to a
fourth grade reading level for hearing students (Gallaudet Research
Institute, 1996). Many Deaf individuals have limited access to
health related information since it is provided through written or
sound communication, such as the television, radio, computers,
newspapers and health professionals (Jones, 2007).
Communication difficulties between Deaf patients and healthcare
providers can lead to misunderstandings. An English phrase can seem
similar to a phrase in ASL but have the opposite meaning. For
example, if a doctor says or writes to a signer without proficient
English skills that one may need surgery, the Deaf person may think
that he or she needs surgery in the month of May (Meador, 2005).
Misunderstandings about the expression of pain are also possible
because many healthcare providers know little to nothing about the
major role that facial expressions play in Deaf communication. There
are over 250 facial expressions in ASL that express different
emotions (Allen, 2002). Facial expressions are important because
they are used to demonstrate where or how much pain is occurring. It
is also crucial for healthcare providers to be cautious when using
facial expressions to minimize miscommunication (Scheier, 2009).
Characteristics of Deaf culture can also lead to difficulties in the
delivery of healthcare. Interpersonal interactions between hearing
healthcare providers and Deaf patients may be awkward if the
healthcare provider does not understand the rules and behaviors of
Deaf culture. For example, the provider may be perceived as impolite
if they do not maintain eye contact when speaking to a Deaf person.
They may be considered rude if they exclude a Deaf person from a
conversation or fail to convey information that a hearing person
would have, such as a knock on the door. It may not be understood
that many Deaf people have a special bond with each other that in
many cases is stronger than that with their hearing family members.
Many healthcare providers also do not understand that many Deaf
people are proud to be Deaf and do not wish to be able to hear.
Historically, Deaf people had been viewed negatively and were
thought to be inadequate and inferior to hearing persons (Scheier,
2009). This can increase the likelihood that a patient does not ask
that information be clarified so that they do not appear stupid.
Deaf communities are relatively small and they are geographically
diverse, which makes health education through in-person
interventions logistically impracticable (Jones, 2010).
Technology can be used to help improve healthcare for Deaf and hard
of hearing people. Telemedicine can increase the opportunities for
healthcare. Patients can have increased access to an interpreter and
a physician through the use of webcams. Patients in waiting or
emergency rooms should be given pagers or vibrators so that they
know when it is their turn. Text telephones (TTY) allow Deaf or hard
of hearing people to participate in phone conversation because TTY
allows messages to be typed back and forth instead of talking and
listening (Scheier, 2009).
A Deaf-friendly Stop-smoking (Df-SS) website is an example of
technology being used to improve health education for the Deaf. This
website provided smoking cessation information in ASL, used webcams
to create real-time video chat rooms for support groups that
communicated in sign language and included an ask the expert feature
to answer questions. Deaf people were included as experts and
moderators. A program like this overcomes language and literacy
barriers by providing information in ASL. Geographic barriers are
overcome because it is an online program. Cultural issues are
addressed by including Deaf instructors (Jones, 2010).
The Deaf Heart Health Intervention (DHHI) is an example of a program
that does not use technology but is specifically designed to provide
health information to the Deaf. Classes were highly interactive and
were taught entirely in sign language by a trained Deaf lay
heart-health teacher. A study of the program showed that the DHHI
was effective in increasing Deaf adults self-efficacy (confidence)
to engage in health behaviors to improve their risk factors for
heart disease (Jones, 2007).
The primary barrier to providing healthcare to the Deaf is
communication. There are few health care providers fluent in sign
language. The use of sign interpreters is costly and takes away from
the privacy of the patient. Sign interpreters, especially ones
knowledgeable in medical terminology, are not always available.
Since English is a second language to many ASL users, written
communication between healthcare providers and Deaf patients or as a
means of health education is also limited in its effectiveness. Deaf
communities tend to be small and geographically diverse, creating
another barrier to healthcare delivery. Technology can be used to
overcome some of these barriers, such as the use of telemedicine or
online health education programs, such as the Deaf-friendly
Stop-smoking web site intervention program. The Deaf Heart Health
Intervention is an example of a program that effectively provided
health education to Deaf people because it was specifically designed
for Deaf people. It is possible to overcome barriers and provide
quality healthcare to the Deaf.
Gallaudet Research Institute. (1996) Stanford Achievement Test, 9th
Edition, Form S, Norms booklet for Deaf and hard-of-hearing
students. Washington DC: Gallaudet University.
Glickman, N. (2003).
Mental healthcare of Deaf people.
Mahwah, New Jersey: Lawrence Erlbaum.
Harmer, L (1999). Health care delivery and Deaf people: Practice,
problems and recommendations for change. Journal of Deaf Studies and
Deaf Education, 4(2), 73.
Jones, E. (2007). Self-efficacy for health-related behaviors among
Research in Nursing & Health,
Jones, E. (2010). Creating and testing a Deaf-friedly, stop-smoking
web site intervention.
American Annals of the Deaf,
Lieu, C (2007). Communication strategies for nurses interacting with
Deaf patients. MedSurg Nursing, 16(4), 239-244.
Meador, H. (2005) Healthcare interactions with Deaf culture. Journal
of the American Board of Family Practice, 18(3), 218-222.
Msall, M. (2008). The spectrum of behavioral outcomes after extreme
prematurity: Regulatory, attention, social and adaptive dimensions.
Seminars in Perinatology, 32(4), 42-50.
Scheier, D. (2009). Barriers to health care for people with hearing
loss: A review of the literature.
Journal of the New York State Nurses Association,
Editor's note: The term "Deaf" has been
capitalized by the editor of this paper (me) as per the emerging
style preference of many leaders in the Deaf Community. I
recognize this is not the norm for many typical publications. On the
other hand, social change has to start somewhere.
- Bill (William G. Vicars, EdD)
You can learn American Sign Language (ASL) online at American Sign Language University ™
ASL resources by Lifeprint.com © Dr. William Vicars