Barriers to health care for people with hearing loss: a review of the literature.
Abstract: Deaf individuals face many barriers when trying to access health care. The reasons why barriers are encountered, difficulties met as a result of the barriers, and ways that health professionals and others working with deaf people can overcome obstacles are included in this review of the literature. A brief summary of Deaf culture and history gives background information to better understand the problems. Misunderstandings by d/Deaf patients and hearing health professionals are addressed, as well as issues related to medical interpreters. This paper aims to make health professionals more aware of the needs and cultural differences that must be considered when providing care to the d/Deaf population.
Subject: Hearing loss (Diagnosis)
Hearing loss (Care and treatment)
Patients (Care and treatment)
Patients (Methods)
Patients (Management)
Physician and patient (Management)
Author: Scheier, Donna B.
Pub Date: 03/22/2009
Publication: Name: Journal of the New York State Nurses Association Publisher: New York State Nurses Association Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 New York State Nurses Association ISSN: 0028-7644
Issue: Date: Spring-Summer, 2009 Source Volume: 40 Source Issue: 1
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 213690021
Full Text: Hearing loss can present difficulties in healthcare delivery in the United States. Those who are prelingually deaf often use American Sign Language (ASL) as their main mode of communication, which can constitute a barrier to being involved and knowledgeable about one's health care. The term prelingually deaf is used to describe people who lose their hearing before they have acquired language (Gilchrist, 2000). Postlingually deaf refers to later-deafened people who have language prior to hearing loss (Bat-Chava, Martin, & Kosciw, 2005). Many healthcare providers are unaware of ways to improve communication with deaf patients in order to provide them with a level of care equal to that of hearing people.

More than 20 million people in the United States have hearing loss (Harmer, 1999; O'Hearn, 2006; Sadler et al., 2001). Barriers that people with hearing loss encounter and their dissatisfaction with the healthcare delivery system have generated recent studies and meta-analyses that address these problems. This paper provides a review of the literature that outlines what the problems are, determines why they exist, and identifies ways to begin solving them.

Overview

It has been noted that people with hearing loss find the entire healthcare system difficult to navigate; in addition, recent research trends illuminate the increased need for mental health services specifically tailored to the deaf population (Glickman & Gulati, 2003). Communication is paramount for the delivery of these services. Lack of background health information and the dearth of English language proficiency among the deaf impede good care.

The population of people with hearing loss is quite heterogeneous. Approximately 10% of Americans have some level of hearing loss and this number is expected to increase as Baby Boomers age. It is estimated that 50% of those age 80 and above have hearing loss. Whether an individual is prelingually or postlingually deaf, the exact age and level of hearing loss may affect how one navigates the world. It is inappropriate to categorize all people with hearing loss together (Tamasker et al., 2000).

Economic issues also present barriers to delivering optimal health care to deaf people; it costs more to spend the time to treat and teach such patients and to hire qualified interpreters. Healthcare workers need to find ways to work with this population to ensure the best care possible.

Methods

Research databases used for this literature review included: CINAHL, ProQuest Nursing Journals, Sociological Abstracts with Full Text, and Medline. The National Technological Institute for the Deaf (NTID) Wallace Library provided access to other deaf publications; NTID is part of the Rochester Institute of Technology in New York. St. John Fisher College's Lavery Library, also in Rochester, permitted the loan of excellent books on historical information, Deaf culture, and the healthcare needs of deaf people. Articles were read and reviewed for relevance to the subject; the majority were descriptive studies. The search was narrowed to articles and books that deal with problems deaf people have accessing health care and maintaining health.

A brief history of hearing loss

Historically, deaf people have been viewed as inadequate and inferior to hearing people. This negative prejudice has been evident since antiquity. Deaf people have been patronized, socially distanced, and discriminated against in a variety of ways (Lane, 1984). The deaf have been characterized by hearing healthcare professionals as aggressive, immature, impulsive, lazy, stubborn, suspicious, and unintelligent (Meador & Zazove, 2005; Parise, 1999).

The New Testament presents deafness as caused by evil spirits and in need of cure (Mark 17:25, The Holy Bible in Four Translations, 1972). Physicians in the past have unsuccessfully poured various potions into peoples' ears and produced loud noises to help them regain their hearing. Aristotle held the belief that thought was contingent on speech. Deaf people were thought to be unable to think because they could not hear or speak. Deaf and dumb or deaf-mute are derogatory terms that have their derivation in Aristotle's time (Van Cleve & Crouch, 1995)

In the 1870s Alexander Graham Bell promoted oralism, using speech for communication, in deaf education. Previously, deaf children used sign language and had deaf teachers (Gannon, 1981). Oral language learning can work for some deaf children, however, it can be unsuccessful and frustrating for the majority, denying them access to a full natural language. In residential institute schools, children were forbidden to use manual (sign) language but did so surreptitiously. Gannon (1981) and Lane (1984) strongly believe that oralism was detrimental to deaf education in this country and that deaf people have been suffering the effects of inadequate education since that time.

Understanding deaf culture

Although much has been written attempting to understand and improve the hardships that having a hearing loss entails, society continues to marginalize deaf people. Deaf people are treated as if their hearing loss is a pathology that needs to be cured. Many Deaf people lead rich and full lives and do not feel a need to be cured. Similarly, many Deaf people are proud to be deaf and part of a Deaf culture (Padden & Humphries, 1988).

Deaf culture has its own set of rules and behaviors that hearing people may not understand. For example, it is impolite not to maintain eye contact when speaking to a Deaf person. Also, rules concerning physical contact, touching, and pointing are different in Deaf culture. Deaf people view it as rude if they are excluded from a conversation. They want the same information that a hearing person would have. Environmental sounds that evoke a response, like a knock on the door, should be conveyed to a Deaf person. Abrupt changes in conversation topics and long goodbyes are commonplace in Deaf culture (Meador & Zazove, 2005).

Deaf people have a special bond with each other that in many cases is stronger than that with their hearing family members. In the past, most deaf students went to residential institute schools, where they lived with deaf peers and were easily understood. They developed a network of relationships that would last a lifetime (Allen, Meyers, Sullivan, & Sullivan, 2002).

Today, most deaf students are mainstreamed in classrooms with hearing children. It is estimated that more than 50,000 students who cannot hear speech, even with hearing aids, are enrolled in mainstream schools. Most school psychologists do not know sign language and students are being evaluated without sign language knowledge, resulting in inaccurate test scores (Vernon & Leigh, 2007).

Lieu and colleagues (2007) noted that "healthcare providers face particular challenges to become culturally and linguistically competent practitioners" (p. 239) and yet, in the first few lines of the article, the authors refer to "hearing impairment" (p. 239), a negative term for deafness. Jones, Renger, and Firestone (2005) refer to the Deaf community as "more than 2 million Americans who were significantly hearing impaired ..." (p. 27). Deaf people are a community and see themselves not as hearing impaired, but as strongly Deaf. In addition, many Deaf people desire Deaf children. They are proud to be Deaf and have no wish to be able to hear or to be cured of their "affliction." This belief fuels the controversy of cochlear implant surgery for Deaf children (Padden & Humphries, 1988).

Misunderstandings

It is difficult to ascertain who is deaf and who is hard of hearing. The difference between audiologically deaf and hard of hearing is nebulous; it is not always clearly evident. Deaf people usually are those with a greater hearing loss or those who identify with Deaf culture. Hearing loss is measured in a variety of frequencies. More than a 90-decibel hearing loss is referred to as profoundly deaf. Anyone with any degree of hearing loss can use the term hard of hearing (Gilchrist, 2000).

The incidence of hearing loss is increasing. Many more premature babies are being born, and they can have complications that may lead to deafness (Msall & Park, 2008). Also, many Baby Boomers are losing their hearing because of exposure to loud noises (Daniel, 2007). High volumes over a prolonged period of time can lead to permanent hearing damage. It is estimated that the majority of hearing loss is attributed to excessive noise exposure (Gilchrist, 2000).

Those who are hard of hearing but not deaf may feel like they are in limbo; they do not fit into the signing Deaf world and they do not fit into the hearing world. People who are hard of hearing may feel frustrated that they cannot hear conversations. They also may be afraid of losing the rest of their hearing and becoming deaf. Animosity exists between hard of hearing and Deaf people (Harvey, 2003).

American Sign Language

American Sign Language (ASL), the sixth most commonly used language in this country, is not related to English (Singleton & Tittle, 2000). It is called American Sign Language because it is used by those in the northern hemisphere. ASL is a mix of native signs and French sign language. Some words are finger-spelled, borrowed from English the same way that the words gourmet, roulette, and taco are borrowed from French and Spanish (Grayson, 2003). ASL does not have a written form; however, deaf people must learn written English, which is quite a challenging feat (Allen et al., 2002).

Learning English for those who cannot hear is not easy. Acquiring a spoken language without the ability to hear requires intense study; the difficulty is mind-boggling. English presents such a challenge for deaf people that the average deaf high school graduate reads at a fourth grade level (Bat-Chava et al., 2005). Steinberg, Wiggins, and Barmada (2002) state that even well-educated deaf people may have difficulty understanding written English. Not understanding written healthcare information or directions for care can negatively affect outcomes (Allen, 2002).

Those who are native signers, that is, who learned sign language before a spoken language, are attuned to the subtleties of facial expression, as well as hand shape, movement, and location that convey meaning in ASL (Boudreault & Mayberry, 2006). Allen (2002) writes about a deaf end-of-life patient whose interpreter missed a vague sign for using the bathroom. If a deaf volunteer had not witnessed the encounter, the patient might have soiled himself and considered incontinent.

Lieu and colleagues (2007) wrote, "signing is not a word-for-word translation of the spoken or written words; rather it is a series of pictures that convey meaning" (p. 242). On the contrary, others feel that ASL is a rich and complicated language. Taken together, hand shape, palm direction, placement of the hand on the body or within the signing space, movement, and non-manuals (facial expressions) make up sign language. Sign order has rules and a strict grammar is followed, and the space that a person uses to sign has meaning (Padden & Humphries, 1988). A signing person may be able to tell where another signer is from by the way that he or she signs (Gilchrist, 2000).

Potential for miscommunication

ASL word order is not the same as English word order. A phrase written in English may have the exact opposite meaning to someone who uses ASL. If a hearing doctor says or writes that one may need surgery to a person who uses sign language and does not have proficient English skills, the person might think that he or she needs surgery in the month of May (Meador & Zazove, 2005).

Misunderstandings can occur in both the provider and patient. The provider may think that his or her intention was understood when it was not. The patient may think that he or she understood the meaning when he or she did not. This can lead to medication errors, missed appointments, and misunderstood diagnoses. Meador and Zazove (2005) report a deaf mother pouring oral antibiotic into her daughter's ear canal to cure an ear infection. Patients do not want to appear unintelligent and will nod "yes" in spite of not understanding. Open-ended questions that cannot be answered with a yes or no should be used to check for understanding (Wood, 2002).

The importance of facial expression

Sign language has multiple parameters beyond hand signs that are used to convey added meaning. A person can indicate the amount of pain they are experiencing through facial expression and movement. There are more than 250 facial expressions that give meaning. In addition, the location of pain is usually signed in the area of the body where the pain is occurring. Although ASL is very different from English, any idea or concept can be explained in ASL (Allen et al., 2002).

Healthcare providers should be especially careful about their own facial expressions. Grimacing when reading a chart can upset a deaf person. Deaf people are more attuned to facial expression than hearing people would be (Gilchrist, 2000).

Tasks that we take for granted may need extra explanation for a deaf person (Allen et al., 2002). A Deaf person may not know how to use a horizontal pictorial scale to rate pain level because they may be unfamiliar with values that increase from left to right, as readers of English routinely do.

The issue of interpreters

The Americans with Disabilities Act (ADA) of 1990 mandates language accommodations for people who are deaf or hard of hearing when they receive health care. Patients should be asked what means of communication they prefer. Some deaf people do not want to use interpreters because of privacy issues or are concerned that an interpreter will judge them (Glickman & Gulati, 2003; Wood, 2002).

Family members may volunteer to interpret, but this does not allow patients to speak frankly with healthcare providers and violates confidentiality laws. A patient might have a difficult time asking for an HIV test if his or her mother is interpreting. Family members may accidentally or intentionally misinterpret communication, be unfamiliar with medical terminology, or may not be fluent in sign language (Glickman & Gulati, 2003; Lieu et al., 2007; Wood, 2002).

Lip-reading needs

Some people prefer interpreters, while others are more oral and prefer lip reading. The best lip reader, however, can only see about 30-45% of English on the speaker's lips (Lieu et al., 2007). Many sounds look the same, for example a "B" and a "P" are identical on the lips. Context and accompanying gestures complete the information. It is easier to lip-read when one is familiar with the subject and the speaker (Iezzoni, O'Day, Killeen, & Harker, 2004).

A moustache or accent can make lip reading very difficult; surgical masks make lip reading impossible. Proper lighting and face-to-face communication is important and respectful to the deaf person. Providers should always face the person they are speaking to and avoid placing their hands near their mouth when speaking, leaving the lips unobstructed. It is important to get the person's attention before one speaks (Hochman, 2000; Wood, 2002).

Lip-reading takes vast amounts of concentration and leaves the hard-of-hearing person physically and mentally exhausted. Conversations in which multiple people are talking at the same time or where the listener is not able to see who is speaking are difficult for those with hearing loss. Background noise can also make speaking difficult to understand (Harvey, 2003).

Special considerations

The adage "one picture is worth a thousand words" holds true for deaf people. Deaf people learn by seeing and doing. Pictorial aids and models can help a patient understand what is happening to his or her body. Showing a person how to use equipment or medication rather that explaining its use yields better results (Steinberg et al., 2005).

Language deprivation has profound effects. Glickman and Gulati (2003) hypothesized that lack of language sophistication contributes to cognitive delays that can never be recovered. According to Harmer (1999), linguistic deprivation "can lead to a preventable form of mental retardation" (p. 88). Arehart and Yoshinaga-Itano (1999) believe that early intervention services for deaf children prevent further developmental delays, but that these services may not negate an existing delay.

Many deaf people lack world knowledge because of linguistic inaccessibity and cognitive deficits caused by missing language during the critical language-learning period (estimated to be somewhere between 5 and 9 years of age). Fluent signers can recognize at what age another signer had learned sign language by his or her fluency and skill level (Glickman & Gulati, 2003).

Deaf people may invent reasons why something occurs to fill in the gaps and make sense of the world. Health-related vocabulary with which an English speaker would be familiar, for example, bowel, hemoglobin, glaucoma, nausea, allergic, or penicillin, might not have meaning for one whose first language was ASL. One should not assume that a patient understands medical terms. The provider should check for understanding, especially when giving information critical to care. Asking a patient to repeat medication directions might avoid errors. Some people with hearing loss feel stigmatized and pretend that they are hearing, further adding to the possibility of miscommunication, errors, and poor care (Bat-Chava, Martin, & Kosciw, 2005; Meador & Zazove, 2005; Tamaskar, 2000).

Reeves and Kokoruwe (2005) report that deaf patients experience heightened anxiety when they visit a doctor. Fear of receiving the wrong medication or not being understood could cause a patient to be anxious. A qualitative study by Steinberg and colleagues (2005) noted that fear was a major emotion for deaf people visiting a physician; they were afraid of not being understood.

Effects on communication

The consequences of healthcare communication inadequacies can be dire. Patients in the United Kingdom reported that they did not understand their diagnosis or medication directions, took a wrong dose, or woke from surgery to unexpectedly find a leg amputated (Reeves & Kokoruwe, 2005). Perhaps because of these negative experiences, the Deaf community is distrustful of the healthcare system (Steinberg, 2002).

The difficulty and frustration associated with communication in a hearing world contributes to proportionately higher rates of mental illness in the deaf population (Harmer, 1999). The inability to communicate with one's peers and family can lead to feelings of inadequacy and low self-esteem. Deaf people report that attending family events where more than one person speaks at a time creates stress and is socially isolating (Glickman & Gulati, 2003).

Deaf people find it difficult to converse with family members who might not be sensitive to their communication needs. Even if hearing parents attempt to learn sign language, they do not learn at the same rate as a young person acquiring language, making sophisticated conversations impossible (Snodden, 2008).

Lack of communication between deaf children and hearing parents can result in gaps of knowledge. Harmer (1999) gives the example of a hearing parent signing to a deaf child to brush his or her teeth. A hearing parent with a hearing child might say, "brush your teeth so you don't get cavities" (Harmer, 1999, p. 84). A hearing parent with a deaf child might only say, "brush your teeth" (Harmer, 1999, p. 84). The inability to use language fully results in inadequate health information conveyed to the child. Also, lack of incidental knowledge (such as what hearing people absorb from listening to conversations, the radio, and other sources) leaves a deaf person at a disadvantage (Harmer, 1999). It is interesting to note that Deaf children of Deaf parents who use sign language score higher on standardized tests than their deaf peers with hearing parents (Singleton & Tittle, 2000).

Glickman and Gulati (2003) mention that few parents become fluent in ASL due to the difficulty involved in learning and the fear that they will lose their child to Deaf culture, alienating him or her from the family. Family communication is sometimes strained because the majority of deaf people have hearing parents who are not fluent signers. Allen and colleagues (2002) estimate that 95% of deaf children have hearing parents, while Glickman and Gulati (2003) place the estimate at 90%. At any rate, most deaf children have hearing parents.

Not only families have difficulty in learning ASL; most healthcare providers do not know any sign language. Sadler (2001) states that it is impractical for physicians to learn sign language, since the average physician will have few deaf patients, if any. Learning just a few signs, however, shows the deaf patient that an attempt is being made to communicate. One of the largest barriers to health care for deaf people is a patronizing attitude (Lieu et al., 2007). Respect for and empowerment of the deaf person were important to the focus groups studied. Respect can be demonstrated by learning a few basic signs. This attempt at finding a way to communicate may also decrease patient anxiety (McAleer, 2006; O'Hearn, 2006).

Mental health services need to meet the communication and cultural needs of people with hearing loss. Glickman and Gulati (2003) recommended a culturally affirmative approach to mental health care for deaf people. They advocated not only accessibility and reasonable accommodation, which is mandated by the 1990 ADA, but a higher level of affirmative care that supports Deaf culture and is sensitive to Deaf needs. One example of the way mental health staff can accomplish this is to avoid the use of idioms that have no exact translation in ASL. Another affirmative action for mental health facilities that serve any Deaf patients is to hire a sufficient number of deaf staff members so the majority of staff are deaf and proficient in ASL. Hiring and training hearing staff with a cursory knowledge of ASL yields less than optimal care, especially in the mental health field where communication is paramount (Glickman & Gulati, 2003).

Mental health services for the deaf rarely have designated units with staff members who are sensitive to Deaf needs and know sign language. The vast majority of states do not provide services that are mandated by law. Gradually, more interpreters are being hired, but only for short time periods during emergency situations (Glickman & Gulati, 2003). Deaf people in most states receive substandard mental health care, worse than any other disability group (Vernon & Leigh, 2007). Sadler and colleagues (2001) stated that physicians often do not hire interpreters, and hospital staff members do not know how to arrange interpreting services or how to ensure that an interpreter is qualified.

DeVinney and Murphy (2002) detailed the experiences of a postlingually deaf woman who was admitted to a hospital for depression. Because she had clear, intelligible speech, the staff presumed she could hear, despite the patient telling them many times that she could not. Her anger was attributed to her illness rather than to the denial of her request for an interpreter and reasonable accommodations. The case ultimately went to court, indicating needed changes in the delivery of services (DeVinney & Murphy, 2002).

The problem seems global. In Brazil, deaf patients have the same communication issues and complain of healthcare providers' illegible handwriting, hurried manner, and lack of knowledge of Portuguese Sign Language (Cardoso, Rodrigues, & Bachion, 2006). Thomas and colleagues (2006) noted that similar barriers in mental health care exist in the United Kingdom.

Deafness and STis

The deaf and hard-of-hearing population is believed to have a higher rate of HIV infection than hearing people (Bat-Chava et al., 2005). The incidence of STIs (sexually transmitted infections) and alcohol and substance abuse are also proportionately higher (Harmer, 1999). Bat-Chava and colleagues (2005) wrote that the largest barrier to AIDS prevention is communication. Deaf people are less likely to know what causes HIV infection and how to prevent it and are less likely to access care once they become ill. Many deaf people were never taught about human sexuality and therefore cannot understand how HIV is transmitted. Literacy levels impinge on health knowledge; educational materials written at an 8th grade level may be too advanced for many deaf people (Bat-Chava et al., 2005).

One study, based in New York State, evaluated knowledge levels of HIV and AIDS transmission routes and symptoms and found that deaf people who used sign language had the most misinformation. The population in Rochester was found to be the most informed of any demographic group, surpassing New York City and Albany. The authors believed that the National Technical Institute for the Deaf (NTID) and Rochester's large deaf population played a role in relaying accurate information (Bat-Chava et al., 2005).

The problem of deaf access to information is worse in developing countries. The Swaziland kingdom in southern Africa reportedly has the one of the largest HIV infection rates; it is estimated that 38.1% of the population is infected. Deaf individuals in Swaziland have limited access to educational materials and rely on their deaf peers for health information. This "deaf grapevine" (Groce, Yousafzai, Dlamini, Zalud, & Wirz, 2006, p. 319) reinforces misinformation. Polygamy and low literacy rates among deaf people amplify the problem (Groce et al., 2006).

Legal obligations

Many healthcare providers, including physicians, do not know that they are obligated by law to provide an interpreter (Gilchrist, 2000). When using an interpreter, it is the responsibility of the healthcare provider to pay the cost of hiring an interpreter as described in the ADA. Such healthcare providers include physicians, nurse practitioners, and advanced practice nurses (Gilchrist, 2000). Federal Medicaid and SCHIP funding for sign language interpreters is available in some states (Youdelman, 2007). An interpreter should be certified with the National Registry of Interpreters and be knowledgeable in medical terminology. An interpreter agency may require a 2-hour minimum, forcing the provider to pay more than he or she can bill. If a deaf person needs to see a physician for a 5-minute visit, the physician might need to pay for 2 hours of interpreting (Sadler, 2001).

Steinberg, Sullivan, and Loew (1998) cautioned that an interpreter does not guarantee adequate communication. A provider may not know to talk directly to the patient and may instead address the interpreter. Languages cannot be translated exactly; at times things get lost in translation. DeBruin and Brugmans (2006) noted that Dutch interpreters for the deaf were not able to maintain neutrality and impartiality. Patients worry about confidentiality and privacy, especially when there is the likelihood that they will see the interpreter in other settings (DeBruin & Brugmans, 2006).

Suggestions for change

New technology that was not available years ago may help improve health care access for deaf people. One promising technological advance is telemedicine, where a patient can access an interpreter and physician by webcam, providing deaf-friendly health care in areas far from most facilities (Thomas, Cromwell, & Miller, 2006).

Pagers or vibrating devices given to patients in emergency room or doctor's office waiting areas can inform them when it is their turn (Lieu et al., 2007). If possible, intravenous lines should not be inserted into hands so the deaf person can continue to sign (McAleer, 2006). Modifications such as access to a TTY communication device, a qualified interpreter, and increased privacy should be offered to deaf patients (DeVinney & Murphy, 2002).

The question remains, however, of how to deliver health care of equal quality for both deaf and hearing patients. Learning a few signs and following the suggestions in this paper will not alleviate all barriers, but they are steps in the right direction. More research needs to be conducted to find ways to educate those who are prelingually deaf and give them access to better health education. Methods of educating healthcare providers in the needs and legal rights of deaf patients should be explored. Empowering those with hearing loss and teaching self-advocacy skills was not stressed in the literature. Also, many of the articles were several years old; perhaps there are newer tools for improving health care for deaf and hard of hearing people. Finally, future research should explore practitioners' feelings and possible buried prejudices toward those with hearing loss.

Conclusion

It is difficult to tell who can hear and who cannot; hearing loss is invisible. The articles in this review of the literature concurred that communication is the major barrier to health care for individuals with hearing loss. Although the ADA mandates interpreters for those who need them, healthcare providers do not use them consistently. Interpreters may not be certified and knowledgeable about medical issues. Other barriers include healthcare workers' lack of sensitivity toward people with hearing loss because of preconceived notions and marginalization of the deaf. Healthcare professionals are often not cognizant of Deaf culture and values and therefore do not understand Deaf behaviors.

Healthcare workers may discount or be unaware of the extreme impact of hearing loss on the ability to communicate, learn, and care for oneself. The pervasiveness of the effects of deafness should not be underestimated. Healthcare professionals should educate themselves about ways to reduce barriers and to ensure access to health care for all people.

Note: Throughout this literature review, the word deaf is written with either an uppercase or lower-case "D." When referring to the audiological condition of deafened people, deaf is written with a lower-case "d." An uppercase "D" is used when writing about the Deaf culture, a group with which many prelingually deaf people affiliate themselves. Culturally Deaf people have their own language, specific customs, and ways of behaving (Padden & Humphries, 1988).

REFERENCES

Americans with Disabilities Act of 1990, Pub. L. No. 101-336, [section]2, 104 Stat. 328 (1991).

Allen, B., Meyers, N., Sullivan, J., & Sullivan, M. (2002). American Sign Language and end-of-life research in the deaf population. HEC Forum, 14(3), 197-208.

Arehart, K. H. & Yoshinaga-Itano, C. (1999). The role of educators of the deaf in the early identification of hearing loss. American Annals of the Deaf, 144, 19-23.

Bat-Chava, Y., Martin, D., Kosciw, J. G. (2005). Barriers to HIV/AIDS knowledge and prevention among deaf and hard of hearing people. AIDS Care, 17(5), 623-634.

Boudreault, P., & Mayberry, R. (2006, August). Grammatical processing in American Sign Language: Age of first-language acquisition effects in relation to syntactic structure. Language and Cognitive Processes, 21(5), 1.

Cardoso, A. H. A., Rodrigues, K. G., & Bachion, M. M. (2006). Perceptions of persons with severe or profound deafness about the communication process during health care. Revista Latino-Americana de Enfermagem, 14(4), 553-560.

Daniel, E. (2007, May). Noise and hearing loss: A review. Journal of School Health, 77(5), 225-231.

DeBruin, E., & Brugmans, P. (2006). The psychotherapist and the sign language interpreter. Journal of Deaf Studies and Deaf Education, 11(3), 360-368.

DeVinney, J., & Murphy, S. (2002). Mental health experiences and deafness: Personal and legal perspectives. Psychiatric Rehabilitation, 25(3), 304-309.

Gannon, J. R. (1981). Deaf heritage: A narrative history of deaf America. Silver Spring, MD: National Association of the Deaf.

Gilchrist, K. L. (2000). Through the looking glass: The lived experience of deaf people communicating with nurses, the meaning of health, and attitudes toward nurses. (Doctoral dissertation, University of Colorado, 2000). Dissertation Abstracts International, 61(07B), 3507.

Glickman, N. S., & Gulati, S. (2003). Mental healthcare of deaf people. Mahwah, NJ: Lawrence Erlbaum.

Grayson, G. (2003). Talking with your hands, listening with your eyes: A complete photographic guide to American Sign Language. Garden City, NY: Square One Publishers.

Groce, N., Yousafzai, A., Dlamini, P., Zalud, S., & Wirz, S. (2006). HIV/AIDS and disability: A pilot study of HIV/AIDS knowledge among a deaf population in Swaziland. International Journal of Rehabilitation, 29, 319-324.

Harmer, L. M. (1999). Healthcare delivery and deaf people: Practice, problems and recommendations for change. Journal of Deaf Studies and Deaf Education, 4(2), 73.

Harvey, M. A. (2003). Psychotherapy with deaf and hard of hearing persons: A systemic model. Mahwah, NJ: Lawrence Erlbaum.

Hochman, F. (2000). Healthcare of the deaf--toward a new understanding. Journal of the American Board of Family Practice, 13(1), 81-83.

Iezzoni, L. I., O'Day, B. L., Killeen, M., & Harker, H. (2004). Communicating about healthcare: Observations from persons who are deaf or hard of hearing. Annals of Internal Medicine, 140(5), 356-362.

Jones, E. G., Renger, R., & Firestone, R. (2005). Deaf community analysis for health education priorities. Public Health Nursing, 22(1), 27-35.

Lane, H. (1984). When the mind hears. New York, NY: Random House.

Lieu, C., Sadler, G., Futterton, J., & Stohlman, P. (2007). Communication strategies for nurses interacting with deaf patients. MedSurg Nursing, 16(4), 239-244.

Mallinson, R. K. (2004). Perceptions of HIV/AIDS by deaf gay men. Journal of the Association of Nurses in AIDS Care, 15(4), 27-36.

McAleer, M. (2006). Communicating effectively with deaf patients. Nursing Standard, 20(19), 51-54.

Meador, H., E., & Zazove, P. (2005). Healthcare interactions with deaf culture. Journal of the American Board of Family Practice, 18(3), 218-222.

Msall, M., & Park, J. (2008). The spectrum of behavioral outcomes after extreme prematurity: Regulatory, attention, social, and adaptive dimensions. Seminars in Perinatology, 32(1), 42-50.

O'Hearn, A. (2006). Deaf women's experiences and satisfaction with prenatal care: A comparative study. Family Medicine, 38(10), 712-716.

Padden, C., & Humphries, T. (1988). Deaf in America: Voices from a culture. Cambridge, MA: Harvard University Press.

Parise, N. (1999). Breaking cultural barriers to healthcare: The voice of the deaf. Unpublished master's thesis, McGill University School of Nursing, Montreal, Quebec, Canada.

Reeves, D., & Kokoruwe, B. (2005). Communication and communication support in primary care: A survey of deaf patients. Audiological Medicine, 3(2), 95-107.

Sadler, G. R., Huang, J. T., Padden, C. A., Elion, L., Galey, T. A., Gunsauls, D. C., & Brauer, B. (2001). Bring healthcare information to the deaf community. Journal of Cancer Education, 16, 105-108.

Singleton, J. L., & Tittle, M. D. (2000). Deaf parents and their hearing children. Journal of Deaf Studies and Deaf Education, 5(3), 221-235.

Snoddon, K. (2008, June). American Sign Language and early intervention. Canadian Modern Language Review, 64(4), 581-604.

Steinberg, A. G., Barnett, S., Meador, H. E., Wiggins, E. A., & Zazove, P. (2005). Health care system accessibility: Experiences and perceptions of deaf people. Journal of General Internal Medicine, 21, 260-266.

Steinberg, A. G., Sullivan, V. J., & Loew, R. C. (1998). Cultural and linguistic barriers to mental health service access: The deaf consumer's perspective. American Journal of Psychiatry, 155(7), 982-984.

Steinberg, A. G., Wiggins, E. A., Barmada, C. H., & Sullivan, V. J. (2002). Deaf women: Experiences and perceptions of healthcare system access. Journal of Women's Health, 2(8), 729-741.

Tamaskar, P., Malia, T., Stern, C., Gorenflo, D., Meador, H., Zazove, P. (2000). Preventive attitudes and beliefs of deaf and hard-of-hearing individuals. Archives of Family Medicine, 9(6), 518-525.

Thomas, C., Cromwell, J., & Miller, H. (2006). Community mental health teams' perspectives on providing care for Deaf people with severe mental illness. Journal of Mental Health, 15(3), 301-2313.

Youdelman, M. (2007, March). Medicaid and SCHIP reimbursement models for language services. Retrieved June 30, 2009, from http://www.fachc.org/pdf/mig_MedicaidSCHIP.2007[1].pdf

Van Cleve, J. V., & Crouch, B. A., (1989). A place of their own: Creating the deaf community in America. Washington, DC: Gallaudet University Press.

Vernon, M., & Leigh, I., (2007). Mental health services for people who are deaf. American Annals of the Deaf, 152(4), 374-381.

Wood, B. (2002). Caring for a limited-English proficient patient. Association of Operating Room Nurses, 75(2), 305-308.

Donna B. Scheier, MS, RN

Donna B. Scheier is a staff nurse at Highland Hospital and an educator of deaf students in the Rochester Central School District, both in Rochester, NY.
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