Iranian Journal of Public Health 2017. 46(11):1465-1474.

Barriers and Facilitators of Health Literacy among D/deaf Individuals: A Review Article



Background: The implication of health literacy is the ability of individuals to find, understand, and use their required health information from reliable sources. It is an indicator of the individuals’ participation in their own medical decision-making. Deaf individuals have limited health literacy and poor health status due to low literacy. Hence, this review was conducted to understand barriers and facilitators influencing health literacy among deaf community.

Methods: We searched the ISI Web of Sciences, Scopus, and Medline from 1987 to 2016. Seventy-three papers were analyzed thematically.

Results: We found three primary themes, including inadequate health literacy, barriers, and facilitators to accessing health information and health care services among deaf individuals. Facilitators were composed of four sub-theme including legal activities protecting the right of deaf patients to accessing health services, training health professionals about effective communication with deaf patients, providing sign language interpreter services, and developing deaf-tailored educational health programs and materials.

Conclusion: Closing the deaf cultural gap and their limited access to health information are achievable through the removal of the communication barriers, allowing deaf individuals with more access to health learning opportunities, and informing the hearing community about the communicative skills of deaf individuals.




Deafness, Health literacy, Barrier, Facilitator

Full Text:



Sørensen K, Pelikan JM, Röthlin F et al (2015). Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). Eur J Public Health, 25:1053-8.

Kindig DA, Panzer AM, Nielsen-Bohlman L (2004). Health Literacy: A Prescription to End Confusion: National Academies Press.

Nouri SS, Rudd RE (2015). Health literacy in the “oral exchange”: An important element of patient–provider communication. Patient Educ Couns, 98:565-71.

Evangelista LS, Rasmusson KD, Laramee AS et al (2010). Health literacy and the patient with heart failure—implications for patient care and research: a consensus statement of the Heart Failure Society of America. J Card Fail, 16:9-16.

Shaw SJ, Huebner C, Armin J et al (2009). The role of culture in health literacy and chronic disease screening and management. J Immigr Minor Health, 11:460-7.

Davis TC, Dolan NC, Ferreira MR et al (2001). The role of inadequate health literacy skills in colorectal cancer screening. Cancer Invest, 19:193-200.

Williams MV, Parker RM, Baker DW et al (1995). Inadequate functional health literacy among patients at two public hospitals. JAMA, 274:1677-82.

Scott TL, Gazmararian JA, Williams MV, Baker DW (2002). Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care, 40:395-404.

Reisi M, Mostafavi F, Hasanzadeh A, Sharifirad G (2011). The Relationship between Health Literacy and General Health Status and Health Behaviors of Elderly People. J Health Syst Res, 7:469-80.(In Persian)

Korth S (2004). Using a root cause analysis process to analyze issues of safety. In Youngberg, B.J. & Hatile, M.J. The patient safety handbook (p. 257). London, Uk: Jones & Bartlett Publishers.

Morgan L (2013). Best Practice Patient Teaching Strategies to Promote Health Literacy When Working with Individuals with Deafness.; Accessed 25.02.16

Mallinson RK (2004). Perceptions of HIV/AIDS by deaf gay men. J Assoc Nurses AIDS Care, 12:27-36.

Oredugba FA (2004). Oral health care knowledge and practices of a group of deaf adolescents in Lagos, Nigeria. J Public Health Dent, 64:118-20.

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

Orsi JM, Margellos-Anast H, Perlman TS et al (2007). Cancer screening knowledge, attitudes, and behaviors among culturally Deaf adults: Implications for informed decision making. Cancer Detect Prev, 31:474-9.

Goldstein MF, Eckhardt EA, Joyner-Creamer P et al (2010). What do deaf high school students know about HIV? AIDS Educ Prev, 22:523-537.

Maddalena V, O'Shea F, Murphy M (2012). Palliative and end-of-life care in Newfoundland's deaf community. J Palliat Care, 28:105-112.

Wei H, Wang YL, Cong XN et al (2012). Survey and analysis of dental caries in students at a deaf-mute high school. Res Dev Disabil, 33:1279-86.

Berman BA, Jo A, Cumberland WG et al (2013). Breast cancer knowledge and practices among D/deaf women. Disabil Health J, 6:303-316.

Napier J, Kidd MR (2013). English literacy as a barrier to health care information for deaf people who use auslan. Aust Fam Physician, 42:896-9.

McKee MM, McKee K, Winters P et al (2014). Higher educational attainment but not higher income is protective for cardiovascular risk in Deaf American Sign Language (ASL) users. Disabil Health J, 7:49-55.

Sheppard K (2014). Deaf adults and health care: Giving voice to their stories. J Am Assoc Nurse Pract, 26:504-510.

McKee MM, Paasche-Orlow MK, Winters PC et al (2015). Assessing Health Literacy in Deaf American Sign Language Users. J Health Commun, 20 Suppl 2:92-100.

McKee MM, Winters PC, Sen A et al (2015). Emergency department utilization among Deaf American Sign Language users. Disabil Health J, 8:573-8.

Smith SR, Kushalnagar P, Hauser PC (2015). Deaf adolescents' learning of cardiovascular health information: Sources and access challenges. J Deaf Stud Deaf Educ, 20: 408-418.

Kushalnagar P, Naturale J, Paludneviciene R et al (2015). Health Websites: Accessibility and usability for american sign language users. Health Commun, 30:830-7.

Kuenburg A, Fellinger P, Fellinger J (2016). Health Care Access Among Deaf People. J Deaf Stud Deaf Educ, 21:1-10.

Terry DR, Lê Q, Nguyen HB (2016). Moving forward with dignity: Exploring health awareness in an isolated Deaf community of Australia. Disabil Health J, 9:281-8.

Chilton EE (1996). Ensuring effective communication: The duty of health care providers to supply sign language interpreters for deaf patients. Hastings Law J, 47:871-911.

Steinberg AG, Sullivan VJ, Loew RC (1998). Cultural and linguistic barriers to mental health service access: The deaf consumer's perspective. Am J Psychiatry, 155:982-4.

Kritzinger J, Schneider M, Swartz L, Braathen SH (2014). "I just answer,'yes' to everything they say": Access to health care for deaf people in Worcester, South Africa and the politics of exclusion. Patient Educ Couns, 94:379-83.

Witte TN, Kuzel AJ (2000). Elderly deaf patients' health care experiences. J Am Board Fam Pract, 13:17-22.

Chaveiro N, Barbosa MA (2005). Assistance to the deaf in the health area as a factor of social inclusion. Rev Esc Enferm USP, 39:417-22.

Folkins A, Sadler GR, Ko C et al (2005). Improving the Deaf community's access to prostate and testicular cancer information: a survey study. BMC Public Health, 5:63.

Groce N, Yousafzai A, Dlamini P et al (2006). HIV/AIDS and disability: A pilot survey of HIV/AIDS knowledge among a deaf population in Swaziland. Int J Rehabil Res, 29:319-24.

Scheier DB (2009). Barriers to health care for people with hearing loss: a review of the literature. J N Y State Nurses Assoc, 40:4-10.

Jones EG, Renger R, Firestone R (2005). Deaf community analysis for health education priorities. Public Health Nurs, 22:27-35.

Chacko MR, Buttler JT, Kirkland RT (1987). Communication and special health care needs of a profoundly hearing impaired adolescent. Clin Pediatr, 26:395-397.

Ubido J, Huntington J, Warburton D (2002). Inequalities in access to healthcare faced by women who are deaf. Health Soc Care Community, 10:247-53.

Chaveiro N, Porto CC, Barbosa MA (2009). The relation between deaf patients and the doctor. Braz J Otorhinolaryngol, 75:147-150.

Pereira PC, Fortes PA (2010). Communication and information barriers to health assistance for deaf patients. Am Ann Deaf, 155:31-7.

Chan YF, Alagappan K, Rella J et al (2010). Interpreter services in emergency medicine. J Emerg Med, 38:133-9.

Haricharan HJ, Heap M, Coomans F, London L (2013). Can we talk about the right to healthcare without language? A critique of key international human rights law, drawing on the experiences of a Deaf woman in Cape Town, South Africa. Disabil Soc, 28:54-66.

Brown HL, Hughes-Bell A, McDuffie AW (2015). Caring for patients who are deaf or hard of hearing. JAAPA, 28:50-5.

Mackinney TG, Walters D, Bird GL, Nattinger AB (1995). Improvements in preventive care and communication for deaf patients - results of a novel primary health-care program. J Gen Intern Med, 10:133-7.

Cardoso AHA, Rodrigues KG, Bachion MM (2006). Perception of persons with severe or profound deafness about the communication process during health care. Rev Lat Am Enfermagem, 14:553-60.

McKee MM, Barnett SL, Block RC, Pearson TA (2011). Impact of Communication on Preventive Services Among Deaf American Sign Language Users. Am J Prev Med, 41:75-9.

Major G, Napier J, Ferrara L, Johnston T (2012). Exploring lexical gaps in australian sign language for the purposes of health communication. Commun Med, 9:37-47.

Margellos-Anast H, Estarziau M, Kaufman G (2006). Cardiovascular disease knowledge among culturally Deaf patients in Chicago. Prev Med, 42:235-239.

Mathews JL, Parkhill AL, Schlehofer DA et al (2011). Role-Reversal Exercise with Deaf Strong Hospital to Teach Communication Competency and Cultural Awareness. Am J Pharm Educ, 75:53.

Hoang L, LaHousse SF, Nakaji MC, Sadler GR (2011). Assessing deaf cultural competency of physicians and medical students. J Cancer Educ, 26:175-182.

Thew D, Smith SR, Chang C, Starr M (2012). The deaf strong hospital program: A model of diversity and inclusion training for first-year medical students. Acad Med, 87:1496-500.

Nagakura H, Schneider G, Morris J et al (2015). Assessing Deaf Awareness Training: Knowledge and Attitudes of Recent Genetic Counseling Graduates. J Genet Couns, 24:104-16.

Adib-Hajbaghery M, Rezaei-Shahsavarloo Z (2015). Nursing students' knowledge of and performance in communicating with patients with hearing impairment. Jpn J Nurs Sci, 12:135-44.

Lapinski J, Colonna C, Sexton P, Richard M (2015). American Sign Language and Deaf Culture Competency of Osteopathic Medical Students. Am Ann Deaf, 160:36-47.

Velonaki V-S, Kampouroglou G, Velonaki M et al (2015). Nurses' knowledge, attitudes and behavior toward Deaf patients. Disabil Health J, 8:109-17.

Ferguson M, Liu M (2015). Communication needs of patients with altered hearing ability: Informing pharmacists' patient care services through focus groups. J Am Pharm Assoc (2003), 55:153-60.

Yuksel C, Unver V (2016). Use of Simulated Patient Method to Teach Communication With Deaf Patients in the Emergency Department. Clin Simul Nurs, 12:281-9.

Gregg AL, Wozar JA, Wessel CB, Epstein BA (2002). Designing a curriculum on Internet health resources for deaf high school students. J Med Libr Assoc, 90:431-6.

Kaskowitz Iii SR, Nakaji MC, Clark KL et al (2006). Bringing prostate cancer education to deaf men. Cancer Detect Prev, 30:439-48.

Jones EG, Renger R, Kang Y (2007). Self-efficacy for health-related behaviors among deaf adults. Res Nurs Health, 30:185-92.

Choe S, Lim RS, Clark K et al (2009). The impact of cervical cancer education for deaf women using a video educational tool employing american sign language, open captioning, and graphics. J Cancer Educ, 24:10-5.

Wilson JB, Wells MG (2009). Telehealth and the deaf: A comparison study. J Deaf Stud Deaf Educ, 14:386-402.

Jones EG, Goldsmith M, Effken J et al (2010). Creating and testing a deaf-friendly, stop-smoking web site intervention. Am Ann Deaf, 155:96-102.

Berman BA, Guthmann DS, Crespi CM, Liu W (2011). Development and testing of an antitobacco school-based curriculum for deaf and hard of hearing youth. Am Ann Deaf, 155:592-604.

Sadler GR, Branz P, Fager M et al (2012). Health Promotion via Deaf-Friendly Ministries. J Cancer Educ, 27:606-11.

Hickey S, Merz EL, Malcarne VL et al (2013). Breast cancer education for the deaf community in American sign language. Oncol Nurs Forum, 40:E86-91.

Chiriac IA, Stoicu-Tivadar L, Podoleanu E (2015). Comparing video and avatar technology for a health education application for deaf people. Stud Health Technol Inform, 210:516-20.

Ahmadi M, Abbasi M, Bahaadinbeigy K (2015). Design and implementation of a software for teaching health related topics to deaf students: The first experience in Iran. Acta Inform Med, 23:76-80.

Pollard RQ, Barnett S (2009). Health-Related Vocabulary Knowledge Among Deaf Adults. Rehabil Psychol, 54:182-5.

Zazove P, Meador HE, Reed BD et al (2009). Cancer Prevention Knowledge of People with Profound Hearing Loss. J Gen Intern Med, 24:320-6.

Oliveira YCA, Celino SDM, de França ISX et al (2015). Deaf people’s knowledge and information sources regarding health and disease. Interface (Botucatu), 19:549-60.

Zazove P, Meador HE, Reed BD et al (2012). Effectiveness of videos improving cancer prevention knowledge in people with profound hearing loss. J Cancer Educ, 27:327-37.

Meador HE, Zazove P (2005). Health care interactions with deaf culture. J Am Board Fam Pract, 18:218-222.

Mprah WK (2013). Perceptions about barriers to sexual and reproductive health information and services among deaf people in Ghana. Asia Pac Disabil Rehabil J, 24:21-36.

Berry JA, Stewart AJ (2006). Communicating with the deaf during the health examination visit. J Nurse Pract, 2:509-515.

Hines J (2000). Communication problems of hearing-impaired patients. Nurs Stand, 14:33-37.

Dickson M, Magowan R (2014). Meeting Deaf patients' communication needs. Nurs Times, 110:12-5.

Shabaik S, LaHousse SF, Branz P et al (2010). Colorectal cancer video for the deaf community: a randomized control trial. J Cancer Educ, 25:518-523.

Chaveiro N, Barbosa MA, Porto CC (2008). Literature revision about the attendance of deaf patient by health professionals. Rev Esc Enferm USP, 42:567-572.

Kutten J, Reedy S (2009). Are you tuned into deaf patients? Nurse Pract, 34:44-9.

Mustafa MS, Addar MH (2000). Obstetric handling of a deaf patient. Saudi Med J, 21:1185-8.

Ali S (2012). Providing Interpreters for Patients with Hearing Disabilities: ADA Requirements. Innov Clin Neurosci, 9:30-33.

Henning MA, Krageloh CU, Sameshima S et al (2011). Access to New Zealand Sign Language interpreters and quality of life for the deaf: a pilot study. Disabil Rehabil, 33:2559-66.

Oliveira YCAD, Celino SDDM, Costa GMC (2015). Communication as an essential tool for deaf people's health care. Physis, 25:307-320.

Alsmark SS, García J, Martínez MR, López NE (2007). How to improve communication with deaf children in the dental clinic. Med Oral Patol Oral Cir Bucal,12:E576-81.

Dean RK, Pollard RQ Jr (2001). Application of Demand-Control Theory to Sign Language Interpreting: Implications for Stress and Interpreter Training. J Deaf Stud Deaf Educ, 6:1-14.

Hsieh E (2010). Provider–interpreter collaboration in bilingual health care: competitions of control over interpreter-mediated interactions. Patient Educ Couns, 78:154-9.

Jensen LG, Nakaji M, Harry KM et al (2013). Ovarian cancer: Deaf and hearing women's knowledge before and after an educational video. J Cancer Educ, 28:647-55.

Yao CS, Merz EL, Nakaji M et al (2012). Cervical cancer control: Deaf and hearing women's response to an educational video. J Cancer Educ, 27:62-6.


  • There are currently no refbacks.

Creative Commons Attribution-NonCommercial 3.0

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.