Health profile of deaf Canadians

DISCUSSION

The CCHS 1.1 estimated that 4% of Canadians have hearing problems to a degree that prevents them from communicating in groups of 3 or more people without the use of hearing aids. This is consistent with earlier studies that estimated prevalence in the range of 4% to 5% for moderate or greater hearing loss.10,11

Across all ages, depending on the auditory threshold used as a definition, an additional 3% to 9% might have less severe hearing impairments.1 The lower prevalence in this study might indicate that the sampling frame was inadequate to acquire responses from some segments of the deaf population. Approximately 37% of interviews were conducted by telephone, a factor that might have affected the survey’s ability to select respondents with hearing loss, but no other Canadian surveys of this size attempt to reach this population. It is unclear whether the household would be bypassed at the time of conducting the survey if the household had no telephone or if it had only a text telephone device, as used by many deaf people to communicate by text over telephone lines.

It is possible that the most vulnerable element of the deaf population has been excluded from these results. Conducting interviews by telephone might create a systemic bias that avoids some deaf households. With the low prevalence of deafness and hearing loss, it might be appropriate to intentionally oversample the deaf population in future CCHS cycles to correct for the possibility that these responses could be biased to the characteristics of those deaf and hard-of-hearing people who have a normal-hearing person in the household.

A higher prevalence of depression was seen in the deaf and hard-of-hearing group. While there is no reason to expect lower incidence,12 reporting more depression could reflect interpersonal barriers at school, in the workplace, and in the community, such as being excluded or the cost of adapting when included. Barriers to work force participation were more pronounced with greater hearing deficit in the United States,13 and deaf Canadians are also believed to experience barriers to equal rates of employment.14 Deaf people in the work-place have a marked impression of not making full use their abilities and skills.14,15 Both hard-of-hearing and deaf people might experience psychological strain and fatigue from the demands of adapting to the hearing environment.16 Part of this strain is linked to the stigma of hearing loss or hearing aids or the fear of being stigmatized.17,18 Those reporting hearing loss did not report less social or emotional support or sense of belonging. Close support networks, often consisting of other deaf and hard-of-hearing people or those who understand and can promote inclusion, are often cited as major assets for adjustment to hearing loss.15,16,18,19

Deaf and hard-of–hearing Canadians are not more likely to smoke or drink excessively, a finding consistent with previous studies,20 but they do report poor adherence to recommendations for healthy body mass and exercise. It is unclear whether this indicates that some health promotion measures are not reaching this subset of Canadians, or whether it reflects a reduced sensitivity to marketing in general, given that such messages are used to promote healthy activities and nutrition promotion, as well as to advertise cigarettes and alcoholic beverages. Previous studies have shown that the deaf and hard-of-hearing have difficulty understanding physicians20 and have lower awareness of the importance of health promotion and disease prevention procedures and behaviours.6

It is apparent that respondents classified as having hearing problems, whether hearing loss or deafness, are also more likely to report health conditions diagnosed by physicians, including heart disease, diabetes, high blood pressure, and other chronic conditions (but not cancer). Respondents with hearing problems are therefore seeing physicians for diagnosis, but this study was not able to assess why the rates of these chronic conditions were higher in this group, after controlling for age and other variables. This group could have higher rates of these conditions, but, conversely, respondents without hearing problems could conceivably be under-diagnosed for other factors not applicable to deaf and hard-of-hearing people.

On several specific utilization indicators, deaf and hard-of-hearing people reported comparable access, but it should be noted that the health care procedures reflecting comparable access were not communication-intensive clinical encounters. Canadians with hearing loss are getting prostate-specifc antigen tests, Papanicolaou tests, and mammograms at comparable rates to those of the general population (as found in previous studies6). Ontario residents with hearing loss had greater access to flu shots, but these can be obtained without physician contact. This data set does not enable us to analyze the quality of communication. Although contact occurs, it might not occur as often as would be appropriate or reflect equal quality of communication. For instance, a study of community mental health services found that access for deaf people disproportionately consisted of case management rather than clinical services.12

Some prior research20 did not find lower physician utilization among deaf and hard-of-hearing people. Our data set did not include an indicator of the rate of utilization, but those respondents with any degree of hearing problem were more likely to report unmet health needs (defined as a time in the previous year when they needed health care that they did not receive), were more likely to cite disability or health problem as the reason for unmet health needs, and were much less likely to describe their health as “good” or better. One explanation for the latter finding could be that communication barriers allow lingering uncertainty about health experiences and prevent professionals from reassuring the worried well individual. Zazove et al20 hypothesized that repeat visits seeking to resolve uncertainty could account for elevated utilization.

The Supreme Court of Canada has affirmed that deaf people who require it are entitled to access to sign language interpreting in the health care system.21 Appropriate accommodations for non-signing deaf and hard-of-hearing people predominantly include real-time captioning and other text media, as well as optimal lip reading environments. Text access is rarely found in health promotion or health care delivery, save for pamphlets and consent forms. Surveys of physicians reflect unrealistic beliefs about the effectiveness of lip reading.22 Optimal lip reading is often elusive, no less in the health care setting than in others, as it might be confounded by face masks, facial hair, accents, poor lighting, and background noise, not to mention unfamiliar terminology and possible anxiety over the situation.

Unfortunately, the current CCHS questions do not afford separate analysis of the health status or access experience of signing versus non-signing deaf people, people with congenital or developmental hearing loss versus people with recent or long-ago-acquired hearing loss, or people with moderate hearing loss versus people with no residual hearing. Simple screening questions cannot adequately define group membership. Use of hearing aids in some situations does not indicate benefit from hearing aids in all situations. A hearing loss that does not benefit from hearing aids does not indicate the ability to sign. Those who can respond in writing cannot necessarily understand complex written information. Those who can speak cannot necessarily hear.

The results in this study should be viewed in light of the cross-sectional design, in which causality cannot be determined. Further, given the difficulties that arise when performing telephone interviews, a potential bias might result if those with hearing loss could not adequately be sampled. Statistics Canada does make every effort to interview selected respondents in a form that is agreeable to both parties (eg, face to face) and therefore expects this bias to be minimal.