Health care utilization and adults who are deaf: Relationship with age at onset of deafness

Health Services Research, Feb, 2002 by Steven Barnett, Peter Franks

Hearing impairment, with a prevalence of 9.35 percent, is the sixth most common chronic condition in the civilian, noninstitutionalized U.S. population (Collins 1997). Of the 20.3-million persons with hearing trouble, 4.8 million cannot hear and understand normal speech (Ries 1994). American Sign Language, the language of the U.S. deaf community, is the third most commonly used language in the United States (Lotke 1995). The prevalence of hearing trouble is increasing faster than the U.S. population is aging (Ries 1994). Despite the size of this population, there is limited information regarding the health services utilization of its constituents. Understanding the health care needs of people with hearing loss has gained legal implications since the passage of the Americans with Disabilities Act.

Prior studies of health care and deaf people have produced conflicting results. Some studies indicate that people with hearing loss have poorer health status and increased health services utilization (Kurz et al. 1991; Ries 1982; Zazove, Niemann, Gorenflo, et al. 1993). Other studies suggest that people with hearing loss have decreased health services utilization (Ebert and Heckerling 1995b; Pollard 1994). Inconsistencies in these findings may be related to how the study populations are defined. Studies have ignored sociodemographics (Ries 1982), the difference between unilateral and bilateral hearing loss (Kurz et al. 1991), or the age at onset of deafness (Kurz et al. 1991; Pollard 1994; Ries 1982; Zazove, Niemann, Gorenflo, et al. 1993). Other limitations include small sample size (Ebert and Heckerling 1995b; Zazove, Niemann, Gorenflo, et al. 1993) and limited generalizability (Ebert and Heckerling 1995b; Pollard 1994).

The relative lack of data and the inconsistencies of previous findings make it difficult to identify and address the health care needs of deaf and hard-of-hearing people. Although typically studied as a single homogeneous population, people with hearing loss form distinctive subpopulations based on sociocultural characteristics (Benderly 1980; Phillips 1996). The age at onset of a severe bilateral hearing loss can have a significant effect on communication and socialization. People deafened after early adulthood and completion of their basic education are more likely to communicate well in English. People deafened prelingually, before the development of language (usually considered to be before the age of 3), are more likely to communicate using a sign language. These different communication modes have significant social implications for their users. They may also have an impact on health services utilization and health status.

We hypothesized that age at onset of deafness differentially affects language barriers and social isolation, which, in turn, influence health services utilization. The Andersen Behavioral Model of Health Services Use explains the interaction of these factors (Andersen 1995). Using this model, language barriers are an impeding factor to health care services use, and social isolation is a predisposing factor for health care services use. We theorized that adults deafened later in life, who are more likely to communicate primarily in English, would find their hearing loss socially isolating. People who are socially isolated are more likely to visit the health care system (Kouzis and Eaton 1998). In contrast with postlingually deafened adults, prelingually deafened adults are more likely to communicate primarily in a sign language, socialize mostly with other deaf people, and not find their hearing loss socially isolating. Because of language barriers, however, we theorized that prelingually deafened adults woul d have less access to the health care system. Having a common language with health care practitioners is an enabling factor for health care services use. Members of other language minority groups are less likely to visit physicians (Horberger, Gibson, Wood, et al. 1996; Woloshin, Bickell, Schwartz, et al. 1995). In the analyses presented here, we tested two hypotheses based on these theories: (1) When compared with the general population, prelingually deafened adults would have lower health care services utilization. (2) When compared with the general population, postlingually deafened adults would have higher health care services utilization.

METHODS

The National Health Interview Survey (NHIS) collects data on the civilian noninstitutionalized population of the United States. Using in-home interviews, these data are obtained in a continuing nationwide sample of households. The sampling follows a multistage probability design and includes oversampling of minority populations. Members of the armed forces, U.S. nationals living abroad, homeless people, and institutionalized persons, including nursing home residents, are excluded from the data collection. Information collected includes sociodemographic and health characteristics of people living in the surveyed households. In addition to core questions asked of all participants, sets of questions are administered to randomly sampled subsets of participants. The overall response rate for the NHIS has been 95 to 98 percent (Ries 1994).