Social Determinants

and Interventions For

Health:
The Canadian Deaf & Hard-of-Hearing
Population

Outline
Basic Info on the Deaf Population
Common Health Problems
Determinants of Health
Priorities of the Deaf Population
Points of Intercention
Evidence of Feasable Interventions
Our Recommendations
Conclusion

Who are the Deaf and Hard of Hearing

Population
?
Definition:
deafness is medically defined as the extent of loss of functional
hearing and by dependence on visual communication (Canadian
Association of the Deaf, 2012)
Types of deafness:
Sensorineural hearing loss, conductive hearing loss, mixed hearing loss

Causes of deafness are numerous

Our focus: the prelingually deaf people
1-2 in 1000 people worldwide (Smith & Chin, 2012)
Overlaps with the culturally Deaf

Where do they live in Canada?

Deafness

38% of DHH
population

(Stats Canada 2006)

Why is there a public health

issue?

~4 in 1,000 Canadian babies

Communication in society

Disability weight:
0.33
For every year you live
with deafness is
comparable to
0.33 years lost
(Rao PSS et al., 2013)

Meet
Charlie

Common health problems

Mental

Emotional and behaviour problems (Fellinger et al., 2011)

2x in deaf children (Fellinger et al., 2009)
Psychosocial difficulties
3x in deaf children (Dammeyer, 2010)
Somatization disorder (Fellinger, 2012)

Physical

MSK and GI problems

3x GI problems, 6x headache (Fellinger, 2012)
Sexually transmitted infections (Peinkofer, 1994.Bat-Chava et al., 2005.Heuttel et al., 2001)
USA HIV/AIDS prevalence 5% (deaf) vs. 3% (hearing) (Gaskins, 1999)
Deaf lag by 8 years in HIV/AIDS knowledge (Gaskins, 1999)
Dental Caries
55.9% (deaf) vs. 13.8% (hearing) (Wei et al., 2012)
Cardiovascular disease

Social

Drug and alcohol abuse

(Guthmann et al., 2005. Titus el al., 2008)

Among abusers, deaf people began earlier and were more severe

Social Determinants of Health

1)
2)
3)
4)
5)
6)
7)
8)
9)

Early Childhood Development

Abuse / Substance Abuse / Risky Behaviour
Social Exclusion
Education
Healthcare Access
Other Public Service Access
(Un)Employment and working conditions
Food Insecurity and Housing
Complementary factors

Key Outcomes

Determinants

Downstream

Upstream

Abuse
Use of Sign
Language
ex ASL/LSQ

Influence
over all
Deafness

Minority in
their own
family

Substance abuse
and/or mental health
issues

Social exclusion
from hearing
people

Sense of
inadequacy

Decrease in
family
connection

Distrust of
hearing
people

Attempts at
correcting
hearing loss

Needless /
Ineffective
Medical
Procedures

Raised in an
environment
where access
to information
is difficult

Family Socioeconomic
situation

Low levels of
literacy

Societys
construct of
disability

Less Education

Lack of
common health
knowledge

Unemployment /
Employment
issues
Reduced access
to non-medical
social services
including welfare

Discrimination

Lack of
interpreters /
good
communication

Food insecurity
/ housing
issues

Decreased
adherence to
medical advice from
hearing
professionals

Decreased
Sexual and
Cardiovascular
health, etc

Important health outcomes for

Deaf
1. Accesspeople
to accurate health-related information.

(Jones et al., 2005)

a.
b.
c.
d.

Heart related diseases

Cancer
Mental health, Sexual health, Substance abuse
Dental care and Nutrition

2. Reduce mental health problems

(Fellinger et al., 2012)

Education
ClassInFocus

Points of Intervention

Upstream
Interventions

Family matters and Mental health:

DEIP

Health Access:
Deaf Strong Hospital

Downstream
Interventions

Current Support Groups

National:
Canadian Hearing Society - Providing corrective treatments
Canadian Deaf Association - Networking / awareness / clubs
Local:
Maison Des Sourds - Organizing housing for the Deaf together
MAB-Mackay Rehabilitation Centre - Child Rehab (English)
Institut Raymond Dewar - Child Rehab (French)
Association Sportive de Sourds Du Quebec - Sports for the Deaf

PICO Question 1: Access to

P:
Healthcare professionals
and studentsCare
Accurate
Health
I: interactive learning about Deaf people, culture and struggles
C: Baseline awareness of the topic
O: Better knowledge (and thus sensitivity)

For healthcare professionals and students, does interactive learning with

Deaf people compared to baseline awareness improve knowledge of Deaf
people and Deaf culture?

Deaf Strong Hospital

An exercise in which hearing students act out illness scenarios in a simulated hospital staffed by
deaf volunteers, with the purpose of increasing awareness of communication barriers in the health
care setting, especially for deaf and hard-of-hearing patients.
Success Stories
Students agreed that the
DSH experience facilitated
their understanding of the
interpreters role in
communication and
provided them insight into
the issues non-English
speaking patients face.
Influenced how physicians
interact with non-English
speaking patients and the
use of interpreters.

Limitations
Cannot determine the
lasting impact of the
program due to the
absence of a formal
longitudinal follow-up study
in physician practices

Ethics
Students who have yet to
be sensitized to Deaf
struggles may approach
the intervention with an
inappropriate attitude,
inadvertently causing
trigger trauma in the Deaf
actors who have lived
through such experiences
in real life.

Recommendation 1:

Provide Deaf Strong

Hospital Workshops

A Deaf Strong Hospital Workshop could be given a couple hours in the medical
curriculum just as some other group awareness sessions are (or held after hours) and at
a staff events at hospitals to raise awareness and help fixing issues downstream while
upstream programs wind up.
OUTCOME MEASURES: Check for increased requests for interpreters, and fewer repeat
visits for clarification by the Deaf patients. Also, knowledge survey by Hoang, Lisa et al.
'Assessing Deaf Cultural Competency of Physicians and Medical Students'.
TARGET PROBLEMS: Lack of interpreters and good communication (with healthcare),
Lack of common health knowledge, Decreased Adherence.
STEP 1: Contact the University of Rochester to organize a knowledge exchange of the
DSH program and petition medical schools and facilities to hold them.

PICO Question 2: Starting Right

P: Deaf preschool children
I: Family centered language acquisition program for deaf children
C: Exposure at a later time
O: Better language skills and family bonding
Would sending deaf preschool children to a specialized family centered
language acquisition program at an earlier age result in them having better
language skills and family bonding?

Diagnostic Early Intervention

Family-centered
language
skills acquisition program for deaf preschool
Program
(DEIP)
children (Moeller et al., 2000)

Success Stories
Early enrolled children
(before 11 months) had
comparable vocabulary
and verbal reasoning
skills as hearing children
at age 5 regardless of
degree of hearing loss
Most important factors
are family involvement
and age of enrollment

Limitations
Small population of 112
No data after preschool
Other language measures
not explored (syntax,
phonology etc.)
RCT unfeasible
Large cost

Ethics / Culture
Family involvement
depends on various
factors e.g. culture, SES

Recommendation 2:
Modified Diagnostic Early Intervention Program
(DEIP)
an
NGO
Deaf childrenas
would
attend
communication programs from 6 months old and families would
attend 1-2 weekly session (cheaper than home visits) in addition to weekly parent support
group meetings (non-profit) and family sign language classes (possibly online or non-profit)

OUTCOME MEASURES:
Peabody Picture Vocabulary Test / Preschool Language Assessment Instrument (for
vocabulary and verbal reasoning skills)
Attendance of parents / Subjective eval. by course instructor (for family involvement)

TARGETS: Parents involvement Mental health improvement, Language skills

STEP 1: Forming a committee (or imploring an existing organization) to find funding for and
start weekly workshops for parents and expand from there

PICO Question 3: Improving

Education
Education Barriers
Quality Interpreters
Visual Dispersion

Poor Academic
Outcomes

Employment
Limitations
CAD, 2012;
Mckenna, 1996

Poor health
outcomes
Ross, 1995;

P: Profoundly Deaf Students

I: Specialized virtual classroom
C: Hearing students or deaf students without it
O: Academic improvement
Would profoundly deaf students with a specialized virtual classroom compare to hearing
students or other deaf students in terms of academic performance?

Interventions
Marschark et al., 2005: Interpreter
Success:

Video-based interpreting = Live interpreting

Better interpreters = Better Grades

Key takeaway: Filmed classes teach the Deaf students
just as well as live classes, so high quality interpreters
and lessons can be seen by more students via the
internet.
Limitations:

Focused on college students

Deaf perform < Hearing

Ethics / Culture: (see other)

ClassInFocus

Cavender et al., 2009: Visual Dispersion

Success:
Incorporates multiple classroom components into one
digital screen and notifies important changes
Well received (4.7/5 rating)
Average score on follow up tests was 73%, those who
enjoyed the program the most averaging 85%
Key takeaway: We can overcome visual dispersion
Limitation:

Did not compare to hearing students

Ethics / Culture:

Many cultures do not see video based learning as

proper school and it must be made clear that it is for
the students benefit

Recommendation 3:

Lobby for E-

Schooling
for the
Lobby for combined video-based
longDeaf
distance learning with software like ClassInFocus. Long
distance learning would decrease visual dispersion and allow for high quality interpreters to reach a
larger student audience, where deaf children would have equal access anywhere in Canada
OUTCOME MEASURES: RCT trial comparing academic scores (+longitudinal follow up for health
measures (mental health, DMII, CVD, depression)
TARGET PROBLEMS: Education
STEP 1: Lobby the government to implement the online classes first (under its pre-existing online
course policies/software), citing financial and academic incentives, first in a trial group, and then
repeat the process for software development or ClassInFocus rights.
Future Directions: Using the intervention to provide a class on basic health information to Deaf
people of all ages, tailored to fill gaps in common knowledge regarding medicine

Non-Health Benefits

A better chance at getting a good education

Better employment prospects
Less financial strain and use of social services
More players in the economy
Tighter family connections and support

Possible Risks
Reduced education for those who do not have access to computers
Over-burdening parents with the DEIP
Marginalizing the Deaf children whose parents cannot or will not attend
DEIP

Proposed
Solutions
Abuse
Use of Sign
Language
ex ASL/LSQ

Minority in
their own
family
DEIP

Conclusion

Key Problems
Downstream
Substance abuse
and/or mental health
issues

Social exclusion
from hearing
people

Sense of
inadequacy

Decrease in
family
connection

Distrust of
hearing
people

Attempts at
correcting
hearing loss

Needless /
Ineffective
Medical
Procedures

Raised in an
environment
where access
to information
is difficult

Lack of
common health
knowledge

Low levels of
literacy
E-Schooling
Less Education

Unemployment /
Employment
issues
Reduced access
to non-medical
social services
including welfare

Deaf Strong
Hospital
Workshops

Lack of
interpreters /
good
communication

Food insecurity
/ housing
issues

Decreased
adherence to
medical advice from
hearing
professionals

Decreased
Sexual and
Cardiovascular
health, etc

Proposed
Solutions
Abuse
Use of Sign
Language
ex ASL/LSQ

Conclusion

Social exclusion
from hearing
people

Reduced
Sense of
inadequacy

Improved family
connection

Reduced
Distrust of
hearing
people

DEIP

Downstream
Reduced Substance
abuse and mental
health issues

Fewer
Needless /
Ineffective
Medical
Procedures

Less Attempts
at correcting
hearing loss
Improved
Family
Cohesion

Key Problems

Raised in an
environment
where access
to information
is improved

Improved
common health
knowledge

Improved levels
of literacy
E-Schooling

Improved
Education

Fewer
Unemployment /
Employment
issues
Improved access
to non-medical
social services
including welfare

Deaf Strong
Hospital
Workshops

ImprovedCom
munication

Reduced food
insecurity /
housing issues

Improved adherence
to medical advice
from hearing
professionals

Improved
Sexual and
Cardiovascular
health, etc

Questions?
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All pictures from flaticon.com

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