Beyond accommodation: institutional and policy drivers of healthcare equity for signing deaf adults

Deaf and hard-of-hearing individuals who use a signed language experience persistent inequities in healthcare access, communication, and outcomes. Although federal accessibility policies mandate effective communication, implementation remains inconsistent and signing Deaf patients continue to report barriers that compromise safety, autonomy, and trust. Existing literature documents communication breakdowns but offers limited qualitative insight into how institutional structures, administrative practices, and policy implementation processes shape Deaf patients' healthcare experiences across the continuum of care.

This qualitative descriptive study examined healthcare experiences of culturally Deaf signing adults in the United States using a socioecological analytic framework. Participants were recruited through Deaf-oriented social media groups in Utah. Eligible participants were adults aged 18 years or older who self-identified as culturally Deaf and were proficient in American Sign Language (ASL). Data were collected through ASL-interpreted focus groups and individual interviews. Transcripts were verified for accuracy and analyzed using iterative deductive and inductive thematic analysis in NVivo with attention to institutional and policy-level influences on healthcare access.

Participants described a healthcare system in which effective communication access was inconsistent and frequently required Deaf patients to self-advocate for accommodations. Findings clustered into three interrelated domains: (1) influencing factors, including policy ambiguity, economic constraints, patient knowledge, and advocacy burden; (2) institutional barriers, including capacity limitations, technological and environmental constraints, personnel knowledge and attitudes, restrictive interpreter contracting practices, fragmented scheduling and record-keeping systems, unclear roles and responsibilities, and compliance-oriented institutional culture; and (3) effects on Deaf patients' lives. Healthcare-specific effects included reduced autonomy, compromised privacy, delayed or inadequate care, healthcare avoidance, trust erosion, and poorer health outcomes. Broader impacts included emotional and mental stress, financial strain, relationship burden, and reliance on litigation or geographic avoidance to secure accessible care.

Despite longstanding accessibility mandates, signing Deaf patients continue to experience structurally produced inequities driven by inconsistent institutional implementation. Communication access functions as a core patient safety and equity mechanism rather than a discretionary accommodation. Achieving healthcare equity for Deaf patients requires system-level reforms that embed accessibility into institutional infrastructure, diversify interpreter contracting, strengthen workforce preparation, and establish accountability mechanisms that move healthcare organizations beyond minimal compliance toward structural equity.

Not applicable.