Table 4 Current status of health literacy among people with hearing impairment and improvement methods

Gregg [14]

To investigate the incorporation of Internet-based instruction regarding excellent health resources into the health curriculum of a deaf high school for hearing impaired pupils

A specific Internet health curriculum enhanced the ability of deaf high school pupils to find quality health information online

Students with hearing impairment often had difficulties in finding sources of health information

Not mentioned

Cultural sensitivity, discrepancies between ASL and English, disjointed patterns of interpersonal communication, and difficulty with medical terminology were all issues

Health science information courses helped students with hearing impairment access health information online

Steinberg [15]

To learn the details of the healthcare experiences of deaf people who communicate using American Sign Language

Communication issues were prevalent. Fear, mistrust, and frustration were the main problems. Many participants admitted to having little knowledge of their legal rights and thought that health care providers should learn more about the social components of deafness

People with hearing impairment had limited access to health information

Not mentioned

People with hearing impairment had communication barriers because translator services were insufficient, and writing was ineffectual due to syntax discrepancies between ASL and English

Improving communication between doctors and patients and addressing the cost of translation

Groce [17]

To determine if there were detectable differences in HIV/AIDS knowledge between hearing people and deaf sign language users in Swaziland

When compared to those with normal hearing, people with hearing disabilities were more likely (p0.05) to believe in inaccurate HIV transmission mechanisms and HIV prevention. 99% of hearing-impaired people had trouble speaking with healthcare workers

People with hearing impairment had knowledge gaps about HIV/AIDS and they have limited access to sources of health information

People with hearing loss had misconceptions about how HIV is transmitted, with 44% believing it can be transmitted through kissing; 42% trusted it can be transmitted through contact; 30% thought it can be transmitted through a dirty environment; and 52% said they do not know the route of mother-to-child transmission

Individuals with hearing disabilities had limited sources of health-related information and they had communication barriers

Disability-friendly sex education and materials need to be developed concerning the needs of people with hearing impairment

Choe [18]

To evaluate HIV awareness among Hard of Hearing and hearing people and determine how well HIV/AIDS messaging reaches deaf members of the community

There were differences in levels of comprehension (p < 0.05) regarding the aspects of how AIDS is propagated, and they found inequalities in information resources among the two groups

Cervical cancer was not well understood among people with hearing disabilities

Not mentioned

There was a need to deliver better cancer information and services to people with hearing loss in a way that they can understand

Cancer education activities are beneficial to persons who have hearing disabilities. By sharing relevant health information with others, participants can also contribute to the spread of knowledge

Pollard [19]

To see if seeing a graphically enhanced American Sign Language (ASL) cervical cancer education video could improve deaf women’s knowledge

Upon viewing the ASL cervical cancer education video, the treatment group gained more cancer knowledge than the control group who only received a basic education

Persons with hearing loss had a limited comprehension of medical terminology

68.4% of participants stated that they comprehended more than 90% of the health-related vocabulary, whereas 31.6% got scores that were deemed to reflect low health literacy

Reading and comprehension of English health-related terms and phrases were inadequate among individuals with hearing loss

Available health care education materials and programs should be developed to overcome knowledge gaps

Hoang [20]

To examine the health-related vocabulary knowledge of a group of deaf adults

On the modified REALM task, 32% of deaf adults received results comparable to REALM levels considered indicative of low health literacy. The patterns of least and most used words diverge from what auditory REALM respondents expect

People with hearing impairment had low health literacy due to language barriers, and health care providers reported a limited understanding of deaf culture

Not mentioned

Health service providers lacked training in deaf culture and there were a limited number of medical staff who could speak sign language

To improve clinicians’ cultural competency through the Deaf Community Training program (DCT), exposure to members of the deaf community in a clinical setting, the classes, or self-paced learning modules

Convery [21]

To evaluate the role of the Deaf Community Training (DCT) program on medical students’ understanding of deaf culture and compare it with that of teachers

DCT medical students had a better understanding of deaf culture and patients with hearing impairment than non-DCT medical students and instructors

Some people with hearing impairment have difficulty understanding the text in the instructions and the accompanying pictures

Not mentioned

Not mentioned

Larger fonts, graphical representations, and non-specialist jargon should be utilized to increase information accessibility for a broader variety of hearing aid users

Maddalena [22]

To ascertain the proportion of hearing-impaired people who can effectively select and construct a hearing aid using illustrated written instructions, and who can place the device into their ear with or without the assistance of a partner

Participants’ ability to complete the assembly activity independently and accurately was greatly influenced by their level of health literacy. Higher levels of health literacy were connected with a greater likelihood of completing tasks independently and successfully

People with hearing impairment had inadequate experience with death and a poor understanding of accessible palliative care services

Not mentioned

Persons with hearing loss had communication challenges with doctors, while healthcare providers had minimal knowledge of deaf culture

ASL interpreters were required to assist with communication in healthcare facilities, and because deaf people had varying levels of ASL fluency, personalized communication is required

Yao [23]

To investigate and explain Deaf people’s and their carers’ experiences at the end of a patient’s life, and to investigate the barriers that impact Deaf people’s choice to the health care system utilization during the terminal condition

Participants had little experience with dying, little understanding of accessible palliative care resources, and healthcare workers had inadequate knowledge of deaf culture. There are also some communication issues between deaf people and health professionals

In the cancer knowledge categories, women with hearing loss had poorer baseline knowledge than hearing individuals

94.5% of people with hearing loss reported “very easy to somewhat easy” to receive information from the video

Communication difficulties restricted people with hearing loss from getting health information and services

The educational video on cervical cancer can provide knowledge about cancer for the hearing impaired

Berman [24]

To compare the change in the cancer knowledge in deaf women and hearing women before and after watching a vividly enhanced educational video about cervical cancer

Hearing women performed better before watching the video. After the intervention, both groups showed a substantial increase in general and cervical cancer knowledge

People with hearing disabilities had misunderstandings about breast cancer risk factors, screening, and management

Just 64.2% of participants successfully classified the purpose of mammography

In clinical settings, people with hearing impairment encountered considerable challenges in getting information, referrals, and assistance

Breast cancer education programs, insurance providers advising hearing loss women of optimal health care practices, and health care providers promoting awareness about people with hearing impairment can all increase health literacy

Jensen [25]

To report the baseline characteristics of the D/deaf women and to test the program they designed to be available to D/deaf women with different education levels

Breast cancer risk factors, screening, and therapy are all misunderstood by the deaf. 64.2% of those surveyed correctly identified the aim of mammograms

Women with hearing disabilities had poorer cancer knowledge ratings than hearing women before the intervention

64% of women with hearing loss said the video was “very easy,” 28% thought it was”somewhat easy” to understand, 6% thought it was “somewhat difficult,” and 2% thought it was “very difficult” to understand

Language and cultural barriers to health information and care were mentioned by people with hearing impairment

A video-based method to educate women with hearing disabilities is practically meaningful

Convery [26]

To see if an ovarian cancer education video in American Sign Language with English annotation and voice-over could help deaf and hearing women bridge the knowledge gap

Hearing women scored considerably higher on the pre-test than deaf women. All the deaf women’s knowledge scores had grown after the intervention, and hearing women’s knowledge had also increased, which lead to a new gap

Some people with hearing impairment have difficulty understanding the guidance documents and are unable to fit hearing aids independently

Not mentioned

Not mentioned

The help of a partner may improve the health literacy of people with hearing impairment

Mckee [27]

To assess hearing-impaired adults and their partners’ ability to operate a pair of BTE hearing aids by a set of written and visual instructions

Better health literacy was substantially related to independent task completion in both two country individuals. Task accuracy was substantially related to greater levels of cognitive functioning among South African participants

Hearing impaired people struggle to obtain health information through the media, and health care communication

In the Peabody Individual Achievement Test-Revised, 74% of the hearing impaired had a reading level below grade 8, 26% were equal to or above grade 8, and the average reading level of the participants was 5.9

Communication and linguistic obstacles, as well as social marginalization, low education, and low income, are all present

Sign language videos can be effective in helping people with hearing impairment access and understand health information

Ferguson [28]

To assess the prevalence and relationship of limited health literacy among deaf ASL users and hearing people

48% of deaf people had low health literacy, and deaf participants were 6.9 times more likely than hearing individuals to have limited health literacy

People with hearing impairment lacked an understanding of pharmaceutical instructions and services in pharmacies

Not mentioned

There were difficulties in communication between people with hearing impairment and pharmacy workers, and there was also a need for more understanding and tolerance between them

Pharmacists need to become more culturally sensitive and competent in their interactions with people with hearing loss and this can be achieved through education and training

Smith [29]

To explore communication challenges and needs for deaf and hard-of-hearing (HOH) patients when they find medical care

Deaf and HOH patients have special needs that pharmacists need to comprehend and solve. Proper communication and literacy evaluation is a key to guarantee safe medication use and first-rank health outcomes

People with hearing loss had inadequate knowledge about cardiovascular disease and have trouble getting health information

Adolescents with hearing impairment had inconsistent knowledge of vascular health, with many unable to identify the reasons or start of heart attacks and strokes and just a few able to appropriately characterize cholesterol

Communication barriers with health care providers, difficulty to understand the jargon in printed health information, and ineffective school health education programs were all problems

Improve interpreter education and disseminate information through social media and create accessible and culturally appropriate health surveys and health education initiatives

Kushalnagar [30]

To eventually use the knowledge gathered to enhance the delivery of cardiovascular health education

Family, health education instructors, healthcare practitioners, written materials, and informal sources were selected as the top five sources of cardiovascular health information

People with hearing impairment with poorer health literacy had a harder time finding information on ASL-accessible health websites

Subjects who indicated ASL as their main language had worse health literacy scores than those who said they favored both languages equally. Furthermore, primary ASL speakers showed poorer levels of health literacy

Whether ASL’s health website is straightforward to use, browse, and comprehend

The health website should not only be available in ASL, but it should also be easy to use. Furthermore, short, clear ASL videos can encourage persons with hearing loss to seek medical attention and communicate any difficulties with their physicians

Smith [31]

To learn about ASL users’ experiences navigating these websites, and their minds on the understanding of the contents

Participants mentioned the benefits of adding captioning and a signer model to health videos. Subjects who had limited health literacy had greater difficulty finding information on the website

Even when functional health knowledge was controlled for, there were still disparities in general health knowledge and cardiovascular health knowledge measures between hearing-impaired and hearing adolescents

Hearing-impaired adolescents with higher health literacy reported having better hearing assistive devices and using them regularly, describing English as their best language, having excellent communication with their parents, and attending hearing schools at least half of the time

Cultural, social, and familial communication issues may all have an impact on the formation of healthy knowledge in teenagers with hearing loss

Improving hearing loss adolescent health literacy should focus on health-related dialogues with their families, access to written health information, and access to relevant information from health care practitioners and educators

Haricharan [32]

Quantifying health literacy in students with hearing impairment and auditory adolescents

People with hearing impairment have inadequate health literacy, which can be improved by intervening in their health-related talks with their family

Although the intervention increased participants’ general awareness of hypertension and healthy living, they still found the medical terminology challenging to understand

SMSs were easy to interpret for 78% of participants but difficult for 13%

People with hearing disabilities had little exposure to health information

Text messaging can enhance the health literacy of people with hearing loss, but it needs to take into account the unique needs and communication preferences of people with hearing disabilities

Palmer [33]

To assess the availability of using short message service (SMSs) in deaf people

An improvement in hypertension knowledge and healthy living in participants; 6 in 19 questions’ answers also showed a significant change, but the medical terminology is still hard to understand. Sone ways to enhance SMS campaigns were identified

People with hearing disabilities had difficulty accessing and understanding health information effectively

Hearing impaired participants with a high level of education showed a significant increase in health knowledge whether they were taught bilingually or monolingually, but participants with a low level of education could increase their knowledge only when they were taught bilingually

Differences in the primary language and educational levels of people with hearing disabilities can be a source of difficulty in accessing health information

Online non-face-to-face teaching using a bilingual approach can enable people with hearing impairment to access health information effectively

Kushalnagar [34]

To investigate the use of bilingual (ASL with English closed captioning) versus monolingual (English text) online cancer genomics information

There was a significant interaction between linguistic modality, education, and change in knowledge scores (p = .01). Regardless of modality, the high education group increased knowledge (Bilingual: p.001; d = .56; Monolingual: p.001; d = 1.08) while bilingual (p.001; d = .85) but not monolingual (p = .79; d = .08) modality boosted knowledge in the low education group

Because they were unable to hear health-related information on television, radio, or public broadcasting, many hearing-impaired people are not fully exposed to health information and must rely on family members or peers for information

Not mentioned

Due to communication problems in the home or health environment, people with hearing disabilities had fewer opportunities to obtain health information

Sign-language-enabled social media can enhance health knowledge and self-advocacy health care practices through interactive health literacy exercises

Pinilla [35]

To explore the association between critical health literacy (CHL) and discussion of health information among participants

The discussion with friends about health-related information is associated with CHL in two groups, while the discussion with family was only related to hearing people

Participants did not actively seek information about diabetes unless they were surrounded by others with the disease or had it themselves

27% of participants knew of two different types of diabetes, 67% had only heard of the disease but were unsure what it was, and one respondent had never heard of diabetes

All participants reported communication challenges as a result of health care providers’ lack of sign language expertise and a scarcity of interpreters

Improve communication between healthcare professionals and patients by incorporating content on common sign language communication skills into medical communication classes or training courses for health service staff

Stevens [36]

To investigate illness ideas encoded in signs, main noncommunicable disease preventive behavior, and communication hurdles among deaf community members

Personal spoken and written language literacy influences health information-seeking behavior among deaf people. Breaking down the walls is critical for establishing a better understanding of diabetes and other disease preventive programs

People with hearing impairment had difficulty receiving and comprehending health information in a healthcare setting

People over the age of 85 years were more likely than the younger group to report misinterpreting medical information conveyed by nurses and doctors

Every interaction between health care providers and people with hearing impairment had inadequate communication and errors

To improve one-on-one provider interactions, avoid phone calls, and provide health information in writing

Gur [37]

To evaluate the experiences of people with hearing impairment in the healthcare setting to identify confusion and unsatisfied needs and provide feasibility recommendations

Three communication circumstances stood out as frequently generating communication challenges between patients and providers. Although 93% of participants said that they informed providers about their hearing impairment, 29.3% of all participants claimed that no adjustments were taken

Had trouble connecting with healthcare providers, made mistakes when taking doctor-prescribed medication, could not grasp prescription drug instructions, and did not understand documents and texts provided by the institution

70.5% of individuals with hearing loss had insufficient health literacy, 19.3% had restricted health literacy, 2.3% had acceptable health literacy, and 8% had exceptional health literacy

People with hearing loss had difficulty communicating with their doctors and taking their medications

Medication instructions can be provided in sign language or writing by health care professionals, and the hearing impaired and health care providers treat each other with respect and improve their relationship

Tolisano [38]

To establish the levels of health literacy among D/HoH teenagers, as well as the challenges and misunderstandings they face while applying for healthcare services

Students who had difficulty communicating with their doctor, administering medication, etc. had low health literacy and wanted their doctor to be able to communicate in sign language or writing. Hearing impairment and health literacy were shown to have a strong association. (R = 0.659, R2 = 0.434) (p < 0.01)

People with hearing impairment had difficulty reading text and accessing health information

Not mentioned

Hearing impaired people had language and reading difficulties

To develop a tool to help people with hearing impairment understand health information

Wells [39]

To better understand the impact of hearing impairment on patient health literacy

9.7% of patients were found to have inadequate health literacy. 284 (95%) patients had available hearing data, of whom 235 (82.7%) had Grade A or B hearing and 49 (17.3%) had Grade C or D hearing. Patients with Grade C or D hearing had a lower median brief health literacy screen (BHLS) composite score (11.6 versus 13.6, p < 0.0001) and an increased rate of inadequate health knowledge (28.6% versus 4.7%, OR = 8.15, 95% CI 3.42–19.37) compared to those with Grade A or B hearing

Health literacy was classified based on one’s confidence in completing medical forms, with responses ranging from a little to not at all labeled as LHL and extreme, quite a little, and somewhat classified as sufficient health knowledge

Individuals with unassisted severe hearing loss were 80% more likely to report limited health literacy (LHL), followed by those with unaided mild hearing loss (46%), aided severe hearing loss (41%), and aided mild hearing loss (4%); those with aided moderate hearing loss were not at elevated risk for LHL

Low health literacy is associated with older age, male gender, poorer income, hearing loss, and not utilizing hearing aids

Hearing aids could be used to increase health literacy

Willink [40]

To investigate the factors related with low health literacy (LHL), health care costs, and treatment gaps based on health literacy, hearing impairment, and cochlear usage status

7% had LHL, whereas 41% suffered hearing loss. Hearing loss, particularly severe unassisted hearing loss, was linked to LHL. LHL will result in greater annual medical costs than individuals with good health literacy, whether they have hearing loss

People with hearing impairment had difficulties in understanding health insurance

Among those who had a lot of difficulty hearing, 21% said they had a little issue, and 28% said they had a lot of trouble locating Medicare information because of their hearing. Those who had a little difficulty hearing reported they had a little (12%) issue and a lot of (3%) trouble locating Medicare information because of their hearing

The methods available to increase Medicare knowledge were not created for persons with hearing problems and did not employ language that people with hearing loss are comfortable with. Furthermore, the system provided limited and variable coverage for hearing loss

More outreach to those who have hearing loss to generate relevant materials and ensure that enough resources are accessible to orient and comprehend the system

Almusawi [41]

To investigate how hearing loss affects Medicare beneficiaries’ comprehension of the Medicare program, their ability to make comparisons and analyses of health plans, and their comfort level with the information provided

Medicare beneficiaries with a little or a lot of trouble hearing had 18% and 25%, increased odds, respectively, of reporting difficulty with understanding Medicare, compared with those with no hearing trouble. About one in five Medicare beneficiaries with hearing loss identified that their hearing made it difficult to find Medicare information

People with hearing impairment have communication barriers and limited sources of health information

Only 30% of persons with hearing impairment were aware of the availability of medical counseling services during isolation, whereas 15% were aware of written therapy services

People with different dialects and sign languages cannot interact with one another, and health information sources are restricted

Increase sign language training and assistance to develop accessible and understanding medical information for individuals with hearing impairment

Tran [42]

To evaluate whether health literacy is related to the degree of hearing loss at the time of the initial hearing examination and the adoption of hearing aids by hearing aid patients

Patients with LHL had a higher likelihood of having significant hearing loss (adjusted mean pure-tone average [PTA] difference, 5.38 dB, 95% confidence interval [CI] 2.75–8.01). Health literacy was not connected to the cochlear adoption rate among hearing aid patients (odds ratio [OR] 0.85, 95% CI 0.40–1.76)

Patients with LHL had a higher likelihood of having significant hearing loss

At the time of first testing, low health literacy was linked to more severe hearing loss

People with hearing loss were difficult to enter the hearing healthcare system or they were not confident to do this

Not mentioned

To evaluate the discrepancies in COVID-19 health knowledge and practice between two groups

Hearing loss and using sign language as the major way of communication were both linked to reduced health literacy. Some differences in the utilization of health information sources