Abstract
Introduction/Objective
Deaf sign language users face persistent barriers to equitable healthcare, yet evidence from non-Western and lower-income contexts remains limited. This study explored the lived experiences of Deaf undergraduate students in Thailand, examining how communication barriers, health literacy gaps, and system design intersect to shape their access to equitable care.
Methods
We conducted a qualitative study using semi-structured, in-depth interviews with ten Deaf undergraduate students (aged 18–22 years). Participants were recruited through purposive sampling and interviews were conducted in Thai Sign Language (TSL), facilitated by two professional interpreters working in tandem. Data were analyzed using Braun and Clarke’s inductive thematic analysis.
Results
The analysis revealed four key themes: (1) communication barriers affecting all dimensions of healthcare experience, (2) inaccessible and hearing-centered health information, (3) the critical need for a Deaf-inclusive healthcare system, (4) the lifelong impact of growing up in hearing families on health literacy. These findings highlight how systemic communication gaps directly influence the quality of care and patient empowerment.
Conclusion
Communication barriers and health literacy gaps are structural features of hearing-centered healthcare systems that require systemic rather than individual solutions. Deaf sign language must be reconceptualized as a central component of equitable public health communication, supported by institutional infrastructure and enforceable policy mandates. These findings contribute to the international effort to address structural determinants of health inequity among Deaf communities globally.
Keywords: deaf, sign language, health equity, healthcare disparities, health literacy, qualitative research, health services accessibility
Introduction
Deaf people who use signed languages have different communication and cultural experiences from hearing people, but most healthcare systems remain structured primarily for hearing people. Previous studies show that Deaf people experience health inequities, including barriers to preventive care, communication issues in clinical encounters, and lower trust in health services.1,2 Communication and information barriers in healthcare—such as staff unfamiliarity with sign language, limited access to trained interpreters, and reliance on spoken or written communication alone—have been linked to reduced autonomy, misdiagnosis, and suboptimal treatment among Deaf patients.3,4
Health literacy constitutes a significant factor in these inequities. Research indicates that Deaf sign language users experience higher levels of inadequate health literacy compared to hearing populations. This difference is caused by limited access to information provided in signed or visual formats and fewer opportunities for everyday communication about health.5,6 Deaf children who grow up in hearing families frequently experience limited communication at home, resulting in a lack of incidental learning about health that hearing children gain through family conversations. Research on language and communication deprivation indicates that early deficits can lead to long-term impacts on how Deaf adults find, understand, and use health information.7,8
Clinical communication is another setting where these disadvantages are repeated. Deaf patients frequently describe difficulties explaining their symptoms, understanding medical information, and taking part in decisions when consultations rely on spoken language, writing, or untrained family members as interpreters. 9 Studies involving sign language interpreters and Deaf communities highlight how limited provider awareness of Deaf culture, inconsistent interpreter availability, and organizational barriers contribute to misunderstanding, reduced trust, and delays in seeking care.10,11 Although these findings predominantly derive from studies conducted in North American and European contexts, the barriers they describe are not geographically confined. Emerging evidence from Asia, the Middle East, and Latin America suggests that limited interpreter access, hearing-centered clinical environments, and inadequate health literacy support represent comparable patterns of inequity across diverse healthcare systems.1,6,11,12
Thailand provides a compelling context in which to examine these challenges. A total of 446,000 individuals in Thailand are registered with a hearing or communication disability, representing 20% of the total registered disability population 13 . Although Thai Sign Language (TSL) was officially recognized in 1999 and the Persons with Disabilities Empowerment Act of 2007, revised in 2013, established a legal framework entitling disabled individuals to free interpreters, medical services, and education, significant gaps remain between policy and practice. 14 Access to university-level education is severely limited, with Deaf students attaining a bachelor’s degree or higher representing fewer than 4% of the registered Deaf population, 13 and Ratchasuda Institute at Mahidol University remaining the only institution in Thailand with a structured higher education program designed specifically for Deaf sign language users. Despite this educational infrastructure, systematic evidence on how legislative provisions translate into accessible healthcare for Deaf individuals remains sparse, reflecting the broader invisibility of Deaf healthcare needs within national systems and highlighting a critical gap between legal entitlement and lived experience.13,14
The lived experiences of Deaf undergraduates navigating healthcare in Thailand and Southeast Asia remain largely unexplored. The absence of locally grounded evidence obscures barriers that are shaped by local context yet reflect universal challenges in achieving equitable, Deaf-inclusive care. This study addresses this gap by exploring how Deaf undergraduate students in Thailand perceive their health needs and navigate communication gaps in healthcare settings. By focusing on their lived experiences—from communication in hearing families to current encounters with healthcare providers—this study examines how communication, health information, and system design intersect, and identifies changes that Deaf students consider essential for more Deaf-inclusive and responsive healthcare. The insights generated aim to contribute not only to the Thai context but to the wider international effort to address the structural determinants of health inequity among Deaf communities.
Methods
Study Design
A qualitative study based on an interpretativism paradigm was conducted to explore how Deaf undergraduate students in Thailand perceive their health needs and manage communication challenges within healthcare settings. This perspective facilitated a comprehensive analysis of the sociocultural and linguistic factors that influence the experiences of Deaf individuals.
The study design and reporting were guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist. 15
Ethical Statement
Ethical approval was obtained from the Human Research Ethics Committee of the Faculty of Medicine Ramathibodi Hospital, Mahidol University on 07 August 2024 (COA No. MURA2024/542).
Participants
Ten Deaf undergraduate students from Ratchasuda Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, participated in the study. Purposive sampling was used to recruit individuals who self-identified as Deaf, used Thai Sign Language (TSL) as their main way of communicating, and agreed to take part in the study. No additional exclusion criteria were applied. Individuals who were hard of hearing but did not primarily use TSL were not recruited, as the study focused specifically on TSL users within the Deaf community. Some participants had prior acquaintance with the interpreters in the research team who had served in their academic courses. This established rapport facilitated more open and authentic communication during the interviews. There were no participant refusals or dropouts.
Data Collection
Semi-structured in-depth interviews were conducted between August 2024 and February 2025 at the Ratchasuda Institute. The interview guide was developed by the research team, including the professional sign language interpreters, and refined through preparatory meetings to ensure linguistic and cultural accuracy. Although the guide was not formally validated, it underwent iterative refinement during early interviews to improve clarity and cultural appropriateness. Data from these interviews were retained and included in the final analysis. The interview guide is provided as a supplementary file. Interviews were led by the first author, a male medical doctor (MD) and a final-year family medicine resident. To ensure linguistic accuracy and minimize communication bias, each session was mediated by two professional female Thai Sign Language (TSL) interpreters working in tandem, selected from a pool of four qualified interpreters. This structure allowed for constant meaning verification during the transition between sign and written text. Interviews lasted 45–60 minutes, were video-recorded with participant consent, and were subsequently transcribed verbatim into written Thai. No repeat interviews were conducted. Data collection proceeded until data saturation was achieved, and only the participant, the interviewer, and the two interpreters were present during each session.
Data Analysis
Data were analyzed using inductive thematic analysis as proposed by Braun and Clarke. 16 The analysis was conducted by three investigators: the first author and two female co-investigators, both of whom are medical doctor (MD) specializing in family medicine with extensive experience in qualitative research. The investigators independently generated initial codes from the verbatim transcripts and subsequently organized them into preliminary themes based on identified patterns. These codes were then iteratively synthesized through team discussions to identify core patterns and themes. By employing an inductive approach, the themes emerged directly from the participants’ narratives, ensuring the findings remained grounded in the lived experiences of the Deaf undergraduate students. To support reflexivity, independent coding was performed by three investigators and refined through iterative team discussion. The role of researcher positionality is addressed in the following statement.
Positionality Statement
No member of the research team identifies as Deaf or hard of hearing. The first author is a hearing physician whose engagement with the Deaf community developed through clinical experience caring for Deaf patients in a primary care setting and an observational visit to the study institution. To mitigate outsider positionality, two TSL interpreters worked in tandem during each interview to ensure continuous meaning verification, and thematic analysis was conducted independently by three investigators with iterative team discussion.
Results
Ten Deaf undergraduate students (aged 18–22 years) participated in this study. Inductive thematic analysis revealed four key themes characterizing their lived experiences within the healthcare system, as detailed below.
Theme 1: Communication Barriers Affect all Dimensions of Deaf Students’ Healthcare Experience
Participants described communication barriers as the most persistent challenge influencing how they accessed, understood, and navigated healthcare. Many struggled with written language, particularly when interpreting hospital signage, completing forms, or following instructions about medication and payment. These difficulties were often overlooked by healthcare providers, who tended to assume that Deaf students could read fluently. As a result, routine tasks—such as locating departments or understanding treatment instructions—became sources of confusion and fear.
“When I have to go to the hospital alone, I get confused because I can’t understand the signs. I also don’t understand the instructions about medication or payment, and that makes me feel scared.”
Beyond these challenges, participants often worried about misunderstanding medical advice or inaccurately describing their symptoms. Limited access to spoken explanations and comprehensible written information created persistent uncertainty, emotional strain, and a lack of confidence in managing their health.
Interpreter availability further influenced these encounters. Professional TSL interpreters were difficult to access, and without one, communication in healthcare settings became significantly more challenging. Some Deaf individuals delayed or avoided seeking care when interpreters were unavailable, particularly during symptoms that required a clear and accurate explanation.
“I once went with another Deaf friend without an interpreter. We didn’t know how to explain our symptoms or how to communicate with the staff.”
Overall, communication barriers operate as structural obstacles rather than isolated challenges. They influenced how Deaf students understood health information, expressed their needs, and felt safe, respected, and confident in clinical encounters.
Theme 2: Inaccessible and Hearing-Centered Health Information
Participants frequently described health information as difficult to understand, inaccessible, and often designed for hearing people. Much of the written material found in healthcare settings—including brochures, hospital forms, medication labels, and educational leaflets—relied heavily on complex text. Many Deaf students experience difficulties with reading fluency, which complicates their ability to interpret these materials and leads to uncertainty regarding diagnoses, treatment instructions, or care process steps.
“Reading and writing are difficult for me, so I can’t understand most health information.”
Participants explained that misunderstanding written health information often led to uncertainty about managing their health, especially when medical terminology or instructions were presented without visual or signed explanations. Several students noted that health literacy was influenced not only by their personal skills, but also by the lack of accessible educational materials. When they were unable to interpret the information provided, they tended to seek clarification from peers rather than healthcare professionals.
“Sometimes I try to read the paper they give me, but it’s too difficult. I ask my Deaf friends because they explain in a way I can understand.”
Overall, participants’ experiences reflected a system in which health information was largely hearing-centered. Because most materials depended on text-heavy explanations without visual or signed support, Deaf students often felt excluded from understanding their own health and making informed decisions.
Theme 3: Deaf-Inclusive Healthcare System
Participants emphasized the need for a healthcare system that recognized their needs as Deaf individuals and enabled them to navigate care independently. Limited access to clear communication and comprehensible information often forced them to rely on family members, peers, or interpreters, which reduced their sense of control and confidence in clinical encounters.
The healthcare system was often described as unprepared to recognize and accommodate Deaf patients. Participants wanted systems that could identify them as Deaf from the outset and provide visual navigation supports—such as clearer signage, color-coded service zones, or numbered queueing systems. These adjustments were viewed as essential for helping Deaf individuals move through healthcare settings without confusion.
“A Deaf-friendly health service should first recognize that the patient is Deaf. There should be sign language interpreters available, and health information should be easy to understand.”
Participants also highlighted the importance of healthcare providers who understood how to communicate respectfully and effectively with Deaf patients. They valued clinicians who used basic sign language, maintained eye contact, or facilitated timely access to interpreters. When such support was absent, participants felt excluded from participating in their care and uncertain about whether they were following medical advice correctly.
“When there is no interpreter, I don’t know how to explain my symptoms. The doctor doesn’t understand me, and I don’t feel confident asking questions.”
Overall, participants envisioned healthcare that was not only accommodating but inherently inclusive—where communication needs were anticipated, and environments were visually accessible. Clinicians possessed the skills and resources to support meaningful participation in healthcare decision-making.
Theme 4: Growing up in Hearing Families and Its Impact on Health Literacy
Participants also described a lack of incidental learning during childhood— instances where children naturally gain health knowledge through family discussions or everyday interactions. Without accessible communication at home, many Deaf students grew up without understanding basic health concepts, illness management, or how the healthcare system worked.
“Since childhood, my parents could not use sign language. When they talked to each other, I did not know what they were saying.”
These early experiences continued to influence their health behaviors in university life. Some participants relied heavily on Deaf peers for clarification when they felt uncertain, noting that their limited health knowledge made it difficult for them to evaluate the information provided by healthcare professionals. The long-term impact of growing up in hearing families was therefore not only linguistic but also structural, shaping their expectations of care and their confidence in interacting with medical staff.
“At home, we rarely communicated. When my parents talked, I didn’t understand anything because I could not hear.”
Overall, participants’ accounts revealed that growing up in hearing families had lasting effects on how they interpreted and acted on health information. These early communication barriers shaped their health literacy, help-seeking behaviors, and sense of security within clinical encounters.
Discussion
The findings of this study reveal how Deaf undergraduate students understand and navigate a healthcare system that does not accommodate their linguistic or cultural needs. Their experiences demonstrate a persistent pattern that begins in childhood and continues throughout their healthcare encounters. Specifically, for Deaf individuals in hearing families, limited accessible communication restricts opportunities for everyday learning about health. This is consistent with evidence indicating that Deaf children often miss incidental information naturally acquired by hearing children through family conversations. 17 Moreover, this pattern reflects studies on language deprivation, which emphasize that early communication barriers can result in long-term disadvantages in obtaining, understanding, and responding to health information.7,8 Our findings build on this work by illustrating how early communication environments continue to shape the ways Deaf young adults engage with health information and interpret clinical interactions.
These early experiences were compounded by a healthcare environment that remains largely hearing-centered. Participants struggled to understand written health materials, such as forms, medication labels, signage, and brochures. This aligns with studies indicating that text-heavy communication fails to address the linguistic needs of many Deaf adults. 5 Our findings reinforce this by showing that Deaf students’ ability to understand and use health information is limited when materials are written mainly for hearing people and lack visual or signed explanation. 6 Participants often depended on Deaf peers when written information was ambiguous, a pattern consistent with evidence that peer support plays a significant role in the health experiences of Deaf college students. 18 The dependence occurs when the healthcare system fails to offer accessible ways to communicate, indicating that these issues result from structural, not individual, barriers to health literacy. 12
Communication challenges occurred throughout their interactions with the healthcare system. Participants described ongoing communication difficulties such as describing their symptoms, understanding medical information, and navigating hospital environments. These difficulties often resulted in fear of misunderstanding medical advice or being misunderstood by healthcare providers. The results align with evidence that Deaf patients prefer direct signed communication and often experience uncertainty when it is not provided. 9 Limited interpreter availability further intensified these barriers, with some participants avoiding or delaying care when professional interpreters were not accessible. These findings align with existing evidence that Deaf individuals experience persistent communication inequities in clinical settings and that healthcare systems frequently fail to provide adequate communication support for Deaf patients.19,20
Participants expressed a vision for a Deaf-inclusive healthcare system rather than isolated adjustments during individual encounters. They emphasized the importance of the healthcare environments that recognize Deaf patients from the beginning of services and provide clear visual navigation supports such as improved signage, color-coded zones, and non-auditory systems for queueing. These strategies aim to reduce confusion and support their ability to navigate the healthcare environment independently. They also highlighted the importance of healthcare providers who understand Deaf culture and know how to communicate effectively with Deaf patients, with access to professional interpreters forming a vital part of this communication support.21,22
The barriers documented across these themes can be understood through three complementary theoretical frameworks. The Human Rights Model of Disability frames the experiences described in Themes 1, 2, and 3 not as inevitable consequences of hearing loss, but as failures of systems to uphold the rights and dignity of Deaf individuals. 23 Under this framework, the absence of sign language interpreters, accessible health information, and inclusive system design represents a failure of institutional obligation rather than an individual shortcoming. The Social Model of Disability further situates the early communication barriers described in Theme 4 as social rather than biological in origin, reflecting environments that were not designed to support Deaf children’s health literacy development. 24 Nutbeam’s health literacy framework bridges these perspectives by illustrating how structural exclusion progressively limited participants' foundational health knowledge, their ability to engage with providers, and their capacity for autonomous decision-making. 25 Together, these frameworks show that the inequities documented in this study are not isolated or coincidental, but the result of systems that have consistently failed Deaf individuals at every level of health literacy development and at every point of contact with care.
These findings carry implications that extend beyond the Thai context. The Human Rights Model of Disability finds its strongest international expression in the UN Convention on the Rights of Persons with Disabilities (CRPD), which explicitly recognizes the right to health without discrimination (Article 25) and the right to access information and communicate through sign languages (Article 21). 26 The WHO Global Report on Health Equity for Persons with Disabilities further calls for health systems to move beyond accommodation toward the proactive inclusion of disabled people in the design and delivery of care. 27 The experiences described in this study reflect a persistent gap between these international commitments and lived reality, a gap not unique to Thailand but documented across diverse healthcare systems globally.11,19,20 Sign Language must therefore be reconceptualized not as a supplementary accommodation but as a central component of equitable public health communication, supported by workforce development, institutional infrastructure, and enforceable policy mandates.
Interacting Themes
To illustrate how the different factors interact and influence one another, Figure 1 summarizes the relationships identified across the themes.
Figure 1.
Interactions among factors affecting Deaf students’ healthcare
Limitations
The findings are situated within a specific sociocultural and linguistic context. Because healthcare experiences for Deaf individuals are shaped by local policies and communication norms, these results may not be directly transferable to populations navigating different national healthcare systems or linguistic frameworks. The interview guide was not formally validated, which may have affected the consistency of data elicited. Additionally, the absence of member checking and peer debriefing may limit the extent to which the findings reflect participants' own interpretations. Finally, no member of the research team identifies as Deaf or hard of hearing, which may have introduced interpretive limitations despite the reflexivity measures employed. Future research should incorporate formal validation and participatory approaches to strengthen methodological rigor.
Conclusion
This study demonstrates that communication barriers and health literacy gaps are not incidental features of individual encounters but structural characteristics of hearing-centered healthcare systems. The findings highlight the need for systemic responses that move beyond individual accommodation toward structural reform. These include communication accessibility, Deaf-informed clinical practice, and institutional support for sign language access. Addressing these barriers requires coordinated action at the policy level, recognizing sign language as a central component of equitable public health communication. Further research across diverse healthcare contexts will be essential to advancing health equity for Deaf communities globally.
Supplemental Material
Supplemental Material for Communication Barriers and Health Literacy Gaps Undermine Equitable Healthcare for Deaf Sign Language Users: A Qualitative Study by Patiparn Srisirirat, Supak Sanguansap, Natwasa Samchusin, Penphak Kaewdee, Wipawee Kiewkam, Wilaiporn Pudchimphet, Saipin Hathirat in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Acknowledgments
We extend our deepest thanks to the participants for their time, cooperation, and contributions to this research.
Author Contributions: Patiparn Srisirirat: Conceptualization, Methodology, Data collection, Analysis, Project administration, Writing-reviewing and editing.
Supak Sanguansap: Methodology, Analysis.
Natwasa Samchusin: Methodology, Data collection, Resources.
Penphak Kaewdee: Methodology, Data collection, Resources.
Wipawee Kiewkam: Methodology, Data collection, Resources.
Wilaiporn Pudchimphet: Methodology, Data collection, Resources.
Saipin Hathirat: Conceptualization, Analysis, Supervision, Writing-reviewing and editing.
Funding: The authors received no financial support for the research, authorship, and publication of this article.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Supplemental Material: Supplemental material for this article is available online.
ORCID iD
Patiparn Srisirirat https://orcid.org/0009-0006-4933-0715
Ethical Considerations
Ethical approval was obtained from the Human Research Ethics Committee of the Faculty of Medicine Ramathibodi Hospital, Mahidol University on 07 August 2024 (COA No. MURA2024/542).
Consent to Participate
Written informed consent was facilitated through professional Thai Sign Language (TSL) interpreters to ensure the participants fully understood the study protocol. Participants were also informed about the primary investigator’s clinical background and professional interest in improving healthcare accessibility for Deaf patients.
Data Availability Statement
The collected data are not publicly available to ensure the privacy of participants and protect the confidentiality of their sensitive accounts.*
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Material for Communication Barriers and Health Literacy Gaps Undermine Equitable Healthcare for Deaf Sign Language Users: A Qualitative Study by Patiparn Srisirirat, Supak Sanguansap, Natwasa Samchusin, Penphak Kaewdee, Wipawee Kiewkam, Wilaiporn Pudchimphet, Saipin Hathirat in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Data Availability Statement
The collected data are not publicly available to ensure the privacy of participants and protect the confidentiality of their sensitive accounts.*