Women

with
Disabilities
educational programs
Communication
Health Professions Curricula

“help”
American Sign Language

Communicating Using Interpreters and

Communication Aids
Women Who Are Blind
Total blindness is the complete
lack of form and light perception.
The term “blind,” however, is
frequently used to describe severe
visual impairment with residual
vision.
Low Vision and Blindness

 Formal definitions exist, but informally,

those who, even with corrective lenses,
cannot read the biggest letter on an eye
chart are considered legally blind.
 Reading Aids and Devices for Women
who are Partially Sighted or Blind
People who are blind or have low vision use various
assistive technologies to enable them to access printed texts.

 Braille
 Large print
 Technology with voice output
 Accessible Internet

The patient will generally bring her own equipment to the

physician visit if she relies on a specific technology.
 Braille
 Braille is not a language. It is a code by which all
languages may be written or read.
 Braille can be read with the fingers by people who are
blind, deaf-blind, or visually impaired.
 The Braille cell is an arrangement of six raised dots.
Different patterns represent letters, numbers, etc.
 The average reading speed is about 125 words per
minute, but skilled Braille users can read at speeds of
several hundred words per minute.
 Reading and Writing Braille

 BrailleNote mPower™
A personal computer that functions like a
sighted person’s laptop—the Braille
keyboard allows the user to input
material and access it later via Braille or
voice synthesizer.

 Reizen RL350 Braille Labeler

Embosses Braille on vinyl or magnetic
tape for labeling files, notes, etc.
 Making Large Print Clear
 Print Size
Generally 18–24 point; depends on individual.

 Color and Contrast

Contrast between background and text is a vital factor in legibility.

 Typeface
Avoid italic or handwriting fonts and instead use a common sans-serif
typeface like Arial; when writing use a thick black felt pen.

 Paper
Use good-quality paper that doesn’t show print through on the other
side and is not glossy.
 How Can I Assist My Patient in My
Office?
 Make Things Bigger
Write using large letters
and magnify.

 Be Bold
Use a thick black felt pen to
contrast against white paper.

 Brighten up
Improve general lighting levels
or provide direct lighting.
Reading Large Print
 People who read large
print may read with:
– prescription lenses
– special magnifiers
– closed circuit television
(CCTV) technology
 A CCTV consists of a
camera, under which the
user places the text; the
camera enlarges and
projects the text image
onto a television-like
screen
 Audio Output Devices

 Patient records information

for later playback
– Digital recorders
– Standard cassette
recorders
Devices & Assistive Technology Aids:
Patient Referrals
 Guide for Funding Assistive Devices
http://www.atnet.org/education/fundingat.htm
 HumanWare
http://www.humanware.com
 The Braille Note
http://www.freedomscientific.com
 The Braille Labeler
http://www.sightconnection.com
 MaxiAid Products for Independent Living
http://www.maxiaids.com
 The Internet

 Speech programs read

information on the screen or
output to Braille printer; blind
person uses keyboard
commands to navigate.
 The Internet transformed
information access for people who
are blind or low vision.
 Federal regulations require
federal websites (NIH) to be
accessible (www.section508.gov).
 Adapting Written Communication
 Encourage patient to record or take notes
during interview
 Communicate medical information and
other written instructions via email
– patient will be able to access at home
 Specific medical information is available
on accessible websites
 Talking Rx® prescription reader
– doctor or pharmacist records prescription
instructions; patient can play back at any
time
Women with
Cognitive Disabilities
The concept of cognitive disability
is extremely broad.
In general terms, an individual
has greater difficulty with mental
tasks than the “average” person.
 Types of Cognitive Disabilities

There are too many cognitive disabilities to

list, but some of the major categories are:

traumatic brain injury

developmental disability
aphasia
mental impairment
learning disability
 Cognitive Disabilities
 Cognitive disability  Individuals with
can affect one or more cognitive disability can
mental processes: exhibit one or more
– thought states:
– perception – confusion
– reasoning – acute memory disorder
– intuition – delirium
– memory – dementia
– information processing – organic brain syndrome
– psychosis
 Determining Competency for Medical Decision-
Making in the Patient with Cognitive
Disabilities
“So long as the patient appears to adequately understand and
appreciate the personal significance of the following:
(a) that she has a general medical or mental disorder,
(b) the nature and course of the disorder, and
(c) the risks and benefits of the proposed intervention and of the
alternatives, including the alternative of no intervention; and so
long as the patient makes a non-coerced choice that does not
appear to be unduly influenced by a mental disorder, then the
patient may be considered to possess capacity even if her choice
appears to the physician to be unreasonable.”

Moore, Randall F., MD, JD, Assistant Professor of Psychiatry, Department of Psychiatry, Texas A & M University Health Science Center College of Medicine. A Guide to the Assessment and Care of the Patient Whose Medical Decision-Making
Capacity is in Question. Medscape General Medicine, November 10, 1999. Online:http://www.medscape.com/viewarticle/408024_1.
 Factors That Affect Communication with
Women Who Have Cognitive Disabilities

 May not be able to report symptoms accurately

 May not understand what is happening during the
physical examination
 May not comprehend or be able to implement follow-up
plan
 Physician may not know what is being understood and
what is not
 Proxy may not be allowing the patient to participate to
the best of her ability
 Communicating with a Woman with
Cognitive Disability
Speak slowly and Make the information
clearly; give the as concrete as
person time to possible.
think through the
Information.

Use short instructions Use gestures,

and simple, direct diagrams, or pictures.
sentences.
 Communicating with a Woman with
Cognitive Disability

The person may or Use gestures,

may not be able to diagrams, or pictures.
read.

If the person has difficulty understanding,

repeat using different wording.
 Resources for Women with Cognitive
Disabilities
The Coleman Institute for Cognitive Disabilities
http://www.colemaninstitute.org

American Association of People with Disabilities

http://www.aapd.com

Ability Hub
http://www.abilityhub.com/cognitive/index.htm

The National Center on Disability and Access to Education

http://ncdae.org

U.S. Dept. of Labor

Communicating With and About People with Disabilities
http://www.dol.gov/odep/pubs/fact/comucate.htm
Communication
women with speech and
language disorders
Women with Speech
and Language
Disorders
Speech and language disorder is a
broad term that refers to problems in
communication and related areas
such as oral motor function.
Communicating with a woman who is nonverbal or whose
speech is difficult to understand
Many times the family or familiar
listeners can understand a
certain percentage of their
speech, but nonfamiliar listeners
have more difficulty.
Many Common Diagnoses That
Affect Speech
 Cerebral palsy
 Stroke
 Brain injury
 Multiple sclerosis
 ALS
 Parkinson's
 Throat cancer
 Autism
 Developmental disabilities
 Distinguishing Between Speech and
Language Disorders
 Language is the
understanding of words.
 Speech is the way
language is voiced or
articulated.
 An individual can have a
speech disorder, a
language disorder or both
conditions.

National Aphasia Association

Implications of Specific Speech and
Language Disorders

 Speech disorders are often the result of

oral-motor problems and can cause
impaired articulation.
 Language disorders, like aphasia, are
limitations in the comprehension and
expression of language.
A Specific Note about Aphasia

Aphasia can result in switching words

that are:
- close in sound like pain and point
- close in meaning like earache and
headache
- opposites like better/worse
 Common Communication Barriers
 Some women with speech and language
disorders have cognitive disabilities;
others do not
 More time is necessary to listen to
what the individual is saying
– verbal communication can be difficult
– may use electronic speech or talking board
 People want to rush or complete
sentences for the person — not take
time to listen to what is being said
What do I Need to Know When
Communicating with a Patient?

 Speech may be difficult to understand or

unintelligible.
 Speech disorders can cause anxiety,
frustration, feelings of inadequacy for the
speaker.
 Tips for Improving Communication
 Pay attention to the woman
and watch her as she talks.
 Be honest and let her know
when you have difficulty
understanding her.
 Repeat the part of the
message that you
understood, so that the
speaker does not have to
repeat her entire message.
More Tips
 If you are unable to understand
the message after repeated
attempts, ask yes/no questions
or have the woman write her
message to you.

 If you ask a question,

sometimes writing down a
number of options can be a
useful way for the individual to
choose the answer they are
looking for.
 Asking Yes/No Questions
Advantage Disadvantage
 Easy for communication  Frustrating for the individual
partner to understand who wants to add more
the yes/no answer. information than just a yes/no.
 The communication partner
may ask yes/no questions that
are difficult to answer, for
example, “You didn’t like that
book, did you?” “No” may
mean that the woman did not
like the book, or that she
disagrees with the statement
and actually liked the book.
 Written Choice

 Technique that allows a person, with help from

the communication partner, to clearly express
opinions, provide information, and make choices
simply by pointing to a written word or phrase.
 The more familiar the
communication partners are,
the better the choices will be.
Written Choice

Guidelines for the

Communication Partner
 Augmentative Communication

Augmentative communication
Refers to “methods of
communication that
enhance, augment or
replace conventional forms
of expression.”

U.S. Society for Augmentative and Alternative Communication.

 Augmentative Communication
High-Tech Systems Have Speech Output and Include the Following:

 Big Mack device that speaks one

message upon activation
 Dedicated communication device that
has 32 messages on a page and
eight different levels
 Communication software
program on a
laptop computer
You Don’t Have to Know
How to Use a Device
 Partner-Assisted Scanning

 Used to communicate in a
situation when a person
cannot point to an alphabet
board, or use an existing
communication system, for
example, when positioned in
bed on the side, or during an
MRI
 Requires no equipment unless
an AEIUO board is available
 Procedure for Partner-Assisted
Scanning
 Communication partner asks if  The partner may want to write
the first letter of the word is in the down the indicated letters on
“a, e, i, o, or u” row, stating one paper if the message is long, to
letter at a time and waiting for a help remember the letters, and
response.
perhaps even
 Person indicates “yes” with a to remind the
motor movement when she hears communicator
the correct letter, for example, what has been
looking up or down, or making a
gesture. said so far.
 Communication partner then
names the letters in that row one
at a time, for instance, if the
communicator indicates the first
letter is in the “i” row, the partner
then repeats i, then says j, k, l, m,
n, until a “yes” is indicated.
 Eye Gaze System

 Can be used when the patient has no use of

the arms/hands to indicate what she wants or
needs
 Relies on the communication partner watching
the person’s eye gaze to the word/picture that
she wants to communicate
 Communication Etiquette

 Be patient.
 Treat the communicator with
respect at all times.
 Don’t assume the person
with an expressive
communication disorder has
a cognitive impairment.
 Communicate on “eye” level
as much as possible.
 And More Communication Etiquette
 Utilize the person’s facial expressions and body
language to augment communication.
 Don’t limit conversation to yes/no questions—
ask choice questions also.
 If you are having significant difficulty
understanding the person, ask permission to ask
questions of the family member/caregiver/
significant other accompanying her when
appropriate.
And most important:
 Don’t pretend to understand someone
when you don’t!
 Communication Etiquette with
Use of a Device
Remember that people who have
a speech impairment may use a
variety of ways to communicate.
A patient may choose to use
American Sign Language, to write,
to speak, to use a communication
device, or to use a combination of
methods. Find out the woman’s
preferred method and use it.
Non Effective Communication With
Person Using Device with Speech Output

Video
Two people interacting
using a word board
Resources for Further Exploration
into Augmentative Communication
 American Speech-Language-Hearing Association (ASHA)
http://www.asha.org/public/speech/disorders/Augmentative-and-Alternative.htm

 International Society for Augmentative and Alternative Communication (ISAAC)

http://www.isaac-online.org/en/home.shtml

 Augmentative Communication, Inc.

http://www.augcominc.com

 The Journal of Augmentative & Alternative Communication

http://www.tandf.co.uk/journals/titles/07434618.asp

 Augmentative Communication Consultants

http://www.acciinc.com

 United States Society for Augmentative and Alternative Communication

http://www.ussaac.org
Women Who Are
Deaf, Deafened, or
Hard of Hearing
Approximately 10% of the
population has some degree of
hearing loss. Communication
needs vary greatly depending on
the degree of loss.
 How Do Deaf and Hard-of-Hearing
People Communicate?

There is no single
answer.
 A Variety of Ways
An individual’s choice of
communication often
depends on the severity
of the hearing loss and
whether spoken
language was acquired
before or after the loss.
 American Sign Language
 Speech reading
 Written notes
 Computer-assisted real-
time transcription
Not all people who
are deaf or hard of
hearing use sign
language to
communicate.
Speech Reading
Some People Speech Read (Lip Read) and Can
Understand Spoken Words Fairly Well with the
Speaker’s Help

 Position yourself so patient can

see your face clearly.
 Speak slowly and distinctly.
 Repeat or rephrase words
if not understood.
 Use natural body language
and gestures.
 Supplement with written
notes when needed.
 Communication Access
Real-Time Transcription (CART)
 Many people who are
deaf or hard of hearing
are not trained in either
sign language or
speech reading.
 CART is a service where
an operator types what is
said into a computer that
then displays the words on
a screen.
 People who have developed a severe hearing loss later
in life often use CART.
A visually
interactive
language that uses
a combination of
hand motions,
body gestures,
and facial
expressions
The group most likely to
use American Sign
Language (ASL) as
primary language are
people deafened at birth or
early childhood, before
acquiring fluency in a
spoken language.
When sign language is the patient’s primary form
of communication, the services of a qualified sign
language interpreter are often necessary.

“sick”
~ American Sign Language
 I Don’t Need an Interpreter. . .

Written Notes
 Many deaf people are not
fluent in written English.
 Writing detailed information
is time-intensive.
 Written notes tend to
condense ideas, leaving out
important information.
 . . . or Do I?

Speech Reading
 Most people overestimate the
accuracy of speech reading.
 40–60% of English sounds look
alike when spoken.
 Speech reading requires
significant guesswork.
What Is the Role
of a Sign Language
Interpreter?
Interpreters bridge the communication gap
between healthcare providers and patients
who are deaf.

“assist”
~ American Sign Language
A sign language interpreter is a trained professional
who facilitates communication so
that hearing and deaf individuals may fully interact.

The Interpreter….
 Maintains the integrity of the
message
 Conveys the content and spirit
of the speaker
 Neither adds or deletes any
information
 Sign Language Interpreters

 Facilitate optimal
communication
 Contribute to optimal
outcomes
 Reduce interpretation errors

 Improve patient satisfaction

What Defines a
Qualified Sign
Language
Interpreter?
Why Not Have a Family
Member Interpret?

“sexual relations”
~ American Sign Language
 Dangers of Ad Hoc Interpreters

Family members, friends, or untrained staff

are significantly more likely to commit
interpretation errors in general and, in
particular, errors with potential or actual
negative clinical
consequences.

Flores G, Laws M, Mayo S, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics
2003; 111:6-14.
 Ad Hoc Interpreters . . .

 Are less likely to tell patients

about medication side effects
 Are more likely to misinterpret or
omit questions asked by
healthcare providers
 Result in significantly lower
patient and clinician satisfaction
than other strategies

Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev 2005; 62: 255-299.
 Risks of Children Interpreting for
Their Deaf Parents

 Frequently embarrassed by and

tend to ignore questions about
menstruation, bowel movements,
and other bodily functions
 More likely to make interpretation
errors with potential or actual
clinical consequence

Flores 2005.
 Patient Safety

Inadequate communication with deaf

and hard-of-hearing patients can lead to:

 Misdiagnosis
 Medication errors
 Patient discomfort
 Patient embarrassment

Iezzoni L, O’Day B, Killeen M, et al. Communicating about health care: observations from persons who are deaf or hard of hearing. 2004; Ann Intern Med
140: 356-362.
In Which Situations Are Interpreters
Needed?

“sign language”
~ American Sign Language
 Any Time the Information to Be Exchanged
Requires Effective Communication, Such as...

 Taking a medical history

 Explaining procedures or
diagnoses
 Planning treatment
 Providing discharge instructions
 Obtaining informed consent
 Instructing medication usage
 Offering educational
presentations, such as a
birthing class
 Not Every Situation
Requires an Interpreter
It depends on the abilities of the person who is deaf or hard of hearing and the complexity and nature
of the communication.

For example,
exchanging written
notes or speech
reading may be
effective for a brief
follow-up visit.
Types of Interpreters

“interpret”
~ American Sign Language
 Sign Language Interpreting

 In most cases, this means

American Sign Language, or ASL,
although there are other forms of
sign language in the United
States, such as Signed Exact
English.
 Qualified interpreters are fluent in
both forms.
 Oral Interpreting

Not all people who are deaf

are trained in sign language,
but they may use an
interpreter just the same.

Oral interpreters are specially

trained to articulate speech
silently and clearly, sometimes
rephrasing words or phrases to
give higher visibility on the lips.
Not all interpreters are skilled
in this form of interpreting.
 Deaf-Blind Interpreting

Interpreter
communicating
with an individual
who is deaf-blind
Interpreting for
persons who are both
deaf and blind requires
specialized skills.
Several interpretation
methods can be used
depending on the
client’s preference.
Not all interpreters
possess these skills.
How Can I
Work Effectively
with an Interpreter?
“connect”
~ American Sign Language
 Speak Directly to
the Person Who Is Deaf

Don’t ask the interpreter:

“Does she have any questions?“

Ask your patient:

“Do you have any questions?”
 Realize That the Interpreter
Cannot . . .

 Provide any information

about the patient
 Counsel, advise, or
interject personal opinions
 Enter the conversation
 Understand That the Interpreter
Must . . .

 Interpret all that is said

in the presence of the
patient who is deaf

 Not edit out anything

spoken as an aside or
to others in the room
 Qualified interpreters adhere to an industry
Code of Ethics.
 Confidentiality is a fundamental tenet of
the code.
 Qualified interpreters respect the privacy
of their clients and hold in strict confidence
all information obtained in the course of
the provider-patient interaction.
Video Clip 2
Provider-patient interaction
with sign language interpreter
a) incorrect etiquette
b) correct etiquette
 As Required by Law
Title III of the Americans with Disabilities Act of 1990
P.L.101-336

 Title III of the ADA obligates healthcare providers to make

reasonable accommodations to meet the needs of people
with disabilities.
 Providers have a duty to provide effective communication
using auxiliary aids and services that ensure
communication with people who have a hearing loss is as
effective as communication with others. 28 C.F.R.
S36.303 (c)
 Qualified interpreters are considered auxiliary aids.
 But I Only Have a Small Practice

Title III of the ADA

applies to all private
healthcare providers,
regardless of size of
the office or number
of employees.
Providing Accessible
Communication
in Your Office
A Step-by-Step Approach
First, in consultation with your patient, determine the
appropriate aid or service needed to facilitate effective
communication.

Courts have found an

ADA violation where the
provider decides not to
use an interpreter and
the method used did not
result in effective
communication.
 Office Management

 Designate a staff person to be an

ADA coordinator.
 Arrange for staff training on
how to respond to patient
requests for accessible
accommodations.
 Develop an office policy
and procedure on
communication with patients who
are deaf and hard of hearing.
 How Do I Find a
Qualified Interpreter?
 Contact an interpreter
service agency in your
community.
 Describe type of interaction.
– routine office visit,
counseling, surgery

 Inquire about credentials of

assigned interpreter.
 Associated Costs

 The healthcare provider or facility

must pay for the cost of an
interpreter.
 Providers cannot impose a
surcharge on the patient either
directly or indirectly to offset
interpreting costs.
 Interpreter costs should be
treated as an overhead expense
for tax and accounting purposes.
 Tax Relief

 An IRS tax credit of up to 50% for

business expenditures made in
compliance with ADA standards is
available.
 Expenditures must exceed $250 but not
$10,250.
 Eligible expenses include
cost of interpreters.

Omnibus Budget Reconciliation Act of 1990 P.L. 101-508, S 44.

 Related Resources
 American Medical Association. Americans with Disabilities Act and
hearing interpreters. www.ama-assn.org.
 Barnett S. Cross-cultural communication with patients who use
American Sign Language. Fam Med. 2002;34(5):76-82.
 National Association of the Deaf. ADA questions and answers for
healthcare providers. www.nad.org.
 Registry of Interpreters for the Deaf. Standard Practice Paper:
Interpreting in medical settings. www.rid.org.
 U.S. Department of Health and Human Services, Office of Civil
Rights. Questions and Answers: Communicating with hearing-
impaired individuals. www.hhs.gov/ocr.
 U.S. Department of Justice, Civil Rights Division. ADA Business
Brief: Communicating with people who are deaf or hard of hearing in
hospital settings. www.ada.gov.
Recognized symbol
denoting availability
of a sign language
interpreter
Women
with
Disabilities
educational programs