Healthcare Access Barriers Among Deaf Adolescents in Nepal: A Cross-Sectional Study to Inform Provider awareness

Healthcare Access Barriers Among Deaf Adolescents in Nepal: A Cross-Sectional Study to Inform Provider awareness | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Healthcare Access Barriers Among Deaf Adolescents in Nepal: A Cross-Sectional Study to Inform Provider awareness Sadikshya Poudel, Bhawana Panta This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7542608/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Feb, 2026 Read the published version in BMC Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Research on healthcare access barriers among people with hearing loss in Nepal is limited, and studies focusing on Deaf adolescents are particularly scarce in low- and lower-middle-income countries. This study explored healthcare access barriers among Deaf adolescents whose primary mode of communication is sign language. Methods: A descriptive, cross-sectional study using quantitative and qualitative methods was conducted at Dhaulagiri Deaf Residential Secondary School in Baglung, Nepal, the only secondary-level institution offering a diploma in computer engineering and enrolling students from across the country. A total of 135 Deaf students from grade eight to diploma level completed structured questionnaires. In-depth, face-to-face interviews were conducted with 10% of diploma-level students, randomly selected by lottery. Four barrier categories were assessed: structural, communication with healthcare providers (HCPs), attitudes of HCPs, and financial. Results: Participants had a mean age of 19.9 years (SD 2.85); 70.4% were male and 53.3% were diploma students. Most participants (90.4%) did not use assistive listening devices, and 74.1% reported congenital hearing loss. Structural barriers included long waiting times (64.4%) and transportation challenges (11.9%). Communication barriers were frequent: 25% had access to interpreters, and 37.8% reported easy communication with HCPs. Attitudinal barriers were reported, with only 31.1% finding HCPs friendly and 27.4% comfortable during interactions, while 15.6% even experienced mistreatment by HCPs. Financial barriers included cost-related difficulties, limited awareness of health insurance (37%), and low coverage (4.4%). Qualitative interviews highlighted difficulties in understanding rapid speech, raising doubts regarding medications. Participants felt that HCPs seemed unaware of their challenges in comprehending communications. Conclusions: Communication difficulties and HCPs’ attitudes were the most prominent barriers to healthcare access among Deaf adolescents. These findings highlight the pressing need for deafness awareness programs for HCPs to improve healthcare accessibility for Deaf and hard-of-hearing people. Healthcare access barriers Deaf adolescents sign language Nepal healthcare provider awareness deafness awareness program Background of the Study Hearing loss impairs communication, leading to poorer health outcomes and difficulties in accessing healthcare. 1,2 Individuals with severe hearing loss are at greater risk for chronic conditions and mental health problems. 3 Effective communication is essential for treatment adherence, positive health outcomes, and patient satisfaction. 4 However, people with hearing loss often encounter communication barriers with healthcare providers (HCPs), resulting in misunderstandings, misdiagnoses, and delayed treatments. 2,5 Despite equitable healthcare access being a recognized right, these barriers remain significant. 1 Globally, nearly 80% of individuals with hearing loss live in low- and middle-income countries (LMICs). 6 Although several studies have highlighted communication difficulties and barriers in LMICs, 7-13 most research is concentrated in high-income countries (HICs). A systematic review (2000 to 2015) also confirmed this imbalance. 3 In Nepal, the burden of ear diseases and hearing loss is high. 14-16 Some studies have examined the severity and impacts of hearing loss, as well as associated mental health needs, 14-18 but evidence on healthcare access barriers remains limited. Contributing factors may include a shortage of professionals, inadequate resources, and limited funding for hearing-related research in Nepal. 19 Due to challenges in reaching individuals with hearing loss, the eligible population is often approached in the community, door-to-door, through personal contacts, or when visiting healthcare facilities or health camps. 15-18 Such approaches, however, capture individuals with varying degrees of hearing loss. For example, a large-scale study in Nepal reported a 5.7% prevalence of hearing impairment among students in mainstream schools, with three-fourths having mild hearing loss and one-fourth moderate to profound. 14 The communication barriers faced by individuals with mild to moderate hearing loss in healthcare settings may not be as severe as those experienced by individuals with profound hearing loss. Studies on healthcare access barriers among Deaf individuals provide deeper insights into these challenges. Yet, studies focusing on young Deaf adolescents are especially scarce in LMICs, 7,12 including Nepal. Identifying individuals with severe or profound hearing loss across mainstream schools and communities is difficult, and many may not be proficient in sign language. To address this gap, the present study was conducted in a Deaf residential secondary school, focusing on adolescents whose primary mode of communication is sign language (signing deaf). To address this gap, the present study was conducted in a Deaf residential secondary school, focusing on adolescents whose primary mode of communication is sign language (signing Deaf). Research Aims This study employed an observational cross-sectional, descriptive design, integrating both quantitative and qualitative methods. Four healthcare access barrier categories were selected based on two guidelines: the National Guidelines for Disability-Inclusive Health Services (NGDIHS) in Nepal and the Health Care Access Barrier (HCAB) model. 20,21 The categories included: structural barriers, communication with HCPs, HCPs' attitudes, and financial barriers. The study aimed to answer the following research question: “What healthcare access barriers do young Deaf students experience across these four barrier categories?” Method Study Setting and Site Nepal has 22 government-run schools for Deaf students where Nepali Sign Language (NSL) is the primary language of instruction. 22 Most schools offer education only up to Class 5 or 8; six extend to Class 10, and four provide secondary-level education. Only one of these institutions offers a bachelor's program, and there are no private schools for deaf students in the country. 23,24 Among the four secondary-level schools, Dhaulagiri Deaf Residential Secondary School is the only institution offering a three-year computer engineering diploma after Class 10, attracting students from across Nepal. The school is in Baglung, a hilly town near Pokhara, a popular tourist center, in western Nepal. Established two decades ago with 24 students, the school had an enrollment of 254 at the time of the study. The study targeted Deaf students from Class 8 through the diploma level, who primarily use NSL. According to WHO, hearing loss is classified as mild (26-40 dB), moderate (41-60 dB), severe (61-80 dB), and profound (over 81 dB). 25 Individuals classified as Deaf typically have severe to profound hearing loss, and the term "Deaf" (capital D) refers to individuals who use sign language as their primary mode of communication. All students resided in hostels, which provided free meals and accommodation. Public hospital HCPs are available on call but lack NSL proficiency. Inclusion and Exclusion Criteria School policy requires that at least 5% of students in each class have typical hearing, selected from socioeconomically disadvantaged backgrounds, to assist during emergencies. Of the 151 students enrolled from Class eight to diploma level, 16 with typical hearing were excluded. The final sample consisted of 135 Deaf students who met eligibility criteria and provided informed consent. Selection of Barrier Categories Health Care Access Barriers were identified using the National Guidelines for Disability Inclusive Health Services (NGDIHS) in Nepal and the (HCAB). 20,21 While neither framework is specific to hearing loss, four barrier categories were selected: structural, communication with HCPs, HCPs' attitudes, and financial barriers. 20,21 The categories of structural, communication, and financial barriers are self-explanatory. Attitudes, defined as enduring beliefs and perceptions that influence individual behavior, play a crucial role in shaping interactions and are often inferred from both verbal and non-verbal cues. 26 Participants provided responses on all four categories through questionnaires and in-depth interviews. Study Design This observational, cross-sectional, descriptive study integrated quantitative and qualitative methods. The questionnaire used for quantitative data collection was developed according to the four barrier categories and pretested with 10% of the eligible students at the Central Deaf School in Kathmandu to further refine and validate the instrument (English version provided in Supplementary File 1). For qualitative data, in-depth, face-to-face interviews were structured around the same four categories. The study was carried out from July to December 2019. Data Collection and Analysis Demographic and quantitative data were collected via self-administered questionnaires from all 135 students and analyzed using SPSS version 16.0. Descriptive statistics included frequencies, mean age, and standard deviation. Qualitative data were collected through in-depth, face-to-face interviews with 10% of senior diploma-level students, randomly selected using a lottery method, including one male and one female from each year. Interviews (~30 minutes each) were conducted by the first author, with interpretation provided by an NSL-proficient teacher. All interviews were audio-recorded, transcribed, translated into English, and key findings summarized. Ethical Considerations Ethical approval was obtained from the Institutional Review Committee at Nobel College (Ref No: BPH IRC 43/2019), and permission was granted by the school management committee (Code no. 0041). Informed consent was obtained from all participants, with confidentiality and anonymity ensured throughout the study. The right to withdraw from the study at any time was ensured. Positionality Statement This study was conducted by two female researchers with typical hearing from Nobel College, Kathmandu, Nepal. Recognizing healthcare access as a significant public health issue, the researchers approached the study with awareness of their positionality and a commitment to ethical and inclusive engagement with the Deaf community. Results Demographics A total of 135 participants were included in the study. Among them, 95 (70.4%) were male and 40 (29.6%) were female, with a mean age of 19.93 years (SD 2.85). Regarding educational level, 46.7% were from grades 8 to 10, while 53.3% were diploma students. Most participants (90.4%) did not use assistive listening devices; among those who did, 7.4% used hearing aids, 0.7% used a cochlear implant, and 1.5% used both. With respect to the causes of hearing loss, 74.1% reported congenital hearing loss. Among those with acquired hearing loss (25.9%), illness was the leading cause (74.3%), followed by trauma (20%) and swimming-related causes (5.7%). The full demographic profile is presented in Table 1. Healthcare Access Barriers Quantitative responses for healthcare access barriers are presented in Table 2. Qualitative findings from face-to-face, in-depth interviews are summarized below to provide context and illustrate participants’ experiences. Structural Barriers Structural barriers to healthcare were limited but notable. Only 11.9% of participants reported experiencing transportation barriers when accessing health facilities. However, long waiting times were a common concern, affecting 64.4% of participants. In-depth interviews revealed that participants faced additional challenges related to accessibility and waiting times: “We do not get disabled seats because we do not look disabled .” “The waiting time in the hospital has bothered me a lot. There is no difference between people with and without hearing loss. Everyone has to wait . I feel there should be separate waiting lines for people with and without disabilities.” “I hate waiting in the hospital—waiting for an appointment, waiting for a doctor, and then waiting for free medicines, which I rarely get.” These narratives illustrate that while physical access may not be a major barrier, structural elements such as seating arrangements and waiting periods significantly impact the healthcare experience. Communication with Healthcare Providers Communication barriers were prevalent among participants. Only a quarter of participants had access to interpreters, while others relied on writing (41.5%), gestures (25.9%), or lip-reading (7.4%) to communicate with healthcare providers. Despite these methods, only 37.8% reported that they could easily communicate with providers, and 17.8% regularly asked providers to repeat instructions when unclear. Qualitative data emphasized the challenges associated with communication and underscored the importance of interpreters: “I can understand them if they speak slowly, but most talk very fast, and I just cannot catch their lip sync .” “I always have doubts about medications because I cannot directly communicate with healthcare providers. I doubt whether I have received the right medication or not... these barriers demotivate us from going to the hospital.” “There is an interpreter only in the central hospital. Every hospital should have an interpreter. An interpreter is like our bridge .” “I think there should be interpreters in every hospital. That will be very helpful.” These findings indicate that communication difficulties are widespread and have a substantial impact on understanding and confidence in healthcare services. Attitudes of Healthcare Providers Perceptions of healthcare providers’ attitudes were mixed but tended toward negative experiences. Only 31.1% of participants found providers friendly, and 27.4% felt comfortable during interactions. While 30.4% received special attention from providers, 15.6% reported feeling mistreated by healthcare providers, and 13.3% felt mistreated by other staff. Participants described instances of perceived discrimination or neglect, which contributed to mistrust and hesitancy in seeking care: “People with typical hearing can understand everything so easily, but we cannot. People should remember this. They always hesitate to explain things to us.” “I write my symptoms on paper when going to the pharmacist. They sometimes laugh at me .” “We fear and hesitate to access healthcare services because of poor communication.” “We mistrust healthcare providers due to such poor communication.” These accounts highlight that interpersonal experiences with providers significantly influence participants’ confidence and willingness to access healthcare services. Financial Barriers Financial barriers were commonly reported. Approximately half of participants (49.6%) sometimes experienced cost-related difficulties, while 17% reported regular financial challenges. Only 37% had heard of health insurance, and coverage was minimal (4.4%). Sources of healthcare financing included school support (82%), out-of-pocket payments (52.3%), free government health services (40.6%), and charitable organizations (40.6%). Qualitative interviews further illuminated the financial challenges faced by participants: “I have never heard about insurance. Nobody informed me about it.” “I do not have health insurance, but I would like to have it.” “We rarely get free medicine supplied by the government health service.” “Health care should be made accessible and affordable, considering all the barriers we face.” “I am so thankful for my school, which has loved and cared for us so well, taken us to the hospital when needed, called our parents in an emergency, and provided lodging and food to them when they visited us.” These findings suggest that financial constraints are a significant barrier to healthcare access, compounded by low awareness and limited utilization of health insurance. Discussion Overview of the Findings This study explored healthcare access barriers faced by young Deaf students in Nepal, addressing a critical gap in the literature from low- and lower-middle-income countries. Barriers were categorized into structural barriers, communication with healthcare providers (HCPs), attitudes of HCPs, and financial barriers, based on two established models. 20,21 Such categorization is less common, as most existing studies focus primarily on general communication issues without explicitly addressing provider attitudes. 8,9,27 Conducted at one of only four secondary schools in Nepal offering a computer engineering diploma, the study provides insights into the healthcare experiences of Deaf youth from across the country. Data were collected from all students in class eight and above, with in-depth interviews conducted among 10% of senior diploma-level students. The sample size aligns with prior international studies on healthcare access among Deaf populations, which have ranged from 13 to 140 participants across interviews, questionnaires, and focus group discussions. 7-13,28 Demographic Characteristics Most participants were male, although national data indicate hearing loss prevalence is generally similar across genders, particularly for mild conductive issues such as otitis media. 14 Children with severe or profound hearing loss may be less likely to attend mainstream schools. The male predominance may reflect higher interest in technical education such as computer engineering among boys, or parental reluctance to send daughters with hearing loss to a residential school. Most participants reported congenital hearing loss, while acquired cases were primarily linked to illness, trauma or swimming-related ear infections. Structural barriers Most participants reported minimal transportation difficulties, likely reflecting the school’s convenient location. However, approximately two-thirds expressed concerns regarding long waiting times at hospitals. In-depth interviews highlighted that communication needs were often unrecognized, as Deafness is an invisible disability. Incorporating universal icons for hearing loss in patient records could help HCPs adapt communication strategies. 4 Participants also reported frustration in waiting areas due to insufficient information about delays, which may increase anxiety and the risk of missing appointments. Visual notifications or proactive staff support could help address these challenges, particularly for unaccompanied patients. These observations are consistent with prior studies reporting similar gaps in waiting-room communication. 29 Communication with Healthcare Providers Communication barriers were prominent. Students primarily relied on writing, gestures, and lip-reading, yet rapid speech and unfamiliar medical terminology often limited comprehension. HCPs tended to communicate in a manner suited for individuals with typical hearing, which may inadvertently exclude Deaf patients. Effective visual communication is essential to ensure understanding. 1 Many participants struggled to request clarification or ask providers to repeat instructions, creating uncertainty regarding medication and care. Previous studies have similarly reported that Deaf patients frequently encounter difficulty understanding medical instructions. 30 Strategies such as teach-back methods, clear written instructions, and routine hearing checks could potentially improve understanding and help identify undiagnosed cases. 2 Attitudes of Healthcare Providers Fewer than one-third of participants reported positive interactions with HCPs, with some experiencing discomfort or perceived mistreatment. Negative attitudes and insufficient communication may reduce confidence in seeking care and could contribute to mistrust of healthcare services. These findings are comparable with reports from Greece and Ecuador, where Deaf and hard-of-hearing adults described dissatisfaction with healthcare providers and staff. 13,30 Participants emphasized the potential value of sign language interpreters in supporting effective communication. 7-13,30 While interpreter availability could be prioritized in high-volume hospitals, many individuals with mild or moderate hearing loss are not proficient in sign language. 31 For them, on-site communication-assistive devices and encouragement to use hearing aids could enhance care. 2 Stigma associated with hearing aids may continue to pose challenges; integrating hearing aids into discreet technologies could support acceptance and use, particularly for children, as even mild hearing loss can affect language development and educational outcomes. 15,31,32 Communication Support Strategies and Innovations While proficiency in sign language among HCPs is ideal, 7,8,11 achieving widespread coverage remains challenging. 4,5 Targeted training for selected healthcare professionals, particularly those working with Deaf students or in specialized care settings, may improve communication and the quality of care. Programs in Rwanda have shown that training nurses and community health workers in health-related signs can be effective. 33 Video remote interpreting services (VRIS) offer an alternative where on-site interpreters are unavailable, and accompaniment by family, friends, or teachers may provide temporary support, though this approach has limitations. 5,8 In this study, only one-fourth of participants had such assistance. Emerging technologies, such as AI-enhanced sign language interpretation, may further support communication in the future. Financial barriers Approximately half of participants reported experiencing financial difficulties, and fewer than 5% were enrolled in Nepal’s national health insurance scheme. 34 Although the scheme covers essential services and disability identity cards provide additional benefits, 35 awareness among students was limited. This suggests a need for improved outreach through schools and Deaf-support organizations to increase awareness and utilization of available support. Implications for practice Communication challenges and HCP attitudes were the most prominent barriers identified in this study. Many HCPs communicated in ways typical for hearing patients, speaking rapidly and using approaches that may not fully support understanding for Deaf individuals. These findings suggest the potential benefit of raising awareness among HCPs regarding hearing loss and practical strategies to facilitate communication. Although the importance of HCP education has recently been emphasized in HICs, 27,36 it is less frequently addressed in LMICs. Morisod et al. (2022), in their systematic review of interventions to improve healthcare equity for Deaf patients, highlighted the role of awareness programs in enhancing HCPs’ interaction with patients with hearing loss. 3 A short deafness awareness course for HCPs and support staff, covering the prevalence and consequences of hearing loss, along with practical communication strategies, may help improve understanding and provider behaviors. Techniques such as clear speech, maintaining eye contact, unobstructed facial expressions, gestures, written communication, and use of interpreters could be applied depending on the clinical context. Integrating these strategies into medical, nursing, and allied health curricula may further prepare future providers to respond effectively to Deaf patients’ needs. In LMICs, retail pharmacists often serve as the first point of contact for health concerns, underscoring the importance of including them in deafness awareness programs. Effective communication strategies include speaking clearly, maintaining eye contact, keeping the face unobstructed for lip-reading, using gestures, written notes, proxy interpreters (family or friends), or video remote or face-to-face interpreters. 4,5,8,37,38 Each method carries advantages and limitations, with applicability depending on the clinical situation. 3–5 The ‘AEIOU’ mnemonic (Ask, Environment, Interaction, Outline, and Understanding) provides a practical framework for communication with individuals who have hearing loss. 37 Beyond short-term training, integrating education on the impact of hearing loss and communication strategies into healthcare curricula can better prepare future providers. 1 In the USA, McKee et al. recently described actionable strategies for reframing healthcare for patients with hearing loss at system, clinic, provider, and patient levels. 2 Based on the study findings, a set of recommendations to support Deaf individuals and enhance access to healthcare is presented in Box 1. Implementing such initiatives in low-resource settings may require collaboration and sustained support from both national and international stakeholders, while remaining adaptable to local contexts. Box 1. Recommendations for Improving Healthcare Access for People with Hearing Loss Half-day deafness awareness programs for healthcare providers, support staff, and retail pharmacists. Integration of deafness education into medical, nursing, and allied health curricula. Availability of hearing devices during medical consultations. Deployment of qualified sign language interpreters in high-volume hospitals. Implementation of video-remote interpreting services in community settings. Basic sign language training for selected healthcare providers working with Deaf individuals. Use of universally recognized hearing loss icons in patient charts to alert healthcare staff. Sign language training for Deaf children, adults, and close family members. Encouragement for Deaf individuals to attend healthcare visits with trusted companions when possible. Provision of visual or personalized notifications for unaccompanied Deaf patients awaiting care. Promotion of disability identity cards and health insurance programs through schools and organizations. Support for research and development of discreet, affordable hearing aids to reduce stigma and improve access. Limitations This study has several limitations. First, it was conducted in a single residential school for Deaf students, which may limit the generalizability of the findings. However, as the school is one of only four secondary institutions in Nepal offering a computer engineering diploma and enrolls students from across the country, the results still provide insights from diverse geographic regions. Second, the study focused specifically on Deaf adolescents, so the experiences of adults or individuals with mild to moderate hearing loss may differ. Third, while quantitative data were collected from all 135 students from grade eight onwards, the qualitative component included only about 10% of senior diploma-level students due to time and resource constraints. A larger qualitative sample or the inclusion of focus group discussions could have yielded a richer understanding of participants’ experiences. Fourth, interviews were conducted in Nepali Sign Language with the assistance of teachers, which may have influenced participants’ openness and introduced potential translation bias, particularly regarding perceptions of local healthcare providers. Finally, as this was a descriptive study, no inferential analyses were performed, limiting the ability to examine relationships or causality between variables. Despite these limitations, the findings provide preliminary evidence and highlight the need for further research across diverse educational settings and populations with varying degrees of hearing loss. Conclusions This exploratory study investigated healthcare access barriers among young Deaf adolescents whose primary mode of communication is sign language, providing preliminary insights into the challenges faced by this population in Nepal. The study focused on a single secondary-level school offering a diploma program and enrolling students from across the country, thus offering a valuable perspective. Healthcare barriers were analyzed under four categories informed by two established models. Communication difficulties and healthcare providers’ attitudes emerged as key challenges, with many HCPs using rapid speech and conventional interaction styles that may not fully meet the needs of individuals with hearing loss. These factors can hinder understanding and reduce confidence in healthcare interactions. The findings underscore the importance of deafness awareness programs for HCPs. The results suggest a need for targeted interventions to enhance healthcare accessibility for Deaf and hard-of-hearing people, although further research across diverse settings is warranted to confirm these findings. Abbreviations HCP: Healthcare providers NGDIHS: National Guidelines for Disability-Inclusive Health Services HCAB: Health Care Access Barrier HIC: High-income country LMIC: Low- and Middle-Income Countries Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Institutional Review Committee at Nobel College (Ref. No: BPH IRC 43/2019), and permission was granted by the school management committee (Code No: 0041). Informed consent was obtained from all participants prior to data collection. Confidentiality and anonymity were strictly maintained, and participants were assured of their right to withdraw from the study at any time without any consequences. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding The study did not receive any specific funding. Authors' contributions SP and BP contributed to the conception and design of the study. SP collected the data. SP and BP analyzed and interpreted the findings. SP and BP drafted the manuscript. All authors read and approved the final manuscript. Acknowledgments We sincerely thank all participants for generously sharing their experiences. We also appreciate the management and staff of Dhaulagiri Deaf Residential Secondary School for their support, and the teachers who assisted with sign language interpretation. Authors’ information Not applicable. References Kuenburg A, Fellinger P, Fellinger J. Health care access among deaf people. 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National Guidelines for Disability Inclusive Health Services. 2019. https://www.nhssp.org.np/Resources/GESI/National_Guidelines_Disability_Inclusive_Health_Services2019.pdf Carrillo JE, Carrillo VA, Perez HR, Salas-Lopez D, Natale-Pereira A, Byron AT. Defining and targeting health care access barriers. Journal of Health Care for the Poor and Underserved. 2011;22(2):562-75. https://doi.org/10.1353/hpu.2011.0037 Snoddon K, Murray JJ. Supporting deaf learners in Nepal via Sustainable Development Goal 4: Inclusive and equitable quality education in sign languages. International Journal of Speech-Language Pathology. 2023 Jan 2;25(1):92-5. https://doi.org/10.1080/17549507.2022.2141325 Bajracharya S. With few options for education and employment, deaf community remains limited to service jobs and skilled work. The Kathmandu Post. 2019 June 23. https://kathmandupost.com/national/2019/06/23/with-few-options-for-education-and-employment-deaf-community-remains-limited-to-service-jobs-and-skilled-work Snoddon K. Report on baseline data collection on deaf education in Nepal. World Federation of the Deaf. 2019. https://wfdeaf.org/wp-content/uploads/2019/07/Report-on-Baseline-Data-Collection-on-Deaf-Education-in-Nepal.pdf World Health Organization. Childhood Hearing Loss: Strategies for Prevention and Care. 2016. https://www.who.int/docs/default-source/imported2/childhood-hearing-loss--strategies-for-prevention-and-care.pdf?sfvrsn=cbbbb3cc_0 Brown T, Isbel S, Yu ML, Bevitt, T. Measuring attitudes: Current practices in health professional education. In: Nestel, D., Reedy, G., McKenna, L., Gough, S. (eds). Clinical Education for the Health Professions , 2020;1-28. Springer, Singapore. https://doi.org/10.1007/978-981-13-6106-7_76-1 Snögren M, Andersson E, Muotka B, Hallgren J. Hearing-impaired and deaf individuals’ perceptions of primary healthcare in Sweden: A mixed-methods study. Nordic journal of nursing research. 2023 Apr;43(2):20571585231171292. https://doi.org/10.1177/20571585231171292 Aragão JD, Magalhães IM, Coura AS, Silva AF, Cruz GK, França IS. Access and communication of deaf adults: a voice silenced in health services. Revista de Pesquisa: Cuidado é Fundamental Online. 2014;6(1):1-7. https://doi.org/10.9789/2175-5361.2014.v6i1.1-7 Stevens MN, Dubno JR, Wallhagen MI, Tucci DL. Communication and healthcare: self-reports of people with hearing loss in primary care settings. Clinical gerontologist. 2019 Oct 20;42(5):485-94. https://doi.org/10.1080/07317115.2018.1453908 Izquierdo-Condoy JS, Abadiano LE, Sánchez W, Rodríguez I, Matías KD, Paz C, Ortiz-Prado E. Exploring healthcare barriers and satisfaction levels among deaf individuals in Ecuador: A video-based survey approach. Disability and Health Journal. 2024 Jul 1;17(3):101622. https://doi.org/10.1016/j.dhjo.2024.101622 Haile LM, Kamenov K, Briant PS, Orji AU, Steinmetz JD, Abdoli A, Abdollahi M, Abu-Gharbieh E, Afshin A, Ahmed H, Rashid TA. Hearing loss prevalence and years lived with disability, 1990–2019: findings from the Global Burden of Disease Study 2019. The Lancet. 2021 Mar 13;397(10278):996-1009. https://doi.org/10.1016/S0140-6736(21)00516-X Swanepoel DW. De Wet Swanepoel: using digital technologies to improve access to hearing health. Bull World Health Organ. 2024;102:232-3. https://doi.org/10.2471/BLT.24.030424 Voluntary Service Oversees. Working with Deaf Adolescents on SRHR in Rwanda Case Study. 2018. https://www.vsointernational.org/sites/default/files/VSO-Deaf-SRH-Rwanda-case-study.pdf Khanal GN, Bharadwaj B, Upadhyay N, Bhattarai T, Dahal M, Khatri RB. Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions?. Health Research Policy and Systems. 2023 Jan 20;21(1):7. https://doi.org/10.1186/s12961-022-00952-w National Federation of the Deaf Nepal. Services available on the basis of disability identity card. https://deafnepal.org.np/en/facilities/disability-id-facilities/ Akeely YY, Alenezi AQ, Albishr NN, Almutairi BA, Alotaibi NF, Almansour RA, Sabi MA, Alenezi Jr AQ, Alotaibi N. Communication challenges while dealing with a deaf patient in the emergency department and suggested solutions. Cureus. 2022 Nov 4;14(11). https://doi.org/10.7759%2Fcureus.31091 Abou-Abdallah M, Lamyman A. Exploring communication difficulties with deaf patients. Clinical Medicine. 2021 Jul 1;21(4):e380-3. https://doi.org/10.7861/clinmed.2021-0111 World Health Organization. World Report on Hearing. 2021. https://www.who.int/teams/noncommunicable-diseases/sensory-functions-disability-and-rehabilitation/highlighting-priorities-for-ear-and-hearing-care#:~:text=Aim,work%20towards%20universal%20health%20coverage Tables Table 1. Demographic Profile of Participants (N = 135) Variables Number (n) Percent (%) Gender Male Female 95 40 70.4 29.6 Mean Age (SD) = 19.93 (2.851) School Grade Grade 8 Grade 9 Grade 10 Diploma 1 st year Diploma 2 nd year Diploma 3 rd year 19 25 19 22 20 30 14.1 18.5 14.1 16.3 14.8 22.2 Use of Assistive Listening Devices Hearing aid Cochlear implant Both None 10 1 2 122 7.4 0.7 1.5 90.4 Self-Reported Causes of Hearing Loss Congenital: Acquired: Illness Trauma Swimming 100 35 26 7 2 74.1 25.9 74.3* 20* 5.7* *Percentages under "Acquired" reflect proportions within that subgroup (n = 35). Table 2. Participants' Responses to Healthcare Access Barriers (N=135) Barrier Category Characteristics n (%) Structural Barriers Faced transportation barriers to reach health facilities Bothered by long waiting times at hospitals 16 (11.9) 87 (64.4) Communication with Healthcare Providers Method used to communicate: Lip-reading Writing Gestures Interpreter Asked providers to repeat unclear instructions Found it easy to communicate with providers 10 (7.4) 56 (41.5) 35 (25.9) 34 (25.2) 24 (17.8) 51 (37.8) Attitudes of Healthcare Providers Found the providers friendly Felt comfortable interacting with providers Received special attention by providers Felt mistreated by providers Felt mistreated by other staff in health facilities 42 (31.1) 37 (27.4) 41 (30.4) 21 (15.6) 18 (13.3) Financial Barriers Frequency of financial difficulties when accessing healthcare: Never Rarely Sometimes Regularly Heard about insurance Had health insurance Funding for Healthcare Services: (multiple responses) School (Government-funded) Out-of-pocket Free government health service Charity Organizations 24 (17.8) 21 (15.6) 67 (49.6) 23 (17) 50 (37) 6 (4.4) 105 (82) 67 (52.3) 52 (40.6) 52 (40.6) Additional Declarations No competing interests reported. Supplementary Files QUESTIONNAIRES.docx Cite Share Download PDF Status: Published Journal Publication published 05 Feb, 2026 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 19 Nov, 2025 Reviews received at journal 18 Nov, 2025 Reviewers agreed at journal 03 Nov, 2025 Reviews received at journal 31 Oct, 2025 Reviewers agreed at journal 20 Oct, 2025 Reviewers invited by journal 16 Oct, 2025 Editor assigned by journal 26 Sep, 2025 Editor invited by journal 22 Sep, 2025 Submission checks completed at journal 21 Sep, 2025 First submitted to journal 21 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Poudel","email":"data:image/png;base64,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","orcid":"","institution":"Nobel College","correspondingAuthor":true,"prefix":"","firstName":"Sadikshya","middleName":"","lastName":"Poudel","suffix":""},{"id":535038608,"identity":"852c471f-17bb-4746-9ff9-057420f9b264","order_by":1,"name":"Bhawana Panta","email":"","orcid":"","institution":"Nobel 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impairs communication, leading to poorer health outcomes and difficulties in accessing healthcare.\u003csup\u003e1,2\u003c/sup\u003e\u0026nbsp; Individuals with severe hearing loss are at greater risk for chronic conditions and mental health problems.\u003csup\u003e3\u0026nbsp;\u003c/sup\u003eEffective communication is essential for treatment adherence, positive health outcomes, and patient satisfaction.\u003csup\u003e4\u003c/sup\u003e However, people with hearing loss often encounter communication barriers with healthcare providers (HCPs), resulting in misunderstandings, misdiagnoses, and delayed treatments.\u003csup\u003e2,5\u0026nbsp;\u003c/sup\u003eDespite equitable healthcare access being a recognized right, these barriers remain significant.\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eGlobally, nearly 80% of individuals with hearing loss live in low- and middle-income countries (LMICs).\u003csup\u003e6\u003c/sup\u003e Although several studies have highlighted communication difficulties and barriers in LMICs,\u003csup\u003e7-13\u003c/sup\u003e most research is concentrated in high-income countries (HICs). A systematic review (2000 to 2015) also confirmed this imbalance.\u003csup\u003e3\u003c/sup\u003e In Nepal, the burden of ear diseases and hearing loss is high.\u003csup\u003e14-16\u003c/sup\u003e Some studies have examined the severity and impacts of hearing loss, as well as associated mental health needs,\u003csup\u003e14-18\u003c/sup\u003e but evidence on healthcare access barriers remains limited. Contributing factors may include a shortage of professionals, inadequate resources, and limited funding for hearing-related research in Nepal.\u003csup\u003e19\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDue to challenges in reaching individuals with hearing loss, the eligible population is often approached in the community, door-to-door, through personal contacts, or when visiting healthcare facilities or health camps.\u003csup\u003e15-18\u003c/sup\u003e Such approaches, however, capture individuals with varying degrees of hearing loss. For example, a large-scale study in Nepal reported a 5.7% prevalence of hearing impairment among students in mainstream schools, with three-fourths having mild hearing loss and one-fourth moderate to profound.\u003csup\u003e14\u003c/sup\u003e The communication barriers faced by individuals with mild to moderate hearing loss in healthcare settings may not be as severe as those experienced by individuals with profound hearing loss.\u003c/p\u003e\n\u003cp\u003eStudies on healthcare access barriers among Deaf individuals provide deeper insights into these challenges. Yet, studies focusing on young Deaf adolescents are especially scarce in LMICs,\u003csup\u003e7,12\u003c/sup\u003e including Nepal. Identifying individuals with severe or profound hearing loss across mainstream schools and communities is difficult, and many may not be proficient in sign language. To address this gap, the present study was conducted in a Deaf residential secondary school, focusing on adolescents whose primary mode of communication is sign language (signing deaf). To address this gap, the present study was conducted in a Deaf residential secondary school, focusing on adolescents whose primary mode of communication is sign language (signing Deaf).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch Aims\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed an observational cross-sectional, descriptive design, integrating both quantitative and qualitative methods. Four healthcare access barrier categories were selected based on two guidelines: the National Guidelines for Disability-Inclusive Health Services (NGDIHS) in Nepal and the Health Care Access Barrier (HCAB) model.\u003csup\u003e20,21\u003c/sup\u003e The categories included: structural barriers, communication with HCPs, HCPs\u0026apos; attitudes, and financial barriers. The study aimed to answer the following research question:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;What healthcare access barriers do young Deaf students experience across these four barrier categories?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e"},{"header":"Method ","content":"\u003cp\u003e\u003cstrong\u003eStudy Setting and Site\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNepal has 22 government-run schools for Deaf students where Nepali Sign Language (NSL) is the primary language of instruction.\u003csup\u003e22\u003c/sup\u003e Most schools offer education only up to Class 5 or 8; six extend to Class 10, and four provide secondary-level education. Only one of these institutions offers a bachelor\u0026apos;s program, and there are no private schools for deaf students in the country.\u003csup\u003e23,24\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the four secondary-level schools, Dhaulagiri Deaf Residential Secondary School is the only institution offering a three-year computer engineering diploma after Class 10, attracting students from across Nepal. The school is in Baglung, a hilly town near Pokhara, a popular tourist center, in western Nepal. Established two decades ago with 24 students, the school had an enrollment of 254 at the time of the study. The study targeted Deaf students from Class 8 through the diploma level, who primarily use NSL.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccording to WHO, hearing loss is classified as mild (26-40 dB), moderate (41-60 dB), severe (61-80 dB), and profound (over 81 dB).\u003csup\u003e25\u003c/sup\u003e Individuals classified as Deaf typically have severe to profound hearing loss, and the term \u0026quot;Deaf\u0026quot; (capital D) refers to individuals who use sign language as their primary mode of communication. All students resided in hostels, which provided free meals and accommodation. Public hospital HCPs are available on call but lack NSL proficiency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSchool policy requires that at least 5% of students in each class have typical hearing, selected from socioeconomically disadvantaged backgrounds, to assist during emergencies. Of the 151 students enrolled from Class eight to diploma level, 16 with typical hearing were excluded. The final sample consisted of 135 Deaf students who met eligibility criteria and provided informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelection of\u003c/strong\u003e \u003cstrong\u003eBarrier Categories\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth Care Access Barriers were identified using the National Guidelines for Disability Inclusive Health Services (NGDIHS) in Nepal and the (HCAB).\u003csup\u003e20,21\u003c/sup\u003e While neither framework is specific to hearing loss, four barrier categories were selected: structural, communication with HCPs, HCPs\u0026apos; attitudes, and financial barriers.\u003csup\u003e20,21\u003c/sup\u003e The categories of structural, communication, and financial barriers are self-explanatory. Attitudes, defined as enduring beliefs and perceptions that influence individual behavior, play a crucial role in shaping interactions and are often inferred from both verbal and non-verbal cues.\u003csup\u003e26\u003c/sup\u003e Participants provided responses on all four categories through questionnaires and in-depth interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis observational, cross-sectional, descriptive study integrated quantitative and qualitative methods. The questionnaire used for quantitative data collection was developed according to the four barrier categories and pretested with 10% of the eligible students at the Central Deaf School in Kathmandu to further refine and validate the instrument (English version provided in Supplementary File 1). For qualitative data, in-depth, face-to-face interviews were structured around the same four categories. The study was carried out from July to December 2019.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection and Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic and quantitative data were collected via self-administered questionnaires from all 135 students\u0026nbsp;and analyzed using\u0026nbsp;SPSS version 16.0. Descriptive statistics included frequencies, mean age, and standard deviation.\u0026nbsp;Qualitative data were collected through in-depth, face-to-face interviews with 10% of senior diploma-level students, randomly selected using a lottery method, including one male and one female from each year. Interviews\u0026nbsp;(~30 minutes each) were conducted by the first author, with interpretation provided by an NSL-proficient teacher. All interviews were audio-recorded, transcribed, translated into English, and key findings summarized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Review Committee at Nobel College (Ref No: BPH IRC 43/2019), and permission was granted by the school management committee (Code no. 0041). Informed consent was obtained from all participants, with confidentiality and anonymity ensured throughout the study. The right to withdraw from the study at any time was ensured.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePositionality Statement\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted by two female researchers with typical hearing from Nobel College, Kathmandu, Nepal. Recognizing healthcare access as a significant public health issue, the researchers approached the study with awareness of their positionality and a commitment to ethical and inclusive engagement with the Deaf community.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 135 participants were included in the study. Among them, 95 (70.4%) were male and 40 (29.6%) were female, with a mean age of 19.93 years (SD 2.85). Regarding educational level, 46.7% were from grades 8 to 10, while 53.3% were diploma students. Most participants (90.4%) did not use assistive listening devices; among those who did, 7.4% used hearing aids, 0.7% used a cochlear implant, and 1.5% used both. With respect to the causes of hearing loss, 74.1% reported congenital hearing loss. Among those with acquired hearing loss (25.9%), illness was the leading cause (74.3%), followed by trauma (20%) and swimming-related causes (5.7%). The full demographic profile is presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare Access Barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative responses for healthcare access barriers are presented in Table 2. Qualitative findings from face-to-face, in-depth interviews are summarized below to provide context and illustrate participants\u0026rsquo; experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStructural Barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStructural barriers to healthcare were limited but notable. Only 11.9% of participants reported experiencing transportation barriers when accessing health facilities. However, long waiting times were a common concern, affecting 64.4% of participants. In-depth interviews revealed that participants faced additional challenges related to accessibility and waiting times:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;We do not get disabled seats because we do not look disabled\u003c/em\u003e.\u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;The waiting time in the hospital has bothered me a lot. There is no difference between people with and without hearing loss. Everyone has to wait\u003c/em\u003e.\u003cem\u003e\u0026nbsp;I feel there should be separate waiting lines for people with and without disabilities.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;I hate waiting in the hospital\u0026mdash;waiting for an appointment, waiting for a doctor, and then waiting for free medicines, which I rarely get.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese narratives illustrate that while physical access may not be a major barrier, structural elements such as seating arrangements and waiting periods significantly impact the healthcare experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunication with Healthcare Providers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommunication barriers were prevalent among participants. Only a quarter of participants had access to interpreters, while others relied on writing (41.5%), gestures (25.9%), or lip-reading (7.4%) to communicate with healthcare providers. Despite these methods, only 37.8% reported that they could easily communicate with providers, and 17.8% regularly asked providers to repeat instructions when unclear. Qualitative data emphasized the challenges associated with communication and underscored the importance of interpreters:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;I can understand them if they speak slowly, but most talk very fast, and I just cannot catch their lip sync\u003c/em\u003e.\u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;I always have doubts about medications because I cannot directly communicate with healthcare providers. I doubt whether I have received the right medication or not... these barriers demotivate us from going to the hospital.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;There is an interpreter only in the central hospital. Every hospital should have an interpreter. An interpreter is like our bridge\u003c/em\u003e.\u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;I think there should be interpreters in every hospital. That will be very helpful.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese findings indicate that communication difficulties are widespread and have a substantial impact on understanding and confidence in healthcare services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttitudes of Healthcare Providers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePerceptions of healthcare providers\u0026rsquo; attitudes were mixed but tended toward negative experiences. Only 31.1% of participants found providers friendly, and 27.4% felt comfortable during interactions. While 30.4% received special attention from providers, 15.6% reported feeling mistreated by healthcare providers, and 13.3% felt mistreated by other staff. Participants described instances of perceived discrimination or neglect, which contributed to mistrust and hesitancy in seeking care:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;People with typical hearing can understand everything so easily, but we cannot. People should remember this. They always hesitate to explain things to us.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;I write my symptoms on paper when going to the pharmacist. They sometimes laugh at me\u003c/em\u003e.\u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;We fear and hesitate to access healthcare services because of poor communication.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;We mistrust healthcare providers due to such poor communication.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese accounts highlight that interpersonal experiences with providers significantly influence participants\u0026rsquo; confidence and willingness to access healthcare services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial Barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinancial barriers were commonly reported. Approximately half of participants (49.6%) sometimes experienced cost-related difficulties, while 17% reported regular financial challenges. Only 37% had heard of health insurance, and coverage was minimal (4.4%). Sources of healthcare financing included school support (82%), out-of-pocket payments (52.3%), free government health services (40.6%), and charitable organizations (40.6%). Qualitative interviews further illuminated the financial challenges faced by participants:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;I have never heard about insurance. Nobody informed me about it.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;I do not have health insurance, but I would like to have it.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;We rarely get free medicine supplied by the government health service.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;Health care should be made accessible and affordable, considering all the barriers we face.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026ldquo;I am so thankful for my school, which has loved and cared for us so well, taken us to the hospital when needed, called our parents in an emergency, and provided lodging and food to them when they visited us.\u0026rdquo;\u003c/em\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese findings suggest that financial constraints are a significant barrier to healthcare access, compounded by low awareness and limited utilization of health insurance.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eOverview of the Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study explored healthcare access barriers faced by young Deaf students in Nepal, addressing a critical gap in the literature from low- and lower-middle-income countries. Barriers were categorized into structural barriers, communication with healthcare providers (HCPs), attitudes of HCPs, and financial barriers, based on two established models.\u003csup\u003e20,21\u003c/sup\u003e Such categorization is less common, as most existing studies focus primarily on general communication issues without explicitly addressing provider attitudes.\u003csup\u003e8,9,27\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eConducted at one of only four secondary schools in Nepal offering a computer engineering diploma, the study provides insights into the healthcare experiences of Deaf youth from across the country. Data were collected from all students in class eight and above, with in-depth interviews conducted among 10% of senior diploma-level students. The sample size aligns with prior international studies on healthcare access among Deaf populations, which have ranged from 13 to 140 participants across interviews, questionnaires, and focus group discussions.\u003csup\u003e7-13,28\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eDemographic Characteristics\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost participants were male, although national data indicate hearing loss prevalence is generally similar across genders, particularly for mild conductive issues such as otitis media.\u003csup\u003e14\u003c/sup\u003e Children with severe or profound hearing loss may be less likely to attend mainstream schools. The male predominance may reflect higher interest in technical education such as computer engineering among boys, or parental reluctance to send daughters with hearing loss to a residential school. Most participants reported congenital hearing loss, while acquired cases were primarily linked to illness, trauma or swimming-related ear infections.\u003c/p\u003e\n\u003cp\u003eStructural barriers\u003c/p\u003e\n\u003cp\u003eMost participants reported minimal transportation difficulties, likely reflecting the school\u0026rsquo;s convenient location. However, approximately two-thirds expressed concerns regarding long waiting times at hospitals. In-depth interviews highlighted that communication needs were often unrecognized, as Deafness is an invisible disability. Incorporating universal icons for hearing loss in patient records could help HCPs adapt communication strategies.\u003csup\u003e4\u003c/sup\u003e Participants also reported frustration in waiting areas due to insufficient information about delays, which may increase anxiety and the risk of missing appointments. Visual notifications or proactive staff support could help address these challenges, particularly for unaccompanied patients. These observations are consistent with prior studies reporting similar gaps in waiting-room communication.\u003csup\u003e29\u003c/sup\u003e\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCommunication with Healthcare Providers\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCommunication barriers were prominent. Students primarily relied on writing, gestures, and lip-reading, yet rapid speech and unfamiliar medical terminology often limited comprehension. HCPs tended to communicate in a manner suited for individuals with typical hearing, which may inadvertently exclude Deaf patients. Effective visual communication is essential to ensure understanding.\u003csup\u003e1\u0026nbsp;\u003c/sup\u003eMany participants struggled to request clarification or ask providers to repeat instructions, creating uncertainty regarding medication and care. Previous studies have similarly reported that Deaf patients frequently encounter difficulty understanding medical instructions.\u003csup\u003e30\u003c/sup\u003e Strategies such as teach-back methods, clear written instructions, and routine hearing checks could potentially improve understanding and help identify undiagnosed cases.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAttitudes of Healthcare Providers\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFewer than one-third of participants reported positive interactions with HCPs, with some experiencing discomfort or perceived mistreatment. Negative attitudes and insufficient communication may reduce confidence in seeking care and could contribute to mistrust of healthcare services. These findings are comparable with reports from Greece and Ecuador, where Deaf and hard-of-hearing adults described dissatisfaction with healthcare providers and staff.\u003csup\u003e13,30\u003c/sup\u003e Participants emphasized the potential value of sign language interpreters in supporting effective communication.\u003csup\u003e7-13,30\u003c/sup\u003e While interpreter availability could be prioritized in high-volume hospitals, many individuals with mild or moderate hearing loss are not proficient in sign language.\u003csup\u003e31\u003c/sup\u003e For them, on-site communication-assistive devices and encouragement to use hearing aids could enhance care.\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eStigma associated with hearing aids may continue to pose challenges; integrating hearing aids into discreet technologies could support acceptance and use, particularly for children, as even mild hearing loss can affect language development and educational outcomes.\u003csup\u003e15,31,32\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eCommunication Support Strategies and Innovations\u003c/p\u003e\n\u003cp\u003eWhile proficiency in sign language among HCPs is ideal,\u003csup\u003e7,8,11\u003c/sup\u003e achieving widespread coverage remains challenging.\u003csup\u003e4,5\u003c/sup\u003e Targeted training for selected healthcare professionals, particularly those working with Deaf students or in specialized care settings, may improve communication and the quality of care. Programs in Rwanda have shown that training nurses and community health workers in health-related signs can be effective.\u003csup\u003e33\u0026nbsp;\u003c/sup\u003eVideo remote interpreting services (VRIS) offer an alternative where on-site interpreters are unavailable, and accompaniment by family, friends, or teachers may provide temporary support, though this approach has limitations.\u003csup\u003e5,8\u003c/sup\u003e In this study, only one-fourth of participants had such assistance. Emerging technologies, such as AI-enhanced sign language interpretation, may further support communication in the future.\u003c/p\u003e\n\u003cp\u003eFinancial barriers\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApproximately half of participants reported experiencing financial difficulties, and fewer than 5% were enrolled in Nepal\u0026rsquo;s national health insurance scheme.\u003csup\u003e34\u003c/sup\u003e Although the scheme covers essential services and disability identity cards provide additional benefits,\u003csup\u003e35\u003c/sup\u003e awareness among students was limited. This suggests a need for improved outreach through schools and Deaf-support organizations to increase awareness and utilization of available support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommunication challenges and HCP attitudes were the most prominent barriers identified in this study. Many HCPs communicated in ways typical for hearing patients, speaking rapidly and using approaches that may not fully support understanding for Deaf individuals. These findings suggest the potential benefit of raising awareness among HCPs regarding hearing loss and practical strategies to facilitate communication. Although the importance of HCP education has recently been emphasized in HICs,\u003csup\u003e27,36\u003c/sup\u003e it is less frequently addressed in LMICs. Morisod et al. (2022), in their systematic review of interventions to improve healthcare equity for Deaf patients, highlighted the role of awareness programs in enhancing HCPs\u0026rsquo; interaction with patients with hearing loss.\u003csup\u003e3\u003c/sup\u003e A short deafness awareness course for HCPs and support staff, covering the prevalence and consequences of hearing loss, along with practical communication strategies, may help improve understanding and provider behaviors. Techniques such as clear speech, maintaining eye contact, unobstructed facial expressions, gestures, written communication, and use of interpreters could be applied depending on the clinical context. Integrating these strategies into medical, nursing, and allied health curricula may further prepare future providers to respond effectively to Deaf patients\u0026rsquo; needs.\u003c/p\u003e\n\u003cp\u003eIn LMICs, retail pharmacists often serve as the first point of contact for health concerns, underscoring the importance of including them in deafness awareness programs. Effective communication strategies include speaking clearly, maintaining eye contact, keeping the face unobstructed for lip-reading, using gestures, written notes, proxy interpreters (family or friends), or video remote or face-to-face interpreters.\u003csup\u003e\u0026nbsp;4,5,8,37,38\u0026nbsp;\u003c/sup\u003eEach method carries advantages and limitations, with applicability depending on the clinical situation.\u003csup\u003e3\u0026ndash;5\u003c/sup\u003e The \u0026lsquo;AEIOU\u0026rsquo; mnemonic (Ask, Environment, Interaction, Outline, and Understanding) provides a practical framework for communication with individuals who have hearing loss.\u003csup\u003e37\u0026nbsp;\u003c/sup\u003eBeyond short-term training, integrating education on the impact of hearing loss and communication strategies into healthcare curricula can better prepare future providers.\u003csup\u003e1\u0026nbsp;\u003c/sup\u003eIn the USA, McKee et al. recently described actionable strategies for reframing healthcare for patients with hearing loss at system, clinic, provider, and patient levels.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eBased on the study findings, a set of recommendations to support Deaf individuals and enhance access to healthcare is presented in Box 1. Implementing such initiatives in low-resource settings may require collaboration and sustained support from both national and international stakeholders, while remaining adaptable to local contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBox 1. Recommendations for Improving Healthcare Access for People with Hearing Loss\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 735px;\"\u003e\n \u003col\u003e\n \u003cli\u003eHalf-day deafness awareness programs for healthcare providers, support staff, and retail pharmacists. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIntegration of deafness education into medical, nursing, and allied health curricula. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAvailability of hearing devices during medical consultations.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDeployment of qualified sign language interpreters in high-volume hospitals.\u003c/li\u003e\n \u003cli\u003eImplementation of video-remote interpreting services in community settings. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBasic sign language training for selected healthcare providers working with Deaf individuals.\u003c/li\u003e\n \u003cli\u003eUse of universally recognized hearing loss icons in patient charts to alert healthcare staff.\u003c/li\u003e\n \u003cli\u003eSign language training for Deaf children, adults, and close family members.\u003c/li\u003e\n \u003cli\u003eEncouragement for Deaf individuals to attend healthcare visits with trusted companions when possible.\u003c/li\u003e\n \u003cli\u003eProvision of visual or personalized notifications for unaccompanied Deaf patients awaiting care.\u003c/li\u003e\n \u003cli\u003ePromotion of disability identity cards and health insurance programs through schools and organizations.\u003c/li\u003e\n \u003cli\u003eSupport for research and development of discreet, affordable hearing aids to reduce stigma and improve access.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, it was conducted in a single residential school for Deaf students, which may limit the generalizability of the findings. However, as the school is one of only four secondary institutions in Nepal offering a computer engineering diploma and enrolls students from across the country, the results still provide insights from diverse geographic regions. Second, the study focused specifically on Deaf adolescents, so the experiences of adults or individuals with mild to moderate hearing loss may differ. Third, while quantitative data were collected from all 135 students from grade eight onwards, the qualitative component included only about 10% of senior diploma-level students due to time and resource constraints. A larger qualitative sample or the inclusion of focus group discussions could have yielded a richer understanding of participants\u0026rsquo; experiences. Fourth, interviews were conducted in Nepali Sign Language with the assistance of teachers, which may have influenced participants\u0026rsquo; openness and introduced potential translation bias, particularly regarding perceptions of local healthcare providers. Finally, as this was a descriptive study, no inferential analyses were performed, limiting the ability to examine relationships or causality between variables. Despite these limitations, the findings provide preliminary evidence and highlight the need for further research across diverse educational settings and populations with varying degrees of hearing loss.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis exploratory study investigated healthcare access barriers among young Deaf adolescents whose primary mode of communication is sign language, providing preliminary insights into the challenges faced by this population in Nepal. The study focused on a single secondary-level school offering a diploma program and enrolling students from across the country, thus offering a valuable perspective. Healthcare barriers were analyzed under four categories informed by two established models. Communication difficulties and healthcare providers\u0026rsquo; attitudes emerged as key challenges, with many HCPs using rapid speech and conventional interaction styles that may not fully meet the needs of individuals with hearing loss. These factors can hinder understanding and reduce confidence in healthcare interactions. The findings underscore the importance of deafness awareness programs for HCPs. The results suggest a need for targeted interventions to enhance healthcare accessibility for Deaf and hard-of-hearing people, although further research across diverse settings is warranted to confirm these findings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHCP: Healthcare providers\u003c/p\u003e\n\u003cp\u003eNGDIHS: National Guidelines for Disability-Inclusive Health Services \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHCAB: Health Care Access Barrier \u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHIC: High-income country\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLMIC: Low- and Middle-Income Countries\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Institutional Review Committee at Nobel College (Ref. No: BPH IRC 43/2019), and permission was granted by the school management committee (Code No: 0041). Informed consent was obtained from all participants prior to data collection. Confidentiality and anonymity were strictly maintained, and participants were assured of their right to withdraw from the study at any time without any consequences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study did not receive any specific funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSP and BP contributed to the conception and design of the study. SP collected the data. SP and BP analyzed and interpreted the findings. SP and BP drafted the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank all participants for generously sharing their experiences. We also appreciate the management and staff of Dhaulagiri Deaf Residential Secondary School for their support, and the teachers who assisted with sign language interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKuenburg A, Fellinger P, Fellinger J. Health care access among deaf people. 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University of Cape Town, South Africa. 2020. https://health.uct.ac.za/sites/default/files/content_migration/health_uct_ac_za/253/files/MHeap_MRC%2520Report%2520Format_Deaf%2520Childrens%2520Access.pdf \u003c/li\u003e\n\u003cli\u003eKritzinger J, Schneider M, Swartz L, Braathen SH. \u0026ldquo;I just answer \u0026lsquo;yes\u0026rsquo; to everything they say\u0026rdquo;: Access to health care for deaf people in Worcester, South Africa and the politics of exclusion. Patient Education and Counseling. 2014 Mar 1;94(3):379-83. https://doi.org/10.1016/j.pec.2013.12.006 \u003c/li\u003e\n\u003cli\u003eRezende RF, Guerra LB, Carvalho SA. The perspective of deaf patients on health care. Revista CEFAC. 2021 Apr 12;23(2):e0620. https://doi.org/10.1590/1982-0216/20212320620 \u003c/li\u003e\n\u003cli\u003eSenayah EA, Mprah WK, Opoku MP, Edusei AK, Torgbenu EL. The accessibility of health services to young deaf adolescents in Ghana. The International Journal of Health Planning and Management. 2019 Jan;34(1):e634-45. https://doi.org/10.1002/hpm.2679 \u003c/li\u003e\n\u003cli\u003eTsimpida D, Kaitelidou D, Galanis P. Barriers to the use of health services among deaf and hard of hearing adults in Greece: a Cross-Sectional Study. European Journal for Person Centered Healthcare. 2018 Dec 5;6(4):638. https://core.ac.uk/download/pdf/533427962.pdf \u003c/li\u003e\n\u003cli\u003eMaharjan M, Phuyal S, Shrestha M. Prevalence of hearing loss in school aged Nepalese children. International Journal of Pediatric Otorhinolaryngology. 2021 Apr 1;143:110658. https://doi.org/10.1016/j.ijporl.2021.110658 \u003c/li\u003e\n\u003cli\u003eSkilton MK, Poole N, Metcalfe CW, Martin TP, Smith MC. The impact of ear disease and hearing impairment on the lives of Nepali patients in Pokhara: a qualitative study. International Health. 2016 Mar 1;8(2):101-7. https://doi.org/10.1093/inthealth/ihv052 \u003c/li\u003e\n\u003cli\u003eThakur SK, Singh SK, Mahato B, Singh A. Ear diseases pattern and hearing impairment in the Eastern Nepal-A study in a combined eye and ear set up. Asian Journal of Medical Sciences. 2015 Mar 3;6(5):51-5. https://doi.org/10.3126/ajms.v6i5.11621 \u003c/li\u003e\n\u003cli\u003eShrestha KK, Shah S, Malla NS, Jha AK, Joshi RR, Rijal AS, Dhungana A. The impact of hearing loss in older adults: a tertiary care hospital based study. Nepal Medical College Journal. 2014;16(2-4):131-4. https://old.nmcth.edu/images/gallery/Original%20Article%20/131-134.pdf \u003c/li\u003e\n\u003cli\u003eCrowe TV, Gimire B, Trollo S. The mental health needs of deaf adults in Nepal. International Social Work. 2016;59(4):508-22. https://doi.org/10.1177/0020872814539983 \u003c/li\u003e\n\u003cli\u003eGhimire A. Audiology in Nepal. Global Audiology. 2021. https://www.earaidnepal.org/wp-content/uploads/2022/10/Audiology-in-Nepal-article-for-Global-Audiology-author-Anup-Ghimire-MSc-2021.pdf \u003c/li\u003e\n\u003cli\u003eNepal Health Sector Support Programme III. National Guidelines for Disability Inclusive Health Services. 2019. https://www.nhssp.org.np/Resources/GESI/National_Guidelines_Disability_Inclusive_Health_Services2019.pdf\u003c/li\u003e\n\u003cli\u003eCarrillo JE, Carrillo VA, Perez HR, Salas-Lopez D, Natale-Pereira A, Byron AT. Defining and targeting health care access barriers. Journal of Health Care for the Poor and Underserved. 2011;22(2):562-75. https://doi.org/10.1353/hpu.2011.0037\u003c/li\u003e\n\u003cli\u003eSnoddon K, Murray JJ. Supporting deaf learners in Nepal via Sustainable Development Goal 4: Inclusive and equitable quality education in sign languages. International Journal of Speech-Language Pathology. 2023 Jan 2;25(1):92-5. https://doi.org/10.1080/17549507.2022.2141325 \u003c/li\u003e\n\u003cli\u003eBajracharya S. With few options for education and employment, deaf community remains limited to service jobs and skilled work. The Kathmandu Post. 2019 June 23. https://kathmandupost.com/national/2019/06/23/with-few-options-for-education-and-employment-deaf-community-remains-limited-to-service-jobs-and-skilled-work \u003c/li\u003e\n\u003cli\u003eSnoddon K. Report on baseline data collection on deaf education in Nepal. World Federation of the Deaf. 2019. https://wfdeaf.org/wp-content/uploads/2019/07/Report-on-Baseline-Data-Collection-on-Deaf-Education-in-Nepal.pdf \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Childhood Hearing Loss: Strategies for Prevention and Care. 2016. https://www.who.int/docs/default-source/imported2/childhood-hearing-loss--strategies-for-prevention-and-care.pdf?sfvrsn=cbbbb3cc_0 \u003c/li\u003e\n\u003cli\u003eBrown T, Isbel S, Yu ML, Bevitt, T. Measuring attitudes: Current practices in health professional education. In: Nestel, D., Reedy, G., McKenna, L., Gough, S. (eds). \u003cem\u003eClinical Education for the Health Professions\u003c/em\u003e, 2020;1-28. Springer, Singapore. https://doi.org/10.1007/978-981-13-6106-7_76-1\u003c/li\u003e\n\u003cli\u003eSn\u0026ouml;gren M, Andersson E, Muotka B, Hallgren J. Hearing-impaired and deaf individuals\u0026rsquo; perceptions of primary healthcare in Sweden: A mixed-methods study. Nordic journal of nursing research. 2023 Apr;43(2):20571585231171292. https://doi.org/10.1177/20571585231171292 \u003c/li\u003e\n\u003cli\u003eArag\u0026atilde;o JD, Magalh\u0026atilde;es IM, Coura AS, Silva AF, Cruz GK, Fran\u0026ccedil;a IS. Access and communication of deaf adults: a voice silenced in health services. Revista de Pesquisa: Cuidado \u0026eacute; Fundamental Online. 2014;6(1):1-7. https://doi.org/10.9789/2175-5361.2014.v6i1.1-7 \u003c/li\u003e\n\u003cli\u003eStevens MN, Dubno JR, Wallhagen MI, Tucci DL. Communication and healthcare: self-reports of people with hearing loss in primary care settings. Clinical gerontologist. 2019 Oct 20;42(5):485-94. https://doi.org/10.1080/07317115.2018.1453908\u003c/li\u003e\n\u003cli\u003eIzquierdo-Condoy JS, Abadiano LE, S\u0026aacute;nchez W, Rodr\u0026iacute;guez I, Mat\u0026iacute;as KD, Paz C, Ortiz-Prado E. Exploring healthcare barriers and satisfaction levels among deaf individuals in Ecuador: A video-based survey approach. Disability and Health Journal. 2024 Jul 1;17(3):101622. https://doi.org/10.1016/j.dhjo.2024.101622 \u003c/li\u003e\n\u003cli\u003eHaile LM, Kamenov K, Briant PS, Orji AU, Steinmetz JD, Abdoli A, Abdollahi M, Abu-Gharbieh E, Afshin A, Ahmed H, Rashid TA. Hearing loss prevalence and years lived with disability, 1990\u0026ndash;2019: findings from the Global Burden of Disease Study 2019. The Lancet. 2021 Mar 13;397(10278):996-1009. https://doi.org/10.1016/S0140-6736(21)00516-X \u003c/li\u003e\n\u003cli\u003eSwanepoel DW. De Wet Swanepoel: using digital technologies to improve access to hearing health. Bull World Health Organ. 2024;102:232-3. https://doi.org/10.2471/BLT.24.030424\u003c/li\u003e\n\u003cli\u003eVoluntary Service Oversees. Working with Deaf Adolescents on SRHR in Rwanda Case Study. 2018.\u003cem\u003e \u003c/em\u003ehttps://www.vsointernational.org/sites/default/files/VSO-Deaf-SRH-Rwanda-case-study.pdf \u003c/li\u003e\n\u003cli\u003eKhanal GN, Bharadwaj B, Upadhyay N, Bhattarai T, Dahal M, Khatri RB. Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions?. Health Research Policy and Systems. 2023 Jan 20;21(1):7. https://doi.org/10.1186/s12961-022-00952-w \u003c/li\u003e\n\u003cli\u003eNational Federation of the Deaf Nepal. Services available on the basis of disability identity card. https://deafnepal.org.np/en/facilities/disability-id-facilities/ \u003c/li\u003e\n\u003cli\u003eAkeely YY, Alenezi AQ, Albishr NN, Almutairi BA, Alotaibi NF, Almansour RA, Sabi MA, Alenezi Jr AQ, Alotaibi N. Communication challenges while dealing with a deaf patient in the emergency department and suggested solutions. Cureus. 2022 Nov 4;14(11). https://doi.org/10.7759%2Fcureus.31091\u003c/li\u003e\n\u003cli\u003eAbou-Abdallah M, Lamyman A. Exploring communication difficulties with deaf patients. Clinical Medicine. 2021 Jul 1;21(4):e380-3. https://doi.org/10.7861/clinmed.2021-0111 \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. World Report on Hearing. 2021. https://www.who.int/teams/noncommunicable-diseases/sensory-functions-disability-and-rehabilitation/highlighting-priorities-for-ear-and-hearing-care#:~:text=Aim,work%20towards%20universal%20health%20coverage\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Demographic Profile of Participants\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(N = 135)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 467px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 467px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e70.4\u003c/p\u003e\n \u003cp\u003e29.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 717px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Age (SD) = 19.93 (2.851)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 467px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool Grade\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 8\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 9\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 10\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDiploma 1\u003csup\u003est\u0026nbsp;\u003c/sup\u003eyear\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDiploma 2\u003csup\u003end\u003c/sup\u003e year\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDiploma 3\u003csup\u003erd\u003c/sup\u003e year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14.1\u003c/p\u003e\n \u003cp\u003e18.5\u003c/p\u003e\n \u003cp\u003e14.1\u003c/p\u003e\n \u003cp\u003e16.3\u003c/p\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 467px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUse of Assistive Listening Devices\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHearing aid\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCochlear implant\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBoth\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003cp\u003e90.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 467px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-Reported Causes of Hearing Loss\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCongenital:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAcquired:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIllness\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTrauma\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSwimming\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e74.1\u003c/p\u003e\n \u003cp\u003e25.9\u003c/p\u003e\n \u003cp\u003e74.3*\u003c/p\u003e\n \u003cp\u003e20*\u003c/p\u003e\n \u003cp\u003e5.7*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e*Percentages under \u0026quot;Acquired\u0026quot; reflect proportions within that subgroup (n = 35).\u003c/em\u003e\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Participants\u0026apos; Responses to Healthcare Access Barriers (N=135)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarrier Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 427px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStructural Barriers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 427px;\"\u003e\n \u003cp\u003eFaced transportation barriers to reach health facilities\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBothered by long waiting times at hospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e16 (11.9)\u003c/p\u003e\n \u003cp\u003e87 (64.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ewith Healthcare Providers\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 427px;\"\u003e\n \u003cp\u003eMethod used to communicate:\u003c/p\u003e\n \u003cp\u003eLip-reading\u003c/p\u003e\n \u003cp\u003eWriting\u003c/p\u003e\n \u003cp\u003eGestures\u003c/p\u003e\n \u003cp\u003eInterpreter\u003c/p\u003e\n \u003cp\u003eAsked providers to\u0026nbsp;\u003c/p\u003e\n \u003cp\u003erepeat unclear instructions\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFound it easy to communicate with providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (7.4)\u003c/p\u003e\n \u003cp\u003e56 (41.5)\u003c/p\u003e\n \u003cp\u003e35 (25.9)\u003c/p\u003e\n \u003cp\u003e34 (25.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24 (17.8)\u003c/p\u003e\n \u003cp\u003e51 (37.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttitudes of\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare Providers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 427px;\"\u003e\n \u003cp\u003eFound the providers friendly\u003c/p\u003e\n \u003cp\u003eFelt comfortable interacting with providers\u003c/p\u003e\n \u003cp\u003eReceived special attention\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eby providers\u003c/p\u003e\n \u003cp\u003eFelt mistreated by providers\u003c/p\u003e\n \u003cp\u003eFelt mistreated by other staff in health facilities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e42 (31.1)\u003c/p\u003e\n \u003cp\u003e37 (27.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41 (30.4)\u003c/p\u003e\n \u003cp\u003e21 (15.6)\u003c/p\u003e\n \u003cp\u003e18 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinancial Barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 427px;\"\u003e\n \u003cp\u003eFrequency of financial difficulties when accessing healthcare:\u003c/p\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003cp\u003eRarely\u003c/p\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003cp\u003eRegularly\u003c/p\u003e\n \u003cp\u003eHeard about insurance\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHad health insurance\u003c/p\u003e\n \u003cp\u003eFunding for Healthcare Services:\u003c/p\u003e\n \u003cp\u003e(multiple responses)\u003c/p\u003e\n \u003cp\u003eSchool (Government-funded)\u003c/p\u003e\n \u003cp\u003eOut-of-pocket\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFree government health service\u003c/p\u003e\n \u003cp\u003eCharity Organizations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24 (17.8)\u003c/p\u003e\n \u003cp\u003e21 (15.6)\u003c/p\u003e\n \u003cp\u003e67 (49.6)\u003c/p\u003e\n \u003cp\u003e23 (17)\u003c/p\u003e\n \u003cp\u003e50 (37)\u003c/p\u003e\n \u003cp\u003e6 (4.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e105 (82)\u003c/p\u003e\n \u003cp\u003e67 (52.3)\u003c/p\u003e\n \u003cp\u003e52 (40.6)\u003c/p\u003e\n \u003cp\u003e52 (40.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Healthcare access barriers, Deaf adolescents, sign language, Nepal, healthcare provider awareness, deafness awareness program","lastPublishedDoi":"10.21203/rs.3.rs-7542608/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7542608/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eResearch on healthcare access barriers among people with hearing loss in Nepal is limited, and studies focusing on Deaf adolescents are particularly scarce in low- and lower-middle-income countries. This study explored healthcare access barriers among Deaf adolescents whose primary mode of communication is sign language.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA descriptive, cross-sectional study using quantitative and qualitative methods was conducted at Dhaulagiri Deaf Residential Secondary School in Baglung, Nepal, the only secondary-level institution offering a diploma in computer engineering and enrolling students from across the country. A total of 135 Deaf students from grade eight to diploma level completed structured questionnaires. In-depth, face-to-face interviews were conducted with 10% of diploma-level students, randomly selected by lottery. Four barrier categories were assessed: structural, communication with healthcare providers (HCPs), attitudes of HCPs, and financial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eParticipants had a mean age of 19.9 years (SD 2.85); 70.4% were male and 53.3% were diploma students. Most participants (90.4%) did not use assistive listening devices, and 74.1% reported congenital hearing loss. Structural barriers included long waiting times (64.4%) and transportation challenges (11.9%). Communication barriers were frequent: 25% had access to interpreters, and 37.8% reported easy communication with HCPs. Attitudinal barriers were reported, with only 31.1% finding HCPs friendly and 27.4% comfortable during interactions, while 15.6% even experienced mistreatment by HCPs. Financial barriers included cost-related difficulties, limited awareness of health insurance (37%), and low coverage (4.4%). Qualitative interviews highlighted difficulties in understanding rapid speech, raising doubts regarding medications. Participants felt that HCPs seemed unaware of their challenges in comprehending communications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eCommunication difficulties and HCPs’ attitudes were the most prominent barriers to healthcare access among Deaf adolescents. These findings highlight the pressing need for deafness awareness programs for HCPs to improve healthcare accessibility for Deaf and hard-of-hearing people.\u003c/p\u003e","manuscriptTitle":"Healthcare Access Barriers Among Deaf Adolescents in Nepal: A Cross-Sectional Study to Inform Provider awareness","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-30 12:22:56","doi":"10.21203/rs.3.rs-7542608/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-19T07:44:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-18T15:05:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140344037639000812131690478420859126464","date":"2025-11-03T09:46:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-31T14:24:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"18211784981351963746711898613975095140","date":"2025-10-20T10:00:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-16T07:42:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-26T18:21:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-22T11:56:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-21T08:37:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-09-21T08:34:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"326cc86a-0c5c-4b0f-8f79-de75a58eb74b","owner":[],"postedDate":"October 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:04:56+00:00","versionOfRecord":{"articleIdentity":"rs-7542608","link":"https://doi.org/10.1186/s12889-026-26492-4","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-02-05 15:57:01","publishedOnDateReadable":"February 5th, 2026"},"versionCreatedAt":"2025-10-30 12:22:56","video":"","vorDoi":"10.1186/s12889-026-26492-4","vorDoiUrl":"https://doi.org/10.1186/s12889-026-26492-4","workflowStages":[]},"version":"v1","identity":"rs-7542608","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7542608","identity":"rs-7542608","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}