Perception of Ghanaian healthcare students towards the learning of sign language as course

Abstract

Communication remains among the top barriers to healthcare for deaf people. One of the reasons is healthcare professionals lack the competence to communicate health information in sign language. Part of the measures to alleviate this challenge was the introduction of sign language into the curriculum of health students. The perceptions of healthcare students on this initiative were assessed in this study. The study used cross-sectional online survey to collect data from 666 randomly sampled health students in Ghana. Participants were recruited through social media platforms. Descriptive statistics, Chi-square was used to analyze the differences between categorical variables at the rate of 95% confidence intervals (p = 0.05), and binary logistic was performed to ascertain predictors of health student’s perception about hospital should provide professional interpreters than students learning GhSL. The study found that about 9 in 10 of all health students support the introduction of GHSL as a course. Student nurses perceive more benefits of learning GHSL to the deaf community than all health students. Logistic regression revealed that students’ midwives were 2.183 times significantly more likely to support the view that hospitals should provide professional interpreters instead of health students learning GHSL as compared with students who study Nursing (AOR: 2.183, CI: 1.104–4.316, p = 0.025). To sustain the interest of students in the learning of GhSL. Appropriate teaching and learning materials should be made available. Likewise, competent instructors should be recruited in the teaching of GhSL. This can be done through a collaborative effort between stakeholders including KNUST, NMC, and the ministry of health.

Keywords:

• Sign Language
• Ghanaian
• Healthcare
• Students
• Perception

1. Introduction

Language, irrespective of its nature, is an indispensable tool for human communication and also separates humans from beasts (Rabiah, 2018; Lederer 1991). Sign languages are normal languages that arise when the channel for oral-aural communication is absent (Zeshan & De Vos, 2012). This implies that the desire for human communication and, for that matter, language is like a stream of water which can never be blocked (Brentari & Coppola, 2012). Sign language is complex in terms of its grammar, and this allows access to information in a natural way and the expression of opinions, desires, and abstract thoughts (Baker et al., 2008). In Ghana, the most common communication means for most deaf people are through Ghanaian Sign Language (GhSL). The actual user of GhSL is unknown, but until recently, few people were observed using GhSL, which can lead to discrimination. Deaf people sometimes suffer discrimination because of their status as minor linguistic or cultural groups Hoffmeister and Hoffmeister (2017). Parents of the deaf who are supposed to know GhSL to facilitate communication between their deaf children failed to learn GhSL, which resulted in communication challenges at home (Opoku et al., 2020). But, the ability to communicate with parents, family members, friends, and educators is crucial in learners’ academic and social progress in life (Ridge, 2016). Studies such as Crowe (2003) and Polat (2003) indicate the importance of sign language as a tool to maintain stronger parent-child relationships among deaf children.

Sign language for communication can be very important to the deaf in the healthcare setting (A. Smeijers et al., 2019; Adib-Hajbaghery & Rezaei-Shahsavarloo, 2015; Amfo et al., 2018). Generally, accessibility for deaf people focuses on bridging the communication gap between the deaf and the hearing world (Johnson, 2013). Studies on deaf people’s access to health care have persistently found communication as a major barrier to health care (Appiah et al., 2019; Harmer, 1991; Naseribooriabadi et al., 2017). Folkins et al. (2005) and Kritzinger et al. (2014) espoused that in many countries, the availability and use of sign language mediation by interpreters is restricted and medical information in sign language is scarce. Also, most physicians and health professionals are not adequately prepared to provide deaf patients with linguistically and culturally competent care (Barn, 2019). Information from deaf clients to determine diagnoses and treatment plans during medical history is crucial to both the health professionals and deaf patients (Hampton, 1975). However, clear communication between the two parties becomes a challenge when there is no common language (Barn, 2019). Clearly, in doctor-patient interaction, the effective and unambiguous exchange of information is particularly important, and misunderstandings may have dramatic consequences (A. Smeijers et al., 2019). The exclusion of the deaf from health care services is fundamentally linked to the difficulties faced by these patients in communicating with members of health care teams (Scheier, 2009). According to Korsah (2011), 80% of respondents find it easy to trust a nurse who understands and speaks their language. Amfo et al. (2018) underscored that communicating health information to a patient in an accessible language is very crucial in the healing process. Deaf people are more likely to avoid going to the hospital not because they are always healthy but due to the communication challenges with healthcare professionals and the lack of interpreters available (A. Smeijers et al., 2019; Dimitra et al., 2014). Evidence indicates that the rate of deaf people’s visits to their health professionals is lower (Kuenburg et al., 2016; Amfo et al., 2018).

Health professionals who lack the skills to communicate with deaf patients are likely to refer them to colleagues with sign language skills or will probably refer them to other facilities with individuals who are competent in sign language (Smith et al. 2004). This could be hazardous because prolonged medical care can lead to serious health complications. Evidence suggests that the health of disabled people, including deaf individuals, worsens when they do not receive quality health services (Smith et al. 2004; Rotarou and Sakellariou, 2017; Grech, 2015). It is known that it is the responsibility of healthcare professionals to build academic training skills to communicate effectively with all people (Allen et al., 2007; Bentes et al., 2011). A study by Hoang et al. (2011) suggests that training medical students in deaf cultural competency can significantly increase their capacity to care for community members and reduce the health disparities experienced by this community. Likewise, Adib-Hajbaghery and Rezaei-Shahsavarloo (2015) indicated that to close the communication gap between deaf people and healthcare providers, academic training courses on effective communication skills are needed. Tonini et al. (2013) added that through established communication with the deaf patient, health professionals such as nurses can understand deaf people as holistic beings and become aware of their vision of the world and their way of thinking, feeling, and acting. Nevertheless, it may be argued that sign language fluency takes a long time to acquire (Andriakopoulou et al., 2007), and students may not get enough time to acquire competencies in sign language. Hence, other means, such as training sign language interpreters for hospitals, should be explored. A variety of factors, which include the limited number of available specialized interpreters and the cost of using the services of an interpreter, and more importantly, confidentiality, privacy, and independence of the deaf, may limit the use of sign language interpreters (Harmer, 1991; Muir & Richardson, 2014; Steinberg et al., 2006). Usage of sign language interpreters in the healthcare setting may result in deaf people withholding vital information, which might end up jeopardizing their health.

Across the globe, there has been several approaches to ensure deaf people face less communication barrier in their quest for healthcare. For example, American Sign Language (ASL) users are supposed to be provided with sign language interpreters in the healthcare setting (America with Disability Act). However, health professionals are still encouraged to have knowledge of deaf culture and basic skills in ASL (Barn, 2019). Deaf culture awareness and sign language skills are appropriate for health professionals to begin care for deaf patients (Barn, 2019). In Brazil, to achieve healthcare equality for deaf people, sign language has been added as a course for undergraduate nursing students (César et al., 2015). Likewise, in Ghana in 2016, it was made known by the Registrar of the Nurses and Midwifery Council (NMC) that sign language has been added to the curriculum of nursing and midwifery training colleges. The initiative, according to the Registrar, was in a partial response to a call from the Ghana National Association of the Deaf (GNAD) due to some avoidable deaths of deaf individuals which resulted from communication barriers. For example, in 2013, the president of the Ghana National Association of the Deaf (GNAD) announced the saddened deaf of their member, a pregnant woman who lost her life due to wrong medication happening because of a communication barrier (Ghana News Agency, 2013). The cost of communication barriers between the deaf and healthcare providers in Ghana has not holistically been documented. Informal conversation with some deaf people indicated similar incidences as reported earlier have occurred without coming to the news. A study by Appiah et al. (2018) in part of Ghana found that due to communication difficulties, deaf people experience disparity, discrimination, neglect, and delays in receiving healthcare from providers.

Primarily, the motive behind the introduction of GhSL for health communication is to equip healthcare students with the skills to communicate with deaf people during healthcare (Amfo et al., 2018; Myjoyonline.com, 2016). Additionally, to appreciate the relevance of deaf culture in healthcare (Barn, 2019). Critically considering the importance of the initiative, some private universities with healthcare students quickly added sign language as a course for their students. Likewise, public universities with colleges offering health-related programs have adopted the idea and revised their curriculums to include sign language. For example, in 2017, Kwame Nkrumah University of Science and Technology (KNUST) became the first public university to include sign language in the various curricula for all students under the College of Health Sciences. Subsequently, in 2019, the University of Cape Coast (UCC) added sign language to its students at the Faculty of Health Science. Gradually, it can be said most, if not all, students pursuing health-related programs in Ghana is been trained to have competencies in GhSL. Sign language in the nursing and midwifery training schools is taken lightly, just a semester as a non-scoring course. Though, in private universities such as Garden City University College and Valley View University sign language is a semester course that requires a pass towards graduation. Yet, among the public universities that have included sign language as a course, students are required to pass two semesters’ courses with varying credit depending on the school to progress.

Furthermore, the introduction of Therapeutic Communication into the curriculum in the same period in Ghana was to help student nurses and midwives appraise the role of language in healthcare and to understand that “competence in an indigenous language, including GhSL, will enhance therapeutic communication” (Amfo et al., 2018). Considering empirical studies (A. Smeijers et al., 2019, 2020; Appiah et al., 2018; Kuenburg et al., 2016; Roelofsen et al., 2021), the introduction of Ghanaian Sign Language into the curriculum of healthcare students seems to be in the right direction. The implementers are really not part of the learners (trainees), yet the sustainability of GhSL in the curriculum might somehow depend on healthcare students who are now learning GhSL. So, in this study, we assessed healthcare students’ perceptions towards the learning of GhSL as a course.

Notably, the pivotal importance behind most of these initiatives is towards achieving the Universal Development Goals, which seek to leave no one behind. Specifically, Goal 3 aims to “ensure healthy lives and promotion of well-being for all at all ages”, in part through the target to “achieve universal health coverage” (UN, 2015). Besides, Ghana, as a signatory to the United Nation Convention on the Rights of Persons with Disability (UNCRPD), recognizes that persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability (UNCRPD Article 25 Health). To that end, the Person with Disability Act (715) mandated that the Ministry of Health to include the study of disability and disability-related issues in the curricula (e.g., Sign Language) of health professional training institutions in order to develop appropriate human resources to provide general and specialized rehabilitation services.

2. Methods

2.1. Participants and recruitment procedures

The present cross-sectional online survey was carried out among health sciences students in tertiary institutions across Ghana. We conducted the online survey within a period of one month, starting from April 29^th to June 1st, 2020, to examine the perception of healthcare students towards the introduction of sign language into the curriculum of health-related programs. Eligibility for the study was open to undergraduate students pursuing any of the health-related programs across Ghana. Participants were strictly required to indicate their program of study. This helped to ensure only students pursuing health-related programs were represented in the study. A total of 847 individuals initially expressed their interest and participated in the study, and 666 (78.6%) met the eligibility criteria (see Table 1). Participants were recruited through social media platforms such as WhatsApp, email, and Facebook. Social media has become a popular method for conducting surveys and online interventions, especially in the era of COVID-19.

Table 1. Demographic Characteristics

Variable	Category	Frequency (n=666)	Percentage (%)
Age
	15–20	96	15.8%
	21–25	178	29.3%
	26–30	184	30.3%
	Above 30	150	24.7%
	Total	608	100%
Gender
	Male	160	24%
	Female	462	69.4%
	Total	622	100%
School
	Public	360	58.4%
	Private	256	74.3%
	Total	616	100%
Tertiary Education
	Nursing/Midwifery T.C	416	65.8%
	University	214	33.9%
	Other	2	3%
	Total	632	100%
Religion
	Christianity	584	90.4%
	Islamic	62	9.6%
	Total	646	100%
Programme
	Nursing	270	41.7%
	Midwifery	218	33.6%
	Other	160	24.7%
	Total	648	100%
Level/Year
	Level 100/Year 1	30	4.6%
	Level 200/Year 2	92	14.2%
	Level 300/Year 3	384	59.1%
	Level 100/Year 1	144	22.2%
	Total	650

Source: Field Survey, 2020

2.2. Survey Instrument

A structured questionnaire was administered using Microsoft Form. The initial items on the questionnaire were self-designed after extensive literature review on similar subjects and with the assistance of co-authors who are experienced in the teaching of GhSL. The questionnaire was pretested on 23 students from a nursing and midwifery training college in Kumasi, Ashanti Region of Ghana. Those students were exempted from the actual studies, and their data were not used for analysis, but they did assist us in merging questions that appeared almost identical, and some questions that were not answered by many were treated as irrelevant, and thus deleted. The final questionnaire consisted of four sections: demography of participants; perceived benefit of learning GhSL to the individual and the deaf community; perception of the introduction of GhSL by the NMC; perception of hospitals should provide interpreters instead of health students learning GHSL. Perception about whether hospitals should provide professional interpreters instead of health students learning GhSL was measured by a single item: “Should hospitals provide professional interpreters instead of health students learning GhSL?” This yielded a yes or no response. No was coded as 0 while yes was coded as 1.

2.3. Data collection

The link to the survey questions was created and shared. To reach more participants throughout the country, contact details of some program/course representatives, students, lecturers, and tutors who have connections with the various healthcare tertiary institutions were obtained. The purpose of the study was explained to those individuals, the link was sent to them, and they were encouraged to share the link with students or colleagues. Because students are mostly connected through students’ associations and similar platforms, part of the link description instructs them to share the link so it can quickly go viral. Yet, to avoid multiple responses, an instruction was provided to respondents to offer only one response. Because the data were collected during the COVID-19 era, when all students were at home, and it was expected that access to the internet would be a problem for many (Akakpo, 2008; Mahama, 2016), reducing the number of respondents, the lead individuals were asked to resend the link each week, so those who missed the exercise could have access and participate again. Each of the participants was made to complete a consent form prior to the question items. The data collection portal was closed after 34 days.

2.4. Data processing and statistical analysis

Data were initially exported to a Microsoft Excel spreadsheet, and checks were performed to clean up some responses that did not meet the inclusion criteria. In all, 181 respondents outside the health-related programs were deleted. Codes were assigned to some responses before the Excel data was exported to IBM SPSS software version 24 for further cleaning, coding, and data analysis. Data was presented using frequencies and percentages. At a rate of 95% confidence intervals (p = 0.05), Chi-square was used to analyze the differences between categorical variables. Finally, logistic regression was applied to examine the predictors of participants’ views on whether hospitals should provide professional sign language interpreters instead of health student learning.

3. Results

3.1. Socio-Demographic Characteristics

Table 1 presents the demographic characteristics of respondents. As shown in Table 1, a total of 666 tertiary health students participated in the study. The highest (30.3%) among the participants was within the ages of 26–30 years. Most (69.4%) of the study participants were females. A little over half (58.4%) of the participants were from public health schools. Almost two thirds (65.8%) of the study population were in the nursing/midwifery training colleges. The majority (90.4%) of the health students were Christians. Regarding their program distribution, close to half (41.7%) of the participants were pursuing nursing education. A lot (59.1%) of the participants were in their third year of education.

3.2. Healthcare students perception on the introduction of GHSL into the curriculum by demographic characteristics

As indicated in Table 2, about nine in 10 respondents (90.1%) perceive that the introduction of GhSL in the curriculum of health-related programs is a good idea. In general, a higher proportion of females than males believe that the introduction of GhSL into the curriculum is a brilliant idea, but the results were not statistically significant (2 = 4.321, p = .115). Nonetheless, a significant proportion of students who think the introduction of GhSL is a good idea were over the age of 26 (2 = 24.059, P.001). Perception that the introduction to GHSL is a good idea sometimes increases with their level of education (level 400, 95.6%, 2 = 26.22, p = .000). 1. Our data further indicates that a significantly higher percentage of students in private schools than in public schools opines that the introduction of GhSL is a good idea (94.9% vs 88.7%, p = .004). Regarding the type of tertiary education, a significant majority of students in training colleges rather than universities think the introduction of GhSL is a good idea (92.9%, 2 = 10.822, p = .029). Students pursing midwifery form a significant majority of respondents among all other health-related programs who perceive that the introduction of GhSL is a good idea (94.8%, 2 = 24.994, p = .000).

Table 2. Health Students Perception on the introduction of GHSL into the curriculum by demographic characteristics

		Incorporating GHSL into Health-Related Programs is a good Initiative
		Agree	Neutral	Disagree	Chi-square (χ2)	P- Value
		N (%)	N %	N %
Age	15–20	72(81.8%)	10(11.4%)	6(6.8%)	24.059***	.001
	21–25	160(94.1%)	8(4.7%)	2(1.2%)
	26–30	150(90.4%)	6(3.6%)	10(6.0%)
	Above 26	130(94.2%)	0(0.0%)	8(5.8%)
Gender	Male	132(88.0%)	6(4%)	12(8.0%)	4.321	.115
	Female	392(92.0%)	18(4.2%)	16(3.8%)
School	Public	298(88.7%)	22(6.5%)	16(4.8%)	11.267**	.004
	Private	222(94.9%)	2(0.9%)	10(4.3%)
Tertiary Education	Training College	364(92.9)	16(4.1%)	12(3.1%)	10.822**	.029
	University	168(86.7%)	8(4.2%)	18(9.4%)
Religion	Christianity	492(91.1%)	22(4.1%)	26(4.8%)	0.452	.798
	Islamic	54(90.0%)	2(3.3%)	4(6.7%)
Programme	Nursing	240(93.8%)	4(1.6%)	12(4.7%)	24.994***	.000
	Midwifery	182(94.8%)	4(2.1%)	6(3.1%)
	Other	128(83.1%)	16(10.4%)	10(6.5%)
Level/Year	Level 100/Year 1	28(93.3%)	2(6.7%)	0(0.0%)	26.221***	.000
	Level 200/Year 2	68 (79.1%)	10(11.6%)	8(9.3%)
	Level 300/Year 3	322(92.0%)	8(2.3%)	20(5.7%)
	Level 400/Year 4	130(95.6%)	4(2.9%)	2(1.5%)

Source: Field Survey, 2020 (*p< .05)

3.3. Perceive advantages of learning GHSL to Individual health students by age

Table 3 below presents the perception of health students on the perceived advantages of learning GhSL as an individual by their respective ages. Generally, the perceived benefit of learning GHSL at the individual level was found to be high among respondents, more specifically students over 26 years of age. For example, a more significant proportion of health students above 30 years of age perceive that learning GhSL will help them become more diverse (95.2%, p = .009*). Also, a high proportion of respondents (95.1%) between 26 and 30 years of age think GhSL is beneficial to all health workers. Likewise, a greater percentage (96.1%) of respondents within the same age group opines that learning GhSL is important even outside the healthcare setting. Similarly, the same age group (95.9%) appeared to be proportionally higher among all respondents who believed that learning GhSL is important for all students, not just healthcare students. All the results were statistically significant (see Table 3). Furthermore, 93.9% of those aged 30 and up believe that learning sign language will help them get a better job (p = .106).

Table 3. Perceive Advantages of learning GHSL to Individual Health Students by Age

Variable		Age
		15–20	21–25	26–30	Above 30
		N %	N %	N %	N %	P-Value
The learning of GHSL can help me to become more diverse	Agree	72(83.7%)	152(93.8%)	144(92.3%)	118(95.2%)	.009*
	Neutral	12(14.0%)	6(3.7%)	8(5.1%)	2(1.6%)
	Disagree	2(2.3%)	4(2.5%)	4(2.6%)	4(3.2%)
Learning of Sign language is important to all health workers	Agree	66(75.0%)	144(88.9%)	154(95.1%)	124(93.9%)	.000*
	Neutral	16(18.2%)	14(8.6%)	2(1.2%)	0(0.0%)
	Disagree	6(6.8%)	4(2.5%)	6(3.7%)	8(6.1%)
The learning of sign language can be of important to me even outside healthcare	Agree	76(88.4%)	154(97.5%)	148(96.1%)	118(95.2%)	.015
	Neutral	10(11.6%)	4(2.5%)	6(3.9%)	6(4.8%)
The learning of sign language is important for all students but not only health sciences	Agree	66(76.7%)	138(87.3%)	142(95.9%)	126(94.0%)	.000*
	Neutral	14(16.3%)	10(6.3%)	2(1.4%)	4(3.0%)
	Disagree	6(7.0%)	10(6.3%)	4(2.7%)	4(3.0%)
Acquisition of sign language skills can enhance my job prospect	Agree	68(81.0%)	134(82.7%)	132(85.7%)	124(	.106
	Neutral	12(14.3%)	22(13.6%)	16(10.4%)	6(4.5%)
	Disagree	4(4.8%)	6(3.7%)	6(3.9%)	2(1.5%)

Source: Field Survey, 2020 (*p< .05)

3.4. Importance of learning GHSL to the deaf community by academic programes

The results as indicated in Table 4 show that in total, respondents irrespective of status as studied or yet to study GhSL across the various health programs view learning of GhSL as important to the deaf community. The students’ nurses who have studied GhSL opine that learning sign language will help them to understand deaf people. The results were statistically significant (p = .005). On the other hand, a significant greater proportion of students’ midwives who are yet to study GhSL agreed that learning sign language will help them to appreciate deaf people. Again, a little to a complete percentage (97.4%), representing a greater portion of nursing students than any other health program, perceive the learning of GhSL will help them to serve deaf patients well. Likewise, the same percentage represented the majority of nursing students than all the health programs espoused that learning GhSL brings togetherness among the deaf and hearing. Yet, none of these results reached significant (p = .132) or (p = .232) respectively.

Table 4. Importance of learning GHSL to the deaf community by Academic programe

		Have you learned sign language before
		Yes				No
		Programme				Programme
		Nursing	Midwifery	Other	P- Value	Nursing	Midwifery	Other	P- Value
		N %	N %	N %		N %	N %	N %
Learning Sign language will help me understand deaf people	Agree	78 (100.0%)	70 (92.1%)	110 (94.8%)	.005	146 (93.6%)	98 (96.1%)	30 (88.2%)	.014
	Disagree	0(0.0%)	4(5.3%)	0(0.0%)		2(1.3%)	4(3.9%)	0(0.0%)
Learning Sign language will help me service my deaf patient well	Agree	74 (97.4%)	72 (92.3%)	98 (87.5%)	.132	152 (96.2%)	98 (94.2%)	30 (83.3%)	.030
	Disagree	0(0.0%)	2(2.6%)	2(1.8%)		2(1.3%)	4(3.8%)	2(5.6%)
The learning of GHSL can help bring the deaf and hearing people together	Agree	76 (97.4%)	76 (92.7%)	104 (94.5%)	.232	140 (90.9%)	90 (88.2%)	26 (81.3%)	.225
	Disagree	0(0.0%)	2(2.4%)	0(0.0%)		4(2.6%)	2(2.0%)	0(0.0%)

Source: Field Survey, 2020 (*p< .05)

3.5. Health student perception towards maintaining GHSL in their curriculum

Generally, about 88% of health students think GhSL should be maintained in their curriculum. Specifically, a significant proportion of the respondents above 30-years old hold that perception (92.4, 2 = 22, p = .001). An insignificant majority of these respondents represented males (88.0%, 2 = .486, p = .783). Our data indicates that the type of school, tertiary education, and respondents’ program of study play a significant role in the opinion that GhSL should be maintained in the curriculum, as a higher proportion of public schools than private schools, training colleges than universities, and nursing programs than other health-related programs perceive that GhSL should be maintained in the curriculum (92.9%, 88.1%, and 90.3%, respectively). However, health students in their 3 years of education mostly (90.7%) perceive that GhSL should be maintained in the curriculum. A higher proportion of students (88.5%) who have yet to study GhSL than those who have learned before perceive that GhSL should be maintained in the curriculum. But none of these results were statistically significant. See details of the results in Table 5.

Table 5. Health Student Perception towards Maintaining of GHSL in their Curriculum

		GHSL should be maintain in the curriculum of health institution
		Yes	Don’t Know	No	Chi-square (χ2)	P value
		N %	N %	N %	22.682***	.001
Age	15–20	72(81.8%)	12(13.6%)	4(4.5%)
	21–25	142(84.5%)	16(9.5%)	10(6.0%)
	26–30	148(90.2%)	6(3.7%)	10(6.1%)
	above	122(92.4%)	0(0.0%)	10(7.6%)
Gender	Male	132(88.0%)	8(5.3%)	10(6.7%)	.489	.783
	Female	364(87.5%)	28(6.7%)	24(5.8%)
School	Public	282(83.9%)	32(9.5%)	22(6.5%)	14.057***	.001
	Private	208(92.9%)	4(1.8%)	12(5.4%)
Tertiary Education	Training College	342(88.1%)	30(7.7%)	16(4.1%)	13.276**	.010
	University	160(86.0%)	6(3.2%)	20(10.8%)
Religion	Christianity	462(87.2%)	34(6.4%)	34(6.4%)	1.911	.385
	Islamic	56(93.3%)	2(3.3%)	2(3.3%)
Programme	Nursing	234(92.9%)	6(2.4%)	12(4.8%)	39.073***	.000
	Midwifery	168(90.3%)	4(2.2%)	14(7.5%)
	Other	120(77.9%)	24(15.6%)	10(6.5%)
Level/Year	Level 100/Year 1	26(86.7%)	2(6.7%)	2(6.7%)	11.199	.082
	Level 200/Year 2	64(78.0%)	10(12.2%)	8(9.8%)
	Level 300/Year 3	312(90.7%)	14(4.1%)	18(5.2%)
	Level 400/Year 4	118(86.8%)	10(7.4%)	8(5.9%)
Have you learned sign language before	Yes	246(87.2%)	20(7.1%)	16(5.7%)	1.128	.569
	No	278(88.5%)	16(5.1%)	20(6.4%)

Source: Field Survey, 2020 (*p< .05)

3.6. Predictors of health students’ perception about hospital providing professional interpreters instead of health students learning GHSL

The issue of whether hospitals should provide professional interpreters rather than health students learning GhSL was keenly debated as a little over half the percentage representing the majority of participants (50.3%) indicated hospitals should provide interpreters rather than health students learning GhSL. However, multivariate logistic regression analysis was performed (see Table 6) to ascertain factors associated with perception about hospitals’ providing professional interpreters instead of health students learning GHSL. The specific determinants included in the analysis were age, gender, type of school of the participant, type of tertiary institution, religion, the programme of study, level/year, and having ever learned sign language. The results show that only one program of study was associated with health students’ perception about whether hospitals should provide professional interpreters instead of students learning GHSL. The study established that the participants who study midwifery were 2.183 times significantly more likely to support the view that hospitals should provide professional interpreters instead of health students learning GHSL as compared with students who study nursing (AOR: 2.183, CI: 1.104–4.316, p = 0.025). The study again found that participants who studied other programmes were 2.106 times significantly more likely to support the view that hospitals should provide professional interpreters instead of health students learning GHSL as compared with students who study nursing (AOR: 2.106, CI: 1.041–4.261, p = 0.038).

Table 6. Predictors of health students’ perception about hospital providing professional interpreters instead of health students learning GHSL

Variables	B	S.E.	Exp(B)	Sig.	95% C.I.for EXP(B)
					Lower	Upper
Age (years)
15–20
21–25	−.011	.411	.989	.978	.442	2.215
26–30	−.469	.282	.625	.097	.360	1.088
Above 30	.028	.231	1.028	.903	.654	1.617
Gender
Male	1.00
Female	.138	.218	1.148	.526	.748	1.762
School
Public	1.00
Private	.189	.237	1.208	.427	.758	1.923
Tertiary Education
Nursing & Midwifery	1.00
University	−20.99	2841.20	.930	.999	.067	1.356
Others	−21.346	2819.20	.871	.999	.235	2.235
Religion
Christian	1.00
Islamic	.294	.313	1.342	.348	.726	2.480
Programme
Nursing	1.00
Midwifery	.780	.348	2.183	.025	1.104	4.316
Others	.745	.360	2.106	.038	1.041	4.261
Level/Year				.
Level/Year (1)	1.00
Level/Year (2)	.151	.464	1.163	.744	.469	2.889
Level/Year (3)	−.476	.361	.621	.188	.306	1.261
Level/Year (4)	−.456	.247	.634	.065	.391	1.029
Ever learn sign language
Yes	1.00
No	−.160	.204	.852	.432	.572	1.270
Model fitting information
−2Log Likelihood					792.376
Hosmer-Lemeshow χ^2 (significance)					17.719
Nagelkerke R^2					0.056

Source: Field Survey, 2020 (*p< .05)

4. Discussion

To the best of our knowledge, no study has been done so far to assess healthcare students’ perceptions toward the learning of GhSL as a course since its introduction into the various curricula of health-related programs. The study findings indicate that the majority of the health students were females; also, most of them were students’ nurses; and this was not surprising as females form the majority of health workers in Ghana and nursing is always the largest workforce among the other healthcare professionals in Ghana (Asamani et al., 2019). Nursing and midwifery training colleges train more healthcare professionals than universities and other tertiary schools in Ghana (Bell et al., 2014), and having a majority of respondents from the training college was anticipated. Likewise, most of the tertiary schools training health professionals are public tertiaries, as was reflected in our study. GhSL is mostly learned during the third year of nursing and midwifery training colleges, so having a majority of respondents from this year group was not surprising as this group will be keen to participate in a study of this nature. Yet, the majority of respondents being between the ages of 26 and 30 years did not reflect the average age range of students in the tertiary schools in Ghana. This was likely because most of the respondents who saw the need to participate in the study were top-up or mature students.

Obviously, students pursuing health-related programs were not consulted prior to the introduction of GhSL in the curriculum of the various health training institutions. So, having a majority of students perceive that the introduction of GhSL into the curriculum is a good idea is a sign of positive attitude towards GhSL and the deaf community at large and likely suggests potential sustainability of GhSL as a course for healthcare students. Previous studies on students’ attitudes towards people with disabilities have indicated a negative attitude (Kwame Butakor et al., 2020; Naami & Hayashi, 2012). This demonstrates further healthcare students’ willingness to contribute to the global effort to achieve a portion of the Sustainable Development Goal (SDG), leaving no one behind (Hashemi et al., 2017). Additionally, it suggests the readiness of healthcare students to deal with the global menace of healthcare professionals’ inability to communicate in sign language (Arulogun et al., 2013; Barnett & Franks, 2002; Bentes et al., 2011; Fellinger et al., 2012). A study by A. Smeijers et al. (2020) found that the majority of deaf patients were worried about the inability of healthcare professionals to communicate in sign language.

Though the ability to learn new languages declines as we age (Malloy, 2003), a higher percentage of healthcare students above the age of 26 years in the current study perceive the introduction of GhSL as a good ideal and should be maintained in the curriculum. The major barrier facing deaf people’s access to healthcare has frequently been reported in many studies as communication (A. S. Smeijers et al., 2011; Barnett & Franks, 2002; Smith, 1992), and healthcare practitioners in the current study might have experienced the same in their field of work, and this likely makes them see beyond the possible challenges associated with learning a new language at such an age. Furthermore, this same group of healthcare students believes that learning GhSL will benefit them more than any other group of healthcare students. The findings contradict a study by Mutswanga and Mapuranga (2014), where hearing people perceive that it is pointless to learn sign language unless one wants to work with deaf people.

Generally speaking, nurses care for many more regular medical conditions compared to other healthcare groups and hence work with a more diverse group of patients. A. Smeijers et al. (2020) discussed that deaf people will seek specialized care only if the regular medical health care system has not succeeded in solving their problems. So, acquiring a new language will be more beneficial to nurses than any other health professionals. So, it was not perplexing to find in the current study that a higher proportion of student nurses than other healthcare students opine that sign language should be maintained in the curriculum. In addition, the same group of healthcare students see far more benefit in learning GhSL for the deaf community. It is worth stating that the introduction of sign language for health communication does not only offer students the opportunity to learn sign language skills, but also learn about deaf culture and its relevance in healthcare practice. Previous studies on issues in doctor-patient relationships have demonstrated that both ethnic/cultural and language differences complicate the establishment of a satisfying and effective doctor-patient relationship (e.g., Van Wieringen et al. 2002; Schouten & Meeuwesen 2006). Appreciating one’s cultural values in healthcare is a part of the healing process (Amfo et al., 2018).

Nevertheless, the full advantages of equipping every healthcare student with GhSl competencies cannot be overemphasized. Organizations of deaf people state that their members often report negative experiences in their contacts with the medical world, which often results from the deaf individuals’ not being able to receive or understand information from healthcare workers (A. Smeijers et al., 2019). However, considering the limited study period and scarcity of resources, it may occur that not all healthcare students can be equipped with the requisite skills to effectively communicate health information in sign language. The other alternatives, including lipreading information from healthcare providers, deaf individuals reading about their health from the internet, or exchanging information through reading and writing, and speech to text interpretation, are never optimal (A. Smeijers et al., 2019). Wood (1999) found that a highly skilled lip-reader is able to “read” only 20–40% of what is said. Regarding the exchange of paper-based information when the deaf person is able to understand written language fluently, writing down information is much more time-consuming than talking, and results in healthcare professionals writing down only a small portion of the information normally given (A. Smeijers et al., 2019). With regards to speech to text interpreters, it may help overcome medical barriers (A. Smeijers et al., 2019). Yet, the amount of information transferred from the physician to the patient and vice versa is restricted (A. S. Smeijers & Pfau, 2009).

Again, the regression results indicated that students pursuing health-related programs aside from nursing are more likely to perceive that hospitals should provide professional sign language interpreters than students learning GhSL. Similarly, a higher proportion of training college students than university students want GhSL to be kept in the curriculum, which is likely because sign language is not required for progression at the training college. Nevertheless, it can be concluded that most students are intrinsically motivated to learn GhSL (Legault, 2017). In the same vein, a lower percentage of students who have studied GhSL than those yet to pursue GhSL think GhSL should stay in the curriculum, and this might be that the aspirations of some students were not met after the course or probably the challenges they encountered as adult learners of a new language have changed their perception (Naif et al., 2017). As already discussed, the two groups (studied versus yet to be studied) perceived several benefits and were interested in learning GhSl but might be concerned if the course is not well thought out it could affect their academic records (Gopalan et al., 2017; Guay, 2022). Also, as GhSl is only introduced to Ghanaian students at the tertiary level, they will have to make an extra effort to meet the requirements of the course.

Despite the findings showing clearly that almost all health students perceive many benefits in the learning of GhSL, a reasonable percentage still perceive hospitals should provide professional sign language interpreters rather than students learning, and this might be that students perceive direct healthcare providers-deaf patient communication can result in wrong diagnosis and may even delay the medical procedure (Van Wieringen et al. 2002) as their competencies are not optimum. Fundamentally, using sign language interpreters in the medical setting will require extra training, which definitely comes with a cost (A. Smeijers et al., 2019; Harwood, 2017; Napier, 2004). Though that will allow the healthcare providers to concentrate fully on the procedure while the interpreter supports the communication (A. Smeijers et al., 2019). In places like Ghana where deaf people seldomly report to healthcare facilities for reasons yet to be established, it will be unwise to permanently engaged the services of sign language interpreter at the hospital. This raises the question of which hospitals should have interpreters. Countries where there is a recognition for professional sign language interpreters. Some deaf people consider it superfluous to bring an interpreter for an appointment for the sound reason that medical consultation takes a few minutes/hours (A. Smeijers et al., 2019 . More so, in many places, deaf people choose to go to the healthcare setting with friends or relatives (A. Smeijers et al., 2019). This option may not be the best in the Ghanaian context, where most people still hold negative beliefs about the deaf and show little concern towards their wellbeing. In addition, relatives or friends who are even ready to assist may not always be available, especially during an emergency. Similarly, accessing interpreters is difficult because many institutions, including those of health institutions, lack access to contact information for sign language interpreters, even if they are aware that such provisions exist. In a systematic review, 2019) found only 30 countries where it is possible for healthcare staff to contact a qualified sign language interpreter. Also, in the advanced countries such as Denmark, France, the United Kingdom (UK), Norway, Spain, Sweden, the USA, Australia, Finland, and Japan, there remain insufficient interpreters to provide service in all situations, and for that, remote (online) interpreting facilities are available to cater for the inadequate sign language interpreters (Coghen & Cokely, 2015). In Ghana with limited internet facilities, it is not possible to efficiently implement this service (Akakpo, 2008; Mahama, 2016). One limitation of this study on the issue of hospitals providing sign language interpreters rather than students learning was that the view of deaf people was not sought. However, a study by Appiah et al. (2018) found that an overwhelming majority, 21 out of the 22 study participants who were engaged in face-to-face interviews, preferred to communicate in sign language than any other means available during healthcare. Future studies are recommended to quantitatively explore reasons why deaf patients might prefer a certain communication mode during health delivery.

5. Conclusion

The evidence indicated in the study demonstrates health students’ opinions that the introduction of GhSL in their curriculum is a smart initiative by the NMC. Likewise, health students are of the view that learning GhSL comes with a lot of advantages, both for the individual learner and the deaf community. To a large extent, demographic characteristics partially influence students’ perception of the learning of GhSL as a course. This was manifested as almost all students’ nurses compared to other health-related programs saw more benefits of learning GhSL to the deaf community. Also, students over 26 years old have a more positive perception towards maintaining GhSL in the curriculum as well as learning GhSL as an individual. Again, students who are yet to learn GhSL hold a favorable perception towards studying GHSL. Considering the study findings, an effort should be made to sustain the interest of health students towards the learning of GhSL, and this can be actualized through a collaborative effort between the NMC and the Kwame Nkrumah University of Science and Technology (KNUST), which is the supervisory institution for almost all the nursing and midwifery training colleges, as well as other private health training and university colleges. The collaborated institutions should audit the teaching and learning materials for GhSL of all the institutions so that any materials lacking can be provided.

Granted, not every student can acquire sign language competencies within the limited time allotted to learning GhSL. Students who do their best to acquire the skills should be motivated. This can be done by identifying such students and ensuring they receive quick post after school to top hospital facilities where they will facilitate communication among the deaf and other hospital staff whenever there is a need. To hold on to their skills, a refresher course will be required.

Finally, in order to make it easier for tertiary students, GhSL should be introduced to students at the elementary level through tertiary. The Ghana Education Service should facilitate this initiative. By doing so, GhSL will be part of the normal language for students.

Author contributions

Prince Peprah offered scientific guidance on the study’s design and data analysis, while Richard Adade participated in data gathering and analysis and wrote the first copy of the publication. The final manuscript was reviewed and approved by all writers.

Acknowledgments

The authors wish to thank all study participants for their time.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The authors solely funded this study.

Notes on contributors

Richard Adade

Richard Adade is an assistant lecturer. Richard’s research interest focuses on the education of students with sensory impairments (deaf and blind), teaching sign language and sign language interpretation. He has produced many teaching and learning materials for sign language learning.

Obed Appau

Obed Appua is an assistant lecturer and PhD student. Obed is interested in the education of the deaf and has co-authored some publications in that area. He is very experienced in the teaching of sign language as a course at the tertiary level.

Prince Peprah

Prince Peprah is a Ph.D. student with research interests in health services, systems, and primary care.

Portia Marfo Serwaa

Portia Serwaa is an MPhil student. Portia’s research interests focus on sign language, healthcare access for deaf people, and sign language interpretation.

Daniel Fobi

Daniel Fobi is a lecturer and graduate program coordinator at the Department of Special Education, University of Education, Winneba (UEW). His research interests focus mostly on deaf education, and he has led publications in the same area.

Rebecca Tawiah

Rebecca Tawiah is an MPhil holder. Rebecca’s research interests include sign language, adolescents’ mental health, disability and employment, and rehabilitation services for children with disabilities.