Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)


Clinical and Translational Sciences

First Advisor

Charles D. MacLean

Second Advisor

Megan A. Morris


Adults with speech and language, voice, hearing, and cognitive difficulties (collectively called communication disabilities (CDs)) have difficulties in understanding or being understood by others when speaking. Adults with CDs face barriers in accessing healthcare and experience poorer healthcare outcomes. When compared to their peers without CDs, adults with CDs experience more emergency room visits, three times higher rates of adverse events, and higher rates of preventable readmissions. This dissertation extends our understanding of cross-sectional health outcomes related to CDs to the longitudinal outcome of mortality. It then considers a potential solution - disability accommodations supporting effective communication and healthcare access.In the first study, we used the National Health and Aging Trends Survey (NHATS) to examine differences between nine-year mortality rates among Medicare beneficiaries aged 65 years and older, with and without CDs. After adjusting for sociodemographic, health, and other disability factors, we found that older adults with CDs were 1.46 times as likely (95% CI: 1.31 - 1.62) to die over a nine-year period as compared to older adults without CDs. In the second study, again utilizing the NHATS, we examined the likelihood of bringing a communication companion (someone who assists with communication at medical visits). We also sought to understand if social equity factors drive the likelihood of bringing a companion. We found that in comparison to their peers without CDs, older adults with CDs were 41% more likely to bring a companion to a primary care visit (Adjusted Prevalence Ratio: 1.41; 95% CI: 1.27 - 1.57). Despite this higher likelihood, over half of older adults with CDs did not bring a communication companion. Among this population, women as compared to men, and black adults as compared to other races were less likely to bring someone. In the third study, we performed qualitative interviews with disability coordinators at 15 US healthcare organizations actively implementing communication accommodations (i.e. aids and services that support effective communication and healthcare access). We aimed to understand organizational level perspectives on operationalizing this practice. We found that these early-adopting organizations were focused on accommodations for hearing and visual disabilities. There were few accommodation options for speech and language, voice, and cognitive CDs. In addition, organizations were largely reliant on clinicians and clinics to identify patients with accommodation needs, prepare the accommodation, and provide the accommodation. Finally, in the fourth study, we performed a scoping review to identify what communication accommodations have been evaluated in the past 20 years and how they have been evaluated. We created a taxonomy of 11 accommodation types, and made recommendations to support future investigations in this area. Despite the enactment of the Americans with Disabilities Act 33 years ago, we still find disparities in mortality outcomes for adults with disabilities in communication. Past research demonstrates that the healthcare system is rife with communication barriers for this population, and this is linked to poorer outcomes. Implementing accommodations in healthcare settings is a path forward that is mandated by law but rarely studied. In this dissertation, we laid out early steps on this path. Future research should address: 1) convening stakeholders from across social, policy, and healthcare service realms in building the evidence-base, 2) improving upon and standardizing the common practice of bringing a companion, 3) organizational-level factors impacting implementation of accommodations including implementation strategies.



Number of Pages

131 p.