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\title{Factors Related to the Quality of Life in the Context of Deaf Sign Language users in Brazil}
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             \author[1]{Israel Bispo dos  Santos}

             \author[2]{,Ana Paula  Berberian}

             \author[3]{Giselle  Massi}

             \author[4]{Rita  Tonocchi}

             \author[5]{Jair Mendes  Marques}

             \author[6]{Everton  Morais}

             \affil[1]{  Universidade Tuiuti do Parana}

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\date{\small \em Received: 9 December 2019 Accepted: 31 December 2019 Published: 15 January 2020}

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\begin{abstract}
        


Introduction: Deaf sign language users population often has been facing linguistic difficulties regarding to interacting with people who are not aware, who have not learnt about using sign language, such difficulties may have been revealing serious consequences to their social, emotional and also cognitive development.Objective: This study has aimed to analyze the factors which may be associated with the best scoring of Quality of Life (QOL) in a group of deaf Brazilian sign language (Libras) users.Methods: It is a quantitative study, whose data collection has been assessing using the WHOQOL-BREF scale and a sample profile questionnaire as well. Sixty (60) deaf Libras users, who has been living in Southern region of Brazil have participated. Statistical analysis was used by means of descriptive statistical methods and inference methods, considering the significance level of 0.05 (5%).Results: Results have evidenced that total mean scoring in the WHOQOL-BREF was 43.3%. The domain with the highest scoring was Social Relationships (64.31%), and the lowest-scoring was Environment (54.77%).

\end{abstract}


\keywords{deafness. quality of life. sign language. health promotion.}

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\section[{I.}]{I.}\par
Background ne of the societal challenges in the 21st century is interacting with the diversity and assuring the right to equality to all shares of the population. It certainly must include the interaction with disabled people, including deaf people which are sign language users \hyperref[b3]{(Ayantoye \& Luckner, 2016)}.\par
Brazilian researchers, \hyperref[b13]{Chaveiro et al. (2014)}, state that this population often has been facing linguistic difficulties to interact with people who do not use sign language and those difficulties may have revealed serious consequences to their social, emotional and also cognitive development.\par
In Brazil, the Brazilian Sign Language (Libras) was recognized by Federal Law number 10.436 in 2002 as a legal mean of communication and expression, it has also been considered a visual-motor linguistic system with its own gramatical structure  {\ref (Brasil, 2002)}. That legislation also sets institutionalized ways to support and disseminate Libras in public health service concessionaires and institutions, which must reassure proper care and treatment to deaf individuals, according to current legal regulations. \hyperref[b11]{Chaveiro et al (2013)} has explained the nonrecognition of deaf individuals' linguistic diversities hinders the access of that share of the population to primary health care services offered by the Unified Health System (SUS). That system was set up in 1988 under the Brazilian Constitution, and states that "Health is a right for all and duty of the State". Although this system has been in effect since late 1980s, Brazilian studies, such as \hyperref[b10]{Chaveiro (2011}\hyperref[b13]{Chaveiro ( , 2014) )} and \hyperref[b17]{Garcia (2016)}, has showed that there are very few sign language interpreters in public institutions over the country, in addition, there is no qualification for public servants, as a whole, to render service to deaf sign language users, which weakens their interactions in these settings \hyperref[b43]{(Quadros, 1997;}\hyperref[b13]{Chaveiro et al, 2014)}.\par
The National Health Policy for impaired people, which came to effect in Brazil in 2002  {\ref (Brasil, 2008)}, states that quality of life and its promotion are shared social responsibilities and the improvement of information mechanisms to drive health and impairment research must be accessible in Braille and Libras. In this light, our greatest interests are studies that assume that the promotion of the quality of life to this share of the population is essential  {\ref (Brasil, 2008)}.\par
Quality of life should be understood as a multidimensional concept in this context, which reflects people's perception regarding to their social, cultural position, their conditions of education, labor, health, housing, security and personal relations. According to the World Health Organization (WHO), quality of life 1  (QOL) is defined as "an individual's perception of their position in life in the context of the culture and value systems where they live and in relation to their goals, expectations, standards and concerns" (The Who QOL Group, 1995, p. 03). The assessment of health-related quality of life has been increasingly used to analyze outcomes of clinical studies and broaden understanding about the impact of certain diseases on an individual's life.\par
By reviewing literature which relates quality of life (QOL) and deafness, it was possible to verify that studies by \hyperref[b2]{Almeida et al (2015)}, Angelo et al (2016), and \hyperref[b23]{Himi \& Takano (2016)} on this subject, are usually carried out with hard of hearing people users of hearing aids and cochlear implants. On the other hand, studies, such as Chaveiro et al (2014), \hyperref[b16]{Fellinger et al (2012)}, and \hyperref[b17]{Garcia (2016)} have addressed to the QOL of deaf sign language users are in lower number and have evidenced the difficulties that this share of the population has been facing to access health care services, in addition to a reduced knowledge on their own life and QOL.\par
International studies show that deaf people who have higher scores in quality of life (QOL) social relations and emotional domains are the ones who participate in deaf communities and use sign language \hyperref[b14]{(Fellinger et al, 2005;}\hyperref[b15]{Fellinger et al, 2007)}. According to Jaiyeola \& Adeyemo (2018), unlike in Europe and North America, the experiences of deaf people and the effects of deafness on their QOL have not been fully studied in developing countries yet. Their study was held in Nigeria, but we can also infer that in Brazil, like many developing countries have had sparse data relating QOL and deaf people sign language users. Such data is required for population who needs assessment, intervention programs design, evaluation and educational placement.\par
A study by \hyperref[b33]{Kushalnagar et al. (2010)}, from the Department of Health Services at the University of Washington in Seattle, USA ha showed important implications in the quality of life of deaf young individuals. Its data shows that several deaf individuals evidence depressive symptoms, which are related by the authors to either their difficult or almost non-existent communication to their parents. The convenience sample in this study comprised 230 young deaf teenagers (mean age =14.1, 24\% users of the Sign Language, 40\% used speech, and 36\% used both, Sign Language and speech). The authors have researched QoL and communication related issues and have noticed that the deaf people who have had good communication with their parentes have featured lower scores of depressive symptoms.\par
Similarly, Zöller \& Archer (2015) carried out a study at the University of Gothenburg, Sweden, addressing the QOL of deaf sign language users. Results from this research have evidenced that, deaf individuals, who communicate better with their families, have had a better quality of life. Likewise, studies by \hyperref[b48]{Vaccari \& Marschark (1997)}, \hyperref[b46]{Steinberg et al (1999)}, Meadow et al. (  {\ref 2004}), \hyperref[b38]{Marschark (2007)}, and \hyperref[b33]{Kushalnagar et al. (2010)} have showed that the access to interactions at home, at school and with their peers is highly important for the development of sign language, and that it is reflected on their QOL.\par
Analyzing and measuring the QOL among the population of deaf sign language users worldwide has shown to be a challenge. \hyperref[b13]{Chaveiro et al (2014)}, carrying out an integrative review of the scientific production on health-related quality of life of deaf sign language users, published between 2000 and 2012, has found only 14 articles using that criterion. Three of them have investigated the quality of life with instruments translated to sign language, six used instruments without translation or with symultaneous translation into the sign language, and five of them described the translation methodology of the instruments into the sign language.\par
Considering the discussion above, this paper has aimed to answer the following research question: which factors have influenced the quality of life among the deaf sign language population? Thus, this study aims to analyse some of the factors associated with better QOL scores among a group of deaf users of the Brazilian sign language by means of the proposed domains in the WHOQOL-BREF and in a sample profiling questionnaire. 
\section[{II.}]{II.} 
\section[{Methods}]{Methods}\par
This is a quantitative study using two instruments: the WHOQOL-BREF (The Who QOL Group, 1995), and a sample profiling questionnaire. This research was carried out in a city located in Southern Brazil, Curitiba, capital city of Paraná State, and in smaller towns around this capital city (Metropolitan Area) -São José dos Pinhais, Campo Largo, Pinhais and Colombo. Those towns were selected due to their proximity to the center where the research was performed and due to the presence of many deaf people, users of the sign language. It is worth elucidating that, according to data by the Instituto Brasileiro de Geografia e Estatística/2015 1 (Brazilian Institute of Geography and Statistics), there are over 2000 deaf-impaired individuals in the studied region.\par
This study was approved by the Ethics Research Board under number 50438915.5.0000.5529. 
\section[{a) Participants}]{a) Participants}\par
Sixty (60) deaf individuals participated in the research and the inclusion criteria were deaf participants, users of Libras, over 18 years old, residents in a city in the Southern Brazil and in towns around it, called Metropolitan Area.\par
Initially, for the participants' selection, institutions that have been attending deaf individuals, such as schools, universities, associations and religious institutions located in the above-mentioned cities were contacted. Such institutions provided deaf individuals' names and contacts from those ones who matched the research inclusion criteria. Then, a researcher e-mailed the participants and explained the study goals and instruments, thus, those deaf individuals, who have already matched the research inclusion criteria, were invited to participate.\par
The study sample consisted of 60 participants, Libras signers, between the ages of 18 and 58 years. 
\section[{b) Instruments used}]{b) Instruments used}\par
It should be elucidated that the WHOQOL-Bref questionnaire was selected for being an instrument objectifying the assessment of the quality of life, translated into several languages, and that presents satisfactory levels of equivalence, so that results reliably reflect the actual quality of life of a given community in its transcultural use. In addition, this instrument was selected for being the only Brazilian instrument with a validated version in the Brazilian sign language (WHOQOL-Bref, Libras 2016).\par
That instrument comprises 26 questions about the respondents Qol, health, other segments of their lives and their experiences in the four weeks prior to the study, which entail the original instrument. All the items in WHOQOL-Bref have five options each ranging from the highest to the lowest score . The questions of the instrument entail diverse aspects of the daily life and approach four domains of the QOL: physical, psychological, environmental and social relationships. Domain scores feature values between zero and one hundred, where the ones closest to zero stand for the worst, and the best ones are the closest to one hundred. The answers follow Likert scale (from 01 to 05), in which the higher the scoring, the better the quality of life. (The WHOQOL Group, 1995).\par
Using the WHOQOL-Bref Libras, one of the researchers e-mailed Chaveiro initially, who was responsible for the Brazilian validation of this instrument, requesting a "key" of the WHOQOL-Bref Libras software with its videos to use it. \hyperref[b13]{Chaveiro et al. (2014)} developed a proper instrument to assess the QOL of deaf in their own language, justifying that it is easier for the deaf to answer these instruments in Libras.\par
It´s important to notice that the WHOQOL-Bref Libras is a video instrument, so the questionnaire questions, instead of use the written language as in the original test, are made through Libras. As it was explained in the introduction, this instrument was validated in Brazil in 2011.\par
This questionnaire was applied to obtain information about each participant and allows crossing and comparing the answers provided at the application of the QOL questionnaire, making the necessary complementations to measure the QOL of Libras, adding other factors that could influence it.\par
The suitability of these tolls to the study population was pretested in a previous study with a similar population in another Brazilian city. 
\section[{c) Data collection}]{c) Data collection}\par
Data collection was held between July 2015 and February 2016, with 60 deaf individuals, in previously scheduled places by the researcher, via e-mail or phone contact. The participants, who have accepted to participate in the research, they have met individually with the researcher. Before answering the instruments, each participant has signed the Free Informed Consent Form.\par
Carrying out the data collection, the responsible researcher, proficient in Brazilian sign language 1 , has explained to the participants, through Libras, that they have had the option to either answer the Written Portuguese Language version or to watch the video of the Sign Language version of the WHOQOL-Bref instrument.\par
Libras version was presented on a video and answers were provided in a printed sheet. Each participant could either choose to watch the videos and answer or only answer the printed version of the questionnaire. After elucidation, each participant has answered the questionnaires individually, with no researchers interference.\par
In addition to the WHOQOL-Bref instrument, each participant has answered the sample profiling questionnaire. It has contemplated questions on participants' sociocultural aspects, such as: gender, age, type of deafness, salary, current employment or unemployment status, use of Libras at work, occupation, schooling, view of each participant about him/herself regarding to the use of Libras and the Portuguese language and use of Libras by his/her family members.\par
This questionnaire was applied to obtain information about each participant and has allowed crossing and comparisons of answers provided at the application of the QOL questio nnaire, making the necessary complementations to measure the QOL of Libras and also adding other factors that could influence it. 
\section[{d) Analysis}]{d) Analysis}\par
The collected data were submitted to statistical analysis by means of descriptive statistical methods (tables of frequency, mean, standard deviation, minimum value, maximum value), and inference methods (Friedman's ANOVA and Statistical Tests -Chisquare Test and Fisher's Test), considering significance level of 0.05 (5\%).\par
The sample profiling questionnaire collected data were analyzed in this research by crossing of the WHOQOL Bref results. In the discussion below, it was chosen to cross only some data from the WHOQOL -Bref questionnaire, especially in the domains of Social Relationships (best scoring), and Environment (worst scoring) with data from the sample profiling Volume XX Issue I Version I3 ( G )\par
questionnaire to meet this study aims and the research question.\par
III. 
\section[{Results}]{Results}\par
Table \hyperref[tab_0]{1shows} the distribution of some variables: gender, age, hearing loss, degree of hearing loss, salary and schooling by absolute and relative frequencies. The mean age of the 60 participants in the study was 28 years, standard deviation of 9.97 years (minimum age of 18 years and maximum age of 58). Regarding to the type of deafness, 91.67\% (n=55) of the participants answered that they had congenital deafness, and only 8.33\% (n=05) had acquired deafness. All of them had a severe to profound hearing loss. 10.00\% of the participants (n=6) concluded Middle School, 30.00\% (n=18) answered that they concluded High School, 31.67\% (n=19) graduated from Higher Education, 21.67\% (n=13) had post-graduation, and 6.67\% (n=4) of the sample concluded a master's degree.\par
Thus 33.33\% of the sample (n=20) work as a production assistant in automotive factories and earn 1 or 2 Brazilian minimum salaries 2 , 25,00\% (n=15) earn 3 or 4 salaries, work as sign language teachers, only 12 participants (20,00\%) earn more than 4 salaries and they work as teachers at the university and 13 of them (21,67\%) are unemployed.\par
Regarding general issues, in the application of the WHOQOL-Bref, it was perceived that more than half of the sample (51.7\%) assesses their quality of life as good or very good, and 55\% report satisfaction with their health.\par
Mean scoring obtained in each domain (physical, psychological, social relationships and environment) of the quality of life is shown in Table \hyperref[tab_1]{2}. Friedman's ANOVA test was applied to organize that table, significance level of 0.05 (5\%), it is being possible to verify the existence of outstanding diferences (p=0.0355) between the results of the domains. Identification of the differences evidences significant results between Environment and Physical domains (p=0.0085), Environment and Psychological domains (p=0.0032), Environment and Social Relationships domains (p=0.0069). Friedman's ANOVA was used because it requires the following assumptions: independence, homoscedasticity and normal distribution, not all of which were satisfied. Friedman's ANOVA is then adequate because the data are related and the scale is at least ordinal (not requiring normal distribution) since the method is non-parametric. The internal reliability of the WHOQOL-Bref questionnaire scale was 0.85. Likewise, for each of its four dimensions, Cronbach's scores were: 0.50 for the Physical domain, 0.51 for the Psychological domain, 0.76 for the Social Relations domain and 0.70 for the the Environment domain. By means of these results, it is possible to affirm that the items are homogeneous and that the scale consistently has measured what was proposed, for the Physical and Psychological domains the values were moderate.\par
It could be observed in the table above that the Environment domain, related to safety in daily life, leisure activities, housing conditions, means of transport and health care service has showed a significantly lower result than other domains. The physical environment, (THE WHOQOL GROUP, 1998).\par
In table 3, the scores for all the questions of the WHOQOL-Bref questionnaire are shown. Additional variances were analysed from the socio demographic variables collected by the sample profiling questionnaire. The results from this instrument, regarding the view about themselves on the use of the Portuguese Language have showed that almost 50\% (n=29) of the participants reported that they currently have a good or very good use of the oral language. Also, for written language proficiency, 80\% (n=49) of the participants reported to have a reasonable or good writing. When asked if they use Libras to interact with their family, only 25\% (n=15) of the sample reported to interact by means of this language. Among those, most of them (n=14) have said that they have been using Libras with their mothers. By correlating data between salary and the use of oral and written language, it was observed by means of the Fisher's Test, significance level of 0.05, significant correlation between salary rate and orality (p=0.0481) and written language (p=0.0329), with frequencies showing that the best results for orality and writing occur among higher salary rates.  According to the table 6 below, through the chisquare test, at the significance level of 0.05, it is verified that there is a significant correlation between schooling and orality (p = 0.0001), written language (p = 0, 0005) and reading (p = 0.0005), evidencing that the best QOL results occur through the improvement of schooling. IV. 
\section[{Volume XX Issue I Version I}]{Volume XX Issue I Version I} 
\section[{Discussion}]{Discussion}\par
The current study is one of the few Brazilian studies which assess the QOL of Brazilian deaf sign language users. In this section only some of the research results, especially the ones related to the Social Relationship (best scores) and Environment (worst scores) domains of the WHOQOL-Bref will be discussed and compared with the variables found in the sample profiling questionnaire.\par
The collected data reveal that most individuals of this sample were female, mean age of 28 years, congenital deafness, working and among the working participants, most of them earn between one and two minimum salaries, the percentage of deaf individuals earning more than two minimum salaries gradually decreases.\par
Crossing those data with question 18 from the physical domain of the WHOQOL-Bref, How satisfied are you with your job performance? it is perceived that the participants, in general, are satisfied with their job environment.\par
However, they have reported dissatisfaction, even graduated and post-graduated deaf individuals, with their low salaries.\par
According to some participants, as they answered in the sample profiling questionnaire, deaf individuals earn less than people with normal levels of hearing. Regarding that comment, it is worth elucidating that, in the literature, it was not found national studies which point out salary discrepancies between people with normal levels of hearing and the deaf population. The fact that many deaf subjects earn between one and two minimum salaries meets national salary average. According to IBGE Census, 2015, over half of Brazilians earn less than a minimum salary per capita \hyperref[b28]{(IBGE, 2015)}. Brazilian minimum salary in 2019 is R\$ 998.00, that is \$ 260.\par
In this regard, a research which was held in Australia by \hyperref[b50]{Willoughby (2011)} has elucidated that some deaf individuals in that study revealed that they have had the same position in their job and earned unequal salaries because they do not have the same level of access to information and communication as people with normal levels of hearing. The study by Perkins-Dock et al.  {\ref (2015)} with 224 deaf participants from a Southern city located in the United States, also has showed that communication disabilities and lack of assistive technologies at workplace preclude the deaf from getting higher job positions and salaries.\par
It seems that most deaf participants in our study despite their lower salaries are satisfied with their jobs. Most of the employed ones do not have access to information and communication by sign language. Sample participants were asked how they interact with people with normal levels of hearing at workplace. Six, or 10\%, answered that they interact orally, as their co-workers did not know sign language. Eight participants, 13.33\%, explained that they use writing Portuguese language at their workplace. It should be clarified that those participants who use Portuguese language inside their jobs earned over four salaries, work at universities and had at least Higher Education. That fact seems to show that the use of written Portuguese language may be a differential for better job positions and salaries, thus facilitating accessibility at workplace. It´s important to notice that 39 participants that earn between one and four minimum salaries do not use Portuguese language inside their jobs, they probably must have less access to communication and information in this environment.\par
This data matches with another Brazilian study from \hyperref[b21]{Guarinello et al. (2017)}, which shows that many Brazilian deaf have difficulties in the use of the written language. The authors also reveal that the use of the Portuguese language by means of more effective social practices may improve deaf individuals' quality of life. Furthermore, \hyperref[b35]{Lustosa et al. (2016)} point out that the use of reading and writing is essential not only in daily life, but also for the appropriation of not-daily productions in human existence. The authors still observe that, in a literate society, the achievement of full citizenship demands the mastery of reading and writing, once it is the way that individuals may privilegedly get appropriated from the information and knowledge produced by mankind.\par
Even though 29 participants have reported that they have had good or very good oral language skills and 49 have affirmed that they have a reasonable or good writing skills, most of them do not use this language at work, perhaps because they have low levels of literacy. Willoughby (2011) also points out, in his study, that many Australian deaf individuals have low levels of literacy, which harms them at workplace, especially regarding the use of eletronic communication based on written texts. The author explains that the researched deaf suffered from prejudice at their workplace. It appears that, countries, like Brazil, should invest more heavily on support services to the deaf, by means of specialized teachers, who mediated reading and writing learning, so that deaf people could get better jobs and salaries.\par
Significant results were found when oral and written language questions where crossed with salaries, so best results for orality and writing skills occur among higher salaries.\par
Regarding occupation and schooling, it was perceived by participants' answers that most of them were graduated or post-graduated. Among the graduated deaf participants, one attended Computer Science; one, Mathematics; two, Physical Education; one, Psychology; two are graduated from Business; five from Education; and seven from Language-Libras 3 . As for post-graduation, only four deaf participants had suchVolume XX Issue I Version I 8 ( G )\par
an educational level; all the others had specialization in special education. The participants, who told that they had a master degree, took this degree in Education.\par
It should be clarified that during their education, most participants relied on the presence of an interpreter of sign language. Such participants also answered how they interacted with their teachers at school; 43.33\% (n=26) reported the use of writing to interact with their teacher, and 36.67\% (n=22) used speech. It should also be observed that 28.33\% (n=17) of the deaf were mediated by one sign language interpreter.\par
Many participants pointed out that they did not have sign language interpreters during elementary and middle school, that probably occurred because, at the time they attended school, the presence of such a professional in the classroom was not mandatory in Brazil. It became mandatory in the country in 2002, due to the Libras Law, which assured the action scope of those professionals in all educational levels. It is agreed that the legal obligation of the presence of that professional enables deaf individuals to interact with the greatest possible number of people in the institutions that they attend \hyperref[b45]{(Silva, 2016)}.\par
Also, in that regard, studies show that the mediation with the interpreter can improved deaf individuals' QOL, (Schubert, 2012; Silva, 2016), during their educational process.\par
Apart from the fact that many participants in this study had the help of an interpreter during their school years, it should also be pointed out that over half of this sample has Higher Education, which is a restricted condition to a small share of the Brazilian population. According to data from the National Research of Residences by IBGE (2015), only 16\% of Brazilian professionals have Higher Education. Moreover, three out of 10 people from Brazilian labour force do not even conclude middle school \hyperref[b28]{(IBGE, 2015)}.\par
Probably the lack of interpreters during their school's years justifies the fact that many participants have answered that they use either written or oral language with their teachers of schools. Despite that, it is necessary to point out that most Brazilian population features limited levels of literacy, even those who attend Higher Education. Research by \hyperref[b35]{Lustosa et al. (2016)}, in which the authors analyzed the practices of literacy from beginners and graduated at a Higher Education institution, elucidates that many hearing students had difficulties in the use of reading and writing in daily practices, regarding the primary genres. Such genres, according to the research, should be acquired until the 9th grade of Middle School. This study also shows that the entrance in Higher Education of Brazilians from different social classes unveils that the greatest part of this population has literacy difficulties \hyperref[b35]{(Lustosa et al., 2016)}.\par
Difficulties in reading and writing are not only deaf people´s, it extended to the whole Brazilian population. Moreover, it should be clarified that despite the considerable increase in the number of enrolments in Higher Education in the past years, data from the Indicator of Functional Literacy (INAF, 2016) evidence that the population schooling level does not match the gains in the skill domains of reading and writing \hyperref[b29]{(Instituto Abramundo, 2014)}.\par
Significant results were found in our study when crossing data between orality, writing and schooling, best results in orality and writing occur by enhancing schooling.\par
The participants were also questioned on their views about themselves regarding the use of Libras and Portuguese language, and the use of Libras by their family members. In this aspect, the results point out that most participants refer to make a reasonable or good use of the Portuguese language, in the oral and writing modes.\par
The answers in this study have shown that the deaf individuals that self-reported to have good skills in orality and writing were exactly those who had better schooling and better answers in the QOL scoring. Participants answers also indicate that despite these deaf individuals being users of Libras, most of their family members do not use that language. Some of them point out that their parents have a tendency to use only the oral language to communicate, even banning sign language.\par
About that, Witkoski (2009) has revealed that it is still common in families with normal hearing levels, the obstination on spoken language and reading training as a normalization measure, disregarding identity formation, cognitive and psychic development of the deaf subject.\par
Concerning the use of the Sign Language by hearing family of deaf subjects, \hyperref[b20]{Guarinello et al. (2013)}, in their study, has clarified that many parents feel not able of taking care of their deaf children, and they often search for help, but do not get appropriate information. Their study reveals that many parents had a lack of explanation on what deafness is and its consequences; in general, they do not use sign language and opt for orality, often guided by professionals who points out only the importance of the oral language to the deaf children \hyperref[b20]{(Guarinello et al., 2013)}.\par
It is essencial to highlight the family on language appropriation process and quality of life of their children. Some studies show that if families had early access to sign language, their linguistic interactions with their deaf children would be more effective \hyperref[b27]{(Hyde \& Punch, 2011;}\hyperref[b10]{Chaveiro, 2011;}\hyperref[b40]{Novogrodsky et al, 2014;}\hyperref[b17]{Garcia, 2016;} {\ref Hrastinski \& Wilbur, 2016)}. Despite of that, the current research reveals that most parents do not use sign language, so most deaf people only learn this language at school. Thinking about changing this hard situation, it is understood that Brazilian public policies shoud prioritize family empowerment in the linguistic development of their children, therefore, Brazilian states should assure families the access to Libras by means of actions prioritizing the use of this language, and its importance as the second oficial language in the country. It is perceived that despite the recognition of the sign language in the Brazilian education policies, there is still the prevalence of monolingual practices in the country, which only prioritize the use of the Portuguese language \hyperref[b19]{(Guarinello et al, 2009)}.\par
In relation to the Environment domain, the worst scored evaluated by participants in this research, questions Q8 and Q9 How safe are you in your daily life? How healthy is your physical environment? (Climate, noise, pollution, attractions), were the ones in which most participants had lower scores.\par
In questions (Q13) How available is for you the information you need in your daily life? And (Q24) How satisfied are you with your access to health care services? data shows that the deaf participants are not satisfied with their access to information, safety and healthcare services. It can be inferred that this occurs because that share of population, in general, has been facing difficulties to perform daily activities due to the lack of interpreters and, mainly, access to the healthcare area, similar data was reported by other studies \hyperref[b4]{(Black \& Glickman, 2006;}\hyperref[b51]{Zöller \& Archer, 2015;}\hyperref[b18]{Gerich \& Fellinger, 2012;}\hyperref[b17]{Garcia, 2016)}.\par
Moreover, it is worth pointing out that Brazilian legislation, Law 13.146/15 determined that public services concessionaires should assure institutional ways to support the use and dissemination of Libras as the means of an objective communication  {\ref (Brasil, 2015)}. Despite the legislation, there is still a lot to be done regarding deaf accessibility to society, once most of institutions do not provide information to the deaf, either by means of the written language (legends) or Libras  {\ref (Brasil, 2015)}.\par
The lowest scoring evidenced in the questions on the Environment was also found in other studies \hyperref[b17]{(Garcia, 2016;}\hyperref[b10]{Chaveiro, 2011;} {\ref Hintermair, 2011;}\hyperref[b18]{Gerich \& Fellinger, 2012;}\hyperref[b36]{Marinho \& Vieira, 2015)}, which show that some factors related to the enviornment affect deaf individuals QOL, such as the lack of sewage system and healthcare services, lack of accessibility to leisure, money and means of transport, among others.\par
It can also be infered that the negative answers to the question related to leisure activities may have relation to money shortage and low salaries from part of this sample.\par
Similar results regarding the environment domain were also perceived in other Brazilian studies with other samples, such as, teachers. \hyperref[b41]{Penteado \& Pereira (2007)} have explained that, in this domain, teachers' devaluing job is evidenced, as in Brazil, they generally have scarce salary to their needs, which makes their possibilities of personal, social and professional investment decrease. Like this study, several participants' job in our sample are in the educational field, which has been suffering salary downsizing, professional scarcity and disqualification in Brazil.\par
In our study, it is perceived that a considerable part of the sample evidences satisfactory levels of literacy and education. Thus, many participants refer to themselves as bilingual, as they consider that they have proficiency in the use of Portuguese language, in the oral and writing modes, and in Libras for their social interaction. That seems to show that the use of the Portuguese language, in addition to the sign language, is one of the factors that may improve the quality of life for this share of the population.\par
Similar findings were evidenced in a research by Hrastinski \& Wilbur (2016), whose results unveil that deaf students, proficient in the sign language and in English, presented better answers than their less fluent colleagues in tests of reading comprehension in English, as well as evaluations on the use of the English language. Those authors have observed that a bilingual environment is essential for the deaf to have a more favorable academic development.\par
Based on the presented findings, it is possible to consider that higher educational level, best salaries associated with better use of Portuguese language could be considered as factors that can influence a higher QOL.\par
It is crucial to notice that the WHOQOL-Bref instrument used in this study is a general instrument for quality of life used for all sorts of population, so further studies should be developed QOL instruments especially to deaf sign language users, which can contemplate their culture, educational and social aspects of life.\par
Despite such limitations, the WHOQOL-Bref does not miss its value as a feasible instrument for the QOL perception, especially when used with other instruments that enable to a deep discussion.\par
V. 
\section[{Conclusion}]{Conclusion}\par
By analyzing the key research question, which factors influence the quality of life among the deaf sign language users population, it was noticed that the best scores of QoL in this group are related to the proficiency in the Portuguese language, in addition to earning the best salaries and higher education. It was also observed that low earnings prevail in great part of the sample, even among those with Higher Education. Moreover, it was perceived that the lower the schooling, the worse is QoL perception.\par
Despite many participants are reasonably satisfied with their quality of life, it can be noticed by their answers, especially in the environment domain, that aspects related to jobs, healthcare services, safety and leisure are unfavorable. These factors should be considered while planning and implementing health promotion actions toward the studied community.\par
It deems to elucidate that, in Brazil, despite the broad formulation of public policies to support deaf individuals accessibility, such as the Libras Law  {\ref (Brasil, 2012)}, and the Law of Accessibility  {\ref (Brasil, 2015)}, there are still many hurdles that this population have to overtake to access some social and cultural institutions. So, it is vital to invest in public policies and affirmative actions to reduce inequality conditions and also get rid of communication obstacles, which prevent their participation in society. \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.48685446009389677\textwidth}P{0.01596244131455399\textwidth}P{0.25140845070422535\textwidth}P{0.09178403755868544\textwidth}P{0.003990610328638498\textwidth}}
Variables\tabcellsep \tabcellsep \multicolumn{2}{l}{Frequency}\tabcellsep \%\\
Gender\tabcellsep \tabcellsep \\
Male\tabcellsep \tabcellsep 20\tabcellsep 33,33\%\\
Female\tabcellsep \tabcellsep 40\tabcellsep 66,67\%\\
Age\tabcellsep \tabcellsep \multicolumn{2}{l}{Mean age 28 years}\\
\multicolumn{2}{l}{Hearing Loss}\tabcellsep \\
\tabcellsep \tabcellsep 55\tabcellsep 91,67\%\\
\tabcellsep \tabcellsep 5\tabcellsep 8,33\%\\
\multicolumn{2}{l}{Degree of hearing loss}\tabcellsep \\
\multicolumn{2}{l}{Severe to profound}\tabcellsep 60\tabcellsep 100\%\\
Salary\tabcellsep \tabcellsep \\
\multicolumn{2}{l}{1to 2 salaries 1 20}\tabcellsep 33.33\%\\
\multicolumn{2}{l}{3to 4 salaries 15}\tabcellsep 25.00\%\\
More than 4\tabcellsep \tabcellsep \\
salaries\tabcellsep 12\tabcellsep 20.00\%\\
\tabcellsep \tabcellsep Occupation\\
\multicolumn{2}{l}{Unemployed}\tabcellsep 13\tabcellsep 21,67\%\\
\multicolumn{2}{l}{Employed}\tabcellsep 47\tabcellsep 78,33\%\\
Schooling\tabcellsep \tabcellsep \\
MiddleSchool\tabcellsep \tabcellsep \\
(9 years)\tabcellsep 06\tabcellsep 10.00\%\\
High School\tabcellsep 18\tabcellsep 30.00\%\\
Graduated\tabcellsep 19\tabcellsep 31.67\%\\
\multicolumn{2}{l}{Specialization 13}\tabcellsep 21.67\%\\
\multicolumn{2}{l}{Master's degree 04}\tabcellsep 06.67\%\\
\tabcellsep \tabcellsep \multicolumn{2}{l}{Source: Research Data}\end{longtable} \par
 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.24950248756218904\textwidth}P{0.03805970149253731\textwidth}P{0.004228855721393035\textwidth}P{0.03383084577114428\textwidth}P{0.1733830845771144\textwidth}P{0.08880597014925373\textwidth}P{0.10149253731343283\textwidth}P{0.1606965174129353\textwidth}}
Domains\tabcellsep R\tabcellsep N\tabcellsep N/R\tabcellsep \multicolumn{2}{l}{Average Rank Sum Of Ranks}\tabcellsep Mean\tabcellsep Standard deviation\\
Physical\tabcellsep 54\tabcellsep \tabcellsep 6\tabcellsep 2,49\tabcellsep 92,00\tabcellsep 58.40\tabcellsep 11.80\\
Psychological\tabcellsep 57\tabcellsep \tabcellsep 3\tabcellsep 2,66\tabcellsep 99,00\tabcellsep 61.26\tabcellsep 14.13\\
Social Relationships\tabcellsep 46\tabcellsep \tabcellsep 14\tabcellsep 2,82\tabcellsep 104,50\tabcellsep 64.31\tabcellsep 21.06\\
Environment\tabcellsep 57\tabcellsep \tabcellsep 3\tabcellsep 2,01\tabcellsep 74,50\tabcellsep 54.77\tabcellsep 14.49\end{longtable} \par
  {\small\itshape [Note: R = number of subjects who answered; N/R = number of subjects who did not answer.]} 
\caption{\label{tab_1}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.6894332939787484\textwidth}P{0.025088547815820542\textwidth}P{0.06322314049586777\textwidth}P{0.012042502951593861\textwidth}P{0.012042502951593861\textwidth}P{0.048170011806375444\textwidth}}
Question\tabcellsep N\tabcellsep \multicolumn{4}{l}{MED MIN MAX STD}\\
1. How you rate your quality of life?\tabcellsep 60\tabcellsep 3.28\tabcellsep 1\tabcellsep 5\tabcellsep 1.28\\
2. How satisfied are you your health?\tabcellsep 60\tabcellsep 3.35\tabcellsep 1\tabcellsep 5\tabcellsep 1.10\\
3. To what extend do you feel that physical pain prevents you\tabcellsep 59\tabcellsep 2.71\tabcellsep 1\tabcellsep 5\tabcellsep 1.20\\
from doing what you need to do?\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
4. How much do you need any medical treatment to function\tabcellsep 60\tabcellsep 2.58\tabcellsep 1\tabcellsep 5\tabcellsep 1.05\\
in your daily life\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
5. How much do you enjoy life?\tabcellsep 60\tabcellsep 3.52\tabcellsep 1\tabcellsep 5\tabcellsep 1.10\\
6. To what extent do you feel your life to be meaningful?\tabcellsep 60\tabcellsep 3.45\tabcellsep 1\tabcellsep 5\tabcellsep 0.91\\
7. How well are you able to concéntrate?\tabcellsep 59\tabcellsep 3.20\tabcellsep 1\tabcellsep 5\tabcellsep 0.80\\
8. How safe do you feel in your daily life?\tabcellsep 59\tabcellsep 3.39\tabcellsep 2\tabcellsep 5\tabcellsep 0.77\\
9. How healthy is your physical environment?\tabcellsep 59\tabcellsep 2.95\tabcellsep 1\tabcellsep 5\tabcellsep 1.06\\
10. Do you have enough energy for everyday life?\tabcellsep 60\tabcellsep 3.23\tabcellsep 1\tabcellsep 5\tabcellsep 0.91\\
11. Are you able to accept your bolidy appearance?\tabcellsep 58\tabcellsep 3.57\tabcellsep 2\tabcellsep 5\tabcellsep 0.88\\
12. Have you enough money to meet your needs?\tabcellsep 60\tabcellsep 3.08\tabcellsep 1\tabcellsep 5\tabcellsep 0.87\\
13. How available to you is the information that you need in\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
your day-to-day life?\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.4895089285714285\textwidth}P{0.10245535714285714\textwidth}P{0.25803571428571426\textwidth}}
Variable\tabcellsep Frequency\tabcellsep \%\\
Oral language proficiency\tabcellsep \tabcellsep \\
Very good\tabcellsep 16\tabcellsep 26,67\\
Good\tabcellsep 13\tabcellsep 21,67\\
Reasonable\tabcellsep 13\tabcellsep 21,67\\
Bad\tabcellsep 18\tabcellsep 30,00\\
Written language proficiency\tabcellsep \tabcellsep \\
Good\tabcellsep 19\tabcellsep 31,67\\
Reasonable\tabcellsep 30\tabcellsep 50,00\\
Bad\tabcellsep 11\tabcellsep 18,33\\
Family use of Libras\tabcellsep \tabcellsep \\
Yes\tabcellsep 15\tabcellsep 25,00\\
No\tabcellsep 45\tabcellsep 75,00\\
\tabcellsep \tabcellsep Source: Research Data\end{longtable} \par
 
\caption{\label{tab_3}Table 4 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{P{0.4655313351498637\textwidth}P{0.04632152588555858\textwidth}P{0.10885558583106267\textwidth}P{0.05095367847411444\textwidth}P{0.12970027247956403\textwidth}P{0.04863760217983651\textwidth}}
Salary\tabcellsep \tabcellsep Orality\tabcellsep \tabcellsep \tabcellsep P\\
\tabcellsep Bad\tabcellsep Medium\tabcellsep Good\tabcellsep Total\tabcellsep \\
1 to 2 salaries\tabcellsep 9\tabcellsep 2\tabcellsep 2\tabcellsep 13\tabcellsep \\
3 to 4 salaries\tabcellsep 8\tabcellsep 7\tabcellsep 5\tabcellsep 20\tabcellsep \\
More than 4 salaries\tabcellsep 1\tabcellsep 8\tabcellsep 6\tabcellsep 15\tabcellsep *0,0481\\
Unemployed\tabcellsep 1\tabcellsep 3\tabcellsep 8\tabcellsep 12\tabcellsep \\
TOTAL\tabcellsep 19\tabcellsep 20\tabcellsep 21\tabcellsep 60\tabcellsep \\
\tabcellsep \tabcellsep \multicolumn{2}{l}{WRITING}\tabcellsep \tabcellsep \\
1 to 2 salaries\tabcellsep 5\tabcellsep 5\tabcellsep 3\tabcellsep 13\tabcellsep \\
3 to 4 salaries\tabcellsep 3\tabcellsep 15\tabcellsep 2\tabcellsep 20\tabcellsep \\
More than 4 salaries\tabcellsep -\tabcellsep 11\tabcellsep 4\tabcellsep 15\tabcellsep *0,0329\\
Unemployed\tabcellsep 2\tabcellsep 4\tabcellsep 6\tabcellsep 12\tabcellsep \\
TOTAL\tabcellsep 10\tabcellsep 35\tabcellsep 15\tabcellsep 60\tabcellsep \\
\tabcellsep \tabcellsep \multicolumn{2}{l}{READING}\tabcellsep \tabcellsep \\
1 to 2 salaries\tabcellsep 3\tabcellsep \tabcellsep 1\tabcellsep 13\tabcellsep \\
3 to 4 salaries\tabcellsep 3\tabcellsep 14\tabcellsep 3\tabcellsep 20\tabcellsep \\
More than 4 salaries\tabcellsep 1\tabcellsep 9\tabcellsep 5\tabcellsep 15\tabcellsep 0,1266\\
Unemployed\tabcellsep 1\tabcellsep 4\tabcellsep 7\tabcellsep 12\tabcellsep \\
TOTAL\tabcellsep 8\tabcellsep 36\tabcellsep 16\tabcellsep 60\tabcellsep \\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{Source: Research Data}\end{longtable} \par
 
\caption{\label{tab_4}Table 5 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{6} \par 
\begin{longtable}{P{0.2149805447470817\textwidth}P{0.08268482490272373\textwidth}P{0.18521400778210118\textwidth}P{0.046303501945525294\textwidth}P{0.07276264591439689\textwidth}P{0.2480544747081712\textwidth}}
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep 7\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Volume XX Issue I Version I\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep G )\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep (\\
\tabcellsep \tabcellsep School Training\tabcellsep \tabcellsep \tabcellsep P\\
Variable\tabcellsep Elementary\tabcellsep \tabcellsep \tabcellsep Total\tabcellsep \\
\tabcellsep School\tabcellsep \multicolumn{2}{l}{High School Higher Education}\tabcellsep \tabcellsep \\
Orality\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Bad\tabcellsep -\tabcellsep 17\tabcellsep 2\tabcellsep 19\tabcellsep \\
Medium\tabcellsep -\tabcellsep 11\tabcellsep 9\tabcellsep 20\tabcellsep *0,0001\\
Good\tabcellsep 1\tabcellsep 2\tabcellsep 18\tabcellsep 21\tabcellsep \\
Writing\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Bad\tabcellsep -\tabcellsep 9\tabcellsep 1\tabcellsep 10\tabcellsep \\
Medium\tabcellsep -\tabcellsep 20\tabcellsep 15\tabcellsep 35\tabcellsep *0,0005\\
Good\tabcellsep 1\tabcellsep 1\tabcellsep 13\tabcellsep 15\tabcellsep \\
Read\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Bad\tabcellsep -\tabcellsep 7\tabcellsep 1\tabcellsep 8\tabcellsep \\
Medium\tabcellsep -\tabcellsep 22\tabcellsep 14\tabcellsep 36\tabcellsep *0,0005\\
Good\tabcellsep 1\tabcellsep 1\tabcellsep 14\tabcellsep 16\tabcellsep \\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Source: Research Data\end{longtable} \par
 
\caption{\label{tab_5}Table 6 :}\end{figure}
 			\footnote{Year 2020 © 2020 Global Journals Factors Related to the Quality of Life in the Context of Deaf Sign Language users in Brazil} 			\footnote{© 2020 Global Journals Factors Related to the Quality of Life in the Context of Deaf Sign Language users in Brazil} 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\end{document}
