Vocational rehabilitation

1. Importance of VR in HI

2. What is Vocational Rehabilitation?
• Vocational Rehabilitation (VR) is a program designed to assist people
with disabilities, illnesses, or injuries, in acquiring and or maintaining
suitable employment.
• VR services are funded by federal and private sources, and are
provided either through state administered programs, Indian tribes,
workers' compensation programs or private insurance (i.e. auto
insurance).

3. • Because many of these programs are mandated by federal and/or
state law, there are specific parameters to which programs must
comply.
• Within these parameters, each program may have its own unique
policies, protocols and eligibility requirements.
• Because of these variables, the audiologist is urged to check with the
VR office administering the program for the most up-to-date and
accurate information.

4. • The Department of Veterans Affairs (VA) also administers the
"Vocational Rehabilitation and Employment Service" for veterans with
service-connected disabilities and for those recently separated from
active duty.
• The VA also offers special rehabilitation services for dependents of
veterans who meet eligibility requirements (see website address in
references).

5. Eligibility & Vocational Needs Assessment
• As the name implies, an Eligibility Assessment determines whether an
individual meets the program eligibility criteria.
• A Vocational Needs Assessment, which may be conducted
concurrently by the VR counselor, determines the goals,
• Nature and scope of rehabilitation services to be included in the
individual's plan for employment.

6. • To assist the counselor in conducting the Eligibility and Vocational
Needs Assessments for a person with hearing loss,
• The audiologist should submit the usual hearing evaluation detailing
the type and degree of hearing loss.
• Audiologist's report should specify the vocational impact of the
hearing loss, including the client's specific, job-related,
communication needs.
• Most important, the audiologist should detail recommendations for
accommodating the hearing loss to meet the vocational needs of the
individual.

7. • These detailed recommendations from the audiologist are important
because
• People with hearing loss are rarely able to articulate the exact nature
and extent of their on-the-job communication difficulties.
• Further, not all VR counselors are savvy to the vocational implications
of hearing loss.

8. • Therefore, it is important that the audiologist effectively
communicate to the VR counselor the impact of hearing loss on the
worker
• Including suggestions and recommendations regarding management
of these hearing loss related difficulties in the job situation.

9. OBJECTIVES OF VOCATIONAL TRAINING
• Acquire basic skills necessary for the job;
• Be aware of the prerequisites necessary for a particular job such as
qualifications, physical fitness and other necessary qualities;
• Understand what formalities need to be completed for entry to the
job;
• Know about the opportunities in the job such as promotions and
better prospects;

10. • Know about the socio-economic status of a particular job;
• Get acquainted with the world of work;
• Get on-the-job practical experience;
• Develop cooperative spirit, social understanding and awareness of
rights and responsibilities as a worker;

11. • Acquire healthy habits of cleanliness, personal and social hygiene,
understand traffic rules;
• Recognize the ill effects of the bad habits such as smoking and
drinking;
• Understand the importance of right choice, good taste and moral
values;
• Assess the social position of the persons working in the field;
• Secure proper economic rehabilitation.

12. NEED FOR VOCATIONAL TRAINING
• Present Position of Schools
• In many schools, there is some provision of vocational training.
• However, it is not sufficient.
• The training available is only in the form of some stereotyped activities such
as bookbinding, knitting, embroidery, candlemaking, chalk making, craft, file
making etc

13. • Typically, the training provided is not on the basis of the interest, skill,
aptitude or intelligence of the children, but as per the convenience of
the school routine.
• There is no provision of any interest inventory, IQ testing or aptitude
testing.
• Most of the finished products are exhibited for sale.
• People purchase them not as a quality product but as a gesture of
charity.

14. • We should be able to give to the individual what is best for him.
• The job or trade should be as per his liking and interest, and it should
also generate a good income, to make him self sufficient.
• In the present day scenario, the social and emotional aspects of
vocational training are not considered.

15. • The main objective of vocational training; which is capacity building
as well as preparation of the individual to select a suitable job, is not
taken into account.
• Only the skill part of some jobs is taught.
• The teachers are not professionally equipped to convey the meaning
of vocational training in its real sense.
• So the skeleton rather than the spirit of any trade is provided to the
individual.

16. Placement of the Hearing Impaired in the
World of Work
• A very small percentage of the adult hearing impaired persons get a
job opportunity.
• The jobs available to them are very few in number.
• Moreover, the hearing impaired do not get up-to-date information
about different avenues of jobs and employment

17. • They are less aware of the entry requirements of different jobs.
• They do not get proper placement in the field.
• In the absence of training in techniques or formalities, the hearing
impaired individuals fail to present themselves efficiently and
effectively.

18. • They often present a low profile at the time of interview.
• They lack confidence and hence they do not get selected for the job.
• The paradox of the situation is that, on the one hand, the hearing
impaired persons do not get jobs and remain unemployed,
• And on the other hand, the vacancies created through special
consideration and reservation are left unfilled.

19. Individual Differences
• According to the modern concept of education, the principle of
individual differences is to be followed.
• Hearing impaired children differ to a large extent with respect to
various factors like aptitude, interests, attitude, and physical fitness.
• In addition, they differ in the degree of hearing loss amount of
residual hearing, and capacity of verbal expression.
• Naturally, they have to be trained for vocations taking into
consideration all these factors.

20. Girls and Vocational Training
• Thinking in terms of training the girl child for a good career or
profession is still not prevalent.
• The question of giving vocational training to girls does not catch the
eye of the persons concerned.
• It is more so in the case of hearing impaired girls.

21. • In the modern world, girls have proved themselves more efficient
than boys.
• Unfortunately, the pressures of domestic work, restrictions at home,
and the preferential treatment to boys by parents, are the main
obstacles in the progress of girls.
• Despite this, by virtue of their sincerity, perseverance and hard work,
girls make excellent use of the few opportunities available to them.

22. • Traditionally, teaching, nursing, housekeeping, tailoring, embroidery,
etc. are some occupations believed to be suitable for girls.
• Except for nursing and teaching, no provisions for training were
thought to be necessary.
• However, in the present high-tech atmosphere, girls should have
access to various types of occupations along with boys.

23. • Their inborn talents should be explored.
• Opportunities should be provided to them.
• Vocational training for hearing impaired girls should be planned right
from the school years.
• Their role in the social change and the modern industrial field
necessitates the provision of vocational training for them

24. • Taking a realistic view, the dual role on their part viz.
• House keeping and child care on one hand, and career and vocational
competence on the other hand,
• Should be taken into account while planning vocational training for
them.

25. NEED
• The primary goal of the state–federal vocational rehabilitation (VR)
system is
• To assist persons with disabilities in obtaining employment
• Which includes any level of competitive employment or self
employment,
• As well as being a homemaker, unpaid family worker,
• Blue-collar positions and significantly underrepresented in
professional, managerial, and technical occupations

26. • One of the earliest national employment outcome studies of deaf
workers
• Also found that they earned only 72% of what the general labor force
earned (Schein & Delk, 1974).
• Mowry (1987) - employed primarily in manufacturing-related, service,
sales, or clerical jobs, earning low incomes with little opportunity for
upward mobility.

27. • Deaf rehabilitants earned on average 19% less than did others
employed in the same type of job,
• Barnartt and Christiansen (1996) evaluated data from the National
Health Interview Surveys (from 1990 and 1991)
• The occupational distribution of deaf adults had become more similar
to that of hearing adults (compared to 1972–1974 data),
• When comparing the broad categories of whitecollar, blue-collar, and
service occupations.

28. • Even though the distributions were more similar,
• 11.5% fewer men who were deaf and 4.4% fewer women who were
deaf were employed in white-collar jobs compared to the general
population.
• However, the relatively large percentage of women who were deaf
employed in white-collar occupations
• Was largely due to their employment in clerical and administrative
support jobs.

29. • Kramer et al (2006)
• Compared the occupational performance of a group of 151
employees with hearing impairment with that of a group of 60
workers with normal hearing.
• The groups were matched for age, gender, educational level, and type
of job.
• The Amsterdam checklist for hearing and work (Kramer et al, 2006)
was used in this study, measuring:

30. • The persons’ work tasks and performance
• E.g. type of job, type of contract, work hours, work tasks, self-
reported environmental noise
• Also, sick-leave was assessed by asking the respondent the number of
days in the past 12 months missed because of illness.
• Additionally, the type of illness was requested.

31. • Auditory demands at work.
• Respondents were asked how often they had to
• ‘Communicate in quiet’,
• ‘Communicate in noise’,
• ‘Detect sounds’,
• ‘Localize sounds’,
• ‘Distinguish between sounds’
• How effortful they regarded each of those hearing activities.
• General working conditions (e.g. job control, job demand,support at
work, and career satisfaction).

32. • An analysis of group differences revealed that the
• ‘Self-perceived environmental noise’ level was significantly higher
among those with hearing loss compared with normally-hearing
subjects
• Similarly, the reported ‘effort in hearing’ needed during listening was
significantly higher in the hearing-impaired group

33. • No differences were found for the general working conditions, except
for ‘job control’ (interrupting work or taking breaks when wanted).
• Hearing-impaired participants perceived themselves to have
significantly less ‘control’ at work compared to their normally-hearing
colleagues
• Also, the reported number of days sick-leave appeared to be
significantly different in the two groups.

34. • In the hearing-impaired group, the proportion of employees reporting
sick-leave (77%) was significantly higher than among the normally-
hearing controls (55%).
• In addition, the proportion of people reporting sick-leave due to
stress-related complaints (fatigue, strain, and burnout)
• Was significantly higher among those with hearing impairment (26%)
than in the normally-hearing group (7%)

35. India
• The situation of people with hearing impairment is still being viewed
from the angle of the benefactor rather than that of beneficiaries
• The primary requirements are education and training.
• In the case of hearing impaired persons, both of these are
inadequate.
• In India, there are hardly a few hundred schools for hearing impaired
children, of which only half a dozen are of secondary school level.
• There are no facilities for college level education

36. • Hearing impaired persons in urban and rural areas
• Have different types of problems and need different types of
rehabilitation assistance.
• Because of access to educational facilities in cities, hearing impaired
persons in urban areas can get some education,
• However rudimentary it may be.
• At least they come to know their names, unlike their rural
counterparts.

37. • As a result, their invariable choice for employment is a government job.
• The one percent reservation for hearing impaired persons in Government
services does help, but only in a limited way.
• Special Employment Exchanges and Vocational Rehabilitation Centres
(VRC) for the Physically Handicapped contribute their bit, though their
combined efforts do not even touch the fringe of the problem.
• The result is that a large number of hearing impaired persons remain
unemployed,
• And are on the live registers of Special Employment Exchanges and VRCs
for more than 10 years.

38. • Additionally, because of their twin physical disabilities,
• They can attain very high concentration which results in better quality
and higher production.
• Being immune to noise pollution they are ideally suited in factories
like textile mills and capsule making units where noise levels are high
• Employers who have hearing impaired employees are usually ready to
accept more persons from this group,
• But such employers are few and far between.

39. • At the Delhi Association of the Deaf, out of a thousand and more
members,
• About 10% continue to be unemployed, though half of them are
matriculates who also know typing.
• Unfortunately, their linguistic skills are woefully inadequate
• Hence it is very difficult for them either to clear the Clerk's Grade
Examination - to obtain a Government job, or to secure a place in a
private organisation.
• They are reluctant to accept a job involving manual work, preferring a
clerical job or that of a peon in a Government office.

40. • The rural scene is not much better.
• Unlettered, untrained and mostly unaware of their very names,
• The rural hearing impaired population could have posed a serious
challenge to a rehabilitation worker.
• It is not uncommon for a rural person to inherit his profession; this is
true for hearing impaired persons too.
• Thus we have hearing impaired barbers, carpenters, farmers, iron
smiths and so on, and there is no question of unemployment or
stigma

41. • Hearing impaired women, by and large, remain as house wives.
• This is not to imply that there are no problems for the rural hearing
impaired persons.
• A cultivator has to have a supplementary means of income like dairy
farming, poultry farming etc.,
• A difficult task for an unlettered hearing impaired person, involving as
it does marketing and other skilled areas of operation.

42. • For hearing impaired tradesmen also problems arise from the supply
and demand position.
• No idea of the various facilities and concessions extended to them by
the Government and are thus unable to have an access to them.

43. • Not only does hearing loss appear to be related to earlier retirement,
• Data suggest that hearing impairment results in greater
unemployment in younger adults.
• Specifically, Parving and Christensen (1993) found that 30% of hearing
impaired adults aged 20-35 years old were unemployed,
• Compared to only a 12% unemployment rate in an age-matched
reference group.

44. VR
• Within the ICF, participation in work is acknowledged as one of the
major areas in life (D8).
• For many people, one of the most significant determinants in their
perceived status and position in society is their job (Scherich &
Mowry, 1997).
• An increasing number of people with hearing loss are seeking help for
occupational problems

45. • In summary, key issues that need to be addressed in the management
of employees with hearing loss are:
• Mental distress
• Effortful listening
• Job control
• Self-reported noise level
• Noisy environments
• Lack of knowledge

46. Vocational enablement protocol (VEP)
• Vocational enablement refers to services for maintaining, facilitating,
or improving
• Integrated (multidisciplinary) approach would be crucial for a
successful management of the rather complex problems.
• As hearing disabilities not only affect the individuals who suffer from
hearing impairment, but also anyone with whom they interact
• Actions on a single level (i.e. restricting the rehabilitation program to
the hearing-impaired employee only) would have little effect on
employment situation.

47. • They identified different domains to be included in the rehabilitation
process: the hearing-impaired person, significant others (family,
friends, colleagues), the workplace, health services, and the society
(population).
• The interventions to be applied were: psychosocial support (coping),
provision of information and knowledge (types of hearing
impairment, consequences) and skill development (hearing tactics).

48. • an optimized protocol addressing the specific needs -The vocational
enablement protocol (VEP) is the product of the Expertise Center for
Hearing and Work.
• Currently, four Dutch organizations are participating in this center:
• Netherlands Center for Occupational Diseases, Amsterdam;
• The audiological center of the academic medical center, amsterdam;
• The audiological center of the VU university medical center, amsterdam;
• The audiological center of the leiden university medical center, leiden.

49. • The VEP - assessment of complex problems conducted by a team of
professionals from multiple disciplines
• Audiologist, otolaryngologist, occupational physician, social worker,
psychologist, and speech-language pathologist
• Based on a standard procedure, the team examines the auditory
functioning of the individual
• And seeks to identify and clarify causes of the problems at work,

50. • Evaluates the existence of additional psychosocial problems in the
individual,
• Investigates the acoustical environment at the workplace (if
indicated),
• Finally makes recommendations for appropriate treatment.
• In sum, the protocol provides:

51. • A multidimensional evaluation of the situation and problems at work
• A thorough diagnostic examination of the individual’s auditory profile
• Assessment of an individual’s coping abilities .
• An examination of the workplace (if indicated) .
• Recommendations for an enablement plan and options available .
• A comprehensive written report
• The final goal is to facilitate participation in and retention of work.

52. • Once an individual is referred, two questionnaires are sent to the
patient’s home.
• Also, to assess a person’s ability to cope with hearing impairment,
• Communication profile for the hearing impaired (CPHI), including
‘maladaptive behaviours’, ‘(non) verbal strategies’, ‘self-acceptance’,
‘acceptance of loss’, and ‘stress and withdrawal’ are administered.
• Patients are instructed to complete the questionnaires and bring
them in during the consultation

53. • In the clinic, the patient’s hearing status is assessed using an
extensive battery of auditory tests, including pure-tone and speech
audiometry and speech-reception-threshold (SRT) tests.
• It adaptively estimates the signal-to noise ratio (SNR) at which the
participant reproduces 50% of the sentences without error.
• Loudness scaling, a test measuring the ability to identify sounds, and
a localization test (Kramer et al, 1996; Boymans et al, 2008) are added
if indicated.
• To examine aided hearing, a free-field version of the SRT noise test is
also performed

54. • Furthermore, a semi-structured interview is conducted by the
psychologist
• Evaluating the patient’s psychosocial history, the individual’s specific
needs, attitude, and expectations and an evaluation of the problems
at work from the patient’s perspective.
• Referral information is taken into account.
• The interview is attended by the occupational physician of the team
to specifically evaluate the work-related problems and possible
solutions, and to discuss legal issues.

55. • At the end of the session, all test results are examined by an
audiologist, psychologist, and occupational physician and explained to
the patient.
• Possibilities of technical, speech-therapeutical, and/or psychosocial
interventions are then discussed.
• If indicated, the workplace is visited and acoustically examined by
conducting a speech-transmission-index (STI) measurement.

56. • The STI provides an assessment of the intelligibility of speech at the
workplace and verifies whether speech is comprehensible for the
employee with hearing problems (Houtgast & Steeneken, 1973).
• The STI measures the combined effect of background noise and
reverberation.
• At the end, all findings are discussed in a broad multidisciplinary team
followed by the construction of a written report including specific
recommendations for the patient and the management plan.
• The report is then sent to the referrer.

57. • Finally, to meet the needs of people complaining about the
• Lack of knowledge among professionals,
• Employers
• Colleagues
• Significant others about issues related to hearing and work,
• An extensive information package presented on CD was developed
(Kramer, 2006).

58. • The package provides information on a large number of matters
related to hearing and work.
• It focuses on a better understanding of the specific difficulties people
with hearing impairment may experience at work.
• It also points out the various options available to reduce the
occupational problems of such people.