J Occup Rehabil (2006) 16:503–512 DOI 10.1007/s10926-006-9033-4 ORIGINAL PAPER
Vocational Rehabilitation Program for Persons with Occupational Deafness Eria Ping-Ying Li · Cecilia Wai-Ping Li-Tsang · Tsor-Kui Lee · Gladys Wai-Man Lee · Eddie Chi-Fung Lam
Published online: 14 November 2006 C Springer Science+Business Media, Inc. 2006
Abstract Introduction: A pilot return-to-work program based on the concept of work readiness and three-month job placement with support was developed to enable people with occupational deafness to return to the workforce. Methods: A convenient sample of six male persons with occupational deafness completed the program. A Pretest-Posttest Single Group Design was utilized to measure the program outcome. Two instruments: the Chinese version of SF-36 Health Assessment Questionnaire and the Chinese version of Lam’s Assessment of Stage of employment readiness were used to measure the participants’ health status and their work readiness respectively. Results: The preliminary findings indicated that the six participants showed improvement in their general health and work readiness. The employment outcome indicated that three of the participants had secured a job and another two participants had attained job offers. Conclusion: This pilot study suggested that a systematic vocational rehabilitation program can facilitate persons with occupational deafness to return to the workforce. Further research using a controlled investigation with larger sample size is recommended for evidencebased practice even though the results of this return-to-work program appear promising. Keywords Occupational deafness . Return-to-work program . Job placement . Vocational counseling . Work readiness
Introduction Occupational deafness is one of the work disabilities acquired in adulthood as a result of prolonged exposure to noisy work environment. To date, the optimal approach to occupational hearing loss is primary risk prevention to both injurious impulsive noise as well as chronic E. P.-Y. Li () · C. W.-P. Li-Tsang · G. W.-M. Lee · E. C.-F. Lam Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong e-mail:
[email protected] T.-K. Lee Department of Applied Social Sciences, Hong Kong Polytechnic University, Hong Kong Springer
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excessive noise through standards and enforcement of them in the industries and hearing conservation surveillance and a variety of control measures [1]. However, despite these efforts, there are workers who have acquired occupational hearing loss both in Hong Kong and overseas. In fact, hearing loss is one of the leading occupational concerns in the industrial countries [1–5]. In 1992, the UK Department of Social Security estimated that 13,000 workers had to rely on social support or compensation as a result of occupational hearing loss [6]. The 1990 UK Labour Force Survey estimated that 103,100 workers had deafness, tinnitus, or other ear conditions caused by work and a further 18,300 workers thought that their hearing abilities had been made worse due to a noisy work environment [7]. Over the last 20 years, Hong Kong has gradually become less industrialized and its economy now relies more on the services sector. Nevertheless, occupational deafness accounts for more than half of the occupational health problems [8]. The Occupational Deafness Compensation Board in Hong Kong was established in 1995 under the Occupational Deafness (Compensation) Ordinance. The aims of this Board are to manage the compensation fund and finance public education programs as well as rehabilitation programs for preventive and rehabilitative purpose. Since 1995, about 2,200 persons with occupational hearing loss (at least 40 dB hearing loss in both ears) had received compensation from the Board, while the number of applications doubled this figure. Since 2002, the number of compensation cases has dropped as a result of mass publicity to protect the ears at work. In 2004, out of 214 claimants who had noise-induced hearing loss, most of them were working in a noisy work environment in which 51.8% were from the construction site such as rock grinding, chiseling or percussion work, 24% from production domain as in metal grinding, pile driving, working near to combustion engines and around 10% from mechanical repairing or weaving and spinning textile industries [9]. The majority of the claimants were skilled manual workers and over 40 years old. When a person’s identity is well established early in life, psychological acceptance of work disabilities would be difficult when it is acquired after adulthood. People with occupational hearing loss face the task of learning a new way to communicate with the world. They are at the risk of job loss because they would encounter difficulties in finding and/or maintaining their employment. For instance, they face many new challenges where employers and co-workers might have misunderstandings about their work abilities. Moreover, most of them are the bread winners of their families [9]. Once they are unemployed, it might lead to substantial family problems that may ruin the family relationship. A number of studies indicated that people with occupational deafness would face the challenges such as lower self-esteem and self-confidence, communication difficulties, adjustment problems, unemployment as well as poor family relationship [10–14]. Noise-induced hearing loss will also cause substantial and permanent morbidity and also affect an individual’s quality of life [15]. In Hong Kong, the rehabilitation efforts for persons with occupational deafness are largely focused on restoring hearing through medical and audiological intervention [9]. Most social and vocational rehabilitation services available in Hong Kong for people with hearing impairment are more sensitive to the needs of persons who have hearing impairment at birth or very young age than those acquired through occupations in adulthood. Therefore, it is timely and important that the needs and aspirations of persons with occupational hearing loss to be carefully studied so that the Hong Kong government and the community would have a clearer picture of how to support them for self-reliance and financial independence, especially those of working age. The aim of this pilot study is to evaluate the effectiveness of a return-to-work program specifically designed for persons with occupational hearing loss in Hong Kong so that a tailored vocational rehabilitation program for this group of people can be developed in the future. Springer
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Lam model (1997) of work readiness
Stage of work readiness
Description
Pre-contemplation (Indifferent stage) Contemplation (Decision stage) Preparation (Readiness stage)
Not consider working Consider working, but not pursue any action Decide to work but may not possess adequate job readiness skills Ready for job placement and actively involve in job seeking and trial Secure a job placement
Action (Placement stage) Maintenance (Retention stage)
The conceptual model of the return-to-work program The return-to-work program of this pilot study is developed based on the Lam’s model of work readiness and supported employment. Lam suggested that a person’s work readiness can be classified into five stages (Lam, unpublished data, 1997) (Table 1). People at the indifferent stage do not consider work. They require motivation and support to get into the later stage. This model is adopted by the present study to provide a structured return-to-work intervention to facilitate people with occupational deafness to move from the indifferent (pre-contemplation) stage to the job maintenance stage. The structured intervention includes individual vocational counseling and group training. The aim of individual vocational counseling is to explore the possible factors contributing to the worker’s change of motivation such as what an individual wants (preference), what an individual thinks he is capable of doing (perceived competence) and what an individual thinks he can get (opportunities). The group training of the model aims at preparing the workers to have action for the future work plan. Based on this model, the Chinese version of Lam Assessment on Stages of Employment Readiness is constructed to assess a person’s work readiness. A good matching between a specific vocational intervention and a person’s stage of job readiness will help promote successful job placement. Corresponding to the stages, three basic factors must be considered during the vocational rehabilitation process: what people want (preference), what they think they are capable of doing (perceived competence) and what they think they can get (opportunities). Individual placement and support The supported employment model assumes that, with appropriate and on-going support, a much higher proportion of people can maintain competitive jobs. The individual placement with support includes job seeking and matching and on-the-jobsite support. It means that successful job placement depends on doing the right things (vocational rehabilitation process) at the right time (stages of a person’s work readiness). Thus, job placement with support can be tailor-made to facilitate the acquisition of competitive jobs. Return to work after long-term leave for persons with occupational deafness can be conceptualized as a complex human behavioral change, involving resolution of psychological problems such as motivation and depression, and adjustment issues to their disabilities. Even though they are prepared and have decided to return to work, they have to face the difficulties of job seeking, work adjustment and job maintenance. Therefore, a structured return-to-work training program should be implemented to strengthen their job preparation and searching skills and to increase their coping abilities and self-confidence. It is expected that a new structured return-to-work Springer
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intervention program specifically designed for people with occupational deafness can improve their work readiness resulting better employment outcome.
Methods Participants This pilot study adopted a Pretest-Posttest Single Group Design to evaluate the effectiveness of the return-to-work program with three-month job placement support for persons with occupational deafness in Hong Kong. The participants of this study were recruited from a survey conducted in 2004 by the Occupational Deafness Compensation Board in Hong Kong. Through this mailed questionnaire survey, 2,061 claimants of occupational deafness were contacted and 655 returned the completed questionnaires. Among the returned questionnaires, 118 claimants (116 males and 2 females) reported the interest of looking for a job and about 60% of them preferred to get a job in the construction industry, followed by security guard or cleaning work in the service industry. In fact, about 10% of them indicated that they would accept any job with income. Their age range was from 44 to over 70, with about 70% above the Hong Kong retirement age of 60. The inclusion criteria of this study were claimants with age below 55 years old and they expressed the interest of returning to work. Based on these two selection criteria, 25 from the 118 claimants were selected. Ten claimants agreed to come after telephone contact but only seven of them attended the briefing session. Six of them were unemployed for one to four years and one was underemployed with less than 60 working days in 2004. One participant at the age of 57 was also recruited because he had expressed a strong desire to return to the workforce. The return-to-work program Each participant received one to three individual counseling sessions of about 1.5 h. The counseling sessions were conducted by professional rehabilitation counselors to enable the participants to review their work values, identify the barriers encountered, and make decisions on the course of return-to-work action. The wife of one participant also attended two counseling sessions to improve the marital relationship. Four structured group training sessions (February–March 2005) of three hours each were held to help the participants to adjust to their current health status and to identify their own strengths and weaknesses in preparation of new work demands of the restructuring Hong Kong job market. A sharing session was arranged for the participants to meet with a guest speaker with a hearing impairment. This guest speaker shared the successful experiences in managing the life challenges. The aim of this sharing session was to encourage the participants to have confidence in themselves in returning to work. After the training and the individual counseling sessions, the participants were coached by two occupational therapists in job matching and job placement with on-going support for three months (April–June 2005). The evaluation of the program effectiveness was divided into quantitative and qualitative assessments. Two assessment tools were adopted for quantitative evaluation: the Chinese version of Lam Assessment of Stages of Employment Readiness and the SF-36 Health Assessment Questionnaire. The rationale of using these two instruments was that the return-to-work program specifically designed for people with occupational deafness might have impact on a person’s work steadiness and health status. The qualitative evaluation had two parts: the employment outcome and feedback from the participants. Data for the employment outcome included the Springer
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number of job applications, the income, the number and nature of the job offer, type of employee retraining program. A meeting in May 2005 was scheduled and the participants were asked about the impact of the job placement support on their abilities to seek and maintain employment. For those who could not attend the meeting, they were contacted by telephone for their comments. Instruments The Chinese version of Lam Assessment of Stages of Employment Readiness (C-LASER) was validated in Hong Kong (Chan et al., unpublished data, 2005). It has 18 items to assess a person’s work readiness. The total scores can be clustered into four stages, namely pre-contemplation, contemplation, preparation and action. A higher score in the stage of pre-contemplation means a person is not ready for returning to work while higher scores in the other three stages: contemplation, preparation and action indicate a positive work readiness to return to the workforce. When a person’s state of work readiness is identified, the return-to-work program can be tailor-made to either facilitate a person’s work readiness or to support job seeking and job retention. The SF-36 Health Assessment Questionnaire (SF-36) is constructed for self-administration by people aged 14 or above. It consists of 36 items to be used to evaluate a person’s health status. Its Chinese version was validated in Hong Kong and Singapore [16, 17]. SF-36 is also widely used in clinical practice and research, health policy evaluations and general population surveys. SF-36 assesses eight health elements: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. A person with a higher score indicates a better health status.
Results One participant decided to quit the participation after the first group training session because he considered that the return-to-work program might not be helpful to him. The remaining six participants completed the training sessions and the individual counseling sessions. Their age ranged from 44 to 57 years (mean age = 49 years). They were all married and lived with their families and they were the breadwinners of the family. All participants were skilled manual workers mainly in the construction sites. Work readiness measured by C-LASER When the pre- and post-training data of the six participants were compared, the scores increased: the contemplation stage ( + 10.44%), preparation stage ( + 15.14%) and action ( + 8.77%), whereas the pre-contemplation stage had a decrease of score ( − 14.97%) (Table 2a and b). Thus, the data indicated that the six participants had increased their work readiness by either showing confidence in returning to work (contemplation stage), getting prepared to look for jobs (preparation stage) and some had taken action to search for new jobs (action stage). The followup measurement showed that two participants were vacillating back and forth about working or not working when they had failure in job interviews as well as considering the possibility of losing the social security benefit from the government ( + 6.81% in pre-contemplation stage). Springer
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J Occup Rehabil (2006) 16:503–512 C-LASER mean score Pre-training (N = 6) Mean Std. deviation
(a) Compare pre- and post- training data Pre-contemplation stage 14.50 Contemplation stage 16.00 Preparation stage 14.33 Action stage 15.17
0.837 2.280 3.204 2.401
Post-training (N = 6) Mean Std. deviation
12.33 17.67 16.50 16.50
2.733 1.633 1.761 1.871
Percentage change Compare data: pre- and post-training (%) −14.97 +10.44 +15.14 +8.77
Follow-up (N = 6) Mean Std. deviation
Percentage change Percentage change Compare post-training and Compare pre-training follow-up (%) and follow-up (%) (b) Compare data from pre-training, post-training and follow-up Pre-contemplation stage 13.17 3.601 + 6.81 −9.17 Contemplation stage 16.83 2.041 − 4.75 +5.19 Preparation stage 16.67 1.751 + 1.03 +16.33 Action stage 16.17 1.941 − 2.00 +6.59
One participant had decided to immigrate with his family to US in May 2005, and thus the score of the action stage decreased ( − 2%) possibly indicating that he stopped the action of job search during the job placement period of this study. General health measured by SF-36 The six participants had shown improvement in 8 out of the 9 domains of SF-36, particularly in the mean scores of the mental health ( + 31.59%) and a further improvement ( + 2.14%) during the follow-up period (Table 3a and b). The reported health was also improved when the pre- and post-training data were compared ( + 36.05%). Employment outcome The employment outcome of the six participants was summarized in Table 4. During the threemonth period of job placement and support, a total of 19 application letters were sent out by the four participants. Six job interviews and six job offers were attained. Three participants joined the Employee Retraining Program for the Middle-Aged group. Two participants obtained the Certificate for Healthcare Attendant and one participant obtained the Certificate for Security Guard. One participant who obtained the Certificate for Healthcare Attendant migrated with his family to US in May 2005. He found a job as a general worker in a supermarket with a daily wage of US$50. He expressed that he would like to find another job as a healthcare attendant which could offer a higher salary. In this way, he could support his family with a better living in US. With this work goal, he had been actively seeking information from the Work Union regarding the vacancies of healthcare attendant. One participant had secured a part-time cleaning job and started his work one month after the job placement period. One participant had a job offer in the construction site which was referred by his former colleague. One participant preferred to take up voluntary work due to a health problem; the decision was supported by his family. One participant Springer
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General health status measured by SF-36 Pre-training (N = 6) Mean Std. deviation
(a) Compare pre- and post- training data Physical functioning 28.00 2.280 Role – physical 7.00 1.673 Bodily pain 9.35 1.666 General health 17.17 4.215 Vitality 16.50 2.950 Social functioning 7.17 1.722 Role emotional 5.00 1.265 Mental health 15.83 6.145 Reported health 2.33 0.817 Follow-up (N = 6) Mean Std. deviation (b) Compare pre-, post-training and follow-up Physical functioning 28.33 2.066 Role – physical 7.50 0.837 Bodily pain 9.30 2.694 General health 17.50 3.834 Vitality 18.67 4.633 Social functioning 7.33 1.862 Role emotional 5.33 0.816 Mental health 21.17 5.231 Reported health 3.00 1.265
Post-training (N = 6) Mean Std. deviation
28.83 7.67 9.72 17.17 18.50 8.17 5.50 20.83 3.17
1.329 0.516 1.970 4.215 4.135 0.753 0.837 4.834 0.983
Percentage change Compare pre- and post-training (%) + 2.96 + 9.57 + 3.96 0.00 + 12.12 + 13.95 + 10.00 + 31.59 + 36.05
Percentage change Compare post-training and follow-up (%)
Percentage change Compare pre-training and follow-up (%)
−1.73 −2.22 −4.32 +1.92 +0.92 −10.28 −3.09 +1.63 −5.36
+ 1.18 + 7.14 − 0.54 + 1.92 + 13.15 + 2.23 + 6.60 + 33.73 + 28.76
who obtained the Certificate for Healthcare Attendant had two job offers: office assistant and school watchman but he rejected the offers due to low salaries. One participant who obtained the Certificate for Security Guard was given a job trial as a security guard in July 2005. Feedback from the participants The six participants indicated that the individual counseling sessions helped them identify their own personal needs and work values. The group training sessions also enabled them to become more aware of the changes of Hong Kong job market, from the industrialized or constructive industries to the services and knowledge industry. They believed that they re-gained their selfconfidence in planning their work goals such that they could be more prepared to cope with the psychological stress that might occur in the new work environment. All the participants expressed that they were aware that it was impossible for them to return to the noisy occupations, as it would cause more damage to their hearing. As a result, five participants decided to try out some other unskilled jobs in the service industry such as security guard, school watchman, health care attendant, kitchen assistant, gardener and messenger. They would never have considered these kinds of jobs before due to their previous assumption that they could only work in the construction industry. They all expressed positive feedback towards the return-to-work training Springer
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J Occup Rehabil (2006) 16:503–512 Employment outcome of the participants (N = 6) Employment outcome (June 2005) Retraining Job interview course applied Job applied offered Job offered
Code
Age/Sex
A1
44/M
Healthcare attendant
2
0
A2
45/M
11
3
A3
45/M
Healthcare attendant 0
0
0
A4
51/M
0
3
2
A5
52/M
0
0
0
A6
57/M
Security Guard 3
1
No job offer; immigrated to US in May 2005 and worked as a general worker in a supermarket (US$50 per day) Rejected 2 job offers due to low salaries Decided to take up volunteer work due to health problem Part-time cleansing worker (US$250 per month) Construction site work referred by former colleague till August 2005 (US$38 per day) Job trial in July 2005 as security guard
program and the job placement with support. The individual comments from the six participants were summarized as follows: A1: “I am happy with the progress I have made so far after the program. I have made friends with some other participants. I treasure this friendship as we had had similar experience in life. In the past, I used to show anger to my wife and son. After the program, I learned to open up my heart to other people. I tried to share my feelings with my wife. I used to feel down and disgrace in being deaf and believe that I was a burden to my family. Now I see that I still have work abilities to earn a living and my family needs me. It is interesting that I no longer feel stressed when I am going to immigrate to US in May 2005. May be at the moment I am working hard towards my life goal with my family! Now, I realize that my wife is supportive.” A2: “I had worked in the construction sites for so long and in the past I thought that I was in the dead end of my life after having deafness. The worst was that I didn’t know how to get myself out. After the program, I am now motivated to find a new job in the service industry and now I know better how to market myself to the potential employers at the job interviews.” A3: “Although I got nasal-pharyngeal cancer that limited my verbal communication skills, I was lucky that my wife and daughter gave me tremendous support. I enjoyed the program because I had the opportunities to interact with other participants who also have occupational deafness. I want to become a volunteer to help those who are in need.” A4: “In the past, I used to blame myself of having deafness. After the program, I have a much clearer goal in my life. I also want to open up my heart to other people. I know that I need to learn as much as I can so that I work until the retirement age of 60.” A5: “I particularly enjoyed the talk presented by the guest speaker who has deafness. The speaker has inspired me that I am not alone and I can do something to help myself out from this terrible situation. During the group training sessions, I learned to equip myself with practical skills in job searching other than just relying on friends and relatives to find a job for me. The staff team had also taken care of my psychological and emotional needs.” A6: “I know that I am a bit old when I joined the program. Before, I had never thought of getting a certificate from the Employee Retraining Program for the Middle-Aged. I was very Springer
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happy that I did get one. This achievement has reminded me that I am still a useful person even after having hearing loss.” The six participants’ comments could be summarized into four areas: (a) re-gaining selfconfidence in problem solving; (b) improvement in the family relationship; (c) acquiring the knowledge and skills in job searching; and (d) having clear life goals and positive thinking.
Discussion Findings of this pilot study appeared to support the positive effect of the proposed return-to-work program specifically designed for persons with occupational deafness. All the six participants were shown to have improvement in their work readiness and their perception of health status from the quantitative analysis. The individual counseling sessions enabled the participants to review their work values leading to positive thinking. The training sessions helped the participants to develop the job searching skills, interviewing skills, as well as better coping strategies to face the challenges in life. After the training sessions, five participants expressed the willingness to try the job positions in the service industry when they developed a better insight about the job market in Hong Kong. The three-month job placement with support had a positive effect on sustaining the participants’ motivation in searching and finding new jobs. Thus, the employment outcomes were very encouraging that three participants (50%) had successfully secured a job after the training program and another two participants had job offers. Studies from both local and overseas show that the rate of returning to work for injured workers ranges from 50 to 85% [18–23]. In this pilot study, the rate was more than 80% (including the two participants had attained job offers) and the results were promising although the sample size of this study was rather small. This pilot program was the first attempt to help persons with occupational deafness to re-enter the workforce. There should be a screening mechanism to provide early identification of people with occupational deafness who are at risk of unemployment so that they could be supported to return to the workforce. The return-to-work program should have three elements: individual counseling, group training and job placement with support. The focus of the individual counseling is to enable people with occupational deafness to review the work values and to promote work readiness so as to formulate possible action for a future work plan. Another local study also suggested counseling can enable people with spinal cord injuries to develop optimism and positive thinking [24]. Group training should be provided to help persons with occupational deafness to develop the necessary knowledge and skills for job seeking and maintenance, especially those with lower educational level and/or higher degree of hearing impairment. Job placement with support can facilitate persons with occupational deafness to secure a job with support to adjust to the new working environment. Indicators of effectiveness of a return-to-work program should include improvement in work readiness and health status. The measurement tools of C-LASER and SF36 could be considered for measurement of program outcomes in future. Employment outcome of persons with occupational deafness should be documented to show their achievement in the work arena. Limitations of the study This pilot uncontrolled study was the first attempt to determine whether the specifically designed return-to-work program could facilitate persons with occupational deafness to enter the workforce. A convenience sample of six participants would definitely affect the external validity of this Springer
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study. Future research using a randomized clinical trial study on the return-to-work program for people with occupational deafness is recommended so that evidence-based practice is supported by research findings. The baseline medical problems and background of each participant were different and there might be some other confounding factors that affect their work readiness, such as age, previous work experiences and education levels etc. Therefore, the results may not be generalized to people with occupational deafness. All these factors have to be considered in future studies. Acknowledgements The research team would like to thank the participants who took part in this study and their active participation was highly appreciated. Funding for this study was supported by the Occupational Deafness Compensation Board in Hong Kong.
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