Vocational rehabilitation services for people with hearing ... - IOS Press

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Work 46 (2013) 151–164 DOI 10.3233/WOR-131743 IOS Press

Vocational rehabilitation services for people with hearing difficulties: A systematic review of the literature Arjenne H.M. Gussenhovena,b,∗, Elise P. Jansmac, S. Theo Govertsd , Joost M. Festena, Johannes R. Anemab,d and Sophia E. Kramera a

Department ENT/Audiology and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands b Department of Public and Occupational Health and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands c Medical Library, VU University, Amsterdam, the Netherlands d Research Center for Insurance Medicine AMC-UWV-VUmc, Amsterdam, the Netherlands

Received 22 March 2012 Accepted 10 January 2013

Abstract. OBJECTIVE: The goal of this review was to list and summarize work-related health programs for employees with hearing difficulties and to summarize the statistical evidence of the effectiveness of these programs. METHODS: A systematic review was performed by searching the PubMed, EMBASE, PsycINFO, CINAHL, and The Cochrane Library databases for relevant citations. From 2313 unique citations retrieved from the search strategy, we included nine programs that met all inclusion criteria. The authors assessed the methodological quality of studies which evaluated the program’s effectiveness, using the Downs and Black checklist. RESULTS: Nine vocational rehabilitation programs for people with hearing difficulties were described. The programs differed in procedure, duration, setting, and content. In four studies, the effectiveness of the program was explored statistically. Measurements showed an improvement in general health (SF-36), communication strategies, and the degree of work readiness, but none of these studies included a control group, a power calculation, nor adjusted for confounding. Hence, the methodological quality to provide evidence of effectiveness was assessed as poor. DISCUSSION: Existing vocational programs for employees with hearing difficulties provide relevant information to demonstrate how to implement the appropriate content of the programs. Future research is required to improve the strength of evidence of the effectiveness of vocational rehabilitation for workers with hearing difficulties. Keywords: Hearing impairment, program, occupation, work, vocational rehabilitation, effectiveness, methodology

1. Introduction Hearing impairment is known to be a prevalent health problem. The World Health Organization (WHO) ∗ Corresponding author: Arjenne H.M. Gussenhoven, Department ENT/Audiology, EMGO Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, the Netherlands. Tel.: +31 20 4440900; Fax: +31 20 4440983; E-mail: [email protected].

calculated that the worldwide burden of hearing loss is extensive [1]. In an attempt to provide insight into the future health of the world, the WHO identified hearing loss as one of the top ten causes of burden of disease in high- and middle-income countries in 2030 [2]. Whereas hearing loss is most prevalent in groups of adults aged 65 years and over, there is a substantial number of adults with hearing difficulties in younger age groups. Estimations of the prevalence of hearing

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loss in the labor force vary, but nevertheless demonstrate that its pervasiveness in the workplace is substantial. For instance, the proportion of adults with hearing loss in the Dutch labor force is about 3% [3]. In the United States (US), communication problems (hearing, language and speech) are estimated to have a prevalence of 5–10% [4]. The National Center for Health Statistics (NCHS) of the US reported that 17% of the adult population (21–64 years) has some degree of hearing loss [5]. Even a much higher percentage was reported in a Swedish study with 31% of the working population suffering from hearing problems (i.e., hearing loss, tinnitus, or both) [6]. Hence, hearing loss in the workforce is an issue that has yet to receive adequate attention in research and clinical practice. Evidence regarding the adverse effects of hearing difficulties in the workplace is beginning to emerge. Recent studies demonstrated that reduced hearing may lead to difficulties for workers in maintaining employment [7,8]. Also, hearing impairment can cause communication challenges that result in work-related fatigue [9], lack of job control [10], sick leave [11], and early retirement [10]. It should be considered that hearing impairment not only affects the individual with hearing impairment. Disadvantages related to hearing loss in the workplace also cause higher costs for companies, and ultimately for society, because of issues related to work productivity loss. According to estimates by Ruben [4], the cost of communication disorders (including speech, language, and hearing problems) to the economy in the US is between $154 billion to $186 billion per year, which is equal to 2.5–3% of the Gross National Product. In this study costs included cost for education, loss of income from underemployment, and cost of unemployment. In addition, Mohr et al. [12] showed that most of the societal costs of hearing impairment are caused by reduced working productivity due to presenteeism (i.e., being present at work but not functioning at full capability). Based on these findings, we argue that services assisting individuals with hearing difficulties to improve and maintain their working condition may not only alleviate the needs of the individual with hearing impairment, but may also result in a lower burden for both companies and society as a whole. The traditional approach to alleviate the problems caused by hearing loss is hearing aid fitting, sometimes in conjunction with the provision of assistive listening devices. In the vast majority of cases worldwide, hearing aid fitting is the only rehabilitation option offered to adults with hearing loss, regardless of the stage of

life they are in (e.g., employed, retired) [13]. It has been argued that to solve the problems of persons with hearing loss in the workplace, the provision of hearing aids only would have little effect, due to the complex nature of the workplace [14,15]. This raises the question as to what would be required to adequately and effectively manage the specific difficulties related to hearing loss at work. What elements should be incorporated in programs aimed at alleviating the hearing related problems at work? To our knowledge there are some protocols in clinical practice that are relevant in relation to these questions, e.g., the protocol of the Dutch Society for Occupational Medicine (NVAB) [16] and the guideline for persons with hearing loss of the Canadian Hard of Hearing Association (CHHA) [17]. Both protocols describe methods ensuring good acoustics in the workplace as well as noise control combined with assistive listening devices. They also recommend suitable visual conditions. However, a close look at the content of these protocols revealed that they still mainly focus on audiological technical solutions (such as hearing aids and assistive listening devices), without paying much attention to the psychosocial and wider communicative barriers often reported by professionals with hearing difficulties. The latter was shown by De Graaf en Van Bijl who conducted a large survey among hard-of-hearing and deaf adults in The Netherlands [18]. They found that support in coping with hearing loss in the workplace was one of the most frequently reported care needs. Their findings reinforce the results of a survey which was conducted by the CHHA. It revealed that 57% of the experienced hearing aid consumers were not informed about counseling services to help them adjust their hearing loss [19]. Rather than only focusing on the technology, several studies suggested that a multi-faceted approach or program is required to support workers with hearing loss and to help them to continue their optimal work performance [8,9,14,15,20–23], in line with the WHO’s International Classification of Functioning Disability and Health (ICF) model [24]. The ICF framework views a person’s disability as an outcome of interactions between an individual’s health condition (e.g., hearing impairment) and contextual factors. Among contextual factors are environmental factors (e.g., room acoustics, colleagues, tasks, schedules), and personal factors (e.g., age, cognitive capacities, coping styles, education). Thus, in order to improve an individual’s functioning at work, not only the individual’s health con-


dition, but also the environmental and personal factors should be addressed in vocational programs. Elements that have been proposed and considered as important in such an approach include the provision of hearing assistive technology, accommodation of the workplace, training in effective coping strategies, training in communication skills, empowerment and supervisor support [8,9,11,21–23,25]. To our knowledge, a large implemented standardized audiological rehabilitation procedure addressing the specific needs of workers with hearing difficulties does not exist yet. The main body of literature on the relationship between hearing and work focuses on the risks of exposure to occupational noise and the effects on workers’ health. Loud noise can cause temporary or permanent hearing impairment. Much research is conducted on the underlying mechanisms of noise-induced hearing loss [26,27] and on the design and effectiveness of hearing protection programs [28,29]. These findings, together with the result of the surveys described above and the content of existing guidelines, illustrate that there is an overall lack of knowledge or awareness among stakeholders (e.g., employers, occupational physicians, and general practitioners) of what steps, other than the provision of technology, can be taken to effectively facilitate participation of employees with hearing difficulties [30–33]. The primary aim of the current study was to systematically review the scientific literature on existing services for workers with hearing difficulties and to outline the characteristics of these programs (e.g., the targeted population, the setting of the intervention, its duration and the content). Such knowledge is important as it may help stakeholders who are considering applying such a program to learn what it actually takes to implement such a service and the content. Some studies go beyond a description of the vocational rehabilitation program. Rather than only describing the content of the program and discussing its clinical relevance, these studies also address the statistical effectiveness in terms of improvement of an individual’s work performance or successful (re-)entrance in the workplace. For these studies, it is relevant to also assess the strength of evidence. In systematic literature review research, the assessment of the methodological quality of health care studies is being increasingly encouraged [34]. Hence, the second aim of this article was to identify which of the included studies also provided a statistical evaluation of the effectiveness of their program. A summary of effectiveness is provided. Since evidence-based medicine categorizes

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different strengths of evidence and rating [35], we assessed the methodological quality of these studies according to a standardized method using a list of criteria.

2. Methodology 2.1. Literature search Systematic searches in databases PubMed, EMBASE.com, PsycINFO (via CSA Illumina), CINAHL (via EBSCO) and The Cochrane Library (via Wiley) were performed from inception to November 7th , 2011. These biomedical and psychological databases are the most relevant and cover most of the audiological journals [36]. Search terms for these databases included controlled terms from ‘MeSH’ in PubMed, ‘EMtree’ in EMBASE.com, ‘thesaurus terms’ in Psyc INFO, and ‘CINAHL Headings’ in CINAHL as well as free text terms. Free text terms only were used in The Cochrane Library. Search terms expressing ‘employees with hearing difficulties’ were used in combination with search terms comprising ‘vocational rehabilitation programs’. Table 1 presents the search strategy in PubMed. 2.2. Selection and data extraction Studies that described a vocational rehabilitation program for employees with hearing difficulties were considered eligible. According to the guidelines for systematic reviews [35], strict inclusion and exclusion criteria for the articles were defined. To be included in the review, studies had to meet the following inclusion criteria: 1) The study population consisted of workingage individuals with hearing difficulties. They could be a part of the general working population or a specific work-related population. 2) The article provided information on the hearing status of the participants. No restrictions were applied to the nature of the measurement method (e.g., self report, pure tone audiometry). Since the studies used different terminology for hearing status (e.g., hearing loss, hearing impairment, hearing problems, or hearing difficulties), we decided to use the term hearing difficulties in the current paper. 3) The intervention in question was a workplace or primary care service, or a program targeting workers with hearing difficulties. 4) The intervention was targeted at the health situation or the employment situation of workers with hearing difficulties through educa-

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A.H.M. Gussenhoven et al. / Vocational rehabilitation services for people with hearing difficulties Table 1 Search strategy in PubMed November 7 2011

Set #1

Search terms (“Hearing”[Mesh:NoExp] OR “Hearing disorders”[Mesh:NoExp] OR “Hearing impaired persons”[Mesh] OR “hearing loss”[Mesh] OR Presbyacusis[tiab] OR Presbyacusia[tiab] OR Presbycusis[tiab] OR hypoacusis[tiab] OR Deaf*[tiab] OR (Hearing[tiab] AND (difficult*[tiab] OR condition*[tiab] OR disabilities[tiab] OR disability*[tiab] OR disabled*[tiab] OR disorder*[tiab] handicap*[tiab] OR impair*[tiab] OR loss[tiab] OR Problem*[tiab]))) AND (Employability[tiab] OR employed[tiab] OR employee[tiab] OR employees[tiab] OR “employment”[mesh] OR employment[tiab] OR labor[tiab] OR labour[tiab] OR “manpower”[Subheading] OR manpower[tiab] OR personnel*[tiab] OR re-employ*[tiab] OR staff[tiab] OR “Unemployment”[Mesh] OR Unemploy*[tiab] OR “at work”[tiab] OR worker*[tiab] OR workforce*[tiab] OR “workplace”[Mesh] OR workplace*[tiab] OR job[tiab] OR jobs[tiab])

Result 3261

#2

“absenteeism”[mesh] OR absenteeism[tiab] OR aural rehabilitation[tiab] OR “convalescence”[mesh] OR disability management[tiab] OR Disability pension[tiab] OR economic consequence*[tiab] OR economic status[tiab] OR “Education”[Mesh:NoExp] OR education[tiab] OR educations[tiab] OR evaluation[tiab] OR evaluations[tiab] OR intervention*[tiab] OR job outcome*[tiab] OR job performance*[tiab] OR “job satisfaction”[mesh] OR job satisfaction[tiab] OR job status[tiab] OR occupational adjustment[tiab] OR “Occupational health”[mesh] OR Occupational health[tiab] OR “Occupational Health Physicians”[Mesh] OR occupational health physician*[tiab] OR “Occupational health services”[mesh] OR occupational health service*[tiab] OR “occupational medicine”[mesh] OR occupational medicine*[tiab] OR occupational outcome*[tiab] OR Occupational rehabilitation*[tiab] OR Occupational status[tiab] OR “program evaluation”[mesh] OR “Rehabilitation”[Mesh:NoExp] OR “Rehabilitation of hearing impaired”[Mesh] OR “rehabilitation of hearing impaired”[tiab] OR “retirement”[mesh] OR retirement[tiab] OR return to work[tiab] OR sick absence[tiab] OR “Sick Leave”[Mesh] OR “sick leave”[tiab] OR sickness absence[tiab] OR sickness leave[tiab] OR “vocational education”[Mesh] OR “vocational guidance”[mesh] OR vocational guidance*[tiab] OR vocational outcome*[tiab] OR “rehabilitation, vocational”[MeSH] OR vocational rehabilitation[tiab] OR work ability[tiab] OR work adjustment[tiab] OR work capacity[tiab] OR “Work Capacity Evaluation”[Mesh] OR work capacity evaluation*[tiab] OR work disabilit*[tiab] OR work factor*[tiab] OR work function*[tiab] OR “workload”[Mesh] OR workload*[tiab] OR work outcome*[tiab] OR work participation[tiab] OR work recovery[tiab] OR work rehabilitation*[tiab] OR work site[tiab] OR work situation*[tiab] OR work status[tiab]

1471835

#3

#1 AND #2

1098

#4

#3 NOT (“addresses”[Publication Type] OR “biography”[Publication Type] OR “comment”[Publication Type] OR “directory”[Publication Type] OR “editorial”[Publication Type] OR “festschrift”[Publication Type] OR “interview”[Publication Type] OR “lectures”[Publication Type] OR “legal cases”[Publication Type] OR “legislation”[Publication Type] OR “letter”[Publication Type] OR “news”[Publication Type] OR “newspaper article”[Publication Type] OR “patient education handout”[Publication Type] OR “popular works”[Publication Type] OR “congresses”[Publication Type] OR “consensus development conference”[Publication Type] OR “consensus development conference, nih”[Publication Type] OR “practice guideline”[Publication Type]) NOT (“animals”[MeSH Terms] NOT “humans”[MeSH Terms])

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tion, coping strategies, communication or hearing therapy, and/or workplace accommodations. 5) The study was reported either in English or in Dutch. Studies were excluded if: 1) The study described an intervention explicitly for Deaf1 employees, because of the different nature of intervention components (e.g., sign language). 2) The study described an intervention targeting prevention of (work-related) noise-induced hearing loss, because programs aimed at preventing noise-induced hearing loss have an essentially different focus. Two reviewers (AG and EP) each screened all potentially relevant titles and abstracts for eligibility. In case of uncertainty or disagreements between the two reviewers regarding inclusion of a study, the two reviewers discussed the article on the basis of the inclusion 1 The use of a capital “D” denotes Deaf people as a cultural/linguistic minority group rather than deafness as a disability characteristic.

criteria until consensus was reached. According to the procedure, a third reviewer (SK) would be consulted when disagreements persisted; this was not necessary for this study. Then the full text of the included articles were retrieved and examined to evaluate whether they met the inclusion criteria. Additionally, the reference lists of the included articles were scrutinized for other relevant publications. After having collected all relevant publications, the first author (AG) extracted the data. According to the first goal of this study, we provided an extensive description of the programs, outlining all the different characteristics, elements, and procedures. 2.3. Effectiveness of the vocational rehabilitation programs The second goal of the study was to identify the studies that provided a statistical evaluation of the effectiveness of the program, and to summarize the em-


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Fig. 1. Flowchart of the search and selection procedure of articles describing vocational rehabilitation programs for people with hearing difficulties.

pirical evidence. According to the guidelines for conducting systematic reviews, not only information about the effectiveness of the programs should be given, but also information about the methodological quality of the effectiveness studies [37]. We completed an assessment of the quality of these effectiveness studies in this review using the Downs and Black quality assessment method [34]. This quality assessment scale is often used in systematic review studies, and has been ranked in the top six quality assessment scales for use in systematic reviews [37]. The scale comprises 27 items divided over five subscales each characterizing an element of the quality of the study; 1) Reporting; 2) External validity; 3) Internal validity of the study; 4) Selection bias and confounding, and 5) Power. Three reviewers (AG, SG, and JF) each assessed the methodological quality of the studies included for this part of the review. Disagreements were mainly due to misreading or different interpretations by the reviewers of the questions of the Downs and Black checklist. Disagreements between the three reviewers were discussed until consensus was reached by majority of votes. The total Downs and Black Quality Assessment Score (QAS) ranged from 0 to 28 points (i.e., one point for every positive answer on the items and one extra

point for a positive answer on the item about the description of principal confounders). The QAS ranges were grouped into 4 quality levels: excellent (26–28), good (20–25), fair (15–19), and poor ( 14).

3. Results 3.1. Literature search and study selection The literature search generated a total of 3215 references: 1062 in PubMed, 1574 in EMBASE.com, 259 in PsycINFO, 273 in CINAHL and 47 in The Cochrane Library. There were 902 duplicates (i.e., the same article appeared in more than one database). After removal of these duplicates, both reviewers (AG and EP) read 2313 titles and abstracts. Disagreements and uncertainty were resolved in a consensus meeting of both reviewers. Based on the inclusion and exclusion criteria, 2182 studies were excluded. After having examined the full text of the remaining 131 articles, another 121 were excluded because they did not meet the inclusion criteria. The most common reasons for exclusion were: ‘not about an intervention program’, ‘the sample of study did not comprise employees’ or ‘the in-

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A.H.M. Gussenhoven et al. / Vocational rehabilitation services for people with hearing difficulties Table 2 Articles included in the systematic review (n = 10)

Authors Fok D., Shaw L., Jennings M.B., and Cheesman M.

Year 2009

Publications specifications Towards a comprehensive approach for managing transitions of older workers with hearing loss. Work, 32, 365-376.

Getty L. and Hétu R.

1991

Development of a rehabilitation program for people affected with occupational hearing loss, 2. Results from group intervention with 48 workers and their spouses. Audiology, 30, 317-329.

Hétu R. and Getty L.

1991

Development of a rehabilitation program for people affected with occupational hearing loss, 1. A new paradigm. Audiology, 30, 305-316.

Jennings M.B., Shaw L., Hodgins H., Kuchar D.A., and Bataghva P.F.

2010

Evaluating auditory perception and communication demands required to carry out work tasks and complimentary hearing resources and skills for older workers with hearing loss. Work, 2010, 101-113.

Kramer S.E.

2008

Hearing impairment, work, and vocational enablement. International Journal of Audiology, 47 (suppl. 2), S124-S130.

Lalande N.M., Riverin L., and Lambert J.

1988

Occupational hearing loss: An aural rehabilitation program for workers and their spouses, characteristics of the program and target group (participants and nonparticipants). Ear and Hearing, 9 (5), 248-254.

Li E.P.Y., Li-Tsang C.W.P., Lee T.K., Lee G.W.M., and Lam E.C.F.

2006

Vocational rehabilitation program for persons with occupational deafness. Journal of Occupational Rehabilitation, 16, 503-512.

Mascia N. and Mascia J.

2008

Audiology on the job: The vocational rehabilitation and audiology partnership. Journal of the American Deafness and Rehabilitation Association, 41(2), 95-112

Myers P.C. and Danek M.M.

1990

Deaf employment assistance network: A model for employment service delivery. Journal of the American Deafness and Rehabilitation Association, 24 (2), 59-67.

Ringdahl A., Brenstaaf E., Simonsson S., Wilroth M., Caprin L., Lyche S., and Wiik H.

2001

A three-year follow-up of a four-week multidisciplinary audiological rehabilitation programme. Journal of Audiological Medicine, 10(2), 142-157.

tervention concerned a hearing conservation program’. No new article was retrieved after screening the references of all included articles. The flow diagram in Fig. 1 shows the details of the search and reasons for exclusion of articles. Finally, ten articles were found eligible for inclusion in this systematic review. Two of these articles by Getty and Hétu [20,38] appeared to describe the same intervention and therefore, they were combined in the review, resulting in a total of 9 programs. Details of the ten included articles are provided in Table 2. In the following paragraphs, the characteristics of the programs, the logistics and procedure of the programs will be described. In the subsequent paragraphs, the content of the programs will be presented. An overview of the empirical evidence and methodological quality of the effectiveness studies will follow in Section 3.6. 3.2. Program characteristics Table 3 presents the characteristics of the nine programs described in the ten retrieved studies. Overall, a division can be made between studies describing a full vocational rehabilitation program and studies describing a tool or instrument to manage the identifica-

tion of auditory perceptual demands in the workplace. Two of the ten studies concerned such a tool. The first is the Canadian Hearing Demands Tool (C-HearD) developed by Jennings et al. [25]. The second is the Universal Design for Hearing (UDH) by Fok et al. [39]. These tools can assist workers, workplace parties and clinicians in identifying and describing workplace demands in a standard and systematic way. 3.3. Target sample Three studies [38,40,41] reported that their service was designed specifically for workers who had developed hearing loss due to excessive noise in the workplace. The remaining articles [5,15,25,39,42,43] reported on programs for workers with hearing difficulties, regardless of the type of hearing impairment. In some of the intervention programs, significant others were involved. The rationale was to help the significant others to better understand the problems related to hearing impairment and to give them better insight into the daily work-related programs of the worker. Significant others were the spouse [5,38,40,43], coworkers [5,39,43], or the manager or supervisor of the employee [25,39].


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Table 3 Characteristics of the nine included vocational rehabilitation programs Author (year) and name of the program

Country

Fok et al. (2009) Canada Universal Design for Hearing (UDH) Canada Getty and Hétu (1991), Hétu and Getty (1991) Vocational rehabilitation program

Study population and kind of hearing loss Older workers with hearing loss

Setting/ responsibility

Workplace Individual NS of employee

Involved profes- Involved Elements of the program sionals in the significant program others in the program Work-related accommodaNS Managetions ment, co-worker

Persons with OHL

Group Local community health centers

Occupational health nurses, audiologist, social worker

Jennings et al. (2010) Canadian Hearing Demands Tool (C-HearD)

Canada

Kramer (2008) Vocational Enablement Protocol (VEP)

The Workers, Netherlands NS

Canada Lalande et al. (1988) Vocational rehabilitation program

Li et al. (2006) Return-to-work program

Older work- NS ers with hearing loss

Persons with OHL

Hong Kong Persons with OHL

Group and/ Duration or Indivi- of the dual level program

Four 2 hr weekly, or 1.5 day session.

Individual NS

Monitoring, listening, comprehending, communicating

NS

Education, hearing aids and assistive listening devices, amplification devices, speech therapy, hearing therapy, coping strategies, workrelated accommodations, and workplace visit.

Spouses

Education, hearing aids and assistive listening devices, speech therapy, hearing therapy, coping strategies, relaxation exercises, and stress management.

Rehabilitation counselors, occupational therapist

NS

Education and job placement with support.

NS Individual 2 hr and group meetings for 7 weeks

Workplace Individual Three 1.5 hr and group individual of sessions and employee four 3 hr group sessions

Education, hearing aids and assistive listening devices, amplification devices, speech therapy, hearing therapy, relaxation exercises, coping strategies.

Experts in work- NS place evaluation and audiology

Audiology Individual one half-day Psychologist, clinic assessment occupational physician, audiologist

NS

Spouses

United Mascia and States of Mascia (2008) Vocational reha- America bilitation program

Individuals Workplace Individual NS who are deaf of employee or hard of hearing

Vocational rehabilitation counselor, audiologist

Co-worker, Education, hearing aid and family assistive listening devices, amplification devices, speech therapy, hearing therapy, job placement, and workplace visit.

Myers and Danek United States of (1990) America Deaf Employment Assistance Network (DEAN)

Deaf people Coordina- Individual NS ting agency

NS

NS

Sweden Ringdahl et al. (2001) Vocational rehabilitation program

Workers, NS

Audiology Group clinic

NS = Not specified in the article, OHL = Occupational Hearing Loss.

4 meetings Social worker, Spouses, co-worker in 4 weeks hearing therapist, audiologist

Employment acquisition services, employment maintenance services, employment accommodation services, and employment enhancement services Education, hearing aids and assistive listening devices, amplification devices, speech therapy, hearing therapy, coping strategies, and workplace visit.

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3.4. Logistics and procedure of the programs The setting of the intervention varied between the programs. For two programs the setting was the Audiology clinic [15,43]. Other programs were conducted in a coordinating agency [42], a local community center [38], or at the workplace of the employee [5,39,41]. Two studies did not report the setting of the intervention [25,40]. The duration of the programs varied from half a day [15] to a 7-week program with one session per week [43]. Furthermore, the programs were provided on an individual level [5,15,25,39,42], in group setting [38,43], or both [40,41]. Different professionals were involved in leading the programs, namely an audiologist or hearing therapist [5,15,38,43], a psychologist or social worker [15, 38,43], an occupational physician or an occupational health nurse/therapist [15,38,41], a (vocational) rehabilitation counselor [5,41], or experts in workplace evaluation and audiology [25]. Five of the nine programs took a multidisciplinary approach, with experts from different disciplines (audiology, psychology, otolaryngology, occupational health) contributing [5,15, 38,41,43]. 3.5. Content 3.5.1. Information provision The provision of information to the employee with hearing difficulties was an important element in almost all interventions [5,15,38,40,41,43]. The education was focused on the anatomy of the ear, technical devices, hearing tactics, sickness absence, security insurance, early retirement, and disability pensions. Although it was not explicitly stated as such in all studies, the aim of the education seemed to be to increase the participant’s knowledge and awareness of hearing loss, and its consequences. In three programs study material such as textbooks, CD’s, written information was distributed among the participants or audiovisual material was used during the sessions [15,38,40]. 3.5.2. Hearing aids and hearing assistive devices Five programs [5,15,38,40,43] included hearing aid fitting or refitting and the provision of assistive devices comprising FM systems, telecoils, infrared systems, amplified telephones, tactile pagers, or visual alerting systems. For some programs, a visit to the Audiology clinic was required as part of the program [5,15,43]. In two other programs [38,40] recommendations to visit an audiologist for a hearing aid (re)fitting and/or assistive devices were offered as a guide to action. It was unknown, however, whether the participants indeed pursued the recommendation.

3.5.3. Communication training Five programs [5,15,38,40,43] offered training in communication strategies, such as speech reading and hearing tactics in different listening settings. In Kramer’s program [15], the participant only received the recommendation for a training session whereas in other programs the employee actually practiced the communication strategies during the sessions [5,38,40, 43]. 3.5.4. Coping strategies Four of the nine programs included training in how to cope with hearing loss in the workplace and how to accept the loss [15,38,40,43]. The training concerned some form of assertiveness training and empowerment using a role playing technique, taking into account a participant’s personality and capacity to adjust to change. In some cases, the role playing was videotaped and participants received feedback on their performance [38,40,43]. Training in relaxation technique was provided in two of the nine programs [38,40]. Furthermore, in the return-to-work program by Li et al. [41], the participants received support in identifying their strengths and weaknesses in preparation for new job placements. 3.5.5. Workplace accommodations In the vocational enablement program described by Kramer [15] recommendations about specific modifications in the workplace were provided. These could concern environmental modifications (replacement of furniture, elimination of noise generating machines) as well as modifications in time schedules (insertion of breaks during the day, rescheduling of effortful listening situations, elimination of nonessential job functions). The program by Myers and Danek [42] included employment acquisition services, employment maintenance services, job (re)training, and professional development. Essential workplace elements of the vocational rehabilitation program by Mascia and Mascia [5] were vocational assessment job training, an individualized plan for employment, and job placement. In two other programs the workplace of the employee was visited by a professional to measure the noise levels and to identify the acoustic disturbances [15,43]. 3.5.6. Integrated approach An integrated approach is characterized by the experts of the team (health care professionals) being in close contact with stakeholders in the workplace of the employee. Both sides need to be actively involved in


the process of diagnosis and in finding solutions for the problem and all (environmental) factors and actors should be taken into account. Such an approach increases the likelihood that the proposed accommodations are actually implemented [15]. Three programs applied an integrated approach [15,25,39]. Hétu and Getty suggested that such an approach would be essential but it was not an element in their vocational program [20]. 3.6. Effectiveness of the rehabilitation programs for workers with hearing difficulties Only four of the ten studies appeared to statistically explore the effectiveness of the described rehabilitation program [38,40,41,43]. These are presented in Table 4. In the study by Li et al. [41], evaluating the returnto-work program, only six persons participated. Two measurements were used for the evaluation; the Lam’s Assessment of Stages of Employment Readiness (CLASER), which identified a person’s work readiness, clustered into four stages (pre-contemplation, contemplation, preparation, and action), and the SF-36 Health Survey, which evaluated the person’s general health status. Both questionnaires were validated for use in Hong Kong. After the follow-up period (note that a time interval was not given), mean work readiness was increased (contemplation (i.e., considering returning to work) (+10.44%), preparation stage (i.e., getting prepared to look for jobs) (+15.14%), and action (i.e., taking action to search for new jobs) (+8.77%), whereas the pre-contemplation stage (i.e., taking no action) had a decreased of score (−14.97%). For the second measurement a mean improvement in general health from pre to post measurement was found. Participation in the program resulted in a 36% improvement in the participant’s general health (SF-36 total score). In the pilot study by Lalande et al. [40], the results of an aural rehabilitation program component were described. The impact of the intervention was evaluated using the (unvalidated) Hearing Handicap Questionnaire and by a semi structured interview held at the participant’s home. Three of the five participating employees (with their spouses) participated in the interview. The main outcomes participants reported in the interviews were an increased understanding of hearing impairment, greater use of communication strategies, and less concern about auditory fatigue. Outcomes of the questionnaire were not provided. The third study is the one by Ringdahl et al. [43]. Their multidisciplinary audiological rehabilitation pro-

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gram was evaluated in a group of 39 participants. Two subscales of the Communication Profile for the Hearing Impaired (CPHI) were used: the Communication Strategies Scale (CPHI-CSS) and the Maladaptive Behavior Scale (CPHI-MAB). These subscales assessed the participants’ handling or coping with their hearing difficulties. In addition, the Symptom Check List 90(R) (SCL90-R) questionnaire, which measured psychological and somatic distress, was used. Questionnaires were administered pre and post program (note that no information on the time interval was reported). Results of the CPHI-CSS and CPHI-MAB indicated an improvement for the total communication scores (p < 0.01) after the program. No significant effects were found for the SCL90-R (note that only the level of significance of the results was reported, the mean pre and post program scores were not given in the article). Finally, Getty and Hétu [38] evaluated their rehabilitation program using the Handicap Questionnaire (HQ) administered one month before and three months after the intervention. Forty-eight workers participated in the study. The results of the HQ showed that workers judged their hearing problems as being significantly less severe after participation in the program. A qualitative analysis focusing on the outcomes of the group meeting indicated that the workers agreed that they were much more confident in dealing with their hearing difficulties in the workplace after participation in the vocational rehabilitation program. Results of the methodological quality of each of the four studies assessed using the QAS is reported in Table 4. The three reviewers initially disagreed on 39 of the (27 × 4 studies) 108 ratings (i.e., 36%). According to the Downs and Black checklist, the four studies received ratings varying from 7 to 14 points. None of the studies included a control group. Thus, the study designs were neither randomized nor controlled. It was also not reported whether the group of participants in the studies were representative for the labor population in their countries. In addition, power calculations were not reported. Three studies reported on a follow-up period and provided exact follow-up data [38,41,43].

4. Discussion 4.1. Main findings To our knowledge, this is the first systematic review of the literature on vocational rehabilitation programs for persons with hearing difficulties. In 2010, Jennings

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A.H.M. Gussenhoven et al. / Vocational rehabilitation services for people with hearing difficulties Table 4 Effectiveness studies of the vocational rehabilitation programs (n = 4)

Study (year) and name of the program Getty and Hétu (1991) Vocational rehabilitation program

N (% male)

Mean age, years (SD)

Mean hearing loss of the participants (SD)

Outcome measures

Follow-up Outcomes measurement

48 (100% 54 (8.65) male)

Hearing threshold levels 30 dB HL averaged over 0.5, 1, 2, and 4 kHz in at least one ear (SD; NS).

1. Handicap Questionnaire (HQ) 2. Group interview

1, 2, and 3 months follow-up

Lalande et al. (1988) Vocational rehabilitation program

5 (%; NS)

Older than 45 (SD; NS)

1 person with 11– 30 dB HL and 4 persons with 30 dB HL (all averaged over 1, 2, 3, and 4 kHz for the worst ear) (SD; NS).

1. Hearing Handicap questionnaire 2. A semistructured interview

No follow-up An increased understand- 7 ing of hearing impairment, greater use of communication strategies, less concern about auditory fatigue.

Li et al. (2006) Return-to-work program

6 (%; NS)

49 (SD; NS)

NS

1. Lam’s Assessment of Stages of Employment Readiness (C-LASER) 2. SF-36 Health Survey

Post-training (time period: NS) and follow-up (time period: NS)

Ringdahl et al. (2001) Vocational rehabilitation program

39 (28% male)

47 (9.3)

Hearing threshold levels averaged over 0.5, 1, 3 kHz right; 46 dB HL (17), left; 49 dB HL (18).

Post 1. Communicament tion Profile for the Hearing Impaired (CPHI) 2. Symptom Check List 90(R) (SCL90-R)

Hearing problems were judged as being significantly less severe after participation in the program. The workers had much more confidence in dealing with hearing difficulties.

QAS [range; 0–28] 14

Increased work readiness 13 (contemplation (+10.44%), preparation (+15.14%), and action (+8.77%)) between preand post-training and improved general health status between pre- and posttraining (+36.05%).

treat- A significant increase for 13 the CPHI-CSS and CPHIMAB between before and after rehabilitation. No significant effects were found on the SCL90-R.

CPHI-CSS = Communication Profile for the Hearing Impaired – Communication Strategies Scale, CPHI-MAB = Communication Profile for the Hearing Impaired – Maladaptive Behavior Scale, dB HL = Decibel hearing loss, NS = Not specified in the article, SD = Standard deviation, QAS = Quality assessment score.

et al. [25] reviewed the literature on tools to guide the evaluation of sensory demands of hearing in the workplace. Rather than only focusing on the demands of hearing in the workplace, their review focused on the actual steps that can be taken to facilitate workers for whom the demands in the workplace do not fit their hearing capacity. As such, the current systematic review complements the literature review of Jennings et al. [25]. The number of different vocational rehabilitation programs focused on hearing is small. Most of the attention on hearing loss in the workplace has predominantly been associated with the risks of exposure to excessive occupational noise and effects on workers’ health. There is a wealth of literature available on the mechanisms underlying noise-induced hearing loss and the prevention of it [44,45]. Efforts are needed to develop vocational rehabilitation programs that support persons in maintaining employment and on in-

tervention effectiveness. Only in the last two decades, specific programs and practice guidelines for managing the work-related problems of people with hearing impairment, regardless of the type of hearing impairment, have begun to receive attention. Five programs in this review used an individual intervention, two programs were group-based, and two programs were a combination. Vocational rehabilitation programs in a group setting provide an opportunity for the attendees to share experiences and employees can feel supported by each other. Furthermore, group sessions can be cost effective because multiple workers can be reached at the same time [38]. On the other hand, specific individual needs of an employee might be better addressed in an individual counseling setting. A combination of group treatment and individual sessions seems ideal, but more evidence is required to draw firm conclusions about which approach would be


best (see below for further details about the effectiveness of programs). The vocational rehabilitation programs of Getty and Hétu, Lalande et al., Mascia and Mascia, and Ringdahl et al. [5,38,40,43] were highly similar in content. Common elements were education, the provision of hearing aids and hearing assistive devices, communication training, such as speech reading and hearing tactics, information about workplace accommodations, and training in coping strategies. Some of these elements were also covered in other, more general, models of auditory enablement. Examples are Stephen’s updated model of audiological rehabilitation [46] and the model proposed by Kiessling et al. [47]. As such, the vocational rehabilitation programs described in this review can be seen as further expansions of existing models in audiology. Working adults require additional (integrated) services that are not provided in regular audiological care models. Existing models of auditory rehabilitation promote a multidisciplinary approach [46]. Audiologists are rarely able to meet all the patients’ needs by themselves. Also for vocational rehabilitation, the involvement of relevant other professionals (e.g., social work, speech pathology, otorhinolaryngology, occupational health, psychology) seems highly relevant in enabling workers with hearing impairment to function to the best of their abilities. Kramer [15] suggested that one professional of the multidisciplinary team should fulfill the role of case manager. This manager should monitor the process from the beginning to the end of the intervention and facilitate communication among professionals and with the participant. This case manager can take primary responsibility for the outcome. Without a case manager, there is a risk that no one will take final responsibility for the process and, with that, the outcome of the program. Future research is needed on the effectiveness of an integrated approach. Only a few of the programs described in this review applied an integrated approach [15,25,39], but none of these studies reported on the statistical evidence of effectiveness of the integrated approach. Nevertheless, based on our clinical experience, we argue that the health care professionals and stakeholders in the workplace being connected in a combined effective unit may be important for vocational program success. The workplace is a complex contextual situation (idem to the ICF model [24]), with many levels of influence. Actions can be taken at micro level (individual), meso level (workplace culture), and at the macro level (legal issues) [25]. This approach is

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in line with the study by Hétu and Getty, who stated that treatments on the micro level of the employee with hearing impairment would have little effect [20]. The remaining programs were directed to the adaptation of only the person with hearing difficulties. Such an approach implies that the person with the disability should adapt so that (s)he better matches the job demands and work environment. It is questionable whether this method would be the most effective and appropriate to meet the needs of workers with hearing difficulties. 4.2. Effectiveness of the observational studies of a vocational rehabilitation program Four of the ten studies evaluated the effectiveness of their program statistically. Overlapping outcomes between the studies were not found due to the differences in outcome measures, and follow-up measurement in these four observational studies. Pre and post measurements showed an improvement in general health (SF36), communication strategies, and the degree of work readiness [38,40,41,43]. However, the statistical evidence of the programs’ effectiveness remained poor. None of the studies included a control group. Sample size calculations, whether the groups of participants were representative for the entire working population, or blinding of participants was not described either. The absence of these elements in the studies was the main reason as to why each of the studies received a weak rating using the Downs and Black quality assessment method. Nevertheless, the low methodological quality of the effectiveness studies does not mean that the findings reported are not relevant. On the contrary, these findings indicate the need for further research. Future studies should address the effectiveness of vocational rehabilitation using (randomized) controlled designs to assess the effectiveness of approaches [36]. One vocational enablement program included in this review, the program described by Kramer [15], will be evaluated on effectiveness and cost effectiveness in a RCT study in the near future [48]. Outcome measurement is an issue that deserves attention in future debates and vocational rehabilitation. For instance, are the outcome measures coherent with the goals of vocational rehabilitation programs? Studies to date evaluate an improvement in general health (SF-36), communication strategies, and the degree of work readiness. Ringdahl et al. [43] suggested more standard measures on disability and handicap be assessed. Given the adverse consequences and high costs

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of hearing impairment [4], it is of utmost importance to investigate whether vocational rehabilitation programs lead to lower burden of hearing difficulties in the workplace. Outcomes relevant for such analyses include prevalence of early retirement, work-related fatigue, sick leave, productivity, and/or related societal costs in groups of workers with hearing difficulties. To our knowledge, such outcomes have never been investigated in studies in the field of Audiology. We argue that such work-related outcomes should be implemented in future research. Also investigation using qualitative research is needed to support the examination of worker viewpoints on outcomes that matter [23, 30,33,49]. 4.3. Limitations of this review The present descriptive review has some limitations. Selection bias may have occurred in the review process; the very wide search made it possible to identify studies about vocational rehabilitation programs. However we cannot be sure that no study was missed. Almost each day, new (open access) journal are launched, and as a result relevant studies published in these journals that are not yet in the electronic database may have been missed. Furthermore, the disagreement score (i.e., 36%) on the Downs and Black quality assessment for the three reviewers was quite large. A reduction in disagreement could have been reached if this quality assessment was pilot tested first with some articles not included in the review. As such, the three reviewers would have received training in using the scale. This is often done as a way to improve the agreement score [35]. Finally, a meta-analysis was impossible due to the different study designs and use of different outcomes measures in the retrieved effect studies.

gram is most effective and for whom. Only four studies provided statistical evidence of the effectiveness of the vocational enablement program. The methodological quality of these studies was poor. Hence, to help clinicians and policy makers decide whether a vocational enablement program will be successful for a person with hearing difficulties experiencing problems at work, more research on the effectiveness of such programs is needed. Researchers are encouraged to use quality assessment lists when designing their studies in order to improve the methodological quality of their work. Specific attention should be paid to reporting randomization procedures, blinding, and sample size calculations. Also, outcome measurement needs attention. Rather than only using generic measures of quality of life, the use of work-related outcomes such as work-related fatigue, sick-leave and productivity is recommended.

Acknowledgements We thank Marieke Pronk for the delivery of the search terms of hearing difficulties for the databases. This study was subsidized by The Netherlands Organization for Health Research and Development (Zon Mw).

References [1]

[2]

[3]

5. Conclusion [4]

Although the nine vocational rehabilitation programs developed so far differed in procedure, duration, setting, and content, they also had elements in common. These common elements included education, the provision of hearing aids, hearing assistive devices, communication training, information about workplace accommodations, and training in coping strategies. Information about the content of existing programs is relevant as it may help professionals in aural rehabilitation to develop programs and implement them in their own clinics. There is little evidence about which pro-

[5]

[6]

[7]

Mathers C, Smith A, Concha M. Global burden of hearing loss in the year 2000. Global burden of Disease. Geneva: World Health Organization, 2000. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006 Nov; 3(11): e442. Cuijpers M, Lautenbach H, Kösters L. Disabled employees 2006. Report of the Dutch Ministy of Social Affairs and Employment, 2007. Ruben RJ. Redefining the survival of the fittest: communication disorders in the 21st century. Laryngoscope 2000 Feb; 110(2 Pt 1): 241-5. Mascia N, Mascia J. Audiology on the job: The vocational rehabilitation and audiology partnership. Journal of the American Deafness and Rehabilitation Association 2008; 41(2): 95112. Hasson D, Theorell T, Westerlund H, Canlon B. Prevalence and characteristics of hearing problems in a working and nonworking Swedish population. J Epidemiol Community Health 2010 May; 64(5): 453-60. Friberg E, Gustafsson K, Alexanderson K. Hearing difficulties, ear-related diagnoses and sickness absence or disability pension – a systematic literature review. BMC Public Health 2012 Sep 12; 12(1): 772.

A.H.M. Gussenhoven et al. / Vocational rehabilitation services for people with hearing difficulties [8]

Hogan A, O’Loughlin K, Davis A, Kendig H. Hearing loss and paid employment: Australian population survey findings. Int J Audiol 2009 Mar; 48(3): 117-22. [9] Nachtegaal J, Kuik DJ, Anema JR, Goverts ST, Festen JM, Kramer SE. Hearing status, need for recovery after work, and psychosocial work characteristics: results from an internetbased national survey on hearing. Int J Audiol 2009; 48(10): 684-91. [10] Danermark B, Gellerstedt LC. Psychosocial work environment, hearing impairment and health. Int J Audiol 2004 Jul; 43(7): 383-9. [11] Kramer SE, Kapteyn TS, Houtgast T. Occupational performance: comparing normally-hearing and hearing-impaired employees using the Amsterdam Checklist for Hearing and Work. Int J Audiol 2006 Sep; 45(9): 503-12. [12] Mohr PE, Feldman JJ, Dunbar JL, Conkey-Robbins A, Niparko JK, Rittenhouse RK, et al. The societal costs of severe to profound hearing loss in the United States. Int J Technol Assess Health Care 2000; 16(4): 1120-35. [13] Laroche CL, Garcia LJ, Barrette. J. Perceptions by persons with hearing impairment, audiologists, and employers of the obstacles to work integration. Journal of the Academy of Rehabilitative Audiology 2000; 63-90. [14] Jennings MB, Shaw L. Impact of hearing loss in the workplace: Raising questions about partnerships with professionals. Work 2008; 30(3): 289-95. [15] Kramer SE. Hearing impairment, work, and vocational enablement. Int J Audiol 2008 Nov; 47 Suppl 2: S124-S130. [16] Sorgdrager B, Doornbusch J, van Gaalen-Mulder P, Hoorenman T.A.M, de Jager H.J, Marinus E, et al. NVAB richtlijn, Preventie beroepsslechthorendheid, door een effectief gehoorbeschermingsprogramma, 2006. [17] Canadian Hard of Hearing Association (CHHA). Universal Design and Barrier-Free Access: Guidelines for Persons with Hearing Loss. Ottawa, Ontario, 2008. [18] de Graaf R, van Bijl R. Determinants of mental distress in adults with a severe auditory impairment: Differences between prelingual and postlingual deafness. Psychosom Med 2002 Jan; 64(1): 61-70. [19] Canadian Hard of Hearing Association (CHHA). Canadian Hard of Hearing Consumer Survey, 2005. [20] Hetu R, Getty L. Development of a rehabilitation program for people affected with occupational hearing loss. 1. A new paradigm. Audiology 1991; 30(6): 305-16. [21] Nachtegaal J, Festen JM, Kramer SE. Hearing ability in working life and its relationship with sick leave and self-reported work productivity. Ear Hear 2012 Jan; 33(1): 94-103. [22] Scherich DL. Job accomodations in the workplace for persons who are deaf or hard of hearing: Current practices and recommendations. The Journal of Rehabilitation 1996; 62. [23] Tye-Murray N, Spry JL, Mauze E. Professionals with hearing loss: Maintaining that competitive edge. Ear Hear 2009 Aug; 30(4): 475-84. [24] World Health Organization. ICF: International Classification of Functioning, Disability, and Health, 2001. [25] Jennings MB, Shaw L, Hodgins H, Kuchar DA, PoostForoosh Bataghva L. Evaluating auditory perception and communication demands required to carry out work tasks and complimentary hearing resources and skills for older workers with hearing loss. Work 2010; 35(1): 101-13. [26] Job A, Raynal M, Kossowski M, Studler M, Ghernaouti C, Baffioni-Venturi A, et al. Otoacoustic detection of risk of early hearing loss in ears with normal audiograms: A 3-year followup study. Hear Res 2009 May; 251(1-2): 10-6.

[27] [28]

[29]

[30]

[31]

[32]

[33]

[34]

[35]

[36] [37]

[38]

[39]

[40]

[41]

[42]

[43]

[44]

163

Ohlemiller KK. Recent findings and emerging questions in cochlear noise injury. Hear Res 2008 Nov; 245(1-2): 5-17. Davies H, Marion S, Teschke K. The impact of hearing conservation programs on incidence of noise-induced hearing loss in Canadian workers. Am J Ind Med 2008 Dec; 51(12): 923-31. Heyer N, Morata TC, Pinkerton LE, Brueck SE, Stancescu D, Panaccio MP, et al. Use of historical data and a novel metric in the evaluation of the effectiveness of hearing conservation program components. Occup Environ Med 2011 Jul; 68(7): 510-7. Detaille SI, Haafkens JA, van Dijk FJ. What employees with rheumatoid arthritis, diabetes mellitus and hearing loss need to cope at work. Scand J Work Environ Health 2003 Apr; 29(2): 134-42. Glass L.E., Elliott H. Work place success for persons with adult-onset hearing impairment. The Volta Review 1993; 95: 403-15. Kramer SE, Gussenhoven A.H.M. Vocational issues for persons with hearing loss. In: Montano J.J., Spitzer J.B., editors. Adult Audiologic Rehabilitation, Second Edition.San Diego: Plural Publishing, Inc; 2013 (In press). Southall K, Jennings MB, Gagne JP. Factors that influence disclosure of hearing loss in the workplace. Int J Audiol 2011 Oct; 50(10): 699-707. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998 Jun; 52(6): 37784. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. J Clin Epidemiol 2009 Oct; 62(10): e1-34. Cox RM. Evidence-based practice in provision of amplification. J Am Acad Audiol 2005 Jul; 16(7): 419-38. Deeks JJ, Dinnes J, D’Amico R, Sowden AJ, Sakarovitch C, Song F, et al. Evaluating non-randomised intervention studies. Health Technol Assess 2003; 7(27): iii-173. Getty L, Hetu R. Development of a rehabilitation program for people affected with occupational hearing loss. 2. Results from group intervention with 48 workers and their spouses. Audiology 1991; 30(6): 317-29. Fok D, Shaw L, Jennings MB, Cheesman M. Towards a comprehensive approach for managing transitions of older workers with hearing loss. Work 2009; 32(4): 365-76. Lalande NM, Riverin L, Lambert J. Occupational hearing loss: An aural rehabilitation program for workers and their spouses, characteristics of the program and target group (participants and nonparticipants). Ear Hear 1988 Oct; 9(5): 24855. Li EP-Y, Li-Tsang CW-P, Lee TK, Lee GW-M, Lam EC-F. Vocational rehabilitation program for persons with occupational deafness. J Occup Rehabil 2006 Dec; 16(4): 503-12. Myers PC, Danek MM. Deaf employment assistance network: A model for employment service delivery. Journal of the American Deafness and Rehabilitation Association 1990 Oct; 24(2): 59-67. Ringdahl A, Brenstaaf E, Simonsson S, Wilroth M, Caprin L, Lyche S, et al. A three-year follow-up of a four-week multidisciplinary audiological rehabilitation programme. J Audiol Med 2001; 10(2): 142-57. Hallberg LR, Carlsson SG. Hearing impairment, coping and

164

[45]

[46] [47]

A.H.M. Gussenhoven et al. / Vocational rehabilitation services for people with hearing difficulties perceived hearing handicap in middle-aged subjects with acquired hearing loss. Br J Audiol 1991 Oct; 25(5): 323-30. Hetu R, Getty L, Quoc HT. Impact of occupational hearing loss on the lives of workers. Occup Med 1995 Jul; 10(3): 495512. Stephens D, Kramer SE. Living with hearing difficulties: the process of enablement. Chichester, United Kingdom, 2010. Kiessling J, Pichora-Fuller MK, Gatehouse S, Stephens D, Arlinger S, Chisolm T, et al. Candidature for and delivery of audiological services: special needs of older people. Int J

[48]

[49]

Audiol 2003 Jul; 42 Suppl 2: 2S92-101. Gussenhoven AHM, Anema JR, Goverts ST, Bosmans JE, Festen JM, Kramer SE. Cost-effectiveness of a vocational enablement protocol for employees with hearing impairment; design of a randomized controlled trial. BMC Public Health 2012; 12: 151. Lockey K, Jennings MB, Shaw L. Exploring hearing aid use in older women through narratives. Int J Audiol 2010 Aug; 49(8): 542-9.