CHAPTER II

REVIEW OF RELATED LITERATURE

2.1 Introduction

The study of related literature implies locating, reading and evaluating reports of research

as well as reports of casual observation and opinion related to the individual planned research

project by analyzing the previous research findings, the researcher gains further insight into the

study topic (Sukia, 2010). In this study the researcher explored the literature related to the tile

and compiled the relevant studies and presented under the following headings

 Concept of stress and its effects – An introduction.

 Stressors associated with visual impairment and its consequences.

 Barriers encountered by working women due to stress at their work place.

 Stressors and women with disabilities.

 Status of women with Disabilities in India

 Stress managing strategies / techniques and its effects.

2.2 Concept ff Stress and its Effects- An Introduction

For the past two decades, stress and its associated mental health problems have been

increasing dramatically (Haquist, 2000) and it has become a serious public concern (SBU, 2010).

Females have shown to be more vulnerable to stress and its negative implications on health and

well-being than males (Haqist, 2009; Schram et al., 2011)

1
 Stress is often defined as mismatch between the demands placed on us and the way

individuals cope with those demands. It can have a positive and negative effect (McMahan,

2001). Lupien, S.J and Briere, S. (2000) has defined stress as “a (perceived) substantial

imbalance between demand and response capability, under conditions where failure to meet

demand has important (perceived) consequences”.

Stress, either quick or constant, can induce risky body-mind disorders. Immediate

disorders such as dizzy spells, anxiety attacks, tension, sleeplessness, nervousness and muscle

cramps can all result in chronic health problems. They may also affect our immune,

cardiovascular and nervous systems and lead individuals to habitual addictions, which are inter-

linked with stress (Davis,M; Eshelman, E & M, McKay ,2000)

In workplace, stress may be discrepancy between the demands of the job and a

person’s skills and abilities to meet those demands, or a discrepancy between a person’s

occupational goals and needs (including career development, monetary rewards and physical

comfort) and the extent to which these goals and needs are met in the work environment. Misfit

in either of these areas is a threat to an individual’s health and well-being (Bhatia, P and Kumar,

A, 2005).

Although stress is a normal part of life, toxic stress can have very serious consequences,

which is defined as strong, frequent or prolonged activation of the body’s stress management

system and it is provoked by stressful events that are chronic, uncontrollable and/or experienced

without the person having access to support from caring persons (National Scientific Council on

Developing the Child, 2009). Early in development, toxic stress can impair emotional wellbeing,

exploration and curiosity, school achievement and other qualities (Nelson, Greenfield, Hyte,

2
Shaffer, & Paul, 2011). It also leads to increased risk in many conditions like heart disease,

diabetes, depression and anxiety disorders (National Scientific Council on Developing the Child,

2009).

Major life events such as a divorce, death, midlife crisis, financial worries, persistent

strain of caring for a chronically sick child, nagging health problems or managing a physically or

mentally challenged family member can act as potential stressors for most of the women . Even

conditions such as prolonged unemployment or a sudden lay-off from a job can leave them under

tremendous stress. One just can't wish away situation. Moreover one has to live through these

situations, in the right spirit, to make living a worthwhile experience (Herbert, C & Wetmore, A,

2002).

2.3 Stressors Associated with Visual Impairment and its Consequences:

2.3.1 Implications of early life visual Impairment

Visual Impairment early in life has profound implications in terms of reduced

educational outcomes (Corn, Wall, Jose, Wilcox, & Perez, 2002), recreational activities and

social experiences (Lifshitz, Hen & Weisser, 2007).

Vision plays an important role in the education and learning. There are anecdotal reports

that up to 80 percent of learning occur through vision (Koutantos, 2000). Vision Demands

increases significantly because of increased work load and a progressive reduction in print size in

books and work sheets, which summarizes for additional burden.

In accordance to Maslow’s (1987) Need Hierarchy, their already acquired competencies

particularly their personal independence, are lost. These losses impact self esteem needs (self-

3
worth and self-efficacy), safety needs, and financial security (loss of jobs). In reality they lose

their secure and stable worlds, producing uncertainty and insecurity. The reactions, attitudes, and

expectations of society and significant other to adults with acquired visual impairments

capabilities may intensify, negatively or positively, and influence their emotional and

psychological responses and impact their need for love and belonging (acceptance and

nurturance) ( Roy and Mackay, 2002; Tuttle 1984; VanHuijgevoort,2002).

Individuals who experience irrevocable loss of sight go through emotions and

psychological reactions, associated with grief (Schainholz, 2000). Adults with acquired visual

impairment experience particular psychological, emotional and practical states and needs which

require specific skills to help to adjust to the numerous losses associated with loss of sight

(Rosen bloom and Goodrich, 2000).

The study of grief and needs of individuals with visual impairments originated from

research where unexplored issues such as the long-term psychological and emotional grief

reactions and needs of adults with acquired visual impairments were revealed. Individuals with

visual impairments can experience an alternate grief process- a chronic reaction to numerous

losses that are integral part of living with chronic impairments ( Lindgren et al., 1992). The full

impact of loss of sight cannot be resolved because the personal and environmental demands of

the visually impaired adults change continually and are accompanied by new problem and losses

(Hewson, 2000)

2.3.2 Fear, Shock, Depression & Maladjustment due to vision loss.

Many people are reported to fear sight loss more than loss of any other sense being

diagnosed with an eye condition can lead to anxiety, worry and uncertainty about the future

4
(Norowzian, 2006; Royal National Institute for the Blind, 2007; Stephens, 2007). The link

between sight loss and depression is well documented (Burmedi et al., 2002; Horowitz and

Reinhardt, 2000) and there is evidence of increased emotional distress in adults with visual

impairment (Scott et al., 2001). Sight loss can negatively affect quality of life (Hassell et al.,

2006) and can lower morale. Shock and grief can be common reactions to sight loss.

According to the world-wide study by the Environics Poll (2008) vision loss is the most

feared disability, and blindness and cancer are the two most feared health conditions. Fear, pity

and stigmatization of visual impairment are not just somewhere out in the atmosphere, they are

within all of us to a degree, until we take the trouble to learn that they are subconsciously

assumed stereotypes that we can correct.

People with sight problems are more likely to feel lonely and lacking in social support

than the general population (Bruce et al., 2007; Percival, 2003). The issue of isolation and the

importance of social support for the blind and low vision adults is a recurring theme in research

literature (Bruce et al., 2007; Burmedi et al., 2002; Cimarolli and Boerner, 2005; Percival and

Hanson, 2007; Pervical et al., 2005).

Horowitz and Reinhardt (2000) discussed visual impairment as a risk factor for

depression in adults, factors associated with depression, socio-demographic characteristic,

disease characteristic co-morbid health status, functional disability, personal resources, social

support relationships, the relationship between depression and utilization of rehabilitation

services, depression as a predictor of rehabilitation outcomes, the effects of rehabilitation

interventions and depression, and treatment for depression.

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 Burmedi etal. (2002) examined depression, well- being, social relations, social

functioning and loneliness among elders with visual impairment. They found that empirical

research strongly and consistently confirmed difficulty in emotional functioning amongst

visually impaired people. In particular, the prevalence of depression in visually impaired people

was at least twice as high as that found in general populations. They also reported losses of social

activity and social support amongst the visually impaired.

Individuals with Retinitis Pigmentosa experience different levels of stress. Those with

advantaged Retnitis Pigmentsa may experience stress due to difficulties with mobility and an

increased fear of falling (Turano KA and et al, 1999). Decision- making abilities, environmental

awareness, self-perception of skills, and overall mental effort, may be some of the factors that

contribute to difficulty with O&M for those with vision loss from RP (Turano KA and et al,

1999). Reduced peripheral visual field requires RP patents to fixate over larger area to view

surroundings and identify targets (Turano KA and et al, 2001). Thus stress among people with

RP may be related in part to the increased mental effort and information processing to

compensate for limited visual information (Ata K. Bittner, Lori Edward, Maureen George,

2010).

2.3.3 Acceptance conflicts.

Southwell Pasty (2012) counseled people who are becoming visually impaired and found

that the clients had difficulty in agreeing to use a white cane or stick and trying not to be seen as

having as impairment.. There is obviously a deep-rooted need to appear ‘normal,’ however that

may be defined. People commonly use the term ‘normal’ to describe the state of having no

obvious disability, including that of sight loss. Fourie (2007: P.224) says ‘individuals may also

6
be threatened by the perceived sudden loss of normality in a society that seems to value the

“normal”’. The desire to appear ‘normal’ seems to be common, if not universal.

2.3.4 Social Disadvantages.

Visual Impairment is also linked with social disadvantages (Cochrane, Lamourex, &

Keeffe, 2008), fewer opportunities to socialize and fewer opportunities to develop interpersonal

skills (Huurre & Aro, 2000). The extent to which visual impairment limits one’s ability varies

but it is not well understood (Jyoti Khadka, Barbara Ryan, Tom H Margrain and J. Margaret

Woodhouse, 2012).

A central feature of stigmatization is non-acceptance by others, which entails a

denial of respect and regard. White (2011) suggests that the discomfort one feel on encountering

someone with impairment is so universal it may be hard-wired. Southwell Pasty (2012) noticed

the stressors reported by the visually impaired clients, which includes sight loss means friends

suddenly disappeared; this is also experienced by people suffering bereavement, and may be a

subconscious fear of contagion, along with embarrassment and helplessness at not knowing what

to say.

Sharma, Sigafoos and Carroll (2000)contended that persons with visual impairments had

problems in developing social skills and friendships establishing (Rosenblum, 2000) that resulted

in some behavioural problems, sometimes they were more reserved and shy in nature, immature

restrained, depressed as compared to their non impaired counterparts. A number of other

researchers also observed positive relationship of visual impairment with psychological distress,

loneliness, tension, nervousness and maladjustment.

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2.3.5 Associated stressors with Visual Impairment

In addition to life events and chronic stressors, there are a number of other types of

stressors: daily hassles, nonevents, traumas and ecological stressors (Wheaton, 1999). Daily

hassles may seem like chronic stress but are defined more as minor stressors that seem to be a

part of everyday life. For the older adult with vision limitations, it may be daily hassle to perform

those ADL (as getting dressed) and IADL (as shopping) activities.

2.3.6 Employment predictors

According to the literature, there are several factors that predict employment for the blind

and VI. Among them, educational level, age, training in blindness skills, and visual status remain

consistent across the research studies. Leonard, D'Allura, and Horowitz (1999) found that both

achieving a higher educational level and attending an integrated school setting for most of one’s

schooling was associated with being employed. In addition, the use of printed material as a

primary reading medium, employment related skills (computer, typing, and use of public

transportation); psychosocial variables (overall satisfaction with social contact and receipt of

encouragement from family and friends), vision rehabilitation service, and technology training

were associated with being employed. In relation to those factors that predicted employment in

higher level positions, they identified higher level of education, technology training, orientation

and mobility (O&M) training, and fewer hours of rehabilitation teaching. All these factors pose

stress in the working sectors of visually impaired individuals irrespective of their gender.

Regarding visual status, Leonard et al (1999) found that this factor had an important

impact on employment outcomes, since those individuals who were blind were more likely to be

employed in higher level positions than those who were partially sighted. A study by

8
Darensbourg (2013) also revealed that the severity of vision loss was a statistically significant

predictor of competitive employment outcomes, however, in this study those consumers with

lesser vision loss where more likely to be competitively employed.

2.3.7 Random level of stress experiences.

Whatever may be the source of stressful experiences, life events themselves are not

necessarily stress producing (Lazarus, 1978; Cohen, 1985) rather; their cognitive appraisal is

central to it. Cognitive appraisal depends upon many factors like person’s emotional and social

maturity, social and financial background, gender, age and experience in similar situations,

education, physical and mental capacity and the perceived social support around him/her. The

aversive and threatening experiences from the stage specific stressors become cumulatively

active in interaction with the presence of impairment. Thus, the environment and the impairment

both impose certain limitations on the impaired individual, which presumable would put them to

quantitatively and qualitatively different levels of stress and to exhibit different types and

number of behavior problems.

2.4 Barriers Encountered by Working Women due to Stress in their Work Place

Stress is the physiological reaction which occurs when people perceive an imbalance

between the level of demand placed upon them and their capability to meet those demands. Most

people view stress as a negative feature in lives (Kroemer, 2001). But there might be individual

differences in response to stress. Stressor- induced physiological, psychological and behavioural

mechanisms (e.g. functional disturbance in hormone production, anxiety, risk-taking behavior)

are activated, leading to work-stress- related mental and physical disease, and decrease in well-

being, satisfaction and quality of life.

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 A 2004 Lluminari Landmark Study found that women who work under stressful

conditions, which can include work/life conflicts or lack of social support, autonomy and control,

are at least twice as likely to experience the following physical and mental effects as other

workers (Benson & Herbert, 2008)

1) Heart and cardiovascular problems 2) Anxiety, Depression and Demoralization

3) Certain cancers 4) Infectious diseases

5) Back pain 6) Conflicts injuries

7) Obesity 8) Substance abuse

A study into the effects of stress on women’s health (Nevin Sanlier & Fatma Arpaci,

2007) revealed that working women have high levels of stress than non-working women.

Randolph (2004) found that disability status was the variable that presented the strongest

negative correlation with employment. The author determined that disability status was a strong

negative predictor of employment, particularly of being competitively employed. He found that

females with a disability, who were less educated and who had young children, were less likely

to be employed.

Today, in order to protect the life standard in a fixed level, many families are dependent

on women’s working in a paid work. Usually the work and family responsibilities become

complicated and the unshared workload of women by their spouses results in stress (Pinna,

1993). The non contribution of men to household duties increases the stress experienced by

women. Due to family and house hold duties, spouse demands professional improvement and

successes are hindered.

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 The workload causes women to be affected from stress. Even when women don’t work

outside home, they are confronted with high level of stress. Such role conflict and may become a

reason of stress (Baltas, 2000). Stress is related to perceiving the world as manageable or

unmanageable. The practice of positive thinking, selecting and reflecting principles on life will

decrease stress and will strengthen the manageability of life (Huges, 2005).

2.5 Stressors and Women with Disabilities

2.5.1 Exposure to Different Levels of Stress.

Women with disabilities may be of greater risk of experiencing high levels of stress as a

result of being both female and disabled. As women they may be more likely to experience life

stress related to violence and other forms of victimization, social isolation, poverty, and chronic

health problems (McGrath, Keita, Strickland & Russo, 2000). Consistent with gender differences

in the general population (Cohen & Williamson, 1988), women with disabilities report higher

level of stressful events and perceived stress compared to men with disabilities (Turner & Noh,

1988). Another study (Huges, Swedlund, Petersen & Nosek, 2001) conducted on data gathered

from a project revealed that greater perceived stress was associated with high levels of

depression in a sample of 64 women with spinal cord injury.

Women with disabilities appear to more vulnerable to experiencing greater level of stress

if they are younger, have less income, have lower levels of mobility and have greater need for

assistance with ADL/IADLS. The women with disabilities may be more vulnerable to

experiencing stress if they are lacking social support, experiencing high levels of pain and/or if

they have experience abuse in the past years (Huges, Taylor, Robinson & Nosek, 2002).

11
2.5.2 Frequent barriers.

The frequent stressors for women with disabilities including difficulties in transportation

(which may include needing extra time, planning and additional cost) and barriers such as

uncovered sidewalks, lack of curb cuts, and inaccessible bathrooms. Even the effects of people

staring may take a psychological toll. For those who need help with personal care, a major

stressor is finding reliable personal care assistance. As women with disabilities are the lowest

paid of any group of workers, the difficulties related to obtaining good personal care may be

exacerbated by an inability to afford consistent attendants. Other stressors can be caused by

women’s experience of abuse by a care giver or partner. Under most state laws, care giver abuse

is not considered domestic violence and a disabled woman who is experiencing abuse by a

personal assistant may find that she is not eligible for services in a shelter (Lynda, 2004). A

disabled woman who is experiencing abuse by a partner may not be able to find accessible

facilities in a battered women’s shelter, and thus may be limited in her ability to find a safe

haven or access support services.

Among the most damaging barriers are attitudinal, including health care providers’

negative attitudes and their refusal to treat a woman with disability, provision of treatment based

on misinformation about how a particular medication or procedure might interact with the

woman’s disability, withholding of disability-related or other information, doing procedures or

treatments without woman’s knowledge and/or failing to involve her in the decision making

process. At the worst, negative attitudes translate into physical or sexual abuse (Gill et al., 2009).

12
2.5.3 Relationship & Marriage

In terms of relationships, it has been shown that women with early onset of blindness

usually date later and have their first sexual experiences later than women without disabilities

(Rousso, 1996). Women with disabilities are less likely to be married than disabled men, and are

more likely to become divorced. Disabled women with children are often single mothers

(Lynda,2004). It is frequently difficult for women who have been “conditioned” to be the

caregiver to accept having to be cared for and they may feel ongoing shame or psychological

conflict over their need to receive care. All of this contributes to lower income, fewer resources

and lack of social support (Lynda, 2004).

2.5.4 Employment and Gender Discrimination.

Special stressors exist for disabled women in certain subpopulations that are subject to

particular difficulties. The “double Jeopardy” was coined to refer to the dual discrimination that

African- American Women face. Glenn (2001) describes African- American women with

disabilities as facing further disadvantage or “triple jeopardy”, because they represent three

distinct minority groups in American society based on their gender, race/ethnicity, and disability.

A woman who is disabled and who is also a woman of color, have to deal with multiple levels of

jeopardy and often, marginalization that cut her off from her expected communities of support,

and cause additional life stress.

Feist-Price S., and Khanna, N. (2003) in their study on Employment inequality for

women with disabilities; Special feature: Women and disability [Part II] has witnessed that

women with disabilities are more likely to experience poor post-school employment outcomes,

consistently earn less money, have more negative employment experiences, and are routinely

13
assigned to stereotypically "female" jobs. They also reported that disabled women fared worse

than either non-disabled women or disabled men, economically, socially and psychologically.

Mostly men are expected to define their own activities and shape their own lives, whereas the

stereotype would have women traditionally waiting for men to select them as workers, mates and

mothers of their children, perceived as incapable of filling economically productive roles,

disabled women have also barred from occupying the traditional female roles of nurturer and

mate because men have not chosen them to play these roles.

Doren, B., & Benz, M. R. (1998) in their study on Employment inequality revisited:

Predictors of better employment outcomes for young women with disabilities, indicates that two

factors predict better outcomes for both young women and young men with disabilities: having

two or more job experiences while in high school, and having used the self-family-friend

network to find their post school job. Females who came from a family with a low household

annual income, who had low self-esteem at the time of exit from high school, and who fit both of

these characteristics were much less likely to be competitively employed out of school than

females who did not fit these characteristics.

2.5.5 Violence and Abuse

Research on access to services for women with disabilities, who are subjected to

violence, (National Committee on Violence Against Women 1993) suggests that support and

legal services generally have failed to respond adequately to women with disabilities who are

subjected to violence. A lack of knowledge of disability in general, and the needs of women with

disabilities in particular, often prevents service providers from effectively supporting women

with disabilities after they have been subjected to violence.

14
 Also women with disabilities experience abuse at similar or increased rates compared to

the general population (Grossman & Lundy, 2008; Martin etal., 2006; Nosek et al., 2001; Powers

et al., 2009; Smith & Strauser, 2008 ). One of their studies comparing the rates of life time

prevalence of emotional, physical and sexual abuse of women with disabilities to women without

disabilities found that 62 % of both the groups had experienced such abuse. The proportion of

women with disabilities to women without disabilities who reported emotional abuse was 51.75

versus 47.5% for physical abuse 35.5% versus 35.6% and for sexual abuse it was 39.9% versus

37.1%. In this study, significant differences were found in the percentage of women abused,

whether or not the individual had a disability, nor by type of abuse.

In most recent study comparing the risk of physical and sexual assault prevalence among

women with and without disabilities, the authors found that women with disabilities experienced

similar rates of physical abuse and were 4 times more likely to have experienced a sexual assault

(Martin et al., 2006). In a study of 1,152 women interviews at family practice clinics, women

who reported experiencing some type of abuse (Physical, sexual and emotional) in their current

relationships were more than twice as likely to report having a disability (Coker, Smith &

Fadden, 2005)

Additionally, women with disabilities suffer from multiple forms of abuse, including

disability related abuse and neglect such as withholding medication, denying access to mobility

devices, neglecting personal care, and preventing attendance of doctor’s appointments (Copel,

2006; Gilson, Depoy & Cramer, 2001; Oktay & Tompkis, 2004: Powers et al., 2009; Saxton et

al., 2001). Abuse can also be contextual, as Cramer, Gilson and Depoy (2003) point out how

legislative and social service agencies differ in how they define abuse, and how difference

translates into differences in assistance that can be offered to these women with disabilities who

15
have experiences abuse. Studies also suggest that women with disabilities experience abuse for

longer periods of time compared to individuals without disabilities (Nosek et al., 2001)

2.6 Stressors Encountered and Status of Women with Disabilities in India

According to the Indian Census of 2001, women constitute 42.457% of the total

population of persons with disabilities in India. Despite the numbers, their voices remain unheard

and the existing legal framework fails to address specific problems faced by women with

disabilities.

For instance, a comprehensive document laying out clearly a National Policy for Persons

with Disabilities was being demanded for quite some time. Such a policy was framed and

released by the Union Ministry of Social Justice and Empowerment on 2nd February 2006. The

policy has total number of 62 sections. The sections 29 to 31 speak for women with disabilities.

The group requires according to the Policy, protection against exploitation and abuse. Special

programmes to be developed as per this Policy statement, for education, employment and

provision of other rehabilitation services. Abandoned disabled women are to be helped,

providing short duration stay homes for women with disabilities , hostel for working disabled

women, homes for ages, also programmes to provide financial help to women with disabilities

that they may hire services to look after their children for certain durations are other salient

features of the stipulations of the group under the Policy. The Policy is indeed, a welcome

initiative, it is just a beginning and suffers from various lacunae. It does not serve as a focused

target oriented road-map to achieve its major objectives. It also lacks provision of time-lines

(Roma Bhagat, 2008).

16
 Similarly in consideration to the ground reality of the Persons with Disability Act having

been passed in the year1995 has not even implemented even to 25 percent of its extent.

Considering this situation, the fact that the Act is general neutral proves to be disadvantageous to

women with Disabilities.

In a situation like this, the status of disabled women can predictably be a lot more

vulnerable and marginalized. A woman in the Indian socio-cultural setting is considered

disadvantage to which if the disability is added, the woman becomes a burden and even her near

and dear ones consider her as a lesser human being devoid of any rights, needs, wants and

personality of her own (Rastogi, 2010)

Briefly stating visually impaired women faces gender discrimination and violent

situations in the life from birth onwards – at home, workplace, on the streets or in the social

norms. The discrimination and violence against women takes such forms as domestic violence,

dowry harassment and deaths, matrimonial cruelty, sexual harassment at work, rape and other

forms of sexual assault and other sexual offences, trafficking for commercial sexual exploitation,

pre- birth sex selection and so on. To begin with even before a child is born preference already is

given to a boy over a girl. Considering the advances in technologies available, even at the time of

conception sex selection is carried out. Other well known methods are sex selective abortions

which, though illegal, are still rampant in the urban and rural parts of the country alike.

Nandini Voice for the deprived (2010) article on problems faced by the visually impaired

working women in India has highlighted the following stress prone issues:

17
 Poverty conditions and poor treatment: Ninety percent of the visually impaired

women belong to lower income group. Most of them are not born as visually

impaired, but have lost their eyesight in the young formative age, due to sickness.

 Family support: Most of the visually impaired women do not get any family

support in substantive manner. The problem becomes particularly difficult after

the death of their parents. Their brothers and sisters, most of whom themselves

belong to lower income group, ignore the visually impaired women in the family

to a large extent (perhaps due to helplessness) and leave them to their fate. Most

of the single visually impaired women live alone or with friends, in difficult

conditions.

 Desperate educational efforts: The visually impaired women are generally

found to be very sensitive and have constant concern about their physical safety

conditions. They realize before too long that they have to get economic

independence to lead a decent life.

 Severe Unemployment Problem: In spite of getting some sort of qualification

and skill, most visually impaired women do not get any jobs and are desperately

seeking one.

 Competitions in Reservations: Though reservations do exist in Government

departments and public sector organizations for job placements, the reservation

for visually impaired persons is only 1% of the total reserved jobs. Again in this

1% quota, both the men and women have to face competition. In several jobs, the

employers would choose men to women, due to nature of the functions. In

18
 practical terms, most of the visually impaired women are not benefited by such

schemes.

 Jobs in Private Sector: Providing jobs for visually impaired women in private

sector, whether schools, offices or factories are extremely rare. Private sector

shows no consideration for visually impaired women at all in providing jobs.

 Marriage: To seek social protection and some sort of economic support, many

visually impaired women find marriage as a way out. However, more than ninety

percent of the visually impaired women could marry only visually impaired men,

as normal men do not prefer visually impaired women as wives. Quite a number

of such marriages between visually impaired men and visually impaired women

have also failed in the past, as the men leave the women after giving birth to one

or two children in several cases. Such failed marriages really add to the problems

of visually impaired women as they not only have to take care of themselves, but

also the children. The visually impaired women can be divided into two

categories, namely, as those who live with their husband (mostly visually

impaired men) and those who live alone (either unmarried or husband left them).

 Having Children: In most cases, the children born to the visually impaired

couple are found to be normal and healthy, without any eye problem.

Unfortunately, due to poor economic and living conditions, such children could

not be given proper education and most of them do not look after their visually

impaired parents adequately later on.

 Unmerited Government Schemes: Government has a number of schemes to

help the visually impaired persons, but only very little for visually impaired

19
 women exclusively. Most of the Government schemes are for providing

educational and skill acquisition opportunities, but not for providing jobs. The

Government provides pension amount to the visually impaired persons of around

Rs. 200 per month, but this is totally inadequate for unemployed and helpless

visually impaired women.

Violence against women with disabilities can range from neglect to physical abuse to

denying them even the traditional roles of marriage and child bearing. Concerns of women with

disabilities continue to remain marginal in India. They have neither been espoused by the

feminist movement nor the disability movement and have largely remained “hidden” and

“silent”. Women with disabilities face discriminatory treatment vis-à-vis women and men

without disabilities, and men with disabilities (Swagath Raha, 2006)

In reconciling the present situation the first and foremost requirement is to help women

with visual impairment to imbibe the required confidence in their own abilities to take the lead.

They have to be made genuinely concerned about the present vulnerable socio-economic status

of those facing similar disabilities and discrimination being faced by them (A.K. Mittal & J.L.

Kaul, 2008) and develop a strong concern for self regulation over stress prone situations to lead a

pleasant life that might pave way for enhanced quality of life.

2.7 Stress Managing Strategies/Techniques and its Effects

2.7.1 Introduction

Stress management is a psycho educational program for dealing with stress in which

individuals are taught to become aware of their appraisal of stressful events (positive, negative,

20
surmountable, impossible) and to develop methods for more effective coping (e.g., managing

problems effectively and with less stress). Stress Management utilizes a variety of techniques,

including self-management skills, relaxation training, bio feedback, behavior modification,

cognitive behavior therapy, social support, emotional expression, and physical activities such as

exercise and yoga (Woolfolk & Lehrer, 2000). Group and individual stress management

interventions are designed to improve coping skills, increase self-confidence and reduce

vulnerability to distress. Managing stress is an integral component of health promotion in the

work place.

Huges et al (2006) study provides the first of its kind, that is, an evaluation of the efficacy

of a stress self-management intervention designed specifically for women with physical

disabilities. The results are consistent with a model in which the stress management intervention

enhances self-efficacy and social connectedness, which leads to reduced stress, which then

contributes to improved mental health.

2.7.2 Strategies Implemented at Worksites.

A variety of stress-management techniques was used in worksite studies, including

muscle relaxation, meditation, biofeedback, cognitive-behavioral skills, and combinations of

these techniques. The most common techniques used were muscle relaxation, cognitive-

behavioral skills, and combinations of two or more techniques. Outcome measures to evaluate

the success of stress interventions included physiologic and psychologic measurements, somatic

complaints, and job-related measures. Nearly three-fourths of the studies offered the training to

all workers and did not specifically recruit high-stress employees. Over half the studies were

randomized control trials, but only 30 % conducted post training follow-up evaluations. The

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effectiveness of stress interventions varied according to the health-outcome measure used; some

techniques were more effective for psychological outcomes (e.g., cognitive-behavioral skills),

whereas others were more effective for physiologic outcomes (e.g., muscle relaxation).

2.7.3 Bio Feedback

Biofeedback was the least frequent technique used in work settings and also seemed to be

the least effective technique. Meditation produced the most consistent results across outcome

measures but was used in only six studies. In general, studies using a combination of techniques

(e.g., muscle relaxation plus cognitive-behavioral skills) seemed to be more effective across

outcome measures than single techniques (Lawrence R. Murphy, 1996)

2.7.4 Relaxation Response

As a pioneer in stress management techniques, Dr. Herbert Benson developed a program

through Harvard Medical School in 1975 which used components from meditation practice for

cardiac recovery and other medical conditions. His book, The Relaxation Response, was revised

and republished in 2000. His technique promoted self-healing and appeared to help not just

hypertension, but headaches, cardiac rhythm irregularities, pre-menstrual syndrome, anxiety, and

mild to moderate depression. The “relaxation response” can decrease the over activity in the

central nervous system, leading to reduction in blood pressure, slowing of heart rate, slowing of

breathing rate, as well as decreased blood lactate, and return of balanced function to the gastro-

intestinal system- all of which can be experimentally measured in the body. Similar findings

have now been found in the use of progressive relaxation techniques and clinical hypnosis.

2.7.5 Eastern Strategies

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 Based at the University of Massachusetts’ Medical Center, Dr. Jon Kabat-Zinn’s stress

management program, based on mindfulness meditation and yoga techniques, has been taught

nationally and now is part of stress management programs at hospitals and clinics across the

country. Meditation can increase a disabled woman’s confidence in her ability to handle physical

and emotional pain as well as to manage the other areas of her life and feel less out of control

(Kabat-Zinn, 1990).

Practices such as meditation, relaxation, hypnosis, and biofeedback may have a direct

physiological impact upon the body, but even when that does not occur, people’s perception of

pain and their ability to cope with it can be altered. Participatory self-help techniques can provide

a woman with a disability with an increased sense of direct control and can also promote healing

in a way that complements medical interventions (Lynda C. Reed, 2004)

Local meditation classes are readily available through religious groups, adult education

programs or community centers. Many forms of meditation utilize diaphragmatic breathing

techniques, which promotes physiological relaxation. Meditation often focuses upon

acknowledgement of suffering and painful emotions, which may be helpful for ongoing

adjustment (Azar.B, 2000).

2.7.6 Relaxation Training

Relaxation training is a behavioural self-management skill designed to affect the physiological

experience of stress by reducing physiological arousal (the stress response) and increasing

parasympathetic (calming) response (Jacobson, 1999). Examples of relaxation training include

progressive muscle relaxation, yoga and hypnosis. Progressive muscle relaxation teaches

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participants to recognize feelings of tension and relaxation by having them tense and then relax

muscle groups throughout the body.

Deep muscle relaxation techniques are described as having the ability to reduce

physiological tension, which is incompatible with anxiety (Davis, et al., 2000). Excellent results

have been found when this is applied in the treatment of tension, anxiety, insomnia, depression,

fatigue, irritable bowel, neck and back pain, and high blood pressure. This technique involves

moving through the body and focusing upon particular muscle groups and learning to distinguish

between sensations of tension versus deep relaxation. Generally, all muscle groups are included

but it is easy to adapt this procedure to just move through the muscle groups for which an

individual is able to have sensations.

2.7.7 Hypnosis

Clinical hypnosis has been found to help enhance patients’ sense of self-control, and

through self-hypnosis an individual can continue to work on symptom reduction in the areas of

pain or stress in the absence of the therapist (Kaye and Schindler, 1990). Hypnotic interventions

can be helpful in reducing anticipatory anxiety.

Generally, hypnosis is established through an induction procedure that includes

suggestions for becoming relaxed and promoting a sense of well-being. Hypnosis is used to

address a wide range of women’s health concerns, including chronic pelvic pain, breast and

gynecological cancers, cardiac disorders in women, childbirth and infertility, menopause, eating

disorders and physical illness (Hornyak and Green, 2000).

2.7.8 Body Image

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 Body image is frequently an area of increased concern for women with a disability.

Hornyak (2000) has designed a treatment model for utilizing hypnosis and body image for

women with physical illnesses. Treatment goals are formulated around seven dimensions: a)

restoring comfort b) restoring a sense of competence c) accepting appearance d) coping with

unpredictability e) addressing body integrity f) enhancing aliveness; and g) evolving identity.

2.7.9 Exercise

Aerobic exercise can be of great value in stress reduction as well as overall health. Some

recreation programs designed specifically for people with disabilities offer weight training with a

volunteer assistant to help one-on-one with set-up and spotting. Swimming can be an excellent

non-weight bearing aerobic exercise. Local classes in Yoga, Tai Chi or other martial arts are

frequently helpful in stress management and relaxation. However, a preliminary call to inquire

about accessibility and adaptation of the class to accommodate disabilities is essential (Azar.B,

2000).

2.7.10 Social Participation

Involvement in local political work or community organizations to create wider

accessibility, education about needs of disabled women, funding for enhanced vocational

rehabilitation and to promote full inclusion are proactive ways to channel anger or frustration

into productive societal change. The ability to take action and channel stress into positive

activities can be an effective way to reduce the debilitating effects of stress (Taylor, et al., 2000).

2.7.11 Psychotherapy

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 Sydney Bloch (2000) outlines how disability can pose multiple threats to one's sense of self

and identity, physical well-being and sense of body integrity, sense of independence, privacy,

ability to fulfill customary roles, pursue life goals and future plans, and one’s ability to sustain

relationships. In chronic disability or illness, anxiety can arise from the threat of these losses.

When support groups do not offer enough help, especially in cases of clinical depression, suicide

risk or anxiety attacks, referral to a psychologist, psychiatrist or licensed clinical social worker is

recommended for psychotherapy sessions

2.7.12 Positive Behaviour Therapy

Dr. Hemalatha Natesan devised PBT which is a package, combining the Western

Techniques based on the Cognitive Behaviour Therapies and Eastern Techniques based on

Yoga, and has made it a full-fledged one, in the year, 1998. The therapy aims at modifying

negative thoughts, beliefs, emotions and behavior by using a number of specific techniques

through which the individual may become more realistic and reasonable in his/her perception,

which will lead to healthy behavior ensuring healthy, happy and successful life.

A number of researches has been carried out in using PBT techniques in different states

of India namely, Tamil nadu, Kerala, Karnataka and Rajastanas well as abroad in combodia

proving the efficacy of PBT in enhancement of Self Efficacy (Hemalatha Natesan and

Rajakumari,2010) Emotional Intelligence (Bhuvaaneswari and Hemalatha natesan, 2009), Well-

being (Hemalatha natesan, 2007), Self-concept and Academic Achievement (Hemalatha Natesan

and Susan Betty Easo,2004) and in the Management of Stress (Hemalatha Natesan and Suchitra,

2010; RajaKumari and Hemalatha Natesan, 2008 and 2006; Hemalatha Natesan and Shah

Dhara, 2007; Hemalatha Natesan, 2007), Anxiety (Hemalatha Natesan and Jeya Bharathi, 2007;

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Hemalatha Natesan and Susan Betty Easo, 2004) and Anger (Hemalatha natesan and

Priyadarshini, 2002)

One of the components of the positive therapy is Laugh therapy. Dr. Lee Berk and fellow

Researcher Dr. Stanley Tan (2009) of Loma Linda University in California have been studying

the effects of laughter on the immune system. To date, their published studies have shown that

laughing lowers blood pressure, reduces stress hormones, increases muscle flexion and boosts

immune function by raising levels of infection fighting T- cells, disease- fighting proteins called

Gamma- interferon and B-Cells which produce disease-destroying endomorphins.

Paul McGhee (2009) also confines that laughter can provide cardiac conditioning,

especially for those who are unable to perform physical exercises. According to Hemalatha

Natesan (2010) the merits of positive behavior therapy are as follows:

 It helps the individual to have a pleasing personality

 It improves both physical and mental health

 It helps in the management of negative emotions such as fear, anger, worry etc and

promotes cheerfulness

 It helps adolescents with problems such as academic failures, test anxiety and inferiority

 It helps with adjustment problems, marital and family problems, insomnia, aches and

pains such as migraine/back ache, anxiety disorders, stress disorders, hypochondria,

depression and suicidal tendencies.

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2.9 Conclusion

In spite of limited studies conducted on visually impaired working women, the in-depth

analysis of related review of related literature helped the researcher to understand the genesis of

the study proposed. The review highlights the need for effective management of stress in visually

impaired working women to cope up with daily chores of life and supportive studies project its

importance. This review benefits the investigator to conduct the study effectively by identifying

the study variables, selecting the therapy, applying the right methodological processes and

systematic analysis with ease.

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