What does the evidence-based literature say on issues in assistive technology provision?

Proceeds of the AEAA Evidence Subgroup 2007-2008, collated by Natasha Layton.

Issue	Premise	Supporting Quotes	Reference / Source
Abandonment, non-use and dissatisfaction	A service system must provide both hard and soft technologies Soft technologies: trial in real environment; training; educational material; customising; follow up; adjustment and maintenance.	A number of studies identify high rates of AT abandonment or non-use are reported, eg Scherer (2002) cites five studies investigating non-use which state abandonment rates ranging from 30-59% (p.125). However Djicks (2006) cites much lower abandonment rates. Variables include the multiplicity of definitions of abandonment / non-use. Also pertinent is the fact that while severely impaired individuals may not have the option to exit their AT devices, they may still not be satisfied or experiencing optimal AT solutions.	- Cook, A. and S. Hussey (2002). Assistive Technologies: Principles and Practices (second edition). USA, Mosby. - Keating, W., D. McLean, et al. (1989). "Survey of Appropriate Provision and Useage of Prescribed Equipment - The Client's Perspective." Australian Occupational Therapy Journal 36(3): 131-135 - Djicks, B. P., L. P. DeWitte, et al. (2006). "Non-use of assistive technology in The Netherlands: A non-issue?" Disability and Rehabilitation: Assistive Technology 1(1-2): 97-102. - Scherer, M. J. (2002). Assistive Technology: matching device and consumer for successful rehabilitation. Washington, American Psychological Association.
Achieving optimal solutions with assistive technology for people with disabilities involves a complexity of issues. AT funding and services therefore need to be appropriately resourced in terms of expertise and funds		Personal (client) factors): age and diagnosis, client and family expectations; emotional maturity of client; whether the disability is acquired suddenly, progresses slowly, or is congenital. Device-related: Quality, appearance,availability of choice between devices, portability, weight, ease of use, presence of multiple devices Related to environment: Social support ; suitability of physical environment to device, opportunities within environment for use. Device market including trial, training, delivery, supply and support.	- Charness, N. and K. W. Schaie (2003). Impact of Technology on successful aging. New York, Springer Publishing Company - Smith, R. O. (2002). Assistive Technology Outcome Assessment Prototypes: measuring "INGO" variables of "OUTCOMES" RESNA 25th International Conference on Technology and Disability. June 27-July1: 239-241. - Wessels, R., B. Djicks, et al. (2003). "Non-use of provided assistive technology devices, a literature overview." Technology and Disability 15.
Legislation and Policy	Lack of political activity by allied health clinicians Difference between rhetoric and reality …the example of funding The issue of funding brings practitioners face to face with practice constraints so severe that clinical recommendations are influenced, Barbera and Whiteford illustrate this point through an interview with a NSW practitioner utilizing the PADP funding system:,	The challenge has (also) been to enthuse and empower therapists to become more involved to policy and legislative feedback. Instead of feeling removed and isolated from policy, involvement in strategic planning can allow the profession to promote its holistic view of health and particularly environmental influences on people’s health. Practicing therapists, as well as managers, researchers and educators, need to understand and address the importance of policy and legislation. Occupational therapy, like other allied health professions, is a valuable resource for modern health care, but is not greatly involved in health-care policy and planning. The fact that therapists have often been restricted mainly to implementing the decisions made by others can contribute to feelings of frustration, detachment and powerlessness’ Barbera & Whiteford ch 20: 337) '… our professional expectation is that governmental policy is formulated, implemented and evaluated through a rigorous system aimed ad accountability and outcomes on key indicators. But how sure are we that much of the policy and legislation we implement will ensure the best outcome for us and our clients? In practice, the complexity of formulating and analyzing policy can bean the distance between policy intent and the actual implementation of policy with our clients, can be vast. The need to include numerous perspectives, including economic, political, sociological and epidemiological, in policy developments make it a challenging process (Barbera & Whiteford ch 20: 338) ‘It is the reality of funding that instantly places this common task of occupational therapists into the legislative or policy sphere. Due to the enormous cost of many items, many clients have access to some form of funding scheme, whether government or private in origin….(eg of PADP in NSW) Research suggests that despite these enabling policy directions articulated at a state level, people are being denied timely and appropriate access to funds to meet their equipment needs…. Further, the persisting medical interpretation required to define or validate need may restrict the acknowledgement of the social aspects of equipment needs’ (Barbera & Whiteford ch 20: 342) …. ‘double-edged sword… in principle enables clients to access equipment. but in reality actually impairs or delimits opportunities for occupational engagement due to a paucity of adequate resourcing’ (Barbera & Whiteford ch 20: 345) She states, ‘…I sometimes think straight away about second hand options, or whatever I know is in the store room, you know sometimes that funding is so tight it is not even worth applying for what you really think is needed’ (p343)	Whiteford, G., & Wright-StClaire, V. (2005). Occupation and Practice in Context. Sydney: Elsevier Whiteford, G., & Wright-StClaire, V. (2005). Occupation and Practice in Context. Sydney: Elsevier
Social view of disability	for exploration of the social model of disability see also Disability and Society Journal	See text	Goggin, G. and C. Newell, Eds. (2005). Disability in Australia: exposing a social apartheid. Sydney, University of NSW Press.
Updated classification systems are appropriate to use in line with the social view of disability: ie. International Classification of Functioning, Disability and Health		'The ICF (in full) combines these two models (medical and social) and classifies people with health-related problems, including disability, on the basis of impairment, activity and participation restrictions.Impairments are identified when a person's body structures and functions mean he or she is unable to function at a level expected in the normal population. Activities refers to tasks the person wishes to do and participation is being involved in a life situation.' (Heather Jensen; Yvonne Thomas ch 16:256)	- WHO (2001). International Classification of Functioning, Disability and Health. Geneva, World Health Organisation. - DHS [2002b] Victorian State Disability Plan 2002-2012, Victorian Government, Department of Human Services, 2002, Melbourne Whiteford, G., & Wright-StClaire, V. (2005). Occupation and Practice in Context. Sydney: Elsevier.
Facts about aging and disability in Australia: Older people:demographics	Steadily ageing population will impact upon requirement for assistive technologies, environmental interventions, universally accessible environments, and adequate resourcing to purchase these	‘by 2051 the projected percentage of our population over the age of 65 will be between 27% and 30%’ Older people: In 2003, there were 3.35 million people aged 60 years and over (17% of the population), which compares to 3.0 million people (16%) in 1998. In 2003, just over half had a reported disability (51%) and 19% had a profound or severe core-activity limitation. Of all people aged 60 years and over, less than half (41%) reported needing assistance, because of disability or old age, to manage health conditions or cope with everyday activities. However, people aged 85 years and over reported a much higher need for assistance than those aged 60-69 years (84% compared with 26%).	- Australian Bureau of Statistics 2003 4430.0 - Disability, Ageing and Carers, Australia: Summary of Findings, 2003 Downloaded Latest ISSUE Released at 11:30 AM (CANBERRA TIME) 15/09/2004
Facts about aging and disability in Australia: Carers: demographics	Providing care is a costly activity in terms of time, economic ramifications and is an activity that significant numbers of Australians perform.	Carers: In 2003, there were 2.6 million carers who provided some assistance to those who needed help because of disability or age. About one fifth of these (19%) were primary carers, that is people who provided the majority of the informal help needed by a person with a disability. Just over half (54%) of all carers were women. Women were also more likely (71%) to be primary carers. Of those providing care, 1.0 million (39%) were in the 35-54 year age range. This age group's caring responsibilities involved children, partners and/or ageing parents. Those who provided care to people with a disability were more likely to be older and/or have a disability than those who did not provide care. Twenty-four per cent of primary carers were aged 65 years and over, compared to 13% of the total population. Of those living in households, the disability rates were 40% for primary carers, 35% for all carers and 20% for non-carers.	- 4430.0 - Disability, Ageing and Carers, Australia: Summary of Findings, 2003 Downloaded Latest ISSUE Released at 11:30 AM (CANBERRA TIME) 15/09/2004
Measuring Satisfaction	Challenges of devising a tool to measure QOL	‘ In the health domain, theoretical models do exist, but there is no consensus on a standard definition, either theoretical or operational, of satisfaction’ (83)	Wessels, R., L. deWitte, et al. (2004). "Measuring effectiveness of and satisfaction with assistive devices from a user perspective: an exploration of the literature." Technology and Disability 16: 83-90
Quality of life measures	Challenges of devising a tool to measure QOL Useability and QOL	' Currently available tools for measuring quality of life are not adequate for assessing the impact of assistive devices. For example. scales have been developed to adjust estimates of life expectancy for improvements in quality of life that are supposed to result from surgical and other forms of medical intervention. Scales scores have been used to compute the cost of each quality-adjusted life year, Definition of the quality of life is based on physician's judgment of what makes for a good life. The approach gives consideration to only very limited aspects of a person's life and sense of well-being' (117) The relative advantage is considered by the potential user after weighing the impact of the device in two overlapping realms - useability (the effectiveness, efficiency and satisfaction) and impact of quality of life (subjective well-being)' (80)	Jutai, J., N. Ladak, et al. (1996). "Outcomes Measurement of Assistive Technologies: an institutional case study." Assistive Technology 8(2): 110-120. Ripat, J. (2006). "Function and impact of electronic aids to daily living for experienced users." Technology and Disability 18: 79-87.
Impairment, disability, handicap	Definitions of stigma and handicap	' closely aligned with the concepts of self-actualization, empowerment and human occupation, restrictions in participation imply stigma or disadvantage, as compared with others of similar age, gender and culture, Stigma results from the social environment within which the individual lives. This phenomonon, described as the handicap creation process, occurs when the physical world and social institutions bear down on and limit individuals because of their impairments' (149) 'There are few, if any, standard measures fo environment' (149)	Stineman, M. (2001). "Defining the population, treatments and outcomes of interest - reconcililng the rules of biology with meaningfulness." American Journal of Physical Medicine and Rehabilitation 80(2).
Multiple variables complicate the measurement of AT outcomes	Statements recognizing complexity	See article	Hammel, J. (1996). "Whats the outcome? multiple variables complicate the measurement of assistive technology outcomes." Rehab Management 9(2): 97-99
Therapists education regarding AT		' it is unlikely that formalized training alone can keep up with the training needs of therapists faced with ever-increasing AT choices' page 232 ' the cost of equipment maintenance is often not accounted for when AT is purchased, even though additional costs are routinely incurred for evaluation , training in equipment use, repair of equipment, maintenance, replacement and customisation. Funding to expand or upgrade hardware and sortware as the child grows and changes must also be considered. These 'hidden' costs place a heavy burden on service providers to make decision as about appropriate technology systems prior to purchase' (235)	Copley, J., & Ziviani, J. (2004). Barriers to the use of assistive technology for children with multiple disabilities. Occupational Therapy International, 11(4), 229-243.
Aging and disability	Not necessarily a linear relationship between age and self-perceptions of disability	Deteriorating function can be associated with reduced mobility, greater dependency, and even shrinking social networks. Thus, changes in the ability to 'go and do' may become salient criteria in percieving disability (128) 'While there are countless medical and service-based criteria to determine whether a person is disabled, it is unknown when in the process of health decline persons begin to define themselves as 'disabled' (128) One possiblity is that older adults may be able to buffer the deleterious effects of progressively limiting function by compensating with resources such as strong support netowrks and adaptive equipment use' (128)	Kelley-Moore, J., H. Schumacher, et al. (2006). "When do older adults become 'disabled'? Social and Health Antecedents of percieved disability in a panel study of the oldest old." Journal of Health and Social Behavior.
Measurement in AT		'Assistive technology is applicable to all age groups, individuals with all levels of impairment severity, and the full spectrum of etiologies. Moreover, assistive technology is applied across a multitude of situations in highly variable environmental contexts (p74/75)	as above
ECONOMICS AND COST		'The economic context and realities of health and disability services are frequently forgotten or invisible in the everyday practice world. However, occupation focussed practitioners ought to be concerned with the economic outcomes of their work with clients, in terms of delivering both individual and public benefits.' Brown; Wright StClair; Law: ch 17:273)	Whiteford, G., & Wright-StClaire, V. (2005). Occupation and Practice in Context. Sydney: Elsevier.
Components of assistive technology service provision	19 components of AT provision: Written by Rob Smith based on Barry Rogers Uni Wisconsin 1985	Identify potential users Establish needs and potential benefits of system Select appropriate components of system form special and general market devices Make necessary modifications Assemble the system Mount the system Fit the system, including adjustments and initial customization Select the most appropriate training materials and plan Perform initial user training Perform training for people in user’s environment Provide ongoing training be on-call for subsequent questions and needs Provide ongoing preventative maintenance and replacement of componentry Provide repairs Update system when improvements are available Periodically reevaluate the degree of integration of the initial system into user’s life Use updated data to refine of improve system Provide a more appropriate system needed by user Provide a more appropriate system when marketplace advances more appropriate products	Smith, R. O. (1996). "Measuring the outcomes of assistive technology: challenge and innovation." Assistive Technology 8(2): 71-81.