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August 2004

Reducing AT abandonment: Proposed principles for AT selection and recommendation

By Trish Wielandt Ph.D., B.App.Sci (Occupational Therapy)
Senior Lecturer, Occupational Therapy School, James Cook University
Email: Trish.Wielandt@jcu.edu.au

Marcia Scherer Ph.D., MDH,
Institute for Matching Person and Technology
Email: SchererMJ@aol.com

Assistive technology (AT) can assist clients who have a disability or who have been unwell to be independent and safe whilst undertaking personally relevant activities of daily living. By recommending AT, occupational therapists can assist in reducing the impact of functional limitations on client's occupational performance roles, facilitating their participation in the wider community, and in turn, enhancing their well-being.

Despite the key role that AT can play, the rate of its discontinuance and non-use reported in the literature highlights the complexities of the interaction between the client, the AT, the activity to be undertaken and the environment in which the activity is to be undertaken. Ideally, incorporation of the recommended AT into a client's daily routine should facilitate better quality of life, but reports of AT abandonment over more than 30 years in the literature indicate a need to understand the human aspects of AT use to optimally achieve such an aim.

Previously occupational therapists working within the medical model would use an equipment-centred approach when providing AT. Such an approach based the prescription of AT on the client's diagnosis, and their subsequent functional limitations. The client had a passive role during this process with little consideration, given to their individual needs. In recent years there has been a move away from the medical model to a more social model of service provision. Additionally people with disabilities have indicated that they want more from rehabilitation. In particular they want services that acknowledge their perceptions, beliefs and attitudes; encourage choice; facilitate autonomy; and foster community integration.

This change in focus is exemplified by the newly revised International Classification of Functioning, Disability and Health (ICF) which recognises the social construct of disability. Therefore the focus of rehabilitation has shifted towards both the environmental factors which inhibit an individual's ability to participate in wider society and the individuals' perceptions and goals. It has been suggested that the move to a more social model of service provision would have far reaching implications, including a change in the way professionals work with individuals. Further, health professionals need to ensure that they provide an individualised service and the use of a collaborative approach is advocated. Therefore, AT recommendations using a client-centred approach would need to focus more specifically on the client and his or her environment rather than just on improved functional independence.

There is little information available concerning the process that occupational therapists use when recommending AT for their clients. Whilst, no particular practice model appears to be used by the therapists when prescribing AT, the MPT model (Scherer, 1998) could easily and effectively be incorporated into daily practice. The key concepts of this model include client-therapist collaboration throughout the entire process. The model and assessment process begins with the identification of the need for AT (i.e., goal, tasks to be accomplished) and then considers milieu, person and technology influences on the optimal match of person and technology for achieving that goal. The comprehensive evaluation process consists of various instruments to gather information about the client's current perceptions. Thus, the MPT model has the ability to determine prior to intervention whether the provision of AT is the most appropriate choice of support. Such a process also assists with the identification of issues that may have a negative effect on AT use, as well as facilitating a process for the therapist and the client to collaboratively work on developing strategies to counter any AT rejection which may occur.

The use of the MPT model which provides a framework to guide the therapist through a simple decision-making process when prescribing AT, would be very useful in ensuring that only the most appropriate item was selected. Furthermore to ensure best practice in this area the following principles would need to be observed.

Client-centred intervention

The provision of a client-centred approach when providing AT would ensure that the intervention is focused on identified clients' goals. Exploration of the client's motivation, lifestyle issues, views about their disability or illness as well as opinions, beliefs and expectations regarding the AT are considered. Involvement of the clients' significant others during all stages of the intervention is highly recommended.

Comprehensive evaluation

Such an assessment would initially evaluate the client's physical status in order to develop a profile of their abilities as well as limitations. Following this, a detailed activity analysis of tasks previously identified as problematic by the client would also be recommended. Therapists would need to consider clients' perceptions regarding their disability, the features of the AT, as well as the need for AT. Where possible home visits should be undertaken in order to observe the client in the environment in which the AT is to be used.

Ensuring an optimal match of client and AT

A good match between the client and the AT requires consideration of the goals and needs of the client, the context in which the AT is to be used, as well as AT characteristics. The trialling of AT is highly recommended as it allows for client testing and experimenting with proposed items, as well as the replacement with other AT should it be found to be unsuitable.

AT training

AT training needs to facilitate the gradual acquisition of mastery of the use of the item in an environment which is supportive of the client's training requirements. Such training should be reinforced using multiple learning styles (auditory, visual and kinesthetic), as well as ensuring that the content is tailored to the individual's preferred learning style. The provision of written material (including a maintenance protocol) will serve to reinforce details provided by the therapist. Where possible the trialling and practice with the AT in its intended environment would be valuable.

Follow-up

The need to incorporate a follow-up into the intervention is essential. This would allow for therapists to determine whether the AT had been obtained, if its performance was satisfactory and whether a good fit between the client and the AT still existed. Additionally the effectiveness of the intervention could be assessed (Is the AT still useful? Are clients able to accomplish tasks as previously identified? Are the tasks easier to accomplish as a result of using the AT?).

The use of the MPT model in conjunction with these proposed guidelines might assist in reducing AT abandonment thereby allowing clients to undertake personally relevant daily living activities at home and/or work, as well as being able to participate in wider society without restriction.

Resources used in writing this article

Scherer, M.J.(2002) Editorial. The change in emphasis from people to person: Introduction to the special issue on assistive technology. Disability and Rehabilitation, 24, (1/2/3), 1-4.

Scherer, M.J. (Ed.). (2002). Assistive Technology: Matching Device and Consumer for Successful Rehabilitation. Washington, DC: APA Books.

Scherer, M.J.(1998).Matching Person & Technology Model: Matching people with technologies. Webster, NY: Author.

Wielandt, T. (2003). The identification of the factors which influence the post-discharge use of prescribed adaptive equipment. Unpublished doctoral thesis. University of Queensland, Brisbane.

World Health Organisation (WHO) (2001). ICF Introduction. In WHO. International Classification of Functioning, Disability and Health. Geneva: Author.

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