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Disabil Rehabil Assist Technol, 2014; 9(5): 421–431! 2014 Informa UK Ltd. DOI: 10.3109/17483107.2014.900574

ORIGINAL RESEARCH

Getting it ‘‘right’’: how collaborative relationships between people withdisabilities and professionals can lead to the acquisition of neededassistive technology

Patricia Johnston1, Leanne M. Currie2, Donna Drynan3, Tim Stainton1, and Lyn Jongbloed3

1School of Social Work, 2School of Nursing, and 3Department of Occupational Science & Occupational Therapy, University of British Columbia,

Vancouver, British Columbia, Canada

Abstract

Purpose: The purpose of this study was to examine the impact of a consumer-led equipmentand device program [Equipment and Assistive Technology Initiative (EATI) in British Columbia,Canada] from the perspective of program participants. The importance of collaborativeassessments for obtaining the right assistive technology (AT) for meeting an individual’s needsis discussed in light of the program’s participant-centered ‘‘Participation Model’’, or philosophyby which the program is structured. Method: A cross-sectional survey with participants andsemi-structured interviews were conducted with participants (�18 years) who held a rangeof disabilities. The survey asked participants to rank their AT and to identify the methodby which they obtained the technology [by self, prescribed by a health professionalor collaborative (self and professional)]. Interviews addressed participants’ opinions aboutobtaining and using AT. Results: In total, 357 people responded to the survey (17% responserate) and 16 people participated in the interviews. The highest ranking AT was assignedto devices assessed via a collaborative method (self¼ 31%, practitioner¼ 26%, collabora-tive¼ 43%; �2 (16, 180)¼ 39.604, p50.001). Conclusions: Shared decision-making betweenhealth professionals and people with disabilities within the assessment process for assistivetechnology leads to what participants perceive as the right AT.

� Implications for Rehabilitation

� Collaborative decision-making can lead to the selection of assistive technology that isconsidered needed and right for the individual.

� Person-centered philosophy associated with assistive technology assessment is contributingto attaining ‘‘the right’’ AT.

Keywords

Abandonment, assessment, assistivetechnology, client-centered,consumer-driven, disability services,equipment, participation

History

Received 14 November 2013Revised 25 February 2014Accepted 28 February 2014Published online 21 March 2014

Introduction

People with disabilities may require assistive devices, technologyand equipment to participate in employment, social and commu-nity activities that are important to them. These devices maysupport individuals with communication, vision and mobilityneeds. Although assistive devices are a key priority for individualswith disabilities, there continues to be a high level of unmetneed in terms of accessing such assistive equipment [1,2]. Thisarticle describes the evaluation of equipment and assistivedevices program in British Columbia, Canada, referred to as theEquipment and Assistive Technology Initiative (EATI), whichoperates from a consumer-driven model for the selection ofassistive technology. The EATI program places no restrictionson what equipment can be obtained and provides opportunitiesfor people with disabilities to self-assess and select the assistive

technology they believe will help them to overcome func-tional barriers to employment. This article describes EATI’s‘‘Participation Model’’, the philosophy of using self-assessmentand the degree to which program participants obtained what theybelieved to be the assistive technology they needed. The Modelwas further explored through an examination of the disuse(or abandonment) of assistive technology.

Assistive technology usage

Assistive technology (AT) can be any item, device or equipmentintended to help someone overcome a functional barrier. AT caninclude generic or ‘‘universal design’’ devices or equipment thatoffers specific utility to people with disabilities as well asdevices designed or custom built for an individual’s particularneeds [3]. AT may be either low-tech (mechanical) or high-tech(electromechanical or computerized) and include equipmentto ‘‘compensate for sensory function losses by providing themeans to move, speak, read, hear, and manage self-care tasks’’[4, p. 439]. AT is intended to facilitate participation in society forpeople with disabilities [5, p. 18].

Address for correspondence: Patricia Johnston, PhD Student, School ofSocial Work, University of British Columbia, 2050 West Mall,Vancouver, BC, V6T 1Z2, Canada. E-mail: patriciajohnston@live.ca

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Unfortunately, much of the AT provided through fundingagencies is not always used. There is a large body of literatureconcerning disuse of AT (or abandonment1 of equipment) [6–8].Disuse of AT is understood to be due to a host of reasons, rangingfrom an individual feeling uncomfortable or embarrassed withtheir AT, to an individual finding the device too heavy orawkward to use [9,10]. Studies have found the disuse of AT maybe ‘‘as low as 8% or as high as 75%’’ where an average disuse ofone-third of all prescribed AT appears to be most common [4,7].The potential for disuse of prescribed assistive devices is of greatconcern in an ‘‘environment where there is an increased need forcost containment and accountability in the provision of AT’’ [6].For this reason, programs that provide AT hold a vested interestin finding the right devices and equipment for each individual.The ‘‘better the match of AT and user, the more effective is theuse of limited resources’’ [11, p. 1329]. Finding the right ATto meet an individual’s needs may greatly reduce the disuse of ATand consequently, better support people with disabilities.

Obtaining the right fit

Determining the right AT for an individual can be challengingdue to a number of variables, such as an individual’s personalpreferences and individual-specific impairments [4,7,12].Although there are theoretical models to guide the assessmentand provision of AT, and to ‘‘match’’ individuals to assistivedevices [4,13,14], there is no consensus regarding how servicedelivery models should function [9,15]. Within this context,health professionals, such as occupational therapists, have trad-itionally performed a key role in assessing and prescribing AT.

For those professionals who conduct AT assessments, acollaborative relationship with the consumer often unfolds [12].This has stemmed from a perspective that stresses the assessmentof consumer preferences, knowledge, experiences and resourcesas well as self-esteem and competence as important to the overallassessment process [16,17]. In practice, such as within the fieldof occupational therapy, a client-centered approach attempts toreduce practitioner power, increase consumer choice and increasethe partnership between the consumer and the professional tofacilitate a collaborative relationship [18]. Unfortunately, peoplewith disabilities do not always report the services they receive‘‘meet this aspiration’’ [18,19]. This may be due to thephilosophical underpinnings of professionals, which can influencetheir decision-making [12]. Most notably, emphasis on ‘‘the valueof the information the client and their family bring into thedecision making process varies’’ [12, p. 22]. Indeed, a provider-centered/controlled approach continues to occur despite researchindicating it is important that the ‘‘process of equipmentprescription [should] be centered on the evaluation of theclient’s environmental and personal needs rather than on diagno-sis alone’’ [20, p. 72]. Yet, without consumer involvement peoplewith disabilities ‘‘may feel disempowered in not being providedthe right piece of technology’’ and the likelihood for a lack of useof the assistive device or equipment may be greater [9, p. 316].

How an individual perceives his/her need for AT can bedifferent from the need for AT as determined by a healthprofessional. Differing perspectives held by individuals andprofessionals concerning what AT is needed can lead to frustra-tion based on the ‘‘different expertise that they [bring] to the pro-curement process’’ [21, p. 170]. Frustration and ‘‘non-agreementbetween the client and the therapist regarding equipment recom-mendations’’ has been found to have a negative impact on the use

of the AT [20, p. 71]. This may be because the perspective someprofessionals bring to the relationship can place some people withdisabilities in a passive role, rather than position them as activeparticipants in the AT selection process [21]. In this way, aprofessional’s position and expertise can silence the knowledgegained through the careers, life experiences and social relation-ships of those with disabilities. Disability movement organiza-tions question professional controls; they advocate a newapproach in which consumers of services have the power todecide what services they will access, the right to monitor serviceprovision and to change services if they so wish [22,23].

Participation model for funding AT

In Canada, provincial governments are responsible for deliveringhealth, social and education services to their residents and thefederal, provincial and territorial governments collectively haverecognized the need for government to support programs thatoffer ‘‘assistive aids and devices’’ [24]. Yet, a lack of organizationconcerning assistive technology has resulted in a disjointedapproach to the provision of AT [25]. This is true in the provinceof British Columbia (BC), which had no universal equipment andassistive device program for people with disabilities untilrecently; in 2004, a coalition of 34 community organizationsformed the Provincial Equipment and Assistive DevicesCommittee (PEADC) and aimed its efforts at improving coordin-ation and funding for such equipment. By 2008, the PersonalSupports Program Working Group, consisting of PEADC andrepresentatives from five BC government ministries developed aplan for personal supports, equipment and devices for people withdisabilities in BC. This group articulated a vision for providingAT built on shared values and developed the person-centeredParticipation Model, which was based on a philosophy forconsumer involvement in the selection of assistive technology[26]. This focus led to the development of the EATI in 2009.

Through a unique partnership, the Government of BritishColumbia’s Ministry of Social Development and the BC PersonalSupports Network (BCPSN) deliver the EATI program. The EATIprogram funds assessment, trialing, acquisition of and/or trainingwith, assistive devices for people with disabilities who haveemployment-related goals. Funded by the federal government’sLabour Market Agreement, this program relies on theParticipation Model as its anchor to enable program participantsto move toward employment. By providing eligible2 programparticipants with the opportunity to assess their own needs anddetermine what AT would best work for them, EATI encouragesparticipants to meet their functional needs and overcome barriers.

Although clinical or professional support can be an importantpart of the self-assessment process for many participants, aprofessional or prescriptive assessment is only required by EATIunder certain conditions, such as when consumers request powermobility equipment (i.e. scooters or motorized wheelchairs) dueto issues of liability3. This is not to suggest the clinician is not an

1This article has chosen to use the term ‘‘disuse’’ rather than ‘‘abandon-ment’’ as it represents ‘‘a more neutral description of the phenomenon’’[10, p. 232].

2To be eligible for EATI funding the individual must be: a person with adisability who has an employment-related goal, which includes volun-teering, 18 years of age or older, a BC resident, unemployed or employedwith low skills and looking to upgrade, ineligible for employmentinsurance, able to demonstrate a need for AT and unable to access fundingthrough other provincial government programs or private insurers. Someof these criteria exist because the program receives funding through theFederal ‘‘Labour Market Agreement’’.3The only criteria that must be met for self-assessing one’s needs are: (1)the individual has been living with their disability for some time, (2) theindividual has used assistive devices previously and (3) the individual isfamiliar with the types of assistive devices available to help them achievetheir employment-related goals [27].

422 P. Johnston et al. Disabil Rehabil Assist Technol, 2014; 9(5): 421–431

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important part of the assessment process, but instead to offermany of the program’s participants an alternative to theprescriptive process. This alternative approach is particularlywell suited to the self-assessment process in certain circumstancesand for certain devices. For example, when participants aimto replace a device that is broken, or out of date; or whenparticipants already have familiarity with a certain device throughtheir friends; family or volunteer work. Not all AT, nor allprogram participants, may be appropriate for self-assessment.In some situations beyond motorized devices, a professional maybe needed to provide further support and/or assessment in theselection or prescription of AT. For example, the support of anaudiologist or optician may be sought if hearing aids or glassesare being requested.

To support the individual in their involvement with EATI,front-line caseworkers referred to as Navigators work directlywith program participants to explore employment goals anddevelop applications for the selected AT. Navigators supportparticipants in the exploration of their employment goals and ATchoices. They also work as advocates for each program participantto access the requested funding by facilitating the AT attainmentprocess. This in part is related to the organization of the programand the approval, or adjudication, of requests that occurs with thegovernment partners. Unlike most programs that provide AT,EATI does not maintain a list of approved devices that partici-pants must select from. Instead, and in keeping with consumercontrol and choice, participants select the device or equipmentthey believe they need to move toward employment and notnecessarily the least expensive device. Navigators work withall participants to complete their applications for AT regardlessof the type of assessment conducted. They can be, however, moreinvolved with those participants who conduct self or collaborativeassessments.

Evaluation of the program

The purpose of this study was to evaluate the program. Theevaluation aimed to explore the impact of the Participation Modelon individuals with disabilities in British Columbia who receivedAT through the EATI. The study focused on how participantsunderstood and experienced the self-assessment process as thisprocess is the foundation of the program’s intent to place them atthe center of decision-making control. Further, the study aimed toassess if participants received the AT they believe they needed.Receiving the right AT was then examined in light of reporteddisuse of AT, the assessment type, and the involvement ofparticipants within the AT selection process. A mixed methodapproach was utilized to explore the experiences of programparticipants who had obtained assistive technology through EATI.A survey was offered and interviews were held with programparticipants. This study commenced following approval by theUniversity of British Columbia’s Behavioural Research EthicsBoard (BREB).

Methods

As of December 2012, all of the 2051 people who engaged withEATI to receive AT were targeted to participate in this study.A survey was developed and participants could take it online, inpaper format or by telephone. The online survey was embeddedwithin a website designed specifically for this study. Anyone418years of age, who had connected with EATI to access assistivetechnology, was eligible to participate in the survey. There wereno additional inclusion or exclusion criteria. A link to the surveywas sent via email by program administrative staff on behalfof the researchers to everyone who provided an email addressto EATI. Those who had not provided an email address received

a hardcopy paper version of the survey by mail at their homeaddress. Individuals could review the consent form and completethe survey online, return the paper version of the survey in thestamped envelope provided or contact the research team to havethe survey conducted with them by telephone.

Survey design

A survey was designed to examine the assessment process forobtaining AT from the perspective of program participants. Thesurvey included questions relating to the AT participants receivedand the type of assessments performed: self-assessment, profes-sional assessment or a collaborative assessment. Self-assessmentswere defined as those that involved program participantsdetermining their own needs and selecting the AT they believedwould best work for them. This type of assessment may haveinvolved the program participant considering his/her past experi-ence, and/or incorporating suggestions from family members,professionals, vendors and friends in order to determine what ATto request through EATI. Professional assessments were definedas those in which an individual met with a health professional todetermine the AT needed and obtained a prescriptive assessment.Collaborative assessments were defined as those when partici-pants chose to incorporate the information from a professionalprescriptive assessment into their selection of AT. Collaborativeassessments represent a working relationship focused on deter-mining the best AT for the individual – where the professionalplaces the individual at the center of the assessment processand the assessment involves the individual’s input, concerns andpreferences.

The first half of the survey was designed to learn the type ofassessment method used to attain AT, overall satisfaction with theAT and if the AT was continuing to be used by the participant(to assess abandonment). Survey respondents were asked toreflect on how they had assessed, or how their needs wereassessed, for the AT they received through EATI. After reviewingdefinitions for each type of assessment, participants were asked,‘‘How did you identify or determine your need for this assistivetechnology (device, equipment or solution)?’’ Other questionsincluded ‘‘Do you believe this assessment led to the assistivetechnology you needed?’’ Participants were also provided theopportunity to respond to statements concerning the impact of ATon employment and life-variables using Likert scales (Table 1).

For some, taking this survey may have involved thinking aboutmore than just one device or piece of equipment they receivedthrough EATI over the course of a few years. Therefore,requesting information within the survey concerning all the ATprogram participants may have constituted an overly complex andtime-consuming process. This approach would not have beenappropriate for surveying those who received only one device orpiece of equipment. Thus, the survey requested respondents toprovide information concerning the AT that had been most usefulto them. To do this, information concerning a participant’s mostuseful top three (or fewer) devices or pieces of equipment wasrequested. In this way, the survey provided respondents the abilityto rank each of their devices in order of utility, offering additionalinformation to the research. As some people received only onedevice or piece of equipment, there were fewer responsesregarding the second most useful AT and again even less for thethird most useful AT. Unfortunately, this approach had onelimitation. For those who obtained only one AT, it wouldhave been ranked as #1 or most useful, limiting the ability totruly assess ranking. Given this, an analysis was performed todetermine if any difference in ranking was associated with theremoval of those who received only one AT. Additionally,determining what constitutes a singular AT or device, or counted

DOI: 10.3109/17483107.2014.900574 Getting it right: assistive technology 423

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as one device, is a very subjective concept. For example,a computer with a monitor, mouse, printer and scanner can beunderstood by different people as anywhere from one to fiveitems. Respondents were advised to ‘‘count’’ their AT as theyunderstood it. Survey data was entered into SPSS StatisticsVersion 20.0 (Armonk, NY) [28]. Descriptive statistics wereperformed. Chi-square or Wilcoxon rank sums were performed oncategorical data and t-tests or ANOVAs were performed oncontinuous dependent variables.

Interviews

Program participants who had obtained assistive technologythrough EATI were also invited to sign up to participate in a semi-structured interview. This invitation was provided alongside thesurvey to everyone who had engaged with the EATI program asof December 2012. Those who obtained AT through EATIcould sign up online by reading the consent form and providingtheir contact information. For those that received the survey andinvitation in the mail, they could return a consent form to theresearch team or contact the research team by email or telephoneto express their interest in participating in the interview. A list ofall those who were interested in being interviewed was compiledand numbered. Data on whether a person who completedthe survey also participated in an interview was not collected.A random number generator (http://www.randomizer.org/) wasused to identify potential participants [29]. Participants werecontacted and, if eligible, an interview was conducted either inperson or by telephone.

Interviews involved questions pertaining to six areas:(1) description of AT obtained by the participant, (2) the processof obtaining AT through EATI, (3) the AT assessment, (4) impactof the AT on the participant’s employment goals, (5) impact of ATon the participant’s life goals and (6) overall perspective of EATI.Participants were asked to describe the AT they received andthe assessment process they completed to attain AT throughquestions such as ‘‘How did you know you needed this AT?’’Questions also included, ‘‘Would you have selected the sameassistive technology or chosen something different?’’ when

participants reported obtaining a professional assessment and‘‘What do you think of having that choice to assess your ownneeds?’’ when a self-assessment was completed. Participants werealso asked to expand on how, if at all, the AT they receivedimpacted their employment or life goals. All interviews wereaudio-recorded, transcribed and coded using NVivo Version 10(QSR International, Burlington, MA) qualitative data analysissoftware. Data were analyzed using thematic analysis, whichrequires data be examined and coded based on patterns andthemes. Latent level thematic analysis was also used to ‘‘identifyor examine the underlying ideas, assumptions, and conceptual-izations – and ideologies that are theorized as shaping orinforming the semantic content of the data’’ [30, p. 84]. Datacollection ceased when saturation was attained.

Findings

A total of 2051 EATI people with disabilities were contacted.About 1571 were contacted by email and 480 were providedsurveys (with an invitation to participate in an interview) in themail. In total, 408 responses to the survey were received; 322responses were received online, 63 by mail and 23 via telephone.After the data were cleaned and duplicates removed, a sampleof 357 people who reported applying to EATI for assistivetechnology was examined. This constituted a response rate of17.4%. About 182 program participants indicated interest in beinginterviewed and a total of 16 interviews were held.4

Participants

Table 2 indicates the number of participants, sex, age and agerange obtained for participants within the survey.

Of all of the survey respondents, including those who hadapplied to EATI, but had not yet received their AT, and those whomay have applied for AT but were ineligible for services, 76.2%had received AT through EATI at the time of the survey. Of thissample, participants held a range of educational backgrounds.For example, 35.9% held up to and including a high schooleducation and 63.6% held some certificate or college or universityeducation. Survey respondents lived throughout the provinceof British Columbia with 54.4% living within the urbanVancouver and Fraser Valley regions.

Interviews were conducted with 9 (56.2%) male participantsand 7 (43.7%) female participants. Slightly more than half(56.2%) of the participants lived in the central urban regions ofVancouver and the Fraser Valley of British Columbia and theremaining (43.7%) lived throughout the rest of the province.Interview participants had been involved with EATI for a range oftime; some had only recently received their AT (within 3 monthsprior to the survey), whereas others had received devices andequipment when the program was first created in 2009 and others

Table 1. Survey questions.

Survey questions

Employment goals My assistive technology has helped me . . .� Use the Internet� Learn new skills� Work on my resume� To take training� Get a job� To communicate� Move closer to becoming employed� To volunteer� Upgrade my skills� Develop employment skills� To attend interviews� To demonstrate my skills to potential employers� Reach my employment goals

Life goals Since receiving my assistive technology . . .� I am able to get out in the community more� I am able to participate in fun things or hobbies� I feel more confident� I am able to do more things at home� I have more energy� I am able to care for myself better� I am able to care for others better� Other impacts on your life since receiving

assistive technology? Please describe:

Table 2. Demographics of survey respondents.

Participants

Male n¼ 107 (48%) Female n¼ 118 (52%)

Age, Mean (SD) 51.03 (13.5) 53.26 (14.5)Age group (in years) n (%) n (%)18–29 7 (6) 9 (7)30–44 24 (22) 18 (15)45–64 64 (58) 67 (52)�65 15 (14) 32 (25)

Percentages have been rounded.

4Interviews ceased when saturation was attained.

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still had received their AT just over a year prior to the survey.Some participants were also in the process of obtaining additionalassistive technology through EATI. Themes identified withinthe interview data closely mirrored the topic areas associatedwith the survey and for this reason, have been interwoven withinthe findings. Themes included assessment type, type of ATreceived and usage (e.g. ‘‘AT is right’’, ‘‘AT is not quite right’’).

Technology received

Survey participants received a range of AT from EATI. In total,244 devices or pieces of equipment were analyzed. Many surveyrespondents reported receiving multiple items. The majorityof this AT was categorized as either computer and computeraccessories (i.e. laptop, printer, rolling cart for large monitor, etc.)or mobility-related AT (i.e. wheelchairs, scooters, stair lift,prosthetics or mobility accessories such as bike lights, wheelchairwheels, walking poles, etc.). Other categories included:� Communication AT (i.e. iPad, Dragon Naturally Speaking

software, telephone box hearing system, equipment toanswer the telephone from a distance, equipment to dialthe operator, etc.).

� Vision AT (i.e. sunglasses, specialty lenses, Braille notetaker, Braille display, Trekker Breeze GPS, etc.).

� Learning AT (i.e. all computer software not includingDragon Naturally Speaking, Jaws or Zoomtext or a LiveScribe pen, etc.).

� AT for the home (i.e. custom desk, office chair, ceiling lift,ramp, automatic door opener, etc.).

� Hearing AT (i.e. hearing aids, FM receiver, tape recorder,bed-shaking alarm clock, blue tooth, etc.).

� Driving AT (i.e. driving lessons, hand controls, six-waypower seat, van conversion, modified brakes, etc.).

� Medical AT (i.e. blood pressure watch, BiPAP machine, foamwedge, etc.).

Interview participants also commented on receiving multipledevices and equipment. For example, one participant describedreceiving ‘‘quite a long list’’ due to having multiple disabilities.This included hearing aids, Q-Link and Quattro Bluetoothdevices, a computer, JAWS and Zoomtext software, a scanner,an Anybook recorder and a Booksense XT.

Assessment methods to acquire AT

Interview participants indicated experiencing different types ofassessments for the different devices and equipment theyreceived; many indicated working with a health professional forone device (professional assessment), whereas self-assessing theirneeds for another or different device. For example, one participantdescribed self-assessing his/her needs for specialized computerequipment and software and requesting a professional assessmentfor a vehicle (van) conversion. For some participants, friendsand community members helped them decide what they needed.Others commented on involving professional assessors, forexample, ‘‘they have a professional—so they’ve seen me. Theyknow where my limits are’’.

Obtaining different assessments for different AT by interviewparticipants was consistent with the findings of the survey. Surveyrespondents reported using self, professional and collaborativeassessments when they obtained multiple assistive devices.Self-assessments were conducted in just over one-third of allassessments reported and were just slightly less common thancollaborative assessments. Frequencies and chi-square resultsfor the different assessment types in relation to the ranked AT arenoted in Table 3.

As Table 3 indicates, there was a statistically significantdifference between frequencies of AT ranked as #1 (most useful)

by assessment type with higher ranking being assigned to devicesassessed via a collaborative method, �2(16, 180)¼ 39.604,p50.001. The proportional differences between the assessmentmethod and the AT ranked as #2 was not statistically significant,�2(14, 82)¼ 16.312, p¼ 0.295, nor was it for AT ranked #3,�2(14, 52)¼ 12.753, p¼ 0.546.

An analysis of those who received only one AT was performed.About 52% of survey respondents received more than one AT(n¼ 93) and the remaining 48% reported only one (n¼ 86). Therewas no proportional difference between those who received onlyone AT and the type of assessment conducted for the AT ranked#1, �2(2, 179)¼ 1.864, p¼ 0.394. Chi-square analyses forAT ranked #2, �2(2, 87)¼ 4.235, p¼ 0.120 and AT ranked #3,�2 (2, 54)¼ 1.350, p¼ 0.509 also indicated no difference,which suggests the ranking of AT by survey participants isuseful for examining assessment types. As the majority ofinterviews participants received more than one AT, it wasnot possible to assess for proportional difference concerningtheir assessments between those who received one and thosewho received multiple AT.

For all of assistive technology ranked as #1 (most useful),professionals most commonly assessed mobility AT. This wasconsistent with the interview findings as participants expressedthe benefit of seeking out a professional assessor for theirexpertise with mobility AT when needed. As an example, oneparticipant stated, ‘‘I went through my OT and she gave me somesort of physical testing that took a couple of hours. And shesays, ‘Okay, enough is enough. You need to get a scooter’’’.Self-assessments were most common for computers and vision-related AT (Figure 1).

Of all the AT ranked #1 (most useful), mobility AT was mostcommonly ranked #1, n¼ 67 (37.2% of total). Mobility AT wasdescribed very positively within the interviews with participantsas well. For example, ‘‘hey come over with the wheelchair. Andyou try it out. Actually, they try you out on different wheelchairsand see which one works the best. . . I thought it was just amazing.I loved it right from the very beginning’’. Computers, n¼ 36 (20%of total) were the next most commonly ranked AT followed bycommunication AT, n¼ 2, (11.7% of total). Interview participantsalso described their computers positively. For example, oneparticipant stated:

When it physically arrived and I went and picked it up andopened the box, I just couldn’t believe it. That I—I had alaptop! And it’s portable. I don’t have to pack up five pieces ofthe other computer to take with me to go somewhere. It’s justawesome. Like, I couldn’t—I knew I was getting it, butactually seeing it and touching it made it more real.

Although mobility AT were most often ranked as #1, the ATranked as #2 (or second most useful) differed slightly. For ATranked #2, self-assessments were again common for computersand vision-related AT. This was confirmed within the interviews.With the support of the Navigator within the self-assessmentprocess, participants came to determine AT they found useful. For

Table 3. Frequencies of assessment type by AT ranked #1, #2 and #3.

Type of assessment

Rank (n)Self

n (%)Professional

n (%)Collaborative

n (%) p Value

AT ranked as #1 (180) 55 (30.6) 47 (26.1) 78 (43.3) 0.001AT ranked as #2 (82) 31 (37.8) 19 (23.2) 32 (39) 0.295AT ranked as #3 (52) 21 (40.4) 17 (32.7) 14 (26.9) 0.546Total (314) 107 (34.1) 83 (26.4) 124 (39.4)

DOI: 10.3109/17483107.2014.900574 Getting it right: assistive technology 425

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example, one participant described how the Navigator ‘‘helped’’as the individual ‘‘did get some discussion through the resourcecentre up here, because I mean these people have dealt with thisfor years. And there were suggestions made, you know, ‘What doyou think of this device?’. . .we managed to come up with the[needed] items’’. Collaborative assessments, however, were mostcommon for AT related to activities around the home and vision-related AT (Figure 2). Consistent with the interview participants’experience, this use of collaborative assessments was explainedby one participant who stated: ‘‘I felt a proper assessment wouldhave been more beneficial for my needs – that would be done byprofessionals plus input from me and my parents – who know mebetter than anyone’’.

Of the AT ranked #2 (second most useful), vision ATrepresented (23.2% of total ranked #2, n¼ 19), followed closelyby ADL’s (20.7% of total, n¼ 17). Computers and communicationAT (both 14.6%) were the next most commonly ranked AT assecond most useful. Consistent with this finding and highlightingthe value placed on computers and communication devices, oneinterview participant stated, ‘‘it became apparent that the iPadwas my best friend’’. Mobility AT (9.8%), hearing AT (7.3%),learning AT (7.3%) and medical AT (2.4%) were ranked #2 lessoften.

Finally, for AT ranked as #3 (or third most useful), self-assessments were most common for vision and communication-related technology. Although still involving other people, such asfriends and family members and the Navigator, one interviewparticipant explained, ‘‘we never really do things totally inisolation. . .I purchased [software through EATI] on the basis ofother people telling me that that’s what worked for them’’.Collaborative assessments were most commonly conducted forvision, computer and mobility-related devices, whereas hearing,driving and medical AT were assessed exclusively by profes-sionals (Figure 3).

Of all the AT ranked #3 (third most useful), vision AT (n¼ 14,26.9% of total ranked at #3), followed closely by computers(n¼ 12, 23.1% of total), were most commonly identified bysurvey participants. Communication AT (21.2%), mobility AT(13.5%), learning AT (9.6%) and hearing and driving AT(both 1.9%) were ranked #3 less often.

As described earlier, the Navigator holds an important rolefacilitating the AT attainment process. As a frontline caseworker,but someone who does not provide prescriptive assessments, theNavigator is involved in all assessments, but often more involvedin the self-assessment and collaborative-assessments. A surprisingfinding from the interviews was the importance of this relation-ship to program participants. The Navigator was perceivedas extremely supportive and helpful, particularly during the self-assessment and collaborative assessment processes. This involve-ment by the Navigator was overwhelmingly reported as a positiveelement in their experience. For many, it was the support of theNavigators that helped to make the self-assessment process apositive experience. As one participant stated:

[The Navigator] just walked me through everything . . . madeit sound very simple, because it—to me, I was justintimidated all to pieces . . . I’m trying to get back into theworkforce and this was all very overwhelming for me. Like,[the Navigator] just talked me through it . . . sent me papers,had highlighted on places that I needed to sign and littlenotes where I needed to read and stuff. [The Navigator] justwas super.

Another participant reiterated, ‘‘I think the self-assessmentwas fine. I was very well supported by [a Navigator], whowas very thorough with helping me through the process’’.Some participants, however, required more support and guid-ance than what the Navigators could offer, but were stillinterested in participating within the assessment process. Forthese individuals the collaborative assessment was oftendescribed as appropriate. For example, one participant explained,‘‘I accepted the [professional] advice that was given. Yeah, Ithink that was the way it went, that she advised me that it shouldbe an advantage to me and so it proved’’. This statementhighlights how the professional’s involvement was seen as‘‘advice’’, offering the participant an opportunity to engagein the process and the decision-making associated with the ATassessment process.

Overall, the survey findings were consistent with howinterview participants described assessments they experienced

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Figure 1. Type of AT ranked as #1 by frequencies of assessment type.

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and the types of AT they received. For example, self-assessmentswere often used for computer and computer-related equipmentand for assistive devices to support vision. For those participantswho were aware of the AT they required, a self-assessment wasdescribed as a useful means for achieving AT. Interviewparticipants routinely explained that conducting a self-assessmentfor something, such as a magnifier (vision-related AT), wasappropriate because they had been long aware of it throughvolunteer work. Given the specific challenges associated withcertain disabilities, however, such as those who possess braininjuries, some interview participants felt the process of the self-assessment was a greater challenge. Themes associated with thedistinctly positive and negative aspects to each assessment type

were developed from the interviews (Table 4). The followingrepresents the interview response themes concerning the positiveand negative aspects associated with the different types ofassessments:

Obtaining the right assistive technology

Given the range of AT and the types of assessments conducted,the question of whether the AT obtained through the Equipmentand Assistive Technology Initiative (EATI) lead to the right ATmust be asked. To answer this question, survey respondents wereasked if the assessment they obtained or conducted led to theAT they needed. Table 5 indicates the percentage of survey

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Figure 3. Type of AT ranked as #3 by frequency of assessment type.

DOI: 10.3109/17483107.2014.900574 Getting it right: assistive technology 427

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respondents that reported receiving the right AT in light of thetype of assessment conducted.

As Table 5 indicates, collaborative assessments were morecommonly conducted for AT ranked #1 and #2 and only usedslightly less often for AT ranked #3. Participating in acollaborative assessment almost always led to the right ATbeing obtained by the participant. It is possible that those whoindicated they did not receive the right AT, and yet rankedtheir assistive technology as #1 (or most useful), may alsorepresent those who received only one device. For the ATranked as #2 and #3, those who conducted collaborativeassessments obtained the right assistive technology for theirneeds 100% of the time. However, chi-square results did notindicate a statistically significant difference between receivingthe needed AT and the assessment type for AT ranked #1 [�2

(2, 188)¼ 5.239, p¼ 0.073], AT ranked #2 [�2 (2, 97)¼ 2.992,p¼ 0.224] or AT ranked #3 [�2 (2, 56)¼ 1.738, p¼ 0.419].Overall, the findings indicate that regardless of the type ofassessment, the right assistive technology was largely obtained(94.4% overall).

These findings were consistent with the information obtainedfrom interviews with program participants as well. Regardlessof the type of assessments the large majority of participantsobtained what they considered to be the right AT. One participantdescribed receiving what s/he believed to be the right AT for theirneeds in the statement:

And, you know, it was totally amazing because by the timeI got the chair and had been fitted for the chair a coupleof times, and did a trial for the chair, you don’t realizethere can be a chair that actually supports your body andcan be modified for your body, and parts of your body thatactually works. I mean, I just love this chair. I’m sitting init now.

This participant also described the process of obtaining thisparticular assistive equipment and involvement of a healthprofessional as part of a collaborative assessment:

EATI sent off a note to [a certain organization], who has theoccupational therapist. We meet up, then there’s a requisitionthat goes back and forth. And that’s approved. Then once that’sapproved that’s given to the people [a company] who makethe chair. They go ahead and make the chair, and when it’sfinished they tell me. And the bill comes to EATI and theypay it.

When asked if the professional, the participant and theNavigator worked together to attain this AT, the participantstated, ‘‘Oh, absolutely’’. This comment represents the positiveand shared process that can occur between a program participantand a health professional resulting in the procurement of the bestpossible AT for an individual’s needs. Perhaps most interestingin this statement is the smoothness of the procedures, the rolesall parties play and the understanding of the process by theparticipant, due to his/her positioning at the center of decisionmaking.

Usage

Individuals who reported not obtaining the right AT for theirneeds were very few in number. Additionally, 93.93% reportedstill using the items they obtained. For those who indicated theywere no longer using their AT (n¼ 25 or 9.4% of the 266 surveyrespondents who reported receiving AT), this was most oftenreported to be because their AT ‘‘needed an adjustment orchange’’, they were ‘‘unable to try the AT out first’’ beforerequesting it and or they required some ‘‘additional training’’ inorder to use it. By following up on this lack of use within the

Table 4. Positive and negative aspects of assessments.

Self-assessmentProfessional (prescriptive)

assessment Collaborative assessment

Positive aspects � Appropriate when participants knew what AT wasneeded or when the participant was able toparticipate in the task of exploring his/her options

� Help from the Navigator made the self-assessmentprocess manageable for most participants

� Provided an opportunity for participants toresearch what they may require

� Relationship with the navigator was particularlyhelpful to the process

� Professionals were awareof what participantsrequired

� Participants appreciated being advised ofwhat AT options were available to them

� Incorporating family members and friends’suggestions into the assessment was usefulfor some participants because ‘‘they knowme better than anyone’’

� Provided an opportunity for participants toresearch what they may require

� Relationship with the Navigator was par-ticularly helpful to the process

Negative aspects � For some people with certain disabilities, theapplication process (paperwork) was perceivedas complex

� Some participants required additional supportbeyond what could be offered by a navigator

� Without face-to-face involvement with a profes-sional, some participants experienced a sense ofdisconnection from the AT procurement process

� Can limit the opportunityfor participants to pro-vide input into theassessment

Table 5. Frequencies of received the ‘‘Right’’ AT by assessment type.

Self n (%) Professional n (%) Collaborative n (%)

Right AT Not right Right AT Not right Right AT Not right p Value

AT Ranked #1 57 (93.4) 4 (6.6) 43 (89.6) 5 (10.4) 78 (98.7) 1 (1.3) 0.073AT Ranked #2 34 (91.9) 3 (8.1) 24 (96) 1 (4) 35 (100) – 0.224AT Ranked #3 19 (90.5) 2 (9.5) 17 (89.5) 2 (10.5) 16 (100) – 0.419Total 110 (91.9) 9 (8.1) 84 (91.7) 8 (8.3) 129 (99.6) 1 (1.3)

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interviews it was learned that occasionally assistive technologycould not be trialed or tested out due to it being new on themarket. As one participant described, ‘‘These hearing aids thatI have, these particular models, came out on the market inOctober. . .And I received them in December so they’re brand,brand new on the market’’. This same participant furtherexplained how this led to challenges pairing certain technologywith his/her new AT. S/he stated: ‘‘Well I couldn’t, my oldhearing aids were not Bluetooth, so I couldn’t try any of theseproducts until I actually had the new hearing aids and discoveredit. So, those two products have been returned to the vendor’’.Although cutting-edge technology may not be available to betrialed, as this participant explained, ‘‘the best piece of equipmentfor me’’ was eventually obtained. Additionally, some interviewparticipants did state that they required additional training andone individual commented on selecting a device (a scooter)that did not fit on public transit and therefore, s/he wasunhappy with the AT. Overall, however, the large majority ofparticipants commented on being highly satisfied with the ATthey received.

Discussion

EATI program participants in this study most commonlyparticipated in collaborative assessments. Given that an over-whelming majority of participants obtained what they believe tobe the right AT to meet their needs, it is not surprising that thepercentage of individuals who also report continuing to use theirAT is so high. It is of interest that when a collaborativeassessment was completed, the assessment almost always led toAT the program participant needed. This finding is consistentwith research that found an interdisciplinary approach to assess-ment ‘‘that directly involves the patient and family, decreases therate of device abandonment’’ [8]. Thus, the involvement of peoplewith disabilities within the selection and assessment process maybe important to obtaining the right AT because ‘‘there arepersonal and psychosocial characteristics that predict predispos-ition to use a given assistive technology and its subsequent matchwith the user’s needs and preferences’’ [11, p. 1329]. AlthoughMcCormack and Collins (2010) and Kjelberg, Kahlin, Haglundand Taylor (2012) both raise concerns surrounding collaborativerelationships suggesting people with disabilities do not alwaysexperience the client-centered approach as it is intended, theresults from this study call such concerns into question [18,19].The findings from this study indicate the framework andunderlying philosophy of the program contribute to truly collab-orative relationships being formed. Thus, such concerns can berefuted. That said, it may be the case that previous studies haveconflated the involvement of consumers within the professionalassessment process with what this study served to delineate asa collaborative assessment. Collaborative assessments throughEATI result in the final decision for AT being left with theconsumer. This may represent why participants in this studyreported their involvement so positively – it truly represented acollaborative approach. Whether the requirement of a profes-sional’s prescription impacts the relationship and outcome ofcollaborative work may be useful to ascertain within futureresearch for greater understanding of this issue.

Although no statistically significant relationships were foundbetween the type of AT and the assessment completed, the datasuggests certain AT may be better suited to particular assessmenttypes. The higher frequency of certain AT such as computers,communication and vision-related AT (e.g. iPads, GPS andcomputers) attained through self-assessment process may sug-gest participants had increased familiarity with them. It may alsoreflect that as relatively similar generic items are obtained by

many people without disabilities and widely perceived as usefuland socially desirable, participants did not feel as compelled toinvolve a professional in the assessment process. This is consistentwith the literature, which indicates social implications and stigma,simplicity and ease of use and esthetics are important factorsassociated with the continued use of AT [6,7].

Additionally, the increasing use of self-assessments, yetdecreasing use of collaborative assessments, within the rankingof AT as #1, #2 and #3 (Table 3) may suggest participants attainedthe more necessary or essential items with the support of aprofessional – often by way of a collaborative assessment.It appears there may be AT attained through the self-assessmentprocess, which was less useful to participants than what wasobtained through collaborative assessments. This, however,cannot be supported through the qualitative interviews, as anequivalent level of detailed information about each specific pieceof assistive technology was not collected. It is important to notethat a rather consistent level of AT assessed by professionals wasranked as #1, #2 and #3 (Table 3). Yet, professional assessmentsmade up the least amount of assessments conducted. As expected,the higher number of professional assessments associated withmobility devices is likely due to the requirement by EATI forparticipants requiring power-operated mobility AT to obtain aprofessional (or prescriptive) assessment. The higher rankingof mobility devices may also reflect the difficulty individualswith disabilities encounter in accessing AT within the communityrelated to mobility, as opposed to a lesser need for medicaldevices, which may be more widely available and accessiblethrough community organizations.

Interestingly, the difference between those who did not receivethe right AT through a self-assessment, and those that did notreceive the right AT through a professional assessment, regardlessof the ranking of AT, was negligible (51%). This is interestinggiven the traditional focus and long-standing use of professionalassessments. It may suggest people with disabilities and profes-sionals bring an equal level of expertise to decision-making forAT. It may also suggest that decision making by either a soleprogram participant or health professional can be limited inability to select the right AT. It does not, however, suggest thereis no role for health professionals within the assessment processor that health professionals in any way undermine the ATselection process. Rather it may indicate that some people withdisabilities, who possess a heightened awareness of their ownneeds, in combination with a thorough knowledge of AT specificto their disability, can be best served by a self-assessment. Thisis consistent with research concerning the many factors thatinfluence AT decision-making [10,12]. This could hold policyimplications and may lead to cost savings within agenciesthat require professional assessment and prescribe AT to allconsumers.

EATI provides an opportunity for program participants toselect the type of assessment for AT.5 Findings from this studysuggest that this flexibility, or not approaching all assessmentsfor AT in a ‘‘uniform’’ way, may be of benefit to AT consumers.The ‘‘differing values and priorities’’ of professionals as wellas the knowledge, understanding of AT and the backgroundof the participant should be factored into a flexible approach toassessing AT [12]. Although a statistically significant differencebetween types of assessments was not evident, such a high rate ofreceiving the right AT through collaborative assessments (99.5%of all reported cases) may suggest that collaborative workingrelationships can be particularly beneficial to the AT selectionprocess.

5See footnote 2.

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These findings appear to provide support for the ParticipationModel, which involves program participants in decision-makingconcerning their needs. So few individuals within this studywho reported not using their AT suggests the incorporationof participants’ perspectives can hold a positive effect onselection of the right AT. This is consistent with literature inthe field [4,31]. Reported usage of AT within this study of EATIparticipants stands in stark contrast to programs that experienceup to a 75% rate of AT disuse by participants [4,7,31].Unfortunately, this study was not able to determine if obtainingthe right AT was a result of the Participation Model, but ratherthe study suggests it is likely that EATI program participantsare obtaining the right AT in part due to their participationin the process. Thus, the Participation Model may be a criticalcomponent of an effective approach to AT assessment andselection.

Limitations

Ranking items within the survey posed limitations as previouslymentioned. However, this method also offered an informal meansto gauge the usefulness of AT received in light of the assessmentconducted. Although the rankings can be useful to highlight howrespondents experienced their assistive technology, the subjectiv-ity of the rankings and the inability to formally identify howindividuals sought to rank the AT must be noted. Additionally, thelow response rate may have resulted in response bias; it is possiblethat only participants who were satisfied with their AT respondedto the survey. Methods to ensure a representative sample shouldbe identified for future research.

Although this study found the vast majority of participantswere continuing to use the AT they obtained through EATI, thisfinding cannot be directly attributed to the type of assessmentconducted or the type of AT obtained. Although the positiverelationships and support provided by Navigators was described inrelation to the self-assessment and collaborative assessments, it ispossible that follow-up provided by EATI had an effect onparticipants continuing to use their AT. This however, was notexamined within this study. Future research concerning follow-upby program staff after the provision of AT may offer greaterinsight into the degree of disuse of AT. The few reports ofdisuse may also be related to the involvement of Navigatorswho hold experience with AT themselves. Navigators are peoplewith disabilities and can offer firsthand information concerningtypes of AT to program participants. It is possible this servesto steer participants away from AT that may not be so widelyused and towards AT that is well received by people withsimilar disabilities, however, this was not examined within thisstudy. Examining ‘‘peer support’’ during the assessment processcould be useful to future research, particularly given therelationship between personal factors, such as ‘‘social circlesupport’’ and disuse of AT [10]. One additional aspect toany discussion concerning the disuse of AT is that not all‘‘abandonment’’ should be perceived as negative or representingan individual obtaining AT that does not meet their needs.Instead, there can be ‘‘‘good’ non-use, [or] the abandonment of adevice that no longer fits the needs of the user’’, for example,when the ‘‘user’s condition has improved. . .or the environmenthas changed’’ [10, p. 237].

Finally, this evaluation was unable to survey health profes-sionals and those who work with people with disabilities toobtain their perspectives on the degree of usage associated withthe self-assessment, the professional assessment and the collab-orative assessment. This may have provided a more comprehen-sive understanding of the assessment process and the degreeof AT use.

Future research

Additional research is required to assess whether there is astatistically significant benefit to providing program participantsthe opportunity to identify AT they desire, rather than selectingdevices and equipment from an already approved list. Suchresearch is of interest because although pre-approved lists maywork well for organizations and governments, they may work lesswell for program participants who must select the best devicefrom a list of items that could not be quite right for their needs.Pre-approved lists may also translate into participants selectingfrom a range of outdated technology. EATI asserts it isadvantageous to provide individuals the opportunity to selectthe device that best meets their needs and emphasizes benefitsassociated with the program’s ability to offer custom-created,‘‘cutting-edge’’ and generic technology to participants. Researchto gauge whether this is in fact the case should be consideredin the future. Finally, a survey of health professionals and thosewho interface with people who have obtained AT through EATIcould provide ancillary insight to the topics of assessment andusage.

Conclusion

The EATI offers program participants funding and support for theprocurement of AT in BC. The large majority of participants whoresponded to this study reported obtaining what they consideredto be the AT they needed. The percentage of participants thatcontinue to use their technology was also reported to be very high.In keeping with the Participation Model as the philosophyunderlying EATI, the participant-centered approach is working tosupport people with disabilities to participate in the assessmentand selection of AT to meet their needs. Just as AT is intendedto increase participation of people with disabilities within society,a flexible approach to AT assessment appears to be contributingto this same goal.

Declaration of interest

The authors report no declarations of interest.This study was funded by Social Sciences and Humanities

Research Council (SSHRC) grant; Community-UniversityResearch Alliances (CURA); Funding and the Government ofBritish Columbia who kindly provided support through LabourMarket Agreement funding this project.

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