Emily J. Steel

Advances in European Assistive Technology Service Delivery and recommendations for further improvement

Seventeen years ago the European Commission funded HEART (Line C) project released a report on rehabilitation technology service delivery, describing the processes from 16 countries and making recommendations for improvement by market stimulation and quality assurance. Service delivery of rehabilitation technology, now more commonly referred to as Assistive Technology (AT), has advanced since the 1994 report. Highlights include the establishment of the EASTIN network of AT databases, expansion of systems that facilitate user choice, and a stronger sector identity promoted through the AAATE. Policies and attitudes toward disability have also changed at a societal level over the intervening years, reflected in key documents such as the UN Standard Rules, the ICF, the UN CRPD and the European DisabilityStrategy 2010-2020. People with disabilities can expect to be provided with information about and access to technologies and services enabling their participation and integration in society. Yet discussion about issues including the ageing population, keeping up with technological advances and containing costs in health and social care budgets, is not new. The message is the same as it was in 1994; we need to work together to meet the challenges. The difference now is that, with progress slower than expected, the voices are more urgent. Aim: This paper reflects the advances in service delivery since the HEART study, the impact of European policy and strategy on development in the AT field, and the current challenges the sector faces. It is intended to stimulate further collaboration and improvements in European AT service delivery. Methods: National contacts from the AAATE were surveyed about the current status of AT service delivery in their respective countries, and asked to comment on the improvements since 1994 as well as the new and continuing challenges and priorities. Survey responses were analysed and recommendations made for further discussion. Results: 13 responses were received, all reporting improvements in elements of AT service delivery, differing in focus across countries. Users frequently have access to AT information but their involvement in decision-making varies. The seven essential steps and six quality criteria for service delivery from the HEART study retain relevance for most respondents, but their use in practice remains limited. The participation of AT practitioners and services in professional development and networking varies from individually organised activities to requisite programmes, and from local to international involvement. Conclusion: European countries have AT service delivery systems that vary in their structure and sophistication, but share some common challenges in meeting the needs of AT service users. Several recommendations are made to inform further discussion and encourage the various stakeholders in AT policy and practice to work collaboratively in improving service delivery across Europe.

The role of the International Classification of Functioning, Disability, and Health and quality criteria for improving assistive technology service delivery in Europe

ObjectivePeople with disabilities are entitled to access assistive technology (AT) to facilitate their full and effective participation in society and may reasonably expect to be central to the decision-making processes of services that provide these technologies. European projects have improved the knowledge and resources available for AT service delivery in many countries, but the outputs are not consistently implemented or published in scientific literature. This article examines European developments in AT service delivery and the barriers to its effective provision. Specifically, it analyzes the role of the International Classification of Functioning, Disability, and Health in service delivery improvement. DesignPublished scientific papers, as well as reports from and descriptions of European projects related to AT service delivery, were reviewed. The publications were analyzed in relation to six criteria for AT service delivery described in an earlier, major European project. The findings and recommendations from the publications are synthesized in this article to identify advances and gaps in AT service delivery and to assess the current status and direction of AT service delivery improvement in Europe. ResultsMulticountry projects have brought together AT researchers from across Europe to work together and produced promising results that are contextually relevant. Access to AT information and training of practitioners has improved, and efforts are being made to facilitate user involvement. ConclusionsMore effort should be put into integrating research and resources from European projects into practice. Use of the International Classification of Functioning, Disability, and Health model and terminology may support coordination of service delivery systems. The AT research and practice communities in Europe may be able to learn from developments in North America, while continuing to work together, sharing resources and strategies, and communicating results internationally.

Mental distress and human rights of asylum seekers

Purpose – This paper studies the experiences of asylum seekers in Australia. The purpose of this paper is to explore the relationship between mental wellbeing, living conditions, and Australia’s detention policies in light of human rights. Design/methodology/approach – Using grounded theory, data were collected via observations, semi-structured interviews, key-informant interviews, and document analysis. Participants included seven asylum seekers and three professionals working with them. Findings – In light of a human rights framework, this paper reports on the mental distress suffered by asylum seekers in detention, the environments of constraint in which they live, and aspects of detention centre policy that contribute to these environments. The findings highlight a discrepancy between asylum seekers’ experiences under immigration detention policy and Australia’s human rights obligations. Research limitations/implications – This research indicates human rights violations for asylum seekers in detention...

The structural-personal interaction: Occupational deprivation and asylum seekers in Australia

ABSTRACT Asylum seekers experience occupational deprivation in the context of restrictive social structures while awaiting refugee visa-status determination. How do social structures of citizenship status and policy shape asylum seekers’ experiences? Asylum seekers’ experiences in Australia are examined using constructivist grounded theory. Field notes from 10 months of weekly participant observation, 11 formal interviews, 34 survey responses and four policy documents are combined to identify a substantive theory - the Structural-Personal Interaction (SPI). The SPI explains how occupational deprivation arises from an interaction between social structures and personal characteristics. Social structures of citizenship status and policy interact with asylum seekers’ personal characteristics, resulting in experiences of “having nothing to do”, a fundamental component of occupational deprivation. From the SPI, new insights regarding occupational deprivation emerge. Occupational deprivation can stem from an interaction between social structures and personal characteristics. While the SPI is a substantive theory and further research across a range of settings would be beneficial for its generalization, occupational deprivations structural roots and connections to human vulnerabilities and resilience are discernable when considered in light of the SPI. Strategies to address occupational deprivation might target changes to social structures as well as build on individual strengths and human diversity.

“An environment built to include rather than exclude me”: Creating inclusive environments for human well-being

Contemporary discourses which challenge the notion of health as the “absence of disease” are prompting changes in health policy and practice. People with disability have been influential in progressing our understanding of the impact of contextual factors in individual and population health, highlighting the impact of environmental factors on functioning and inclusion. The World Health Organization’s (WHO) more holistic definition of health as “wellbeing” is now applied in frameworks and legislation, and has long been understood in occupational therapy theory. In practice, however, occupational therapists and other professionals often address only local and individual environmental factors to promote wellbeing, within systems and societies that limit equity in population health and restrict inclusion in communities. This paper presents an in-depth analysis of the supports and accommodations identified by a cohort of individuals (n-100) living with disability. A range of environmental facilitators and barriers were identified in peoples’ experience of “inclusive community environs” and found to influence inclusion and wellbeing. The roles and responsibilities of individuals, professionals, and society to enact change in environments are discussed in light of these findings. Recommendations include a focus on the subjective experience of environments, and application of theory from human rights and inclusive economics to address the multiple dimensions and levels of environments in working towards inclusion and wellbeing.

Linking instruments and documenting decisions in service delivery guided by an ICF-based tool for assistive technology selection

This paper demonstrates how information from existing instruments can be linked within a new framework and tool for AT selection, using the International Classification of Functioning, Disability and Health (ICF). A case study is presented to illustrate how this might work in practice, and describes the steps followed by practitioners using the tool and gathering assessment data through links to existing instruments. The potential added value of using the ICF in AT service delivery is discussed, and planned developments for the tool outlined.

Challenges of user-centred assistive technology provision in Australia: shopping without a prescription

Abstract Purpose: People with disability have a right to assistive technology devices and services, to support their inclusion and participation in society. User-centred approaches aim to address consumer dissatisfaction and sub-optimal outcomes from assistive technology (AT) provision, but make assumptions of consumer literacy and empowerment. Policy discourses about consumer choice prompt careful reflection, and this paper aims to provide a critical perspective on user involvement in assistive technology provision. Methods: User-centred approaches are considered, using literature to critically reflect on what user involvement means in AT provision. Challenges at the level of interactions between practitioners and consumers, and also the level of markets and policies are discussed, using examples from Australia. Results: There is no unanimous conceptual framework for user-centred practice. Power imbalances and differing perspectives between practitioners and consumers make it difficult for consumers to feel empowered. Online access to information and international suppliers has not surmounted information asymmetries for consumers or lifted the regulation of publicly funded AT devices. Conclusions: Ensuring access and equity in the public provision of AT is challenging in an expanding market with diverse stakeholders. Consumers require personalised information and support to facilitate their involvement and choice in AT provision. Implications for Rehabilitation Variations in approaches informing AT provision practices have a profound impact on equity of access and outcomes for consumers. An internationalised and online market for AT devices is increasing the need for effective information provision strategies and services. Power imbalances between practitioners and consumers present barriers to the realisation of user-centred practice.

Choice and Control: Assistive Technology within Australia's New National Disability Insurance Scheme

Government policy influences the individual and societal outcomes potentiated by assistive technology (AT) and related supports. Political theory suggests that concurrent problem recognition, potential policy solutions, and active political will, are necessary triggers for concerted government action. This has occurred in Australia, with the advent of a National Disability Insurance Scheme (NDIS), which will revolutionize disability services and, it is hoped, deliver equity for Australians living with impairment. Analysis of the stakeholders and processes involved in developing an NDIS provides a useful case study for others seeking policy change.

Understanding assistive technology as a pre-requisite for choice and participation

ABSTRACT Assistive technology (AT) is an often-used intervention to enhance participation and occupational performance, but disparities in access to and outcomes from its use are common. An occupational perspective of being and becoming an AT user is missing from the discourse on the right to, and choice of, assistive technology, and policies guiding its provision. This study investigated the experiences of people operating outside of public AT programs in Australia, and their experiences of access to, choice of, and outcomes from AT. Interpretive Phenomenological Analysis (IPA) of interviews with two participants with extensive and diverse experiences of AT provision demonstrates how a person becomes an AT user over time. The emergent themes discussed are becoming an AT user, self-management by AT users, and the risks and responsibilities of choice without awareness or support. The findings illustrate that being an AT user is an occupation that involves ongoing learning and problem-solving as part of self-management, and support the notion that AT is a pre-requisite for participation and choice. AT users can only make and realise choices if facilitating conditions are present. These include the existence and awareness of options, support to explore and experience new products and skills, respect for preferences, and ongoing servicing responsibilities. Policies emphasising individual consumer choice discount the iterative processes, risks and responsibilities involved in AT provision and the importance of relationships. Policymakers require an understanding of what is involved in being and becoming an AT user, and how this precedes participation and choice for people with disability.

Assistive technology provision: towards an international framework for assuring availability and accessibility of affordable high-quality assistive technology

Abstract Purpose: This is a position paper describing the elements of an international framework for assistive technology provision that could guide the development of policies, systems and service delivery procedures across the world. It describes general requirements, quality criteria and possible approaches that may help to enhance the accessibility of affordable and high quality assistive technology solutions. Materials and methods: The paper is based on the experience of the authors, an analysis of the existing literature and the inputs from many colleagues in the field of assistive technology provision. It includes the results of discussions of an earlier version of the paper during an international conference on the topic in August 2017. Results and conclusion: The paper ends with the recommendation to develop an international standard for assistive technology provision. Such a standard can have a major impact on the accessibility of AT for people with disabilities. The paper outlines some the key elements to be included in a standard. Implications for Rehabilitation Assistive technology is a key element in rehabilitation, but many people have no access to affordable AT solutions. The recommendations in the paper aim to inform policies, systems and service delivery procedures on how to improve access to AT across the world.