Sarah Atkins^{1, *}, Sally Fowler Davis²

¹Clinical Specialist Occupational Therapist (Dip COT SROT) Sheffield Teaching Hospitals NHS Foundation Trust
²Associate Professor Organization in Health and Care, Sheffield Hallam University and Sheffield Teaching Hospitals NHS Foundation Trust

^*Corresponding Author: Sally Fowler Davis, Associate Professor Organization in Health and Care, Sheffield Hallam University

Abstract
People with tetraplegia are rightly expecting that digital technologies will allow them to compensate for an element of their personal impairment. Technologies can enable people to navigate environmental challenges, access on-line products and provide   information about services. Occupational therapists (OT’s) working with people who have spinal injuries need to be aware of digital devices and methods that can support their patients and facilitate the process of deploying technology, enabling the adoption by people in varying stages of their adaptation to disability. A rapid literature review was undertaken within an NIHR clinical academic internship: To gain a critical understanding of technology adoption in the practice of OT with people who have post-acute spinal injury. The study demonstrated a limited focus on the personalized deployment of 'smart' technologies. The Technology Adoption Model (TAM) was used to synthesize findings, based on the key principles that acceptance of technology is based on devices or methods that are a) unobtrusive, b) high performance, c) required little or no maintenance and d) where a device achieved practical restorative functional gains. Studies showed that setting up technologies for example, environmental control systems was a lengthy process that required a technical skill that was highly varied in the patient population. People disabled with spinal injuries who chose to adopt technology reported strong benefits associated with successful use yet had to overcome difficulties with learning, maintenance, and lack of technical support.

Keywords: environmental controls, spinal cord injury, digital technology, adoption of computer

Introduction
Digital Technologies Including
The personal computer, mobile telephones, tablets, and the internet are now embedded in the day-to-day living in the UK and other Organisation for Economic Co-operation and Development (OECD) countries. There is a recognition that the value to individuals is matched by economic benefits in terms of gross domestic product for connected countries [1]. Digital methods provide new methods of communication, control of everyday devices and play an increasingly essential role in work and leisure. They benefit the user by enabling them to undertake a range of daily activities, including study, and employment, and wider communication wherever there is a sufficient internet connection. The demand for 'smart' home-based digital technologies to enable activities of daily living is also being articulated by people with tetraplegia. Navigating a home; opening curtains, doors, regulating heating, and home devices are now within smart home technologies [2]. Vocational rehabilitation often depends on computing capabilities [3] with self-management invariably depending on social media, networking sites, and home-based internet [2]. OTs working within Spinal Injury Centres and N.H.S assistive technology teams, together with those working within charities such as Aspire, seek to provide rehabilitation to people who have been paralyzed by Spinal Cord Injury, helping them move from injury to independence. Aspire, who fund technology, volunteers, and assistive technologists to work within Spinal Cord Injury Centres, have debated the usefulness of mainstream smart home technologies for people with spinal cord injuries [4]. The technology debate includes concerns regarding compatibility, maintenance, and reliability of devices, particularly where the supply of equipment is dependent on internet connectivity. Risks are understood to be based on poor universal coverage, unreliable wi-fi and practitioner can be apprehensive about devices that fail, particularly in an emergency. At this time, the NHS environmental control provision criteria include traditional environmental control systems but do not include mainstream smart home technology [5]. This highlights the need for OTs to incorporate an understanding of digital technology adoption into their practice, to be able to advise on products and services, as part of treatment planning. This is based on a professional commitment to enable patients to engage in the occupations they value and overcome the barriers presented when they cannot access technology [6]. Use of assistive technology has long been used as a tool by occupational therapists to enable a return to daily occupations [7].

Assistive technology is defined as “any piece of equipment, or product, whether it is acquired commercially, modified or customized; that is used to increase maintain or improve the functional capabilities of individuals with disabilities”[8]. In 2013 The World Health Organisation (WHO) and International Spinal Cord Society Report [9], highlighted the value of allocating resources to enable people with Spinal Cord Injuries to access assistive technology. They advise that assistive technology is beneficial to maximize independence, including using Environmental Control Systems. These enable control over the immediate environment such as the T.V. computer, telephone lights, and doors. They advocate the use of computer technology to provide access to information on the internet, a method of communication, participation in education, work, and leisure. Also, they emphasize that assistive technology provides economic benefits to society by reducing the costs associated with care and unemployment. In addition to traditional assistive technologies specifically designed for people with disabilities, global advances in technology have resulted in, commercially available methods of controlling the environment and accessing a computer, which does not require hand function and can be retrofitted to the home environment to enable independence and quality of life [2]. The mainstreaming of home-based digital controls depends on the assessment of the benefits of the on-line service or device, i.e., enhancing daily living providing additional control or functionality beyond the norm, or the additional vulnerability i.e., remotely monitoring utilities or reducing security risks. In some cases, the assessment includes personal preferences for social connectivity via remote communication methods and on-line networks. A major factor in the assessment is an individual's willingness to accept technology as part of their normal routine. The Technology Acceptance Model (TAM) is one of the few methods proposed as a useful predictor of technology acceptance. This behavioural model was developed in the 1980s to understand information technology use in the workplace. It states that the information technology user’s acceptance is influenced by; their pre- use beliefs regarding perceived usefulness and ease of use, which leads to their attitude, intention to use, and actual use [10].

Digital Assistance Within Spinal Cord Injury
A previous systematic review reported on the use of computers and task performance at home for people without upper limb movement associated with tetraplegia [11]. They found that assistive technology devices such as voice command software, modified mice, switches, and typing sticks could be used to provide access to computers and controlling the home environment. The review concluded that people with spinal cord injury who used assistive technology for computer access believed that they had a better quality of life with improved participation, independence, and self-esteem. Some people with spinal cord injuries are interested in commercially available mainstream technology are becoming interested in the application of further digital services and devices; also expressing a level of frustration with traditional assistive technologies available through NHS provision,[12,13]. This stimulus contributed to the completion of this study, undertaken within a National Institute of Health Research (NIHR) Pre-Masters Clinical Academic Internship Programme [5].

Methodology
A rapid review methodology was selected and completed in six months of clinical academic development. Rapid reviews are an assessment of what is already known by using systematic review methods. This is accomplished by setting out a protocol to focus the question and set out the scope and limits of the search. The rapid review is rigorous and explicit and thus systematic but makes concessions to the breadth or depth of the process by limiting particular aspects of the systematic review process [14]. The study was devised using the PICOS tool. This was the most appropriate tool for a fully comprehensive search where time and resources are limited [15].

Results/Findings
Literature was selected if it met all the inclusion criteria and none of the exclusion criteria as summarised in the PRISMA flow diagram (Figure 1). 218 records were identified after duplicates were removed. After screening by title and abstract 85 articles were screened for eligibility. Full-text versions were obtained of all relevant articles and evaluated for inclusion according to the criteria. These were collated by the first author in a spreadsheet tabulating the relevance to the search protocol, this was reviewed by the second author. Six studies were agreed as suitable for inclusion. Data extraction was undertaken to identify the salient elements of the literature about the TAM- From the data extraction sheet, (Table 1 and Table 2) and subsequently, the key findings were identified. Due to small-scale studies with a qualitative design and only one large- scale survey, the level of evidence was not suitable for a meta- analysis. The five qualitative studies using interview methods had low numbers of participants; Folan et al. [3] had 3 community-dwelling participants, Hooper et al. had 5 participants [2], Myburg et al. had 15 participants [18]. In the first study by Verdonck, M. et al (2014) [19] there were six participants and then further analysis of five of those participants was   reported   in   a further   study   published   in 2018. Therefore, the total number of participants from these studies was 29. Of these only five were women, although this is not unexpected within a spinal cord demographic. A higher proportion of men is thought to be representative of the UK Spinal Cord Injured Population [19]. The studies were carried out in Australia [3,2,18] and The Republic of Ireland [20,21]. They all had convenience or purposive samples. The numbers were not large enough to analyse according to each level of injury. The sixth study was a large survey, studying 156 participants with tetraplegia due to traumatic spinal cord injury [3]. This sought to assess the pre-use attitudes of the spinal cord injured population in the United States of America, using a range of theoretically presented Brain Control Interfaces. The participants were 18- 81 years old. They had received C1- C7 injuries 40 % of which were complete. This data was subdivided into groups C1-4 with 54 participants, and C5 – C7 with 102 participants. All were stated to be due to traumatic causes with time since injury ranging from one month to 62 years. The proportion of males to females was not stated. The participants were recruited from the community, via advertisements using websites, paper adverts, and using forums, and support groups for people with spinal cord injuries. The large numbers of participants and recruitment from several sources add weight to the relevance of the findings for the American population. But the data were presented as percentages without any statistical analysis to aid consideration of the level of bias.

The survey [3] sought to ascertain user attitudes towards eight technologies. There were 13 theoretical control opportunities including three relating to accuracy and speed of typing and two relating to control and accuracy of a computer cursor. The survey sought to assess the attitudes of the participants towards using technology to achieve benefits gave the burdens of each system, using a 5-point Likert scale, to rate the likelihood of use. The results of the survey [3] showed that respondents were concerned about the appearance of devices, issues with daily maintenance, and the potential requirement for technician intervention. For brain control interfaces to achieve widespread adoption they need to allow unobtrusive, high performance, autonomous use and require little or no maintenance. When rating the potential output control opportunities there was a preference for achieving restorative functional movements. However, a substantial 80 % of C1- C4 people with tetraplegia injured for 10 years or more were likely to adopt technology if it could naturally control a computer cursor. This figure was 56 % for those injured for 10 years or more in the C5-7 group. The study did not document the user's reasoning behind this difference between the higher-level and lower-level groups. A possible further study is needed to investigate the hypothesis that the C5-7 group, who have more upper limb function, can use other devices already. Further framework analysis using the Technology Acceptance Model and themes identified by the authors [22], results are presented in (Table 2). In TAM perceived usefulness and perceived ease of use, feed into the users' attitudes towards technology. Within the literature analyzed participants saw technology as useful for completing tasks independently [23] with specific goals including controlling a mainstream mobile telephone or tablet [12], autonomous control of the home environment [18], and natural control of a computer cursor [3]. Participants pre-use ease of use expectations were that; for technology to be accepted, they wanted it to be fast, accurate, and natural [21]. Technologies that do not require maintenance or carer intervention and be unobtrusive are preferred [21]; however, the evidence was that in reality setting up environmental controls systems was lengthy, with technical issues and required reprogramming and that troubleshooting was required by someone with hand function and additional training was insufficient [18]. Assistive technology to access computers was found to be challenging and slow to use with participants' pre-injury level of knowledge of computers being variable. The users with less knowledge found learning harder [3]. In line with TAM theory, participants attitude to technology showed a clear interplay of usefulness and ease of use [2] describes “opportunities and costs” [18] described that the device, “has to pass a threshold of practicality over options such as asking a carer for help” [24] also described this as; “The interplay between hassle and engagement”.

Figure 1: PRISMA 2009 Flow Diagram

Table-1

Table 2: Data Extraction TAM and themes

• The technology-enabled users achieve independence with everyday activities [3,2,18,24,21].
• A sense of safety by being able to call for help with environmental controls [2,18,24,21] and the resultant psychological benefit from being able to spend time alone [2,21].
• Computer access enabled a return to previous life roles as well as new ones including work [3].
• Modern “Smart” environmental control use enables telephone, messaging, social media, and computer access allowing valued access to the outside world [2].
• Users preferred mainstream devices because they look less disabled [18].
• Assistive technology use was enjoyable [3,24,21] and helped alleviate discomfort, pain, and boredom [18].
• Environmental control users felt less of a burden to their carers [18,21].

Challenges to Ease of Use

• Assistive technology users found learning time-consuming and frustrating [3,2,24,21].
• Frustration with technical issues and maintenance [2,18,24,21].
• Lack of technical support [2,18]
• Poor prescriber knowledge [2]
• Due to a psychological response to injury and trauma, the introduction of technology as an inpatient was too soon for some participants [3,18].
• Where technology was introduced long after hospital discharge participants were used to dependency and the changing habit was a hassle [24].
• Difficulty with ease of use. Switch scanning is slow [18].
• Dated and obtrusive the appearance of devices reinforced feeling disabled [18].

TAM outlines that attitude becomes 'intention to use’ and 'actual use' [10]. In all of the studies where participants used the technology participants chose to accept and use the devices trialed, with the exception of one participant in Verdonck et al. 2014 [18]. He is described as having expressed only one goal of being able to change television channels. It is reported that his wife was always nearer and quicker! But also, he had the technology introduced 19 years post-injury by which time he had developed dependency which was perhaps difficult to change.

Discussion
This study sought to identify the international literature related to technology adoption in people with a severe and enduring disability who may want and need to regain an element of control of their environment following impairment.  The complex nature of technology adoption across different healthcare systems is an important topic for OTs working with clients who are accommodating to disability [25]. This includes the assessment of the acceptability of digital services and devices and the range of purpose and uses for people with spinal injury, across the world.  It is also important to recognize that whilst some devices are tested in a research context, the application is dependent on access via purchase or procurement on the open market or through health provision.  This study focuses on the latter, the adoption of technology outside the research environment.  People with spinal injuries who chose to adopt technology reported strong benefits associated with successful use yet had to overcome difficulties with learning, maintenance, and lack of technical support [3,2,18,24,21]. The focus of OT has generally been to assess individuals' functional needs and to match the technology to their requirements; what works well for them to achieve particular functional goals.  This depends on the level of injury and the opportunities and limitations within the community/ home environment. An additional requirement with the emergence of mainstream digital services is to make the patient aware of the enabling methods and services that could supplement their care, providing that they are willing to accept technology-based solutions.  This variation in the willingness and ability to use technology is an additional part of the assessment process as OTs co-design the home with the patient and enable the patient and their family to prioritize resources and become an expert in selecting the most appropriate technologies.

This research draws in the experiences of successful assistive technology users, providing further information about the range of ways that a patient responds to digital devices in the community.  The barriers to using or non-adoption are also highlighted but this evidence is limited by the fact that the majority of the studies [3,2,18,24,21] used purposive sampling and therefore may have reduced the number of patients who were non-adopters. The literature reviewed demonstrates that participants displayed a strong interest in technology to achieve autonomous computer access and control the environment. Including the view that mainstream technology was more desirable because its appearance was not additionally stigmatizing and normalized the user in society. This evidence is somewhat limited by small numbers of participants and purposive sampling  [3,2,18,24,21]. Whilst impossible to generalize this result is important and reflects the potential of technology to enable full participation in community and a further degree of independence and self-management; profoundly changing the expectations of disabled living [26]. The survey [9], had large numbers of participants but gauged their pre-use beliefs and needs only and did not include any statistical analysis. In 2018 a Parliamentary committee reviewed the use of mainstream technology versus traditional assistive technology to enable people with disabilities to return to work [27]. They found that assistive technology was a critical employment resource with benefits for the user and economy. They found that traditional assistive technology was outdated and recognized the value of mainstream technology. This adds weight to the need to investigate which mainstream technologies work well for which groups of users.  The matching Person with Technology (MPT) model [28] is an alternative model that could be used to assess the needs of the user and apply these to technology selection.  Significantly the MPT includes a perspective on the timing of the adoption which is not included in the Technology Acceptance Model [10]. For disabled people returning to employment, the TAM is useful because it relates specifically to computer technology that can be applied to all populations and applied within a rehabilitation context.

Study participants placed value on their devices not only to achieve the expected independence goals but also to report psychological benefits from being able to be alone [2,21]. The qualitative studies showed a depth of evidence in some narrative accounts of people using devices including “freedom because if you can’t get out of bed you can still talk to people’ (Tom) and “It has allowed me to work and allowed me to make money, and good money” (Jarred) [3]. Similarly, important, being alone is enabled by using a digital device to call for help if needed and highlights the importance of the ways that mainstream technologies need to be consistent and reliable, even in the context of potentially unreliable internet connections. The Technology Acceptance Model [10] applied to the literature was found to be useful for highlighting how users’ attitude to technology influences the likelihood of successful continued use of the equipment. The Needs Assessment Checklist is a recognized assessment tool and outcome measure for people with Spinal Cord Injuries [29]. This is used to structure rehabilitation to focus the team on providing a patient-centered goal-setting approach which is essential to facilitate good outcomes. The psychological response to injury and trauma often means that the introduction of assistive technology during inpatient assessment is too soon for some future users [3,18]. Furthermore, inpatient participants were not yet sure about perceived use due to injury-causing an altered state of being [3]. Yet for others, the introduction seemed to be too late with participants who had been at home for 3 – 35 years being used to dependency on carers. [24]. Further research is needed about the transference of dependency from carer to technology, as it becomes accessible talking about [29], Reports of participants benefitting from not being dependent on their careers, such as feeling less of a burden [18,21] and the benefit of being alone [2, 21] are significant here.

The timing of an assistive technology intervention has been usefully critiqued [22] who addressed the importance of adoption within a wider outcome’s framework.  This work recognized the importance of managing the expectations of the user in the delivery of assessment services and also the capability of the user in the planning for technology.  It is highly relevant to this review that the conceptual framework for technology preparation and adoption is used in occupational therapy practice to improve person-centered outcomes [28]. The pervasiveness, complexity, and sophistication of technology are increasing at a phenomenal rate and while this growth is enabling technology to play a more prominent role in supporting people living with life-limiting conditions and their care partners in a wide variety of ways, it is more critical than ever to consider who chooses and advises on the adoption [29]. One of the models discussed in Gitlin’s model (1998): Biopsychological framework and concept of career, as a person with disability [30]. It identifies a pathway of changing needs as the user progresses from novice as an inpatient through early user at home to experienced user and expert user. It highlights the different needs of the user at different stages and importantly the concept of a change in “environmental fit” at home. This concept of suitability for use in the environment is a common theme throughout all the six models discussed by Lenker et al. [30]. The conclusion of this review was, “The lack of a fully realized predictive model for assistive technology outcomes research indicates the need for development and validation” [31]. A more recent review [17] reported that new conceptual models of assistive technology are under development and Scherer’s Matching Person with the technology model (MPT) was the most mentioned. This has three guiding elements. Technology – its functions and characteristics, Social medium/environment, personal and psychosocial factors. The International Spinal Cord Society states that “without outcomes research in the area of assistive technology for people with spinal cord injury, it will be difficult to determine what works, how well it works and for whom it will work” [8]. Since there was no evidence found relating to the U.K. population there is a need for further research. There is a standard for classifying the neurological level and extent of spinal cord injury, The American Spinal Injury Association Impairment Scale (AIS A-E), (International Perspectives on Spinal Cord Injury page 30), this will enable future researchers to compare which technologies work best for each level of injury.

Strengths and Limitations

• The studies which explored actual technology use [3,2,18,24,21] had low numbers of participants, so it is not possible to draw conclusions about which technologies work well for each level of injury or any demographic group.
• Within the published literature there were no studies relating to participants within the United Kingdom.
• This study aimed to take a contemporary view and so the literature reviewed was limited to within the last 6 years. This may have excluded some literature relevant to the discussion relating to technology acceptance and adoption.
• Some critical factors have been explored that serve to promote the assessment, acceptance, and adoption of computer / digital technology and environmental controls.
• The study limited scope to those in the community seeking to use technologies and has not explored hospital-based technology use.

Conclusions
People with Spinal Cord Injuries are beginning to provide compelling testimonies of the benefits of assistive technology to access computers and control their environments. The literature associated with the adoption of digital assistive technology in the community is somewhat limited but practical aspects associated with individual need and capability are clear.  New users need support, over a period of time, to enable them to benefit from the range of devices available. The role of the OT is to assess the user’s capability and capacity by exploring their priorities for occupations and activities and to be sufficiently knowledgeable about the usefulness of the technology in the context/home environment.  This study was an initial inquiry into evidence that could support OT practices and services within a UK Spinal Injury Unit and potentially inform how service users might engage with and adopt technology in their rehabilitation.  The goal was to highlight the process of technology adoption when the person with Spinal Cord Injury is psychologically receptive and in the right supportive environment for them. There is a need to increase access to digital technologies to enable patients to express opinions and priorities for ways to overcome new impairments. Technology adoption has not so far been explored fully by Occupational Therapists and this study is important because it highlights the need for a radical approach to the knowledge, understanding, and capability of practitioners to advocate for people living with disabilities; to independently participate in a society where digital technology is increasingly becoming part of daily living. Technology has the potential to promote increased self-esteem and economic benefits such as employment. Further research is needed to investigate which technologies work well for people, according to the level of injury within the community environment. The review identifies a gap in studies that inform digital technology adoption by people with spinal cord injury and the best practice by rehabilitation practitioners in the U.K

Conflict of interest: No other conflict of interest.

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