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Factors Associated with Assistive Technology Discontinuance Among Individuals with Disabilities.

Assistive technology devices enable individuals with disabilities to participate in society as contributing members. These devices are also credited with helping individuals with disabilities achieve optimal functional ability and independence (Phillips & Zhao, 1993). Furthermore, technology is recognized as a means for individuals with disabilities to access the mainstream society (Uslan, 1992) and as a mode to potentially equalize the capabilities of persons with and without disabilities (Scherer, 1993a). According to the National Center for Health Statistics, more than 17 million Americans used an assistive technology device in 1994 to accommodate for an impairment (National Center for Health Statistics, 1997, November 13).

The increase in assistive technology use may be attributed to the federal laws passed which support funding for assistive technology devices and services. Although these laws increase the accessibility of assistive technology, many recipients are dissatisfied with devices and services. Dissatisfaction typically results in discontinuance of assistive technology devices. A national survey on technology abandonment found that 29.3% of all devices obtained were abandoned (Phillips & Zhao, 1993). Discontinuance of assistive technology represents a waste of time and money. There is however, limited research documenting factors related to assistive technology discontinuance from consumers' perspectives. It is important to gain an understanding of these factors to aid professionals in designing assistive technology service delivery techniques. The purpose of this study was to determine the factors associated with assistive technology continuance or discontinuance. This article discusses the concepts of Rogers' diffusion of innovation theory and the background literature related to assistive technology discontinuance. The methodology, participants, results and implications of this study are also summarized.

This research is guided by Rogers' theory of diffusion (1995) which offers a comprehensive philosophy regarding the processes involved in accepting or discontinuing use of technology. According to this theory, discontinuance is a decision to discard an innovation after previously accepting it. The two types of discontinuance are replacement (rejection of an innovation for an improved one) and disenchantment (rejection of an innovation due to dissatisfaction). Relative advantage, compatibility, trialability and re-invention are concepts derived from the diffusion of innovations theory. They are examined in the present study to determine if they are related to continuance/discontinuance of assistive technology devices by individuals with disabilities.

Relative advantage is identified as a significant factor associated with continuance or discontinuance of technology. This factor relates to the characteristics of the device itself (Rogers, 1995) and examines the relative advantage that continued use of a device offers a user over discontinuing its use. A study of long term consumers of assistive technology devices indicated that three of the four most important criteria consumers used to assess assistive technology devices (effectiveness, operability and durability) were related to relative advantage (Batavia & Hammer, 1989).

The second concept, compatibility, refers to the degree an innovation is perceived as consistent with the needs of the adopter (Rogers, 1995). According to Rogers, compatibility is a factor related to continued use of an innovation.

Trialability, the degree to which the user can experiment with the technology prior to acquisition, was also related to continued use of technology (Rogers, 1995). Research demonstrated, however, that individuals with disabilities are not often given the opportunity to try out assistive technology devices prior to purchasing them. For instance, Parette, VanBiervliet and Holbrook (1990) found that almost half of the individuals with visual impairments sampled were unable to try out their devices prior to purchasing them. Individuals denied the opportunity to try out technology before purchasing it must rely on the judgment of the professional who selects the device for them (Parette & VanBiervliet, 1992). Theoretically, and pragmatically, trialability has been noted as an effective means to prevent technological discontinuance and promote ongoing use (Parette & VanBiervliet, 1992). It has not, however been fully incorporated into the process of distributing technology to individuals with disabilities.

The degree to which technology is changed or modified by a user in the process of its adoption and implementation is termed re-invention (Rogers, 1995). Many individuals with disabilities have devised additions or modifications to their devices to meet their unique needs (Zola, 1982). As a result of re-invention, technology can become more appropriate in meeting an individual's present needs and more responsive to future needs that arise (Rogers, 1995). Although re-invention was studied extensively from a broad theoretical perspective in the diffusion of innovations theory, empirical research relating re-invention to continued use of assistive technology by individuals with disabilities is nonexistent.

Professional support (`change agent contact') is also a factor related to ongoing use of technology in the diffusion of innovations theory (Rogers, 1995). Rogers indicated that professional support is one of the variables most highly related to continued use of technology. Additionally, research on assistive technology contends that individuals with disabilities without support are typically less successful than those who have it. For instance, individuals without social support often discontinue technology (Scherer, 1993b) with a loss of functioning, learning capacity, employment and/or quality of life (Galvin & Wobschall, 1996). Support services in the form of device training (Raskind, 1993; Scherer, 1993a; Scherer & Galvin, 1996), and device maintenance (Batavia, Dillard, & Phillips, 1990; Scherer & Galvin, 1996; Tewey et al., 1994) were also documented as essential to continued use of assistive technology. Device training and maintenance are not always provided to individuals with disabilities receiving assistive technology devices. Parette and VanBiervliet (1992) found that out of the 680 individuals with mental retardation who were involved in the study, 32% reported not having enough training and more than one-third were dissatisfied with the amount of time required for service of their technology.

In summary, diffusion theorists claimed that innovations that are perceived by individuals as having greater relative advantage, compatibility, trialability and re-invention will be rapidly adopted and slowly discontinued (Rogers, 1995). These concepts are examined in the present study to determine if they are applicable to continuance/discontinuance of assistive technology devices by individuals with disabilities.

In addition to the variables in Rogers' theory described above, researchers identified two other factors associated with abandonment. These are consumer involvement and changes in consumers' needs. A review of the literature revealed that there is consensus that consumer involvement in the selection, acquisition, use and maintenance of assistive technology devices is important (Carroll & Phillips, 1993; Freeman & Field, 1994; Phillips & Broadnax, 1992; Scherer, 1993a; Tewey et al., 1994; Turner et al., 1995). Other research results demonstrated that devices are discontinued less frequently when users believe their opinions are taken into consideration in the selection process (Gradel, 1991; Phillips & Zhao, 1993).

A change in consumers' needs has also been cited as a significant cause of discontinuance of assistive technology devices (Tewey et al., 1994). Researchers indicated that changes in individuals with disabilities' priorities and/or needs, rather than problems with assistive technology devices, often results in device discontinuance (e.g., Parker & Thorslund, 1991; Phillips & Broadnax, 1992: Scherer & Galvin, 1996). Overall, some technological discontinuance is to be expected as individuals with disabilities experience changes in their lives.

In summary, researchers have studied a variety of consumer and assistive technology device variables in an effort to predict use versus discontinuance of assistive technology devices. However, to date, no studies examine the relationship between continuance/discontinuance of assistive technology devices and a combination of predictor variables (relative advantage, compatibility, trialability, re-invention, support, consumer involvement, and changes in consumers). The hypothesis of this study was that there is a relationship between assistive technology discontinuance among individuals with disabilities and a combination of independent variables (relative advantage, support, consumer involvement, trialability, changes in consumers, re-invention and compatibility).

Method

Instrument Development

A survey was designed to identify those factors most closely associated with assistive technology device discontinuance among individuals with disabilities. It was based upon the diffusion of innovations theory and background literature regarding assistive technology use and discontinuance. The survey was developed to be appropriate to a wide range of individuals with disabilities and to be administered over the telephone. It was primarily a structured, closed form interview with four open-ended questions. Content and construct validity were assessed through a panel of five experts with disabilities who used assistive technology, and two professionals in the field of rehabilitation and assistive technology. Each panel member worked independently and made recommendations directly to this researcher. Any recommendation received two or more times was incorporated into the survey. The instrument was revised four times based on the input received from the expert panel.

The final survey contained items requesting information relating to the dependent variable and each of the independent variables. The dichotomous dependent variable was assistive technology continuance/discontinuance and was measured by the question, `Are you still using your assistive technology?'

The independent variables were factors associated with the continuance/discontinuance of assistive technology devices. Questions related to these variables addressed the issues of relative advantage of device use, support received for ongoing use, consumers' perceptions of their involvement in the assistive technology device selection process, their ability to try out devices prior to purchasing them, the degree to which their devices were `re-invented,' and the compatibility of their devices.

Separate scales were developed to assess each independent variable on the instrument. The independent variable, relative advantage, was measured by asking respondents nine questions. For instance the questions, `How dependable would you say your assistive technology is?' (-l=not dependable, l=dependable, 2=very dependable), and `How hard is your assistive technology device to use?' (-2=very hard, -1 =hard, 1 =easy, 2=very easy) were asked to measure relative advantage. Response categories that measured the benefits of device use were given positive rankings, whereas the categories that measured the costs of device use were given negative rankings. The items were added and a relative advantage score was determined for each respondent. The higher the score the more the device benefited the consumer. The scores for relative advantage ranged from 4 to 29 with a mean score of 18.25.

The independent variable compatibility was measured by the question; `Does your assistive technology meet your needs?' Participants could respond with scores ranging from 0 to 2. A score of 0 represented an assistive technology device that did not meet any of the respondent's needs, and a score of 2 represented a device that met all of the respondent's needs. Scores for compatibility ranged from 0 to 2 with a mean score of 1.13.

Trialability was measured by the following question: `How long did you get to try out your device before it was purchased?' (1=I did not get to try it out at all, 5=I got to try it out for more than one month). The scores ranged from 1 to 5 with a mean score of 1.65.

Re-invention was measured by asking the participants to respond to the following question: 'Your device was customized/modified before you began using it due to: (l=it was not changed, l=its appearance, l=professional/family/friend told me to, l=for ease of use, l=for personal safety, l=for comfort). Participants were prompted to select all response categories that applied. The number of categories selected were counted to obtain each respondent's total score for re-invention. The higher the measured score, the more the consumer's device had been changed. Scores ranged from 0 to 3 with a mean score of 1.06.

The questions, `Was any training provided for your assistive technology?' (l=yes, 0=no) and `Does/did anyone encourage you to use your assistive technology?' (l=yes, 0=no) were asked to measure assistive technology support. This variable was measured by seven items on the instrument. These items were added to determine a score for support for each respondent. The higher the measured score, the more assistive technology support the consumer received. Scores ranged from 0 to 20, with a mean score of 5.09.

Consumer involvement was measured by asking respondents, `Do you feel you were (0=not, l=somewhat, 2=very) involved in deciding upon the device?' Scores ranged from 0 to 2 with a mean score of 1.

The variable changes in consumers, was measured by asking respondents the following two questions: `Have you changed since you started using your assistive technology?' (0=no, 1 =yes) and if so, `How have you changed?' (l=physicaly, l=mentally, 1=emotionally). Participants were instructed to select as many of the response categories that applied and these categories were counted to determine a score for changes in consumers. The higher the measured score, the more the consumer changed since first receiving his/her assistive technology device. The scores ranged from 0 to 4 with a mean score of 1.51.

Procedure

The Local Resource Teams (LRTs), responsible for the distribution of the assistive technology devices provided from four to 56 individuals with disabilities with funding for assistive technology through the Technology-Related Assistance for Individuals with Disabilities Act (1988) grant. Twelve LRTs provided funding for assistive technology and 10 participated in this study.

Of the 10 participating LRTs, five had complete information regarding recipients of assistive technology. The names of the recipients were provided by three of the LRTs. Telephone and Internet searches were used to locate these recipients. The remaining two participating LRTs contacted the recipients directly to request that they contact the author if they were willing to participate.

A letter was sent to individuals that explained the intent of the study, assured that confidentiality would be maintained, and indicated that the researcher would be contacting each participant by telephone to schedule a convenient time to conduct the survey. Additionally, the first eight questions of the survey were included with a self-addressed, stamped envelope. It was requested that the participants complete these background questions and return them to the researcher. The total number of individuals with disabilities who received funding for assistive technology, as indicated by the 10 participating LRTs was 205. Of these 205 individuals, 115 (56%) participated in this study.

Several research methods increased the reliability and predictive power of this study. The recommended sample size of 15 participants per predictor variable (Stevens, 1992) was employed to increase the chance of rejecting a false null hypothesis. Additionally, all interviews were administered consistently at the consumers' convenience to increase the reliability of the instrument.

Participants

The sample used in this study was comprised of the 115 individuals with disabilities who were selected to receive funding for 136 assistive technology devices and agreed to participate. The majority of the individuals reported receiving one assistive technology device (72.8%), however 16% reported receiving two devices and 11% received three devices. Each device was analyzed as an individual case as the consumers who received more than one device treated the devices differently. Assistive technology devices went to 71 males and 65 females. Many of the devices were provided to individuals under age 20 (30.1%), however devices were funded for individuals of all age categories up to and including individuals over the age of 70. Individuals with physical disabilities accounted for the highest number of recipients (30.9%) followed by cerebral palsy (24.3%), visual impairments (21.3%), hearing impairments (13.2%), learning disabilities (7.4%), brain injuries (5.9%), developmental disabilities (3.7%), and mental disorders (2.9%). Other disabilities included autism, seizure disorder, Tourette's syndrome, fetal alcohol syndrome, non-verbal disorder and vocal cord scarring.

The education level of the people who received funding for devices ranged from less than high school degrees (38.2%) to doctorate degrees (7.4%). At the time of the interview, 27.2% of the recipients were employed, 43.4% were not employed and 28.7% were under 18 years of age.

Results

Frequency distributions related to assistive technology devices distributed to individuals with disabilities were computed (Table 1). These devices ranged from 'high tech' devices such as personal computers to 'low tech' devices such as canes and reachers. The three devices obtained most frequently were computers (21%), followed by communication devices (16%), and adapted software (7%).

Table 1

Assistive Technology Devices Received by Individual with Disabilities and the Distribution of Devices that were Discontinued in Use
Device # Recipients % # Discontinued

Computer 29 21 8
Communication device 22 16 8
Adapted Software 9 7 3
Scanner 7 5 2
Van lift 7 5 2
Braille embosser 6 4 1
Hearing aids 6 4 0
Battery operated scooter 5 3.7 2
Wheelchair 4 3 2
Computer upgrades 3 2.2 1
Printer 3 2.2 1
TDD 3 2.2 2
Adapted keyboard 2 1.5 0
Amplified phone 2 1.5 1
Chair lift 2 1.5 0
Environmental control unit 2 1.5 1
Hand controls 2 1.5 1
Reacher 2 1.5 0
Shower chair 2 1.5 1
Standing frame 2 1.5 0
Adapted knife 1 .7 0
Adapted toys 1 .7 1
Adapted tricycle 1 .7 1
Auditory trainer 1 .7 1
Cane 1 .7 1
CCTV 1 .7 0
Computer mount 1 .7 1
Leg braces 1 .7 1
Microphone 1 .7 1
Page turner 1 .7 1
Phone 1 .7 0
Reading light stand 1 .7 0
Tens unit 1 .7 0
Tape recorder 1 .7 0
Word processor 1 .7 0

Total 136 100 44


The assistive technology devices that were still in use or replaced by an updated version made up 67.6% of the sample. The assistive technology devices that were updated were classified in the 'continued use' group, as the recipients were still using the devices. The devices that were discontinued and not replaced by an updated version made up 32.4% of the sample. Of the individuals who discontinued their devices, the largest category of recipients (46.7%), used their technology one to three years prior to discontinuing its use, however 6.4% of the devices were never used.

The independent variables were examined in relation to discontinuance of assistive technology via logistic regression analysis. This model was employed to determine which factors as a group were related to assistive technology discontinuance. Backward elimination procedures were used to test the full model and to ascertain the individual contributions of the predictor variables. The likelihood ratio test was the criterion in these procedures applied to determine the independent variables to be removed from the model. As a result of this analysis all variables were eliminated by this analysis except relative advantage and consumer involvement. The classification model with relative advantage and consumer involvement present correctly classified 74.59% of the assistive technology devices. These results indicate that there is a relationship between relative advantage and consumer involvement and assistive technology discontinuance among individuals with disabilities.

Individual t-tests were conducted to further examine the independent variables and determine if there was a significant difference between those who discontinued using assistive technology devices and those who continued to use the devices in relation to each independent variable. The tests were all two-tailed with an alpha level of .05 (Table 2). The results of the t-tests indicated that individuals who continued to use their technology had significantly higher mean scores than those who discontinued use of their technology in relation to relative advantage, consumer involvement and compatibility.

Table 2

Results of t-Tests Related to Assistive Technology Discontinuance and Independent Variables
Variable n Mean SD t-value p

Relative Advantage
 Discontinued 44 16.40 4.44 -3.89 .000(*)
 Use 92 19.14 3.48

Compatibility
 Discontinued 44 .87 .72 -3.01 .004(*)
 Use 92 1.25 .51

Trialability
 Discontinued 42 1.83 1.19 1.22 .22
 Use 88 1.57 1.14

Re-invention
 Discontinued 44 .98 .26 -1.86 .066
 Use 92 1.10 .49

Support
 Discontinued 37 5.81 3.60 1.26 .210
 Use 91 4.80 4.3

Consumer Involvement
 Discontinued 44 .64 .84 -3.40 .001(*)
 Use 91 1.18 .88

Changes
 Discontinued 44 1.55 1.27 .25 .81
 Use 92 1.49 1.24


(*) p < .05, two-tailed

Discussion

The results of the study are consistent with Rogers' innovation diffusion theory. The fact that relative advantage was significantly related to continuance/discontinuance lends support to this theory. Diffusion of innovation theorists claimed that an individual's perception of the benefits and costs (relative advantage) of using an innovation will affect its rate of adoption or discontinuance (Rogers, 1995). Furthermore, diffusion scholars found relative advantage to be one of the best predictors of an innovation's rate of adoption or discontinuance. The current study supported these claims as relative advantage was associated with continuance/discontinuance of assistive technology.

This result is also consistent with the literature on assistive technology discontinuance. Several characteristics of relative advantage have been related to consumers' decisions to use or discontinue use of assistive technology devices. A survey on assistive technology abandonment by 25 new users demonstrated that characteristics of relative advantage (effectiveness, reliability, ease of use, comfort, enhancement of the user's performance) were significantly related to abandonment of technology (Carroll & Phillips, 1993).

Compatibility was not a significant predictor of assistive technology via logistic regression analysis (p [is greater than] .05). This may be due to the slight intercorrelation (r=.24) between the independent variables compatibility and relative advantage. Relative advantage was a significant predictor in the logistic regression equation, and compatibility did not improve upon the predictive value that relative advantage offered.

Consistent with the literature on assistive technology, consumer involvement was related to assistive technology continuance/discontinuance. The literature demonstrated that consumers who do not believe that they are involved in the selection of their assistive technology devices, are more likely to discontinue using them than individuals who feel involved (Carroll & Phillips, 1993; Freeman & Field, 1994; Phillips & Broadnax, 1992; Tewey et al., 1994; Turner et al., 1995). The significant inverse relationship between consumer involvement and discontinuance of assistive technology provides further justification for professionals to involve individuals with disabilities in all aspects of decision making. Consumer involvement is not a new concept in the field of rehabilitation and has been discussed extensively in the literature. Several authors noted that a consumer-driven model provides the consumer with a sense of ownership and responsibility which often leads to continued use of assistive technology (Mallik & Elder, 1993; O'Day & Cocoran, 1994; Reed, Fried, & Rhoades, 1995; Scherer, 1993a).

Although the idea of consumer involvement is not new, many professionals in the field of rehabilitation continue to function within a medical model. The medical model is the traditional service delivery model, and supports a role of passivity for the consumer and the role of decision-maker for the rehabilitation professional (Gradel, 1991; Reed et al., 1995; Williams, 1991).

Therefore, the findings from this study support the literature on assistive technology regarding the importance of consumer involvement. However, consumer involvement has not become a practice fully implemented into the rehabilitation process. A recommended procedure for decreasing the rate of discontinuance of assistive technology devices and increasing user satisfaction is to involve consumers in the selection, acquisition, training, implementation and ongoing use of assistive technology devices.

Based on the results of this study several recommendations are appropriate for future researchers and practitioners to consider. The recommendations are based upon insight gained from conducting this research, and an understanding of the literature related to assistive technology discontinuance.

1. The results generated from this study should be regarded as exploratory due to the small sample size drawn from the state of Colorado. Future research examining assistive technology continuance/discontinuance using a random sample of persons receiving assistive technology across the nation is necessary to increase the generalizability of the findings.

2. Future research is necessary to breakdown assistive technology discontinuance into meaningful categories such as age, gender, educational level and disability.

3. Discussion relating to the rate of discontinuance (in addition to the existent discussion of rate of adoption) would be an asset to the diffusion of innovations theory. Longitudinal outcome studies conducted on various assistive technology devices could help researchers examine patterns of device use and discontinuance. This would aid in determining the average time various devices are functional.

4. Careful analysis of the costs and benefits of device use from the consumer's perspective is necessary for professionals to conduct prior to device selection. The advantage a device offers a user must outweigh the costs of using it or the device will most likely be discontinued.

5. Consumers must be involved in the selection of their assistive technology. Abandonment would be decreased if a collaborative, consumer-oriented model were utilized in all technology service delivery environments.

A recommended model acknowledges both consumers and professionals as team members. Initially, the consumer is educated about assistive technology choices, financing options, training and resources for maintenance. The consumer then contributes knowledge of his/her personal needs, goals, values and preferences. Solutions are generated through an open exchange of information with all the team members. Finally, the consumer selects the assistive technology that best fits his/her needs. Overall, the findings of this study support two key elements related to successful use of assistive technology. The consumer must be involved in the entire process and the technology must meet an important functional need.

References

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Robbyn R. Wacker University of Northern Colorado

Marti Riemer-Reiss, Ph.D., CRC, Montana State University-Billings, Department of Counseling and Human Services, 1500 North 30th Street, Billings, MT 59101.
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Author:Wacker, Robbyn R.
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Date:Jul 1, 2000
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