SP2-2-1
LIFE2012

2012 年 11 月 2 日－4 日 愛知 (名古屋大学)

Function and Feelings: Assessing Psychosocial Outcomes for Assistive Technologies
Jeffrey W. Jutai 1,2
1Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada
2
Bruyère Research Institute, Ottawa, Canada

Abstract:
Purpose. The aim of this paper is to highlight the achievements and limitations of research on assessing the outcomes ofassistive technology interventions for enhancing function and wellbeing.
Method. The research evidence for the impact of assistive technologies on psychosocial outcomes is examined. Several
approaches to improving the quality of outcomes research pertaining to assistive technologies are described. They include
acknowledging that assistive technologies are complex health interventions, the importance of grounding research inwell-developed conceptual frameworks and theories, and the need for measurement tools that are accessible and easy to use.
Results and Conclusions. There have been significant advances in approaches to assessing psychosocial outcomes forassistive technologies. Several promising measurement tools have been developed; however, fulfilling the promise ofpsychosocial assessment has been difficult because of slow adoption of measurement tools by researchers and health care
professionals. More effective methods for knowledge translation are needed.
Key Words: Assistive technology, outcomes research, psychosocial outcomes, quality of life, wellbeing
1. Psychosocial outcomes for assistive technologies
1-1 Conceptual framework
Assistive technologies are tools that enhance the independentfunctioning of individuals who have physical limitations or
disabilities. They include products such as wheelchairs, lowvision aids, prosthetic limbs, and environmental control devices.
Without their assistive technology devices, the many individuals
with disabilities and chronic conditions in the world today
would have severe restrictions on their ability to perform life
activities and participate in society.

Fig. 1 Conceptual framework for relating technology to
improvement in quality of life and wellbeing.
Source:adapted from Ohnabe, 2006.
It is helpful to distinguish the effects of medical and assistive
technologies since the latter are especially important insupporting function (Figure 1; Jutai et al., 2009). Medical
technologies are more narrowly defined, and are designed forassessment and intervention at the level of physical health andhealing or, in the language of the International Classification of
Functioning, Disability and Health (ICF), body function andstructures (World Health Organization, 2001).
Medicaldevices are not designed to directly and appreciably improve
quality of life (QoL) and wellbeing. These improvements aremuch more influenced by assistive technology (AT) which helps−1−

individuals to engage in life activities and participate in society.
Assistive technology provides a platform to support health andwellbeing as defined by the WHO.
Well-being and related constructs of quality of life andpsychological functioning are part of a constellation that makes
up the human experience with technology and so may be
inseparable. There is no universally accepted definition ofquality of life (QoL) but some approaches to definition lendthemselves to measuring the impact of technology better thanothers. In our research on the impact of assistive devices forindividuals who have a physical or sensory disability (Jutai etal., 2009), we have adopted the position that QoL refers to thedegree to which a person enjoys the important possibilities ofhis/her life. This is a definition that speaks directly to thethemes of this conference because it compels us to focus on themost important goals for technology in supporting humanexistence. In defining wellbeing, we refer to the degree to which
individuals have positive appraisals and feelings about theirlives, considered altogether or in terms of particular domains,such as health and recreation (Fuhrer, 2000). Research has
examined how devices make users feel more competent,
confident, and motivated to exploit life’s possibilities (Jutai,
1999; Jutai and Day, 2002).
Assumptions about these
constructs and how they are affected by technology include thatthey (1) are complex and multidimensional; (2) are dynamic,changing over time and over a person’s life; (3) arise from theindividual’s interaction with his/her environment; and (4) areexperienced differently from person to person, but have thesame components for everyone (Jutai, 1999). Approaches tooutcome measurement should be faithful to these assumptions.
The relationship of technology to function and wellbeing isdifficult to measure but not impossible (Fuhrer et al., 2003;
Jutai et al., 2005).
We have published frameworks for research that are
significantly advanced over previously published formulations(Demers et al., 2009; Fuhrer et al., 2003; Jutai et al., 2005;

Scherer et al., 2007). They are richly detailed in accounting forthe most influential sources of variation in AT outcomes, as
identified in classification systems such as the ICF. They haveinvited the application of promising innovations in longitudinal
data analysis to more sensitively examine the dynamic processes
for assistive technology device (ATD) procurement, utilization,and outcome. Rather than being merely descriptive, they haveprovided a sound structure for rigorous hypothesis testing andevaluation of extant instruments, to support measurable growthin the knowledge base in this area. These developments havelaid a firm foundation for the meaningful measurement of the
impact that various ATDs and services have on the lives ofpeople who have disabilities.
1-2 Research evidence
Answering the question, Does assistive technology work?, isdifficult. In large part this is due to the limitations of existing
health and rehabilitation outcome measures, the preponderanceof which has one of three limitations: (a) AT impact is not at all
considered; (b) use of AT lowers the functional impact score; or(c) the impact is not attributed to specific AT devices (Rust &Smith, 2005). These limitations are reflected in the AT outcomes
research literature. Our review of 20+ years of published AT
outcomes research (Lenker et al., 2005) revealed several
measurement trends. Device usage and usability accounted foralmost 70% of the dependent variables appearing in theliterature. Outcome domains such as functional level,
participation, and quality of life accounted for less than 30% ofreported outcome variables. Of 212 outcome variables reported
in 82 reviewed articles, 79% (N=168) of the variables were
measured using non-standardized, study-specific measurement
tools. Among these studies, there was scant reporting of thepsychometric properties of the measurement tools used. As aresult of the field’s approach to measurement, the AT outcomes
research literature is vulnerable to one of three fundamental
flaws: (a) genuine treatment effects may be undetected becauseof measures that have weak reliability; (b) tools lacking validity
may result in systematic underestimation, overestimation, or
misrepresentation of treatment effects; or (c) the impacts of AT
in outcome domains of interest are simply not measured (Jutai,2011).
Other limitations of measurement tools include narrowly
defined outcomes domains, lack of comparability of results
across instruments, and unacceptable tradeoffs between
instrument precision and practical implementation. Additionally,
many measurement tools cannot be used across the variety ofsettings in which physical rehabilitation services are provided,
nor along the continuum of care (Jutai & Southall, 2012).
From both a clinical and policy viewpoint, a principal
justification for providing AT to people with disabilities is that it
reduces their dependence on human assistance. In the proposed
Taxonomy of Assistive Device Outcomes (Jutai et al., 2005), theimpacts of AT on caregiving relate to objective and subjective
assessments of the nature and amount of effort involved inproviding care for the AT user. Assistive technology outcome
studies have paid scant attention to the impacts of thattechnology on users’ caregivers. To appreciate the full impact of−2−

AT intervention on particular activities, one must understandhow both users and caregivers are affected. In a related vein, thecurrent literature provides little information about the benefitsof providing AT interventions in the home, especially as they
impact on caregivers (Mortenson et al., 2012).
2. Improving the quality of outcomes research
Assistive technology devices readily qualify as “complex healthinterventions” to which the structural framework for
hypothesis-driven experimental work outlined in Figure 2
applies.

Fig. 2 Structural framework for development and evaluation of
randomized controlled trials for complex health interventions
The measurement of QoL impact is considered to be very
important in the management of AT outcomes (Minkel, 1996;
Scherer, 1996). Emphasis on collecting data from the patient’s
perspective parallels a shift in theoretical premises in the fieldof rehabilitative technology, from a medical assessment model
to a client-centered perspective (Oldridge, 1996; Scherer, 1996).
The task of examining the impact of AT on QoL represents a
considerable and unique challenge compared to measuring theother important outcome domains, including clinical results,
functional status, satisfaction, and cost, because it focuses on
the individual’s subjective experiences. As such, it is subject
to multiple personal, technological and environmental
influences.
To measure the QoL impact of assistive technology in astandardized, objective and measurable fashion requires
specifically designed tools. One such tool, the Psychosocial
Impact of Assistive Devices Scale (PIADS) (Day & Jutai, 1996)
is available to the English- and French-speaking communities in
Canada (Demers et al., 2002). The PIADS is an assessment
tool which has been shown to reliably predict the adoption of AT.
The scale has a good reputation in Canada and the USA and has
been shown to reliably predict the successful use of AT (Jutai etal., 2003, 2006; Saladin & Hansmann, 2008).
AT outcomes, including impact on participation as defined by
the ICF (WHO, 2001) must be understood and measured within
the context of personal choices and activity-level factors. The
inherent complexities of this model can only be measured

efficiently using dynamic assessment techniques, such as
computer adaptive testing (CAT) built on item response theory(IRT) approaches (Jutai & Southall, 2012).
Our research has also revealed that ATD users have some
expectations for the impact of assistive technology that are noteasily measured. Assistive technology outcome assessment
should consider approaches that combine questionnaires withother methods for obtaining end-user perspectives onparticipation (Jutai & Southall, 2012).
3. Adoption of approaches to outcome assessment
While the field of assistive technology has in general beenlacking specific instruments relating to outcomes measurement,
there are a few standardized/non-standardized instruments
available along with several new instruments currently underdevelopment. For those existing instruments, each requires
paper/pencil completion resulting in significant effort andresources for entry into a central database and subsequent data
analysis. The collection and capture of outcomes data should
be at the point of service and could be greatly facilitated throughthe utilization of web-based interfaces and/or platform
independent portable devices for direct outcomes data entry.
In addition, the management and reporting of AT outcome data
could also be organized through web-based interfaces. We
have made several proof-of-concept and beta-testing efforts todemonstrate feasibility and functionality of improved AT
outcome data capture, management and reporting tools (Figure
3; DeRuyter et al., 2010).

research, and thereby the potential benefits from its results, topopulations of persons with disabilities worldwide. The topic
is very timely given the significant interest worldwide in
developing international standards relating to AT, and recent
developments in emerging global consensus on the role of AT inpromoting health and well being (Lenker & Jutai, 2002).
Also, recent demographic trends identify a need for having
available measurement instruments in languages other thanEnglish, to accommodate the large linguistically and culturally
diverse populations of AT users in North America.
Internationally-translated and evaluated PIADS questionnaires
will also allow developers of AT to develop devices which havegreater uptake and will therefore benefit the companies making
AT, as well as the users. The questionnaire can be used toevaluate the different features of technology that are preferredby users of all ages from many culturally diverse groups. This
will ensure that “one size fits nobody” technology is identified
and rejected in favour of technology which is preferred bypeople with a wide range of backgrounds and needs.
International translations of the PIADS questionnaire will also
allow purchasers of AT to recognize which technology ispreferred by users and therefore, with a higher adoption rate,
more people will benefit.
4. Conclusions and Recommendations
Few doubt the general proposition that AT has the potential toenhance users’ functioning, and in the process, to allow them tobe less dependent on the assistance of others. However, for avariety of stakeholders, that generality needs to be buttressed bysystematic evidence applicable to defined users and specifictypes of AT. A more in-depth perspective of the multiple
outcomes that people with disabilities and their caregivers
obtain from an AT intervention would enable service providers
to derive recommendations that are adapted to their concerns.
Without research and resultant improvements in measurement
tools, consumers are denied access to highest quality AT
outcomes research and, therefore, the benefits to their quality oflife and wellbeing that might come from this research.

Fig. 3 AT outcome data collection tools
It is imperative to invest in improving the evidence base for theeffectiveness of AT.
Another approach is to encouragesignificant development in international collaboration on
guidelines and standards for AT outcome measurement. We
have established a working collaboration with international
colleagues to research and develop translations for the PIADS.
Currently, there is no international scale to assess the impact ofATs, although we have begun to translate the PIADS scale dueto the pressing need for this type of outcome measure. The
many important advantages to having AT outcome measurement
instruments, such as the PIADS, available in different world
languages include: (1) increased opportunities for international
scientific collaboration in AT research and advancement of AT
knowledge base; and (2) improved accessibility of AT outcome−3−

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