Elderly People's Use of and Attitudes Towards Assistive Devices
Elderly People’s Use of and Attitudes towards Assistive Devices
Hui-Ching (Anita) Yeh BBE(ID) GDID n4405277
BN71 Masters of Applied Science (Research)
Principal Supervisor: Professor Vesna Popovic Associate Supervisor: Dr Alethea Blackler
Keywords
Elderly people, activities of daily living, quality of life, assistive devices, attitudes, performance, frequency of use, effectiveness, sensory devices, bathroom devices, mobility devices.
i Abstract
People in developed countries are living longer with the help of medical advances. Literature has shown that older people prefer to stay independent and live at home for as long as possible. Therefore, it is important to find out how to best accommodate and assist them in maintaining quality of life and independence as well as easing human resources. Researchers have claimed that assistive devices assist in older people’s independence, however, only a small number of studies regarding the efficiency of assistive devices have been undertaken of which several have stated that devices are not being used.
The overall aim of this research was to identify whether the disuse and ineffectiveness of assistive devices are related to change in abilities or related to the design of the devices. The objective was to gather information from the elderly; to identify what assistive devices are being used or not used and to gain an understanding on their attitudes towards assistive devices.
Research was conducted in two phases. The initial phase of the research was conducted with the distribution of questionnaires to people over the age of fifty that asked general questions and specific questions on type of devices being used. Phase One was followed on by Phase Two, where participants from Phase One who had come in contact with assistive devices were invited to participate in a semi-structured interview. Questions were put forth to the interviewee on their use of and attitudes towards assistive devices.
Findings indicated that the reasons for the disuse in assistive devices were mostly design related; bulkiness, reliability, performance of the device, difficulty of use. The other main reason for disuse was socially related; elderly people preferred to undertake activities on their own and only use a device as a precaution or when absolutely necessary. They would prefer not having to rely on the devices. Living situation and difference in gender did not affect the
ii preference for the use of assistive devices over personal assistance. The majority strongly supported the idea of remaining independent for as long as possible.
In conclusion, this study proposes that through these findings, product designers will have a better understanding of the requirements of an elderly user. This will enable the designers to produce assistive devices that are more practical, personalised, reliable, easy to use and tie in with the older people’s environments. Additional research with different variables is recommended to further justify these findings.
iii Table of Contents
Keywords ...... i Abstract...... ii Table of Contents...... iv Statement of Original Authorship ...... vi Acknowledgements ...... vii
Chapter 1 Introduction ...... 1 1.1 Problem ...... 2 1.2 Research Question...... 6 1.3 Thesis Structure...... 7
Chapter 2 Life for Older People...... 9 2.1 Activities of Daily Living ...... 10 2.2 Instrumental Activities of Daily Living ...... 13 2.3 Personal Activities of Daily Living ...... 20 2.4 Quality of Life...... 21 2.5 Differences in Quality of Life in Various Environments...... 27 2.6 Informal Caregivers ...... 29 2.7 Summary...... 31
Chapter 3 Assistive Devices...... 33 3.1 Ownership and Use of Devices...... 35 3.2 Factors Affecting Use of Assistive Devices ...... 49 3.3 Summary...... 55
Chapter 4 Research Plan ...... 57 4.1 Phase One...... 58 4.2 Phase Two...... 60 4.3 Coding of Data ...... 62 4.4 Summary...... 64
Chapter 5 Phase One – Questionnaires ...... 65 5.1 Results...... 66 5.2 Discussion ...... 71 5.3 Summary...... 72
Chapter 6 Phase Two – Interviews ...... 75 6.1 Participants...... 76 6.2 Methodology ...... 77 6.3 Findings...... 77 6.4 Summary...... 97
Chapter 7 Conclusion and Future Directions...... 99 7.1 Recommendations...... 101 iv 7.2 Future Directions...... 102
References …...... 105
Appendices …...... 113
Appendix 1 – Phase One Questionnaire (Sample)...... 114 Appendix 2 – Covering Letter (Sample)...... 116 Appendix 3 – Participant Information Sheet...... 117 Appendix 4 – Aged Care Living Establishments ...... 119 Appendix 5 – Consent Form ...... 120 Appendix 6 – Interview Questions (Sample)...... 121 Appendix 7 – Definition of Codes ...... 122 Appendix 8 – Analysis (Sample)...... 127 Appendix 8 – Assistive Devices...... 130
v Statement of Original Authorship
“The work contained in this thesis has not been previously submitted for a degree or diploma at any other higher education institution. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made.”
Signature: ______Date: ______
vi Acknowledgements
I would like to thank first and foremost my principle supervisor, Professor Vesna Popovic, and associate supervisor Dr Alethea Blackler, for their guidance, support and patience throughout my research. Thank you also to my fellow research colleagues and staff at QUT, for their support, advice and encouragement.
vii
Chapter 1 Introduction
1 1.0 Introduction Developed countries like America, Sweden, Japan and Australia are faced with an issue of an increase in the ageing population. With improved health and technology, people will have a longer life expectancy than in previous generations. For example, Australia’s ageing population is ever increasing, along with life expectancy. “In 1976, 9% of the population was aged 65 years and over. By 2002, this proportion had increased 13% and is expected to increase to 16% by 2016” (Lim & Taylor, 2005 p.34). Hobbs & Damon (1996, in Crist, 2005) suggest that in the USA alone, the percentage of the population which includes people aged 65 years old and above will increase from 12.5% to 20% between the years 1990 and 2030.
According to statistics published by the Australian Bureau of Statistics (2005), Australia’s population of people 65 years and over was 13.1%. There was a 2.4% increase from 2004 to 2005. The proportion of people aged 85 years and over was 1.5% and the people in this population have increased by 6.6% (19,400 people) between 2004 and 2005. The gender ratio for people aged 65 years and older in Australia was 23% higher in females than males, presenting a gender ratio (number of males per 100 females) of 81.6. As age increases to 85 years and older the gender ratio becomes 47.8. This means there are 2.09 females to every male; twice as many females than males. It can be said that women have a greater life expectancy than men (Australian Bureau of Statistics, 2005).
1.1 Problem
There are also, as Quine & Carter (2006) state, 5.5 million baby boomers (born 1946-1965) in Australia. By 2011 the first will reach 65 and by 2021 they will be 75 years of age and yet there is limited published research on what the baby boomers in Australia expect from their old age. The majority of the published works are “speculative rather than evidence based” (Quine & Carter, 2006 p.3). Quine & Carter (2006) state that “in retirement, boomers may refuse to accept that they are ‘old’, may be more ethnically heterogeneous, more selfish, socially polarised,
2 demanding and belligerent, and less accepting, trusting and conforming than their parents’ generation” (p.4). There is also a growth in Australians above 65 years of age wishing to live alone in their homes. It is predicted that the ageing population will increase to 17.3% by 2021 (Fricke & Unsworth, 2001).
In relation to health “it is predicted that Australian baby boomers will not want to move into the new ‘aged care’ phase of their lives, instead striving to continue their current lifestyle into retirement” (Quine & Carter, 2006 p.4). A qualitative study was conducted by Quine, Bernard & Kendig (2006) on Australian baby boomers expectations and plans for their retirement. This was carried out with focus groups with cross-sectional participants. However, the paper only presented findings with topics related to planning, finances, health insurance and responsibility. The most alarming key finding was that many baby boomers had not planned for their retirement. Also, low socioeconomic status baby boomers were the least likely to have planned for their old age due to limited resources and hold the government responsible for future finances as they do not have sufficient superannuation (Quine et al., 2006). Apart from these findings there does not seem to be any further research on Australian baby boomers expectations and ideas for old age.
Consumer products and marketing are already targeting the baby boomers, from household products to automobiles. However, the key to prospering is to avoid mentioning that the product is designed for the aged or ageing market (Hamilton, 1999). The Ford Focus was developed and researched to cater for the needs of older drivers, it was developed “for the first time to ensure the car would be comfortable and usable by all sections of the community” (Wilks, 1999). Many professions and businesses are now shifting design to cater for the older market; the growing ageing population. Professionals in engineering, gerontology, ergonomics and architecture are supporting universal design to enhance independence, lifestyle and choice (Demirbilek & Demirkan, 2004).
It is known that the environment can enhance or decline the independence, quality of life and well being of the elderly. Therefore, it is important that designers should
3 involve the elderly in the design process, as they are the users and have greater knowledge and experience. Although they may all have different criteria and needs older people together share a common interest, which is “living life with dignity” (Demirbilek & Demirkan, 2004 p.369).
In the USA, Hobbs & Damon (1996, in Crist, 2005) estimate “the percentage of elders needing help with at least one activity of daily living (ADL), for example, walking, getting outside, bathing or showering, transferring, dressing or toileting, now ranges from 10% for those 65-74 years to 50% for those 85 and older” (p.485).
It is suggested that basis activities of daily living (BADL) and instrumental activities of daily living (IADL) measurements determine how well older people perform in everyday activities and an ergonomic approach combined with gernotechnology will improve the balance of the user and the environment. Gernotechnology solutions can assist in visual impairments in elderly people, which may reduce the number of falls (Pinto et al., 2000). For example, an age related effect on the human body is the decline in muscular strength and posture. Prolonged sitting and standing creates mechanical stress on joints and muscles. A solution to this problem is the recommendation of an adjustable chair, which can relieve strains and stress placed on the neck and back. Placement of handle bars and grab rails can support elderly during prolonged standing while they are performing an activity (Pinto et al., 2000). In summary, it is using a similar concept as child proofing an environment. Instead of child proofing, it is elderly proofing the environment with an ergonomic and gernotechnological approach which also allows the environment to adapt to change over time (Pinto et al., 2000).
Demirbilek & Demirkan (2004) suggests that a usability, safety, attractiveness participatory (USAP) model could be used to assist in design for the elderly. Babyak (2004) recommended also that knowledge of “ageing, cognition and attention” is needed by professions, to enable them to design for the elderly, to enhance their safety, quality of life and assist in activities of daily living (p.27). However, there are difficulties in designing for the elderly. For instance, it is important to involve older
4 people in the design process, to understand their needs and wants. Professions can only help those that reveal their real concerns and problems. Borglin et al. (2006) comment that older people do not always address their issues when meeting with health or social care professionals, to enable the professions to effectively or correctly assist the elderly in need. The care could therefore be hindered.
Another design issue is poor design. Products may be difficult to use as the targeted market was not addressed. Another common fault among products is degree of difficulty in instruction manuals provided by the manufacturers. They are difficult to follow (Babyak, 2004). A study conducted in association with the Atlanta Diabetes Association tested the use of blood glucose monitors, to observe the problems encountered by novice and experienced users (Babyak, 2004). The results showed that "75% of older adults committed errors on their first attempt to use the device and 25% of younger adults committed errors on the first try" (Babyak, 2004 p.29). This is an example of poor or incorrect design.
Blood glucose monitors would be a good and effective tool to use by individuals in the home. However, this medical device was originally designed to be used in medical practices with trained staff with knowledge in how to use the equipment. When the product was transferred into the home, as Babyak (2004) states, “knowledge needed to properly use them has not always migrated with them” (p.27). To prove the degree of difficulty in using the home blood glucose monitors a study was conducted, which showed that 60% of experienced users made clinically significant errors. “A clinically significant error is defined as something that leads the diabetic user to improperly adjust medication, diet or exertion levels” due to incorrect use and misinterpretation (Babyak, 2004 p.29). This may be a reason for the non-use of products by older people.
Therefore, it is important to involve the users into the design. As Demirbilek & Demirkan (2004) suggest, the mixing of these two approaches; design by users and design for users, “gives better results with higher success rates” (p.362). Although it may be a difficult process as it is not a design for a homogenous group, the outcome
5 of enhancing quality of life and independency in older people is beneficial, as the ageing population is increasing by the year and it will be greater for all people and the environment.
Older people can be classified into “young-old”, “old-old” or “oldest-old”. Young-old refers to people aged between 60-69. Old-old describes people aged between 70-79 and the oldest-old are people that are above 80 years of age (Garfein & Herzog, 1995). The term “elderly” has been defined as people aged 65 or older. “Early elderly” are people aged from 65 through to 74 years and people aged over 75 years are referred to as “late elderly” (Orimo et al., 2006). However, the definitions for the classification of older people vary and are inconsistent. It is also inappropriate to define older people in chronological terms alone (Lloyd-Sherlock, 2000; Zajicek, 2004). There is diversity within older people as they experience the effects of ageing at different rates (Zajicek, 2004). Older people can also be categorised in many other ways; physical appearance, key life events and social roles. However, there is no universally appropriate alternate approach in defining and classifying older people (Lloyd-Sherlock, 2000). Therefore, in this instance people aged 65 years or older will be referred to as either elderly or older people, unless otherwise specified.
1.2 Research Question
As the elderly often wish to remain in their current homes and are less inclined to live with their children or be institutionalised, professionals need to learn and study how to better cater for older peoples’ needs and assist them in going about activities of daily living (ADL) independently and with dignity. Hence, the research question is:
What are elderly people’s use and attitudes towards assistive devices?
6 Aim The aim of this research is to investigate whether the use and non-use of assistive devices by the elderly are related to their abilities or in the design of the product.
Objectives The objectives for this study are to: • identify which assistive devices are being used and not used, • gain an understanding of their attitudes towards the assistive devices, and • inform designers on areas that needs improvement and attention.
1.3 Thesis Structure
This thesis will firstly investigate through literature review the activities of daily living and the quality of life for older people. Followed by literature on assistive devices; ownership, use and non-use of assistive devices and their effectiveness. A research plan was drawn up in preparation for the research. The research study was conducted with participants carried out in two stages, with a questionnaire data collection followed by interview data collection. The data were analysed, compared against the literature review and discussed, to investigate whether assistive devices are effective and efficient in assisting the elderly and whether the cause of disuse in assistive devices is related to change in abilities or to the design of the product.
7 8
Chapter 2 Life for Older People
9 2.0 Life of Older People
It is important to understand and gain an insight into the activities of older people and to investigate what activities older people engage in throughout their everyday living. It is believed that for older people to continue living safely in the community, they need to be independent in personal and instrumental activities of daily living (Fricke & Unsworth, 2001). Also, it has been suggested that in the United States three quarters of elderly people live with a chronic condition and one half of the elderly population suffer from a chronic condition that limits their activities (Blake, 1981 & US Department of Health and Human Services, 1986, in Bowling & Grundy, 1997). Therefore, this chapter will aim to identify what activities older people engage in, have difficulty with and need assistance with, to enable them to go about their daily lives. This chapter will also identify factors that influence older peoples’ quality of life, in the terms of social, environmental, physical and psychological factors.
2.1 Activities of Daily Living
Throughout the years, researchers have been measuring activities of daily living (ADL) in various contexts and settings. They have built on Katz’s original ADL scale, which included six activities; dressing, bathing, eating, getting to and from the bathroom, transferring from bed to chair and continence (Jagger, Arthur, Spiers, & Clarke, 2001). Depending upon the researcher, these tasks and activities have been excluded, further expanded and classified. Continence is no longer measured in ADL estimates as it is seen as a function that can exist with or without a physical disability (Jagger et al., 2001).
Activities of daily living can be categorised into instrumental activities of daily living (IADL), personal activities of daily living (PADL) and basic activities of daily living (BADL). Spector & Fleishman (1998, in Roe, Whattam, Young, & Dimond, 2001) identified activities of daily living as “instrumental activities, which includes using a telephone, shopping, meal preparation, housekeeping, laundry, taking medication,
10 travel away from home and managing finances; and personal activities, such as bathing or showering, dressing, moving or transferring, going to the toilet and feeding” (p.390). In summary, PADL usually refers to tasks that involve personal hygiene, feeding and dressing (Ekwall, Sivberg, & Hallberg, 2004). BADL are tasks or activities that target the essentials necessary for daily living, such as bathing, dressing, feeding, grooming, transferring and mobility in and around the house (Pinto et al., 2000). A majority of these activities tie in with PADL. Instrumental activities of daily living are tasks that are more complicated to complete or undertake, which involve domestic and community participation (Fricke & Unsworth, 2001).
A study was conducted by Hayase, Mosenteen & Thimmaiah (2004) to examine the relationships between ADL ability and age amongst people aged 3 to 93 years. Its aim was to uncover when motor ability and ADL process ability peaks in a person’s lifespan and when it deteriorates or slows down. The participants consisted of males and females from around the world; North America, United Kingdom, Nordic countries, other European, Australasia, Asia and other. There were a total of 4398 participants. They were placed into groups depending on age, with each group consisting of more than 60 people.
The participants were tested on 16 ADL motor and 20 ADL process skills. The findings showed that ADL ability increased dramatically from age three to six years. It increased again from 6 to 15 and then again from 15 to 50. From the age of 50 ADL ability began to decline. Both ADL motor and ADL process ability presented similar readings. The only finding that did not follow the pattern was the age group 80 - 82. This group’s ADL motor ability produced a higher score than 70-79 age brackets. According to Hayase, Mosenteen & Thimmaiah (2004) from further review, their instruments and testing were accurate. Therefore, the reason for the irregularity was from the testing sample, as there were less than 100 people in that age bracket. This may have affected the results. Another reason could be that the ability of the elderly people stabilizes for a brief period in the group that survives to
11 this age. Therefore, further research with a higher number of participants in the oldest age groups is needed to further justify their findings.
It seems clear that a person’s ADL ability begins to deteriorate at around 50 years of age. The next step is to identify which activities deteriorate first and in what sequence. A study was conducted by Jagger, Arthur, Spiers & Clarke (2001) in the UK to investigate the order in which older people become restricted in ADL, to see if different genders and age groups altered the order. There were a total of 1,684 subjects (aged 75 years and above) in the study; they were independent and did not have difficulties in all ADL at first assessment (Jagger et al., 2001). The study showed that “lower-extremity disability (bathing, mobility, toileting) precedes upper- extremity disability (feeding), with difficulty in dressing being either upper- extremity disability (through loss of manual dexterity for example) or lower- extremity (through hip fracture)” (Jagger et al., 2001 p.408). The order of deterioration did not differ between sexes or age group. However, one alarming factor which arose in the study was the dramatic increase in risk for older people of becoming disabled.
While Jagger et al. (2001) looked into the patterns of onset, Bowling and Grundy (1997) conducted a study with the aim of assessing health and well-being, social and domestic circumstances and need for health and social services among the elderly and very elderly in three sample areas. Elderly people were referred to as being 65 – 84 years of age and the very elderly were classed as 85 years and above. The three sample areas consisted of two different areas in England; East London (City of London and Hackney) and Braintree in Essex.
The findings showed that decreasing levels of physical ability were associated with poor mental health and people that had problems with feet, muscle and joint movement. There were also no associations “between changes in level of physical functioning and social network or support” (Bowling & Grundy, 1997 p.113). In fact, carer relief services, social workers, occupational therapy, physiotherapy or contact with general practitioner were only used by some of the participants in all three
12 sampled areas. The use or non-use of these preventative or rehabilitation services also had no association with the participants’ level of physical functioning.
This section identified that there are different categorisations for activities of daily living. The main sub-classifications for activities of daily living are instrumental activities of daily living and personal activities of daily living, which will be further explained in Sections 2.2 and 2.3. People begin to deteriorate after 50 years of age. Lower-extremity disability precedes upper-extremity disability. Furthermore, decreasing levels of physical ability are associated with people with poor mental health and those that have difficulty in movement. Further investigation is needed into the reason behind the non-use of preventative services to assist in the delay in becoming disabled and whilst undertaking activities of daily living.
2.2 Instrumental Activities of Daily Living
As people get older they spend more time doing IADL tasks and their competence in this area diminishes over time. Domestic activities increase in both males and females during retirement. In particular, Australian women after retirement spend double their time doing chores, such as laundry, cleaning and ironing (Fricke & Unsworth, 2001). Bierman & Clancy, (1998, in Roe et al., 2001) claims that “women were more likely than men (after adjusting for age) to have limitations with their instrumental activities of daily living and personal activities of daily living, and to require help” (p.396). Therefore, this section aims to highlight the issues that arise in instrumental activities of daily living for the elderly using examples from two case studies.
2.2.1 Case Study 1 A study was conducted by Roe et al. (2001) to investigate older people’s “experiences of receiving formal and informal care for their activities of living in home and institutional settings” (p.390). The tasks investigated were shopping, meal preparation, housework, washing clothes, transportation, taking medication and finances. This qualitative study was conducted in Southeast Washington, USA,
13 interviewing 20 elders. The participants stated that shopping was a task that was mainly provided by a family member. Assistance was also given by friends or care providers. However, it was found that there was one person who managed her own shopping and was the most disabled. This participant had multiple sclerosis but had adapted her life and home to suit (Roe et al., 2001).
Meal preparation provided mixed views from the participants. Some missed cooking and others preferred dinning out, gathering in the dining room for meals, seizing the opportunity to socialise with new people (Roe et al., 2001). Participants that gathered in dining rooms were elderly people who lived in assisted living or nursing homes. Those that missed cooking, either receiving formal or informal care, commented that they used to enjoy cooking for the family and adult children when they visited. One of the participants still cooked, however, she claimed it is difficult to cook for one. What was surprising in the research was to find one woman comment on there “being too much food readily available in the nursing home as some were becoming overweight" (Roe et al., 2001 p.392).
In relation to housework a major portion of the participants needed assistance with chores such as cleaning, changing of bed linen and throwing out refuse (Roe et al., 2001). Those participants receiving home care had care providers to clean their homes. However, one participant felt that “they did not do the work as she would like it or how she would have done it herself. " (Roe et al., 2001 p.392). This view was also reinforced amongst the women. Some frustration was felt when the care providers could not do work that the seniors could not do either, such as cleaning windows or only cleaning places where they can reach without the use of a ladder. One elderly person rejected the initial help as she lived alone and did not want people entering her house invading her privacy (Roe et al., 2001).
Doing the laundry was an activity that most of the participants did themselves as it provided them with something to do (Roe et al., 2001). "Continuing to undertake their own laundry not only gave these women something to do but also provided a
14 social activity.... this gave them an opportunity for social connectedness as well as independence" (Roe et al., 2001 p.396).
Taking medication was seen to be done with no assistance amongst the elderly, unless they were in a nursing home and it was a requirement for care providers to oversee the medication process. Little information is given in relation to handling of finances. However, the overall consensus was that the participants received support from their children, friend or spouse (Roe et al., 2001).
The ADL of travel away from home produced a varied response. There were some participants who still drove long distances. Those that were no longer able to drive took it as a great loss and this affected their quality of life. However, some participants utilised Dial-A-Ride service. The majority of the “seniors restricted their travel to stay within local destinations” (Roe et al., 2001 p.393). Older people who wished to travel away from home also relied on family and friends (Roe et al., 2001).
It seems that participants in this case study all receive assistance with ADL, either formally or informally. Those that were less satisfied with their current situation were those that had to give up an ADL that they previously enjoyed doing, such as cooking or driving.
2.2.2 Case Study 2 Another study was conducted by Fricke & Unsworth (2001) to investigate what IADL tasks older people performed and how important the tasks were to the elderly participants and occupational therapists (OTs).
The study group involved people aged between 66-95 years, which comprised seven males and 26 females (n=33) with a mean age of 78.4 years. Subjects chosen also had to be English speaking and living at home. This did not include people that lived in a supported or institutional environment. Data collection was via time diaries and questionnaires with follow up interviews.
15
Occupational therapists are professionals who assess, treat and prevent disability in older people. There is currently a shift towards client centered practice among occupational therapists, where the therapist uses their skills and knowledge to expose their clients to a range of possibilities that the clients had not previously known. This is different from when occupational therapist forces their value system onto the client (Fricke & Unsworth, 2001).
Fricke and Unsworth (2001) included reading, leisure activities, bank and postal activities, writing notes, garden maintenance and filling in forms as part of activities undertaken in IADL. The results from Fricke and Unsworth’s (2001) study showed that the most common illness amongst the elderly was arthritis (30.3%). 39.4% claimed they did not suffer from a major illness. Falls and hip replacements were not regarded as a major illness. In this study all of the participants underwent occupational therapy (OT) whereas, in Roe et al., (2001), the use of occupational therapy was minimal.
69.7% of participants used an assistive mobility device and 45.5% of this portion used a single point stick (cane). 60.6% of the total number of mobility users reported limitations in mobility (Fricke & Unsworth, 2001). In relation to living arrangements the majority of participants lived either alone or with a spouse, only a few lived with family as illustrated in Figure 1 (Fricke & Unsworth, 2001).
16 Participants' Living Situations
60% 48.20% 50% 42.20% 40% 30% 20% 9.10% 10% Percentage (%) i (%) Percentage 0% Lived Alone Lived with Spouse Lived with Family
Living Situation
Figure 1. Participants’ living situations (Fricke & Unsworth, 2001)
Community support (Table 1) was mostly received in form of home help, followed by meals on wheels and care from community or district nurse. In terms of transportation, 13 subjects reported they still drove cars. However, the study does not state the use of public transportation or how frequently help was given (Fricke & Unsworth, 2001).
Table 1. Most common community support received amongst participants (Fricke & Unsworth, 2001) Community Support Percentage Home Help 63.36% Meals on Wheels 24.4% District Nurse or Community Carer 15.2%
The three important tasks that elderly considered vital for independent living in the community were the use of the telephone as most important, then driving or use of transportation and reading, leisure and medication management (Fricke & Unsworth, 2001). An interesting finding came from the male participants, as they valued driving, shopping, handling of money and meal preparation more than their female counterparts. Whereas, when it came to IADL required to live independently
17 in the community, for females it was reading, leisure activities, use of transportation and medication management (Fricke & Unsworth, 2001). However, transportation is important to maintain mobility, independence and social contact. Therefore, further investigation is needed as there were only seven males participating in the study.
Occupational therapists rated use of the telephone, medication management, meal preparation and snack preparation as the most important IADL tasks for elderly to maintain independence in the community. Use of transportation was rather low in the agenda. "These results may have occurred because the occupational therapists interpreted the question by considering what is needed to live in the community rather than what is enjoyed and meaningful while living in the community. For the older person, leisure activities are essential for a rewarding and contented lifestyle" creating an even balance to their daily activities (Fricke & Unsworth, 2001 p.126).
Activities that were disliked were housework, inability to sleep, having to get up during the night and undertaking activities that may bring pain or discomfort. In relation to time usage the majority was spent on IADL (46.92% or 11.9hours) out of the 24 hour period. IADL activities are a combination of various activities, such as passive leisure, housework, travel and purchasing of goods. The rest of the time spent in the 24 hour period was sleeping (32% or 7.6 hours), personal care and rest (Fricke & Unsworth, 2001). The distribution of activities over a 24 hour period can be better evaluated in Figure 2.
18 Mean percentage of Time Spent in a 24 Hour Period
35% 31.85% 30% 25% 21.04% 20% 15.07% 14.69% 15% 10.81% 10%
Percentage (%) i (%) Percentage 6.46% 5% 0% Passive Leisure Housework Other IDAL Personal Care Sleep Rest Activity
Figure 2. Mean percentage of activities in a 24 hour period for elderly people (Fricke & Unsworth, 2001)
Living in a community may be considered as a positive as all subjects in this study were living in the community. However, subjects in this study were all "volunteers currently attending a community facility" (Fricke & Unsworth, 2001 p.127). This may limit the variables in the data collection, as the participants that volunteered to participate may be the ones that are more active and willing to travel to a community gathering. Out of the participants, there were gender activity differences. Women spent more time doing housework, purchasing goods and services, resting and using the telephone. Men spent more time doing domestic tasks such as gardening, they devoted time to passive leisure and travelling (Fricke & Unsworth, 2001). However, since there were only seven males in the study, the data collected to identify gender activity differences may be subjective. There are too few male participants to support the findings.
There are different interpretations of importance between older people and occupational therapists (OT). Older people regard important as doing something meaningful, whereas occupational therapists define it as tasks necessary to stay independent in the home (Fricke & Unsworth, 2001). Both values from older people and OTs need to be taken into account to provide and promote health and well-
19 being. Further research is needed to confirm the differences in female and male desired IADL.
2.3 Personal Activities of Daily Living
In a study conducted by Roe et al. (2001), in relation to personal activities of daily living (PADL), a majority of subjects needed assistance in bathing or showering and only a limited number required help with dressing, moving and transferring, going to the toilet and feeding. This study was conducted in Southeast Washington, USA, with 20 older participants who were living in community or institutional settings. This is similar study as case study 1 in Section 2.2.1.
There were two forms of assistance given for bathing or showering. One was “direct assistance such as help getting in and out of the shower, or supervision whereby the care provider was around in the home while the senior had their shower" (Roe et al., 2001 p.395). Those that needed assistance in PADL, such as moving and transferring, also needed help going to the toilet. This is due to their limited physical ability and fear of falling. However, “some seniors managed to go to the bathroom using aids and equipment” (Roe et al., 2001 p.396).
In a study conducted by Borg, Hallberg & Blomqvist (2006), results showed women were having more difficulty with PADL compared to men as shown in Table 2.
Table 2. Gender comparisons with difficulties in activities (Borg et al., 2006) Activity Female Male Walking by themselves 48.5% 16.1% Taking a bath 26.5% 8.2% Getting to toilet on time 25% 9.9%
Similar statements were made by Bierman & Clancy (1998, in Roe et al., 2001), where women were more likely than men to have limitations with all activities of daily living and to require assistance. Men had the same difficulties but at a lower
20 rate. The majority of older people need assistance with PADL, whether directly or indirectly. Men have the same difficulties as women at a lower rate but they still require some form of assistance.
2.4 Quality of Life
There is a need to address quality of life (QoL) issues that arise amongst older people and as Borglin, Jakobsson, Edberg & Hallberg (2006) state “this is especially important in the care of older people, where cure or complete relief is not always possible” (p.137). This importance is also seconded by Godfrey (2001) and Holmes (2005), and “promoting and improving people’s quality of life is seen as one of health and social care’s most important goals” (Borglin et al., 2006 p.137). Just as quality of life is regarded of great importance amongst researchers and health professionals, it is also regarded of great importance by older people. Older people themselves value quality of life more than their health. Browne et al. (1994) found that people (mean 73.7 years) considered leisure and social activities to be the most important contributing factor to quality of life. The second most important factor was health (Borglin et al., 2006).
Longitudinal studies show that “regular physical activity improves survival and functional ability, and can improve quality of life” (Lim & Taylor, 2005 p.33). At least thirty minutes of moderate intensity work-out should be prescribed to each individual to maintain a healthy lifestyle (Levine, 2004; Lim & Taylor, 2005). A study was conducted in various languages; English, Arabic, Chinese, Greek and Italian, to examine the factors associated with physical activity within the New South Wales older population (Lim & Taylor, 2005). The study consisted of participants aged 65 or older. It was concluded from the research that improved independence in travel and maintaining independence as people age can assist in their physical activity levels and mental well-being (Lim & Taylor, 2005). Another interesting finding was from Browne et al. (1994), who found that life satisfaction, psychological and subjective well-being levels were higher in the old-old than the young-old.
21 Components that affect the quality of life of older people are mainly social, environmental, psychological and physical (Borglin et al., 2006; Hellstrom, Persson, & Hallberg, 2004). However, the majority are more usually psychological and social than physical. Bowling et al. (2003, in Borglin et al., 2006), state that “there is more to older people’s QoL than health. Social and environmental factors may influence their quality of life, and social support and participation have been shown to be associated with how they rate quality of life” (p.137). Therefore, this section will look into the factors that influence older peoples’ quality of life.
2.4.1 Social and Environmental Factors It has been reported that a majority of women present a lower quality of life as they are often older, widowed and live alone (Borglin et al., 2006 p.143). This leads to the issue of social support and participation. As Farguhar & Bowling (1993, in Borglin et al., 2006), state “as friends and family die, support shrinks and so may their possibilities to participate and engage in activities and even if a majority are able to maintain independent living some may have difficulties affecting their ability to participate in activities” (p.137). Mann, Hurren & Tomita (1995) commented that there were subjects that missed doing activities that they once were able to do actively and to enjoy in their leisure time. This is an important factor to consider as occupational therapists provide services that regard activities of daily living as higher than leisure pursuits.
These contributing factors of quality of life, as outlined by Borglin et al. (2006), were also addressed by Grewal et al.(2006). Five attributes were identified towards quality of life. They were attachment, role, enjoyment, security and control. Within these five attributes the most important factors were relationships; either with family or others, health; of their own or close others, independence, emotional and psychological health, religion and spirituality, finances, standards of living and finally social and leisure activities. The loss of a family member or friend can lead to negative quality of life as this impacts on older people’s sense of security and attachment experience. However, it can be argued that those who present a higher quality of life are those that can more easily adapt to a new environmental and
22 social setting. Wenger (1991) and Antonovsky (1996) commented in Borglin et al. (2006), that "personal and external resources in terms of a high sense of coherence (SOC) and social support suggest that this group had better coping resources and sufficient emotional and practical support compared to those with low present quality of life" (p.143).
Home and surroundings, along with family and other relationships, are just as important to the elderly informants. Home and surroundings created a sense of security and attachment as well as pleasure. Relationships were considered rather important to the participants. Relationships included members of the family, close friends, work colleagues, neighbours, pets, and other people in the community; via church, rotary club and school governing body (Grewal et al., 2006). The transition from living independently to receiving assistance from others is suggested to contribute to change of values and attitudes in life (Hellstrom et al., 2004). However, when the values and attitudes are not positive this may lead to low quality of life. Hellstrom et al. (2004) mention that psychological factors (depressed mood, loneliness) along with physical factors (fatigue, pain) result in low quality of life, especially amongst those who are receiving help.
Standard of health was considered important amongst informants as good health makes the ability to undertake activities possible (Grewal et al., 2006). Consequently, the activity undertaken gives the informants a sense of role and enjoyment. It is also important as it allows elderly people to maintain their independence, giving them a sense of control in life (Grewal et al., 2006). A similar conclusion was made by Borg, Hallberg & Blomqvist (2006), as they found the key factors that lead to low life satisfaction among older people were poor overall health with reduced self-care capacities, financial issues, impaired abilities to perform ADL, loneliness and feeling worried. Religion, faith and spirituality received mixed responses in the study in terms of rate of importance because it depended on whether or not the informants believed in religion or not (Grewal et al., 2006).
23 Poor health reduces the ability to experience forms of enjoyment, previous roles and sense of control, creating a negative influence on quality of life (Grewal et al., 2006). Poor finances and surroundings also place negative influences on security, enjoyment and control. However, if the elderly have a better transition from living independently to receiving assistance from others it can improve their quality of life.
2.4.2 Psychological and Physical Factors Older people who are more active or have a positive outlook have a higher quality of life satisfaction. Those that are depressed, lonely and often fatigued are more prone to having a lower quality of life. Hellstrom et al. (2004) commented that “the more restricted a person’s ability to manage by themselves, the lower their quality of life” (p.591). "Those with high present quality of life stood out as those being more active in light exercising and time outdoors, indicating more external activities " (Borglin et al., 2006 p.144). Fatigue as a contributing factor to a lower quality of life was also supported by Steen et al. (2001, in Hellstrom et al., 2004), who found that mobility and fatigue can lead to ADL dependence for the old-old that are living in the community or special accommodation. Abdominal pain was also found to be a contributing factor.
Undergoing activities or simply the action of doing something was an important factor for older people. These activities included travelling, politics, a bridge game, continuing work and doing things for others (Grewal et al., 2006). Maintaining independence and control in life was also another important factor for informants in a study conducted by Grewal et al. (2006).
Sense of coherence (SOC) was defined by Antonovsky (1987, in Larsson & Kallenberg, 1996) as a “global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that i) the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable, and explicable; ii) the resources are available to one to meet the demands posed by these stimuli; and iii) these demands are challenges, worthy of investment and engagement” (p. 175). Greyer (1997) summarises sense
24 of coherence to be the theoretical construct that is used to explain why some people fall ill after a stress related incident and how some do not.
It is understood that social support and sense of coherence are related to high quality of life. However, little is known about how these factors change in the ageing process (Borglin et al., 2006). It can be suggested that there are various stages which a person experiences in feeling old and ageing. People in their earlier phases of transition have an increased negative quality of life. Transition has been categorised into four stages: “beginning to feel old, fear of being helpless, recognising one’s former self and feeling different from others” (Hellstrom et al., 2004 p.591).
Dignity is also a contributing factor to quality of life. Dignity is defined as “an inherent characteristic of being human, it can be subjectively felt as an attribute of the self, and is made manifest through behaviours that demonstrate respect for the self and others” (Jacelon, Connelly, Brown, Proulx, & Vo, 2004 p.82). Dignity can be categorised into four themes; philosophical, behavioural, attribution and developmental. Loss of dignity depends upon ones own values and social influences.
2.4.3 Fear of Falling It is known that older people can limit their physical activity and mobility due to psychological influences such as fear of falling and anxiety. This effects the quality of life of older people and especially females as they have higher chance of falling and of injury compared to males (Suzuki, Ohyama, Yamada, & Kanamori, 2002). Also it has been reported that half the people who claim to have a fear of falling have not had a fall (Lach, 2005).
In a study conducted by Suzuki et al. (2002), 19.5% of females had a fear of falling compared to 9.3% of males. Also, of females in the study aged 60-69, 66% of them expressed a fear of falling. Elderly that were self-selected housebound (people who choose to remain indoors, in the house), had immobility disorders or suffered from post-fall syndrome have a greater possibility of falling. Post-fall syndrome refers to
25 when an ambulatory person develops an intense fear of walking after a fall. Becoming house bound or bed ridden from previous falling incidents creates fear of falling. This can lead to a downward trend of fall and increased frequency of falling (Suzuki et al., 2002). Lach (2005) also suggests that fear of falling is common amongst community dwelling older adults and is associated with poor physical and mental health.
No research was found on the relationship between fear of falling and ADL in males, however, there is in females, especially in walking and bathing. In general, participants who required assistance with dressing and toileting were significantly associated with fear of falling (Suzuki et al., 2002). Fear of falling can affect their self image and self-confidence. Even if it does not effect them physically it may effect them mentally, contributing to low quality of life and shorter life expectancy and causing depression (Roe et al., 2008; Suzuki et al., 2002). Therefore, it is suggested that older people in this category should seek help in psychological and physical care to cope with changes in the ability to complete tasks in ADL (Suzuki et al., 2002). Assessments and interventions need to be made in order to prevent fear of falling in elderly people.
Roe et al. (2008) also adds findings from a qualitative study on older people’s experience of falls, indicating that participants with a mean age of 87 years experienced falls that were more injurious than participants with a mean age of 81 years. Although both groups experienced falls, participants with the mean age of 81 years had more frequent falls. This indicated older people’s deterioration in medical co-morbidity (Roe et al., 2008). Falls were related to suddenness and feeling alone. Loss of confidence and fear of falls were related to the severity of injuries received from falls. Also, participants that did not reflect on their fall or tried to understand the reason behind the fall restricted their lives. This was a minority amongst the participants. On a positive note, the majority of participants that reflected on their falls, confronted their fears and took steps to maintain control, choice and autonomy. Older people took steps to minimise falls and accepted the risks (Roe et al., 2008). It was also concluded that assisting older people in understanding the
26 reasons behind the fall lessens the fear of falling, helps prevent future falls, assists in retaining confidence and aid rehabilitation in activities of daily living (Roe et al., 2008).
2.4.4 Summary It can be concluded that the old-old have a higher quality of life than the young-old. The more active and positive the elderly person is, the better their quality of life. Having a sense of attachment, role, enjoyment, security and control are important to older people to have a good quality of life, as well as dignity. However, dignity can be rated differently depending on the person’s values and social influences.
Fear of falling, loneliness and loss of a physical ability contribute to a lower quality of life. Women are found to have a lower quality of life, due to the decrease in social support, being widowed and living alone. Older people need support in social and environmental settings, as well as psychological and physical assistance and encouragement in reflecting and facing fears. The combination of these factors can improve the quality of life in older people.
2.5 Differences in Quality of Life in Various Environments
Elders in Western societies had viewed receiving family care negatively, as many held values of “individualism, productivity, autonomy, competence, stoicism, and privacy, even within kinship relationships” (Bellah et al. 1986, in Crist, 2005 p.490). Crist (2005) comments that previous research findings have shown that elders perceive themselves as failures or feel indebted to family members for providing care when they can no longer conform to accepted norms.
However, more recent findings show that this is not often the case. Four key issues arose in a study conducted by Crist (2005) on the views of older people receiving family care. These findings were: a) elders had a more positive attitude towards incorporating family care whilst still considering themselves autonomous; b) positive relationships with family carers; c) acceptance in receiving family care was
27 the result of positive relationships between the elderly and the carers; d) most elders believed that even though they received more help than necessary, they could still strike the balance of receiving care and maintaining their own autonomy if desired.
The findings suggest that not only do elderly people value autonomy highly, they also regard receiving family care as a sense of validation for a strong, positive relationship with family members (Crist, 2005). "The interpretation that most of the elders still viewed themselves as leading autonomous lives, even when receiving various levels of family care, has important implications for nurses because it challenges conventional assumptions that elders in Western society view receiving family care negatively" (Crist, 2005 p.490). However, elderly people receiving help from a family carer to do an activity that they can perform themselves, from a rehabilitation-orientated professional perspective is viewed as negative and dysfunctional (Crist, 2005 p.491).
In terms of quality of life for elderly people in a nursing home setting a study was conducted in Turkey by Luleci, Hey & Subasi (2007), with 107 participants to determine the relationship between socio-demographic factors, health related behaviours, satisfaction and functional disability levels. Findings conclude that there is an importance in encouraging nursing home residents to undertake regular physical or leisure time activities. Also, as commented by Rojo Perez et al. (2001, in Luleci et al., 2007), resident satisfaction in relation to psychological well-being is a key factor in successful ageing.
It can be concluded that personal resources (high sense of coherence) and external resources (social support) offset losses in failing health and other limitations. It can also be suggested that social resources and personal resources are susceptible to decline in functional ability (Borglin et al., 2006). Therefore, it does not matter where the elderly person is situated, whether in a home or community environment. Quality of life depends upon how well an elderly person can adapt to change and ease themselves into the transition of ageing. However, further
28 research needs to be conducted on how to more effectively provide for this diverse group of older people to be able to cater for their various levels of abilities, and to assist in informing nurses and professionals on how to implement rules and procedures for the elderly (Borglin et al., 2006; Hellstrom et al., 2004).
2.6 Informal Caregivers
Informal caregivers are carers who are usually family members of the person acquiring the services. They are presumably a spouse, an adult child or relative. Studies conducted in Sweden have shown that 14% of persons over 75 years of age were involved in informal care of an elderly person (Ekwall et al., 2004). Caregiving can be defines as “help with personal activities for daily living and/or instrumental activities of daily living, although it is likely to include other aspects as well” (Ekwall et al., 2004 p.239). Section 2.6 illustrates that older people do not mind and some welcome help from informal caregivers. However, it has been shown to contribute to a negative quality of life for the informal caregiver (Ekwall et al., 2004; Grewal et al., 2006). This creates a negative influence upon attachment, enjoyment and security.
According to Bower’s typology there are five levels of caregiving; anticipatory, preventive, supervisory, instrumental and protective (Ekwall et al., 2004). Anticipatory caregiving involves decisions and behaviours on the persons’ possible needs, usually conducted from a distance and invisible to the cared person. Preventive caregiving involves more active monitoring than the first stage, it consists of preventing illness, injury, physical and mental deterioration. Supervisory caregiving requires the carer to keep a close watch and arrange things for the person in care as well as trying to maintain the carers’ own self-esteem and dignity. Instrumental caregiving has more of a physical involvement. This stage is mostly recognised as caregiving. Finally, protective caregiving is to protect from consequences which cannot be avoided, such as cognitive decline and depression (Ekwall et al., 2004).
29 Ekwall et al. (2004) conducted a study in Sweden to investigate the dimensions of informal caregiving of elderly people that was provided by another elderly person with impaired health. The results showed that there were different effects on male and female caregivers. Women carried heavy burdens as caregiving decreased their quality of life. Studies conducted in the UK, Brazil and Sweden have shown that women have a lower satisfaction in life than men. Full time caregivers also had a lower quality of life than part time caregivers (Ekwall et al., 2004).
A low socio-economic factor also contributed to lower satisfaction in life as well as the carers themselves needing assistance with IADL (Ekwall et al., 2004). Women provided more assistance with PADL. Men provided more assistance in IADL. This may be due to the fact that Instrumental activities of daily living better physical ability to perform. Therefore, men could be more physically able. Another reason is that physical activities improve quality of life (Ekwall et al., 2004).
A reason for the lower quality of life in informal caregivers can be due to the fact that the caregivers and person cared for are going through a transition and the personal resources are exceeding the environmental demands. As they adapt the balance will be reinstated. Low quality of life for caregivers is common amongst those that are providing care in the early stages, such as anticipatory and preventative care (Ekwall et al., 2004).
Informal caregivers are important as they provide care and assistance to their family members. However, when informal caregivers provide constant care, the longer the duration the lower quality of life the caregiver has, especially during the transition period of anticipatory and preventative care. Therefore, it is important to provide informal caregivers with assistance, which may be in the form of assistive devices. This assists the elderly in care with personal activities of daily living, which are activities that place more strain on caregivers than instrumental activities of daily living. Assistive devices will be discussed in Chapter 3.0.
30 2.7 Summary
It is known that for the elderly, deterioration of lower-extremities precedes upper- extremities. Decreasing levels of physical ability is associated with poor mental health. The elderly regard transportation as an important activity, which maintains mobility independence and social contact. Whereas, Occupational Therapists regard more importantly telephoning, meal preparation and medicine management over transportation, for elderly to maintain independence in the community. Elderly people prefer to undertake leisure activities, activities which are meaningful and rewarding to maintain independence in the community.
The majority of elderly people presented in the case studies need assistance with PADL and IADL. More women than men need assistance in activities of daily living, either formally or informally. However, some do not welcome the assistance or are not satisfied with the assistance, such as house keeping. However, some participants welcomed the assistance, such as meal preparation, as it gave them more time to socialise. Elderly people who had to give up an activity that they enjoyed, such as driving, and had not adapted had a poorer quality of life.
Quality of life is important to older people, caregivers and health professionals. It is the most important factor, followed by health. A persons’ quality of life can be affected by social and environmental factors, as well as physical and psychological influences. It does not matter where older people live; either in independent living or in a community facility. Quality of life depends upon whether elderly people have a sense of attachment, role, enjoyment, security and control. Women have a reported lower quality of life, along with informal caregivers. Therefore, more assistance is needed in activities of daily living to help maintain elderly people’s quality of life.
31 32
Chapter 3 Assistive Devices
33 3.0 Assistive Devices
Edwards & Jones (1998) believe that “assistive devices can potentially compensate for disability and lessen handicap and thus increase independence and improve quality of life” (p.463). Therefore, this chapter addresses the ownership and use of assistive devices and contributing factors towards the disuse of assistive devices and their effectiveness.
“Assistive devices are defined as mechanical implements specifically designed to aid people with disabilities to accomplish what they need and want to do” (Brooks, 1991 p.1417). Assistive devices in this situation are products or devices which assist the elderly in their activities of daily living in and around the home. Walking sticks, walking frames, wheelchairs, crutches, commodes, lavatory rails, raised lavatory seats, bathroom rails, non-slip bath mats, bath seats, bath boards, hearing aids, spectacles, stair rails and bed hoists can be classified as assistive devices. Roelands, Oost, Depoorter & Buysee (2002) also classify shower seats and sock aids as assistive devices. Assistive devices are sometimes referred to in various literature as technological assistance or assistive technology (Hoenig, Taylor Jr, & Sloan, 2003; Tinker & Lansley, 2005).
"The relationship between symptoms, diseases and activities of daily living is not fully understood" (Hellstrom et al., 2004 p.585). However, some studies have suggested that assistive devices may assist to maintain and preserve the amount of physical activity the older person does and to also allow a task to be more efficiently performed (Hoenig et al., 2003). Avorn and Langer and Penrod et al. commented, in Hoenig et al. (2003), that the greater the level of disability the greater the level of informal and formal assistance is needed.
Metz (2000) concludes that “there is an important relationship between mobility and quality of life of older people,” however, the “lack of an established relationship between mobility and quality of life” makes the enhancement of mobility difficult to evaluate (p.149). It is believed that the enhancement of mobility
34 in older people is the key to improving their quality of life and in turn assisting them in living in their own homes independently (Metz, 2000).
3.1 Ownership and Use of Devices
In order to investigate the reasons behind the attitudes towards the use of assistive devices in elderly people, it is necessary to first identify the rate of ownership and use of assistive devices. "In the age group of 65 to 74 years old, 22% of the US population use mobility assistive devices (ADs), which increases in the age group of 75 years old and older to 43%" (Roelands et al., 2002 p.39). A study was conducted on a random sample of 1405 older people aged 65 years and over who lived at home, to investigate the ownership and use of various assistive devices (Edwards & Jones, 1998). The results showed that the ownership of assistive devices depended upon the age, gender, living arrangements and degree of disability of the user. This study showed that users who owned assistive devices used them. Another interesting fact with regards to ownership of assistive devices was that the study revealed devices such as walking frames and bathroom rails are used by more women than men (Edwards & Jones, 1998). It is also believed that elderly people who live alone are more likely to substitute human assistance with assistive devices (Resnik & Allen, 2006). This section will look into the ownership and use of assistive devices.
3.1.1 Case Study 3 Ivanoff & Sonn (2005) conducted a longitudinal study on the old-old population in Goteborg, Sweden, to identify the changes in use of assistive devices over a five year period. There were a total of 195 longitudinal participants. These participants had to be living at home and not in institutions, hospitals, independent living areas or in nursing homes. The results showed there were 50 participants who did not use assistive devices at the beginning of the study. By the time the participants reached 90 years of age, 37 of these 50 participants were using assistive devices. Only 13 participants at the end of the five year study still did not use assistive devices. After the five year study, 73% (n=143) of the total participants were permanent users of
35 assistive devices. Only 1% (n=2) of the total participants that were using devices had stopped using them when they reached the age of 90.
The assistive devices were categorised into four major groups; bathing, mobility, toileting and personal care. Results showed the use of bathing, mobility, personal care and toileting devices all increased with age, except the use of bathtub seats and eating assistive devices. Bathing devices had an increase in use over the five year period of 53 and toileting a total of 76. Out of these two device categories the grab rail (n=28) was a device that had the greatest difference in use between ages 85 and 90. Grab rails for bathing were already used by a high number of people (n=64) at the age of 85 compared to grab rails for toileting (n=9) (Ivanoff & Sonn, 2005). It can be suggested that elderly people start using bathing devices at a younger age and toileting devices are needed at a later stage. This may be due to increasing chronic health problems, weakness in upper body strength and the slipperiness caused by wet floor surfaces.
Ivanoff & Sonn (2005), also found that the participants possession and use of bathing and mobility devices were used at a younger age and more readily, which was then followed by toileting and personal care products. Although mobility devices are used first and more readily, there were also a growing number of elderly people using mobility devices at 90 years of age. The total difference in use between ages 85 and 90 was 88. This study showed that the majority of the participants used assistive devices. However, this study was conducted with people living at home, therefore, it is not understood whether a similar result would occur to people that live in aged care facilities (eg. if more assistive devices are used due to regular professional intervention or less assistive devices are used due to the combination of personal and device assistance).
3.1.2 Case Study 4 Another longitudinal study was conducted by Haggblom-Kronlof & Sonn (2007) to study elderly people’s use of and experience with assistive devices in daily occupations over a duration of ten years. The study was also conducted in Goteborg,
36 Sweden, with participants (n=199) at 76 years of age and still living at home. The approach to the data collection was by the use of structured and open-ended interviews with the participants during home visits, as Hoggblom-Kronlof & Sonn (2007) state “the only way to understand the advantage, meaning and value, of assistive device and their impact on a person’s daily life is to ask the users” (p.336).
The longitudinal study showed 69% of the elderly people used assistive devices at 86 years of age, compared to 43% using devices at the age of 76. New users of assistive devices at the age of 86 was 34% and permanent users 35%. Permanent users are referred to participants that have been using assistive devices for the ten year duration, from 76 to 86 years of age. 23% of the total participants were non users of assistive devices. Haggblom-Kronlof & Sonn (2007) found that out of the participants that were dependent (needing assistance) in activities of daily living there were 19% that were non-users of assistive devices at the age of 86 years. 81% of dependent in daily activities participants were users of assistive devices. Among participants that were independent in activities of daily living, there was a higher number (45%) of non-users of assistive devices.
When data was analysed for percentage of persons that use assistive devices in certain activity domains at the age of 86 years with reference to gender, it was discovered that the majority of assistive devices were used for mobility. 66% of them were women and 52% of them were men. The other activity domains were hygiene, transfer bed and chair and lastly, grip and reach activity (Haggblom-Kronlof & Sonn, 2007). Women were found to use assistive devices slightly more than men in all domain activities. The only exception is in the hygiene activity domain where 62% of the females used assistive devices compared to 37% of males (Haggblom- Kronlof & Sonn, 2007).
Usage rates for the assistive devices in hygiene, mobility and transfer chair and bed were quite high. Hygiene (93%) and transfer chair and bed (98%) devices were regularly used. The most readily owned assistive devices were the cane, tub boards, raised toilet seats and rollators for outdoor use. However, the usage rates for non-
37 use of assistive devices resulted in 18% in mobility and 26% in grip and reach activities. The devices that were not used were canes and rollators for outside use in the mobility domain and tub boards and shower stools in the hygiene domain (Haggblom-Kronlof & Sonn, 2007). The main reason given for the non-use of assistive devices was the lack of need for a device, due to recovery or deterioration in abilities. This applied to canes and rollators for outside use. Devices that were difficult to use was another reason for disuse as well as the device being broken. This applied to assistive devices in the grip and reach domain. There were some participants that did not use assistive devices as they preferred personal assistance. This applied to hygiene and mobility devices. One positive aspect from the non-use category is that none of the participants blamed not knowing how to use the device as a reason for disuse (Haggblom-Kronlof & Sonn, 2007). This can suggest that the participants were knowledgeable in the assistive devices that they owned. Attractiveness of an assistive device was also not mentioned in the non-use of assistive devices. It may be assumed that practicality of an assistive device comes before the aesthetics of a product, as this issue was not brought up by Haggblom- Kronlof & Sonn (2007).
In relation to the usefulness of assistive devices Haggblom-Kronlof & Sonn (2007) discovered that the most common response amongst the participants was that they felt ‘more secure’. The other reasons to usefulness are ‘less effort’ and ‘absolute necessary to use’. When Haggblom-Kronlof & Sonn (2007) analysed the experience of being a user of assistive devices amongst 86 year olds, they summarised the findings into three key aspects; personal, practical and social. Haggblom-Kronlof & Sonn (2007) placed the experiences on a continuum as illustrated in Table 3 .
38 Table 3. Experience of being a user of assistive devices (Haggblom-Kronlof & Sonn, 2007)
Personal Aspects Normal Mark of old age Pleasant Unpleasant Safe Unsafe
Practical Aspects Usable Inappropriate Essential Cumbersome Social Aspects Feel Respect Afraid Do not mind Embarrassing
Personal aspects referred to users of assistive devices’ inner feelings and attitudes. The feelings ranged from positive to negative. Overall, the responses from the users showed that the personal aspects were feeling more normal, pleasant and safe. There was one participant who referred to his cane as his ‘companion’. There were others that had unsatisfied feeling towards devices. They were seen as a ‘mark of age’, as they made them feel old. One participant remarked “It doesn’t feel good. Now, I’ve become old” (Haggblom-Kronlof & Sonn, 2007 p.341). Pleasant experiences were expressed with positive words such as happy, wonderful, lucky, good and grateful. On the other continuum of feeling safe and pleasant, one woman expressed unpleasant feelings towards the use of having a free standing toilet chair in her bedroom. The woman replied, “simply the thought of having it standing in my bedroom is unaesthetic and inconceivable” (Haggblom-Kronlof & Sonn, 2007 p.341).
In terms of practicality, the users of assistive devices found them generally usable for daily living activities. When assistive devices were regarded as inappropriate and impractical is when the assistive devices did not adapt to various environments, they became obstacles. The example used was the use of rollators outdoors or on a slope or getting through a doorway where the door is difficult to open. Assistive devices being cumbersome was also expressed. One woman explained that her
39 cane was cumbersome as she would forget it, drop it and it was in the way (Haggblom-Kronlof & Sonn, 2007).
Social aspects refer to the use of assistive devices amongst other people and in the community environment. The general response to the use of assistive devices was a sense of respect. Participants that felt afraid of their environment avoided using the assistive devices. One participant did not want to show that he had visual impairment and used a white cane. His response was: “I have a foldable white cane that I do not use because then I become a victim of my surroundings”. Another feeling was embarrassment. Some participants were ashamed of using assistive devices and some users felt their company were embarrassed by their using of assistive devices (Haggblom-Kronlof & Sonn, 2007). This is a distressing finding as it shows that assistive devices are necessary for some users and yet they do not use them due to embarrassment and being afraid of becoming victims of their surrounding environment.
Overall, the population in the ten year longitudinal study showed that the majority of users did use assistive devices for activities of daily living. Use of assistive devices was seen as a positive experience by most participants. However, there were still responses on the continuum from the negative end, which were especially evident in relation to assistive devices that were used outdoors, in a social context. Haggblom-Kronlof & Sonn (2007) gave a good insight into the users’ experience of assistive devices among 86 year olds through the data collection of interviews with the users. Further research can be conducted in this manner for elderly people in other ages and locations to see if these findings are consistent.
3.1.3 Case Study 5 Roeland, Van Oost, Depoorter & Buysse (2002) studied the use and non-use of assistive devices to identify the contribution of psychological variables. The study was conducted in Flanders with Dutch speaking elderly people (70 to 89 years old) from community based dwellings. Community based or community-dwelling, refers to individuals who reside independently in the community in their own private
40 home. It does not refer to individuals who live in aged care complexes, nursing homes or any dwelling that provides aged assisted living (Grayson, Lubin, & Van Whitlock, 1995).
The mean number of assistive devices owned by the participants was 3.11 and there was a high percentage (80.6%) of elderly people that used at least one assistive device that they owned (Roelands et al., 2002). However, the mean non- use of assistive devices from the respondents was 51%. The highest ownership of non-use devices were the cane (22.2%), toilet seat (15.9%) and the long shoehorn (15.6%) (Roelands et al., 2002). The non-use of canes is consistent with findings from Haggblom-Kronlof & Sonn (2007) as described in Section 3.1.2. Other than the cane, the findings did not show any other similarities in terms of ownership and usage of assistive devices. It was also difficult to compare the two studies (Haggblom-Kronlof & Sonn, 2007; Roelands et al., 2002) as the information provided on assistive devices varied. Haggblom-Kronlof & Sonn (2007) provided information on the usage rates of assistive devices and gave an overall percentage rate for each domain. They did not detail the usage rate of each type of assistive device. Roelands et al. (2002) on the other hand did provide information on the awareness, possession, use and non-use on each type of assistive device. However, they did not test on the participants’ usage rate of assistive devices, resulting in difficulty comparing the two sets of data.
In relation to the intention to use assistive devices, the respondents’ mean score was 12.54, the maximum is 15. The intention to use assistive devices refers to the respondent being unable to perform an activity on their own, would they use an assistive device to complete the task even if it is tiring and difficult (Roelands et al., 2002). The respondents’ attitudes towards the use of assistive devices will be discussed in Section 3.2. However, it can be quickly summarised that the community dwelling older people had a positive attitude toward assistive device use (Roelands et al., 2002). The elderly people also believed that the use of assistive devices would increase autonomy and decrease the need for personal care. They valued the ability to maintain their own homes and lives through the use of assistive
41 devices. There was also agreement amongst the respondents that assistive devices cannot exclude personal care.
3.1.4 Bathroom Devices A sample study of community based (living at home) older people in the United Kingdom conducted by Edwards & Jones (1998), found that participants who owned a bathroom rail were usually people that lived alone. This accounted for 32% of the total respondents. Within the 32%, 21% owned a bathroom rail and lived with a spouse, 11% lived with spouse and others (Edwards & Jones, 1998). In terms of ownership and use of assistive devices for bathroom aids there was a low percentage of respondents who did not use the assistive devices that they owned. 5% was the highest non-use rate which attributed to non-slip bath mats. This was followed by commodes (3%), bath seats (3%), rail in lavatory (2%), rail in bathroom (2%) and raised lavatory seat (1%) (Edwards & Jones, 1998).
The usage rate was also high from participants in the study conducted by Clemson & Martin (1996). This study investigated the usage and effectiveness of rails, bathing and toileting aids for elderly people who lived at home. Participants that were selected had an association with a large Sydney teaching hospital. The study was conducted through the medium of a questionnaire with specific questions about each rail and aid with yes and no and multiple choice responses and questions towards attitudes that could be answered on Likert scales (Clemson & Martin, 1996). The usage rates of bathroom aids (86%) and rails (76%) were high. However, there was still disuse in the assistive devices. There was 4% of equipment that was never used. The disuse rate was calculated over the duration of approximately two years; from when the assistive devices were in use at time of survey to a two year period. The disuse rate of rails ranged from 6% to 20%, the 20% attributing to shower rails. The disuse rate of aids ranged from 12% in bathmats, 24% in shower chairs to 56% from raised toilet seats. Raised toilets seats were quickly discarded in less than three months (Clemson & Martin, 1996). Compared to the study conducted by Edwards & Jones (1998) the disuse of bathroom devices in terms of type varied. Raised toilet seats received a 1% disuse
42 rate and the highest disuse came from bath mats(5%), whereas Clemson & Martin (1996) claim a disuse rate of 56% from raised toilet seats and 12% from bath mats, which was one of the lowest non-use rates. These are conflicting results which need to be explored further.
The main reason for non-use of rails and aids was due to the participants’ improvement in abilities. Other reasons included the worsening in their condition, incorrect aid prescription and items seen as unsafe. Items considered unsafe were shower chair, front step rail and shower hose. There were no evident relationships on the usage rate between bathroom devices and gender, age or marital status (Clemson & Martin, 1996).
In terms of satisfaction with the bathroom devices, participants were questioned on the ease of use, fit, ease of cleaning and the quality of the product. Raised toilets seats received the least satisfaction. The overall satisfaction for rail placement was high. Dissatisfaction came from the positioning of rails; being out of reach, just within reach or undesirable vertical positioning. Vertical positioning rails may not be able to aid in leverage and weight bearing as well as oblique and horizontal positioned rails (Clemson & Martin, 1996). Other dissatisfaction of bathroom devices was attributed to the incorrect assessment in rail placement, issues with aid prescription and design of equipment. However, further research is needed to identify whether the satisfaction or dissatisfaction of bathroom aids and rails is related to the characteristics of the user (Clemson & Martin, 1996).
3.1.5 Mobility Devices Edwards & Jones (1998) found the most commonly owned mobility device to be the walking stick. 30% of the respondents owned one and 3% owned two. Edwards & Jones (1998) state that the ownership of assistive devices increases in number with age. 67% of elderly people 75 years of age and under had one or more assistive devices, compared with 83% of elderly people over the age of 75 years. The aids that were most common among the elderly of 75 years of age and above were walking sticks, walking frames and wheelchairs (Edwards & Jones, 1998). Sonn &
43 Grimby (1994) also share the same views as they state that “assistive devices increase with age among the elderly, and that hygiene and mobility devices are the ones most frequently used” (p.91).
The type of ownership of assistive devises depended upon the persons’ living arrangements (Edwards & Jones, 1998). Ownership of wheelchairs, walking frames and commodes were compared to the participants’ living arrangements. Out of the participants that owned a wheelchair, 12% lived with others, 3% lived with their spouse, 2% lived alone and another 2% lived with their spouse and other people. Similar figures were shown for the comparison with ownership of walking frames and commodes (Edwards & Jones, 1998).
The use of mobility devices also varied depending on race and ethnicity. In the United States, the Black population have been reported to use more mobility devices than Whites and Hispanics for elderly people over the age of 65 (Kaye et al., 2000 in Resnik & Allen, 2006). The differences in usage of assistive devices between the various ethnicities are unknown. Resnik & Allen (2006) investigated the difference in use of mobility devices by participants with varying race and ethnicity and also sought to identify if the effects changed based upon age. Results showed Blacks were more likely to use mobility devices at a younger age, however, is not evident in the older age group. The reason may be that Blacks have a lower prevalence of disabling chronic diseases and diabetes when they reach the older age groups. Hispanics and Whites use of mobility devices share the same pattern at younger ages, however, at an older age from 65 years and over the use increases with the Whites (Resnik & Allen, 2006). It is suggested that the Hispanic culture encourages informal caregiving from family, neighbours and friends. Therefore, informal caregiving is not replaced with the use of assistive devices (Resnik & Allen, 2006). There do not seem to be longitudinal studies conducted in Australia that look into assistive device use amongst elderly people with various race and ethnicity.
In the United States alone there are four million people that use canes and 1.5 million that use walkers (Bateni & Maki, 2005). Most of the users are older people,
44 65 years of age or older. Older people living in low care residential settings were found to be the most common users of gait aids. The approximate usage was four in every five subjects (Watson, Chipchase, & Mackintosh, 2004). Canes and walkers can be classified as gait aids. The term gait aid can be used to classify assistive devices that are used for ambulation.
A pilot study was conducted by Watson et al. (2004) in Adelaide, South Australia. Participants were living in residential care facilities that only required low level care. The 31 participants had a mean age of 86 years. The study aimed to investigate the influences of balance, fear of falling and pain on the use of gait aids among the users. It was concluded that users who maintained a good sense of balance, less fear of falling and suffered from less pain relied less on gait aids. Participants who had poorer balance, greater fear of falling and pain resorted more to gait aids for support and stability.
Gait aids assist the users by reducing their lower-limb loading. This alleviates pain by reducing the pressure that is placed on the joints. The use of these aids also improves balance by “providing mechanical advantages as well as somatosensory feedback” as weight can be distributed to the stick or frame (Bateni & Maki, 2005 p.134). It can be proposed that a gait aid that provides the most support in stability, redistributes loads and alters weight bearing patterns would be one that has the greater number or points of contact to increase the area of base of support (BOS). For example, the frame is the most stable as it has four points of contact and has a wide BOS, whereas a stick only has one point of contact (Watson et al., 2004). A loss of balance happens when the “centre of mass (COM) is displaced in relation to the BOS” due to external influences such as slips, trips or pushes. The use of gait aids increases the BOS and therefore, allows for a greater movement in the centre of mass without the user losing balance and stability (Bateni & Maki, 2005 p.136).
There are four types of gait aid users. There are cane users, walker users, those that alternate between the cane and walker and finally non-users. The types of gait aids prescribed to people are generally influenced by the evaluation of the persons’
45 balance. Sticks or canes are usually prescribed to people who have a mild to medium impairment. Walkers or frames are recommended to people who have a higher level of difficulty in lower-limb weight bearing, have poor balance, general weakness or weakening conditions (Bateni & Maki, 2005). However, research conducted by Charron, Kirby & Macleod, 1995, and Simpson & Pirrie, (1991, in Watson et al., 2004), has suggested that inappropriate use or incorrect prescriptions of these gait aids can lead to negative effects on the users, increasing the risk factor for falls. It has been reported that over a period of 12 months, 50% of the older people in residential care facilities have taken a fall (Watson et al., 2004).
As well as placing the elderly in risk of falling the use of gait aids has been reported to contribute to upper-limb stress. Bateni & Maki (2005) have reported that excessive stress on the upper portion of the body can lead to bone fractures. Incorrect use of the aids and repetitive strain on the joints in the upper-limb can lead to the development of further disabilities and pathologies such as tendonitis, osteoarthritis and carpal tunnel syndrome. Another negative effect in the use of gait aids is the ability for elderly to maintain or recover balance. Bateni & Maki (2005) suggests that the response rate in older people in relation to a postural disturbance is impaired. They are less able to switch from one task to another quickly, unlike younger people. The elderly need to concentrate the majority of their attention to one main task. Therefore, when there is a disturbance or interruption to their current postural position it would be difficult for them to recover from it. The use of gait aids may hinder the ability for older people to maintain or recover balance (Bateni & Maki, 2005).
Even when gait aids are used correctly and they are of benefit to the users, they are often abandoned and not used. Bateni & Maki (2005) commented that results from clinical observations and empirical evidence indicate that the non-use rate of gait aids is between 30 and 50 percent. This data was collated soon after patients received their assistive devices. Responses to the non-use of the devices were that the gait aids were either too difficult or risky to use.
46 Watson et al. (2004) aimed to investigate the non-use or use of gait aids in older people with a hypothesis that fear of falling and pain contributed to the type of aid used or not used. It was concluded that fear of falling dictated the type of gait aid that was used and there may be a psychological influence which needs to be further researched. Investigation is needed to understand the relationship of the older peoples’ true balance ability and fear of falling. Pain, however, was not found to influence the type of gait aids used or not used.
3.1.6 Other Devices A study was conducted in Taiwan to identify the feasibility of hip protectors for older people. This was conducted by Huang, Lee & Wu (2006) with ten elderly women. They were required to wear a hip protector for the duration of six months. It is believed that hip protectors prevent hip fractures and are cost effective and assist in maintaining the quality of life of older people. “Hip protectors work by directing the force of a fall away from the hip joint and towards the surrounding soft tissue”(Swerissen & DenneKamp, 2006 p.9). However, from the results of this study and existing studies it was found that compliance and correct wearing of the hip protector was low (Huang et al., 2006). The reasons for low compliance were discomfort, worn only during the day, lack of family or carer assistance and unaccustomed to use. Participants were more comfortable and familiar with undergarments that were loose fitting and not tight around the abdomen. Another hip protector study was conducted in Victoria, Australia, in twelve public sector residential aged care facilities (Swerissen & DenneKamp, 2006). In that study the compliance rate for hip protectors was on average 64% and the most common comment of non-use was the discomfort and the lack of perceived benefits. Some other reasons were cognitive impairment, incontinence and protector loss or unavailability. Van Schoor et al., (2002, in Swerissen & DenneKamp, 2006) state that from various researchers the compliance rate for hip protectors varies from 37 to 72%, with a median rate of 56%.
Stathakis et al., (2002, in Swerissen & DenneKamp, 2006), state that there has been a steady increase in the number of admissions to hospitals in Victoria, Australia
47 from fall related injuries, most commonly amongst people aged 65 and over, from 1995 to 2001. Most patients admitted to hospital with a hip fracture had to stay for an average of 16.3 days. Hip Protectors can limit the severity of a fall. Falls can be prevented through exercise, psychotropic medication withdrawal, through careful home assessments by trained staff and medication (Swerissen & DenneKamp, 2006).
However, Tavener-Smith & De Vet (2006) explored hip protector adherence in high- risk older people and discovered that not only did the respondents describe the hip protector as being uncomfortable and expensive, some acknowledged the benefits but chose a fatalistic approach which resulted in disuse. These frail elderly people chose to risk a hip fracture as they had a philosophical view about their life stage.
The most prevalent issue in Tavener-Smith & De Vet’s (2006) study was that participants regarded hip protectors as an item of clothing, therefore, it would be worn during the normal process of dressing and undressing. The hip protector was not worn when the elderly people dressed following a shower or during the night, as there were general discomforts and inconvenience during night toileting. Therefore, there are hours when the user is unprotected from a hip fracture. Carer support was also an issue in the adherence (constant wearing) of hip protectors. The more encouragement and support given the more the participant adhered to hip protectors and continued their use. Family support was shown to be an important motivation to continue use and also assisting in the cost of hip protectors.
Participants that had upper limb weakness described the great physical effort to wear the hip protectors. There was also loss of independence and problems with incontinence through the usage, as the firm fit and bulkiness resulted in discomfort in undertaking daily activities (Tavener-Smith & De Vet, 2006). Some participants also saw the introduction to hip protectors as a threat, as it disrupted the comfort and familiarity of lifelong routines (Tavener-Smith & De Vet, 2006). Therefore, further research into the design of hip protectors to ensure safety and comfort,
48 along with encouragement and support from peers, family members and carers is needed in order to insure maximum adherence to hip protectors.
3.1.7 Summary It is understood that assistive devices can assist older people, even the frail, in maintaining independence and having the ability to undertake activities of daily living. Mobility and bathing devices are used first and most readily. Assistive devices such as hip protectors, shoe horns, wheel chairs, raised toilet seats, canes and rollators are some of the devices that are not always used by elderly people but do assist them with safety and mobility. Case studies three (Ivanoff & Sonn, 2005), four (Haggblom-Kronlof & Sonn, 2007) and five (Roelands et al., 2002) were conducted in community-dwelling settings. Therefore, it is uncertain whether similar results on the ownership and usage of assistive devices will occur for elderly people in assisted living and nursing home settings. Some of the reasons of disuse were due to personal, practical and social factors surrounding the usage of assistive devices. There were also expressions of assistive devices being unaffordable for users on the pension. Further factors affecting the usage of assistive devices will be explored in Section 3.2.
3.2 Factors Affecting Use of Assistive Devices
Ownership of assistive devices such as mobility, bathroom and personal care devices varies depending on the degree of disability of the elderly people. It is found that the rates of ownership and use of assistive devices by the minimally impaired and frail are high (Edwards & Jones, 1998; Haggblom-Kronlof & Sonn, 2007; Ivanoff & Sonn, 2005; Mann, Goodall, Justiss, & Tomita, 2002; Mann, Hurren, & Tomita, 1993). On the other hand, there was a number of elderly people, some with high degrees of disability, that lacked the necessary assistive devices (Edwards & Jones, 1998; Mann et al., 1993). Edwards & Jones (1998) reported out of the very frail elderly people, 80% had no raised lavatory seats, 68% had no lavatory rails, 62% had no bathroom rails and 46% had no non-slip bath mats. However, the reasons behind the lack of assistive devices were not reported. Mann et al., (1993)
49 & Mann et al., (1995) suggested that some of the reasons were affordability of assistive devices and also uncertainty; if the device will function properly and if it is really needed.
Non-use of assistive devices was not limited to the frail elderly; there was still non- use amongst the general aged population. Some of the reasons for disuse were due to the device not being suited to the person, the assistive device not adequately meeting all the needs that the person required or, although the assistive device did benefit the user, it drew unnecessary attention (Mann et al., 1993). Brooks (1991) states that the acceptance scale on assistive devices varies according to research. The scale can go from high utilisation of assistive device to rejection. One reason for rejection was due to the lack of personal touch and communication in the assistive devices (Rush, 1983 in Brooks, 1991). Therefore, Sections 3.2.1 to 3.2.4 will further investigate the reasons affecting the use of assistive devices amongst elderly people, such as awareness, cost, social implications and dissatisfaction.
3.2.1 Awareness There may be some issues with public awareness of assistive devices. Findings from the Consumer Assessments Study indicate that subjects do not have current information on available assistive devices and stresses the importance of assisting elderly people in identifying appropriate assistive devices (Mann et al., 1995 p.817). Roelands et al. (2002) reported that respondents had an awareness mean of 20.51 assistive devices out of 32. Recently developed assistive devices such as personal alarm systems and devices that assist in pulling up socks are tools which can benefit the elderly in living independently and increase efficiency in undertaking activities of daily living. However, they are not owned by the elderly people due to their lack of awareness of the new products. This is more evident in elderly that are aged between 70 and 90 years (Roelands et al., 2002).
Although there is non-use in recent products there is also non-use of typical well known products such as the cane, toilet seat and shoehorns. They are easy to obtain and inexpensive to buy. Roelands et al. (2002) suggest that the non-use of
50 these products may be due to the fact that they may be hand me downs. They are devices that are passed on from one generation to another. They are stored until there is a need for a person to use them. However, it is also suggested that expensive products are not being used, which is a waste of resources. Expensive assistive devices include, hydraulic hospital beds, wheelchairs, walking frames and chair lifts. To better understand this trend “a socio-cognitive model of human behaviour” should be conducted to understand the use of assistive devices (Roelands et al., 2002). At present there does not seem to be a socio-cognitive model of human behaviour conducted by Roelands or by another author.
Bathing and mobility are the most common areas where the elderly would use an assistive device (Mann et al., 2002; Roelands et al., 2002). What is of concern in the use of assistive devices within the elderly is that if a task required the use of an assistive device all the time to complete the activity it would be used, even if the assistive device caused tiredness and difficulty in use and also, there are elderly people that need them but do not use them (Mann et al., 2002). To better introduce elderly people to assistive devices and influence them, Mann et al., (2002) suggest understanding the users environment, creating a positive atmosphere, and assurance about the use of the assistive device during introduction. This should then be followed with on-going assessment of the users’ needs.
General practitioners, the users’ children and partner would be the most persuasive people in introducing and encouraging the use of assistive devices. General practitioners (63.4%) were reported to be regarded as the most valued and persuasive people in the use of assistive devices. This is then followed by children (53.8%), partner (47.2%), nurses (21.3%) and lastly friends (12.3%). 4.1% of the respondents said they would not value anyone’s opinion on the use of assistive devices (Roelands et al., 2002).
3.2.2 Cost The use of assistive devices also benefits the elderly as it reduces the amount of time spent on each activity. It also relieves some strain placed on caregivers.
51 Technological assistance may not replace personal assistance. Furthermore, the use of assistive devices has been reported to reduce personal assistance or care-giving by four hours per week (Hoenig et al., 2003). The use of canes and crutches has been shown to reduce personal assistance hours, but not wheelchairs or walkers. Hoenig et al. (2003) also comments that there are social and medical factors that vary the way elderly cope with their impairments. These variations need to be taken into consideration when designing for the elderly. However, prescription of assistive devices to elderly users will not be beneficial if the users are not able to purchase devices due to costs.
Sonn, Davegardh, Lindskog & Steen (1996) found 16% of participants (70 years and over in community-based dwellings) had un-met needs of assistive devices. The devices related to mobility, balance and safety. The reason for disuse is not known. Mann et al., (1993) also stated there were elderly people who needed devices that assisted in safety to prevent falls that did not own them. The reasons the respondents gave were due to the required assistive devices being too expensive to purchase from their own pockets or that the devices were not reimbursable under the third-party payment system in the United States. This was seconded by Tavener-Smith & De Vet (2006) in that some assistive devices like the hip protector were too expensive for people on a pension and the high expense would outweigh the benefits of the device.
Nonetheless, there were respondents who were willing to purchase assistive devices that were necessary and cost was not an issue. This result was found to be supported by most of the respondents (Roelands et al., 2002). The respondents disagreed with the idea of not paying for an assistive device that they needed themselves in the study conducted by Roelands et al., (2002) described in Section 3.1.3. However, some assistive devices are inexpensive to purchase and when cost is not an issue there is still hesitation in the purchasing of a device. The delay in purchasing is due to uncertainty (Mann et al., 1993). Users are unsure whether the device is really needed, how useful it will be or if the device will function properly (Mann et al., 2002; Mann et al., 1993). Mann et al. (1993) suggest that users should
52 be given the opportunity to try before buying and encourage professional assistance in the assessing and recommending of assistive devices.
3.2.3 Social Influences upon Device Use From a survey conducted with participants from the Resource Group of disabled scientists and engineers, it was shown that they were most likely to use assistive devices for mobility, transportation and employment. They were least likely to use assistive devices for housekeeping and child care purposes (Brooks, 1991).
Culture and historical periods can influence the meaning of the devices and affect social interaction (Brooks, 1991). The World Health Organisation, (1980, in Roelands et al., 2002) have stated that a person’s attitude towards assistive device use, the self-efficacy and the subjective norm are the variables that decide a person’s intention to use assistive devices. The subjective norm refers to a person’s perception of the value of significant others’ expectations to use assistive devices and willingness to conform to expectations. In this case, the most influential people to elderly people, their subjective norms, are medical practitioners, when proposing assistive devices and seeking advise, as explained in Section 3.2.1 (Roelands et al., 2002).
Brooks (1991) states that there are ways in which assistive devices play a social role when related to disability. Assistive devices can alter the social appearance by causing a disability to become public or by placing a social strain on the general public due to devices that are unfamiliar. Safilios-Rothschild (1970 in Brooks, 1991) commented that “people with disabilities have been collectively stereotyped with numerous negative characteristics, including the frequent assumption that a disabled body is associated with lower intelligence and poor judgment” (p.1418).
“The existing distribution systems exercise strong social control over assistive devices. Making changes to add user involvement will challenge the minority placement and evaluation of people with disabilities” (Brooks, 1991 p.1423). Aminzadeh & Edwards (2000) suggest also that to ensure safety and older people’s
53 needs, health professionals need to improve training and assessment approaches. It is recommended that there should be social marketing strategies that market the use of assistive devices such as canes with a more positive message; assistive devices are tools for safety and independent living. Furthermore, to design more attractive and convenient canes to improve the image of assistive devices (Aminzadeh & Edwards, 2000). Edwards and Jones (1998) states that with the use of assistive devices, users will continue to be independent individuals in the home. Through the use of aids this may reduce the strain on resources such as informal care-givers, social services and health care professionals.
Brooks (1991) found with regards to age that there was little relationship with the devise use, disability type, or even the social context. However, it was found that older people tended to disclose their use of aids in a working environment more than younger people. Gender is another contributing factor to aid use. Walking frames and bathroom rails were used more used by women than men (Edwards & Jones, 1998). However, there is belief amongst some elderly people that assistive devices foster loneliness. Nonetheless, nearly as many disagreed with statement of loneliness (Roelands et al., 2002). Care substitution and stigmatisation were the least expected from the use of assistive devices. The respondents expected autonomy, speed of performance, safety and efficiency as the outcome of using assistive devices (Roelands et al., 2002).
There is also conflict between assistive device researchers on the use and non-use of assistive devices. Some state that in some studies it has been shown that older people have a need and desire for assistive devices (Mann, Marchant, Tomita, Fraas, & Stanton, 2002; Schweitzer, Man, Nochajski & Tomita, 1999), other studies have stated that “elders choose not to use some assistive devices available to them” (Mann et al., 2002 p.131).
3.2.4 Safety and Dissatisfaction Assistive devices that elderly were less inclined to use or were dissatisfied with were mobility devices. These mobility devices are canes, walkers and wheel chairs.
54 In particular to wheelchairs, there seemed to be a poor relationship between the device and the user. Other assistive devices older people were displeased with were sensory devices; hearing aids and magnifiers (Mann et al., 2002). One contributing factor to dissatisfaction is the inappropriateness of the assistive devices in certain environments. There may be a lack of fit between the assistive device and the user’s environment, producing undesirable effects and characteristics (Kraskowsky & Finlayson, 2001).
Participants were dissatisfied with hearing aids. Almost half of Mann et al.s’ (2002) study participants were unhappy with the hearing aids they owned. It was found that participants had the lowest satisfaction rate (72.5%) from hearing aids (Mann et al., 2002). Some of the reasons for dissatisfaction were not receiving enough assistance from the hearing aids, they did not work, had problems with sound control, not being able to filter out background noise and being uncomfortable (Mann et al., 2002). There were similar responses toward magnifiers. The reasons behind the dissatisfaction with magnifiers were more powerful magnifying device was needed to enable the user to view items, the device was too small or did not help at all (Mann et al., 2002). In relation to mobility devices, participants were least satisfied with the wheel chairs. They were said to be uncomfortable, unable to travel through various terrain and need repair (Mann et al., 2002). Therefore, suitability, design and the maintenance of assistive devices need to be better monitored and assessed in reducing dissatisfaction amongst elderly users.
3.3 Summary
It is known that there is a high level of ownership and use of assistive devices amongst elderly people, even in the frail elderly. Assistive device use increases with age and mobility and bathroom devices are most readily used. However, there is also disuse of assistive devices amongst elderly people. Some of the reasons are due to improvement or decline in abilities, awareness, cost, negative social influences, incorrect prescription and placement. There are still some inconsistencies within the studies on usage rates and the effectiveness of assistive devices. The
55 relationships between the usage and attitudes towards assistive devices are still unclear.
It is necessary to conduct research in order to find out how effective assistive devices are to older people. This will assist researchers and health professionals in recommending the appropriate assistive devices to the elderly. Investigation is also needed to identify whether the non-use of assistive devices is related to the abilities of the elderly or to the design of the product or social influence. This will allow researchers to recommend how the design of assistive devices can be improved for the heterogeneous group of older people in an Australian community or similar.
56
Chapter 4 Research Plan
57 4.0 Research Plan
To obtain the most suitable information to achieve the research objectives as outlined in Section 1.2 within the given timeframe a research plan was devised. This research plan consisted of two phases, which allowed for qualitative and quantitative data collection.
4.1 Phase One
The first phase of the research was to gather quantitative data to gain an understanding on the types of people that use and disuse assistive devices and identify which to interview later on in the research. This was conducted in the form of a recruitment questionnaire. A recruitment questionnaire is ideal in identifying which participants may be eligible for further research (Brace, 2004). The benefit of using a paper questionnaire is it allows the respondent time to answer each question to enable them to write lengthy full answers, ability to give an honest answer to sensitive questions and removes any bias. The disadvantages in conducting a self-completion survey in paper form is the inability to prevent respondents from reading the entire questionnaire before answering (Brace, 2004). This can be a problem if the researcher wishes to have questions revealed in a certain sequence. The other disadvantage is the security of material sent to respondents. The material sent may be commercially sensitive material.
For this research, there were no commercially sensitive material and the questions in the questionnaire could be browsed through before answering. There is one disadvantage in using a questionnaire as some questions asked are on memory regarding behaviour. Retrieval of information that happened in the past can be unreliable depending on the data required. A participant will most likely not be able to remember which brand of bread they bought three weeks ago, however, will be more likely to remember which bank they bank with (Brace, 2004). This questionnaire (Appendix 1) has some questions that ask the participant to recall and name the assistive devices they have used. In this case because assistive
58 devices are devices one would use for certain duration, like the bank example, the participants will be able to complete the questions in the questionnaire.
The questionnaire consists of ten questions. The first three questions are closed questions, which ask the participant about his or her age, gender and living situation. The next four questions are questions relating to the persons’ health, physical abilities and quality of life. This is answered on a Likert scale from zero to ten; poor to excellent. The Likert scale assists in understanding attitudinal dimensions within the research group (Brace, 2004). The last three questions are also closed questions which ask participants if they have ever used assistive devices before. These questions have a list of pre-coded prompts that aid the respondent in simply ticking which assistive devices they have previously used and if they are not in the pre-coded answers there are spaces to fill in other devices. The pre-coded prompts act as an example for the respondents to gain a better understanding to the meaning of assistive devices, to save energy in ticking boxes that are applicable rather than writing down each answer, and this method can be easily recorded.
The questionnaires and interview questions were approved by the QUT ethics committee and ready for commencement of research. Independent living homes and aged care facilities were contacted to see if their residents would be interested to participate in the project. Formal letters (Appendix 2) were addressed to the managers and head nurses with a Participant information sheet (Appendix 3) and questionnaire for perusal. The researcher contacted numerous establishments throughout Brisbane (Appendix 4).
There were five establishments that agreed to participate in the research. These were: Marycrest Retirement Centre (Hostel) – Kangaroo Point Garden City Retirement Home – Upper Mount Gravatt The Plains Retirement Village – Eight Mile Plains Sunny Cove – Sunnybank Hills
59 Residents at Aveo Carindale were introduced to the research through the establishments’ manager. Those that wished to participate filled out the questionnaire through self completion. Residents at Garden City Retirement Home were introduced to the research by a member of the staff. Those that wished to participate had the assistance of the staff to fill out the questionnaire on their behalf. Residents at The Plains Retirement Village and Marycrest Retirement Centre received a different approach. The residents were introduced to the research by the researcher and they responded to the questionnaire.
The face to face interviewing allows for clarification in questions, correction in misunderstood questions, the ability to gather deeper responses to open questions and the ability to present stimulus material (Brace, 2004). The disadvantages of this method may be biases introduced from the interviewer; inaccurately recorded responses, questions asked inaccurately and mistakes made in the interview through fatigue and boredom (Brace, 2004). There is no cause for concern as the questionnaire constructed for this exercise was designed with the aim that the questions could be answered within five to ten minute duration. The questions were all closed questions and stimulus material in the form of diagrams was at hand if respondents needed clarification on the names of assistive devices. The questionnaire also had an explanation of the term assistive devices with examples for participants who chose to complete the questionnaires themselves. Participants that self-administered their questionnaires had access to stimulus material. The questionnaires were then collected for analysis. An in depth analysis of the findings from the questionnaires are presented in chapter 5.0. The results from Phase one assisted with the selection process for Phase two.
4.2 Phase Two
As the aim of the research is to identify whether elderly people’s non-use in assistive devices are related to change in abilities or from the product itself it was important to interview participants that had experience with an assistive device; either currently using or previously used. Therefore, participants from phase one
60 that had not used an assistive device were eliminated from phase two. Participants that had declined to proceed with phase two were also left out. The rest of the participants were invited to participate in phase two of the research.
Participants from Sunny Cove, Aveo Carindale and The Plains Retirement Village were contacted by the researcher via telephone to see if they wished to participate in the exercise. A time was then arranged with the participant for an interview. Participants from Marycrest Retirement Centre were approached in person by the researcher.
Again, the participants were reintroduced to the study verbally by the interviewer and formally through the Participant Information Sheet. If they wished to proceed they consented through signing the consent form (Appendix 5). Participants were interviewed individually with a semi-structured interview format (Appendix 6) and also recorded audibly for accuracy in data collection.
A semi-structured interview is ideal for these interviews as it allows the participants to feel more relaxed and at ease. Furthermore, as Haggblom-Kronlof & Sonn (2007) comment, “the only way to understand the advantage, meaning and value, of assistive device and their impact on a person’s daily life is to ask the users” (p.336). Dialogue could flow between the interviewee and interviewer more freely. Some participants give answers to several questions all at once before it is asked. Therefore, some questions are skipped and the format of the interview has to be changed (Bailey, 2007). The series of questions that were already prepared for the interview aids the interviewer to keep the interviewee on track when needed and aids as a checklist to see if all the major questions are addressed. This not only ensures the interviewer does not do most of the talking or get side tracked, it also allows for flexibility in the interviewee to address any issues she or he has or tell stories of events that were slightly related to assistive devices (Bailey, 2007). This additional information given may or may not be relevant to the study. However, in some cases there may be some interesting points towards attitudes or behaviours that arise during analysis that were not picked up before.
61 4.3 Coding of Data
Once the data collection is completed from phase two, the data is then transcribed and coded for analysis. The analysis software used was ATLAS.ti. It is software that assists in data interpretation. ATLAS.ti processes text, images, graphics and sound by affixing codes. Codes can be represented in categories in a conceptual network format. Text can be categories and super categories and then retrieved through the allocated codes or through combinations of codes (Flick, 2006).
Table 4 illustrates the categorisation and coding process undertaken for phase two. The coding scheme is to be read from ‘start’ on the right, following the arrow to the left. Each interview was first coded with a gender, either male or female. Then it was coded against the participants’ living situation; low care or independent living. Once that was completed, the responses to the interviews were coded into the family of assistive devices. The assistive device categories are sensory, mobility, bathroom and other devices. Definitions of these categories are explained in Appendix 7, (Table 2, p.116). From the four main device categories, they were further categorised into the actual assistive devices. The responses made towards the assistive devices were then coded into eight domains (eg. use, disuse, assist and feel). Each domain represents the various responses (eg. bulky, unreliable, don’t want to use) made within the domain. Explanations of the response domains and responses are in Appendix 7, (Tables 4 and 5, p.118). The responses within the domains were introduced to code the common responses received from the interviews. This was formed by the initial analysis of the participants’ responses. In Table 4, some codes are highlighted. They are coded as shown in the legend in three different shades. The yellow shade represents codes that are related to the design of the product. The green shade represents codes that are related to the design of the product and the abilities of the user. The orange shade represents codes that are related to the abilities of the user. This in turn assists with the analysis, whether the disuse or use of assistive devices are related to the users’ abilities or in the design of the product, or a combination of the two.
62 Table 4. Coding scheme for phase two
Start
Occasionally Hearing aid Use Sometimes Frequently
Sensory Magnifying Glass Bulky Unreliable Cane
Male Unattractive Don’t want to use Rollator Disuse Replaced Difficult Stick Chair Got Better
Gender Gender No Need
Mobility Mobility Mobility Scooter Balance Assist Confidence Wheelchair Everything Safe Quad Stick
Female Don’t Like Feel Alright Toilet surround High Satisfaction
Assistive Devices Devices Assistive Neutral Grab rails Get Up
Bathroom Indoors Shower chair Help Reach Relieve Pressure Reacher Responses towards assistive devices devices assistive towards Responses Outdoors Low Care Personal Independence Hip Protector Assistance Combination vs. ADs Assistance
t Lift & Recline Chair Excellent Other Living Situation Living Situation Very Good Shoe Horn Good Living Performance Need Improvement Independen Bed stick Need Legend Can go without Yes Ease of Use Design Design & Abilities Abilities No
The definitions of the codes used are explained in Appendix 1. These codes were applied to the textual data transcribed from the interviews. Interview data were coded with the assistance of Atlas.ti software. This is illustrated in Appendix 8.
63 4.4 Summary
To research the objectives outlined in Section 1.2, a research plan was devised. The design of the research plan consisted of two phases, which allowed for qualitative and quantitative data collection. Phase one consisted of a questionnaire that was sent out to elderly people. The questionnaire asked participants on general questions and what types of assistive devices they had previously owned or used.
Respondents from phase one who previously owned or used an assistive device were the criteria for phase two. Interviewing of participants in phase two allowed for qualitative and quantitative collection. These results were then analysed using a coding scheme, which was applied to the textual data using analysis software (Atlas.ti). The design of this research plan with the combination of questionnaire and interview data gathering provided accurate and sufficient results for this research. Results from the findings gathered from this research plan are discussed in Chapter 5 and 6.
64
Chapter 5 Phase One – Questionnaires
65 5.0 Phase One - Questionnaires In order to investigate the use or non-use of assistive devices in the elderly, the researcher created a data collection instrument; a questionnaire (Appendix 1) consisting of ten questions. The questions were in relation to the participants’ health, overall physical abilities, age, gender, assistive devices owned, previously used and currently used. The questionnaire was termed phase 1 of the research. During phase 1, questionnaires were sent out to potential participants who were over 50 years of age. 64 (30.5%) out of the 210 questionnaires were completed and returned. The participants included people who lived at home, in independent living/serviced apartments or aged care facilities with low-medium care. The results from the questionnaires are analysed in Section 5.1.
5.1 Results
The average age of the respondents was 81.7 years. The youngest age was aged 59 and the oldest was 100. 72% of the participants were female, with only 18 males in the initial study. The distribution of the ages can be seen in Figure 4. It can be noted that the bulk of the participants were aged between 80 to 94 years. There is a steady climb from 50 years of age, peaking at the 85-89 year bracket with a sharp decline at 95 years of age.
66 Age & Gender of Participants in Phase One
16
14
12
10
8
6
4 Number of People i People of Number 2
0 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-100
Age Groups (Years) Female Male
Figure 4. Age of participants in Phase one.
The majority of the respondents lived alone either in independent serviced apartments or in an aged care facility (low care). Nine participants lived with their spouses mostly in private homes or in one case, the couple lived together in low care. When relating the participants back to their age, it was found that the majority in the living with spouse category were less than 64 years of age. Therefore, it could be suggested that once elderly people reach 65 and is without a spouse, they are more likely to move into independent serviced apartments and other aged care facilities.
When participants were questioned about their overall health, they were asked to give a rating from 1-10, 10 being excellent. The average rating for overall health was 6.84, which is just above good (Figure 5). Participants were also asked to rate their upper and lower body abilities. This is movement from the waist up and waist down. On a scale from one to ten, results showed participants had slightly better upper body abilities compared to lower. The upper body scored a 6.98 average while the lower body scored 6.08. This is consistent with findings from Jagger et al., (2001), as explained in Section 2.1; lower-extremity disability precedes upper-
67 extremity disability. Differences in gender and age cannot be compared as there are not enough participants in each category to make an accurate comparison. Although participants rated their overall health and physical abilities slightly above average on the scale, they rated their quality of life (QoL) higher on the same scale. The average quality of life amongst the participants was 7.31. This can suggest that people suffering from illnesses, deteriorated health and restricted body movements can perceive that they have a more than average quality of life. Browne et al. (1994) made a similar comment that older people themselves valued quality of life more than their health.
Averages 10 9 8 7 6 7.31 6.84 6.98 5 6.08 4 Scale (1-10) i (1-10) Scale 3 2 1 Overall Health Upper Body Abilities Lower Body Abilities Quality of Life
Categories
Figure 5. Response averages to questionnaire categories.
The final questions in the questionnaire were regarding the use or non-use of assistive devices. Out of the 64 participants, nine people reported that they had not used an assistive device. There were 26 people who had previously used or owned but did not use certain assistive devices. The ownership of assistive devices ranged from one to eight devices per person. On average participants owned 3.5 assistive devices.
The various types of assistive devices owned and/or currently used can be seen in Figure 6. The greatest difference between previously owned and currently use for an assistive device was the cane. Over 40% of the participants had owned a cane
68 and at time of study fewer than 20% of the elderly have continued use. This concurs with many other studies (Bateni & Maki, 2005; Haggblom-Kronlof & Sonn, 2007; Roelands et al., 2002).
Usage of Assistive Devices (ADs)
80 Bathroom
70
60
50 Mobility
40
30 Sensory Percentage (%) i (%) Percentage
20
10
0 er s h r r t as es ep at ils o ft r Aid g Aid h tick nc e a i und oo Gl n c S e St S R ect Chai o Sc i t Cane mmode B h h t e Othe ing ru ad g Frameo r t in urr y ar ying RollatorC u in C fe at Pro cl Stair L S it if k s B Ba Grab p He /Stock Q l le n i let obil gn k a a Shower Chair H i W Tr nd Re To M Ma Soc Mobi a ft Li Type of Assistive Devices (ADs)
Previously Owned Currently Use
Figure 6. Percentage of assistive device ownership.
It can be seen that over 50% of participants have access to grab rails and a shower chair (Appendix 9). A number of participants have owned and used a hearing aid, magnifying glass and cane. Assistive devices in the “other” column were shoe horns, massage and elevated head and foot beds, bed sticks, reachers, chair sticks, speaking clocks, wheelchairs and a Daisy; device that tells stories through a CD. The bedstick and reacher (Appendix 9) are two products that were used by several
69 people in the survey. The bedstick was only associated with participants in low care. Whereas the reacher (a device that acts as an extended arm assists in picking objects up from the ground without the need to bend down) can be seen in independent living apartments through to low care.
Figure 6 shows evidence of three distinct groups of assistive devices being used. They were bathroom, mobility and senses. Bathroom devices consist of toilet surrounds, shower chairs and grab rails. The mobility group has quad stick, cane, stick chair, rollator and walkers. Hearing aids and magnifying glasses are classified under senses. Figure 7 illustrates the assistive devise in the three described categories.
Usage of Assistive Devices within the Categories
60% Previously Owned Currently Use 50% 50% 46%
40%
30% 23% 23%
Percentage (%) I (%) Percentage 20% 14% 16%
10%
0% Senses Mobility Bathroom
Categories
Figure 7. Usage of assistive devices within the categories.
The sense and mobility categories each show that 23% of the users have owned or have previously used devices in those categories, however, over time some stopped using the devices. All three categories showed continued use of assistive devices by a percentage of their participants. The decline in usage ranged from four to nine
70 percent. The highest uptake and continued use of assistive devices were devices in the bathroom category.
5.2 Discussion
Phase One results showed that a number of assistive devices were being used; among the highest were the grab rails, shower chairs and rollators. This corresponds with findings from Edwards and Jones (1998) that they are the most commonly used devices, with the exception that the majority of current users have upgraded and opted for walking frames with wheels (rollators), instead of the walking frame itself.
Although literature (Huang et al., 2006) shows that hip protectors are ideal in the prevention of a hip fracture during a fall, none of the participants in Phase One owned one of these devices. Participants that had poor lower body abilities and owned rollators should have hip protectors. However, they were never owned.
Some of the reasons for disuse of the sensory aids may be that participants have gone blind and a magnifying glass would be deemed useless or have undergone laser eye surgery to correct their vision. The disuse of hearing aids may be due to dissatisfaction in the poor quality of the sound received or the discomfort or appearance of the product. Again, this corresponds with the statements of Mann et al. (2002) that there was dissatisfaction with magnifiers and hearing aids. However, these are assumptions and needed to be verified with further research in Phase Two.
The reason behind the decline in use of mobility devices may be due to the decline in cane use, as illustrated in Figure 6. It can be hypothesised that participants have opted for rollators or walkers, which offer more stability while walking due to the decline of lower body abilities. Informants in Mann et al.’s (2002) study also showed non-use in mobility devices, they were canes and walkers. Another reason that contributes to the higher rate of use in mobility devices compared to Mann et al.
71 (2002) may be that wheelchairs were not included in the questionnaire. Social influences, as mentioned by Haggblom-Kronlof & Sonn (2007), Resnik & Allen (2006), Brooks (1991), Roelands et al. (2002), need to be further investigated.
Disuse of bathroom or hygiene devices was quite minimal. This may lead to the conclusion that the devices in this area are effective and efficient to the user. Edwards and Jones (1998) along with Sonn and Grimby (1994), shared the view that the ownership on the number of assistive devices increased with age and hygiene and mobility devices are more readily used. Findings in the data collection share their views as the average age of participants was 81.7 years of age. Also, some bathroom and hygiene devices such as the grab rails and toilet surround are fitted into the area, hence, they are always there and as a result will be used more.
Findings from Phase One presented some positive results. It showed that assistive devices were being used by participants, meaning they are staying independent and active. They are still maintaining a good quality of life even though they have poorer upper and lower body abilities. However, there are assistive devices owned by participants that are not being used. Further research in the form of interviews was conducted in Phase Two, which aimed to verify the assumptions made, to identify the disuse of assistive devices; whether the devices are inefficient, inappropriate or if the participants no longer have a need for them.
5.3 Summary
The findings from Phase One supported the concept of older people using assistive devices to help them maintain living at home, independently and with good quality of life is very feasible (Edwards & Jones, 1998; Haggblom-Kronlof & Sonn, 2007; Roelands et al., 2002). Also, elderly suffering from illnesses, deteriorated health and restricted body movements can perceive that they have a more than average quality of life (Browne et al., 1994). The continued use of bathroom aids and mobility devices indicates that they are efficient and aid in elderly people’s independence. Further investigation was undertaken into the reason behind the
72 disuse of assistive devices such as hearing aids, magnifying glasses, canes and hip protectors by the participants in Phase One, in order to further identify if they are related to change in abilities or in the design of the product. These results and findings are presented in Chapter 6.0.
73 74
Chapter 6 Phase Two – Interviews
75 6.0 Phase Two – Interviews
After the analysis of the questionnaires in the first phase of data collection, interview questions were drawn up (Appendix 6). The questions aimed to investigate whether the disuse or use of assistive devices were related to the older people’s change in abilities or to the design of the product. Some of the questions devised asked the participants when they used each of their assistive devices, how the devices assisted them, how useful they were, what their feelings were towards the devices, the reason for disuse and also their preference between assistive devices and personal assistance. An example of the type of questions asked by the interviewer can be found in Appendix 6. These questions formed the basis of the interview. Since it was a semi-structured interview there were several follow-on questions, which depended on relevance or if further information was needed.
6.1 Participants
Participants for the interview were required to have the prerequisites of having previously owned or used an assistive device and participated in phase one of the research. The ideal scenario for phase two was to have an equal number of participants from independent living and low care environments, including a mix of female and male participants. This however, was not realised. For phase two, 27 participants were available for interviewing. They consisted of four females and five males from independent living arrangements and sixteen females and two males from aged care facilities (low care). Participants interviewed were from the following places: • Sunny Cove – Sunnybank Hills • Marycrest Retirement Centre – Kangaroo Point • The Plains Retirement Village – Eight Mile Plains • Garden City Retirement Home – Upper Mt Gravatt
The locations were suburbs in the region from inner Brisbane to Brisbane’s south side.
76 6.2 Methodology
The interviews were conducted at the participants’ residence. Interviews were one on one; the interviewer and interviewee. The environment where the interviews were conducted was usually in the rooms belonging to the interviewee or in a private environment, away from other residents. This allowed the interviewee to be more open about the questions that were asked and since it was in an environment chosen by the interviewee, they were more comfortable.
A digital hand held recorder was used to record each interview. Consent was given by the participants prior to the interviews. The interviewer was also equipped with data from phase one to confirm the assistive devices they previously owned and used or were currently using and a phase two interview questions sheet to record observations and make notes during the interview. The length of the interviews depended on the assistive devices used by the participant. The higher the number of assistive devices used the longer the duration of the interview. The approximate duration of the interviews ranged from three and a half minutes to sixteen minutes.
6.3 Findings
Once the interviews were completed, they were then transcribed and inserted into a program named ATLAS ti., for analysis. The coding scheme used to attach the quotes to the specific codes is as outlined in Section 4.3. Analysis sample of the coding applied to textual data is shown in Appendix 8.
Participants were asked how often they used their assistive devices. Their responses were then categorised into frequently, sometimes and occasionally. For example if the reply for use of a grab rail was “all the time”, then it would be categorised under frequently. If the reply for use of grab rail was “not often”, it would be placed under occasionally.
The most commonly used assistive devices at a high frequency were the grab rails and rollators. The majority of participants frequently used their assistive devices;
77 there were a portion that used their assistive devices occasionally. This is illustrated in Figure 8.
Frequency of Use on Assistive Devices amongst Participants
16
14
12
10
8
6 Number of People i People of Number 4
2
0 r s nd r s r ai u e e a ick Ch o ator an t r ll C er r o ing Aid ng Gl eache u R Scoo R ed St Grab Rails w ar fyi B Protector et S Stick Chair Shoe Horn ip Sho il He gni H To Ma Lift & Recline Chair Assistive Devices Frequently Sometimes Occassionally
Figure 8. Frequency of Use on Assistive Devices.
Figure 8 indicates that grab rails, shower chairs and rollators have a higher number of frequent use by people. This corresponds with findings from Haggblom-Kronlof & Sonn (2007) that usage rates for assistive devices in hygiene, mobility and transfer chair and beds were quite high. However, transfer chair and beds were not included in this research (Phase Two) as none of the participants during phase one had owned one. In phase two assistive devices that were used by participants on an occasional basis were magnifying glasses and canes. The frequency and usage rate on types of assistive devices that were sometimes used were not listed in Haggblom-Kronlof & Sonns’ (2007) study. It only indicated that there were a percentage of participants that sometimes used mobility and grip and reach devices. Magnifying glasses were not included in the study either. There does not seem to be other studies conducted with the frequency and usage rate of assistive devices.
78
Disuse To gain an understanding of the disuse of assistive devices, participants were asked the reason for not using the assistive device that they were given. Their answers were categorised into eight responses. Table 5 shows the results of the participants’ responses to the disuse of certain assistive devices. There were 19 responses of disuse that were regarded as “no need”, 12 people disused products because they did not want to use them and 13 people stopped using certain products because the assistive device was replaced with another. Nine of the superseded products were canes. Some of the responses for “no need” did not necessarily mean the respondent had improved in ability so as to not require an assistive device. Some of the reasons attributed to deterioration in health, therefore, had to change to a different assistive device. For example, on most occasions it was the cane being replaced with the rollator. Haggblom-Kronlof & Sonn (2007) had participants that expressed lack of need for a device due to recovery or deterioration in abilities, in the mobility domain. Nonetheless, there were respondents who did not deteriorate or improve in health, however, answered “no need” towards the use of certain assistive devices. This may be due to the participants’ feelings towards assistive devices, which will be discussed in Section 6.3.
Mobility devices in particular seemed to be unreliable to some participants. The most unreliable device was the cane followed by the rollator, mobility scooter and hearing aid. This is consistent with findings from Mann et al. (2002). Haggblom- Kronlof & Sonn (2007) did express that the non-use of assistive devices were in mobility and grip and reach devices. In their study, mobility devices were not seen as unreliable, only grip and reach devices were. Bulkiness and difficulty in use were less of an issue for respondents in Phase two, however, they were still evident for mobility and sensory devices. There were only three participants that stopped using their devices due to improvement in physical ability.
79 Table 5. Responses to disuse of assistive devices.
Responses
Design Abilities Abilities Abilities & Design
Total Bulky to use Difficult No Need Replaced
Unreliable Better Got want Don't Cane 1 3 1 1 9 2 1 18 Rollator 0 2 1 1 0 2 0 6 Mobility Scooter 1 1 0 0 0 0 0 2 Quad stick 0 0 0 0 1 0 0 1 Stick Chair 0 0 1 0 1 0 0 2 Hearing Aid 3 1 0 1 0 2 0 7 Sensory Magnifying Glass 0 0 0 0 1 1 1 3 Bathroom Grab Rails 1 0 0 0 1 2 0 4 Shower Chair 4 0 0 0 0 7 0 11 Assistive Devices Lift & Recline Other Chair 1 0 0 0 0 2 0 3 Bed Stick 1 0 0 0 0 0 0 1 Reacher 0 0 0 0 0 1 1 2 Total 12 7 3 3 13 19 3 60
From Table 5, an alarming result has arisen with over half of the responses for disuse being related to the design of the assistive device (n=38). This is excluding the responses from assistive devices being replaced by another. The responses related to “Don’t want to use” is of concern, as this means that the participants have owned a particular device and not used it for reasons other than the lack of need. It meant that participants have chosen not to use the assistive device that would help them in some way. Another interesting finding is that, when asked for the reason for disuse of an assistive device, no one used “unattractiveness” as an explanation. It can be suggested that for the elderly practicality comes before aesthetics.
The general comments made by participants for not wanting to use assistive devices that they owned was nicely summed up by one participant as saying “I can get away
80 with it”. These participants still have the physical ability to undertake an activity without reliance on the assistive devices. Therefore, the participants try to complete tasks unassisted until absolutely necessary.
The responses to the disuse of assistive devices other than those being replaced with another product that is more reliable and fitting to their needs is the response of ‘don’t want to use’. This means that the use of assistive devices still comes attached with a social stigma. To some participants the use of assistive devices is seen as a burden and is the beginning of a down hill trend in physical abilities. A participant from Haggblom-Kronlof & Sonn (2007) explained that he did not want to use his cane because then he would become a victim of his surroundings.
As for hearing aids, participants that no longer wish to use the devices had related it to being unnecessary in certain situations. One participant states it is only needed when going to places where there is a crowd. However, another participant adds that it is “pretty useless”, commenting that hearing aids do not block noise and therefore, is unclear and nothing can be heard. The majority felt they could “get by” without the hearing aid and that their hearing wasn’t bad enough to warrant it. One participant has resorted to lip reading when conversing. Respondents from Mann et al. (2002) also expressed similar problems with hearing aids, stating they were uncomfortable. It was not reported if their participants thought they could ‘get by’ without the hearing aid.
Four participants commented that they do not want to use shower chairs. The reason was they preferred to stand when showering. Two participants commented that they prefer to use grab rails when showering. One participant said it is only there for emergencies and another commented that “there may come a day when I do”.
There was a high number of respondents that did not use the cane (n=18), the highest assistive device disuse amongst all the devices recorded. The responses to the disuse of canes were mostly unreliable, replaced with another device or no
81 need. The cane was deemed difficult and unreliable when the respondent had difficulty with balance. Respondents were then advised to use rollators after falls and loss of balance from the use of canes and after strokes. Respondents also had difficulty balancing with a cane on uneven surfaces and holding onto objects in their hands whilst grasping a cane. If the cane had been replaced by a rollator, the cane then becomes a backup, or used only when participants go to places where it is inconvenient to use rollators. However, in relation to rollators, one participant found it hard to manoeuvre outdoors on gravel surfaces and another chose to disuse it due to its’ bulkiness on public transportation. Haggblom-Kronlof & Sonn (2007) and Kraskowsky & Finlayson (2001) commented on the inappropriateness of assistive devices in certain environments; the lack of fit leads to undesirable effects and characteristics.
One participant did not use the cane that he owned, claiming there was no need for one. Through observation, the participant was very mobile without the use of a cane. However, the participant did explain that he walks to his local shopping centre. The route he takes consists of level ground with a few steep hills mid-way. The participant claims to use a bush-stick: “because after I walk up the long hill I hide the stick alongside of a tree and then leave it, go and do my business at the shopping centre then on the way back I pick up that stick. Why I use the stick is going up the steep hill. I don’t use any stick walking level.”
The explanation for the preference of using a bush stick compared to a normal cane was that it was cheaper than a cane, and if lost or stolen it would not matter. When asked further why the user does not carry around a cane, the reply was: “Well I could, I could. (Pause…) I suppose I’m keeping it for when I really need it”.
82 Performance When participants were questioned on the performance of their assistive devices, the majority of the responses were good, very good or excellent. Hence, they were positive responses to the assistive devices used and owned. However, there were ten responses that suggested that certain assistive devices need to be improved. The main devices that needed improvement were hearing aids followed by grab rails. Assistive devices that were deemed excellent were rollators, magnifying glasses, grab rails, shower chairs and shoe horns. This can be seen in Table 6.
There were 18 responses to the need for an assistive device. This was related to abilities. The participant cannot perform an activity without the assistive device. There were 14 responses of “can go without”, which meant that even though the participant can perform an activity without a device; they prefer to use it, to aid in their performance of the activity. The most common assistive device needed was the rollator. Assistive devices that participants could go without but preferred to use were both bathroom devices; grab rails and shower chairs.
Table 6. Response to performance in assistive devices.
Design Abilities Assistive Devices Very Need Can go Excellent Good Need Good Improvement without Cane 0 3 1 0 2 2 Rollator 4 4 2 1 13 3 Mobility Scooter 0 1 0 1 0 0 Wheel Chair 0 0 0 1 0 0 Hearing Aid 0 0 3 5 0 0 Magnifying Glass 1 1 1 0 0 0 Grab Rails 4 3 3 2 0 5 Shower Chair 1 0 2 0 1 3 Toilet Surround 0 0 2 0 0 0 Lift & Recline Chair 0 1 0 0 0 0 Bed Stick 0 0 0 0 0 1 Reacher 0 0 0 0 2 0 Shoe Horn 1 0 0 0 0 0 Hip Protector 0 1 0 0 0 0 Total 11 14 14 10 18 14
83 The overall consensus on grab rails for participants was that they were a “wonderful assistance”, agree with the “whole set-up” and are handy, firm and secure. However, when they are located at a place that is not ideal for the user, the grab rail is categorised negatively in performance; needing improvement. Complaint was made about a single vertical grab rail situated too far forward along the toilet wall. Clemson & Martin (1996) also found dissatisfaction of grab rails placed vertically.
For mobility devices, the rollators and canes were regarded as positively performing assistive devices. They were also products that the elderly depended upon to stay mobile. From the findings, rollators are seen as the most essential mobility item. They allow the user to push the frame along with ease, brake when necessary, offer a seat, a basket to carry parcels and are also collapsible for transportation in a car. They have been described as “marvellous”, “hate to be without it”, “wonderful” and “with the walker I’m right”. It was also found that some participants use both the rollator and cane, due to the fact that the rollator is bulkier in size and the user can not enter dining rooms or some spaces with them. The cane is used in these situations.
The hearing aid, a sensory device, was categorised mostly in the “good” and “need improvement” columns. Participants were not excited or happy with the product. Respondents that were in the “good” category said their hearing aids were an improvement to their hearing. However, one respondent replied to how well the hearing aid works as “well I guess it would, hmm”. Participants also commented that the hearing aid “could work better” or wished they “could get something done that would be able to hear quite well”. One participant that owned one did not use the one he owned because he said: “It’s only partly successful. I (pause…) I wasn’t prepared to purchase an appliance which may be, only satisfactory for (my) needs”
The participant claimed that to purchase a decent hearing aid that would cater for the various environments would be around $10,000 and the normal hearing aid
84 which he owned is around $2,000. Also, another comment was made by a respondent who said people living in the aged care facility that owned hearing aids would still tell the person to speak up because they could not hear what was being said.
There were not enough respondents who had devices that fall into the ‘other devices’ category to gain quantitative data. However, it seemed that if assistive devices were owned in the ‘other’ category, the feedback was positive in terms of product performance. One interesting comment was made in relation to hip protectors. During phase two, the researcher visited a participant for interviewing. While in conversation, the participant commented on her hip protector and explained how it was recommended to her and how a number of people living at her aged care facility owned one and did not use them: “Yes, well they, yes (pause…) and they’re very good. And I lie down with them and they seem to (pause…) they do hurt a bit in a way. But I find that they’re worth it. I wear them all the time. A lot of them have got them and haven’t worn them but I wear them because I find that I’ve got osteo bad……… But it’s protection. You know, if I fell and broke my hip”.
According to the data collected in phase one, the questionnaire that was completed for this participant did not mention that she owned and used a hip protector. During phase one, participants were asked what assistive devices they previously owned and used. A list of pre-coded assistive devices were listed on the questionnaire that the respondents could read through and tick off or be read out to by the interviewer. Images of assistive devices could be shown to participants by the researcher during the interviewer-administered survey if they were unsure about an assistive device. During phase two, the use of assistive devices were reconfirmed and hip protectors were not mentioned. Therefore, it can be hypothesised that some elderly people have difficulty in identifying what is regarded as an assistive device, or have forgotten or do not wish to mention which assistive devices they had previously owned and currently use.
85
Feelings about Devices Participants were also asked about how they felt about the devices they had used. The results are represented in Table 7. They have been categorised into two positive responses, one neutral and two negative responses. The “alright” category is classified as a neutral response, as there is no expression of dislike neither a keen liking for an assistive device. “Have to use” is classified as a negative response rather than neutral as respondents did not comment that they felt alright with the device, it was a straight “Have to use”.
Table 7. Participants feelings towards assistive devices.
Design Design & Assistive Abilities Devices High Have to Safe (D) Alright (D) Don't Like (D) Satisfaction (D) Use (A) Cane 1 5 6 2 0 Rollator 5 7 5 1 3 Mobility Scooter 0 0 0 1 0 Stick Chair 0 0 1 0 0 Hearing Aid 1 0 1 1 1 Magnifying Glass 0 0 1 1 0 Grab Rails 1 5 6 0 0 Shower Chair 0 1 3 0 1 Toilet Surround 0 0 2 0 0 Lift & Recline Chair 0 0 1 0 0 Bed Stick 0 0 2 0 0 Total 8 18 28 6 5 <------Positive ------Neutral ------Negative ------>
There are a high number of responses to assistive devices being just “alright”. From the responses given by the participants there seems to be an association with feeling safe and feeling alright towards an assistive device. One reason that one participant gave for feeling alright towards the rollator was:
86 “Well I don’t worry about that, but nearing everyone has a walker here. When we go down to the dining room we take it and they bring it to us to use it. They’re very good”.
It may be due to the fact that the people the participants are surrounded with all use rollators, or that they are a common sight, which leads to more acceptance of assistive devices. The environment (assistive living and aged care facility) that these elderly people are in are encouraged by staff and carers to use assistive devices, which therefore blend in with the environment. Haggblom-Kronlof & Sonn (2007) had participants who expressed the use of assistive devices as feeling normal, pleasant and safe.
Another perspective on how participants felt towards their assistive devices can be illustrated through this respondent. She commented on how she has been using her cane for a while and did not like to use it at first. However, due to the security it provided and the feeling of safety, she has accepted the cane and now does not “mind at all”. Her reason for not liking the cane initially was due to pride.
Another respondent mentioned that he knew a lady friend of his that was reluctant to use a cane, whereas he felt comfortable using his cane and did not mind having to use it. The respondent goes on, saying: “I don’t’ feel uncomfortable with the walking stick, not at all. As a matter of fact every time ah, ah, that I used to go out with the walking stick someone would admire it. (laughter) They’d say what a lovely stick you know (laughter)”.
The reason that people stop to admire this respondent’s cane is because it is not the common cane that can be purchased at a pharmacy. It was described as a cane that was passed down from his father from Ireland. The cane is wooden with a dark brown finish, decorated with knots from the tree it was made from (Figure 9). The cane had a story of its own. However, the respondent at the time did recently purchase a collapsible cane for travelling. He has not yet used it, however, he states that he would not mind having to use a metal cane.
87
Figure 9. Irish wooden cane.
When participants were asked how they felt about using their rollator there were three respondents who responded with “have to use”. One participant said, “Well I have to use it so I just (pause…), you know”. Another participant responded with, “Well I wouldn’t go without it. There’s a terrible lot of people here (that) do though”, and lastly another respondent stated: “Oh I find (pause…) I mean I know It’s secure but I wish I didn’t have to. I suppose it’s only in the last 12 months that I’ve been using the walker, prior to that I was just using the stick”.
This shows that the respondents have a slightly negative feeling towards the rollator they had to use. This may be attributed to the loss of control (Grewal et al., 2006) participants once had and now need to rely on assistive devices to maintain their independence. Participants did not express that the use of assistive devices gave them a sense of “respect” or on the other side of the scale were “embarrassed” by its’ use, as mentioned by Haggblom-Kronlof & Sonn (2007).
88 Therefore, it may be suggested that the relationship between social stigma and the use of assistive devices for participants in this study was minimal. Social stigma was also least expected from participants in Roelands et al. (2002).
In relation to sensory devices, respondents had a neutral to negative feeling towards them. One respondent commented on hearing aids that “some people sort of feel embarrassed about it but it’s a small one. Half of them say they don’t’ know I’ve got it on”. This respondent is not worried about wearing a hearing aid and can hide it under her hair. However, she stated that some people will not use it due to embarrassment. Again, another reason for disliking the hearing aid is due to the outside noise that can be heard using the device.
One participant felt alright with using a magnifying glass as she mentions she is usually on her own when using the device. From the results of how participants felt towards their sensory devices, the overall consensus was that some have adjusted to using the assistive device and some still hold a negative feeling towards the devices as they could not simply undertake an activity easily without the use of an aid. Hellstrom et al. (2004) comments that the transition from living independently to receiving assistance from others contributes to change of values and attitudes in life and if the elderly person remains negative it may lead to low quality of life.
Assistance Preference The participants were asked to state whether they preferred personal assistance over assistive devices. Findings indicate (Table 8) that the majority of the participants preferred their own independence and they would rather use the assistive devices than obtain help from others.
Table 8. Participants Assistance preference in relation to living situation.
Independence Combination Assistance Independent Living 9 1 0 Low Care 17 1 1 Total 26 2 1
89 This was evident in both low care and independent living participants. Overall, people living in independent homes expressed that they would rather use their assistive devices to assist them with their activities for as long as possible. They are happy with their current arrangement. One participant summed up the participants thoughts on assistance preference with: “It all depend how bad you are too isn’t it. I mean if you are really bad well you’d like some of your family to be with you rather than be on your own. But if it’s not… um… if it’s not too bad, um, well the devices I’d just rely on those, you know”.
Another participant stated he would only use a rollator if it was deemed necessary. This participant wants to resist using assistive devices for as long as possible. He stated: “I suppose I’d use it, but, but, ah, but I’d want to be a bad case to use it, you know”.
Participants that lived in low care had the same responses as people in living in independent living areas. They all preferred the freedom and independence that the assistive devices offer. There was only one participant who had to have personal assistance and the use of assistive devices. This was due to the fact that the participant was physically unable to undertake daily activities on his own. Again, participants expressed a want for personal assistance only when necessary. As mentioned in Section 3.1.3, elderly people value the ability to maintain their own homes and lives through the use of assistive devices and also agree that assistive devices cannot exclude personal assistance (Roelands et al., 2002).
The use of assistive devices for independence was preferred in both genders (Table 9). There did not seem to be a difference in either gender or in living situation. There were only two participants that commented on desiring a combination of assistance; personal assistance and assistive devices and one participant that preferred personal assistance.
90 Table 9. Assistance Preference amongst genders.
Independence Combination Assistance Female 18 1 1 Male 6 1 0 Total 24 2 1
When asked whether personal assistance was preferred over assistive devices, one participant replied: “I suppose I could, like when my daughter comes and we go out anywhere I just hold onto her arm. I don’t take either of them”. She continues: “I just hold onto my daughter’s arm when we go, you know, if we’re going out for dinner or anything like that”.
Not all of the participants preferred the use of assistive devices, as indicated. Some choose not to use the device until really necessary and when some were offered assistance, for example from a family member, assistance was preferred over assistive devices. However, there were a handful of participants who found the loss of independence quite hard to deal with, as some have stated: “I’m very independent. I like to do things myself”, “I hate personal assistance. I’m hopelessly independent”, “Just because I’m so independent. I like to do it myself. I know and I dread the day that I’m going to have to have people shower me and all those things” and “Well I’d like to do it myself, whatever it is, yes, rather than having assistance”.
Attractiveness and Personalisation Although attractiveness was not an issue to participants when using an assistive device, it is the opinion of the researcher that the design and attractiveness of an assistive device does play a minor role in the usage and does slightly affect the users’ attitude towards it. As Brooks (1991) mentioned the rejection of assistive devices is attributed to the fact that the devices lack the capacity for “meaningful
91 personal touch and communication” (p.1419). The ability to personalise or customise assistive devices may enhance ownership and usage rate. Designs should allow for personalisation as it contributes to the end-user experience (Kramer, Noronha, & Vergo, 2000). “Personalisation is a toolbox of technologies and application features used in the design of an end-user experience” (Kramer et al., 2000 p.45).
When participants were asked if they would change anything about the devices they were using, such as the rollator, the majority said no. They liked how it worked, functioned and thought it contributed to their independence. When participants were asked if they liked the look of their rollator, one lady commented she liked the look of the new rollators and would like her next rollator to have a basket underneath the seat so it would be easier to access. She also commented in relation to her rollator: “So see that’s all scratched. Well you go out somewhere, they’re all thrown in and they get scratched”.
Therefore, making rollators more durable and scratch resistant so they retain their colour coating may be an area that could be improved. When asked if she had an option in choosing a colour for her new rollator what it would be, she replied that she thought they only came in two colours and would pick green again because that is the colour of her current rollator and she was too old for bright sparkly colours.
One participant responded to the question of change and the look of her rollator as: “Well, no, it’s nice and light. I just find that that’s good. ……Well, it’s functional isn’t it. You know, and I’m 87 and what I wanted is for it to be helpful to me, not the appearance you know”.
Another respondent replied “not really, no” to changing her rollator and “yes, yes” to the appearance.
92 Respondents generally did not have an opinion on the aesthetics of their assistive devices. What mattered most was that it be safe and practical. However, from observation there were elderly people who decorated or personalised their rollators or had canes with a floral pattern (Figure 10). Figure 11 is an example of an elderly persons’ rollator, decorated with several ribbons affixed to the front of the rollator with a soft toy; teddy bear. There was a participant who had artificial flowers wrapped around the front of her rollator. The participant commented that her friend from the same aged care facility as her decorated it for her. Her friend does the same thing to her own rollator. She also adds that they decorate their rollators on special occasions such as Christmas. The decorating also makes identifying their rollators easier when they are placed outside the dining room, during meal times or in similar circumstances where many rollators are placed together during an event where rollators are not admissible in certain spaces.
Figure 10. Floral patterned cane.
93
Figure 11. Decoration on a rollator.
Although personalisation was not addressed by the participants, it does not mean that it is not an important factor to the disuse of assistive devices. Kramer et al. (2000) points out that designers often create the error of designing a product with new features and tools and forget the initial focus of designing for the end user. The design approach of personalisation in the form of mass customisation would be suitable in the design of assistive devices for elderly people, (as mass customisation is a form of personalisation on a large scale). It is the assembly of components and judicious componentisation which reduces costs and produces personalised products at a reasonable price (Duray, 2002; Kramer et al., 2000).
Other Factors One male participant did not want to be recorded onto digital media as he commented that the council had access to information and nothing remained
94 private anymore. When the interviewer explained that she wanted to ask questions relating to the assistive devices that he has used and was using, such as the rollator and the mobility scooter, the male participant replied immediately that he did not want to be asked about the rollator that was sitting outside this room. He said he did not need it anymore, had recovered from his injury and would be returning it soon, therefore he did not want to talk about the mobility scooter. It seemed the participant did not want to be associated with any assistive devices. Maybe, in some elderly people, there are still some negative social influences attached to the use of assistive devices. As Brooks (1991) mentioned there are ways in which assistive devices play a social role when related to disability. It makes the disability public and places a social strain to the public as it is unfamiliar and people with disability have been stereotyped with negative characteristics, such as lower intelligence and poor judgment (Brooks, 1991).
Summary It can be concluded from the findings that participants prefer to use assistive devices to assist in their everyday activities. Living situation and difference in gender did not effect in the preference of elderly people preferring the use of assistive devices over personal assistance. Independence was very important to the quality of life of the participants. Participants that had used assistive devices and realised the security and safety they offered were more accepting and had a neutral to positive feel towards the devices. However, initial use of the assistive device and “have to use” has resulted in a negative feel towards devices.
When it came to the performance of the assistive devices, the majority of respondents rated them from good to excellent. There were only ten respondents that suggested the devices needed improvement. This was aimed towards the design of the assistive devices. When studying the respondents performance abilities in relation to the products there were a high number of users that needed rollators. Grab rails and shower chairs and canes were some of the devices that respondents could go without but chose to use. Hearing aids were regarded as needing improvement by five respondents. The major cause was to do with the
95 design of the product and cost. The average hearing aid could not block out unwanted outside noise, which was undesirable to participants.
Reasons for the disuse of assistive devices were mostly due to the design of the product and social stigma. A dozen respondents did not want to use the devices that were given. The comment made was they preferred to undertake activities on their own and only use assistive devices as a precaution or when absolutely necessary. They would prefer not having to rely on the devices. Unreliable, bulkiness and difficulty of use were the other factors for disuse in assistive devices. There were thirteen respondents that claimed the disuse was a result of replacing the device with another. The most popular device replaced was the cane. It was often replaced by the rollator which provided more security, balance, and a place to sit and store things while mobile. In relation to participants’ abilities, the reason for disuse was due having no further need for the assistive device or having recovered from a disability to no longer warrant the need for the device. In terms of ownership and the use of the assistive devices, the rollator and grab rail were the devices that most participants interviewed owned and used. Also, bathroom and mobility aids are the devices that are used most frequently.
6.3.1 Limitations The ideal aim in phase two was to interview an equal number of male and female participants and with a fairly equal amount of participants from independent living and low care, to obtain a fair result that covered the desired demographic. However, when approaching the existing participants from phase one to do an interview for phase two, a number of participants were discouraged by the idea of being recorded on digital media and having to sign a consent form for the recording of the interview.
Some of the participants were contacted via telephone by the interviewer and declined to be interviewed as they did not remember participating in the initial questionnaire stage, thought the interviewer was a telemarketer or were hard of hearing and did not want to participate. A number of participants who had agreed
96 to an interview during phase one declined due to the reasons above, or they were feeling under the weather, in hospital or on holiday during the duration of the interview stage of the research.
Another factor that may have influenced the results on the ownership of assistive devices may be due to miscommunication. Participants were asked to identify and name all the assistive devices they have previously used and owned. However, participants may not have understood the full meaning of what an assistive device is. The definition given was: “Assistive devices are implements or products that aid a person in completing activities they need or wish to do, eg. walking sticks, commodes and bath mats”. Another reason may be that elderly people have difficulty in remembering what assistive devices they have owned and used in the past and cannot recall all the devices they use in a short period of time. As Brace (2004) explains, there is a disadvantage in using a questionnaire to ask questions on memories regarding behaviour. Although, the questionnaire did not ask when they used the assistive device, it did ask what types. It is still regarded as some form of information retrieval.
6.4 Summary
From Phase Two, there were some interesting findings on the attitudes and use towards assistive devices amongst elderly people. From the interviews, results showed the majority of elderly people had a neutral to positive attitude towards the use of assistive devices. Findings showed there was desire to maintain independence and rely less on personal assistance. There was no significant association between the use of assistive devices and living situations, as described by Edwards & Jones (1998).
Social influences were present in the use of assistive devices, however they were minimal. Negative attitudes tended to be during the initial use of an assistive device and over time, elderly people accepted and came to enjoy their assistive devices using words to express them such as “wonderful” and “my other half”.
97
The major issue that designers could address is the issue of “don’t want to use”. There was still some resistance in the use of assistive devices as participants wanted to undergo activities of daily living on their own and only have their assistive device as a precaution. Recommendations and future research directions to further investigate and explore the usage of assistive devices in elderly people are explored in Chapter 7.
98
Chapter 7 Conclusion and Future Directions
99 7.0 Conclusion and Future Directions
It can be concluded that this research has given an insight into the needs and desires of elderly people in relation to activities of daily living, quality of life and assistive device use. This research has also investigated through means of questionnaires and interviews the attitudes of elderly people towards assistive devices in assisted living and aged care settings. It has investigated what types of devices are used amongst the elderly, the least used, most commonly owned and non-used. Through research the reasons behind non-use and attitudes were explored.
Overall, it can be suggested that the use and non-use of assistive devices amongst elderly people are related to change in abilities and in the design of the product. It is also driven by elderly people’s desire to stay mobile and active for as long as possible. They will use assistive devices to assist them in staying independent in undertaking activities of daily living. Disuse of the devices was related to the dislike in the product, reliability, bulkiness, performance and ease of use.
The most important issue designers need to address is the issue of “don’t want to use”. The reason behind participants not wanting to use their assistive devices might be due to the design of the product and social stigma. It is important for elderly people who may require assistive devices to use them. However, some elderly people have opted to go without. Assistive devices have been designed without the capacity for meaningful personal touch and communication. They can be seen as a burden and a catalyst to old age and decline in abilities. Once a person starts using an assistive device, it will be difficult for them to relinquish their dependence on it. It is seen as a negative social outlook for elderly people to use assistive devices, especially if the device is for outdoor environments. The personalisation or customisation of assistive devices is not offered as an option to the current end-user (elderly people). The ability for elderly people to personalise their assistive devices is just as important and of equal value to the use of devices being safe, reliable, easy to use and perform.
100 7.1 Recommendations
Based on the outcomes of the literature review and research conducted, listed below are recommendations for designers, researchers and health-care professionals to consider. They are categorised into design and general recommendations.
Design To design assistive devices that ease the user into the use of devices. The literature review and findings from this research have suggested that assistance is needed in the transition from non-use of assistive devices to initial use. Assistive devices should blend in more with the surrounding environments; both in and out of the community setting. Therefore, users will not feel that they have become victims to their surroundings (Haggblom-Kronlof & Sonn, 2007). Reliability should be carefully addressed in the design of assistive devices. For example, the rollator should be able to be used outdoors and be used on varying terrains (eg. sealed and unsealed surfaces, coarse surfaces and surfaces with inclines and declines). Hearing aids should be improved to block out background noise, to improve effectiveness and usage rate. To design assistive devices that offer personalisation through mass customisation, to enhance the capacity of personal touch and communication between the product and the user and to enhance the end-user experience. Improve the practicality of assistive devices, especially rollators to make them less cumbersome (ie. walking through doors and public transportation). Rollators to have the ability to carry canes and other items (eg. bags, laundry) for when necessary.
101 General Hearing aids and hip protectors should be more affordable for people on the pension. Ongoing assessment of assistive device suitability with user is needed. Further encouragement is needed by general practitioners, carers, and spouse and family members to improve the usage rate of assistive devices and to reduce negative social implications.
7.2 Future Directions
Further research is required to better justify the findings from this research. A larger sample of participants could assist. An equal number of male and female participants can help identify if there are differences in the usage of assistive devices between genders.
When evaluating the number and types of assistive devices participants use, it would be ideal to gather this information from the spouse, family or carer to obtain more accurate data and to ensure validity.
A longitudinal study over a period of five or ten years with participants from community-dwellings and assisted living settings is the future direction. Other studies have used these timeframes in undertaking research of elderly people (Haggblom-Kronlof & Sonn, 2007; Ivanoff & Sonn, 2005; Kraskowsky & Finlayson, 2001). This could further investigate qualitatively and quantitatively the use and attitudes towards assistive devices amongst older people with detailed investigations into certain types of devices for the practical, social and personal aspects of use. Also, a case study could be conducted to examine the design of an assistive device in order to get feedback from the users. The introduction of focus groups may be beneficial in the design phase, to obtain feedback and gain an understanding on what elderly people desire and need in an assistive device.
102 This research has contributed to knowledge through the investigation into the relationship of elderly people and their use of and attitudes towards assistive devices for designers, researchers and the general community. This work is significant as it has identified areas for further understanding and development of assistive devices for use by elderly people.
103 104
References
105 References
Aminzadeh, F., & Edwards, N. (2000). Factors Associated with Cane use among community dwelling older adults. Public Health Nursing, 17(6), 474-483. Australian Bureau of Statistics. (2005, 5 September 2008). 3235.0.55.001 - Population by Age and Sex, Australia - Electronic Delivery, June 2005. Retrieved 5 November, 2008, from www.abs.gov.au Babyak, R. J. (2004). Fighting Unhealthy Design. Appliance Manufacturer, 52(7), 27. Bailey, C. A. (2007). A guide to qualitative field research (2 ed.): Pine Forge Press. Bateni, H., & Maki, B. E. (2005). Assistive devices for balance and mobility: Benefits, demands, and adverse consequences. Archives of Physical Medicine and Rehabilitation, 86(1), 134-145. Borg, C., Hallberg, I. R., & Blomqvist, K. (2006). Life satisfaction among older people (65+) with reduced self-care capacity: the relationship to social, health and financial aspects. Journal of clinical Nursing, 15, 607-618. Borglin, G., Jakobsson, U., Edberg, A.-K., & Hallberg, I. R. (2006). Older People in Sweden with Various Degrees of Present Quality of Life: Their Health, Social Support, Everyday Activities and Sense of Coherence. Health and Social Care in the Community, 14(2), 136-146. Bowling, A., & Grundy, E. (1997). Activities of daily living: changes in functional ability in three samples of elderly and very elderly people. Age and Ageing, 26, 107-114. Brace, I. (2004). Questionnaire design: how to plan, structure and write survey material for effective market research. London: Kogan Page. Brooks, N. A. (1991). Users Responses to Assistive Devices for Physical Disability. Social Science & Medicine, 32(12), 1417-1424. Browne, J. P., O'Boyle, C. A., McGee, H. M., Joyce, C. R. B., McDonald, N. J., O'Malley, K., et al. (1994). Individual quality of life in the healthy elderly. Quality of Life Research, 3, 235-244. Clemson, L., & Martin, R. (1996). Usage and Effectiveness of Rails, Bathing and Toileting Aids. Occupational Therapy in Health Care, 10(1), 41-59.
106 Crist, J. D. (2005). The meaning for elders of receiving family care. Journal of Advanced Nursing, 49(5), 485-493. Demirbilek, O., & Demirkan, H. (2004). Universal product design involving elderly users: a participatory design model. Applied Ergonomics, 35(4), 361-370. Duray, R. (2002). Mass customization origins: mass or custom manufacturing? International Journal of Operations & Production Management, 22(3), 314- 328. Edwards, N. I., & Jones, D. A. (1998). Ownership and use of assistive devices amongst older people in the community. Age and Ageing, 27(4), 463-468. Ekwall, A., Sivberg, B., & Hallberg, I. R. (2004). Dimensions of informal care and quality of life among elderly family caregivers. Scandinavian Journal of Caring Sciences, 18(3), 239-248. Flick, U. (2006). An introduction to qualitative research. London: Sage Publications Ltd. Fricke, J., & Unsworth, C. (2001). Time use and importance of instrumental activities of daily living. Australian Occupational Therapy Journal, 48, 118-131. Garfein, A. J., & Herzog, A. R. (1995). Robust aging among the young-old, old-old, and oldest-old. Journal of Gerontology, 50, s77. Godfrey, M. (2001). Prevention: developing a framework for conceptualizing and evaluating outcomes of preventive services for older people. Health and Social Care in the Community, 9(2), 89-99. Grayson, P., Lubin, B., & Van Whitlock, R. (1995). Comparison of depression in the community-dwelling and assisted-living elderly. Journal of Clinical Psychology, 51(1), 18-21. Grewal, I., Lewis, J., Flynn, T., Brown, J., Bond, J., & Coast, J. (2006). Developing attributes for a generic quality of life measure for older people: Preferences or capabilities? Social Science & Medicine, 62(8), 1891-1901. Greyer, S. (1997). Some conceptual considerations on the sense of coherence. Social Science & Medicine, 44(12), 1771-1779. Haggblom-Kronlof, G., & Sonn, U. (2007). Use of assistive devices - a reality full of contridictions in elderly persons' everyday life. Disability and REhabilitation: Assistive Technology, 2(6), 335-345.
107 Hamilton, W. L. (1999, Jun 27). You're Not Getting Older. Products Are Getting Better. New York Times, p. 4.1. Hayase, D., Mosenteen, D., Thimmaiah, D., Zemke, S., Atler, K., & Fisher, A. G. (2004). Age-related changes in activities of daily living ability. Australian Occupational Therapy Journal, 51, 192-198. Hellstrom, Y., Persson, G., & Hallberg, I. R. (2004). Quality of Life and Symptoms Among Older People Living at Home. Journal of Advanced Nursing, 48(6), 584-593. Hoenig, H., Taylor Jr, D. H., & Sloan, F. A. (2003). Does assistive technology substitute for personal assistance among the diabled elderly? American Journal of Public Health, 93(2), 330-337. Holmes, S. (2005). Assessing the quality of life - reality or impossible dream? A discussion paper. International Journal of Nursing Studies, 42(4), 493-501. Huang, H.-C., Lee, C.-H., & Wu, S.-L. (2006). Hip protectors: a pilot study of older people in Taiwan. Journal of Clinical Nursing, 15, 436-443. Ivanoff, S. D., & Sonn, U. (2005). Changes in the use of assistive devices among 90- year old persons. Aging, 17(3), 246-251. Jacelon, C. S., Connelly, T. W., Brown, R., Proulx, K., & Vo, T. (2004). A concept analysis of dignity for older adults. Journal of Advanced Nursing, 48(1), 76- 83. Jagger, C., Arthur, A. J., Spiers, N. A., & Clarke, M. (2001). Patterns of Onset of Disability in Acitivities of Daily Living with Age. Journal of American Geriatrics Society, 49, 404-409. Kramer, J., Noronha, S., & Vergo, J. (2000). A user-centred design approach to personalization. Communications of the ACM, 43(8), 45-48. Kraskowsky, L. H., & Finlayson, M. (2001). Factors Affecting Older Adults' Use of Adaptive Equipment: Review of the Literature. American Journal of Occupational Therapy, 55, 303-310. Lach, H. W. (2005). Incidence and Risk factors for Developing Fear of Falling in Older Adults. Public Health Nursing, 22(1), 45-52.
108 Larsson, G., & Kallenberg, K. O. (1996). Sense of coherence socioeconomic conditions and health - Interrelationships in a nation-wide Swedish sample. European Journal of Public Health, 6(3), 175-180. Levine, R. (2004). Aging with Attitude: Growing Older with Dignity and Vitality. Westport: Praeger Publishers. Lim, K., & Taylor, L. (2005). Factors associated with physical activity among older people--a population-based study. Preventive Medicine, 40(1), 33-40. Lloyd-Sherlock, P. (2000). Population ageing in developed and developing regions: implications for health policy. Social Science & Medicine, 51(6), 887-895. Luleci, E., Hey, W., & Subasi, F. (2007). Assessing selected quality of life factors of nursing home residents in Turkey. Archives of Gerontoloty and Geriatrics. Mann, W. C., Goodall, S., Justiss, M. D., & Tomita, M. (2002). Dissatisfaction and Nonuse of Assistive Devices Among Frail Elders. Assistive Technology, 14(2), 130-139. Mann, W. C., Hurren, D., & Tomita, M. (1993). Comparison of assistive device use and needs of home-based older persons with different impairments. The American Journal of Occupational Therapy, 47(11), 980-987. Mann, W. C., Hurren, d., & Tomita, M. (1995). Assistive Devices Used by home- Based Elderly Persons with Arthritis. The American Journal of Occupational Therapy, 49(8), 810-820. Metz, D. H. (2000). Mobility of older people and their quality of life. Transport Policy, 7(2), 149-152. Orimo, H., Ito, H., Suzuki, T., Araki, A., Hosoi, T., & Sawabe, M. (2006). Reviewing the definition of "elderly". Geriatrics and Gerontology International, 6(3), 149- 158. Pinto, M. R., De Medici, S., Van Sant, C., Bianchi, A., Zlotnicki, A., & Napoli, C. (2000). Ergonomics, gerontechnology, and design for the home-environment. Applied Ergonomics, 31, 317-322. Quine, S., Bernard, D., & Kendig, H. (2006). Understanding baby boomers' expectations and plans for their retirement: findings from a qualitative study. Australasian Journal on Ageing, 25(3), 145-150.
109 Quine, S., & Carter, S. (2006). Australian Baby Boomers' Expectations and Plans for their Old Age. Australasian Journal on Ageing, 25(1), 3-8. Resnik, L., & Allen, S. (2006). Racial and Ethnic Differences in Use of Assistive Devices for Mobility: Effect Modification by Age. Journal of Aging and Health, 18(1), 106-124. Roe, B., Howell, F., Riniotis, K., Beech, R., Crome, P., & Ong, B. N. (2008). Older people's experience of falls: understanding, interpretation and autonomy. Journal of Advanced Nursing, 63(6), 586-596. Roe, B., Whattam, M., Young, H., & Dimond, M. (2001). Elders' needs and experiences of receiving formal and informal care for their activities of daily living. Journal of Clinical Nursing, 10(3), 389-397. Roelands, M., Van Oost, P., Depoorter, A., & Buysse, A. (2002). A Social-Cognitive Model to Predict the Use of Assistive Devices for Mobility and Self-Care in Elderly People. The Gerontologist, 42(1), 39-50. Sonn, U., Davegardh, H., Lindskog, A.-C., & Steen, B. (1996). The use and effectiveness of assistive devices in an elderly urban population. 18(3), 176- 183. Sonn, U., & Grimby, G. (1994). Assistive Devices in an Elderly Population Studied at 70 and 76 of Age. Disability and Rehabilitation, 16(2), 85-92. Suzuki, M., Ohyama, N., Yamada, K., & Kanamori, M. (2002). The relationship between fear of falling, activities of daily living and quality of life among elderly individuals. Nursing and Health Sciences, 4(4), 155-161. Swerissen, H., & DenneKamp, M. (2006). Effect of hip protectors in residential aged care settings. Australasian Journal on Ageing, 25(1), 9-13. Tavener-Smith, K., & De Vet, G. (2006). Further Exploring Hip Protector Use. Australasian Journal on Ageing, 25(4), 215-217. Tinker, A., & Lansley, P. (2005). Introducing assistive technology into the existing homes of older people: feasibility, acceptability, costs and outcomes. Journal of Telemedicine and Telecare [NLM - MEDLINE], 11 Supplement 1, 1. Watson, S. C., Chipchase, L. S., & Mackintosh, S. (2004). Balance, Fear of Falling, Pain and Gait Aid Use by Low Care Older People: Pilot Study. Australasian Journal on Ageing, 23(2), 77-81.
110 Wilks, N. (1999). Old ideas prove their worth. Professional Engineering, 12(21), 30. Zajicek, M. (2004). Successful and available: interface design exemplars for older users. Interacting with Computers, 16(3), 441-430.
111 112
Appendices
113 Appendix 1 – Phase One Questionnaire (Sample)
114
115 Appendix 2 – Covering Letter (Sample)
D Block, Level 4, Room 401 QUT Gardens Point Campus 2 George Street, Brisbane QLD 4000 Australia
Garden City Retirement Home 33 Tryon Street UPPER MT GRAVATT QLD 4122
11 March 2008
Dear Sir/Madam,
Re: QUT Masters Research Project on Older People and Assistive Devices
I am a Masters student at Queensland University of Technology (QUT). My current project is on older people and assistive devices. I am trying to investigate whether or not assistive devices are being used and which items are preferred. To also gain an understanding to the reasons behind older peoples decision to use or not use assistive devices.
Assistive devices are implements or products that aid a person in completing activities they need or wish to do, eg. walking sticks, commodes walking frames and bath mats.
If you are interested in this project all you need to do is to fill out the Questionnaire provided and if you answered yes in some of the questions you will be contacted for an Interview. The questions in the interview will be similar to the Questionnaire with some going more in depth.
A copy of the Participant Information Sheet and Ethics Approval is attached. If you have any queries or require any further information please do not hesitate to contact myself on 0413 258 515. I look forward to hearing from you.
Kindest regards,
Anita Yeh e: [email protected] mob: 0413 258 515
116 Appendix 3 – Participant Information Sheet
PARTICIPANT INFORMATION for QUT RESEARCH PROJECT
“How useful are assistive devices to the elderly? Are they even used?”
Research Team Contacts Anita Yeh Prof. Vesna Popovic Dr Alethea Blackler (Researcher) (Principal Supervisor) (Associate Supervisor) 0413 258 515 (07) 3138 2669 (07) 3138 7030 [email protected]. [email protected] [email protected] au
Description This project is being undertaken as part of a Masters Project for Anita Yeh. The purpose of this project is to investigate whether or not assistive devices are being used and which items are preferred, and to gain an understanding to the reasons behind older peoples decision to use or not use assistive devices. Assistive devices are implements or products that aid a person in completing activities they need or wish to do, eg. walking sticks, commodes and bath mats. The research team requests your assistance in identifying the above concepts by your participation through a questionnaire and in the second phase an interview. Participation Your participation in this project is voluntary. If you do agree to participate, you can withdraw from participation at any time during the project without comment or penalty. Your decision to participate will in no way impact upon your current or future relationship with QUT. Your participation will involve a questionnaire which consists of 10 quick answering questions that can be filled out in your own time and mailed back to QUT. If you fit the criteria of answering yes to questions 9 or 10 you will be contacted for an interview. The interview will be recorded by hand by the chief investigator and through audio-visual equipment. The interview will consist of 17 questions similar to the questionnaire, which will take approximately 15 to 45 minutes to answer. The data collected will be recorded and analysed at a later date. The interview will be conducted in the Human-Centred Design Research and Usability Laboratory located in Level 4, D Block, QUT, Gardens Point Campus. Key findings from the questionnaire and interviews will be published in my thesis, as well as any published research papers or conferences. Expected benefits It is expected that this project will benefit the broader design community and older people in the future through its contribution to knowledge.
117 Risks There are no risks beyond normal day-to-day living associated with your participation in this project. You will be in a constant air-conditioned environment and seated throughout the interview. The questionnaire and interview will not consist of any physical activity. Confidentiality Only the research team will be able to connect you with your personal information. All comments and responses are anonymous and will be treated confidentially. All audio- visual recordings will be kept after being transcribed as backup and stored securely in a lockable space within the Human-Centred Research Laboratory, which can only be accessed by the research team. Comments made during the questionnaire and interview will be published without verification of the participants. Your anonymity and confidentiality will be safeguarded in any publication of the results of this research through the use of pseudonyms. Consent to Participate We would like to ask you to sign a written consent form (enclosed) to confirm your agreement to participate. Questions / further information about the project Please contact the researcher team members named above to have any questions answered or if you require further information about the project. Concerns / complaints regarding the conduct of the project QUT is committed to researcher integrity and the ethical conduct of research projects. However, if you do have any concerns or complaints about the ethical conduct of the project you may contact the QUT Research Ethics Officer on (07) 3138 2340 or [email protected]. The Research Ethics Officer is not connected with the research project and can facilitate a resolution to your concern in an impartial manner.
118 Appendix 4 – Aged Care Living Establishments
Inner Brisbane Area Marycrest Retirement Centre (Hostel) – Kangaroo Point Nazareth Residential Aged Care – Woolloongabba Georgina Aged Persons Hostel – Morningside St Nicholas Hostel – Highgate Hill
North Brisbane Area Aveo Clayfield – Albion
South Brisbane Area Garden City Retirement Home – Upper Mt Gravatt Mt Gravatt Private Hostel – Mt Gravatt Wishart Village Hostel – Wishart The White House – Eight Mile Plains The Plains Retirement Village – Eight Mile Plains Tall Trees Rochedale – Rochedale South Aveo Sunnybank Green – Sunnybank Sunny Cove – Sunnybank Hills
East Brisbane Area Village Life Wynnum 2 – Wynnum Aveo Carindale – Carindale Blue Care Salvin Park Hostel – Carina Heights
West Brisbane Area St John’s Home - Toowong
119 Appendix 5 – Consent Form
CONSENT FORM for QUT RESEARCH PROJECT
Are disuse and ineffectiveness of assistive devices related to change in abilities or product design related?
Statement of consent
By signing below, you are indicating that you: • have read and understood the information document regarding this project • have had any questions answered to your satisfaction • understand that if you have any additional questions you can contact the research team • understand that you are free to withdraw at any time, without comment or penalty • understand that you can contact the Research Ethics Officer on 3138 2340 or [email protected] if you have concerns about the ethical conduct of the project • agree to participate in the project • understand that the project will include audio and/or video recording
Tick box if you: □ Do not wish your image or the direct recording of your voice to be used for publication
Name Signature Date / /
120 Appendix 6 – Interview Questions (Sample)
When did/ do you use it? (For each assistive device) How did/ does it help you? (For each assistive device) What are your reasons for not using each of the devices? How does the assistive device/s work for you? Are you able to perform the activity/activities without using the assistive device/s? Are the assistive devices easy to use for you? How do you feel about using the assistive devices? Do you prefer personal assistance over assistive devices?
121 Appendix 7 – Definition of Codes
Table 1. Definition of codes applied to textual data
Code Definition of the Code Gender Male Participant is male Female Participant is female Living Situation Low Care Living arrangement that classifies as assisted living in a nursing home or retirement hostel Independent Living arrangement that classifies as assisted Living living in a unit with communal facilities and minimal care.
Table 2. Definition of assistive device category codes applied to textual data
Code Definition of the Code Assistive devices Implements or products that aid a person in completing activities they need or wish to do Implements or products that are used by a person to Sensory enhance and assist in a sensory impairment Implements or products that are used by a person to Mobility enhance and assist in a mobility impairment Implements or products that are used by a person to Bathroom assist in activities in the bathroom Implements or products that are used by a person that Other assists in activities of daily living that are not classified Assistive Device Categories as sensory, mobility or bathroom devices
122
Table 3. Definition of assistive device codes applied to textual data
Code Definition of the Code Magnifying Glass Product that provides magnification of articles Electronic device that is placed in the ear to magnify Hearing aid hearing A stick with a single point that is manufactured to Cane provide support to the user A walking frame that is one wheels and has brakes. Also Rollator includes rollators that have arm support. Stick Chair A cane that doubles as a seat when folded out Mobility Scooter An electrical ride on device that needs to be registered Wheelchair Electrical or manual ride on device A stick with four point contact to the ground that is Quad Stick manufactured to provide support to the user Grab rails that fit around the toilet for support. May or Toilet surround may not have a raised toilet seat attached Bars that are fixed on to walls for support, either Grab rails vertically, horizontally or diagonally A water resistant chair, usually plastic that is used in Shower chair
Assistive Devices the shower Hand held device with an extended arm to pick things Reacher up from the ground or hard to reach places An undergarment with padding at specified areas that Hip Protector is worn to support the hips An electronic single sofa that reclines and elevates the users legs, as well as tilting the chair forwards and Lift & Recline Chair upwards to provide easy manoeuvrability in and out of the chair Long or short stick that is contoured to the heel to Shoe Horn assist with slipping the foot into the shoe Protruding stick from either side of the bed to assist Bed stick the user in pulling themselves up from the bed
123 Table 4. Definition and examples of participant response category codes applied to textual data
Code Definition of the Code Examples Use Frequency of use on Use all the time assistive devices Non use of assistive Do not use them Disuse devices How users feel about the Feel safe Feel use of assistive devices How the assistive device It assists with my balance Assist assists the user Makes me feel confident How the assistive device Helps me to get up Help helps the user Help to relieve pressure How well the assistive The grab rails are wonderful device aids the user and I need my cane Performance the users reliance on the The rollator is excellent and assistive device I can’t go anywhere without it. Users preference over I like my independence Personal Assistance personal assistance or I choose devices vs. Assistive Devices the use of assistive devices
Responses towards assistive device within categories How easy the assistive Yes, very easy to use Ease of Use device is to use
124 Table 5. Definition and examples of response codes applied to textual data
Code Definition of the Code Examples
Occasional or sporadic use I don’t use it so much… Occasionally of an assistive device Just occasionally to check something More than sporadic use of Oh sometimes Sometimes an assistive device Regular or constant use of All the time Frequently an assistive device Assistive device is It was too bulky to use… Bulky cumbersome and bulky to use Assistive device is unreliable You get all tangled up Unreliable to the user User or owner does not Well I can still stand up and Don’t want to want to use assistive device shower (laughter) and I’d use rather do that User replaced assistive Up until they gave me the Replaced device with another kind of walker assistive device Assistive device is difficult to I find it um (pause…) a lot to Difficult use sort of manage Improvement in users’ The cataract operation physical abilities which no improved my eyesight Got Better longer warrants the use of an assistive device When user states there is no I don’t need to use it… No Need need to use an assistive device When assistive device assists If my leg’s a little bit out it’s Responses towards assistive device use Balance the user in balance good support When assistive device assists It gives me confidence Confidence the user in confidence When assistive device assists I need it all the time Everything the user with every activity of daily living User feels safe from the use I feel more secure with it Safe of the assistive device User does not like the use of Reluctant to use a cane Don’t Like the assistive device I didn’t like to use it… User feels alright or gives a It’s alright… Alright neutral response to the use I don’t mind having to use… of the assistive device User feels a high satisfaction I’d hate to be without it High from the use of the assistive Satisfaction
125 device Assistive device helps the To get up Get Up user to get up Assistive device helps the In the house Indoors user to move around indoors Assistive device helps the Picks things up Reach user to reach objects Relieve Assistive device helps the Helps to relieve pressure Pressure user in relieving pressure Assistive device helps the Can’t go outside without Outdoors user to move around them outdoors User prefers to use assistive I’m so independent. I like to Independence devices and be independent do it myself User prefers the assistance I got to have the two Combination of assistive devices and personal assistance User prefers the assistance I just hold onto my Assistance from a person daughter’s arm… User rated performance Oh it’s wonderful Excellent from the use of the assistive Oh marvellous device as excellent User rated performance Mighty handy Very Good from the use of the assistive Very good device as very good User rated performance Good, they’re handy Good from the use of the assistive Oh I found it good device as good User rated performance I feel as thought it’s not in Need from the use of the assistive the right place Improvement device as needing improvement User can not perform I’d be in trouble without Need activity without the use of them now assistive device User can perform activity Oh I suppose I could… Can go without without the use of assistive Oh yes, I think so device Assistive device is easy to Yes Yes use Assistive device is not easy No No to use
126 Appendix 8 – Analysis (Sample)
Figure 1. Extract from Atlas.ti
127 To explain how the coding scheme was applied to the textual data, the coding of Appendix 8, (Figure 1, p.122) will be explained. First a recorded interview is transcribed into a rich text format and then inserted into Atlast.ti. Each transcript is coded individually. Appendix 8, (Figure 1, p.122) shows an extract of interview 15. Each quote where applicable is coded against one or several codes as listed in Table 4.
Participant 15 was asked about ability to shower without the assistance of the grab rails. She replied: “Well I should, I, I, I could I suppose if I had to but I like to have the hand rail.” This quote was then affixed with the codes bathroom, grab rails, performance and can go without. It was coded bathroom, because the participant was talking about a device in the bathroom category. Grab rails were affixed to the quote because the participant was talking about the grab rails she uses. Participant 15 was also saying how she could shower without using the hand rails (grab rails) and this is related to the performance of a product. Hence, the quote is also coded under the performance domain and under the sub-category of ‘can go without’.
The next question asked by the interviewer was if participant 15 could go about daily activities without the use of her walking stick (cane). Her response to the question was: “Oh I wouldn’t go out without it”. Due to the fact participant 15 was referring to her walking stick and how she would not go places without it, the quote is coded with mobility, cane, performance and need. It is coded under mobility and canes because that is what the quote is referring to. It is coded in the performance domain because the quote is in response to her ability and the extent of reliance on the assistive device. If the respondent replies that she can conduct activities of daily living without the use of her assistive device, then it is coded under ‘can go without’. If she cannot go without her assistive device to conduct activities, then it is coded under ‘need’.
128 The interviewer asked participant 15 if she found the assistive devices easy to use. Her response was that they were easy to use. Therefore, the quote is coded with assistive devices, ease of use and yes. The quote is not coded under any sub- categories of assistive devices, because the participant was referring to all the assistive devices she had used. There was no mention of a specific assistive device. Participant 15’s response was also coded under the ‘ease of use’ domain and within the ‘yes’ sub-category. If the response for the ease of use of devices were hard or difficult to use, the quote would be coded under ‘no’ in the ease of use domain.
Lastly, in Figure 3, the participant was asked about how she felt about using her walking stick (cane). Her response was: “How do I feel about using the walking stick, well I’ve used one for quite a while but I mean I didn’t like to use it at first. But then when I, for security, I felt so much safer”. The question followed on with why she did not like to use her walking stick at the beginning of use. Her response was: “Oh pride”. For the two quotes, because they were a response to the same question, they were coded identically. The codes that were affixed to the quotes were mobility, cane, feel, safe and don’t like. They were coded under mobility devices and cane because the device in question was a walking stick, which is in the mobility category. Her response to how she felt about the use of her cane was at first negative and had a dislike to the product and sense of pride. Therefore, it was coded with ‘don’t like’. As how she felt about the use of the cane changed and felt safer using it. The quote was also coded under ‘feel’ and ‘safe’. This is how each transcript (textual data) was coded, according to the participants’ responses against the coding scheme (Table 4).
129 Appendix 8 – Assistive Devices
Reacher
Stick Chair Note: The researcher, Hui-Ching (Anita) Yeh has copyright on all images.
130
Rollators/ Wheelie Walkers
Note: The researcher, Hui-Ching (Anita) Yeh has copyright on all images.
131
Grab Rails
Shower Chair
Note: The researcher, Hui-Ching (Anita) Yeh has copyright on all images.
132
Toilet Surround
Bed Stick
Note: The researcher, Hui-Ching (Anita) Yeh has copyright on all images.
133