Good practices in assistive technology service delivery for children: a commentary on van Niekerk et al. study

Reporting recently on Disability and Rehabilitation, van Niekerk et al. [1] focused on the South African context to explore factors that may hinder or facilitate the appropriate selection of assistive technology (AT) solutions for children with disabilities. Regardless of the context in which AT is provided, various AT solutions are available to children and their families to choose from, and one of the main challenges to healthcare is provision of the most adequate AT to the child. An important mediator between the child and the most appropriate AT is the AT service provider. The main function of the AT provider is to evaluate, together with the child and the other stakeholders (e.g., parents and teachers), which AT best fits the child’s specific needs, and to help achieve informed decisions on appropriateness of the technology. However, as rightly recognized by van Niekerk et al., AT service delivery for children is a complex process and a breakdown in such process might prevent the use or adversely affect the impact of the AT intervention. For instance, children are often less likely than adults to gain access to AT, and this occurrence is more frequent in children with more severe disabilities. These children are further more likely to be reported as having unmet AT needs, failings which are considered the consequence of ineffective AT service delivery practices. Therefore, knowledge of factors that influence AT selection may help AT and rehabilitation professionals identify weaknesses in their practices.

The van Niekerk et al.’s paper is a timely and important contribution, not only for the improvement of the South African AT service delivery system, but also for the advancement of AT service delivery research, especially in light of the recent Global Cooperation on Assistive Health Technology (GATE) initiative established by the World Health Organization to promote global access to AT [2]. In particular, as stressed in the Global Priority Research Agenda recently published by the GATE community [3], “Evidence of what good practices exist and the most suitable approaches in given situations are important in order for countries to develop or improve policies, service provision systems and models” (p. 10). Producing such good practice examples, however, implies that AT and rehabilitation professionals are able to illustrate that specific aspects or factors associated with their service delivery are linked to positive AT outcomes (e.g., AT use; increased participation).

Unfortunately, robust evidence on effectiveness of AT service delivery targeting children is rather scant [4]. This weakness at present limits the availability of good practice examples to inform the development or improvement of AT services for children at a global scale. Possible reasons for the scarce attention so far paid to this topic by the AT field may be connected to the complexities associated with both the heterogeneity of the target population and the organization of the service delivery systems. Concerning the latter aspect, since there is no standard organization of the process establishing which AT services are delivered, AT selection differs broadly within and between countries and may vary in relation to each country’s disability policy, socio-economic context and history. It follows that various service delivery systems and models exist, each with its own characteristics, mechanisms and outcomes. Given such variability, identifying what works for whom and when it works is almost impossible without a common framework to which researchers can refer to describe their AT service delivery contexts, to identify context-specific strengths and weaknesses, and to report their findings to the wider AT and rehabilitation communities in order to build a shared base of experiences as recommended by the GATE community.

This issue is laudably addressed by van Niekerk et al. by employing the AT Device Selection (ATDS) Framework. This framework contends that environmental factors (such as cultural and financial priorities, as well as policies and legislation) together with personal factors regarding AT users and providers (e.g., their knowledge and expectations) interact to influence the AT decision-making and selection process [1,5]. The framework thus provides AT and rehabilitation professionals working in different contexts with a taxonomy to describe their AT service delivery systems and to illustrate which factors might most prominently affect their AT selection practices. According to Scherer [5], this framework also offers “a conceptual structure of characteristics associated with varying outcomes of ATD[evice] use” (p. 3). In this view, the ATDS Framework may also be used as a guide to hypothesize functional relationships between specific AT selection practices and AT outcomes in order to identify strategies to propose corrective actions when necessary. For instance, according to the framework [5, p. 6], achieving the best match between the person and the AT solution is the result of the integration between – among other factors ‒ information from a functional assessment (i.e. “the user cannot walk 50 feet on a smooth surface”) and the user’s subjective predispositions (“strong desire to independently move 50 feet on a smooth surface”). This is consistent with available literature emphasizing the importance of considering user preferences and subjective factors in AT selection to achieve positive AT outcomes [6]. In their study, van Niekerk et al. report that (p. 920) “None of the participants reported asking the children regarding their needs directly” and that “the majority of therapists tended to have a functional approach to the assessment for selection of AT for young children”, thus suggesting a strong functional-oriented approach to AT selection in the context. In following the ATDS Framework, it can thus be hypothesized that, by including children’s preferences in their AT assessment practices, AT professionals can get a more complete view on children’s AT needs.

Importantly, based on their findings, van Niekerk et al. suggest expanding the ATDS Framework by including the characteristics of AT itself as an important determinant in the AT selection process. This aspect is crucial in low-resourced settings where people may only have at their disposal products designed and developed for inhabitants of high-income countries who normally have access to basic services such as electricity [7]. Including this additional element in ATDS would make the framework ideally applicable to any context (e.g., low-resourced settings and high-income countries), providing AT and rehabilitation professionals with a model that allows analysis of their operational methodology, and results, by means of a language shared by a community of operators which is ever vaster and from diverse cultural backgrounds.

To add to the findings reported in the van Niekerk et al. study, the use of internationally validated tools and evidence-based methodologies to guide AT selection is a crucial factor to achieve desired AT outcomes. However, AT professionals’ resistance towards standardizing their practice is a well-recognized issue. It is hoped that the emphasis of the GATE community on developing quality standards for AT service delivery [3,8] would further contribute to stimulating the development and adoption of validated practices in order to improve AT selection and provision for children worldwide.

Disclosure statement

No potential conflict of interest was reported by the author.