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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 52  |  Issue : 2  |  Page : 43-49

Utilization of assistive devices in occupational therapy practice in Tamil Nadu, India: A statewide survey


External and Regulatory Affairs, NBCOT Inc., Gaithersburg, MD, USA

Date of Submission29-Nov-2019
Date of Acceptance20-Feb-2020
Date of Web Publication6-Jun-2020

Correspondence Address:
Dr. Karthik Mani
335, W Side Dr, Gaithersburg, MD 20878
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijoth.ijoth_31_19

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  Abstract 


Background: The provision of assistive devices (ADs) to enable function is a well-established component of occupational therapy (OT) practice. However, multiple client and therapist factors prevent the utilization of ADs in practice. Objectives: This study aimed to explore the utilization of ADs in OT practice in Tamil Nadu (TN). Study Design: The survey research design was used to conduct this study. A ten-item electronic survey was developed based on the research question. Methods: The survey was E-mailed to 295 occupational therapists in TN identified through convenience sampling. The survey link was also shared on four WhatsApp Messenger groups (Tamil Nadu Branch of All India Occupational Therapists' Association Official Group, OTist Group, Clinic OT, and Santosh Alumni) with many occupational therapists belonging to TN (snowball sampling). Data were collected between August 29, 2019, and September 20, 2019. Results: Thirty-five occupational therapists responded to the survey. Writing and eating utensils were the commonly prescribed ADs in TN OT practice. Client factors, cultural factors, lack of availability, cost, and therapists' skill may contribute to the limited usage of ADs in Indian OT practice. Innovating low-cost culturally acceptable ADs, educating stakeholders, and training practitioners on how to prescribe/utilize ADs in practice may mitigate the barriers related to ADs use. Conclusion: The usage of ADs in TN OT practice is limited. Multiple factors affect the utilization of ADs in the Indian context of practice. A multipronged approach focusing on innovative device development, advocacy, and skill development is needed to promote the utilization of ADs in Indian OT practice.

Keywords: Lifestyle, Occupational Therapists, Self-Help Devices, Surveys and Questionnaires


How to cite this article:
Mani K. Utilization of assistive devices in occupational therapy practice in Tamil Nadu, India: A statewide survey. Indian J Occup Ther 2020;52:43-9

How to cite this URL:
Mani K. Utilization of assistive devices in occupational therapy practice in Tamil Nadu, India: A statewide survey. Indian J Occup Ther [serial online] 2020 [cited 2020 Jul 5];52:43-9. Available from: http://www.ijotonweb.org/text.asp?2020/52/2/43/286117




  Introduction Top


The Rights of Persons with Disabilities Act (2016) recognizes the use of assistive devices (ADs) to promote the occupational performance of persons with disabilities (PWD).[1] ADs are defined as “any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.”[2] Prescribing ADs is an integral component in occupational therapy (OT) practice. ADs effectively assist the daily functioning of PWD. They help overcome impairments, prevent accidents, promote independence and comfort, and improve quality of life.[3],[4],[5] For PWD, ADs “mean the difference between dependence and independence, inactivity, and productivity.”[6]

Multiple factors such as therapists' awareness, availability of AD, funding, patient factors (willingness to use ADs, perceived importance, confidence in the device, type/severity of impairment, availability of help, age, etc.), and social factors (culture, stigma, etc.) affect the use of ADs.[7],[8] Studying ADs utilization in practice may help uncover barriers related to the use of ADs, which would assist the OT community in identifying strategies to overcome the barriers. This study aims to explore the utilization of ADs in OT practice in Tamil Nadu (TN).


  Methods Top


This study was conducted adhering to the principles of the Declaration of Helsinki guidelines. The guidelines were reviewed before the survey was sent to the participants. In addition, the invitation E-mail that was sent to participants clearly identified that participation in the survey was “strictly voluntary and the responses will be kept anonymous.”

Sample

The population of this study was OTs currently practicing in TN. A list of 350 E-mail addresses belonging to OT practitioners in TN (as these individuals were once practiced in TN) was identified from the author's E-mail lists and archives. The possibility of two or more E-mail addresses belonging to the same practitioner cannot be ruled out. Furthermore, the possibility of practitioners moving to other states or countries cannot be ruled out. To reach out to all OT practitioners in TN, the author decided to share the survey invitation E-mail on four WhatsApp messenger groups that have many TN OT practitioners (Tamil Nadu Branch of All India Occupational Therapists Association [TNAIOTA] TNAIOTA Official Group, OTist Group, Clinic OT, and Santosh Alumni). The first page of the survey clarified that the survey was intended for TN OT practitioners. It also clarified that OT practitioners who work outside TN should refrain from taking the survey.

Instrumentation

The author developed a ten-item survey [Appendix A] by reviewing the literature and following survey-writing guidelines. The survey tool gathered information about participants' (i) demographics (gender, years of experience, practice area, and practice setting), (ii) ADs prescribing behavior and frequency, (iii) reasons for not/rarely prescribing ADs, (iv) most commonly prescribed ADs, and (v) views on why ADs are not so popular in the Indian context of practice and strategies to overcome barriers in the utilization of ADs in practice. For the item on the most commonly prescribed ADs, thirty ADs spanning multiple practice areas were provided as response options. This list was generated by reviewing the literature and vendor catalogs and did not include orthotic and mobility devices. An “other” option was provided for participants to identify ADs that were not included in the list. The survey tool was reviewed by five OTs with at least 10 years of experience in the field for clarity and face validity. No revisions were made post review.

Procedure

The survey was conducted using SurveyMonkey® (SurveyMonkey, San Mateo, California). On August 29, 2019, the survey invitation was shared on the four identified WhatsApp messenger groups. On September 1, 2019, an invitation to participate in the survey was sent to all 310 E-mail addresses. Fifteen E-mails bounced back due to invalid E-mail addresses. The invitation identified the response deadline as September 20, 2019.

Following the Tailored Design Method,[9] the author designed a simple survey and contacted participants three times during the open survey period to maximize the response rate. The first reminder E-mail was shared in the groups 8 days after the original invitation E-mail, and the final reminder was shared a day before the response deadline.

Data Analysis

Descriptive statistics were used to summarize and report the responses received. Data are reported as percentages and aggregate numbers to protect the identity of respondents. Fisher's exact test was performed to determine the association between “utilization of ADs in OT practice” and each of the following variables: gender, years of work experience, and practice area.


  Results Top


Thirty-five responses were received by the survey response deadline. There were five incomplete responses. [Table 1] presents the sample characteristics. More than 80% (n = 29) of the respondents have prescribed an assistive device in their practice. Of 28 respondents who responded to the item on the frequency of prescribing ADs, 14% (n = 4) reported that they prescribed often, 57% (n = 16) prescribed sometimes, and 29% (n = 8) prescribed rarely.
Table 1: Sample Characteristics

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Thirty respondents identified the reasons for not or rarely prescribing ADs in their practice. [Figure 1] presents the responses. Thirty respondents identified the devices they prescribed or utilized the most. Most frequently prescribed ADs were heavyweight pen/pencils (n = 18), triangle pencil grip (n = 16), soft pencil/pen grips (n = 13), gripper (n = 12), universal cuff (n = 11), and heavyweight eating utensils (n = 10). Participants' responses [Figure 2] were mixed to the item on their views on why ADs was not so popular in the Indian context of practice. The top four identified reasons were clients' reluctance to use ADs, lack of availability, cultural factors, and clients' lack of understanding.
Figure 1: Reasons for Not Prescribing or Rarely Prescribing Assistive Devices

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Figure 2: Respondents' Views on Why Assistive Devices are Not So Popular in Indian Occupational Therapy Practice

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The final item inquired participants' view on what Indian OT community could do to overcome the barriers in the utilization of ADs in practice. Twenty-nine respondents responded to this item [Figure 3]. Innovating low-cost ADs and conducting training programs on ADs were selected by many respondents. One respondent who selected the “other” option identified “more programs” as his/her comment.
Figure 3: Respondents' Views on What Should Indian Occupational Therapy Community Do to Overcome the Barriers in the Utilization of Assistive Devices in Practice

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Univariate analysis using Fisher's exact test was performed to determine the association, if any, between the variables. The analysis yielded nonsignificant P > 0.05, explaining the lack of association. The relationship of gender, years of experience, and practice area to the utilization of ADs gave an exact P = 1.00 (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 0.19–7.82), 0.67 (OR: 1.87; 95% CI: 0.29–11.84), and 0.45 (OR: 0.38; 95% CI: 0.029–5.10), respectively.


  Discussion Top


This study explored the utilization of ADs in TN OT practice. Although many OTs in the state utilize ADs in their practice, the usage is limited to writing and eating utensils. This could be due to variegated reasons. There is no association between the ADs utilization and gender, years of experience, and practice area.

Since TN is one of the two populous states in India in terms of OT population[10] and the final two items on the survey explored participants' views at the national level, the following sections examine factors that may affect the utilization of ADs in OT practice at the national level.

Pediatrics versus Geriatrics

Most of the ADs identified by respondents as most commonly prescribed are related to the pediatric arena of practice such as heavyweight writing utensils (60%; n = 18), triangle pencil grip (53%; n = 16), and gripper (40%; n = 12). This could be due to pediatrics being the major area of OT practice in India.[10] In contrast, the literature identifies the use of ADs mostly with elderly clients. Several studies examined the use of ADs among older adults and related user experience.[3],[4],[7],[11] This suggests that older adults are a major consumer group of ADs. One of the reasons for low usage of ADs in OT practice in India could be due to the low number of practitioners working in the area of geriatrics.[10]

Cultural Factors

Bynum and Rogers stated that cultural acceptability and societal differences may influence ADs utilization.[8] In Western countries, cultural values and lifestyles emphasize functional independence and individualism, whereas, in Eastern countries, they uphold interdependence and collectivism.[12],[13] These differing value systems may also be a reason for the limited utility value placed on ADs by patients and practitioners. In a study conducted in Sweden, Pettersson et al. identified that family members of stroke patients provided too much of help to patients, thereby avoiding opportunities for patients to use ADs.[5] One could also apply this observation to the Indian population as cultural values and beliefs in India support the assertion of helping family members in need.

Lifestyle Practices

Western OT literature identifies that ADs related to dressing and bathing were the most commonly prescribed devices.[7] In India, bathing and dressing tasks are accomplished differently (bucket bathing, shower bathing, river bathing, etc.; dhoti, kurta, salwar, saree, etc.).[14],[15],[16] Shower rooms are only common in socioeconomically better households in urban India. Further, the bathroom architecture (walk-in shower room, open bath area, Indian style of toilet, etc.) also differs notably between households. These factors limit the use of bathing-related ADs in the Indian context of practice, despite their reported effectiveness in fall prevention and activities of daily living (ADL) safety.[3] In this study, of the thirty devices listed as response options, as expected due to varied lifestyle practices, ADs related to dressing and bathing such as dressing stick, shoehorn, sock aid, and shower chair were prescribed by none of the respondents. Only one respondent reported that he/she prescribed a transfer bench and handheld shower. Six respondents reported that they prescribed a long-handled bath sponge.

Another lifestyle factor that could restrict the utilization of ADs is patients' time use patterns.[5] As many PWD in India are unemployed, they may have plenty of time to complete the required tasks in a slower and less efficacious manner and hence may fail to recognize the value of ADs in conserving time and energy.

Lack of Availability

Thirty-seven percent (n = 11) of the respondents in this study reported lack of availability as one of the reasons for why ADs are not popular in the Indian context of practice. As India's E-commerce is growing, online retail sales had made products and services more accessible.[17] This applies to ADs such as reachers, jar openers, and commode chair. Reachers, for instance, could be a beneficial device for many patients with limited mobility and flexibility. They can be used to pick up items (keys, television remote, newspaper, etc.), retrieve and place items in a shelf/cupboard, open and close drawers, etc.[7] In the current study, only a few respondents reported that they prescribed reachers and commodes. The low usage of these devices, despite their availability, could be due to the lack of therapists' awareness related to their availability or purpose.

Clients Reluctance to Use

It appears that one of the barriers that limit ADs utilization in Indian OT practice is clients' reluctance to use ADs, as 14 respondents identified it as a reason for ADs being not so popular in the Indian context of practice.

The literature identifies multiple reasons for clients' reluctance to use ADs. According to Lund and Nygard, the willingness to accept and use ADs is influenced by the interaction between the patient, setting in which the device is used, and the device.[18] Mann et al. found that patients consider ADs as important only if they improve safety, balance, mobility, and independence in ADL and reduce safety hazards and fall risk.[7] Lund and Nygard stated that clients may have a double-edged meaning when using ADs (i.e., finding ADs useful and cumbersome). They also highlighted that highly visible ADs may advance the handicap identity of clients and increase stigmatization, thereby decreasing clients' inclination to use.[18]

Cost

Seventy-six percent (n = 22) of the respondents recognized a need for low-cost, innovative adaptive devices, which suggests that the cost of the devices may prevent the utilization of ADs. In developed countries, public funding is available for ADs, which covers the device and training costs.[5] In India, public funding for ADs is limited, which may reduce the accessibility of ADs to the economically disadvantaged sectors of the society, thereby reducing ADs utilization in practice.

Therapists Skill

Nearly two-thirds of the respondents stated that there is a need for additional training programs targeting OT practitioners. This suggests that therapists' skill related to prescribing and training patients on ADs may interfere with the utilization of ADs in practice.

Limitations

This survey was administered electronically and yielded 35 responses. A mail or telephone survey may have increased the number of responses. Some respondents may have had trouble in decoding the survey items due to linguistic challenges associated with comprehending English (Tamil is the commonly spoken language in TN). It was assumed that all survey recipients interpret the term “ADs” the same way, as the survey was sent only to OTs. However, the possibility of differences in the interpretation, thereby differences in responses, cannot be ruled out.

Recommendations

As India is a country with a rich diversity, ADs usage in practice may vary between states. Hence, this study could be replicated in other states, which would help perform statewide comparisons to generate additional insights related to the use of ADs in Indian OT practice. A qualitative study involving practitioners belonging to different practice areas may also yield valuable insights. Further, administering a similar survey among prosthetists and orthotists to determine the impact of sociocultural, economic, and lifestyle factors on the acceptance and utilization of ADs in India may provide worthy insights.

Implications for Practice

To promote the utilization of ADs in OT practice in India, OTs shall:

  • Advocate for public funding for ADs to encourage its use by the needy people
  • Advocate for the use of ADs among the elderly population as it may minimize the effect of age-related changes and conserve energy[11]
  • Collaborate with OT schools to identify the need for ADs among different patient groups through student projects
  • Compile a manual of available ADs in India by soliciting institutions, practitioners, and researchers to send the information about their innovative ADs in a specified format (device name, its purpose, suitable patient population, cost, how to obtain it, contact information of the designer, etc.). This task could be better accomplished through professional organizations or educational institutions
  • Educate clients, caregivers, and other stakeholders about the potential of ADs in enabling patients' functional independence and quality of life, while reducing caregiver burden
  • Engage in efforts needed to alter the perception about ADs to promote their acceptance among patient groups
  • Ensure adequate follow-up services when utilizing ADs as the need for ADs change over time.[3] Follow-up visits are also essential for encouraging clients to continue to use ADs as needed and weaning ADs when positive outcomes are achieved
  • Ensure that patients are satisfied with their ADs and do not feel inferior due to the usage of ADs, as higher satisfaction and achievement of desired self-image are linked with long term usage[6]
  • Explore the feasibility of establishing a loan system for ADs that are costly
  • Innovate devices that appear natural, compact, and easy to use to increase acceptance and utilization
  • Investigate patients' experience in terms of differences and similarities between using ADs and ordinary tools[5]
  • Invite experienced speakers, experts, and vendors who manufacture ADs to train practitioners on ADs prescription and usage at workshops, conferences, and continuing education events
  • Place emphasis on context-based training when training patients on the use of ADs as clients may find it difficult to translate the skills learned from a clinical setting to a home setting
  • Prescribe ADs after conducting relevant assessments, including environmental assessment. Practitioners must consider the following when prescribing ADs: need, acceptance, satisfaction with device use, efficacy, durability, and utility
  • Provide adequate instruction and practice when prescribing ADs to clients
  • Train clients and caregivers on the maintenance of ADs.



  Conclusion Top


In TN OT practice, the use of ADs is limited to writing and eating utensils and pediatric area of practice. The ADs pertaining to dressing, bathing, toileting, and instrumental ADL tasks are used sparingly. From the perspective of TN OTs, multiple cultural and lifestyle factors, clients' unwillingness, cost, lack of availability, and therapists' skill set limitations contribute to the low usage of ADs in Indian OT practice. OT practitioners in India must develop innovative, need-based, cost-effective, and culturally acceptable ADs and engage in advocacy efforts, to better assist their clients in what they want and need to do.

Acknowledgments

I extend my sincere thanks to all occupational therapists who responded to this survey and reviewed the survey tool for validation.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.


  Appendix A: Utilization of Assistive Devices in Occupational Therapy Practice in Tamil Nadu, India Top


Instructions

The provision of assistive devices (ADs) to enable function is a well-established component of occupational therapy (OT) practice. This survey aims to determine the utilization of ADs in OT practice in Tamil Nadu (TN), India. Please respond to this survey only if you are an OT practitioner currently practicing OT in TN. When responding to questions, please reflect on your OT practice in TN if you have ever practiced OT in other parts of India or abroad.

Please DO NOT complete this survey if:

Your current job is not related to the field of OT

You are working outside TN

Please do not provide your name or contact details anywhere on this survey.

  1. Gender


  2. Male

    Female

  3. How long have you been an OT practitioner?


  4. Less than 1 year

    1–3 years

    3–5 years

    5–10 years

    10–20 years

    20+years

  5. What is your area of practice?


  6. Pediatrics

    Physical dysfunction (orthopedics/neurology)

    Geriatrics

    Community-based rehabilitation

    Others (please specify)

  7. Please identify your practice setting (government hospital, private hospital, outpatient clinic, rehabilitation institute, etc.)


  8. Have you prescribed an assistive/adaptive device for a patient or used one in practice?


  9. Yes

    No

  10. How often do you prescribe assistive devices?


  11. Often

    Sometimes

    Rarely

  12. If you have not or rarely prescribed or utilized assistive device, please identify the reason (s) (Check all that apply)


  13. I have never come across a patient who needs an adaptive/assistive aid

    I don't know what type of aids is available

    I don't know where to find adaptive/assistive aids

    I don't know what or how to prescribe

    Others (please specify)

  14. Reflecting on your caseload, which of the following adaptive or assistive device (s) have you prescribed or utilized the most? (Check all that apply)




  15. In your view, why assistive or adaptive devices are not so popular in Indian occupational therapy practice? (Check all that apply)


  16. Lack of availability

    Therapists lack of understanding/awareness

    Clients' lack of understanding

    Clients' lack of affordability

    Clients' reluctance to use

    Cultural factors

    Others (please specify)

  17. In your view, what should Indian occupational therapy community do to overcome the barriers in the utilization of adaptive or assistive devices in practice? (Check all that apply)


  18. Innovate need-based low-cost adaptive/assistive devices

    Compile already designed adaptive/assistive devices into a manual and make it easily accessible

    Conduct training programs on adaptive/assistive devices for occupational therapy practitioners

    Others (please specify)



     
      References Top

    1.
    Ministry of Law and Justice. The Rights of Persons with Disabilities Act, 2016. New Delhi: Ministry of Law and Justice; 2016. Available from: http://www.disabilityaffairs.gov.in/upload/uploadfiles/files/RPW D%20ACT%202016.pdf. [Last accessed on 2019 Nov 20].  Back to cited text no. 1
        
    2.
    US Government Printing Office. Technology-Related Assistance for Individuals with Disabilities Act of 1988. Catalogue No. 850. Washington DC: US Government Printing Office; 1988; Statute 102; p. 1044-65.  Back to cited text no. 2
        
    3.
    Chiu WY, Man DW. The effect of training older adults with stroke to use home-based assistive device. Occup Ther J Res 2004;24:113-120.  Back to cited text no. 3
        
    4.
    Mann WC, Hurren D, Tomita M. Comparison of assistive device use and needs of home-based older persons with different impairments. Am J Occup Ther 1993;47:980-987.  Back to cited text no. 4
        
    5.
    Pettersson I, Appelros P, Ahlström G. Lifeworld perspectives utilizing assistive devices: Individuals, lived experience following a stroke. Can J Occup Ther 2007;74:15-26.  Back to cited text no. 5
        
    6.
    Garber SL, Gregorio TL. Upper extremity assistive devices: Assessment of use by spinal cord-injured patients with quadriplegia. Am J Occup Ther 1990;44:126-131.  Back to cited text no. 6
        
    7.
    Mann WC, Llanes C, Justiss MD, Tomita M. Frail older adults self-report of their most important assistive device. Occup Ther J Res 2004;24:4-12.  Back to cited text no. 7
        
    8.
    Bynum HS, Rogers JC. The use and effectiveness of assistive devices possessed by patients seen in home care. Occup Ther J Res 1987;7:181-191.  Back to cited text no. 8
        
    9.
    Dillman DA, Smyth DJ, Christian LM. Internet, Mail, and Mixed Mode Surveys: The Tailored Design Method. 3rd ed. New Jersey: John Wiley & Sons; 2009.  Back to cited text no. 9
        
    10.
    Mani K, Sundar S. Occupational therapy workforce in India: A national survey. Indian J Occup Ther 2019;51:45-51.  Back to cited text no. 10
      [Full text]  
    11.
    Chen TY, Mann WC, Tomita M, Nochajski S. Caregiver involvement in the use of assistive devices by frail older persons. Occup Ther J Res 2000;20:179-199.  Back to cited text no. 11
        
    12.
    Hocking C, Pierce D, Shordike A, Clair VW, Bunrayong W, Vittayakorn S, et al. The promise of internationally collaborative research for studying occupation: the example of the older women's food preparation study. Occup Ther J Res 2008;28:180-190.  Back to cited text no. 12
        
    13.
    Iwama MK, Thomson NA, Macdonald RM. The Kawa model: The power of culturally responsive occupational therapy. Disabil Rehabil 2009;31:1125-1135.  Back to cited text no. 13
        
    14.
    Chatterjee R. In India's Sultry Summer, Bucket Bathing Beats Indoor Showers. NPR; 2014. Available from: https://www.npr.org/sections/goatsandsoda/2014/07/25/335250270/our-india-correspondent-cant-kick-the-bucket-bathing-habit. [Last updated on 2014 Jul 25; Last accessed on 2019 Nov 22].  Back to cited text no. 14
        
    15.
    Doctor, V. Showering satisfaction: The Indians and their bucket bath. The Economic Times; 2019. Available from: https://m.economictimes.com/news/politics-and-nation/showering- satisfaction-the-indians-and-their-bucket-bath/articleshow/69491341.cms. [Last updated 2019 May 25; Last accessed on 2019 Nov 22].  Back to cited text no. 15
        
    16.
    Cultural India. Indian clothing. Cultural India. Available from: https://www.culturalindia.net/indian-clothing/index.html. [Last accessed on 2019 Nov 22].  Back to cited text no. 16
        
    17.
    International Trade Administration. India – E-commerce. International Trade Administration; 2019: Available from: https://www.export.gov/article?id=India-e-Commerce. [Last updated 2019 Jul 31; Last accessed on 2019 Nov 22].  Back to cited text no. 17
        
    18.
    Lund ML, Nygard L. Incorporating or resisting assistive devices: Different approaches to achieving a desired occupational self-image. Occup Ther J Res 2003;23:67-75.  Back to cited text no. 18
        


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