9. Medical Condition (e.g., MS, infection, tumor, myelitis, stenosis). 42 ... gaming device (0%), Cellphone (34%), Tablet (59%), Laptop ( 9%), Other (16%), None.
Rehabilitation Teamwork to Close the Disability Digital Divide 1
2
1
Nancy Merbitz, Ph.D. , Donn Hilker, M.S., ATP , Lindsey Bisgrove, M.A. , 1 2 Cait Campbell, Psy.D. & Seong Hee Yoon, B.S., ATP 1
2
Louis Stokes Cleveland VA Medical Center, University of Michigan Health System
Presented at the American Psychological Association Division 22 Annual Convention, Albuquerque, New Mexico, February 17-19, 2017
INTRODUCTION While digital communication technologies (DCTs) including digital devices and software potentially bring the world of information and social contact within reach for all, the gap is widening for less connected populations. Barriers dynamically associated with socioeconomic status, age, gender and disability are increasingly documented in scientific and policy oriented publications. The service catchment area for University of Michigan (U of M) SCI/D rehabilitation includes Ann Arbor, rural/small town areas of intersecting corners of MI and OH, as well as an urban/metropolitan area (Detroit). For patients from these diverse communities acutely hospitalized after spinal cord injuries (SCIs) or spinal cord disorders (SCDs), disability and isolation present new barriers to social communication, recreation, and information at a time when these are most needed. Available and accessible DCTs can be a remedy. Rehabilitation Engineers at U of M introduce many SCI/D inpatients to Assistive Technology (AT) options to interface with DCTs but, prior to this project, lacked resources to give patients 24/7 use for ongoing practice and modifications. OBJECTIVES Rehabilitation Engineering and Psychology collaborated to expand resources (including equipment and one-on-one time with patients) in order to: assess individual patient needs and preferences, pair digital communication devices with individualized AT, supply accommodation for 24/7 use on the unit with assistance by Nursing, provide ongoing training towards independent use, solicit feedback on usage and satisfaction, and identify and prepare for post-discharge needs. The primary objective was to provide access to DCTs for social and recreational pursuits, with secondary objectives to explore how accessible DCTs (including video capability) could be applied to support patient learning. With efforts to address individual needs and preferences on an ongoing basis, it was hoped that older patients and those with severe physical limitations would benefit. METHOD Grant support was obtained from the Craig H Neilsen Foundation to bring 24/7 individualized access to DCTs and AT for SCI/D patients during their inpatient rehabilitation. Additional grant support was obtained from internal U of M awards and the Eagles Fund (private Michigan foundation). DCT and AT devices were purchased and matched to patients, and with assistance of Nursing were made available to SCI/D patients at bedside 24/7 for contact with family and friends, for recreation and diversional pursuits, and to enhance rehabilitation. A Digital Preferences survey was administered during Engineering’s initial assessments, inquiring about patients’ prior DCT use as well as their preferences during the inpatient stay, to provide more details for the matching process. During the next month, another survey was administered to assess Digital Use and Satisfaction. Interviews with Engineering, as well as information gathered during Psychology contacts, helped to prepare for post-discharge needs. Patients often took DCTs and ATs home as ‘loaners’ while they decided on purchases, or items were gifted according to financial circumstances. Educational videos about the rehabilitation program, and personalized videos of rehabilitation progress, were also created as part of this project and will be described in future.
RESULTS Over the grant period 1/2015 – 6/2016, 80 patients on the Spinal Cord Injury unit were provided with individualized technology accommodations. Of those, 60 (75%) completed a survey of prior digital technology use and preference, and 37 (46%) completed a follow-up survey of use and satisfaction with DCTs and AT. Women were more likely to complete surveys. More patients with upper extremity impairment completed surveys, possibly due to more frequent clinical encounters with project staff for AT needs. Based on close examination of other clinical and demographic variables that did not differ between survey completers and non-completers (see Table 2), a plausible explanation for missing data is variation over the course of the project in staff availability to administer surveys, as well as illness/debility. TABLE 1. Sample Characteristics Age:
Mean = 48, range 18-88 (SD 19)
Gender:
%
Male
Mean age = 43
67.5
Female
Mean age = 49
32.5
Race/Ethnicity: Caucasian/White
72
Hispanic/Latino
1
Black/African American
22.4
Asian
5
Other
4
SCI/D Level of Injury (8 patients required mechanical ventilation) Cervical
77.5
Thoracic or Lower
22
Completeness of Injury Complete
29
Incomplete
71
Cause of SCI/D Traumatic (e.g., falls, MVA, violence, sports)
49
Surgery or Spinal Stroke
9
Medical Condition (e.g., MS, infection, tumor, myelitis, stenosis)
42
Education (11% were still in high school or college while in rehab) < 12 years
8
High School Diploma
42
Some college, Vocational/Technical Training
6
Bachelor’s Degree
33
Graduate Degree
11
No Internet in Home:
17% (of 60)
FIGURE 1. Initial Survey of Prior DCT Use and Preferences “Which of the following devices have you used prior to this hospitalization?”
Music player (48%), Portable DVD player (50%), Unconnected gaming device (20%), Cell phone (97%), Tablet (57%), Laptop (70%), Other (50%)
Among responders to the initial Digital Preferences survey, desire to continue using DCT devices during rehabilitation was expressed by 94%; 98% reported some use of DCT during their rehabilitation, typically cell phone and/or tablet, and 61% used one or more new DCTs. New AT was used by 70% of the patients, such as tablet or cell phone mounts, styluses and joysticks, or hands-free electronic pointing devices. The survey results are relevant for addressing barriers to DCT use that may exist before and/or after the onset of physical disability. In Table 2, although older age was associated with fewer DCT devices and activities at baseline, age did not predict who would adopt new DCTs during hospitalization. This suggests that an active program integrating DCTs into day to day life on the rehab unit can counteract more than one digital divide (age and disability). Interestingly, in keeping with literature reporting progress in the gender digital divide, women did not report significantly less DCT use prior to hospitalization, and were more likely than the male patients to try one or more new DCTs. •
Activities: In descending order of frequency, patients used digital devices to visit websites, use social media, listen to music, watch videos, play games, learn about rehab and disability, read/listen to books, review personal finances, take video of self during therapy, write or make videos about their experiences, track activities with an app, and other (e.g. shopping, checking crop prices online).
Benefits: Substantial majorities reported that access to digital communication technologies became easier over time, helped them be closer to family and friends, do things they wanted to do, and reduced boredom.
FIGURE 2. Follow-up Survey of Input DCT, AT Use and Satisfaction “Which device(s) have you used since our last visit with you?”
Music player (26%), Portable DVD player (0%), Unconnected gaming device (0%), Cellphone (34%), Tablet (59%), Laptop ( 9%), Other (16%), None (0%)
CONCLUSIONS Collaboration by Engineering, Psychology, and Nursing allowed the majority of patients in this project, most with upper extremity impairment, to continue or begin accessing digital technologies for communication, recreation and learning during rehabilitation. Pairing “mainstream,” “off the shelf” tablets, smartphones, and other DCTs with AT during rehabilitation was a cost-efficient way to enhance the rehabilitation experience and community transition, and was acceptable to patients. This feasibility study affirms that people in the inpatient rehabilitation environment do not simply “adjust to” their disability but may actively engage with opportunities they are offered to stretch their boundaries. The project team also believes that the repeated success in matching patients with DCTs and AT that they used and took home eagerly is a result of reaching people early, giving them the experience of agency when so much control has been lost, and adapting DCT/AT set-ups as patient needs and preferences changed over time during the acute healing process. In the provision of AT after disability onset, early efforts toward matching and modification according to individual characteristics are crucial if long-term use and benefit are to be achieved.
TABLE 2. Describing DCT use by a Diverse Sample of SCI/D Rehabilitation Inpatients Prior DCT use
SCI/D
Upper extremity impairment
New DCT use in rehab
Completed Survey on prior DCT use
Completed F/U Survey on DCT use & satisfaction
Gender
NS Prior DCT use did not differ by gender
* More MEN with SCI; more WOMEN with SCD
NS No gender difference in level of impairment
* WOMEN were more likely to use new DCT in rehab
NS Completion did not vary by gender
* WOMEN were more likely to complete
Age
* Older patients had less prior use
NS No age difference in SCI vs SCD
NS No age difference in level of impairment
NS Age did not predict new DCT use in rehab
NS Completion did not vary by age
NS Completion did not vary by age
Education
* More education = more prior DCT use
NS Education did not predict new DCT use in rehab
NS completion did not vary by education
NS completion did not vary by education
Ethnicity
NS For Black vs White (but trend for less use in this small sample)
NS New DCT use in rehab did not differ by Black vs White
NS Completion did not vary by Black vs White
NS Completion did not vary by Black vs White
NS completion did not vary by level of impairment
* Those w/ upper extremity impairment were more likely to complete.
Upper extremity impairment
Prior DCT < 7 vs > 7 different DCT devices &/or activities
Cognitive impairment
NS Prior DCT use did not predict new DCT use in rehab. Small N, could not test for significance, but trend for noncompletion.
LEGEND: ● NS: non-signif ● Impairment level: Upper extremity impairment Y/N ● SCI/D: Injury vs Disorder ● Prior DCT: Previous reported number of devices and activities, 7 ● Education: < High School, HS grad, some college, 4 yr degree, post-grad ● * significant at p < 0.05 ● Analyses included t-test, Chi square, Mann Whitney U, and Wilcoxin Rank-Sum test
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