# data[].attributes.body
"As a basic part of the human condition, sexuality is an ADL addressed with older adults; clients who are lesbian, gay, bisexual, and transgender; clients with physical disabilities; clients with developmental disabilities or delays; and other recipients of occupational therapy services as part of a holistic approach to treating the whole person."

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Download a printable copy of this fact sheet here.
Sexuality is a core characteristic and formative factor for human beings. It is a state of mind, representing our feelings about ourselves, what it's like to be male or female, how we relate to people of our own gender and those of the opposite gender, how we establish relationships, and how we express ourselves. It is basic to our sense of self. As such it is an important part of development and growth. It is the ability to be intimate with another in mutually satisfying ways. Sexual feelings and actions can cover a gamut of expressions. Holding hands, flirting, touching, kissing, masturbating, and having sexual intercourse are just some of the ways in which sexuality can be expressed (MacRae, 2010). Religion, culture, ethnicity, and education can also affect how sexuality develops and is expressed (e.g., how sexuality was handled within one's family can affect how one's own sexuality develops).

The Occupational Therapy Practice Framework: Domain and Process, 2nd Edition (AOTA, 2008) lists sexual activity as an activity of daily living (ADL). As such occupational therapists include sexuality as part of a routine evaluation of clients, and occupational therapists and occupational therapy assistants address this area in occupational therapy interventions. Following an acute health crisis or as part of a chronic condition, clients may worry about how their health issues will affect their sense of self, their ability to function physically, and their opportunities to engage in sexual activity. Concerns may also relate to misconceptions or expectations of others, including partners, caregivers, and health care providers.

Occupational Therapy Interventions

As a basic part of the human condition, sexuality is an ADL addressed with older adults; clients who are lesbian, gay, bisexual, and transgender; clients with physical disabilities; clients with developmental disabilities or delays; and other recipients of occupational therapy services as part of a holistic approach to treating the whole person.

Occupational therapy is a safe place for addressing sexuality, allowing the client to express fears and concerns, and offering assistance with problem solving. Empathy, sensitivity, and openness are necessary aspects of the therapeutic relationship, the foundation of occupational therapy, and are used in addressing sexuality. Partners are often included in occupational therapy interventions to achieve goals of mutual concern, such as sexual expression and satisfaction.

Sexuality can be addressed by practitioners in any setting. Intervention can occur in homes, group homes, nursing homes, rehabilitation centers, community mental health centers, pain centers, senior centers, hospitals, retirement communities, and other venues. The following are types of interventions offered by occupational therapy practitioners.

Health promotion: This approach consists of support groups, educational programs, and stress-relieving activities. For example, an occupational therapy practitioner could offer an educational program about safe sex for teenagers with developmental delays. Occupational therapy practitioners may also provide in-service training to assist caregivers in institutions such as skilled nursing facilities to understand the sexual needs of older adults and those with diverse sexual orientations. Such in-services might include introducing ways for insuring privacy when partners are visiting.

Remediation: This approach consists of restoring skills, such as range of motion, strength, endurance, effective communication, and social engagement, as part of meeting sexual needs. An example is rehabilitation for clients following a hip replacement and addressing their concerns about physically being able to have sexual intercourse during the recovery process. Another example is developing leisure interests to help meet potential romantic partners when working with clients who report social isolation.

Modification: This approach consists of changing the environment or routine to allow for sexual activity. Examples include resting prior to sexual activity for those with poor endurance; placing pillows under stiff or painful joints or preceding sexual activity with a warm bath; learning new positions to compensate for amputated limbs; and using positions that incorporate weight bearing to compensate for tremors.

Conclusion

Enhancing an individual's ability to participate in sexual activities can have a profound effect on that person's life. By acknowledging the importance sexuality plays in all of our lives and displaying sensitivity to the personal nature of this ADL, occupational therapy practitioners help ensure that all aspects of their clients' lives are addressed in therapy. Providing empathy and appropriate information, devising adaptations, and encouraging experimentation to find resolutions can be invaluable services to clients. When practitioners routinely discuss sexuality as an ADL, clients can talk about and address any issues in this area. Collaborative problem solving can empower clients to gain control over this most intimate of areas. It can be self-validating, allow personal expression of sexuality in ways that are meaningful, strengthen self-esteem, and allow that person to become whole again.
References
American Occupational Therapy Association. (2008). Occupationaltherapy practice framework: Domain and process (2nded.). American Journal of Occupational Therapy, 62, 625-683. doi:10.5014/ajot.62.6.625

MacRae, N. (2010). Sexuality and aging. In R. H. Robnett & W. C. Chop (Eds.), Gerontology for the Health Care Professional (pp. 235-258). Sudbury, MA: Jones and Bartlett.

By Nancy MacRae, MS, OTR/L, FAOTA, for the American Occupational Therapy Association. Copyright © 2013 by the American Occupational Therapy Association. This material may be copied and distributed for personal or educational uses without written consent. For all other uses, contact copyright@aota.org.

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Sexuality and the Role of Occupational Therapy

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Download a printable copy of this fact sheet here. Sexuality is a core characteristic and formative factor for human beings. It is a state of mind, representing our feelings about ourselves, what it's like to be male or female, how we relate to people of our own gender and those of the opposite gender, how we establish relationships, and how we express ourselves.

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"...promote success in the workplace by improving the fit between the person, the job tasks, and the environment. They work with employers and employees to adapt or modify the environment or task, facilitate successful return to work after illness or injury, and help prevent illness or injury to promote participation, health, productivity, and satisfaction in the workplace."

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Occupational therapy practitioners promote success in the workplace by improving the fit between the person, the job tasks, and the environment. They work with employers and employees to adapt or modify the environment or task, facilitate successful return to work after illness or injury, and help prevent illness or injury to promote participation, health, productivity, and satisfaction in the workplace. They may work with children and adults with developmental and intellectual disabilities to help them prepare for work and transition into the workforce. Occupational therapy practitioners also provide services related to ergonomics, accessibility, the aging workforce, and workplace health and wellness issues.

Occupational therapists must have a master's degree for entry-level practice, and occupational therapy assistants must have an associate's degree. Both must pass an initial certification exam.

The Fact Sheets below provide information on occupational therapy's role with a variety of conditions related to work.

Work & Industry
Work Rehabilitation Occupational Therapy Services at the Workplace: Transitional Return-to-Work Programs Returning to Work With Cognitive Impairments Functional Capacity Evaluation
Ergonomics
Occupational Therapy Practitioners & Ergonomics Ergonomics and Occupational Therapy: Improving Workplace Productivity
Developmental & Intellectual Disabilities
Supporting Community Integration and Participation for Individuals With Intellectual Disabilities
The Role of Occupational Therapy in Facilitating Employment of Individuals With Developmental Disabilities - pdf

Other Resources
Grip and Grin: How to Survive Handshaking on the Campaign Trail
Occupational Therapy and the Care of Persons With Spinal Cord Injury - pdf

Occupational Therapy's Role in Sleep - pdf

Occupational Therapy's Role in Health Promotion - pdf

The Role of Occupational Therapy for Rehabilitation of the Upper Extremity - pdf

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Occupational therapy practitioners promote success in the workplace by improving the fit between the person, the job tasks, and the environment. They work with employers and employees to adapt or modify the environment or task, facilitate successful return to work after illness or injury, and help prevent illness or injury to promote participation, health, productivity, and satisfaction in the workplace.

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OT practitioners promote healthy lifestyles, emphasize engagement in occupation as means to improve overall health, and provide interventions related to health & wellness.

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Occupational Therapy in the Promotion of Health and Well-Being | American Journal of Occupational Therapy

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"...promote the essential services of the pediatric occupational therapy practitioner across a range of ages, contexts, and environments. The documents highlight the evidence-based practices that comprise our roles and responsibilities and can help promote our value in addressing both mental and physical health."

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Occupational therapy's distinct value is to improve health and quality of life through facilitating participation and engagement in occupations, the meaningful, necessary, and familiar activities of everyday life. Occupational therapy is client-centered, achieves positive outcomes, and is cost-effective.
The Children & Youth Distinct Value resources offer a key tool to promote the essential services of the pediatric occupational therapy practitioner across a range of ages, contexts, and environments. The documents highlight the evidence-based practices that comprise our roles and responsibilities and can help promote our value in addressing both mental and physical health.

The resources target two different audiences: (1) administrators and policy makers; and (2) occupational therapy practitioners. The administrator and policy makers' document includes evidence about OT's role in promoting participation in numerous daily routines and in all areas of occupation, and it includes testimonials from multiple partners such as families, principals, and educators to reflect our valuable contributions. The practitioner document offers talking points within key topic areas to demonstrate value during collaborations within interprofessional teams. These topics include increasing inclusion, improving transitions, and enhancing growth and development.

Both documents could be shared during an IEP meeting, when conducting a PTO in-service, and when meeting with an administrator to recommend additional staffing. The resources may also help to launch dialogue in a discussion group or in a classroom.

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Occupational Therapy's Distinct Value in Children & Youth

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Occupational therapy's distinct value is to improve health and quality of life through facilitating participation and engagement in occupations, the meaningful, necessary, and familiar activities of everyday life. Occupational therapy is client-centered, achieves positive outcomes, and is cost-effective.

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"Disability and Human Rights are at the core of our work, publications and standards as we advocate for the human right to inclusion and participation in meaningful occupation. Our work within this program area pioneers the development and evolution of the profession at international, regional and national levels through; strategy and vision, standards and governance, collaboration and representation, support and information."

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We are finding and supporting the voices in occupational therapy to enhance our role in world health and wellbeing.

As the international representative for the occupational therapy profession, the executive team is responsible for a range of projects focused on leadership and advocacy. Disability and Human Rights are at the core of our work, publications and standards as we advocate for the human right to inclusion and participation in meaningful occupation.

Our work within this programme area pioneers the development and evolution of the profession at international, regional and national levels through; strategy and vision, standards and governance, collaboration and representation, support and information.

We are capacity building for the future of the profession by supporting the development of the profession in countries where it does not exist, facilitating the WFOT approved status of education programmes and providing labour force data and resources to support the growth of the profession.

Strategic and operational plans determine the organisation's development and business in addition to a range of projects that include:

Collaboration plans with the World Health Organisation, strategic engagement and liaison with the UN, WHO, International Labour Organisation, Humanity & Inclusion and many other International Non-Government Organisations.

Master Plan on Human Rights, Education, Mental Health, Disaster Preparedness and Response, Assistive Technology

Council Meetings and Congress

WFOT Bulletin

Global Health

Marketing, Promotion, website and social media

Student involvement

Human Resources

Sustainable occupational therapy practice

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We are finding and supporting the voices in occupational therapy to enhance our role in world health and wellbeing. As the international representative for the occupational therapy profession, the executive team is responsible for a range of projects focused on leadership and advocacy.

# data[].attributes.body
"...ensure that people recovering from illness or injury, or with a disability, can function in all their environments with the ability they have. They reduce health care costs by promoting independence and self-care."

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Occupational therapy practitioners ensure that people recovering from illness or injury, or with a disability, can function in all their environments with the ability they have. They reduce health care costs by promoting independence and self-care.

Occupational therapists must have a master's degree for entry-level practice, and occupational therapy assistants must have an associate's degree. Both must pass an initial certification exam.

The Fact Sheets below provide information on occupational therapy's role with a variety of conditions related to rehabilitation and disability.

Brain Injury
Occupational Therapy and Community Reintegration of Persons With Brain Injury
Cancer
Occupational Therapy's Role in Breast Cancer Rehabilitation
The Role of Occupational Therapy in Oncology - pdf, 573 kb

Chronic Diseases

The Role of Occupational Therapy in Chronic Disease Management - pdf, 3.1 mb

Occupational Therapy's Role in Managing Arthritis - pdf, 774 kb

Community Mobility and Driving
Driving and Transportation Alternatives for Older Adults Behind the Wheel: Occupational Therapy and Older Drivers The Role of Occupational Therapy in Providing Seating and Wheeled Mobility Services
Developmental & Intellectual Disabilities
Supporting Community Integration and Participation for Individuals With Intellectual Disabilities
The Role of Occupational Therapy in Facilitating Employment of Individuals With Developmental Disabilities - pdf, 764 kb

Occupational Therapy's Role With Autism - pdf, 484 kb

Addressing Sensory Integration Across the Lifespan Through Occupational Therapy - pdf, 176 kb

Home Modifications
Home Modifications and Occupational Therapy Home Modifications Promote Independent Living
OT's Role in Facilities
Occupational Therapy in Acute Care
Occupational Therapy's Role in Skilled Nursing Facilities - pdf, 4 mb

Hands and Upper Extremity
The Unique Role of Occupational Therapy In Rehabilitation of the Hand The Occupational Therapy Role in Rehabilitation for the Person With an Upper-Limb Amputation
The Role of Occupational Therapy for Rehabilitation of the Upper Extremity

Stroke
Recovering from Stroke with Occupational Therapy: Living Life To Its Fullest™ The Role of Occupational Therapy in Stroke Rehabilitation
Other Topics
Occupational Therapy and the Care of Persons With Spinal Cord Injury The Role of Occupational Therapy in Providing Assistive Technology Devices and Services Occupational Therapy in Polytrauma Sexuality and the Role of Occupational Therapy Students With Disabilities in Postsecondary Education Settings: How Occupational Therapy Can Help
Occupational Therapy's Role in Sleep - pdf, 603 kb

Occupational Therapy's Role in Restraint Reduction or Elimination - pdf, 620 kb

Occupational Therapy's Role in Health Promotion - pdf, 3.1 mb

Occupational Therapy: A Vital Role in Dysphagia Care - pdf, 1.4 mb
Into the Swing of Things

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Occupational therapy practitioners ensure that people recovering from illness or injury, or with a disability, can function in all their environments with the ability they have. They reduce health care costs by promoting independence and self-care. Occupational therapists must have a master's degree for entry-level practice, and occupational therapy assistants must have an associate's degree.

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OT practitioners assist clients to promote health, support aging in place, maintaining important roles and routines, and increasing engagement in community occupations.

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"...provide mental health treatment and prevention services for children, youth, the aging, and those with severe and persistent mental illness, with a focus on function and independence."

# data[].attributes.attachment_link.readable_text
Mental health is a component of all occupational therapy interventions,. Occupational therapy practitioners provide mental health treatment and prevention services for children, youth, the aging, and those with severe and persistent mental illness, with a focus on function and independence.

Occupational therapists must have a master's degree for entry-level practice, and occupational therapy assistants must have an associate's degree. Both must pass an initial certification exam.

The Fact Sheets below provide information on occupational therapy's role with a variety of mental health conditions.

Fact Sheets
Occupational Therapy in Polytrauma Occupational Therapy's Role in Community Mental Health Returning to Work With Cognitive Impairments Dementia and the Role of Occupational Therapy
Occupational Therapy's Role in Sleep - pdf, 603 kb
Mental Health in Children and Youth: The Benefit and Role of Occupational Therapy
Occupational Therapy's Role in Health Promotion - pdf, 3.1 mb
Occupational Therapy's Role in Mental Health Recovery
Occupational Therapy's Role with Posttraumatic Stress Disorder - pdf, 493 kb

Occupational Therapy's Role in Restraint Reduction or Elimination - pdf, 620 kb

Occupational Therapy Using a Sensory Integration-Based Approach With Adult Populations - pdf, 583 kb

The Role of Occupational Therapy in Oncology - pdf, 573 kb

Articles
Occupational Therapy's Role in Disaster Relief Occupational Therapy and Depression: Reconstructing Lives

# data[].attributes.attachment_link.description
Mental health is a component of all occupational therapy interventions,. Occupational therapy practitioners provide mental health treatment and prevention services for children, youth, the aging, and those with severe and persistent mental illness, with a focus on function and independence. Occupational therapists must have a master's degree for entry-level practice, and occupational therapy assistants must have an associate's degree.

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- Stand Desk
- Screen Clip
- Seat Cushion
- Lifting Straps
- Built-up Hammer

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- Long-Handled Sponge
- Reacher
- Shoe Horn
- Toilet Tissue Aide
- Sock Aide
- One-handed Cutting Board

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- Button Hook
- Bathtub Bench
- Handheld Shower-head
- Book Page Holder
- Non-slip shoes
- Built-up Knitting Needles

# data[].attributes.body
- Ergonomic Keyboard
- Microphone Headset
- Screen Reader
- Mechanical Lift Machine
- Outdoor Mobility Aide

# data[].attributes.body
- Electric Can Opener
-  Automatic Pill Crusher
- Uplift Seat Assist
- 3-Wheel Scooter
- Automatic Tilt-In Space Wheelchair

# data[].attributes.body
- Ear Plugs
- Fidget Spinner
- Journal
- Stress Ball/ Putty
- Weighted Blanket

# data[].attributes.body
- TV Ears
- Amazon Echo
- BeClose
- Audio Books
- Personal Emergency Response System

# data[].attributes.body
- Gripping Gloves
- Theraband
- Meal Calendar
- Pill Organizer
- Writing Prompt Journal

# data[].attributes.body
- Medication Alarm
- FitBit
- Electronic Calendar
- Mood Tracker Apps
- Meditation Apps (Calm, Insight Timer, etc.)

# data[].attributes.body
Understanding the Provision of Assistive Mobility and Daily Living Devices and Service Delivery to Veterans After Stroke

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Understanding the Provision of Assistive Mobility and Daily Living Devices and Service Delivery to Veterans After Stroke | American Journal of Occupational Therapy

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- Vitaglide
- Electric Mattress
- Treadmill
- Nutribullet Blender
- Electric Facial Cleansing Brush
- MyFitnessPal App

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AT for Aging in Place

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Impact of Pillbox Customization on Device Satisfaction and Medication Adherence

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Impact of Pillbox Customization on Device Satisfaction and Medication Adherence | American Journal of Occupational Therapy

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World Health Organization (WHO)

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Countries, territories and areas in the WHO Western Pacific Region:

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- Universal Cuff
- Cushions (Liberator Shape)
- Intimate Rider
- Gooseneck Clamps
- Grab Bar
- La Palma Hand Harness
- Ceiling Swing

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Independent Living Aides

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AliMed offers a wide selection of Aids for Daily Living (ADLs) to help patients with physical limitations remain independent in each of the six primary Activities of Daily Living: mobility, dressing, grooming and hygiene, bathing, toileting, and self-feeding.

Self-Transfer Aids, including Self-Transfer Boards and Swivel Cushions, help patients maneuver safely on their own, while easy-to-use tools like all-purpose and Dressing Aids allow those who have limited reach or difficulty bending to be more self-sufficient throughout their day. Bathing and Hygiene Aids such as Extendable Sponge Kits and Long-Handled Combs support patients with limited dexterity in dental, grooming and washing tasks, and Toileting Aids help to ensure patient comfort and privacy while maintaining personal hygiene. Assistive Dining Aids, including Weighted Utensils and High-Sided Dishes, help patients in reducing the challenges of eating to improve food intake and overall nutritional health.

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ADL | Aids & Activities for Daily Living Products | AliMed

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AliMed offers a wide selection of Aids for Daily Living (ADLs) to help patients with physical limitations remain independent in each of the six primary Activities of Daily Living: mobility, dressing, grooming and hygiene, bathing, toileting, and self-feeding.

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Assistive Devices for Daily Living: Home living - Long handled aids

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Assistive Devices for Daily Living: Home living - Long handled aids

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Work Rehabilitation

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Assistive Devices for Spinal Cord Injury Patients | Occupational Therapy Month

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San Joaquin Valley Rehabilitation Hospital

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Assistive Devices for Spinal Cord Injury Patients | Occupational Therapy Month

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- Wahl Massager
- Vibrator
- MHP Tongue Vibrator
- We Vibe

# data[].attributes.body
A Rehabilitative Approach to Assistive Device Interventions

# data[].attributes.attachment_link.title
A Rehabilitative Approach to Assistive Device Interventions | American Journal of Occupational Therapy

# data[].attributes.body
Aging in Place: Measuring Quality of Life of the Aging Population

# data[].attributes.attachment_link.title
Aging in Place: Measuring Quality of Life of the Aging Population | American Journal of Occupational Therapy

# data[].attributes.body
Ergonomics

# data[].attributes.body
AT for Mental Health Conditions

# data[].attributes.body
Assistive Technology During a Pandemic: Empowering people with disabilities

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Assistive Technology During a Pandemic: Empowering people with disabilities

# data[].attributes.body
Research articles and books related to high tech AT for various populations and practice areas

# data[].attributes.body
- Picture Exchange Communication System (PECS)
- Fidget toys
- Wobble Seat Cushion
- Spring-operated Scissors
- Pencil Grips
- Slant Board
- Golf Pencil

# data[].attributes.body
- Electronic Reading IPad Apps
- Graphic Organizer
- Livescribe Echo Smart Pen
- Proloquo2Go
- Switch Interface

# data[].attributes.body
Individualized Support in Higher Education Using Assistive Technology (AT)

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Individualized Support in Higher Education Using Assistive Technology (AT) | American Journal of Occupational Therapy

# data[].attributes.body
TIME TIMER | Assistive Technology For Students with Learning Disabilities

# data[].attributes.attachment_link.title
TIME TIMER | Assistive Technology For Students with Learning Disabilities

# data[].attributes.body
Powerpoint Presentation regarding AT for Young Learners

# data[].attributes.body
School-Based Occupational Therapists’ Use of Assistive Technology

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School-Based Occupational Therapists' Use of Assistive Technology | American Journal of Occupational Therapy

# data[].attributes.body
Online company which focusing on custom product to improve functional engagement for all populations.

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Like many girls her age, Hillary loves singing and listening to music. Hillary's iPad Wireless switch allows her to be her own DJ, choosing songs she wants to hear. Hillary says "I have cerebral palsy, but it doesn't stop me from doing many things on my own."

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Toys For Children With Special Needs | Enabling Devices

# data[].attributes.attachment_link.description
Like many girls her age, Hillary loves singing and listening to music. Hillary's iPad Wireless switch allows her to be her own DJ, choosing songs she wants to hear. Hillary says "I have cerebral palsy, but it doesn't stop me from doing many things on my own."

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USA Medical Supply

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US Medical Supplies is the largest retailer for lift chairs, stair lifts and wheelchair lifts in the country. Call now to speak with an expert. 1 (800) 790-4792

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Managing Social Isolation and Depression Through Assistive Technology Tools

# data[].attributes.attachment_link.title
Managing Social Isolation and Depression Through Assistive Technology Tools,  May 14, 2020

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Sexuality & Intimacy AT

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Institute for Sex, Intimacy & Occupational Therapy

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Sign up for our email list to receive your FREE conversations starters for bringing up sex with your OT clients, tips to improve how you address sexuality with your patients, and other great resources to help you become a confident sex + intimacy champion.

# data[].attributes.body
Rate and Duration of Adaptive Equipment Use and Factors Affecting Use After Discharge From Inpatient Rehabilitation

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Rate and Duration of Adaptive Equipment Use and Factors Affecting Use After Discharge From Inpatient Rehabilitation | American Journal of Occupational Therapy

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Exploring Assistive Technology (AT) Decision-Making Among Older Adults (OA) Aging in Place

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Exploring Assistive Technology (AT) Decision-Making Among Older Adults (OA) Aging in Place | American Journal of Occupational Therapy

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Return to Work Programs

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Using Assistive
Technology to promote
positive changes with
mental health challenges

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Adaptive Exercise Equipment

# data[].attributes.body
Virtual reality remote psychotherapy for body weight and shape concerns

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ABSTRACT

ABSTRACT
Recent years have seen a growing research interest towards designing computer-assisted health interventions aiming to improve mental health services. Digital technologies are becoming common methods for diagnosis, therapy, and training. With the advent of lower-cost VR head-mounted-displays (HMDs) and high internet data transfer capacity, there is a new opportunity for applying immersive VR tools to augment existing interventions. This study is among the first to explore the use of a Multi-User Virtual Reality (MUVR) system as a therapeutic medium for participants at high-risk for developing Eating Disorders. This paper demonstrates the positive effect of using MUVR remote psychotherapy to enhance traditional therapeutic practices. The study capitalises on the opportunities which are offered by a MUVR remote psychotherapeutic session to enhance the outcome of Acceptance and Commitment Therapy, Play Therapy and Exposure Therapy for sufferers with body shape and weight concerns. Moreover, the study presents the design opportunities and challenges of such technology, while strengths on the feasibility, and the positive user acceptability of introducing MUVR to facilitate remote psychotherapy. Finally, the appeal of using VR for remote psychotherapy and its observed positive impact on both therapists and participants is discussed.

1. Introduction

To the best of our knowledge, only one study so far has investigated the efficiency of VR where a patient and a therapist are engaged in therapeutic sessions using MUVR. However, in that study the patient and the therapist were present in the same physical location. The study investigated the use of VRET for reducing the fear of heights (Krijn et al., 2004) and showed a positive effect on acrophobia and a decrease in user's anxiety which was maintained at a 6-month follow-up.

The present study aims to explore the design opportunities and challenges of introducing MUVR to facilitate remote psychotherapy. The study presents the development of an MUVR program to be utilized as an intervention medium for females at high-risk for developing an Eating Disorder. It also examines the feasibility and acceptability of using VR for remote psychotherapy by therapists and participants at high-risk for developing an Eating Disorder. In particular, the study aimed to tackle the following questions: a) What are the design opportunities and challenges of MUVR for females with body shape and weight concerns deemed to be at high-risk for developing Eating Disorders?, and b) Is the MUVR developed feasible and acceptable for therapists and participants at high-risk for Eating disorders?

2. Muvr co-design process

The research and development team consisted of psychologists with experience in working with Eating Disorders (n = 4; one in each of the following specializations: clinical, cognitive/experimental, developmental/social, and school psychology), and Human-Computer Interaction (HCI) in healthcare experts (n = 3; one in each of the following specializations: engineering/social gaming, computer science graphics, and digital health). The team was thus comprised of experts who were able to cover all the relevant areas for the development of this program (clinical content, system usability and technical development).

Nine design iterations, over a six-month period, were conducted to design and develop the MUVR system (Table 1). Each iteration involved focus groups and/or interviews and/or pilot evaluations to improve the design, including three different representative participants, individuals at high-risk for developing an Eating Disorder. Each pilot evaluation lasted approximately two hours.

"Now i can see me" designing a multi-user virtual reality remote psychotherapy for body weight and shape concerns

Published online:

16 October 2020

2.1. Development of the MUVR avatars

Through team discussions and the co-design process, it was decided that both participants and therapists should be represented in VE as cartoon avatars. Based on user feedback (see Table 1), the therapist was represented as a cartoonish non-anthropomorphic box rather than a realistic figure (see Figure 1). This decision was in line with previous research findings suggesting that the use of animated cartoons could help reduce stress in therapy (Cohen et al., 1997; Lee et al., 2012). Moreover, the research team purported that the use of cartoon avatars in MUVR psychotherapy would provide a degree of anonymity and security for participants.

Regarding the participant avatar a cartoonish anthropomorphic figure was decided upon (see Figure 2). As part of the intervention goals (treatment of individuals who present with high body shape and size concerns), it was decided that participants would have the opportunity to modify the avatar to their likeness (i.e., represent their own body shape and size).

2.2. Development of the MUVR therapeutic content

Different VEs were developed to comprise the MUVR Remote Psychotherapy. The content of the VEs developed were based on Acceptance and Commitment Therapy (ACT) values clarification components (Karekla & Nicolaou, 2015) or a Play Therapy approach, and also included the behavioral technique of exposure to one's (in this case the avatar's) body shape (Mirror Exposure technique). Different environments were created for content testing at a later stage of research development, which go beyond the aims of the present paper.

The overall approach to intervention for body shape and weight concerns utilized to create the content of MUVR Remote Psychotherapy was based on ACT (Hayes et al., 2011) and specifically the AcceptME protocol (Karekla & Nicolaou, 2015), which is a digital gamified program for youth with body shape and weight concerns, at-risk for Eating Disorders. The aim of ACT is for the individual to learn to accept their inner thoughts and feelings about troubling situations (including body shape and weight thoughts and emotions), and commit to behavior change, regardless of unwanted internal thoughts and feelings (Hayes et al., 2011; Juarascio et al., 2013; Merwin & Wilson, 2009). In general, ACT emphasizes altering the individual's behaviors rather than shifting attention away from troubling thoughts and feelings (Juarascio et al., 2013).

For purposes of this project, the component of values was chosen as the motivational force within ACT that provides meaning for behavior change to occur, even in the presence of uncomfortable thoughts and feelings (Gloster et al., 2017; Hayes et al., 2011; Juarascio et al., 2013; Merwin & Wilson, 2009). Two virtual tasks were developed within the MUVR system, where the individual comes into contact with valued life domains and recognizes how actions related to concerns about body shape and weight get in the way of living a valued life.

Figure 3 shows the second task, the values clarification task, where the participant builds their own "life values-based map". The therapist within the MUVR system, located in the same VE as the user, guides the participant to explore what is important to the person. The participant develops a personal life map that allows her to outline her important life valued domains through embodied interactions (i.e., "grabbing and placing"; "grabbing" the valued domain and "placing" it into the blue rings to form the life map). This process provides the participant with clarity as to what is of most importance in their life and links it with behavioral choices (i.e., how to act in everyday life). All intractable objects were highlighted in yellow as soon as the participant/therapist touched them with a VR controller.

Additionally, the VEs created included two game tasks (a virtual painting task and a virtual basketball-type ball-throwing task) based on Play Therapy (PT; Schaefer, 2003). PT is utilized for younger individuals with various difficulties (Leblanc & Ritchie, 2001; Schaefer, 2003), where play is used as a means of helping the person express and communicate thoughts and feelings. Previous research demonstrated the usefulness of PT in reducing impulsivity and enhancing emotion regulation in people suffering from Eating Disorders (Claes et al., 2012; Fagundo et al., 2013; Jiménez-Murcia et al., 2009). The two games included were selected because of their ability to reduce the attentional resources devoted to processing worrisome thoughts (e.g., drawing activities and target reaching - shooting task). Figure 4 shows the virtual coloring game, where the participant was instructed to use the virtual palette (variety of colors and tones provided) and the brush to color inanimate objects.

Another VE created within this MUVR included an Exposure Therapy exercise. The Mirror ET involves confrontation in a mirror to ones' shape and body (in this case a virtual mirror showing the avatar created to depict the participant). The Mirror ET has demonstrated efficacy in reducing negative body-related concerns (Vocks et al., 2007) and leads to improvements in body image among individuals dealing with Eating Disorders and significant concerns about their body shape and size (Hildebrandt et al., 2012). In this MUVR, the participant faces the virtual avatar. The avatar is customized by the participant to match her own physical body. For these purposes, an avatar customization system was developed. This system allows participants to create body shapes using virtual sliders, change clothing, skin tone, as well as hair style and color (see Figure 2).

The Mirror exposure progresses gradually by making the avatar's clothing scantier until the avatar is left only in underwear (see Figure 5). During this process, the participant is asked to look carefully at each part of the body and perform the appropriate adjustments while describing her feelings, thoughts and concerns. Each part of the body, thoughts, and feelings are discussed with the therapist during the whole process. Thus, exposure to ones' body shape and size (via the avatar) occurs with progressively less clothing based on the hierarchy of concerns created by the participant at the beginning of the session.

Overall the full session consisted of three stages: 1) MUVR user tutorial; 2) Starting location where the therapist greets the participant and participants create their virtual avatar; 3) Three VEs (2 ACT values VEs or 2 games, and a Mirror Exposure VE).

3. Methods

3.1. Ethics

The study was approved by the National Bioethics Committee (REF: ΕΕΒΚ/ΕP/201305). All participants signed an informed consent prior to study commencement. No compensation was provided to participants and therapists. Participants could receive course credit if this was offered by their professors.

3.2. Participants

Participants were recruited through convenience sampling from undergraduate classes at the University. Only females were recruited in this study as Eating Disorders phenomenology presents differently between the sexes (Stanford & Lemberg, 2012). One hundred and thirty women aged between 18 to 25 years, completed online screening questionnaires (Eating Disorder Diagnostic Scale (EDDS) and Weight Concerns Scale (WCS); see section 3.4).

Participants scoring above a symptom composite cutoff score of 16.5 (n = 34) on the EDDS, were considered to present as either high-risk for the development of an Eating Disorder or with a possible Eating Disorder (Krabbenborg et al., 2012) and were referred to the university counseling services for a full diagnostic mental health assessment. Based on the EEDS criteria, 10 individuals were judged as possible to have Anorexia Nervosa (n = 2) or Bulimia Nervosa (n = 8), and this was corroborated by the clinical assessment. Three more participants were diagnosed with Anorexia and/or Bulimia Nervosa based on the clinical assessment. All 13 participants with the possible diagnosis of Eating Disorders were excluded from the study and were offered services at the university counseling clinic. The remaining participants who did not meet criteria for an Eating Disorder but were considered at high risk were invited to participate in the VR part of the study. Seven participants declined participation, thus the final sample included 14 females deemed to be at high-risk for developing an Eating Disorder within the next four years. None of the participants had undergone any form of cognitive behavior therapy in the past.

Their mean age was 20 years (M = 19.93, SD = 1.77), with a mean weight 64.36 kg (SD = 10.68) range from 47.30 kg to 86.00 kg while the participants mean Body Mass Index (BMI) was 24.25 kg (SD = 3.23). We also measured the size of the Arm (M = 23.64, SD = 2.65), Waist (M = 78.19, SD = 12.16), Hips (M = 100.5, SD = 9.42) and Thighs (M = 64.86, SD = 6.16). All participants reported normal or corrected-to-normal vision (so as to ensure visual ability within the VR) and none reported any disability that could affect the use of the VR technology. Participants were assigned to each version using counterbalancing.

Seven therapists were recruited to lead the sessions. Each therapist led at least two MUVR Remote Psychotherapy sessions. The therapists were graduate students in clinical (n = 3) or school psychology (n = 4). All therapists were trained to the approach and the specific protocol by an expert ACT trainer (>10 hours of training offered), who supervised their practice. They were also trained in the use of the VR and underwent the same tutorial as participants.

3.3. Study design and procedure

The study design emerged from rigorous discussions among the co-design team that comprised of experts in their respective fields (psychology/psychotherapy, working with Eating Disorders and HCI in healthcare (see section 2 for details on the co-design process).

Recruited participants and therapists (see section 3.2) were placed in two separate rooms within the same building (approximately 50 meters apart) and never met face-to-face. Upon arrival at the laboratory (participants room), participants were greeted by a study researcher (not the therapist) and had their weight, body mass, and height measured. These measurements were used to calculate the participants' BMI using the formula: BMI = Kg/m ². The BMI provided an indication of whether the participant was underweight, overweight, or of normal weight. Next, participants proceeded with the MUVR therapeutic session and were reassured that they had the option to stop the session at any time.

The participant was then fitted with the VR Head-Mounted Display (HMD) and was instructed to first follow a tutorial of about 25 minutes in order to become familiar with the use of the VR system and the interaction devices. Then, the participant and the therapist were introduced within the VR system. Both participant and therapist appeared in a neutral VE in front of the virtual avatar ( Figure 2). In this VE, the therapist greeted the participant and asked her to customize the virtual avatar according to her look (body shape and size, skin tone and hair color and shape). After setting up the avatar, both the participant and therapist were "teleported" to the first intervention VE. Upon completion, they were teleported to the second intervention VE and finally to the last mirror exposure VE (see Figure 6 for the MUVR session procedure). Throughout the process, qualitative observational notes and video/audio recordings were captured by two researchers (one located in the room with the participant and another located with the therapist).

The MUVR therapeutic session lasted approximately one hour. Upon completion, both participant and therapist (in separate rooms) were asked to complete post-session questionnaires and a semi-structured interview was conducted by the researchers. Overall, the entire trial lasted approximately two hours.

3.4. Instruments

3.4.1. Screening questionnaires

Eating Disorder Diagnostic Scale (EDDS; Stice et al., 2000) is a self-report scale consisting of 22 statements based on DSM-IV criteria for assessing Eating Disorders symptoms. Items are assessed in a variety of formats, as determined by the nature of the question including a 6-point Likert scale (1 = not at all to 6 = extremely), yes/no responses and frequency ratings from 1 to 14. The EDDS was used to identify individuals at high-risk and those who possibly meet the criteria for an Eating Disorder diagnosis. A symptom composite cutoff score of 16.5 was used to reflect the best trade-off of the EDDS symptom composite score regarding the determination of the presence or absence of eating pathology. The scale was found to have high test-retest reliability (r = .87; Stice et al., 2000).

Weight Concerns Scale (WCS; Killen et al., 1996, 1994) is a five statement self-report scale assessing the participant's risk for developing an Eating Disorder in the next four years. Items are assessed on a 4-point, a 5-point, and a 7-point Likert scale (1 = lower rate, and 4-7 = highest rate). A cutoff of 52 points was used to separate individuals with high (≥ 52 points) or low likelihood (< 52 points) of developing Eating Disorders (Killen et al., 1994). Previous studies (e.g., Killen et al., 1996) reported adequate reliability (Cronbach's alpha > .7). The WCS was used to identify participants at high-risk for developing an Eating Disorder in the future.

3.4.2. VR experience assessment questionnaires

Two questionnaires were completed by both therapists and participants so as to capture the level of usability, presence and immersion: (1) System Usability Scale (SUS; Brooke, 1996) is a 10-statement self-report scale used to evaluate satisfaction and usability of the system. It is rated on a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. (2) Presence (Nichols et al., 2000) is a 6-item self-report scale used to evaluate: a) the sense of "being there" in the scenarios as compared to being in a place in the real world, b) how much the scenarios became the dominant reality, and c) the extent to which participants remembered the scenarios as a place visited rather than as a computer-generated text or image. Presence was rated on a 7-point Likert scale ranging from 1 = strongly disagree to 7 = strongly agree.

3.4.3. Qualitative assessment

Detailed Observation Notes were taken by two researchers during the MUVR session, a psychologist and an HCI in healthcare. One researcher was located in the room with the therapist and another was located with the participant. The goal of these observations was to classify the interactions and behavioral responses toward the MUVR experience. This was done to identify the design opportunities and challenges, which can be useful for future MUVR development and utilizations.

Semi-structured interviews were conducted at the end of the MUVR session by the two researchers. The interviews were conducted with the aim of exploring participants' experience with VR regarding technology acceptance, the impact of MUVR on the user, and the emotional or behavioral reactions during the session. In particular, the interviews with the participants focused on three main areas: (a) General Experience (e.g., "How easy/hard did you find the systems use? Explain."); (b) Attitudes toward the MUVR session (e.g., "What did you like/dislike about the VR session?"); and (c) Reactions toward the virtual intervention compared to traditional practices (e.g., "What did you think about this experience? Do you think it is similar to traditional face-to-face interventions? Do you have a preference for VR vs. face-to-face interventions?").

The interviews with the therapists aimed to capture their reflections about their observations of the participants using MUVR as well as their professional opinion on the usability and suitability of VR to support remote psychotherapy in a simulated environment designed and personalized with an eye on optimizing therapeutic benefits. The interviews focused on three main areas: (a) Usability Evaluation (e.g., "Did you find the VR use simple/difficult? Explain."); (b) Attitudes toward the MUVR (e.g., "What thoughts/emotions emerged for you during the session? How does it compare with face-to-face treatment?"); and (c) Reflections on the participants (e.g., "What are your observations regarding the participant and their engagement, acceptability, likeability of the system?"). To ensure the reliability of the interviews, the same questions were asked more than once and sometimes in a different format.

3.5. Apparatus

Two Oculus Rift ¹ VR HMD systems, one for the therapist and one for the participant, were used to stream the audial and visual content. The Oculus Touch Controllers were used as interactivity devices to allow the users to navigate through the VE. Each system was paired to two Oculus Sensors that captured the user's physical position and movements and incorporated them into the VE. The Oculus Rift tracks the head movement to present the correct virtual-world image to the eyes (LaValle et al., 2014), and it analyzes the user's head movement in real-time to control the view. This results in natural interactions between the user and the VE, leading to high levels of presence and immersion (Desai et al., 2014). The HMD includes an adjustable head strap that sets the hands free for the controllers. The combined weight of the HMD (470 grams) and controllers (169 grams/per controller) is 808 grams, which facilitates comfortable use for extended periods.

The VR system was developed using Unity3D 5 ² and SteamVR. The 3D models (human body and the VE) were created in Adobe Fuse CC ³ and Maya ⁴ version 2016, enhanced by Unity Assets. ⁵ In order to create a sense of embodiment, we used the Oculus Rift controllers to synchronize the movement of the avatar in the virtual space, reflecting the movement of the user in the physical space. The buttons on the Oculus Rift controller were marked in the virtual environment with different colors to improve the identification of each corresponding task (e.g., we associated the red button with object grabbing). Moreover, Salsa Lip-Sync RandomEyes ⁶ version 1.5.5 and Photon Voice ⁷ version 1.16 were integrated to allow the synchronous verbal communication between the therapist and the participant. Audio dialogue files were processed in real time to automate the lip synchronization process and animate the avatar's facial expression. Photon Unity Networking ⁸ version 1.91 was used to implement multiuser capability (up to 20 simultaneous users).

The VR content was streamed to an external laptop screen, mirroring the users' real-time virtual interactions and allowing the two researchers to observe silently the procedure. The Open Broadcaster Software 23.0.1 was used as a video screen recorder to record the virtual session, the interactions and the discussion between the therapist and the participant. Two Dictaphones were used when interviewing the therapists and the participants, and 2 separate laptops were used to answer the questionnaires by both participants and therapists.

3.6. Analysis plan

The qualitative data were analyzed using a thematic analysis method that allows for the identification, interpretation, and report of patterns within datasets (Braun & Clarke, 2006). Team researchers coded and classified the information into themes so as to answer the research questions. The thematic analysis was carried out on data from the interviews and the observation notes made by the researchers. To ensure the reliability of the observation notes, video recordings of each session were transcribed and compared. Quotes that illustrate the findings were taken from transcribed interviews and video recordings. The quantitative data analyzes were carried out using SPSS version 26. Data are reported as Means (M) and Standard Deviations (SD).

4. Results

4.1. Eating disorder diagnostic scale (EDDS) and weight concerns scale (WCS)

The EDDS was used to identify individuals who possibly meet criteria for an Eating Disorder diagnosis. Participants scoring above a symptom composite cutoff score of 16.5 on the EDDS were considered to be at high-risk for the development of an Eating Disorder (Krabbenborg et al., 2012). The average EDDS score for our sample was 30.64 (SD = 15.36). The WCS inventory identifies the possibility of participants developing an Eating Disorder in the following four years. The average WCS score in this sample was 71.07 (SD = 13.89).

4.2. System usability and presence

The overall System Usability Scores (SUS) for both participants (78.93%) and therapists (84.96%) indicated high rates of system usability, with an average score of 81.5%. High rates of presence (max score of 7) were also reported by both participants (M = 4.71, SD = .99) and therapists (M = 5.76, SD = 0.6), average score was 5.15 (SD = 0.95).

4.3. Interviews and observations

To explore how MUVR was used by participants and therapists and to identify design challenges and opportunities, an in-depth thematic analysis was carried out. The qualitative thematic analysis suggested four core themes and ten subthemes ( Figure 7): (1) "Virtual Reality Experience"; (2) "Real vs Unreal"; (3) "Interactions in Virtual Environments" and (4) "Remote Psychotherapy".

4.3.1. Virtual reality experience

This theme concerns the general relationships between the users and the VR technology and consists of three subthemes: (1) Technology Acceptability; (2) Technology Skepticism; and (3) Opportunities Generated.

The therapists found the system useful in facilitating therapy and user-friendly.

"I found the system very easy to use, and in general, the graphics were nice and helped the participant to work with her body image" [T1, 6, 3]. ⁹ "I can see myself using this system in the future to run more therapeutic sessions and I trust that once I get used to the system, my use of the sessions will improve a lot [...] "This was my first use of VR to run a psychotherapeutic session and so I was very concentrated to use the system correctly, this might have affected a bit negatively my performance during the session" [Int: T2, 5].

Participants also expressed a positive attitude toward the system. Their statements also emphasized the need for familiarization with user interfaces prior to therapy. Specifically, they stated that the tutorial included in MUVR was crucial in improving technology acceptability.

"I found myself feeling comfortable using the system. It was easy for me to memorize all the buttons because of the tutorial. I was able to interact naturally with the VR system, the objects and the therapist" [Int: P1, 1].

"I felt that she was quite tense, and for sure she was skeptical about the VR use. She was very introverted but, during the games, something magical happened, she started to enjoy the VR and engage with the activities. She was interacting with me and at the same time, she was revealing her worrisome thoughts" [Int: T1, 14].

Three participants refused to respond to the therapist at the beginning of the virtual therapy. Specifically, they referred to the therapist in an impersonal way, as if the therapist were not a human being but an object ("something") and sought help and reassurance from the researcher who was physically present in the room with them. One of these participants was especially stressed and asked the researcher in the room for help.

"I am so scared, I don't want to touch the virtual object. I am scared, I don't want to move from my spot, I might get hurt"; "Oh God, something is talking to me, is this normal? [Referring to the Therapist Avatar] Oh My God! [Researcher's name] Do I have to reply to this?"; "I am lost. I am in the middle of nowhere, I am in a desert. [Researcher's name] did you lose me? I don't know where I am!" [Obs: P10].

However, the participants initial hurdle and skeptical attitude were quickly overcome through the virtual interactions and none of them chose to end the session.

"At the beginning of the session I got frustrated and stressed but during the activities [...] for example, the basketball game, I got relaxed. I felt closer to the therapist, I started trusting her. During the games, she was hearing me illustrating my problem very kindly and responded to my worries appropriately. [...] I mean her words; her statements were very straightforward, she made me think of myself in a way I haven't thought of me before. To be honest, I was not expecting it, but via this VR therapy, I got that much help that I feel that I was the one who gained from this rather than your research. This research helped me so much, the experiment on its own was my reward. Thank you" [Int: P10, 10].

"I felt that the participant was sharing with me her troubling thoughts and emotional concerns. I can surely say that at the beginning of the Exposure Therapy she got frustrated about the way she looks [...] her voice was breaking, and I could observe a tremulous voice, but as time passed, she started being more confident. She was engaging with the exposure and accepting her looks [...] I think at the end of our session, she was pretty optimistic about herself, her body and the future" [Int: T3, 9].

Participants stated that the intervention helped them to accept their body image. When asked to provide general feedback about the MUVR remote psychotherapy, most participants focused on their resulting positive attitudes toward their bodies.

"Via this VR app, I was able to create my "true" self. Through this process, I felt capable enough to see and create my body accurately. I started creating a large body figure, but through the app and the whole process, I realized that I was overreacting. At the end of the process, I was able to create an avatar similar to my body. Some parts of my body are still bothering me but not that much anymore. I am not that strict and judgmental with myself now. I feel that this is myself and myself -the avatar that I am looking at is a normal person. It was like all of these years I was looking at myself, but I wasn't seeing myself, I never concentrated and focused on what my body really looks like. This VR app did it. For the first time, I realized that the idea I have about my body is different from my actual body" [Int: P6, 6, 1].

4.3.2. Real vs Unreal

This theme describes the interplay between what is real and what is virtual, and how it impacts on therapy. Two subthemes were identified: (1) Virtual World, Real Therapy; and (2) Emotional Responses.

"I think that this kind of technology-based therapy is very useful for people who are dealing with any kind of phobia since it provides the therapist and the participant with many options to accurately experience the phobic situation. During this session, the participant was not only able to observe, discuss and shape her body, but she was also able to share this image with me. Which placed me in the position to help her to deal with her troubling thoughts" [Int: T4, 10].

Participants supported the notion that MUVR can provide a realistic experience especially through the discussion they had with the therapist, during which the participants not only reacted emotionally but also referred to their online avatar as if it were their physical self.

"The mirror phase made me uncomfortable. It was a realistic experience, I was feeling like I was looking directly at myself in a real mirror and that was kind of disturbing" [Int: P9, 9]. "I don't want to remove my clothes. I feel that I will be embarrassed to be close to naked in front of you, in front of another person" [Obs: P8].

A key observation that showed that the VR system provided a realistic experience for the participants was the avatar customization activity. From the existing literature, it is known that many people dealing with Eating Disorder symptoms tend to overestimate their body shape and proportions (Bruch, 1974). Participants indeed tended to create a much bulkier virtual body figure compared to their real body size ( Figure 8). Interestingly, when the therapist asked the participant to explain the similarities between the way they looked and the way their avatar looked, they all said that this is exactly what their real body looks like. This further suggests that participants were able to engage with the virtual avatar as if it were their own body and created a realistic therapy experience.

" I felt uncomfortable in front of the VR Mirror. Trying to create yourself - not who you want to be but who you really are is not just uncomfortable, it's miserable [...] However, I really - really liked it. It was a great experience and it helped me a lot, it helped me to understand several things about myself and my body and all the concerns I have. I enjoyed it and it made me think, [...] it made me think a lot" [Int: P12, 12].

Interestingly it was observed that the therapist was not only able to interpret correctly the participants' emotions but was also able to respond properly. We believe this is partly because the VR was designed using gamification principles that aided in establishing a game-like feel to the program and a friendly relationship between the two users (therapist and participant).

" Playing games made me feel closer to the therapist, it was like we bonded, like having fun with a friend. This helped me to trust her and feel that I can share my emotions and thoughts with her. She was not a therapist, she was a friend with whom I had some fun and shared some thoughts and emotions, a friend that counselled me" [Int: P10, 10].

4.3.3. Interactions in virtual environments

This theme captures various issues regarding interactions in the virtual environment and potential design directions. Two subthemes emerged: 1) Therapy Content Preference, and 2) Formal and Informal Interactions.

"My personal observation is that the use of playful or game-like activities within the psychotherapy process promotes a sense of trust and understanding between the therapist and the participant in such environments, even for highly anxious individuals. However, the type of virtual game should be in line with the participants interests since some individuals seemed to benefit more from coloring activities, whereas others were interested more in active types of games such as basketball" [Int: T1, 5].

Participants' statements largely supported this observation.

"In general, my stress levels are high, and several worrying thoughts are troubling me a lot. During the VR coloring game, I concentrated on the virtual coloring and this distracted me from my anxious thoughts. In the end, it made me feel much calmer. I would like to do this activity on a regular basis, I believe it will help me to calm" [Int: P5, 5]. "I don't want to move to the next task, but since I have no other option, I have to agree ... Let's move, however, if I could I would have chosen to stay here for much longer, but I understand, there are other tasks and we have to move on" [Int: P14, 14].

"During the games, she was interacting more naturally with me ... I got a second role, I was not only her therapist, I was her friend as well [...] In some cases she was less concentrated on our talk, but generally this made her much more talkative and a lot less worried about the way she had to express herself" [T4, 14].

"I feel that exercising is offering [...] my basketballs are gone, I need extra balls [Therapist fills the tray with balls] is offering you a good quality of life [...] can you give me some more balls? I really liked this task even though I didn't reach the target [giggles] I really liked it, oh thank you for the balls, so I was saying that exercising is helping me to maintain a good quality of life [...]." [Obs: P14].

Notably, this informal interaction was not observed when participants experienced the more traditional therapeutic techniques, during which they tended to behave and interact with the therapist in a more formal manner.

" I think during the values exercises [...] the participants were behaving more [...] let's say more formally. They were behaving similarly to a face-to-face therapy. This time I had just one role, I was their therapist. [...] And they were taking their time to form their phrases correctly, [...] they were less spontaneous" [Int: T4, 11].

" Please allow me to move into the virtual space so as to have a full view of all the virtual world" [Obs: P12]. " In general, the VR helped me to recognise my emotions toward myself. It made me think about my values and the important things in my life but in a fun and entertaining way [Int: P11, 11].

4.3.4. Remote psychotherapy

This theme presents the advantages and new possibilities of VR technology as an anonymous platform to facilitate remote psychotherapy. Three subthemes emerged: 1) Trust and Security, 2) Therapist Representation, and 3) Approving self through blindness.

" I feel that the VR remote psychotherapy allows the participant to express her emotions more freely. Not being able to be seen makes her comfortable to disclose emotions and ideas about her body shape that trouble her. I feel that this kind of psychotherapy will be more suitable than face-to-face psychotherapy for the introverted individual" [Int: T7, 11].

The findings pointed to "two levels of safety" perceived by the participants. On one level, VR provided an insulated world shielding the participants from the "messy outside world they are struggling to cope with." The "second level of safety" refers to the protection of the private and personal emotional space of the participant. For instance, participants liked the fact that the therapist could not physically see their true self:

" I felt that the virtual environment was a safe and protected space where only the two of us exist" [Int: P1, 1]. "I liked that the therapist was not able to see me and therefore she was not judging me because of how I look. I was my avatar and that was a safety net for me" [Int: P13, 13].

" Well, I was positively impressed by the participants' reactions. Some of them were initiating the talk as if I was not their therapist or even a human being. One of the participants actually said to me: Oh, you are so cute!" [Int: T6, 13].

" It was easier to express my feelings because the therapist was just a cute cube, she had no human face and therefore she could not judge me. It was like talking to myself. I could be myself without feeling threatened, without being worried about what she is thinking about me. I feel that this was the most important part of this psychotherapy. I was free to be myself. I was free to be my ideas. I was free to be me. If the therapist was standing next to me, I wouldn't be able to express my emotions, my worries, my concerns. I would have been more reserved" [Int: P13, 13].

" I felt that being located in another room and especially not being able to see how her body looked like was a big relief for her, and not just for her, but for many participants. I felt that in general the participants were communicating their fears and thoughts freely without restrictions, and without being worried of what I might think of them" [Int: T1, 6].

" I know how I look, and even though everyone else is telling me differently, this is what I see that I trust. I liked being in VR, where the therapist was listening to me, without being able to see me, and therefore without being able to judge and project her beliefs about how I look on me. Someone eventually was listening to me, was paying attention to my emotions, to the way I see myself" [Int: P5, 5].

5. Discussion and conclusion

The key aim of this study was to develop and investigate the potential for using MUVR for remote psychotherapy. This paper examined the acceptability of MUVR among therapists and participants (individuals found to be at high-risk for developing an Eating Disorder). MUVR is an innovative medium for psychotherapeutic interventions that allows for the physical separation of therapist and patient, providing thus more 'comfortable' openness by the patients. We found that the participants reacted positively to the virtual therapy, liked the environment, the therapist, and the tasks included in the MUVR.

Addressing the first research question about design opportunities and challenges of MUVR, our study showed that the virtual representation of the therapist was important. It was interesting that the co-design process indicated that the preferred representation for the therapist avatar was a cartoonish cube. This cartoonish cube seemed to support openness and turned out to be a successful approach. Participants claimed that a human figure connotates judgmental behavior, whereas a cartoonish representation is less stress-provoking and further enhances the feeling of trust and a positive relationship with the therapist. Therefore, designers of VR remote psychotherapy should not only focus on the virtual presentation of the VE and the avatar design for participants but should also consider the design of the therapist avatar. Animated cartoon-like elements, as opposed to photorealistic representations, should be considered by designers. Notably, similar observations have been made in previous research showing that the use of animated cartoons reduced stress and anxiety when expose in virtual environments (Cohen et al., 1997; Lee et al., 2012; Matsangidou et al., 2019), this finding was even validated by Electrocardiography Conformation (Matsangidou, Mauger et al., 2020). Yet, in certain situations cartoonish non-human figures may not be preferred, as reported by a digital smoking cessation study for sexual and gender minority young adults (Watson et al., 2019). Therefore, further research on the optimal design of therapist avatars within digital environments is needed; this research could examine for example, what types of designs work better for which problems or types of populations.

Despite the observed benefits of immersive VR, we must be cautious of the potential negative side effects of presence brought by it. For example, in the current study we observed phobic reactions in some participants which is in line with previous findings suggesting that phobias, anxiety and level of presence, are correlated. Indeed, it seems that enhanced presence may increase anxiety in highly anxious individuals (Robillard et al., 2003), since presence considers to be a psychological state in which the person is not able to vitalize the experience (Lee, 2004). It is, therefore, possible that the increased level of anxiety and phobic reactions of some of our participants during the MUVR session was caused by high levels of presence. Indeed, both therapists and participants reported experiencing high levels of presence in this study. Even though the participants knew that this was a VR simulation and not a real-life scenario, they tended to behave as if it was completely real (Slater), which led to the triggering of phobic or embarrassing reactions such as being unconformable about removing the avatar's clothes during exposure. Interestingly, despite strong feelings of stress or fear, none of the participants chose to end the session prematurely and instead proceeded to complete the whole MUVR trial. This can in part be attributed to the degree of social presence experienced. Social presence via a communication medium has been defined as the degree of being present and able to determine the way people interact and communicate (Lowenthal, in press). Overall, presence in VR may act as a double-edged sword, an issue which needs to be considered carefully in VR design for psychotherapy. For purposes of exposure to one's worries about body shape and size however, the ability to exhibit anxious reactions and experience high levels of presence, may elicit new learning that helps shape new experiences (Craske et al., 2014).

5.1. Design implications

The work presented in this study provides a foundation for future research related to MUVR psychotherapy, going beyond past work which has focused on single-user VR or co-located VR therapy experience. Crucially, we identified some key design issues, pointing to the benefits and potential pitfalls of using MUVR in real-world therapy sessions. We believe that these issues and their implications can potentially be translated to and examined with other mental health conditions, such as anxiety problems, provided that the characteristics, preferences, and skills of participants are taken into account. Having said that, it is important to note that the content of the therapy should be designed to account for specific therapeutic requirements relating to the different problems. Apart from ensuring high level of usability design of the system, designers of MUVR need to: (a) consider conflicting design requirements on VR presence/immersion (e.g., high level of immersion to enhance the therapeutic relationship vs. high anxiety-inducing immersive world); (b) balance private and social space design in VR to ensure that participants can feel safe with emotional disclosure and at the same time feel secure knowing the therapist is "there" with them when needed; (c) design activities that can strengthen the bond between therapists and participants including games and fun activities; and (d) accommodate for different participant preferences and therapeutic needs, allowing the therapists to customize the therapy pathway as they see fit.

6. Limitations

Our study had methodological strengths and limitations. Strengths included the involvement of end-users, both therapists and participants deemed at high-risk for developing an Eating Disorder, in the development of the MUVR system. The qualitative approach was also a strength: interview data from both therapists and participants were very valuable in gaining an in-depth understanding of this relatively novel intervention throughout the development process. This person-based approach is recommended when developing digital health-related applications and interventions (Karekla et al., 2019; Yardley et al., 2015).

Limitations include the running of a single-site trial. Though the qualitative interview data provided valuable information, conclusions may not be generalizable to other samples or populations. Prior experience with VR was not assessed in either therapists or participants, which can constitute an extraneous variable affecting outcomes. Also, participants were asked to express whether they prefer face-to-face or the MUVR intervention, however prior experiences with therapy were not assessed, thus participants may not have had direct experiences to be able to choose face-to-face over MUVR. Finally, this study did not evaluate the effectiveness of the intervention, which leads to the need of future research to formally examine this.

7. Future directions

The purpose of the present study was to present the design process and examine the appeal of using VR for remote psychotherapy on therapists and participants at high-risk for developing an Eating Disorder. Future research should proceed to examine the effectiveness and efficacy of this approach both for individuals at high-risk for developing eating disorders and for other populations, mental health problems (e.g., anxiety) and individuals with an actual eating disorder diagnosis. The potential of remote psychotherapy within a VR environment and having a non-co-located therapist, provides unique opportunities not only for individuals who suffer from eating related difficulties, but for other problems where embarrassment or stigma may be involved (e.g., social anxiety, sexual disfunctions etc). The application of MUVR for such additional conditions should be explored in the future.

As part of the development process of this project, various psychotherapeutic VE were created whose comparative effectiveness needs to be formally examined in future trials. We found that participants reacted positively to the virtual therapy, reporting a reduction in the occurrence of troubling thoughts. However, we did not design this study to specifically examine the effectiveness or efficacy of the therapeutic approach, thus formal trials should be planned for the future. Future studies should also take into consideration extraneous variables, such as prior experiences with therapy or with VR, before drawing firm conclusions about the utility of MUVR psychotherapy.

8. Conclusion

This paper presented with several novelties and innovations for VR approach to treatment. The key motivation for this study was to investigate the potential for using VR to support multi-user remote psychotherapy. Our results showed that MUVR can be a viable medium for the treatment of individuals at high-risk for developing an Eating Disorder. In addition, this study demonstrated the acceptability and feasibility of using VR for remote psychotherapy by therapists and participants. Indeed, both therapists and participants found this type of remote psychotherapy useful, as it allowed the participant to comfortably disclose emotions and ideas about her body shape and weight, and accept the intervention including the difficult parts of engaging in exposure to feared stimuli (e.g., via the mirror exposure exercise). The use of a cartoon like avatar for the therapist seems to further support openness, yet this needs to be further explored in future research. Embodying traditionally face-to-face intervention techniques in a playful and gamified virtual world, also constitutes an innovation in this study. Particularly the embodiment of the mirror exposure exercise, where the participant was able to create and adjust the avatar to resemble themselves provides new opportunities for the treatment of eating and other similar disorders. Notably, when participants were asked to engage in the mirror exposure exercise, they reported high levels of presence and felt as if they were really being exposed to their own bodies. Overall, high levels of presence and immersion were achieved throughout the MUVR session, making it a feasible medium for advancing the delivery of psychotherapy.

Stage

Objectives (Ox.x)

Major Tasks (Tx.x)

Outcomes (Rx.x)

1

O1.1 Create a shared vision of how VR can support Eating Disorders Prevention and Psychotherapy.

T1.1 Conducted a literature review on current prevention and psychotherapeutic practices and technologies for the treatment of Eating Disorders.
T1.2 Demonstration of the technological possibilities of VR by HCI Professionals.
T1.3 Psychology Professionals developed scenarios/interventions of use.

R1.1 VR is a promising solution for psychotherapy but MUVR has not been previously tested.
R1.2 Individuals at high-risk for eating disorders constitute a group for whom MUVR could be a good therapeutic medium and can constitute the group on which to explore the designing of an MUVR therapeutic environment.

2

O2.1 Articulate how the MUVR remote psychotherapy will be adapted to address psychotherapeutic needs of the chosen group.
O2.2. Articulate the User Interface (UI) elements for the MUVR.

T2.1 Refined the scenarios/interventions.
T2.2 Developed system requirements.
T2.3 Constructed paper and technology prototypes of MUVR remote psychotherapy.

R2.1 Decision on the therapeutic approach and treatment scenarios to be included.
R2.2 Identification of the UI elements for the therapist (e.g., navigation process) and the participant (e.g., avatar body shape scales).

3

O3.1 Specify how the therapist and partcipant will interact with the virtual objects and tasks in the MUVR.
O3.2 Specify the design factors for the participants' avatar appearance.

T3.1 Internal test of prototypes with a clinical psychologist and a developer.
T3.2 Developed and Tested the VE navigation mechanisms: (1) Point and Click Teleportation, (2) Navigation by Hand movement.
T3.3 Evaluated remote connectivity.
T3.4 Revised the 1 st Version of the MUVR.
T3.5 Developed and Tested avatar representation (conducted a focus group with representative participants): Photorealistic vs. Cartoonish.

R3.1 Navigation by Hand movement removed due to motion sickness.
R3.2 Cartoonish avatar was preferred and selected due to development restrictions (e.g., customization of the avatar's body).

4

O4.1 Specify the design factors for the virtual representation of the objects.
O4.2 Execute the Systems Usability for the therapeutic scenarios.

T4.1 Internal test of prototypes with a clinical psychologist, a school psychologist, 2 HCI experts, and a developer.
T4.2 Revised the 2 ndVersion of the MUVR.
T4.3 Developed and Tested virtual objects representation.
T4.4 Developed and Tested intervention use scenarios.

R4.1 Cartoonish presentation of the virtual world was selected to match the participants' avatar representation.
R4.2 Creations of supporting documents and designs for the intervention use scenarios.

5

O5.1 Create the participant's avatar customization technique.

T5.1 Internal test of prototypes with clinical psychologists (n = 3) and a developer (n = 1).
T5.2 Revised the 3 rd Version of the MUVR.
T5.3 Developed and Tested the UI elements for the participants' avatar customazation.
T5.4 Developed and Tested intervention VE (e.g., mirror exposure virtual room).

R5.1 Agreed on the functionality of the UI elements for the participant's avatar body representation.
R5.2 Agreed to exaggerate on the participant's avatar body representation to represent extreme ends of body type.
R5.3 Cultural adaptions (e.g., skin and hair colors, hair styles).

6

O6.1 Specify the interaction mechanisms.

T6.1 Internal test of prototypes with a clinical psychologist, a cognitive psychologist, a school psychologist, 2 HCI experts, & a developer.
T6.2 Revised the 4 th Version of the MUVR.
T6.3 Developed and Tested the body representation and cultural adaptions of the participants avatar.
T6.4 Developed virtual interaction mechanisms: (1) Button Hold, (2) Automatic Hold.
T6.5 Refined the presentation of the intervention use scenarios by incorporating gamified features to improve participants' engagement.

R6.1 Creation of supporting documents and designs for the intervention use scenarios incorporating gamified features.

7

O7.1 Test and Execute the final application with end-users.

T7.1 End-User test of prototypes with a clinical psychologist, a school psychologist and 2 representative participants.

R7.1 Positive feedback received from both therapists and participants.
R7.2 Virtual interaction mechanisms "Button Hold" was preferred by the participants as it imitated natural activity (e.g., close of fist to grab an object).
R7.3 Minor issue noted: Difficulty to identify controller's buttons.
R7.4 All other minor comments noted.

8

O8.1 Finilize the MUVR application.

T8.1 Revised the 5 th Version of the MUVR.
T8.2 Virtual representation of the controllers' buttons were colored for visual identification of activity (e.g., red to grab, blue to move, etc.).
T8.3 Developed a tutorial to inform the participant of how to use the MUVR.

R8.1 All aspects ready and work well.
R8.2 The system deemed ready for testing with end-users.

9

O9.1 Testing and Execution.

T9.1 End-User test of prototypes with a clinical psychologist, a school psychologist and 2 representative participants.

R9.1 Two pilot sessions were carried out to "iron out" further issues with the system design and use scenarios. Only minor issues noted and fixed.

Acknowledgement

We acknowledge and thank the University of Kent for the funding and support to this project. This project has received funding from the European Union's Horizon 2020 Research and Innovation Programme under Grant Agreement No 739578 and the Government of the Republic of Cyprus through the Directorate General for European Programmes, Coordination and Development.

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"Now i can see me" designing a multi-user virtual reality remote psychotherapy for body weight and shape concerns

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ABSTRACT ABSTRACT Recent years have seen a growing research interest towards designing computer-assisted health interventions aiming to improve mental health services. Digital technologies are becoming common methods for diagnosis, therapy, and training. With the advent of lower-cost VR head-mounted-displays (HMDs) and high internet data transfer capacity, there is a new opportunity for applying immersive VR tools to augment existing interventions.

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Evidence-Based Perspective on the Effect of Automobile-Related Modifications on the Driving Ability, Performance, and Safety of Older Adults

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Evidence-Based Perspective on the Effect of Automobile-Related Modifications on the Driving Ability, Performance, and Safety of Older Adults | American Journal of Occupational Therapy

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Virtual reality assisted psychotherapy for anxiety in older adults

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ABSTRACT
Objective: This review integrates literature to discuss the potential use of virtual reality (VR) in treatment of anxiety in Parkinson's disease (PD) and inform next steps.

Methods: A systematic search was performed to identify studies of VR use in PD, using four databases. Data were reported in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analyzes extension for Scoping Reviews (PRISMA-ScR).

Results: Thirty-two studies met the inclusion criteria with four VR studies from the same study group directly assessing the effects of anxiety on motor symptoms in PD. P rimary studies implementing a VR protocol in PD identified focus areas of understanding and alleviating freezing of gait (FOG), balance training, and cognitive and motor rehabilitation, and informed design considerations.

Conclusion: VR in PD studies suggested established feasibility. With appropriate design considerations, a VR based protocol could improve anxiety outcomes in PD.

Clinical implications: VR in PD provides control of a patient's field of view, which can be exploited to induce specific responses, provide visual feedback, analysis of patient actions, and introduce safe challenges in the context of training. VR assisted Cognitive Behavioral Therapy (CBT) tailored to suit subtypes of anxiety disorders in PD have the potential to improve the efficacy and effectiveness of psychotherapy in PD.

Acknowledgments

We acknowledge the Lions Medical Research Foundation, and National Health, and Medical Research Council for supporting Dr Nadeeka Dissanayaka's salary. Royal Brisbane & Woman's Hospital Foundation and Brain & Behaviour Foundation competitive grant schemes for funding VR studies in PD.

Disclosure statement

No potential conflict of interest was reported by the authors.

Clinical implications

Promising outcomes of VR assisted anxiety treatment, and VR use in PD for cognitive and motor rehabilitation, provide a strong grounding for novel VR assisted anxiety treatment in PD.

Design considerations include addressing PD-specific anxiety symptoms, limiting complexity, safety considerations, and engaging patients with real-time feedback.

VR assisted psychotherapy has the potential to advance clinical practise in PD with long-term benefits, and inform a novel psychotherapeutic guidelines for older adults.

Supplemental Material

Supplemental data for this article can be accessed here.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by the Brain and Behavior Research Foundation; National Health and Medical Research Council; Lions Medical Research Foundation; Royal Brisbane and Women's Hospital Foundation.

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Designing Virtual Reality Assisted Psychotherapy for Anxiety in Older Adults Living with Parkinson's Disease: Integrating Literature for Scoping

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ABSTRACT Objective: This review integrates literature to discuss the potential use of virtual reality (VR) in treatment of anxiety in Parkinson's disease (PD) and inform next steps. Methods: A systematic search was performed to identify studies of VR use in PD, using four databases.

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Assistive technology designed to support self-management of people with dementia: user involvement, dissemination, and adoption. A scoping review

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International Psychogeriatrics

Cited by 3

This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

Heintz, Hannah L. and Vahia, Ipsit V. 2020. Implementing adaptive technologies in dementia care: local solutions for a global problem. International Psychogeriatrics, Vol. 32, Issue. 8, p. 897.

Kruse, Clemens Scott Fohn, Joanna Umunnakwe, Gilson Patel, Krupa and Patel, Saloni 2020. Evaluating the Facilitators, Barriers, and Medical Outcomes Commensurate with the Use of Assistive Technology to Support People with Dementia: A Systematic Review Literature. Healthcare, Vol. 8, Issue. 3, p. 278.

Vollmer Dahlke, Deborah and Ory, Marcia G. 2020. Emerging Issues of Intelligent Assistive Technology Use Among People With Dementia and Their Caregivers: A U.S. Perspective. Frontiers in Public Health, Vol. 8, Issue. ,

Background:

Assistive technology is advocated as a key solution to the need for support among people living with dementia. There is growing awareness of the benefits of user involvement in the design and test of these technologies and the need to identifying applicable and effective methods for implementation. The aim of this review was to explore and synthesize research addressing assistive technology designed to be used by people with dementia for self-management. Further research aims were to explore if and how user involvement, dissemination, and adoption of assistive technology were addressed.

Method:

Electronic databases were searched using specified search terms. Key publications and grey literature sources were hand-searched. Materials published until year end 2018 were included. The results were summarized according to the research aims.

Results:

Eleven papers derived from eight studies were included. The studies presented data from prototype design and testing, and the review showed great variation in study scope, design, and methodology. User involvement varied from extensive involvement to no user involvement. Methods for adoption also varied widely and only targeted prototype testing. None of the studies addressed dissemination.

Conclusion:

The results of this review underline the need for well-designed high-quality research into all the aspects that are essential to deliver applicable, effective, and sustainable assistive technology to support self-management of people with dementia. There is a need for evidence-based methods to promote and qualify user involvement, dissemination, and adoption. The results also point to the need for standardized outcome measures and standards for conducting and reporting research to improve its quality and impact.

Cited by 3

This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

Heintz, Hannah L. and Vahia, Ipsit V. 2020. Implementing adaptive technologies in dementia care: local solutions for a global problem. International Psychogeriatrics, Vol. 32, Issue. 8, p. 897.

Kruse, Clemens Scott Fohn, Joanna Umunnakwe, Gilson Patel, Krupa and Patel, Saloni 2020. Evaluating the Facilitators, Barriers, and Medical Outcomes Commensurate with the Use of Assistive Technology to Support People with Dementia: A Systematic Review Literature. Healthcare, Vol. 8, Issue. 3, p. 278.

Vollmer Dahlke, Deborah and Ory, Marcia G. 2020. Emerging Issues of Intelligent Assistive Technology Use Among People With Dementia and Their Caregivers: A U.S. Perspective. Frontiers in Public Health, Vol. 8, Issue. ,

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Assistive technology designed to support self-management of people with dementia: user involvement, dissemination, and adoption. A scoping review | International Psychogeriatrics | Cambridge Core

# data[].attributes.attachment_link.description
International Psychogeriatrics Cited by 3 This article has been cited by the following publications. This list is generated based on data provided by CrossRef. Heintz, Hannah L. and Vahia, Ipsit V. 2020. Implementing adaptive technologies in dementia care: local solutions for a global problem. International Psychogeriatrics, Vol. 32, Issue. 8, p.

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Information Management for the Assistive Technology Provision in Community: Perspectives of Local Policymakers and Health Service Providers

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Background. Assistive technology (AT) is a way to enhance the performance of daily activities in people with disabilities and help them live more independently. However, an important problem in providing AT lies in the effectiveness of information management. Local policymakers and health service providers have become aware of this problem and their perspectives are the key to solving it. Methods. This study explored the types of AT provided for people with disabilities in the community and the perspectives on information management of local policymakers and health service providers. A survey checklist and semistructured in-depth interview were the instruments of this study. The key informants in this study included administrators, nurses, and physical therapists from four community areas in Chiang Mai, Thailand. Results. The medical records showed that the types of AT provided were mostly second-hand (57.24%) and borrowed devices (57.73%). All of them were low-tech devices (crutch, cane, walker, wheelchair, and adaptive tricycle). In addition, the results indicated three perspective aspects related to information management: (1) problems in the database recording system, (2) different policies and processes of information management, and (3) improvement of the AT provision system. Conclusion. The perspectives of local policymakers and health service providers indicated related problems, impacts of policies, and ways to improve the AT provision system by applying information technology.

1. Introduction

Information management is essential for a successful community and district health system, where the information from local, national, and other available resources is linked. District health systems for primary health care are concerned with health systems management and other sectors such as health care service providers, district health managers, and agencies [ 1]. Willem and Buelens [ 2] suggested that information from other units can provide interunit knowledge sharing to enhance a positive organizational outcome. Management of information from one or more sources in community health at the district health level is useful for both community and national policy. Information in the community helps the health service providers and public health officials direct the community in meeting its needs. Village health volunteers (VHVs) in Thailand are key persons in gathering data on community resources for national policy, and community-based resource management requires information from many different related groups such as community hospitals, local governments, and village health volunteers. The information from each group is used for support in qualifying disability rights and making decisions in providing direct and indirect services and disability benefits. Jokandan et al. [ 3] showed that Information and Communication Technology (ICT) had heavy impact on the formality of municipal and urban management as well as all employees. ICT functions are able to manage the complex information of community health services and provide assistive technology (AT) in community contexts. Thus, this study aimed to explore the information process among the people at the community level.

Assistive technology (AT) includes adaptive and assistive devices that enable improved performance in living independently for people with disabilities. AT not only impacts these people directly, but also could provide caregivers with immediate relief, reduced stress, and help in providing care more easily and safely [ 4]. Mann et al. [ 5] found that AT and home modifications can reduce home care costs.

Many countries have laws and legislations regarding AT: for example, Bausch and Hasselbring [ 6] reported that types of AT and related services were regulated many years ago in the Individuals with Disabilities Act Amendments PL 105-17 (USA). However, many studies reported that people with disabilities could not use the technologies because of the time it takes to learn, train in, and practice their use, and some clients refused to use them. Besides the problem of use, the provision of AT is an important issue for people with disabilities in the community. Indeed, some communities receive a great deal of AT from the government and through donations, while many communities lack some types of the technology. Different situations create various problems; for example, some communities have maintenance and storage problems, while others lack AT. A main cause of this situation is the need for an information management system or an incomplete one. Based on the concept of "access for all," AT could make an important contribution to the care of dependent people, such as those with disabilities, children with special needs, and elderly people in institutions and at home. This could be carried out by video-monitoring, remote health monitoring, electronic sensors, assistive devices, and adaptive equipment [ 7]. Cooper et al. [ 8] pointed out that not only modern or high technologies, but also problem trends in developing AT are related to ineffective delivery systems, changes to public policy, and coordination among people with disabilities, policymakers, manufacturers, researchers, and service providers. These concerns highlight the current ineffectiveness of AT. Ocepek et al. [ 9] reported that using AT improved quality of life in the majority of the participants. AT was recommended to the user mostly by a general practitioner or consultant physician, nurse, specialist, or relatives, as there are no AT specialists in community hospitals or community healthcare centers. As medical teams or a public health team carry out work in the municipality, the information management system providing AT is recorded in medical or informal records that are difficult to locate. For these reasons, this study explored the types of AT and perspectives of local policymakers and health service providers on information management in providing AT for people with disabilities in the community.

2. Materials and Methods

This study used quantitative and qualitative research methods in four community areas in Chiang Mai, Thailand. A survey checklist explored the types of AT provided for people with disability in the community, and a semistructured in-depth interview was used to study the perspectives of local policymakers and health service providers.

A survey method was planned and processed for the objective of exploring types of AT provided for people with disabilities in the community. Information was collected during 2015 and 2016 from secondary sources of data in the medical and informal records of community hospitals and subdistrict municipalities in four community areas of Chiang Mai province, Thailand. In addition, a semistructured in-depth interview was administered for the objective of studying the perspectives of local policymakers and health service providers on information management in providing AT for people with disabilities in the community. This objective applied to the information management system in community health at the district health level [ 10] in order to create the scope of the interview, as shown in Figure 1.

Probing questions comprised four points as follows:(1) Related local policy of AT provision for people with disabilities in the community (2) Problems and problem solving regarding related local policy of AT provision for people with disabilities in the community (3) Process of information management regarding AT provision for people with disabilities in the community (4) Problems and problem solving regarding the process of information management regarding AT provision for people with disabilities in the community

There were 16 key informants in this study comprising 10 administrators of subdistrict municipalities and 6 health service providers, including nurses, physical therapists, and community-developers of local community hospitals in four community areas in Chiang Mai, Thailand. They were interviewed and recorded individually. Data from interviewing were analyzed by content analysis.

3. Results and Discussion

The results showed that all four community areas did not have a database management system of AT provision, which was recorded in the hospitals' general medical records for 2015 and 2016. It was found that 289 people with disability were provided with AT in the four community areas. The results showed that 55.71% and 44.29% were female and male, respectively. Besides gender, there was no other personal information in the database of these people. In addition, the types of AT provided were mostly second-hand (57.24%) and borrowed devices (57.59%). One person was provided with two AT devices, a walker and cane; therefore, the number of AT devices was greater than that of people with disabilities. All of the devices were low-tech such as a crutch, cane, walker, wheelchair, and an adaptive tricycle, as shown in Table 1.

In addition, the results indicated three perspective aspects related to the information management system that emerged from the local policymakers and health service providers. The first aspect was a problem in database records, including lack of a type of AT system, lack of personal and disability information of clients receiving AT, and an incomplete system of lending and returning AT. The second aspect was the policy and process of different organizations. There are three main related organizations providing AT; the local community hospital, district hospital, and subdistrict municipality. Policies of the local community and district hospital come under the Provincial Health Office. On the other hand, those of the subdistrict municipality come from the mayor. Therefore, there are different policies and processes of information management regarding AT provision. The local community hospital has a system of finding people in the community who need AT, assessing which AT meets their needs, coordinating with district hospitals for receiving AT, and providing AT directly to the people, as well as participating in home visit teams with the district hospital and subdistrict municipality. District hospitals that participate in home visit teams with the subdistrict municipality directly provide evaluation, training, and repair of AT (both new and used) and issue certificates of disabilities. Subdistrict municipalities register people with disabilities in the community in order to provide living allowance, home visits, and coordination with the provincial hospital or disability center that receives AT. The last aspect was improvement of the AT provision system. The local policymakers and health service providers pointed out the importance of a lending system, which is a way to manage and exchange second-hand AT between communities. Furthermore, they indicated that when the lending system is linked between communities, the information management system and resource sharing occur, as well as an increase in the efficiency of services for the people in the community. In addition, they also thought of setting up the AT center in the community, as a hub of sharing information, demonstrating, evaluating, training and repairing AT, and modifying the home for independent living. Moreover, the AT specialists provide services that help to decrease waiting times and transportation or traveling costs (as it is extremely difficult for some clients to get to and from the hospital). Content analysis of these perspectives is shown in Figure 2.

The findings indicated that the types of AT provided in the community were low-tech and used for the purpose of mobility. These findings were related to Putthinoi et al. [ 11] in that AT homes of the elderly were assistive products and technology for personal use in daily living, indoor-outdoor mobility, and transportation. This was because the legal rights of people with disabilities in Thailand are still limited by government budgets. Low-tech AT devices are inexpensive, simple to make, and easily obtainable for all [ 12]. This result relates to Lersilp [ 13], who indicated that although there was a related regulation and an assistive technology provision system in each university, many types of assistive technologies were not used, and some were not even received.

Furthermore, these findings were fundamental to the design of an effective information management system by applying information technology in providing AT for people with disabilities in the community. According to the above results, it was found that the database records on providing AT in community hospitals and subdistrict municipalities were recorded in informal notebooks and did not contain any personal information, except for name and gender. This was because the community hospitals and subdistrict municipalities were not responsible for providing AT directly. Community hospitals have the role of a hybrid health service, including health promotion, disease prevention and control, medical treatment, rehabilitation, and health risk factor management [ 14]. AT provision is a part of rehabilitation; therefore, no AT specialist or specific AT officer is responsible for the database recording system in community hospitals.

The results above show that communities incur problems of the database recording system and related policy. According to Lersilp et al. [ 15], this information shows that a major problem in the provision and use of AT was the criteria of educational policy. When developed countries are considered in similar contexts, Japan is a good model of AT provision, as the rental system is an interesting AT provision system in that country. After hospital discharge, people or local residents usually start using AT rental services under Long-Term Care Insurance, which came into force in 2000. Approximately 67% of these people receive advice from a care manager and about 68% select AT rental agencies near their home through the "care manager advisory," usually without comparing prices. People pay only 10% of the rental charge under Long-Term Care Insurance. Although prices are not the same between agencies, they are often within the standard price area [ 16].

The charge in this system can be determined freely for some products by each AT rental agency. Wholesale AT rental agencies are responsible for profit and general, distribution, and maintenance costs; consecutively, while "in-house" or retail rental agencies are responsible for maintenance cost, profit, and general and distribution costs, consecutively. Sometimes people buy their own AT according to specific needs, while considering the rental charge per month, purchase price, frequency of everyday use, and so on. Unfortunately, there are no good websites such as "comparison shopping websites" providing comprehensive information that shows comparisons of specific AT rental charges or purchases prices [ 17, 18].

Care managers, who are under Long-Term Care Insurance, play an important role in managing each person's future plan of care/rehabilitation service and AT rental according to the severity of disability. However, it is possible that they only have information on AT depending on their own specialty (e.g., nurse and dentist). Important information includes not only the rental details, but also AT safety, especially physical safety after long-term use. Some cases indicated the need for AT that had been discontinued. The AT business model should be considered in terms of the AT distribution system. Manufacturers of AT mainly contact rental agencies without having information of individual users, thus making it difficult for the former to understand user needs [ 16- 18]. An AT supply system set up by the medical and welfare combination team will be needed to solve these problems.

Regarding Japanese Occupational therapists, there are 47 branches of the Japan Association of Occupational Therapists in all prefectures of Japan. Thirty-four of them have had the "AT advice system" since July 2014 to support occupational therapists who have problems with AT matching/adaptation for their patients. Several occupational therapists, who have specialized in AT, are registered as mentors in each branch, and inexperienced occupational therapists can communicate with them whenever necessary. It is important to set up both a hard and soft AT supply system in the aging community [ 17, 18].

4. Conclusion

This study explored the types of AT provided for people with disabilities in the community and the perspectives on information management of local policymakers and health service providers. Results showed that 289 people with disabilities were provided with AT in the study areas. The types of AT provided were mostly second-hand and borrowed devices. All of them were low-tech such as a crutch, cane, walker, wheelchair, and an adaptive tricycle. However, it was found that the hospitals' general medical records of information on AT provision were incomplete in the AT database and contained no personal information of people receiving AT. The local policymakers and health service providers reflected three perspective aspects related to the information management system such as problems of the database recording system, different policies and processes of the information management system, and improvement of the AT provision system. These findings were fundamental to the development of an effective information management system providing AT for people with disabilities in the community by applying information technology.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

Acknowledgments

This research was supported by a grant from the International College of Digital Innovation, Chiang Mai University, under the ASEAN+3 Cross Border Research Project.

References

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Information Management for the Assistive Technology Provision in Community: Perspectives of Local Policymakers and Health Service Providers

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Background . Assistive technology (AT) is a way to enhance the performance of daily activities in people with disabilities and help them live more independently. However, an important problem in providing AT lies in the effectiveness of information management. Local policymakers and health service providers have become aware of this problem and their perspectives are the key to solving it.

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Research articles and books related to low tech AT for various populations and practice areas

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Low-tech Assistive Technology to Support Students with Disability in Low-income Countries

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Low-tech Assistive Technology to Support Students with Disability in Low-income Countries

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Low-tech Assistive Technology to Support Students with Disability in Low-income Countries - Author: Vaibhav Jadhav, Dianne Chambers, Dipak Tatpuje

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Massachusetts Department of Elementary and Secondary Education

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Assistive Technology and Accessibility - Special Education

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The goal of the Massachusetts public K-12 education system is to prepare all students for success after high school. Massachusetts public school students are leading the nation in reading and math and are at the top internationally in reading, science, and math according to the national NAEP and int…

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Sexuality After SCI

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Below are websites, additional videos, e-books and more to help you understand more about your body and the impact of SCI.

Model Systems Knowledge Translation Center: The MSKTC is a national center that helps facilitate the knowledge translation process to make research meaningful to those with spinal cord injury (SCI), traumatic brain injury (TBI) and burn injury (Burn). The MSKTC works closely with researchers in the 14 Spinal Cord Injury (SCI) Model Systems to develop resources for people living with spinal cord injuries and their supporters. See http://www.msktc.org/sci for general information or for sexuality and sexual function after spinal cord injury, see http://www.msktc.org/sci/factsheets/sexuality .

Spinal Cord injury BC -website of the Sexual Health Rehabilitation Service. This site has invaluable information for both consumers and medical professionals that covers every aspect of sexuality and spinal cord injury. They really have set the gold standard bar in terms of sexual health in both the SCI population and the disabled population in general. See http://sexualhealth.sci-bc.ca.

SCI-U is a series of 10 multimedia courses about learning to live with spinal cord injury. The courses have been designed to give you the information you need to live a healthy, active life. They were developed by people who live with SCI, in collaboration with researchers and clinicians. See http://www.sci-u.ca/

Facing Disability.com is an excellent website for families facing spinal cord injury that has more than 1,500 videos of family members answering real-life questions about how they cope with a spinal cord injury. For videos and information related to sexuality, see https://facingdisability.com/

MobileWOMEN.org is an online magazine for women in wheelchairs, created by women in wheelchairs, who were having difficulty finding answers to their questions about health, fashion, and other topics. Their mission is to bring together current and accurate information on issues of interest to our community. It is a website where women can ask questions and share experiences. See mobilewomen.org

Dr. Mitch Tepper.com is an internet site on sexuality and pleasure pertaining to men and women with paralysis or disability. Operated by Mitch Tepper, Ph.D., a sexuality counselor who is quadriplegic. See http://www.drmitchelltepper.com

Numerous devices are designed to enhance sexual experiences and are available from a variety of sources, including internet sites, drug stores, mail order catalogues, "sex shops," and adult bookstores.

These websites and suppliers have been found helpful by people with Spinal Cord Injury:

features products that assist with body positioning and leverage

provides a superior shopping experience for women's sex toys, men's sex toys, and sex accessories.

discreet intimacy supplies and products; reliable information and tips

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Additional Resources - Sexuality after SCI

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Model Systems Knowledge Translation Center: The MSKTC is a national center that helps facilitate the knowledge translation process to make research meaningful to those with spinal cord injury (SCI), traumatic brain injury (TBI) and burn injury (Burn).

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Smart Apps vs. Renovated Low-tech Devices with DIY Assistive Technology: A Case of a Banknote Identifier for Visually Impaired People

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In this research, the author analyzes the merits of smart device apps and low-tech solutions as examples of assistive technology with identification of banknotes by the visually impaired. In particular, the focus of this research is on the potential of low-tech devices that are often neglected in exploring emerging technology. Applying these devices to DIY assistive technology using ICT sometimes opens up new possibilities. In the latter part of this paper, the author attempts to illustrate such possibilities by developing a Web-based system that enables users to freely create 3D data of banknote identification plates according to individual needs.

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Smart Apps vs. Renovated Low-tech Devices with DIY Assistive Technology | Proceedings of the 5th EAI International Conference on Smart Objects and Technologies for Social Good

# data[].attributes.attachment_link.description
In this research, the author analyzes the merits of smart device apps and low-tech solutions as examples of assistive technology with identification of banknotes by the visually impaired. In particular, the focus of this research is on the potential of low-tech devices that are often neglected in exploring emerging technology.

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Getting started with AAC: Access to low tech symbol based resources when pointing is difficult

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The aim of this resource is explore access to low tech symbol based AAC when accessing standard resources is difficult physically or visually. It is aimed at people who are familiar with low tech AAC, but want to find out more about how to adjust and adapt the resources to meet individual needs.

For a more general all round introduction to low tech symbol based AAC, you could see another resource in this AAC Information Series, Getting Started with AAC: Using low tech symbol based systems with children.

While this resource is all about access to symbol based resources, it is important to also provide individuals with an alphabet chart, to enable them to explore and develop their use of letters. You can find lots more information about how to design and adapt alphabet charts in the resource, Getting Started with AAC: Designing and using alphabet charts.

Please note that this resource is not suggesting that low tech is 'best', or that low tech is a prerequisite to a more high tech communication aid. It is simply about valuing the role of paper based communication systems, and sharing lots of ideas and strategies to help develop and support them. You may well find that many of the ideas and strategies are useful when it comes to other forms of communication too.

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Getting started with AAC: Access to low-tech symbol based resources when pointing is difficult

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The aim of this resource is explore access to low tech symbol based AAC when accessing standard resources is difficult physically or visually.

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A systematic review of the barriers and facilitators to the provision and use of low-tech and unaided AAC systems for people with complex communication needs and their families

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Purpose: Speech-language pathologists may introduce augmentative or alternative communication (AAC) systems to people who are unable to use speech for everyday communication. Despite the benefits of AAC systems, they are significantly underutilized by the people with complex communication needs. The current review aimed to synthesize the barriers and facilitators to the provision and use of low-tech and unaided AAC systems.

Materials and methods: Relevant literature was identified via a systematic search strategy. Included articles ( n  = 43) were evaluated using the Critical Appraisal Skills Programme. Qualitative framework analysis was then completed with reference to the International Classification of Functioning, Disability, and Health (ICF).

Results and conclusion: Most barriers and facilitators were coded as contextual factors within the ICF. Of most prominence were environmental factors, including attitudes of and supports provided by professionals, family members, and the society at large. Themes were also identified which related to the personal factors, including the user's own attitude, socioeconomic status, and culture. Beyond these contextual factors, the remaining codes related to body functions such as cognition and movement. There are numerous barriers to the provision and use of low-tech and unaided AAC systems, which may contribute to the inadequate use of these systems by people with complex communication needs. Suggestions for reducing these barriers are presented with regards to the person with complex communication needs, their family, and the professionals involved in their care.

Implications for Rehabilitation

AAC systems can reduce participation restrictions for people with complex communication needs.

The provision and use of AAC systems is influenced by environmental factors, personal factors, and features of a person's body function.

SLPs may need to collaborate with a large multidisciplinary team to successfully introduce AAC systems.

SLP, teaching, and nursing students require theoretical and practical experience in AAC throughout their training to enable the provision and use of these systems.

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augmentative and alternative communication (aac)

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A systematic review of the barriers and facilitators to the provision and use of low-tech and unaided AAC systems for people with complex communication needs and their families

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(2019). A systematic review of the barriers and facilitators to the provision and use of low-tech and unaided AAC systems for people with complex communication needs and their families. Disability and Rehabilitation: Assistive Technology: Vol. 14, No. 7, pp. 710-731.

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Positioning and adaptive devices to improve intimacy after spinal cord injury

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Positioning and adaptive devices to improve intimacy after spinal cord injury

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Using Low-Tech Assistive Technology to Promote the Successful Inclusion of Children with Disabilities in the Early Childhood Setting

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Client-Centered Advocacy: Every Occupational Therapy Practitioner’s Responsibility to Understand Medical Necessity

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Client-Centered Advocacy: Every Occupational Therapy Practitioner's Responsibility to Understand Medical Necessity | American Journal of Occupational Therapy

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The Impact of Assistive Equipment on Intimacy and Sexual Expression

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Introduction:

Sexuality is a holistic concept that involves more than the sexual act. Despite being a quality of life domain that promotes meaningful existence, it is an aspect of life that is often avoided by health care practitioners.

In this Heideggerian phenomenological study, conversational interviews were conducted with 13 people with motor neurone disease, and 10 of their partners, in order to understand their experiences of sexuality and intimacy.

The findings provide evidence for the value of touch in people's lives and shed light upon the impact that assistive equipment has on intimacy, sexual expression and maintaining emotional and physical connection between couples. None of the people interviewed had previously been given the opportunity to discuss these issues with their occupational therapist.

Conclusion:

There is a place in occupational therapy practice for discussing the value of emotional and physical connection for individuals in the context of any equipment provided.

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The Impact of Assistive Equipment on Intimacy and Sexual Expression - Bridget Taylor, 2011

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Introduction: Sexuality is a holistic concept that involves more than the sexual act. Despite being a quality of life domain that promotes meaningful existence, it is an aspect of life that is often avoided by health care practitioners.

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AOTA's Legislative Action Center

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In the 2021 proposed Medicare Physician Fee Schedule rule released on August 3rd, the Centers for Medicare & Medicaid Services (CMS) recommends significant payment reductions to more than three dozen health care professions, including occupational therapy. CMS is using the revenue from these cuts to offset an increase in payments for primary care physicians. As a part of these payment reductions, occupational therapy practitioners are facing up to a 9% cut to Medicare Part B reimbursement, despite ongoing advocacy with Congress, the Department of Health and Human Services, CMS, and the Office of Management and Budget by AOTA, the American Physical Therapy Association (APTA) and the American Speech-Language-Hearing Association (ASHA), and multiple physician specialty groups throughout 2019 and 2020. If adopted in the final rule, the cuts will be effective January 1, 2021, at a time when providers and patients will still be feeling effects of the COVID-19 pandemic. These cuts are the result of a Medicare statutory requirement known as "budget neutrality" which requires that any increase in costs to the Medicare program must result in decreased spending elsewhere in the Medicare program.

We will continue to advocate against these cuts with CMS, and are asking Congress to intervene to stop these payment reductions, but we need you to take action now.

Check back for more opportunities to communicate with your Members of Congress to stop these cuts! We will continue to post new information on https://cqrcengage.com/aota/Fight_The_Cut

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In the 2021 proposed Medicare Physician Fee Schedule rule released on August 3rd, the Centers for Medicare & Medicaid Services (CMS) recommends significant payment reductions to more than three dozen health care professions, including occupational therapy. CMS is using the revenue from these cuts to offset an increase in payments for primary care physicians.

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Unleash your assistive technology advocacy

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How to: Unleash Your Assistive Technology Advocate

Assistive technology makes a world of difference to people with disabilities. At the same time, getting that life-changing technology often involves frustrating red tape that stretches from your doctor's office to your insurance payor to the offices of state and federal lawmakers.

Laws and policies that prioritize better outcomes for people with disabilities and their families would be a great and much-needed move forward. But it takes a village of stakeholders to get that movement started. So how can you get involved? How can you learn about the issues that impact you and your family, and what's the best way to make your voice heard?

Say Hello to NCART

The National Coalition for Assistive & Rehab Technology (NCART) is an organization of providers and manufacturers of Complex Rehab Technology (CRT), which includes the medically necessary, individually configured wheelchairs, seating/positioning systems, and other adaptive equipment like standing devices and gait trainers used by people with significant and chronic medical conditions. Their Web site is www.ncart.us.

Some common primary diagnoses that often require CRT are spinal cord injury, cerebral palsy, multiple sclerosis, muscular dystrophy, ALS, spina bifida, brain injury and amputations.

NCART's goal is to ensure that the people who need this equipment have access to it and to related services. NCART works with policy makers and lawmakers at state (Medicaid), federal (Medicare), and private insurance payor levels to educate them about how CRT produces better outcomes for people with disabilities and their families.

NCART collaborates with clinicians, consumers and consumer advocacy groups to protect access to the power and manual wheelchairs, standing frames, seating and positioning, and critical components/accessories that provide better outcomes for everyone involved.

How Can I Help?

The voice of the constituent - you! - is the most important voice of all to lawmakers. There are multiple ways you can help to improve and maintain optimal access to CRT:

Learn the issues impacting CRT. Go to www.access2crt.org to get started. Watch a video about CRT, then read about consumer-related issues NCART is fighting for. Finally, sign up to get updates on access issues and Calls To Action.

March on Washington, D.C., when NCART goes annually to Capitol Hill to speak to Representatives, Senators and their staffers. NCART is always looking for CRT users who can personally talk about how assistive technology impacts their lives.

Network locally when your Representative and Senators are home during Congressional recesses. Forging personal relationships with lawmakers helps them to remember you when related bills need their support or their votes. Find out how to contact your Rep and Senators on the homepage of NCART's Web site.

People with disabilities and their families are major influencers to lawmakers and policy makers. NCART's free and easy-to-access support can help you share your experiences and hopes with the people who will help to determine CRT's future. Your voice needs to be heard... loud and clear!

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How to: Unleash Your Assistive Technology Advocate -- The Mobility Project

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Assistive technology makes a world of difference to people with disabilities. At the same time, getting that life-changing technology often involves frustrating red tape that stretches from your doctor's office to your insurance payor to the offices of state and federal lawmakers.

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How to Advocate for Assistive Technology Tools and Services

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Share This: `

What is Assistive Technology?

Assistive Technology (AT) refers to both tools and services that facilitate access to grade-level curriculum for students with disabilities. Access to the curriculum means that students are able to take in and understand the material being taught in school, understand and complete assignments, and demonstrate what they have learned.

An AT tool is a physical device that "is used to increase, maintain, or improve functional capabilities of individuals with disabilities." It can be a device that is available commercially "off the shelf," and it can also be a device or software that has been modified or customized to meet the specific needs of a student. An AT service is "any service that directly assists an individual with a disability in selection, acquisition, or use of an assistive technology device" (https://ectacenter.org).

AT is the bridge that provides an entry point to the content (the information that students need to understand and learn) that cannot otherwise be accessed. AT tools and services are used when a student cannot access the traditional curriculum independently. Until a student with dyslexia has received sufficient intervention to be reading and writing at grade level, he or she will need assistance in accessing grade-level content. This access is essential, as it minimizes gaps in knowledge that will result if grade-level content is too difficult for the student to read and comprehend without the technology.

AT tools can include specialized physical devices and equipment as well as computers and software. Examples include the following:

text-to-speech devices that read text to a student;

speech-to-text devices that allow students to dictate what they want to write and then types it for them; and

spelling, grammar, and vocabulary support options (part of most word processing programs) or web extensions or "plug-ins" that can be added to a web browser that can assist with grammar, word choice, and sentence structure.

AT services should be provided along with AT tools to select and use the tools effectively. Examples of AT services include the following:

evaluation procedures;

selection and customization of devices;

the development of plans to integrate AT tools with other aspects of the student's educational program; and

training for students and professionals who work with the student.

How is AT different from Instructional Technology?

Instructional Technology (IT) is technology that is designed to provide additional practice and exposure to educational content, and it's often available for all students. An example of IT is an app that provides additional practice for a particular skill, such as learning the states and capitals or reviewing multiplication facts. IT can be very useful for students with learning disabilities, but it is often available to students without disabilities as well. AT is uniquely critical for students with disabilities, to provide the same access to the curriculum that other students have.

How are AT services obtained?

The consideration of AT services for a student with an active IEP is required by law. The laws have been rewritten and reworded since 1975 and have had a variety of names. The Individuals with Disabilities Education Act (IDEA), originally created in 1997 and last updated in 2006, explicitly stated "school districts were required to consider the need for assistive technology whenever a child's Individualized Education Plan (IEP) was developed." As of 2011, IDEA applies to children ages birth to three years old, as well as school-aged children ( https://ectacenter.org/topics/atech/laws.asp). For more details on AT and the law, please go to www.gpat.org/Georgia-Project-for-Assistive-Technology/Pages/Legal-Mandates-for-Assistive-Technology.aspx.

The forms associated with an IEP vary from state to state, but the wording that relates to AT will generally be a variation of the following:

OR

Before an IEP meeting, the parent and/or caregiver should find the section referring to AT in the IEP and highlight it. During the IEP meeting, if the team does not offer it, insist that an AT evaluation be conducted to determine if AT services are needed for the student to access grade-level curriculum.

Implementation of AT services

Once the AT evaluation has been completed, the team must reconvene to determine appropriate tools and services and plan for their implementation. It is essential that these steps take place only after the SETT framework has been considered.

SETT stands for Student, Environment, Tasks, Tools (Zabala). The order of this acronym is essential as the following three factors should be considered first: 1) S: the strengths and challenges of the student; 2) E: the environment in which the student needs to complete the work; 3) T: the task the student needs to complete. Only after considering the first three factors should the team decide on 4) T: the tools or services needed. At times, a school district may want to suggest a specific tool because it is available within the district already, but it is essential to start with the student's specific needs and only decide on tools and services after discussing the student's strengths and challenges, the environment and the tasks to be completed. The types of tools and services that are readily available within the district may be different than what the student needs.

In addition to using the SETT framework, the tools chosen must "support achievement of goals and progress in the general curriculum (." Each tool must take into consideration the unique needs of the student and it is important to identify a way to measure and observe whether the AT device is working as intended (www.qiat.org).

It's also critical to ensure that use of the tool is helping the student meet his or her IEP goal(s). The IEP should be written with specific, measurable criteria to assess whether this is occurring.

Advocates should insist on transparent data collection and set a date to review this data to assess the effectiveness of the tool.

Rather than requesting a specific brand (for example: an iPad) make sure to write the features that are needed within the technological tool to support the learning goal.

Engage a a qualified AT specialist do the AT evaluation.

If the school does not have an AT specialist on its faculty, they must contract with an outside provider.

The school district pays for the evaluation and any tools or services needed as determined by the AT evaluation. The law states in Section 300.105 "that the school system is responsible for addressing assistive technology when it is required as a part of the student's special education services, related services, or supplementary aids and services. Use of school-provided assistive technology is not limited to the school setting" (www.gpat.org).

Follow the SETT framework.

Determine who will capture data about the effectiveness of tools and services, when the data will be collected, and the environments in which the data will be collected.

Once an AT plan has been put into place, it is important to set a time to reconvene to discuss how the tool(s) are working. Make sure to get feedback from the student, as well as the teacher(s) and parent(s). Make sure to discuss whether proper training for use of the tool was provided, review the data on effectiveness, and alter the AT plan as needed.

If a school states that it cannot provide an AT evaluation or any type of AT support, refer to the resource entitled " Strategies for Assistive Technology Negotiations " by Dave Edyburn, Ph.D. If the building principal will not comply, go directly to the director of special education at the district level.

AT provides an access point to the curriculum that is essential for students who have learning challenges. All students, including those with disabilities, have the right to access the information being taught in school and to demonstrate what they have learned, and AT can be the key to making that happen.

When advocating for AT, it is essential that communication is open, clear, and transparent. Although advocating for a student can be stressful and challenging, obtaining services that will facilitate access to grade-level curriculum is vital.
https://osepideasthatwork.org/node/121 https://www.understood.org/en/school-learning/assistive-technology/assistive-technologies-basics https://www.edutopia.org/article/assistive-technology-resources https://www.atia.org/at-resources/what-is-at/ http://www.joyzabala.com/ The International Dyslexia Association (IDA) thanks Nanci Shepardson for her assistance in the preparation of this fact sheet.
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How to Advocate for Assistive Technology Tools and Services - International Dyslexia Association

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Share This: ` What is Assistive Technology? Assistive Technology (AT) refers to both tools and services that facilitate access to grade-level curriculum for students with disabilities. Access to the curriculum means that students are able to take in and understand the material being taught in school, understand and complete assignments, and demonstrate what they have learned.