Finding Context

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December 2003

By Jennifer L. Womack, MS, OTR/L

When selecting assistive devices, therapists should consider more than just the client’s environment.

Adults 65 and over are among the most frequent consumers of assistive devices, particularly those designed to aid in the performance of self-care, mobility, and basic household and community living skills.¹ Several studies indicate that use of assistive devices by older adults is not only cost-effective but also beneficial in granting a sense of self-efficacy when the need for caregiver assistance is reduced.^2,3 Low-cost, low-tech devices are particularly in demand by the current generation of older Americans, who rely daily on these devices to carry out personal activities of daily living, maintain safety in their households, and increase community mobility.

While many older adults express satisfaction with the assistive devices they use, there are also examples of dissatisfaction regarding the availability and suitability of assistive technologies. This discontent may lead to abandonment of a device, along with the potential consequence of distrust in the clinician or system recommending it. Gitlin et al identified six major reasons why older consumers abandon the use of assistive devices recommended for them.⁴ Among these reasons, two primary issues were the lack of fit between the device and the environment in which it is used, and the client’s perception that use of the device required too much time and effort to learn and maintain effectively.

How is it that well-trained clinicians who know to include aspects of the environment in their assessments might contribute to this eventual abandonment of the recommended devices? One possible explanation is the consideration of environment without an expanded view of the context.

Looking at Environment

The concept of environment has traditionally been addressed as consisting of physical and social realms, and recommended procedures in the practice of assistive technology provision always emphasize consideration of these factors as essential parts of any device evaluation.^5,6 Yet, even these considerations fall short of regarding the myriad of factors that can impact device use, particularly for the older adult. These issues might be more thoroughly anticipated and assessed through a consideration of contextual rather than solely environmental factors.

CONTEXT	Issues to consider when recommending assistive devices
Cultural	How will the device be accepted in the clients community? Is use of the device congruent with the client's cultural beliefs and activities?
Personal	What is the client's learning style? Educational level? Financial status? Is there a strong gender orientation that will influence the use of the device?
Physical	What are the physical attibutes of the device in relation to the client's abilities and physical environment in which it will be used? Consider weight, texture, size and interface.
Social	How is the use of this device viewed by significant others in the client's life? Does its use require support/participation from others? Is there potential to impact a relationship either positively or negatively?
Spiritual	Is use and maintenance of the device in line with client's basic beliefs and value sytem? Are there ethical considerations?
Temporal	What are the client's daily and important sporadic routines? How will the device use and maintainenance impact or be supported by them?
Virtual	Does maintenance or technical support rely on use of a computer or telephone? What is the clients comfort level relative to this? Access?
Table 1. Suggested considerations for assistive devices from the Occupational Therapy Practice Framework.7

Context is defined as “the interrelated conditions in which something exists or occurs.” This differs from a view of environment in which we consider circumstances or people that surround our clients. In considering contextual factors, clinicians must recognize the multitude of issues that impact our clients’ acceptance and eventual effective use of assistive devices, determining the meaning our clients assign to the device, and what impact the introduction of a device has on their lives. How do we translate this seemingly vague concept into practical terms for clinical use?

The American Occupational Therapy Association (AOTA) has provided a structure through which to view contextual factors in its 2002 Occupational Therapy Practice Framework.⁷ As part of our domain of practice, occupational therapists are compelled to consider the personal, social, spiritual, temporal, cultural, virtual, and physical contexts within which a person functions. This means that in all dealings with our clients—be they individuals or groups or systems—we need to bear in mind the interplay of each of these areas of concern. It seems a daunting task, and yet many clinicians solve complex problems with clients every day that take into account many of the factors addressed in these contextual categories.

What may be lacking, however, is a means of formally addressing these factors in evaluation procedures. Toward that end, two case examples illustrate these contexts, followed by suggested issues that can be considered when implementing the use of this contextual framework in evaluation procedures.

Personal and Cultural Contexts

Martha is a 73-year-old widow who lives in an assisted living facility. She spent 2 weeks in inpatient rehabilitation following a total hip arthroplasty (THA) and was issued a long-handled reacher, long shoehorn, long-handled bath sponge, and sock aid at discharge. She practiced using the devices while in therapy and demonstrated the ability to dress and bathe with intermittent supervision. When the therapist went to retrieve another item from Martha’s room following discharge, she found the shoehorn, sock aid, and sponge left behind.

The therapist called Martha at home later that day and asked if she could mail the items to her. Martha explained that she had been having difficulty donning her shoes and socks for months prior to her surgery, and that she had two favorite nursing assistants in the facility where she lived that help her every morning and evening. She feared offending them if she took home the equipment, saying, “It would look like I wanted to replace them.” She said she did not want them to think she could do without the help because “competition for their time is fierce.” When the therapist asked if she wanted them just in case, Martha replied that her relationship with these two caregivers was too important to her to risk offending them.

In this example, the therapist has neglected to consider two important contextual issues: the personal context of Martha’s functional status prior to the THA, which had already necessitated that she problem-solve a strategy to gain assistance with self-care, and the cultural context of the facility in which Martha lives. This therapist had appropriately evaluated Martha’s ability to use the devices, and asked questions about the physical environment before recommending them. She had known about the presence of nursing assistants and that they were available to help Martha when needed. What she failed to consider was the meaning of their presence to Martha, and the culture of her living situation in which residents value receiving assistance and fear losing that privilege if they offend the staff.

Temporal and Spiritual Contexts

Ted is an 87-year-old man with left hemiplegia living in an apartment complex housing older adults. He has used a manual wheelchair for 3 years for long-distance mobility but was recently fitted for a motorized scooter due to a chronic decubitus ulcer on his left foot. In the process of recommending the scooter, the therapists and vendor talked with Ted about the need to change the battery packs for the scooter on a regular basis in order to keep them charged. Since he is unable to lift the battery packs himself, the vendor asked if anyone visited him regularly and Ted replied that his pastor comes every week. The vendor felt this was a good solution and inquired no further.

Ted felt uncomfortable asking his pastor for help with this task, however. While he knew the minister would have gladly helped him, he came each week to provide Ted a prayer service, and Ted felt it was not an appropriate time to ask him for a favor. Instead, he asked one of the maintenance workers in the building to change the battery packs. The man said he would do it only if he could come in before his work shift. Several times he came in while Ted was asleep or in the middle of dressing, and they could not reach a solution about the timing. Ted stopped using his scooter after 6 weeks. One might argue that in Ted’s situation, his unwillingness to change his routines is the reason for abandonment of the device; however, the therapists and the vendor may have been better prepared to assist Ted with the logistics of his new purchase had they considered the contextual factors that contributed to the abandonment of the scooter.

In this case, Ted’s spiritual context was important to consider in that he valued preserving his weekly worship time as it was rather than as a time when he could get assistance from someone. His temporal context was impacted in many ways: the batteries needed to be recharged on a regular schedule and help was available only at a time that interrupted his normal routine. It is often easy for health care providers to assume that someone can change their habits and routines to accommodate new responsibilities that come with assistive devices. Yet it is exactly that which becomes more problematic for older adults. Not every older adult faces devastating medical problems or becomes functionally impaired at a certain age, yet every older adult has had experiences that contribute to the establishment of routines that not only determine how their time is spent, but also serve to strategically support them in aging.⁸ When we as outsiders unfamiliar with those routines introduce something that requires a change, we must consider how the shift in habits will be absorbed. How do we ensure that we consider these contextual issues in our assessments regarding the use of assistive devices? One way is to include in our assessment a consideration of factors related to each of the contextual realms mentioned here. See Table 1 (page 32) for suggestions for each of the contextual areas in the Occupational Therapy Practice Framework.⁷

While contextual factors are not the only considerations in recommending assistive devices, adding these concerns to the rich repertoire of assessment procedures can enhance our ability to serve older adults. It is only fitting that we look at their life situations through a lens as complex as their life routines.

Jennifer L. Womack, MS, OTR/L, is clinical assistant professor, Division of Occupational Science, Program in Occupational Therapy, at the University of North Carolina-Chapel Hill.

References

Mann WC, Ottenbacher K, Fraas L, et al. Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for the frail elderly: a randomized control trial. Arch Fam Med. 1999;8:210-217.
Hoenig H, Taylor DH Jr, Sloan FA. Does assistive technology substitute for personal assistance among the disabled elderly? Am J Pub Health. 2003;93:330-337.
Hammel J, Lai JS, Heller T. The impact of assistive technology and environmental interventions on function and living situation status with people who are ageing with developmental disabilities. Disabil Rehabil. 2002;24:93-105.
Gitlin LN, Levine R, Geiger C. Adaptive device use by older adults with mixed disabilities. Arch Phys Med Rehabil. 1993;74:149-152.
Mann WC, Beavers KA. Assessment services: person, device, family and environment. In: Mann WC, Lane JP, eds. Assistive Technology for Persons with Disabilities. Bethesda, Md: American Occupational Therapy Association; 1995:299-317.
Bryen DN, Goldman AS. Contexts: assistive technology at home, school, work and in the community. In: Olson DA, DeRuyter F, eds. Clinician’s Guide to Assistive Technology. St Louis: Mosby; 2002:15-40.
Occupational Therapy Practice Framework: domain and process. Am J Occup Ther. 2002;56:609-639.
Rowles G. The geography of aging and the aged: toward an integrated perspective. Progress in Human Geography. 1986;10:511-539.

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