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Assistive technology for the inclusion of students with disabilities: a systematic review

  • Cultural and Regional Perspectives
  • Open access
  • Published: 10 June 2022
  • Volume 70 , pages 1911–1930, ( 2022 )

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  • José María Fernández-Batanero 1 ,
  • Marta Montenegro-Rueda 1 ,
  • José Fernández-Cerero 1 &
  • Inmaculada García-Martínez 2  

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The commitment to increase the inclusion of students with disabilities has ensured that the concept of Assistive Technology (AT) has become increasingly widespread in education. The main objective of this paper focuses on conducting a systematic review of studies regarding the impact of Assistive Technology for the inclusion of students with disabilities. In order to achieve the above, a review of relevant empirical studies published between 2009 and 2020 in four databases (Web of Science (WoS), Scopus, ERIC and PsycINFO) was carried out. The sample consists of 31 articles that met the inclusion criteria of this review, out of a total of 216 identified. Findings of this study include that the use of Assistive Technologies is successful in increasing the inclusion and accessibility of students with disabilities, although barriers such as teacher education, lack of information or accessibility are found.

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Introduction

In the educational field, students with disabilities face a set of barriers that limit their learning and achievement in different activities that take place in the classroom setting. It is essential that these students have access to the same opportunities to participate in society as their peers. In this context, digital technologies are a tool to access the curriculum. In this regard, evidence has shown that digital technologies (computers, laptops and mobile devices) have changed many students’ lives (Bond, 2014 ). Despite these changes affecting education, little attention has been paid to how students with disabilities have incorporated technologies into their daily lives (Passey, 2013 ; European Schoolnet, 2014 ). This is not surprising, given that existing research on children with disabilities is scarcely developed (McLaughlin et al., 2016 ), while generic research often excludes this sector of the student population (Connors & Stalker, 2007 ). This may be a challenge in terms of ensuring equal opportunities to access and benefit from digital technologies.

This concern to ensure equality and equity is evidenced in most of the international initiatives over the past decade, for example the UNESCO-Weidong Group project “Harnessing ICTs for Education 2030” which will, over four years, support participating Member States in harnessing the potential of ICTs to achieve ODS 4 by 2030. The United Nations also adopted, during its General Assembly on 13 December 2006, the resolution drafted by the International Convention on the Rights of People with Disabilities, in order to promote measures for research and development of disability-friendly technologies and their availability and use, including specific technical devices designed to improve the daily lives of people with disabilities.

Conceptualization

“Assistive Technology” (hereinafter AT) according to the World Health Organization (WHO), is a generic term that designates all systems and services related to the use of assistive products and the performance of services (WHO, 2001 ). Generally and according to the Assistive Technology Act of 1998, in the U.S. it is defined as “any item, piece of equipment or system, whether acquired commercially, modified, or customized, that is commonly used to increase, maintain, or improve the functional capabilities of people with disabilities” (Buning et al, 2004 , p. 98). For Lewis ( 1993 ), AT has two main purposes: on the one hand, to increase a person’s capabilities so that his or her abilities balance out the effects of any disability. And second, to provide an alternative way of approaching a task so that disabilities are compensated.

AT is proposed as an alternative for the interaction between students with disabilities and new digital devices (Emiliani et al., 2011 ), which:

Refers to the technologies (devices or services) used to compensate for functional limitations, to facilitate independent living, to enable older people and people with activity limitations to realise their full potential. Some technologies, even if not purposely designed for people with activity limitations, can be configured in such a way as to provide assistance or assistive functions when needed. The term AT covers any kind of equipment or service capable of meeting this definition. Examples include wheelchairs, prosthesis, communicators and telecommunication services. In eInclusion, AT includes, for example, equipment and services for access to information (e.g., for seeing, hearing, reading, writing), interpersonal communication and control of the environment. (p. 102)

AT is divided into low technologies, which do not use programming, such as magnifiers and pencil holding devices, and high technologies, which use programming, such as computers (McCulloch, 2004 ). Authors such as Cook and Hussey ( 1995 ) and Bryant & Crews ( 1998 ) also classify AT into two types: low or simple technology and high and complex technology. Low or simple technology has been described as equipment that is most often low cost and easy to create or obtain. These require a simplified process for operation (pencils, calculator loupes, paper communication boards, wheelchairs, etc.). Complex technology concerns equipment that has electronic technology (computers, electronic communication boards, electric wheelchairs, etc.).

To understand the role of AT regarding people with disabilities, it becomes necessary to review the concept of disability as well. In this regard, it must be said that disability has had different readings depending on the era and the predominance of health models. The contexts have been varied and even complementary, so explaining disability is a difficult task. The International Classification of Functioning, Disability and Health (ICF), published by the World Health Organization (WHO, 2001 ), is a bridge between the medical and social models, since it understands disability as the interrelationship between a person’s health condition and the environmental factors that affect his/her lifestyle. Thus, disability is understood as the circumstance of negative aspects of the individual’s interaction and its contextual factors, activity limitations and participation barriers. In the traditional medical model, a “disability” is defined as any form of impairment or limitation placed on an individual’s normal functioning, so “impairment” implies a reduction or weakening of normal functioning, and “limitation” implies a reduction of normal activity. In this way, we understand limitation as the multiple barriers that limit student learning and participation (Echeita, 2013 ).

AT is the basis for creating inclusive education systems in which students with disabilities enjoy the same training and learning as their peers who are not limited in their daily activities.

The scientific literature reports both the benefits of AT for students with disabilities and the barriers to teaching and learning processes. Regarding the possible benefits, authors such as Angelo ( 2000 ) studied how specialized technologies contribute to the development of skills that provide stimulation and support to this group of students. For Murray & Rabiner ( 2014 ), AT is able to fit instantly to a student’s level and provide instant feedback for improved learning. In addition, they support students with disabilities in performing tasks or functions that they would otherwise be unable to do (Sullivan & Lewis, 2000 ). For their part, Nelson et al., ( 2013 ) focused on improvements in academic performance and language development. Howard-Bostic et al., ( 2015 ) conducted research on the use of Multimedia Assistive Technology (MAT), finding that these tools improve the performance of university students.

NcNicholl et al., ( 2019 ) in a systematic review of AT use for students with disabilities in higher education identified four analytical themes: AT as a facilitator of academic engagement; barriers to effective AT use can hinder academic participation; the transformative possibilities of AT from a psychological perspective; and AT as a facilitator of participation. In this regard, other studies conclude that the potential use of AT for students with disabilities will promote inclusion and decrease stigma (De Witte et al., 2018 ; Asongu et al., 2019 ).

In relation to potential barriers, Byrd and Leon (2017) focused on three main aspects that prevent the inclusion and approach of students with disabilities in the use of so-called specialized Assistive Technologies: 1- AT is not available or accessible to students with disabilities. 2- High costs and precarious financing represent a limitation for the placement of AT for students with disabilities. 3- Lack of training in the use of virtual devices and platforms is the most prevalent barrier to the development of students with disabilities.

Copley & Ziviani ( 2004 ) identified limitations to their use in the field of education for people with disabilities. These include lack of suitable training and support for teachers, negative attitudes, insufficient assessment and planning processes, inadequate funding, difficulties in managing equipment and time-related barriers. Along these lines, there are many studies that have highlighted the lack of teachers’ training in the application of Assistive Technology programs (Murray & Rabiner, 2014 ; Howard-Bostic et al., 2015 ).

Purpose and research questions

AT aims to help people with disabilities overcome their limitations (Sauer et al., 2010 ). Due to the rapid development of technology, there is a need to update research results on the impact of AT for the inclusion of students with disabilities. Therefore, the purpose of this research is aimed in two directions: on the one hand, to assess the overall state of AT research to improve the inclusion of students with disabilities. On the other hand, to investigate the themes and future lines of research in this field.

The specific research questions addressed are:

Q1. What are the trends in scientific production on assistive technology for students with disabilities in the field of education? Q2. What are the findings on the use of Assistive Technology for students with disabilities between 2009 and 2020 in education? Q3. What are the limitations on the application of Assistive Technology among students with disabilities in education? Q4. What are the main lines of research in this field according to the keywords of the reviewed papers in the field of education?

A systematic review of bibliographic analysis has been carried out using analytical screening techniques and document quantification (Fernández-Batanero, Reyes-Rebollo & Montenegro-Rueda, 2019 ) in accordance with the guidelines and standards for systematic reviews of the PRISMA Statement (Preferred Reporting Items for Systematic reviews and Meta-Analyses) (Liberati et al., 2009 ), as an effort to locate all relevant scientific studies that aim to assess the impact of AT on improving the inclusion of students with disabilities. Likewise, social network analysis techniques have been used (Knoke & Yang, 2008 ) using visual representation with the VOSviewer software. This methodology enables the quantification of scientific output related to inclusion and assistive technology.

Data sources and search strategy

To carry out this review of the literature, four databases have been used to find eligible studies on Assistive Technology for students with disabilities. The databases included were Web of Science, Scopus, ERIC and PsycINFO. Consequently, the main reasons for choosing these four databases were their scientific impact and internationally recognized prestige in the academic community of the social sciences and education fields.

To obtain the articles, we applied an advanced search model using the following descriptors in the title, summary or key words fields: assistive technology (AT), inclusion and disability. To give greater accuracy to the study, Boolean operators “AND” and “OR” were incorporated into the different searches. We also tracked reference lists from relevant papers. Searches for studies were limited from 2009 to 2020, in order to extract the most current research in this field. The bibliographic search was carried out in March 2021, and obtained 741 results. After the elimination of duplicate studies, 321 articles remained for eligibility screening.

Eligibility criteria

Firstly, the PICO strategy (Population, Intervention, Comparison, and Outcome) was used to define the eligibility criteria. In this regard, we followed the recommendations of Pertegal-Vega, Oliva-Delgado and Rodríguez-Meirinhos ( 2019 ): population, phenomenon of interest, context, and study design.

The procedure for the selection of publications, in order to obtain in-depth evaluation about the validity of all included studies, was carried out through a double screening using the inclusion-exclusion criteria. Articles were restricted to peer-reviewed journal articles in the last decade. The following inclusion and exclusion criteria were used to identify study articles (Table  1 ):

Process flow of the systemactic review

Using these inclusion and exclusion criteria, we filter the publications following the recommendations for systematic reviews and meta-analyses. Figure  1 shows the PRISMA flow diagram followed for search, identification, screening, eligibility and inclusion processes (Moher et al. 2009). To increase reliability, all authors of the manuscript participated in the selection of the studies to include.

A first initial search, based on a combination of the different selected descriptors, identified 188 articles in the four selected databases. It was also completed with a manual search by reviewing the reference lists of the identified articles, selecting 28 articles. In total, 216 articles have been selected.

After a first reading of titles and abstracts, duplicate articles were removed, resulting in the elimination of 86 items. Subsequently, an exhaustive verification of the remaining 130 articles was carried out, assessing the established selection criteria, and 99 items were deleted for the following reasons: type of document (52) or inadequate context (47). Finally, 31 articles were obtained (Fig.  1 ).

figure 1

Sample selection flowchart

Coding procedures and data analysis

To analyse the 31 selected studies, a data extraction table was developed to facilitate the review, which included (a) identification of authors and year of publication, (b) participants’ information, (c) methodological design of the study, (d) results and AT included in the study, (e) number of citations of article, and (f) country, resulting in a database that has subsequently been presented descriptively (Appendix 1).

This section reports the results, both quantitative and qualitative, obtained in this study. The data are shown in the following sections in response to each of the research questions stated above.

Overview of research on Assistive Technology for students with disabilities

This systematic literature review has drawn 31 articles from the different databases analysed. The review focused on scientific articles produced between 2009 and 2020, which aimed to evaluate the impact of the use of assistive technology in the education of students with disabilities. As see in Fig.  2 (below), where the distribution of the relevant studies published during this period is shown, there is an increasing trend in research in this field. Looking at the analysis of the year of publication of these studies, it is shown that the publication trend starts from the year 2017 to the present. Between the years 2009–2016 there was a small number of articles published. However, from 2017 onwards, an increase in the number of publications on this topic can be observed.

figure 2

Distribution of articles by year

Figure  3 displays the number of studies provided by each country. Looking at the location of the countries where these studies analysed were carried out, we can show that they were mainly carried out in the USA (n = 16), followed, although less substantially, by Brazil (n = 4) and Turkey (n = 3). The figure shows that research attracts interest in countries all over the world.

figure 3

Distribution of the articles analysed by country

The analysis of the study design used does not provide an overview of how research in this field is being approached. These data indicate that, in terms of study design, 58.06% of the studies are conducted qualitatively. Quantitative studies are less common (38.71%), while only one study reviewed is classified as mixed (3.23%) (Fig.  4 ).

figure 4

Type of methodology used

Research into the use of assistive technology applied to any stage of education has been undertaken. Thus, the data show that the educational level with the highest application of assistive technology is secondary education (41.94%), followed by primary education (38.71%). Studies aimed at the university stage are lower (12.90%). In the case of Early Childhood Education, there are very few (6.45%).

Citation analysis is one of the types of research that determine the impact of publications in scientific processes (Cañedo Andalia, 1999 ). In this way, the quality and impact of the research in this field is not yet relevant, because most of the publicationshave received between 0 and 5 citations (70.97%), 19.35% between 5 and 10 citations and only 9.38% have received more than 10 citations.

Benefits of using Assistive Technology for students with disabilities

Among the type of Assistive Technology used for this group of students, we find a wide variety of tools. Among them, the use of Web 2.0 stands out (28.57%), such as the use of social networks, websites, browsers…; mobile learning (25%), among which we find the Tablet, the iPad or the mobile phone; or the use of hardware or software (21.43%) (Fig.  5 ).

figure 5

Main Assistive Technology for student inclusion

Considering the articles reviewed, these tools are being used mainly with visually impaired students (25%), followed by hearing impaired students (21.43%) and physically impaired students (14.29%). Students with autism (10.71%), intellectual disability (7.14%) or behavioural disorder (3.57%) are less likely to be used. The rest of the publications (17.86%) do not specify the type of disability (Fig.  6 ).

figure 6

Students using assistive technology

AT provides students with a set of benefits such as inclusion (20.95%) and accessibility (20.95%) to school, as stated by the articles selected in this review. Among other benefits, we find that they improve the teaching-learning process (13.51%), the development of autonomy and independence (18.92%), the acquisition of social skills (11.49%), the participation (9.46%) and the motivation (4.73%) of students (Fig.  7 ).

figure 7

Benefits of the use of Assistive Technology

Limitations of the use of Assistive Technology with students with disabilities

All the articles reviewed point out the importance of the use of Assistive Technology as a required tool for students with disabilities at school. However, there are still different challenges that schools must overcome in order to apply these tools with their students. Among the main difficulties found, there are mainly the need for teacher training and education (42.86%), as well as the difficulties of access to them (32.14%) (Fig.  8 ).

figure 8

Difficulties in the use of Assistive Technology

Lines of research on the use of Assistive Technology with students with disabilities

In order to analyse the research topics addressed in the literature in this field, an analysis of the relationships between the automatically extracted keywords or Key Words Plus (KW+) from the 31 studies analysed was carried out using the VOSviewer programme. Using the process of analysing the network map, three main themes were identified through analysis in the data. These were: “AT as an enabler of inclusion and participation” (cluster 1), “barriers to effective use of AT” (cluster 2) and “possibilities and benefits of AT” (cluster 3).

Therefore, a total of 45KW + has been extracted. In Fig.  9 , the 3 groups or clusters can be clearly observed, which have been generated according to the similarity between them. The size of each node and their distance from each other sets the relationship between them.

figure 9

Labelled bibliometric map

The 3 thematic clusters that defined the main research topics in this field are:

Cluster1: identified in red, this is the main theme on which this study focuses, i.e. the impact of Assistive Technology on the inclusion and accessibility of students with disabilities. It can be noted that this cluster includes terms such as assistive technology, inclusion, technology, resource, impact, software, web, tablet, support, social technology, and robotic.

Cluster 2: it appears in blue, and it is related to the barriers or obstacles that hinder the application of Assistive Technology in education. In this group some of the most prominent elements are teacher training, education, higher education, society, school, context, training, and evidence.

Cluster 3: is shown in green. This group stands out for the benefits of applying these tools to students with educational needs. It also refers to the possibilities offered by Assistive Technology to make accessible education for all. It highlights items such as: autonomy, participation, social skill, access, assistant teacher, inclusive education, motivation, disability, and skill.

On the other hand, we include the bibliometric density map where it is shown the relevance of the analyzed keywords. Therefore, the following cores can be highlighted (Fig.  10 ):

In the middle zone of the map (yellow color) are placed, due to their importance and co-occurrence, those most relevant keywords in the scientific production about Assistive Technology for students with disabilities (student, disability, assistive technology, teacher).

In the peripheral zone of the map (colors that tend to green), evidence shows less interest and level of co-occurrence in the current scientific production (impact, inclusive education, social technology, experience, assistant teacher).

figure 10

Bibliometric map tagged

Discussion and conclusions

This review explores the impact of scientific production related to Assistive Technology on the inclusion of students with disabilities published between 2009 and 2020. According to our findings, these tools emerge as suitable instruments for both accessibility and inclusion of students, as well as for meeting their educational needs during their learning process (Clouder et al., 2019 ; Satsangi et al., 2019 ).

Thus, among the papers reviewed, several noteworthy findings will be discussed, in response to the research questions proposed in this study. First, considering the first question on trends in scientific production over time (RQ1), we can mention that there are possible trends and indications that suggest an increase in the use of AT in education in the last few years. Research in this field over the last decade is not very relevant; however, from 2017 to the present, a progressive increase has taken place. We can also highlight that the impact and repercussion of these studies is not very high, since most of the articles have a very low citation rate. The more frequently a paper is cited, the more often the scientific community recognises the influence or impact of the cited topic (Cañedo Andalia, 1999 ). The scarce existence of scientific literature and its low impact is one of the main problems that may hinder the implementation of these tools in the classroom, because this field is underdeveloped. Similarly, the limited existence of scientific literature on the use of AT for the care of students with disabilities makes it difficult to answer the research questions posed. Even so, the findings help us to lay the foundations for working to improve the education of these people, both by offering technological solutions and by working on training and awareness-raising in this regard (Molero-Aranda et al., 2021 ).

With respect to the countries that concentrate the greatest scientific production in this field, it should be said that AT is of world-wide attention, so that AT research has been developed in different countries, mainly in the United States, followed by Brazil and Turkey. This fact enables a reflection on future research in order to know if the country and its context affect the use of these technologies for the inclusion of students.

In relation to the research designs that prevail in the studies analyzed, it should be noted that these mainly show a qualitative approach, with observation and interviews prevailing as data instruments, followed by quantitative ones.

The second research question (RQ2), related to the results of using AT with students with disabilities, aims to synthesise the positive impacts in terms of the improvements or benefits they bring to students. AT has a significant impact on academic engagement. The use of these tools was found to improve the academic performance of students with disabilities (Fortes Alves & Pereira, 2017 ; Tamakloe & Agbenyega, 2017 ; Bouck et al., 2020 ; Sivakova, 2020 ). Some articles also reported the benefits of AT for the development of autonomy and participation (Harper et al., 2017 ; Mercado de Queiroz & Presumido Braccialli 2017 ; McNicholl et al., 2020 ). The results show an increase in the acquisition of social skills (Ari & Inan, 2010 ; Murry, 2018 ). Finally, it is worth mentioning that these tools promote motivation and increase students’ attention (Paula, 2003 ; Arpacik et al., 2018 ; Bondarenko, 2018 ). The results analysed point out that there are different types of Assistive Technology used according to the functionality that they want to provide, highlighting mainly the use of Web 2.0. Although there are still digital gaps, most schools and teachers have access to the Internet which means that they can use this available and low-cost resource, and it can support both student inclusion and learning (Lyner-Cleophas, 2009; Kamali Arslantas et al., 2019 ; Ok & Rao, 2019 ). Mobile learning also stands out (25%), including the iPad or smartphone. These devices are very useful because they are small and portable, and they enable the installation of relevant applications for these students (Ismaili & Ibrahimi, 2017 ; Brinsmead, 2019 ), a fact that has resulted a trend in the use of these tools in recent years, agreeing with previous studies (Fichten et al., 2014 ). In this way, we can outline that the most generic resources are mainly used (McNicholl et al., 2020 ). The use of other useful resources to encourage the participation of this group of students using hardware or software should also be highlighted (21.43%) (Emcarnaçao et al., 2017 ).

These tools are mainly relevant for visually impaired students, followed by hearing impaired and physically handicapped students (Quinn et al., 2009 ; Ferreira et al., 2013 ; Ismaili & Ibrahimi, 2017 ). Thus, it can be stated that AT is successful and necessary to ensure the inclusion of this population in the classroom; however, although it has many benefits for all students, its use also involves challenges and barriers associated with the use of AT in the classroom. These barriers can hinder the effective use of AT.

In this regard, in response to the third research question (RQ3), all articles identified situations where AT cannot be used effectively. These include inadequate training in the use of ATs with learners with disabilities by teachers or difficulties in accessing these tools (Copley & Ziviani, 2004 ; Johnstone et al., 2009 ; Coleman et al., 2015 ; Alammary et al., 2017 ; Ismaili & Ibrahimi, 2017 ; Byrd & León, 2017 ). Teacher training in AT is related to improved student academic performance by being able to select the most appropriate tool to meet the needs of their students (Jones & Hinesmon-Matthews, 2014 ; Laloma, 2005 ; Malcolm & Roll, 2017 ; Yankova, 2019 ). Difficulties of access hinder the implementation of AT in education. These are mainly associated with economic factors, lack of adequate supports or lack of funding (McNicholl et al., 2019; Atanga et al., 2020 ).These tools may effectively support student inclusion by providing adaptations, but their high cost, because some resources such as the iPad are quite expensive, limits their access to wealthier consumers (Flanagan et al., 2013 ; Koch, 2017 ; Brinsmead, 2019 ). As a result, it is clear that rural areas have less resources and greater difficulties to access them than urban areas (Davis et al., 2013 ).

The main research topics in this field (RQ4) taking into account both the review of the articles and the analysis of the bibliometric maps helped to identify the different main topics involved within this field of research. Firstly, the importance of the use of AT as a facilitating element for school inclusion is highlighted, providing access for all students to education, including those with some kind of disability or educational need. Secondly, it highlights the benefits of implementing Assistive Technology with students with disabilities. Finally, it is related to the barriers or obstacles that hinder the application of Assistive Technology in the education of students with disabilities. As well as the possibilities offered by Assistive Technology to access education for the whole population. Research and applications of the use of assistive technology with learners with disabilities have been conducted around the world. However, despite these efforts, it has not been possible to integrate the appropriate tools to satisfy the main needs of these students. This review has identified important directions for future research and possible ways in which schools should consider integrating AT into the learning of students with disabilities. Teachers have a primary role in promoting the use of ATs, therefore, in order to achieve inclusion of students with disabilities, teacher need to acquire the necessary skills and competences (De Sousa, 2014 ; Roque, Perreira, Neto & Macario, 2018 ; Ahmed, 2020 ; Viana & Fontoura Teixeira, 2019 ; Arori, Al Attivah, Dababneh & Hamaidi, 2020 ). The results show that many of the generic devices (smartphones, digital board...) are used as AT, due to the fact that many offer accessibility features. Looking ahead, it is a need to integrate universal design into teacher technology training to maximise the benefits for all learners (Messinger-Willman & Marino, 2010 ).

Implications for further research

The limitations found have been addressed taking into account the results of this review because, although it has been possible to note how current research in this field is developing worldwide, it would be useful to identify the most appropriate AT to meet the needs of students according to their disabilities, as well as to promote training plans for teachers in order to implement these tools properly in the classroom.

In this way, researchers should explore the use of AT in relation to the type and degree of disability of learners. In this sense, it is also necessary to investigate effective teaching and learning strategies for these learners. In order to do so, it is necessary for teachers to have an adequate level of training, so that they can apply these tools in the classroom.

Limitations

A limitation of this paper is that the selection of the articles analyzed is restricted to the databases selected by the authors, although they are the most important for the educational scientific community. Therefore, in future research it would be desirable to study this topic with a wider and more extensive scope, including other articles from journals indexed in other databases with less scientific recognition, but which may include good practices.

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Fernández-Batanero, J.M., Montenegro-Rueda, M., Fernández-Cerero, J. et al. Assistive technology for the inclusion of students with disabilities: a systematic review. Education Tech Research Dev 70 , 1911–1930 (2022). https://doi.org/10.1007/s11423-022-10127-7

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Assistive technology: a ‘life changer’ for those most in need

A woman being fitted for a receiver-in-canal (RIC) hearing aid.

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Almost one billion people with disabilities and older persons are being denied access to assistive technology, according to a UN report published on Monday, calling on governments and industry to fund and prioritize access.

Produced jointly by the World Health Organization (WHO) and UN Children’s Fund ( UNICEF ), The Global Report on Assistive Technology presents new evidence of the global need for - and access to – tech that can make a fundamental difference.

“Assistive technology is a life changer – it opens the door to education for children with impairments, employment and social interaction for adults living with disabilities, and an independent life of dignity for older persons,” said WHO chief Tedros Adhanom Ghebreyesus.

We call on all countries to fund and prioritize access to assistive technology – WHO chief

Huge disparities

Although more than 2.5 billion people require one or more assistive products to support communication and cognition – such as wheelchairs or hearing aids – a shocking one billion simply have no access to them.

The report highlights the vast gap between low and high-income countries, with an analysis of 35 States revealing that admittance varies from three per cent in poorer nations, to 90 per cent in wealthy countries.

“Nearly 240 million children have disabilities,” said UNICEF Executive Director Catherine Russell.

Denying them the right to the products they need to thrive not only harms individual children, “it deprives families and their communities of everything they could contribute if their needs were met,” she added.

Identifying obstacles

Affordability is a major barrier to access, the report notes.

Around two thirds of people using assistive products reported paying out-of-pocket while others have had to financially rely on family and friends.

Meanwhile, aging populations and rising cases of noncommunicable diseases, mean that the number of people in need of assistive technology is likely rise to 3.5 billion, by 2050.

A survey of 70 countries found large assistive technology gaps in services and levels of workforce training, especially in cognition, communication and self care.

Other key barriers revealed in previous WHO surveys included unaffordable prices, a lack of awareness and services, inadequate product quality, and procurement and supply chain challenges.

In Kosovo, a father helps his son, who suffers from cerebral palsy, get back into his electric wheelchair.

Multiple gains

Assistive products are generally considered a means to participate in life on an equal footing with others.

Without them, people risk isolation, poverty and hunger; suffer exclusion, and depend more on family, community and government support.

And the users are not the only ones to reap benefits: families and societies also profit.

“Denying people access to these life-changing tools is not only an infringement of human rights, it’s economically short-sighted,” said Tedros.

Enabling more access to quality-assured, safe and affordable assistive products reduces health and welfare costs, such as recurrent hospital admissions or state benefits, and promotes a more productive labour force, indirectly stimulating economic growth.

Raising children

Access to assistive technology for children with disabilities is often the first step for development, access to education, participation in sport and civic life, and preparation for employment like their peers, the report says.

However, as they grow, they are faced with additional challenges, such as frequent adjustments or the need to replace tech aids.

“Without access to assistive technology, children with disabilities will continue to miss out on their education, continue to be at a greater risk of child labor and continue to be subjected to stigma and discrimination, undermining their confidence and wellbeing,” warned the UNICEF chief.

Around the world, an estimated 93 million children under the age of 15 are living with some kind of disability.

Improving access

The Global Report provides a series of recommendations to expand availability and access, raise awareness, and implement inclusion policies to improve the lives of millions.

It specifically advocates for improving access within education, health and social care systems; ensuring the availability, effectiveness and affordability of assistive products; enlarging, diversifying and improving workforce capacity; and investing in research, innovation, and an enabling ecosystem.

The brief also underscores the need to increase public awareness and combat stigma; develop and invest in enabling environments and evidence-based policies and include this vital technology in humanitarian responses.

“We call on all countries to fund and prioritize access to assistive technology and give everyone a chance to live up to their potential,” underscored the top WHO official.

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PERSPECTIVE article

Intellectual disability and assistive technology: opening the gate wider.

\r\nFleur Heleen Boot*

  • 1 Centre for Global Health and School of Psychology, Trinity College Dublin, Dublin, Ireland
  • 2 Centre for Practice and Healthcare Innovation, Trinity College Dublin, Dublin, Ireland
  • 3 GATE Group, Essential Medicines & Health Products, World Health Organization, Geneva, Switzerland
  • 4 Centre for Rehabilitation Studies, Stellenbosch University, Stellenbosch, South Africa
  • 5 Olomouc University Social Health Institute, Palacky University, Olomouc, Czech Republic

The World Health Organization has launched a program to promote Global Cooperation on Assistive Technology (GATE). The objective of the GATE program is to improve access to high quality, affordable assistive technology for people with varying disabilities, diseases, and age-related conditions. As a first step, GATE has developed the assistive products list, a list of priority assistive products based on addressing the greatest need at population level. A specific group of people who can benefit from user appropriate assistive technology are people with intellectual disabilities. However, the use of assistive products by people with intellectual disabilities is a neglected area of research and practice, and offers considerable opportunities for the advancement of population health and the realization of basic human rights. It is unknown how many people with intellectual disabilities globally have access to appropriate assistive products and which factors influence their access. We call for a much greater focus on people with intellectual disabilities within the GATE program. We present a framework for understanding the complex interaction between intellectual disability, health and wellbeing, and assistive technology.

Only 10% of the people who are in need of assistive products actually have access to them, despite such access being claimed to be a human right ( 1 , 2 ). An assistive product is any product (including devices, equipment, instruments, and software), either specially designed and produced or generally available, whose primary purpose is to maintain or improve an individual’s functioning and independence and thereby promote their wellbeing ( 3 ). Common examples of assistive products are spectacles, hearing aids, wheelchairs, prosthetics, communication boards, incontinence products, pill organizers, and therapeutic footwear. Assistive products can improve the quality of life for people with impairments, including the extent of their inclusion and participation in society. However, the use of assistive products by people with an intellectual disability (ID) is a neglected area of research and practice and offers considerable opportunities for the advancement of population health and the realization of basic human rights. About 1% of the total population have ID, with higher prevalence rates in low- and middle income countries ( 4 ). ID is defined by the American Association on Intellectual and Developmental Disabilities, the Diagnostic and Statistical Manual of Mental Disorders V, and the International Classifications of Diseases 10 (mental retardation) as an IQ below 70, manifested during the developmental period (<18 years of age), with impairments in adaptive functioning, such as communication skills, social skills, personal independence, school, or work functioning ( 5 – 7 ).

The World Health Organization has launched a program to promote Global Cooperation on Assistive Technology (GATE) to implement those parts of the United Nations Convention on the Rights of Persons with Disabilities referring to assistive technology ( 3 , 8 , 9 ). The GATE program’s objective is to improve access to high quality, affordable assistive products for people with varying disabilities, diseases, and age-related conditions. As a first step, GATE has developed the assistive products list (APL) of priority assistive products to address the greatest needs at population level ( 10 ). To be effective, the APL will require countries to develop national assistive technology policies; source appropriate products; train specialized personnel; and develop effective and efficient systems of provision ( 10 ).

However, barriers that people with ID experience regarding access to assistive products have not yet been sufficiently considered. Worldwide, people with ID are still generally regarded as a devalued and stigmatized group, and at least part of their relatively poor health status is due to health inequities. People with ID are still often disadvantaged when attempting to access or secure health services and assistive products ( 11 , 12 ). It is unknown what proportion of people with ID globally actually has access to appropriate assistive products. It has been suggested that for people with ID there is a high rate of underdiagnosis and misdiagnosis; so that too often they do not receive the correct treatment and that the need for rehabilitation arises as a result of absent or ineffective health care ( 13 ). The atypical presentation of symptoms by people with ID is often a challenge for their care system. With accurate assessment and appropriate interventions, the use of assistive products can be not only enabling and empowering, but also transformative in facilitating new life skills and opportunities for people with ID.

Compared to the general population, people with ID have a higher prevalence of comorbidities which could be better managed with assistive products (see Figure 1 ). For instance, motor disabilities are present in a significant proportion (26%) of people with ID ( 14 ). Visual impairment has a prevalence of 19.2% in adults with ID compared to 1.9% in adults of the general population. For hearing impairment, the prevalence is 30 vs 17%, respectively; and for dementia, it is 13.1 vs 5.4%, respectively ( 15 ). People with ID are now recognized as a group with a disproportionately greater need for assistive products due to higher rates of frailty and multimorbidity (including increased severity and earlier onset) than the general population ( 16 , 17 ). The result is a greater prevalence of disabilities in daily functioning and mobility with increased care needs and support required ( 18 – 20 ). Multimorbidity (the presence of two or more chronic conditions) is of particular concern with an 80% prevalence rate in adults >50 years with ID ( 17 ). Besides the association with age, multimorbidity, and frailty are also associated with a severe and profound level of ID ( 16 , 17 ). The life expectancy of people with ID is increasing in line with the general population trends. Therefore, the prevalence of older people with ID is also likely to increase along with the demand for access to assistive products ( 21 ).

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Figure 1. Factors related to the use of assistive technology by people with intellectual disabilities .

Access to assistive products presents three distinct challenges if people with ID are going to benefit from the increased provision aspired by GATE (see Figure 1 ). First, impairments in cognitive and adaptive functioning intrinsic to ID should be adequately catered for within population-level systems of assistive technology policy, products, health care personnel, caregivers, and provision. That means, communication skills and physical examinations by health care personnel need to be adapted to the intellectual and emotional level of the person with ID, to get the correct diagnosis and ensure the appropriate assistive product(s) are prescribed. The use of assistive products requires information, instruction, and support that are both accessible and understandable to the person with ID, if it is to be used effectively. In addition, a multidisciplinary approach to develop protocols for the training and support of people with ID is needed in order to direct the effective use and evaluation of the assistive products. For example, hearing aids require a customized habituation training program adjusted to an individual’s level of ID. This needs to be implemented in collaboration with the speech and language therapist, behaviorist, and caregiver together to help the person with ID to accept and benefit from the use of the new product.

A second challenge for people with ID to benefit from the APL is increased awareness among caregivers and health personnel of comorbidities that people with ID often experience; such as sensory impairments and dementia. These comorbidities may require the use of assistive products, and so the needs of the users with ID must be more often taken into account.

Third, people with ID will experience physical impairments not necessarily associated with ID, which are equally common in other sections of the population. For instance, a person with ID may need to learn to use a prosthesis or walking aids and—as above—the effective use of such products requires information, instruction, and support that is as accessible and understandable as possible. While it is known that the use of assistive products, such as a prosthesis, is influenced by a range of psychosocial factors, such research derives almost exclusively from users of assistive products without ID ( 22 , 23 ).

Without a concerted and systematic approach to consider the challenges that ID presents, for the users, caregivers, and providers of assistive products, profound inequities in health, in life opportunities, and therefore in the quality of life for people with ID will persist. We call for a much greater focus on people with ID within the GATE program and in particular regarding national initiatives to adopt the APL.

Author Contributions

FB: substantial contributions to the conception and design of the work; drafting the work; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JD, CK, and MM: substantial contributions to the conception and design of the work; revising the work critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflict of Interest Statement

The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. None of the authors have any competing interests in the manuscript.

The reviewer DB and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.

This research was supported by funding from the charity RESPECT and the People Programme (Marie Curie Actions) of the European Union’s Seventh Framework Programme (FP7/2007-2013) under REA grant agreement no. PCOFUND-GA-2013-608728.

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Keywords: intellectual disabilities, assistive technology, assistive devices, global health, public health policy, health inequality, World Health Organization

Citation: Boot FH, Dinsmore J, Khasnabis C and MacLachlan M (2017) Intellectual Disability and Assistive Technology: Opening the GATE Wider. Front. Public Health 5:10. doi: 10.3389/fpubh.2017.00010

Received: 08 December 2016; Accepted: 19 January 2017; Published: 22 February 2017

Reviewed by:

Copyright: © 2017 Boot, Dinsmore, Khasnabis and MacLachlan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Fleur Heleen Boot, bootf@tcd.ie

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Visisense: a comprehensive iot-based assistive technology system for enhanced navigation support for the visually impaired, article sidebar, main article content.

The field of visually impaired assistive technology looks for novel approaches to enhance independence and navigation. In this field, systems have to reliably identify and transmit environmental data in order to facilitate visually impaired users' safe and effective navigation. Developing a sophisticated framework for assistive technology that significantly enhances visually impaired navigation is the goal of this research. Make object detection and environmental awareness more efficient, dependable, and intuitive. This study introduces VISISENSE, "A Comprehensive IoT-Based Assistive Technology System for Enhanced Navigation Support for the Visually Impaired." VISISENSE is an IoT-based system with multiple components that enhances object detection. For primary environmental sensing, a handstick with implant sensors, a visual capture and transmission unit for processing visual data, and edge computing for object detection and classification are used. The system makes use of the R-CNN global computer vision model hosted on a cloud server, Mobinet computer vision models, and Logistic Regression with Iterative Learning. VISISENSE's effectiveness is demonstrated by a performance analysis of its object detection accuracy, processing speed, resource utilization, energy consumption, latency, and false positive rate. In all of these categories, VISISENSE performs better than Smart Stick and Smart Navigation. The data includes the fastest processing time of 17 ms, the most efficient resource utilization of 41%, and object detection accuracy of up to 99% at 2 Mbps load. Across all load conditions, VISISENSE has the lowest false positive rate, energy consumption, and latency. The VISISENSE assistive technology system is developed for the visually impaired. Its excellent object detection and navigation accuracy, speed, and efficiency enhance user experience and hold the potential to increase the independence and quality of life for visually impaired people. This research contributes to a significant advancement in assistive devices-smart, responsive technologies for the visually impaired.

Article Details

  • Kate Kalcevich
  • Feb 19, 2024

Mobile Accessibility Barriers For Assistive Technology Users

  • 10 min read
  • Accessibility , Usability , Design
  • Share on Twitter ,  LinkedIn

About The Author

Kate Kalcevich is the Head of Accessibility Innovation at Fable, a leading accessibility testing platform powered by people with disabilities. Kate has … More about Kate ↬

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I often hear that native mobile app accessibility is more challenging than web accessibility. Teams don’t know where to start, where to find guidance on mobile accessibility, or how to prevent mobile-specific accessibility barriers.

As someone who works for a company with an active community of mobile assistive technology users, I get to learn about the challenges from the user’s perspective. In fact, I recently ran a survey with our community about their experiences with mobile accessibility, and I’d like to share what I learned with you.

If you only remember one thing from this article, make it this:

Half of assistive technology users said that accessibility barriers have a significant impact on their day-to-day well-being.

Accessibility goes beyond making products user-friendly. It can impact the quality of life for people with disabilities.

Types Of Mobile Assistive Technology

I typically group assistive technologies into three categories:

  • Screen readers : software that converts information on a screen to speech or braille.
  • Screen magnifiers : software or system settings to magnify the screen, increase contrast, and otherwise modify the content to make it easier to see.
  • Alternative navigation : software and/or hardware that replaces an input device such as a keyboard, mouse, or touchscreen.

Across all categories of assistive technology, 81% of the people I surveyed change the accessibility settings on their smartphone and/or tablet. Examples of accessibility settings include the following:

  • Increasing the font size;
  • Turning on captions;
  • Extending the tap duration;
  • Inverting colours.

There are smartphone settings such as dark mode that benefit people with disabilities even though they aren’t considered accessibility settings.

Now, let’s dive into the specifics of each assistive technology category and learn more about the user preferences that shape their digital experiences.

Screen Reader Users

Both iPhone and Android smartphones come with a screen reader installed. On iPhone, the screen reader is VoiceOver, and on Android, it is TalkBack. Both screen readers allow users to explore by touching and dragging their fingers to hear content under their fingers read out loud or to swipe forwards and backward through all elements on the screen in a linear fashion. Both screen readers also let users navigate by headings or other types of elements.

The mobile screen reader users I surveyed tend to have several devices that work together to cover all their accessibility needs, and they support businesses that prioritize mobile accessibility.

  • Nearly half of screen reader users also own a smartwatch.
  • Half use an external keyboard with their smartphone, and a third use a braille display.
  • Almost all factor the accessibility of apps and mobile sites into deciding which businesses to support.

That last point is really important! Accessibility truly inspires purchasing decisions and brand loyalty.

Screen Magnification Users

In addition to magnification, Android smartphones also have a variety of vision-related accessibility features that allow users to change screen colours and text sizes. The iPhone Magnifier app lets users apply colour filters, adjust brightness or contrast, and detect people or doors nearby.

My survey showed that screen magnification users had the highest percentage of tablet ownership, with 77% owning both a smartphone and a tablet. Alternative navigation users followed closely, with 62% owning a tablet, but only 42% of the screen reader users I surveyed own a tablet.

Screen magnification users are less likely to investigate the accessibility of paid apps before purchasing (63%) compared to screen reader and alternative navigation users (89% and 91%, respectively). I suspect this is because device magnification, contrast, and colour inversion settings may allow users to work around some design choices that make an app inaccessible.

Alternative Navigation Users

Switch Access (Android) and Switch Control (iOS) let users interact with their devices using one or more switches instead of the touchscreen. There are a variety of things you can use as a switch: an external device, keyboard, sounds, or the smartphone camera or buttons.

Item scan allows users to highlight items one by one and select an item in focus by activating the switch. Point and scan moves a horizontal line down from the top of the screen. When this line is over the desired element, the user selects their switch to stop it. A vertical line then moves from the left of the screen. When this line is also over the element, the user stops it with their switch. The user can then select the element in the cross hairs of the two lines. In addition to these two methods, users can also customize buttons to perform gestures such as swipe down or swipe left.

Android and iPhone devices can be controlled through Voice Access and Voice Control. Both allow users to speak commands to interact with their smartphone instead of using the touchscreen. The command “Say names” can expose labels that aren’t obvious. The command “Show numbers” allows users to say “tap two” to select the element labeled with the number 2. “Show grid” is a command often used as a last resort to select an element. This approach overlays a grid across their screen area and allows users to select the grid square where the element is in focus.

Alternative navigation users were least likely to own a smartwatch (26%) out of all three assistive technology categories, according to my survey. All the alternative navigation users that own a smartwatch, except for one, use it for health tracking. 24% use an external switch device with their smartphone.

Most Common Mobile Accessibility Barriers

Now that you know about some of the assistive technologies available on Android and iPhone devices, we can explore some specific challenges commonly encountered by users when navigating websites and native apps on their smartphones.

I’ll outline an inclusive development process that can help you discover barriers that are specific to your own app. If you need general tips on what to avoid right now , here are common mobile accessibility issues that assistive technology users encounter. To get this list, I asked the community to select up to three of their most challenging accessibility barriers on mobile.

Unlabelled Buttons Or Links

Unlabelled buttons and links are the number one challenge reported by assistive technology users. Screen reader users are impacted the most by unlabelled elements, but also people who use voice commands to interact with their smartphone.

Small Buttons Or Links

Buttons and links that are too small to tap with a finger or require great precision to select using switch functions are a challenge for anyone with mobility issues. Tiny buttons and links are also hard to see for anyone with low vision.

Gesture Interactions

Gestures like swipe to delete, tap and drag, and anything more complex than a simple tap or double tap can cause problems for many users. Gestures can be difficult to discover, and if you’re not a power mobile user, you may never figure them out. Your best bet is to include a button to perform the same action that a gesture can perform. Custom actions can expose more options, but only to assistive technology users and not to people with disabilities that may not use assistive technology, for example, cognitive disabilities.

Elements Blocking Parts Of The Screen

A chat button that is always hovering and may cover parts of the content. A sticky header or footer that takes up a big portion of the screen when the user zooms in or magnifies their screen. These screen blockers can make it very difficult or impossible for some users to view content.

Missing Error Messages

Keeping a submit button inactive until a form is correctly filled out is often used as an alternative to providing error messages. That approach can be a challenge for assistive technology users in particular, but also anyone with a cognitive disability or who isn’t tech-savvy. Sometimes, error messages exist, but they aren’t announced to screen reader users.

Resizing Text And Pinch And Zoom

When an app doesn’t respect the font size increases set by a user through accessibility settings, people who need larger text must find alternative ways to read content. Some websites disable pinch and zoom — a feature that is not just useful for enlarging text but is often used to see images better.

Other Mobile Accessibility Barriers

The accessibility barriers that weren’t mentioned as often but still represent significant challenges for assistive technology users include:

  • Low contrast If the contrast between text and background is low, it makes it harder for folks with low vision to read. Customizing contrast settings can make content more legible for a broader range of people.
  • No dark mode For some people, black text on a white background can be painful to the eyes or trigger migraines.
  • Fixed orientation Not being able to rotate from portrait to landscape can impact people who have their device in a fixed position on a wheelchair or people with low vision who use landscape mode to make text and images appear larger.
  • Missing captions No captions on videos were also cited as a barrier. This is one that I relate to personally, as I rely on captions myself because of my hearing disability.

I knew I couldn’t capture all of the mobile accessibility barriers in my list of choices, so I gave the survey respondents a free text field to enter their own. Here’s what they said:

  • Screen reader users encounter unlabelled images or labels that don’t make sense. AI-based image recognition technology can help but often can’t provide the same context that a designer would. Screen reader users also run into apps that unexpectedly move their screen reader’s focus, changing their location on the screen and causing confusion.
  • Voice Control users find apps and sites that aren’t responsive to their voice commands. They have to try alternate commands to activate interactive elements, sometimes slowing them down significantly.
  • Complex navigation, such as large, dynamic lists or menus that expand and collapse automatically, can be challenging to use with assistive technologies. There aren’t often workarounds to interacting with navigation, so this can influence whether a user will abandon an app or website.

Inclusive Design Approaches For Mobile

It’s important to avoid getting overwhelmed and not doing anything at all because mobile accessibility seems hard. Instead, focus on fixing the most critical issues first, then release, celebrate, and repeat the process.

Ideally, you’ll want to change your processes to avoid creating more accessibility issues in the future. Here’s a high-level process for inclusive app development:

  • Do research with users to understand how their assistive technology works and what challenges they have with your existing app.
  • Create designs for accessibility features such as font scaling and state and focus indicators.
  • Revise designs and get feedback from users that can be applied in development.
  • Annotate design files for accessibility based on user feedback and best practices.
  • Create a new build and use automated testing tools to find barriers.
  • Do manual QA testing on the new build using your phone’s accessibility settings.
  • Release a private build and test with users again before the production release.

Fixing and, more importantly, avoiding mobile accessibility barriers can be easier if you understand how assistive technologies work and the common challenges users encounter on mobile devices. Remember the key takeaway from the beginning of this article: half of the people surveyed felt accessibility barriers had a significant impact on their well-being . With that in mind, I encourage you not to let a lack of understanding of technical accessibility compliance hold you back from building inclusive apps and mobile-friendly websites.

When you look at accessibility from the lens of usability for everyone and learn from assistive technology users, you take a step towards empowering everyone to independently interact with your products and services, playing your part in building a more equitable Internet.

Further Reading On SmashingMag

  • “ Making Sense Of WAI-ARIA: A Comprehensive Guide ,” Kate Kalcevich
  • “ A Guide To Accessible Form Validation ,” Sandrina Pereira
  • “ Windows High Contrast Mode, Forced Colors Mode And CSS Custom Properties ,” Eric Bailey
  • “ Testing Sites And Apps With Blind Users: A Cheat Sheet ,” Slava Shestopalov & Eugene Shykiriavyi

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Smart glove teaches new physical skills

Press contact :.

Collage of four images of a hand wearing a white, fabric-based glove with black fingertips and haptics and sensors sewn in. Two use cases shown include manipulating a robotic arm and playing a piano.

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You’ve likely met someone who identifies as a visual or auditory learner, but others absorb knowledge through a different modality: touch. Being able to understand tactile interactions is especially important for tasks such as learning delicate surgeries and playing musical instruments, but unlike video and audio, touch is difficult to record and transfer.

To tap into this challenge, researchers from MIT’s Computer Science and Artificial Intelligence Laboratory (CSAIL) and elsewhere developed an embroidered smart glove that can capture, reproduce, and relay touch-based instructions. To complement the wearable device, the team also developed a simple machine-learning agent that adapts to how different users react to tactile feedback, optimizing their experience. The new system could potentially help teach people physical skills, improve responsive robot teleoperation, and assist with training in virtual reality.

An open-access paper describing the work was published in Nature Communications on Jan. 29.

Will I be able to play the piano? To create their smart glove, the researchers used a digital embroidery machine to seamlessly embed tactile sensors and haptic actuators (a device that provides touch-based feedback) into textiles. This technology is present in smartphones, where haptic responses are triggered by tapping on the touch screen. For example, if you press down on an iPhone app, you’ll feel a slight vibration coming from that specific part of your screen. In the same way, the new adaptive wearable sends feedback to different parts of your hand to indicate optimal motions to execute different skills.

The smart glove could teach users how to play the piano, for instance. In a demonstration, an expert was tasked with recording a simple tune over a section of keys, using the smart glove to capture the sequence by which they pressed their fingers to the keyboard. Then, a machine-learning agent converted that sequence into haptic feedback, which was then fed into the students’ gloves to follow as instructions. With their hands hovering over that same section, actuators vibrated on the fingers corresponding to the keys below. The pipeline optimizes these directions for each user, accounting for the subjective nature of touch interactions. “Humans engage in a wide variety of tasks by constantly interacting with the world around them,” says Yiyue Luo MS ’20, lead author of the paper, PhD student in MIT’s Department of Electrical Engineering and Computer Science (EECS), and CSAIL affiliate. “We don’t usually share these physical interactions with others. Instead, we often learn by observing their movements, like with piano-playing and dance routines. “The main challenge in relaying tactile interactions is that everyone perceives haptic feedback differently,” adds Luo. “This roadblock inspired us to develop a machine-learning agent that learns to generate adaptive haptics for individuals’ gloves, introducing them to a more hands-on approach to learning optimal motion.”

The wearable system is customized to fit the specifications of a user’s hand via a digital fabrication method. A computer produces a cutout based on individuals’ hand measurements, then an embroidery machine stitches the sensors and haptics in. Within 10 minutes, the soft, fabric-based wearable is ready to wear. Initially trained on 12 users’ haptic responses, its adaptive machine-learning model only needs 15 seconds of new user data to personalize feedback. In two other experiments, tactile directions with time-sensitive feedback were transferred to users sporting the gloves while playing laptop games. In a rhythm game, the players learned to follow a narrow, winding path to bump into a goal area, and in a racing game, drivers collected coins and maintained the balance of their vehicle on their way to the finish line. Luo’s team found that participants earned the highest game scores through optimized haptics, as opposed to without haptics and with unoptimized haptics.

“This work is the first step to building personalized AI agents that continuously capture data about the user and the environment,” says senior author Wojciech Matusik, MIT professor of electrical engineering and computer science and head of the Computational Design and Fabrication Group within CSAIL. “These agents then assist them in performing complex tasks, learning new skills, and promoting better behaviors.” Bringing a lifelike experience to electronic settings

In robotic teleoperation, the researchers found that their gloves could transfer force sensations to robotic arms, helping them complete more delicate grasping tasks. “It’s kind of like trying to teach a robot to behave like a human,” says Luo. In one instance, the MIT team used human teleoperators to teach a robot how to secure different types of bread without deforming them. By teaching optimal grasping, humans could precisely control the robotic systems in environments like manufacturing, where these machines could collaborate more safely and effectively with their operators.

“The technology powering the embroidered smart glove is an important innovation for robots,” says Daniela Rus, the Andrew (1956) and Erna Viterbi Professor of Electrical Engineering and Computer Science at MIT, CSAIL director, and author on the paper. “With its ability to capture tactile interactions at high resolution, akin to human skin, this sensor enables robots to perceive the world through touch. The seamless integration of tactile sensors into textiles bridges the divide between physical actions and digital feedback, offering vast potential in responsive robot teleoperation and immersive virtual reality training.” Likewise, the interface could create more immersive experiences in virtual reality. Wearing smart gloves would add tactile sensations to digital environments in video games, where gamers could feel around their surroundings to avoid obstacles. Additionally, the interface would provide a more personalized and touch-based experience in virtual training courses used by surgeons, firefighters, and pilots, where precision is paramount. While these wearables could provide a more hands-on experience for users, Luo and her group believe they could extend their wearable technology beyond fingers. With stronger haptic feedback, the interfaces could guide feet, hips, and other body parts less sensitive than hands. Luo also noted that with a more complex artificial intelligence agent, her team's technology could assist with more involved tasks, like manipulating clay or driving an airplane. Currently, the interface can only assist with simple motions like pressing a key or gripping an object. In the future, the MIT system could incorporate more user data and fabricate more conformal and tight wearables to better account for how hand movements impact haptic perceptions.

Luo, Matusik, and Rus authored the paper with EECS Microsystems Technology Laboratories Director and Professor Tomás Palacios; CSAIL members Chao Liu, Young Joong Lee, Joseph DelPreto, Michael Foshey, and professor and principal investigator Antonio Torralba; Kiu Wu of LightSpeed Studios; and Yunzhu Li of the University of Illinois at Urbana-Champaign.

The work was supported, in part, by an MIT Schwarzman College of Computing Fellowship via Google and a GIST-MIT Research Collaboration grant, with additional help from Wistron, Toyota Research Institute, and Ericsson.

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  • Wojciech Matusik
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The Effectiveness of Assistive Technologies for Older Adults and the Influence of Frailty: Systematic Literature Review of Randomized Controlled Trials

Marina liselotte fotteler.

1 DigiHealth Institute, Neu-Ulm University of Applied Sciences, Neu-Ulm, Germany

2 Research Unit on Ageing, Agaplesion Bethesda Clinic Ulm, Ulm, Germany

3 Institute for Geriatric Research, Ulm University, Ulm, Germany

4 Geriatric Center Ulm/Alb-Donau, Ulm, Germany

Viktoria Mühlbauer

Simone brefka, sarah mayer, brigitte kohn.

5 Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany

6 Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, United States

Walter Swoboda

Petra gaugisch.

7 Fraunhofer-Institute for Industrial Engineering, Stuttgart, Germany

Beate Risch

Michael denkinger, dhayana dallmeier.

8 Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States

Associated Data

PRISMA Checklist.

Search string.

Crossover vote.

Excluded articles based on full-text review.

Quantitative outcome data.

The use of assistive technologies (ATs) to support older people has been fueled by the demographic change and technological progress in many countries. These devices are designed to assist seniors, enable independent living at home or in residential facilities, and improve quality of life by addressing age-related difficulties.

We aimed to evaluate the effectiveness of ATs on relevant outcomes with a focus on frail older adults.

A systematic literature review of randomized controlled trials evaluating ATs was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Ovid Medline, PsycINFO, SocIndex, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and IEEEXplore databases were searched from January 1, 2009, to March 15, 2019. ATs were included when aiming to support the domains autonomy, communication, or safety of older people with a mean age ≥65 years. Trials performed within a laboratory setting were excluded. Studies were retrospectively categorized according to the physical frailty status of participants.

A total of 19 trials with a high level of heterogeneity were included in the analysis. Six device categories were identified: mobility, personal disease management, medication, mental support, hearing, and vision. Eight trials showed significant effectiveness in all or some of the primary outcome measures. Personal disease management devices seem to be the most effective, with four out of five studies showing significant improvement of disease-related outcomes. Frailty could only be assessed for seven trials. Studies including participants with significant or severe impairment showed no effectiveness.

Conclusions

Different ATs show some promising results in well-functioning but not in frail older adults, suggesting that the evaluated ATs might not (yet) be suitable for this subgroup. The uncertainty of the effectiveness of ATs and the lack of high-quality research for many promising supportive devices were confirmed in this systematic review. Large studies, also including frail older adults, and clear standards are needed in the future to guide professionals, older users, and their relatives.

Trial Registration

PROSPERO CRD42019130249; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130249

Introduction

Advancements in medicine and public health have led to a rise in life expectancy and are among the main reasons for the changing demographic structure in many countries. In the European Union, the share of people aged 65 years and over is projected to rise by almost 31 million (or 7%) until 2040, while the overall population is estimated to decrease by approximately 1 million [ 1 ]. The growing number of older citizens, often with multiple morbidities, leads to an increased demand for health care services and professionals [ 2 ]. Coupled with rising costs for diagnosis and treatment, politicians and stakeholders anticipate difficulties in providing adequate care in the near future. One essential approach is to empower older adults to manage their own health and remain independent as long and extensive as possible [ 3 ].

The use of assistive technologies (ATs) in older persons’ care has been fueled by these developments, helping to maintain seniors’ autonomy, safety, or communication at home or in residential facilities [ 4 - 8 ]. Thus, ATs may not only increase older adults’ quality of life (QoL) but also contribute to a relief of health care systems and, in particular, formal and informal caregivers [ 2 ]. In recent years, a variety of devices addressing problems associated with, for example, dementia [ 9 - 11 ], hypertension [ 12 , 13 ], Parkinson disease [ 14 , 15 ], and loneliness [ 16 ] have entered the market. In the literature, the term AT is used to include, among others, telemedical applications [ 17 , 18 ], robotics [ 4 , 19 ], virtual reality [ 20 , 21 ], and sensors [ 22 ], but can also cover more conventional technologies such as hearing or vision aids [ 23 , 24 ]. The lack of a uniform definition and the resulting heterogeneity preclude harmonized recommendations, guidance, and structured research [ 4 , 25 - 27 ]. Despite a large amount of existing literature on the use of ATs for older people, the effectiveness of these devices remains unclear [ 3 , 18 , 28 - 30 ]. Users, as well as their formal and informal caregivers, are often overwhelmed by the different options, and up-to-date guidance from insurance companies or other institutions is lacking [ 31 - 33 ].

Previous research has shown that, so far, AT is not likely to replace personal care but rather to supplement it [ 34 ]. Ideally, older adults should be able to use ATs with no or little help or supervision to avoid adding workload to the caregiver [ 35 ]. In particular, frail older adults with increased dependency could benefit from AT. However, this population often expresses a mixed attitude toward ATs and needs special support when using these devices [ 36 ]. The process of becoming a regular user of AT as an older adult is complex [ 3 , 36 - 38 ]. Usability, the ease of integration into daily life, access and affordability, and individual aspirations and characteristics are some factors influencing the use of AT among older adults [ 29 , 38 , 39 ].

In this study, we systematically reviewed randomized controlled trials (RCTs) to provide a synthesis of high-quality evidence on the effectiveness of ATs for nonfrail and frail older adults. In this context frailty is defined as “a state of increased vulnerability to poor resolution of homeostasis following a stress, which increases the risk of adverse outcomes including falls, delirium and disability” [ 40 ]. It has been previously suggested that frailty also firmly relates to functional status [ 41 ]. We defined the effectiveness of ATs as the capability to positively impact issues related to autonomy, communication, and/or safety. These three areas of impact were chosen by an expert committee within the project Future City Ulm 2030, which aims to design a holistic and sustainable urban environment with the inclusion of digital solutions such as ATs. RCTs are widely considered to be the gold standard for effectiveness research, providing the highest level of evidence for causality [ 42 ]. The analysis in this review was based on this concept. Three research questions were defined:

RQ1: What are the primary measures used to evaluate ATs?

RQ2: What types of ATs have effectively influenced autonomy, communication, and/or safety in adults aged 65 years and older?

RQ3: What influence does frailty have on the effectiveness of an AT?

A systematic literature review was performed using the guidelines from the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [ 43 ] (see the PRISMA Checklist in Multimedia Appendix 1 ). The analysis was based on a protocol published in the PROSPERO register under registration number CRD42019130249.

Search Strategy

The following databases were searched: Ovid Medline, PsycINFO, SocIndex, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and IEEEXplore. The search string was composed of three parts, focusing on age, methodology, and technology, respectively, combined by the operator AND. The three parts were (1) a previously published search filter for geriatric medicine [ 44 ], adapted slightly for the purpose of this study; (2) a sensitivity- and precision-maximizing version of the Cochrane RCT filter in the Ovid format [ 45 ]; and (3) a string for technology developed with experts and terms used for AT identified through other related systematic reviews [ 28 , 37 , 46 ]. The complete search string in the Ovid syntax is provided in Multimedia Appendix 2 ; the string was adapted to fit the requirements of other databases. Searches were performed on March 15, 2019, and all records were imported to the web-based software Covidence for screening. Reference lists of the selected studies and other systematic reviews on the topic were screened for additional records.

Inclusion and Exclusion Criteria

Eligible for inclusion were peer-reviewed studies published in English or German between January 1, 2009, and March 15, 2019, reflecting the momentum that research on the effectiveness of AT has gained in the last decade. The date restriction was the only filter used in the database search. We included technologies that can assist with issues regarding autonomy, communication, or safety. Other inclusion criteria were (1) a study population with a mean age of 65 years or higher; (2) the study design being an RCT, including a control group with no intervention, an alternative intervention, or a placebo device; (3) the home of the senior, a residential facility, a nursing home, or similar as the study setting; and (4) any sort of technical, socioeconomic, ethical, or medical outcome measuring the impact of the technology on stakeholders (eg, patients, relatives, nurses, physicians).

Exclusion criteria were (1) studies performed in a laboratory setting; (2) studies analyzing robotics, virtual reality, telemedicine, or lifestyle interventions or technologies for rehabilitative or therapeutic purposes; (3) technologies demanding regular involvement of formal or informal caregivers; and (4) applications that have to be used in periodic training units. These exclusion criteria were selected to focus the analysis on technologies that are affordable and usable for the target population in their daily life without external support from relatives, caregivers, or medical staff.

Data Extraction and Analysis

Two authors (MLF and VM) independently screened all records and the studies selected for full-text analysis. Discrepancies were discussed and a third person was consulted, if necessary, until consensus was reached. Data extraction was carried out independently by both authors. The effectiveness of devices was recorded by extracting outcome data and statistical significance for primary outcome measures ( P <.05). RCTs with a crossover design were individually analyzed for potential carryover effects by three authors (MLF, VM, and MD) (see Multimedia Appendix 3 ). If a serious impact was expected, only the first part of the study until the crossover was considered to ensure comparability with noncrossover trials. In semicrossover or delayed-start trials, where the control group switches to the intervention after a predefined period, only the first study phase was analyzed, making such studies identical to RCTs with a parallel-group design.

In cases of missing data, authors were contacted via email up to twice. The study population’s frailty status was categorized retrospectively according to their functional level into one of the four following categories: not impaired/independent (nonfrail), slightly impaired (prefrail), significantly impaired, and severely impaired/disabled (frail) [ 41 ]. A risk of bias (RoB) analysis was performed according to the Cochrane RoB tool to judge the quality of the selected studies [ 47 ]. Funding and the recruitment process were also assessed. Due to the heterogeneity of interventions and outcomes, it was not possible to perform a meta-analysis. A qualitative synthesis and a narrative review were performed to interpret study results and draw conclusions. To identify additional insights, subgroups according to frailty status and device category were considered. Figures were created using Microsoft PowerPoint and Excel for Mac Version 16.35.

Included Studies

After removal of duplicates, the search yielded 11,399 records. No articles were identified through other sources as described above. A total of 54 full texts were assessed for eligibility, 21 of which were included in the review ( Figure 1 ). Reasons for exclusion of full texts were (1) the kind of intervention (such as the evaluation of training sessions or the use of therapeutic devices; n=10), (2) a study protocol without full publication (n=6), (3) the patient population being too young (n=6), (4) a different setting (mostly laboratory, n=6), and (5) a different study design (n=6) (also see Multimedia Appendix 4 ). The 21 records covered 19 individual trials with a total study population of 1768 participants.

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PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram for the study selection process.

Description of Studies

Table 1 summarizes data on the design and participants of the 19 studies included in the analysis. The articles were published between 2010 and 2018. The trend shows an increase in research output across 2017 and 2018, the years with the highest number of publications respectively (n=4). Overall, most studies were conducted in Europe (n=10), followed by five studies from the United States. Among the 19 studies, 10 were confirmatory RCTs and the rest were pilot or feasibility RCTs. Most studies employed a regular parallel-group design. Two studies were conducted using a delayed-start/semicrossover approach [ 23 , 48 ] and five studies employed a crossover design [ 8 , 11 , 14 , 24 , 27 ]. Of those five, two trials were judged to have a low risk of carryover, one studying an electronic vision enhancement system [ 24 ] and the other evaluating the benefit of video calls versus regular phone calls for patients with dementia [ 8 ].

Overview of included studies, describing the study design and participants.

a IG: intervention group.

b CG: control group.

c Crossover study with expected carryover effect.

d Crossover study without expected carryover effect.

Having a mean age ≥65 years as an inclusion criterion for our search, there were still large differences in the inclusion criteria at the study level: ≥18 years in three studies [ 13 , 14 , 24 ], 45-90 years in one study [ 17 ], 55-79 years in one study [ 49 ], ≥60 years in one study [ 11 ], and ≥65 years in six studies [ 7 , 23 , 50 - 53 ]. The other seven trials did not have age as an inclusion criterion but targeted conditions present specifically in older adults, such as cardiovascular conditions, dementia, or being a senior housing resident [ 6 , 8 , 12 , 22 , 27 , 48 , 54 ]. Table 1 provides the mean (SD) age for each study stratified by intervention and control group.

Most studies had participants’ homes as their study site (n=14). The investigation period varied from 1 month [ 8 , 11 , 14 , 17 ] to 12 months [ 7 , 22 , 23 ]. The largest trial included 203 study participants [ 52 ]. The mean ages of study populations ranged from 68.9 years to 87.8 years. Only one study assessed frailty at baseline based on the Fried Frailty Score [ 53 ]. Frailty could be estimated retrospectively for six other studies [ 7 , 14 , 22 , 23 , 50 , 54 ]. On average, the frailty levels were found to be slightly impaired/prefrail (n=4), significantly impaired/frail (n=1), and severely impaired/frail (n=1) ( Table 2 ).

Frailty assessment.

a Categorized according to a method proposed by Brefka et al [ 41 ], except for Schoon et al [ 53 ].

b ADL: activities of daily living.

c Collection of ADL and IADL also mentioned with no data reported but provided by the authors upon request.

d IADL: instrumental activities of daily living.

e Timed-Up-and-Go test also performed with inconclusive results.

Types of ATs and Effectiveness

The 19 selected trials evaluated devices representing the following six domains: (1) mobility (n=5 [ 6 , 7 , 14 , 52 , 53 ]), (2) personal disease management (n=5 [ 13 , 22 , 48 , 51 , 54 ]), (3) medication (n=4 [ 12 , 17 , 27 , 50 ]), (4) mental support (n=2 [ 8 , 11 ]), (5) hearing (n=2 [ 23 , 49 ]), and (6) vision (n=1 [ 24 ]). All devices addressed at least one of the areas of autonomy, safety, or communication. An overlap was noticeable in the categories mobility and medication with devices targeting both autonomy and safety issues ( Table 2 ). Interventions, controls, and primary outcomes studied in the included trials are presented in Table 2 .

Significant effectiveness was only reported in a pilot study for a nightlight path, which reduced falls among older people classified as slightly impaired/prefrail who had mild and moderate Alzheimer disease (odds ratio 0.73, 95% CI 0.15-0.88) [ 7 ]. Home automatization for people with dementia living in group homes [ 6 ], a mobile safety alarm with a drop sensor for community-dwelling older persons [ 52 ], and a gait-speed monitoring and feedback device for older people at risk for falling [ 53 ] were not effective. In a crossover study on the use of a metronome to improve QoL in individuals classified as slightly impaired/prefrail who were suffering from Parkinson disease, no evidence of effectiveness could be shown. The authors reported the possible impact of a carryover effect, which we agree with. Unfortunately, separate data were not reported for the first part of the study and could not be obtained from the authors [ 14 ].

Personal Disease Management

A system consisting of a tablet computer connected to a patient scale was effective for participants classified as slightly impaired/prefrail who had heart failure. Both primary endpoints, the effect on self-care behavior and health-related QoL, improved in the intervention group after a 90-day trial. System adherence was high with a median of 88% (IQR 78%-96%) [ 54 ]. In a semicrossover trial of a device reminding participants suffering from type 2 diabetes to perform self-monitoring of blood glucose, between-group comparison did not show improved levels of glycated hemoglobin. However, participants in the intervention group experienced a statistically significant decrease. Furthermore, the intervention group missed 6% of their measures and the control group missed 22% of measures, representing a statistically significant difference [ 48 ]. In another study, a medical alert protection system for older persons living alone was found to be effective in reducing the length of stay for hospital admissions. However, the number of emergency department visits and hospitalizations could not be significantly reduced [ 51 ]. In a pilot RCT evaluating the effect of a tablet computer–based self-monitoring system for older people suffering from type 2 diabetes and/or hypertension, systolic blood pressure was significantly more reduced in the intervention group compared with the control group. No significant differences were observed for diastolic blood pressure, blood glucose, glycated hemoglobin, chronic disease knowledge, and monitoring frequency. The within-group comparison showed a significant improvement of diastolic blood pressure in the intervention group (∆=–5.7, 95% CI –9.3 to –2.2). Approximately 30% (9/33) of participants in the intervention group reported technical problems [ 13 ]. An environmentally embedded sensor system for early illness alerts was not effective for a severely impaired/frail population [ 22 ].

A study of a tablet-based app for medication self-management reported a significant improvement in adherence as well as the number of missed doses (27.3% reduction in the intervention group) in a slightly impaired/prefrail population. A reduction of medication errors was only found for patients with a higher error rate prior to the study. Although the mean satisfaction score with the AT in the intervention group was high (8.5 out of 10), 59% (30/51) of intervention group participants required assistance using the AT and almost 12% (6/51) stated that the device did not help at all [ 50 ]. In a trial evaluating a “talking pill bottle,” informing hypertensive adults with low health literacy about the correct administration and dosage of their medication, no between-group effect but a significant reduction in blood pressure within the intervention group was reported. Additionally, a vast majority of participants found the device easy to use (63/68, 93%) and many agreed that it helped them to understand (77%) and correctly take their medication (74%) [ 12 ]. Two telemedical medication reminders (smartphone and pillbox) did not improve medication adherence [ 17 ]. A crossover trial of electronic blisters with an expected carryover did not report significant results [ 27 ].

Mental Support

A multimedia device with personalized music, videos, messages, and pictures installed by family members was tested in a pilot sample of 11 nursing home residents. Almost half of the participants needed assistance operating the device due to limited sensory or cognitive abilities. Nevertheless, staff and family members agreed they would recommend the AT for residents with dementia. During the 2-month crossover period, depression and anxiety were significantly reduced in the intervention group. However, a carryover effect seems likely, and no data are available for the precrossover phase of the study [ 11 ]. In the second study, video calls with family members were not effective in reducing agitation in nursing home residents with dementia [ 8 ]. A retrospective analysis of frailty was not possible for the studies evaluating ATs for mental support.

Humes et al [ 49 ] compared the best-practice service for hearing aids to an over-the-counter and a placebo device, and found that both the best-practice and the over-the-counter device did effectively benefit participants. Only participants testing the best-practice device showed greater satisfaction than the placebo group. No differences in usage (hours/day) were detected among the groups [ 49 ]. In another RCT, hearing aids did not significantly improve dementia-related symptoms or QoL in older adults classified as significantly impaired/frail or benefit their caregivers [ 23 , 55 ].

A portable electronic vision enhancement system was compared to conventional optical magnifiers in a crossover trial that was published in two articles [ 24 , 56 ]. The authors did not report separate data for the first study phase before the crossover. However, a carryover effect was not expected in this study. Near-vision visual function was significantly improved (∆=0.57, 95% CI 0.33-0.81) [ 24 ]. Although reading speed did not significantly increase when using the portable device, the researchers significantly associated the accessibility of smaller print sizes and the ease of carrying out other tasks with the portable device. When considering frequency of use, the study participants seemed to prefer optical low-vision aids to the electronic system (unstandardized effect size estimate –0.93, 95% CI –1.29 to –0.57) [ 56 ]. An economic evaluation was also performed, and the authors concluded that the AT was a cost-effective way to improve near-vision visual function with an incremental cost-effectiveness ratio of US $997.12 (95% CI US $651.89-2066.92) per unit. Improvements in QoL did not prove cost-effective [ 24 ]. A retrospective analysis of frailty was not possible for these studies evaluating ATs supporting vision.

Evaluation of Risk of Bias of the Included Studies

Figure 2 and Figure 3 show the results of the RoB analysis. In four categories, we considered more than 30% of the studies to have a high RoB due to issues in blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, and recruitment bias. The crossover studies had a lower RoB. In three studies, analyzing a medication self-management app [ 50 ], electronic vision enhancement system [ 24 , 56 ], and multimedia device for people with dementia [ 11 ], no category was judged to have a high RoB ( Figure 3 ). All studies had incomplete reporting for at least one category. A full RoB assessment was therefore not possible.

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Judgment of risk of bias categories for each included study presented as percentages across all included studies.

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Judgment of risk of bias categories for each included study, ordered by assistive technology category and publication year.

From the available information, it appears that testing an AT often purports difficulties with blinding participants and personnel. Nevertheless, unblinded studies are considered to have a higher RoB. In six studies, outcome assessors were not blinded, although it would have been possible [ 6 , 7 , 12 , 17 , 22 , 48 , 54 ]. These studies were thus judged to have a high RoB. Several studies had missing data or skewed dropout rates, and were thus considered to be at high RoB for incomplete outcome reporting [ 14 , 22 , 23 , 27 , 51 , 53 , 54 ]. The recruitment process was deemed to be sufficient in most studies. For six studies, it was judged that there was a high risk for the study population not being representative of the target population [ 8 , 17 , 22 , 48 , 49 , 52 ]. Only one study was judged to have a high RoB due to funding. The rationale for this decision was that the manufacturing company of the devices tested was the study sponsor and had a major influence on the study design [ 27 ].

Outcome Assessment

A total of 70 primary outcome measures were extracted from the 19 trials ( Table 3 and Multimedia Appendix 5 ). ATs were evaluated using measures focusing on efficacy (n=30), functionality (n=8), mental status (n=8), QoL (n=7), health-related impact (eg, knowledge, behavior; n=5), usability (n=5), effect on caregivers (n=5), and economic aspects (n=2). The two trials with two publications each reported the largest diversity of measures with five (QoL, functionality, mental status, health impact, caregivers) [ 23 , 55 ] and four (QoL, efficacy, usability, economic) [ 24 , 56 ] outcome categories covered, respectively. The highest overall number of primary outcomes was collected by two studies with eight measures, respectively [ 6 , 22 ].

Overview of interventions, domain(s) of interest, and outcomes studied in the included trials.

a If no distinction between primary and secondary outcomes was made, all outcomes are listed.

b A: autonomy.

c S: safety.

d C: communication.

e QoL: quality of life.

f Automatic measurement of certain variables (eg, velocity, step length) while participants walk across the GAITRite Mat.

g ADL: activities of daily living.

h IADL: instrumental activities of daily living.

Unfortunately, six outcome measures from crossover studies with expected carryover could not be analyzed due to a lack of data for the first phase of the study. Of the remaining 64 outcomes, 13 (20%) showed a significantly positive effect of the AT in the categories efficacy, usability, and QoL. However, considering the RoB, seven of those outcomes, covering all three categories, might be impacted [ 7 , 13 , 48 , 49 , 51 , 54 ] ( Table 4 ). More detailed data on individual quantitative outcomes (test statistics, effect sizes, significance levels) can be found in Multimedia Appendix 5 .

Statistically significant outcome measures including a judgment of high risk of bias (RoB).

a QoL: quality of life.

b IG: intervention group.

c CG: Control group.

Principal Findings

To our knowledge, this systematic review is the first to collect and synthesize evidence exclusively from RCTs evaluating the effectiveness of ATs for older adults in a realistic living environment (ie, no laboratory setting), taking into account participants’ frailty status. More than 11,000 records were identified from a broad range of databases with different focuses. Only 19 RCTs fulfilled the inclusion criteria. The selected trials were very heterogeneous with respect to the ATs applied as well as the outcomes, which made it difficult to summarize the evidence [ 57 ]. Our analysis did not provide strong confirmation for the overall effectiveness of AT in older adults. Only personal disease management apps seem to be promising for this population.

Many older citizens wish to remain independent and continue living at home for as long as possible [ 58 ]. The hope is that AT can support this goal, positively impacting QoL, reducing health care utilization, and relieving caregivers [ 2 ]. The results of this review suggest some effectiveness of personal disease management apps. Four of the five personal disease management trials showed a significant improvement in self-care and monitoring of health- or disease-related indicators [ 13 , 48 , 51 , 54 ], effectively influencing safety and, in some cases, autonomy (related to RQ2). A recent review investigated the effectiveness of mobile health apps for blood pressure management in populations with digital barriers, among other older adults. The authors confirmed the promise of ATs for chronic disease management but also emphasized the need for more studies including vulnerable populations [ 57 ]. The willingness for and success of AT-supported self-management can also be dependent on the disease [ 59 ]. This could not be confirmed, as our analysis did not provide any additional insights for the effectiveness of personal disease management when stratifying by disease.

Considering other existing research, hearing aids seem to be an effective way to improve the domain of communication in adults aged 65 years and older [ 49 , 60 , 61 ]. With respect to other devices, the study evaluating a portable vision enhancement system reported an effective improvement due to the AT, but the authors stated that no other comparable evidence supported these results [ 24 ]. Further research is needed in all categories for a more reliable assessment.

Regarding frailty of older adults (RQ3), only one study included this population characterization in their evaluation of a gait speed feedback device [ 53 ]. Although no significant effectiveness could be shown, similar compliance and success rates for frail participants were found, suggesting that this mobility-supporting device can also be appropriate for this subgroup. We were able to retrospectively estimate the frailty status for a total of 6 out of the 19 studies ( Table 2 ). However, some instruments used might not be ideal for the estimation of frailty, as they are influenced by the underlying disease of the study population [ 14 , 23 ]. In studies where, on average, participants were categorized to have significant or severe impairment (frailty), the AT did not show any effectiveness. As an example, out of the five personal disease management trials, only the one including participants categorized as severely impaired/frail did not show significant results in terms of improvement [ 22 ]. Additionally, ATs were also not effective in the four studies that were conducted in nursing homes. Overall, nursing home residents are known to be more dependent, with a high prevalence of frailty [ 40 , 53 ].

Altogether, our results indicate that ATs might not yet suitably address the needs of frail older adults. A possible explanation is the fact that ATs are not usually developed with the specific needs of this population in mind. A recent systematic review on the use of communication technologies to improve social well-being in older adults found that more off-the-shelf products exist than devices designed specifically for older adults [ 62 ]. A qualitative study on the use of AT by frail older people showed specific needs of this subgroup when becoming users of AT, such as prescription support, training, and follow-ups [ 36 ]. This highlights that frail older adults might face specific challenges when using AT that could affect the performance of such technologies. Further research should focus more on this vulnerable group, including measures of frailty for the study populations.

We also showed that the evaluation of an AT is usually unidimensional (RQ1). Many factors, especially social, economic, or ethical aspects, are hardly investigated [ 29 ]. For example, only two studies analyzed in this review evaluated the impact of the AT for formal caregivers, showing no improvement for their working conditions or health [ 6 , 23 ]. Two trials considered economic aspects of ATs [ 22 , 24 ]. Ethical challenges have not been taken into account at all, despite their importance for data management issues and in the setting of smart housing technology [ 29 , 63 ].

The unclear findings on the effectiveness of ATs for older adults align with those of other systematic literature reviews on the topic [ 18 , 28 - 30 , 62 ]. Our strict inclusion and exclusion criteria, especially the requirements for the type of technology, mean age, and setting, resulted in the inclusion of 19 RCTs in the final analysis. Almost half of the studies included were pilot or feasibility trials. This shows that there is still a lack of research addressing the use of ATs for older adults at home or in similar settings [ 57 , 62 , 64 ]. A crossover design, where the control group changes to the intervention after a predefined period, was found to be commonly used when evaluating ATs. Possible reasons for this could be the easier recruitment as every participant can test the device, which might also lead to a reduction of dropout numbers due to an increased motivation to remain in the study. However, the average dropout rates were similar among the two RCT types (parallel design: 13.8%; crossover design: 12.6%). In this context, three studies with a regular parallel-group design reported noticeably higher dropout rates in the intervention group and were judged to have a high RoB for incomplete outcome data [ 51 , 53 , 54 ]. The retraction of consent and complexity of ATs were mentioned as possible reasons for this. Several records were excluded because they evaluated ATs in a laboratory setting. To gain insightful and reliable evidence on the actual effectiveness of AT, it is necessary to evaluate the devices being used by older persons within a realistic setting [ 57 ]. The challenges that arise in terms of ethical, economic, and logistic issues when performing studies with older adults in their own homes are part of the reason for the current lack of research [ 35 , 65 ].

Limitations

There is a lack of a uniform definition concerning ATs for older people. This makes searching for and selecting suitable studies difficult, and increases the risk of missing relevant research. The search string resulted in almost 11,400 records. Only 19 were selected for the review, indicating an insufficient precision caused on the one hand by the lack of standardized terminology and on the other hand by the vast amount of existing literature evaluating AT in clinical settings rather than in the home environment. Additionally, the technologies considered in this analysis are heterogenous, thus limiting the possibilities for analysis, in particular the performance of a GRADE (Grading of Recommendations, Assessment, Development and Evaluations) assessment to rate the certainty of evidence as suggested by the Cochrane Collaboration. The number of trials per device type is not sufficient to form a definite conclusion of the effectiveness of AT. When the analysis for this review was performed, the new RoB 2 tool from the Cochrane Collaboration [ 66 ] was still undergoing pilot testing, and therefore we used the original RoB tool, first published in 2008 [ 47 ], for our analysis. Although the mean age of participants across all trials was 76.3 years, six identified trials included participants below the age of 65 years. Unfortunately, the authors did not present a stratified analysis by age, thus limiting the generalizability of the results to the older population.

Researchers, politicians, and health care professionals across the globe have high hopes for AT to support older adults. Many devices are freely available on the market and are often used even though the effectiveness is not supported by current research, as shown in this review. The number of available RCTs evaluating ATs in older populations is limited and many only include a small number of study participants. Further studies with larger, well-characterized samples of older adults are necessary to allow for further stratification (eg, for frailty). Additionally, it is important to expand the focus and include economic, social, ethical, and technological aspects besides the medical outcomes. Formal and informal caregivers may, in some cases, benefit from AT even more than the older adults themselves and should therefore be included in future studies. The new Medical Devices Regulation of the European Union includes stricter controls and requires an evaluation of all medical devices before certification. In this context, our review intends to add value by identifying the current gaps in the literature, emphasizing the importance of addressing several health-related dimensions while taking into account the heterogeneity of older adults by providing a good characterization of the participants with respect to frailty.

Acknowledgments

This study was partially supported through funds from the German Federal Ministry of Education and Research for the project Future City 2030 (grant 13ZS0054A). The funding party neither influenced the study design, data collection, analysis, or interpretation nor the writing of the manuscript.

Abbreviations

Multimedia appendix 1, multimedia appendix 2, multimedia appendix 3, multimedia appendix 4, multimedia appendix 5.

Authors' Contributions: MLF, MD, and DD developed the study design and determined the inclusion and exclusion criteria. MLF and VM developed and tested the search strategy, independently screened the records, and selected the final trials to be included in the analysis. MLF and VM extracted the data and performed the RoB analysis. MD and DD were consulted in case of discrepancies. SB assisted with the frailty assessment. MLF prepared the manuscript and all authors read and commented on the final manuscript.

Conflicts of Interest: None declared.

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  22. Assistive Technology: Vol 36, No 1 (Current issue)

    Heather M. Capel et al. Article | Published online: 8 Jan 2024. Diversity beyond Disability in Assistive Technology. Emma M. Smith et al. Editorial | Published online: 13 Dec 2023. View all latest articles. Explore the current issue of Assistive Technology, Volume 36, Issue 1, 2024.

  23. Assistive Technology to Improve Collaboration in Children with ASD

    1. Introduction Autism Spectrum Disorder, hereinafter ASD, is a neurological disorder; it encompasses different types of needs, making it difficult to develop product and service solutions that are adaptable to everyone [ 1 ].

  24. Mobile Accessibility Barriers For Assistive Technology Users

    Half of assistive technology users said that accessibility barriers have a significant impact on their day-to-day well-being. Accessibility goes beyond making products user-friendly. It can impact the quality of life for people with disabilities. Types Of Mobile Assistive Technology. I typically group assistive technologies into three categories:

  25. Full article: Assistive technology and people: a position paper from

    Assistive technology and people: a position paper from the first global research, innovation and education on assistive technology (GREAT) summit Deirdre Desmond , Natasha Layton , Jacob Bentley , Fleur Heleen Boot , Johan Borg , Bishnu Maya Dhungana , show all

  26. Smart glove teaches new physical skills

    A smart glove developed at MIT CSAIL is embroidered with tactile sensors and haptics, transferring touch-based feedback via adaptive optimization. Smart textiles can fabricate this human-machine interface to potentially teach people physical skills and improve robot teleoperation and virtual reality training.

  27. The Effectiveness of Assistive Technologies for Older Adults and the

    The use of assistive technologies (ATs) to support older people has been fueled by the demographic change and technological progress in many countries. These devices are designed to assist seniors, enable independent living at home or in residential facilities, and improve quality of life by addressing age-related difficulties. Objective

  28. Global Disabled and Elderly Assistive Technology Research

    The global market for Disabled and Elderly Assistive Technology estimated at US$24.9 Billion in the year 2022, is projected to reach a revised size of US$41.7 Billion by 2030, growing at a CAGR of ...

  29. A study on the four-phase design and development process of 3D printed

    Myung-Joon Lim is primarily interested in research and development of assistive technology, provision of assistive technologies, user experience, co-designing, and service designing. He takes great interest in knowing how the results of research and development created by the needs of people with disabilities are delivered to users, and how ...