1. ATRAS: WP3 Understanding barriers and facilitators to acceptance of ATs
Jane Burridge, Caroline Ellis-Hill, Ann-Marie Hughes,Sara Demain and Lucy Yardley

2. Exhibition of upper limb technologies for rehabilitation exhibition 2009
7th October from 10:30 for healthcare professionals
8-9th October for patients and carers
At Building 45, University of Southampton
Buffet lunch provided

3. WP3 team Caroline Ellis-Hill Lucy Yardley Ann-Marie Hughes Sara Demain
Jane Burridge

4. Introduction to WP3 Investigation into the users’ views on ATs
Barriers to ATs from users’ perspective
Interactive Exhibition – plans
Focus groups
Questionnaire
Field studies

5. WP 3 - Objectives To explore:
►Participants’ perceptions of how AT addresses their
needs
►Participants’ perceptions of the barriers to using ATs
►Positive and negative aspects of including ATs within a
clinical service

6. Purpose To inform the decision about what ATs are tested in the RCT
To inform the design of the RCT
Information will be added to the systematic review so that the choice is made on:
Clinical evidence
Users’ views
Critical issue – how is the information generated from WP3 integrated into the decision making process

7. Study Methods 1) Qualitative design (geographic boundaries)
Interactive exhibition recruit for focus groups
Focus groups inform questionnaire study
2) Quantitative questionnaire study (national)
- Provide data on acceptability of ATs in service provision
Inform design of the clinical trials
3) Usability field trials
Qualitative (observation and interview)
Quantitative (questionnaire)

8. Qualitative design Interactive Exhibition
Focus groups (6-8) – purposive sampling
Patients
Carers
MD healthcare professionals
Managers, budget holders and commissioners
End effector – exoskeletal
Reviews: Prange (8 prox upper limb), Teasell (20 upper limb) , Mehrholz (11 RCTs electromechanical and robot-assisted arm training for recovery of arm function with other rehabilitation interventions or no treatment for patients (sub acute to chronic) and Kwakkel (10 RCTs upper limb)
Limitations (wide variety of outcome measures used and weak methodologies (Prange et al, 2006; Teasell, Foley et al, 2007); variations between the trials in the duration, amount of training and type of treatment and in the patient characteristics (Mehrholz, Platz et al, 2008))
Advantages: therapist Fulfilling the motor learning requirements, robots can provide patients with: intense movement practice; continuous feedback and games (which if not functional tasks, may be motivating or entertaining); a degree of independence during therapy; and a record of progress. The advantages for therapists are that robots are both objective assessment and intervention tools. As with most technologies, there will be a number of barriers to their use which may include: cost; ease of accessibility; location for storage; a limited evidence base; acceptability and usability issues.
User perceptions - patients (Coote & Stokes, 2003 (8 patients 6 physio simulating); Krebs et al, 1998 (20)), or therapists (Lee et al, 2005 or both (Doornebosch et al, 2007 (10 sub acute +? therapists))
Robot assisted therapy is well accepted and tolerated by the therapist
Common limitations with existing surveys include: lack of clarity on question development; questionnaires were often administered by treating therapists; questions or statements used are not always published; psychometric properties of the questionnaires are not established; and frequently no clear tables of results are published.

9. Questionnaire Designed, piloted, revised, piloted, final version
Target Audience: Patients and Carers ( ), MD healthcare professionals (75-100), Managers, budget holders and commissioners (30-60)
Method: phone, (Website), paper
Advertised: UK stroke units, rehab centres, stroke clubs and GP practices
End effector – exoskeletal
Reviews: Prange (8 prox upper limb), Teasell (20 upper limb) , Mehrholz (11 RCTs electromechanical and robot-assisted arm training for recovery of arm function with other rehabilitation interventions or no treatment for patients (sub acute to chronic) and Kwakkel (10 RCTs upper limb)
Limitations (wide variety of outcome measures used and weak methodologies (Prange et al, 2006; Teasell, Foley et al, 2007); variations between the trials in the duration, amount of training and type of treatment and in the patient characteristics (Mehrholz, Platz et al, 2008))
Advantages: therapist Fulfilling the motor learning requirements, robots can provide patients with: intense movement practice; continuous feedback and games (which if not functional tasks, may be motivating or entertaining); a degree of independence during therapy; and a record of progress. The advantages for therapists are that robots are both objective assessment and intervention tools. As with most technologies, there will be a number of barriers to their use which may include: cost; ease of accessibility; location for storage; a limited evidence base; acceptability and usability issues.
User perceptions - patients (Coote & Stokes, 2003 (8 patients 6 physio simulating); Krebs et al, 1998 (20)), or therapists (Lee et al, 2005 or both (Doornebosch et al, 2007 (10 sub acute +? therapists))
Robot assisted therapy is well accepted and tolerated by the therapist
Common limitations with existing surveys include: lack of clarity on question development; questionnaires were often administered by treating therapists; questions or statements used are not always published; psychometric properties of the questionnaires are not established; and frequently no clear tables of results are published.

10. Questionnaire analysis
Generate quantitative data concerning the issues identified in the qualitative study
Analysis will aim to indicate critical factors in the RCT design generated from the classes of responders:
Patients and carers (e.g. where the intervention should take place, how long each day is reasonable to ‘practice’)
Healthcare professionals (e.g. time post-stroke of intervention, selection of patients, training / ease of application)
Managers / Budget holders (e.g. cost/patient)

11. Usability field trials
Evaluate ATs from patient and clinician perspective
Qualitative interview (n=12)
Questionnaire developed, piloted and trialled at the end of clinical trial
Video of patients using technology
Patient diaries
End effector – exoskeletal
Reviews: Prange (8 prox upper limb), Teasell (20 upper limb) , Mehrholz (11 RCTs electromechanical and robot-assisted arm training for recovery of arm function with other rehabilitation interventions or no treatment for patients (sub acute to chronic) and Kwakkel (10 RCTs upper limb)
Limitations (wide variety of outcome measures used and weak methodologies (Prange et al, 2006; Teasell, Foley et al, 2007); variations between the trials in the duration, amount of training and type of treatment and in the patient characteristics (Mehrholz, Platz et al, 2008))
Advantages: therapist Fulfilling the motor learning requirements, robots can provide patients with: intense movement practice; continuous feedback and games (which if not functional tasks, may be motivating or entertaining); a degree of independence during therapy; and a record of progress. The advantages for therapists are that robots are both objective assessment and intervention tools. As with most technologies, there will be a number of barriers to their use which may include: cost; ease of accessibility; location for storage; a limited evidence base; acceptability and usability issues.
User perceptions - patients (Coote & Stokes, 2003 (8 patients 6 physio simulating); Krebs et al, 1998 (20)), or therapists (Lee et al, 2005 or both (Doornebosch et al, 2007 (10 sub acute +? therapists))
Robot assisted therapy is well accepted and tolerated by the therapist
Common limitations with existing surveys include: lack of clarity on question development; questionnaires were often administered by treating therapists; questions or statements used are not always published; psychometric properties of the questionnaires are not established; and frequently no clear tables of results are published.

12. Qualitative component of the Clinical Trial
Interviews – patients and clinicians using AT
Observation – videos record of people using AT
Participant Diaries – document usage and problems
Data → Questionnaire design
Sent to all trial participants at end of study

13. WP3 Gantt chart
Interaction Exhibition Oct 7-9

14. How the output of WP3 will be used to inform the trial design
Transforming textual data into metrics
Done partly but not wholly by the questionnaire
Identifying the bottle-necks
e.g. comfort of ATs, ease of wear, cosmetic etc. It might be important for to consider these factors in the specific choice of ATs evaluated in the trial
e.g. robots are great but in a gym or own home -if this was identified the trial design would need to consider how the intervention was monitored
Softer issues e.g. patients love it but therapists unconvinced. This would indicate a need for a culture change among therapists and would need to be considered / addressed prior to the clinical trial
Bottom line – until we gather the data we cannot identify the critical factors relating to users’ perceptions and preferences

15. Qualitative research – a quick introduction
Quantitative research
material reality
physical properties
measurable
Qualitative research
social reality
concepts, ideas, beliefs
not measurable

16. Qualitative research – a quick introduction
Understanding meanings
Meaning of objects or events is as important as the ‘facts’ of the event because meaning influences thoughts and actions
Subjective meanings therefore affect the material world
Talk to people and observe their actions

17. Focus groups
“a way of collecting qualitative data, by engaging a small number of people in an informal group discussion, focussed on a particular topic or set of issues” (Wilkinson, 2003)

18. Focus groups Facilitated by researcher - flexible topic schedule
Group dynamics important
participants asking questions of each other,
seeking clarification from each other,
probing for greater depth (Finch and Lewis, 2003)
Analysis
identify key themes and concepts
understand how these relate to each other and the topic under investigation

19. Purposive Sampling – Quantitative research
Aim: generalise to whole populations
Strategy: select statistically representative sample of people/objects/events
Sample: matches proportions in population
Qualitative research
Aim: understand phenomenon
Strategy: select people/objects/events from whom we can learn the most
Sample: people/objects/events with a range of experiences and opinions. Deliberately try and include outlying views and people with expertise.

20. Purposive sampling
Example Focus group 1 – People who have had a stroke
Have/have not used AT
Different genders
Levels of ability
Time since stroke
Age groups

21. Purposive sampling Example Focus group 1 – Health care professionals
Which professionals?
Different levels expertise?
Experts in one or other form UL AT?

22. Analysis - thematic Identifying themes and relationships between them
Purpose:
Understand phenomenon inductively (→ publications)
Questionnaire validity
Content: what questions we ask
Language: using the precise terms used by focus group participants

23. Focus group formats People with stroke x 2
Existing/previous users of AT
Those who have never used an AT
Carers/family of people with stroke (naïve and experienced)
Coal-face health professionals (therapists, medics, engineers)
Managers/Budget holders (different professions)
Commissioners
Option for interviews if necessary
People with cognitive/language deficits