In this study the authors sought to describe the AT needs and psychosocial impact of AT of a sample of older adults living in Puerto Rico and to identify methodological challenges and lessons learned in using the Puerto Rican version of the PR-PIADS with this population. The participants of this study provided evidence that older adults face unmet needs for AT devices that could support their performance and participation in daily living activities. The results of this study also demonstrated that AT appears to have a positive impact on the perceived quality of life of community-living Hispanic older adults with functional limitations.
4.1. Assistive Technology Needs
The participants identified needs for AT devices predominantly in the categories of cooking, home tasks, and home safety. Specifically, the top three devices that the participants reported that they would use it if they have them were jar openers, seat lifts, and laundry baskets with wheels. These devices compensate for diminished energy and strength in the performance of daily activities. It is well known that the physiological effects of aging, such as loss of strength and endurance, might decrease tolerance for performing physically demanding activities [29
]. The findings of this study are consistent with the findings of Cheek Nikpour and Heather [29
] in which older adults from Brazil demonstrated a significant unmet need for assistive devices to compensate for energy and strength deficits in the performance of basic and instrumental activities of daily living. However, the results of the current study differ from the results of the study conducted by Gitlow and her colleagues [31
] in exploring the AT needs of 57 community-dwelling older adults from Tompkins County. Gitlow stated that the most frequently identified needs existed in the categories of aids for hearing, aids for laundry, and aids for vision. These findings highlight the variation that exists among the needs of different older populations, thus requiring a client-centered approach when assessing AT needs.
Moreover, our study findings related to the socio-demographic characteristics of the sample are consistent with previous study results examining the disparities in usage of AT among people with disabilities. As such, the participants of this study were predominantly older women, with low educational levels and low monthly income. An early study showed that female gender was associated with a decreased likelihood of using AT devices, suggesting having a higher need for access to AT devices [15
]. Previous studies have also found that having lower educational levels, lower household income, and later disability onset significantly put people at disadvantage in accessing and using AT devices [16
]. These findings highlight the need for approaches to expand the usage of AT as well as to promote equal access to AT devices that enable greater autonomy and social participation for older people from disadvantaged populations.
4.2. Psychosocial Impact of AT
Our findings showed a positive psychosocial impact for assistive devices used for daily living activities. This finding comes from a sample that predominantly reported having hypertension and musculoskeletal disorders. This validates the assumption that assistive technologies help older people with mobility disabilities increase their quality of life and adapt or cope better with age-related functional disabilities. The self-esteem sub-score, although positive, showed lower ratings than all the other sub-scores. This result is consistent with previous studies conducted with individuals with neuromuscular disorders [33
] and multiple sclerosis [34
] using mobility devices, those with amyotrophic lateral sclerosis using wheelchairs, communication devices and environmental control units [36
], and those with stroke [19
] using a variety of AT devices. Social stigma associated with AT use has extensively been reported in the literature as a barrier to the uptake of AT devices [7
]. It has been argued that the willingness to use assistive devices will depend on whether it supports or undermines the personal identity and self-image of the individual [7
]. In the qualitative study conducted by Resnik and his colleagues [40
], users of mobility devices expressed feelings of shame for needing help and felt that people with mobility problems were not seen as normal. Similarly, in a systematic review about the barriers older adults find for using AT devices, it was found that the participants were worried that people may perceive them to be in poor health or frail if they use AT devices [41
4.3. Methodological Challenges and Lessons Learned
There were some culturally-based methodological concerns that emerged during the administration of the PR-PIADS to Hispanic older adults who live in Puerto Rico related to the format of administration, level of abstraction, and structure of the questionnaire. Most of the participants were reluctant to use a self-administered format (as recommended in the PIADS manual) to fill the PR-PIADS. These participants preferred a personal relationship provided by the interview format. The sample preference for an interview format instead of self-administration could be explained by two main factors. First, literacy issues could have played a role since 80% of the participants reported educational levels of high school or less. Second, the Hispanic population preference of a personal relationship or “personalismo” could have also been an influential factor. Since Hispanics expect health providers to be warm, friendly, and personal as well as to take an active interest in the patient's life [42
], an interview format constitutes a perfect fit in the administration of the PR-PIADS for older Hispanics.
As to the level of comprehension, some of the participants also demonstrated poor understanding of the graded numerical response format indicated in the manual of the PIADS original version from −3 to +3. The response trends of these participants were to use positively skewed extreme responses (excessive use of positive endpoints of the PR-PIADS). The results support earlier studies that indicate the use of Likert scales among immigrant Latinos is often problematic [43
] and that Hispanic Americans are more likely to agree with a given item, preferring extreme responses on rating scales more than non-Hispanic Americans do [44
]. Hence, instructions and scale items may need to be evaluated for their ability to be understood by older Hispanic respondents.
Similarly, most of the participants demonstrated difficulty with the level of abstraction required by the PR-PIADS instructions. The PIADS original version’s instructions require making distinctions between the extents of the impact each device has made in the participant’s life in each of the PR-PIADS items. For example, when asked the abstract question about “How your assistive devices make you feel in relation to independence?” with numerical response options, rather than appear indecisive, they tended to give “very” or “somewhat” answers. Preferred were straightforward questions and categorical response options, for example, “Does your assistive technology make you feel more independent?” with responses options from very much to not at all. Difficulty in this sample’s level of comprehension could be explained by the low educational level of the majority of the participants of this study. Based on these findings, we suggest changing the type and the direction of the numerical Likert scale to categorical responses when used with older Hispanics with low educational levels. We also suggest to first ask participants to answer "Yes" or "No" to the question of how much have their devices make them feel in relation to each PIADS item. For example, the interview question related to the PIADS item of “competence” will be: “Has your AT device made you feel more competent?” If the answer is "Yes", the participant is then instructed to indicate (on the scale from “very much” to “not at all”) how the AT device makes them feel in relation to the PIADS item of competence.
Finally, some of the participants also demonstrated difficulty in understanding how to answer the PR-PIADS items when they were asked to use the structure of the list format. The instructions of the PR-PIADS ask the participants to describe how an assistive device affects their life and makes them feel in relation to each of the PR-PIADS items. Participants constantly asked for repetition of the instructions for each of the items. Therefore, it is recommended that a modified script of the instructions to answer the PR-PIADS be provided and repeated in each of the PR-PIADS items to increase understandability and recording of the instructions. For example, instead of item number five being “confusion”, it can be enhanced to “Does your assistive technology makes you feel more confused?”
In spite of these methodological challenges, this study’s results indicated that the PR-PIADS is still useful for assessing quality of life effects attributable to AT among Hispanic older adults living in Puerto Rico. It also provided valuable information that can be used to evaluate the effectiveness of AT to enhance its users’ competence, adaptability and self-esteem.
4.4. Limitations of the Study
The results may have limited generalizability to other populations and locations due to the use of a convenience snowball sample and small sample size. Further, the ATCA was not tested for construct validity and reliability. Therefore, if this questionnaire is used again, different results could be obtained. Moreover, the ATCA did not include all the range of AT devices currently available for the older population. Therefore, this study was not able to identify the sample’s needs for other AT devices that were not included in the ATCA questionnaire.