Abstract
Background: As people live longer with more complex disability in their own homes, adaptive equipment is one way to enable their safety and participation. However, it is not well understood how people with stroke use adaptive equipment and how they interact with the services which provide equipment. The reasoning used by therapists who issue equipment, the outcomes achieved by equipment provision and the cost of equipment remain ambiguous. A theoretical framework which explains how services for equipment provision currently operate, with specific attention to the relationships between health policy, health provider behaviour, and equipment user experiences and outcomes was required.
Aim and objectives: The aim of this study was to explore whether the policies and procedures for provision of adaptive equipment to people with stroke are fit for purpose in terms of maximising safety, independence and choice. The objectives for this research were to: 1) describe who is more likely to receive publicly-funded equipment after stroke and what outcomes are achieved by them using equipment, 2) estimate the annual cost of adaptive equipment prescription for people with stroke, 3) explore the experiences of people with stroke about equipment provision services and, 4) explore the perspectives of therapists who prescribe equipment.
Methods: A sequential explanatory mixed methods approach was used to gather data over three phases, initially from people with stroke who use equipment (n = 258 surveyed using a postal survey, with n = 15 interviewed using a semi-structured schedule) and then therapists via six focus groups (n = 30).
Results: Findings indicated that no one demographic characteristic significantly increased the likelihood of equipment receipt. The most valued equipment after stroke was mobility related which made people feel safer, more confident and in control. The cost of new equipment for people who had a stroke in 2012 was estimated to be NZD $1.2 million. Overall satisfaction with equipment provision services was high. People with stroke initially relied on their therapist to guide equipment choice as they transitioned out of hospital; thereafter they assumed greater control for decision making regarding equipment. As time passed, equipment became more meaningful in the context of their lives, often happening when equipment enabled community participation. A theoretical framework was developed which illustrated seven inter-related influences on the reasoning of therapists during equipment provision: ‘client engagement (willingness and capacity)’, ‘others (family members and healthcare staff)’, ‘risks vs benefits’, ‘environment (physical and cultural)’, ‘professional philosophy’, ‘equipment provision system’ and the ‘wider health system’.
Discussion: Adaptive equipment and equipment services were found to provide a low cost, useful and valued service. Some challenges existed for equipment provision services, however, including a tension between policy objectives to limit costs associated with provision of equipment for use outside of the home and clinical, person-centred objectives to encourage community participation. Challenges like this resulted in moral distress for therapists and raised questions about the degree to which the health system may be increasing disease burden, and potentially long-term health costs, by failing to fully address equipment-related barriers to outdoor mobility and participation.