Maria Larsson Lund, Ann-louice Lövgren-engström a & Jan Lexell a Department of Health Sciences, Luleå University of Technology, Luleå, Sweden

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1 This article was downloaded by: [Lund University Libraries] On: 23 August 2015, At: 13:21 Publisher: Taylor & Francis Informa Ltd Registered in England and Wales Registered Number: Registered office: 5 Howick Place, London, SW1P 1WG Disability and Rehabilitation: Assistive Technology Publication details, including instructions for authors and subscription information: Using everyday technology to compensate for difficulties in task performance in daily life: experiences in persons with acquired brain injury and their significant others Maria Larsson Lund, Ann-louice Lövgren-engström a & Jan Lexell a Department of Health Sciences, Luleå University of Technology, Luleå, Sweden b Department of Community Medicine and Rehabilitation, Division of Occupational Therapy, Umeå University, Umeå, Sweden c Department of Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden d Department of Health Sciences, Lund University, Lund, Sweden Published online: 02 Apr To cite this article: Maria Larsson Lund, Ann-louice Lövgren-engström & Jan Lexell (2011) Using everyday technology to compensate for difficulties in task performance in daily life: experiences in persons with acquired brain injury and their significant others, Disability and Rehabilitation: Assistive Technology, 6:5, To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the Content ) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at

2 Disability and Rehabilitation: Assistive Technology, September 2011; 6(5): RESEARCH PAPER Using everyday technology to compensate for difficulties in task performance in daily life: experiences in persons with acquired brain injury and their significant others MARIA LARSSON LUND 1,2, ANN-LOUICE LÖVGREN-ENGSTRÖM 1 & JAN LEXELL 3,4 Downloaded by [Lund University Libraries] at 13:21 23 August Department of Health Sciences, Luleå University of Technology, Luleå, Sweden, 2 Department of Community Medicine and Rehabilitation, Division of Occupational Therapy, Umeå University, Umeå, Sweden, 3 Department of Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden, and 4 Department of Health Sciences, Lund University, Lund, Sweden Accepted March 2011 Abstract Purpose. The purpose of this study is to illuminate how persons with acquired brain injury (ABI) and their significant others experienced individualised occupation-based interventions using commonly available everyday technology (ET) to compensate for perceived difficulties with performance of tasks in daily life. Method. Qualitative research interviews were conducted with 10 persons with ABI and with one of their significant others. The data were analysed according to qualitative content analysis. Results. The persons with ABI experienced that they mastered their lives in a better way by the compensatory use of ET. They became capable of doing tasks independently and experienced themselves as being a new person. During the intervention process, persons with ABI became aware of the compensatory potential of familiar ET, and they were supported to use effective compensatory strategies and incorporate them into their habits. Their significant others felt a relief in daily life, and their mood was positively affected as they experienced reduced responsibility and need of control. Conclusions. This qualitative study has shown that persons with ABI, as well as their significant others, experienced a multitude of benefits from occupation-based interventions using commonly available ET to compensate for their difficulties in the performance of tasks in daily life and that the goals achieved affected their overall contentment with life. Keywords: Activities of daily living, assistive technology, brain injury, occupational therapy, rehabilitation, evaluation programmes, carer Introduction Commonly available everyday technology (ET) that already exists in peoples life today, such as mobile phones and computers [1], has the potential to facilitate daily life for people with acquired brain injury (ABI) and to compensate for their disabilities [2 4]. However, it can be difficult to differentiate ET from assistive technology (AT) that comprises both low-tech and high-tech devices and is defined as any item, piece of equipment or product system that is used to improve or maintain functional capabilities of people with disabilities [5]. Research has mostly evaluated the efficacy of electronic AT or prototypes [6 10], also called electronic aids, in reducing different kinds of cognitive impairments after ABI. Some studies [11 14] have evaluated the effects of a certain ET designed for the general population in compensating for cognitive disabilities. Even if ET, such as computers, has been used, it has often been adapted with a purpose-designed application and a limited accessibility for those not involved in the research project. Moreover, regardless whether AT, ET with special applications or ET designed for the public has been used, the interventions have, in most cases, focused on improving clients performance of experimental tasks or the same pre-defined tasks behaviours rather than on the clients own Correspondence: Maria Larsson Lund, Department of Health Sciences, Division of Occupational Therapy, Luleå University of Technology, SE Luleå, Sweden. maria.larsson-lund@ltu.se ISSN print/issn online ª 2011 Informa UK, Ltd. DOI: /

3 prioritisation of problems in tasks in daily life. Thus, our knowledge is very limited about how people with ABI can learn to use their existing ET in new ways and common ET available off-the-shelf to compensate for problems in the performance of occupations in daily life, such as self-care, home management, productivity and leisure. We have recently carried out a muliple case study [15] to describe how individualised occupationbased interventions using commonly available ET for people with ABI can compensate for their disabilities. The results showed that the participants could perform tasks in daily life independently and also improve their satisfaction with their performance. To more fully understand the effects of the rehabilitation interventions and the process by which the effects evolved, the use of both qualitative and quantitative methods has been emphasised [16]. With qualitative methods, the experiences of those involved, e.g., clients and their significant others, can be explored to support professionals in designing and implementing interventions that meet different individuals needs. However, as research about the use of commonly available ET in interventions after ABI is lacking, the experiences of this process and of those involved have not been described. Two studies [17,18] have qualitatively addressed the experiences of electronic AT or aids in people with ABI. Women reported both positive and negative experiences related to electronic memory aids [17], such as a fear of the technology and of being extremely pleased with the compensatory function of the technology. The results also showed that the persons go through a transitional period were they learn to accept and use their aids. Similarly, Erikson and colleagues [18] found that the use of new equipment in the form of electronic AT or aids in a training apartment can be experienced as challenging by the users and that they go through a process to incorporate them in their daily lives. Even if the involvement of significant others in rehabilitation following an ABI is emphasised [19], no study has, to the best of our knowledge, focused on significant others experiences of interventions involving electronic AT or aids. As experiences of interventions involving clients own existing ET or ET off-the-shelf might differ from interventions involving AT, further research is needed. For example, on one hand, it is possible that ET can be difficult to learn to use for compensatory purposes as it is not adapted to persons with cognitive impairments on the other hand, it can be advantageous as the persons have used them before their injury. Therefore, knowledge about clients and their significant others experiences can enhance professionals readiness to facilitate the use of ET as a mean to compensate for disabilities after ABI. The aim of this study was, therefore, to illuminate how persons with ABI and their significant others experienced individualised occupation-based interventions using commonly available ET to compensate for perceived difficulties in the performance of tasks in daily life. Method Participants Everyday technology 403 This study builds on qualitative interview data collected as part of a project that focused on how individualised occupation-based interventions with commonly available (ET) could compensate for difficulties in the performance of task in daily life after an ABI. Participants were recruited from a brain injury unit at a rehabilitation centre in southern Sweden (for further information see [15]). The inclusion criteria were that the participant: (i) had an ABI; (ii) had self-perceived difficulties when performing tasks in day life; (iii) was motivated to compensate for his/her ineffective performance with ET and (iv) had verbal communication skills that enabled participation in the study. In total, 10 persons with ABI participated in the intervention designed as a multiple case study. All of them, as well as their significant others, received written and verbal information about this study and gave their informed written consent to participate. The regional ethical review board in Lund, Sweden approved this study (Dnr 603/2006). Ten persons (six men and four women) with ABI and their significant others (five women and five men) participated in the present study. Eight of the persons with ABI were either married or cohabiting and lived in the same household as their partner. All of their partners worked, and five of the couples had underage children living at home. Two of the persons with ABI lived alone, and their closest relative was a parent who was retired. The persons with ABI were years of age (mean 44 years) and had lived with their ABI between 1.5 and 40 years (median 4.5 years). Three of them worked, and the remaining had temporary or permanent disability pension. One of them had support with their activities of daily living from the social services. The individualised occupation-based intervention The client-centred occupation-based intervention process [20] started with the occupational therapist (OT) gathering information to obtain a general picture of the context of the clients performance of

4 404 M. L. Lund et al. daily life tasks, including internal personal characteristics and external factors. Simultaneously, the OT began to develop a therapeutic report to serve as a foundation for the collaborative relationship with the clients throughout the intervention process. Those tasks that the clients had difficulties with were identified as a potential focus for the intervention. Further evaluation of the tasks that the clients prioritised was then continued by using interviews, observations and self-reports. Thereafter, goals were established in collaboration with each client and documented in a written intervention plan. Models for matching person and technology [21] guided the selection of the ET that would match the participants goals and abilities. When selecting the ET, the clients own available ET were first considered, but if these did not match, ET off-the-shelf were chosen. The implementation of the compensatory use of ET was, together with the model for the intervention process, guided by error-free learning [22,23]. Depending on the clients and their significant others own desire, need and situation, the significant others participation varied during the different steps of the intervetion. Five of the clients significant others participated in the intervention process during one or several occasions. In these cases, the personal meeting with the OT could be combined with telephone contacts. Four of the significant others had a short personal meeting with the OT when they received general information about the intervention. The remaining significant others had no contact with the OT. After the intervention [15], all the persons with ABI had achieved their goals and successfully learnt to use ET to compensate for their difficulties. The participants rated an increased self-perceived occupational performance and increased satisfaction with their performance of the tasks they had prioritised in their goals [15]. All participants used at least one of their own ET to compensate for their self-perceived difficulties, and the ET used varied from those with a simple function (timer) to more advanced technology including several functions and steps to perform (navigator and computer). The length of the intervention programme varied between the participants as well as the number of visits, their prioritised goals and the number of ET needed to attain these. Data collection Qualitative research interviews [24] were carried out with the participants about 3 months after the intervention was completed. The interviews were performed by the second author who was not involved in their rehabilitation or the intervention process. The interview questions had an open-ended format [24] to enhance the possibilities of both groups of participants to describe experiences from their point of view. The persons with ABI were asked to tell about their problems in tasks in daily life before the intervention, the goals identified, how the process of selecting and learning to use ET to compensate unfolded, and the consequences of the compensation in their lives. The significant others were asked to describe how they were involved in the intervention process and their experiences of it, and also the consequences of the intervention on their lives. To increase the quality of the data collected from the persons with ABI [25], different techniques were applied to bridge memory and concentration problems, such as asking concrete questions and repeating. Six of the persons with ABI and their significant others were interviewed separately (not listening to each other s interviews). The interviews carried jointly for four couples were according to their requests. In these cases, the persons with the ABI were interviewed first and their significant others immediately afterwards, and both were listening to each other s interview. The interviews, which lasted approximately 1 hour each, were recorded and transcribed verbatim. Data analysis To illuminate the content of their experiences, a qualitative content analysis [26] was used. The interviews were first repeatedly read to grasp the content of them as a whole. Next, meaning units were identified in the text based on the aim of the study and given a code, formulated as close to the participants expressions as possible. Codes in each interview that seemed to pertain to the same experience were put together in preliminary categories. Thereafter, these preliminary categories were compared between the different interviews of the persons with ABI and of their significant others. During the analyses, data, codes and preliminary categories of both groups of participants were compared with each others to examine whether they had similar contents. The comparison revealed that it was not possible to place the experiences of the persons with ABI on par with the significant others experiences, as the contents of their data were divergent. All these comparisons resulted in subcategories that were identified for both groups of participants and, finally, in the over-arching category for each group. To ensure the trustworthiness that the results were grounded in the data, a peer review of an OT experienced in brain injury rehabilitation was carried out.

5 Results The experiences of individualised occupation-based interventions using ET among the persons with ABI Mastering daily life. The content of how the persons with ABI experienced the use of ET to improve their performance of tasks in daily life was conceptualised as Mastering daily life. This category was formed by four sub-categories: Becoming aware of the potential of ET to compensate ; Being supported to use effective compensatory strategies ; Incorporating compensatory use of ET into habits and Becoming capable of doing tasks by the compensatory use of ET makes one feel like a new person (Table I). Overall, the persons with ABI experienced that they were able to be engaged in and have control over tasks in different ways. This made them feel that they mastered their own daily life in a better way than before they started using ET. Depending on their goals before the intervention, some persons experiences reflected that they mastered their whole existence in a better way, whereas others said that they mastered certain situations or tasks in a better way. Becoming aware of the potential of ET to compensate. The persons with ABI described how they, together with the OT, and based on their abilities, problems and needs in daily life, identified tasks in which they could try learning to use ET to compensate for their Table I. The content of the experiences of individualised occupation-based interventions using ET among persons with ABI and their significant others. Persons with ABI Significant others Category Mastering daily life A relief in daily life Sub-categories Becoming aware of the potential of ET to compensate Integration of ET in daily life can go smoothly or be challenging Being supported to use effective compensatory strategies Incorporating compensatory use of ET into habits Becoming capable of doing tasks independently by the compensatory use of ET makes one feel like a new person Increased ability by the compensatory use of ET affects the mood of both of us positively Decreased responsibility and reduced need of continuous control by the support of ET Everyday technology 405 problems. The persons said that they, at this point, often had missed appointments and tasks that needed to be done. They had also had difficulties remembering and passing on information and agreements. The problems were often complex and combined, as illustrated in this quotation: I have left pans [on hot plates] and the iron... I have great difficulties with it and I am also very easily stressed, I am worried, I start to do a lot of things because I do not remember and I go from one thing to another. All this created feelings of being unsure and anxious. Stress arose and they also said that they came to suffer from fatigue. According to the persons, this reduced their possibility to mange different tasks and their memory problems became even worse. The goals they wanted to achieve by using ET in a new way varied. Some told that they wanted to make daily life easier or to make it work. Others said that they wanted to compensate for their poor memory and not being able to recall information, remember appointments, find places and stop using memory notes as it was not convenient for them. The persons with ABI described how they were suggested to use their own ET to compensate for their problems after the injury. They were suggested to try functions that they had not used before or functions that they had used but not thought about the potential it had to support the tasks they had problems with, as illustrated in this quotation: At first we went through my problems and later she [the OT] talked about using the mobile phone, I admitted that I used the mobile phone to call and receive calls, so I had not been in to it [in other functions], [I thought] it would not be wrong [to use it compensatory], I bring it with me all the time...she [the OT] had knowledge about functions in it, so she looked at it and we found these functions. In a similar way, they were also suggested to use commonly available ET that they had not used before. Their experiences reflected that the products they were suggested were simple to use, often having only a few functions that were easy to manage. One woman said: I have looked at others who have a global positioning system (GPS) and they [the other GPS] seem to be much more difficult to use than mine, I think they [the OT] have been successful in the choice of it. Being supported to use effective compensatory strategies. The persons with ABI described how the OT showed and verbally instructed them step by step about the easiest way to use the functions they needed in the ET: The OT was here, we looked at how it [the Dictaphone] worked and it was so simple. They described how they were taught to use only the functions they needed; one man said: It [the Dictaphone] has many functions but you only use the recording function and the listening function, and also how products were synchronised and

6 406 M. L. Lund et al. adapted: I got shortcuts in the mobile, they helped me with them, so it became much easier. The verbal instructions were often combined with learning to use written instructions. They said that at times when they forgot how to use them, they contacted the OT who gave them repeated instructions or asked their significant others to support them. With the support they received, they found it easier to start using ET to compensate for their disabilities, although they needed to put effort into training to use them on their own. One person said: When she [the OT] made me start [use the mobile phone], when I sat in the evenings and worked myself into it [the mobile phone] again and then I came rather fast in [using] it. Some persons described that they did not need to put any effort into learning to use their ET as a compensatory aid, as illustrated by one man who started to use the reminder function in the mobile phone: I only did it once [after that I could do it]... direct, so it is not bad. Their experiences also reflected that they needed to put less effort into learning to use familiar ETs, as reflected in this quotation: The telephone... I had used it before... so it was not much new really [to learn]. Incorporating the compensatory use of ET into habits. The experiences of persons with ABI showed that changing and integrating the compensatory use of ET in their habits were important for the outcome of the intervention in their daily life. Some described this as a process over time that they had managed by repeated use of the ET by themselves in daily life, sometimes in cooperation with the OT or a significant other. One person said: It takes time to get used to things, to really begin to use it, I had no regrets, definitively not, but it takes time to take it in and become comfortable with it. According to the persons, the establishment of habits supported the continued use of ET, as reflected in this quotation: I put in information as soon as it is possible... when I come to work I can start it up and check what s up now but the preparation I do in the evening. A few reported that the establishment of habits was the most difficult part of the intervention process and that they still struggled with making the use of ET to a habit. Some of these persons described that although they found the ET both easy to use and useful in daily life, they forgot to use them, even if they kept them in places that would facilitate the use, e.g., in their pockets. One person said: I got this Dictaphone, I have not used it so frequently, I admit that... It is a thing you have to get used to...that is that, that I forget it. Others, who had difficulties making the use of ET to a habit, were not fully convinced of the need of the technology or reported that they had problems using them due to limitations in the design of the technology. This was apparent even if they experienced that the most appropriate ET on the market had been selected. For example, problems related to the design were that the pace of technology was too fast or that it took too much time and effort to put in information in the technology. Another example was that the GPS were adapted for car driving, which caused problem when it was used for walking. The experiences of the persons with ABI reflected that the incorporation of ET into their habits also meant they established a new relation with the ET. Some described an overall relation of ET to their life, such as: It [ET] is worth gold, and sometimes the relation was a double-edged sword, such as I can t live without the technology, but it should not have such huge importance I think, but it s really good to have as a help and Technology is a part of my life now, I must have it. Others expressed a more personal relation with the ET, as exemplified by two persons: the Dictaphone is a friend to me because it makes tasks easier for me and It [the ET] is my extra memory. Becoming capable of doing tasks independently by the compensatory use of ET makes one feel like a new person. According to the persons with ABI, the use of ET that provided reminders and a clear structure for their daily life, such as handheld computers, mobile phones and Dictaphones, meant that they could have control over and take responsibility for tasks that needed to be done. Furthermore, they could carry them out in time, as reflected in this quotation: I have more control over everything, I write [in the handheld computer] the evening before what we should have for supper. The persons expressed that the use of ET meant that they did not need to think all the time on possible tasks they needed to do or things that they might have missed. One person said: I have become safer and more calm [by the use of ET], one get strained [reflecting on the time before the use of ET]... and this strain makes one more tired, it push one down in some way... I put much time on what I needed to think on, now I do the things that need to be done through the signals [from the ET]. The use also meant that they became more capable of doing tasks independently and regained confidence in their own abilities. This affected their mood; they described themselves as more harmonious, relaxed and content, as illustrated in this quote: When I shall meet people and remember things I can always put it in the mobile, then I am safe and can relax and that is very different from walking around and feeling bad all the time. Some who had problems with bad temper felt that it was reduced, and some persons experienced that they forgot fewer things than before. They also experienced that they got more time and energy to do

7 important tasks, as illustrated in this quotation: When I have structured my life [by the use of ET], I get more time so we [me and my child] can sit and play instead. The persons expressed that their view of themselves and their life changed when their ability in and control over tasks in daily life increased. One person said: It [the ET] has changed my life very much and in many ways, I have become another person..., calm, happy, have more time for significant others... I have become whole, so to speak and that is important. The persons described that they, before the compensatory use of ET, were disappointed by themselves when they were not able to manage and take responsibility for basic tasks in daily life. The changes experienced were described by two persons: I become proud of myself when I manage to do the tasks that need to be done and It feels much better to be able to take care about oneself, I have to, I am an adult. I have to take responsibility for my own acts. The experiences of individualised occupation-based interventions using ET among the significant others A relief in daily life. The content of the significant others experiences of the use of ET to improve task performance in daily life for the persons with ABI formed the category A relief in daily life. This category was formed by three sub-categories: Integration of ET in daily life can go smoothly or be challenging ; Increased ability through the compensatory use of ET affects the mood of both of us positively and Decreased responsibility and reduced need of continuous control by the support of ET (Table I). The significant others overall experiences of the compensatory use of ET were conceptualised as a relief, as illustrated in this quotation from one of the significant other: It is a relief both for the individual and for the significant other. The relief was either emotional or both emotional and practical. The significant others involvement in the intervention and the kind of relief experienced by them varied depending on the persons with ABI need of their support in the tasks concerned, if the significant other lived in the same household and the vocational situation for the significant other. When an ET was used to compensate in tasks that the significant others was not involved in, such as work tasks, they told of an emotional relief in their life, as the person with ABI became more harmonious. In other cases, as when the ET limited their provision of support, the compensation was described as very important for their own life, both from an emotional and practical point of view. A few significant others, who Everyday technology 407 described great burdens, pointed out that even if they experienced a relief in their life as a result of the ETs, the overall feeling of stress and burden in their daily life continued to exist. Integration of ET in daily life can go smoothly or be challenging. The significant others had diverse experiences of the process when the persons with ABI learnt to compensate with their ET. Those significant others who were not involved in the intervention experienced that the person with ABI rather smoothly and without problems had learnt to compensate by the use of ET. Others described their experiences of how the person with ABI successively, over time, had learnt to use their ET. One significant other said: It is much less notes, it (the information) has been put in the technology...but when I think about it, I haven t thought about that the notes are gone. They described how they also tried to learn to use the ET to be able to support the person with ABI, as one significant other said: The Dictaphone, we [the significant other and the person with ABI] sat and looked at it together, we tried to record and play the recording. Another significant other told of how she supported the use by providing information that the user needed to put in the ET. One significant other had previously used the same product (handheld computer) as the person with ABI now used. According to the significant other, this made it easier for him to provide support that successively enabled the independent use. The process of learning to use ET was, in a few cases, experienced as challenging by the significant others when the person with ABI frequently forgot to use it. This meant that the significant other repeatedly had to remind the person with ABI to use it. They felt frustrated when they did not know if they could trust that the ET was used, especially as it had great potential to make both their lives easier, as one significant other said: If he forgets to use it [the Dictaphone], he does not use it as the resource it actually is and then we are back to all our notes, boards, messages and all my nagging. Some significant others had the experiences that they had to be frequently involved when the person with ABI started to use the ET to check if they had done the right thing, as illustrated in this quotation: Even if he has these aids, he wants to check that he has not forgotten anything... he does not trust that he has inserted all information. One significant other described how she felt ashamed when the person with ABI had lost one of his ET, even if it was not her responsibility. Increased ability by the compensatory use of ET affects the mood of both of us positively. The significant others described how the person with ABI, with the use of the ET, had increased their ability to perform tasks,

8 408 M. L. Lund et al. increased their independence and had achieved confidence to try to do tasks that they had not dared to do before. According to the significant others, this had made the persons with ABI happier and more pleased, at the same time as they become less frustrated and stressed. This positive change of the users mood also influenced their own mood in a positive direction. Based on previous experiences, a significant other told how it would have been without the handheld computer: It gets more irritating, more stress, she becomes like that, you know because she forget things...and that affects me negatively, because isn t she happy, I m not happy either. The significant others described that they became happy for the sake of the person with ABI and that they also felt more content, as illustrated in these quotations: It makes me happy that she can go wherever she wants [using the GPS] and It feels better [for me] when he has the possibility to manage life better by himself [referring to use of mobile phone, GPS and handheld computer]. Some expressed that this meant that they felt less inadequate and experienced an increased strength in providing support and in managing their own daily life as a significant other to a person with ABI. Decreased responsibility and reduced need of continuous control by the support of ET. The significant others described how they, before the compensatory use of the ET, had become responsible, to various degrees, for the persons with ABI tasks in daily life, such as remembering appointments and checking if any messages or information needed to be passed on to them as significant others. This responsibility could also imply that they had to check the person with ABI, when he or she carried out tasks, to be ready to provide support to overcome obstacles or avoid problems. It could also imply that they had to check if tasks that needed to be done by the persons with ABI had been accomplished. All these responsibilities and the continuous need of control decreased or completely disappeared when the ET had become integrated in the task performance of persons with ABI. For example, one woman said: For my sake it is very good, because when I know that he uses his mobile phone, he gets a reminder, when he does not forget, you can imagine how it was before, if he should go to the hair dresser, to the dentist or whatever, when I had to call him, I had to remind him...for me it has meant so much, that I have been able to let go all of these [reminders]. Another aspect described by a significant other was that she, before the compensatory use of ET, needed to stay in control as the person with ABI repeatedly contacted her to check things, as illustrated in this quotations: It feels better... before [the compensatory use of ET] he called everyday... he has not called me for several days and asked anything in particular [he needs to remember]... but I have to say, when I think about it, it can go a week without him contacting me. One significant other described that he had started to provide another type of support: I help her less with the things she had problems with previously... I do not help her less, but I help her with other things. The significant others described how ET made them feel safer at times when they were not present and when tasks were carried out by the person with ABI. Some were now confident that the person with ABI would find the way to different places using the GPS. Some significant others were not afraid of fires now when timers were used, as one said: I do not need to control him, the stove timer sounds. Others described that they no longer needed to go with the person with ABI to appointments to receive information that most likely would be forgotten, as the meeting was now being recorded. A woman expressed how feelings of safety aroused by the use of a Dictaphone, as illustrated in this quotation: I feel safer when he brings it [the Dictaphone] with him, if he goes to the physician, when, for example, that I now know for sure if some medication is changed. Discussion The experiences of the individualised occupationbased interventions among the persons with ABI and their significant others showed that the compensatory use of commonly available ET changed both lives remarkably. The persons with ABI described that they mastered their daily life in a better way, and the experiences of the significant others matched these, by a feeling of relief in daily life. Thus, the results indicate, somewhat unexpectedly, that the specific task-related goals achieved in the intervention affected the overall contentment with life of both the persons with ABI and their significant others. The achievement of the task-related goals also had an impact on their experiences of mood, control, autonomy and of themselves as persons. One possible explanation to these positive results is that the intervention focused on the problems in tasks of daily life that were highly prioritised by the persons with ABI. Fisher [20] emphasises the importance of understanding priorities and inner drives of task performance when designing effective client-centred interventions. In line with this, Scherer [27] states that a key factor to the utility of an aid is the extent to which it meets the users needs. However, even if a complexity of factors is considered when it comes to identifying factors that determine the use of technology [10,28], the importance of the task for the individual is often

9 neglected. The focus on the tasks in daily life that the clients prioritise may have been important not only for the outcome but also for facilitating their learning in the intervention process. Recent research confirms [29] that tasks prioritised by persons with ABI increase their efforts in finding effective adaptations in using ET. It was also found that [13] in learning clients to use technology to compensate for memory difficulties, clients perform better in tasks in daily life than in experimental contrived tasks. The results reflect that the persons with ABI and those around them were not aware of the potential that the ET that already existed in their lives, or could be purchased off-the-shelf, could compensate for their difficulties. Previous research [30,31] has found that the lack of information about the available AT, their potential benefits and, also, too limited access to them is a barrier to their use. In contrast, most people in the western world have knowledge of the ET available in the society of today and access to many ET. An increased awareness and knowledge of how ET can be used to compensate for difficulties among the clients, their significant others and professionals have the potential to promote a more equal access to compensatory technology and expand the usage of them in brain injury rehabilitation. The fact that the persons with ABI had no doubts to use ET to compensate for their difficulties is in contrast to previous research on electronic aids [17,18]. It has been shown that starting to use technology can cause mixed feelings, such as experiences of fear and of being challenged. Moreover, no feelings of stigmatisation or embarrassment were apparent among the participants experiences, something that commonly have been described as hampering the use of AT [32,33]. This might be explained by the fact that ET are products and services that are used by the public and, therefore, are not attached with negative feelings that can result in non-compliance in the use of them. Interestingly, the results indicate that persons with ABI can incorporate the use of the ET in their view of themselves, something that has been found [33] to be important for continued compliance in the use of ET. This suggests that the compensatory use of ET among these persons is experienced as a natural part of their tasks in daily life. In most cases, both groups of participants experienced that it was easy to learn to use the functions in the ET. This indicates that the OT chose an ET that matched the person and appropriately adjusted the error-free learning strategies used to support their ability to learn. In line with this, Wilson and Evans [22] have argued that by supporting the patient not to make mistakes, a more efficient learning can be faciliated as compared to a trial-and-error approach. On the other hand, some persons with ABI and their Everyday technology 409 significant others had the experience that it could be a challenge to habitually use them. In line with this, Clark et al. [34] state that habits are a powerful source that can have both a positive and a negative influence on rehabilitation interventions as well as on peoples life. Thus, as found in the results, it can be difficult to change pre-existing habits to establish new ones, like starting to use ET as a compensatory aid in rehabilitation. On the other hand, our results indicate that the habits of regularly using an ET can be a source in rehabilitation that facilitates establishing additional habits related to the ET, e.g., using new functions during compensatory interventions. This suggest that ET, in this way, has an advantage over AT, which is often completely new for the user. Similarly, previous research [13] has also found that it can be difficult for persons with memory impairments to habitually remember to use their AT. Furthermore, it has been suggested that specific adaptations need to be considered for those with severe memory problems. The results indicate a limitation, that it was not possible to adapt the use of certain ET to the needs of some of the persons with ABI. Emiliani [3] has also stated that the restricted possibilities to adapt commonly available ET can be a limitation in the use of them. However, it is important to note that some of the difficulties reported here, e.g., that the ET sometimes was not used, had been difficult to resolve even with an AT. In line with this, Lopresti et al. [35] state that it is complicated to accommodate AT to each user s unique combinations of abilities. An interesting finding was that the persons with ABI, due to their increased ability to manage tasks in daily life with the use of ET, started to see themselves as new persons and their capability in a positive way. This can be explained by the co-development of identity and competence in a continuous process during engagements in tasks [36]. Thus, focus on task-related goals in the intervention process and fulfilment of these might also be important in helping persons with ABI to find a desired identity after their injury. Some of the benefits of the compensatory use of ET described by the significant others, such as avoidance of hazardous situations (e.g., fires and lost location of the persons with ABI) and increased independence in tasks of daily life, are similar to the needs, regarding advanced technology, identified among other carer to persons with cognitive impairments [37]. The results indicate that significant others can provide a complementary view of the persons difficulties before and during the intervention process and, also, provide practical support during the learning process. It is important that professionals are ready to support significant others in their support of the ABI person s adoption of ET

10 410 M. L. Lund et al. and, also, to avoid that feelings of guilt and distress arise when the ET is not used as intended. Previous research [12] has also found that significant others can feel insecure whether the aid works effectively. Therefore, it is also important to involve them to reduce their stress and support them in reducing their control over the task the persons with ABI need to perform. A methodological limitation of this study is that the persons with ABI suffered from memory impairments and that the interviews were conducted about 3 months after the intervention was completed, and this might have influenced the quality of the interview. However, as the adoption of ET had become a significant event in their life, this probably reinforced their abilities to give an accurate description. This was also reflected in the interviews, as they clearly described the changes in their life. Yet, it is reasonable to believe that they were not able to recall all the details from the intervention process. In future research, it is, therefore, important to collect data during the process to deepen our knowledge. Another limitation is that all participants had positive outcomes of the intervention. Therefore, data from a sample that experience both positive and negative outcomes would be desirable in future research to broaden our knowledge. The intervention was individualised and carried out until the goals for each participant was reached. However, the intention with this qualitative study was not to focus on exactly what was done over what period of time or how the participants reactions varied by any individual or intervention characteristics, but such questions can be of great interest in future research. As the significant others participation in the intervention varied, this had an impact on the content of their interviews. Some of the significant others that were involved only to a small extent in the intervention did not have much to tell about the process, but instead about the outcome. Finally, the intention with this qualitative study was not to generalise [38] but rather to describe the intervention process including compensatory use of ET and the outcome of the process in order to provide opportunities for transferability to other persons in similar situations. In conclusion, this qualitative study has shown that both persons with ABI and their significant others experience a multitude of benefits from occupation-based interventions by using ET to compensate for difficulties in the performance of tasks in daily life. The persons with ABI felt that they mastered their life in a better way, and their significant others felt a relief in daily life, which taken together affected their overall contentment with life. The increased awareness of the potential of ET to compensate, and the knowledge about how the compensatory use of ET could be facilitated, can support professionals to increase the use of ET in brain injury rehabilitation. Acknowledgements The authors are grateful to the participants for their willingness to share their experiences of the intervention. The authors are also grateful to Anita Lindén, MSc, OT, for her comments on the manuscript. Declaration of interest: This study was part of the Cognition and Technology (CogniTech) project, conducted within the Swedish Institute of Assistive Technology and supported financially by the Swedish Inheritance Fund. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References 1. Nygard L, Starkhammar S. The use of everyday technology by people with dementia living alone: mapping out the difficulties. Aging Ment Health 2007;11: Bodine C, Scherer MJ. 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