The experiences and perceptions of health-care professionals regarding assistive technology training: A systematic review

ABSTRACT Worldwide, there is an increasing demand for assistive technologies (ATs) that can support people to live independently for longer. Health-care professionals (HCPs) often recommend AT devices, however there exists a lack of availability of devices and appropriate training in the field. This systematic review aimed to synthesize the available evidence into the experiences and training needs of HCPs in relation to AT. Six electronic databases were searched without date restrictions: MEDLINE, PsycINFO, SPP, SSCI, CINAHL, and ASSIA. Journal handsearching, searching reference lists of included studies and relevant reviews, and contacting experts in the field of AT were also conducted. Findings were analyzed using narrative synthesis. Data from 7846 participants from 62 studies were synthesized, eliciting perceived challenges in access to and provision of training, resulting in knowledge gaps across disciplines and geographic locations. Mechanisms to mitigate these issues included ongoing support following training and tailoring education to meet individual needs since comprehensive training is essential to maintain and improve competence, knowledge, and confidence. Further research is required to explore the impact and effectiveness of AT training for HCPs to ensure that users of devices are supported to live independent and healthy lives.


Introduction
Disabilities often result in a loss of autonomy and a breakdown of social interaction (Tough et al., 2017), and thus there is a demand for assistive technology (AT) solutions that ensure people feel enabled to live independently for as long as possible.AT is an increasingly important aspect of many fields of health and care practice, and consequently the issue of transdisciplinary terminology and the potential for misunderstanding is an ongoing challenge (Elsaesser et al., 2022).The definition of AT used for this systematic review was reported by the World Health Organization (WHO) as: "An umbrella term covering the systems and services related to the delivery of assistive products and services.Assistive products maintain or improve an individual's functioning and independence, thereby promoting their wellbeing" (WHO, 2018).
It is predicted that demand for AT devices will increase significantly and become more widespread in the coming years, with more than 2 billion people needing at least one assistive product by 2030 and many older people needing two or more (WHO, 2018).This is partly due to a rise in non-communicable diseases and people worldwide living longer, with one in six people expected to be aged 60 years or older by 2030 (WHO, 2022a).The MHRA (2021) suggests that there will be an increasing need for AT devices that compensate for or alleviate injury, disability, or illness or replace physical function including, for example, mobility aids, wheelchairs, walking aids, artificial limbs, communication, and hearing aids.It is vital to ensure that people with disabilities, the older population, and those affected by chronic diseases are included in society and enable to live healthy and dignified lives (WHO, 2018), and predicted increased demand will require a related increased in trained AT providers.
Evidence has highlighted the key role innovative AT devices have in enhancing mobility and social inclusion (WHO, 2018).However, factors such as environmental obstacles (both within and outside of the homes of users), lower rates of prescription, challenges in accessing AT equipment, rapid advances in new technologies, the perceived stigma of AT, and low uptake of users can contribute to lower levels of AT usage (Bright et al., 2018;Kamal et al., 2020;Vignier et al., 2008).Consequently, there is an increasing need for clinicians and rehabilitation professionals to be aware of relevant, current, and novel technology and how it may be utilized in their work to fully support service users (Brose et al., 2010).
Comprehensive needs assessment for AT devices is important to ensure they are appropriately matched to the individual user's needs, lifestyle, motivation, attitude to risk, and home environment (Andrich et al., 2015;Gibson et al., 2019).Appropriate prescription of devices is vital to ensure their uptake and sustained use, and therefore comprehensive needs assessment and customized, systematic instruction to optimize the long-term benefits for users are vital (Lannin et al., 2014;Powell et al., 2015;Scherer & Craddock, 2002).Without adequately trained AT providers, assistive products are often of no benefit to users, may be abandoned and may even cause physical harm (WHO, 2018).Technology and Disability), and other review reference lists reference lists of included studies were also searched in order to identify articles missed from the electronic searches.

Study screening and selection
Following duplicate removal, two review authors independently screened the titles and abstracts to identify studies potentially fitting the inclusion criteria.The authors then scrutinized full texts of the selected articles.Where there was uncertainty about inclusion, consensus was achieved by discussion or with the help of a third reviewer.A PRISMA flowchart was constructed to show the flow of articles through the process of identification through to inclusion or reasons for exclusion (Page et al., 2021).

Data extraction and management
Data were extracted using standardized data extraction forms and subsequently entered into an Excel file before being entered into standardized tables.An Excel database was used to remove duplicate articles and manage the titles and abstracts.Data extracted included details of database, country, study design, methods, participant characteristics, findings related to the research questions of this review, and study conclusions.

Quality appraisal
The quality of articles was appraised using the Mixed Methods Appraisal Tool (MMAT; Hong et al., 2018).The MMAT was chosen because it is a critical appraisal tool developed to assess the quality of the studies with multiple methodologies and designs, which were expected to be retrieved in this review.Data were entered into standardized tables, which included the main findings from each included study.Studies were not excluded based on quality score, rather they were used to interrogate the data and the robustness of the conclusions that could be drawn from the review synthesis.The MMAT has five questions for each type of study (which were assigned a score of 0 for "no", 1 for "can't tell", or 2 for "yes") and two screening questions that can be applied to all studies.However, if the answer to the screening questions was either "no" or "can't tell", the study would not be primary research.As primary research was an inclusion criterion for this systematic review, we felt it unnecessary to score the screening questions as they would already have been filtered out.Therefore, studies could score a minimum of zero and a maximum of 10.

Data synthesis
Narrative synthesis (Dixon-Woods et al., 2005) was undertaken due to the heterogeneous nature of the included articles.This method is inclusive, allows integration of qualitative and quantitative data from a wide variety of sources, and can be more descriptive and interpretive than other review types, for example, to explore relationships in the data and between groups of studies pertaining to research questions.Gowran, 2019;Papadopoulos et al., 2018;Smith et al., 2018;Zanatta et al., 2022) were retrieved and their reference lists screened for studies possibly fitting the inclusion criteria.This revealed a further 10 potentially relevant articles.After screening titles and abstracts, two full-texts were retrieved and both were included in the synthesis (Aldersea et al., 1999;White et al., 2003).

Electronic
Handsearching of three relevant peer-reviewed journals: Assistive Technology; Disability and Rehabilitation; Technology and Disability, resulted in 29 potentially relevant articles.After screening titles and abstracts, nine potentially relevant articles were sought for full-text retrieval.Of these, three fitted the inclusion criteria and were included in the synthesis (Bourassa et al., 2021;Rasouli et al., 2021;Worobey et al., 2020).Four experts in the area of AT identified during the electronic searches were contacted via e-mail to find relevant articles not revealed by the electronic searches.Three responded, suggesting five articles.However, two of these did not fit the inclusion criteria, and three were repeats of those found during the electronic searches.
Finally, reference list searching, of articles already included in the synthesis, led to the screening of further 38 titles and abstracts.Of these, 15 full-texts were retrieved, with six fitting the inclusion criteria and included in the synthesis.A total of 62 studies fitted the inclusion criteria and were included in the synthesis.Full details of the process of including and excluding articles, with reasons, are viewable in Figure 1.

Study details and methods
Study publication dates spanned more than three decades, with one published in 1987 (Glass & Hall, 1987) and the most recent ones published in 2022 (Graham et al., 2022;Papadopoulos et al., 2022;Rathiram et al., 2022;Worobey et al., 2022;Wright et al., 2022).Forty-one (66%) of the included studies were published since 2010, showing increasing recent research interest on the topic of AT.Most studies were conducted in Europe or North America (76%), with 26 conducted in Europe (the United Kingdom − 14; Norway − 5; Sweden − 2; The Netherlands − 2; Ireland − 1; and Cyprus − 1) and 21 in North America (the United States of America − 16 and Canada − 4).There were seven (11%) in Australasia (five in Australia and two in New Zealand); four in the Far East (one each in Pakistan, India, Taiwan, and the Philippines); two in Africa (one in Egypt and one in South Africa); and one each in South America (Brazil) and the Middle East (Israel).
Almost half of the included studies were quantitative (30), followed by qualitative (23), mixed methods (6), and multiple methods (3).Most studies (43) used convenience sampling to recruit participants, with a smaller number employing purposive sampling (10).Others used probability, random, snowball, criterion, or theoretical approaches.More than half of the studies (32) used surveys -online, paper, or a mixture of both -for data collection.Types of analysis varied by study methods, with qualitative studies using mainly thematical, framework, or content analysis and quantitative studies largely using descriptive statistics, frequencies, and percentages.
Included studies either investigated one or more assistive technologies or were generally looking at AT training needs.Specific types of AT investigated included, for example: wheelchairs, hearing aids, robotic technology, and health information and eHealth technologies.Full details of the types of AT investigated, where applicable, are viewable in Table 2. Full details of the included study methods are viewable in Table 3.

Participant characteristics
Data from a total of 7846 participants from the 62 studies were synthesized.Less than half of the studies (30) reported participant gender, with females (1499) far outweighing the number of males (388).Age was also sparsely and inconsistently reported, with 30 studies including data on this demographic, ranging from 16 to 77 years.Age was reported in various ways, for example, some reported participants' mean age and/or range, whereas others categorized ages by decade, e.g., 20-29 years.
Participant ethnicity was reported in seven studies (Compton et al., 2009;Graham et al., 2022;Long et al., 2007;Papadopoulos et al., 2022;Sax, 2002;Weakley et al., 2019;Worobey et al., 2022).Of these, participants were primarily White, except for in Papadopoulos et al. (2022) where White participants made up less than 40% of the total.Similar to participant ethnicity, whether the study was conducted in urban or rural locations was reported by just five studies (Compton et al., 2009;Gitlow & Sanford, 2003;Hall et al., 2017;Magnusson, 2019;Magnusson & Ramstrand, 2009).Three studies were conducted in a mixture of urban and rural locations, with another one each conducted in solely rural or urban settings.
There were a variety of health-care professional participants in the studies.However, some occupations were more prevalent than others.For example, occupational therapists/students = 2853; nurses/nursing students = 1645; speech and language therapists/pathologists = 911; and physiotherapists = 65.Taken together, these HCPs and students make up 70% of the total participant number.Full details of participant characteristics are available in Table 2.

Quality appraisal
All studies included in the synthesis were independently assessed by two members of the review team (SM, EH, JM, DT, and MS).Study quality scores ranged from 1 (10%) to 10 (100%) out of a maximum of 10 using the Mixed Methods Appraisal Tool (MMAT; Hong et al., 2018).Overall, the study quality was high, with 47 scoring 80% or above and 18 of these scoring the maximum 100%.However, the qualitative studies largely outperformed other studies that used quantitative or mixed methods.For example, of the 23 included qualitative studies, all score 80% or above, and 22 of the 31 quantitative studies score 80% or over.Further, of the eight mixed methods studies, just two scored 80% or above, with five scoring 50% or below.Mixed methods studies generally scored poorly to the question: "Do the different components of the study adhere to the    Jarvis et al. (2017) [Australia] Quantitative cross-sectional survey Convenience Online and paper survey Descriptive statistics, including frequencies and percentages.Karlsson et al. (2018) [Australia] Qualitative multiple case study Purposive; snowball Focus groups Linked coding Leite et al. (2018) [Brazil] Qualitative, descriptive, cross-sectional Convenience Semi-structured interviews Content analysis Liang et al. (2019) [Taiwan] Qualitative, descriptive, cross-sectional Purposive One-on-one, semi-structured interviews Content analysis Long and Perry (2008) [  quality criteria of each tradition of the methods involved?," with half scoring zero.Quantitative descriptive studies more often scored poorly to the question: "Is the risk of nonresponse bias low?," with seven studies not scoring any points here.Full details of the quality scores, including how each study was scored against each of the MMAT questions, are viewable in Table 4.

Knowledge-related issues
A lack of knowledge regarding AT was reported in over half (32) of the studies, eleven of which involved specialist HCPs who commonly work with AT (e.g., occupational therapists; speech and language therapists; and physiotherapists).Gaps in AT knowledge were mainly related to a lack of familiarity and experience of using devices.These knowledge gaps caused some HCPs to report a lack of competence and confidence, as well as uncertainty regarding the needs and requirements or AT users.For example, it was found that 79% of speechlanguage pathologists had little confidence in managing cochlear implant technology due to a lack of adequate training (Compton et al., 2009).
For HCPs and students who had received some form of AT training, interventions were mostly effective in increasing basic to intermediate knowledge and competency (Giesbrecht, 2021).Participants felt prepared to apply learning to practice as a result of their increased skills and expertise.However, more detailed and comprehensive knowledge was required, for example, training should incorporate practical experience with specific devices, rather than generic AT information (Brophy-Arnott et al., 1992;Long & Perry, 2008).This will better prepare HCPs with the clinical skills needed for AT technologies used in their specialty.

Training needs
Various training needs were reported in almost half of the included studies.Knowledge of AT assessment, for example, obtaining the best fit and use of devices by patients and clients, were the most commonly identified training needs (Flynn et al., 2019;Graham et al., 2022).There was also an awareness that the evidence-based benefits of AT on users were important for training to cover (Bourassa et al., 2021;Hughes et al., 2014).Participants reported needing further information regarding regulation and legislation surrounding AT and AT services, to fully understand when and where to use it and for whom it was designed for use with (Bergem, 2020;Long & Perry, 2008).Further, there is a need for greater awareness of cultural issues and influences in relation to AT, as training programs contained limited information on the cultural influences which impact AT use (Brady et al., 2007).Also, AT training needs to be adjusted to various countries' regulations to effectively deliver person-centered rehabilitation (Magnusson, 2019).However, with a reported lack of funding for AT training and education, it is currently unclear how these needs and knowledge gaps can be improved.Studies from which the data were synthesized are viewable in Table 5.

Accessing AT training
Poor availability of AT training was reported across a range of health-care professions and student groups (Magnusson & Ramstrand, 2009;Rathiram et al., 2022).Further, there was variable provision of training in the AT field across professions and geographical locations, particularly in terms of structure, inadequate content, and insufficient time allocated to the subject (Brady et al., 2007;Long et al., 2007;Matthews, 2001).

Improving provision of AT training
A third of the included studies recommended that dedicated time for ongoing in-service training for professionals was important to ensure targeted education and increased awareness of the latest AT devices (Holthe et al., 2020;Leite et al., 2018).Also reported was a need for enhanced instruction and curricula for health-care education specifically related to AT (Giesbrecht, 2021;Somerville et al., 1990).Curriculum content should be sufficiently in-depth and embedded for those who will be entering health-care professions, as well as made an integral part of basic health-care education (Pampoulou et al., 2018).Furthermore, the importance of providing opportunities for regular updated training and continuing professional development (CPD), was necessary to ensure up-to-date AT knowledge, enhanced clinical practice, and improved AT user satisfaction (Gitlow & Sanford, 2003;Long et al., 2007).

Importance of multidisciplinary approach
There were reported benefits of applying a multidisciplinary approach to AT training, including the strength of a whole systems approach (Demain et al., 2013), enhanced collaboration and communication, shared responsibility, and provision of the best solutions for AT users (Magnusson & Ramstrand, 2009).Other benefits included opportunities for networking and collaboration between HCPs from different academic and professional backgrounds (Gitlow & Sanford, 2003).Furthermore, it was suggested that AT education and training should include those using AT devices and their informal carers, as shared experience and collaboration on multiple levels is a key facilitator in preventing abandonment of devices by service users (Demain et al., 2013).As there are variations in AT knowledge between disciplines (Bergem, 2020), applying    the above approaches to education may enhance knowledge about AT across health-care sectors.

Different means of education
Providing various modes of training as opposed to solely lecture-based approaches to learning was reportedly important for successfully engaging learners in course content (Chua & Gorgon, 2019;Leite et al., 2018).Learners valued and preferred hands-on experiential learning from other HCPs.Suggestions for other means of education included blended and distance learning approaches and providing learning opportunities via attendance at symposia and conferences.Valuable sources of information to enhance learning included journal articles, textbooks, telephone information services with AT specialists and newsletters (Chmiliar, 2007).Studies from which data were synthesized are viewable in Table 6.

Ongoing support following training
In order for professionals to practice and maintain optimal operational skills, there was a need for ongoing support following AT training.Employing organizations and educational institutions were suggested as potentially effective options by providing educational updates and acting as conduits for information sharing (Liang et al., 2019;McGrath et al., 2017).Internal organizational support mechanisms could include facilitating peer support between colleagues, implementing mentoring programs, and recruiting internal experts or "AT champions" (De Leeuw et al., 2020;Wright et al., 2022).Furthermore, within organizations and institutions, the support of managers who recognize challenges faced by HCPs and facilitate training opportunities is vital for maintaining clinicians' AT knowledge (Aldersea et al., 1999;Rasouli et al., 2021).
External support from AT specialists and device manufacturers was also reported as a possible way of providing ongoing technical support and guidance (Taherian & Davies, 2018).

Individual variables
HCPs reported challenges, including fear and lack of confidence, in using information technology needed in order to use AT effectively (Graham et al., 2022).Others reported time constraints as a barrier to undertaking AT training (Bergem, 2020), which is particularly important for some individuals who may need more time than others to learn how to use new and sometimes complex devices (Boman & Bartfai, 2015).Furthermore, HCPs reported limited time to undertake AT training, with higher priority tasks, such as providing care to patients and clients, taking precedence (Farsjø et al., 2019).
Generic "one-size-fits-all" strategies for AT training that do not cater for individual learning needs and styles were not well received by participants (De Leeuw et al., 2020), with interventions tailored to individual learning needs and goals being preferred were preferred (Gitlow & Sanford, 2003;Sax, 2002).Tailored training could include setting up programs that are available as a series, as well as stand-alone courses.Furthermore, the importance of enhancing accessibility, such as giving due consideration to the location of training, providing online/web-based courses, and developing captioned videotapes and alternate formats for all training materials were discussed.These findings suggest that tailoring education to meet individual needs, skills, and learning styles could be a valuable solution to support effective AT training.Studies from which data were synthesized are viewable in Table 7.

Discussion
This systematic review set out to explore the experiences of HCPs who had undertaken training in the area of AT and to  Synthesis of the included studies uncovered that for HCPs and students who had received some form of AT training, such training was effective in increasing basic to intermediate AT knowledge and competency.Despite the support and education of professionals working in the field being highlighted as vital to maintain the use of AT and increase user participation (Widehammar et al., 2019), the synthesis uncovered a lack of availability and varying provision of training across health disciplines and geographic locations.In fact, just one study reported on the variation of AT knowledge between disciplines (Bergem, 2020), suggesting further research needs conducting to explore this important issue.The perceived challenges in accessing and the poor provision of AT training found here were largely responsible for numerous gaps in AT knowledge across disciplines and countries.Some reported a lack of knowledge about AT, in general, whereas others reported specific gaps, such as: assessment, availability of specific devices, evidence-based practice, regulation and legislation, funding, and the impact of cultural issues and influences.This was also found by Copley and Ziviani (2006), highlighting a worldwide problem with access to AT training.
Despite the importance of systematic evaluation of educational programs (Arthanat et al., 2007;Tao et al., 2020), only a small number of studies reported on evaluation of AT training here.This suggests that a more robust exploration is necessary to understand the impact and effectiveness of such interventions.
Findings from the synthesis suggested a number of perceived facilitating factors that enable HCPs to access AT training throughout their career.This is important given the rapid development of new technologies which require continuous lifelong learning (Liang et al., 2019).For example, the provision of enhanced graduate training, in-service training, opportunities for ongoing support and continuing professional development.The importance of a multidisciplinary approach to AT training also emerged as a perceived facilitating factor, however only two studies mentioned the importance of opportunities for networking, suggesting that this is an area that could be further developed or researched.
The synthesis revealed that HCPs' individual abilities and circumstances, such as varying IT skills and knowledge, time constraints, and learning styles, are perceived as potential barriers to accessing AT training.Different means of education are therefore warranted to ensure training is tailored to meet individual needs and preferences.This could include different modes of learning, such as online or blended approaches, providing opportunities for experiential practice, developing training programs that can be undertaken either as a series or stand-alone units, and providing opportunities to attend symposia and conferences.Consideration needs giving to the location of training and provision of alternate formats for training materials, to make it as flexible and accessible as possible, and to the potential time and financial costs involved in tailoring training to individuals.This echoes earlier research which suggests customized, systematic instruction to optimize the long-term benefits for users is vital (Lannin et al., 2014;Powell et al., 2015;Scherer & Craddock, 2002).These findings echo the WHO recommendation to enlarge, diversify, and improve workforce capacity in relation to AT (WHO, 2022b).

Limitations
Given the various challenges that exist in defining what is meant by AT (Elsaesser et al., 2022), and the great lengths the review team went to in deciding on an overarching definition of AT, some studies about AT training may have been missed where the subject was not reported as being AT.However, the thorough search strategies developed and the extensive searching for peer reviewed articles will have mitigated the negative impact that selection bias may have had on the findings.Further, despite the comprehensive literature search, none of the included studies were randomized-controlled trials.
Since the objectives of this review did not include mapping what AT training did exist, nor whether any recommendations proposed in the vast amount of studies the searches elicited were taken up in practice, further research to investigate active programs and identify additional existing gaps in training the AT workforce would be of value.There was also a lack of participants from black and minority ethnic backgrounds, which limits how these findings may apply to HCPs from minority ethnic groups.It is therefore unclear if findings in relation to AT training needs will be applicable to HCPs from different cultures or communities.
As only studies published in English were included, the generalizability of the findings is limited to English speaking and Western countries.

Future directions
More studies in the field of AT training for HCPs are required.More high-quality, robust research would be valuable to provide statistical evidence regarding the efficacy and impact of AT training.
Since most studies were conducted in Europe or North America, future studies should explore whether there are any variations in the training needs of HCPs in the Global South compared to other geographic areas and cultures.Further, whether studies were conducted in urban or rural areas was an area largely unreported by those included in this review.Prior to the COVID−19 pandemic, access to training was often centralized in urban areas that may be difficult for those living in rural or remote areas to reach, especially individuals with physical or mental impairment (Chmiliar, 2007).Future research exploring or comparing the impact and effectiveness of innovative online health-care professional education is therefore warranted.

Conclusions
Comprehensive and ongoing training in the field of AT is essential in a world where new technologies are rapidly developing and established ATs are underused.Effective training improves skills, competence, and knowledge of HCPs.However, challenges in accessing and providing training have resulted in numerous knowledge gaps across disciplines and geographic locations.Further research is needed to explore the impact and effectiveness of AT training to ensure that HCPs are able to continue supporting patients and clients to live independent and healthy lives.

Figure 1 .
Figure 1.PRISMA 2020 flow diagram (Page et al., 2021) showing the process of article identification and selection.
The United States of America] Multiple methods cross-sectional survey Random Paper survey -with both closed and open-ended questions Descriptive statistics, including frequencies and percentages, Kruskal-Wallis tests, ANOVA.Qualitative data analyzed through coding.Long et al. (2007) [The United States of America] Multiple methods cross-sectional survey Random Paper survey -with both closed and open-ended questions Descriptive statistics, including frequencies and percentages.Qualitative data analyzed through coding.
of the included 62 studies led to the development of three main themes which link to the review's research questions: (1) gaps in assistive technology training knowledge of HCPs and students; (2) perceived facilitators and barriers to assistive technology training; (3) mechanisms to support effective assistive technology training.These themes are reported in detail along with their subthemes.

Table 1 .
Example search strategy conducted in MEDLINE.
searching of six databases was originally conducted in May 2021 and updated in June 2022.These searches resulted in 3667 results before duplicate removal: MEDLINE − 969; PsycINFO − 915; CINAHL − 151; ASSIA − 512; SPP − 122; and SSCI − 998.Following duplicate removal, 3170 titles and abstracts were screened by two members of the review team (SM and RS), leading to the retrieval of 161 full texts.Of these, 51 fitted the inclusion criteria and were included in the synthesis.From the electronic searches, four literature reviews relevant to the topic ofAT and training needs (McSweeney &

Table 2 .
Aims and participant demographic characteristics of the included studies.
NR NR = not reported (where possible, study authors were contacted to retrieve missing data); NA = not applicable; AT = assistive technology; OT = occupational therapist; PT = physiotherapist; GP = general practitioner; CDSS = clinical decision support system.

Table 3 .
Methods of included studies.

Table 4 .
Quality scores of included studies.

Table 5 .
Gaps in at knowledge of health-care and social care professionals and students.

Table 6 .
Perceived facilitators and barriers to at training.