See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/248380956

Application of the Human Activity Assistive Technology model for occupational

therapy research

Article in Australian Occupational Therapy Journal · August 2013

DOI: 10.1111/1440-1630.12054

CITATIONS READS
38 14,674

1 author:

Edward M Giesbrecht
University of Manitoba
48 PUBLICATIONS 509 CITATIONS

SEE PROFILE

All content following this page was uploaded by Edward M Giesbrecht on 16 March 2019.

The user has requested enhancement of the downloaded file.

Title: Application of the Human Activity Assistive Technology model for occupational
therapy research

Author: Ed Giesbrecht, PhD (Cand.), OT(C)

Assistant Professor, Department of Occupational Therapy

Address: School of Medical Rehabilitation

University of Manitoba
R214 – 771 McDermot Avenue
Winnipeg, Manitoba, Canada R3E 0T6
School of Medical Rehabilitation
University of Manitoba
Phone: 1.204.977.5630
Fax: 1.204.789.3927
Email: Ed.Giesbrecht@umanitoba.ca

Abstract:
Background/Aim: Theoretical models provide a framework for describing practice and
integrating evidence into systematic research. There are few models that relate specifically to
the provision of assistive technology in occupational therapy practice. The Human Activity
Assistive Technology (HAAT) model is an enduring example that has continued to develop by
integrating a social model of disability, concepts from occupational therapy theory, and
principles of assistive technology adoption and abandonment.
Methods: This paper first describes the core concepts of the HAAT model and reviews its
development over three successive published versions. A review of the research literature
reflects application of the model to clinical practice, study design, outcome measure selection
and interpretation of results, particularly among occupational therapists. An evaluative
framework is used to critique the adequacy of the HAAT model for practice and research,
exploring attributes of clarity, simplicity, generality, accessibility and importance. Finally,
recommendations are proposed for continued development of the model and research
applications.
Results: Most of the existing research literature employs the HAAT model for background and
study design; there is emerging evidence to support the core concepts as predictive factors.
While the concepts are generally simple, clear and applicable to occupational therapy practice
and research, evolving terminology and outcomes become more complex with the conflation of
integrated theories.
Conclusions and significance: The development of the HAAT model offers enhanced access and
application for occupational therapists, but poses challenges to clarity among concepts.
Suggestions are made for further development and applications of the model.
Key words: assistive technology, rehabilitation, models (theoretical), occupational therapy

1
Introduction

In rehabilitation, greater emphasis is being placed on designing and interpreting research within

a theoretical framework (Fuhrer, Jutai, Scherer & Deruyter, 2003; Siegert, McPherson & Dean,

2005). To advance credibility and evidence-based practice in occupational therapy, conceptual

models are needed to integrate evidence for systematic research and measurement of

treatment outcomes (Friederich, Bernd & De Witte, 2010). The Human Activity Assistive

Technology (HAAT) model (Cook & Hussey 1995) is a widely-accepted theoretical framework for

assistive technology (AT) provision, yet limited attention has been paid to exploring its

application for practice and research. Within the last fifteen years the HAAT model has

undergone substantial development, and the most current version (Cook & Miller Polgar 2008)

has not yet been reviewed in the literature. The purpose of this paper is to critically evaluate

the HAAT model and its adequacy as a theoretical framework for both clinical practice and

research in occupational therapy. This critique will include a brief overview of the HAAT model.

The main tenets will be summarized, followed by a discussion of the model’s advancement over

time. Existing literature will be explored and incorporated into the model evaluation. Finally,

directions for further development will be suggested.

The HAAT Model

Model Overview

Cook & Hussey’s original intent of the HAAT model was to describe a process for prescribing a

solution, or assistive technology system, optimally suited for a person with a disability (Cook &

Hussey 1995). The model was designed to guide assessment and prescription, as well as
2
evaluate the result. The functional outcome of an assistive technology system is defined as

“someone (person with a disability) doing something (an activity) somewhere (within a

context)” (p. 46). The performance of the entire system, rather than evaluation of human

performance, was considered paramount. Dissemination of the HAAT model has occurred

primarily through publication of the textbook referenced above. It has served principally as a

descriptive model, outlining clinically relevant variables for consideration in practice. However,

in successive versions, the authors introduced concepts that may potentially explain and predict

successful outcomes. In the following section, the origin and consolidation of concepts central

to the HAAT model will be outlined.

Core Concepts

The HAAT model is among the earliest published models of AT and is a principal framework

within the field (Lenker & Paquet, 2003). Citation as a primary text in peer-reviewed

publications is a testament to its value and constancy. The original authors represent two

disciplines often involved in AT service delivery; Cook from rehabilitation engineering and

Hussey from occupational therapy. Both professions espouse a conceptual model that

incorporates three common elements: the human/person; the activity/occupation; and the

context/environment. The HAAT model is built on the foundation of Bailey’s (1989) human

performance model used in human factors engineering. Figure 1 (A & B) illustrates how the

HAAT model advances Bailey’s earlier framework by incorporating two substantive changes.

First, assistive technology is delineated as a separate and uniquely important element, having a

direct and interdependent relationship with the human, activity and contextual factors. This is
3
evident by its inclusion within the circle of the model as a core component, while in Bailey’s

model technology is not explicitly identified. This omission has particular relevance when the

outcome is defined for an individual rather than a generic commercial application. Second, the

context shifts to a more pervasive position, as illustrated by the bounding rectangle in the HAAT

model (Figure 1B). The context is understood to be more than the location and physical

conditions in which an activity occurs. The impact of social, cultural and institutional factors is

embedded and the relevance of the activity to the individual is paramount.

Four core concepts of the HAAT model influence successful engagement in meaningful

occupation: the human; the activity; the AT; and the context - physical, social, cultural and

environmental. There is a “dynamic interaction between the initial three factors and the

pervasive influence [of the context] on them, both individually and collectively” (Cook & Miller

Polgar, 2008, p. 36), with the human explicitly identified as the central focus (“client-centred”).

In Figure 1B this is illustrated by the human, activity and AT components situated in the inner

circle, surrounded by the larger contextual square. The culmination of a human performing a

functional activity using an assistive device within a given context is defined as the assistive
Figure 1: Development of the HAAT Model

technology system. While the core concepts and principle outcome have remained constant

4
over time, the HAAT model continues to mature in its development. An overview of these

changes is provided next.

Model Development

The HAAT model has undergone modifications over the three published versions. The original

publication (Cook & Hussey, 1995) described the four core concepts, which have remained

intact over time. Several changes were made in the second publication (2002), most notably

expansion of the conceptualization of context with more attention to about the impact of

culture on the individual and the assistive technology system, mirroring advances in the

occupational therapy literature (Awaad, 2003). This 2002 version introduced emerging ideas

about disability and the disablement process – another social construct that was gaining broad

acceptance (Tregaskis, 2002). Cook and Hussey (2002) identified relevance to the emergent

World Health Organization (WHO) model (i.e., ICIDH and ICF), incorporating new definitions of

disability and handicap (World Health Organization, 2001).

There was substantial change in the 2008 version (Cook & Miller Polgar, 2008). A new

co-author, Miller Polgar, is a Canadian occupational therapist and new references reflect this

perspective. This 2008 version emphasizes the occupational therapy model of practice,

specifically the Canadian Model of Occupational Performance (CMOP). There is increased

emphasis on ‘occupation’ and ‘occupational performance’ as a central component and outcome

of the assistive technology system, and greater attention to activity (i.e., occupation) within the

assistive technology system, serving as both a component and outcome. A fuller integration of

the ICF framework and CMOP form the foundation of the 2008 model, distancing itself from
5
Bailey’s human performance model. The 2008 schematic diagram reflects a more three-

dimensional representation of the concepts than in earlier versions. In Figure 1C the human,

activity, and AT are now portrayed as interlocking in a sphere and situated within a shallow box

depicting the context. This suggests a more dynamic relationship between concepts and the

context appears broadly influential to the other three, although perhaps not pervasive. Cook

and Miller Polgar identify several factors with predictive value in AT uptake, including meaning

ascribed to a particular occupation and Bandura’s theory of self-efficacy. Training, identified as

a soft technology, is also linked as a contributing factor to outcomes. Despite its availability,

only one study in the literature was identified citing the 2008 version (Chang & Wang, 2010)

and the authors do not highlight any of the conceptual changes. A review of relevant literature

related to all versions of the HAAT model is presented in the following section.

Related Literature and Research

To capture the breadth of material where the HAAT model is addressed, a search was

conducted employing scientific databases (CINAHL, PubMed, SCOPUS). Search terms were

related to the model specifically (“human activity assistive technology”); AT models generally

(“assistive technology” and “conceptual models”); and the HAAT authors. Over 50 articles were

identified; those containing only a singular reference to the HAAT model, lacking discussion, or

related to professional education were excluded. Peer-reviewed sources that referred

specifically to the HAAT model in research were included and summarized in Table 1.

6
Table 1. Publications incorporating the HAAT model

HAAT
Author (year) Title Design Category Content related to HAAT
Model
Angelo (2000) Factors affecting the use Qualitative; Background 1995 Overview of HAAT model
of a single switch with focus group Review HAAT is complementary to the Skill
assistive technology Application & Acquisition model
devices Evaluation Study results discussed in context of HAAT
model; suggest validation of HAAT model
Aquilano et al Assistive technology: A Quasi- Background 1995 HAAT concepts used to identify outcome
(2007) new approach to experimental Study design parameters of AT outcome evaluation
evaluation single group
post-test
Arthanat & Wheelchair ergonomics: Literature Background/ 2002 Overview of HAAT model
Strobel (2006) Implications for review, prior Theory Relevance of interactive concepts in HAAT
vocational participation research Review to a framework for ergonomic
intervention
Arthanat et al Conceptualization and Qualitative; Background 2002 Overview of HAAT model
(2007) measurement of assistive interviews Review HAAT concepts used to frame interview
technology usability and survey Study design guide and study survey
Application Study results interpreted in context of HAAT
model
Arthanat et al Development of the Survey and Background 2002 HAAT concepts contributed to framework
(2009) Usability scale for quasi- of tool design
Assistive Technology - experimental
Wheeled Mobility: A single group
preliminary psychometric post-test
evaluation

7
Bernd et al Existing models and Systematic Review 2002 Overview of HAAT model
(2009) instruments for the review HAAT one of 3 AT-specific models
selection of assistive
technology in
rehabilitation practice
Brandt et al Older people’s use of Cross- Background 2002 Application of to research and practice in
(2004) powered wheelchairs for sectional Study design AT
activity and participation interview Application & HAAT concepts used to construct
Evaluation questionnaire
Study results interpreted in context of HAAT
model and application to public policy
Results suggest validation of HAAT model
Chang & Wang Comparing picture and Quasi- Study design 2008* HAAT concepts used to construct a model
(2010) video prompting in experimental of wayfinding devices and design a
autonomous indoor repeated prototype
wayfinding for individuals measures
with cognitive impairment crossover
Driscoll et al Factors that prevent or Qualitative; Background 1995 Brief overview of HAAT model and
(2001) assist the integration of interviews Application exploration of concepts in relation to
assistive technology into target population
the workplace for people Suggest HAAT model concepts are useful for
with spinal cord injuries: understanding successful AT integration
Perspectives of the users
and their employers and
co-workers
Friederich et al Methods for the selection Descriptive Background 2002 HAAT one of 11 AT models
(2010) of assistive technology in exploratory Application Study results identified HAAT as only AT-
neurological survey specific model used in clinical practice
rehabilitation practice Relevance of interactive/holistic concepts in
HAAT to occupational therapy

8
Giesbrecht Comparing satisfaction Mixed Background 2002 HAAT model used as theoretical framework
(2006) with occupational methods, Study design for study design
performance using a repeated Application HAAT concepts used in selection of
pushrim-activated power- measures outcome measures
assisted wheelchair and a crossover Study results interpreted in context of HAAT
power wheelchair among model
task-specific power
wheelchair users
Giesbrecht et al Participation in Quasi- Background 2002 HAAT model process related to wheelchair
(2009) community-based experimental mobility and participation
activities of daily living: repeated
Comparison of a pushrim- measures
activated, power-assisted crossover
wheelchair and a power
wheelchair
Hersh & On modeling assistive Literature Critque/ 2002 Overview and critique of HAAT concepts
Johnson (2008) technology systems – review, Review and application for describing and
Part I: Modelling commentary Application analyzing AT
framework Description of a new model that extends
the HAAT concepts and application
Ivanoff et al Occupational therapy Literature Background/ 2002 Relevance of interactive/holistic concepts in
(2006) research on assistive Review Theory HAAT to occupational therapy
technology and physical HAAT as a complementary conceptual
environmental issues: A model for occupational therapy research
literature review
Lenker & A review of conceptual Literature Background 2002 HAAT origins identified
Paquet (2003) models for assistive review Review Overview and critique of HAAT concepts
technology outcomes and application for outcome
research and practice measurement

9
 Louie et al Use of a tailor-made Qualitative; Study design 2002 HAAT concepts used to describe
(2009) feeding device to improve interview Application & prescription and application of
the self-feeding skills of a Evaluation intervention
woman with congenital Results support interactive/holistic
upper limb deficiency concepts in HAAT and suggest validation
of model
Routhier et al Mobility of wheelchair Literature Application 1995 Concepts identified in HAAT used to
(2003) users: A proposed review; evaluate conceptual frameworks of
performance assessment commentary wheelchair mobility
framework
Van der Woude Manual wheelchairs: Commentary, Background 1995 Relevance of HAAT model to an integrative
et al (2006) Research and innovation prior ergonomics approach in rehabilitation
in sports and daily life research
Wiart & Darrah Changing philosophical Commentary Background/ 2002 HAAT model provides a clinical application
(2002) perspectives on the Theory for Dynamic Systems Theory
management of children Relevance of interactive/holistic concepts in
with physical disabilities – HAAT to family-centred care approach
their effect on the use of
powered mobility
* Authors cite the 2008 publication but use the 2002 model diagram

10
Articles were drawn widely from rehabilitation journals, with the majority (13/19) authored by

occupational therapists. Application of the HAAT model in the literature is evident in four broad

themes: literature reviews supporting research and practice; providing a framework for

research design; application of conceptual elements; and critique or review of conceptual

models of AT. Many articles incorporated content across multiple themes. A summary of each

of the four themes will now be presented, highlighting different applications of the HAAT

model.

Literature Reviews Supporting Research and Practice

A number of authors make reference to the HAAT model when providing a background

context for their study (Arthanat, Nochajski et al., 2009; Arthanat, Wu et al., 2009; Arthanat &

Strobel, 2006; Giesbrecht et al., 2009; Ivanoff et al., 2006; Van der Woude et al., 2006; Wiart &

Darrah, 2002). An a priori position for the relevance and validity of the HAAT framework is

typically assumed, particularly in relation to the four core concepts. These core concepts are

often related to other theoretical frameworks (e.g., dynamic systems theory, person-

environment-occupation theory) rather than how the HAAT model was integrated into the

research design. The number of studies citing the HAAT model suggests widespread use in

research and clinical applications. Friederich et al. surveyed rehabilitation clinicians in Western

Europe and found the HAAT was the only AT-specific model reportedly used, although a

majority of respondents indicated not using any theoretical framework to direct their practice.

HAAT as a Framework for Research Design

11
 Several authors moved beyond using the HAAT model for background, to structure their

research design and select outcomes. For example, in repeated-measures study conducted in

Taiwan, Chang and Wang (2010) used it as a framework for developing a prototype way-finding

system for individuals with cognitive impairment, including a modified conceptual diagram.

Similarly, Aquilano et al. (2007) described a novel approach to AT evaluation by engineers in

Italy that integrated device characteristics and validation tasks specifically using the 2002 HAAT

model.

Application of Conceptual Elements

Some studies adopted a more proactive and comprehensive application of the HAAT

model, integrating it from stages of conceptualization to analysis. A number of authors

incorporated HAAT conceptual elements in their study design and interpretation of findings.

Brandt et al. (2004) utilized the HAAT model as a central framework for their research exploring

older adults’ use of power wheelchairs in Denmark including development of the primary

outcome measure. Louie et al. (2009), an occupational therapist in Hong Kong, integrated each

of the HAAT core concepts in a qualitative evaluation of the effectiveness of a customized

feeding device. Driscoll et al (2001), an Australian occupational therapist, identified the HAAT

model as being particularly useful in framing the results of their qualitative exploration of AT

integration in the workplace among individual with spinal cord injury. Giesbrecht et al. (2006)

used the HAAT model as a conceptual framework for designing their Canadian study of power-

assisted wheelchair use in the community, selecting outcome measures corresponding to the

four core concepts, and relating results back directly to these concepts.

12
 Several authors have applied their findings to validate the HAAT model. For example,

Angelo (2000) conducted a qualitative study among occupational therapists in the United States

to identify critical elements in the assessment process when prescribing an accessible switch

and concluded that the findings provide validation for the tenets of the HAAT model. Brandt et

al (2004) also concluded their findings support the theory concepts, although they recommend

the specific relationships and direction require additional study. Still others have used the HAAT

model to develop new assessments. Routhier et al. (2003), a Canadian rehabilitation engineer,

conceived a framework for assessing wheelchair mobility performance in which the HAAT

model contributed to design and structure, and served as a ‘gold standard’ to validate the

factors incorporated into their own model. Arthanat et al. (2007), another occupational therapy

researcher from the United States, used the HAAT model to direct construction of their

Usability Scale for Assistive Technology and to evaluate the scale components.

Critique of AT Conceptual Models

Several articles provided critique or review of existing AT models. There was general

consensus that the HAAT model (2002) provides a strong application for AT prescription in

clinical practice but there is limited evidence for relationships between concepts or how they

impact outcomes as the model lacks substantive testing (Bernd et al., 2009; Lenker & Paquet,

2003). Two engineers from the Scotland, Hersh and Johnson (2008), critiqued three AT-related

frameworks and proposed a new model loosely based on the HAAT, but addressing several

perceived limitations such as lack of a user-friendly coding scheme, insufficient description of

concepts, and a lack of focus on end-user goals. These shortcomings were attributed to Hersch

13
and Johnson’s perception of a medical model focus inherent in the ICF and occupational

therapy approaches, which ultimately limit the range of applications for the HAAT model. The

varying use of any conceptual model within the research literature can be attributed in part to

its structure, relevancy, and ease of application. What follows is a structured evaluation of the

HAAT model and implications for its application to occupational therapy research.

Adequacy of the HAAT model

In this section, a critique of the 2008 HAAT model’s adequacy for practice and research will be

undertaken. Chinn and Kramer (2004) developed a framework for evaluating theory that

incorporates accepted methods without imposing normative criteria, which has proved useful

in critiquing theory used by occupational therapists (Zwicker & Harris, 2009). They suggested

five elements to consider in evaluating theory, reflecting on the degree to which it is clear,

simple, general, accessible and important.

Clarity

The ease of comprehension and consistency of concepts with many occupational therapy

models has facilitated the HAAT model’s incorporation within the field. The four core concepts

are well established, both in the broader rehabilitation literature and in occupational therapy

specifically. The authors make explicit the terms that are comparable within the HAAT concepts

(e.g., human and person; activity and occupation; context and environment) and provide a clear

discussion of each concept, linking them to the ICF framework to further enhance clarity. In

14
doing so, this presents a potential challenge in assuming terms can be used interchangeably

while still maintaining a common meaning for different readers. For example, activity and

occupation are implied to be synonymous; are composed of smaller tasks; and enable

fulfillment of life roles. The ICF concept of activity is defined within the text as “performance of

a task or action” (Cook & Miller Polgar, 2008; p. 36), but not within the individual’s life role or

situation, as this is considered participation. Thus, activity and occupation have different

meaning while being used synonymously.

Semantic issues related to the assistive technology system outcome also impact

structural clarity. In the two earlier versions, the HAAT model referred specifically to ‘system

performance’. The 2008 version departs from this term, ostensibly to increase the human-

centredness of the model and more explicitly reflect an occupational therapy perspective.

Activity is described as the “fundamental element of the HAAT model … and defines the overall

goal of the assistive technology system” (Cook & Miller Polgar, 2008; p. 37). The four core

concepts create an assistive technology system; however, this system is not necessarily a

measure of what results but rather a description of the intervention. The model describes

adaptation of all four concepts in arriving at a satisfactory outcome, but the focus is largely on

the assistive device selected and adapted to best suit the human requirements. The primary

outputs of the assistive technology system are described as “communication, mobility,

manipulation and cognition”, which are not activities per se. If the assistive technology system

is ‘more than’ the activity component, then these assistive technology system outputs may be

too rudimentary. The outcome of the evaluation process is an assistive technology system;

however, the goal of the assistive technology system is functional performance of the activity,

15
which is also a core concept within the assistive technology system. What precisely the

outcome is remains unclear, and whether activity is both component and outcome. Alternately,

if occupational performance is the outcome, then the definition of the assistive technology

system might integrate this idea.

The structural consistency of the HAAT model is an area of strength. The four core

concepts are clearly related in a holistic and interdependent gestalt. The text illustrates the

relationship and impact of each element, particularly in how the components are situated

within the overall context. However, the 2008 HAAT version transforms the 2-dimensional

model into a 3-dimensional one, with the human, activity and AT incorporated into a sphere,

which sits within a contextual tray. What seems to be lost graphically is the omnipresence of

the context, appearing now to only influence a portion of the sphere.

Simplicity

The foundation of the HAAT model is comprehensible, identifying the four core concepts and

their interrelationship, although the outcome being described in a variety of ways tends to

detract from this simplicity. The two foundational theoretic frameworks are highly compatible,

with parallels between activity and participation in the ICF and occupation and occupational

performance in the CMOP (Townsend & Polatajko, 2007), but their inclusion adds to the

complexity of the model. Addition of these secondary concepts enhances explanation of the

person-occupation interaction, focusing on roles across the life span, and the person-AT

interaction is addressed through the influence of self-efficacy on AT adoption and adherence.

These additions begin to transition the HAAT model from description to explanation of the
16
phenomenon of interest. Tertiary theoretical material related to factors predisposing

technology adoption/abandonment is also incorporated. Examples of this include Bandura’s

(1977) concept of self-efficacy, meaning associated with activity (Spencer 1998), and references

to device abandonment literature (Pape et al., 2002; Trefler & Hobson, 1997). These predictive

variables are less explicit in terms of the core model, but are presented as relevant evidence

that contributes to successful prescription of an assistive device. Their inclusion demonstrate

progress in the model and its ability to stay current and relevant, but as more and broader

ideas and influencing factors are integrated, maintaining consistency in the concept definitions

has become challenging.

Generality

Generality refers to theory scope and breadth. The HAAT model provides a description of the

factors that contribute to the fit/success of an assistive technology system for individuals with a

disability. Consequently, it offers broad practice application within a finite population in the

field of occupational therapy by incorporating the principles and language of the ICF and

making it accessible to many professions within in the field of AT. The strong emphasis on

occupation (activity) and relevance/meaning for the individual is consistent with occupational

therapy and client-centred principles. Many published studies incorporate the model concepts

in the background and study design, confirming a strong applicability for rehabilitation

researchers. The current model incorporates additional concepts proposed to explain successful

outcomes, and includes suggestions for tools that measure the specific HAAT concepts. By

making these explicit, the model becomes increasingly applicable to the research community.
17
Moreover, the HAAT text applies the four core concepts to many specific realms of disability

and technology, enhancing specificity of application to particular areas of practice within the

phenomenon (e.g., mobility, communication, environmental control). The value of this is borne

out by the fact that several articles apply the broad principles to specific cases or studies.

Accessibility

The HAAT model has maintained consistency with the broader rehabilitation literature. Initially

integrating the ideas of the social model of disability (Tregaskis, 2002), and then the ICF, has

allowed the model to stay current and accessible through the use of a common language.

Incorporating contemporary theoretical constructs, such as self-efficacy and occupational

competence, and associated supportive evidence has also facilitated accessibility and increased

the potential for testability and empirical evaluation. As discussed earlier, the model has been

used by investigators to inform their study design and outcome measures (Brandt et al., 2004;

Friederich et al., 2010; Giesbrecht, 2006; Louie et al., 2009). The potential ambiguity around

what defines the ‘outcome’ of the assistive technology system remains a threat to testing the

overall validity of the HAAT model, as reflected by limited evidence to date in the literature.

Importance

The value of the HAAT model is substantial. Its use among educators in AT and occupational

therapy is common-place (Rodger, 2010). In a recent survey of clinicians in Western Europe, the

HAAT model was the only AT-specific paradigm reported in clinical use (Friederich et al. 2010).

18
Earlier HAAT versions have been used extensively by occupational therapists to develop their

research design, select outcome measures, and evaluate findings. While application of the 2008

version is still finding its way into the literature, it is developing beyond the descriptive phase,

incorporating explanatory and even predictive functions. Incorporation of additional parallel

theories, either as foundational or associative, could potentially erode the integrity of the core

model and compromise its original intent as a clinical model of practice. The influence of

occupational therapy theory has grown in the successive iterations of the HAAT model,

particularly in defining outcomes. It remains to be seen whether this influence will continue, for

example in articulating what the ‘outcome’ of the assistive technology system is, and whether

incorporating terminology such as occupation and occupational performance (rather than ICF

language) will compromise accessibility and uptake among other rehabilitation disciplines.

Recommendations

Given the strengths and limitations outlined in the previous sections, several directions could

be suggested for continued dialogue and development of the HAAT model.

1. Core concepts. While the foundation remains intact, the HAAT model authors have

articulated a stronger integration of core concepts with the principles of occupational

therapy, particularly the CMOP, creating some tension within the terminology employed.

For example, the model continues to use ‘human’ rather than ‘person’ and ‘activity’ rather

than ‘occupation’ - a carryover from the originating human performance model. With

additional confusion around the definition of activity within the ICF model, the semantic

clarity and consistency of this term within the HAAT model is challenged. A change in
19
 terminology from activity to occupation would provide a more explicit and consistent

definition, but would also have substantive impact, not the least of which being the model

name. Resolving this issue may rest in deciding where the strongest theoretical allegiance

lies - in the CMOP or the ICF or the model origins.

2. Definition of assistive technology system outcome. The four core concepts, taken together,

produce an assistive technology system. The model emphasizes a process for achieving this

assistive technology system, but ultimately evaluating assistive technology system success

determines effectiveness of the process. What constitutes a measure of the assistive

technology system is not always clear: the appropriateness of the device in addressing the

disability; acceptance and continued use of the device; or activity (occupational)

performance? If the assistive technology system process outcome(s) can be more explicitly

identified, further testing of the model’s adequacy could be pursued.

3. Outcome measurement. Currently, the linkages between outcome measures and core

concepts are growing stronger. The current authors have proposed a variety of existing

measures that correspond to each concept, and propose using these to evaluate the HAAT

model elements. Confirming the validity and reliability of these measures specific to the

HAAT concepts would enhance this relationship. There may be potential to establish a

composite measure of assistive technology system performance, particularly as this

outcome is further elucidated.

4. Further refinement of the diagram. The representation of the HAAT model has undergone

transition over the course of its development and currently employs a 3-dimensional

design. What the image loses in simplicity, it gains in capturing the dynamic nature of the

20
 concept relations. In its makeover, the newer diagram may not fully capture the inherent

omnipresence of the context that permeates the other three core concepts, nor the

centrality of the person. Figure 1C depicts the human as one of three central, but equal,

components (the sphere) resting within, but not enclosed by, a context (the box). Figure 2

proposes a revision to the model diagram to address these issues. A series of 3 successively

enveloping spheres portray the dynamic and interactive relationship between the four core

concepts. The inner sphere is the human, positioned at the centre of the model. The activity

and AT are intertwined in the middle sphere, representing the need to optimize fit between

these two and adequately address the human interface. The outer sphere represents the

all-permeating context that influences and encompasses all the other elements.

Figure 2: Model Diagram Revised to Reflect Human as Central and Context as Encompassing

21
Conclusion

The HAAT model continues to be highly relevant and applicable to occupational therapists. While

the core concepts provide a simple and clear description of the AT prescription process, the

model continues to be developed with new theoretical components integrated, particularly with

respect to providing a conceptual framework for the interaction between the person and

assistive technology. Integration of additional theoretical components in the model may present

challenges to consistency in terminology, clarity in defining outcomes, and creating a

representative diagram. However, the maturing model’s complexity has expanded its application

and serves not only as a backdrop for research but also influencing study design and

interpretation of results. Emerging connections between essential concepts and outcome

measures extends this explanatory function and may create the opportunity for testing the

validity of the model and predictive applications in research. The HAAT model serves well as a

conceptual guide to clinical practice and framework for research design in occupational therapy.

References

Angelo, J. (2000). Factors affecting the use of a single switch with assistive technology devices.

Journal of Rehabilitation Research and Development, 37(5), 591-598.

Aquilano, M., Salatino, C., & Carrozza, M. (2007). Assistive technology: A new approach to

evaluation. Proceedings of the 2007 IEEE 10th International Conference on Rehabilitation

Robotics. Noordwijk, The Netherlands, pp 809-819.

Arthanat, S., Bauer, S.M., Lenker, J.A., Nochajski, S.M. & Wu, Y.W. (2007). Conceptualization

and measurement of assistive technology usability. Disability and Rehabilitation: Assistive

Technology, 2(4), 235-248.

22
Arthanat, S., Nochajski, S.M., Lenker, J.A., Bauer, S.M. & Wu, Y.W. (2009). Measuring usability of

assistive technology from a multicontextual perspective: The case of power wheelchairs.

American Journal of Occupational Therapy, 63(6), 751-764.

Arthanat, S. & Strobel, W. (2006). Wheelchair ergonomics: Implications for vocational

participation. Journal of Vocational Rehabilitation, 24, 97-109.

Arthanat, S., Wu, Y., Bauer, S., Lenker, J.A. & Nochajski, S.M. (2009). Development of the

Usability Scale for Assistive Technology-Wheeled Mobility: A preliminary psychometric

evaluation. Technology and Disability, 21, 79-95.

Awaad, T. (2003). Culture, cultural competency and occupational therapy: A review of the

literature. British Journal of Occupational Therapy, 66(8), 357-362.

Bailey, R. (1989). Human performance engineering. Upper Saddle River, NJ: Prentice Hall.

Bandura, A. (1977) Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.

Bernd, T., Van der Pijl, D. & De Witte, L. (2009). Existing models and instruments for the

selection of assistive technology in rehabilitation practice. Scandinavian Journal of

Occupational Therapy, 16, 146-158.

Brandt, A., Iwarsson, S. & Stahle, A. (2004). Older people's use of powered wheelchairs for

activity and participation. Journal of Rehabilitation Medicine, 36(2), 70-77.

Chang, Y. & Wang, T. (2010). Comparing picture and video prompting in autonomous indoor

wayfinding for individuals with cognitive impairments. Personal and Ubiquitous

Computing, 14, 737–747

Chinn, P. & Kramer, M. (2004). Integrated knowledge development in nursing. New York:

Mosby.

23
Cook, A. & Hussey, S. (1995). Assistive technologies: Principles and practice. St. Louis: Mosby

Year Book, Inc.

Cook, A. & Hussey, S. (2002). Assistive technologies: Principles and practice (2nd ed). St. Louis:

Mosby, Inc.

Cook, A. & Miller Polgar, J. (2008). Cook & Hussey's assistive technologies: Principles and

practice (3rd ed). St. Louis: Mosby Elsevier.

Driscoll, M., Rodger, S. & de Jonge, D. (2001). Factors that prevent or assist the integration of

assistive technology into the workplace for people with spinal cord injuries: Perspective of

the users and their employers and co-workers. Journal of Vocational Rehabilitation, 16,

53-66.

Friederich. A., Bernd, T. & De Witte, L. (2010). Methods for the selection of assistive technology

in neurological rehabilitation practice. Scandinavian Journal of Occupational Therapy,

17(4), 308-318.

Fuhrer, M., Jutai, J., Scherer, M. & Deruyter, F. (2003). A framework for the conceptual

modelling of assistive technology device outcomes. Disability and Rehabilitation, 25(22),

1243-1251.

Giesbrecht, E.M. (2006). Comparing satisfaction with occupational performance using a

pushrim-activated power-assisted wheelchair and a power wheelchair among task-specific

power wheelchair users. Masters Thesis, University of Manitoba.

Giesbrecht, E.M., Ripat, J.D., Quanbury, A.O. & Cooper, J.E. (2009). Participation in community-

based activities of daily living: comparison of a pushrim-activated, power-assisted

24
 wheelchair and a power wheelchair. Disability and Rehabilitation: Assistive Technology,

4(3), 198-207.

Hersh, M. & Johnson, M. (2008). On modelling assistive technology systems - Part I: Modelling

framwork. Technology and Disability, 20, 193-215.

Ivanoff, S., Iwarsson, S. & Sonn, U. (2006). Occupational therapy research on assistive

technology and physical environmental issues: A literature review. Canadian Journal of

Occupational Therapy, 73(2), 109-119.

Lenker, J.A. & Paquet, V.L. (2003). A review of conceptual models for assistive technology

outcomes research and practice. Assistive Technology, 15(1), 1-15.

Louie, S., Lai. F., Poon, C. & Wong, S. (2009). Use of a tailor-made feeding device to improve the

self-feeding skills of a woman with congenital upper limb deficiency. British Journal of

Occupational Therapy, 72(9), 401-404.

Matheson, L. & Bohr, P. (1997). Occupational competence across the life span. In: C

Christiansen, C Baum, eds. Occupational therapy: Enabling function and well-being.

Thorofare, NJ: Slack, 428-457.

Pape, T., Kim, J. & Weiner, B. (2002). The shaping of individual meanings assigned to assistive

technology: A review of personal factors. Disability and Rehabilitation, 24, 5-20.

Rodger, S. (2010). Occupation-centred practice with children: A practical guide for occupational

therapists. West Sussex, UK: Wiley-Blackwell.

Routhier, F., Vincent, C., Desrosiers, J. & Nadeau, S. (2003). Mobility of wheelchair users: a

proposed performance assessment framework. Disability and Rehabilitation, 25(1), 19-34.

25
 Siegert, R.J., McPherson, K.M. & Dean, S.G. (2005). Theory development and a science of

rehabilitation. Disability and Rehabilitation, 27(24), 1493-1501.

Spencer, J. (1998). Tools or baggage? Alternative meanings of assistive technology. In: D. Gray,

L. Quatrano & M. Lieberman, eds. Designing and using assistive technology: The human

perspective. Baltimore: Paul H Brookes Publishing Company, 89-98.

Trefler, E. & Hobson, D. (1997) Assistive technology. In: C. Christiansen & C. Baum, eds.

Occupational therapy: Enabling function and well-being. Thorofare, NJ: SLACK, 482-506.

Townsend, E.A. & Polatajko, H.J. (2007). Enabling occupation II: Advancing an occupational

therapy vision for health, well-being , & justice through occupation. Ottawa, ON: CAOT

Publications ACE.

Tregaskis, C. (2002). Social model theory: the story so far ... Disability & Society, 17(4), 457-470.

Van der Woude, L.H.V., de Groot, S. & Janssen, T.W.J. (2006). Manual wheelchairs: Research

and innovation in sports and daily life. Science & Sports, 21(4), 226-235.

Wiart, L. & Darrah, J. (2002). Changing philosophical perspectives on the management of

children with physical disabilities: Their effect on the use of powered mobility. Disability

and Rehabilitation, 24(9), 492-498.

World Health Organization (2001). International classification of functioning, disability and

health. Geneva: WHO.

Zwicker, J.G. & Harris, S.R. (2009). A reflection on motor learning theory in pediatric

occupational therapy practice. Canadian Journal of Occupational Therapy, 76(1), 29-37.

26

View publication stats