Effectiveness of Training of Assistive Technology

for Frail Elders and Their Caregivers: Onsite and

Online EducationPresented at ASA-NCOA Joint Conference at

Philadelphia on March 10-12, 2005

Machiko R. Tomita Ph.D.Kimberly Sewall, OTR/LBin-Min Tsai, MS, OT

Aging and TechnologyDepart. of Rehabilitation Science

Universtiy at Buffalo, State Universtiy of New York

AcknowledgementAcknowledgement

The Community Health Foundation The Community Health Foundation of Western and Central New Yorkof Western and Central New York

for funding this projectfor funding this project Area Agency on Aging in 8 Area Agency on Aging in 8

Counties in Western New YorkCounties in Western New York Dr. Michael Noe, Dept. of Dr. Michael Noe, Dept. of

Rehabilitation Science, University Rehabilitation Science, University at Buffalo at Buffalo

The Assistive Technology (AT) Act of 2004

Supporting state efforts to improve the provision of AT to individuals with disabilities through comprehensive statewide programs of technology-related assistance for individuals with disabilities of all ages.

Providing states with financial assistance that supports programs designed to maximize the ability of individuals with disparities and their family members and others to obtain AT devices and services.

Process of Knowledge Diffusion

Frail elders own an average of 14 devices and use 11 devices.

As frail elders’ cognition declines, informal caregivers use of devices increases.

Most devices were obtained from or by recommendation of healthcare professionals when they are discharged from skilled nursing facilities

Healthcare professionals do not have time to update newly marketed AT.

Workshops on AT for healthcare professionals are needed..

Onsite and Online AT Onsite and Online AT WorkshopWorkshop

Some states offer conferences that Some states offer conferences that include AT workshops but health include AT workshops but health professionals who can attend these professionals who can attend these conferences are limited.conferences are limited.

Online workshops have been rarely Online workshops have been rarely offered.offered.

We conducted both onsite and online We conducted both onsite and online workshops offering 7 CEUs.workshops offering 7 CEUs.

Purpose of the StudyPurpose of the Study

To find the effectiveness of onsite To find the effectiveness of onsite and online workshops in comparison and online workshops in comparison to a control group. to a control group.

Attitudes toward AT, general and Attitudes toward AT, general and specific knowledge of AT, role specific knowledge of AT, role caregivers, and Teaching Methods for caregivers, and Teaching Methods for ATAT

Literature ReviewLiterature Review Elders who use AT:Elders who use AT:

Increase their active participation and Increase their active participation and overall independence with their ADLsoverall independence with their ADLs (Mann, Hurren, Tomita, & Charvat,1995, Taylor & Hoenig, 2004),(Mann, Hurren, Tomita, & Charvat,1995, Taylor & Hoenig, 2004),

Decrease their level of residual Decrease their level of residual disabilitydisability (Taylor & Hoenig, 2004; Verbrugge, Rennert, & (Taylor & Hoenig, 2004; Verbrugge, Rennert, & Madans,1997; Agree, 1999),Madans,1997; Agree, 1999),

Decrease the days they remain in bedDecrease the days they remain in bed (Taylor & Hoenig, 2004),(Taylor & Hoenig, 2004),

Decrease their need for caregiver Decrease their need for caregiver assistanceassistance (Hoenig, Taylor, & Sloan, 2003, Taylor & Hoenig, 2004),(Hoenig, Taylor, & Sloan, 2003, Taylor & Hoenig, 2004),

Delay their decline in functional health Delay their decline in functional health statusstatus (Mann, Ottenbacher, Fraas, Tomita and Granger; 1999),(Mann, Ottenbacher, Fraas, Tomita and Granger; 1999),

Reduce their health-care costsReduce their health-care costs (Mann, (Mann, Ottenbacher, Fraas, Tomita and Granger; 1999)Ottenbacher, Fraas, Tomita and Granger; 1999)

Literature ReviewLiterature Review

Caregivers who attend Caregivers who attend educational interventions educational interventions on AT:on AT: Illustrate fewer negative Illustrate fewer negative

attitudes towardattitudes toward AT AT (Kane,1999),(Kane,1999), Illustrate higher satisfaction ratesIllustrate higher satisfaction rates

(N(Nochajaski, Tomita, & Mann, 1996),ochajaski, Tomita, & Mann, 1996), Increase the frequency of their AT Increase the frequency of their AT

useuse (N(Nochajaski, Tomita, & Mann, 1996),ochajaski, Tomita, & Mann, 1996),

Use more ATsUse more ATs (N(Nochajaski, Tomita, & Mann, 1996).ochajaski, Tomita, & Mann, 1996).

Research QuestionsResearch Questions Part I: Effectiveness of onsite AT Part I: Effectiveness of onsite AT

workshop workshop

Comparisons of onsite Comparisons of onsite workshop workshop attendants and the attendants and the control group.control group.

Part II: Effectiveness of online Part II: Effectiveness of online AT workshopAT workshop

Comparisons of online and Comparisons of online and onsite onsite workshop attendants.workshop attendants.

Research Questions Part 1Research Questions Part 1

1.1. Do scores of onsite AT workshop Do scores of onsite AT workshop attendants increase from the attendants increase from the pretest to the posttest onpretest to the posttest on

1)1) Favorable attitudes toward AT,Favorable attitudes toward AT,

2) 2) General knowledge of AT, roles of General knowledge of AT, roles of caregivers, caregivers, and effective teaching and effective teaching methods, andmethods, and

3)3) Knowledge of specific AT ? Knowledge of specific AT ?

Pretest Pretest Onsite workshopOnsite workshopPosttestPosttest

Research QuestionsResearch Questions Part 1Part 12.2. Are the scores of AT workshop Are the scores of AT workshop

attendants higher than that of the attendants higher than that of the control group on the post test incontrol group on the post test in

1)1) General knowledge of AT, roles of General knowledge of AT, roles of caregivers, caregivers, and effective teaching and effective teaching methods, methods, 2)2) Knowledge of specific AT, and Knowledge of specific AT, and3)3) Favorable attitudes towards AT Favorable attitudes towards AT

PosttestPosttestAttendantsAttendants O O

VV Control GroupControl Group O O

Method: Research Method: Research DesignDesign

Quasi Experimental StudyQuasi Experimental Study Pretest Posttest Controlled DesignPretest Posttest Controlled Design

PretestPretestPosttestPosttest

OnsiteOnsiteOO XX OO (7 hour Interval)(7 hour Interval)

ControlControl OO OO( 1 month Interval)( 1 month Interval)

OnlineOnlineOO XX OO( 3 hour to 6 days- Interval ( 3 hour to 6 days- Interval

))

Method: SampleMethod: Sample

Convenient sampling method was used.Convenient sampling method was used. Onsite workshops were advertised in Onsite workshops were advertised in

newsletters and flyers through the Area newsletters and flyers through the Area Agency on Aging in the 8 counties of Agency on Aging in the 8 counties of Western New York. People who registered Western New York. People who registered became the treatment group and people became the treatment group and people who knew that they could not attend the who knew that they could not attend the workshop became the control group. workshop became the control group.

For the online workshop, we recruited For the online workshop, we recruited interested people from HMOs, County interested people from HMOs, County Senior Services, and Nursing and Rehab Senior Services, and Nursing and Rehab Science courses at the University at Science courses at the University at Buffalo. Buffalo.

Method: QuestionnaireMethod: Questionnaire

Demographic InformationDemographic Information 3 overall AT questions (knowledge of 3 overall AT questions (knowledge of

AT, value of AT in caring people, AT, value of AT in caring people, effectiveness of AT in reducing effectiveness of AT in reducing caregiver burden)caregiver burden)

9 general AT/role of 9 general AT/role of caregiver/teaching method questionscaregiver/teaching method questions

10 new AT questions (7 existing AT & 10 new AT questions (7 existing AT & 3 non existing AT)3 non existing AT)

Sample Characteristics (N = 227)Sample Characteristics (N = 227)

Table 1 Table 1

________________________________________________________________________________________________________________________________

OnsiteOnsite ControlControl Online Online

SexSex

(n= 89)(n= 89) (n=96)(n=96) (n=42)(n=42)

________________________________________________________________________________________________________________________________

F F 77 7977 79 3737

(86.5%) (82.3%)(86.5%) (82.3%) (88.1%)(88.1%)

M M 2929 12 17 12 17

(13.5%) (17.7%) (13.5%) (17.7%) (11.9%)(11.9%)

______________________________________________________________________________________________________________________________________________

χχ2 = 1.03 (p=.598)2 = 1.03 (p=.598)

Sample Characteristics (N = Sample Characteristics (N = 227)227)

Table 2Table 2__________________________________________________________________________________________________________________________________________ OnsiteOnsite ControlControl OnlineOnline Age Age (n = 89)(n = 89) (n = 96)(n = 96)

(n=42)(n=42)__________________________________________________________________________________________________________________________________________

18-34 yrs. 18-34 yrs. 20 (22.5%)20 (22.5%) 49 (51.0%)49 (51.0%) 25 (59.5%) 25 (59.5%)

35-54 yrs. 35-54 yrs. 50 (56.2%)50 (56.2%) 43 (44.8%)43 (44.8%) 15 (35.7%)15 (35.7%)

55 + yrs55 + yrs 19 (21.3%) 4 (4.2%)19 (21.3%) 4 (4.2%) 2 2 (4.8%)(4.8%)

__________________________________________________________________________________________________________________________________________

χχ2 = 30.178 ( 2 = 30.178 ( p < .001p < .001))

Bold figures indicate the cells contributing statistical significanceBold figures indicate the cells contributing statistical significance

Sample Characteristics (N = Sample Characteristics (N = 227)227)

Table 3Table 3______________________________________________________________________________________________________________________________________________ OnsiteOnsite ControlControl

Online Online ProfessionProfession

(n= 89) (n= 89) (n=96)(n=96) (n=42)(n=42)______________________________________________________________________________________________________________________________________________

Nurse Nurse 24 (27.0%)24 (27.0%) 58 (60.4%)58 (60.4%) 8 8 (19.0%)(19.0%)

Case manager Case manager 25 (28.1%)25 (28.1%) 7 (7.3%) 7 (7.3%) 1 1 (2.4%)(2.4%)

Therapists 19 (21.3%) Therapists 19 (21.3%) 23 (24.0%)23 (24.0%) 27 27 (64.3%)(64.3%)

Aides Aides 7 (7.9%) 7 (7.9%) 1 (1.0%) 1 (1.0%) 2 (4.8%)2 (4.8%)

Other Other 14 (15.7%) 14 (15.7%) 7 (7.3%) 7 (7.3%) 4 4 (9.5%) (9.5%)

______________________________________________________________________________________________________________________________________________ χχ2 = 65.092 ( 2 = 65.092 ( p < .001p < .001)) Bold figures indicate the cells contributing statistical significanceBold figures indicate the cells contributing statistical significance

Sample Characteristics (N = Sample Characteristics (N = 227)227)

Table 4Table 4________________________________________________________________________________________________________________________________________________

OnsiteOnsite Control ControlOnlineOnline

Education Education (n = 89) (n = 89) (n = 96)(n = 96) (n=42)(n=42)

____________________________________________________________________________________________________________________________________________

High School Degree 6 (6.7%) 0High School Degree 6 (6.7%) 0 2 (4.8%)2 (4.8%)

Associates Degree 21(23.6%) 13 (13.5%)Associates Degree 21(23.6%) 13 (13.5%) 2 (4.8%)2 (4.8%)

Bachelor’s Degree 43(48.3%) 69 (71.9%)Bachelor’s Degree 43(48.3%) 69 (71.9%) 22 (52.4%)22 (52.4%)

Master’s Degree 16 (18.0%) 13 (13.5%)Master’s Degree 16 (18.0%) 13 (13.5%) 16 (38.1%)16 (38.1%)

Doctorate Degree 0Doctorate Degree 0 1 (1.0%) 1 (1.0%) 00

Other 3 (3.4%) 0 Other 3 (3.4%) 0 0 0 ________________________________________________________________________________________________________________________________________________

χχ2 = 33.008 (2 = 33.008 ( p< .001) Bold figures indicate the cells contributing statistical p< .001) Bold figures indicate the cells contributing statistical significancesignificance

Sample Characteristics (N = 227)Sample Characteristics (N = 227)Table 5Table 5_________________________________________________________________________________________________ _________________________________________________________________________________________________

WorkplaceWorkplace OnsiteOnsite ControlControl Online Online (n = 89)(n = 89) (n = 96)(n = 96) (n=42) (n=42)

__________________________________________________________________________________________________________________________________________________________________________________________________ Home healthcare agency Home healthcare agency 27 (30.3%)27 (30.3%) 4 (4.2%) 4 (4.2%) 6 6 (14.3%)(14.3%)

Nursing Home 10 (11.2%)Nursing Home 10 (11.2%) 4 (4.2%) 4 (4.2%) 4 (9.5%) 4 (9.5%) Hospital Hospital 7 (7.9%)7 (7.9%) 51(53.15)51(53.15) 7 7 (16.7%)(16.7%)

School 3 (3.4%) School 3 (3.4%) 7 (7.3%)7 (7.3%) 5 (11.9%)5 (11.9%) Private Practice 3 (3.4%) Private Practice 3 (3.4%) 7 (7.3%) 7 (7.3%) 1 (2.4%)1 (2.4%) Unemployed 6 (6.7%) Unemployed 6 (6.7%) 8 (8.3%)8 (8.3%) 00 Government Government 31(34.8%)31(34.8%) 15 (15.6%)15 (15.6%)

2 (2.8%)2 (2.8%) Other Other 2 (2.25) 2 (2.25) 00 17 17 (40.5%)(40.5%)

____________________ ____________________________________________________________________________________ ________________________________________________________________

χχ2 = 145.314 (2 = 145.314 ( p< .001) p< .001)

Sample Characteristics (N = Sample Characteristics (N = 227)227)

Table 6 Table 6

How long have you been working in your profession?How long have you been working in your profession?

______________________________________________________________________________________________________________________________________________________________________

OnsiteOnsite ControlControlOnlineOnline (n = 89)(n = 89) (n = 96)(n = 96) (n=42) (n=42)

____________________________________________________________________________________________________________________ YearsYears 14.0 14.0 11.311.3 10.810.8

(11.4)(11.4) (10.0) (10.0) (10.6) (10.6) ________________________________________________________________________________________________________________________________________________________________________

F = 1.902 (p = .152)F = 1.902 (p = .152)

Part 1: Onsite WorkshopPart 1: Onsite Workshop8 Counties in Western New 8 Counties in Western New

YorkYork

Device Display at Onsite Device Display at Onsite WorkshopWorkshop

Results 1: Results 1: Can you please rate Can you please rate yourself on your own knowledge yourself on your own knowledge

of AT?of AT?

0

0.5

1

1.5

2

2.5

3

3.5

Onsite Control

PretestPosttest

a paired t = 9.260 (p < .001)a paired t = 9.260 (p < .001) Significant increaseSignificant increase b paired t = 1.471 (p = .144)b paired t = 1.471 (p = .144) Remained sameRemained same c ANCOVA controlling for the pretest F= 87.583 (p<.001) Onsite is c ANCOVA controlling for the pretest F= 87.583 (p<.001) Onsite is

significantly highersignificantly higher

Results 2: Results 2: How valuable do you How valuable do you believe the use of AT is in the role believe the use of AT is in the role

of caregiving?of caregiving?

3

3.2

3.4

3.6

3.8

4

Onsite Control

PretestPosttest

a paired t = 3.967 (p < .001) Significant increasea paired t = 3.967 (p < .001) Significant increase b paired t = 2.322 (p = .022) Remained sameb paired t = 2.322 (p = .022) Remained same c ANCOVA controlling for the pretest F = 21.274 (p < .001) Onsite is c ANCOVA controlling for the pretest F = 21.274 (p < .001) Onsite is

significantly highersignificantly higher

Results 3Results 3: Do you believe the use : Do you believe the use of AT can of AT can decreasedecrease caregiver caregiver

burden?burden?

3

3.2

3.4

3.6

3.8

4

Onsite Control

PretestPosttest

a Paired t = 3.810 (p < .001) Significant increase a Paired t = 3.810 (p < .001) Significant increase b Paired t = .173 (p = .863) Remained same b Paired t = .173 (p = .863) Remained same c ANCOVA controlling for the pretest F = 39.696 (p c ANCOVA controlling for the pretest F = 39.696 (p < .001) Onsite is significantly higher< .001) Onsite is significantly higher

Sample Questions for General Sample Questions for General Knowledge of AT, Role of Knowledge of AT, Role of Caregivers, and Teaching Caregivers, and Teaching

MethodsMethods What is an assistive device?What is an assistive device? What is the role of a caregiver?What is the role of a caregiver? What are some barriers to AT use or What are some barriers to AT use or

reasons for non-use?reasons for non-use? What is the most effective teaching What is the most effective teaching

method of assistive device use for method of assistive device use for elderly people? elderly people?

Results 4: Total Scores for General Results 4: Total Scores for General Knowledge/ Role of Caregivers, and Knowledge/ Role of Caregivers, and

Teaching MethodsTeaching Methods

10.5

11

11.5

12

12.5

Onsite Control

PretestPosttest

3.4

3.5

3.6

3.7

3.8

3.9

Onsite Control

PretestPosttest

Onsite Paired t-test <.001Onsite Paired t-test <.001 Onsite Paired t-test<.05Onsite Paired t-test<.05Control Paired t-test > .05Control Paired t-test > .05 Control Paired t-test > .05Control Paired t-test > .05ANCOVA F< .001ANCOVA F< .001 ANCOVA F > .05ANCOVA F > .05

Sample Questions for Sample Questions for Specific ATSpecific AT

ATAT A turntable-style pivot disk which aids in A turntable-style pivot disk which aids in

standing transfers with people who have standing transfers with people who have trunk and hip mobility problems. (physical)trunk and hip mobility problems. (physical)

A Global Positioning System (GPS) watch A Global Positioning System (GPS) watch which provides a person with directions to which provides a person with directions to his/her home within a 10 miles radius. his/her home within a 10 miles radius. (Cognitive)(Cognitive)

Heat sensitive bath appliqués which Heat sensitive bath appliqués which prevent burns. (Sensory)prevent burns. (Sensory)

Results 5: Total scores for Results 5: Total scores for Knowledge of Specific ATKnowledge of Specific AT

PhysicalPhysical

SensorySensory

CognitiveCognitive

Change score Independent t Change score Independent t <.001<.001

0

5

10

15

Onsite Ctl

PretestPosttest

02468

Onsite Ctl

PretestPosttest

0

5

10

15

Onsite Ctl

Pretest

Posttest

Results 6: Do you believe the Results 6: Do you believe the AT would be useful?AT would be useful?

17

17.5

18

18.5

19

19.5

20

Onsite Control

Pretest

Posttest

Change score Independent t <. 01Change score Independent t <. 01

Part II. Online WorkshopPart II. Online Workshop

Online WorkshopOnline Workshop PretestPretest Seven modulesSeven modules

OverviewOverview Devices to address physical impairmentsDevices to address physical impairments Devices to address Meal Devices to address Meal

Preparation/Eating/Medication Preparation/Eating/Medication Sensory: Vision and Taste/Smell Sensory: Vision and Taste/Smell Sensory: Hearing and Touch/Dexterity Sensory: Hearing and Touch/Dexterity Cognitive-Home Cognitive-Home Cognitive-Nursing Home Cognitive-Nursing Home

PosttestPosttest

Comparisons between Comparisons between Onsite and Online AT Onsite and Online AT

workshopworkshop Are the scores of Online and Onsite AT Are the scores of Online and Onsite AT

workshop attendants similar at the post test onworkshop attendants similar at the post test on

1)1) Favorable attitudes toward AT, Favorable attitudes toward AT,2) 2) General knowledge of AT, roles of caregivers, and General knowledge of AT, roles of caregivers, and

effective teaching methods, andeffective teaching methods, and3)3) Knowledge of specific AT ? Knowledge of specific AT ?

PosttestPosttestOnsiteOnsite O O

║║ OnlineOnline O O

Results 7: Results 7: Can you please rate Can you please rate yourself on your own knowledge yourself on your own knowledge

of AT?of AT?

0

0.5

1

1.5

2

2.5

3

3.5

Onsite Online

PretestPosttest

a paired t = 1.952 (p < .05) Significant increases in Posttest b ANCOVA controlling for pretest scores F = 32.110 (p

< .001) Onsite is higher

Results 8: Results 8: How valuable do you How valuable do you believe the use of AT is in the role believe the use of AT is in the role

of caregiving?of caregiving?

3.5

3.6

3.7

3.8

3.9

4

Onsite Online

PretestPosttest

a paired t = 1.738 (p < .05)a paired t = 1.738 (p < .05)b ANCOVA controlling for pretest scores F= 3.049 (p=.083) b ANCOVA controlling for pretest scores F= 3.049 (p=.083)

Onsite and Online scores are not differentOnsite and Online scores are not different

Results 9: Results 9: Do you believe the Do you believe the use of AT can use of AT can decreasedecrease caregiver caregiver

burden?burden?

3.3

3.4

3.5

3.6

3.7

3.8

3.9

Onsite Online

PretestPosttest

a paired t = 3.579 (p < .001) Significant increase in posttesta paired t = 3.579 (p < .001) Significant increase in posttestb ANCOVA controlling for pretest scores F=.299 (p=.586) b ANCOVA controlling for pretest scores F=.299 (p=.586)

Onsite and Online scores are not differentOnsite and Online scores are not different

Results 10:Results 10: Total Scores for General Total Scores for General Knowledge/Role of Caregivers, and Knowledge/Role of Caregivers, and

Teaching MethodsTeaching Methods

0

2

4

6

8

10

12

14

Onsite Online

Pretest

Posttest

3.65

3.7

3.75

3.8

3.85

Onsite Online

PretestPosttest

Online Paired t-test < .001Online Paired t-test < .001 Online Paired t-Online Paired t-test >.05test >.05

ANCOVA F<.001ANCOVA F<.001 ANCOVA F > .05ANCOVA F > .05

Results 11:Results 11: Total scores for Total scores for Knowledge of Specific ATKnowledge of Specific AT

PhysicalPhysical

SensorySensory

CognitiveCognitive

Online paired t-test < .001Online paired t-test < .001Physical ANCOVA F < .001 Online is Physical ANCOVA F < .001 Online is

higherhigherCognitive ANCOVA F < .001 Online Cognitive ANCOVA F < .001 Online

is higheris higherSensory ANCOVA F > .05 Sensory ANCOVA F > .05

0

5

10

15

Onsite Online

PretestPosttest

0

5

10

15

Onsite Online

PretestPosttest

02468

Onsite Online

PretestPosttest

Results 12: Do you believe the Results 12: Do you believe the AT would be useful?AT would be useful?

17

18

19

20

Onsite Online

PretestPosttest

a Paired t = 4.231 (p < .001) Significant increase in posttesta Paired t = 4.231 (p < .001) Significant increase in posttestb ANCOVA controlling for pretest scores F= .567 (p=.453) b ANCOVA controlling for pretest scores F= .567 (p=.453)

Onsite and Online scores are not differentOnsite and Online scores are not different

SummarySummary1.1. Online workshop attendants were Online workshop attendants were

significantly younger, having a higher significantly younger, having a higher education (MS), and working as a education (MS), and working as a therapist (mostly occupational therapists) therapist (mostly occupational therapists) than onsite workshop attendants. than onsite workshop attendants.

2.2. Both onsite and online AT workshop Both onsite and online AT workshop attendants significantly increased attendants significantly increased favorable attitude toward AT, their favorable attitude toward AT, their knowledge of general and specific AT, knowledge of general and specific AT, role of caregivers, and teaching methods role of caregivers, and teaching methods after the workshop.after the workshop.

SummarySummary Onsite Workshop attendants perceived Onsite Workshop attendants perceived

higher for being knowledgeable of AT higher for being knowledgeable of AT after the workshop than online attendants after the workshop than online attendants and scored significantly higher for and scored significantly higher for knowledge of specific AT (Physical and knowledge of specific AT (Physical and cognitive); however, they scored cognitive); however, they scored significantly lower for general AT significantly lower for general AT knowledge. knowledge.

Attitude toward AT, knowledge of sensory Attitude toward AT, knowledge of sensory devices and effective teaching methods devices and effective teaching methods were the same for both attendants. were the same for both attendants.

DiscussionDiscussion

Advantage of online education is that Advantage of online education is that individuals who are interested can take individuals who are interested can take it at his/her own convenience and at it at his/her own convenience and at home. home.

Online workshop is almost as effective Online workshop is almost as effective as onsite workshop; however, one of the as onsite workshop; however, one of the reasons that people attend an onsite reasons that people attend an onsite worship is so that they can see how AT worship is so that they can see how AT is operated. Therefore, incorporation of is operated. Therefore, incorporation of a video may be important.a video may be important.

DiscussionDiscussion

AT education and home modification AT education and home modification for persons with disability and their for persons with disability and their formal and informal caregivers is formal and informal caregivers is important. Effective methods such as important. Effective methods such as online education by States should be online education by States should be encouraged and beyond this knowledge encouraged and beyond this knowledge gain, benefits of the education that lead gain, benefits of the education that lead to better quality of life and cost to better quality of life and cost effective ness of AT use should be effective ness of AT use should be documented. documented.