Occupational Therapy In Health Care, 28(4):394–409, 2014 C 2014 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/othc DOI: 10.3109/07380577.2014.933379
ARTICLE
Understanding the Needs of Hand Control Users, Driver Rehabilitation Specialists, and Dealers/Installers Evan Lowe1 , Nathalie Drouin2 , Paul J. Venhovens3 , & Johnell O. Brooks4 1
Clemson Univiersity, Automotive Engineering, CU-ICAR, Greenville, USA, 2 Roger C. Peace Rehabilitation Hospital, Occupational Therapy, Greenville, USA, 3 Clemson University, Automotive Engineering, CU-ICAR, and 4 Clemson University, Automotive Engineering, CU-ICAR and Greenville Health System, Greenville, USA
ABSTRACT. Understanding unique perspectives from key stakeholder groups involved in the hand control (HC) industry, including driver rehabilitation specialists (DRSs) who train users how to use their HCs, dealers/installers, and users, may become increasingly important in the United States due to increases in elderly, diabetic, and wounded warrior amputee driving populations. In this exploratory study, phone interviews were conducted with 20 DRSs, 20 dealers/installers, and 20 users regarding their perspectives about HC training, maintenance and operation, and design improvements. Results revealed common views and differences in perspectives about whether HC users should receive training and for how long, when and how often users should receive maintenance on their HCs, and what DRSs, dealers/installers, and users would like to see in the future. KEYWORDS. Adaptive equipment, dealers, design, driver rehabilitation specialists, driving, hand controls, manufacturers, training
Many adults rely on personal vehicles for transportation for activities including work, leisure, maintaining personal health, and fulfilling instrumental activities of daily living (Dickerson, Reistetter, Schold-Davis, & Monaham, 2011). Most adults without disabilities rarely consider the impact of the ability to drive on their daily lives. However, most individuals with disabilities are intimately aware of the independence that driving affords. Individuals who are unable to operate standard, factory-produced vehicles require adaptive driving devices, such as hand controls (HCs), for vehicle operation. HCs are devices that allow drivers to operate a vehicle’s accelerator and brake pedals with their hands, when they cannot do so using their feet (Pilkey, Thacker, & Shaw, 2001) and are either electronic or mechanical. Address correspondence to: Johnell O. Brooks, Clemson University International Center for Automotive Research, Automotive Engineering, 4 Research Drive, Greenville, 29607 USA (E-mail: jobrook@ clemson.edu). (Received 13 May 2013; accepted 7 June 2014)
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While there are large design variations and user customizations in electronic HCs, mechanical HCs consist of four main types: push/pull, push/right angle, push/rock, and push/twist. These mechanical HC names describe the motions that the HCs require for actuation of the brake pedals and accelerator, respectively. Three key groups of individuals who interact with HCs include DRSs who train HC users to drive with HCs, HC dealers and installers, and drivers who use HCs (HC users). This paper investigates the perspectives of these three groups about HC training, maintenance and operation, and future HC designs through individual interviews to determine how their perspectives align and differ. BACKGROUND The first widespread HC usage in personal automobiles came in 1918 after World War I, which left over 4,000 US service personnel with limb amputations (DePalma et al., 2002). Early HC user perspectives in the US were published in the mid 1940s, like the (Colpus et al., 1945) edition of the Chair Warmers’ Club Outwitting Handicaps magazine. These periodicals were largely influenced by the 15,000 United States service people receiving amputations during World War II (DePalma et al., 2002), which resulted in many veterans coming back from the war needing HCs to drive. Research documents relating practices of HC specialists were not published in the US until the early 1960s like that by Altobelli (1964), and in larger numbers starting in the 1970’s such as that by Less, Colverd, DeMauro and Young (1978). When these documents were published, their motivation included explanations of why training and evaluation for drivers new to using HCs was important. Some of these explanations suggested that HC driver training helped HC users find the most effective HC type and (possibly) vehicle, in addition to techniques for driving with HCs and how to transfer (from wheel chair to vehicle, and back) properly (Less et al., 1978). Marketing material for HCs has existed since the first manufacturing of HCs in the US in the early 20th century. However, HCs were produced in limited quantity, due to the low number of HC users who were wealthy enough to commission custom controls to be built for their vehicles (Murphy, 1979). A unified group of HC manufacturers, dealers, installers, and driver rehabilitation specialists (DRSs) who regularly discussed and documented perspectives on the HC industry did not exist until the late 20th century when the National Mobility Equipment Dealer’s Association (NMEDA) was established in 1989 (National Mobility Equipment Dealer’s Associaition, 2012). HC dealers/installers are recognized as important stakeholders with respect to the installation and maintenance of HCs. In fact, the installation and maintenance of HCs have been considered equally as important as the design of the HC itself (Haslegrave, 1985) because often the HCs come as “kits,” that allow for a large range of motion variation and general positioning depending on the type of vehicle and how they are installed in the vehicle. More importantly, poor installation could restrict access to the HCs or cause dangerous clearance issues between the HCs and drivers’ bodies (Haslegrave, 1985). Improper maintenance can cause the same issues. A document created by the Society of Automotive Engineers (SAE) and
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issued by the Adaptive Devices Standards Committee (e.g., SAE J1903 - Automotive Adaptive Driver Controls, Manual) enumerated testing practices and methods recommended for HCs sold commercially. These standards were a major step forward with documenting suggested practices for HC dealers, installers, and manufacturers (Society of Automotive Engineers Technical Standards Board, 1997). Summary Although HCs have been used for decades, understanding the unique perspectives from key stakeholder groups involved in the HC industry has the potential to become very important due to the dramatic increases in elderly (Rosenbloom, 1999), diabetic (Massey, Botman, & Harris, 2010), and wounded warrior amputee (Fischer, 2010) populations in recent years. Frequently, the wounded warrior population is afflicted not only with amputations but also spinal cord injuries (SCIs) that has returned from a war with significant injuries (Fischer, 2010). The objective of this exploratory paper is to promote a greater understanding of the DRSs, dealers/installers and users involved in the HC industry in order to identify current issues as well as opportunities for potential advancements in HC training, maintenance and operation, and design improvements through the use of individual interviews. METHODS Participants This exploratory study consisted of structured interviews conducted in person or over the phone. Three groups of participants were recruited to complete the surveys, specifically 20 DRSs who provide HC training, 20 dealers/installers, and 20 users. Participants were recruited through the ADED (2011) and NMEDA (2011) on-line membership directories, by word of mouth, and from a convenient sample population of HC users. While the majority of the participants were local to the Southeastern region of the US, participants were also recruited from areas outside of the Southeastern United States to ensure that the results of the study reflect broader perceptions than those just in the Southeast. This study was approved by the Clemson University Institutional Review Board, and all participants provided consent prior to participation. Driver Rehabilitation Specialists All of the HC instructors that participated in this study were specialists, in that (16) were certified driver rehabilitation specialists (CDRS), and four were DRSs with the professional backgrounds being predominantly occupational therapists. The DRSs were from 10 different states. On average, the DRSs had 16 years of experience using HCs (range 0.5–37 years). On a scale from 1 to 10, where 1 is beginner and 10 is expert, the mean rating of DRSs’ own abilities using HCs was 8.5 (range 5–10). Dealers/installers The HC dealer/installer participants consisted of HC business owners, sales personnel, installers, general managers, service managers, and service technicians, as
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many dealer/installer participants held multiple occupations. The dealers/installers reported an average of nine years (range 1–20 years) selling or installing HCs. When asked about the number of years of experience they had with HCs, the dealers/installers had an average of 8.3 years of experience (range 0–20 years). On a scale from 1 to 10, where 1 is beginner and 10 is expert, dealers/installers rated their own average level of abilities to install or use the HCs as 5.5 (range: 1–10). The dealers/installers were predominantly located in the southeast United States. Users The HC users consisted primarily of drivers with disabilities. The participants’ injuries were mostly spinal cord, followed by amputations and genetic diseases. One participant without disabilities often drove with HCs as a result of living with a family member who only drove with HCs. Of the 20 HC users, 17 drove prior to having their disability and three did not. On average, HC users reported having 19.3 years of experience using HCs (range 1.5–60 years). On a scale from 1 to 10, where 1 is beginner and 10 is expert, the average level that users rated their own abilities with HCs was 9 (range 6–10). The users resided throughout North America. Procedure On average, the interviews lasted 20 minutes with DRSs, 25 minutes with dealers/ installers, and 15 minutes with users. The interviews were predominantly conducted over the phone, while a few were done locally in-person. Most of the questions asked allowed for yes/no responses, while just a few were open-ended. The openended responses were organized into common responses and tabulated. RESULTS There were 14 types of diagnoses or injuries that the DRSs reported in their clients who required HC driver training. The most common disability reported was spinal cord injury, with 18 out of 20 DRSs reporting that an average of 43% of the clients were individuals with SCIs. This statistic was consistent with the surveyed users, as 13 out of the 20 reported having a spinal cord injury. Specifically, six of the 13 users with a spinal cord injury were higher level (Cervical 5–7), followed by four midlevel (Thoracic 9–12), two upper middle (Thoracic 5–7), and one lower (Lumbar 1–2) spine injury. Lower extremity amputations were the second most common disability reported by the DRSs, with 11 out of 20 DRSs indicating that an average of 22% of their clients had amputations. Training for Using HCs DRSs and dealers/installers. When asked if all clients that need HCs to drive should have formal training, 16 out of 20 DRSs responded yes, and 18 DRSs said that training should be mandatory. All of the dealers/installers reported having driver education for the disabled available in their geographical location; 19 out of 20 of them responded that the training was effective; and all of them said training should be mandatory.
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DRSs and dealers/installers were asked to estimate how many HC users received formal training. Sixteen out of 20 DRSs thought an average of 50% of HC users received training, with the other four DRSs indicating they did not know. Conversely, the dealers/installers reported that 94% of their clients receive HC training, though it may not be formal training by a DRS. Dealers/installers were asked if the HC user always received dealer/installer training before driving the car back home. Fifteen dealers/installers responded yes; two responded yes, making sure to document the training; and three responded that the HC users do not receive the training at the dealership. Then the dealers/installers were asked if a family member without disabilities drove the vehicle (with HCs installed) home. Three dealers/installers answered yes, 15 responded sometimes, and two responded no. When asked if their clients have driving experience prior to needing HCs to drive, the DRSs’ average response was that about 80% of their clients had prior driving experience. This was consistent with the 17 out of 20 (85%) of HC users who responded that they drove prior to having their disability. Users. When the HC users were asked about their HC training experience, eight had training at rehabilitation centers, 11 were self-taught, and one learned from a friend. These results are similar to the DRSs’ estimates of how many HC users get formal training. Of the eight HC users who received training, seven responded that they received training from a DRS, and one user could not remember the details of his/her formal training. The HC users who received formal training responded that they located an instructor from various sources. Two users found an instructor through their hospital or rehabilitation hospital, two through the Veterans Administration, one through therapy training, one through vocation rehabilitation, and one while receiving rehabilitation therapy at home. In contrast, 18 out of 20 dealers/installers reported contacting a DRS directly for training. As for training when HC users purchase a new vehicle, two responded that they get re-evaluated or go to a DRS; 18 responded that they do not get re-evaluated or trained when they purchase a new vehicle. HC users were also asked a question regarding the physicians with whom they interacted, concerning their injuries that caused them to need HCs to drive. Specifically, users were asked if they believed that those physicians had much knowledge about HCs. Out of all of the HC users, two responded yes, 16 responded no, and two responded that some (physicians) do have knowledge about HCs. Training cost. DRSs were asked if they thought training was too expensive for most clients (that required HCs) to afford in their geographical location, and 18 out of 20 DRSs responded yes. The eight HC users who responded that they had formal HC training were asked about how their formal training was funded. Only one responded that he/she paid for it himself/herself. Three were funded through vocational rehabilitation, two through the Veterans Administration (VA), one through a local hospital, and one did not respond. Training time. We asked all HC users how much time was necessary for them to become proficient with HCs, and most of them (six) responded less than one week. Five users responded either one to two weeks or two weeks to one month, and three users responded greater than one month. Those HC users who received formal training were asked how long they spent in training. One responded less than one
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14 12 10 8 6 4 2 0 open/empty parking lot
instructor training
any practice remote area
short trips with heavy traffic
straight roads
FIGURE 1. Dealers’/Installers’ Responses to the Question Asking How They Suggest Their HC User Clients Get Comfortable Using HCs.
hour; four responded 1–12 hours; two responded 1–5 days; and one responded two weeks while in rehab at the VA hospital. When the dealers/installers were surveyed about how they recommend their clients get comfortable using HCs, only six dealers/installers suggested receiving instructor training, as seen in Figure 1. HC Operation/ Maintenance Delivery and installation. We asked HC dealers/installers specifically how they deliver HC systems to their customers, and how they assure HC installation in their customers’ vehicles. The answers to these questions were vastly different, suggesting practices between dealers/installers vary widely. The range included minimal dealer/installer interaction with customers paying for the HCs and installation without training or instruction, to an in-depth experience when the customer received training on HCs, adjustments for custom fitment, a test drive with the dealer, and a final test drive to confirm ability of the driver to use the HCs. One issue we looked to address in this study was what happens with HC users after they get their HCs installed. Therefore, DRSs were asked if they saw HC user clients after their clients’ HCs were installed. Seven said yes, while seven responded sometimes, and six responded typically no, or not at all. In contrast, the majority of HC dealers/installers (19) responded that they do see HC clients after the clients have had their HCs installed. When DRSs and dealers/installers were asked if they educated clients to have their HCs adjusted or to receive HC maintenance on a regular basis, 16 DRSs responded yes, while all 20 dealers/installers responded yes. At the very least, this shows that both DRSs and dealers/installers believe that having regular maintenance and adjustments made on HCs are important for HC users. However, only
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seven of the HC users got maintenance on their HCs once a year, while seven never did, and three responded that they did as needed or greater than once every 1.5 years. Part of this variance in the amount of time between HC maintenance for users might be due to the difference in suggested time between scheduled maintenance recommended by HC dealers/installers. When HC users were asked how they knew when to service HCs, only three responded it was an annual routine, and one responded he/she does it when the dealership suggests. In addition, the majority of HC users (eight) reported only having their HCs adjusted or serviced when the HCs feel too loose, tight, or tough to operate. It should be noted that each HC user who reported having annual maintenance on their HCs also had other adaptive equipment or his/her vehicle serviced at the same time. User errors with HCs. The following list of items reflects responses by dealers/ installers when asked what types of problems related to HCs that they have seen with user clients. (The number of times each item was mentioned by dealers/installers is in parentheses.)
• • • • • • • • • • • •
Lack of routine inspection/maintenance for HCs (3) Drivers not reporting having spasms while driving (1) Drivers without disabilities driving with HCs (1) High-level injury drivers using inappropriate HCs (1) Snag of colostomy bags in vehicle (1) Mechanical failure of HCs or loose/worn out HCs (3) Lack of leg room, poor installation of HCs (3) User adjustment of HCs instead of dealer (1) Lack of education/training of drivers (3) Users buying HCs off the internet (1) Users not prepared to drive with HCs even after training (1) Use of HCs on vehicles besides cars (golf carts, all-terrain vehicles, etc.) (1)
HC users were asked to respond to one of the concerns of HC dealers/installers when users answered the question, “Have you ever used HCs on a vehicle other than a car?” Nine HC users responded yes and 11 responded no. Of those nine who responded yes, two either used them on a go-kart, John Deere Gator, or some other all-terrain vehicle, and one either used them on a forklift, golf cart, or some other utility vehicle. Recommendations for types of HCs DRSs and dealers/installers provided multiple answers when they were asked how they decided on HCs for their clients (Figure 2). Eleven DRSs use the strength/physical abilities of their clients to guide the decision of what type of HC to recommend, and they try various types of HCs during training to determine what works best for their clients. In contrast, nine of the HC dealers/installers responded that they actually do not recommend HC types for HC users or that they just use whatever HC type is recommended by the DRS who trained the user. Even though nine dealers/installers reported not
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FIGURE 2. Responses of DRSs and Dealers/installers When Asked How They Decide On HCs For Their Clients.
making recommendations, three HC dealers/installers did make recommendations based on either strengths or comfort of the client, or client disability type. We also asked HC users how they decided on the HCs that they currently use in their vehicles, and nine responded that they use whatever was available to them, followed by (five) what was recommended to them by the sales person/dealer. HC information/education. HC users were asked where they got their information/education about HCs. Figure 3 shows the user responses, of which medical professionals were the primary source of HC information/education, followed by HC dealers/installers or manufacturers. When HC dealers/installers were asked how they stayed current on new mechanical HC designs and operating techniques, half (10) of them responded that they got information from the HC manufacturers and from NMEDA (four listed this). Some participants provided multiple sources of information. Unlike HC users, it seems that very few dealers/installers get their HC information from the internet, as only two of the 20 surveyed dealers/installers listed the internet as a source to help them stay current with mechanical HC designs and operating techniques. In addition, HC dealers/installers were asked how they kept their installers informed of the most recent designs and formal training, and most of them (16) also responded that the manufacturers are the main sources, followed by NMEDA (eight). Some participants provided multiple sources of information.
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None
Vocational rehab
Support group
Medical / professional
Internet / reading
Friend
Dealer / manufacturer
8 7 6 5 4 3 2 1 0
FIGURE 3. Responses of HC Users When Asked Where They Get Their Information/ Education About HCs.
HC Design Current designs. DRSs and dealers/installers were asked which models of HCs they recommended most frequently. While most dealers/installers did not recommend a specific model of HC, the two actual HCs that were selected predominantly for both groups were push/right angle and push/rock. As a follow-up question, we asked dealers/installers what the most popular HC models were that they installed in client vehicles (see Figure 4). HC safety. DRSs and users were asked if they thought HCs reduced vehicle crashworthiness. Only five DRSs responded yes, and two users responded yes. 18 16 14 12 10 8 6 4 2 0
Dealers/installers
Non-specific
Throttle only
Accelerator ring
Floor-mounted
Push/twist
Push/rock
Push/right angle
Push/pull
Instructors
FIGURE 4. The Model of HCs That DRSs and Dealers/Installers Recommend Most.
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The two users explained why they thought HCs reduced the crashworthiness; their responses can be summarized as, that by adding another mechanism to the vehicle more potential problems can occur, and that mechanical HCs cause knees to be easily injured during an impact. HC users were asked if they had any fears about HCs, and most of them (12) responded no. Four users responded that they had fears of the HCs becoming loose or malfunctioning. Each of the other four participants had unique fears of HC application errors, for example simultaneously applying the gas and brake, rolling backwards on a hill, and getting into any accident in general. Likewise, when asked if they had any unexpected events while using the HCs in the vehicles they drove, 15 HC users listed none as the answer. Of those who did have unexpected events, two users listed leg spasms, and one each listed application error, foot caught under a pedal, or a leg accidentally engaging the HC lockout. When HC users were asked if they were ever involved in accidents or low speed fender benders because of difficulty using the HCs in the vehicles they were driving, 18 responded no, and two said yes, due to cables breaking while using the HCs. Self-designed systems. HC dealers/installers were asked about what types of selfdesigned systems they have seen. The dealers/installers listed the following types of self-designed systems that customers have used to drive before purchasing manufactured HCs: stick, baseball bat, broom, crutch, crutch taped to end of amputated limb, cane, two canes (one for gas and one for brake), having a child push gas and brake while the adult driver steers, shovel handle, tennis racket, 2 × 4 piece of wood, and copy of production HCs made from household items. Portable HCs. As another design question, we asked DRSs, dealers/installers, and users if they believe that portable HCs are useful. Portable HCs are designed to be moved in and out of vehicles often, usually for the purpose of driving rental cars that are not already equipped with HCs (National Mobility Equipment Dealers Association, 2010). Ten DRSs responded yes, eight responded no, and two did not answer. Eight dealers/installers responded yes, 10 responded no, and two did not know enough about them to answer. Only five out of 20 HC users had used portable HCs before, yet 14 responded that portable HCs are useful; two responded that they are not useful, and the other four users responded that they did not know enough about portable HCs to comment. However, when asked how safe portable HCs were on a scale from 1 to 10, where 1 is not at all safe and 10 is completely safe, DRSs reported an average answer of 3, and dealers/installers reported an average answer of 1. Similarly, when users were asked if they believe that portable HCs are safe, only four responded yes, 11 responded no, and five were not sure. Future designs. DRSs, dealers/installers, and users were all asked what improvements and updates they would like to see in HC designs (Table 1), where multiple answers were allowed. DISCUSSION/IMPLICATIONS This exploratory study investigated the perspectives of DRSs, dealers/installers, and users of HCs through survey questions to see how the participants’ responses align and conflict in regards to HC training, operation and maintenance, and design improvements.
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TABLE 1. HC Improvements and Updates Suggested by DRSs, Dealers/Installers, and Users. Suggestions identified by five or more total participants are in bold Rank 1 2 3 4 4 5 6 7 8 8 8 8 8 9 9 9 9 9 10 10 10 10 10 10
Suggestion
Instructors
Dealers/Installers
Users
Total
Knee room/ legroom/ less intrusive Safety lockout Inclusion secondary controls Clean/easy installation Integrate HC into vehicle electronics More user friendly Vehicle specific brackets Right side option Better aesthetics/style More/easier adjustability More styles/options All controls on wheel More comfortable handle/more tacky Safer Training for users Smaller controls Independent gas brake Manual transmission capable Quick disconnect for drivers without disabilities Independent gas and brake Bring controls closer to body Less fatiguing Testing/regulation of HCs Maintenance free
9 0 4 0 0 0 0 3 2 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0
9 16 1 4 3 3 5 0 1 1 0 0 0 2 2 0 0 0 0 1 0 0 1 1
2 0 4 3 4 3 0 1 0 2 0 3 3 0 0 2 2 2 1 0 1 1 0 0
20 16 9 7 7 6 5 4 3 3 3 3 3 2 2 2 2 2 1 1 1 1 1 1
Training The DRSs’ guesses of the number of users who received formal training was consistent with the number of HC users in the survey who responded that they received formal training (about 50% for each). Dealers/installers responded nearly all (94%) of their clients received formal training, which suggests that if clients went to dealers for their HCs, they also received formal training to use HCs. If this statistic is true (all HC clients of dealers/installers receive training), this also suggests that nearly half of HC users do not go to dealers/installers for their HCs. However, the definition of “training” is not precise, thus many interpretations are possible. Dealers may believe formal training includes an hour of showing the client how to use the HC, while the user understands formal training as working with the DRS for more than an orientation. While it would seem that at least as many DRSs as dealers/installers would believe that HC training should be mandatory, when asked this, only 18 out of 20 DRSs responded yes, while all of the dealers/installers responded yes. Another peculiarity in instructor responses was that only 16 out 20 DRSs said that HC users should have formal training. For two DRSs, this contradicts their responses about mandatory training. Upon closer inspection, all of these contradictions seem to be related to poorly worded questions. In the future, questions about the need for formal training and mandatory training should be more carefully worded. Also, the mandatory training questions should always follow the formal training questions so that participants can give more accurate responses. For those DRSs who do not
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believe formal training should be mandatory, it would be interesting to know why; therefore, this should be asked in the future. With the majority (18 out of 20) of DRSs agreeing that HC training was too expensive for most clients in their geographical areas, and only one HC user with formal training paying for instruction out-of-pocket, the cost of HC training seems to be an important issue. Addressing ways to better fund drivers with disabilities for HC training might be one way to increase the number of formally trained HC users on the road. Also, exploring the variation in cost for HC training and differences in training practices among DRSs is an important next step in this research. A detailed examination of the training practices among DRSs as well as dealers/installers may be helpful to ensure adequate training procedures are used by instructors with different educational backgrounds. Also, exploration into the variation of cost for HC training should occur to help shed light as to why a large percentage of HC users choose not to get training at all. Operation/Maintenance From those interviewed, there seems to be a miscommunication among DRSs, dealers/installers, and users about how often users should have their HCs adjusted and maintained. While most of the participants surveyed in each group believe that users should take their HCs in for maintenance, exactly when and how often is not clear between and within the groups. Establishing general guidelines for maintenance of various types of HCs developed and shared amongst DRSs, dealers/installers, users, or perhaps by NMEDA—could be an important step for improvement in the safe use of HCs. The issue of drivers without disabilities using HCs should be looked at more closely. Dealers/installers indicated that sometimes family members need to drive vehicles with newly installed HCs home from the dealership. However, dealers/installers responded that it is a problem when drivers without disabilities use HCs. Another important topic to explore is the need for clarification on when it is appropriate for drivers without disabilities to use HCs and if these drivers should also receive training. Eight HC users responded that they get their information about HCs from two or more sources (i.e., healthcare provider, internet/social networking, and friends/family). Follow-up questions about the types, makes, and manufacturers of the HCs available to users and how users found them, would be useful to ask in a future study. Such follow-up questions would be especially relevant for those who responded with whatever is available to the question of how they decided on their current HCs. Design While many DRSs are trained to care for clients with a variety of injuries and illnesses that drivers with disabilities have, knowing that spinal cord injuries (SCIs) and amputations are the most common may be useful in designing new HCs and HC training. However, a more detailed study looking at statistics of the injuries and ailments of HC users in the US would provide more evidence to confirm this conclusion about the most common injuries that require HCs for driving. Also, the
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level of SCI can substantially vary the mobility of the HC user, and this should be considered in a future analysis. While dealers/installers listed that users operating vehicles other than cars with HCs is problematic, almost half (nine) of users said they have operated vehicles other than cars with HCs. This suggests that HC users either do not heed HC dealers/installers’ suggestions with respect to this or they do not know that HC dealer/installers recommend against this. Depending on the reason why HC users use HCs on vehicles other than cars, HC dealers/installers could either promote newly designed HCs that can be used safely on vehicles other than cars, or they could take more opportunities to educate HC users not to use HCs on vehicles other than cars. DRSs and dealers/installers were consistent in seeking less intrusiveness/more legroom, a safety lockout feature, and more common inclusion of secondary controls in HC designs. However, HC users desired integration of primary controls with vehicle electronics and inclusion of secondary controls in more HC designs. All of these design characteristics are important, as each of the three participant groups have strong voices in the HC industry. These suggestions could be combined in new HC designs, where HCs that are more integrated into vehicle electronics also have an electronic lockout feature and integration of secondary controls, reducing intrusiveness around the legs since mechanical connections would not be necessary. If these features were available at prices that rival current mechanical HCs, many of the requests from DRSs, dealers/installers, and users would be addressed. It should be noted that while nearly 50% of DRSs and dealers/installers and more than 50% of users responded that portable HCs were useful, all of these groups thought that current portable HCs were not safe to use. Limitations/Future Research The major limitation of this study was that it involved exploratory questions focusing on HC training, maintenance and operation, and design. However, it has not been pursued before. In addition to finding useful information about the perspectives of DRSs, dealers/installers, and users about the HC industry, we also found that there are opportunities for future studies in this area that could build on this study. In general, the common responses to some of the questions that did not require a yes or no answer could be used in a future study as responses in a list that the participants must choose from. This would limit the extraneous variation in responses, while still showing the variation in participant thoughts and opinions. This approach would also allow for more robust statistics about the responses to several survey questions. Training Method Specifics The HC training practices administered by DRSs and dealers/installers, and the training experienced by users were highly variable, based on interview results of this study; therefore, a dedicated study questioning the variation in training processes around the US that involves DRSs, dealers/installers, and users could be highly
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informative. It is known that HC training is an important part of making drivers with HCs more comfortable and safer while driving (Benoit, 2006); thus, proper exploration of the various practices used by DRSs to train drivers in the US is worth a study of its own. Necessary training time for users learning to operate HCs is another area of future work where more detail could be useful. Comparing the time that DRSs and dealers/installers believe it takes for users to become proficient, versus the amount of time users say it took them to become proficient, could be a useful analysis. Also, comparing these items to the amount of time DRSs report spending with clients could show interesting results. Also, exploring the price of the HC training is important because it might limit the number of times a user can afford to attend training sessions if price pays out-of-pocket. Based on responses from questions in this study, it could be useful to understand if DRSs and dealers/installers are consistent when considering whether family members of HC users should ever drive a vehicle with newly installed HCs. In this study we asked dealers/installers, “Will a non-disabled family member drive the car home?” It would be useful to ask DRSs this same question in a future study. Also, a good follow-up question would be, “Do family members without disabilities, who drive home vehicles with newly installed HCs, have any HC training? If not, why?” These questions, as well as other specific questions for DRSs and dealers/installers, would allow for a better understanding of why there might be differences in approaches (such as only allowing drivers with HC training to use HCs, making sure family members without HC training and without disabilities know how to disengage HCs properly, giving family members without disabilities brief HC training just to get the vehicle home, etc.). Dealer/Installer Reported Issues This exploratory study yielded an extensive list of HC dealer/installer reported problems with clients related to HCs. The HC dealers/installers in our study responded that drivers without disabilities using HCs are problematic; yet, when dealers/installers were asked if they allowed family members without disabilities to drive a vehicle with HCs installed home, three answered yes, 15 responded sometimes, and two responded no. To understand this contradiction better and to provide clarification, more detailed questions in future work should address the circumstances that HC dealer/installers agree that drivers without disabilities can drive vehicles with HCs. Specific problems that were exposed in this survey could be pursued further in a future study. HC users should be asked questions about self-designed HC systems employed by some HC users. It is likely that the price of HCs and HC training plays a role in the use of self-designed systems, but specific questions about such systems and their use should confirm or deny this idea. Also, dealers/installers and DRSs should be asked their opinions about these self-designed systems, if such systems should be eliminated, and why or why not. In a follow-up study, HC dealers/installers should be asked if they think currently available HCs reduce vehicle crashworthiness, and all groups should be asked about why or how they believe this to be true (not just the users).
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User Decisions on HC Purchases HC users were asked, “how did you decide on the hand controls that you currently use?” Follow up questions for the HC users who responded “whatever was available,” would be useful. Also, asking these users how they found these HCs would be a useful question. Specific questions that address whether users’ physicians know about HCs or even need to know about HCs could reveal helpful information to the HC industry. HC users were asked one question in this survey about if they believe that physicians know much about HCs, and while it would be useful to get a more detailed perspective about this from users, it would also be worthwhile to get similar perspectives from DRSs and dealers/installers. CONCLUSION This exploratory study examined interview responses from key groups involved in the HC industry, including DRSs, dealers/installers, and users regarding HC training, maintenance and operation, and design. Survey questions were asked to participants in each group over the phone or in person, and participant responses were tabulated in a meaningful manner. This study points out the perspectives of these participants about important issues, such as whether HC training should be mandatory, when/how often HCs should receive maintenance, and desired improvements in HC designs. In addition, the study exposes areas where more detailed questions about HC training, maintenance and operation, and design would be useful for each of the groups in the industry. ACKNOWLEDGMENTS The authors would like to thank Connie Truesdail, Stan Healy, Jimmy Bacon and the Fullerton Foundation for supporting this project. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. ABOUT THE AUTHORS Evan Lowe, Clemson University, Automotive Engineering, CU-ICAR, 4 Research Drive, Greenville, 29607 United States. Nathalie Drouin, Roger C Peace Rehabilitation Hospital, Occupational Therapy, 701 Grove Road, Greenville, 29606 United States. Paul J. Venhovens, Clemson University, Automotive Engineering, CU-ICAR, 4 Research Drive, Greenville, 29607 United States. Johnell O. Brooks, Clemson University, Automotive Engineering, CU-ICAR, 4 Research Drive, Greenville, 29607 United States; Greenville Health System, Department of Medicine, 701 Grove Road, Greenville, 29606, United States. REFERENCES Altobelli FD. (1964). The handicapped as automobile drivers. Rehabilitation Record, 5, 36–38. Association for Driver Rehabilitation Specialists. (2011). Member Directory. Retrieved from Association for Driver Rehabilitation Specialists: http://www.driver-ed.org/custom/ directory/?pageid=209&showTitle=1
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